The Converse Scalping Flap: A Systematic Review of Clinical Applications and Technical Evolution

Background: The Converse scalping forehead flap has been used for eight decades in nasal and craniofacial reconstruction, yet its use and evolution have not been systematically synthesized. Methods: A systematic review was performed according to PRISMA 2020. PubMed, Embase, Scopus, Web of Science, and CENTRAL were searched for studies describing craniofacial reconstruction using a Converse scalping flap or direct modification. Results: Thirty-five studies describing 188 cases from 1959 to 2023 were included. The nose was the primary reconstructive site in 128 cases (68%). Other sites included the midface in 8 cases (4.3%), periorbital and other facial regions in 22 cases (12%), and cranium or cranial base in 30 cases (16%). Seven cases reported successful Converse flap use in previously compromised donor territory. Technical variations were reported in 26 cases (14%), including tissue expansion, split flap and single stage designs, prefabrication, and Raulo modification. Flap survival data was reported in 99 cases, of which 98 survived. Conclusions: The Converse scalping flap demonstrated reliability across diverse craniofacial applications, including salvage. Although its role has narrowed with modern forehead and free flap techniques, its evolution highlights enduring principles of regional tissue transfer, multilayer reconstruction, and adaptation to complex donor site and defect constraints.