Using the Reversed Temporal Island Flap to Cover Small Forehead Defects from Titanium Mesh Exposure After Cranial Reconstruction

doi:10.1016/j.wneu.2018.01.070

World Neurosurgery

Volume 112, April 2018, Pages e514-e519

https://doi.org/10.1016/j.wneu.2018.01.070 Get rights and content

Highlights

•
Reversed temporal island flap can be used to cover small defects from titanium mesh exposure after cranial reconstruction.
•
Flaps were survived completely and the titanium meshes were reimplanted with no complications.
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The results were aesthetically and functionally sufficient with minimal donor-site morbidity in all cases.

Background

Skin ulcers and alloplastic implant exposure are intractable complications that arise after cranial defect reconstruction. Many methods have been used to repair these defects, including skin grafting, local flaps, and free flaps; however, in most cases, alloplastic implants must be removed to control infections. Here, we describe the use of a reversed temporal island flap to repair exposed titanium mesh without removing it.

Methods

Eight cases of skin and titanium mesh exposure were included from 2010 to 2015. A preauricular flap pedicled on the reversed superficial temporal artery was designed to repair forehead defects. The titanium mesh was retained, resterilized, and reimplanted.

Results

Flaps were survived completely, and the titanium meshes were reimplanted with no complications. The results were aesthetically and functionally sufficient, with minimal donor-site morbidity in all cases during the 10- to 24-month follow-up period.

Conclusions

The described method is easy to design and perform. The flap has a reliable blood supply to help fight infection. The titanium mesh is preserved completely, avoiding a second cranioplasty.

Introduction

Cranial defects caused by trauma, tumor excision, and fracture must be repaired with allograft materials when the skull is unavailable for use. Custom-made titanium mesh, which is easily shaped, sterilized, nonabsorbable, strong, light, and has high tissue compatibility, is widely used in cranioplasty.1, 2, 3 However, skin or scalp ulcers resulting from titanium exposure may cause infections or poor blood circulation, resulting in physiological and psychological damage to the patient. From 2010 to 2015, we used a preauricular flap pedicled on the reversed superficial temporal artery (STA) to repair forehead defects in 8 patients without removing the titanium mesh. Successful aesthetic and functional results were achieved.

Section snippets

Patients and Methods

The inclusion criteria were as follows: 1) ulcers had to have occurred in the forehead area; 2) ulcers had to be relatively small, in the range of 1.0 cm × 1.0 cm to 2.5 cm × 2.5 cm; and 3) the STA had to be available for reconstruction. From 2010 to 2015, 8 patients (3 females and 5 males) were treated using this method (Table 1). The average age of the patients was 37.6 years (range, 29–56 years). The size of the defect ranged from 1.0 cm × 1.2 cm to 2.0 cm × 2.5 cm. The follow-up period was

Results

For the 8 patients who underwent this procedure, the flaps survived completely without blood supply problems, titanium exposure, or secondary infection during the 10- to 24-month follow-up period. Subcutaneous hydrops occurred in 1 patient but resolved after suction with a syringe on the seventh postoperative day. The smallest ulcer was 1.0 cm × 1.2 cm and the largest was 2.0 cm × 2.5 cm. The scalp incision scar was hidden by hair, and the donor site scar was inconspicuous.

Discussion

Cranial defects caused by trauma, tumor excision, or fracture are a common challenge that often occur as a result of neurosurgery and craniomaxillofacial surgery and can cause functional and aesthetic complications requiring reconstruction. The materials for cranioplasty include autograft and prosthesis implants, such as titanium mesh, polymethylmethacrylate, poly-ether-ether ketone, and hydroxyapatite cement. Titanium is considered by many to be the material of choice, as it is biocompatible,

Conclusions

A reversed temporal island flap can be successfully used to repair exposed titanium mesh after cranial defect reconstruction with satisfying results. A pedicled flap maintains blood supply and reduces infection rate. Sterilizing and reimplanting titanium mesh is a practicable method, which can reduce the economic burden of patients. Although this technique has several clinical applications, it can only be used to repair small defects. Further study evaluating long-term outcomes will help

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Cited by (8)

