Maximal resection for malignant scalp tumors: is it valuable for long-term follow-up?

Introduction

Scalp wounds resulting from malignant tumor resections pose significant challenges, particularly in preserving patients’ self-esteem and quality of life. These wounds are typically repaired using skin flap transfers or skin grafting techniques (1-3). Once the defect is confirmed to be free of tumor involvement, reconstructing defects involving the scalp and forehead requires addressing unique aesthetic and functional complexities. Among these, reconstructions following tumor excisions are particularly demanding for surgeons due to the intricate balance of restoring both form and function. Wide excision of scalp tumors often involves the removal of skin, periosteum, skull, and dura mater, resulting in a complex wound. Successful reconstruction of scalp defects requires a thorough understanding of scalp anatomy and careful consideration of surgical techniques, as well as the patient’s personal expectations. Ideally, scalp reconstruction should be as straightforward as possible while achieving optimal functionality and aesthetic outcomes.

Numerous studies have highlighted the versatility of flaps for soft tissue coverage in managing defects caused by scalp tumors (4-6). However, there are relatively few reports detailing the use of these flaps as a reconstructive option for defects following malignant scalp tumor surgery, particularly with comprehensive and long-term follow-up. Additionally, controversy persists regarding the extent of tissue removal necessary to achieve clear surgical margins and optimal therapeutic outcomes. Striking a balance between ensuring adequate surgical margins and facilitating effective repair and reconstruction remains a critical challenge in the management of malignant scalp tumors.

This study presents a comprehensive retrospective analysis of 103 cases of malignant scalp tumors, aiming to define the optimal surgical and therapeutic approaches for tumor resection and subsequent reconstruction at this complex anatomical site. In treating these patients, we adhered to the principle of anticipating the feasibility of skin flap repair while maximizing the surgical margin expansion in line with clinical guidelines and pathological findings to ensure optimal oncologic outcomes. The selection of the repair method was tailored accordingly. Our objective was to conduct an evidence-based evaluation of clinical presentations, patient demographics, tumor characteristics, and the extent of resections, aiming to identify approaches associated with lower recurrence rates. We present this article in accordance with the STROBE reporting checklist (available at https://tcr.amegroups.com/article/view/10.21037/tcr-2024-2223/rc).

Methods

Study design and population

This is a retrospective cohort study of patients who underwent resection of malignant scalp tumors followed by reconstruction with flaps. The surgeries were performed between January 2008 and December 2022 at the Department of Musculoskeletal Oncology, Fudan University Shanghai Cancer Center, Shanghai, China. All patients had complete follow-up information, and there were no losses to follow-up regarding recurrence or survival outcomes.

The inclusion criteria for this retrospective study encompassed all patients who underwent flap coverage following excision of a malignant scalp tumor. Patients who were unable to complete follow-up were excluded from the analysis. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Fudan University Shanghai Cancer Center (Approval No. 1612167-18). Each patient signed an informed consent document during the preoperative conversation. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article. Data collected included tumor site, histopathologic stage, clinical and radiological findings, and surgical treatment outcomes.

Operative technique

For malignant melanoma patients, surgical resection was performed only after excluding pulmonary metastasis through routine preoperative positron emission tomography-computed tomography (PET-CT). Sentinel lymph node biopsy (SLNB) was not routinely performed.

Expansion surgery for malignant scalp tumors was performed for all patients in accordance with the guideline-recommended expansion range for each specific type of malignancy. A resection margin of at least 2 cm was maintained while simultaneously assessing the feasibility of flap repair to ensure optimal reconstruction. We adopted the approach of maximizing the resection margin when the preoperative assessment indicated that the flap area would be sufficient to repair the defect. Following wide excision, the resection margin was verified to be tumor-free using frozen section analysis. The exact size of the defect was then measured. In our study, the resection margins were ultimately determined based on the postoperative pathological reports. Although intraoperative frozen sections were occasionally used to preliminarily assess margin status, the margin width data reported in the manuscript reflect measurements from formalin-fixed specimens after pathological processing.

