1. Skull flaps: autologous tissue
Paige klem. Or consortium 2019
Some of the notes are added by Jaimeson Hatch, RN

2. The Basics What does autologous mean? Reason for a skull flap?
Cells or tissues obtained from the same individual
Reason for a skull flap?
Craniectomy: Surgical removal of a portion of the skull.
Relieve pressure on the brain
Due to bleeding or swelling
Trauma
Stroke
Typically drains placed
Video:
Main reasons: an immediate emergency craniectomy/craniotomy for a brain bleed/relief of pressure or tumor removal. 

3. Removal of skull flap
After the procedure is done (evacuating a clot) the brain will continue to swell
To allow the brain to swell upward rather than downward (compressing the brainstem)
If there is infection, the bone flap may be discarded
Also depending on the type of trauma (shattered or broken)
Note: The brain may not immediately swell, or the swelling may be
minimal which results in the flap being replaced after the surgery and
then the patient coming back to have the flap removed.
Just to note, the brain may not immediately swell... or the swelling may be minimal which results in the flap being replaced after the surgery and then the patient coming back to have the flap removed. 
The bone flap isn’t usually discarded at the time of removal unless it is shattered or broken I.e the surgeon is using an existing opening in the skull due to trauma to make the opening bigger. If they are concerned about infection, it is usually when they are replacing the flap. Either way, the surgeon will usually due some culture swabs of the bone to determine if there is anything growing

4. Storage of bone flap options
Freezer
Abdominal Pocket flap:
A pocket is made in the subcutaneous tissue of the patients abdomen
It is protected by the fatty tissue of the patient
Pros and Cons?
Higher risk of infection with pocket flap
Storage- most of the time it is going to go into the freezer... I have only seen an abdominal pocket done twice... and one of those was for religious purposes. The patient’s family wanted all of the patient’s body parts to be with him. There is a higher risk of infection or degradation of the skull flap if it is implanted under the skin. 

5. guideline: Autologous cranial bone flaps
May be frozen or cryopreserved, at −4° F (-20° C) or colder for six months or less.
Autologous bone may be stored at −40° F (-40° C) or colder for up to five years with verification that the facility has registered with FDA as a tissue establishment, or verification that registration as a tissue establishment is not required.
May be stored in a subcutaneous pocket within the patient in a location determined by the physician, and
Will not be subjected to the steam sterilization process unless
there is a clinical indication to do so (eg, to destroy tumor cells) and
the facility has registered with US Food and Drug Administration as a tissue establishment.
A hospital has to be registered for it to be able to keep bone flaps longer than 6 months. Also, each facility has to have a tracking system in place for each specimen. Each facility also has to have a system for cataloguing the specimen. If the patient becomes deceased, the hospital has to make every attempt to return the specimen to the patient’s family (if desired) or it has to follow protocol for disposal. Sometimes if a patient dies during their hospital stay, the medical examiner or the funeral home will collect the skull flap along with the patient

6. Temperature monitoring of fridge/freezer
Provide continuous temperature monitoring and should be monitored regularly with daily temperature checks recorded;
Have an alert or alarm system that notifies personnel when the temperature is not within the acceptable range; and
Have an emergency power system.
The alert or alarm should sound in an area where an individual is present at all times to initiate corrective action or notify personnel who are available to respond. Processes should be established for maintaining the temperature and integrity of stored autologous tissue in the event of a refrigerator or freezer malfunction and for responding to a malfunction of the refrigerator or freezer that occurs when the facility is closed or when the area where the tissue is stored is unoccupied.

7. Replacement of bone flap
Typically 2-3 months after craniectomy
Dependent upon patient disease process
Concerns:
Bone resportion
Can be avoided if replantation is in less than 6 months
Infection
- Once the danger of swelling is over, the flap can be replaced. If the patient is going to have more surgeries, it is better to leave it off. 
- Every time the flap is removed from the freezer and defrosted, there is a higher chance of infection and degradation of the flap. 
- The bone flap is defrosted and rinsed in antibiotic irrigation. Depending on each facility, the defrost occurs either inside the package  or directly in the irrigation. 
- Surgeon may repeat culture swabs upon implantation even if they did swabs at removal
- there are multiple matrixs that can be used to fill in the missing space... 
- screws and plates to connect flap to skull come in many shapes and sizes... main one used looks like a dog bone :-)
- brains do not grow back...

8. What does your policy say?
Find your hospital policy
How do you label this?
What do you document?
Where is your freezer?
Also, with outlying facilities... if their patient gets transported to Anchorage, what is the policy on transporting the specimen with the patient...