Pedicled Scalp Reconstruction After Radiation Therapy

BACKGROUND: Reconstruction of large scalp defects in patients who have previously received external beam radiation therapy (EBRT) is technically challenging due to radiation-induced vascular compromise and poor wound healing. While free tissue transfer is commonly used, pedicled scalp flaps may offer a simpler, more reliable alternative in certain patients. The objective of the study is to evaluate the outcomes of pedicled scalp flap reconstruction in a large cohort of irradiated patients with substantial scalp defects and to identify risk factors associated with flap complications. METHODS: The authors conducted a retrospective review of 216 patients treated by a single surgeon from January 1998 to December 2024. Inclusion criteria were prior EBRT to the scalp, a defect size ≥15 cm2, use of pedicled scalp flaps, and a minimum follow-up of 6 months. Data collected included demographics, prior scalp surgeries, indication for reconstruction, flap design, complications, flap survival, and need for reoperation. RESULTS: Of the 216 patients (143 men, 73 women; mean age: 79.4 and 77.8 y, respectively), 149 had prior scalp surgery (including skin grafts, biologics, or previous flaps). Indications were recurrent/persistent malignancy in 187 and necrotic or exposed calvarium in 29. Complete healing without complications occurred in 189 patients (87.5%). Sixteen patients developed wound breakdown managed with local flaps; 8 had partial flap loss (≤50%) requiring further scalp flap in 5 or free flap in 3; and 3 had major flap loss (>50%) necessitating free-flap reconstruction. All patients with partial or major flap loss had a history of prior scalp flaps. CONCLUSIONS: Pedicled scalp flaps, when designed and executed with careful respect to vascular principles, provide a reliable reconstructive option even in radiated patients with large defects. A history of prior scalp flap significantly increases the risk of flap loss. These findings support the continued use of pedicled scalp flaps in this demanding population and suggest that prior flap history must factor into risk stratification and planning.