RIPER reduced IL-6 and IL-12p40 secretion during reperfusion of porcine musculocutaneous flaps, when compared with hypothermic ischemic flaps and normothermic ischemic flaps without RIPER. © 2016 Wiley Periodicals, Inc. Microsurgery 37:148-155, 2017.

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Free flaps are applied to scalp and calvarial defects when local flap coverage is inadequate. Commonly used flaps are the free latissimus dorsi muscle flap and the free anterolateral thigh fasciocutaneous flap. 1,2Flap coverage of nonfrontal scalp regions is at risk of flap and pedicle compression, when patients are supine. This results in difficult patient positioning with risk of partial or complete flap necrosis. Hence, we have introduced perioperative halo ring placement on the reconstructed scalps, to avoid pressure on the flaps in the early postoperative weeks.The PMT Model 1200 Series Halo (PMT Corporation, Chanhassen, MN), medium size, was applied reverted with the opening anteriorly. The ring is fixated on the skull with usually four titanium pins. Three consecutive cases are presented below with perioperative halo ring placement in microsurgical scalp reconstruction. Case 1A 68-year-old man was admitted with nonmalignant chronic scalp ulcerations and cranial bone necrosis in the left parietal and occipital region. In childhood, the patient had been exposed to an unintended overdose of radiotherapy for tinea capitis. Affected scalp and skull were excised leaving a 10 Â 14 cm defect with dura preserved. The defect was covered with a free latissimus dorsi muscle flap anastomosed to the right facial artery and vein with vein grafting. Split skin grafts were placed on the muscle flap. Postoperatively, a distal part of the flap in the occipital region was lost due to pressure necrosis, from when the patient had been lying down or sitting, resulting in cranial bone exposure (►Fig. 1).Thirty-five days later, the exposed bone was successfully covered with a free rectus abdominis flap anastomosed to the left facial artery and vein with two vein grafts, and split skin grafts were placed on the muscle. A halo ring was placed perioperatively to avoid pressure on the flap and pedicle. After 17 days, the halo ring was removed and both muscle flaps healed without further complications. Case 2A 45-year-old man was referred with chronic open wounds and dural defects in the occipital region, following several resections of radiation-induced meningioma (►Fig. 2). After a failed procedure with a rotation flap, the defect was successfully covered with a free latissimus dorsi muscle flap and split skin grafts. The thoracodorsal vessels were anastomosed to the right superficial temporal artery and vein, and in the end of the procedure a halo ring was applied. Twenty-seven days postsurgery, the halo ring was removed. Six weeks postsurgery, the flap had healed without complications (►Fig. 3). Case 3A 67-year-old woman was admitted with recurrent malignant schwannoma in the right parietal scalp region. The patient had previously undergone nonradical tumor resection and reconstruction with a cervical rotation flap, a free radial forearm flap, and a free latissimus dorsi flap at another center. Scalp tissue, bone, and dura were excised in a region posterior to the right ear from the superior sagittal sinus to the transverse sinus....