Hemispheric brain volume replacement with free latissimus dorsi flap as first step in skull reconstruction

Large skull defects lead to progressive depression deformities, with resulting neurological deficits. Thus, cranioplasty with various materials is considered the first choice in therapy to restore cerebral function. A 31-year-old female presented with a massive left-sided hemispheric substance defect involving bone and brain tissue. Computed tomography showed a substantial convex defect involving the absence of calvarial bone as well as more than half of the left hemisphere of the brain, with a profound midline shift and a compression of the ventricular system. There was a severe problem due to multiple deep-skin ulcerations at the depression margin, prone to skin perforation with a probability of intracranial infection. In a first step, a free myocutaneous latissimus dorsi flap was transplanted for volume replacement of the hemispheric brain defect, and 4 months later, artificial bone substitute was implanted in order to prevent progressive vault depression deformity. Healing was uneventful, and the patient showed definite neurological improvement postoperatively. Free tissue transfer can be a valuable option in addition to cranioplasty in the treatment of large bony defects of the skull. Besides providing stable coverage for the reconstructed bone or its substitute, it can also serve as a volume replacement.