An algorithm for one-stage malignant oncologic scalp reconstruction.

Background: Scalp reconstruction has always been a challenging problem after oncological resection. Advanced surgical techniques can reconstruct any defects, but there are a large number of patients who cannot benefit from surgery for immature strategies. The authors here describe an algorithm for selecting the best reconstructive categories and minimizing complications according to the surgical defect of scalp tumors.

Methods: A single-institution retrospective review was conducted that included 173 patients with scalp tumors treated with surgery followed by reconstruction. Patients were identified by tumor type and nature; the location of scalp defect, size, and depth; the types of reconstructions and surgical. A systematic algorithm was developed according to our findings and current literature.

Results: Small defects (≤4 cm) could be closed by primary closure. Medium defects (4-30 cm) were reconstructed by local flaps. We routinely used skin graft for significant surgical defects (30-90 cm). And the tumor's location did not have an impact on reconstructive categories of above three types of defects. Free flaps should reconstruct very large-sized defects (>90 cm) in frontal, temporal, and vertex locations while pedicle flaps suited for occipital defects due to its anatomic vicinity. The reconstruction algorithm of recurrent disease was like the management in primary tumors except for the medium size defect in the occipital region that was primarily reconstructed by a skin graft. Multiple free flaps reconstruction is the best possibility for total scalp resection. Free flap reconstruction is used mainly for composite resection of the scalp, calvarium, and dura.

Conclusions: Successful scalp reconstruction requires careful preoperative assessment, flexible and precisely intraoperative management. The algorithm based on defect size, depth, and location can supply some degree of guidelines when considering choosing suitable reconstructive procedures.