Advanced Cranial Reconstruction Utilizing Intracranial Free Flaps and Cranial Bone Grafts: An Algorithmic Approach Developed From the Modern Battlefield

Background:  Warfare-related craniofacial injuries involving the orbits, facial sinuses, or with large endocranial dead spaces present unique reconstructive challenges.  The objective of this study is to report outcomes after initiation of an algorithmic approach utilizing intracranial free flaps, cranial bone autografts, and dermal/fat grafts to treat various cranial frontal-facial defects after war-related decompressive craniectomy.

Methods: A retrospective review of injured personnel undergoing cranial defect reconstruction involving the orbital bar or were associated with large endocranial dead spaces that subsequently required free flap interpositions for space obliteration, and/or required cranial bone grafting and dermal/fat grafts was performed over a 52-month period.

Results: From March 2003 to July 2011, 13 patients were identified who underwent complex craniofacial defect reconstruction using an algorithmic approach.  All patients were male (average age 25 years) with an average follow up of 1324 days or 3.6 years.  Initial Glasgow Coma Score (GCS) was 7 and 9 on arrival to the continental United States.  Average time to evacuation to the continental United States was 4.2 days.  Forty-six percent of injuries were IED blast injuries. Nine patients (69%) underwent hemi-craniectomies and four patients (31%) bi-frontal craniectomies.  Two patients required only free flaps and four patients required both free flaps and cranial bone grafts for facial sinus-cranial base separation.  Five patients required cranial bone grafts only and two patients required both cranial bone grafts and dermal fat grafts for reconstruction.  All 13 patients were complication free at the completion of the study period.  Initial free flap success rate was 85% (6/7 flaps). Successful frontal bar/free flap reconstruction was present in 100% and successful secondary cranioplasty with retention was present in 77% (alloplast implant n=6, cranial bone grafts n=4).  Morbidity included a second salvage free flap, seizures after reconstruction (n=4), contour abnormalities occurred in n=7.  The mode Glasgow Outcome Score was 3 (range 3 – 4).  No mortalities occurred during the study period.

Conclusions: Reconstruction of high-risk orbital bar defects and large endocranial dead space using an algorithmic approach resulted in improved secondary cranioplasty retention rates.  Despite initial heavy contamination associated with war wounds and communication with facial sinuses, decompressive craniectomy defects associated with orbital, sinus, and skull base defects can be successfully reconstructed using an algorithmic approach with low morbidity and high success rates.