title: Advanced cranial reconstruction using intracranial free flaps and cranial bone grafts:  an algorithmic approach developed from the modern battlefield.
abstract: BACKGROUND
  The objective of this study was to report outcomes after initiation of an algorithmic approach (Bethesda protocol) using intracranial free flaps, cranial bone autografts, and dermal/fat grafts to treat warfare-related cranial frontofacial defects after war-related decompressive craniectomy.
  
  
  METHODS
  A retrospective review of personnel undergoing complex cranial defect reconstruction that required free flap interpositions for dead space obliteration, cranial bone grafting, or dermal/fat grafting for orbital defects was performed over a 52-month period.
  
  
  RESULTS
  From March of 2003 to July of 2011, 13 patients were identified who underwent complex craniofacial defect reconstruction. All patients were male (average age, 25 years). Average follow-up was 3.6 years. Glasgow Coma Scale score was 7 initially and 9 on arrival to the continental United States. Average evacuation time was 4.2 days. Forty-six percent of injuries were blast injuries. Nine patients (69 percent) underwent hemicraniectomies and four (31 percent) underwent bifrontal craniectomies. Two patients required free flaps and four required free flaps and cranial bone grafts for skull base reconstruction. Five patients required cranial bone grafts and two required cranial bone grafts with dermal fat grafts for reconstruction. All patients were complication free at conclusion of the study. The initial free flap success rate was 86 percent (six of seven flaps). Successful frontal bar/free flap reconstruction was present in 100 percent and the secondary cranioplasty rate was 77 percent.
  
  
  CONCLUSIONS
  Decompressive craniectomy defects associated with orbital, sinus, and skull base defects can be successfully reconstructed using an algorithmic approach with low morbidity and high secondary cranioplasty retention rates.
  
  
  METHODS
  Therapeutic, IV.
authors.affiliation: Bethesda, Md.; and Pittsburgh, Pa. From the Departments of Plastic and Reconstructive Surgery and Neurosurgery, Walter Reed National Military Medical Center; the Department of Surgery, Uniformed Services University of the Health Sciences; and the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Pittsburgh.
authors.forename: Anand R
authors.initials: AR
authors.lastname: Kumar
authors.forename: Diya
authors.initials: D
authors.lastname: Tantawi
authors.forename: Rocco
authors.initials: R
authors.lastname: Armonda
authors.forename: Ian
authors.initials: I
authors.lastname: Valerio
mesh_terms: D000273:Adipose Tissue / Q000637:transplantation; D000293:Adolescent; D000328:Adult; D055826:Afghan Campaign 2001-; D000465:Algorithms; D001753:Blast Injuries / Q000601:surgery*; D016025:Bone Transplantation; D056424:Decompressive Craniectomy; D005260:Female; D058752:Free Tissue Flaps; D005624:Frontal Bone / Q000601:surgery; D006801:Humans; D054542:Iraq War, 2003-2011; D008297:Male; D008889:Military Personnel; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D012886:Skull / Q000293:injuries* / Q000637:transplantation*; D019291:Skull Base / Q000601:surgery; D014182:Transplantation, Autologous; D055815:Young Adult