The Shunt Valve Recession Technique as a Neuroplastic Surgery Adjunct in Complex and High-Risk Shunt Revisions: Technical Note and Case Series.

BACKGROUND AND OBJECTIVES: Ventricular shunting is one of the most common procedures in neurosurgery. However, complications and revisions are frequent. Patients requiring multiple revisions often suffer secondary issues with scalp healing over hardware. Many common ventricular shunt valves have an obligate thickness that creates a visible protrusion and can potentially cause local tissue ischemia and breakdown in the setting of repeated surgery. The authors present a simple technique for recessing the shunt valve into the underlying bone to alleviate protrusion in high-risk cases. Three example cases utilizing this technique are presented. METHODS: The skull directly underlying the planned valve site is uniformly recessed with a cutting burr several millimeters as desired while maintaining the inner cortical bone layer. The valve is fixed with standard cranial plating hardware. EXPECTED OUTCOMES: Three patients are reported who underwent shunt valve recession as an adjunct to their shunt revision with neuroplastic surgery assistance. All patients had undergone multiple prior surgeries that had resulted in thin and high-risk fragile scalp. In 1 patient, the prior valve was eroding through the scalp before the described revision. All patients had satisfactory cosmetic outcomes, and there were no revisions in the 2-month follow-up period. DISCUSSION: Complex and high-risk ventricular shunt patients should be considered for shunt valve recession into the bone to reduce wound-related complications and enhance healing. This is a technically simple, safe, and effective technique to include as a neuroplastic adjunct.

Skull and Scalp En-Bloc Harvest Protects Calvarial Perfusion: A Cadaveric Study.

BACKGROUND: Calvarial defects are severe injuries that can result from a wide array of etiologies. Reconstructive modalities for these clinical challenges include autologous bone grafting or cranioplasty with biocompatible alloplastic materials. Unfortunately, both approaches are limited by factors such as donor site morbidly, tissue availability, and infection. Calvarial transplantation offers the potential opportunity to address skull defect form and functional needs by replacing "like-with-like" tissue but remains poorly investigated. METHODS: Three adult human cadavers underwent circumferential dissection and osteotomy to raise the entire scalp and skull en-bloc. The vascular pedicles of the scalp were assessed for patency and perfused with color dye, iohexol contrast agent for computed tomography (CT) angiography, and indocyanine green for SPY-Portable Handheld Imager assessment of perfusion to the skull. RESULTS: Gross changes were appreciated to the scalp with color dye, but not to bone. CT angiography and SPY-Portable Handheld Imager assessment confirmed perfusion from the vessels of the scalp to the skull beyond midline. CONCLUSION: Calvarial transplantation may be a technically viable option for skull defect reconstruction that requires vascularized composite tissues (bone and soft tissue) for optimal outcomes.

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.

Skull and Scalp En-Bloc Harvest Protects Calvarial Perfusion: A Cadaveric Study.

BACKGROUND: Calvarial defects are severe injuries that can result from a wide array of etiologies. Reconstructive modalities for these clinical challenges include autologous bone grafting or cranioplasty with biocompatible alloplastic materials. Unfortunately, both approaches are limited by factors such as donor site morbidly, tissue availability, and infection. Calvarial transplantation offers the potential opportunity to address skull defect form and functional needs by replacing "like-with-like" tissue but remains poorly investigated. METHODS: Three adult human cadavers underwent circumferential dissection and osteotomy to raise the entire scalp and skull en-bloc. The vascular pedicles of the scalp were assessed for patency and perfused with color dye, iohexol contrast agent for computed tomography (CT) angiography, and indocyanine green for SPY-Portable Handheld Imager assessment of perfusion to the skull. RESULTS: Gross changes were appreciated to the scalp with color dye, but not to bone. CT angiography and SPY-Portable Handheld Imager assessment confirmed perfusion from the vessels of the scalp to the skull beyond midline. DISCUSSION/CONCLUSION: Calvarial transplantation may be a technically viable option for skull defect reconstruction that requires vascularized composite tissues (bone and soft tissue) for optimal outcomes.

