Lessons learned reconstructing complex scalp defects using free flaps and a cranioplasty in one stage.
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.
Afifi
Ahmed
A
Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA.
Djohan
Risal S
RS
Hammert
Warren
W
Papay
Frank A
FA
Barnett
Addison E
AE
Zins
James E
JE
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
D019904:Polymethyl Methacrylate