PMC4310057_01
This picture shows the patient after the subdural hematoma and bone flap were removed. There is a large wedge-shaped necrosis to the skin flap. Anterior to the necrosis, there is an opening in the scalp with exposed brain parenchyma.
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F1
Subsequently, there was a wedge-shaped necrosis that developed on the flap [Figure 1].
After the scalp was elevated, the dural defect was to the anterior margin of the craniectomy. After meticulously separating the dura, more frontal bone was removed to expose native, intact dura mater
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F2
The dura was noted to be frail, shredded, and portions were missing [Figures 2-4].
This shows the measurements of the dural defect, measuring approximately 7 x 4 cm
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F3
The dura was noted to be frail, shredded, and portions were missing [Figures 2-4].
This shows the measurements of the dural defect, measuring approximately 7 x 4 cm
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F4
The dura was noted to be frail, shredded, and portions were missing [Figures 2-4].
This picture shows the amount of scalp tissue resection, incorporation the necrotic portion and the scalp breakdown with exposed brain tissue. In the middle, the synthetic dural graft has been secure with a water-tight closure
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F5
After achieving securable edges, Durepair  (Medtronic, Inc.) [Figure 5]. was sutured in to native dura with 4-0 Nurolon (Ethicon).
This picture shows the wound vac in place with a good seal to maintain negative pressure
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F6
Negative pressure therapy was set to -50 mmHg [Figure 6].
After days of negative pressure therapy, there is granulation tissue on native dura
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F7
The wound vac was changed approximately every 3 days until adequate granulation tissue was noted and the infection had subsided [Figure 7].
This pictures shows the anterolateral thigh free flap immediately after surgery and in a postoperatively clinic visit, respectively
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F8
The anterolateral thigh free flap was performed without any complications [Figure 8].
This pictures shows the anterolateral thigh free flap immediately after surgery and in a postoperatively clinic visit, respectively
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F9
The patient has been followed for 14 months after surgery with the reconstruction intact [Figure 9].