The use of free myocutaneous flap and implant reinsertion for staged cranial reconstruction in patients with titanium mesh exposure and large skull defects with soft tissue infection after cranioplasty: Report of 19 cases

Combined skin dilator and titanium mesh application to repair scalp and skull defects: a case report

We report a case of skin dilator combined with titanium mesh to repair scalp and skull defects. An 18-year-old male with a scalp defect and skull necrosis due to high-voltage electrical burns was admitted to our hospital. In the first stage, the wound was debrided, antibiotics were applied to control the infection, and two skin dilators were embedded under the scalp after debridement. In the second stage, necrotic skull material was removed, the skull defect was repaired using titanium mesh, and the scalp defect was repaired by transferring expanded flaps. The patient was followed up for 6 months, recovering well and achieving a satisfactory head shape.

Soft tissue Reconstruction Using Pedicled Trapezius Musculocutaneous Flap for Cranial Bone Flap Infection in the Occipital Region

When managing cranial bone flap infections, infected bone flaps are typically removed and subsequently replaced with artificial bones 6 to 12 months after the inflammation subsides. However, defects in the occipital region pose challenges due to concerns regarding brain protection when patients lie in the supine position. Herein, the authors report the case of a 73-year-old woman with an occipital bone flap infection, which was successfully managed by reconstruction with a trapezius musculocutaneous flap immediately after removing the infected bone flap. One year and 2 months postoperatively, the wound had fully healed, and the patient remained symptom-free without any complications, such as sunken flap syndrome. Soft tissue reconstruction using pedicled trapezius musculocutaneous flap is a viable strategy for managing occipital bone flap infections. This flap ensures stable blood flow and requires minimal vascular manipulation, thereby reducing operation time as the patient does not need to change position.

Outcomes of Cranioplasty Reconstructions: Review of Cranioplasty Implants and Free Flap Coverage Variables that Affect Implant Exposure

BACKGROUND

Complex scalp wounds with cranial/dural involvement are challenging to reconstruct. Successful reconstruction can be achieved with cranial implants/hardware and free flap coverage. Wounds can breakdown and require revision procedures. We addressed reconstructive outcomes of different implants requiring free flaps.

OBJECTIVE

To determine the factors associated with implant exposure.

DESIGN

Multi-institutional retrospective review of 82 patients, 2000-2020, repaired with cranial implants and free flap coverage.

RESULTS

Implant exposure occurred in 13/82 (16%) reconstructions. Flap atrophy or thinning leading to implant exposure occurred in 11/82 (13%) reconstructions, including partial flap atrophy OR 0.05 (95% CI 0.0-0.35) and total flap atrophy OR 0.34 (95% CI 0.02-19.66). Revision surgeries that occurred subsequent to flap reconstruction were also associated with implant exposure (OR 0.02 (95% CI 0.0-0.19)). Implant exposure was not associated with radiation therapy, patient health history, implant type, flap type, or postoperative complications.

CONCLUSIONS

Implant exposure is associated with free flap atrophy, leading to inadequate implant coverage and the need for revision surgeries. Completing reconstruction with adequate soft tissue bulk and coverage and avoiding revision surgery may decrease the risk for implant exposure over time.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2954-2958, 2023.

Full-thickness skin regeneration beneath the exposed titanium mesh in cranioplasty: Two cases report

RATIONALE

Titanium mesh is one of the most widely used implant materials applied in cranioplasty; however, it has been reported to encounter the risk of progressive scalp thinning and implant exposure over time. Here we present 2 cases of exposed titanium mesh (TM) and unusual phenomena of full-thickness skin regeneration beneath the mesh.

PATIENT CONCERNS

Two patients, 1 with an 8-year and 1 with a 2-year history of implant exposure after cranial TM implantation.

DIAGNOSES

The patients were diagnosed with scalp ulcers and cranial TM exposure.

INTERVENTION

The exposed part of the implant was removed, and the full-thickness skin beneath the mesh was directly used as functional soft tissue coverage to repair the scalp defect.

OUTCOMES

Full recovery for both patients with cosmetic satisfaction.

LESSONS

Though the exact mechanism of this epithelisation phenomenon beneath the TM remains to be elucidated, it provided a feasible choice for clinicians to reconstruct the scalp's integrity without exerting complicated procedures when dealing with similar cases.

