The complex nature and magnitude of scalp defects, the relative paucity and often compromised nature of local tissue, the remoteness of this site from regional donor sites, and the often compromised overall status of patients pose a significant reconstructive challenge. Titanium mesh cranioplasty is both functional, in terms of cerebral protection and aesthetic, in terms of contour maintenance. Fasciocutaneous free flap reconstruction has the advantages of importing large amounts of well-vascularized tissue, ease of contour, and good aesthetic outcomes. This reported case series reviewed the technique of titanium mesh cranioplasty and fasciocutaneous free tissue transfer for patients who have undergone resection of locally advanced malignancy of the scalp.
Data from 9 men and 2 women were retrieved by review of the patient's record and clinical review of the patient. Patient demographics, comorbidities, and radiation exposure were compiled. Eleven titanium mesh cranioplasties and 11 fasciocutaneous free flaps (8 anterolateral thigh flaps and 3 radial forearm flaps) were performed as primary reconstructions for 11 defects. The mean follow-up was 18 months, with a range of 6 to 36 months. Of the 11 free flaps, all survived, although one was salvaged in the face of arterial thrombosis. All patients have achieved satisfactory soft tissue coverage of their respective defects without the need for further surgery. No patients have had wound infections at the scalp reconstruction site, although there was one donor site (ALT) wound infection that cleared with local wound care and antibiotics. All radial forearm donor sites were skin grafted; 2 of 6 anterolateral thigh flaps were skin grafted while the others were closed primarily. Two of the anterolateral thigh defects that were closed primarily developed subacute donor-site seromas despite perioperative suction drainage. All titanium mesh cranioplasties remained intact. There were no titanium extrusions, development of fistulae or sinus tracts, or need for cranioplasty revision. Six of 11 patients have undergone tumoricidal doses of adjuvant radiation therapy without adverse effect to or from their titanium mesh/fasiocutaneous flap constructs.
The treatment of locally advanced cutaneous malignancies of the scalp and calvariuim remains a difficult challenge for both the extirpative and the reconstructive surgeon. The combination of titanium mesh cranioplasty coupled with fasciocutaneous free tissue transfer has gained favor at the authors' institution because of the ability to obtain a reliable, safe, aesthetically pleasing result.
