Complex scalp, skull, and dural defect reconstruction using a turnover "tournedos" myocutaneous free flap

The latissimus dorsi flap is one of the most commonly used flaps for calvarial defect reconstruction. In the setting of radiation and/or chronic infection and when skeletal reconstruction of the cranium is not recommended, standard calvarial reconstruction needs to be refined. The standard use of the latissimus dorsi only was associated with potential dead space over the dura, limited skin paddle size, and potential external contour irregularities.

In this study, we present our approach to complex calvarial reconstruction with free tissue transfer without bone grafting while avoiding contour deformities in 1 efficient surgical procedure. We propose the "tournedos" turnover de-epithelialized latissimus dorsi flap, which provides stable dermal and subdermal tissue that will not undergo atrophy over time over the dura. To reach an adequate aesthetic result, we used a uniform, unmeshed, thick split-thickness skin graft over the muscular portion of the tournedos flap. Patients who underwent this procedure, from March 1992 to March 2012, at McGill University Health Center and the Montreal Neurological Institute were included.

Thirty-three complex microsurgical procedures for oncologic calvarial defect reconstructions were performed from March 1992 to March 2012. Among them, 6 patients benefited from the tournedos procedure. The average age was 74 years. Scalp defects sizes ranged from 4 × 10 to 16 × 18 cm (40-288 cm). All latissimus dorsi flap donor sites were closed primarily. Patients kept their donor-site drains for approximately 18 days (±5 days). One patient developed a seroma at the donor site after drain removal that was treated conservatively. All patients were satisfied with their reconstructions, and no secondary procedures were necessary. We present our most recent case with good photographic documentation.

Our approach using the tournedos turnover de-epithelialized free flap provides durable and stable coverage for irradiated and/or previously infected calvarial defects. It is a safe procedure in those challenging complex cases and offers many advantages.