Outcome of Cranioplasty with Different Materials in Pediatric Patients :

Experience in a limited facility centre

Mohamed Adawi MD1 , Walid Younis MD1 , Abdelaal Abdelbaky MD1,

Mohammed El-Sayed , MD2,Hassan Elsayed Badra MD.

Department of Neurosurgery1, and ENT & Maxillofacial surgery2, Faculty of

Medicine, Benha University, Egypt.

Abstract

Background: Cranioplasty is a well established neurosurgical procedure for

reconstructing cranial defects and is indicated for cerebral protection, cosmetic
restoration and reversing the altered cerebral physiology. Cranioplasty had been
evolved over several decades with progressive advancement regarding the surgical
technique and the implant materials .

Objective: To assess the outcome of cranioplasty with different materials in pediatric

patients.
Patients and Methods: A total of fifty consecutive cranioplasties in 46 patients were
studied. The gender, age, reason for skull defect, type of implant used, number of
cranioplasties done per patient, cosmetic result, wound healing, complications and
management of complications were recorded. The mean follow-up interval was range
from one – six years.
Results: There was no mortality from the cranioplasty procedure. Six (30%) out of 20
patients with autologus graft cranioplasty developed complications in the form of
subcutaneous surgical emphysema at the donor site of rib graft in two cases, and four
cases develpoed graft resorption underwent reoperation using titanium mesh. Two
(6.6%) out of 30 cases of synthetic graft cranioplasty developed complications, in the
form of infection in acrylic cranioplasty resolved with antibiotic.4 cases of acrylic
was a cracking of it and its fragmentation into pieces, which forced us to reoperated.

Conclusion: Autologous bone graft has higher incidence of spontaneous resorption in

pediatric patients. Synthetic material can be used safely in cranioplasty for patients
above 5 years. Acrylic cranioplasty is readily available, safe and effective method in
centers with limited facilities. But it is on long term efficacy should be studied in
more comprehensive manner.
Keywords:
Cranioplasty, skull defect.

Introduction

Most skull defects are due to trauma, infection, tumors, elective removal, growing
fractures, bone disorders and congenital malformations. Loss of the cranium results in
aesthetic and functional deficiencies. Without the cranium, the direct effect of
atmospheric pressure on scalp and dura causes closure of subarachnoid space and
reducing the brain perfusion pressure. As a result, some of patients experience
"syndrome of the trephined" which characterized by severe headache, dizziness,
undue fatigability, poor memory, irritability, epilepsy, discomfort, and psychiatric
symptoms (1, 2).
The goal of a cranioplasty procedure is to achieve a life long, stable, structural
reconstruction of the cranium covered by a healthy skin that eliminates the
psychological problems of patients, increases the quality of life and improves social
adaptation (3, 4).Replacing the cranium is not only a cosmetic and protective measure
but may also reverse the altered physiological state that occurs following craniectomy
and improve electroencephalographically abnormalities, aberrations of cerebral
blood flow, cerebrospinal fluid dynamics and clinically apparent neurological
abnormalities (5, 6, 7).

There is a large selection of possible materials for repair of skull defects, which
may be categorized into autografts, allografts, xenografts and bone substitutes (9, 8).

In recent years the medical practice has been implemented with modern computer
technologies for manufacturing of individual implants to reconstruct skull defects
based on spiral computed tomography data (3). The ideal cranioplasty material should
be radiolucent, resistant to infections, not conductive of heat or cold, resistant to
biomechanical processes, malleable to fit defects with complete closure, inexpensive,
and ready to use(10,11).

Patients and methods

This retrospective study was conducted on patients who underwent cranioplasty in

the Department of Neurosurgery, Benha University Hospital in the period between
January 2014 and September 2021. A total of 56 consecutive cranioplasties in 56
patients were studied. The patients’ age ranged from 5 to 16 years. There were 19
girls and 37 boys. The sex, age, reason for skull defect, type of implant used, number
of cranioplasties done per patient, cosmetic result, complications and management of
complications were recorded. The mean follow-up interval was range 1–6 years.

