Late Cranioplasty Research Articles

The impact of cranioplasty on the patients' quality of life

ObjectiveTo evaluate the quality of life in patients with moderate or large cranial bone defects before and after late cranioplasty. MethodsAuthors performed a prospective clinical trial including all consecutive patients that filled inclusion criteria during a period of 1 year. All patients answered the quality of life SF-36 questionnaire in 5 different times. Besides authors gathered information about the primary trauma and demographic characteristics. ResultsA total of 70 consecutive patients were admitted to the hospital during the study period, and 62 were included in the project. Cranioplasty statistically improved patients' quality of life in all 8 domains after a 24 months follow-up. ConclusionCranioplasty has a significant impact over the quality of life in brain trauma victims who survived the primary trauma and harbor a large cranial bone defect.

Defining "early" cranioplasty to achieve lower complication rates of bone flap failure: resorption and infection.

Although cranioplasty (CP) is a frequently performed and simple procedure, complications are common, particularly bone flap resorption and infection. The timing of surgery is as an important contributory factor, but the optimal timing has not been clearly determined. We retrospectively investigated bone flap resorption and surgical site infection after CP to determine the optimal timing of surgery for reduction of complications. The study enrolled 126 patients who underwent decompressive craniectomy (DC) and subsequent CP. Patients with bone flap resorption or surgical site infection were analyzed as the "complication" group. Receiver operating characteristic curve analysis was performed and the Youden index was used to dichotomize "early CP" and "late CP" groups. Univariate and multivariate survival analyses were performed. The complication group included 42 patients. The Youden index was used to identify a cutoff value for the DC-CP interval of > 44days, and this was used to define early (< 45days) and late (≥ 45days) CP. Late CP was a significant risk factor in univariate and multivariate Cox regression analyses. This study showed that early CP before 45days after DC is associated with a lower rate of bone flap resorption and surgical site infection than late CP.

Early autologous bone flap cranioplasty following decompressive craniectomy in recovery treatment of children with severe TBI

DC is one of the options in the staged therapy of refractory intracranial hypertension. A significant drawback of this technique is the formation of a complicated complex of pathophysiological disorders, which develops due to an extended defect in the calvarium (disorders of brain perfusion, venous outflow, CSF-circulation, etc.). Assess the effectiveness of early calvarium reconstruction with cryopreserved bone in children after decompressive craniotomy. Fifty-one patients had cranioplasty with cryopreserved bone after decompressive craniotomy during 2005–2016. The autobone was stored in the freezer at the temperature −40 °C. Before and after the surgery patients had CT-perfusion and MRI examination. In 70% of cases cranioplasty was made during the first two months. In 30% of followed cases the restoration of skull integrity took place up to 65 days. Late cranioplasty was caused by trophic disorders in soft tissues as well as by intracranial and extracranial infective–inflammatory complications. After the defect closure one could see restored brain perfusion, venous outflow. At the early postoperative period the auto transplant infectioning was seen in 5.5%. More than 75% of patients had clinical improvement, and 30% improved their outcome. The follow-up period lasted from 3 months until 10 years. Complete bone resorption was registered in one patient. Early closure defects of the calvarium should be regarded as a surgical intervention which provides maximally possible conditions for the early restoration of cerebral functions. Despite the higher risk of infection and resorption of the autobone remains the effective material for early cranioplasty in children.

Early or late cranioplasty following decompressive craniotomy for traumatic brain injury: A systematic review and meta-analysis.

