Purpose: The use of free tissue transfer has been well-documented in the literature regarding maxillofacial reconstruction as well as the use of split calvarial bone grafts. However, there is a paucity of information regarding the use of free tissue transfer and split calvarial bone graft to reconstruct the anterior calvarium in a single stage. A patient may present with a large anterior calvarial defect resulting from previous trauma, tumor extirpations, or complications resulting from a previous neurosurgical procedure. These patients may have a significant bony defect, resultant intracranial dead space, and open communication to adjacent sinus cavities. We present a series of patients successfully treated with a single stage procedure including microsurgical free tissue transfer to the intracranial space with simultaneous anterior calvarial reconstruction.

Methods: A retrospective review of all patients undergoing intracranial free tissue transfer and simultaneous anterior calvarial reconstruction at the same institution was performed. Three patients were identified.

Results: Three patients underwent free tissue transfer to obliterate the intracranial dead space as well as obliterate open communication to adjacent sinuses while simultaneously undergoing split calvarial bone graft to reconstruct the bony defect of the anterior calvarium. One patient underwent free transfer of omentum, and two underwent radial forearm free flaps. All three patients had reconstruction of the bony defects with split calvarial graft at the same time. No flap loss occurred in these patients. One revision was performed at seven months postoperatively for aesthetic improvement. Another patient underwent scar revision at five months. No other complications or revisions were performed in these patients.

Conclusion: Intracranial placement of allografts may be indicated in the presence of non-collapsible intracranial dead space, with bony defects in the base of the skull leading to communication with adjacent sinuses, or in a situation with unavailability of local or distant flaps due to trauma, infection, or chronic insult. In addition, the reconstruction of the anterior calvarium serves both a protective and aesthetic function. These difficult cases require a multidisciplinary approach including neurosurgeons, reconstructive microsurgeons, and hospital staff familiar with the care of patients undergoing free tissue transfer. However, in the appropriate setting, this procedure may be done safely in a single stage with minimal complications and acceptable rate of secondary procedures.