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Scalp defects from trauma, burns, infection, tumor excision, or prior surgery present complex reconstructive challenges, requiring restoration of function and aesthetics. Traditional reconstructive methods often involve subjective decision-making, with variable outcomes based on surgeon experience and patient factors.
This study proposes an algorithmic approach to scalp defect reconstruction that standardizes decision-making and optimize outcomes. By considering patient-specific factors and defect characteristics, the algorithm provides a stepwise guide for selecting the most appropriate reconstructive techniques.

A retrospective three-year review of scalp reconstructions was performed. Defects were assessed by etiology, size, site, depth, and surrounding tissue availability. Techniques included split-thickness skin grafts, local flaps, and free flaps. Cases suitable for primary closure or secondary healing were excluded. Primary endpoints were wound healing and complication rates. Secondary endpoints included functional recovery, cosmetic outcome (assessed via Likert scale), and patient satisfaction (Patient Satisfaction Index).

The study included one-hundred-six patients (mean age: 39.6 years; male-to-female ratio 4:1). Trauma (51%) was the most common etiology. Combined-region defects (39.6%) were the most frequent location, and bone exposure was present in 88% of cases. Scalp reconstruction techniques included skin grafting, loco-regional flaps, and free flaps. Rotation flaps were the most frequently performed procedure (36.8%), followed by transposition flaps (29.7%), free flaps (20.7%), and skin grafting (12.8%). Specifically, 92% of patients treated with rotation flaps demonstrated statistically superior outcomes compared to other modalities, and achieved 'Good' functional recovery, and 77% achieved 'Good' cosmesis. Conversely, STSG was associated with intermediate functional results and poor cosmesis in 100% of cases. The overall complication rate was 8.5% (n=9), including partial graft loss (n=5), partial necrosis of local flaps (n=3), and one free latissimus dorsi flap failure.

The algorithmic approach to scalp defect reconstruction offers a standardized, evidence-based framework that optimizes cosmetic and functional outcomes. It enhances surgical precision, minimizes complications, and improves overall patient satisfaction.

Sarcopenia refers to a systemic loss of skeletal muscle mass with an associated decline in muscular function. Sarcopenia has been shown to accurately predict patients at risk of perioperative morbidity and inferior survival rates pre-operatively. This systematic review and meta-analysis aimed to compile and synthesise the currently available data evaluating the impact of sarcopenia on perioperative complication rates and postoperative survivorship following head and neck cancer resection with free tissue reconstruction.

A systematic search was performed of online research repositories in accordance with PRISMA guidelines. Studies reporting on perioperative complication rates and postoperative outcome measures in patients undergoing head and neck cancer resection with reconstruction were identified. Included studies reported data relevant to radiologically defined sarcopenic and non-sarcopenic patient cohorts as per cross-sectional imaging skeletal muscle volumes.

Thirteen studies met inclusion criteria, of which eleven were retrospective cohort studies, which report data representative of 2,211 patients undergoing resection and reconstruction for cancers of the head or neck. The prevalence of sarcopenia within the included cohorts ranged from 16-32%. Pre-operative sarcopenia was associated with significantly shortened overall survival (HR=2.53, CI=1.67,3.84, p<0.05) and disease-free survival (HR=2.35, CI=1.48,3.73, p<0.05). Clavien-Dindo Grade 3-5 complications occurred more frequently among sarcopenic patients, with sarcopenic patients more likely to require blood transfusion in the perioperative period. Sarcopenia was further associated with poor overall treatment tolerance and delays to initiation of adjuvant therapies.

The role of sarcopenia in head and neck cancer resection and free tissue reconstruction remains under-defined. There are strong associations between reduced skeletal muscle mass and associated decreases in OS and DFS. The current literature-base suggests that perioperative complications are more prevalent among sarcopenic cohorts, with these patients demonstrating inferior tolerance to adjuvant therapies.

Reconstruction of large cranial and scalp defects remains challenging due to limited tissue elasticity and the need for durable coverage of the cranial vault. The aim of this report is to present a staged reconstructive approach using tissue expansion and cranioplasty for management of a complex cranial defect following infection.

We present a patient with a history of craniotomy, subarachnoid hemorrhage, meningoencephalitis, and subsequent osteomyelitis of the temporal bone, resulting in a cranial defect with associated scalp tissue loss. Reconstruction was performed in two stages. Initially, a tissue expander was implanted in the temporo-parieto-occipital region and gradually expanded to generate sufficient local scalp tissue. In the second stage, cranioplasty with an acrylic implant was performed, followed by reconstruction of the soft-tissue defect using an expanded rotational scalp flap

The procedure achieved stable cranial coverage with well-vascularized tissue and preservation of hair-bearing scalp. Adequate soft-tissue contour was obtained without postoperative complications.

