We present the case of a 68-year-old patient with absence of hair on the scalp, with a history of right inguinal hernia that had not been operated on and with actinic keratosis that had been present for years, initially treated with retinoids and cryotherapy. Two years later the patient reported the appearance of several crusty lesions in the parieto-occipital region. Biopsies of the lesions were taken and reported as moderately differentiated squamous cell carcinoma. The lesions were excised, leaving one of the margins of the resection affected by the tumour. The patient was given maximum dose radiotherapy to the scalp. Six months later the patient reported the appearance of several lesions similar to the previous ones in the same area. New biopsies were taken and reported as squamous cell carcinoma. The patient was then referred to our department to assess the therapeutic possibilities. On arrival the patient presented two crusty lesions of approximately 2 and 3 cm in diameter respectively and other smaller lesions suspicious of malignancy. Likewise, as a consequence of the radiotherapy, there was fibrosis and complete retraction of the scalp which prevented any type of reconstruction by means of local flaps. During the clinical session, it was decided to perform a wide scalp resection and immediate reconstruction of the defect with a free omentum flap, as well as a herniorrhaphy to reduce the inguinal hernia that the patient presented. 

The patient is operated on together with the General Surgery Service and a two-team approach is performed simultaneously. On the one hand, a wide scalp excision is performed together with a bilateral preauricular approach to identify and isolate the superficial temporal vessels. On the other hand, a median laparotomy is performed. Once the abdominal cavity has been explored, the omentum is tractioned and dissected from the transverse mesocolon upwards. The vascular pedicle corresponding to the right gastroepiploic vessels is then identified and the small vascular branches leading to the posterior and anterior area of the greater curvature of the stomach are exposed and ligated. Once the vascular pedicle of the greater curvature of the stomach is freed, the pedicle of the left gastroepiploic artery is ligated, leaving the omentum pediculated to the right gastroepiploic artery and ready to be transferred to the defect area. The omentum is then sutured to the remaining scalp and anastomoses are performed. Some authors use both vascular pedicles with double anastomoses to the facial and superficial temporal vessels.8 In our case we performed the anastomoses using only the right gastroepiploic pedicle and the superficial temporal artery and vein as recipient vessels. Finally, the entire omentum flap is covered with a meshed dermoepidermal graft and a compressive bandage is applied for 1 week. The surgical specimen reported as moderately differentiated epidermoid carcinomas and two carcinomas in situ, all with disease-free resection margins. The postoperative period was uneventful and the patient was discharged 12 days after surgery. The patient is followed up in multiple revisions and, 2 years after surgery, shows no signs of local recurrence. From an aesthetic point of view, the patient is very satisfied with the result as the skin mesh marks have disappeared with time and it is a uniform tissue along the entire scalp.