Cranioplasty Reconstruction Research Articles

Neuroplastic Surgery Principles of Computerized Surgical Planning in Complex Cranioplasty Reconstruction.

This article explores the evolution and implementation of three-dimensional (3D) models and Computerized Surgical Planning (CSP) for complex cranioplasty reconstruction and the advances in neuroplastic surgery principles for improved surgical outcomes. Over recent years, CSP has revolutionized the field by employing detailed medical imaging to enhance the accuracy and efficacy of 3D models and for the creation of customized cranial implants (CCIs). The study discusses the advancements of solid alloplastic implants to the future of implants with sophisticated and integrated neurotechnology to treat or enhance patient outcomes. CSP can be used to identify and mitigate complications that can occur within cranioplasty reconstruction and to create CCIs to address the postoperative challenge of temporal hollowing. Despite the promising advancements, the article acknowledges the current limitations of CSP, including cost and technological accessibility, and proposes future directions for research and development. The findings suggest that with further improvements in imaging, biomaterials, and manufacturing techniques, CSP in neuroplastic surgery and other specialties will continue to significantly enhance the precision and personalized care of cranioplasty reconstruction.

Meningioma with Hyperostosis: A Clinical Review up to Acrylic Cranioplasty Reconstruction in 3 Cases

Meningioma is a type of tumor that commonly occurs in the central nervous system (CNS). Hyperostosis can occur in meningiomas. Hyperostosis is a condition in which the bone surrounding a meningioma thickens abnormally. Although hyperostosis is usually benign, leaving a small portion of bone that still has hyperostosis can increase the risk of recurrence. The case report was carried out by reviewing 3 medical records of meningioma sufferers with hyperostosis.

Utilization of carbonated calcium phosphate cement for contouring cranioplasty in patients with syndromic craniosynostosis.

Carbonated calcium phosphate (CCP) cement is an alloplastic material which has been increasingly utilized for cranioplasty reconstruction; however, there is a paucity of data investigating its use in patients with syndromic craniosynostosis. The purpose of this study was to characterize our institutional experience with CCP cement for secondary contouring cranioplasty in these patients to establish safety and aesthetic efficacy. Patients with syndromic craniosynostosis undergoing cranioplasty with CCP cement from 2009 to 2022 were retrospectively reviewed for prior medical and surgical history, cranioplasty size, cement usage, and postoperative complications. Aesthetic ratings of the forehead region were quantified using the Whitaker scoring system at three timepoints: preoperative (T1), < 6months postoperative (T2), and > 1year postoperative (T3). Twenty-one patients were included. Age at surgery was 16.2 ± 2.8years, forehead cranioplasty area was 135 ± 112 cm2, and mass of cement was 17.2 ± 7.8g. Patients were followed for 3.0 ± 3.1years. Whitaker scores decreased from 1.9 ± 0.4 at T1 to 1.4 ± 0.5 at T2 (p = 0.005). Whitaker scores at T2 and T3 were not significantly different (p = 0.720). Two infectious complications (9.5%) were noted, one at 4.5months postoperatively and the other at 23months, both requiring operative removal of CCP cement. Our results suggest that aesthetic forehead ratings improve after CCP contouring cranioplasty and that the improvement is sustained in medium-term follow-up. Complications were uncommon, suggesting that CCP is relatively safe though longer-term follow-up is needed before reaching definitive conclusions.

Discussion on: "Let's Smarten Up: Smart Devices and the Internet of Things, an Untapped Resource for Innovation in Craniofacial Surgery".

