Page 150 - Clinical relevance of current materials for cranial implants

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Chapter 7
Different critical decisions have to be made when addressing composite scalp and calvarial defects after tumor removal of the skull. Various techniques and timing are described in literature for both soft tissue coverage and hard tissue reconstruction. Concerning soft tissue coverage, irradiated wound beds or need of adjuvant radiotherapy, sizeable defects and prior surgeries make microvascular free tissue transfer frequently unavoidable in their management. Various free flaps have been described to reconstruct scalp defects. These include the LD30–32 and the anterolateral thigh flap (ALT)33,34, which have been accepted as the workhorse flaps for reconstruction of large scalp defects. Alternatives include radial free forearm flap (RFFF)32, rectus abdominis flap32,35,36 and others32,37,38. Certain authors consider the LD flap the first choice because of its large surface, predictable blood supply, ease of harvesting, excellent vascularity and long vascular pedicle15,39,40. Others, consider the ALT flap the preferable choice, because of its minimal donor site morbidity, lengthy and sizeable pedicle and possibility to harvest in supine position41–43. It is well known that immobilized denervated muscles are vulnerable to atrophy44. The ALT might be associated less with atrophy related complications compared to LD flaps, although there is lack of evidence to support one superior flap choice over the other43.
Some authors have managed composite defects in the same manner as scalp only defects to successfully avoid potential complications and morbidity, with application of a soft tissue flap alone8,45. Although they heal satisfactory and demonstrate no major recipient site complications in the postoperative course, the limitations of this strategy are an abnormal cranial contour and absence of protection of cranial contents that is conferred by cranioplasty. These patients have to adhere to the standard precautions of patients who do not have solid protection of their intracranial contents.