Retrospective cohort study of combined approach for trunk reconstruction using arteriovenous loops and free flaps

Otoplasty in Adults: Psychological Impacts on Quality of Life

Psychological distress, emotional trauma, and behavioral problems related to prominent ears can cause complicated situations in children and adults. This study aimed to investigate the changes in the psychological impact on quality of life after Otoplasty. The study used several measures, including the Glasgow Benefit Inventory, Social Appearance Anxiety Scale (SAAS), Body Image Scale (BIS), Rosenberg Self-Esteem Scale (RSES), and Visual Analogue Score (VAS), which were completed before and six months after the surgery. The GBI questionnaire was used to detect the health-related quality of life changes after Otoplasty, as it is a reliable, valid, and responsive measure. Six months after the surgery, BIS total scores, VAS scores, and SAAS scores decreased significantly, while RSES scores were not significantly different. These results suggest that Otoplasty can significantly impact adult patients' psychological well-being and quality of life and that the surgery should be considered regardless of age.

Head and neck reconstruction in vessel-depleted necks: Case report of a labio-mental and mandibular reconstruction using an arteriovenous loop

Major defects of the facial structures cause severe functional and esthetic impairment. Difficulty in head and neck reconstruction lies in cases of secondary, tertiary, or further reconstruction. This is not a rare situation for patients who had cancer of the upper airways, since the rate of recurrence, second location, or osteoradionecrosis is high. Multiple surgeries and radiation therapy cause significant fibrosis and scar tissues, making any further reconstruction a major challenge for the surgeon when operating patients with vessel- depleted neck. We report our experience with a clinical case of a patient to whom we performed a double free flap reconstruction anastomosed on a vascular loop in a context of vascular cervical desert. In our case, the use of an arteriovenous loop proved to be a reliable approach for a vessel-depleted free tissue reconstruction. This technique has received insufficient attention, yet it provides a means to establish dependable vascular alternatives.

Heterogeneous Maturation of Arterio-Venous Fistulas and Loop-Shaped Venous Interposition Grafts: A Histological and 3D Flow Simulation Comparison

Vascular graft maturation is associated with blood flow characteristics, such as velocity, pressure, vorticity, and wall shear stress (WSS). Many studies examined these factors separately. We aimed to examine the remodeling of arterio-venous fistulas (AVFs) and loop-shaped venous interposition grafts, together with 3D flow simulation. Thirty male Wistar rats were randomly and equally divided into sham-operated, AVF, and loop-shaped venous graft (Loop) groups, using the femoral and superficial inferior epigastric vessels for anastomoses. Five weeks after surgery, the vessels were removed for histological evaluation, or plastic castings were made and scanned for 3D flow simulation. Remodeling of AVF and looped grafts was complete in 5 weeks. Histology showed heterogeneous morphology depending on the distribution of intraluminal pressure and WSS. In the Loop group, an asymmetrical WSS distribution coincided with the intima hyperplasia spots. The tunica media was enlarged only when both pressure and WSS were high. The 3D flow simulation correlated with the histological findings, identifying “hotspots” for intimal hyperplasia formation, suggesting a predictive value. These observations can be useful for microvascular research and for quality control in microsurgical training.

A Myocutaneous Latissimus Dorsi Propeller Flap Based on a Single Dorsal Intercostal Perforator

This study presents a novel surgical technique for the reconstruction of highly challenging large lower back defects. In this case, a 72-year-old man initially diagnosed with renal cell carcinoma received nephrectomy followed by the dissection of an iliac crest metastasis and repeated high-dose irradiation therapy. Several years later, an osteocutaneous fistula at the right caudal posterior trunk made the reconstruction of the lower back defect necessary. High-dose irradiation of the lower back and poor vascular conditions at the pelvic region disqualified the patient for previously published local or free flap options. The initial strategy of an arteriovenous loop anastomosed to the femoral vessels and a free latissimus dorsi flap transfer had to be withdrawn due to repeated intraoperative loop thrombosis. For that reason, the entire latissimus dorsi muscle was used as a myocutaneous propeller flap receiving its blood supply solely through a single dorsal intercostal artery perforator. The flap survived completely and no fistulous formation occurred postoperatively. The time to complete wound healing was 4 months. This new technique is considered a valuable addition for the reconstruction of challenging posterior caudal trunk defects.

