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

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.