ObjectiveTo evaluate the effectiveness of early (<3 months) cranioplasty (CP) and late CP (>3 months) on post-operative complications in patients receiving decompressive craniotomy (DC) for traumatic brain injury (TBI).MethodsThe Cochrane Library, PubMed and EMBASE databases were systematically searched for studies published prior to May 21, 2017. A meta-analysis examined post-operative overall complication rates, infection rates, subdural fluid collection and operating times according to early and late CP.ResultsOf the initial 1675 references, five studies, all cohort, involving a total of 413 patients, were selected for the review. There was no difference between early and late CP in post-operative overall complication rate (RR=0.68, 95%CI [0.36, 1.29]) and the post-operative infection rate (RR=0.50, 95%CI [0.20, 1.24]) in patients receiving DC for TBI. However, there was a significant difference in post-operative subdural effusion (RR=0.24, 95%CI [0.07, 0.78]) and mean operative time (mean difference = −33.02 min, 95%CI [−48.19, −17.84]) both in favour of early CP.ConclusionsNo differences were found between early and late CP in post-operative overall complications and procedural related infections in patients receiving DC for TBI, but early CP reduced the complication of subdural effusion and the mean operating time. These findings need to be confirmed by large, randomised controlled trials.

How Early Can We Perform Cranioplasty for Traumatic Brain injury After Decompressive Craniectomy? A Retrospective Multicenter Study.

Decompressive craniectomy (DC) is used to treat intractable intracranial hypertension after severe traumatic brain injury (TBI). Cranioplasty (CP) is typically performed weeks or months later. However, the optimal timing for CP is unknown. We aimed to determine the earliest possible time point for CP. We retrospectively reviewed brain computed tomography images from 159 patients who underwent CP after DC for TBI at 3 hospitals. We determined the earliest possible day for CP by reviewing the resolution of intracranial pressure in serial brain computed tomography images between DC and CP. The early CP group was defined as the group within the earliest possible timing of CP; other cases constituted the late CP group. We compared complications and the Glasgow Outcome Scale scores at 6 months between groups. The mean initial Glasgow Coma Scale score was 8.33 ± 3.46. The time interval between DC and CP was 94.75 ± 143.98 days. The earliest possible timing for CP was determined to be 34.60 ± 34.36 days after DC. The incidence of complications did not differ significantly between groups, except for ventriculomegaly, which occurred more frequently in the late CP group (P= 0.026). Predictors of good outcome were revision because of infection, preoperative epidural hematoma, early cranioplasty, and no ventriculomegaly after DC. CP can be performed at around 34 days after DC for TBI. Ventriculomegaly occurred less frequently and the 6-month Glasgow Outcome Scale score was better in the early CP group than in the late CP group.

Cranioplasty Complications and Costs: A National Population-Level Analysis Using the MarketScan Longitudinal Database.

To characterize cranioplasty complications and costs at a population level using a longitudinal national claims database. We identified patients undergoing cranioplasty between 2007 and 2014 in the MarketScan national database. We evaluated age, autograft usage, cranioplasty size, and cranioplasty timing stratified by postoperative outcomes. We further analyzed associated costs. A subset analysis of adult patients with emergent indications, including stroke and trauma, was performed. We identified 8275 patients (mean age 44.0 years ± 20.0, 45.2% male), including 13.8% children (<18years old), 76.0% adults (18-64 years old), and 10.2% elderly adults (≥65 years old). Overall complication rate was 36.6%, mortality rate was 0.5%, and 30-day readmission rate was 12.0%. Elderly patients had the highest complication rate (P< 0.0001). Large cranioplasties (>5 cm) had higher complication rates than small cranioplasties (≤5 cm; P=0.047). In patients with emergent indications (n= 1282), size did not influence complications, althoughlarge cranioplasties showed higher infection risk (P=0.02). Autograft use did not affect outcomes but was associated with higher complication risk, including infections, in the subset with emergent indications (P < 0.001, P= 0.001). Late (>90 days) cranioplasty timing had higher complication rates in the overall cohort and the subset with emergent indications (P < 0.001, P < 0.001). Index costs of care were mainly driven by hospital payments in both the overall cohort and the cohort with emergent indications. A high complication rate is associated with cranioplasty in the United States. Older age, large cranioplasties, and delayed cranioplasties increased complication risk overall. Among patients with emergent indications, complications were associated with delayed time to cranioplasty and autograft usage.

Early vs late cranioplasty: what is better?

