An Evidence-Based Approach to Oncologic Scalp Reconstruction

Objectives: Describe an algorithm for oncologic scalp reconstruction based on a single institution’s surgical experience and analysis of outcomes. Methods: This is a single institution, retrospective review of patients requiring oncologic scalp ablation with subsequent reconstruction from 1992-2012. Demographics include patient age, sex, immunosuppressive state, and type of malignancy. Measured endpoints include defect size/location/depth, the reconstruction method used, concomitant surgery (ie lymphadenectomy), adjunctive chemotherapy or radiotherapy, complication rate, and length of follow-up. Results: A total of 140 patients are reviewed with an average age of 70.4 years; 76% being male. Approximately 51% of all patients required postoperative radiation, chemotherapy, or both. Defect widths range from 0.7cm to 24cm, with an average of 7.5cm. Depths range from full-thickness skin to full-thickness skull, the majority being up to pericranium (30%). Reconstruction varies from simple granulation to free tissue transfer. The overall complication rate for both primary and reoperative reconstruction is approximately 11%. Specific complications, spanning from hematoma to total flap failure, are statistically enumerated. Complication rates more than doubled when patients received radiation, chemotherapy, or both (14.1% versus 6.5%). Average length of follow-up is 2.4 years. Conclusions: The armamentarium of scalp closure techniques is vast and can range from conservative therapy to free tissue transfer. Exposure to chemotherapy and radiation increases complication probability, propounding the need for healthy tissue coverage and tension free closure. Complication rates do not change signigicantly for primary versus revision surgery. Defect size plays only a minor role in complication rate, provided the appropriate method of reconstruction.