At the end of the study period (April 2012), all but one patient survived and all flaps remained viable. One patient expired due to local recurrence of angiosarcoma, 4 months after chemotherapy and radiotherapy. Table 1 is a summary of

all nine patients’ data. In July 2008, a 40-year-old male patient with a history of epilepsy presented with rupture of an intracranial arterio-venous malformation in the temporoparietal lobe, for which an emergent decompression selleck compound craniectomy was performed. Four months later, the patient underwent cranioplasty using prosthesis for cranial vault resurfacing and a local advancement scalp flap for coverage. Prosthesis exposure developed subsequently and this problem persisted despite another two advancement procedures in the following year (Fig. 1). The patient was then referred for scalp reconstruction, for which a free ALT flap was used for the final defect, measuring 15 × 6 cm2 (Fig. 2). Microvascular end-to-end anastomosis was performed to the right superficial temporal artery and vena comitants using 9-0 nylon, while the thigh donor-site was closed primarily. At 1-month follow-up, the flap healed uneventfully, and the patient was discharged without complications (Fig. 3). This 36-year-old male was involved in multiple traumas and suffered from head

injury 10 years ago, during which he underwent craniectomy followed by cranioplasty using buy Z-VAD-FMK prostheses. He presented in December of 2011 with an exposed and infected prosthesis at the left temporoparietal area. Following excisional debridement and removal of the prosthesis, a scalp defect measuring 30 × 7 cm2 was noted (Fig. 4). A free ALT flap was performed via end-to-end anastomosis to the left facial artery and vein. The CYTH4 left thigh donor site was closed primarily.

At 1 week, the distal flap tip developed necrosis and required debridement of a 2.5 cm segment, followed by a small Z-plasty to close the defect. Subsequent healing proceeded uneventfully at 1-year follow-up (Fig. 5). For uncomplicated small- to moderate-sized defects, local flap coverage is the best option for reconstruction, typically involving a single or multiple transposition procedures depending on the defect size and location.[23, 24] However, local and regional flaps reach their limit when defects extend beyond 200 cm2, especially when compounded by complications such as infection, radiation therapy, multiple prior surgeries and composite tissue and bone loss. Although tissue expansion has been proven to be successful for resurfacing large scalp defects, its role is limited due to the requirement of prior planning, patient compliance, and absence of infection. In complex cases, only well-vascularized free-tissue transfer can meet both structural and protective requirements, albeit resulting in a hairless reconstruction.