Application of two-stage operation on free latissimus dorsi myocutaneous flap transplantation and skull contour reconstruction in treatment of head titanium mesh exposure with soft tissue infection_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LIU Xin ^1,2 , HAN Yudi ¹ , CUI Lei ¹ , SHU Jun ¹ , GUO Lingli ¹ , TAO Ran ¹ , LEI Yonghong ¹ ,  HAN Yan ¹

1. Department of Plastic and Reconstructive Surgery, the First Medical Center of Chinese PLA General Hospital, Beijing, 100853, P. R. China;
2. Medical College of Nankai University, Tianjin, 300071, P. R. China;

Corresponding author：

HAN Yan, Email: 13720086335@163.com

Keywords：

Skull defect; titanium mesh exposure; infection; skull repair; latissimus dorsi myocutaneous flap

DOI：

10.7507/1002-1892.202202061

Video：

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Objective To explore the effectiveness of two-stage operation on free latissimus dorsi myocutaneous flap transplantation and skull contour reconstruction in the treatment of head titanium mesh exposure complicated with soft tissue infection. Methods Between January 2015 and December 2021, 13 patients with head titanium mesh exposure complicated with soft tissue infection were admitted. There were 9 males and 4 females with a mean age of 42.9 years (range, 23-64 years). The duration of titanium mesh exposure was 22-609 days (median, 102 days). The wound site located at the frontal part in 3 cases, the parietal part in 1 case, the occipital part in 2 cases, the frontal-parietal part in 1 case, the temporal-parietal part in 4 cases, and the frontotemporal part in 2 cases. The titanium mesh had been taken out in 5 patients before admission, leaving skull defect and shape collapse, with signs of infection. The bacterial culture was positive in 7 cases and negative in 6 cases. The imaging examination revealed that the size of the skull defect ranged from 6 cm×5 cm to 21 cm×17 cm and the scalp defect ranged from 1 cm×1 cm to 15 cm×10 cm. The soft tissue infection did not reach dura in 5 cases, reached dura in 6 cases, and reached frontal sinus in 2 cases. The two-stage surgical protocol was used in all patients. In the first-stage operation, the latissimus dorsi myocutaneous flap was designed to repair the skull and scalp defects after removing the titanium mesh and thorough debridement. The size of muscle flap ranged from 13.5 cm×4.0 cm to 21.0 cm×17.0 cm, and the skin flap ranged from 7.0 cm×4.0 cm to 15.0 cm×10.0 cm. After the flap survived and stabilized, the second-stage operation was performed. The titanium mesh was implanted to reconstruct the skull contour. The size of titanium mesh ranged from 7.0 cm×6.0 cm to 21.5 cm×17.5 cm. The interval between the first- and second-stage operations was 3.7-17.8 months, with an average of 11.4 months. The survival of the skin flap, the appearance of the head, and the presence of re-exposed titanium mesh and infection were observed after operation. Results At the first-stage operation, venous embolism occurred in 1 case, and no obvious abnormality was observed after treatment. All the flaps survived and the incisions healed by first intention. Besides, the incisions of the second-stage operation healed by first intention. All patients were followed up 1-96 months (median, 14 months). During follow-up, no exposure to titanium mesh, infection, or other complications occurred. The appearance satisfaction rate of the patients was 92.31% (11/13). There was no significant difference in the skull contour between the affected side and the healthy side in all patients. Conclusion For the head titanium mesh exposure with soft tissue infection, the application of two-stage operation on free latissimus dorsi myocutaneous flap transplantation and skull contour reconstruction can reduce the risks of implant exposure and infection again by increasing the thickness of the scalp and blood supply, filling the wound cavity, and obtain good effectiveness.

Citation： LIU Xin, HAN Yudi, CUI Lei, SHU Jun, GUO Lingli, TAO Ran, LEI Yonghong, HAN Yan. Application of two-stage operation on free latissimus dorsi myocutaneous flap transplantation and skull contour reconstruction in treatment of head titanium mesh exposure with soft tissue infection. Chinese Journal of Reparative and Reconstructive Surgery, 2022, 36(7): 828-833. doi: 10.7507/1002-1892.202202061 Copy