A suitable skin flap was selected while ensuring the integrity of the pedicle. When triangular flaps could not adequately cover the defect, alternative local flaps such as O-Z and O-S flaps were employed to complete the repair and reduce the need for skin grafting. The O-Z flap was designed with two opposing rotational arcs along relaxed skin tension lines, allowing bilateral rotation to close central defects with minimal tension and distortion (7). The O-S flap was used for larger or marginal defects, especially near the scalp edge, and combines rotational and advancement elements, often with a standing cone excision to reduce closure tension and maintain contour (8). These flap designs follow reproducible geometric principles and are widely adopted in head and scalp reconstruction.

Secondary treatment included the administration of anti-infective, anticoagulant, antispasmodic, and blood circulation-promoting medications. Daily dressing changes were performed to clean oozing blood and scabs, as well as to prevent compression-related necrosis. Careful monitoring was conducted to observe flap color, skin temperature, and capillary refill reactions, ensuring the viability of the repair. In cases where lymph node metastasis was confirmed postoperatively, regional lymphadenectomy and adjuvant immunotherapy with pembrolizumab were administered based on current clinical guidelines.

Aesthetic evaluation

Aesthetic outcomes were assessed postoperatively using a structured five-point Likert scale covering three domains: local skin texture, contour evenness, and scar concealment. Patients rated each domain from 1 (very dissatisfied) to 5 (very satisfied). A patient was classified as “overall satisfied” if they scored ≥4 in at least two of the three domains. The final satisfaction rate was calculated as the proportion of overall satisfied patients among all respondents. For patients who scored ≤3 on any domain, additional qualitative feedback was collected and analyzed to identify reasons for dissatisfaction.

Follow-up and survival analysis

Follow-up was conducted via telephone interviews and outpatient re-examinations until the study cutoff date and its subsequent amendments. The initial postoperative outpatient visit was scheduled within the first month after surgery, followed by annual visits during the second to fifth years, and every 2 years thereafter. For patients who underwent recurrent surgeries at the same tumor site, survival calculations were based on the date of the initial surgery performed at our institution.

Results

Demographic and clinical characteristics

Table 1 presents the demographic and clinical characteristics of the 103 patients included in this study. The patients had an average age of 52.5 years [standard deviation (SD): 18.4 years; range, 14.0–91.0 years] and a mean body mass index (BMI) of 23.3 kg/m² (SD: 4.0 kg/m²; range, 16.7–30.7 kg/m²). Among them, 45 patients (43.7%) were women, and 58 (56.3%) were men. Thirty-four patients (33.0%) were current smokers, and 9 (8.7%) were former smokers. Pathology reports revealed that 61 patients (59.2%) had primary skin cancer, 37 (35.9%) had sarcoma, and 5 (4.9%) had metastatic cancer. Within the primary skin cancer group, 33 patients (32.0%) had malignant melanoma, 8 (7.8%) had basal cell carcinoma (BCC), 9 (8.7%) had squamous cell carcinoma, and 6 (5.8%) had adenocarcinoma. The tumor locations included the occipital bone in 21 patients (20.4%), the parietal bone in 26 patients (25.2%), the temporal bone in 28 patients (27.2%), and the frontal bone in 27 patients (26.2%). Only one patient (1.0%) had tumors spanning multiple locations. Regarding medical comorbidities, 36 patients (35.0%) had cardiovascular disease, 34 (33.0%) had chronic obstructive pulmonary disease, 25 (24.3%) had diabetes, 34 (33.0%) had hypertension, and 9 (8.7%) had immunosuppression. Preoperative ASA scores indicated that 96 patients (93.2%) were classified as ASA I, while 7 (6.8%) were classified as ASA II.

