Staged reconstruction of a chronically infected large skull defect using free tissue transfer and a patient-specific polyetheretherketone implant

Abstract

Reconstructions of extensive composite scalp and cranial defects are challenging due to high incidence of postoperative infection and reconstruction failure. In such cases, cranial reconstruction and vascularized soft tissue coverage are required. However, optimal reconstruction timing and material for cranioplasty are not yet determined. Herein, we present a large skull defect with a chronically infected wound that was not improved by repeated debridement and antibiotic treatment for 3 months. It was successfully treated with anterolateral thigh (ALT) free flap transfer for wound salvage and delayed cranioplasty with a patient-specific polyetheretherketone implant. To reduce infection risk, we performed the cranioplasty 1 year after the infection had resolved. In the meantime, depression of ALT flap at the skull defect site was observed, and the midline shift to the contralateral side was reported in a brain computed tomography (CT) scan, but no evidence of neurologic deterioration was found. After the surgery, sufficient cerebral expansion without noticeable dead-space was confirmed in a follow-up CT scan, and there was no complication over the 1-year follow-up period.

Keywords: Cranioplasty; Free tissue flap; Polyetheretherketone.

Fig. 1.

Preoperative photograph of the skull and scalp defect on the right temporo-parietal area. The artificial dura is exposed. Klebsiella pneumoniae, methicillin-resistant Staphylococcus aureus, and Acinetobacter baumannii were identified in the wound culture.

Fig. 2.

(A) Intraoperative photograph after debridement and duroplasty. (B) The defect is covered with a latissimus dorsi myocutaneous free flap and split-thickness skin graft.

Fig. 3.

Depression of the anterolateral thigh flap on the temporoparietal cranial defect.

Fig. 4.

Planning computed tomography image and design of the patient-specific implant (PSI). Shifting of brain parenchyma and decrease in ventricular size was observed. The irregular thickness of the reconstructed scalp flap was considered to achieve a smooth and concave head shape after cranioplasty.

Fig. 5.

Intraoperative photograph after dura tenting suture and fixation of the patient-specific polyetheretherketone implant.

Fig. 6.

Computed tomography scan at 1 week after the cranioplasty.

Fig. 7.

Photograph of the patient at the 1-year follow-up.