- Email: [email protected]
Cranial reconstruction after a post-craniotomy empyema
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e131ee135
CASE REPORT
Cranial reconstruction after a post-craniotomy empyema J-F. Chabas a,*, C. Dellavolpe a, Y. Riah a, T. Bron a, Y. Reynier b, J-M. Kaya b, D. Casanova a a b
Department of plastic and reconstructive surgery, Hoˆpital Nord, chemin des Bourrelly 13915 Marseille Cedex 20, France Department of neurosurgery, Hoˆpital Nord, chemin des Bourrelly 13915 Marseille Cedex 20, France
Received 12 June 2008; Accepted 29 September 2008
KEYWORDS Cranioplasty; Cerebral empyema; Muscular free flap; Bioceramic implant
Summary This article presents a case report of a cranioplasty performed after a post-craniotomy empyema with osteitis. The skull reconstruction was performed using a bioceramic implant and a combined muscular free flap of latissimus dorsi and serratus anterior. This procedure not only provided coverage of a wide skull defect but also allowed the filling of the intracranial dead space. Clinically, we observed an improvement of the patient’s preoperative neurological status with a near-complete correction of her right hemiparaesis and phasic disorders. Eight months after the cranioplasty, (1) no recurrence of infection was noticed; (2) no distortion of the skull was noticeable and (3) the patient again experienced a normal social life. Using computed tomography (CT) scan images, we observed a re-expansion of the left cerebral hemisphere without any dead space or extradural collection. The only observable sequelae were a temporoparietal alopecia (10 cm 4 cm) and a winging of the scapula, induced by the skin graft and the removal of the lower-third of the serratus anterior muscle, respectively. The use of a muscular free flap associated with a customised biomaterial allows a singlestage reconstruction of extensive skull defect (120 cm2) in a previously infected area. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ33 4 91 96 86 90; fax: þ33 4 91 96 43 50. E-mail address: [email protected] (J.-F. Chabas).
Post-craniotomy cerebral empyema with osteitis is a rare and potentially lethal neurosurgical complication.1e3 When the infection is under control, plastic surgeons have to reconstruct skull defect not only for aesthetic reasons but also for protecting the patient against potential future trauma. The goals of this cranioplasty were to (1) fill the
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.10.001
e132 extradural dead space to prevent intracranial collection, (2) perform a wide (120 cm2) cranial vault reconstruction by an alloplastic implant and (3) cover the reconstruction by a muscular flap in a previously infected area. For these reasons, we have chosen a bioceramic implant and a combined muscular free flap composed of latissimus dorsi and serratus anterior.
Patient and methods We report the clinical case of a 39-year-old female patient (Figure 1) who was initially operated for a left temporoparietal meningioma. In the early stage, she developed an extradural haematoma which became an empyema with osteitis. The management of post-craniotomy infection consisted of surgical debridement and removal of the cranial piece. The patient was treated with an antibiotic therapy directed against Staphylococcus Haemolyticus and Pseudomonas Aeruginosa. A delayed cranioplasty was performed 15 months later when the infection was focalised with normalisation of biological parameters (C-reactive protein (CRP) and white blood cells (WBC)). Our preferred choice was a bioceramic implant (Bioverit) and a combined muscular free flap composed of latissimus dorsi and serratus anterior, harvested from a single thoracodorsal vascular pedicle (Figure 2A). We performed microsurgical anastomosis with 9/0 nylon. The donor artery and vein were sutured to the superficial temporal vessels with an end-to-end anastomosis technique. The serratus anterior muscle was in direct contact with the dura mater to fill the intracranial dead space (Figure 2B). Then a computer-designed bioceramic implant (Figure 2C),
J.-F. Chabas et al. tailored to the shape of the cranial defect, was sutured to the cranial vault with resorbable transosseous stitches (Vicryl 0) (Figure 2D). Finally, the latissimus dorsi flap and the remaining scalp were used to cover the implant (Figure 2E). The drains were placed under the flaps. Eight days later, a split-thickness skin graft was harvested from the contralateral temporal scalp to cover the muscle (Figure 2F). Complete wound healing was achieved in 3 weeks.
