title: Lessons learned reconstructing complex scalp defects using free flaps and a cranioplasty in one stage.
abstract: BACKGROUND
  The purpose of this study was to review our experience in single-stage reconstruction of skull and scalp defects, aiming to highlight pitfalls in our management.
  
  
  METHODS
  We performed a retrospective chart review of all patients who had a single-stage cranioplasty and free-tissue transfer at our institution over the last 10 years. Thirteen patients (9 men and 4 women) with an average age of 66.5 years (range, 34-83 years) were identified. Etiology of the defects included malignancy (n = 7), osteoradionecrosis (n = 3), and infection (n = 3). The size of the bony defect averaged 103.1 cm(2) (range, 12-300 cm(2)). Cranioplasty procedures included reconstruction by methylmethacrylate and titanium mesh (n = 10), methylmethacrylate only (n = 1), or mesh only (n = 2). Free flaps used were anterolateral thigh (n = 10), latissimus dorsi (n = 2), or a rectus flap (n = 1).
  
  
  RESULTS
  Five patients (38%) developed at least 1 complication. These included 2 anastomotic problems that were successfully salvaged, 5 cases of wound dehiscence, and 1 mortality due to a respiratory event. Four patients developed a recurrence, and 2 patients required flap contouring at a second stage. Two patients had further reconstruction using 1 (1 patient) or 2 (1 patient) additional free flaps.
  
  
  CONCLUSIONS
  Given the complexity of these procedures, the high recurrence rate, and the likelihood of complications, methylmethacrylate is contraindicated in 1-stage cranioplasty and soft-tissue reconstruction in high-risk patients. For unfavorable local conditions (eg previous infection, radiotherapy), the surgeon can either postpone the cranioplasty until the soft-tissue reconstruction has healed, or use a nonanatomical titanium mesh alone. The soft-tissue flap should be harvested of larger dimensions than anticipated.
authors.affiliation: Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Afifi
authors.forename: Risal S
authors.initials: RS
authors.lastname: Djohan
authors.forename: Warren
authors.initials: W
authors.lastname: Hammert
authors.forename: Frank A
authors.initials: FA
authors.lastname: Papay
authors.forename: Addison E
authors.initials: AE
authors.lastname: Barnett
authors.forename: James E
authors.initials: JE
authors.lastname: Zins
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000075202:Contraindications; D005260:Female; D006258:Head and Neck Neoplasms / Q000601:surgery; D006801:Humans; D007239:Infections / Q000601:surgery; D008297:Male; D008875:Middle Aged; D010025:Osteoradionecrosis / Q000601:surgery; D019904:Polymethyl Methacrylate / Q000627:therapeutic use; D011183:Postoperative Complications / Q000453:epidemiology; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D012535:Scalp / Q000601:surgery*; D012886:Skull / Q000601:surgery*; D013524:Surgical Flaps; D013526:Surgical Mesh
chemical_list: D019904:Polymethyl Methacrylate