Lessons Learned Reconstructing Complex Scalp Defects Using Free Flaps and a Cranioplasty in One Stage

A Comparison of Postoperative Outcomes Based on Muscle versus Fasciocutaneous Flaps in Scalp Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

 Scalp reconstruction in plastic and reconstructive surgery often necessitates the transfer of soft-tissue flaps to restore form and function. The critical decision lies in choosing between muscle-containing (MC) and fasciocutaneous (FC) flaps for scalp reconstruction, and while both variants have their merits, flap composition remains a subject of ongoing debate. This scientific discussion aims to explore this contentious issue through a comprehensive meta-analysis, shedding light on the rationale behind the choice of these flaps and the potential impact on clinical outcomes.

METHODS

 A comprehensive systematic review was conducted following PRISMA-P guidelines, encompassing six prominent databases up to the year 2023. Data were collected from studies assessing outcomes of MC and FC flaps for scalp reconstruction. Quality evaluation was performed using ASPS criteria and the ROBINS-I tool. Statistical analysis included descriptive statistics, meta-analysis, sensitivity analysis, and assessment of bias using STATA software.

RESULTS

 The meta-analysis included 28 nonrandomized studies, totaling 594 flaps (MC: 380, FC: 214). MC flaps were significantly larger than FC flaps. There were no significant differences in flap loss, flap necrosis, or wound dehiscence between the two flap types. However, the incidence of venous congestion was significantly higher in FC flaps. Sensitivity analysis confirmed the robustness of results, and publication bias assessment showed no significant evidence of bias.

CONCLUSION

 While both MC and FC flaps offer viable options for scalp reconstruction, the choice should be tailored to individual patient characteristics and defect size. FC flaps may provide advantages such as shorter operative times and reduced morbidity, whereas MC flaps could be preferred for addressing larger defects. Future research should focus on prospective studies and strategies to mitigate venous congestion in FC flaps, enhancing their safety and efficacy in scalp reconstruction.

Establishment and characterization of a rat model of scalp-cranial composite defect for multilayered tissue engineering

Composite cranial defects have individual functional and aesthetic ramifications, as well as societal burden, while posing significant challenges for reconstructive surgeons. Single-stage composite reconstruction of these deformities entail complex surgeries that bear many short- and long-term risks and complications. Current research on composite scalp-cranial defects is sparse and one-dimensional, often focusing solely on bone or skin. Thus, there is an unmet need for a simple, clinically relevant composite defect model in rodents, where there is a challenge in averting healing of the skin component via secondary intention. By utilizing a customizable (3D-printed) wound obturator, the scalp wound can be rendered non-healing for a long period (more than 6 weeks), with the cranial defect patent. The wound obturator shows minimal biotoxicity and will not cause severe endocranium-granulation adhesion. This composite defect model effectively slowed the scalp healing process and preserved the cranial defect, embodying the characteristics of a "chronic composite defect". In parallel, an autologous reconstruction model was established as the positive control. This positive control exhibited reproducible healing of the skin within 3 weeks with variable degrees of osseointegration, consistent with clinical practice. Both models provide a stable platform for subsequent research not only for composite tissue engineering and scaffold design but also for mechanistic studies of composite tissue healing.

Pushing boundaries: Anterolateral thigh free flaps for extensive scalp defects beyond previous limits, leveraging imaging modalities with ultrasound and indocyanine green

BACKGROUND

Scalp defect reconstruction poses considerable challenges, with ongoing debates regarding the most effective strategies. While the latissimus dorsi (LD) flap has traditionally been favored, the anterolateral thigh (ALT) flap has been well described as a versatile alternative for addressing extensive scalp defects. This study underscores the success of scalp reconstruction using ALT flaps, notably pushing the boundaries of previously reported flap sizes. Our approach leverages the use of indocyanine green (ICG) perfusion to guide precise preoperative planning and vascular modification, contributing to improved outcomes in challenging cases.

METHODS

We performed 43 ALT flap reconstructions for scalp defects between 2016 and 2023. We collected patients' demographic and clinical data and evaluated flap size and recipient vessels and additional surgical techniques. Detailed preoperative plans with ultrasound and ICG use for intraoperative plans were performed to find perforators location. The cohort was divided into two, with or without complications on flaps, and analyzed depending on its surgical details.

RESULTS

This study involved 38 patients with extensive scalp defects (mean age: 69.4 ± 11 years) who underwent ALT perforator flap transfers (mean flap size: 230.88 ± 145.6 cm2). There was only one case of unsuccessful flap transfer, and four cases had a few complications. The characteristics of the complication group included a large flap size (303.1 ± 170.9 vs. 214.9 ± 136.6 cm2, P = .211), few perforator numbers without pedicle manipulation, lack of intraoperative indocyanine green administration (75% vs. 25%, P = .607), and the use of superficial temporal vessels as recipient vessels.

CONCLUSIONS

Scalp reconstruction using large ALT free flaps with the aid of imaging modalities facilitates the optimization of surgical techniques, such as pedicle manipulation, perforator numbers, and vein considerations, thereby contributing to successful reconstruction.

Cranioplasty is not required in the reconstruction of small combined scalp and calvarial defects

BACKGROUND

Treatment of scalp malignancies may include the need for craniectomy. The decision to perform cranioplasty is not straightforward and is frequently subjective. The purpose of this study was to assess the clinical outcomes after reconstruction of complex scalp and calvarial defects by comparing patients with and without cranioplasty.

METHODS

Retrospective review of the clinical records of a consecutive series of patients who underwent scalp soft tissue reconstruction after craniectomy for malignancy or osteoradionecrosis between 2014 and 2022 at Royal Melbourne Hospital was conducted. Demographics, previous treatments, surgical details, and post-operative complications were assessed. Traumatic injuries and decompressive craniectomies were excluded. Minimum follow-up of 6 months.

RESULTS

Thirty-seven patients were included in the study. Indications for surgery included skin malignancies, osteoradionecrosis, or both. There was one reconstructive failure (in the non-cranioplasty group). Infection and metalware exposure were common complications in patients who underwent cranioplasty (38.5%). No patient developed neurological symptoms subsequent to craniectomy. One patient needed revision surgery due to esthetic reasons (cranioplasty group). Transposition flaps were associated with more complications and revision procedures.

CONCLUSION

Combined scalp and calvarial defects pose a difficult reconstructive challenge. Stable soft tissue coverage is more reliably achieved with free flap reconstruction. Cranioplasty is not always mandatory and should be reserved for cases with a very large bony defect or when the defect is located in a cosmetically sensitive area.

