Postcraniectomy Cranioplasty Using Autologous Split Calvarial Graft.

Sir,

Skull defects and craniofacial defects following head injuries may cause crippling and debilitating psychosocial ramifications on the life of a patient in terms of lost cosmesis, neurocognitive functions, and verbal expressions.[12] The reconstruction of large defects postcraniectomy has always been a challenge in the repertoire of maxillofacial surgeon. The maxillofacial surgeon plays an important role in decision-making as regards to the timing of cranioplasty and counseling of the patient regarding the same. This 35-year-old patient who presented to us with “sinking skin flap syndrome” [Figure 1] postdecompressive craniectomy for evacuation of extradural hematoma was managed with a autogenous split-calvarial bone graft [Figures 2 and 3] harvested from right parietal bone using the same incision [Figure 4]. An overall improvement in the speech fluency, cognitive domains as well as quality of life was achieved at 6 months’ follow-up.

Figure 1

Preoperative photograph showing the defect

Figure 2

Exposure of the defect

Figure 3

Graft harvest to fill in the defect

Figure 4

Graft secured using miniplates and standard fixation screw

The optimal timing of cranioplasty remains widely debated. Delayed cranioplasty does offer fewer chances of postoperative infection.[3] The reasons to do early cranioplasty can be conceptually explained as the inability to dissect the dura mater from the scalp-muscle flap at a later stage.[4] The potential benefits of delayed intervention for reducing the risk of infection must be balanced with the incidence of hydrocephalus due to altered CSF fluid dynamics. The correct timing of cranioplasty is dictated by the resolution of brain edema and status of the wound. We chose delayed cranioplasty as this patient had suffered traumatic brain injury with a severely contaminated wound.

The outer table of parietal bone as graft material as it could be harvested from the same incision offers low donor site morbidity and adequate amounts of membranous bone that can be harvested to fill the large defect. We highlight the importance of cranioplasty following skull defects as it induces more energy efficient mitochondrial function thereby improving cerebral blood flow and distribution as was seen in our patient who demonstrated speech fluency and improvement in motor and cognitive domains.[5] Autologous cranial grafts harvested with piezoelectric saw is a good choice in cranioplasty as it provides adequate structural support, low-donor site morbidity and the obvious advantage of being harvested from the same incision and the piezoelectric saw can be an excellent tool for harvesting the required graft as it allows for excellent cutting efficiency of the bone without the risk of accidentally damaging the dura. A delayed cranioplasty lowers the infection rate and allows fibrous adhesions on the dura that facilitates safe placement of grafts.

Declaration of patient consent

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.