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Autologous Immediate Cranioplasty with Vascularized Bone in High Risk Composite Cranial Defects
Justine C. Lee, MD, PhD, Grant M. Kleiber, MD, Aaron T. Pelletier, MD, Russell R. Reid, MD, PhD, Lawrence J. Gottlieb, MD.
University of Chicago Medical Center, Chicago, IL, USA.

PURPOSE: Composite cranial defects in the setting of infection, radiation, or cerebrospinal fluid leak present a significant risk for devastating neurologic sequelae. Although physiologic soft tissue coverage reigns as the first and most crucial goal, immediate soft tissue reconstruction alone results in contour deformity and loss of cerebral protection. Restoration of the skeletal contour in high risk defects frequently fails when alloplastic materials are used. In addition, successful immediate reconstruction of complex high risk cranial defects is rarely reported. We present the largest reported series of autologous immediate cranioplasties in high risk composite cranial defects using vascularized chimeric flaps.
METHODS: Patients with high risk composite cranial defects treated with free flap reconstruction with a vascularized osseous component from 2003-2011 at the University of Chicago Medical Center were retrospectively reviewed. Etiology, microbial spectra, flap type, reoperations, and complications were examined.
RESULTS: Thirteen patients received autologous vascularized cranioplasties between 2003-2011 with a mean age of 53.1 years (range 18-76 years) and a mean followup of 14.1 months (range 34 days-3.9 years). Preoperatively, all patients had infection, radiation, cerebrospinal fluid leak, or a combination thereof. Twelve patients (92.3%) were reoperative cases for recurrent tumor, infection, or both. Tissue biopsy-proven infection was present in 9 patients (69.2%) with calvarial osteomyelitis (6 patients), meningitis (1 patient), both osteomyelitis and meningitis (1 patient), or scalp soft tissue infection only (1 patient). The most common organisms included methicillin resistant Staphylococcus aureus (33%), Pseudomonas aeruginosa (33%), and fungus (33%). Eight patients (61.5%) suffered from malignancy and 5 of these patients (71.4%) received radiation therapy preoperatively. Osseous reconstruction was achieved with vascularized rib in 8 patients (61.5%), vascularized scapula in 2 patients (23.1%), both vascularized rib and vascularized scapula in 2 patients (23.1%), and vascularized ilium in 1 patient (7.7%). In 1 patient, the cranioplasty was supplemented with split calvarial bone graft to optimize the aesthetic contour. Vascularized duraplasty using serratus anterior fascia was performed in 3 patients as part of the chimeric free flap reconstruction. Two patients required arterial anastomotic revision with salvage of both flaps. Four patients required operative debridement of soft tissue necrosis of the distal flaps. There were no flap losses and long term CT evaluation (mean 10.7 months) of 9 patients in our series demonstrated osseous integration of the vascularized bone. All patients had resolution of infection and without removal of vascularized osseous cranioplasties.
CONCLUSION: Soft tissue and skeletal contour are the two critical components of composite cranial reconstruction. We report outcomes of the largest series of one stage immediate cranioplasty consisting of vascularized autologous soft tissue and vascularized bone in high risk composite cranial wounds and suggest its application in the most complex of such defects.


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