Customized acrylic implants for reconstruction of extensive skull defects: an exception approach for selected patients

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Abstract

ABSTRACT Objective: to present our experience in the surgical treatment of extensive skullcap defects with customized acrylic implants. Methods: we conducted a retrospective analysis of patients with extensive skull defects undergoing acrylic cranioplasties between 2004 and 2013. We carefully selected all patients and classified surgical results based on three scales (craniofacial esthetics, improvement of facial symmetry and need for additional surgery). Results: fifteen patients underwent cranioplasty with intraoperative acrylic implants, whether manually customized (46.67%) or made with prototyped three-dimensional biomodels (53.33%). There were two (13.33%) complications (one infection with implant withdrawal and one seroma). We considered the craniofacial aesthetics excellent (50%), the degree of improvement of craniofacial symmetry satisfactory (57.14%), and the overall mean of surgical results according to the need for new surgeries was 1.5±0.52. Conclusion: cranioplasties of patients with extensive skullcap defects should obey careful and predetermined criteria, both for selection and for the acrylic implant customization method.

Translated abstract

RESUMO Objetivo: apresentar nossa experiência no tratamento cirúrgico dos defeitos extensos da calota craniana com implantes de acrílico customizados. Métodos: análise retrospectiva de pacientes com defeitos extensos da calota craniana submetidos à cranioplastias com acrílico entre 2004 e 2013. Todos os pacientes foram criteriosamente selecionados e os resultados cirúrgicos foram classificados com base em três escalas (estética craniofacial, melhora da simetria facial e necessidade de cirurgia adicional). Resultados: Quinze pacientes foram submetidos à cranioplastia com implantes de acrílico customizados manualmente no intraoperatório (46,67%) e confeccionados com base em biomodelos tridimensionais prototipados (53,33%). Mesmo respeitando critérios de seleção, houve duas (13,33%) complicações (infecção com retirada do implante e seroma). A estética craniofacial foi considerada excelente (50%), o grau de melhora da simetria craniofacial foi considerado satisfatório (57,14%) e a média global dos resultados cirúrgicos de acordo com a necessidade de novas cirurgias foi 1,5±0,52. Conclusão: as cranioplastias dos pacientes com defeitos da calota craniana extensos devem ser criteriosamente indicadas, obedecendo a critérios pré-determinados de seleção dos pacientes, bem como, do método de customização do implante de acrílico.

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Complications of cranioplasty following decompressive craniectomy: analysis of 62 cases.

Cynthia Gooch, N E Gin, J German … (2009)

Decompressive craniectomy is a potentially life-saving procedure used in the treatment of medically refractory intracranial hypertension, most commonly in the setting of trauma or cerebral infarction. Once performed, surviving patients are obligated to undergo a second procedure for cranial reconstruction. The complications following cranial reconstruction are not well described in the literature and may very well be underreported. A review of the complications would suggest measures to improve the care of these patients. A retrospective chart review was undertaken of all patients who had undergone cranioplasty during a 7-year period. Demographic data, indications for craniectomy, as well as preoperative, intraoperative, and postoperative parameters following cranioplasty, were recorded. Perioperative and postoperative complications were also recorded. Patients were classified as having no complications, any complications, and complications requiring reoperation. The groups were compared to identify risk factors predictive of poor outcomes. The authors identified 62 patients who had undergone cranioplasty. The immediate postoperative complication rate was 34%. Of these, 46 patients did not require reoperation and 16 did. Of those requiring reoperation, 7 were due to infection, 2 from wound breakdown, 2 from intracranial hemorrhage, 3 from bone resorption, and 1 from a sunken cranioplasty, and 1 patient's cranioplasty procedure was prematurely ended due to intraoperative hypotension and bradycardia. The only factor statistically associated with need for reoperation was the presence of a bifrontal cranial defect (bifrontal: 8 [67%] of 12, requiring reoperation; unilateral: 8 [16%] of 49 requiring reoperation; p < 0.01) Cranioplasty following decompressive craniectomy is associated with a high complication rate. Patients undergoing a bifrontal craniectomy are at significantly increased risk for postcranioplasty complications, including the need for reoperation.

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Materials used in cranioplasty: a history and analysis.

Aatman M Shah, Henry Jung, Stephen Skirboll (2014)

Cranioplasty, one of the oldest surgical procedures used to repair cranial defects, has undergone many revolutions over time to find the ideal material to improve patient prognosis. Cranioplasty offers cosmetic and protective benefits for patients with cranial defects. The first primitive cranioplasty procedures date back to 7000 bc and used metal and gourds to repair cranial defects. Cranioplasty was first documented by Fallopius who described repair using gold plates; the first bone graft was documented by van Meekeren. The first significant improvement for this procedure began with experimentation involving bone grafts in the late 19th century as a more natural approach for repairing cranial defects. The next impetus for advancement came because of wartime injuries incurred during World Wars I and II and involved experimentation with synthetic materials to counter the common complications associated with bone grafts. Methyl methacrylate, hydroxyapatite, ceramics, and polyetheretherketone implants among other materials have since been researched and used. Research now has shifted toward molecular biology to improve the ability of the patient to regenerate bone using bone growth factors. This paper reviews the evolution of materials used over time in addition to the various advantages and pitfalls associated with each change. It is important for neurosurgeons to be mindful of how these techniques have evolved in order to gain a better understanding of this procedure and how it has been adapted.

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A plastic surgery application in evolution: three-dimensional printing.

Theodore Gerstle, Ahmed Ibrahim, Peter Kim … (2014)

Three-dimensional printing represents an evolving technology still in its infancy. Currently, individuals and small business entities have the ability to manufacture physical objects from digital renderings, computer-aided design, and open source files. Design modifications and improvements in extrusion methods have made this technology much more affordable. This article explores the potential uses of three-dimensional printing in plastic surgery.