Aim of the study: Cranioplasty is the surgical repair of skull defects, which commonly is performed after traumatic skull injuries due to tumor removal or decompressive craniectomy. Several studies reported improvement in cognitive functions following cranioplasty in patients with severe brain damage. The reasons why exist such clinical improvement is not completely understood, although the increase in cerebrospinal fluid hydrodynamics with the potential improvement of local and global cerebral hemodynamics, blood flow, and metabolism may play a pivotal role. We investigated whether the cranioplasty improved neurological recovery and the whole array of cognitive functions or just some specific domains. Materials and methods: A total of 30 consecutive brain-injured subjects with craniectomy were enrolled and underwent a structured neuropsychological assessment immediately before the cranioplasty, 1 month after the cranioplasty and 1 year after the surgical procedure. Results: Our results showed that cranioplasty may facilitate the cognitive recovery, independently from the surgical timing. Particularly, we observed an important cognitive recovery in the period immediately after cranioplasty, while the improvement trend settles after a lapse of time, and the recovery starts to slow down. Conclusions: Cranioplasty seems to significantly improve neuropsychological and motor status in the patients with skull defects, independently from cranioplasty timing and patient's clinical status.

Early Cranioplasty in Patients With Posttraumatic Decompressive Craniectomy and Its Correlation with Changes in Cerebral Perfusion Parameters and Neurocognitive Outcome

Decompressive craniectomy is a life-saving procedure in many patients after traumatic brain injury. Delayed recovery in such patients can be attributed to various causes. Cranioplasty (CP) helps in early improvement of neurocognitive function along with better brain protection and cosmesis. The mechanism responsible for this functional improvement and the ideal time to perform cranial reconstruction is less understood. We studied 16 patients who underwent CP after decompressive craniectomy (DC) for traumatic brain injury. These patients were divided in 2 groups, early and late CP, depending on the interval between DCand CP. Three months was the cutoff time for early CP. Neurocognitive status was assessed by Glasgow Coma Scale, Glasgow Outcome Scale, and Mini-Mental State Examination scores prior to and after CP. Computed tomography (CT) perfusion was done to correlate the improvement in neurologic status and CT perfusion parameters. We observed that there was a positive influence of CP on neurologic and psychologic function in all of the patients. The neurocognitive improvement after CP was more remarkable in the early CP group. More complications were noted in patients in the late CP group. Brain perfusion after CP showed improvement in all parameters in both of the groups, both on the operated and contralateral side. Neurocognitive improvement is noted after CP in all of the patients. CP should be offered once the brain edema subsides, at the earliest. Improved cerebral perfusion may be the key factor for the improved functional outcome.

Decompressive Craniectomy for Stroke: Early Cranioplasty Is a Predictor for Postoperative Complications

Previous clinical studies assumed that early cranioplasty (CP) was mandatory for a favorable neurologic recovery after decompressive craniectomy (DC) for malignant stroke. However, the appropriate timing of the CP procedure after DC remains controversial. This study assessed patients who underwent DC because of cerebral ischemia to determine the appropriate time point of CP and surgical-associated complications. Data from the period 2007-2014 were retrospectively evaluated. CP was performed in 75 patients who previously underwent DC because of supratentorial cerebral infarction. Patients were divided into 2 groups (early CP vs. late CP) according to the time from DC to CP (<3 months vs. ≥3 months). Patient characteristics, timing of CP, and postoperative complications associated with CP were analyzed. CP was performed early in 12 patients (16%) and late in 63 patients (84%). The complication rate after CP was 18%; complications included wound healing disturbance in 8 patients (11%), epidural hematoma or subdural hematoma in 4 patients (4%), and others in 2 patients (3%). Patients with early CP experienced significantly more complications compared with patients with late CP after initial DC (5 of 12 patients [42%] vs. 8 of 63 patients [13%]; P= 0.02). In multivariate analysis, early CP was a significant predictor of postoperative complications after CP (odds ratio= 6.04; 95% confidence interval, 1.4-24.9; P= 0.01). The present data suggest that patients who underwent DC for stroke might benefit from CP performed >3 months after DC owing to a lower rate of wound infection.

