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  • Title: [Application of two-stage operation on free latissimus dorsi myocutaneous flap transplantation and skull contour reconstruction in treatment of head titanium mesh exposure with soft tissue infection].
    Author: Liu X, Han Y, Cui L, Shu J, Guo L, Tao R, Lei Y, Han Y.
    Journal: Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi; 2022 Jul 15; 36(7):828-833. PubMed ID: 35848178.
    Abstract:
    OBJECTIVE: To explore the effectiveness of two-stage operation on free latissimus dorsi myocutaneous flap transplantation and skull contour reconstruction in the treatment of head titanium mesh exposure complicated with soft tissue infection. METHODS: Between January 2015 and December 2021, 13 patients with head titanium mesh exposure complicated with soft tissue infection were admitted. There were 9 males and 4 females with a mean age of 42.9 years (range, 23-64 years). The duration of titanium mesh exposure was 22-609 days (median, 102 days). The wound site located at the frontal part in 3 cases, the parietal part in 1 case, the occipital part in 2 cases, the frontal-parietal part in 1 case, the temporal-parietal part in 4 cases, and the frontotemporal part in 2 cases. The titanium mesh had been taken out in 5 patients before admission, leaving skull defect and shape collapse, with signs of infection. The bacterial culture was positive in 7 cases and negative in 6 cases. The imaging examination revealed that the size of the skull defect ranged from 6 cm×5 cm to 21 cm×17 cm and the scalp defect ranged from 1 cm×1 cm to 15 cm×10 cm. The soft tissue infection did not reach dura in 5 cases, reached dura in 6 cases, and reached frontal sinus in 2 cases. The two-stage surgical protocol was used in all patients. In the first-stage operation, the latissimus dorsi myocutaneous flap was designed to repair the skull and scalp defects after removing the titanium mesh and thorough debridement. The size of muscle flap ranged from 13.5 cm×4.0 cm to 21.0 cm×17.0 cm, and the skin flap ranged from 7.0 cm×4.0 cm to 15.0 cm×10.0 cm. After the flap survived and stabilized, the second-stage operation was performed. The titanium mesh was implanted to reconstruct the skull contour. The size of titanium mesh ranged from 7.0 cm×6.0 cm to 21.5 cm×17.5 cm. The interval between the first- and second-stage operations was 3.7-17.8 months, with an average of 11.4 months. The survival of the skin flap, the appearance of the head, and the presence of re-exposed titanium mesh and infection were observed after operation. RESULTS: At the first-stage operation, venous embolism occurred in 1 case, and no obvious abnormality was observed after treatment. All the flaps survived and the incisions healed by first intention. Besides, the incisions of the second-stage operation healed by first intention. All patients were followed up 1-96 months (median, 14 months). During follow-up, no exposure to titanium mesh, infection, or other complications occurred. The appearance satisfaction rate of the patients was 92.31% (11/13). There was no significant difference in the skull contour between the affected side and the healthy side in all patients. CONCLUSION: For the head titanium mesh exposure with soft tissue infection, the application of two-stage operation on free latissimus dorsi myocutaneous flap transplantation and skull contour reconstruction can reduce the risks of implant exposure and infection again by increasing the thickness of the scalp and blood supply, filling the wound cavity, and obtain good effectiveness. 目的: 探讨分阶段游离背阔肌皮瓣移植及颅骨轮廓重建治疗头部钛网外露合并软组织感染的疗效。. 方法: 2015年1月—2021年12月，收治13例头部钛网外露合并软组织感染患者。男9例，女4例；年龄23～64岁，平均42.9岁。钛网暴露时间22～609 d，中位时间102 d。创面部位：额部3例，顶部1例，枕部2例，额顶部1例，颞顶部4例，额颞部2例。其中5例该次入院前钛网已取出，遗留颅骨缺损和外形塌陷，存在感染征象。细菌培养阳性7例，阴性6例。影像学检查示颅骨缺损范围为6 cm×5 cm～21 cm×17 cm，头皮缺损范围为1 cm×1 cm～15 cm×10 cm；软组织感染深度：未侵及硬脑膜5例，侵及硬脑膜6例，侵及额窦2例。采用分阶段手术方案，第1阶段取出钛网、彻底清创后，切取背阔肌皮瓣修复颅骨及头皮缺损。背阔肌皮瓣切取范围：肌瓣13.5 cm×4.0 cm～21.0 cm×17.0 cm，皮瓣7.0 cm×4.0 cm～15.0 cm×10.0 cm。待皮瓣成活稳定后行第2阶段手术，再次植入钛网，重建颅骨轮廓；钛网范围为7.0 cm×6.0 cm～21.5 cm×17.5 cm。两次手术间隔时间3.7～17.8个月，平均11.4个月。术后观察皮瓣成活、头部外观，有无钛网再次外露和感染等情况发生。. 结果: 第1阶段术后1例出现皮瓣静脉栓塞，经处理后未见明显异常；背阔肌皮瓣全部成活，供受区创面均Ⅰ期愈合。第2阶段术后切口均Ⅰ期愈合。13例患者均获随访，随访时间1～96个月，中位时间14个月。随访期间无再次钛网外露、感染等情况发生。末次随访时，患者外观主观满意率为92.31%（11/13）。所有患者创区颅骨轮廓与健侧无明显差异。. 结论: 对于头部钛网外露合并软组织感染，分阶段游离背阔肌皮瓣移植及颅骨轮廓重建方案通过增加头皮厚度及血供、填塞死腔，减少了钛网再次暴露和二次感染风险，临床疗效确切。.
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