Results Clinically, we observed an improvement of her preoperative neurological status with a complete correction of her right hemiparaesis and a nearly thorough recovery of verbal fluency. No recurrence of infection was noticed 8 months after the cranioplasty. This reconstruction allowed restoration of the skull contour and enabled the patient to lead a normal social life (Figure 3A,B and C). On CT scan, we observed a re-expansion of the left cerebral hemisphere without any dead space or extradural collection (Figure 3D). Temporoparietal alopecia (10 cm 4 cm) induced by the skin graft (Figure 3A,B and C) and a winging of the scapula due to the removal of the lower-third of the serratus anterior muscle were the only sequelae.
Discussion A wide craniectomy is often associated with a deterioration of the neurological symptomatology and is named syndrome of the sinking-skin flap (SSSF).4,5
Figure 1 Preoperative clinical and CT scan views of the patient. Skull deformation with left temporoparietal depression (A, B and C). Compression of the left temporoparietal hemisphere on CT scan views (D, E and F).
Cranial reconstruction after a post-craniotomy empyema
e133
Figure 2 Surgical procedure.Free muscular flap of latissimus dorsi and serratus anterior raised on a single thoracodorsal vascular pedicle (A). Filling of the intracranial dead space by the serratus anterior flap (B). Glass-bioceramic implant, shaped from computed tomography (C), was tailored to the shape of the cranial defect and was adapted accurately to the skull defect (D). Coverage of the implant by latissimus dorsi flap and the remaining scalp (E). Split-thickness skin graft was harvested on the contralateral temporal scalp to cover the muscle (F).
As a consequence, cranioplasty can improve neurological status in patients with skull-bone defects. The observed improvement in neurological status is likely due to an increased cerebral blood-flow (CBF) velocity,6,7 following the elimination of the effects of atmospheric pressure. This has been clearly demonstrated by several studies using the technique of transcranial Doppler sonography or CT perfusion imaging.8,9 The absence of recurrent infections can be explained by the use of muscle flaps10 which provide blood supply and prevent immediate intracranial fluid accumulation by the filling of the dead space. Later on, the expansion of the cerebral hemisphere compensates the denervated muscle bulk. This could explain the continual improvement in neurological status. As no local pedicled muscular flap could be found in the vicinity to cover this large area, free
flaps were the preferred choice. Among these, the free transfer of a latissimus dorsi muscle associated with a serratus anterior muscle exhibits the following advantages: they are large and flexible (vs. gracilis muscle) with a reliable anatomy, an appropriate pedicle length and an acceptable donor-site morbidity (vs. rectus abdomini muscle11e13). This flap could be removed and transferred in dorsal decubitis, allowing the two teams to work simultaneously. As the flaps were harvested from the same vascular pedicle, the viability of the serratus flap was monitored by the latissimus dorsi flap on the scalp. Great omentum free flap was an alternative therapeutic approach with an excellent blood supply, a large area and a recognised resistance to infection.14 Nevertheless, this omentum-based reconstruction has a poor pliability and fails to allow separation of the intracranial and extracranial structures.
e134
J.-F. Chabas et al.
Figure 3 Postoperative clinical and CT scan views of the patients. This reconstruction allowed restoration of skull contour and normal social life. Temporoparietal alopecia (10 cm 4 cm) secondary of the skin graft (A, B and C). On CT scan, we observed a re-expansion of the left cerebral hemisphere without any dead space or extradural collection (D). The computer-designed bioceramic implant was able to maintain volume for a long term following implantation without resorption (E and F).
The main objective of a cranioplasty is to achieve functional and cosmetic reconstruction. Optimal cranial vault reconstruction should be (1) readily available, (2) biocompatible with the surrounding tissues, (3) easily shaped and moulded to fit the deformity, (4) able to maintain the normal skull volume on the long term and (5) based on a biomechanically reliable material.15 Autologous bone and polymethylmethacrylate (PMMA) are the most widely used material for skull reconstruction.