Tissue expansion combined with staged cranioplasty provides an effective and reliable option for reconstruction of complex cranial defects after infection, allowing durable coverage and good aesthetic integration.

To present the staged reconstructive management of a 47-year-old female patient with a total scalp avulsion injury and bilateral auricular involvement following roller machinery trauma, with particular focus on microsurgical reconstruction after failed primary replantation.

A 47-year-old woman sustained total scalp avulsion from the frontal to the nuchal region, with bilateral auricular involvement, hemorrhagic shock, and multiple two-digit amputations after her hair became entangled in roller machinery. Immediate surgery involved an attempted microsurgical scalp replantation, although it had suffered severe avulsion and crush injury, with end-to-end anastomoses of the superficial temporal vessels, using cephalic vein interposition grafts, along with temporary wound coverage, auricular repositioning, and hand debridement with stump formation. The replantation failed, and the scalp was deemed non-viable, necessitating resection and temporary coverage. Definitive reconstruction employed a free myofascial latissimus dorsi flap with split-thickness skin grafting. On postoperative day 21 and during follow-up, small residual occipital defects with exposed calvarium required additional grafting and acellular dermal substitution.

Primary scalp replantation failed due to irreversible mechanical damage to the avulsed tissue. Salvage free tissue transfer achieved stable, well-vascularized coverage of the extensive scalp defect with sustained flap perfusion. The patient left intensive care on postoperative day 8 and was discharged home on postoperative day 28. Repeated wound revisions were necessary due to some residual outer calvarial table exposure; however, the overall reconstruction provided stable cranial coverage. Definitive auricular reconstruction remains pending.

Total scalp avulsion with bilateral auricular involvement is a rare and challenging reconstructive case. When replantation fails despite technically successful revascularization, a free latissimus dorsi flap transfer combined with split-thickness skin grafting offers a reliable microsurgical salvage option for durable cranial coverage and staged restoration.

Simultaneous free flap reconstruction following neck dissection is routinely performed in head and neck malignancies. The influence of dissection extent and recipient vessel selection on flap survival and major complications remains debated. This study evaluated how dissection type and recipient vessel choice affected postoperative outcomes in oncologic resection patients undergoing simultaneous microvascular reconstruction.

A retrospective analysis of 90 patients with head and neck malignancies was conducted. The otorhinolaryngology team performed tumor resections and neck dissections, while reconstruction was performed by the plastic surgery team with free flaps. Flap types included fibula, anterolateral thigh, medial sural artery perforator, superficial circumflex iliac perforator, and radial forearm flaps. Neck dissections were classified as selective, modified radical, or radical. Recipient arteries were facial, superior thyroid, or lingual. Recipient veins included the facial vein, superior thyroid vein, external jugular vein, anterior jugular vein and retromandibular vein. All anastomoses were performed end-to-end under microscopic magnification using 9/0 monofilament nylon sutures, selecting ipsilateral recipient vessels. Major complications were defined as hematoma, partial or total flap loss, infection, or dehiscence requiring resuturing. Chi-square and Fisher's exact tests were used for statistical analyses.

Mean age was 63.3 +/- 12.6 years. Nine patients developed total flap necrosis. Neither dissection type nor bilateral neck dissection was significantly associated with flap survival. Recipient vessel selection did not affect total flap loss or the need for arterial or venous reanastomosis. Preoperative radiotherapy was not associated with total flap necrosis but was significantly associated with major complications (p=0.002). There were no significant associations between demographic factors, comorbidities, flap type, or recipient vessel selection and the development of major complications.

In simultaneous neck dissection and free flap reconstruction, dissection extent and recipient vessel choice did not significantly affect flap survival. Preoperative radiotherapy was the only factor associated with increased major complications, highlighting the importance of careful perioperative management in previously irradiated patients.

This study evaluated deep cervical lymph node dissection as an independent risk factor for postoperative delirium (POD) and examined the association between POD and mortality in head and neck cancer patients.