Free Flap Reconstruction of Posterior Trunk Soft-Tissue Defects: Single-Institution Experience and Systematic Literature Review

BACKGROUND

The posterior trunk is a technically demanding location for microvascular free tissue transfer. In this study, the authors report their own institutional experience with soft-tissue free flap reconstruction of the posterior trunk and provide a systematic review of the literature regarding this uncommon clinical scenario.

METHODS

A systematic review was performed using the PubMed database in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A single-institution retrospective review was also performed including all patients who received a soft-tissue free flap for a posterior trunk defect between 1990 and 2019.

RESULTS

The database search yielded 15 articles, representing 61 patients; the most commonly used flap was the latissimus dorsi (45.9 percent) and the most commonly reported defect location was the lumbosacrum (42.3 percent). Retrospective review of the authors' database identified 26 patients, with the latissimus dorsi being the most common flap and the sacrum the most common defect site. The authors' institutional case series showed a 30.7 percent major complication rate and 7.7 percent total flap loss rate; 38.4 percent of flaps required vein grafting.

CONCLUSIONS

In this study, the authors provided a systematic literature review and described their own long-term institutional experience with these rare and difficult reconstructions. Although the overall complication rate is high, these reconstructions are frequently necessary, and an algorithmic approach can improve outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Potential Complications With Cryopreserved Cadaveric Veins in Arteriovenous Loop Formation for Head and Neck Microvascular Reconstruction

ABSTRACT

Vessel depletion in the head and neck from radiation or previous surgical intervention adds to the operative complexity by limiting reconstructive options. Arteriovenous (AV) loop vascular grafts provide a conduit to bypass these nonviable local vessels to provide adequate blood flow. In certain situations, autologous donor vascular options are deficient or not readily available for creation of the AV loop. Cadaveric vein grafts provide an alternative option in these circumstances, but the efficacy and safety has not yet been delineated. In this study we discuss our experience utilizing cryopreserved cadaveric vein grafts for AV loop creation in head and neck reconstruction. In our initial cohort we aim to elucidate potential challenges and complications associated with the use of cadaveric vein grafts.

Active drain system with reticulated open-pore foam-surface dressing for postoperative pancreatic fistula in a rat model

Background

Postoperative pancreatic fistula (POPF) is one of the most harmful complications after pancreatic resection. Efficient drainage affects the clinical outcome of POPF. Inefficient drain of the fluid collection should contribute greatly to the need of additional interventional drainage, secondary morbid complications, and death.

Methods

A rat model of POPF was established by distal pancreatosplenectomy. A novel active drain system (ADS) for POPF was developed by wrapping polyvinyl alcohol sponges (PVA) to an end of the drainage tube. Passive drain system (PDS), ADS and ADS with PVA were used for POPF in rat models. The volume and amylase of ascites were measured. CT scan was applied to assess abdominal fluid collection. Rats pancreatic transection stumps were stained by hematoxylin and eosin (H&E).

Results

The volume of drainage of ADS with PVA group was less than that of PDS group and ADS group at late stage. CT scan showed obvious abdominal fluid collections in 2/8, 2/8 and 0/8 rats in PDS, ADS and ADS with PVA group separately. Macrofindings showed significant intra-abdominal adhesions and inflammation in PDS and ADS group but not in ADS with PVA group. H&E staining showed less inflammatory cells and destroyed pancreatic glands in ADS with PVA group.

Conclusion

ADS with PVA drained ascites effectively in the rat model of POPF. The effective drainage of pancreatic juice reduced the inflammation of abdominal organs and pancreatic resection stumps, and might promote the healing of POPF.

Common Carotid-to-Internal Jugular Arteriovenous Loop for Single-Stage Microsurgical Reconstruction in the Radiated Vessel-Depleted Neck

ABSTRACT

Management of head and neck defects in a radiated field can be quite challenging owing to the dearth of vasculature and significant degree of post-radiation fibrosis. In this setting, arteriovenous (AV) loop vascular grafts can bypass nonviable local vessels to provide viable and reliable inflow and outflow vessels for free tissue transfer in an otherwise hostile environment. Prior reports of the Corlett loop utilizing a cephalic vein transposition has been described however a common carotid-to-internal jugular AV loop has not been recently reported. Three patients underwent carotid artery to internal jugular vein AV loop creation to facilitate free-flap reconstruction secondary to radiation-induced vessel depletion. The specific technique described utilizes the saphenous vein as a donor and spares the cephalic vein for the possibility of flap complication. All three cases resulted in successful reconstruction, maintaining healthy tissue, vascular flow, and flap viability at all follow-up intervals. In our experience, vascular augmentation via AV loop formation provides reliable vascular inflow and outflow in the vessel-depleted neck to facilitate microvascular reconstruction. Sparing the cephalic vein yields an additional salvage mechanism in the event of venous congestion.

