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Advanced Cranial Reconstruction Utilizing Intracranial Free Flaps and Cranial Bone Grafts: An Algorithmic Approach Developed From the Modern Battlefield.
Diya H. Tantawi, MD1, Anand Kumar, MD1, Rocco Armonda, MD2, Ian Valerio, MD3.
1UPMC / Univeristy of Pittsburgh Medical Center - Department of Plastic Surgery, Pittsburgh, PA, USA, 2Department of Neurosurgery, Walter Reed National Military Medical Center., Washington, DC, DC, USA, 3Department of Plastic and Reconstructive Surgery, Walter Reed National Military Medical Center., Washington, DC, DC, USA.

Background: Warfare related craniectomy defects that include the upper orbits, facial sinuses or are associated with large endocranial dead space are a unique reconstructive challenge. The objective of this study is to report outcomes after initiation of an algorithmic approach using intracranial free flaps, cranial bone autografts and dermal/fat grafts to treat complicated cranial frontal-facial defects after war related decompressive craniectomy.
Methods: A review of injured personnel undergoing cranial defect reconstruction using alloplast, which included the orbital bar or associated with large endocranial dead space that subsequently required free flaps, cranial bone grafts and dermal/fat grafts in the National Capital Area was performed over a 52 month period. Collected data included mechanism of injury, evacuation time, initial GCS, GCS on arrival to the continental United States, type of decompressive craniectomy, type of implant initially used for reconstruction, complications including implant removal, subsequent reconstruction method including type of free flap and or cranial bone/dermal fat grafts if used for salvage secondary reconstruction.
Results: From March 2003 to July 2011, 13 patients were identified who underwent decompressive craniectomy and met inclusion criteria. Patient average age was 25 (range from 18 to 29 years) and all patients were males. Average follow up was 870 days (2.4 years). Average GCS at initial presentation was 7 and was 9 on arrival to the continental United States. Average time to evacuation to the continental United States was 4.2 days. Forty-six percent of all injuries were associated with an IED blast. Nine patients (69%) underwent hemi-craniectomies and four patients (31%) bi-frontal craniectomies. All 13 patients were complication free at the completion of the study period. Successful frontal bar/free flap reconstruction was present in 100% and successful secondary cranioplasty was present in 77% of the cohort. Cranial contour abnormality occurred in 7 patients (54%). One patient underwent a contour improvement procedure. One patient required a second free flap after loss of the primary flap. The mode Glosgow Outcome Score was 3 (range 3 -4). No mortality occurred during the study period.
Conclusions: Battlefield decompressive craniectomy for severe cranial injury has resulted in many unique reconstructive challenges. Reconstruction of high-risk orbital bar defects and large endocranial dead space using an algorithmic approach resulted in high secondary cranioplasty retention rates. Despite initial heavy contamination associated with war wounds and communication with facial sinuses, decompressive craniectomy defects associated with orbital, sinus, and skull base defects can be successfully reconstructed using an algorithmic approach with low morbidity and high success rates.


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