Staged Tissue Expansion for Scalp Reconstruction in Post-Burn Cicatricial Alopecia: A Case Series and Salvage Strategy for Flap Necrosis

Background: Full-thickness scalp burns often leave permanent, hairless scars, which may have a substantial psychosocial impact on patients. Tissue expansion, which recruits the surrounding hair-bearing scalp, is an established approach to restoring a natural hairline in these cases; however, flap complications may compromise the outcome, and their management warrants clear documentation. Aim: This case series describes staged tissue expansion for scalp reconstruction and the management of partial distal flap necrosis. Methods: We retrospectively reviewed four patients treated in our department for post-burn scalp alopecia using staged tissue expansion. For each patient, we recorded the expander's volume, shape and site, the duration of expansion, the flap used for coverage, postoperative outcomes and the management of the single complication. Results: Four expanders (200–320 cc, each with an internal valve) were inflated over 54 to 70 days, beginning two weeks after placement, with weekly increments of approximately 10% of the nominal volume. Coverage was achieved with an advancement flap in two patients and a rotation–transposition flap in the other two. Postoperative healing was uneventful in three patients. The fourth patient developed partial flap necrosis on postoperative day 7, necessitating necrosectomy on day 10, followed by 17 days of directed wound care and subsequent skin grafting. Ultimately, all four alopecic areas were covered: entirely with expanded hair-bearing flaps in three patients and with an additional skin graft in the fourth. Conclusion: In this series, staged tissue expansion provided coverage of post-burn scalp alopecia. The procedure requires considerable patient commitment and tolerance, and flap ischaemia remains a potential complication; in the patient with distal flap necrosis, necrosectomy, directed wound healing and skin grafting enabled completion of the reconstruction. Given the small sample and the incompletely documented follow-up, these observations are descriptive and should be confirmed in larger series.