Refining reconstructive arsenal: Free omental flap with autologous bone graft for complex craniofacial defects after tumor resection and frontal osteoradionecrosis

Skull osteoradionecrosis may happen after radiation therapy for head and neck cancer. Here in, the authors present a case of intracranial carcinoma with osteoradionecrosis and exposure of frontal bone with a large communication between nasal cavity and anterior fossa associated. The patient was successfully treated with resection of the tumor and reconstruction omentum free flap wrapped around autologous bone graft.

Craniectomy with soft tissue reconstruction for locally advanced non-melanoma skin cancer of scalp with calvarial invasion: The Nottingham experience

INTRODUCTION

Locally advanced non-melanoma skin cancer (NMSC) involving the periosteum or calvarium poses a clinical challenge for patients who are unfit for immunotherapy due to medical comorbidities and/or frailty. This case series aims to investigate outcomes for patients undergoing craniectomy and soft tissue reconstruction.

METHOD

Patients who underwent craniectomy and soft tissue reconstruction for invasive NMSC with calvarium or periosteal invasion between 2016 and 2022 were included. Data, including demographics, operative details, and clinical outcomes, were gathered from Nottingham University Hospitals' digital health record and the histopathology electronic database.

RESULT

Eight patients (average age: 78.4 years, 3 females 5 males) with significant comorbidities and varying degrees of periosteal or bone invasion fulfilled the inclusion criteria. Diagnoses included four squamous cell carcinomas, two basal cell carcinomas, and two pleomorphic dermal sarcomas. Five patients had a history of prior incomplete deep margin excision. The median sizes for soft tissue defect, tumor and bone defect size were 51.83 cm2, 34.63 cm2 and 42.25 cm2, respectively. Intraoperative complications included one dural tear. Four patients underwent local flap reconstruction and with split-thickness skin grafting, four patients underwent free flap reconstruction. Adjuvant radiotherapy was administered to three patients. Complications comprised partial graft loss in two and complete graft loss in one. There was partial flap loss in one case. One patient required subsequent parotidectomy due to regional progression before achieving disease control. All patients achieved lasting locoregional disease control (average follow-up 29.7 months).

CONCLUSION

Craniectomy with soft tissue reconstruction proves to be a safe and effective treatment option in advanced NMSC of the scalp in patients unsuitable for immunotherapy due to frailty or medical co-morbidity.

The free anterolateral thigh flap substituted for a pedicled biparietal flap in reconstructing complex frontal defect

Complex scalp defects involving soft and hard tissues pose challenges for plastic surgeons. The solution for each defect must depend on various factors and even the technical development of the infrastructure. We present a case study in which the patient had a significant total frontal defect. The first surgery was a bi-parietal flap as a salvage option to cover the defect. However, aesthetic satisfaction was not achieved. The second surgery used the anterolateral thigh flap to enhance the aesthetic result, and the placement of titanium mesh was an appropriate choice. This case may be an example of how different solutions can lead to variable results and what needs to be considered when dealing with complex scalp defects.

Generative design approach to combine architected Voronoi foams with porous collagen scaffolds to create a tunable composite biomaterial

Regenerative biomaterials for musculoskeletal defects must address multi-scale mechanical challenges. Repairing craniomaxillofacial bone defects, which are often large and irregularly shaped, requires close conformal contact between implant and defect margins to aid healing. While mineralized collagen scaffolds can promote mesenchymal stem cell osteogenic differentiation in vitro and bone formation in vivo, their mechanical performance is insufficient for surgical translation. We report a generative design approach to create scaffold-mesh composites by embedding a macro-scale polymeric Voronoi mesh into the mineralized collagen scaffold. The mechanics of architected foam reinforced composites are defined by a rigorous predictive moduli equation. We show biphasic composites localize strain during loading. Further, planar and 3D mesh-scaffold composites can be rapidly shaped to aid conformal fitting. Voronoi-based composites overcome traditional porosity-mechanics relationship limits while enabling rapid shaping of regenerative implants to conformally fit complex defects unique for individual patients. STATEMENT OF SIGNIFICANCE: Biomaterial strategies for (craniomaxillofacial) bone regeneration are often limited by the size and complex geometry of the defects. Voronoi structures are open-cell foams with tunable mechanical properties which have primarily been used computationally. We describe generative design strategies to create Voronoi foams via 3D-printing then embed them into an osteogenic mineralized collagen scaffold to form a multi-scale composite biomaterial. Voronoi structures have predictable and tailorable moduli, permit stain localization to defined regions of the composite, and permit conformal fitting to effect margins to aid surgical practicality and improve host-biomaterial interactions. Multi-scale composites based on Voronoi foams represent an adaptable design approach to address significant challenges to large-scale bone repair.

Staged Intracranial Free Tissue Transfer and Cranioplasty for a Refractory Nasal-cranial Base Fistula

After a transnasal endoscopic resection of a high-grade adenoid cystic carcinoma that underwent adjuvant chemoradiation, there was delayed recurrence managed by en bloc resection through an open craniofacial approach. Subsequently, the patient developed a chronic nasocranial fistula with secondary infection and bone flap resorption. This resulted in infectious episodes with secondary scalp incisional dehiscence and hardware exposure which required multiple bone debridement procedures, hardware removal, prolonged IV antibiotics, and hyperbaric oxygen treatment. The nasocranial fistula and chronic frontal bone osteomyelitis persisted despite the previous interventions. The patient underwent a frontal bone removal and obliteration of the anterior cranial base fistula with a free vastus lateralis muscle flap. At 4 weeks postoperatively, the intranasal portion of the muscle flap had completely mucosalized. After a 6-week course of IV antibiotics, a secondary cranioplasty using a custom-made poly-ether-ether-ketone implant was performed. The patient remained disease- and infection-free for the duration of follow-up (17 months).

Generative design approach to combine architected Voronoi foams with porous collagen scaffolds to create a tunable composite biomaterial

Regenerative biomaterials for musculoskeletal defects must address multi-scale mechanical challenges. We are developing biomaterials for craniomaxillofacial bone defects that are often large and irregularly shaped. These require close conformal contact between implant and defect margins to aid healing. While we have identified a mineralized collagen scaffold that promotes mesenchymal stem cell osteogenic differentiation in vitro and bone formation in vivo, its mechanical performance is insufficient for surgical translation. We report a generative design approach to create scaffold-mesh composites by embedding a macro-scale polymeric Voronoi mesh into the mineralized collagen scaffold. The mechanics of architected foam reinforced composites are defined by a rigorous predictive moduli equation. We show biphasic composites localize strain during loading. Further, planar and 3D mesh-scaffold composites can be rapidly shaped to aid conformal fitting. Voronoi-based composites overcome traditional porosity-mechanics relationship limits while enabling rapid shaping of regenerative implants to conformally fit complex defects unique for individual patients.

Outcomes of Mesh Cranioplasty in Scalp-Free Tissue Reconstruction: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically review the literature to determine the prevalence and risk of the free flap and postoperative complications in scalp-free tissue reconstruction with synthetic mesh cranioplasty.