Prior to Dr. Paul Tessier's teachings in the 1960's, many neurosurgeons and craniofacial surgeons took shortcuts and employed alloplastic materials fraught with complication, and soon thereafter, both surgical specialties moved the pendulum towards the side of bone grafts being the gold standard for neurosurgical reconstruction and the art of cranioplasty. But now half a century later, neuroplastic surgery is moving the pendulum the other way. Without a doubt, the brain is a critical organ that needs some form of modulation as opposed to replacement. The intervention delivered can be in the form of electricity, light, medicine, etc. Regardless of the medium, it needs to be housed somewhere. And there is no better real estate than to be housed within a sterile alloplastic case with embedded smart technologies; in a way that prevents obvious, visual deformity. For example, it would be naïve to think that the future of embedded neurotechnologies will one day be housed safely and dependably within one's own bone flap. Hence, moving forward, time-tested alloplastic materials will become the new gold standard for cranioplasty reconstruction as the world starts to welcome a generation of smart cranial devices; some of which may house Bluetooth-connected, Wifi-enabled, MRI-compatible pumps to perform convection-enhanced delivery of time-tested medicines - thereby forever changing the way we approach chronic neurological disease and the forever-obstructing, blood-brain barrier. As this happens, I feel confident saying that both Tessier and Cushing are somewhere applauding and smiling on these efforts.

SURG-40. SINGLE-STAGE RECONSTRUCTION FOLLOWING ONCOLOGIC RESECTION OF BRAIN TUMORS WITH SKULL INVASION

Abstract BACKGROUND: Craniectomies requiring skull reconstruction are indicated following oncological resection of masses involving the underlying brain and/or skull. Immediate cranioplasties have previously been performed using suboptimal hand-bending or molding techniques using ‘‘off – the – shelf’’ products. Today with computer – aided design, customized craniofacial implants have become widely available for personalized reconstruction of resected bone and soft tissue. We present the largest series to date of single stage reconstruction using alloplastic biomaterials in consecutive patient series with oversized customized implants.In total, 56 patients underwent resection of skull neoplasms and subsequent cranioplasty reconstruction using customized implants. The most common neoplasms were meningiomas (39%). The most common complications seen among patients were dehiscence – (7%), and extrusion of implant – (3.5%). There was no significant difference in the incidence of postoperative complications between patients who had postoperative chemotherapy/radiotherapy versus those that did not (22.2% versus 13.1%, P 0.39). One-year follow-up revealed acceptable cranial contour and symmetry in all 56 cases.

Cranioplasty With Customized Craniofacial Implants and Intraoperative Resizing for Single-Stage Reconstruction Following Oncologic Resection of Skull Neoplasms.

Craniectomies requiring skull reconstruction are indicated following oncological resection of masses involving the underlying brain and/or skull. Immediate cranioplasties have previously been performed using suboptimal hand-bending or molding techniques using "off - the - shelf" products. Today with computer - aided design, customized craniofacial implants have become widely available for personalized reconstruction of resected bone and soft tissue. We present here the largest series to date of single stage reconstruction using alloplastic biomaterials in consecutive patient series with oversized customized implants. A single-surgeon, retrospective, 8-year study was conducted on all consecutive patients undergoing single stage cranioplasty with prefabricated implants using a myriad of biomaterials. All outcomes were analyzed in detail and compared with previous studies utilizing similar alloplastic implants. In total, 56 patients underwent resection of skull neoplasms and subsequent cranioplasty reconstruction using customized implants. The most common neoplasms were meningiomas (39%). The most common complications seen among patients were dehiscence - (7%), and extrusion of implant - (3.5%). There was no significant difference in the incidence of postoperative complications between patients who had postoperative chemotherapy/radiotherapy versus those that did not (22.2% versus 13.1%, P = 0.39). One-year follow-up revealed acceptable cranial contour and symmetry in all 56 cases. This is a consecutive case series of prefabricated single-stage cranioplasty, following resection of brain tumors with bone extension or skull bone neoplasm, demonstrating excellent results with regards to safety and patient satisfaction. There are several advantages such as comprehensive resection and reconstruction plan using 3D models, shorter operative time, and better restoration of complex anatomy.

Decision-Making in Adult Cranial Vault Reconstruction.

After studying this article, the participant should be able to: 1. Define and classify different types of cranial defects 2. Compare both autologous and alloplastic options for reconstruction 3. Develop an optimal approach for cranial vault reconstruction in various clinical scenarios. Defects of the cranium result from various causes, including traumatic loss, neurosurgical intervention, skull tumors, and infection. Cranial vault reconstruction aims to restore both the structural integrity and surface morphology of the skull. To ensure a successful outcome, the choice of appropriate cranioplasty reconstruction will vary primarily based on the cause, location, and size of the defect. Other relevant factors that must be considered include adequacy of soft-tissue coverage, presence of infection, and previous or planned radiation therapy. This article presents an algorithm for the reconstruction of various cranial defects using both autologous and alloplastic techniques, with a comparison of their advantages and disadvantages.

