Abstract
When alloplastic cranial implants present some complications, the classical strategy has been to remove them. Removal of the custom-made artificial skull, however, requires a second cranioplasty. We describe two representative cases of intractable scalp ulcer over the cranial prosthesis treated by vascularized calvarial flap without totally removing the implant. One patient had a previous ceramic implantation and the other a large titanium mesh, whose precedent local skin flap methods to treat the scalp ulcer were not successful. After the implant beneath the scalp ulcer was partially removed, a vascularized calvarial flap was raised. The calvarial graft of the flap was utilized to repair the implant defect and the galeal part of the flap was utilized to patch the ulcer from the reverse side. The clinical outcome is excellent. Our experience clearly demonstrated that the vascularized calvarial flap contributes to maintain a sufficient blood supply for the calvarial graft, reduces the risk of infection and provides a new tissue bed for the healing of a skin ulcer over a cranial implant for this difficult-to-treat cranial reconstruction.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Ali F, Halim AS, Najihah SZ, Ibrahim M, Abdullah J (2005) Combination of vascularized outer-table calvarial bone graft based on the superficial temporal vessels and allomatrix for the repair of an orbito-frontal blow-out fracture in a child. J Craniomaxillofac Surg 33:326–330
Auguste KI, McDermott MW (2006) Salvage of infected craniotomy bone flaps with the wash-in, wash-out indwelling antibiotic irrigation system. Technical note and case series of 12 patients. J Neurosurg 105:640–644
Casanova R, Cavalcante D, Grotting JC, Vasconez LO, Psillakis JM (1986) Anatomic basis for vascularized outer-table calvarial bone flaps. Plast Reconstr Surg 78:300–308
Cutting CB, McCarthy JG, Berenstein A (1984) Blood supply of the upper craniofacial skeleton: the search for composite calvarial bone flaps. Plast Reconstr Surg 74:603–610
Hasegawa M, Torii S, Fukuta K, Saito K (1995) Reconstruction of the anterior cranial base with the galeal frontalis myofascial flap and the vascularized outer table calvarial bone graft. Neurosurgery 36:725–729 discussion 729–731
Hayward RD (1999) Cranioplasty: don't forget the patient's own bone is cheaper than titanium. Br J Neurosurg 13:490–491
Heller F, Hsu CM, Chuang CC, Wei KC, Wei FC (2004) Anterolateral thigh fasciocutaneous flap for simultaneous reconstruction of refractory scalp and dural defects. Report of two cases. J Neurosurg 100:1094–1097
Matic D, Phillips JH (2002) A contraindication for the use of hydroxyapatite cement in the pediatric population. Plast Reconstr Surg 110:1–5
Okuda T, Akimoto M, Kuroda S, Hyakusoku H (2003) Three cases of skin necrosis in frontal-temporal region after neurosurgical procedure. Journal of the Japan Society of Cranio-Maxillo-Facial Surgery 19:261–266
Ozerdem OR, Sen O, Anlatici R, Erdogan B, Aydin V (2002) Osteogaleal flaps in pediatric cranioplasty. Ann Plast Surg 49:127–132
Psillakis JM, Grotting JC, Casanova R (1986) Vascularized outer-table calvarial bone flaps. Plast Reconstr Surg 78:309–317
Takumi I, Akimoto M (2008) Catcher's mask cranioplasty for extensive cranial defects in children with an open head trauma: a novel application of partial cranioplasty. Childs Nerv Syst 24:927–932
Takumi I, Akimoto M (2009) Advantage of Catcher’s mask cranioplasty for post-surgical infectious skin trouble. Childs Nerv Syst 25:493–495. doi:101007/s00381-008-0793-3
Yano H, Tanaka K, Matsuo T, Tsuda M, Akita S, Hirano A (2006) Cranioplasty with auto-purified bone flap after infection. J Craniofac Surg 17:1076–1079
Conflict of interest
None
Author information
Authors and Affiliations
Corresponding author
Additional information
Comments
Isao Date, Okayama, Japan
Takumi and Akimoto reported nicely their method to repair intractable scalp ulcers associated with cranial implants using a vascularized calvarial flap. Most commonly, cranial implants will be totally removed to cure scalp ulcers but the authors' new idea could induce cure of ulcers without removing all implants. The importance of "vascularized" tissue has long been mentioned when this type of reconstruction is considered. The authors' idea is to remove the part of implants beneath the ulcer and reconstruct that area with vascularized calvarial flap (the outer layer of the calvarium). By using two schematic drawings which are compatible with intraoperative photo, the readers can realize clearly how to perform this procedure.
This paper is a practical paper and the authors' surgical procedure is worthwhile to try when one encounters a similar case.
Louis J. Kim, Seattle, Washington, USA
Takumi and Akimoto describe an elegant treatment strategy for complex wound repairs involving intractable scalp ulcers over prior craniotomy sites. Fortunately, this is a rare problem in neurosurgery. While their technique may be well-known to reconstructive plastic surgeons, it is worthwhile for neurosurgeons to be aware of their adaptation of the technique. Osteoplastic cranial procedures have lost some popularity in recent times; however, these case examples underscore their continued usefulness in the skill sets of cranial surgeons.
J. Humberto Tapia-Pérez, San Luis Potosí, México
The technique described by Tamuki et al. is an interesting approach to physiopathological aspects regarding the origin of intractable scalp ulcers. Healing requires an optimal vascular supply and through this surgical procedure the goal was achieved. The trend for implanting prosthesis, as stated by the authors, could be linked to a relative easiness; whether it is compared with a rib or calvarial graft. Despite the results often are not optimal. Moreover, the prosthesis could contribute to stimulate more inflammation and with this increase the vascular deterioration. The one-stage technique seems to be easier to perform, reduces, or eliminates the necessity of removing prosthesis that could be harmful for tissue, and covers the main problem of vascular deficits. The results appear good, inclusive from aesthetical view. From an economical point of view, it is possible to reduce the number of surgeries and costs directly generated by prosthesis, issue in special important for poor countries. New studies are warranted with application of the one-stage reconstruction, inclusive as initial therapy.
This work was supported by Mitsui Life Social Welfare Foundation.
Rights and permissions
About this article
Cite this article
Takumi, I., Akimoto, M. One-stage reconstruction using a vascularized calvarial flap for intractable scalp ulcers in relation with cranial implants without removing the whole prosthesis. Neurosurg Rev 32, 363–368 (2009). https://doi.org/10.1007/s10143-009-0196-2
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10143-009-0196-2