DATA SOURCES

Search strategies created with a medical librarian were implemented using multiple databases in May 2021.

REVIEW METHODS

Two reviewers independently performed the review, data extraction, and quality assessment. Cohort studies of patients with scalp-free tissue reconstruction with or without mesh cranioplasty were included. Studies that did not report whether mesh was used or did not separate outcomes by mesh use were excluded. The primary outcomes were free flap failure and postoperative complications. A random-effects model was used for the meta-analysis to estimate prevalence and prevalence ratios (PRs).

RESULTS

A total of 28 studies and 440 cases of scalp-free tissue reconstruction were included. The pooled prevalence of free flap failures and postoperative complications in patients with mesh cranioplasty was estimated at 7% (95% confidence interval [CI], 3%-17%; p = .85, I²  = 0%) and 21% (95% CI, 14%-31%; p = .44, I²  = 0%), respectively. In a subgroup analysis, mesh cranioplasty was not associated with a significantly increased risk of free flap failure or postoperative complications when compared to cases without mesh cranioplasty; pooled PR 1.21 (95% CI, 0.50-2.88; p = .90, I²  = 0%) for free flap failure and PR 1.85 (95% CI, 0.89-3.85; p = .28, I²  = 19) for postoperative complications.

CONCLUSION

Synthetic mesh cranioplasty does not significantly increase the risk of free flap compromise or postoperative complications. A higher prevalence of postoperative recipient site complications was observed in patients with mesh cranioplasty.

Surgical Treatment of Radiation-Induced Late-Onset Scalp Wound in Patients Who Underwent Brain Tumor Surgery: Lessons from a Case Series

Objective. The management of late-onset scalp wounds following irradiation is troublesome, especially in patients with a surgical history of intracranial neoplasms. It, insidiously, starts with wound dehiscence or discharge and never heals spontaneously without appropriate surgical treatment. Nevertheless, definite treatment guidelines have not yet been established. Here, we present our clinical experience with radiation-induced scalp wounds and suggest a surgical principle for their treatment. Patients and Methods. The medical records of 13 patients with brain tumors, who were treated for intractable scalp wounds after irradiation between January 2000 and August 2015, were retrospectively reviewed. All the patients underwent a craniotomy for brain tumor resection. Surgical treatment for a late-onset scalp wound was decided based on the “reconstructive ladder” and according to the status of bone flap and scalp tissue. The patients’ clinical characteristics and information regarding irradiation, surgery, and postoperative complications were recorded. Results. Scalp wounds developed 4.4 years, on average, after the completion of irradiation. Revision operations were performed an average of 2.3 times, and 6 patients (46%) required more than 2 operations. The bone flap was removed in 11 patients (84.6%) to achieve complete wound healing. Among them, 3 patients underwent a cranioplasty using artificial materials, but 2 patients underwent removal due to recurrent wound problems. Conclusions. Postirradiation scalp wounds are difficult to treat and have a high risk of recurrence. If osteoradionecrosis is suspected, the bone flap should be removed. It is important to debride unhealthy tissues aggressively and cover defects with robust tissue.

Microsurgical Scalp Reconstruction: An Overview of the Contemporary Approach

BACKGROUND

 Microsurgical scalp reconstruction has evolved immensely in the last half-century. The core concepts of microsurgical scalp reconstruction have always been to transfer soft tissue of a sufficient quality to within the defect while minimizing donor site morbidity. Refinements in scalp reconstruction consist of both improvement in reducing donor site morbidity and enhancing recipient site contour and balance. Furthermore, technical advancements and the vast experience within our field have allowed for preoperative evaluation of recipient vessels that are more favorable in proximity to the scalp.

METHODS

 In this review, we aim to describe the contemporary approach to microsurgical scalp reconstruction. This is to include the indications of choosing free flaps as well as how to select the ideal flap based on patient-oriented factors. The need for cranioplasty, recipient vessel selection, operative technique, and reoperations is also reviewed. In addition, our considerations and the nuances within each category are also described.

SUMMARY

 Scalp reconstructions involve the fundamental tenants of plastic surgery and demand application of these principles to each case on an individual basis and a successful reconstruction must consider all aspects, with backup options at the ready. Two workhorse free flaps, the anterolateral thigh perforator and latissimus dorsi muscles flaps, serve a primary role in the contemporary approach to microsurgical scalp reconstruction.

CONCLUSION

 We hope this review can lay the foundation for which future plastic surgeons may continue to build and advance the approach to complex microsurgical scalp reconstruction.

Trends and Outcomes of Cranioplasty Alone Versus Single-Stage Composite Scalp and Calvarial Reconstruction

BACKGROUND

Cranioplasty is a critical intervention to restore the calvarium using autologous or alloplastic materials with single-stage composite scalp and calvarial reconstruction reserved for complex cases. This study aims to identify 30-day outcomes in scalp and calvarial reconstruction using the American College of Surgeons National Surgical Quality Improvement Program database.

METHODS

The authors conducted a retrospective analysis of the 2010 to 2018 American College of Surgeons National Surgical Quality Improvement Program database. Adult patients who underwent cranioplasty were identified using current procedural terminology coding and included by exposure type (autologous, alloplastic, composite, or other). Subjects with missing exposure or outcome data were excluded. Primary outcome was 30-day reoperation, whereas secondary outcomes were 30-day unplanned readmission and transfusion. Univariate analysis was completed to assess differences in demographics, comorbidities, and postoperative complications. Multivariable logistic regression was used to control for confounders.

RESULTS

In total, 1719 patients underwent cranioplasty (mean age 54.7 ± 15.3 years, 43.5% male), including 169(9.8%) autologous, 1303(75.8%) alloplastic, 32(1.9%) composite, and 215(12.5%) other procedures. Cranioplasty procedures were associated with 30-day complication and mortality rate of 16.5% and 2.4%, respectively. Composite cranioplasty was associated with decreased 30-day reoperation (adjusted odds ratios 0.11, 95% confidence interval 0.014-0.94, P = 0.044). There was no statistically significant difference in readmission between cranioplasty groups. Alloplastic cranioplasty was associated with decreased odds of postoperative transfusion (adjusted odds ratios 0.47, 95% confidence interval 0.27-0.84, P = 0.01).

CONCLUSIONS

Cranioplasty is an increasingly common procedure. Alloplastic cranioplasty is associated with decreased 30-day transfusion requirement, whereas single-stage composite reconstruction is a viable option and associated with decreased 30-day reoperation with no difference in readmission.

