Hemispheric brain volume replacement with free latissimus dorsi flap as first step in skull reconstruction

Abstract

Large skull defects lead to progressive depression deformities, with resulting neurological deficits. Thus, cranioplasty with various materials is considered the first choice in therapy to restore cerebral function. A 31-year-old female presented with a massive left-sided hemispheric substance defect involving bone and brain tissue. Computed tomography showed a substantial convex defect involving the absence of calvarial bone as well as more than half of the left hemisphere of the brain, with a profound midline shift and a compression of the ventricular system. There was a severe problem due to multiple deep-skin ulcerations at the depression margin, prone to skin perforation with a probability of intracranial infection. In a first step, a free myocutaneous latissimus dorsi flap was transplanted for volume replacement of the hemispheric brain defect, and 4 months later, artificial bone substitute was implanted in order to prevent progressive vault depression deformity. Healing was uneventful, and the patient showed definite neurological improvement postoperatively. Free tissue transfer can be a valuable option in addition to cranioplasty in the treatment of large bony defects of the skull. Besides providing stable coverage for the reconstructed bone or its substitute, it can also serve as a volume replacement.

Intracranial Microvascular Free Flaps

“…When the cranial bone graft is lost, differential intracranial and external atmospheric pressure can result in contour deformities, skin ulceration, and cerebral hypoperfusion. 5 The study presented here demonstrates the advantages of free tissue transfer as salvage treatment for large cranial defects, which include (1) obliteration of the dead space, (2) a conduit for immune cells, antibodies, and systemically administered antibiotics, and (3) assistance in restoring volume and contour. Moreover, the availability of safe and reliable reconstructive options may improve the confidence of the extirpative neurosurgeon and the soft tissue and bony debridement by the assisting plastic surgeon.…”

“…4 More recently, Schwabegger et al performed a two-stage myocutaneous microvascular reconstruction of a massive hemispheric defect. 5 Here, we review our experiences with microvascular free-flap (MVFF) salvage of intracranial infections in the setting of large dead space lesions. Three clinical cases are provided to highlight different types of MVFFs that are designed not only to reduce intracranial dead space, but also facilitate alloplastic calvarial reconstruction.…”

Outcomes and Utility of Intracranial Free Tissue Transfer

“…Furthermore, the definition of “intracranial” is often ambiguous. 8-13,15 Publications often exclude whether the cranial vault was anatomically reconstructed following flap placement and there is a large variability in the type of flap used these reports. In both the Largo et al 8 and Schwabegger et al, 12 intracranial flaps occasionally had delayed cranioplasties to reconstruct the calvarial vault over the free tissue transfer.…”

“…Limited case reports and a few small cases series have described the feasibility of free tissue transfers to obliterate intracranial dead space and provide dural coverage, often conducted in the setting of delayed reconstruction of the cranial vault. 8-13 However, the use of a completely intracranial free flap in the setting of a closed cranial vault is not well reported in the literature. 10,11…”

Multidisciplinary approach for reconstruction of cranial defect with polymethyl methacrylate resin reinforced with titanium mesh

“…[123] In addition to compromising the patient's esthetics, these defects also expose a significant area of the brain. [45] Reconstruction of the large cranial vault defects thus still continues to be a challenge to craniofacial surgeons and neurosurgeons. Various types of materials are now available for reconstruction of cranial defects so as to construct the rigid framework of the skull.…”