Afifi Ahmed, Djohan Risal S, Hammert Warren, Papay Frank A, Barnett Addison E, Zins James E
Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA.
J Craniofac Surg. 2010 Jul;21(4):1205-9. doi: 10.1097/SCS.0b013e3181e17c1e.
The purpose of this study was to review our experience in single-stage reconstruction of skull and scalp defects, aiming to highlight pitfalls in our management.
We performed a retrospective chart review of all patients who had a single-stage cranioplasty and free-tissue transfer at our institution over the last 10 years. Thirteen patients (9 men and 4 women) with an average age of 66.5 years (range, 34-83 years) were identified. Etiology of the defects included malignancy (n = 7), osteoradionecrosis (n = 3), and infection (n = 3). The size of the bony defect averaged 103.1 cm(2) (range, 12-300 cm(2)). Cranioplasty procedures included reconstruction by methylmethacrylate and titanium mesh (n = 10), methylmethacrylate only (n = 1), or mesh only (n = 2). Free flaps used were anterolateral thigh (n = 10), latissimus dorsi (n = 2), or a rectus flap (n = 1).
Five patients (38%) developed at least 1 complication. These included 2 anastomotic problems that were successfully salvaged, 5 cases of wound dehiscence, and 1 mortality due to a respiratory event. Four patients developed a recurrence, and 2 patients required flap contouring at a second stage. Two patients had further reconstruction using 1 (1 patient) or 2 (1 patient) additional free flaps.
Given the complexity of these procedures, the high recurrence rate, and the likelihood of complications, methylmethacrylate is contraindicated in 1-stage cranioplasty and soft-tissue reconstruction in high-risk patients. For unfavorable local conditions (eg previous infection, radiotherapy), the surgeon can either postpone the cranioplasty until the soft-tissue reconstruction has healed, or use a nonanatomical titanium mesh alone. The soft-tissue flap should be harvested of larger dimensions than anticipated.
本研究的目的是回顾我们在颅骨和头皮缺损一期重建方面的经验，旨在强调我们治疗中的陷阱。
我们对过去10年在本机构接受一期颅骨成形术和游离组织移植的所有患者进行了回顾性病历审查。确定了13例患者（9例男性和4例女性），平均年龄66.5岁（范围34 - 83岁）。缺损病因包括恶性肿瘤（n = 7）、放射性骨坏死（n = 3）和感染（n = 3）。骨缺损大小平均为103.1平方厘米（范围12 - 300平方厘米）。颅骨成形术包括用甲基丙烯酸甲酯和钛网重建（n = 10）、仅用甲基丙烯酸甲酯（n = 1）或仅用网（n = 2）。使用的游离皮瓣包括股前外侧皮瓣（n = 10）、背阔肌皮瓣（n = 2）或腹直肌皮瓣（n = 1）。
5例患者（38%）发生了至少1种并发症。这些并发症包括2例成功挽救的吻合口问题、5例伤口裂开和1例因呼吸事件导致的死亡。4例患者出现复发，2例患者需要二期皮瓣塑形。2例患者使用1个（1例患者）或2个（1例患者）额外的游离皮瓣进行了进一步重建。
鉴于这些手术的复杂性、高复发率和并发症发生的可能性，甲基丙烯酸甲酯在高危患者的一期颅骨成形术和软组织重建中是禁忌的。对于不利的局部情况（如既往感染、放疗），外科医生可以要么推迟颅骨成形术直到软组织重建愈合，要么单独使用非解剖型钛网。软组织皮瓣的切取尺寸应比预期大。