Reconstruction of Large Tissue Defects After the Resection of Brain Tumors Using a Skin Flap With Vascular Pedicle

The reconstruction of large tissue defects after the resection of brain tumors is challenging for every neurosurgeon. The authors describe the benefits of a skin flap with vascular pedicle in the reconstruction of large tissue defects after the resection of brain tumors. In this retrospective analysis, a skin flap with vascular pedicle reconstruction was used in 5 patients who underwent intracranial tumor resection, accompanied by tissue defects, cerebrospinal fluid leakage and scalp infection. The surgical techniques are described, and the outcomes were discussed. The harvested flaps showed well-vascularized healing of the transplanted skin without partial necrosis in all 5 patients. One patient had cerebrospinal rhinorrhea, which was successfully treated by endoscopic repair. Another patient had cerebrospinal fluid leakage, which was successfully treated by continuous lumbar drainage. A skin flap with vascular pedicle is an effective choice for the reconstruction of large tissue defects after the resection of brain tumors.

The Second Free Tissue Transfer After the First Free Flap Loss for a Complex Scalp Reconstruction: Our Strategy to Success With a Staged Approach

ABSTRACT

Scalp reconstruction for a critical neurosurgical patient, as lifesaving efforts continued, can be challenging and a free tissue transfer is often needed to achieve reliable soft tissue coverage. However, the patient's labile perioperative condition may compromise successful reconstruction and perioperative hypotension is one of the major known factors for the failure of free tissue transfer. In this report, the authors encountered such an instance, and present our strategy in overcoming this hurdle toward obtaining successful scalp reconstruction with second free tissue transfer after the first free flap loss. After optimizing the patient's medical condition, the second free tissue transfer was performed in 2 stages with recipient vessel dissection during the first stage and the flap harvest and microvascular anastomoses during the second stage. Our staged approach is warranted to ensure the patient can tolerate the stressor of general anesthesia and to precondition the patient for ultimate successful second free tissue transfer.

Custom surgical management of invasive malignant tumors of the scalp

BACKGROUND

There is no universal management protocol concerning invasive malignant tumors of the scalp with bone and dura mater invasion. The aims of this study were to report and discuss our experience in the management of these forms of tumors.

METHODS

We retrospectively reviewed all consecutive patients of microsurgical scalp reconstruction performed after resection of invasive cutaneous malignancies of the scalp, calvarium, and dura mater from 2017 to 2019, at Pitié-Salpêtrière University Hospital (Paris, France).

RESULTS

Five patients met inclusion criteria. There were three squamous cell carcinomas and two sarcomas. Mean age at surgery was 63.6 years. The sex ratio male/female was 4. Two received radiation prior to resection and two patients had a history of prior scalp tumor surgery. All the patients underwent craniectomy and the mean cranial defect size was 41 cm². Cranioplasty was performed in one patient. Soft tissue coverage was provided by free tissue transfer of latissimus dorsi muscle in all patients. In four patients, split thickness skin graft was performed in a second surgical stage few weeks later. There were no intraoperative complications and no complications into the donor site for the tissue transfer or the skin graft. Two patients had flap necrosis that healed after a new free flap of latissimus dorsi.

CONCLUSIONS

Wide resection with craniectomy and reconstruction with microvascular free tissue transfer provides safe and reliable treatment of recalcitrant invasive scalp skin cancers. The surgical management of these complex patients is a challenge that must be conducted by trained, experienced, and multidisciplinary teams.

Modified Cranioplasty and Latissimus Dorsi Flap for an Exophytic Invasive Brain Tumor

ABSTRACT

We describe the clinical case of a 62-year-old man with an atypical grade II meningioma, invading bone and scalp, and present a step-by-step video description of a modified technique for cranioplasty and scalp reconstruction with latissimus dorsi flap. By using this technique, we aim to minimize the space between the dura and the flap, which would decrease the risk of fluid collections and infections.

Long-term Effect of Cranioplasty on Overlying Scalp Atrophy

Scalp thinning over a cranioplasty can lead to complex wound problems, such as extrusion and infection. However, the details of this process remain unknown. The aim of this study was to describe long-term soft-tissue changes over various cranioplasty materials and to examine risk factors associated with accelerated scalp thinning.

Scalp and Skull Reconstruction in Patients Irradiated for Tinea Capitis in Childhood: The Scalp Exchange Procedure

Background Approximately 70,000 Israelis underwent scalp irradiation for tinea capitis infection during their childhood, as did many other children worldwide. Long-term follow-up data showed that these children had an increased risk of aggressive and multiple nonmelanoma skin cancers, meningiomas, and other malignancies. Resection of these lesions creates a defect of soft tissue, bone, and dura, and requires scalp and skull reconstruction with local or free flaps in the irradiated field.

Methods Sixteen patients with a history of childhood scalp irradiation underwent scalp and skull reconstruction in our department (2000–2018). Data on demographics, oncological status, operative details, and postoperative outcome were retrospectively collected and analyzed.

Results The study group included 11 males and 5 females (average age at surgery, 70 years). The most common lesions were meningiomas (n = 9) and basal cell carcinomas (n = 8), and the most common indication for reconstruction was chronic exposure of deep structures (skull, dura, brain tissue, and titanium mesh; n = 9). Thirteen patients underwent primary free flap reconstruction and three underwent primary local flap reconstruction. Flap failure requiring reoperation occurred in one patient of the free flap reconstruction group (7%) and in all three patients of the local flap reconstruction group.

Conclusion Long-term consequences of childhood depilatory treatments of the scalp by irradiation are now surfacing. Our experience showed that in such cases, surgeons should aim for a more aggressive approach with wide resection and primary free flap reconstruction, and that favorable long-term functional and aesthetic results can safely be achieved using this reconstruction approach.

CSF disturbances and other neurosurgical complications after interdisciplinary reconstructions of large combined scalp and skull deficiencies

Combined scalp and skull deficiency due to malignant scalp tumors or sequelae of intracranial surgery present challenging entities for both neurosurgeons and reconstructive treatment. In complex cases, an interdisciplinary approach is needed between neurosurgeons and cranio-maxillofacial surgeons. We present a considerably large series for which we identify typical complications and pitfalls and provide evidence for the importance of an interdisciplinary algorithm for chronic wound healing complications and malignomas of the scalp and skull. We retrospectively reviewed all patients treated by the department of neurosurgery and cranio-maxillofacial surgery at our hospital for complex scalp deficiencies and malignant scalp tumors affecting the skull between 2006 and 2019, and extracted data on demographics, surgical technique, and perioperative complications. Thirty-seven patients were treated. Most cases were operated simultaneously (n: 32) and 6 cases in a staged procedure. Nineteen patients obtained a free flap for scalp reconstruction, 15 were treated with local axial flaps, and 3 patients underwent full thickness skin graft treatment. Complications occurred in 62% of cases, mostly related to cerebrospinal fluid (CSF) circulation disorders. New cerebrospinal fluid (CSF) disturbances occurred in 8 patients undergoing free flaps and shunt dysfunction occurred in 5 patients undergoing local axial flaps. Four patients died shortly after the surgical procedure (perioperative mortality 10.8%). Combined scalp and skull deficiency present a challenging task. An interdisciplinary treatment helps to prevent severe and specialty-specific complications, such as hydrocephalus. We therefore recommend a close neurological observation after reconstructive treatment with focus on symptoms of CSF disturbances.

