Salvage reconstruction of an irradiated and infected scalp–calvarial defect following recurrent atypical meningioma: recipient-vessel strategy and multidisciplinary decision-making

Reconstruction of complex scalp defects associated with calvarial involvement represents a significant challenge, particularly in patients who have undergone radiotherapy, experienced infection and undergone multiple surgical procedures. In these settings, locoregional reconstructive options are often unreliable and free tissue transfer plays a central role in achieving stable, well-vascularized coverage. We present a case of a 50-year-old woman with recurrent atypical meningioma who underwent multiple neurosurgical resections and radiotherapy. The postoperative course was complicated by wound dehiscence, infection, and cranioplasty failure. Upon evaluation, the patient exhibited a large posterior scalp defect (14 × 5 cm) with exposed calvarium. A multidisciplinary approach was adopted. Following neurosurgical debridement, tumor resection and calvarial reconstruction using a titanium mesh, soft-tissue coverage was achieved with a free latissimus dorsi muscle flap combined with a split-thickness skin graft. Microvascular anastomosis was performed using the superior thyroid artery and the jugular venous system, selected outside the irradiated field. The postoperative course was uneventful, with no signs of flap ischemia or venous congestion. At eight months of follow-up, the patient demonstrated complete wound healing, stable coverage, and a satisfactory morphofunctional outcome, with minimal donor-site morbidity. This report emphasizes that successful salvage reconstruction of irradiated scalp defects complicated by osteomyelitis depends not only on vascularized tissue transfer but also on meticulous recipient vessel selection. In particular, the superior thyroid artery represented a reliable recipient vessel outside the irradiated field, allowing safe microvascular reconstruction despite previous surgery, infection and radiation-induced vascular compromise.