FIG. 19-01. The bony defect and the exposed artificial dura. Front view.

FIG. 19-02. Side view.

FIG. 19-03. The latissimus flap is outlined on the back, and approached through a long posterior axillary line. The patient is in a full right lateral position.

FIG. 19-04. Muscle is mobilized from a distal-to-proximal direction.

FIG. 19-05. After wound debridement, the Dacron dura, which was adherent to the underlying cortex, was removed. The large latissimus muscle is ready for insertion into the defect created by the neurosurgical team.

FIG. 19-06. The muscle has been used to replace the dural defect placed directly on the underlying cortex. The residual skin flap was replaced, and the exposed muscle was covered with mesh grafts. The thoracodorsal vessels were repaired to the occipital vessels, and the motor nerve from the latissimus to the occipital sensory nerve.

FIG. 19-07. The muscle transplant has controlled the infection and closed the wound. Oblique view.

FIG. 19-08. Cap hides defect.

FIG. 19-09. Donor site healed well. The patient was comfortable and no longer posed a wound management problem. He died of recurrent meningioma 3 years postoperatively without infection.

CASE 2

An 80-year-old man had undergone excision and skin grafting of a scalp burn by Dr. Sterling Bunnell in 1940.

FIG. 19-10. Forty years later, the patient complained of a headache and recurrent ulceration of the site. Biopsies were negative for cancer.

FIG. 19-11. The unstable scalp coverage was excised, along with full-thickness skull, to allow wide excision of suspected tumor despite the biopsy results.

FIG. 19-12. Tumor specimen.

FIG. 19-13. The latissimus muscle was elevated and prepared for transplantation.

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