An algorithmic approach of reconstruction for cranioplasty failure: A case series

Abstract

Rationale: Cranioplasty is a surgical procedure used to repair cranial defects for both cosmetic and functional reasons. The complication rate of cranioplasty is between 10% and 50%. The failure of cranioplasty is associated with various factors, including etiologies, types of material, and the timing of cranioplasty. In this study, a case series of managing cranioplasty complications at a single institution.

Patient concerns: Eighteen patients were identified who underwent craniofacial defect reconstruction due to the failure of their initial cranioplasty between January 2010 and May 2020. Five men (27.78%) and thirteen women (72.22%) were included. The mean age was 39.61 years old. The average follow-up duration was 5.94 years.

Diagnoses: The indication for initial cranioplasty included previous decompressive craniectomy (77.78%, n = 14), traumatic cranial defects (16.67%, n = 3), and congenital cranial deformity (5.56%, n = 1). The reported complications were infection (50%, n = 9), implant exposure (50%, n = 9), wound dehiscence (22.22%, n = 4) and cranial deformity (11.11%, n = 2).

Interventions: More than half of the materials used for initial cranioplasty were synthetic [titanium mesh: 44.44%, n = 8; polymethyl metacrylate: 5.56%, n = 1; titanium mesh and polymethyl metacrylate: 5.56%, n = 1], while 44.44% of the patients received autologous bone graft.

Outcomes: Of all reconstructive procedures for cranioplasty failure, 55.56% was local flap with or without skin graft (n = 10), 16.67% was free flap (n = 3), 11.11% was skin graft only (n = 2), 5.56% was regional flap (n = 1). The free flap survival rate was 100% (3/3), and implant removal with sebsquent second cranioplasty was performed on 27.78% (n = 5) of the patients.

Lessons: Management of cranioplasty failure can be challenging due to infection, refractory implant exposure, and wound dehiscence. The principles of management are based on adequate infection control and reconstructive ladder. Meanwhile, collaboration with plastic surgery and neurosurgery should be strengthened in order to achieve the best clinical outcomes.

Figure 1.

Analysis of defect classification and reconstructive procedures. (A) The association between scalp defect size and the reconstructive procedures. For scalp defect size larger than 30cm², the patients underwent free flap surgery. *, P < .05. (B) The association between location of scalp defect and the reconstructive procedures. The majority the scalp defects were in the vertex region, and these patients had a local/regional flap or skin graft performed. The second most affected location was the temporoparietal region, and about half of these defects were treated with local/regional flap.

Figure 2.

A 26-year-old woman with frontal implant exposure after cranioplasty (Case No. 3 of Table 1). (A) The preoperative image showed frontal implant exposure. (B) Customized 3-dimensional titanium mesh. (C) Intraoperative image. The first-stage reconstruction of titanium mesh reshaping and ALT flap for the scalp defect were performed. (D) Postoperative image took 1 week after the surgery. (E) The postoperative image was taken 5 months the surgery. A depression in the frontal region was noted. (F) Immediate postoperative image. The second-stage reconstruction of autologous fat graft for frontal depression was performed 5 months after the first-stage of reconstruction.

Figure 3.

A 45-year-old woman with cranioplasty wound dehiscence and implant exposure (Case No. 3 of Table 1). (A) Preoperative image. (B) Intraoperative image. Titanium mesh reshaping and the scalp reconstruction with rotation flap. (C) Postoperative image was taken immediately after the surgery.

Figure 4.

The algorithm for management of cranioplasty failure. The strategy for reconstruction of cranioplasty failure should follow the principles of the reconstructive ladder and the concept of “like with like” in order to achieve satisfying functional and aesthetic outcomes. The location and size of the defect, etiology, wound quality, infection, underlying tissue exposure, hairline involvement, and presence of skull deformity should all be carefully considered. Primary closure can be used for small defects in the loose region of the scalp. Local flap with or without skin grafting has been used for small defect with hairline involvement, medium-to large-sized scalp defects. Free flaps are indicated in medium-to large scalp defects with implant or cranial exposure and poor healing wounds. The choice of synthetic or autologous materials to treat skull deformity is determined by the infection condition and material availability.