Coverage is not cure: Infected cranioplasty as a deep and recurrent infection - a single-surgeon series of latissimus dorsi free flap reconstruction.

Abstract

Infection or exposure of a cranioplasty is a frequent complication that is usually regarded as resolved once reconstructed. Whether that view holds over years, given that the underlying infection can be deep and life-threatening, is unclear. This study reports a single-surgeon experience of latissimus dorsi (LD) free flap reconstruction for infected or exposed cranioplasty. Consecutive patients undergoing LD free flap reconstruction for infected or exposed cranioplasty between 2010 and 2020 were reviewed retrospectively. Demographic data are reported per patient (n = 23) and operative, microbiologic, and reconstructive data per operation (n = 24). Prosthesis management (removal, saving, partial saving), flap configuration, and outcomes - flap loss, mortality, and recurrence requiring a further free flap - were recorded. Twenty-four LD flaps were performed in 23 patients (median age, 58 years; 56.5% male). The failed construct was autologous-containing in 65.2% and purely alloplastic in 34.8%. Deep extension to the epidural space, cerebrospinal fluid, or intracranial compartment was documented in four patients. No flap was lost. One patient died of septic shock from a deep polymicrobial infection (4.3%). One patient required a second free flap for recurrence approximately four years after the index operation; two others developed late infection, including one late intracranial infection, without a further flap. Late or fatal infection occurred across all management strategies and materials. The median follow-up was 17 months (range, 2-106). Infected cranioplasty is a deep, recurrent, and sometimes fatal infection, largely independent of the buried material. The LD free flap is a reliable, repeatable platform for soft-tissue coverage - but coverage is not cure, and prognosis is governed by the underlying infection, warranting thorough source control and long-term surveillance.