Autologous bone graft is the ‘gold standard’ material for reconstruction of the craniofacial skeleton. Due to its mechanical properties and the low incidence of infections, it is the most cost-effective reconstructive material. Nonetheless, bone graft, a tissue in short supply, often undergoes significant resorption.15,16 Moreover, this technique often induces a donor-site morbidity17e20 and length the surgery time for harvesting and shaping the cranial piece.17
Cranial reconstruction after a post-craniotomy empyema Alternatively, vascularised bone grafts overcome these drawbacks. As shown by various teams, the free osteomuscular flap of serratus anterior21e24 or temporoparietal permit a satisfactory vault reconstruction.25 PMMA15,16 has long been used for reconstructing a traumatic skull defect. It is a well-tolerated material which is rigid, readily available, easy to shape at the right dimensions within the operating theatre and cost-effective. However, several disadvantages limit its use. A cooling of the material is required to prevent thermal damage to adjacent tissues. Due to the high fixation rate of bacteria on this material, PMMA is poorly tolerated by tissues with recent infection. Furthermore, thinning of the overlying skin and implant exposure has been reported. We chose an implant made of Bioverit, a biocompatible glasseceramic material, which is a computer-assisted designed implant for each individual. As a consequence, it fits perfectly the skull defect and reduces the operating time. This implant has been used frequently in other skeletal regions and all studies converge to ascertain its excellent biocompatibility.26 It should however be pointed out that this procedure is costly and time consuming. On average, there is a lag of 2 days between the ordering and the reception of the implant. The combined free muscular flap of latissimus dorsi and serratus anterior, removed from a single thoracodorsal vascular pedicle, is a flexible reconstruction which (1) improves the neurological status and (2) provides coverage of a wide skull defect, while it allows a satisfactory filling of the intracranial dead space. In addition, an adequate blood supply to the surrounding tissues limits further infections.
Conflict of interest None.
Funding None.
References 1. Hlavin ML, Kaminski HJ, Fenstermaker RA, et al. Intracranial suppuration: A modern decade of postoperative subdural empyema and epidural abscess. Neurosurgery 1994;34:974e81. 2. Blomstedt GC. Infections in neurosurgery: A retrospective study of 1143 patients and 1517 operations. Acta Neurochir (Wien) 1985;78:81e90. 3. Blomstedt GC. Considerations of infections after craniotomy. In: Schmidek HH, Roberts DW, editors. Schmidek & Sweet operative neurosurgical techniques. 5th ed. Philadelphia: W.B. Saunders; 2006. p. 1600e6. 4. Stula D. The problem of the sinking skin flap syndrome in cranioplasty. J Maxillofac Surg 1982;10:142e5. 5. Dujovny M, Aviles A, Agner C, et al. Cranioplasty: cosmetic or therapeutic? Surg Neurol 1997;47:238e41. 6. Richaud J, Boetho S, Guell A, et al. Incidence des cranioplasties sur la fonction neurologique et le debit sanguin cerebral. Neurochirurgia 1985;31:183e8.
e135 7. Isago T, Nozaki M, Kikuchi Y, et al. Sinking skin flap syndrome: a case of improved cerebral blood flow after cranioplasty. Ann Plast Surg 2004 Sep;53:288e92. 8. Kuo JR, Wang CC, Chio CC, et al. Neurological improvement after cranioplasty - analysis by transcranial doppler ultrasonography. J Clin Neurosci 2004 Jun;11:486e9. 9. Sakamoto S, Eguchi K, Kiura Y, et al. CT perfusion imaging in the syndrome of the sinking skin flap before and after cranioplasty. Clin Neurol Neurosurg 2006 Sep;108:583e5. 10. Mathes SJ, Alpert BS, Chang N. Use of the muscle flap in chronic osteomyelitis: experimental and clinical correlation. Plast Reconstr Surg 1982 May;69:815e29. 11. Kroll SS, Baldwin BJ. Head and neck reconstruction with the rectus abdominis free flap. Clin Plast Surg 1994 Jan;21: 97e105. Review. 12. Robson MC, Zachary LS, Schmidt DR, et al. Reconstruction of large cranial defects in the presence of heavy radiation damage and infection utilizing tissue transferred by microvascular anastomoses. Plast Reconstr Surg 1989 Mar;83: 438e42. 