Extensive scalp soft-tissue reconstruction with free flaps: A simplified therapeutic algorithm for donor site selection based on a retrospective analysis

Introduction: Extensive scalp defects present a significant reconstructive challenge due to the complex needs of patients that are often beyond the scope of conventional therapies, which makes free flaps the most reliable solution. Despite the variety of free flaps available for such cases, there is a lack of clear criteria for selecting the most suitable option. The primary objective of this study was to provide a simplified guide for the selection of donor sites for free flaps for achieving optimal reconstruction outcomes. Materials and Methods: A retrospective study was conducted on 15 patients who underwent scalp reconstruction with free flaps between 2017 and 2022: 4 latissimus dorsi (LD), 4 omental (OM), 5 anterolateral thigh (ALT), and 2 radial forearm free (RFF) flaps. Reconstructive and postoperative data for all patients were collected, evaluated, and compared. Results: The mean defect size to be restored was 110.60 ± 14.55 cm² (LD 162.23 ± 23.1 cm2, OM 141.68 ± 11.80 cm2, ALT 73.83 ± 14.69 cm2, and RFF 37.13 ± 4.88 cm2). Seven complications were reported, with partial flap loss being the most common: LD n = 2 and OM = 3. Mean healing time of the donor and recipient sites was 2.53 ± 0.27 and 1.8 ± 0.31 months, respectively, with OM having the longest average period for recipient site healing (3.65 ± 0.24 months). Conclusion: Reconstructing extensive scalp defects requires careful consideration of critical factors such as defect size, donor tissue availability, need for adjuvant therapies, and patient comorbidities when selecting a flap. This underscores the importance of tailored approaches to enhance clinical outcomes. We propose a simplified algorithm for free flap selection to streamline the decision-making process in complex cases.