A poorly designed scalp closure with excessive tension in time yields a wide, atrophic, and unsightly scar. In many patients, this complication proves refractory to corrective surgical attempts. Successful reconstruction depends on an appreciation of how the unique anatomic composition of the scalp influences tissue movement. The galea does not stretch but slides over the pericranium, accounting for most overlying scalp tissue movement. Consequently, flaps require incision of the galea and undermining in the subgalcal plane. The presence of hair is a second unique feature that must be considered before reconstruction. Because it has both functional and cosmetic roles, the surgeon should strive to preserve hair follicles and hide incisions within hair- bearing regions whenever possible. For defects that cannot be closed primarily, flaps are often the preferred method of reconstruction. Specifically, a generously designed rotation flap recruits sufficient tissue and spreads tension over a large area, allowing reconstruction of most scalp defects. The simple pivoting movement of rotation flaps is better suited to the scalp as compared with the lifting and stretching movements of transposition and advancement flaps, respectively. Last, depending on defect size, location, and hair growth pattern, skin grafting may be an appropriate reconstructive option. This article focuses on practical reconstruction following tumor removal. Flaps designed specifically for aesthetic correction of alopecia or scalp repair following trauma are not discussed. The reader also is directed to several well-written articles on scalp reconstruction and related topics at the end of the article.
