Single-Unit Elevation of the Scalp, Skull, and Dura: A Modification of the Classic Osteoplastic Flap

Wound healing and infection is a concern for all surgeons, especially in cases of repeat surgical intervention. The osteoplastic flap is a technique that was previously used frequently in cranial surgery but since the introduction of cranial plating systems, it is now used only rarely. A retrospective study showed that although the infection rates of osteoplastic flaps were similar to free flaps, the need for another surgery for surgical washout and bone flap removal was lower (but not statistically significant) in the osteoplastic flap group [1]. This was possibly due to continued vascularization and viability of the bone flap. This was demonstrated by Shelef et al. [2], using a SPECT scan that showed bone viability remained after osteoplastic flaps vs. free flaps [2]. More recently in the neurosurgical literature, there have been descriptions of osteoplastic flap use in decompressive surgeries for TBI, in order to spare patients a second cranioplasty operation [3-5]. We present a case from our institution of the use of an osteoplastic flap in a unique circumstance that required a technical modification of the classic procedure, by elevating the dura while still attached to the bone flap. To our knowledge, this is the first report of a three-layer cranial access flap including the dura.