scalp reconstrction with free latissimus dorsi muscle flap and forehead flap

sirisurgchild
6 days ago
3 min read

Scalp defects can result from trauma, tumor removal, or infection, often leaving complex wounds that require careful reconstruction. Restoring both function and appearance is challenging due to the scalp’s unique anatomy and limited local tissue availability. Two effective surgical options for large or complicated scalp defects are the free latissimus dorsi muscle flap and the forehead flap. This post explores how these techniques work together to achieve successful scalp reconstruction.

Understanding Scalp Defects and Reconstruction Challenges

The scalp consists of skin, connective tissue, galea, and pericranium overlying the skull. When a defect exposes the skull or involves significant tissue loss, simple closure or skin grafts often fail. The scalp’s limited elasticity and blood supply make reconstruction difficult, especially for defects larger than 50 cm².

Key challenges include:

Restoring durable coverage to protect the skull and brain.
Maintaining scalp contour for aesthetic appearance.
Ensuring adequate blood supply to promote healing.
Minimizing donor site morbidity to reduce complications.

For small defects, local flaps or skin grafts may suffice. Larger defects require more complex solutions like free tissue transfer.

The Role of the Free Latissimus Dorsi Muscle Flap

The latissimus dorsi muscle, located in the back, is a large, well-vascularized muscle commonly used in reconstructive surgery. When transferred as a free flap, it brings its own blood supply, making it ideal for covering extensive scalp defects.

Advantages of the Latissimus Dorsi Flap

Large surface area coverage suitable for extensive defects.
Reliable blood supply through the thoracodorsal vessels.
Muscle bulk provides padding over exposed bone.
Versatility allows shaping to fit irregular defects.

Surgical Procedure Overview

Flap Harvesting: The latissimus dorsi muscle is carefully dissected with its vascular pedicle.
Recipient Site Preparation: The scalp defect is debrided, and recipient vessels (usually superficial temporal or occipital arteries or the facial arteries) are identified.
Microvascular Anastomosis: The flap’s vessels are connected to recipient vessels under a microscope.
Flap Inset: The muscle is positioned to cover the defect, and skin grafts or local flaps cover the muscle surface.

This approach provides robust coverage and promotes healing even in previously irradiated or infected areas.

Using the Forehead Flap for Scalp Reconstruction

The forehead flap is a local flap based on the supratrochlear or supraorbital arteries. It is a reliable option for reconstructing defects in the frontal scalp or hairline areas.

Benefits of the Forehead Flap

Excellent color and texture match with scalp skin.
Good vascularity ensures flap survival.
Can be designed as a pedicled flap for staged reconstruction.
Minimal donor site morbidity with well-hidden scars.

Typical Applications

Reconstruction of defects near the hairline or forehead.
Coverage of smaller or medium-sized defects where local tissue is available.
Complementing free flaps by providing skin coverage over muscle.

Combining Free Latissimus Dorsi Flap and Forehead Flap

In complex scalp defects, combining these two flaps offers a comprehensive solution:

The latissimus dorsi muscle flap provides bulk and vascularized tissue to cover large or deep defects.
The forehead flap supplies skin coverage with a good aesthetic match, especially in visible areas.

This combination allows surgeons to reconstruct both the deep and superficial layers effectively.

Case Example

A patient with a large scalp defect after tumor excision underwent reconstruction with a free latissimus dorsi muscle flap to cover the exposed skull. After muscle transfer and healing, a forehead flap was used to cover the muscle with skin, restoring the scalp’s natural appearance. The patient achieved durable coverage and satisfactory cosmetic results.

Postoperative Care and Outcomes

Successful scalp reconstruction requires careful postoperative management:

Monitoring flap viability through clinical signs and Doppler ultrasound.
Preventing infection with antibiotics and wound care.
Managing donor site wounds to minimize scarring and functional loss.
Physical therapy if shoulder function is affected by latissimus dorsi harvest.

Most patients recover well, with restored scalp integrity and acceptable cosmetic outcomes. Complications like flap necrosis or infection are rare with proper technique.

Summary

Reconstructing large or complex scalp defects demands reliable, well-vascularized tissue coverage. The free latissimus dorsi muscle flap offers extensive, durable coverage, while the forehead flap provides excellent skin match and aesthetic restoration. Using these flaps together addresses both functional and cosmetic needs, improving patient outcomes.

If you or someone you know faces scalp reconstruction, discussing these options with a reconstructive surgeon can help tailor the best approach. Advances in microsurgery continue to expand possibilities for restoring scalp defects with strong, natural results.

My article - Taliat G., Kumar K.M., Shivalingappa S. Salvage of a large exposed cranial implant on irradiated necrosed scalp using free latissimus dorsi and forehead flaps – a case report. Acta Chir Plast 2022; 64(2): 89–92.