We report the case of a 68-year-old patient with absence of hair in the scalp, with a history of right non-operated and untreated keratosis in the scalp. She was initially treated with inguinal hernia and cold therapy.
Two years later, the patient reported several crusted lesions in the parieto-occipital region.
Biopsy of the lesions was taken, reporting squamous cell carcinoma of moderate degree of differentiation.
The lesions were removed leaving one of the resection margins affected by the tumor.
The patient is given radiation therapy at maximum doses on the scalp.
6 months later the patient reported appearance of several lesions similar to previous ones in the same area.
New biopsies were taken reporting epidermoid carcinoma.
The patient is then referred to our service to assess the therapeutic options.
At his arrival, the patient presents two crusted lesions of approximately 2 cm and 3 cm in diameter, respectively, and other lesions of smaller size somatous malignancy.
Similarly, as a consequence of radiotherapy, the patient presents fibrosis and complete retraction of the scalp, which prevents any type of reconstruction using local flaps.
Seen in clinical session it was decided to perform a wide resection of the scalp and immediate reconstruction of the defect with an omentum-free flap while a herniorrhaphy to reduce the inguinal hernia presented by the patient.
1.
The patient is operated along with the General Surgery Service and an approach is performed with two teams simultaneously.
On the one hand, a wide excision of the scalp is performed along with a bilateral preauricular approach to identify and isolate the superficial temporal vessels.
On the other hand, a midline laparotomy was performed.
Once the abdominal cavity is explored, the omentum is pulled and dissected from the transverse mesocolon up.
Next, vascular stenosis corresponding to the right gastroepiploic vessels is identified, and the small vascular branches that go to the posterior and anterior zones of the greater curvature of the stomach are exposed and ligated.
Once the vascular axis of the greater curvature of the stomach is released, the stenosis of the left gastroepiploic artery becomes the pedunculated omentum to the right gastroepiploic artery and is prepared to be transferred
The omentum was sutured to the remaining scalp and anastomoses were performed.
Some authors use both temporary vascular anastomoses with double anastomosis to the facial vessels and superficial vessels.8 In our case we did the anastomoses using only the right temporal epiploic vein and the right superficial temporal vessels as receivers the artery and
Finally, the entire omentum flap is covered with a meshed dermoepidermal graft and a compression bandage is placed for 1 week.
The surgical specimen reported squamous cell carcinoma of moderate differentiation and two Carcinomas in situ, all with disease-free resection margins.
The postoperative period was uneventful and the patient was discharged 12 days after surgery.
The patient is followed up in multiple revisions and 2 years after surgery, there are no signs of local recurrence.
From the aesthetic point of view the patient is very satisfied with the result since the marks of the meshwork of the skin have existed over time and constitute a uniform tissue throughout the scalp.
