Cranial defects are often managed with cranioplasty, where synthetic substances are still extensively used despite the advantages of using biological materials. Among the complications of cranioplasty, skin defects with implant exposure are the most common, with a particularly high incidence when titanium mesh is used. This is a case report of a 32-year-old patient who underwent cranioplasty with titanium mesh. After 2 years, a forehead skin defect with mesh exposure occurred, onto which a latissimus dorsi free flap was applied without removing the mesh. Ten months later, the patient was consulted for another skin defect, and a second latissimus dorsi free flap was applied with near-total mesh removal. After 6 months, another cranioplasty with hydroxyapatite bone cement and flap modification was performed. Lastly, revision surgery with complete removal of the mesh remaining in the right eyebrow was executed after 1 year, and no major complications were seen during the 4 months of follow-up. Through this experience, we suggest that skin defects with mesh exposure need to be managed with total removal of the metal material, followed by cranioplasty using another material and appropriate soft tissue coverage over the reconstructed cranium.
Full-thickness cranial bone defects commonly occur after head trauma or infection; repair by solid cranioplasty using autogenous or alloplastic materials is usually war-ranted for protection and aesthetics [
This report presents the case of a patient with a recurrent forehead skin defect with mesh exposure who underwent cranioplasty with titanium mesh, following craniectomy to manage intracranial hemorrhage and frontal bone fracture. To treat the skin defect with mesh exposure, two latissimus dorsi (LD) free flaps were applied, along with additional cranioplasty with hydroxyapatite bone cement. The study was ap-proved by the Institutional Review Board of Inje University Ilsan Paik Hospital (IRB No. 2021-03-018) and the patient provided written informed consent for the publication and the use of his images.
The patient was a 32-year-old man without any medical history. He had first presented to the department of neurosurgery when he was 24 years old, in a state of unconsciousness with contusional intracranial hemorrhage accompanying a frontal bone fracture caused by a motorcycle accident. The patient underwent emergent craniectomy of the frontal bone. After 6 months, as his symptoms improved, the patient had cranioplasty with titanium mesh to reconstruct the bony defect. Two years after the cranioplasty, the patient presented to the department of plastic and recon-structive surgery with a skin defect of the forehead. The defect was 2.5 cm in diameter and was accompanied by mesh exposure and signs of infection including leaking pus and redness of skin around the defect (
Photographs obtained when the first skin defect occurred. (A) The defect was 2.5 cm in diameter and accompanied by mesh exposure. (B) Ten months after the first latissimus dorsi free flap, a round defect 1 cm in diameter with mesh exposure was observed.
As signs of infection were observed at the site of the defect, the musculocutaneous flap was harvested and placed on the forehead with end-to-end anastomosis to the right superficial temporal artery and vein. Also, intravenous ciprofloxacin was used for 1 month to treat the
Six months after the second latissimus dorsi free flap. (A) Frontal view. (B) Right lateral view. Owing to the absence of mesh under the flap, downward repositioning of the flap was observed.
Photographs taken after the cranioplasty using hydroxyapatite bone cement. (A) Cranioplasty was executed with hydroxyapatite bone cement. (B) Photograph taken immediately postoperatively. The excessive skin below the second latissimus dorsi flap was excised.
Photographs taken after the revisional operation with cranioplasty. (A) Frontal view. (B) Right lateral view. The downward repositioning of the flap improved satisfactorily.
Skull X-ray before and after near-total removal of mesh. (A) Skull X-ray taken before the near-total removal of titanium mesh and second latissimus dorsi free flap. (B) Skull X-ray taken after the cranioplasty with hydroxyapatite bone cement. Near-to-tal removal of mesh except for the area of right eyebrow.
Photographs obtained 4 months after the complete removal of mesh. (A) Frontal view. (B) Right lateral view. The aesthetic problems caused by titanium mesh have been resolved and no major complications occurred during the 4-month follow-up period.
As cranial bone plays a role in not only protecting vital structures but also maintaining the shape of the head, cranioplasty is a widely used technique to manage skull defects and bony abnormalities. Depending on the material used, cranioplasty can be categorized into the two main categories of biological and synthetic. Although the former has the advantages of a lower rejection rate, higher biogenic compatibility, moldability and ability to integrate with bones, especially in pediatric patients, the latter is commonly used because cranioplasty using synthetic implants reduces the duration of operation and pro-vides better aesthetic results via three-dimensional printing and computer-based customization. Use of titanium mesh cranioplasty is particularly preferred because it prevents aesthetic deformity, decreases the vulnerability of brain tissues, and minimizes the risks and expenses associated with secondary procedures [
Meanwhile, there are a number of complications following cranioplasty, such as hematoma, infection and the occurrence of skin defects. When titanium mesh is used, skin defect with implant exposure has been reported in 17.0% of patients [
Standard management of skin defects with titanium mesh exposure involves wound debridement, and removal or ex-change of implants to prevent secondary infection and to achieve suitable aesthetic outcomes [
As our case and previous studies show, titanium mesh underneath the skin leads to a higher rate of soft tissue defects with mesh exposure compared to other materials used for cranioplasty. Therefore, the metal implant should be completely removed to prevent the recurrence of exposure [
After removal of the metal component, another cranioplasty with different foundational material, such as hydroxyapatite bone cement, as in our case, should be applied to maintain the ideal shape of the forehead and prevent downward repositioning of the overlying skin. Additionally, a valid skin-covering procedure should be chosen in consideration of the condition of the wound and for complete coverage of the metal mesh with a flap of sufficient thickness if the mesh cannot be completely eliminated. From this perspective, we chose to harvest large, durable LD musculocutaneous free flaps to manage the infection and minimize donor site morbidity.
As soft tissue defects are the most common complication after cranioplasty using titanium mesh, and can lead to destructive consequences, appropriate and organized management strategies should be applied. We expect our case study to serve as a lesson when faced with similar conditions. As the exposure rate of titanium mesh is higher than that of other materials used for cranioplasty, and skin defects are highly likely to recur if the titanium is not completely removed, we propose that skin defects with titanium mesh exposure must be treated with complete removal of the involved metal component, followed by cranioplasty using another substance and proper reconstruction of the overlying soft tissue to prevent further recurrence of the skin defect.
No potential conflict of interest relevant to this article was reported.