(0740) The Omental Flap: A Salvage Flap for Complex Skull Reconstruction

Introduction: Complex reconstruction of the scalp in a heavily pretreated patient is best accomplished with free tissue transfer. Occasionally the patient will have expanded the most common options. The omental free flap was one of the first flaps utilized for scalp reconstruction but has not been described recently. Its use in a patient who had undergone four previous free flaps is demonstrated.

Methods: Retrospective case report.

Results: A 64-year-old woman with a remote history of large meningioma resection and cranioplasty presented with recurrent scalp wound breakdown due to infected hardware. This patient had previously undergone two latissimus dorsi and two radial forearm free flaps for scalp reconstruction. She had persistent infection resulting in chronic drainage and exposed hardware along the suture line where the free flaps met her native scalp. Therefore, an omental free flap was planned to cover the cranial implant and native skull. A custom polyether ether ketone (PEEK) cranioplasty implant was designed by neurosurgery.
The omental flap was pedicled on the left gastric epiploic artery and vein. Given her previous free flap reconstructions, a vein graft was required to reach the right facial artery and vein for microvascular anastomosis. This was harvested from the right lesser saphenous vein. The omental flap was folded over the PEEK implant to increase tissue thickness and was secured under the native scalp and previous free flaps. Areas of the exposed omental flap were covered with a split thickness skin graft.
The flap developed venous congestion on post-operative day one, but the flap was salvaged and remained viable in the remainder of her post-operative course. Photo documentation of the free flap at different stages of its healing was obtained to demonstrate the appearance of the omental flap during its healing process.

Conclusions: Omental free tissue transfer is a viable option for scalp reconstruction when a large surface area of tissue is required to reconstruct complex and previously operated scalps.