Cranioplasty Outcomes From 500 Consecutive Neuroplastic Surgery Patients.

BACKGROUND: Cranioplasty is critical to cerebral protection and restoring intracranial physiology, yet this procedure is fraught with a high risk of complications. The field of neuroplastic surgery was created to improve skull and scalp reconstruction outcomes in adult neurosurgical patients, with the hypothesis that a multidisciplinary team approach could help decrease complications. OBJECTIVE: To determine outcomes from a cohort of cranioplasty surgeries performed by a neuroplastic surgery team using a consistent surgical technique and approach. METHODS: The authors reviewed 500 consecutive adult neuroplastic surgery cranioplasties that were performed between January 2012 and September 2020. Data were abstracted from a prospectively maintained database. Univariate analysis was performed to determine association between demographic, medical, and surgical factors and odds of revision surgery. RESULTS: Patients were followed for an average of 24 months. Overall, there was a reoperation rate of 15.2% (n = 76), with the most frequent complications being infection (7.8%, n = 39), epidural hematoma (2.2%, n = 11), and wound dehiscence (1.8%, n = 9). New onset seizures occurred in 6 (1.2%) patients.Several variables were associated with increased odds of revision surgery, including lower body mass ratio, 2 or more cranial surgeries, presence of hydrocephalus shunts, scalp tissue defects, large-sized skull defect, and autologous bone flaps. importantly, implants with embedded neurotechnology were not associated with increased odds of reoperation. CONCLUSIONS: These results allow for comparison of multiple factors that impact risk of complications after cranioplasty and lay the foundation for development of a cranioplasty risk stratification scheme. Further research in neuroplastic surgery is warranted to examine how designated centers concentrating on adult neuro-cranial reconstruction and multidisciplinary collaboration may lead to improved cranioplasty outcomes and decreased risks of complications in neurosurgical patients.

The Impact of Hydrocephalus Shunt Devices on Quality of Life.

BACKGROUND: Despite advances in hydrocephalus shunt technology and improvement in hydrocephalus management, many patients have chronic disability and require multiple surgeries throughout their lifetime. There is limited data from patients' perspective regarding the impact of shunt devices on quality-of-life. METHODS: A cross-sectional survey was developed to evaluate the impact of shunt devices on patient quality-of-life. The survey was distributed via social media platforms of the Hydrocephalus Association, and patients self-selected to anonymously complete the online questionnaire. A literature review was performed to contextualize the findings from the survey. RESULTS: A total of 562 survey responses were obtained from a network encompassing 35,000 members. The mean age was 30 years old (0.5-87), and 65% identified as female. Eighty one percent underwent at least 1 shunt revision surgery, with a reported average of 10 shunt revision surgeries per patient (1-200 surgeries). Occlusion, shunt migration and infection were the leading causes for revision at 60%, 47%, and 35%, respectively. In addition, 72% of patients reported pain and discomfort from the device, and 68% expressed avoidance of certain activities due to "fear of bumping shunt." Despite numerous articles discussing shunt technology, a review of the literature indicated a paucity of studies specifically evaluating the burden of shunt devices from a patient/caregiver perspective. CONCLUSIONS: The findings from this study suggest long-term physical and psychosocial burden associated with shunt devices. Importantly, this study highlights the need for concerted efforts to develop validated tools to study patient reported outcomes as it relates to neurocranial implanted devices.

Risk of Complications in Primary Versus Revision-Type Cranioplasty.