13. Mikami T, Minamida Y, Sugino T, et al. Free flap transfer for the treatment of intractable postcraniotomy subdural empyemas and epidural abscesses. Neurosurgery 2007 Feb;60(2 Suppl. 1): ONS83e7. discussion ONS87-8. 14. Barrow DL, Nahai F, Tindall GT. The use of greater omentum vascularized free flaps for neurosurgical disorders requiring reconstruction. J Neurosurg 1984 Feb;60:305e11. 15. Moreira-Gonzalez A, Jackson IT, Miyawaki T, et al. Clinical outcome in cranioplasty: critical review in long-term followup. J Craniofac Surg 2003;14:144e53. 16. Govindaraj S, Costantino PD, Friedman CD. Current use of bone substitutes in maxillofacial surgery. Fac Plast Surg 1999;15: 73e81. 17. Kline Jr RM, Wolfe SA. Complications associated with the harvesting of cranial bone grafts. Plast Reconstr Surg 1995;95: 5e13. 18. Nickell WB, Jurkiewiez MJ, Salyer KE. Repair of skull defects with autogenous bone. Arch Surg 1972;105:431e3. 19. Wolfe SA. Autogenous bone grafts versus alloplastic material in maxillofacial surgery. Clin Plast Surg 1982;9:539e40. 20. Edwards MSB, Ousterhout DK. Autogenic skull bone grafts to reconstruct large or complex skull defects in children and adolescents. Neurosurgery 1987;20:273e80. 21. Serra MP, Longhi P, Carminati M, et al. Microsurgical scalp and skull reconstruction using a combined flap composed of serratus anterior myo-osseous flap and latissimus dorsi myocutaneous flap. J Plast Reconstr Aesthet Surg 2007;60: 1158e61. 22. Netscher D, Alford EL, Wigoda P, et al. Free composite myoosseous flap with serratus anterior and rib: indications in head and neck reconstruction. Head Neck 1998 Mar;20:106e12. 23. Ueda K, Harashina T, Inoue T, et al. Microsurgical scalp and skull reconstruction using a serratus anterior myo-osseous flap. Ann Plast Surg 1993 Jul;31:10e4. 24. Tanaka Y, Miki K, Tajima S, et al. Reconstruction of an extensive scalp defect using the split latissimus dorsi flap in combination with the serratus anterior musculo-osseous flap. Br J Plast Surg 1998 Apr;51:250e4. 25. Bouetel V, Roule ´ P, Danton A, et al. Free temporoparietal osteomuscular flap for cranioplasty. Rev Stomatol Chir Maxillofac 2005 Feb;106:22e6. French. 26. Klein M, Glatzer C. Individual CAD/CAM fabricated glass-bioceramic implants in reconstructive surgery of the bony orbital floor. Plast Reconstr Surg 2006 Feb;117:565e70.
CASE REPORT
Cranial reconstruction after a post-craniotomy empyema J-F. Chabas a,*, C. Dellavolpe a, Y. Riah a, T. Bron a, Y. Reynier b, J-M. Kaya b, D. Casanova a a b
Department of plastic and reconstructive surgery, Hoˆpital Nord, chemin des Bourrelly 13915 Marseille Cedex 20, France Department of neurosurgery, Hoˆpital Nord, chemin des Bourrelly 13915 Marseille Cedex 20, France
Received 12 June 2008; Accepted 29 September 2008
KEYWORDS Cranioplasty; Cerebral empyema; Muscular free flap; Bioceramic implant
Summary This article presents a case report of a cranioplasty performed after a post-craniotomy empyema with osteitis. The skull reconstruction was performed using a bioceramic implant and a combined muscular free flap of latissimus dorsi and serratus anterior. This procedure not only provided coverage of a wide skull defect but also allowed the filling of the intracranial dead space. Clinically, we observed an improvement of the patient’s preoperative neurological status with a near-complete correction of her right hemiparaesis and phasic disorders. Eight months after the cranioplasty, (1) no recurrence of infection was noticed; (2) no distortion of the skull was noticeable and (3) the patient again experienced a normal social life. Using computed tomography (CT) scan images, we observed a re-expansion of the left cerebral hemisphere without any dead space or extradural collection. The only observable sequelae were a temporoparietal alopecia (10 cm 4 cm) and a winging of the scapula, induced by the skin graft and the removal of the lower-third of the serratus anterior muscle, respectively. The use of a muscular free flap associated with a customised biomaterial allows a singlestage reconstruction of extensive skull defect (120 cm2) in a previously infected area. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ33 4 91 96 86 90; fax: þ33 4 91 96 43 50. E-mail address: [email protected] (J.-F. Chabas).