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.

Which One Is Better to Reduce the Infection Rate, Early or Late Cranioplasty?

ObjectiveDecompressive craniectomy is an effective therapy to relieve high intracranial pressure after acute brain damage. However, the optimal timing for cranioplasty after decompression is still controversial. Many authors reported that early cranioplasty may contribute to improve the cerebral blood flow and brain metabolism. However, despite all the advantages, there always remains a concern that early cranioplasty may increase the chance of infection. The purpose of this retrospective study is to investigate whether the early cranioplasty increase the infection rate. We also evaluated the risk factors of infection following cranioplasty.MethodsWe retrospectively examined the results of 131 patients who underwent cranioplasty in our institution between January 2008 and June 2015. We divided them into early (≤90 days) and late (>90 days after craniectomy) groups. We examined the risk factors of infection after cranioplasty. We analyzed the infection rate between two groups.ResultsThere were more male patients (62%) than female (38%). The mean age was 49 years. Infection occurred in 17 patients (13%) after cranioplasty. The infection rate of early cranioplasty was lower than that of late cranioplasty (7% vs. 20%; p=0.02). Early cranioplasty, non-metal allograft materials, re-operation before cranioplasty and younger age were the significant factors in the infection rate after cranioplasty (p<0.05). Especially allograft was a significant risk factor of infection (odds ratio, 12.4; 95% confidence interval, 3.24–47.33; p<0.01). Younger age was also a significant risk factor of infection after cranioplasty by multivariable analysis (odds ratio, 0.96; 95% confidence interval, 0.96–0.99; p=0.02).ConclusionEarly cranioplasty did not increase the infection rate in this study. The use of non-metal allograft materials influenced a more important role in infection in cranioplasty. Actually, timing itself was not a significant risk factor in multivariate analysis. So the early cranioplasty may bring better outcomes in cognitive functions or wound without raising the infection rate.

Cranioplasty optimal timing in cases of decompressive craniectomy after severe head injury: a systematic literature review

Abstract Object Cranioplasty has been considered for several decades as a protective and cosmetic procedure. It has recently been postulated that cranioplasty may have a therapeutic role, and improve the patient’s functional outcome after decompressive craniectomy (DC). The appropriate timing for cranioplasty remains unknown. In our current study, we review the literature for evaluating the relationship of cranioplasty timing and its complication rate and outcome. Methods The PubMed database was searched to identify any relevant articles. The following terms were used as keywords: “cranioplasty”, “timing cranioplasty”, “early cranioplasty”, “late cranioplasty”, “delayed cranioplasty”, “early versus late cranioplasty”. Clinical studies with more than 10 participants, and closed head injury as the underlying cause for DC were included in our study. The study design, the timing performing cranioplasty, the complication rate, and the patients’ outcome were evaluated. Results Ten clinical series met our inclusion criteria. The observed complication rate associated to cranioplasty after DC is not negligible. Several reports have demonstrated that late cranioplasty may minimize procedure-associated complications. Early cranioplasty has been associated with complications, but improves CSF dynamics, and regional cerebral perfusion and metabolism, minimizes the complications from a sunken scalp, reduces the overall length of hospitalization, and thus the overall cost of care. Conclusions Cranioplasty is a relatively simple procedure that is nevertheless burdened by considerable morbidity. However, an early cranioplasty procedure may improve the outcome in selected cases. Prospective, large-scale studies are necessary to outline the actual complication rate, the neurological outcome, and define the optimal timing for a cranioplasty.

Timing of cranioplasty after decompressive craniectomy for trauma.