Two-stage free flap reconstruction of the scalp and calvaria for large neurosurgical resections

BACKGROUND

Free tissue transfer is occasionally necessary during reconstruction of large scalp and calvarial bone resections. A single-stage procedure is usually performed but if a flap becomes necrotic it exposes brain tissue or the meninges. Performing a two-stage procedure, the surgeon must preserve flap vitality and manage flap complications before resecting a tumor, and therefore before exposing the brain or meninges. We report here the first series of two-stage free-flap reconstruction during major neurosurgical resection.

METHODS

From 2012 to 2018, nine free-flaps were performed to eight patients (61 years-old, on average). Average skull resection was 10.1 cm × 15 cm (range 6-18 cm × 9-24 cm). It was performed in all cases due to large malignant tumors. Resection/reconstruction was performed in all case in a two-step procedure: during the first step, the free-flap was harvested and anastomosed to the cranial site; during the second step, resection was performed and the flap was positioned into the defect to assure coverage.

RESULTS

Average flap size was 11.3 cm × 17.7 cm (range: 7-20 cm × 11-30 cm). Two flap complications occurred after the first stage and one flap did not survive. One patient died before the second stage. Seven patients had the second procedure; no flap complication occurred. All procedures ended in complete wound healing. Follow-up period was 41.5 months on average (range: 10-83 months). Final outcome was total remission for two patients, recurrence for four patients, and two patients died.

CONCLUSIONS

Our data suggest that the two-stage free-flap reconstruction may be employed for major scalp and calvaria resection.

Is Three-Dimensional Virtual Planning in Cranial Reconstruction for Advanced Cutaneous Squamous Cell Carcinoma of the Skull a Feasible Option?

BACKGROUND

Cutaneous squamous cell carcinoma (cSCC) is a common type of malignant skin disorder. An uncommon feature is local bony invasion, as can rarely be seen in lesions on the scalp. The optimal treatment strategy in these rare cases is still under debate.

OBJECTIVE

The aim of this case report is to present a 1-stage three-dimensional planned surgical resection and reconstruction of a cSCC with bony invasion into the scalp and to discuss the alternative options and potential pitfalls.

MATERIALS AND METHODS

A patient diagnosed with rT4N0M0 cSCC of the scalp underwent a cranial resection and reconstruction in 1 stage. With the use of computer-assisted design and computer-assisted manufacturing a patient-specific implant (PSI) of poly (ether ether ketone) was manufactured. After the PSI was inserted, it was covered with a latissimus dorsi muscle and a split-thickness skin graft.

RESULTS

Intraoperatively the resection template generated an accurate resection and accurate and fast placement of the PSI. The reconstruction had a clinical satisfactory esthetic result, but was hampered by the development of a small wound dehiscence was observed over the postoperative course.

CONCLUSION

Three-dimensional planned resection and reconstruction for composite defects of the skull after resection of a cSCC of the scalp with bony invasion may lead to an accurate and predictable resection and accurate and fast placement of the PSI. However, patient specific characteristics should be considered to assess potential risks and benefits before opting for this one-stage treatment strategy.

The Timing of Alloplastic Cranioplasty in the Setting of Previous Osteomyelitis

BACKGROUND

Management of cranial osteomyelitis is challenging and often includes débridement of infected bone and delayed alloplastic cranioplasty. However, the optimal interval between the removal of infected bone and definitive reconstruction remains controversial. The authors investigated the optimal time for definitive reconstruction and factors influencing cranioplasty reinfection.

METHODS

A retrospective review of 111 alloplastic cranioplasties for osteomyelitis between 2002 and 2015 was performed. Patients were divided into four subgroups based on timing of reconstruction: group 1, less than 3 months; group 2, 3 to 6 months; group 3, 6 to 12 months; and group 4, more than 12 months. Multivariate logistic regression was used to calculate the probability of cranioplasty reinfection based on risk factors. Median follow-up was 45.9 months (range, 12.4 to 136.9 months).

RESULTS

The combined reinfection rate was 23.4 percent. The reinfection rate in group 1 was 39.6 percent; group 2, 12.5 percent; group 3, 8.0 percent; and group 4, 0.0 percent (p < 0.001). The mean interval between the infected bone removal and cranioplasty was shorter in patients with reinfection than in patients without reinfection (2.2 ± 3.9 months versus 6.1 ± 8.3 months; p < 0.001). The strongest independent predictors of reinfection were chemotherapy (OR, 10.1; 95 percent CI, 2.9 to 35.2), composite defect requiring scalp reconstruction at the time of cranioplasty (OR, 3.3; 95 percent CI, 1.2 to 8.9), and early reconstruction. Each month of delay in reconstruction reduced the reinfection rate by 10 percent (OR, 0.9 per each month of delay; 95 percent CI, 0.8 to 1.0). Cranioplasty material was not significant.

CONCLUSIONS

Early alloplastic cranioplasty following osteomyelitis carries an unacceptably high risk of reinfection. This risk decreases by 10 percent with each month of delay. The authors' regression model can be used to predict the probability of reinfection for all time periods.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Vacuum-assisted closure (VAC) for craniocerebral wounds in severely injured patients: technical note of a damage control procedure

The management of a craniocerebral wound (CCW) remains challenging, particularly in a severely injured patient. Considering the complexity of the multilayer insult and damage control care in an unstable patient, every procedure performed should promptly benefit the patient. We report an illustrative case of a patient with a gunshot wound to the head that resulted in a CCW for which we applied vacuum-assisted closure (VAC) therapy according to damage control principles. We describe the technical approach and discuss the indications, results and technique by considering the literature available. VAC can be used for CCWs, particularly for large defects in selected patients according to clinical and CT evaluations following immediate resuscitation. In severely injured and unstable patients, VAC aims to delay definitive reconstructive and time-consuming treatment. Interestingly, it appears to be a safe treatment based on the previously described-but not exclusively trauma-cases with no secondary cerebrospinal fluid leakage encountered.

The Role of Free Tissue Transfer in the Management of Chronic Frontal Sinus Osteomyelitis

OBJECTIVES/HYPOTHESIS

Chronic frontal sinus infection is managed with a combination of medical and surgical interventions. Frontal bone osteomyelitis due to recurrent infection following trauma or prior open surgery may require more significant debridement. Free tissue transfer may allow for extensive debridement with replacement of tissue, and definitive eradication of osteomyelitis.

