Scalp reconstruction after avulsion or other injury is complicated by the dual problems of providing durable coverage to the skull and restoring the cosmetically important hairbearing tissue.

Microvascular techniques have allowed primary replantation of avulsed scalps 1-7 and reconstruction with hairbearing pedicled and free flaps.8-14 Double free-scalp flap transplants between identical twins have been previously reported,15 and late follow-up, including tissue expansion of previously transplanted flaps and a third free scalp transplant, has recently been presented.16 This complicated scalp reconstruction was performed in three parts, consisting of three sequential scalp transplants and recipient and donor tissue expansion. Initially, free scalp grafts were considered and dismissed because they were considered unlikely to survive on the poorly vascularized bed of the scarred scalp defect.

The first two scalp transplants were performed to reconstruct a frontal hairline, and are described in the case report. 15 A residual defect remained on the recipient twin, leading to a third operation, described in this chapter.16

For the final reconstructive procedure, the scalp of the donor twin was expanded using an expander to a total volume of 400 cc over an 8-week period. This fulfilled the goals of providing a flap of adequate size and allowed primary closure of the donor site.

Expansion of the previously transplanted scalp flaps in the recipient twin was considered and rejected because it was felt that this would cause a noticeably sparse distribution of hair on the expanded scalp and potentially jeopardize the viability of the flap.

To complete the final reconstruction, the 7 x 15 cm expanded right scalp flap was harvested, based on the anterior branches of the occipital vessels in the donor twin. A second team of surgeons isolated the left superficial temporal vessels in the recipient twin and prepared them for microsurgical anastomoses. Preoperatively, angiograms and ultrasound Doppler were used to delineate the position of the vessels in each twin. This greatly facilitated the operative procedures, ensuring correct design and orientation of the donor flap and recipient site.

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