Introduction: Coverage of scalp defects after previous craniotomy can be challenging. Scalp rotation flaps may unavailable due to previous scars, radiation therapy, infection, or fibrosis. All too often, CSF leaks are present. Although numerous case reports have been published, a useful reconstructive algorithm is lacking. The purpose of this study was, therefore, to evaluate our experience with scalp reconstructions in a wide variety of clinical situations and to identify an appropriate reconstructive ladder.

Methods: This was a retrospective review of all patients treated by the plastic surgery service for scalp defects over a 15-year period. Reconstructive methods used, previous surgery/radiation, presence of CSF leaks, and outcomes were analyzed.

Results: A total of 69 procedures were performed in 63 patients. Techniques for reconstruction included primary closure (4.3%), skin grafts (18.8%), local flaps (37.7%), and free flaps (39.1%). 14 complications (20.2%) overall were reported and included wound infections (15.9%) and systemic complications (4.3%). Three patients died within 30 days of operation due to medical complications. Complication rates associated with each method of reconstruction were as follows: primary repair =33.3%; skin grafts = 0%; local flaps =19.2%; free flaps =14.8%. There were no microsurgical flap losses. Of the 30 patients with a history of radiation therapy, 26.7% had complications. In contrast adverse events were seen in only 2.9% of non-irradiated patients.

Discussion: Successful management of scalp defects is based on adequate debridement, blood supply, and drainage. Primary wound repair in these cases is usually not feasible. A combination of local flap closure with skin grafting of the donor site is often necessary, particularly in radiated tissues, due to the fibrosis and lack of elasticity in the skin. A combination of CSF decompression and local drains should be used in situations where CSF leaks are detected. Microsurgical tissue transfer is necessary in selected patients and particular care must be paid to selection of recipient vessels.