STUDY DESIGN

Retrospective chart review.

METHODS

Patients undergoing free flap obliteration of the frontal sinus for frontal bone osteomyelitis at a single institution were included in the study. Clinical, radiologic, and surgical data were collected. Surgeries before and after free flap obliteration were compared by Wilcoxon signed rank test.

RESULTS

Fifteen patients were identified; however, one patient had less than 6 months of follow-up and was excluded from analysis. Of the remaining 14 patients, mean follow-up duration was 26 months (range, 6-120 months). Mean number of surgeries prior to free flap was 3.7 (range, 1-8 surgeries). Free flap obliteration resolved chronic frontal sinusitis in all patients. Two patients experienced postoperative infection, and the overall complication rate was 29%. Eight patients underwent cranioplasty (six immediate, two delayed) without complication. All patients received planned courses of postoperative antibiotics. A statistically significant decrease in the number of surgeries after free flap obliteration was observed P ≤ .01).

CONCLUSIONS

Extensive debridement followed by free tissue transfer and antibiotics offers a definitive treatment for complicated, recurrent frontal osteomyelitis. Simultaneous cranioplasty provides immediate protective and aesthetic benefit without complication. Consideration should be given for free tissue transfer and cranioplasty earlier in the algorithm for treatment of refractory frontal sinus osteomyelitis.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1497-1504, 2019.

Comparison of Musculocutaneous and Fasciocutaneous Free Flaps for the Reconstruction of the Extensive Composite Scalp and Cranium Defects

Composite scalp and cranium defects, which require microsurgical reconstruction, result from tumor resection, radiation, trauma, severe burn injuries, and rarely vasculitic disorders. In the current study, the authors aim to compare the outcomes of the fasciocutaneous flaps and musculocutaneous free flaps used for the reconstruction of extensive composite scalp and cranium defects. From 2010 to 2017, 21 patients who underwent composite scalp and cranium defect reconstruction with a free flap were retrospectively identified. Eighteen patients had squamous cell carcinoma, 2 patients had meningioma, and 1 patient had Ewing sarcoma. Thirteen musculocutaneous free flaps including latissimus dorsi and vertical rectus abdominis flaps and 9 free fasciocutaneous flaps including radial forearm and anterolateral thigh flaps were used. Only 1 flap loss was encountered. No neurologic impairment in postoperative period was reported. The mean length of stay in the hospital, the duration of surgery, and total volume of blood transfusion for the fasciocutaneous flap group were significantly shorter than those for musculocutaneous flap group. No flap atrophy was reported in fasciocutaneous flap group. Reconstruction of the composite scalp and cranium defects with fasciocutaneous free flaps allows shorter hospitalization, less blood transfusion and less flap atrophy than those of musculocutaneous flaps. To this respect, their usage should be prioritized in such challenging patients.

Strategies for Complex Scalp Reconstruction in Patients With Poor Recipient Vessels

Complex scalp defects with poor recipient vessels represent a challenge for plastic surgeons. In these cases, free flaps are the last resort for solving the problem. The authors present 5 difficult cases with complex large scalp and calvarium defects with unsuitable small recipient vessels for anastomoses. For these cases, the lesser saphenous vein was harvested and used as an interposition graft between the external carotid artery, the jugular vein, and the flap. Latissimus Dorsi, Anterolateral Thigh, and serratus anterior were the flaps used for reconstruction. Cranioplasty was simultaneously performed in 4 cases. The scalp defects varied from 83 to 288 cm. All flaps survived. In 1 case (extended Latissimus Dorsi) there was local infection and wound dehiscence with marginal flap necrosis that required flap readvancement. In conclusion, end-to-end anastomosis to the external carotid artery offers strong outflow through the vein graft and flap. A large vein graft allows good outflow and is more resistant to the pressure of the skin envelope. Anastomosis to large neck vessels (internal or external jugular) facilitates drainage since there is also an aspiration effect due to the venous flow circulation through it.

Bioinspired Collagen Scaffolds in Cranial Bone Regeneration: From Bedside to Bench

Calvarial defects are common reconstructive dilemmas secondary to a variety of etiologies including traumatic brain injury, cerebrovascular disease, oncologic resection, and congenital anomalies. Reconstruction of the calvarium is generally undertaken for the purposes of cerebral protection, contour restoration for psychosocial well-being, and normalization of neurological dysfunction frequently found in patients with massive cranial defects. Current methods for reconstruction using autologous grafts, allogeneic grafts, or alloplastic materials have significant drawbacks that are unique to each material. The combination of wide medical relevance and the need for a better clinical solution render defects of the cranial skeleton an ideal target for development of regenerative strategies focused on calvarial bone. With the improved understanding of the instructive properties of tissue-specific extracellular matrices and the advent of precise nanoscale modulation in materials science, strategies in regenerative medicine have shifted in paradigm. Previously considered to be simple carriers of stem cells and growth factors, increasing evidence exists for differential materials directing lineage specific differentiation of progenitor cells and tissue regeneration. In this work, we review the clinical challenges for calvarial reconstruction, the anatomy and physiology of bone, and extracellular matrix-inspired, collagen-based materials that have been tested for in vivo cranial defect healing.

Reconstruction of a large calvarial traumatic defect using a custom-made porous hydroxyapatite implant covered by a free latissimus dorsi muscle flap in an 11-year-old patient

Reconstruction of complex skull defects requires collaboration between neurosurgeons and plastic surgeons to choose the most appropriate procedure, especially in growing children. The authors describe herein the reconstruction of an extensive traumatic bone and soft tissue defect of the cranial vault in an 11-year-old boy. The size of the defect, quality of the tissues, and patient's initial condition required a 2-stage approach. Ten months after an initial emergency procedure in which lacerated bone and soft tissue were excised, reconstruction was performed. The bone defect, situated on the left frontoparietal region, was 85 cm² and was filled by a custom-made porous hydroxyapatite implant. The quality of the overlying soft tissue did not allow the use of classic local and locoregional coverage techniques. A free latissimus dorsi muscle flap branched on the contralateral superficial temporal pedicle was used and left for secondary healing to take advantage of scar retraction and to minimize alopecia. Stable well-vascularized implant coverage as well as an esthetically pleasing skull shape was achieved. Results in this case suggest that concomitant reconstruction of large calvarial defects by cranioplasty with a custom-made hydroxyapatite implant covered by a free latissimus dorsi muscle flap is a safe and efficient procedure in children, provided that there is no underlying infection of the operative site.