This is a multicentre study at the departments of otorhinolaryngology surgery, Oxford University Hospitals, Oxford, UK. The dataset collected a total of 997 patients who underwent head and neck region cancer management between May 2020 to April 2025 was analysed. From this collective, 180 patients had complete documentation of delirium, a comprehensive survey of comorbidities, and reconstruction of free flaps. Pre and postoperative risk factors for POD were collated for the analysis, including alcohol abuse, nicotine anatomical subset of the tumour, and stage of the carcinoma. Tomor resections, cervical lymph node dissection, type of reconstruction, duration of the surgery, intra and post-surgery complications, intensive care unit stay and durations. Type and size of the reconstructions the flap success, duration of the surgery and tracheostomy.

The association between head and neck cancer cervical lymphatic dissection (CLND) level I-III, I-IV and IV-V and postoperative delirium (POD) were analysed respectively. This study demonstrated CLND IV-V with odds (OR 4.84, CI 95%, p=0.0017) compared to (I-III) odds (OR 0.323, CI 95%, p=0.29). The extent of nodal excision was also associated with higher rate of mortality odds (OR 4.04, CI 95%, p=0.00054 and OR 4.01, CI 95% P=<;0.0001). The overall POD was (808/180) 22.23% with mean age of 66.3±12.6.

Emerging data highlight the role of deep cervical lymph nodes in draining brain-derived waste products such as amyloid and tau. Based on this concept, microsurgical reconstruction of cervical lymphatic drainage (LVA) might offer a novel approach to mitigating postoperative delirium and preventing subsequent cognitive deterioration.

Gorham–Stout disease is a rare lymphangiogenic osteolytic disorder, with fewer than 400 cases globally. (1) Holocranial involvement, causing near-total loss of the frontal, parietal, temporal, and occipital bones, is among the most severe and technically challenging forms (2). The absence of calvarial bone prevents standard fixation, and chronic scalp thinning increases the risk of wound failure and implant exposure.

A 40-year-old male with biopsy-confirmed Gorham–Stout disease and a decade of progressive cranial deformity underwent total cranial vault reconstruction. Preoperative CT showed near-complete holocranial osteolysis with intact intracranial structures (Figure). Surgery used a bicoronal approach: a titanium mesh restored the left supraorbital rim, followed by assembly of a patient-specific, modular, 3D-printed PGLA cranial implant designed via virtual surgical planning(3)(4) (Figure). Postoperative wound complications, management, and functional and quality-of-life outcomes were assessed.

On postoperative day 39, a sterile midline wound dehiscence with implant exposure occurred, without infection. Implant salvage was attempted, and on day 89 (Figure), a rotational scalp advancement flap provided vascularized coverage (Figure)(4). By 45 days post-flap, complete epithelialization was achieved with no recurrent dehiscence, ischemia, or implant instability (Figure). Neurological status remained normal. Functional outcomes were excellent: Modified Rankin Scale 0, Glasgow Outcome Scale Extended Good Recovery High, Karnofsky Performance Status 100%, Functional Independence Measure 126, and Quality of Life after Brain Injury score 95.

This case shows that modular 3D-printed PGLA implants can achieve stable cranial reconstruction in Gorham–Stout disease with total calvarial loss. Even with sterile implant exposure, timely salvage using vascularized scalp flaps can preserve the implant and result in optimal neurological, functional, and quality-of-life outcomes. This approach broadens reconstructive options for severe cranial manifestations of Gorham–Stout disease and is relevant to complex skull base and craniofacial complex reconstructive surgery.

Artificial implants are often used for reconstruction of orbital wall fractures. However, there has always been concern about infection because implants are directly exposed to the airway. This study was conducted to determine the effectiveness of a combination of resorbable plates and antibiotic-impregnated collagen sheets and to determine whether it had an effect in reducing postoperative antibiotic use.

The retrospective study was conducted on 195 patients who underwent orbital wall reconstruction from March 2019 to August 2022. The 176 patients in the control group underwent reconstruction using only resorbable plates and were administered postoperative antibiotics for 5 to 7 days. On the other hand, the 19 patients in the experimental group underwent reconstruction using a combination of resorbable plates and antibiotic-impregnated collagen sheets and only received antibiotics once before surgery (Figure 1).

No significant ocular complications were observed in the experimental group during a follow-up period of more than 1 year. Regarding postoperative infections, there were two cases of infection in the control group (infection rate: 1.14%), while no infection was found in the experimental group. The hospitalization period of the experimental group was significantly shorter than that of the control group (p < 0.01), and the incidence of total adverse effects of antibiotics, especially nausea, was lower in the experimental group (p = 0.02) (Figure 2).

The combined use of resorbable plates and antibiotic-impregnated collagen sheets allows effective orbital wall reconstruction without infection, with a shorter hospital stay, and with fewer antibiotic adverse effects.