Acrylic implants were used in 9 cases of bony destruction with tumors, in 3

patients with skull osteomyelitis and in 6 patients with post-traumatic skull defect. A
titanium mesh was used in 5 patients with an infected wound requiring a craniectomy
following a craniotomy for a space-occupying lesion, in 5 patients with post-traumatic
skull defect, and in 5 patients with bone resorption following cranioplasty with rib
graft, and split calvarial graft. Rib grafts were used in 4 patients with post-traumatic
skull defect and in 8 cases following infection. Split calvarial grafts were used in 8
post-traumatic patients. Own craniotomy bone flap was used in 3 patients with
traumatic intracranial hemorrhage.
Technical notes:

The first step in all procedures is good exposure of the skull defect, preparation of
the dura by freeing any dehiscence, repairing any defects and fashioning dural tack-up
sutures around the edges of the skull defect. At end of the procedure we use subgaleal
drain for 48 hours.

For split calvarial bone graft a bicoronal incision was done, exposure , preparation
and measurement of the defect area, the designed cranioplasty bone flap was
harvested and split through the diploe with an oscillating saw into two layers with
the inner table covering the donor site and the outer table covering the skull defect.

The rib graft was harvested through infamamary skin incision where about 5- 6 cm
of the osseous parts of 2 ribs (Usually 5th and 6th ribs) are separated from the
chondral part by bon cutting. The rib was split through its thickness into two halves
and fixed to the edges of the defect by sutures.

For the craniotomy flap used in 3 patients we had stored the bon flap in the
abdominal subcutaneous tissue of the then reused it in a later setting again to cover
the defect.

In acrylic cranioplasty, the acrylic mixture is molded into plate with thickness
similar to the skull and having the shape of the defect then we create several holes in
the plate and apply it before hardening to fit it by hand compression to the skull
edges. Continuous irrigation with saline containing gentamycin is used to guard
against the exothermic reaction and as antiseptic.

In cranioplasty with titanium mesh, after fixing the mesh to the skull with screws,
we used to stretch the pericranium with sutures over the edge of the mesh as we
thought that this technique eliminate the risk of pressure necrosis on the thin, scarred
pediatric scalp.

Results

There was no mortality from the cranioplasty procedure. We had 2 cases of

infection with wound discharge following acrylic cranioplasty but resolved with

wound toilet and antibiotic. Another 2 cases of subcutaneous surgical emphysema at

the donor site of rib graft resolved spontaneously. Four cases of graft resorption

underwent reoperation using titanium mesh. One case of subdural fluid collection was

observed in one patient, treated conservatively and resolved during follow up.

Cosmetic outcome was rated according to feedback from parents in addition to

clinical follow up. Among the complications that occurred after five years of acrylic
was a cracking of into pieces, which forced us to install titanium mesh after that, and

this happened to 4 cases.

Table 1 : Summary of the different variables and outcome in our study

Variable Number

Median age (years) (5-16)

Gender:

Male 37 (69.6%)

Female 19 (30.4%)

Etiology of bone defect

Tumor 12

Infection 18

Trauma 26

Resorped cranioplasty 4

Material used in cranioplasty

Split calvarial graft 8

Rib graft 12

Acrylic 18

Titanium mesh 15

own craniotomy bone flap 3

Number of cranioplasties

1 48

2 8

Mean Follow up period 14 (8-25) months

Complications

Infection 3

subcutaneous surgical emphysema 3

Graft resorption 5

Fragmentation of acrylic after 5 years 4

subdural fluid collection 1

Cosmetic outcome

Excellent 36

Good 18

Poor 2

IllustrativeCases:

Case 1:

A fifteen years old female presented with scalp swelling causing cosmetic
disfigurement, CT brain with bone window and MRI brain revealed dermoid cyst with
underlying skull defect. The mass was totally excised en block and immediate acylic
cranioplasty was performed (Fig. 1).

a b c

Fig. 1 (a-c) : (a) Coronal T2 weighted MRI showing the dermoid cyst and skull defect. (b) Intra-
operative image showing the cyst. (c) The view after appliction of acrylic.

