Microsurgical scalp reconstruction and cranioplasty refined

Abstract

**Introduction** Microsurgical free flap scalp reconstruction is commonly the only reconstructive option in certain challenging patient cohorts. We describe the technical refinements that have streamlined our approach to microsurgical scalp reconstruction and cranioplasty. **Methods** Virtual surgical planning for multiple failed cranioplasty cases involves fashioning an implant with a 3 mm offset. Intramuscular dissection of the latissimus dorsi (LD) vascular pedicle, distal to its bifurcation, is routinely performed, and can increase pedicle length by up to 4 cm without the need for tedious dissection in the axilla. Anastomoses to the superficial temporal vessels distal to their bifurcation in the parietal scalp are reliable and safe. The sequence of surgery is in reverse to the conventional sequence, with the free flap vascularised before craniectomy/cranioplasty is performed to decrease the duration of synthetic implant exposure. **Results** Thirty-nine cases were performed in 35 patients over a five-year period. An LD-based free flap in various permutations was the commonest free flap option (_n_ = 31). The superficial temporal artery and vein were choice recipient vessels in 82 per cent and 74 per cent of cases, respectively, with the former demonstrating higher anatomical consistency. Complications included free flap venous congestion successfully salvaged (_n_ = 1), infected polymethylmethacrylate cranioplasty requiring explantation (_n_ = 1), subdural haematoma requiring craniotomy for evacuation (_n_ = 1) and free flap donor site haematoma (_n_ = 2). **Conclusion** Our technical refinements offer a streamlined and reliable procedure of complex scalp reconstruction and cranioplasty.