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Vacuum-assisted scalp repositioning: a novel temporizing approach to acute sinking skin flap syndrome. Illustrative cases

Evan Courville, Joshua Marquez, Michael Homma, Michael Conley, Georgios P Skandalakis, Peter Shin, James Botros, and Christian Ricks


This report describes the use of a novel approach to address acute sinking skin flap syndrome (SSFS), a postcraniectomy complication arising from brain dysfunction beneath the skull defect. The authors present a case series of two patients, emphasizing the prospective application of an external plaster cast in tandem with a vacuum-assisted closure (VAC) device (wound VAC) to promptly reposition the scalp and relieve brain compression.


Following intervention, one patient showed immediate neurological improvement, with complete resolution of symptoms within hours. Conversely, the second patient developed nonconvulsive status epilepticus. Computed tomography scans postintervention validated the successful scalp repositioning and mass effect resolution in both instances. This temporary approach proved successful in one patient with moderate symptoms, serving as a bridge to cranioplasty.


The integration of an external plaster cast and wound VAC offers a cost-effective and prompt solution for patients with acute SSFS pending cranioplasty. Appropriate patient selection and heightened caution for those with severe symptoms should be exercised.