Background:The optimal timing of cranioplasty after decompressive craniectomy for trauma is unknown. The aim of this study was to determine if early cranioplasty after decompressive craniectomy for trauma reduces complications.Methods:Consecutive cases of patients who underwent autologous cranioplasty after decompressive craniectomy for trauma at a single Level I Trauma Center were studied in a retrospective 10 year data review. Associations of categorical variables were compared using Chi-square test or Fisher's exact test.Results:A total of 157 patients were divided into early (<12 weeks; 78 patients) and late (≥12 weeks; 79 patients) cranioplasty cohorts. Baseline characteristics were similar between the two cohorts. Cranioplasty operative time was significantly shorter in the early (102 minutes) than the late (125 minutes) cranioplasty cohort (P = 0.0482). Overall complication rate in both cohorts was 35%. Infection rates were lower in the early (7.7%) than the late (14%) cranioplasty cohort as was bone graft resorption (15% early, 19% late), hydrocephalus rate (7.7% early, 1.3% late), and postoperative hematoma incidence (3.9% early, 1.3% late). However, these differences were not statistically significant. Patients <18 years of age were at higher risk of bone graft resorption than patients ≥18 years of age (OR 3.32, 95% CI 1.25-8.81; P = 0.0162).Conclusions:After decompressive craniectomy for trauma, early (<12 weeks) cranioplasty does not alter the incidence of complication rates. In patients <18 years of age, early (<12 weeks) cranioplasty increases the risk of bone resorption. Delaying cranioplasty (≥12 weeks) results in longer operative times and may increase costs.

Beneficial impact of early cranioplasty in patients with decompressive craniectomy: evidence from transcranial Doppler ultrasonography

A cranioplasty (CP) is often performed after decompressive craniectomy (DC) for cosmetic and protective reasons; however, the timing of CP needs to be better evaluated to maximize beneficial outcomes and neurological recovery. We investigated the effects and mechanisms of early CP compared to late CP on neurological recovery, from the perspective of cerebral blood flow (CBF). This study retrospectively reviewed 43 patients undergoing early (<12 weeks) or late (≥ 12 weeks) cranioplasty after DC. The CBF velocity was measured by transcranial Doppler ultrasonography and was analyzed prior to and after CP in every patient. Complications were recorded. The CBF velocity in the middle cerebral artery (MCA) ipsilateral to the CP was increased in both groups and was statistically different between groups (p < 0.05). On the contralateral side, however, the CBF in the MCA was increased in the early CP group, but not the late CP group. Change (expressed as delta, Δ) was defined as the difference in CBF velocity between pre- and postoperative status in the early and late CP groups. A statistically significant difference was detected in the Δ of MCA on the ipsilateral side between the early and late groups. There were no differences in the incidence of complications between groups. Our results show better post-DC improvements in the CBF of patients receiving CP < 12 weeks after DC, compared to those receiving CP ≥ 12 weeks after DC. Therefore, early CP has potential benefits for cerebral perfusion.

Cranioplasty after decompressive hemicraniectomy: Underestimated surgery-associated complications?

ObjectiveDecompressive hemicraniectomy (DC) and duroplasty after malignant brain infarction or traumatic brain injury is a common surgical procedure. Usually, preserved bone flaps are being reimplanted after resolution of brain swelling. Alloplast cranioplasties are seldom directly implanted due to the risk of wound healing disorders. While numerous studies deal with DC, little is known about the encountered problems of bone flap reimplantation. Thus, aim of the study was to identify surgery-associated complications after bone flap reimplantation. MethodsWe performed a retrospective chart analysis of patients that underwent DC and subsequent bone flap reimplantation between 2001 and 2011 at our institution. We registered demographic data, initial clinical diagnosis and surgery-associated complications. ResultsWe identified 136 patients that underwent DC and subsequent reimplantation. Forty-one patients (30.1%) had early or late surgery-associated complications after bone flap reimplantation. Most often, bone flap resorption and postoperative wound infections were the underlying causes (73%, n=30/41). Multivariate analysis identified age (p=0.045; OR=16.30), GOS prior to cranioplasty (p=0.03; OR=2.38) and nicotine abuse as a prognostic factor for surgery-associated complications (p=0.043; OR=4.02). Furthermore, patients with early cranioplasty had a better functional outcome than patients with late cranioplasty (p<0.05). ConclusionsAlmost one-third of the patients that are operated on for bone flap reimplantation after DC suffer from surgery-associated complications. Most often, wound healing disorders as well as bone flap resorption lead to a second or even third operation with the need for artificial bone implantation. These results might raise the question, if subsequent operations can be avoided, if an artificial bone is initially chosen for cranioplasty.

