Two-Staged Three-Layered Cranial Reconstruction: Galeocapsular Flaps Through Tissue Expansion and Slit-Designed CAD/CAM Titanium Implants

Abstract

The formation of extradural dead space in cranial reconstruction increases the risk of seroma, hematoma, and abscess formation, necessitating complex procedures such as free flap reconstruction. This study presents a novel approach combining a customized CAD/CAM-designed titanium implant with strategically placed slots and tissue expansion to generate galeocapsular flaps, ensuring both vascularized implant coverage and improved aesthetic outcomes. A 10-year-old male patient with a large cranial defect underwent a 2-stage procedure. Initially, tissue expansion was performed using bilateral expanders placed in the parietal region. A patient-specific titanium implant with predesigned slots was fabricated to facilitate galeocapsular flap transposition. After sufficient expansion, the expanders were removed, and 3 vascularized galeocapsular flaps were harvested. Two flaps were advanced through the slits in the implant, effectively filling the extradural dead space, while the third flap was positioned over the implant, creating a vascularized barrier between the implant and overlying skin. The implant was secured, and the expanded skin was advanced to ensure tension-free closure. The dual-layer vascularized coverage technique successfully minimized dead space while simultaneously reducing the risk of implant exposure and infection. The additional vascularized layer between the implant and skin provided an extra protective barrier, preventing adhesion and improving long-term integration. Furthermore, the use of expanded scalp tissue allowed for hair-bearing skin coverage, enhancing the final aesthetic outcome. At the 12-month follow-up, no complications, such as seroma, infection, implant extrusion, or scarring-related alopecia were observed.