[Reconstruction of oncological defects of the perianal region]

In addition to the progressive development of surgical oncological techniques for malignant tumors of the rectum, anal canal and vulva, reconstructive procedures after oncological interventions in the perianal region represent a cornerstone in the postoperative quality of life of patients. Modern treatment modalities for rectal cancer with neoadjuvant chemoradiotherapy increase the survival rate and simultaneously reduce the risk of local recurrence to 5-10%, especially by cylindrical extralevatory extirpation of the rectum. The price for increased surgical radicality and improved oncological safety is the acceptance of larger tissue defects. Simple suture closure of perineal wounds often does not primarily heal, resulting in wound dehiscence, surgical site infections and formation of chronic fistulas and sinuses. The interdisciplinary one-stage or two-stage reconstruction of the perianal region with well-vascularized tissue has proven to be a reliable procedure to prevent or control such complications.

Arteriovenous Vascular Loops in Latissimus Free Flap Reconstruction of Cervical and Cervicothoracic Spine Wounds

Introduction  Wound dehiscence is the most common complication after spinal fusion procedures, resulting in an increase in mortality rate and hospital length of stay. Reconstruction of these wounds presents a challenge, as the spine is dependent on these implants for stability and must be maintained throughout the wound dehiscence treatment protocol. We describe a method for extending the thoracodorsal pedicle with an arteriovenous loop to permit an increased excursion of the latissimus dorsi muscle in patients with exposed implants and present the results of this procedure. Materials and Methods  A retrospective review of patients treated with a latissimus free flap with saphenous vein pedicle extension for posterior spinal wounds from 2010 to 2020 were reviewed. Patient charts were reviewed for demographic information including comorbidities, previous spine operations, wound size and location, and postoperative complications including total flap loss, flap dehiscence, and need for secondary surgery. Results  Six patients were identified who underwent a total of eight extended pedicle free flaps. Mean age was 64.8 years with a mean follow-up of 12.3 months (range, 6-20 months). Four wounds were in the cervicothoracic region with two wounds in the cervical region. Mean number of previous spine surgeries was 3.5 (range, 2-4). Mean wound size was 189 cm ² with a mean vein graft length of 28 cm. Wound coverage was successful in five of six patients. Major complications occurred in five of six patients. Total flap loss occurred in two patients (33%) and both underwent a second extended latissimus flap from the contralateral side. Three patients developed postoperative flap dehiscence which resolved with regular dressing changes. Conclusion  Extended pedicle latissimus flaps are an effective treatment for posterior spine wounds but are associated with a high complication rate, secondary to medically complex patients with multiple prior surgeries. Careful patient selection is critical for success.

Perforator-Based Flaps for Defect Reconstruction of the Posterior Trunk

INTRODUCTION

Full-thickness soft tissue defects of the back remain challenging clinical problems for reconstructive surgeons. Among a vast variety of local flap options, perforator-based local flaps gain increasing popularity lately. Because mostly heterogeneous patient cohort comparison of different perforator flaps is difficult and decision-making algorithms are lacking.

METHODS

Patients, who received a local perforator-based soft tissue reconstruction between 2012 and 2019, were evaluated retrospectively. Patients' data were evaluated in terms of flap type and dimension, wound size and cause, surgery time, postoperative complications, and hospitalization. A focus was set on decision making concerning reconstructive techniques and flap choice for defect closure.

RESULTS

Thirty-six patients (17 women, 19 men) were included, who received 40 perforator-based local flaps to reconstruct extended defects of the posterior trunk. Mean patient age was 56.3 years and mean hospitalization was 29 days. Average time of flap surgery was 179.7 minutes. Mean flap size was 160.8 cm and average defect size was 110 cm. Defects occurred because of tumor resection (50%), orthopedic/trauma surgery (16.7%), or pressure sores (33.3%). Twenty-eight propeller flaps (PPFs, 70%) and 12 perforator-based VY-advancement flaps (P-VYF, 30%) were transferred. In 4 patients, a bilateral approach using more than one flap was necessary. Revision surgery was required in 9 patients (25%) because of postoperative hematoma (n = 3), postoperative wound infection (n = 3), partial flap necrosis (1× P-VYF) and 2 flap losses (2× PPFs).

