Introduction: Patients occasionally present with extensive tumors, burns or infections involving the facial skin and scalp. The majority are basal cell and squamous cell carcinomas, neglected or recurrent, with peripheral or deep extension, involving the skull, dura, orbit and maxillary sinus. These patients present a difficult ablative problem and a formidable reconstructive challenge. In addition to the large defects (any cutaneous defect larger than 100 cm2 was considered to be massive), the exposure of vital structures (dura, brain) and the presence of a direct communication between the oropharynx and intracranial contents adds to the complexity of the problem.

Materials and Methods: Twenty-five patients with massive defect of the scalp and face underwent microvascular free tissue transfer following excision of neglected or recurrent tumors, debridement of full-thickness burns and infections. These large defects of the scalp and skull exceeding 100 sq.cm. required coverage of the large surface area and exposed dura/brain. The facial defects including the orbit and palate required "complex" three-dimensional volume reconstruction. The flaps utilized were: latissimus dorsi (n=11), omentum (n=3), radial forearm (n=3), scapular (n=8). The age range was 25-70 years. There were 17 males, 8 females. The etiology of the defects was: neoplasm (n=17) and other--burns, infections (n=8). There were 9 scalp and forehead defects and 16 midface and palate defects.

Results: Twenty-three of 24 patients healed without complications. There was one flap loss due to thrombosis. All patients received significant pain relief. All tumor patients survived over two years, the longest survived 9 years.

Conclusions: 1) Microsurgical free tissue transfer allows coverage of virtually any defect of almost any size with greater flexibility than prior local/regional flaps. 2) This technique frees the oncologic surgeon from the constraint imposed by conventional reconstructive techniques.