(A426) Subtotal Calvarium Reconstruction Following Necrotizing Soft Tissue Infection

Introduction: Complex full-thickness scalp defects often require reconstruction with free tissue transfer; however, when the defect is significant one free flap may not provide enough soft tissue coverage. This case report describes a latissimus dorsi/serratus anterior free flap for subtotal calvarium coverage after an aggressive necrotizing soft tissue infection.

Methods: Retrospective chart review.

Results: A 75-year-old female patient was treated for a necrotizing soft tissue infection involving the majority of her scalp: bilateral frontal, temporal, parietal, and occipital distributions. The infection was treated with serial debridement followed by wound vac placement for 10 days. The resultant defect with exposed bone measured 28 cm x 25 cm. On hospital day 16, a cutting burr was used to debride the outer cortex of the skull, and the wound was covered with a latissimus dorsi/serratus myogenous free flap based on the subscapular vessels. The serratus muscle was used to cover the occipital region and the latissimus the remaining scalp. The right superficial temporal vessels were used for revascularization and the flap was then covered by a split-thickness skin graft. The flap remained viable throughout the perioperative period and has continued to heal with adequate coverage.

Conclusions: Necrotizing soft tissue infections are often treated with multiple debridements of non-viable tissue, which can result in a large soft tissue defect that can be challenging to reconstruct. Synthetic skin replacements or skin grafts can be considered, but they often heal poorly over bare exposed bone. A subscapular system free flap can provide multiple tissue options pedicled on one vessel to achieve wide surface area coverage with a single procedure.