Haiyan Shen,* Yanwen Xu,* Xiangsheng Wang, Jufang Zhang

Department of Medical Cosmetic Center, Affiliated Hangzhou First People’s Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang, 310006, People’s Republic of China

*These authors contributed equally to this work

Correspondence: Jufang Zhang, Department of Medical Cosmetic Center, Affiliated Hangzhou First People’s Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang, 310006, People’s Republic of China, Email zhjuf@vip.sina.com

Abstract: This case report describes a pioneering approach to address severe alopecia following free flap reconstruction for malignant scalp tumor resection. A 41-year-old female with recurrent malignant fibrous histiocytoma underwent extensive scalp resection (10 cm × 21 cm defect) repaired with a free anterolateral thigh flap. While the flap healed successfully, the resulting baldness caused significant psychological distress, leading her to decline conventional scalp expansion due to its invasiveness. Instead, we performed staged autologous hair transplantation directly onto the flap—a technically challenging endeavor given the flap’s thin skin, thick subcutaneous fat, and compromised vascularity. Using follicular unit extraction (FUE), the first session (2,289 grafts) followed partial flap resection, and the second session (2,571 grafts) was conducted 18 months later. Key adaptations included low-density implantation (30– 40 FU/cm²), controlled graft depth, and tumescent solution to maintain skin tension. Follow-up revealed encouraging graft survival (~60% initially, rising to ~70% in the second session), achieving complete coverage at ~35 FU/cm² with no complications. The patient expressed high satisfaction with the natural aesthetic outcome. To our knowledge, this represents the first such case reported in China and only the third globally, demonstrating that staged FUE transplantation on free flaps is a viable, minimally invasive solution for post-oncologic alopecia when traditional methods are contraindicated or refused. This technique expands reconstructive options for patients prioritizing both cure and quality of life.

Keywords: malignant scalp neoplasms, free flap transplantation, follicular unit extraction, hair transplantation, alopecia management, staged surgery