Post-craniotomy cerebral empyema with osteitis is a rare and potentially lethal neurosurgical complication.1e3 When the infection is under control, plastic surgeons have to reconstruct skull defect not only for aesthetic reasons but also for protecting the patient against potential future trauma. The goals of this cranioplasty were to (1) fill the
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.10.001
e132 extradural dead space to prevent intracranial collection, (2) perform a wide (120 cm2) cranial vault reconstruction by an alloplastic implant and (3) cover the reconstruction by a muscular flap in a previously infected area. For these reasons, we have chosen a bioceramic implant and a combined muscular free flap composed of latissimus dorsi and serratus anterior.
Patient and methods We report the clinical case of a 39-year-old female patient (Figure 1) who was initially operated for a left temporoparietal meningioma. In the early stage, she developed an extradural haematoma which became an empyema with osteitis. The management of post-craniotomy infection consisted of surgical debridement and removal of the cranial piece. The patient was treated with an antibiotic therapy directed against Staphylococcus Haemolyticus and Pseudomonas Aeruginosa. A delayed cranioplasty was performed 15 months later when the infection was focalised with normalisation of biological parameters (C-reactive protein (CRP) and white blood cells (WBC)). Our preferred choice was a bioceramic implant (Bioverit) and a combined muscular free flap composed of latissimus dorsi and serratus anterior, harvested from a single thoracodorsal vascular pedicle (Figure 2A). We performed microsurgical anastomosis with 9/0 nylon. The donor artery and vein were sutured to the superficial temporal vessels with an end-to-end anastomosis technique. The serratus anterior muscle was in direct contact with the dura mater to fill the intracranial dead space (Figure 2B). Then a computer-designed bioceramic implant (Figure 2C),
J.-F. Chabas et al. tailored to the shape of the cranial defect, was sutured to the cranial vault with resorbable transosseous stitches (Vicryl 0) (Figure 2D). Finally, the latissimus dorsi flap and the remaining scalp were used to cover the implant (Figure 2E). The drains were placed under the flaps. Eight days later, a split-thickness skin graft was harvested from the contralateral temporal scalp to cover the muscle (Figure 2F). Complete wound healing was achieved in 3 weeks.
Results Clinically, we observed an improvement of her preoperative neurological status with a complete correction of her right hemiparaesis and a nearly thorough recovery of verbal fluency. No recurrence of infection was noticed 8 months after the cranioplasty. This reconstruction allowed restoration of the skull contour and enabled the patient to lead a normal social life (Figure 3A,B and C). On CT scan, we observed a re-expansion of the left cerebral hemisphere without any dead space or extradural collection (Figure 3D). Temporoparietal alopecia (10 cm 4 cm) induced by the skin graft (Figure 3A,B and C) and a winging of the scapula due to the removal of the lower-third of the serratus anterior muscle were the only sequelae.
Discussion A wide craniectomy is often associated with a deterioration of the neurological symptomatology and is named syndrome of the sinking-skin flap (SSSF).4,5
Figure 1 Preoperative clinical and CT scan views of the patient. Skull deformation with left temporoparietal depression (A, B and C). Compression of the left temporoparietal hemisphere on CT scan views (D, E and F).
Cranial reconstruction after a post-craniotomy empyema
e133
Figure 2 Surgical procedure.Free muscular flap of latissimus dorsi and serratus anterior raised on a single thoracodorsal vascular pedicle (A). Filling of the intracranial dead space by the serratus anterior flap (B). Glass-bioceramic implant, shaped from computed tomography (C), was tailored to the shape of the cranial defect and was adapted accurately to the skull defect (D). Coverage of the implant by latissimus dorsi flap and the remaining scalp (E). Split-thickness skin graft was harvested on the contralateral temporal scalp to cover the muscle (F).
As a consequence, cranioplasty can improve neurological status in patients with skull-bone defects. The observed improvement in neurological status is likely due to an increased cerebral blood-flow (CBF) velocity,6,7 following the elimination of the effects of atmospheric pressure. This has been clearly demonstrated by several studies using the technique of transcranial Doppler sonography or CT perfusion imaging.8,9 The absence of recurrent infections can be explained by the use of muscle flaps10 which provide blood supply and prevent immediate intracranial fluid accumulation by the filling of the dead space. Later on, the expansion of the cerebral hemisphere compensates the denervated muscle bulk. This could explain the continual improvement in neurological status. As no local pedicled muscular flap could be found in the vicinity to cover this large area, free
flaps were the preferred choice. Among these, the free transfer of a latissimus dorsi muscle associated with a serratus anterior muscle exhibits the following advantages: they are large and flexible (vs. gracilis muscle) with a reliable anatomy, an appropriate pedicle length and an acceptable donor-site morbidity (vs. rectus abdomini muscle11e13). This flap could be removed and transferred in dorsal decubitis, allowing the two teams to work simultaneously. As the flaps were harvested from the same vascular pedicle, the viability of the serratus flap was monitored by the latissimus dorsi flap on the scalp. Great omentum free flap was an alternative therapeutic approach with an excellent blood supply, a large area and a recognised resistance to infection.14 Nevertheless, this omentum-based reconstruction has a poor pliability and fails to allow separation of the intracranial and extracranial structures.
