DS17 Management of postradiotherapy nonhealing scalp defects using local flap reconstruction

Abstract

Nonhealing wounds following adjuvant radiotherapy present a reconstructive challenge due to radiation-induced tissue hypovascularity, dermal atrophy and impaired wound healing. Scalp defects overlying calvarium are particularly vulnerable, especially in case of high-risk skin cancer requiring aggressive oncological management. Optimizing reconstruction in this context is paramount to restore durable coverage and reduce morbidity. We present two cases of postradiotherapy scalp defects that were reconstructed with local flaps. A 65-year-old patient with a very high-risk squamous cell carcinoma (T3N0M0) of the right parietal scalp underwent Mohs micrographic surgery in July 2024. The lesion was excised down to the periosteum and the resultant defect was repaired with an advancement flap. Histology demonstrated perineural invasion (> 0.1 mm), and the patients subsequently received adjuvant radiotherapy (55 Gy in 20 fractions) in October 2024. Following radiotherapy, he developed a persistent nonhealing wound within the irradiated field. Given the compromised tissue bed and limited granulation potential, the defect was reconstructed using a finger transposition flap to provide well-vascularized local tissue. The secondary donor defect was closed with a full-thickness skin graft harvested from the right supraclavicular region. Similarly, an 85-year-old patient with a high-risk squamous cell carcinoma on the frontal scalp underwent excision, followed by adjuvant radiotherapy. As the wound continued to persist despite supportive measures, it was reconstructed using a finger transposition flap and the secondary defect was closed with a split-thickness skin graft. In irradiated, nonhealing scalp wounds, prioritizing vascularized flap reconstruction can improve healing outcomes compared with graft-only approaches. A transposition flap combined with graft closure of the secondary defect offers a reliable method to introduce healthy perfused tissue while minimizing tension and donor-site morbidity. Alternative strategies include burring exposed calvarium to stimulate granulation tissue; however, flap-based reconstruction may provide more predictable healing in radiotherapy-damaged tissue.