Warfare-Related Craniectomy Defect Reconstruction: Early Success Using Custom Alloplast Implants
ABSTRACT Cranial bone defects secondary to decompression craniectomy associated with the Global War on Terror pose a unique reconstructive challenge. The objective of this study was to evaluate the outcome of alloplastic reconstruction using custom-designed implants for large craniectomy defects from warfare-related cranial trauma.
A review of injured personnel who underwent decompression craniectomy reconstruction and subsequent alloplastic cranial reconstruction in the National Capital Region was performed from 2003 to 2008 (n = 99). Collected data included mechanism of injury, evacuation time, Glasgow Coma Scale score, decompression craniectomy type, and implant type. Outcomes included complications and retention of implants.
Average patient age was 25 years (range, 18 to 53 years). All patients were men. Follow-up was 2.4 years. Improvised explosive device blasts were responsible for 46 percent of injuries. The initial Glasgow Coma Scale score was 7. On arrival to the continental United States, it was 9. Time for evacuation to the continental United States was 6 days. Eighty-eight percent had hemicraniectomies and 12 percent had bifrontal craniectomies. Successful reconstruction with retention of the implant occurred in 95 percent. Five (three hemicraniectomy and two bifrontal) patients underwent implant removal because of infection. Seventy-three patients were complication-free. The reoperation rate with recontouring, drainage, or removal was 18 percent. After reconstruction, seven patients developed hematomas/hygromas, three patients developed seizures, and 10 percent had contour abnormalities (temporal hollowing) requiring revisions.
Despite war wound contamination, massive cranial defects can be successfully reconstructed using custom alloplastic implants. However, reconstruction of frontal cranial defects in proximity to the airways and orbits was associated with infection and implant removal.
- SourceAvailable from: Nobutaka Yoshioka
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- "The author considers that this method is also useful for patients with ventricular shunts because the epidural spaces of these patients are likely to remain after cranial reconstruction, and the resultant dead space can increase the risk of postoperative infections or hematomas.16 Although high rates of brain re-expansion and gradual resolution of the epidural space below the implant after cranial reconstruction have been reported,17,18 large dead spaces can become infectious foci, especially in patients with ventricular shunts.19,20 Moreover, adjusting the pressure or occluding the ventricular shunt tube is also recommended to reduce the risk of potential complications, including epidural hematoma, effusion, and infection.21,22 "
ABSTRACT: Background: The objective of this study was to describe the outcomes of an algorithmic approach to cranial reconstruction following the removal of an infected synthetic dura mater substitute due to postcraniotomy infection. Methods: A retrospective review was conducted of the cases of 12 patients who underwent cranial reconstruction from 2006 to 2013 after the removal of an infected expanded polytetrafluoroethylene sheet (a synthetic dura mater substitute) due to postcraniotomy infection. Results: Average patient age was 46 years (range, 19–70 years). Follow-up was 4.6 years. The expanded polytetrafluoroethylene sheets were implanted after decompressive craniectomy or after combined resection of the dura mater and a tumor. Epidural, but not subdural, abscesses were found in 6 patients, in whom a sufficient capsule developed underneath the synthetic dura mater. Both epidural and subdural abscesses were found in the remaining 6 patients, and the capsule remained intact after debridement of the subdural abscesses in half of them. Secondary cranial reconstruction was safely performed by leaving the capsule intact in the 9 cases in which no additional dural reconstruction was performed. In the remaining 3 patients, in whom no capsule remained after debridement, secondary cranial reconstruction was carried out by leaving the pericranium over the brain surface. None of the patients developed postoperative complications in follow-up periods. Conclusions: Staged cranial reconstruction after the removal of an infected synthetic dura mater substitute using an algorithmic approach is feasible and safe, produces satisfactory cosmetic results, and is not associated with any complications.04/2014; 2(4):e134. DOI:10.1097/GOX.0000000000000087
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- "In cases where the scalp is intact and there is an isolated defect of the calvaria, polymethyl-methacrylate has been used successfully for recontouring. Kumar et al. reported a 95 % success rate using customized methylmethacrylate implants to reconstruct craniectomy defects. Disadvantages of the autogenous bone grafts are developing of donor site morbidity and they may sometimes prove inadequate. "
ABSTRACT: Background:The management of advanced cutaneous malignancies has been controversial. Thirteen patients with nonmelanoma skin neoplasias that had invaded the bone of the calvarium and scalp were treated in our centre.Objective:The purpose of this study was to evaluate our experience in treating these malignancies with scalp resection and full or partial thickness cranium reconstruction.Patients and Methods:From June 2008 to March 2012, thirteen patients with locally advanced tumours of the scalp invading the calvarium were treated with wide local excision of the scalp combined with an underlying craniectomy and dural resection if needed.Results:Using histopathological diagnosis eleven patients were diagnosed with basal cell carcinoma and two patients with squamous cell carcinoma. A full thickness cranium resection was performed in seven patients and partial in six patients.Conclusion:These large cancers occasionally invade adjacent structures, as well as bone, presenting a challenging surgical problem. In general, giant rotational or island scalp flaps and free tissue transfers are needed to close the area. Finding clean margins are an important part of treating patients with bone involvement and can usually be attained using outer tabula curettage thus preventing unnecessary morbidity.Indian Journal of Plastic Surgery 03/2014; 47(1):36-42. DOI:10.4103/0970-0358.129621
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ABSTRACT: : The objective of this study was to report outcomes after initiation of an algorithmic approach (Bethesda protocol) using intracranial free flaps, cranial bone autografts, and dermal/fat grafts to treat warfare-related cranial frontofacial defects after war-related decompressive craniectomy. : A retrospective review of personnel undergoing complex cranial defect reconstruction that required free flap interpositions for dead space obliteration, cranial bone grafting, or dermal/fat grafting for orbital defects was performed over a 52-month period. : From March of 2003 to July of 2011, 13 patients were identified who underwent complex craniofacial defect reconstruction. All patients were male (average age, 25 years). Average follow-up was 3.6 years. Glasgow Coma Scale score was 7 initially and 9 on arrival to the continental United States. Average evacuation time was 4.2 days. Forty-six percent of injuries were blast injuries. Nine patients (69 percent) underwent hemicraniectomies and four (31 percent) underwent bifrontal craniectomies. Two patients required free flaps and four required free flaps and cranial bone grafts for skull base reconstruction. Five patients required cranial bone grafts and two required cranial bone grafts with dermal fat grafts for reconstruction. All patients were complication free at conclusion of the study. The initial free flap success rate was 86 percent (six of seven flaps). Successful frontal bar/free flap reconstruction was present in 100 percent and the secondary cranioplasty rate was 77 percent. : Decompressive craniectomy defects associated with orbital, sinus, and skull base defects can be successfully reconstructed using an algorithmic approach with low morbidity and high secondary cranioplasty retention rates. : Therapeutic, IV.Plastic and Reconstructive Surgery 11/2012; 130(5):1101-9. DOI:10.1097/PRS.0b013e318267d5cb · 3.33 Impact Factor