Two-stage free flap reconstruction of the scalp and calvaria for large neurosurgical resections

BACKGROUND Free tissue transfer is occasionally necessary during reconstruction of large scalp and calvarial bone resections. A single-stage procedure is usually performed but if a flap becomes necrotic it exposes brain tissue or the meninges. Performing a two-stage procedure, the surgeon must preserve flap vitality and manage flap complications before resecting a tumor, and therefore before exposing the brain or meninges. We report here the first series of two-stage free-flap reconstruction during major neurosurgical resection. METHODS From 2012 to 2018, nine free-flaps were performed to eight patients (61 years-old, on average). Average skull resection was 10.1 cm × 15 cm (range 6-18 cm × 9-24 cm). It was performed in all cases due to large malignant tumors. Resection/reconstruction was performed in all case in a two-step procedure: during the first step, the free-flap was harvested and anastomosed to the cranial site; during the second step, resection was performed and the flap was positioned into the defect to assure coverage. RESULTS Average flap size was 11.3 cm × 17.7 cm (range: 7-20 cm × 11-30 cm). Two flap complications occurred after the first stage and one flap did not survive. One patient died before the second stage. Seven patients had the second procedure; no flap complication occurred. All procedures ended in complete wound healing. Follow-up period was 41.5 months on average (range: 10-83 months). Final outcome was total remission for two patients, recurrence for four patients, and two patients died. CONCLUSIONS Our data suggest that the two-stage free-flap reconstruction may be employed for major scalp and calvaria resection.