Early versus Late Cranioplasty after Decompressive Craniectomy

Early versus Late Cranioplasty after Decompressive Craniectomy

Cranioplasty after Decompressive Craniectomy: The Effect of Timing on Postoperative Complications

Decompressive craniectomy (DC) due to intractably elevated intracranial pressure mandates later cranioplasty (CP). However, the optimal timing of CP remains controversial. We therefore analyzed our prospectively conducted database concerning the timing of CP and associated post-operative complications. From October 1999 to August 2011, 280 cranioplasty procedures were performed at the authors' institution. Patients were stratified into two groups according to the time from DC to cranioplasty (early, ≤2 months, and late, >2 months). Patient characteristics, timing of CP, and CP-related complications were analyzed. Overall CP was performed early in 19% and late in 81%. The overall complication rate was 16.4%. Complications after CP included epidural or subdural hematoma (6%), wound healing disturbance (5.7%), abscess (1.4%), hygroma (1.1%), cerebrospinal fluid fistula (1.1%), and other (1.1%). Patients who underwent early CP suffered significantly more often from complications compared to patients who underwent late CP (25.9% versus 14.2%; p=0.04). Patients with ventriculoperitoneal (VP) shunt had a significantly higher rate of complications after CP compared to patients without VP shunt (p=0.007). On multivariate analysis, early CP, the presence of a VP shunt, and intracerebral hemorrhage as underlying pathology for DC, were significant predictors of post-operative complications after CP. We provide detailed data on surgical timing and complications for cranioplasty after DC. The present data suggest that patients who undergo late CP might benefit from a lower complication rate. This might influence future surgical decision making regarding optimal timing of cranioplasty.

An ultrasound study of brain tissue biomechanics in patients following craniectomy

So far, little attention has been paid to the biomechanical aspects of decompressive craniectomy. The brain tissue deformation occurring in these patients is difficult to quantify. Twenty-six patients suffering from a large bone defect after craniectomy were examined in supine position. The third ventricle's axial diameter was measured by transcranial ultrasound. Subsequently, the patient was brought into a sitting position. After 5 minutes, another measurement was taken. This procedure was repeated about 7 days after cranioplasty. The patients were grouped according to "early cranioplasty" (cranioplasty within 40 days after craniectomy, median 30 days) and "late cranioplasty", (cranioplasty more than 40 days, median 80 days). Data of 13 healthy volunteers were used as a reference standard. In the healthy volunteers, the third ventricle was enlarging after reaching the sitting position. The median diameter was 2.35 mm in the lying and 2.9 mm in the sitting position (p > 0.05). In the patients before early cranioplasty, a decrease of the diameter after reaching the sitting position was observed. The mean diameter was 7.0 mm in the lying and 5.9 mm in the sitting position (p > 0.01). This difference was not significant in patients before late cranioplasty (9.7 vs. 9.4 mm). After cranioplasty, the mean diameter was 6.6 and 6.2 mm in the early cranioplasty group and 9.2 mm and 9.4 mm in the late cranioplasty group (lying and sitting position, respectively). This data demonstrate for the first time that unphysiological orthostatic brain tissue deformation occurs in patients after craniectomy.

