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Table of Contents    
COMMENTARY
Year : 2020  |  Volume : 68  |  Issue : 1  |  Page : 71

Transcending Autologous Cranioplasty


Department of Neurosurgery, Sagar Hospital, Bangalore, Karnataka, India

Date of Web Publication28-Feb-2020

Correspondence Address:
Dr. Murali Mohan Selvam
Sagar Hospital, Bangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.279662

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How to cite this article:
Selvam MM, Nandini Y, Gupta RH. Transcending Autologous Cranioplasty. Neurol India 2020;68:71

How to cite this URL:
Selvam MM, Nandini Y, Gupta RH. Transcending Autologous Cranioplasty. Neurol India [serial online] 2020 [cited 2020 Jul 5];68:71. Available from: http://www.neurologyindia.com/text.asp?2020/68/1/71/279662




Majority of the patients undergoing cranioplasty are young men. The average age was 38.3 years with 2.5 times male preponderance as noted by Prasad et al.[1] This statistics can be explained by the incidence of RTA and higher frequency of stroke involving young men. Cranial defects produce aesthetic and functional alteration described as the 'Syndrome of the trephined.' The symptoms are headache, dizziness, irritability, anxiety, intolerance to noise, or vibrations.[2] Reconstruction of the cranial-vault defect is very important in functional and morphological rehabilitation of the patient.[3] Cranioplasty can be performed either with autologous bone-flap or with alloplastic implants. The choice of cranioplasty material and the timing of the procedure remains debatable. Current day practice of autologous bone preserved either in the abdominal wall or sterilized and clean preserved is slowly being given up across the globe. This is due to the frequent occurrence of infection. Many centres now prefer to perform the procedure using the autologous bone flap, within 14–30 days after the day of decompression. If for any reason, the procedure is postponed beyond a month, synthetic flap is preferred.[4] Preformed implants have the advantage of shorter surgical time, lesser risk of contamination that can otherwise occur when large flaps are contoured intraoperatively. They are less inflammatory due to the surface finish that renders them inert. Titanium or PEEK are best alternatives as of today, although the availability and cost remains a concern in third world countries. Pre-formed PMMA flap with long curing cycle is cheaper alternative as the auto-polymerizing PMMA (bone cement) used intraoperatively is more inflammatory and exothermic in nature. Moreover, It is hard to shape and contour once the polymerization has commenced and desired aesthetics may not always be achievable.[4],[5]

A major challenge remains regarding the reconstruction of the temporalis muscle, which is the main factor in the aesthetic outcome of the procedure. Proper preservation of vascularity and nerve supply of the muscle during Craniectomy may not always be possible due to the emergency nature of the surgery. The plane of separation between the muscle and dura/the cerebral cortex may not be distinct in many cases during re-exploration for cranioplasty.[6] The temporalis also may contribute to cerebral circulation by recruitment of capillaries in long-standing cases. This dissection is one of the commonest cause for postoperative complications such as fresh neurological deficit and operative site hematoma. Use of synthetic materials such as polypropylene mesh as a barrier to prevent this adhesion during the initial surgery can aid in easier dissection during cranioplasty. Once the plane is established and the muscle dissected, the next major challenge lies in the reconstruction of the muscle fanning the temporal squamous region. This step is important to prevent unaesthetic hollow often noted in the temporal region.



 
  References Top

1.
Prasad GL, Menon GR, Kongwad LI, Kumar V. Outcomes of Cranioplasty from a Tertiary Hospital in a Developing Country. Neurol India 2020;68:63-70.  Back to cited text no. 1
  [Full text]  
2.
Rotaru H, Baciut M, Stan H, Bran S, Chezan H, Iosif A, et al. Silicone rubber mould cast polyethylmethacrylate-hydroxyapatite plate used forrepairing a large skull defect. J Craniomaxillofac Surg 2006;34:242-6.  Back to cited text no. 2
    
3.
Chiarini L, Figurelli S, Pollastri G, Torcia E, Ferrari F, Albanese M, et al. Cranioplasty using acrylic material: A new technical procedure. J Craniomaxillofac Surg 2004;32:5-9.  Back to cited text no. 3
    
4.
Morton RP, Abecassis IJ, Hanson JF, Barber J, Nerva JD, Emerson SN, et al. Predictors of Infection after 754 cranioplasty operations and the value of intraoperative cultures for cryopreserved bone flaps. J Neurosurg 2016;125:766-70.  Back to cited text no. 4
    
5.
Yamini N, Murali M, Sudhakar A, Srivastsa G, et al. Reconstruction of cranial defect with a preformed acrylic implant: Case reports. Clin Dent 2018;XII: 10-4.  Back to cited text no. 5
    
6.
Kamalabai PR, Nagar M, Chandran R, Suharanbeevi MHS, Prabhakar BR, Peethambaran A, et al. Rationale behind the use of Double – Layer Poly propylene patch (G-patch) dural substitute during Decompressive Craniectomy as an adhesive preventive material for subsequent cranioplasty with special reference to flap elevation time. World Neurosurg 2018;111:105-12.  Back to cited text no. 6
    




 

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