Healing Exposed Calvarial Hardware Using Negative-Pressure Wound Therapy and Vashe Wound Solution: Case Report

OBJECTIVE

The management of cranioplasty infections has historically been explantation followed by delayed reimplantation/reconstruction. This treatment algorithm necessitates surgery, tissue expansion, and prolonged disfigurement. In this report, the authors describe a treatment approach consisting of serial vacuum-assisted closure (VAC) with hypochlorous acid (HOCl) solution (Vashe Wound Solution; URGO Medical) as a salvage strategy.

METHODS

A 35-year-old man who sustained head trauma, neurosurgical complications, and severe syndrome of the trephined (SOT; devastating neurologic decline treated by cranioplasty) underwent titanium cranioplasty with free flap. Three weeks postoperation, he presented with pressure-related wound dehiscence/partial flap necrosis, exposed hardware, and bacterial infection. Given the severity of his precranioplasty SOT, hardware salvage was critical. He was treated with serial VAC with HOCl solution for 11 days followed by VAC for 18 days and definitive split-thickness skin graft placement over resulting granulation tissue. Authors also conducted a literature review of cranial reconstruction infection management.

RESULTS

The patient remained healed 7 months postoperatively without recurrent infection. Importantly, his original hardware was retained, and his SOT remained resolved. Findings from the literature review support the use of conservative modalities to salvage cranial reconstructions without hardware removal.

CONCLUSIONS

This study investigates a new strategy for managing cranioplasty infections. The VAC with HOCl solution regimen was effective in treating the infection and salvaging the cranioplasty, thus obviating the complications associated with explantation, new cranioplasty, and recurrence of SOT. There is limited literature on the management of cranioplasty infections using conservative treatments. A larger study to better determine the efficacy of VAC with HOCl solution is underway.

Anterolateral thigh adipofascial flap combined with skin paddle in three-dimension scalp reconstruction: A case report

INTRODUCTION AND IMPORTANCE

Management of cranial and scalp defects is always challenging. Complication rates following cranioplasty are still high (10-40 %), including bone graft resorption, infection, and T-mesh implant exposure due to thinning of soft tissue (Yeap et al., 2019; Alkhaibary et al., 2020; Cho and Kang, 2017 [1-3]).

CASE PRESENTATION

We present a case of a 38-year-old male with autologous bone graft resorption accompanied by thinning of the forehead skin. He underwent cranioplasty with titanium mesh (T-mesh) and scalp reconstruction with an anterolateral thigh (ALT) flap in a single-stage operation. A 2-component ALT flap was used: the skin paddle covered the scalp defect to reduce closure tension, and especially the adipofascial flap lining beneath the forehead skin to increase thickness. Postoperative results were great in terms of coverage function and aesthetics.

CLINICAL DISCUSSION

The phenomenon of soft tissue thinning causing titanium mesh exposure is a common complication with a rate of 10-14 % (Yeap et al., 2019; Dong et al., 2020; Maqbool et al., 2018 [1, 4, 5]). Using adipofascial ALT flap as a sub-scalp filler material has many advantages over the latissimus dorsi (LD) flap to increase scalp thickness but still ensure aesthetics.

CONCLUSION

The results suggest a new direction in using adipofascial ALT flap as filler material to increase scalp thickness to reduce T-mesh exposure following cranioplasty.

Comparison of Infection Rates Following Immediate and Delayed Cranioplasty for Postcraniotomy Surgical Site Infections: Results of a Meta-Analysis

Postoperative surgical site infections (SSIs) in neurosurgery are rare. However, they pose a formidable challenge to the treating neurosurgeon and substantially worsen patient outcomes. These infections require prompt intervention in the form of débridement, including removal of craniotomy bone. Reconstruction of the craniotomy defect can be performed along with the débridement or can be performed at a later time. Although there have been concerns about performing cranioplasty at the same time as débridement, recent studies have advocated performance of cranioplasty at the same time as the débridement, as it avoids the morbidity associated with having a craniectomy defect and avoids the need for another surgical procedure. We conducted a literature review and meta-analysis to examine the data on immediate cranioplasties and delayed cranioplasties performed for postcraniotomy SSIs. We analyzed 15 articles with a total of 353 patients. Our analysis revealed that the pooled proportion of treatment failure was 10.4% (95% confidence interval [CI] 5.9%-17.8%) when an immediate cranioplasty was done and 16.1% (95% CI 7.2%-32.1%) when delayed cranioplasty was done. The pooled proportion of treatment failure was 12% (95% CI 5.9%-22.9%) when the same bone was used for cranioplasty and was 8% (95% CI 3%-20%) when prosthetic material such as titanium was used for cranial vault reconstruction. Thus, the rate of treatment failure was less when an immediate single-stage cranioplasty was done compared with a delayed cranioplasty following SSIs.

