Multiple delayed scalp reconstruction for complicated cranial defects

In cases of skull trauma, emergency surgery for cranial decompression typically involves the shortest approach, with the incision lying directly on or immediately near the bony defect. Subsequent reconstructive plastic surgery for the skull is difficult in such cases because incisions taken on the previous scar overlying the bony defect are prone to dehiscence and infection. Herein, we describe a technique for creating a well-vascularized delayed skin flap via multistaged operation before the actual skull reconstruction. Four patients (age range, 10–25 y) were prepared for skull reconstruction using this technique. Flap elevation was performed in 3 stages, with adequate time intervals (4 wk between each stage) to allow for adequate delay. Dissection under the galea aponeurotica was performed only after initial flap elevation allowing for adequate vascularization. Skull reconstruction was then performed using custom-made implants. The patients were followed up for 6 to 12 months. No complications, including infections, exposure of the artificial bone, or flap necrosis, were observed. All the patients were satisfied with the cosmetic results. Despite the multiple stages required, we consider that our technique of using a delayed, well-vascularized bipedicled skin flap can be successfully used in the skull reconstruction of patients in whom the initial scar lies close to the bone defect. We recommend scalp incision be shifted outside of the foreseen bony flap to limit infectious risks during primary or subsequent cranial reconstruction.