Experiences of Chi-Mei medical center in Taiwan Shin-Huei Huang (Kathy) Chun-Chia Chen, Yu-San Lin, Kuo-Feng Huang, Haw-Yen Chiu Nothing to disclose

Introduction  Complicated scalp wound has been a challenge for both functional and aesthetic reconstruction. Free tissue transfer such as a forearm flap, rectus abdominis flap, latissimus dorsi flap and serratus anterior flap,is required.  We notice scalp wounds with chronic infection accompanied with bone or prosthesis exposure are difficult task to reconstruct.

Material and methods  Retrospective data analysis of reconstruction for scalp wounds with infection between January of 2008 and August of 2015 in our hospital was performed, and 9 cases meet the criteria.  Etiology, size of defects and details of reconstruction was recorded.

Name Age/sex Etiology Scalp Surgery locationSize (cm) Flap type Recipient vessels R/TMorbidity 1 施 55/F Contact burn - Cheek 7X5 RFFacial(STA was burned)- 2 郭 60/F Recurrent meningioma with epidural abscess 4 Frontal 8X5 RFSTAYMinimal discharge 3 黃 51/F Metastatic (colon) adenocarcinoma 4 Temporal 6X4 RFSTAY 4 許 45/F Intra-cranial AVM 7 Temporal X3 scalpX1 12X6 RFSTA-Dehiscence 5 李 71/F Recurrent meningioma 2 Frontal 7X5.5 RFSTAY 6 黃 31/M Electrical burn TBSA 21% - Scalp 14X10 ALTSTA-ALT Flap failure  LD flap 7 蔡 30/M Traumatic ICH with epidural abscess 4 Frontal 12X4 ALTSTA 1a2V - 8 郭 49/M Traumatic ICH with skull osteomyelitis 2 Temporal 10X8 LDSTA- 9 杜 42/M Multiple trauma with CSF rhinorrhea 2 Frontal and skull base 7X6 SA+ribsSTA to Ext. jugular vein with AV loop - *RF: radial forearm flap, * STA:superior temporal artery * ALT:anteriorlateral thigh flap * LD:latissmus dorsi

Case1, contact burn with zygoma exposure 1 st stage: Free radial forearm + STSG 2 nd stage: Tissue expander insertion for left neck and shoulder 3 rd stage: Scar release and rotation flap

Case.4 Intracranial huge AVM s/p excision with bone cement exposure, s/p scalp surgery X 7, heavy smoker 1 st stage: Rotation flap 2 nd stage: Free radial forearm

Case 5. recurrant frontal meningioma s/p wide excision, persistent discharge for weeks and pre-shaped titanium mesh exposure. Free radial forearm transfer

Case 9. Traumatic ICH with repeated CSF rhinorrhea and meningitis for 2 years. Frontal and anterior skull base defect 7X6 cm Free serratus anterior myo-osseous flap (with 7 th and 8 th rib) reconstruction

myo-osseous flap (case 9) Primary or local flap Free flap (as our series,5RF,2ALT,1LD) Bone defect after debidement Small size 1.Medium or large size 2.Poor tissue quality 3.Infection 4.Hair-line involved region No bone defect Scalp infected defect Algorithm in our hospital

Results 1. Patient often had multiple scalp surgeries,4 times in average in our patients. Poor tissue quality after radiation and multiple surgeries preclude local flap transfer. 2. The mean extent of the scalp defect was 57.7cm 2, ranging from 35 cm 2 to 140 cm Fascio-cutaneous flap is a workhorse in reconstruction of infected defect. Superior temporal artery and vein is best choice as recipient vessels. 4. One ALT flap failed due to venous congestion. Wound dehiscence in case 4 owing to heavy smoking.

Discussion 1. To date, no reports had focus on the management of scalp defects with infection. 2. Antoinette A et al. conduct a systematic review and state forehead and temporal defects are better covered with thin fasciocutaneous flaps for cosmetic results. Antoinette A et al 2010 Plast. Reconstr. Surg. 126: 460, 2010 Aesthetic and Oncologic Outcome after Microsurgical Reconstruction of Complex Scalpand Forehead Defects after Malignant Tumor Resection: An Algorithm for Treatment

Discussion 3. Schus-terman et al. reviewed 308 cases and >90 percent of their recipient vessels were large-caliber vessels of the neck. But we preferred STA and use in 8/9 of our cases except burn injury in case 1. Scott L. Hansen et al. also value superior temporal artery as primary recipient vessels of the upper two-thirds of the face and scalp with 96% successful rate. Superficial Temporal Artery and Vein as Recipient Vessels for Facial and Scalp Microsurgical Reconstruction (Plast. Reconstr. Surg. 120:1879, 2007.)

Conclusion 1. Free flap is often necessary for reconstruction in infected scalp wounds 2. Use of the superficial temporal artery and vein as recipient vessels is reliable and safe. (90% successful rate) It’s easier to dissect and requires less pedicle length compared to neck vessels.

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