Scalp Reconstruction Using the Latissimus Dorsi Free Flap: A 12-Year Experience

BACKGROUND

Complex scalp defects are regularly reconstructed using microvascular tissue transfer. The latissimus dorsi free flap is one of the workhorse flaps used in scalp reconstruction. These cases necessitate, particularly in the elderly, a close cooperation between plastic surgeons and neurosurgeons. The purpose of this study was to evaluate the suitability of the latissimus dorsi free flap for complex scalp reconstructions and to analyze potential risk factors.

METHODS

A retrospective study identified 43 patients undergoing complex scalp reconstruction using a latissimus dorsi free flap at our department between 2010 and 2022.

RESULTS

The mean patient age was 61 ± 18 years. Defects were mostly caused by oncologic tumor resections (n = 23; 55%), exposure to a cranioplasty (n = 10; 23%) or infection (n = 4; 9%). The most frequent recipient vessels were the superficial temporal artery (n = 28; 65%), external carotid artery (n = 12; 28%) and the venae comitantes (n = 28; 65%), external jugular vein (n = 6; 14%). The reconstructive success rate was 97.7%. There was one total flap loss (2%). Partial flap loss occurred in five cases (12%). Follow-up was 8 ± 12 months. Major complications were seen in 13 cases, resulting in a revision rate of 26%. Multivariate logistic regression identified active tobacco use as the only risk factor for major complications (odds ratio 8.9; p = 0.04).

CONCLUSION

Reconstruction of complex scalp defects using the latissimus dorsi free flap yielded high success rates. Among the potential risk factors, active tobacco use seems to affect the outcome of complex scalp reconstructions.

Biomimetic Design of Double-Sided Functionalized Silver Nanoparticle/Bacterial Cellulose/Hydroxyapatite Hydrogel Mesh for Temporary Cranioplasty

A structurally stable and antibacterial biomaterial used for temporary cranioplasty with guided bone regeneration (GBR) effects is an urgent clinical requirement. Herein, we reported the design of a biomimetic Ag/bacterial cellulose/hydroxyapatite (Ag/BC@HAp) hydrogel mesh with a double-sided functionalized structure, in which one layer was dense and covered with Ag nanoparticles and the other layer was porous and anchored with hydroxyapatite (HAp) via mineralization for different durations. Such a double-sided functionalized design endowed the hydrogel with distinguished antibacterial activities for inhibiting potential infections and GBR effects that could prevent endothelial cells and fibroblasts from migrating to a defected area and meanwhile show biocompatibility to MC3T3-E1 preosteoblasts. Furthermore, it was found from in vivo experimental results that the Ag/BC@HAp hydrogel with 7-day mineralization achieved optimal GBR effects by improving barrier functions toward these undesired cells. Moreover, this BC-based hydrogel mesh showed an extremely low swelling ratio and strong mechanical strength, which facilitated the protection of soft brain tissues without gaining the risk of intracranial pressure increase. In a word, this study offers a new approach to double-sided functionalized hydrogels and provides effective and safe biomaterials used for temporary cranioplasty with antibacterial abilities and GBR effects.

An algorithmic approach of reconstruction for cranioplasty failure: A case series

RATIONALE

Cranioplasty is a surgical procedure used to repair cranial defects for both cosmetic and functional reasons. The complication rate of cranioplasty is between 10% and 50%. The failure of cranioplasty is associated with various factors, including etiologies, types of material, and the timing of cranioplasty. In this study, a case series of managing cranioplasty complications at a single institution.

PATIENT CONCERNS

Eighteen patients were identified who underwent craniofacial defect reconstruction due to the failure of their initial cranioplasty between January 2010 and May 2020. Five men (27.78%) and thirteen women (72.22%) were included. The mean age was 39.61 years old. The average follow-up duration was 5.94 years.

