36-year Follow-up on Scalp Reconstruction Using Free Latissimus Dorsi Muscle Flap, Skin Grafting, and Scalp Expansion

Abstract

Background:

Immediate coverage of a large area of exposed skull is the first step in reconstructing a major scalp loss. In the 1970s, the free omental flap was used for scalp reconstruction, replacing removal of the external table and skin grafting only. Introduction of flaps and expanders has revolutionized reconstruction of major scalp losses. A free muscle flap is used to cover the exposed skull. Skin graft covers the muscle flap, and next, the expanded scalp is used to restore the scalp to its original shape. In certain cases, a hair transplant could help create a more natural hairline.

Methods:

In this case, in 1987, a free latissimus dorsi muscle flap and skin grafting were used in a 27-year-old man with major scalp loss. The left latissimus dorsi muscle was harvested with its vascular pedicle intact. Left superficial temporal vessels were used as recipients. After complete healing of the free flap, scalp and forehead skin were expanded and used to restore the scalp to its preinjury shape.

Results:

Coverage of the exposed parietal skull with free latissimus dorsi muscle flap and skin graft was successful. Then, scalp tissue surrounding the defect and forehead skin were expanded and used to restore the scalp to its original shape.

Conclusions:

This 36-year follow-up in a patient who had major scalp reconstruction using free latissimus dorsi muscle and skin grafting followed by scalp and forehead expansion shows that this method provides an excellent and reliable long-term coverage for such an injury.

Takeaways

Question: Is the free latissimus dorsi muscle flap the best choice for reconstructing a major scalp loss?

Findings: Reporting a 36-year follow-up on reconstructing a major scalp loss using free latissimus dorsi muscle flap, skin grafting, and scalp expansion, this article shows the durability of this type of reconstruction for a major scalp loss.

Meaning: The free latissimus dorsi muscle flap could be used for reconstruction of a major scalp loss successfully, and this long-term follow-up is one example of it.

INTRODUCTION

In the early morning hours of July 10, 1987, a 27-year-old Korean man fell asleep at the wheel while driving home from work. He rolled over his convertible car, and he was dragged on the road on his head. As a result, he sustained a major loss of his frontoparietal scalp and the periosteum in this area.

Initial evaluation showed the scalp defect to be 10 × 8 inches, and the open wound showed a significant amount of dirt at its edges as well as tissue necrosis. He did not have any other significant injuries. The computed tomography scan of his head and C-Spine x-ray were both negative.

METHOD

His treatment was done in four stages, which took over 9 months.

Stage 1: Radical Debridement of Scalp Defect and Antibiotics

Due to the presence of dirt embedded in the edges of the scalp defect and periosteum, a radical debridement was performed, and the open wound was dressed with Xeroform and gauze. Intravenous antibiotics was administered for a week, and daily wound care was done for 12 days. Then the wound became clean and ready for the next stage (Figs. 1–3).

Fig. 1.

Frontoparietal scalp defect.

Fig. 3.

Scalp defect after cleaning and debridement.

Fig. 2.

Scalp defect left, lateral view.

Stage 2: Free Latissimus Dorsi Muscle Flap and Skin Grafting

For the coverage of scalp defect with exposed bone, several treatments have been used:

• A. Skin grafting only, which would require creating holes in the external table or even removing it to allow for creation of granulation tissue as the bed for skin grafting. In this case, the patient would need to wear a hard hat for the rest of his life.¹

• b. In the 1970s, the free omental flap was used for major scalp defect reconstruction.

• c. Covering the exposed bone and defect with a free muscle flap and skin graft to cover the muscle.^2–6

In this case, option C was chosen. The ideal free flap is the latissimus dorsi muscle because of its large surface area and rather thin thickness.

Thirteen days after his injury on July 23, 1987, the patient had free latissimus dorsi muscle flap and skin grafting for reconstruction of his scalp defect. The left latissimus dorsi muscle flap was harvested with its vascular pedicle intact. The left superficial temporal vessels were used as recipient vessels for a microanastomosis. Then the muscle was laid over the exposed skull, and the edges of the muscle were positioned underneath the surrounding scalp and sutured in place. Split-thickness skin graft was taken from his thigh and used to cover the muscle completely. The procedure was successful (Figs. 4–6).

Fig. 4.

Scalp defect before covering it with free latissimus dorsi muscle flap.

Fig. 6.

Split-thickness skin graft covering latissimus dorsi muscle flap and its pedicle.

Fig. 5.

Latissimus dorsi muscle flap covering the scalp defect. A, Left temporal view (pedicle area). B, Parietal and left temporal view.

Stage 3: Insertion of Expanders

After complete healing of the latissimus dorsi muscle flap and the skin graft covering it, the patient had a large area of baldness in the frontoparietal area of his scalp (Fig. 7). He was asked to provide a picture of himself before the accident to decide where his frontal hairline should be. After reviewing his photograph, it was decided to expand his forehead skin as well as lateral parietal and occipital scalp. On October 5, 1987, 2.5 months after the free latissimus dorsi muscle flap procedure, expanders were inserted under the scalp surrounding the defect and forehead skin (Fig. 8).

Fig. 7.

Healed free muscle flap covered by split thickness skin graft. A, Latissimus dorsi muscle and skin graft completely covering the parietal defect. B, Well-healed latissimus dorsi flap covered by skin graft 2.5 months postoperative.

Fig. 8.

Scalp and frontal skin expanders have been expanded to the desired volume. A, Frontal view. Expanded forehead. B, Right lateral view. Expanded scalp and forehead. C, Left lateral view. Expanded scalp and forehead.

Stage four: Covering the Bald Frontoparietal Area Using Expanded Scalp and Forehead Skin

On December 28, 1987, almost 3 months after the insertion of expanders, this procedure was done, and his defect was reconstructed to resemble the way he looked before his injury (Fig. 9).

Fig. 9.

Scalp reconstruction is completed, and 9 months post-injury, it matches the patient’s pre-injury picture. A, Frontal view. B, Right lateral view. C, Left lateral view.

RESULT

The final result showing restoration of frontal hairline to what it was before the injury is displayed in Figures 9–10. The patient’s scalp looked normal at his last follow-up appointment on April 20, 1988, and he was very happy with his results. The patient’s results 36 years later are very satisfactory (Fig. 11).

Fig. 10.

The patient’s preinjury picture.

Fig. 11.

The patient’s frontal and lateral photographs 36 years postparietal scalp reconstruction using free latissimus dorsi muscle flap, skin grafting, and scalp and frontal skin expansion. A, Frontal view. B, Right lateral view. C, Left lateral view.

CONCLUSIONS

This is a long-term follow-up in a patient who had his major scalp loss (Fig. 12) reconstructed using free latissimus dorsi muscle flap and skin grafting followed by scalp and forehead skin expansion 36 years ago. The result shows that this method of major scalp reconstruction provides an excellent and reliable long-term coverage for such injuries.

Fig. 12.

Scalp defect.

DISCLOSURE

Dr. Ghorbani has no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

The patient provided written consent for the use of his image.

ACKNOWLEDGMENT

The author thanks Ms. Margret Reimann for her valuable help in preparing the earlier draft of this article.