Multidisciplinary approach for improved outcomes in secondary cranial reconstruction: introducing the pericranial-onlay cranioplasty technique.
BACKGROUND
Although materials for secondary cranial reconstruction have evolved with time, the overall approach in terms of bone flap/implant reconstruction after necessary delay has remained constant.


OBJECTIVE
To present our cases series of 50 consecutive secondary cranial reconstruction patients and to describe a multidisciplinary cranioplasty approach developed to reduce morbidity, to minimize infection, and to improve aesthetic appearance.


METHODS
Standard technique teaches us to place the bone flap and/or alloplastic implant directly over the dura or dural protectant after scalp flap re-elevation. However, this procedure is fraught with high complication rates, including infection. While raising the previously incised scalp flap overlying the full-thickness calvarial defect, the dissection is performed within the loose areolar tissue plane beneath the galea aponeurosis, thus leaving vascularized pericranium intact over the dura.


RESULTS
A total of 50 consecutive patients were treated by the senior author encompassing 46 cranioplasties using the pericranial-onlay approach, along with 4 isolated temporal soft tissue reconstructions with liquid poly-methyl-methacrylate. Of the 46 cranioplasties (> 5 cm), only 1 autologous bone flap developed deep infection necessitating bone flap removal (1 of 46, 2.17%; 95% confidence interval, 0.003-11.3). None of the alloplastic custom implants placed have developed any infection requiring removal.


CONCLUSIONS
This multidisciplinary approach illustrated in our case series, including our "pericranial-onlay" technique described here for the first time, has the potential to improve patient outcomes, to decrease perioperative morbidity, and to minimize costs associated with postoperative infections after secondary cranial reconstruction.
*Department of Plastic and Reconstructive Surgery and §Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; ‡Johns Hopkins University School of Medicine, Baltimore, Maryland.
Chad R
CR
Gordon
Mark
M
Fisher
Jason
J
Liauw
Ioan
I
Lina
Varun
V
Puvanesarajah
Srinivas
S
Susarla
Alexander
A
Coon
Michael
M
Lim
Alfredo
A
Quinones-Hinojosa
Jon
J
Weingart
Geoffrey
G
Colby
Alessandro
A
Olivi
Judy
J
Huang
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001932:Brain Neoplasms / Q000601:surgery*; D002648:Child; D003399:Craniotomy / Q000379:methods*; D005260:Female; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D013524:Surgical Flaps; D016896:Treatment Outcome; D055815:Young Adult