The scalp, the hair-covered skin that covers and protects the skull, is a relatively thin multi-layered tissue of great esthetic importance. The need to perform reconstructive surgery on the scalp can arise from birth defects, an accident, the removal of malignant or benign tumors, or the removal of large birth marks.

depth and location. The scalp tissue is not elastic, so it is only possible to push together Reconstructing a defect on the scalp is dependent upon the size of the defect, as well as its the edges of the missing area for primary closure when the defect covers a relatively small area. When the missing area is larger, it becomes necessary to recruit scalp tissue from the surrounding area. Scalp tissue can be moved in large sections, called flaps, which are based on the major blood vessels supplying the scalp. The secondary defect that is created by taking the flap can be closed by primary closure when the elasticity of the tissue is sufficient, or by using a skin graft taken from another non-prominent, hairless area of the body such as the front of the thigh. This transplanted skin can then be covered by local hair.

In those cases where it is necessary to reconstruct a relatively large defect in a hair-bearing area of the scalp, recruiting and moving proximal scalp tissue is possible with the use of two-stage surgery. In the first stage, one or more silicone capsules (tissue expanders) are introduced, their size matched to the size of the defect being treated. Each capsule is equipped with a special valve that enables gradual expansion during a period of six to eight weeks through the injection of a physiological saline solution. The second surgery removes the capsules, and it is then possible to move the expanded scalp. When the defect is so large that it cannot be closed after a single expansion, the capsules can be introduced a second time to continue expanding the proximal scalp once part of the defect is closed.

In cases where the defect is too large to be closed by making use of the remaining scalp, or where it is desirable to refrain from making incisions in the proximal scalp, it becomes necessary to transfer tissue from elsewhere on the body, with the blood vessels that supply the tissue. This free transfer of flaps connected to recipient blood vessels of the head is a micro-surgical technique that makes use of a surgical microscope. The most commonly used flap for this purpose is the large muscle of the back (latissimus dorsi), which is later covered with a skin graft. Over time, the muscle becomes thinner until its thickness approaches that of the adjacent scalp, as a result of its disconnection from the nerve that activated it. The functional loss as a result of harvesting this muscle is minimal, significant only to athletes or wheelchair users. Another flap is often taken from the skin-fat tissue on the anterior area of the thigh. The defect created in the donor site undergoes primary closure without functional damage to the underlying appendage. This flap may require later reduction of the fatty layer’s thickness by liposuction in a second surgery.