Authors of section

Authors

Nicolas Homsi, Paulo Rodrigues, Gregorio Sánchez Aniceto, Beat Hammer, Scott Bartlett

Executive Editors

Edward Ellis III, Eduardo Rodriguez

General Editor

Daniel Buchbinder

Open all credits

Camouflage

1. Introduction

Surface irregularities and depressions may be secondary to treated or untreated frontal bone fractures.

The most common camouflaging techniques are the following:

  • Titanium mesh
  • Bone cements
  • Dermal grafts
  • Fat injections

Small full thickness craniotomy defects, usually as a result of trephination (eg. burr holes) can also be repaired using titanium mesh.

Frontal sinus drainage evaluation is critical in the treatment planning, and should be assessed with detailed imaging and/or endoscopy. Direct communication with the frontal sinus results in an increased risk of infection.

Note: The use of bone cement is contraindicated in cases with frontal sinus communication.

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2. Approaches

The surgical indication is usually cosmetic and therefore minimally invasive approaches should be considered.

Although, existing scars afford direct access, remote incisions avoid the potential wound dehiscence and material exposure.

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The endoscopically assisted approach to the anterior table of the frontal sinus is useful for camouflaging and limited cranioplasty procedures.

Subperiosteal dissection is necessary when contouring bony irregularities with a burr, augmenting with bone cements, or recontouring with titanium mesh.

Subgaleal dissection is recommended for soft tissue camouflaging procedures including fat or dermal graft techniques.

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3. Contouring

Bony irregularities commonly result from bony depressions or bony prominences secondary to frontal bone fractures.

These irregularities may be contoured with a burr or osteotome to re-establish the pre-morbid frontal bone contour.

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4. Titanium mesh

Titanium mesh can be used to recontour acquired frontal bone contour abnormalities.

A more extended approach may be required in these cases.

For more details on this technique please refer to cranial vault contouring using cranioplasty.

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5. Dermal graft

Dermal grafts may be harvested from the groin, are useful to cover minor irregularities especially in areas with thin skin coverage eg. frontonasal region.

Alternatively, fascia lata, allografts or xenografts may be used.

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A graft slightly larger than the defect is designed and put in place.

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Two or three layers of dermis may be used in the procedure if necessary. This technique is not suitable for deep defects.

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The graft can be secured using tissue glue or sutures.

frontobasal cranial vault depressions

6. Fat injections

Autogenous fat injection is a useful procedure when minor irregularities exist.

An acceptable soft tissue thickness over the defect is needed for a successful result.

Centrifuged fat is injected radially.

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7. Aftercare following camouflage

Postoperative positioning

Head of bed elevation may significantly reduce edema and pain.
A cooling mask may be used to further reduce edema.
A compressive head dressing is left in place until suction drains are removed (24-48 hours postoperatively). Thereafter routine wound care should be instituted.

orbital reconstruction

Medication

  • Analgesia as indicated
  • The use of antibiotics in the perioperative period is recommended
  • Regular patient follow-up after discharge including periodic imaging is recommended.