title: Management of the Repeatedly Failed Cranioplasty Following Large Postdecompressive Craniectomy: Establishing the Efficacy of Staged Free Latissimus Dorsi Transfer/Tissue Expansion/Custom Polyetheretherketone Implant Reconstruction.
abstract: BACKGROUND
  Postdecompressive craniotomy defect management following failed prior cranioplastyis challenging. The authors describe a staged technique utilizing free muscle transfer, tissue expansion, and custom polyetheretherketone (PEEK) implants for the management of previously failed cranioplasty sites in patients with complicating local factors.
  
  
  METHODS
  Consecutive patients with previously failed cranioplasties following large decompressive craniectomies underwent reconstruction of skull and soft tissue defects with staged free latissimus muscle transfer, tissue expansion, and placement of custom computer-aided design and modeling PEEK implants with a 'temporalis-plus' modification to minimize temporal hollowing. Implants were placed in a vascularized pocket at the third stage by elevating a plane between the previously transferred latissimus superficial fascia (left on the skin) and muscle (left on the dura/bone). Patients were evaluated postoperatively for cranioplasty durability, aesthetic outcome, and complications.
  
  
  RESULTS
  Six patients with an average of 1.6 previously failed cranioplasties underwent this staged technique. Average age was 33 years. Average defect size was 139 cm. Average time to procedure series completion was 14.9 months. There were no flap failures. One patient had early postoperative incisional dehiscence following PEEK implant placement that was managed by immediate scalp flap readvancement. At 21.9 month average follow-up, there were no cranioplasty failures. Three patients (50%) underwent 4 subsequent refining outpatient procedures. All patients achieved complete coverage of their craniectomy defect site with hear-bearing skin, acceptable head shape, and normalized head contour.
  
  
  CONCLUSIONS
  The described technique resulted in aesthetic, durable craniectomy defect reconstruction with retention of native hear-bearing scalp skin in a challenging patient population.
authors.affiliation: *Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA†Walter Reed National Military Medical Center, Bethesda, MD‡Department of Neurosurgery, University of Washington, Seattle, WA.
authors.forename: Gerhard S
authors.initials: GS
authors.lastname: Mundinger
authors.forename: Kerry
authors.initials: K
authors.lastname: Latham
authors.forename: Jeffery
authors.initials: J
authors.lastname: Friedrich
authors.forename: Otway
authors.initials: O
authors.lastname: Louie
authors.forename: Hakim
authors.initials: H
authors.lastname: Said
authors.forename: Craig
authors.initials: C
authors.lastname: Birgfeld
authors.forename: Richard
authors.initials: R
authors.lastname: Ellenbogen
authors.forename: Richard A
authors.initials: RA
authors.lastname: Hopper
mesh_terms: D000328:Adult; D000368:Aged; D001577:Benzophenones; D017076:Computer-Aided Design; D056424:Decompressive Craniectomy / Q000379:methods; D004955:Esthetics, Dental; D005260:Female; D058752:Free Tissue Flaps; D006801:Humans; D007659:Ketones / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D011092:Polyethylene Glycols / Q000627:therapeutic use*; D011108:Polymers; D011183:Postoperative Complications / Q000209:etiology; D019736:Prostheses and Implants; D012189:Retrospective Studies; D012535:Scalp / Q000601:surgery; D012886:Skull / Q000601:surgery; D064171:Superficial Back Muscles / Q000601:surgery; D013529:Surgical Wound Dehiscence / Q000601:surgery; D015626:Tissue Expansion / Q000379:methods*; D016896:Treatment Outcome
chemical_list: D001577:Benzophenones; D007659:Ketones; D011108:Polymers; C063834:polyetheretherketone; D011092:Polyethylene Glycols