Cranioplasty is indicated to correct significant defects causing aesthetic concerns or compromising brain protection.
Etiologies include history of trauma, surgery, infection, or combinations.
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.
The standard approach is a coronal incision. However, previous craniotomy incisions may also be utilized.
Cranioplasty without sinus involvement
Cranioplasty defines the procedure of recreating the solid covering of the skull that protects the brain from injury.
When there is no sinus involvement, the standard cranioplasty technique described in the trauma section "Cranial vault & Skull base" can be utilized.
Cranioplasty in presence of significant frontal sinus communication
When there is a significant communication with a functional frontal sinus, long term follow up has demonstrated that implant infections may occur even several years after the cranioplasty procedure.
The cranioplasty is then usually combined with a sinus obliteration/cranialization procedure to prevent complications.
Cranioplasty in presence of small frontal sinus communication
If there is a small communication with the sinus, a sinus obliteration may be avoided.
During the standard cranioplasty procedure, a pericranial or galeal-pericranial flap can be used as a vascularized interpositional barrier between the sinus cavity and the implant.
Care must be taken not to compress the flap when the implant is secured. Slotting of the bone margin limits compression.
Cranioplasty in presence of compromised soft tissue coverage
In case of compromised soft tissue coverage, local, pedicled, or free flaps may be needed to provide predictable coverage of the cranial reconstruction.
Head of bed elevation may significantly reduce edema and pain. A compressive head dressing is left in place until suction drains are removed (24-48 hours postoperatively). Thereafter routine wound care should be instituted.
The patient's neurological status should be evaluated as soon as it is feasible. Regular postoperative neurological checks should be performed.
Nose-blowing should be avoided for at least 3 weeks following frontal sinus and skull base repair.
The use of some of the following perioperative medication is controversial.
Analgesia as necessary
Antibiotics (many surgeons use perioperative antibiotics. There is no clear advantage of any one antibiotic, and the recommended duration of treatment is debatable.) The spectrum should be according to the existing bacterial flora, especially in the combined intra and extra cranial procedures.
Corticosteroids may help with postoperative edema.
A head CT scan is obtained postoperatively to provide a patient baseline and evaluate for intracranial bleeding, dead space, and pneumocephalus.
Remove sutures from skin after approximately 7 days if non resorbable sutures have been used. Moisturizing lotion should be used on the skin wounds to minimize excessive scarring after sutures are removed.
Avoid sun exposure and tanning to skin incisions for several months.
Regular patient follow-up after discharge including periodic imaging is recommended.