CONCLUSIONS

Pedicled perforator flaps are a reliable option for soft tissue reconstruction of complex wounds of the posterior trunk. A flexible surgical strategy is mandatory, and the individual perforator anatomy has to be considered. In most cases, P-VYFs or PPFs are reliably possible and allow sufficient defect reconstruction. However, skin incisions should always be performed in a way that classic random pattern flaps are still possible. Even in large defects combined, local perforator flaps may lead to sustainable soft tissue reconstructions without functional donor site deficits.

One-stage double free flap arteriovenous loop reconstruction of a massive abdominothoracic defect following necrotizing fasciitis: A case report

We report the case of a 67-year old male with necrotizing fasciitis after injection of the glenohumeral joint. After extensive debridement a massive defect from the left hip joint to the left upper arm, exposing ribs, scapula, axillary vessels and brachial plexus (45 × 40 cm) was present. Reconstruction was performed with a conjoined right myocutaneous tensor fasciae lata/vastus lateralis flap and a left myocutaneous vastus lateralis flap in combination with an arteriovenous loop originating from the axillary vessels using the greater saphenous vein. Revisional surgeries were necessary including ribs resection and flap re-advancements. Due to multiorganic failure invasive ventilation, renal replacement- and extensive transfusion therapy was required. After 241 days the patient was discharged for rehabilitation. At the 12 months follow-up wounds were sufficiently closed without the need for further intervention. This case illustrates that immediate diagnosis followed by an aggressive multidisciplinary treatment approach is crucial for the patient survival.

Plastic-Reconstructive Treatment Algorithm for Dead Space Management Following Septic Total Hip Arthroplasty Removal: AV Loop and Two-Stage Free Myocutaneous Latissimus Dorsi Flap

BACKGROUND

A 61-year-old patient presented with a right Girdlestone hip and wound dehiscence due to extensive dead space after radical debridement and septic arthroplasty removal. A two-stage reconstruction with the application of a subcutaneous autologous arterio-venous (AV) loop using an autologous vena saphena magna (VSM) interposition graft followed by a free latissimus dorsi flap was performed.

METHOD

We decided to perform a two-stage procedure with AV loop creation in the first step and free flap transplantation seven days after it. In the first step, an AV vascular loop was prepared by transplanting the contralateral VSM interposition graft to the inguinal femoral vessels with subcutaneous passage of the venous loop. In the second step after 7 days, the wound was closed by a two-team approach. One surgical team completed the wound debridement, while the other team harvested the flap by microsurgical preparation of the thoracodorsal pedicle in the right axilla. Upon completed harvest, the flap was placed into the wound to fill the periosseous dead space, and the anastomosis was performed in an end-to-end fashion.

RESULT

The patient remained free of infection with a well-healed flap. He was mobilized on crutches with partial weight bearing on the operated leg. A lower extremity prosthesis with pelvic support was customized.

Limb salvage procedure in immunocompromised patients with therapy-resistant leg ulcers-The value of ultra-radical debridement and instillation negative-pressure wound therapy

The purpose of this study was to analyse the outcome of our established triple treatment strategy in therapy‐resistant deep‐thickness chronic lower leg ulcers. This limb salvage approach consists of ultra‐radical surgical debridement, negative‐pressure wound therapy (NPWT) with or without instillation, and split‐thickness skin grafting. Between March 2003 and December 2019, a total of 16 patients and 24 severe cases of lower leg ulcers were eligible for inclusion in this highly selective population. A total of seven patients received immunosuppressive medication. Complete wound closure was achieved in 25% and almost 90% of included lower leg ulcer cases after 3 and 24 months of our triple treatment strategy, respectively. The overall limb salvage rate was 100%. Bacterial colonisation of these wounds was significantly reduced after multiple surgical debridements and NPWT. Fasciotomy and radical removal of devitalised tissue such as deep fascia, tendons, and muscles combined with NPWT showed promising results in terms of the overall graft take rate. This treatment strategy was considered as last resort for limb salvage in such a critically ill and immunocompromised patient population. Surgeons should be aware of its efficacy and consider the triple treatment strategy especially if no other limb salvage option remains.

