Lessons learned reconstructing complex scalp defects using free flaps and a cranioplasty in one stage

Area of Science:

• Plastic Surgery
• Craniofacial Reconstruction
• Microsurgery

Background:

• Single-stage reconstruction of skull and scalp defects presents management challenges.
• Reviewing institutional experience highlights potential pitfalls in these complex procedures.

Purpose of the Study:

• To review institutional experience with single-stage cranioplasty and free-tissue transfer.
• To identify and highlight management pitfalls in skull and scalp defect reconstruction.

Main Methods:

• Retrospective chart review of 13 patients undergoing single-stage cranioplasty and free-tissue transfer over 10 years.
• Defect etiologies included malignancy, osteoradionecrosis, and infection.
• Reconstruction utilized methylmethacrylate, titanium mesh, or both, with anterolateral thigh, latissimus dorsi, or rectus flaps.

Main Results:

• 38% of patients experienced complications, including anastomotic issues, wound dehiscence, and one mortality.
• Four patients had defect recurrence, and two required secondary flap contouring.
• Two patients needed additional free flaps for further reconstruction.

Conclusions:

• Methylmethacrylate is contraindicated for single-stage cranioplasty in high-risk patients due to high complication and recurrence rates.
• For unfavorable local conditions, consider staged reconstruction or titanium mesh alone.
• Harvest larger soft-tissue flaps than initially anticipated to ensure adequate coverage.