Adult Cranioplasty Reconstruction With Customized Cranial Implants: Preferred Technique, Timing, and Biomaterials

Introduction: Complex cranial defects requiring delayed reconstruction present numerous challenges. Delayed cranioplasties accompany frequent complications approaching an incidence of 35 to 40%. Therefore, the authors sought to collate their experience in hopes of sharing their perspective on several topics including technique, timing, and preferred biomaterials. Methods: The authors' 5-year consecutive experience over 430 customized cranial implants is described herein. Since its inception in 2012, the authors' team has employed the pericranial-onlay cranioplasty technique instead of the standard epidural approach. Optimal timing for cranioplasty is determined using objective criteria such as scalp healing and parenchymal edema, close collaboration with neuroplastic surgery, conversion from autologous bone to sterile implant in instances of questionable viability/storage, and the first-line use of solid poly(methylmethacrylate) implants for uncomplicated, delayed cases, first-line porous polyethylene (MEDPOR) implants for single-stage cranioplasty, and first-line polyether-ether-ketone implants for cases with short notice. Furthermore, the use of the pterional design algorithm with temporal bulking for all customized implants has helped to correct and/or prevent temporal hollowing deformities. Results: The authors' team has observed a three-fold reduction in reported complications as compared with the existing literature, with a major complication rate of 11%. The multidisciplinary center has provided an optimal stage for synergy and improved outcomes versus standard cranioplasty techniques. Conclusion: Secondary cranial reconstruction, or cranioplasty, can be challenging due to numerous reasons. These best practices, developed in collaboration with neuroplastic surgery and neurosurgery, appear to encompass the largest published experience to date. The authors find this approach to be both safe and reliable. Address correspondence and reprint requests to Chad Gordon, DO, FACS, Associate Professor of Plastic Surgery and Neurosurgery, Johns Hopkins University School of Medicine, 601 N. Caroline St, JHOC 8th floor, Baltimore, MD 21287; E-mail: cgordon@jhmi.edu Received 15 November, 2017 Accepted 22 December, 2017 CG is a consultant for Stryker Craniomaxillofacial (CMF) and Longeviti Neuro Solutions. The authors report no conflicts of interest. AW and GFS should be considered co-first authors. This paper was supported in part by a research grant received from Stryker Craniomaxillofacial (Kalamazoo, MI), which was reviewed and approved by the Johns Hopkins University in accordance with its conflict of interest policies. © 2018 by Mutaz B. Habal, MD.

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