Discussion of Surgical and Patient-Reported Outcomes in Patients With PEEK Versus Titanium Cranioplasty Reconstruction.

Discussion of Surgical and Patient-Reported Outcomes in Patients With PEEK Versus Titanium Cranioplasty Reconstruction.

Surgical and Patient-Reported Outcomes in Patients With PEEK Versus Titanium Cranioplasty Reconstruction.

Several materials are available for cranioplasty reconstruction and consensus regarding the ideal material is lacking. The goal of this study is to present surgical and patient-reported outcomes with PEEK versus Titanium alloplastic cranioplasty. A retrospective review of all patients who underwent alloplastic cranioplasty with PEEK or Titanium from 2010 to 2017 was conducted. Patient demographics and complications were abstracted and analyzed. Information regarding patient-reported outcomes was collected through a telephone survey. A total of 72 patients (median age 55 years) who underwent 77 cranioplasties were identified (38% PEEK, n = 29; 62% Titanium, n = 48). Overall complication rates were similar between the PEEK (24%, n = 7) and Titanium groups (23%, n = 11), P = 0.902. Similarly, implant failure was similar between the 2 groups (7% in PEEK (n = 2), 13% in Titanium (n = 6), P = 0.703). History of radiation was associated with increased rate of infection in patients with Titanium mesh cranioplasty (38% in radiated patients (n = 3), 3% in nonradiated patients (n = 1), P = 0.012) but not PEEK implants (0% infection rate in radiated patients (n = 0), 15% in nonradiated patients (n = 4), P = 1.000). A total of 24 patients (33% response rate) participated in the telephone survey. All PEEK cranioplasty patients who responded to our survey (n = 13) reported good to excellent satisfaction, while 72% of our titanium mesh cohort (n = 8) described good or excellent satisfaction and 27% (n = 3) reported acceptable result. Cranial reconstruction is associated with high satisfaction among cranioplasty patients with PEEK or Titanium showing comparable complications, failure, and patient-reported satisfaction rates. Patients with history of radiotherapy demonstrated a higher infection rate when titanium mesh was used.

Translucent Customized Cranial Implants Made of Clear Polymethylmethacrylate: An Early Outcome Analysis of 55 Consecutive Cranioplasty Cases.

Large skull reconstruction, with the use of customized cranial implants, restores cerebral protection, physiologic homeostasis, and one's preoperative appearance. Cranial implants may be composed of either bone or a myriad of alloplastic biomaterials. Recently, patient-specific cranial implants have been fabricated using clear polymethylmethacrylate (PMMA), a visually transparent and sonolucent variant of standard opaque PMMA. Given the new enhanced diagnostic and therapeutic applications of clear PMMA, we present here a study evaluating all outcomes and complications in a consecutive patient series. A single-surgeon, retrospective, 3-year study was conducted on all consecutive patients undergoing large cranioplasty with clear PMMA implants (2016-2019). Patients who received clear PMMA implants with embedded neurotechnologies were excluded due to confounding variables. All outcomes were analyzed in detail and compared with previous studies utilizing similar alloplastic implant materials. Fifty-five patients underwent cranioplasty with customized clear PMMA implants. Twenty-one (38%) were performed using a single-stage cranioplasty method (ie, craniectomy and cranioplasty performed during the same operation utilizing a prefabricated, oversized design and labor-intense, manual modification), whereas the remaining 34 (62%) underwent a standard, 2-stage reconstruction (craniectomy with a delayed surgery for cranioplasty and minimal-to-no implant modification necessary). The mean cranial defect size was 101.8 cm. The mean follow-up time was 9 months (range, 1.5-39). Major complications requiring additional surgery occurred in 7 patients (13%) consisting of 2 (4%) cerebrospinal fluid leaks, 2 (4%) epidural hematomas, and 3 (4%) infections. In addition, 3 patients developed self-limiting or nonoperative complications including 2 (4%) with new onset seizures and 1 (2%) with delayed scalp healing. This is the first reported consecutive case series of cranioplasty reconstruction using customized clear PMMA implants, demonstrating excellent results with regard to ease of use, safety, and complication rates well below published rates when compared with other alloplastic materials. Clear PMMA also provides additional benefits, such as visual transparency and sonolucency, which is material specific and unavailable with autologous bone. Although these early results are promising, further studies with multicenter investigations are well justified to evaluate long-term outcomes.