Plastic Surgery Reconstruction of Chronic/Non-Healing Wounds

In western countries, approximately 1 % of individuals are affected by chronic wounds during their lifetime. Due to changing demographics, this incidence will likely increase in the future. Additionally, the high prevalence is accompanied by substantial treatment expenditures. Therefore, it is of global interest to find effective treatment algorithms. In this article, we present up-to-date solutions for treating chronic / difficult to heal and complex wounds by means of plastic and reconstructive surgery. We outline the principles of chronic wounds and how to perform an appropriate diagnosis. Close cooperation and interdisciplinary exchange are important for optimizing treatment. We report the principles of wound debridement and the role of negative pressure wound therapy. Moreover, we discuss the state of the art of defect reconstruction by means of skin grafting, with or without acellular dermal matrices, local tissue transfers and free tissue transfers. In very complex cases, the local macrovascular blood flow is greatly reduced and there are few, if any, recipient vessels for free flap reconstruction. We discuss the role of arteriovenous loops to overcome this problem.

Topical negative-pressure wound therapy: emerging devices and techniques

Introduction: The treatment of chronic wounds constitutes a massive financial burden to society and our health-care system. Therefore, efficient wound care is of great importance to all kinds of medical fields. The implementation and modification of negative-pressure wound therapy can be seen as a major improvement in wound healing. Many different NPWT applications evolved trying to address various wound etiologies.Areas covered: This review aims to give an overview of various NPWT applications, show its effects on wound healing, and discuss future modifications.Expert opinion: NPWT as a delivery device for cold plasma, growth factors, or targeted stem cells to the wound bed and the ability to monitor the inflammatory activity, bacterial load and wound healing factors can be seen as possible future steps to individualized wound care. In addition, it requires high-quality experimental studies to develop the ideal foam in terms of microstructure, pore size, and material properties.

Reconstruction of segmental mandibular defects: Current procedures and perspectives

Background

The reconstruction of segmental mandibular defects remains a challenge for the reconstructive surgeon, from both a functional and an esthetic point of view.

Methods

This clinical review examines the different techniques currently in use for mandibular reconstruction as related to a range of etiologies, including the different bone donor sites, the alternatives to free flaps (FFs), as well as the contribution of computer‐assisted surgery. Recent progress and the perspectives in bone tissue engineering (BTE) are also discussed.

Results

Osseous FF allows reliable and satisfying outcomes. However, locoregional flap, distraction osteogenesis, or even induced membrane techniques are other potential options in less favorable cases. Obtaining an engineered bone with satisfactory mechanical properties and sufficient vascular supply requires further investigations.

Conclusions

Osseous FF procedure remains the gold standard for segmental mandible reconstruction. BTE strategies offer promising alternatives.

Wound closure by means of free flap and arteriovenous loop: Development of flap autonomy in the long-term follow-up

Free flaps in combination with arterial reconstruction by means of arteriovenous loops or bypass have, meanwhile, been established as a therapeutic option in defect reconstruction for areas without recipient vessels. Our aim was to analyse the long‐term performance, flap autonomy, and the flap perfusion. Patients receiving this combined reconstruction at a single‐centre institution were included. During follow‐up examination, the patency of arterial reconstruction was investigated by duplex ultrasound. Flap micro‐circulation was assessed by laser Doppler flowmetry and white light tissue spectrometry (O2C) as well as by indocyanine green fluorescence angiography. Twenty‐three patients could be clinically followed up. Duplex ultrasound showed, in four cases, arterial pedicle occlusion in spite of vital flap. Comparison of the O2C perfusion parameters between flaps with occluded pedicles and those with intact inflow showed no significant difference (parameters sO2: P = .82; Flow: P = .31). Similar results were obtained by fluorescence angiography; no significant difference could be detected between both groups (parameters Ingress P = .13; Ingressrate P = .54). Combined vascular reconstruction with free tissue transfer is associated with a good long‐term outcome and wound closure. Even after flap transplantation to areas with critical tissue perfusion, the flap can develop autonomy and thus survive after pedicle occlusion.

AV loop free flap: an interdisciplinary approach for perineal and sacral defect reconstruction after radical oncological exenteration and radiation in a colorectal cancer patient

Background

The free flap transfer of a latissimus dorsi flap (LDF) for the closure of sacral wound defects after pelvic exenteration and radiation therapy offers a successful tool of the plastic surgeon. This case report shows the successful coverage using an upstream arterio-venous (AV) loop in combination with an LDF.

