title: Skin flap complications after decompressive craniectomy and cranioplasty: Proposal of classification and treatment options.
abstract: BACKGROUND
  The list of complications reported after decompressive craniectomy (DC) and cranioplasty is progressively increasing. Nonetheless, the exact incidence of these events is still ill-defined. Problems affecting skin flaps after DC and cranioplasty have never been accurately analyzed in papers and their impact on patients' prognosis is largely underestimated.
  
  
  METHODS
  In a 10-year time, we treated by DC 450 patients, 344 of whom underwent cranioplasty, either with autologous bone or artificial implants (hydroxyapatite, polyetheretherketone, titanium, polymethylmethacrylate). Complications involving skin flaps and requiring re-surgery were observed and treated in 38 cases. We classified three main types of lesions: (1) dehiscence, (2) ulcer, and (3) necrosis. In all cases surgical decision making was performed in cooperation with plastic surgeons, to select the best treatment option.
  
  
  RESULTS
  Dehiscence was reported in 28 cases, ulcer in 6, and necrosis in 4. Surgeries included flap re-opening and re-suturing, Z-plasty, rotational, advancement, or free flaps. Treatment complications required further surgical procedures in six patients.
  
  
  CONCLUSIONS
  In our experience, complications involving skin flaps after DC and post-DC cranioplasty cannot be considered a minor event because of their potential to further compromise the yet fragile conditions of these patients. Their management is complex and requires a multidisciplinary approach to get the better results.
authors.affiliation: Department of Neurosurgery, Polytechnic University, Ancona, Marche, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Di Rienzo
authors.affiliation: Department of Plastic and Reconstructive Surgery, Operative Unit of Hand Surgery and Microsurgery, Polytechnic University, Ancona, Marche, Italy.
authors.forename: Pier Paol
authors.initials: PP
authors.lastname: Pangrazi
authors.affiliation: Department of Plastic and Reconstructive Surgery, Operative Unit of Hand Surgery and Microsurgery, Polytechnic University, Ancona, Marche, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Riccio
authors.affiliation: Department of Neurosurgery, Polytechnic University, Ancona, Marche, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Colasanti
authors.affiliation: Department of Neurosurgery, Polytechnic University, Ancona, Marche, Italy.
authors.forename: Ilaria
authors.initials: I
authors.lastname: Ghetti
authors.affiliation: Department of Neurosurgery, Polytechnic University, Ancona, Marche, Italy.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Iacoangeli
keywords: Cranioplasty; decompressive craniectomy; dermal graft; free flap; necrosis; skin flap