Discussion of Elective Sonolucent Cranioplasty for Real-Time Ultrasound Monitoring of Flow and Patency of an Extra- to Intracranial Bypass.

Discussion of Elective Sonolucent Cranioplasty for Real-Time Ultrasound Monitoring of Flow and Patency of an Extra- to Intracranial Bypass.

Adult Cranioplasty Reconstruction With Customized Cranial Implants: Does Radiation Therapy Affect Outcomes?

Adult Cranioplasty Reconstruction With Customized Cranial Implants: Does Radiation Therapy Affect Outcomes?

Dural Reconstruction With Autologous Rectus Fascia: A New Technique for Addressing Large-Sized Defects During Cranioplasty.

Patients requiring cranioplasty reconstruction with customized cranial implants may unexpectedly present with cerebrospinal fluid (CSF) leaks and durotomies following previous neurosurgical procedures. As such, multiple factors influence the type of dural reconstruction chosen at this time, which are essential for achieving long-term success. Overall, the most common material used for duraplasty is currently an "off-the-shelf" xenograft construct. However, some believe that they are not suitable for large-sized defects and accompany a higher incident of complications. Therefore, based on our success and experience with scalp augmentation using rectus fascia grafts, the authors herein present our preliminary experience with duraplasty using autologous rectus fascia grafts (ARFGs). A retrospective review of our database, consisting of 437 cranial reconstructions from 2012 to 2017, was performed under institutional review board approval. Selection criteria included all adult patients (n = 6) requiring dural reconstruction (duraplasty) with ARF grafting for an active CFS leak with concomitant skull defect. Cadaver study and patient illustrations are also presented to demonstrate clinical applicability. All outcomes, including complications, were reviewed and are presented here. A total of 6 patients underwent autologous duraplasty with either unilateral or bilateral ARFGs. All patients (6/6) of large-sized (>3 cm) defect repair with ARFGs were indicated for repair of secondary CSF leaks following previous craniotomy by neurosurgery. To date, none have demonstrated recurrent leaking and/or dura-related complications. At this time, all 6 patients were reconstructed using customized cranial implants with a mean follow-up of 10 months. Based on our preliminary experience presented here, the use of rectus fascia grafts for autologous dural reconstruction appears to be both safe and reliable. This new technique adds another tool to the neurosurgical armamentarium by reducing the additional risk of "off-the-shelf" dural substitutes.

Introducing the Rectus Fascia Scalp Augmentation Technique: A New Method for Improving Scalp Durability in Cranioplasty Reconstruction.

Patients with cranioplasty in need of skull reconstruction are at increased risk of complications when presenting with abnormally thin scalps. As such, the authors sought to develop and investigate a new technique for scalp augmentation using autologous rectus fascia grafts (ARFGs) for prevention of implant extrusion and long-term scalp durability. A retrospective review of our database, consisting of 450 consecutive cranial reconstructions from 2012 to 2017, was performed under institutional review board approval. Selection criteria included all adult patients requiring implant-based cranioplasty reconstruction and concomitant scalp augmentation using ARFGs. All long-term outcomes were reviewed for scalp-related complications and are presented here. In total, 12 consecutive patients receiving ARFGs were identified. Average follow-up was 10 months (range = 2-17 months). Average graft size and dimension was 82 cm (range = 12-360 cm). All patients (n = 12) underwent concomitant cranioplasty reconstruction and had a history of at least 5 or greater previous neurocranial operations. Six patients had radiation therapy prior to cranioplasty. Two major complications (2/12, 17%) were identified related to deep, recurrent intracranial infections. More importantly, none of the patients (n = 12) in this study cohort developed scalp breakdown and/or implant extrusion in the areas of rectus fascia scalp augmentation. The use of ARFGs for underlay scalp augmentation appears to be both safe and reliable based on our preliminary experience. This new approach is extremely valuable when performing large-size cranioplasty reconstruction in patients with abnormally thin scalps, an extensive neurosurgical history, and/or suboptimal tissue quality. Furthermore, this method has been successful in avoiding free tissue transfer and/or staged tissue expansion as first-line surgery in our complicated cranioplasty population.

