Two-Stage Cranioplasty: Tissue Expansion Directly over the Craniectomy Defect Prior to Cranioplasty

Abstract

Performing a skull reconstruction for a long-term existing large cranium defect usually needs either skin enhancement or skin flaps and cranioplasty. This procedure can be accompanied with aesthetic and functional complications. The presented case describes a 27-year-old man in need of a cranial reconstruction following decompressive craniectomy as treatment for severe traumatic brain injury. Autologous cranioplasty after decompressive craniectomy failed due to bone flap infection. Because of cognitive behavioral problems, a protective helmet needed to be worn in awaiting cranioplasty. The final titanium cranioplasty was placed subsequent to scalp expansion. The expansion was realized by placing a temporary and custom-made polymethylmethacrylate (PMMA) plate over the defect with a tissue expander on top of it, using the existing scar and skull defect. Our reported technique avoids additional skin flap creation and accompanied complications such as additional scalp and bone damage. In cognitive damaged patients who need to wear a helmet constantly, this simple method provides, concurrently, protection of the brain and tissue expansion. We demonstrate a successful novel technical manner to provide scalp enhancement by positioning a temporary PMMA graft over the skull defect and placing the tissue expander on top of it.

The use of free myocutaneous flap and implant reinsertion for staged cranial reconstruction in patients with titanium mesh exposure and large skull defects with soft tissue infection after cranioplasty: Report of 19 cases

“…Some patients had high requirements for aesthetic appearance, and in these patients scalp skin expansion was used before the second‐stage procedure and thus the expanded skin flap transfer could be performed simultaneously with replacement of the implant (Zhai et al, 2019). This allowed correction of the hair‐less skin of the recipient site, and tension‐free closure of the normal scalp (Dos Santos Rubio et al, 2016). However, the use of scalp expansion is limited by the amount and quality of the remaining hair‐bearing tissue.…”

Tissue Expanders in Staged Calvarial Reconstruction: A Systematic Review

“…Regarding type of calvarial implant used in the procedure, 10.7% of patients received an autologous implant, while 89.3% received an alloplastic implant. With respect to type of soft tissue coverage performed, 75.3% of patients received skin expansion only, 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 20% received additional scalp or pericranial flap coverage, 11 18 26 27 28 29 30 31 32 33 34 35 and 4.7% received additional skin grafting 31 33 to provide adequate skin coverage for the defect. Among those patients who received skin grafts, three patients (75%) received pericranial flap coverage as well.…”

Stepwise Reconstruction of a Large, Self-Inflicted Calvarial Defect

“…In addition to recruiting additional surface area for the scalp, expansion also improves the vascularity of the existing scalp tissue before a rotational flap 13 . Prior reports have described scalp expansion using tissue expanders, but primarily involved more conventional defects with single expanders of smaller volume 14–17 …”

“…13 Prior reports have described scalp expansion using tissue expanders, but primarily involved more conventional defects with single expanders of smaller volume. [14][15][16][17] Accurate assessment of surface area expansion is required to recruit an adequate soft tissue envelope, particularly as expansion over the convex calvarium requires more area. When properly executed, the expander can increase surface area by as much as 35% over the expanded region with estimated implant diameters of 2.5 times the defect size.…”