Case presentation

We describe the case of a patient who underwent a pelvic exenteration and radiation therapy due to a local recurrence of rectal cancer. The initially used VRAM flap could not ensure a satisfactorily wound closure. An interdisciplinary approach first yielded an AV loop using both greater saphenous veins and was connected to the arteria and vena femoris followed by a free LDF transfer, which was performed 11 days later. The result was an excellent reconstructive and plastic coverage of the sacral wound defect with a well-perfused LDF. The long-term result showed a perfectly integrated flap in the sacral region.

Conclusion

We recommend the free LDF for the coverage of large wound defects in irradiated areas after the failure of VRAM flap. If an AV loop is necessary within the flap transfer, we recommend conducting two procedures to guarantee the perfusion of the AV loop.

Successful free flap salvage upon venous congestion in bilateral breast reconstruction using a venous cross-over bypass: A case report

Abdominal free flaps such as the muscle sparing transverse rectus abdominis myocutaneous (ms-TRAM) or deep inferior epigastric artery perforator (DIEP) flap represent the gold standard in autologous breast reconstruction. We describe a salvage procedure during bilateral free flap breast reconstruction due to insufficient venous drainage using a venous cross-over bypass. A 54-year-old woman with a thrombosis of the left subclavian port-system in the medical history was elected for simultaneous bilateral breast reconstruction with ms-TRAM and DIEP flaps. Intraoperatively, a venous congestion of the DIEP flap, which was connected to the left cranial internal mammary vessels, appeared. In the absence of sufficient ipsilateral venous recipient vessels, we performed a salvage procedure requiring a 15 cm small saphenous vein graft and presternal subcutaneous tunneling. The flap vein was anastomosed end-to-end with the contralateral caudal internal mammary vein using a coupler system. The postoperative course was uneventful and both flaps survived. We describe the cross-over venous emergency bypass as a useful tool in unexpected venous thrombosis during bilateral free flap breast reconstruction.

Reconstruction of Lumbar Spinal Defects: Case Series, Literature Review, and Treatment Algorithm

Background:

Lumbar spinal defects present a distinct challenge for the reconstructive surgeon and are often complicated by previous spinal surgery, the presence of hardware, and prior radiation. There are a variety of reconstructive options described but no clear treatment algorithm for these challenging defects.

Methods:

A literature search was performed to review the described treatment options for lumbar spinal soft-tissue defects. Treatments for myelomeningocele or pressure ulcers were excluded. In addition, a retrospective case review was performed for patients with lumbar defects treated with pedicled superior gluteal artery perforator (SGAP) flap reconstruction.

Results:

A literature review revealed 2,022 articles pertaining to lumbar defect reconstruction, of which 56 met inclusion criteria. These articles described 13 individual reconstructive techniques for this anatomic area. The most commonly described techniques were evaluated and a treatment algorithm designed based on patient and wound characteristics. The clinical course of 5 patients with radiated lumbar spinal defects treated with SGAP flaps is presented.

Conclusions:

There are many treatment options for lumbar spinal defects and treatment should be tailored to the patient and the characteristics of the defect. For large or radiated lumbar wounds, the pedicled SGAP flap is an excellent reconstructive choice, as it has reliable anatomy that is outside the zone of injury, adequate bulk, and minimal donor-site deficits.

Reconstruction of composite defects of the scalp and neurocranium-a treatment algorithm from local flaps to combined AV loop free flap reconstruction

Background

Reconstruction of cranial composite defects, including all layers of the scalp and the neurocranium, poses an interdisciplinary challenge. Especially after multiple previous operations and/or radiation therapy, sufficient reconstruction is often only possible using microsurgical free flap transplantation. The aim of this study was to analyze the therapy of interdisciplinary cases with composite defects including the scalp and neurocranium.

Methods

From 2009 to 2017, 23 patients with 18 free flaps and 10 pedicled/local flaps were analyzed. First choices for free flaps were muscle flaps followed by fasciocutaneous flaps.

Results

Except for four patients, a stable coverage could be reached in the first operation. Three of these patients received a local scalp rotation flap in the first operation and needed an additional free flap because the local flap was no longer sufficient for coverage after wound healing deficiency or tumor relapse. The superficial temporal artery or external carotid artery served as recipient vessels. In special cases, venous grafts or an arteriovenous loop (AV loop) were used as extensions for the recipient vessels.

Conclusions

In summary, an interdisciplinary approach with radical debridement of infected or necrotic tissue and the reconstruction of the dura mater are essential to reach a stable, long-lasting reconstructive result. Based on our experience, free flaps seem to be the first choice for patients after multiple previous operations and/or radiation therapy.