A thin superficial temporalis artery revealed by total necrosis of an island scalp flap, a case report

INTRODUCTION AND IMPORTANCE: The superficial temporalis artery (STA) counts as one of the most reliable blood supplies capable of supporting the vascularization of the entire scalp. Therefore, total necrosis of a scalp flap based on the superficial temporalis artery is a rare complication. CASE PRESENTATION: A 43-year-old woman with a history of hypertension and cerebral stroke presented to our consultation for fronto-parietal scalp alopecia. The scar was the result of spontaneous healing of a chemical burn that occurred eight months earlier. We performed the first step of scalp expansion and raised a parietal expanded goblet island flap based on the right STA. In the postoperative period, the flap developed progressive necrosis. Despite the release of tension and stab incisions, the flap failed in a week. An angio-MRI revealed a thin STA on the right compared to the left side. After debridement, the necrosis was superficial, deep galea, and some subcutaneous tissues were viable. We performed a split-thickness skin graft that achieved a total wound closure. CLINICAL DISCUSSION: An extensive exploration of the vascular supply of the scalp before raising a scalp flap is not a common rule. The anatomical variation that we discovered as a thin superficial temporal artery may have explained the total failure of this flap surgery. CONCLUSION: Surgeons should keep in mind the possible existence of a detrimental anatomical variation when planning a single pedicled scalp flap.