The Role of the Visor Flap in Scalp Reconstruction: A Case Series of 21 Patients

BACKGROUND Full-thickness scalp defects pose a reconstructive problem, especially in the setting of infection, chemotherapy/radiation, and underlying cranial defects. Current options include dermal matrices, skin grafts, and local flaps. Local flaps often fail, requiring subsequent microvascular free flap reconstruction. OBJECTIVE To describe the visor flap, a novel bipedicled advancement flap design, and its role in reconstruction of scalp defects. METHODS A retrospective review of 21 adult patients who developed scalp defects reconstructed using the visor flap from 2013 to 2017. The visor flap is a large bipedicled advancement flap design with a triangular extension at the base, which allows redistribution of a large surface area of the scalp. RESULTS All 21 patients achieved complete and viable soft tissue coverage of the recipient site, but 19.0% developed complications unrelated to flap viability, requiring reoperation (infected bone flap, epidural hematoma, and recurrent glioblastoma with subdural abscess). Only 1 patient required conversion to free flap reconstruction due to cerebrospinal fluid leak. Etiologies included cancer (76.1%), cerebrovascular disease (19.0%), and traumatic brain injury (4.8%). Preoperative radiation (42.9%), bone/hardware exposure (57.1%), and previous craniotomy (85.7%) were widely prevalent. Defect size ranged from 3 to 50 cm2 (mean, 16.9 cm2), and flap size ranged from 90 to 500 cm2 (mean, 222 cm2). CONCLUSION The visor flap provides an innovative solution for closure of scalp defects. This technique optimizes immediate closure of tissue compromised by infection or chemotherapy/radiation without burning bridges to more complex reconstructive options.