Case 2:

A six years old boy presented with right frontal skull defect after history of trauma,
acrylic cranioplasty was done after molding the acrylic into a thin plate and creation
of multiple holes aiming at preventing collection and infection (Fig.2).

a b c

Fig.2 (a-c) : (a)The bone window of CTbrain axial cuts showing right frontal skull defect. (b) X-ray
skull lateral view showing closure of the defect with acrylic " the created holes in the acrylic plate are
appearant" (c) Post-operative CT after cranioplasty.
Case 3:

A six years old boy subjected to post-traumatic skull defect two years ago treated with
rib graft that was almost comletely resorbed six months after surgery with recurrence
of the defect. We closed the defect with titanium mesh with satisfactory results on
follow-up (Fig.3).

a b c

d e
Fig.3(a-e) : (a) CT brain axial cut showing reconstruction of left parietal skull defect with rib graft
(a)Bone window of CT brain "coronal view" showing recurrence of the skull defect due to resorption
of rib graft. (b)CT 3D reconstruction demonstrating the defect and remaining part of the graft .(c)
Intra-operative image showing the titanium mesh in place , note sutures stretching the perioteom over
the edge of the mesh that avoid erosion of the scalp over the mesh edges. (d) Follow-up CT 3D
reconstruction revealing adequate skull reconstruction.

Case 4:

A sixteen years old male patient presented with post-traumatic skull defect treated
with split calvarial graft cranioplasty (Fig.4).
 a b c
Fig.4 (a-c) : (a) Pre-operative CT bone window of axial cuts showing the skull defect.(b) Intra-
operative image showing splitting of skull bone into two layers through the diploe. (c) Post-operative
CT showing closure of the defect and correction of the deformity.

Case 5:
A nine years old boy presented with skull osteomyelitis secondary to scalp abscess,
treated with drainge of the abcess and debridment of the infected bone followed by
adequate course of systemic antibiotic. Six months later, upon family request, patient
was subjected to autologous cranioplasty using rib graft (Fig. 5).

a b c
Fig. 5 : (a) Pre-operative CT showing the defect. (b) Intra-operative imge of the defect
with freshening of edges. (c) Image of the rib grft used for cranioplasty.

Case 6:
A ten years old boy present with traumatic depressed fracture of skull and operated
with acrylaic cranioplasty and after six momths ocure fragmentation to acrylic and
need to reoperation by titanium mesh (fig 6).

a b
C d

e f

Fig 6 : (a ,b,c,d) acrylic cranioplasty operated to depressed fracture skull (e,f)

reoperated by titanium mesh.

Discussion

Cranioplasty is a surgical procedure to repair cranial defect or deformity that’s

left behind after a previous operation or injury. Nowadays there are many different
techniques and materials that can be used in repair of cranial defect. Surgeons’
preferences for different types of implant materials for cranioplasty vary depending
on many factors such as training, personal experiences, traditions of the units they
work in and available resources (13). Some surgeons prefer using autologous bone
graft while others prefer synthetic materials, each materials has advantages and
disadvantages and until now it is unclear which material provides the best overall
result. In our study we present outcome of cranioplasty in pediatric patients using
different materials and techniques.
 Autologous bone grafting is still the method of choice at many centers in the world
acquiring widespread popularity even with progression into the 21th century and (12).
Advantages of autologous bone graft includes high biocompatibility, absent risk of
disease transmission, easy return of the former cranial contour, allow remolding of
cranial bone and continuous growth, readily accepted by the host and integrated back
into the skull and cost-efficiency (13).

Disadvantages include donor site morbidity, high rate of bone flap resorption which
results in structural breakdown (9, 14).

Symptomatic bone resorption is defined as a defect large enough to cause concern

about the risk of damage to the brain or result in a cosmetic defect unacceptable to the
family or treating physicians (7). Reported rates of autologous bone flap resorption
vary in the literature Gruber et al. (15) reported a 33.3% resorption rate, Grant et
al.(7) reported a 50% resorption rate, and Piedra et al. (16) found a 29.5% resorption
rate.