DIAGNOSES

The indication for initial cranioplasty included previous decompressive craniectomy (77.78%, n = 14), traumatic cranial defects (16.67%, n = 3), and congenital cranial deformity (5.56%, n = 1). The reported complications were infection (50%, n = 9), implant exposure (50%, n = 9), wound dehiscence (22.22%, n = 4) and cranial deformity (11.11%, n = 2).

INTERVENTIONS

More than half of the materials used for initial cranioplasty were synthetic [titanium mesh: 44.44%, n = 8; polymethyl metacrylate: 5.56%, n = 1; titanium mesh and polymethyl metacrylate: 5.56%, n = 1], while 44.44% of the patients received autologous bone graft.

OUTCOMES

Of all reconstructive procedures for cranioplasty failure, 55.56% was local flap with or without skin graft (n = 10), 16.67% was free flap (n = 3), 11.11% was skin graft only (n = 2), 5.56% was regional flap (n = 1). The free flap survival rate was 100% (3/3), and implant removal with sebsquent second cranioplasty was performed on 27.78% (n = 5) of the patients.

LESSONS

Management of cranioplasty failure can be challenging due to infection, refractory implant exposure, and wound dehiscence. The principles of management are based on adequate infection control and reconstructive ladder. Meanwhile, collaboration with plastic surgery and neurosurgery should be strengthened in order to achieve the best clinical outcomes.

Application of Autogenous Dermis Combined With Local Flap Transplantation in Repair of Titanium Mesh Exposure After Cranioplasty

OBJECTIVES

To investigate the clinical outcome of autogenous dermis combined with local flap transplantation in the treatment of titanium mesh exposure after cranioplasty.

METHODS

We studied a total of 8 patients with titanium mesh exposure after cranioplasty. After debridement of the head wound, the autogenous dermal tissue from the lateral thigh was transplanted to the surface of titanium mesh, and the local skin flap was then applied after suturing and fixation to repair the wound on the surface of the dermis. To repair the lateral thigh dermal tissue area, a local skin flap was obtained, and a blade thick skin graft was used.

RESULTS

Both dermal tissue and local skin flap survived. In the meanwhile, the donor skin area of the lateral thigh healed well, with only slight scar hyperplasia, and the titanium mesh was preserved. There was no recurrence after 6 months of follow-up.

CONCLUSIONS

The application of autogenous dermis combined with local skin flap to repair titanium mesh exposure can effectively avoid skin flap necrosis, potential re-exposure of titanium mesh, sub-flap effusion, infection, and other problems. This method has an ideal effect, has easy access to materials, and reduces patients' economic burden. It is worth popularizing.

Clinical Applications of Poly-Methyl-Methacrylate in Neurosurgery: The In Vivo Cranial Bone Reconstruction

Background: Biomaterials and biotechnology are becoming increasingly important fields in modern medicine. For cranial bone defects of various aetiologies, artificial materials, such as poly-methyl-methacrylate, are often used. We report our clinical experience with poly-methyl-methacrylate for a novel in vivo bone defect closure and artificial bone flap development in various neurosurgical operations. Methods: The experimental study included 12 patients at a single centre in 2018. They presented with cranial bone defects after various neurosurgical procedures, including tumour, traumatic brain injury and vascular pathologies. The patients underwent an in vivo bone reconstruction from poly-methyl-methacrylate, which was performed immediately after the tumour removal in the tumour group, whereas the trauma and vascular patients required a second surgery for cranial bone reconstruction due to the bone decompression. The artificial bone flap was modelled in vivo just before the skin closure. Clinical and surgical data were reviewed. Results: All patients had significant bony destruction or unusable bone flap. The tumour group included five patients with meningiomas destruction and the trauma group comprised four patients, all with severe traumatic brain injury. In the vascular group, there were three patients. The average modelling time for the artificial flap modelling was approximately 10 min. The convenient location of the bone defect enabled a relatively straightforward and fast reconstruction procedure. No deformations of flaps or other complications were encountered, except in one patient, who suffered a postoperative infection. Conclusions: Poly-methyl-methacrylate can be used as a suitable material to deliver good cranioplasty cosmesis. It offers an optimal dural covering and brain protection and allows fast intraoperative reconstruction with excellent cosmetic effect during the one-stage procedure. The observations of our study support the use of poly-methyl-methacrylate for the ad hoc reconstruction of cranial bone defects.