INTRODUCTION: Cranioplasty (CP) is a multifaceted procedure in a heterogenous patient population, with a high risk for complication. However, no previous large-scale studies have compared outcomes in primary (ie, first attempt) CP versus revision CP (ie, following previous attempts). The authors, therefore, analyzed long-term outcomes of 506 consecutive primary and revision CPs, performed by a single surgeon. METHODS: All CPs performed between 2012 and 2019 were analyzed under IRB protocol approval. Surgeries were categorized as either primary (no previous CP; n = 279) or revision CP (at least one previous CP; n = 227). Complications were defined as either major or minor. Subgroup analyses investigated whether or not CP complication risk directly correlated with the number of previous neuro-cranial surgeries and/or CP attempts. RESULTS: The primary CP group experienced a major complication rate of 9% (26/279). In comparison, the revision CP group demonstrated a major complication rate of 32% (73/227). For the revision CP group, the rate of major complications rose with each additional surgery, from 4% (1 prior surgery) to 17% (2 prior surgeries) to 39% (3-4 prior surgeries) to 47% (≥5 prior surgeries). CONCLUSION: In a review of 506 consecutive cases, patients undergoing revision CP had a 3-fold increase in incidence of major complications, as compared to those undergoing primary CP. These results provide critical insight into overall CP risk stratification and may guide preoperative risk-benefit discussions. Furthermore, these findings may support a center-of-excellence care model, particularly for those patients with a history of previous neuro-cranial surgeries and/or CP attempts.

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

INTRODUCTION: 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). METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Sonolucent Cranial Implants: Cadaveric Study and Clinical Findings Supporting Diagnostic and Therapeutic Transcranioplasty Ultrasound.

BACKGROUND: Previously, sonographic evaluation of the intracranial contents was limited to intraoperative use following bone flap removal, with placement of the probe directly on the cortical surface or through a transsulcal tubular retractor. Cranioplasty with sonolucent implants may represent a postoperative window into the brain by allowing ultrasound to serve as a novel bedside imaging modality. The potential sonolucency of various commonly used cranial implant types was examined in this study. METHODS: A 3-phase study was comprised of cadaveric evaluation of transcranioplasty ultrasound (TCU) with cranioplasty implants of varying materials, intraoperative TCU during right-sided cranioplasty with clear implant made of poly-methyl-methacrylate (PMMA), and bedside TCU on postoperative day 5 after cranioplasty. RESULTS: The TCU through clear PMMA, polyether-ether-ketone, and opaque PMMA cranial implants revealed implant sonoluceny, in contrast to autologous bone and porous-polyethylene. Intraoperative ultrasound via the clear PMMA implant in a single patient revealed recognizable ventricular anatomy. Furthermore, postoperative bedside ultrasound in the same patient revealed comparable ventricular anatomy and a small epidural fluid collection corresponding to that visualized on an axial computed tomography scan. CONCLUSION: Sonolucent cranial implants, such as those made of clear PMMA, hold great promise for enhanced diagnostic and therapeutic applications previously limited by cranial bone. Furthermore, as functional cranial implants are manufactured with implantable devices housed within clear PMMA, the possibility of utilizing ultrasound for real-time surveillance of intracranial pathology becomes much more feasible.

Full-Thickness Skin Grafting for Local Defect Coverage Following Scalp Adjacent Tissue Transfer in the Setting of Cranioplasty.

INTRODUCTION: Numerous techniques have been described to overcome scalp deficiency and high-tension closure at time of cranioplasty. However, there is an existing controversy, over when and if a free flap is needed during complex skull reconstruction (ie, cranioplasty). As such the authors present here our experience using full-thickness skin grafts (FTSGs) to cover local defects following scalp adjacent tissue transfer in the setting of cranioplasty. METHODS: By way of an institutional review board-approved database, the authors identified patients treated over a 3-year period spanning January 2015 to December 2017, who underwent scalp reconstruction using the technique presented here. Patient demographics, clinical characteristics, technical details, outcomes, and long-term follow up were statistically analyzed for the purpose of this study. RESULTS: Thirty-three patients, who underwent combined cranioplasty and scalp reconstruction using an FTSG for local donor site coverage, were identified. Twenty-five (75%) patients were considered to have "high complexity" scalp defects prior to reconstruction. Of them, 12 patients (36%) were large-sized and 20 (60%) medium-sized; 21 (64%) grafts were inset over vascularized muscle or pericranium while the remaining grafts were placed over bare calvarial bone. In total, the authors found 94% (31/33) success for all FTSGs in this cohort. Two of the skin grafts failed due to unsuccessful take. Owing to the high rate of success in this series, none of the patient's risk factors were found to correlate with graft failure. In addition, the success rate did not differ whether the graft was placed over bone verses over vascularized muscle/pericranium. CONCLUSION: In contrary to previous studies that have reported inconsistent success with full-thickness skin grafting in this setting, the authors present a simple technique with consistent results-as compared to other more complex reconstructive methods-even in the setting of highly complex scalp reconstruction and simultaneous cranioplasty.