Muscle Forehead Flap: Salvage Surgery for Closure of Cutaneous Fistula After Cranioplasty Exposure
2019, World Neurosurgery
Citation Excerpt :
In addition, in cases of forehead skin fistula, this procedure can impede the forehead closure because of secondary skin loss. Another technique has been described to cover frontal titanium plate exposure using a temporal island flap.9 This procedure is based on a preauricular skin flap pedicled on the reversed superficial temporal artery to close skin fistula with similar color, thickness, and texture to the forehead skin.
Infection and skin fistula are well-known complications after cranioplasty leading to reconstruction exposure and usually requiring new surgical procedure with poor condition for cutaneous closure. We describe 2 cases using muscle forehead flap (MFF) to treat skin fistula and cranioplasty exposure.
The first case was a 43-year-old man who underwent a calvarial bone graft of the frontal sinus anterior wall after craniofacial trauma. Three months postoperatively, osteitis of the bone reconstruction and a skin fistula occurred in the median frontal region.
The second case was a 37-year-old woman treated for a cingular glioblastoma by 3 surgeries, concomitant chemoradiation therapy, and frontal reconstruction using a titanium plate. She presented a plate exposure associated with cerebrospinal fluid leak and meningitis.
Both patients were successfully treated by surgical removal of the frontal cranioplasty and skin closure using MFF. We observed a satisfying cosmetic result with no recurrence of infection or fistula at 12 and 4 months, respectively.
MFF is a surgical option to treat complex cases of cutaneous fistula secondary to cranioplasty exposure of the anterior cranial fossa.
Titanium Mesh Implant Exposure Due To Pressure Gradient Fluctuation
2018, World Neurosurgery
Citation Excerpt :
Several studies have reported on the complications of titanium mesh implants (TMIs), including thinning of the overlying skin and implant exposure.1-3
Titanium mesh implants (TMIs) are used for various purposes in craniotomy. Although delayed implant exposure and thinning of the overlying skin are well-known complications, the mechanism has not yet been elucidated. We reviewed our cases and propose a mechanism for TMI exposure.
From 2009 to 2018, we treated 14 patients with delayed titanium implant exposure after craniotomy. The exposed titanium implant was a TMI in 4 patients, a titanium mesh plate in 6 patients, and a titanium fixation plate with holes in 4 patients. We reviewed the preoperative computed tomography (CT) scans and operative findings.
The interval between craniotomy and implant exposure was 13 years (range, 5–27). Implant exposure occurred at the temporal region in 7 patients, frontal region in 6 patients, and parietal region in 1 patient. The skin ulcer size ranged from 0.25 to 10 cm² (mean, 1.95). In the patients with TMI exposure, the dura was expanded, and no residual epidural space was identified on the CT scans; however, epidural dead space was revealed on the CT scan in the patients with titanium mesh plate or titanium fixation plate exposure.
We believe that the key factor resulting in delayed titanium mesh exposure is the pressure gradient between the atmosphere and the intracranial space. Fluctuation of this gradient exerts dynamic stress on the tissue in the mesh holes and the adjacent tissue, resulting in tissue damage and implant exposure.
Healing Exposed Calvarial Hardware Using Negative-Pressure Wound Therapy and Vashe Wound Solution: Case Report
2023, Advances in Skin and Wound Care
Treatment strategy and therapeutic effect analysis of implant exposure after skull defect repair
2023, Chinese Journal of Neurosurgery
Application of Autogenous Dermis Combined with Local Flap Transplantation in Repair of Titanium Mesh Exposure after Cranioplasty
2023, Journal of Craniofacial Surgery
The use of free myocutaneous flap and implant reinsertion for staged cranial reconstruction in patients with titanium mesh exposure and large skull defects with soft tissue infection after cranioplasty: Report of 19 cases
2021, Microsurgery

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: Conflict of interest statement: This work was supported by the education financial support of Peking Union Medical College [grant numbers 10023201504022].

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Original ArticleUsing the Reversed Temporal Island Flap to Cover Small Forehead Defects from Titanium Mesh Exposure After Cranial Reconstruction

Highlights

Background

Methods

Results

Conclusions

Introduction

Section snippets

Patients and Methods

Results

Discussion

Conclusions

World Neurosurg

J Plast Reconstr Aesthet Surg

Br J Plast Surg

Complications of titanium cranioplasty—a retrospective analysis of 174 patients

Acta Neurochir (Wien)

Cranioplasty: don't forget the patient's own bone is cheaper than titanium

Br J Neurosurg

Individual prefabricated titanium implants in reconstructive craniofacial surgery: clinical and technical aspects of the first 22 cases

Plast Reconstr Surg

Long-term results following titanium cranioplasty of large skull defects

Neurosurg Focus

Titanium cranioplasty and the prediction of complications

Br J Neurosurg

Cranioplasty with custom-made titanium plates—14 years experience

Neurosurgery

Original Article
Using the Reversed Temporal Island Flap to Cover Small Forehead Defects from Titanium Mesh Exposure After Cranial Reconstruction