Predictors of bone flap resorption are young age, thin skull, large bone defect, an
underlying contusion and fragmentation of the explanted bone graft (7, 15). Method
of bone flap preservation was suggested to be a risk factor as the bone matrix may be
destroyed by freezing or autoclaving. (16) Recently, investigators proved low
resorption rate in frozen autologous bone flaps in contrast to autoclaving which is not
routinely performed (17). In pediatric patients who undergo bone flap resorption,
revision cranioplasty is generally quite successful with higher success rates with
custom synthetic implants than with autologous split-thickness bone grafts (18).

Re-placement of the original bone removed during craniectomy is optimal as it is

readily available, avoids other graft or foreign materials, guarantees low infection rate
and reintegrates well in the maturing skull. (11,20) This bone can be preserved either
by cryopreservation, autoclaving or by placement in a subgaleal or subcutaneous
abdominal pocket. Many studies have validated the efficacy, low infection rate, and
low cost of storing a cranioplasty flap in the subcutaneous pouch of the abdominal
wall. (21, 22, 23). Drawbacks include difficult storage either due to limited facilities
or in children with reduced abdominal subcutaneous tissue and failure of shape
matching especially in delayed cranioplasty due to new bone formation at the edges of
the defect (11).

We used decompressive craniectomy technique in 3 traumatic cases who

underwent cranioplasty using own craniectomy flap stored in the abdominal
subcutaneous tissue without complications.

Autogenous split calvarial graft is easily harvested from same operating site, of
enhanced survival, volume available with favourable contour and simplified
reconstruction of the donor site reducing morbidity but calvarial graft is difficult in
children with poor differentiation of the dipolic bone (7,24,25).

Advantages of rib graft are availability, regeneration (neovascularization,

osteoclastic activity and subsequent bone formation) and minimal blood loss. Splitted
rib is easily fixed, more elastic conforming easily to the calvarial contour (27).Some
of the drawbacks include longer operating time, extensive resorption, contour
deformities and requirement of multiple ribs for large defects (28,29).

We used autologous bone graft in 20 patients with 30% reported complications

including 2 cases of subcutaneous surgical emphysema at the donor site of rib graft
resolved spontaneously and 4 cases of graft resorption.

Synthetic alternatives (metals, ceramics, plastics, and later, resorbable polymers

and biomaterials) have been used throughout history and are necessary in current
practice for selected cases when autograft reconstruction is not an option (such as
cases with severe bony comminution, bone graft resorption, infection, and limited
donor site options) (30, 31). The use of synthetic materials is not ideal before the age
of 5 years because they lack growth potential hence fail to adapt with the developing
neurocranium (32).

Methyl methacrylate is the most frequently used matrial in cranioplasty because of

its advantages which are low cost, biologically inert , lightweight, non-magnetic,
non-thermo conductive, similar to bone in strength, can be moulded easily during
surgery to fit the contour defects and does not interfere with computed tomography or
magnetic resonance imaging studies (8,33) , but its main disadvantage is the
exothermic reaction produced during setting of the polymer which can cause thermal
damage to the underlying brain tissue, the surgeon can counteract this rise in
temperature by irrigating the implant with cold saline while it sets and placing layers
of wet cotton in between acrylic and dura other reported complications are infection
and breakage (1,28,34).

Titanium is widely used for cranioplasty because of its strength, good resistance to
infection, biocompatibility, malleability, good cosmetic results and suitability for
postoperative imaging techniques (32, 35).

In our study synthetic graft was used in 30 patients with good cosmetic outcome
Methyl methacrylate was used in 20 patient with satisfactory cosmoses in most of
them achieved with 2 reported wound infection resolved with antibiotics. We used
titanium mesh in 10 patients with no reported complications.

Conclusion

Autologous bone graft has higher incidence of spontanous resorption in pediatric

patients. Synthetic material can be used safely in cranioplasty for patients above 5
years. Acrylic cranioplasty is safe and effective method in centers with limited
facilities. Long term follow up indicates that acrylic cranioplasty isn’t the ideal
option in pediatric patients. We recommend further researches for ideal method for
cranioplasty in patients below 5 years.
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