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

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. 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. 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. 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.

Anticoagulation for Hypercoagulable Patients Associated with Complications after Large Cranioplasty Reconstruction.

Despite advancements in materials and techniques used for cranial reconstruction, complication rates following reconstructive cranioplasty remain significant. In this study, the authors assessed the association of perioperative anticoagulation use and/or a hypercoagulable state with minor (i.e., not requiring surgical intervention) and major (i.e., surgical intervention required) complications after reconstructive cranioplasty for large skull defects. A retrospective cohort review of 108 consecutive cranioplasties performed between 2011 and 2014 was conducted. A multiple logistic regression analysis was performed to identify the adjusted association between the predictor variables and complications. Twenty-three primary (21.3 percent) and 85 secondary (78.7 percent) cranioplasties were performed on 94 patients with a median age of 50 years (interquartile range, 38 to 63 years). Median full-thickness calvarial defect size was 154 cm (interquartile range, 104 to 230 cm). Eleven minor (10.2 percent) and 18 major postoperative complications (16.7 percent) occurred in 26 cases (24.1 percent). Multiple logistic regression analysis revealed that coagulation status (i.e., perioperative use of anticoagulation therapy or hypercoagulable state) was statistically significant in predicting minor complications (OR, 7.8; 95 percent CI, 2.4 to 25.2; p = 0.001). Of note, the odds of a minor complication were an order of magnitude higher when both perioperative anticoagulation and a hypercoagulable state were present. To the authors' knowledge, this is the first study to document that the use of perioperative anticoagulant therapy for patients with thromboembolic conditions is a positive predictor of complications following cranioplasty reconstruction. Therapeutic, III.

Time Interval Reduction for Delayed Implant-Based Cranioplasty Reconstruction in the Setting of Previous Bone Flap Osteomyelitis.

Reinfections following implant-based cranioplasty, in the setting of previous bone flap osteomyelitis, are common and associated with significant morbidity. The timing of reconstruction following initial osteomyelitic bone flap removal remains controversial; most advocate for prolonged time intervals of approximately 6 to 12 months. Thus, the authors investigated their delayed cranioplasty outcomes following both early (between 90 and 179 days) and late (≥ 180 days) time intervals with custom craniofacial implants to determine whether timing affected outcomes and rates of reinfection. An institutional review board-approved retrospective cohort review of 25 consecutive cranioplasties, from 2012 to 2014, was conducted. A nonparametric bivariate analysis compared variables and complications between the two different time interval groups, defined as early cranioplasty (between 90 and 179 days) and cranioplasty (≥ 180 days). No significant differences were found in primary and secondary outcomes in patients who underwent early versus late cranioplasty (p > 0.29). The overall reinfection rate was only 4 percent (one of 25), with the single reinfection occurring in the late group. Overall, the major complication rate was 8 percent (two of 25). Complete and subgroup analyses of specific complications yielded no significant differences between the early and late time intervals (p > 0.44). The results suggest that early cranioplasty is a viable treatment option for patients with previous bone flap osteomyelitis and subsequent removal. As such, a reduced time interval of 3 months--with equivalent outcomes and reinfection rates--represents a promising area for future study aiming to reduce the morbidity surrounding prolonged time intervals. Therapeutic, III.

Polymethylmethacrylate imbedded with antibiotics cranioplasty: An infection solution for moderate and large defects reconstruction?

