Cranioplasty is not required in the reconstruction of small combined scalp and calvarial defects

Background Treatment of scalp malignancies may include the need for craniectomy. The decision to perform cranioplasty is not straightforward and is frequently subjective. The purpose of this study was to assess the clinical outcomes after reconstruction of complex scalp and calvarial defects comparing patients with and without cranioplasty. Methods Retrospective review of the clinical records of a consecutive series of patients that underwent scalp soft tissue reconstruction after craniectomy for malignancy or osteoradionecrosis between 2014 and 2022 at Royal Melbourne Hospital. Demographics, previous treatments, surgical details and post-operative complications were assessed. Traumatic injuries and decompressive craniectomies were excluded. Minimum follow-up of 6 months. Results 37 patients were included in the study. Indications for surgery included skin malignancies, osteoradionecrosis or both. There was one reconstructive failure (in the non-cranioplasty group). Infection and metalware exposure was a common complication in patients who underwent cranioplasty (38.5%). No patient developed neurological symptoms subsequent to craniectomy. One patient needed revision surgery due to aesthetic reasons (cranioplasty group). Transposition flaps were associated with more complications and revision procedures. Conclusion Combined scalp and calvarial defects pose a difficult reconstructive challenge. Stable soft tissue coverage is more reliably achieved with free flap reconstruction. Cranioplasty is not always mandatory and should be reserved for cases with a very large bony defect or when the defect is located in a cosmetically sensitive area.