Tumor resection and scalp reconstruction

The surgical methods are detailed in the “Methods” section. During surgery, efforts were made to maximize the resection margins to ensure complete tumor removal. The average resection margin was 3.1 cm (SD: 0.4 cm; range, 2.2–3.8 cm). To address the variability in surgical margin recommendations across tumor types, we summarized tumor characteristics stratified by histologic subtype in Table S1. Notably, the mean margin for BCC was 2.85 cm, while for sarcoma and melanoma, margins were larger, aligning with their clinical guidelines. Tumor depth and grading information [Fédération Nationale des Centres de Lutte Contre le Cancer (FNCLCC) for sarcoma, Clark levels for melanoma] were also included to reflect subtype-specific prognosis. Following tumor resection, scalp reconstruction was performed. In scalp reconstruction, 56 patients (54.4%) were treated with a triangular flap, 32 (31.1%) with an O-Z flap, 11 (10.7%) with an O-S flap, and 4 (3.9%) with other methods (Table 1). The average operative time was 82.2 minutes (SD: 26.8 minutes; range, 34.0–124.0 minutes), with an average blood loss of 155.0 mL (SD: 80.9 mL; range, 30.0–400.0 mL). The average length of hospital stay was 4.4 days (SD: 1.1 days; range, 3.0–6.0 days).

Complications and outcomes

Our results indicated that complications and recurrences were rare, and most patients expressed satisfaction with the aesthetic outcomes after surgery. Postoperative complications included wound dehiscence in two patients (1.9%), hematoma in three patients (2.9%), and infection in two patients (1.9%), while the remaining patients experienced no complications. Regarding aesthetic outcomes, only one patient (1.0%) expressed dissatisfaction, six patients (5.8%) were neutral, 16 patients (15.5%) were satisfied, and 80 patients (77.7%) were very satisfied. Follow-up results revealed that four patients (3.9%) experienced local recurrence, while 10 patients (9.7%) developed lymph node metastasis. Among these, eight cases of lymph node metastasis were observed in patients with malignant melanoma of the scalp (Table S1). The analysis concluded that the incidence of lymph node metastasis in patients with scalp malignant melanoma following extended margin surgery was 24.2%.

Case presentation

Figures 1-3 illustrate three unique cases of scalp tumor resection and reconstruction, with detailed descriptions provided below.

Figure 1 A 61-year-old female presented with a right parietal mass (A-E). The tumor was resected and repaired using an O-Z skin flap for suturing and fixation. Postoperatively, all flaps remained viable, and the aesthetic outcome was satisfactory.

Figure 2 A 52-year-old male presented with a scalp mass that had been present for 52 years (A-E). Following tumor resection, a triangular skin flap was used for repair and suturing. All flaps remained viable, with no recurrence, and the aesthetic outcome was satisfactory.

Figure 3 A 43-year-old male presented with a left parietal-frontal mass that had been present for one and a half years (A-E). An O-Z skin flap was used for repair and suturing postoperatively. All flaps remained viable, and the aesthetic outcome was satisfactory.

A 61-year-old woman presented with a right parietal mass (Figure 1). Two months prior, a 2.3 cm × 1 cm mass in the right parietal region had been resected. Postoperative pathology revealed nodular malignant melanoma with necrosis. Two months later, a new mass approximately 2 cm in diameter was identified near the scar, resembling the initial lesion. The tumor was completely resected with a margin of approximately 3.3 cm, and frozen section analysis confirmed that the resection margins were tumor-free. An O-Z flap was utilized for suture fixation. Postoperatively, all flaps remained viable, with no tumor recurrence observed. The patient was satisfied with the aesthetic outcome.

A 52-year-old man presented with a scalp mass that had been present for 52 years (Figure 2). A preoperative pathological biopsy indicated a malignant skin tumor. The patient was admitted for tumor resection, during which the tumor was completely excised with a 2.2-cm margin. Pathology confirmed a moderately differentiated squamous cell carcinoma measuring 5 cm × 4.3 cm × 3 cm. A triangular skin flap was used for repair and suturing. Postoperatively, all flaps remained viable, with no tumor recurrence observed. The patient was satisfied with the aesthetic outcome.

A 43-year-old man presented with a left parietal-frontal mass that had been present for one and a half years (Figure 3). The mass had ulcerated, bled, and caused pain. Pathological diagnosis confirmed malignant melanoma with a Breslow thickness exceeding 4 mm. One month after diagnosis, extensive resection was performed with a surgical margin of 2.5 cm. An O-Z flap was used for repair, suturing, and fixation. Postoperative analysis revealed no residual tumor cells. All flaps remained viable, and the patient was satisfied with the aesthetic outcome.