Comparative Cost Analysis of Single and Mutli-Stage Temporal Deformity Correction Following Neurosurgical Procedures.

PURPOSE: Temporal hollowing deformity (THD) is a visible concavity/convexity in the temporal fossa; a complication often seen following neurosurgical/craniofacial procedures. Although numerous techniques have been described, no study to date has shown the healthcare costs associated with temporal hollowing correction surgery. Thus, the purpose here is to compare and contrast the direct costs related to temporal cranioplasty using various methods including: liquid poly-methyl-methacrylate (PMMA) implants with screw fixation, prebent, modified titanium mesh implants, and customized cranial implants (CCIs) with dual-purpose design. Understanding the financial implications related to this frequently encountered complication will help to motivate surgeons/healthcare facilities to better prevent and manage THD. METHODS: This is a single-surgeon, single-institution retrospective review of 23 THD patients randomly selected from between 2008 and 2015. Cost analysis variables include length of hospital stay, facility/professional fees, implant material fees, payer information, reimbursement rate, and net revenue. RESULTS: Of the 23 patients, ages ranged from 23 to 68 years with a mean of 48.3 years (SD 11.6). Within this cohort, 39.1% received dual-purpose PMMA CCIs (CCI PLUS), 17.4% received modified titanium mesh implants, and 43.5% received hand-molded, liquid PMMA implants with screw fixation. Total facility and/or professional charges ranged from $1978.00 to $126478.00. Average total facility charges per patient with dual-purpose CCIs were $34775.89 (SD ±â€Š$22205.09) versus $35826.00 (SD ±â€Š$23509.93) for modified titanium mesh implants and $46547.90 (SD ±â€Š81061.70) for liquid PMMA implants with screws. Mean length of inpatient stay was 5.7 days (SD = 8.1), and did not differ between implant types (P = 0.387). CONCLUSION: Temporal hollowing deformity is an expensive complication post-neurosurgery, and in the most severe form, requires a revision surgery for definitive correction. Therefore, surgeons should take further initiatives to employ reconstructive methods capable of minimizing risk for costly revision surgery, reducing morbidity related to visible deformity and accompanying social stigmata, and improving overall patient satisfaction.

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

OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Improving Postoperative Nasal Airway Patency in Le Fort-Based, Maxillofacial Trauma Patients Via a Modified Nasal Packing Technique.

INTRODUCTION: Combined mid-face and nasal apparatus trauma injuries pose a significant challenge to airway patency (AW), in the immediate postoperative setting following fracture reduction. As such, the authors describe a modified technique with the goal of maintaining a patent nasal AW, while at the same time, minimizing nasopharyngeal bleeding and nasal AW edema-which can complicate patients requiring intermaxillary fixation (IMF) in the setting of pan-facial trauma. METHODS: A modified technique was devised to assist the reconstruction surgeon in avoiding the risks associated with tracheostomy placement. In an effort to avoid surgical AW complications and improve nasal AW patency in the setting of concurrent IMF and nasal trauma, the authors developed a 2-stage technique drawing upon knowledge from the literature and the authors' own experiences. TECHNIQUE: Following safe extubation, the authors insert open lumen nasal splints in both the nostrils, and suture them together to the nasal septum. If additional inner nasal support is required, polyvinyl alcohol nonabsorbable nasal packing dressing is covered with antibiotic ointment, and then placed within the nasal cavity lateral to the open lumen splints-as a way to further bolster the internal valve and mid-vault anatomy. DISCUSSION: Given the fact that traditional nasal packing with merocele/gauze dressing in concomitant to IMF reduced patients ability to ventilate, the authors felt that a modified technique should be applied. The authors' preferred materials in such patients are open lumen splint, which provides nasal AW patency along with some septum support accompanied by merocele dressing. The authors feel that by applying this technique they achieve dual objectives by supporting the traumatized nose and maintaining nasal AW patency.

