Abstract: Outcomes in Reconstruction of Composite Scalp and Calvarial Defects – Revisiting the Role of Alloplastic Cranioplasty in High Risk Patients (Plastic Surgery The Meeting)

Saturday, September 24, 2016: 8:35 AM

Grzegorz Kwiecien, MD , Plastic Surgery, Cleveland Clinic, Cleveland, OH

Steven Rueda, MD , Plastic Surgery, Cleveland Clinic, Cleveland, OH

Ahmed M Hashem, MD , Plastic Surgery, Cleveland Clinic, Cleveland, OH

Rafael A Couto, MD , Plastic Surgery, Cleveland Clinic, Cleveland, OH

James E Zins, MD, FACS , Plastic Surgery, Cleveland Clinic, Cleveland, OH

Brian Gastman, MD , Plastic Surgery, Cleveland Clinic, Cleveland, OH

Presentation PDF file

PURPOSE:

Advances in cranioplasty have enabled repair of increasingly complex defects. This led to widespread use of alloplastic materials in high-risk patients, including those with previous history of osteomyelitis, radiation, frontal sinus involvement, and soft–tissue deficits. The long-term outcomes of these reconstructions have been largely understudied. The aim of this study was to evaluate the natural history of cranioplasty in high-risk patients with soft-tissue defects requiring flap coverage.

MATERIALS AND METHODS:

A retrospective review of patients treated with 466 cranioplasties between 2002 and 2014 was performed.

RESULTS:

Materials used for reconstructions included non-titanium alloplastic cranioplasty in 52% (n=243), titanium mesh in 38% (n=177), and autologous bone in 10% (n=46). Mean cranial defect size was 59±60cm2. Sixteen percent (n=74) of the reconstructions included full-thickness scalp defect with a mean area of 22±74cm2. Mean follow-up was 3.9±3.0 years. Cumulative revision rate was 22% (n=104) and the cumulative reconstructive failure rate (defined as removal of the cranioplasty) was 13% (n=60). When soft-tissue reconstruction was needed, 2-year failure rate for autologous bone was 14%, for non-titanium alloplastic cranioplasty 29%, and for titanium mesh 39%. At the end of follow-up, failure rate remained stable for autologous bone – 14%, and for non-titanium alloplastic cranioplasty – 37% (p>0.05). The failure rate for titanium mesh continued to increase overtime to 53% (p<0.05).

CONCLUSIONS:

Simultaneous scalp and calvarial reconstruction is associated with significantly worse outcomes than calvarial reconstruction alone. When composite soft-tissue and bone reconstruction is needed, alloplastic cranioplasty, in particular titanium mesh, is associated with surprisingly high failure rate of over 50%. Titanium mesh cranioplasty in high-risk patients should be either discouraged, or used as a temporary treatment until more permanent coverage option is available.

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