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2.	Mashiko T, Minabe T, Ohnishi F, et al. Restoration of bilateral cranial defects by hybridization of microvascular free flaps and artificial bones. Plast Reconstr Surg Glob Open, 2019, 7(9): e2428. doi: 10.1097/GOX.0000000000002428.
3.	Zhao J, Song G, Zong X, et al. Using the reversed temporal island flap to cover small forehead defects from titanium mesh exposure after cranial reconstruction. World Neurosurg, 2018, 112: e514-e519.
4.	Soto E, Restrepo RD, Grant JH, et al. Outcomes of cranioplasty strategies for high-risk complex cranial defects: A 10-year experience. Ann Plast Surg, 2021. doi: 10.1097/SAP.0000000000003019.
5.	Yoon HG, Ko Y, Kim YS, et al. Efficacy of 3D-printed titanium mesh-type patient-specific implant for cranioplasty. Korean J Neurotrauma, 2021, 17(2): 91-99.
6.	叶宏权, 魏大伟, 谢峥, 等. 颞肌外钛网修补颅骨缺损48例临床分析. 中国基层医药, 2020, 27(17): 2150-2153.
7.	Yoshioka N, Tominaga S. Titanium mesh implant exposure due to pressure gradient fluctuation. World Neurosurg, 2018, 119: e734-e739.
8.	Henry J, Amoo M, Murphy A, et al. Complications of cranioplasty following decompressive craniectomy for traumatic brain injury: systematic review and meta-analysis. Acta Neurochir (Wien), 2021, 163(5): 1423-1435.
9.	Goedemans T, Verbaan D, van der Veer O, et al. Complications in cranioplasty after decompressive craniectomy: timing of the intervention. J Neurol, 2020, 267(5): 1312-1320.
10.	Kwiecien GJ, Rueda S, Couto RA, et al. Long-term outcomes of cranioplasty: Titanium mesh is not a long-term solution in high-risk patients. Ann Plast Surg, 2018, 81(4): 416-422.
11.	Kwiecien GJ, Sinclair N, Coombs DM, et al. Long-term effect of cranioplasty on overlying scalp atrophy. Plast Reconstr Surg Glob Open, 2020, 8(8): e3031. doi: 10.1097/GOX.0000000000003031.
12.	Di Rienzo A, Colasanti R, Gladi M, et al. Timing of cranial reconstruction after cranioplasty infections: are we ready for a re-thinking? A comparative analysis of delayed versus immediate cranioplasty after debridement in a series of 48 patients. Neurosurg Rev, 2021, 44(3): 1523-1532.
13.	李阳, 张连阳. 伤口感染的前世今生. 创伤外科杂志, 2022, 24(1): 78-80.
14.	刘代宏, 冯剑, 孙超峰, 等. 颅骨缺损修补术后钛网外露31例. 中华烧伤杂志, 2013, 29(2): 212-213.
15.	Yano T, Okazaki M, Tanaka K, et al. The flap Sandwich technique for a safe and aesthetic skull base reconstruction. Ann Plast Surg, 2016, 76(2): 193-197.
16.	Maqbool T, Binhammer A, Binhammer P, et al. Risk factors for titanium mesh implant exposure following cranioplasty. J Craniofac Surg, 2018, 29(5): 1181-1186.
17.	Chen F, Ju H, Huang A, et al. Treatment of large and complicated scalp defects with free flap transfer. Biomed Res Int, 2020, 2020: 2748219. doi: 10.1155/2020/2748219.
18.	Dong L, Dong Y, Liu C, et al. Latissimus dorsi-myocutaneous flap in the repair of titanium mesh exposure and scalp defect after cranioplasty. J Craniofac Surg, 2020, 31(2): 351-354.
19.	Wang W, Vincent A, Bahrami A, et al. Progressive scalp thinning over mesh cranioplasty and the role of lipotransfer. Laryngoscope, 2020, 130(8): 1926-1931.
20.	贡荃, 张宏文. 颅骨修补术后钛网外露四例临床分析. 中国基层医药, 2017, 24(24): 3814-3816.
21.	柳大岗, 郭庆雷, 邹积典. 颅骨修补术后反复钛网外露一例并文献复习. 国际医药卫生导报, 2016, 22(9): 1267-1269.
22.	陈黎明, 刘毅, 张诚, 等. 带肌瓣的嵌合穿支皮瓣修复合并深部死腔的难愈性创面. 中华整形外科杂志, 2020, 36(3): 279-283.
23.	刘士强, 唐银科, 楚菲菲, 等. 扩张后头皮瓣修复额、面部病损. 中华整形外科杂志, 2020, 36(7): 776-779.