Post-Neurosurgical Temporal Deformities: Various Techniques for Correction and Associated Complications.

INTRODUCTION: An irregular craniofacial contour along the temporal fossa, known commonly as 'temporal hollowing deformity,' (THD) can arise from multiple etiologies. In fact, up to half of all patients who undergo neurosurgical pterional dissections develop some form of temporal contour deformities. Unfortunately, temporal hollowing correction remains surgically challenging with many techniques resulting in high rates of failure and/or morbidity. METHODS: Herein, we describe anatomy contributing to postsurgical temporal deformity as well as time-tested prevention and surgical correction techniques. In addition, a review of 25 articles summarizing various techniques and complication profiles associated with temporal hollowing correction are presented. RESULTS: Complications included infection, implant malposition, revision surgery, pain, and implant removal because of implant-related complications Augmentation with either autologous fat or dermal filler is associated with the highest number of reported complications, including catastrophic events such as stroke, pulmonary embolism, and death. No such complications were reported with use of alloplastic material, use of autologous bone, or free tissue transfer. Furthermore, careful attention to adequate temporalis muscle resuspension and position remain paramount for stable restoration of craniofacial symmetry. CONCLUSIONS: Catastrophic complications were associated with injection augmentation of both fat and dermal filler in the temporal region. In contrast, use of alloplastic materials was not found to be associated with any catastrophic complications. As such, for the most severe cases of THD, we prefer to employ alloplastic reconstruction.

Algorithmic Approach to Overcome Scalp Deficiency in the Setting of Secondary Cranial Reconstruction.

BACKGROUND: Multidisciplinary approaches have shown improved outcomes in secondary cranial reconstruction, however, scalp deficiency remains a common obstacle for tension-free scalp closure during cranioplasty. Therefore, our objective was to create an algorithmic approach using a novel concept of "component separation" to help minimize potential complications. METHODS: The authors tested the hypothesis of achieving greater scalp mobility by way of "component separation" in a half-scalp, bilateral cadaver study, and describe within 2 clinical examples. Pterional-sized (N = 2) and hemicraniectomy-sized (N = 2) scalp flaps were dissected on 2 cadaveric heads using an internal control for each scenario. All flaps (N = 4) were created with (experimental group) and without (control group) "retaining ligament release." Total amounts of scalp mobility were measured bilaterally and compared accordingly. RESULTS: Scalp flap mobility was calculated from the sagittal midline using identical arcs of rotation. With zero tension, we observed an increased distance of movement equaling 1 cm for the "experimental" pterional flap, compared with the contralateral "control." Similarly, we found an increase of additional 2 cm in scalp mobility for the "experimental" hemicraniectomy-sized flap. CONCLUSIONS: Tension free scalp closure is most critical for achieving improved outcomes in secondary cranial reconstruction. In this study, we show that a range of 1 to 2 additional centimeters may be gained through a component separation, which is of critical value during scalp closure following cranioplasty. Therefore, based on our high volume cranioplasty experience and cadaver study presented, we offer some new insight on methods to overcome scalp deficiency accompanying secondary cranial reconstruction.

A Craniomaxillofacial Surgical Assistance Workstation for Enhanced Single-Stage Reconstruction Using Patient-Specific Implants.