Discussion

Scalp tumors are common but highly variable in terms of tumor type, size, location, and depth. As such, the resection of scalp tumors and subsequent reconstruction require systematic study and careful planning. In tumor resection, achieving complete excision is crucial to minimize the risk of recurrence and ensure long-term therapeutic success. This is the primary objective of our surgical approach. Scalp reconstruction presents unique challenges due to the convexity of the skull and the fixed nature of the scalp layers, which result in high tension and make suturing difficult. Small defects, in particular, are challenging to close effectively (9,10). Consequently, scalp repair remains a significant concern in orthopedic surgery. In the early stages of scalp reconstruction, the primary concern was to achieve adequate coverage with healthy tissue. However, with advancements in modern surgical techniques, the focus has shifted toward achieving both functional and aesthetically pleasing reconstruction (11). Maintaining the hairline and promoting hair growth are now central to the aesthetic aspect, as hair not only enhances appearance but also helps conceal surgical scars. This, in turn, plays a significant role in supporting the psychological recovery of many patients. In our retrospective analysis, we observed that female patients were more likely to have long hair, while male patients often had short hair or being baldness during the recovery period. This difference appears to reflect the greater emphasis women place on aesthetic concerns. Additionally, younger patients demonstrated a stronger desire to return to normal life.

The key challenge in scalp tumor resection lies in balancing the surgical margin with effective repair. We firmly believe that achieving an adequate surgical margin is the most critical factor in ensuring successful tumor treatment (12,13). If a patient experiences local recurrence though having achieved good aesthetic repair, it is ultimately regarded as a failure in terms of oncological treatment outcomes. Furthermore, previous studies have demonstrated that while large reconstructive procedures are more invasive, they carry a lower overall risk (14,15). Consequently, over the past decade, we have prioritized achieving the widest possible tumor resection margins. Our data also indicate that the recurrence rate of scalp tumors in our cohort is lower compared to similar levels reported internationally (16-21). Internationally, reported recurrence rates for scalp tumors exceed 5%, with most studies indicating rates greater than 10%, which are higher than those observed in our study. In addition to overall recurrence rates, we also examined histology-specific outcomes in our cohort. Among the 19 patients with angiosarcoma, the local recurrence rate was 15.8%, which is substantially lower than the 58% recurrence rate previously reported for cutaneous angiosarcoma of the scalp (22). Similarly, in 33 patients with malignant melanoma, only one case of recurrence was observed (3.0%), compared to a recurrence rate of 25.5% in head and neck melanoma reported in a previous study (23). Other tumor types in this study did not show recurrence and were therefore excluded from subtype-specific comparison. The number of angiosarcoma cases was not listed separately in the main table, so we have included this clarification in the text. These findings support the conclusion that enlarged resection margins are essential for achieving curative tumor removal and effectively reducing recurrence rates, provided that the repair area remains feasible. Therefore, we believe that maximizing the resection margin is of paramount importance in the treatment of scalp tumors.

Despite expanding the resection margin to ensure complete tumor removal, postoperative complications were rare. Only a small number of patients experienced wound dehiscence, hematoma, or infection, while the majority of patients had no complications. Our complication rate was lower than levels reported internationally (3,19,24-28), suggesting that expanding the resection margin does not necessarily lead to an increase in complications. Some studies have argued that the success of complex scalp defect reconstruction depends primarily on thorough debridement of all nonviable and compromised tissues prior to reconstruction, rather than the size of the defect or the type of flap used (26,29). This finding aligns with our results.