e134
J.-F. Chabas et al.
Figure 3 Postoperative clinical and CT scan views of the patients. This reconstruction allowed restoration of skull contour and normal social life. Temporoparietal alopecia (10 cm 4 cm) secondary of the skin graft (A, B and C). On CT scan, we observed a re-expansion of the left cerebral hemisphere without any dead space or extradural collection (D). The computer-designed bioceramic implant was able to maintain volume for a long term following implantation without resorption (E and F).
The main objective of a cranioplasty is to achieve functional and cosmetic reconstruction. Optimal cranial vault reconstruction should be (1) readily available, (2) biocompatible with the surrounding tissues, (3) easily shaped and moulded to fit the deformity, (4) able to maintain the normal skull volume on the long term and (5) based on a biomechanically reliable material.15 Autologous bone and polymethylmethacrylate (PMMA) are the most widely used material for skull reconstruction.
Autologous bone graft is the ‘gold standard’ material for reconstruction of the craniofacial skeleton. Due to its mechanical properties and the low incidence of infections, it is the most cost-effective reconstructive material. Nonetheless, bone graft, a tissue in short supply, often undergoes significant resorption.15,16 Moreover, this technique often induces a donor-site morbidity17e20 and length the surgery time for harvesting and shaping the cranial piece.17
Cranial reconstruction after a post-craniotomy empyema Alternatively, vascularised bone grafts overcome these drawbacks. As shown by various teams, the free osteomuscular flap of serratus anterior21e24 or temporoparietal permit a satisfactory vault reconstruction.25 PMMA15,16 has long been used for reconstructing a traumatic skull defect. It is a well-tolerated material which is rigid, readily available, easy to shape at the right dimensions within the operating theatre and cost-effective. However, several disadvantages limit its use. A cooling of the material is required to prevent thermal damage to adjacent tissues. Due to the high fixation rate of bacteria on this material, PMMA is poorly tolerated by tissues with recent infection. Furthermore, thinning of the overlying skin and implant exposure has been reported. We chose an implant made of Bioverit, a biocompatible glasseceramic material, which is a computer-assisted designed implant for each individual. As a consequence, it fits perfectly the skull defect and reduces the operating time. This implant has been used frequently in other skeletal regions and all studies converge to ascertain its excellent biocompatibility.26 It should however be pointed out that this procedure is costly and time consuming. On average, there is a lag of 2 days between the ordering and the reception of the implant. The combined free muscular flap of latissimus dorsi and serratus anterior, removed from a single thoracodorsal vascular pedicle, is a flexible reconstruction which (1) improves the neurological status and (2) provides coverage of a wide skull defect, while it allows a satisfactory filling of the intracranial dead space. In addition, an adequate blood supply to the surrounding tissues limits further infections.
Conflict of interest None.
Funding None.
References 1. Hlavin ML, Kaminski HJ, Fenstermaker RA, et al. Intracranial suppuration: A modern decade of postoperative subdural empyema and epidural abscess. Neurosurgery 1994;34:974e81. 2. Blomstedt GC. Infections in neurosurgery: A retrospective study of 1143 patients and 1517 operations. Acta Neurochir (Wien) 1985;78:81e90. 3. Blomstedt GC. Considerations of infections after craniotomy. In: Schmidek HH, Roberts DW, editors. Schmidek & Sweet operative neurosurgical techniques. 5th ed. Philadelphia: W.B. Saunders; 2006. p. 1600e6. 4. Stula D. The problem of the sinking skin flap syndrome in cranioplasty. J Maxillofac Surg 1982;10:142e5. 5. Dujovny M, Aviles A, Agner C, et al. Cranioplasty: cosmetic or therapeutic? Surg Neurol 1997;47:238e41. 6. Richaud J, Boetho S, Guell A, et al. Incidence des cranioplasties sur la fonction neurologique et le debit sanguin cerebral. Neurochirurgia 1985;31:183e8.
