Reliable Outcomes of Free Fasciocutaneous Flaps for Complex Oncologic Scalp Reconstruction: A Multicenter Comparative Analysis

Scalp reconstruction following oncologic resection can be challenging due to the presence of complicating factors such as extensive defects, cranioplasty, and radiotherapy, frequently requiring the need for free tissue transfer. While musculocutaneous flaps have traditionally been used, fasciocutaneous flaps are increasingly favored. However, their safety in these high-risk conditions remains unclear. This study examines whether flap type influences outcomes in oncologic scalp reconstruction.A retrospective review was performed of patients who underwent microsurgical scalp reconstruction for oncologic defects between 2018 and 2024 at two tertiary centers. Patients were grouped into musculocutaneous and fasciocutaneous flap cohorts. Postoperative complication rates were compared between the groups across various clinical settings.A total of 109 patients were included: 35 (32.1%) underwent musculocutaneous flap reconstruction, and 74 (67.9%) received fasciocutaneous flaps. The most commonly used flaps were the latissimus dorsi and anterolateral thigh flaps, respectively. The musculocutaneous group had more comorbidities, more frequent irradiation history, and larger defects. Postoperative complications occurred in 37 patients (33.9%), most commonly delayed wound healing. Overall and specific complication rates were similar between groups, except for late complications (occurring or persisting beyond 3 months), which were more frequent in the musculocutaneous group. This pattern held across subgroups defined by cranioplasty, radiotherapy, and defect size. Flap type did not independently predict complications on multivariable analysis.Our results suggest that both musculocutaneous and fasciocutaneous flaps are effective for oncologic scalp reconstruction. Fasciocutaneous flaps appear to be a reliable alternative, even in complex cases involving radiotherapy, cranioplasty, or extensive defects.