Preoperative external tissue expansion for complex cranial reconstructions

Abstract

OBJECTIVE Reconstruction of large solitary cranial defects after multiple craniotomies is challenging because scalp contraction generally requires more than simple subcutaneous undermining to ensure effective and cosmetically appealing closure. In plastic and reconstructive surgery, soft tissue expansion is considered the gold standard for reconstructing scalp defects; however, these techniques are not well known nor are they routinely practiced among neurosurgeons. The authors here describe a simple external tissue expansion technique that is associated with low morbidity and results in high cosmetic satisfaction among patients. METHODS The authors reviewed the medical records of patients with large cranial defects (> 5 cm) following multiple complicated craniotomies who had undergone reconstructive cranioplasty with preoperative tissue expansion using the DermaClose RC device. In addition to gathering data on patient age, sex, primary pathology, number of craniotomies and/or craniectomies, history of radiation therapy, and duration of external scalp tissue expansion, the authors screened patient charts for cerebrospinal fluid (CSF) leak, meningitis, intracranial abscess formation, dermatitis, and patient satisfaction rates. RESULTS The 6 identified patients (5 female, 1 male) had an age range from 36 to 70 years. All patients had complicating factors such as recalcitrant scalp infections after multiple craniotomies or cranial radiation, which led to secondary scalp tissue scarring and retraction. All patients were deemed to be potential candidates for rotational flaps with or without skin grafts. All patients underwent the same preoperative tissue expansion followed by standard cranial bone reconstruction. None of the patients developed CSF leak, meningitis, intracranial abscess, dermatitis, or permanent cosmetic defects. None of the patients required a reoperation. Mean follow-up was 117 days. CONCLUSIONS Preoperative scalp tissue expansion with the DermaClose RC device allows for simple and reliable completion of complicated cranial reconstruction with low morbidity rates and high cosmetic satisfaction among patients.

Multidisciplinary Application of an External Tissue Expander Device to Improve Patient Outcomes: A Critical Review

“…A retrospective, single-center study of six patients underwent definitive cranioplasty with preoperative CETE reported an average 16% increase in scalp surface area (range, 6.6–35.0%), resulting in all patients having adequate tissue for tension-free closure. 37 The DermaClose device was well tolerated, and all patients were satisfied with the cosmetic outcome. No instances of delayed wound closure, infection, dermatitis, or cerebrospinal fluid leakage were reported.…”

“…The device was applied an average of 238 days (standard deviation = ±60 days) after craniectomy, and the surgeon adjusted the device over the following 7–10 days. 37 …”

“…The device was applied an average of 238 days (standard deviation = -60 days) after craniectomy, and the surgeon adjusted the device over the following 7-10 days. 37 A prospective case series reported seven patients managed with CETE for scalp and forehead reconstruction after extirpation of malignant neoplasms. 35 DermaClose was applied intraoperatively and remained for 6-14 days.…”

“…One study reported placing the tension line circumferentially, with plastic tubes to protect the underlying skin. 37 This may be useful in unique circumstances, but generally the authors consider the shoelace technique to be more effective.…”

Scalp Tissue Expansion Above a Custom-Made Hydroxyapatite Cranial Implant to Correct Sequelar Alopecia on a Transposition Flap

“…Other techniques described in the literature to correct sequelar alopecia of the scalp include external tissue expansion 18 and hair grafting in the alopecia zone. 19 In our experience, the outcome of hair grafting is very disappointing in large zones of scar tissue, but this technique can be attempted in small zones, such as enlarged scars.…”