Chicago, Ill. From the Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medical Center.
Plast Reconstr Surg. 2013 Oct;132(4):967-975. doi: 10.1097/PRS.0b013e31829f4b59.
Composite cranial defects in the setting of infection, irradiation, or cerebrospinal fluid leak present a significant risk for devastating neurologic sequelae. Such defects require soft-tissue coverage and skeletal reconstruction that can withstand the hostile environment of a precarious wound.
Patients with high-risk composite cranial defects treated with free flap reconstruction containing a vascularized osseous component from 2003 to 2012 were reviewed retrospectively.
Fourteen patients received autologous vascularized cranioplasties between 2003 and 2012 with a mean age of 55.7 years and a mean follow-up of 14.1 months. Preoperatively, all patients had infection, irradiation, cerebrospinal fluid leak, or a combination thereof. Thirteen patients (92.9 percent) were reoperative cases for recurrent tumor, infection, or both. Six patients (42.9 percent) failed previous reconstructive procedures. Tissue biopsy-proven infection was present in 10 patients (71.4 percent) with calvarial osteomyelitis, both osteomyelitis and meningitis, or scalp soft-tissue infection only. Nine patients (64.3 percent) suffered from malignancy and six of these patients were irradiated preoperatively. Cranioplasty was achieved as part of a chimeric free flap using rib, scapula, both rib and scapula, or ilium. Vascularized duraplasty using serratus anterior fascia as a component of the chimeric flap was performed in three patients. No flap losses occurred and all patients had resolution of infection.
Soft-tissue and skeletal restoration are the two critical components of composite cranial reconstruction. The authors report outcomes of the largest series of one-stage immediate cranioplasty consisting of autologous soft tissue and vascularized bone in high-risk composite cranial wounds and suggest its application in defects associated with compromised wound beds.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
感染、放疗或脑脊液漏导致的复合性颅骨缺损存在严重的神经后遗症风险。这些缺损需要软组织覆盖和骨骼重建，以承受不稳定伤口的恶劣环境。
回顾性分析了 2003 年至 2012 年间采用含血管化骨成分游离皮瓣重建治疗的高危复合性颅骨缺损患者。
2003 年至 2012 年间，14 例患者接受了自体血管化颅骨修补术，平均年龄 55.7 岁，平均随访 14.1 个月。术前所有患者均有感染、放疗、脑脊液漏或三者的组合。13 例（92.9%）为复发性肿瘤、感染或两者均有的再手术病例。6 例（42.9%）先前的重建手术失败。10 例（71.4%）患者组织活检证实存在感染，包括颅骨骨髓炎、骨髓炎合并脑膜炎或头皮软组织感染。9 例（64.3%）患有恶性肿瘤，其中 6 例患者术前接受过放疗。颅骨修补术是使用肋骨、肩胛骨、肋骨和肩胛骨或髂骨的嵌合游离皮瓣来实现的。3 例患者采用胸大肌前筋膜作为嵌合皮瓣的一部分进行血管化硬脑膜修复。没有皮瓣丢失，所有患者的感染均得到治愈。
软组织和骨骼修复是复合性颅骨重建的两个关键组成部分。作者报告了最大系列的高危复合性颅骨缺损中立即自体软组织和血管化骨一期重建的结果，并建议在涉及受损创面的缺损中应用。
临床问题/证据水平：治疗性，IV。
