Warfare-Related Craniectomy Defect Reconstruction: Early Success Using Custom Alloplast Implants

Walter Reed National Military Medical Center, Washington, Washington, D.C., United States
Plastic and Reconstructive Surgery (Impact Factor: 2.99). 03/2011; 127(3):1279-87. DOI: 10.1097/PRS.0b013e318205f47c
Source: PubMed


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.

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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 "
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    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.[36] Disadvantages of the autogenous bone grafts are developing of donor site morbidity and they may sometimes prove inadequate. "
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    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.
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