Scalp reconstruction: A 10-year retrospective study

Scalp reconstruction is a challenging task for the reconstructive surgeon. In consideration of the anatomical and cosmetic characteristics, the defect depth and size, an armamentarium of reconstructive procedures ranging from skin grafts over local flaps to free tissue transfer has been described. In this 10-year retrospective study, 85 operative procedures for scalp reconstruction were performed at our department. The underlying entity, defect size/depth, reconstructive procedure, complications, and mean hospital stay were analyzed. In most cases, scalp reconstruction was necessary after oncologic resection (67%) or radiation therapy (16%). A total of 85 operative procedures were performed for scalp reconstruction including local flaps (n = 50), free tissue transfer (n = 18), and skin grafts (n = 17). Regarding the complication rate, we could detect an overall major complication rate of 16.5% with one free flap loss. Briefly, local flaps are an adequate and safe procedure for limited scalp defects. In the case of extensive scalp defects affecting the calvarium, prior multiple surgical interventions and/or radiation, we prefer free tissue transfer.

Esthetic Craniofacial Bony and Skull Base Reconstruction Using Flap Wrapping Technique

For a safe and esthetic skull base reconstruction combined with repair of craniofacial bone defects, the authors introduce the flap wrapping technique in this study. This technique consists of skull base reconstruction using the vastus lateralis muscle of an anterolateral thigh (ALT) free flap, and structural craniofacial bony reconstruction using an autologous calvarial bone graft. The key to this technique is that all of the grafted autologous bone is wrapped with the vascularized fascia of the ALT free flap to protect the grafted bone from infection and exposure. Two anterior skull base tumors combined with craniofacial bony defects were included in this study. The subjects were a man and a woman, aged 18 and 64. Both patients had preoperative proton beam therapy. First, the skull base defect was filled with vastus lateralis muscle, and then structural reconstruction was performed with an autologous bone graft and a fabricated inner layer of calvarial bone, and then the grafted bone was completely wrapped in the vascularized fascia of the ALT free flap. By applying this technique, there was no intracranial infection or grafted bone exposure in these 2 patients postoperatively, even though both patients had preoperative proton beam therapy. Additionally, the vascularized fascia wrapped bone graft could provide a natural contour and prevent collapse of the craniofacial region, and this gives patients a better facial appearance even though they have had skull base surgery.

Osteogenesis on nanoparticulate mineralized collagen scaffolds via autogenous activation of the canonical BMP receptor signaling pathway

Skeletal regenerative medicine frequently incorporates deliverable growth factors to stimulate osteogenesis. However, the cost and side effects secondary to supraphysiologic dosages of growth factors warrant investigation of alternative methods of stimulating osteogenesis for clinical utilization. In this work, we describe growth factor independent osteogenic induction of human mesenchymal stem cells (hMSCs) on a novel nanoparticulate mineralized collagen glycosaminoglycan scaffold (MC-GAG). hMSCs demonstrated elevated osteogenic gene expression and mineralization on MC-GAG with minimal to no effect upon addition of BMP-2 when compared to non-mineralized scaffolds (Col-GAG). To investigate the intracellular pathways responsible for the increase in osteogenesis, we examined the canonical and non-canonical pathways downstream from BMP receptor activation. Constitutive Smad1/5 phosphorylation with nuclear translocation occurred on MC-GAG independent of BMP-2, whereas Smad1/5 phosphorylation depended on BMP-2 stimulation on Col-GAG. When non-canonical BMPR signaling molecules were examined, ERK1/2 phosphorylation was found to be decreased in MC-GAG but elevated in Col-GAG. No differences in Smad2/3 or p38 activation were detected. Collectively, these results demonstrated that MC-GAG scaffolds induce osteogenesis without exogenous BMP-2 addition via endogenous activation of the canonical BMP receptor signaling pathway.

Two-Stage Cranioplasty: Tissue Expansion Directly over the Craniectomy Defect Prior to Cranioplasty

Performing a skull reconstruction for a long-term existing large cranium defect usually needs either skin enhancement or skin flaps and cranioplasty. This procedure can be accompanied with aesthetic and functional complications. The presented case describes a 27-year-old man in need of a cranial reconstruction following decompressive craniectomy as treatment for severe traumatic brain injury. Autologous cranioplasty after decompressive craniectomy failed due to bone flap infection. Because of cognitive behavioral problems, a protective helmet needed to be worn in awaiting cranioplasty. The final titanium cranioplasty was placed subsequent to scalp expansion. The expansion was realized by placing a temporary and custom-made polymethylmethacrylate (PMMA) plate over the defect with a tissue expander on top of it, using the existing scar and skull defect. Our reported technique avoids additional skin flap creation and accompanied complications such as additional scalp and bone damage. In cognitive damaged patients who need to wear a helmet constantly, this simple method provides, concurrently, protection of the brain and tissue expansion. We demonstrate a successful novel technical manner to provide scalp enhancement by positioning a temporary PMMA graft over the skull defect and placing the tissue expander on top of it.

Lessons Learned in Scalp Reconstruction and Tailoring Free Tissue Transfer in the Elderly: A Case Series and Literature Review

This article aims to demonstrate an individualized approach to an elderly patient requiring scalp reconstruction, to describe the methodology in flap selection, lessons learned, and report outcomes. A retrospective review of a single surgeon's experience of scalp reconstruction (E. D. R.) using free tissue transfer from 2005 to 2011, in patients older than 70 years, was completed. A total of eight patients met the inclusion criteria, five males and three females, with a mean age of 80.4 years (range, 73-92). Free tissue transfer achieved 100% soft tissue coverage. Six of the eight patients required cranioplasty. The mean size calvarial defect was 92 cm(2) (range, 35-285 cm(2)). The mean flap size was 117.6 cm(2) (range, 42-285 cm(2)). Free flaps included three ulnar, three anterolateral thigh, one latissimus dorsi, and one thoracodorsal perforator flap. The mean follow-up time was 18.4 months (range, 3-46 months). Donor site morbidity was minimal. Mortality was 0%. Immediate flap failure was 0%. Other complications occurred in six of the eight patients. Mean revisionary procedures were 1.25 procedures per patient. It was concluded that chronological age does not increase mortality or catastrophic flap complications; however, morbidity is increased in the elderly and revisionary surgery is likely.

Outcomes of calvarial reconstruction in cancer patients

BACKGROUND

Limited data exist on outcomes of calvarial reconstruction in cancer patients, including the relative efficacy of various cranioplasty materials, and risk factors for complications.

METHODS

A retrospective review was performed of cancer patients who underwent calvarial reconstruction over a 12-year period.

