Scalp reconstruction

By defect size

< 3 cm with normal laxity

Primary closure with wide undermining in subgaleal plane and galeal scoring as needed.

3–10 cm

• Local rotation / advancement flap — single-flap rotation; donor closes by secondary intention or split-thickness skin graft.
• O-to-Z or O-to-T double advancement.
• Three-flap (Worthen, Orticochea) or four-flap closure — multiple rotation flaps share the burden of advancement; for crown / vertex defects.

10 cm or larger

• Tissue expansion (delayed reconstruction) — best aesthetic result for hair-bearing scalp; needs 6–12 weeks expansion + reconstruction.
• Dermal regenerative template (Integra, Matriderm) over pericranium or burred bone, then split-thickness skin graft 3–4 weeks later.
• Free tissue transfer — radial forearm (thin pliable cover), ALT, latissimus dorsi (large defects).

Defects involving bone or dura

• Outer-table burr holes encourage granulation if pericranium is lost.
• Cranioplasty (titanium mesh, PEEK, autologous bone) for full-thickness skull defects, often staged after free flap consolidation.
• Joint working with neurosurgery essential for dural reconstruction.

Pitfalls

• Underestimating the rigidity of scalp — defect that 'looks closable' often is not without galeal scoring.
• Forgetting hair direction in flap design.
• Tension closure → wound dehiscence and exposure.
• STSG over bare bone without pericranium → graft failure.