Full-Thickness Skin Grafting for Local Defect Coverage Following Scalp Adjacent Tissue Transfer in the Setting of Cranioplasty

Abstract

Introduction: Numerous techniques have been described to overcome scalp deficiency and high-tension closure at time of cranioplasty. However, there is an existing controversy, over when and if a free flap is needed during complex skull reconstruction (ie, cranioplasty). As such the authors present here our experience using full-thickness skin grafts (FTSGs) to cover local defects following scalp adjacent tissue transfer in the setting of cranioplasty. Methods: By way of an institutional review board-approved database, the authors identified patients treated over a 3-year period spanning January 2015 to December 2017, who underwent scalp reconstruction using the technique presented here. Patient demographics, clinical characteristics, technical details, outcomes, and long-term follow up were statistically analyzed for the purpose of this study. Results: Thirty-three patients, who underwent combined cranioplasty and scalp reconstruction using an FTSG for local donor site coverage, were identified. Twenty-five (75%) patients were considered to have “high complexity” scalp defects prior to reconstruction. Of them, 12 patients (36%) were large-sized and 20 (60%) medium-sized; 21 (64%) grafts were inset over vascularized muscle or pericranium while the remaining grafts were placed over bare calvarial bone. In total, the authors found 94% (31/33) success for all FTSGs in this cohort. Two of the skin grafts failed due to unsuccessful take. Owing to the high rate of success in this series, none of the patient's risk factors were found to correlate with graft failure. In addition, the success rate did not differ whether the graft was placed over bone verses over vascularized muscle/pericranium. Conclusion: In contrary to previous studies that have reported inconsistent success with full-thickness skin grafting in this setting, the authors present a simple technique with consistent results—as compared to other more complex reconstructive methods—even in the setting of highly complex scalp reconstruction and simultaneous cranioplasty.

Stepwise Reconstruction of a Large, Self-Inflicted Calvarial Defect

“…Designing the donor sites to be distant from and posterior to the cranial implant can minimize both the possibility of contamination of the implant and the visibility of the non-hair-bearing graft. 11 Important benefits of tissue expansion, however, include improved aesthetic appearance with hair-bearing tissue that matches the remaining scalp contour, color, texture, and thickness. 12 In addition to recruiting additional surface area for the scalp, expansion also improves the vascularity of the existing scalp tissue before a rotational flap.…”

Extensive Convexity Flattening of a Synthetic Skull Implant the Overcome Major Scalp Deficiency After Multiple Craniotomies

“… 19 In addition, complex secondary reconstructive procedures without a plastic surgeon might increase the risk of complications and subsequent infections. 20 In the setting of highly complex scalp reconstruction with simultaneous cranioplasty, Wolff et al 21 reported on a simple technique using full-thickness skin grafting to cover local defects in order to obtain scalp closure in a tension free manner. This technique represents a valuable option improving aesthetic outcome, which was less favorable in our patient.…”

“… 6 Although the posterior auricular artery bridging flap is vascularized by horizontal and vertical branches of the contralateral occipital artery, with their supply preoperatively confirmed by Doppler flowmetry, the incision for the bridging flap transected the occipital vessels thus increasing the risk of ischemia and subsequent infections. 19 20 21 For tension-free skin coverage, Mikami et al 16 reported on a total of 25 cranioplasty patients with minor flattening the curvature achieved skin release with acceptable cosmetic outcome. Unlike in the patient presented here, the major restraints of the extensive skin scarring, along with existing bridging flap forced us to consider an extensive flattening of the PEEK cranioplasty, in spite of obviously diminished cosmetic outcome.…”

Soft tissue coverage of cranial defects: an update

“…When pericranium cannot be left intact, a large pericranial flap or sub-galeal fascial flap can be rotated into the defect and a skin graft placed over this in the same procedure [5,22,23] . Alternatively, the outer cortex of the skull can be burred down, exposing blood supply for the grafted skin within the diploic space [24] . In this case, better outcomes have been reported with the use of full-thickness skin grafts, although this is controversial [25] .…”