e135 7. Isago T, Nozaki M, Kikuchi Y, et al. Sinking skin flap syndrome: a case of improved cerebral blood flow after cranioplasty. Ann Plast Surg 2004 Sep;53:288e92. 8. Kuo JR, Wang CC, Chio CC, et al. Neurological improvement after cranioplasty - analysis by transcranial doppler ultrasonography. J Clin Neurosci 2004 Jun;11:486e9. 9. Sakamoto S, Eguchi K, Kiura Y, et al. CT perfusion imaging in the syndrome of the sinking skin flap before and after cranioplasty. Clin Neurol Neurosurg 2006 Sep;108:583e5. 10. Mathes SJ, Alpert BS, Chang N. Use of the muscle flap in chronic osteomyelitis: experimental and clinical correlation. Plast Reconstr Surg 1982 May;69:815e29. 11. Kroll SS, Baldwin BJ. Head and neck reconstruction with the rectus abdominis free flap. Clin Plast Surg 1994 Jan;21: 97e105. Review. 12. Robson MC, Zachary LS, Schmidt DR, et al. Reconstruction of large cranial defects in the presence of heavy radiation damage and infection utilizing tissue transferred by microvascular anastomoses. Plast Reconstr Surg 1989 Mar;83: 438e42. 13. Mikami T, Minamida Y, Sugino T, et al. Free flap transfer for the treatment of intractable postcraniotomy subdural empyemas and epidural abscesses. Neurosurgery 2007 Feb;60(2 Suppl. 1): ONS83e7. discussion ONS87-8. 14. Barrow DL, Nahai F, Tindall GT. The use of greater omentum vascularized free flaps for neurosurgical disorders requiring reconstruction. J Neurosurg 1984 Feb;60:305e11. 15. Moreira-Gonzalez A, Jackson IT, Miyawaki T, et al. Clinical outcome in cranioplasty: critical review in long-term followup. J Craniofac Surg 2003;14:144e53. 16. Govindaraj S, Costantino PD, Friedman CD. Current use of bone substitutes in maxillofacial surgery. Fac Plast Surg 1999;15: 73e81. 17. Kline Jr RM, Wolfe SA. Complications associated with the harvesting of cranial bone grafts. Plast Reconstr Surg 1995;95: 5e13. 18. Nickell WB, Jurkiewiez MJ, Salyer KE. Repair of skull defects with autogenous bone. Arch Surg 1972;105:431e3. 19. Wolfe SA. Autogenous bone grafts versus alloplastic material in maxillofacial surgery. Clin Plast Surg 1982;9:539e40. 20. Edwards MSB, Ousterhout DK. Autogenic skull bone grafts to reconstruct large or complex skull defects in children and adolescents. Neurosurgery 1987;20:273e80. 21. Serra MP, Longhi P, Carminati M, et al. Microsurgical scalp and skull reconstruction using a combined flap composed of serratus anterior myo-osseous flap and latissimus dorsi myocutaneous flap. J Plast Reconstr Aesthet Surg 2007;60: 1158e61. 22. Netscher D, Alford EL, Wigoda P, et al. Free composite myoosseous flap with serratus anterior and rib: indications in head and neck reconstruction. Head Neck 1998 Mar;20:106e12. 23. Ueda K, Harashina T, Inoue T, et al. Microsurgical scalp and skull reconstruction using a serratus anterior myo-osseous flap. Ann Plast Surg 1993 Jul;31:10e4. 24. Tanaka Y, Miki K, Tajima S, et al. Reconstruction of an extensive scalp defect using the split latissimus dorsi flap in combination with the serratus anterior musculo-osseous flap. Br J Plast Surg 1998 Apr;51:250e4. 25. Bouetel V, Roule ´ P, Danton A, et al. Free temporoparietal osteomuscular flap for cranioplasty. Rev Stomatol Chir Maxillofac 2005 Feb;106:22e6. French. 26. Klein M, Glatzer C. Individual CAD/CAM fabricated glass-bioceramic implants in reconstructive surgery of the bony orbital floor. Plast Reconstr Surg 2006 Feb;117:565e70.