Part 1: Introducing the Rectus Fascia Scalp Augmentation Technique A New Method for Improving Scalp Durability in Cranioplasty Reconstruction

Objective: Patients with cranioplasty in need of skull reconstruction are at increased risk of complications when presenting with abnormally thin scalps. As such, the authors sought to develop and investigate a new technique for scalp augmentation using autologous rectus fascia grafts (ARFGs) for prevention of implant extrusion and long-term scalp durability. Methods: A retrospective review of our database, consisting of 450 consecutive cranial reconstructions from 2012 to 2017, was performed under institutional review board approval. Selection criteria included all adult patients requiring implant-based cranioplasty reconstruction and concomitant scalp augmentation using ARFGs. All long-term outcomes were reviewed for scalp-related complications and are presented here. Results: In total, 12 consecutive patients receiving ARFGs were identified. Average follow-up was 10 months (range = 2–17 months). Average graft size and dimension was 82 cm2 (range = 12–360 cm2). All patients (n = 12) underwent concomitant cranioplasty reconstruction and had a history of at least 5 or greater previous neurocranial operations. Six patients had radiation therapy prior to cranioplasty. Two major complications (2/12, 17%) were identified related to deep, recurrent intracranial infections. More importantly, none of the patients (n = 12) in this study cohort developed scalp breakdown and/or implant extrusion in the areas of rectus fascia scalp augmentation. Conclusion: The use of ARFGs for underlay scalp augmentation appears to be both safe and reliable based on our preliminary experience. This new approach is extremely valuable when performing large-size cranioplasty reconstruction in patients with abnormally thin scalps, an extensive neurosurgical history, and/or suboptimal tissue quality. Furthermore, this method has been successful in avoiding free tissue transfer and/or staged tissue expansion as first-line surgery in our complicated cranioplasty population. Address correspondence and reprint requests to Chad R. Gordon, DO, FACS, Neuroplastic and Reconstructive Surgery, Associate Professor of Plastic Surgery & Neurosurgery, Johns Hopkins University School of Medicine, JHOC 8th Floor, 601 N Caroline St, Baltimore, MD 21287; E-mail: cgordon@jhmi.edu Received 27 February, 2018 Accepted 23 April, 2018 Amir Wolff and Gabriel Santiago should be considered as co-first authors. Presented, in part, at the "Third Annual Selected Topics in Craniomaxillofacial Surgery: An International Symposium on Cranioplasty and Implantable Neurotechnology" held at Harvard Medical School in November 2017. The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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