BACKGROUND: Craniomaxillofacial reconstruction with patient-specific, customized craniofacial implants (CCIs) is ideal for skeletal defects involving areas of aesthetic concern-the non-weight-bearing facial skeleton, temporal skull, and/or frontal-forehead region. Results to date are superior to a variety of "off-the-shelf" materials, but require a protocol computed tomography scan and preexisting defect for computer-assisted design/computer-assisted manufacturing of the CCI. The authors developed a craniomaxillofacial surgical assistance workstation to address these challenges and intraoperatively guide CCI modification for an unknown defect size/shape. METHODS: First, the surgeon designed an oversized CCI based on his/her surgical plan. Intraoperatively, the surgeon resected the bone and digitized the resection using a navigation pointer. Next, a projector displayed the limits of the craniofacial bone defect onto the prefabricated, oversized CCI for the size modification process; the surgeon followed the projected trace to modify the implant. A cadaveric study compared the standard technique (n = 1) to the experimental technique (n = 5) using surgical time and implant fit. RESULTS: The technology reduced the time and effort needed to resize the oversized CCI by an order of magnitude as compared with the standard manual resizing process. Implant fit was consistently better for the computer-assisted case compared with the control by at least 30%, requiring only 5.17 minutes in the computer-assisted cases compared with 35 minutes for the control. CONCLUSION: This approach demonstrated improvement in surgical time and accuracy of CCI-based craniomaxillofacial reconstruction compared with previously reported methods. The craniomaxillofacial surgical assistance workstation will provide craniofacial surgeons a computer-assisted technology for effective and efficient single-stage reconstruction when exact craniofacial bone defect sizes are unknown.

Development and refinement of computer-assisted planning and execution system for use in face-jaw-teeth transplantation to improve skeletal and dento-occlusal outcomes.

PURPOSE OF REVIEW: To describe the development and refinement of the computer-assisted planning and execution (CAPE) system for use in face-jaw-teeth transplants (FJTTs). RECENT FINDINGS: Although successful, some maxillofacial transplants result in suboptimal hybrid occlusion and may require subsequent surgical orthognathic revisions. Unfortunately, the use of traditional dental casts and splints pose several compromising shortcomings in the context of FJTT and hybrid occlusion. Computer-assisted surgery may overcome these challenges. Therefore, the use of computer-assisted orthognathic techniques and functional planning may prevent the need for such revisions and improve facial-skeletal outcomes. SUMMARY: A comprehensive CAPE system for use in FJTT was developed through a multicenter collaboration and refined using plastic models, live miniature swine surgery, and human cadaver models. The system marries preoperative surgical planning and intraoperative execution by allowing on-table navigation of the donor fragment relative to recipient cranium, and real-time reporting of patient's cephalometric measurements relative to a desired dental-skeletal outcome. FJTTs using live-animal and cadaveric models demonstrate the CAPE system to be accurate in navigation and beneficial in improving hybrid occlusion and other craniofacial outcomes. Future refinement of the CAPE system includes integration of more commonly performed orthognathic/maxillofacial procedures.

Craniofacial reconstruction with poly(methyl methacrylate) customized cranial implants.

BACKGROUND: Secondary cranioplasty with customized craniofacial implants (CCIs) are often used to restore cerebral protection and reverse syndromes of the trephined, and for reconstruction of acquired cranial deformities. The 2 most widely used implant materials are polyetheretherketone and poly(methylmethacrylate) (PMMA). Previous series with CCIs report several major complications, including implant infection leading to removal, extended hospital stays, and surgical revisions. With this in mind, we chose to review our large case series of 22 consecutive PMMA CCI cranioplasties treated by a single craniofacial surgeon. METHODS: A cohort of 20 consecutive patients receiving 22 PMMA implants during a 2-year period was identified and outcomes reviewed. The mechanism of initial insult, time from craniectomy to cranioplasty, anesthesia time, major and minor postoperative complications, radiation history, and length of follow-up were statistically analyzed. RESULTS: There were no complications related to infection, hematoma/seroma, or cerebrospinal fluid leak (0/22, 0%). Two patients experienced major complications related to persistent temporal hollowing (PTH) following standard CCI cranioplasty, which required revision surgery with modified implants (2/22, 9%). One minor complication of self-resolving transient diplopia was noted (1/22, 5%). CONCLUSIONS: In this consecutive series, PMMA CCIs were associated with a very low complication rate, suggesting that PMMA may be a preferred material for CCI fabrication. However, with 10% (2/20) of patients experiencing PTH and dissatisfaction related to asymmetry, future research must be directed at modifying CCI shape, to address the overlying soft-tissue deformity. If successful, this may increase patient satisfaction, prevent PTH, and avoid additional costs of revision surgery.