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Plastic Surgery Closure of Craniotomy Incisions Reduces the Incidence of Wound Complications in Patients with Previous Neoadjuvant Bevacizumab (Avastin) and Radiation
Alyssa R. Golas, MD, Tatiana Boyko, MD, John A. Boockvar, MD, Theodore H. Schwartz, MD, Philip E. Stieg, MD, PhD, Jason A. Spector, MD, FACS.
Weill Cornell Medical Canter, New York, NY, USA.
INTRODUCTION: Craniotomy incisions are often associated with wound healing complications, particularly in the setting of re-operative craniotomy, radiation (XRT) and/or intra-arterial or intra-venous bevacizumab (Avastin) therapy. In the setting of these obstacles to wound healing, wound complication rates may be as high as 44%. As a result of these strikingly high complication rates, plastic surgeons have increasingly become consulted for management of craniotomy incisions in patients deemed to be at “high risk” for wound healing complications. We therefore hypothesized that plastic surgery closure following craniotomy in these patients would decrease the rate of postoperative wound complications.
METHODS: A retrospective review was performed of all patients who underwent craniotomy incision closure at a single institution by a single plastic surgeon between 2006 and 2013. Charts were reviewed for previous operative interventions, the presence of pre-existing infection, indication for plastic surgery involvement, neoadjuvant and adjuvant XRT and/or bevacizumab administration, and the need for surgical intervention following the index plastic surgery closure.
RESULTS: Forty-three patients (64 procedures) were included in the study. Forty-two patients (97.7%) underwent previous craniotomy for indications including intracranial neoplasia (n=32), intracranial hemorrhage (n=5), seizure disorder (n=4), and hydrocephalus (n=1). Average follow-up was 295d (range, 1-1715d; median, 124d). Nine patients (20.9%) required reoperation after their index plastic surgery intervention. Twenty-two patients (51.2%) received 24 “prophylactic” plastic surgery closures (i.e., in the absence of infection) for indications including previous craniotomy (n=22), XRT (n=19), and prior bevacizumab therapy (n=11). Three patients (13.6%) who underwent prophylactic closure (for indications including previous craniotomy +/- XRT) required further surgical intervention (12.5% of prophylactic procedures). Of note, none of the 11 patients who underwent prophylactic closure for previous craniotomy+neoadjuvant bevacizumab+XRT required repeat intervention. Fourteen patients (32.6%) in this series received neoadjuvant bevacizumab+XRT. Of these, only 2 patients (14.3%) required additional plastic surgical intervention for wound complications after their index plastic surgery procedure. Of the 7 patients who received neoadjuvant XRT and adjuvant bevacizumab, 2 (28.6%) required reoperation for wound complications (both patients had also received neoadjuvant bevacizumab). Lastly, 25 patients in this series received neoadjuvant XRT, 5 of whom (20.0%) developed wound complications requiring intervention.
CONLCUSIONS: Plastic surgery involvement in “high risk” patients undergoing re-operative craniotomy and who received neoadjuvant bevacizumab+XRT reduces the incidence of wound complications. This is particularly true when plastic surgery closure is performed “prophylactically.” As the cohort of “high risk” neurosurgery patients undergoing craniotomy continues to grow, further collaboration between the neurosurgical and plastic surgery teams is warranted.
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