Reconstruction of composite defects of the scalp and neurocranium-a treatment algorithm from local flaps to combined AV loop free flap reconstruction

Abstract

Background: Reconstruction of cranial composite defects, including all layers of the scalp and the neurocranium, poses an interdisciplinary challenge. Especially after multiple previous operations and/or radiation therapy, sufficient reconstruction is often only possible using microsurgical free flap transplantation. The aim of this study was to analyze the therapy of interdisciplinary cases with composite defects including the scalp and neurocranium.

Methods: From 2009 to 2017, 23 patients with 18 free flaps and 10 pedicled/local flaps were analyzed. First choices for free flaps were muscle flaps followed by fasciocutaneous flaps.

Results: Except for four patients, a stable coverage could be reached in the first operation. Three of these patients received a local scalp rotation flap in the first operation and needed an additional free flap because the local flap was no longer sufficient for coverage after wound healing deficiency or tumor relapse. The superficial temporal artery or external carotid artery served as recipient vessels. In special cases, venous grafts or an arteriovenous loop (AV loop) were used as extensions for the recipient vessels.

Conclusions: In summary, an interdisciplinary approach with radical debridement of infected or necrotic tissue and the reconstruction of the dura mater are essential to reach a stable, long-lasting reconstructive result. Based on our experience, free flaps seem to be the first choice for patients after multiple previous operations and/or radiation therapy.

Keywords: Composite defects of the neurocranium; Free flap coverage of the neurocranium; Interdisciplinary reconstruction.

Fig. 1

Preoperative imaging. CT angiography imaging with 3D reconstruction (a). Digital subtraction angiography of the head and neck vessels (b). Intraoperative fluorescence angiography using the SPY Elite Imaging System demonstrating excellent flap perfusion and the superficial temporal vessels (c)

Fig. 2

Clinical case (patient 13): composite defect of the cranium after recurrence of an adenoid cystic carcinoma. Intraoperative situs after tumor resection and dura replacement (a). Clinical aspect 2 years after reconstruction with a latissimus dorsi free flap (recipient vessels: superior thyroid artery and retromandibular vein) (b)

Fig. 3

Clinical case (patient 3): chronic infected composite defect after several operations because of dermatofibrosarcoma protuberans and cranioplasty. 3 weeks after transplantation of a latissimus dorsi free flap (recipient vessels: lingual artery/internal jugular vein) (a, b). 4 weeks after partial excision of the latissimus flap and forehead lift (c). Final aspect after brow lift and blepharoplasty (d)

Fig. 4

Clinical case (patient 10): recurrent abscess and wound healing disorder following meningioma resection. Intraoperative situs demonstrating the rectus abdominis free flap with a perforator-based monitor island (recipient vessels: external carotid artery/retromandibular vein) (a). Clinical aspect approximately 6 months later (b)

Fig. 5

Flow process chart: the reconstructive approach is dependent on the defect components, size as well as the quality of the surrounding soft tissue

Fig. 6

Clinical case (patient 9): chronic infected wound healing disorder following craniocerebral trauma and reconstruction of the cranial vault with a bioglass CAD model (a). Clinical aspect approximately 3 years later after reconstruction with a radial forearm flap (b)