Background:In cases where autologous bone graft reconstruction is not possible (such as comminuted fractures, bone graft reabsorption, or infection) and the use of synthetic material is required, polymethylmethacrylate (PMMA) use is a safe and efficient solution. Studies comparing the incidence of postoperative complications between autologous and synthetic cranioplasty are heterogeneous, not allowing a conclusion of which is the best material for skull defects reconstruction. Current medical literature lacks prospective well-delineated studies with long-term follow-up that analyze the impact of antibiotic use in PMMA cranial reconstruction of moderate and large defects.Methods:A prospective series of patients, who underwent cranioplasty reconstruction with PMMA impregnated with antibiotic, were followed for 2 years. Authors collected data regarding demographic status, clinical conditions, surgical information, and its complications.Results:A total of 58 patients completed full follow-up with a mean group age of 40 years and a male predominance (77%). Major complications that required surgical management were identified in 5 patients, and 10 patients evolved with minor complications. Postoperative surgical site infection incidence was 3.2%.Conclusion:The infection rate in patients submitted to PMMA flap cranioplasty impregnated with antibiotic is significantly inferior comparing to the data described in medical literature. A lower infection incidence impacts secondary endpoints such as minimizing surgical morbidity, mortality, hospitalization period, and, consequently, costs.

Quantitative analysis of dual-purpose, patient-specific craniofacial implants for correction of temporal deformity.

The development of computer-assisted design, virtual modeling, and computed tomography has allowed precise customization of implants for patients who undergo neurosurgical or craniofacial surgery procedures. However, such techniques and implant designs have not adequately addressed temporal asymmetry due to postoperative bone resorption, temporalis muscle malposition/foreshortening, and/or temporal fat pad atrophy. We hypothesized that an alteration in customized craniofacial implant (CCI) design with a strategic extension inferolaterally and excessive material bulking would provide simultaneous reconstruction of coexisting temporal skull defects and therefore reduce the effect of soft tissue deformities. A single-surgeon, single-institution retrospective cohort study was performed to include 10 consecutive subjects who underwent cranioplasty reconstruction with modified implants during a 3-year period. Implants were placed with the use of our previously described pericranial-onlay technique. With the use of a computed tomography-based, computer-assisted design/manufacturing methodology, novel dual-purpose implants were designed to prevent and/or correct persistent temporal hollowing. The efficacy of the new CCI shape and design for cranial restoration of temporal symmetry was analyzed in both 2 and 3 dimensions. In 2-dimensional analyses, the modified implant provided enhanced lateral projection (21%; 1.06 cm(3)) in areas closest to the temporal arch. Three-dimensional volumetric analyses demonstrated that additional bulking totaled 24 ± 11 cm(3) (range, 9-43 cm), which essentially replaced 40 ± 13.7% (range, 26%-60%) of the absent temporal volume contributing to persistent temporal hollowing. Computer-designed, dual-purpose CCIs can be safely created with unprecedented shape to prevent and/or eradicate postoperative temporal deformity.

Surgical treatment of craniofacial fibrous dysplasia in adults

Craniofacial fibrous dysplasia (FD) is a rare disorder that may require neurosurgical expertise for definitive management; however, surgical management of FD in adult patients is uncommon. Although other therapies have been shown to slow progression, the only definitive cure for adult craniofacial FD is complete resection with subsequent reconstruction. The authors review the biological, epidemiologic, clinical, genetic, and radiographic characteristics of adult FD, with an emphasis on surgical management of FD. They present a small series of three adult patients with complex FD that highlights the surgical complexity required in some adult patients with FD. Because of the complex nature of these adult polyostotic craniofacial cases, the authors used neurosurgical techniques specific to the different surgical indications, including a transsphenoidal approach for resection of sphenoidal sinus FD, a transmaxillary approach to decompress the maxillary branch of the trigeminal nerve with widening of the foramen rotundum, and complete calvarial craniectomy with cranioplasty reconstruction. These cases exemplify the diverse range of skull base techniques required in the spectrum of surgical management of adult FD and demonstrate that novel variations on standard neurosurgical approaches to the skull base can provide successful outcomes with minimal complications in adults with complex craniofacial FD.