• Justine C Lee, Grant M Kleiber, Aaron T Pelletier, Russell R Reid, and Lawrence J Gottlieb.
• Chicago, Ill. From the Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medical Center.
• Plast. Reconstr. Surg. 2013 Oct 1; 132 (4): 967-75.

BackgroundComposite 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.MethodsPatients with high-risk composite cranial defects treated with free flap reconstruction containing a vascularized osseous component from 2003 to 2012 were reviewed retrospectively.ResultsFourteen 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.ConclusionsSoft-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 EvidenceTherapeutic, IV.

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