1. Alkhaibary A, Alharbi A, Alnefaie N, et al. Cranioplasty: A comprehensive review of the history, materials, surgical aspects, and complications. World Neurosurg, 2020, 139: 445-452.
2. Mashiko T, Minabe T, Ohnishi F, et al. Restoration of bilateral cranial defects by hybridization of microvascular free flaps and artificial bones. Plast Reconstr Surg Glob Open, 2019, 7(9): e2428. doi: 10.1097/GOX.0000000000002428.
3. Zhao J, Song G, Zong X, et al. Using the reversed temporal island flap to cover small forehead defects from titanium mesh exposure after cranial reconstruction. World Neurosurg, 2018, 112: e514-e519.
4. Soto E, Restrepo RD, Grant JH, et al. Outcomes of cranioplasty strategies for high-risk complex cranial defects: A 10-year experience. Ann Plast Surg, 2021. doi: 10.1097/SAP.0000000000003019.
5. Yoon HG, Ko Y, Kim YS, et al. Efficacy of 3D-printed titanium mesh-type patient-specific implant for cranioplasty. Korean J Neurotrauma, 2021, 17(2): 91-99.
6. 叶宏权, 魏大伟, 谢峥, 等. 颞肌外钛网修补颅骨缺损48例临床分析. 中国基层医药, 2020, 27(17): 2150-2153.
7. Yoshioka N, Tominaga S. Titanium mesh implant exposure due to pressure gradient fluctuation. World Neurosurg, 2018, 119: e734-e739.
8. Henry J, Amoo M, Murphy A, et al. Complications of cranioplasty following decompressive craniectomy for traumatic brain injury: systematic review and meta-analysis. Acta Neurochir (Wien), 2021, 163(5): 1423-1435.
9. Goedemans T, Verbaan D, van der Veer O, et al. Complications in cranioplasty after decompressive craniectomy: timing of the intervention. J Neurol, 2020, 267(5): 1312-1320.
10. Kwiecien GJ, Rueda S, Couto RA, et al. Long-term outcomes of cranioplasty: Titanium mesh is not a long-term solution in high-risk patients. Ann Plast Surg, 2018, 81(4): 416-422.
11. Kwiecien GJ, Sinclair N, Coombs DM, et al. Long-term effect of cranioplasty on overlying scalp atrophy. Plast Reconstr Surg Glob Open, 2020, 8(8): e3031. doi: 10.1097/GOX.0000000000003031.
12. Di Rienzo A, Colasanti R, Gladi M, et al. Timing of cranial reconstruction after cranioplasty infections: are we ready for a re-thinking? A comparative analysis of delayed versus immediate cranioplasty after debridement in a series of 48 patients. Neurosurg Rev, 2021, 44(3): 1523-1532.
13. 李阳, 张连阳. 伤口感染的前世今生. 创伤外科杂志, 2022, 24(1): 78-80.
14. 刘代宏, 冯剑, 孙超峰, 等. 颅骨缺损修补术后钛网外露31例. 中华烧伤杂志, 2013, 29(2): 212-213.
15. Yano T, Okazaki M, Tanaka K, et al. The flap Sandwich technique for a safe and aesthetic skull base reconstruction. Ann Plast Surg, 2016, 76(2): 193-197.
16. Maqbool T, Binhammer A, Binhammer P, et al. Risk factors for titanium mesh implant exposure following cranioplasty. J Craniofac Surg, 2018, 29(5): 1181-1186.
17. Chen F, Ju H, Huang A, et al. Treatment of large and complicated scalp defects with free flap transfer. Biomed Res Int, 2020, 2020: 2748219. doi: 10.1155/2020/2748219.
18. Dong L, Dong Y, Liu C, et al. Latissimus dorsi-myocutaneous flap in the repair of titanium mesh exposure and scalp defect after cranioplasty. J Craniofac Surg, 2020, 31(2): 351-354.
19. Wang W, Vincent A, Bahrami A, et al. Progressive scalp thinning over mesh cranioplasty and the role of lipotransfer. Laryngoscope, 2020, 130(8): 1926-1931.
20. 贡荃, 张宏文. 颅骨修补术后钛网外露四例临床分析. 中国基层医药, 2017, 24(24): 3814-3816.
21. 柳大岗, 郭庆雷, 邹积典. 颅骨修补术后反复钛网外露一例并文献复习. 国际医药卫生导报, 2016, 22(9): 1267-1269.
22. 陈黎明, 刘毅, 张诚, 等. 带肌瓣的嵌合穿支皮瓣修复合并深部死腔的难愈性创面. 中华整形外科杂志, 2020, 36(3): 279-283.
23. 刘士强, 唐银科, 楚菲菲, 等. 扩张后头皮瓣修复额、面部病损. 中华整形外科杂志, 2020, 36(7): 776-779.

Chinese Journal of Reparative and Reconstructive Surgery

Application of two-stage operation on free latissimus dorsi myocutaneous flap transplantation and skull contour reconstruction in treatment of head titanium mesh exposure with soft tissue infection

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