Common scalp reconstruction methods include primary closure, skin grafting, and flap-based techniques. Research has shown that complex defects require more advanced reconstructive procedures (30). Consequently, for cases involving larger resection margins, skin grafting and skin flaps are our preferred methods of reconstruction. Based on our findings, we advocate avoiding skin grafting whenever possible due to the associated risk of necrosis. Studies have suggested that skin grafts can only achieve viability when the pericranium or galea remains intact following radical resection (24,31). In addition, skin grafting has notable aesthetic limitations (5). It often results in unsightly scars, hair loss, and skin discoloration that contrasts sharply with the surrounding scalp, leading to poor outcomes from both functional and aesthetic perspectives (1,24). In contrast, our results showed high patient satisfaction with the aesthetic outcomes of scalp reconstruction using flaps. This demonstrates that flap-based reconstruction can effectively meet the aesthetic expectations of patients. This preference is also supported by the biomechanical and tensiometric properties of the scalp. The scalp’s limited elasticity and firm adherence to the galea aponeurotica and pericranium make tension-free closure challenging. These features often necessitate the use of rotational or advancement flaps, such as O-Z or O-S flaps, to accommodate the convex scalp anatomy while minimizing closure tension and preserving perfusion (32,33).

In this article, three representative cases are presented, detailing the patients’ medical histories, surgical processes, and prognoses. These cases illustrate the practical application of our surgical approach, specifically highlighting the resection margins, scalp reconstruction techniques, postoperative healing, and aesthetic outcomes. Additionally, in the cases mentioned, scar formation was observed in the areas where skin flaps healed, with no hair regeneration in these regions. However, surrounding hair effectively concealed the scars, resulting in no significant impact on the patients’ overall aesthetic recovery.

This study represents the largest surgical series of scalp malignancy resections with long-term, complete follow-up conducted at a single center to date. Through our retrospective analysis, we propose maximizing resection margins to ensure effective oncological treatment, while simultaneously prioritizing the feasibility of the estimated repair area—a novel approach introduced in this study.

However, there are certain limitations in this study. First, we did not conduct controlled studies during the surgical process to systematically compare outcomes based on the principle of maximizing resection margins within the guideline-recommended range. As a result, although our local recurrence rate is lower compared to similar studies worldwide, we lack objective evidence to further substantiate this finding. Second, the low number of recurrence events (n=4) limited our ability to conduct multivariate analysis. As robust regression models require adequate event numbers per variable to ensure statistical validity, we were unable to adjust for potential confounders such as tumor size, depth, and adjuvant therapy. This limitation should be considered when interpreting the recurrence outcomes. Third, while extended resections have proven effective in reducing local recurrence rates, we observed that the proportion of lymph node metastases in patients with malignant melanoma remains high. This rate is comparable to those reported in other studies (20,34,35). This may contribute to an ineffective improvement in overall survival, likely because lymph node metastasis had already occurred in some patients before surgery. Fourth, although flaps were used for scalp reconstruction, some patients still developed postoperative scarring, and local hair regeneration did not occur. This remains a drawback, particularly for patients with high aesthetic expectations.

Conclusions

Through this retrospective study, we found that widening the resection margin significantly reduced the local recurrence rate in postoperative patients (3.9%) without increasing the risk of complications (5.8%). This approach is crucial for improving patient prognosis. Furthermore, scalp reconstruction using skin flaps effectively met the aesthetic expectations of most patients (93.2%) and contributed to an enhanced quality of life.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tcr.amegroups.com/article/view/10.21037/tcr-2024-2223/rc

Data Sharing Statement: Available at https://tcr.amegroups.com/article/view/10.21037/tcr-2024-2223/dss

Peer Review File: Available at https://tcr.amegroups.com/article/view/10.21037/tcr-2024-2223/prf

Funding: This study was supported by grants from the National Natural Science Foundation of China (No. 82003351 to Q.Z.) and the Shanghai Municipal Health Commission Research Project (No. 20194Y0242 to Y.S.).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tcr.amegroups.com/article/view/10.21037/tcr-2024-2223/coif). Q.Z. reports receiving grants from the National Natural Science Foundation of China (No. 82003351). Y.S. reports receiving grants from the Shanghai Municipal Health Commission Research Project (No. 20194Y0242). The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Fudan University Shanghai Cancer Center (Approval No. 1612167-18). Each patient signed an informed consent document during the preoperative conversation. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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