Loss of substance from the cranial vault: alternative technique in reconstructive surgery.

I n the reconstruction of the cranial vault, the fundamental objectives must be not only the restoration of the anatomic and functional integrity of the corporeal zone involved but also the restoration of the homeostasis of the local tissue; this goal can only be reached through the use of tissue endowed with excellent vascularization, which allows the exercise of a trophic action on the adjacent tissues, this way making it possible to attain a definitive, satisfactory, and stable result over time. We present a clinical case in which the exposure of the bone of the cranial vault was treated with reconstruction through the use of pedunculated muscle, fascia temporalis, and pericranial flaps in a patient under the treatment of radiation therapy and diverse surgical interventions for neoplasia cutaneous recidivism. This treatment method is discussed in comparison to the techniques described in international literature for the covering of the loss of substance with osseous exposure of the cranial vault. An 83-year-old male patient underwent 3 surgical interventions for the treatment of a spinal-cellular carcinoma of the cutis of the vertex region and reconstructions with local cutaneous flaps and grafts. The first intervention, a removal done by another institute, was not followed. The patient arrived under our observation 1 month after and underwent treatment for enlarging of the margins with closing through the rotation of cutis galley and pericranial spiral flaps. After this intervention, the histologic examination showed the complete remission of the tumor and the indemnity of the margins in closeness and depth, which also happened with the removal of the pericranial. After 6 months, the patient showed neoplastic recidivism of the cutis flap and intracranial infiltration, which happened with the erosion of the vault osseous. The neoplasia then reached close contact, without infiltrating, with the upper sagittalis sinus. We then proceeded with another intervention for the removal of the extracranial neoplasia and successive radiation therapy on the site of the removal. The clinical controls showed remission of the disease and absence of recidivisms in the successive 2 years. At 6 months, the presence of cutaneous ulcerization was manifested. The area showed distrophy and discromy, 5 5 cm in size, with an erosive cutaneous ulcer that affected the surface osseous with consequent exposure of the plateau osseus. As a result of the serious lesion, the patient, after having followed the routine preoperational investigations (ematochimic examinations, electrocardiogram, Rx Thorax), was put under general anesthesia and operated on with a tracheal tube. We then proceeded with the removal of the new ulcerated formation between the vertex and occiput with the lozenge depth of cutis finishing at the pericranial. We then proceeded to eliminate the necrotic surface osseous and that which was affected by radiodermatitis through curettage until we reached the healthy osseous.4 To substitute the loss of substance produced by the erosion from the ulcer, an incision was made in the parietal-temporalis region, and we proceeded with the turnover of the fascia-pericranial. To recover the area of exposed bone, we prepared a flap of muscle, pedunculized, rotated, and tunnelized through the undercutis. To cover the fascia of temporalis muscle that remained exposed, a skin graft was drawn in the thickness of the right inguinal region. In this work, the reconstruction with pericranial muscle and fascia temporalis has constituted the ideal solution for the reparation of a defect in the cranial vault region, radiation treated, and under a multiplicity of surgical interventions for aggravated recidivism of the cutaneous neoplasia. The unique side effect could be caused by radiating cranial facial residue, making the local flaps less secure from a vascular point of view. Local flaps can be used like the pericranial or galeal flap or the temporalis muscle flap or a rotation with an overturned de-epithelized cutis flap, but in the case of extensive defects or places where the local flaps cannot be transposed, like the middle cranial hole, because their arch of rotation does not permit them to reach distant locations, the revascularized free flaps become fundamental because they represent the most valid alternative to transpose vascularized tissue. To this end, the most suitable flaps are those that carry large mass and are well vascularized, which are dorsal latissimus of the back, the rectum