Introduction: Treatment of recurrent and intractable fistula after multiple craniotomies or postoperative radiation therapy is challenging. The perifascial areolar tissue (PAT) is the thin layer below the fatty tissue and immediately above the deep fascia, which contains rich vascular plexus. The PAT above the abdominal rectus muscle or gluteus maximus muscle can be safely harvested, and implanted under the skin to cover the fistula sufficiently. Here we report tree cases with intractable skin defect following craniotomy successfully cured by means of PAT.

Methods: Three patients (2 women; age 60-81 years) between March 2015 and February 2017 who had a PAT transplant were reported. Two patients after multiple craniotomy and one after radiation therapy had skin defect which could not be cured by original debridement followed by suturing on multiple occasions. For Pat transplantation, we selected the inguinal region in tow and the gluteus maximus muscle in one as donor site. Successful engraftment was judged with visual inspection by senior doctor (T.K.), and thereafter whether the wound dehiscence was followed up in out-patient clinic.

Results: The mean duration of successful engraftment was 14.7 days. (14-16 days) During the mean follow-up period of 7 months (1-17 month) no recurrence occurred.

Conclusions: PAT is likely safe and effective for treatment intractable skin defect in the field of neurosurgery.

Patient Care: PAT will make it safe and effective to treatment of intractable fistula after craniotomy.

Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of safer and more effective method to treat intractable skin defects, 2) Discuss, in small group, indications for PAT treatment. For example "After how many time of original treatment failure should we use PAT ?", 3) Identify an effective treatment PAT as a free-flap with vascular plexus to transplant for intractable skin defect after craniotomy.

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