Early Single-Stage Repair of Complex Craniofacial Trauma

The traditional surgical management of complex craniofacial injuries is performed in three stages: immediate craniotomy, orbitofacial repair in 7 to 10 days, and cranioplasty delayed 6 to 12 months because of the perceived risks of infection and prolonged anesthesia in the head-injured patient. Cosmetic considerations have always played a secondary role; however, there are reports that suggest that bone fragments and grafts can be safely placed even in contaminated wounds. In addition, advances in neuroanesthetic technique allow for prolonged administration of anesthesia without untoward effects on the patient. The purpose of this prospective study was to determine if early single-stage repair of complex craniofacial injuries could be accomplished with acceptable morbidity and mortality. In this study, 13 patients (9 men, 4 women) ranging in age from 3 to 53 years, with Glascow Coma Scale scores of 10 to 15, all had a combined single-stage repair of their complex craniofacial injuries within 24 hours of their trauma. After initial assessment and resuscitation, all patients were evaluated with computerized tomography of the face and head before surgery. Bicoronal skin flaps were used for maximum exposure for frontal sinus exenteration as well as dural repair, cortical debridement, and calvarial reconstruction. Dural grafts were necessary in 12 of 13 patients (92%), and supplementary bone grafting was required in 9 of 13 patients (69%), of which 3 of the 9 (33%) had iliac bone grafts, where split calvarial grafts were used in the other 6 of 9 (67%). No artificial cranioplasty material was used.(ABSTRACT TRUNCATED AT 250 WORDS)

Early Single-Stage Repair of Complex Craniofacial Trauma

The traditional surgical management of complex craniofacial injuries is performed in three stages: immediate craniotomy, orbitofacial repair in 7 to 10 days, and cranioplasty delayed 6 to 12 months because of the perceived risks of infection and prolonged anesthesia in the head-injured patient. Cosmetic considerations have always played a secondary role; however, there are reports that suggest that bone fragments and grafts can be safely placed even in contaminated wounds. In addition, advances in neuroanesthetic technique allow for prolonged administration of anesthesia without untoward effects on the patient. The purpose of this prospective study was to determine if early single-stage repair of complex craniofacial injuries could be accomplished with acceptable morbidity and mortality. In this study, 13 patients (9 men, 4 women) ranging in age from 3 to 53 years, with Glascow Coma Scale scores of 10 to 15, all had a combined single-stage repair of their complex craniofacial injuries within 24 hours of their trauma. After initial assessment and resuscitation, all patients were evaluated with computerized tomography of the face and head before surgery. Bicoronal skin flaps were used for maximum exposure for frontal sinus exenteration as well as dural repair, cortical debridement, and calvarial reconstruction. Dural grafts were necessary in 12 of 13 patients (92%), and supplementary bone grafting was required in 9 of 13 patients (69%), of which 3 of the 9 (33%) had iliac bone grafts, whereas split calvarial grafts were used in the other 6 of 9 (67%). No artificial cranioplasty material was used. Neurosurgical outcome at both early and late evaluation was judged as good in 11 of 13 patients (85%) and moderate in 2 of the 13 (15%). No patient had a neurological outcome below that predicted by age and presenting Glascow Coma Scale score using the Jennett and Bond outcome scale, despite prolonged anesthesia required for single-stage craniofacial repair. No patient required late cranioplasty. Plastic surgical outcome at early evaluation showed 9 of 13 (69%) to be excellent, 2 of 13 (15%) to be good, and a single patient (8%) in each category to be fair and poor. At late reevaluation, the poor had improved to fair without further intervention and the fair had improved to good with just one additional reconstructive procedure. There were no wound infections and no osteomyelitis, graft resorption, or intracranial abscesses. Complications included 2 patients (15%) with delayed cerebrospinal fluid leaks, 1 with concurrent meningitis, both requiring delayed operative repair. Maxillary sinusitis developed in 2 of 13 patients (15%). These results compare favorably with historical data in which an overall infection rate for a staged repair would be 12.5 to 17.7%. We conclude that early single-stage repair of complex craniofacial injuries can be performed with an acceptable rate of morbidity and mortality, a decreased need for reoperation, and an improved cosmetic and functional outcome.