PURPOSE: Reconstruction of complex cranial defects presents numerous challenges, especially when combined with radiation therapy (RT). As such, the goal of this study was to investigate whether pre- or postoperative RT increases the risk of complications in the setting of cranioplasty (CP) with customized cranial implants.
MATERIALS AND METHODS: A retrospective cohort study was performed on our Institutional Review Board–approved database spanning January 2012 to March 2018.1 All CPs performed by the senior author (C.R.G.) were included. Variables abstracted from patient records include demographic data, medical/surgical history, intraoperative data, and postoperative history. Further analyses were performed on “primary” CPs (defined as no prior CP attempts to correct their index cranial defects). “Revision” CPs (defined as having prior CP reconstruction performed by either the senior author/different surgeon) were excluded. The primary outcome was complication incidence in patients who underwent pre- or postoperative RT. Complications were categorized as major or minor. “Major” required reoperation, whereas “minor” was self-limiting. Recurrences of the indication for index craniotomy/craniectomy were not considered CP-related complications. Complication rates were further assessed by implant material. Standard descriptive analyses were performed. Chi-square tests were used to examine for significant differences across categorical variables, with significance set at P < 0.05.
RESULTS: Two hundred twenty-seven primary CPs were performed between January 2012 and March 2018. Eighteen patients underwent pre-RT, and 11 underwent post-RT. Mean age was 50 years (SD ± 16.3; range, 17–92 years). Of the 199 patients who did not undergo radiation, 23 (12%) had major complications. Of the 18 pre-RT patients, 3 (17%) had major complications. Two patients had tumor recurrence requiring further surgery. None of the 10 post-RT patients had complication; 2 had tumor recurrence requiring additional surgery. There was no statistically significant difference among the groups (P > 0.05). Across all groups, most patients underwent CP reconstruction with solid, prefabricated poly(methyl methacrylate) (no liquid mixing intraoperative). The use of autologous bone compared to synthetic implants did not result in statistically significant differences in complications in any of the groups.
CONCLUSIONS: In this study, neither pre-RT nor post-RT significantly increase the risk of major complications in primary CP. We hypothesize that our patient-specific algorithm for choosing solid implants over titanium mesh, combined with various neuroplastic surgery techniques such as scalp augmentation with fascia,2 contribute to these findings. Further studies are needed to determine whether this holds true in revision surgeries.
1. Wolff A, Santiago GF, Belzberg M, et al. Adult cranioplasty reconstruction with customized cranial implants: preferred technique, timing, and biomaterials. J Craniofac Surg. 2018;29:887–894.
2. Wolff A, Santiago G, Weingart J, et al. Introducing the rectus fascia scalp augmentation technique: a new method for improving scalp durability in cranioplasty reconstruction. J Craniofac Surg. 2018;29:1733–1736.