RESULTS

A total of 269 patients underwent 289 calvarial reconstructions. Materials used for cranioplasty included titanium mesh (49.8 percent), methylmethacrylate (16.3 percent), porous polyethylene (4.8 percent), polyetheretherketone (4.5 percent), calcium phosphate cement (3.8 percent), autologous bone grafts (2.1 percent), or a combination of materials (18.3 percent). Perioperative (≤30 days after surgery) complications occurred in 42 cases (14.5 percent), of which 29 (10.0 percent) were at the recipient site, most commonly infection (2.8 percent) and cerebrospinal fluid leak (2.4 percent). Risk factors for perioperative complications included radiation therapy (p = 0.012), prior surgery (p = 0.003), and prior infection (p = 0.014). Late recipient-site complications (>30 days after surgery) occurred in 20 cases (6.9 percent), including infection (3.8 percent) and wound dehiscence (3.1 percent), and for which radiation therapy was identified as a risk factor (p = 0.011). The use of calcium phosphate cement in combination with titanium mesh was associated with a higher long-term complication rate (p < 0.001). Twenty-five cases (8.7 percent) required cranioplasty removal, with infection and dehiscence being risk factors for implant loss (p < 0.001 for both).

CONCLUSIONS

Alloplastic cranioplasty is effective in cancer patients with calvarial defects. Commonly used materials have similar complication profiles, with the possible exception of calcium phosphate cement, which is associated with a higher rate of complications when combined with titanium mesh and used to reconstruct larger defects.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Autologous immediate cranioplasty with vascularized bone in high-risk composite cranial defects

BACKGROUND

Composite cranial defects in the setting of infection, irradiation, or cerebrospinal fluid leak present a significant risk for devastating neurologic sequelae. Such defects require soft-tissue coverage and skeletal reconstruction that can withstand the hostile environment of a precarious wound.

METHODS

Patients with high-risk composite cranial defects treated with free flap reconstruction containing a vascularized osseous component from 2003 to 2012 were reviewed retrospectively.

RESULTS

Fourteen patients received autologous vascularized cranioplasties between 2003 and 2012 with a mean age of 55.7 years and a mean follow-up of 14.1 months. Preoperatively, all patients had infection, irradiation, cerebrospinal fluid leak, or a combination thereof. Thirteen patients (92.9 percent) were reoperative cases for recurrent tumor, infection, or both. Six patients (42.9 percent) failed previous reconstructive procedures. Tissue biopsy-proven infection was present in 10 patients (71.4 percent) with calvarial osteomyelitis, both osteomyelitis and meningitis, or scalp soft-tissue infection only. Nine patients (64.3 percent) suffered from malignancy and six of these patients were irradiated preoperatively. Cranioplasty was achieved as part of a chimeric free flap using rib, scapula, both rib and scapula, or ilium. Vascularized duraplasty using serratus anterior fascia as a component of the chimeric flap was performed in three patients. No flap losses occurred and all patients had resolution of infection.

CONCLUSIONS

Soft-tissue and skeletal restoration are the two critical components of composite cranial reconstruction. The authors report outcomes of the largest series of one-stage immediate cranioplasty consisting of autologous soft tissue and vascularized bone in high-risk composite cranial wounds and suggest its application in defects associated with compromised wound beds.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Aesthetic refinement of secondary cranioplasty using methyl methacrylate bone cements

BACKGROUND

Cranioplasty using alternate alloplastic bone substitutes instead of autologous bone grafting is inevitable in the clinical field. The authors present their experiences with cranial reshaping using methyl methacrylate (MMA) and describe technical tips that are keys to a successful procedure.

METHODS

A retrospective chart review of patients who underwent cranioplasty with MMA between April 2007 and July 2010 was performed. For 20 patients, MMA was used for cranioplasty after craniofacial trauma (n = 16), tumor resection (n = 2), and a vascular procedure (n = 2). The patients were divided into two groups. In group 1, MMA was used in full-thickness inlay fashion (n = 3), and in group 2, MMA was applied in partial-thickness onlay fashion (n = 17). The locations of reconstruction included the frontotemporal region (n = 5), the frontoparietotemporal region (n = 5), the frontal region (n = 9), and the vertex region (n = 1). The size of cranioplasty varied from 30 to 144 cm(2).

RESULTS

The amount of MMA used ranged from 20 to 70 g. This biomaterial was applied without difficulty, and no intraoperative complications were linked to the applied material. The patients were followed for 6 months to 4 years (mean, 2 years) after MMA implantation. None of the patients showed any evidence of implant infection, exposure, or extrusion. Moreover, the construct appeared to be structurally stable over time in all the patients.

CONCLUSIONS

Methyl methacrylate is a useful adjunct for treating deficiencies of the cranial skeleton. It provides rapid and reliable correction of bony defects and contour deformities. Although MMA is alloplastic, appropriate surgical procedures can avoid problems such as infection and extrusion. An acceptable overlying soft tissue envelope should be maintained together with minimal contamination of the operative site.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Vacuum-assisted closure for complex cranial wounds involving the loss of dura mater

The aim in this study was to describe the safety and efficacy of vacuum-assisted closure (VAC) in patients with complex cranial wounds with extensive scalp, bone, and dural defects who were not candidates for immediate free tissue transfer. Five patients (4 men and 1 woman) ages 24–73 years with complex cranial wounds were treated with VAC at Wake Forest Baptist Medical Center. Etiologies included trauma, squamous cell carcinoma, and malignant meningioma. Cutaneous wound defects measured as large as 15 cm in diameter. Four of the 5 patients had open skull defects with concomitant dural defects, and 1 patient had dural dehiscence. After surgical debridement, all 5 patients were treated with the direct application of a VAC device to a reapproximated dura mater (1 patient), to a pericranial flap (1 patient), or to a regenerative tissue matrix overlying CNS tissue (3 patients). In all cases involving open cranial wounds, the VAC device promoted granulation tissue formation over the dural substitute, prevented CSF leakage, and kept the wounds free from local infection. The duration of VAC therapy ranged from 16 to 91 days. Although VAC therapy was intended as a temporary measure until these patients could be stabilized for larger tissue transfer procedures or they succumbed to their primary pathology, 1 patient had a successful skin graft following VAC therapy. Hydrocephalus requiring shunt placement developed in 2 patients during VAC therapy. The VAC dressings applied to a tissue matrix or other barrier over brain tissue in extensive cranial wounds are safe and well tolerated, providing a functional barrier and preventing infection.

Free flap reconstruction for complex scalp and forehead defects with associated full-thickness calvarial bone resections

Extensive defects of the scalp and forehead associated with calvarial bone resections demand complex reconstructions. Free flaps offer vascularized tissue of excellent quality and quantity. We report six patients with extensive scalp and forehead defects associated with calvarial bone resections reconstructed with free flaps. Five patients also required a cranioplasty. The flaps used were two anterolateral thigh flaps, one vastus lateralis flap, one myocutaneous latissimus dorsi flap, one latissimus dorsi flap, and one radial forearm flap. All flaps survived with no partial necrosis. There were no donor site complications. One patient presented an exposure of the alloplastic material used for cranioplasty. We strongly recommend the use of free flaps for this kind of reconstruction.