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TECHNICAL STRATEGY

Complications of Cranioplasty
Nanda Kishore Sahoo, MDS, FIBOMS, Kapil Tomar, MDS,y
Ankur Thakral, MDS,z and N. Mohan Rangan, MDS
ranging from 88.3  34.4 cm2 with improvement within
Abstract: Cranioplasty is a time-honoured surgical procedure to 3.8  3.9 days after cranioplasty.
restore the calvarial form and function that is associated with a Complication is not related to the time of cranioplasty and it
relatively high complication rate. The present article analyzed can be done as early as 2 weeks following craniectomy to lower
various complications and reviewed the complications based on the overall cost.3 We follow a delayed protocol of 4 to 6 months
study of the relevant research in the craniofacial literature. depending upon local healing, neurological status, and general
Complications were broadly divided into 2 groups, intraoperative condition of the patient but before the onset of syndrome of the
and postoperative, for ease of understanding. The etiological trephined. Various types of autogenous grafts and alloplastic
materials are used for reconstruction of the defects. Inspite of
factors, local and systemic condition of the patient, prevention,
cranioplasty being a fairly straight-forward, time-honored pro-
and management of various complications were widely dis- cedure, it is still associated with a relatively high complication
cussed. The article also highlighted problems and complications rate, ranging from 12% to 50%.3 – 10 The complications of cra-
associated with various reconstructive materials. Insights into nioplasty may be associated with residual underlying pathology,
various complications of cranioplasty enable surgeon to under- surgical procedure, and reconstruction material. In case autoge-
stand them better, minimize the chances of occurrence, and nous reconstruction material is selected, the donor site complica-
improve surgical outcome. In spite of reported high rate of tions are also to be taken into consideration.
complications, serious complications like meningitis, air embo-
lism, and death are rare.
CLASSIFICATION OF COMPLICATIONS
The complications associated with cranioplasty can be
Key Words: complications, cranioplasty, management broadly divided into 2 groups, that is intraoperative and post-
operative.
(J Craniofac Surg 2018;00: 00–00)
1. Intraoperative complications
(a) During exposure of the defect
C ranial defects may be congenital or acquired. The defects of
superficial calvarial bones like frontal, parietal, temporal, and
occipital are of clinical significance, hence require reconstruction.
- Bleeding
- Button hole of the flap
In case of acquired (secondary/residual) defects, the duration after - Dural tear and cerebrospinal fluid (CSF) leak
which the reconstruction is carried out depends upon various factors - Damage to venous sinus
like cause of defect, condition of recipient site, age and general (b) During graft harvest (calvarial/rib)
condition of the patient, concomitant chemoradiotherapy, and - Full thickness calvarial harvest
availability of preserved bone. - Fragmentation
Cranioplasty is a surgical procedure to restore the calvarial - Damage to dura/brain
form and function with hard tissue replacement. It has also
- Pleural tear
recently been postulated that performing cranioplasty has a
Postoperative complications
therapeutic role in improving the patient’s functional and neu-
rological outcome after decompressive craniectomy (DC). Syn- 2. (a) Early post operative complications
drome of the trephined, first described by Grant and Norcoss,1 - Hematoma/CSF collection
refers to constellation of neurological dysfunction symptoms in - Wound dehiscence
patients with cranial deformity. A systematic review done by - Flap necrosis
Ashayeri et al2 concluded that it commonly occurs in male - Graft/implant infection
patients at 5.1  10.8 months after craniectomy with defect (b) Delayed post operative complications
- Draining sinus
- Exposure of the reconstruction material
From the Department of Oral & Maxillofacial Surgery, CMDC (CC),
- Contour defect
Lucknow, Uttar Pradesh; yINHS Ashwani, Colaba, Mumbai, Maharash- - Resorption of graft
tra; and zBhopal, India. - Step deformity
Received August 21, 2017. - Loss of fixation
Accepted for publication January 25, 2018. - Thermal sensitivity
Address correspondence and reprint requests to Dr. Nanda Kishore Sahoo,
MDS, FIBOMS, Department of Oral & Maxillofacial Surgery, CMDC - Skin discoloration
(CC), Lucknow 226002, Uttar Pradesh, India; - Migration of reconstruction material
E mail colnksahoo@gmail.com. - Palpable implant/fixation device
The authors report no conflicts of interest. - Reaction to implant
Copyright # 2018 by Mutaz B. Habal, MD
ISSN: 1049-2275 - Temporal hollowing
DOI: 10.1097/SCS.0000000000004478 - Alopecia

The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2018 1
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Sahoo et al The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2018

BLEEDING
Scalp and calvarium are rich in vascularity. Intraoperative bleeding
may be encountered during exposure of the defect to prepare the
recipient bed and harvesting of calvarial graft. Intraoperative
bleeding can be controlled by injecting adrenaline 1:200,000 dilu-
tion as tumescence along the proposed line of incision. Hemostatic
sutures can be used on both the sides of incision line, which may be
time-consuming (Fig. 1A). Dandy forceps easily engage pericra-
nium to achieve hemostasis. However, multiple forceps may inter-
fere in surgical procedure. The most effective method to control
bleeding is application of Raney clips. It exerts adequate pressure to
control bleeding without crushing the tissue and interfering in the
surgical field. It can be applied quickly and removed easily. The
reusable metallic clip tends to get loose over a period of time.
Disposable clips are expensive. We have also used sterilized paper
clips that provide good hemostasis. Diploic venous oozing follow-
ing harvest of split calvarial graft can be easily managed with
bone wax.

BUTTON HOLE OF FLAP

All the cases of residual calvarial defect have undergone surgical
intervention in the area of defect. Frequent surgical intervention,
trauma, infection, wound dehiscence, and failure of previous recon- FIGURE 1. (A) Hemostatic sutures. (B) Button hole. (C) Pedicled flap (D) Patchy
struction result in scarring and poor differentiation of tissue layers. full thickness harvest. (E) Flap necrosis. (F) Puncture by metallic mesh. (G)
Irregular contour. (H) Palpable fixation device. (I) Hollowing effect.
Subpericranial dissection is difficult when pericranium is adherent
to underlying dura. Superficial dissection may lead to button hole
defect of the flap (Fig. 1B). Careful dissection along the loose challenging. Split calvarial graft harvesting is restricted to parietal
areolar tissue plane away from the dura alleviates the difficult bone. A limited amount can be harvested from frontal and occipital
epidural dissection, preserves the vascularized pericranium as a bone. In children younger than 9 years it is not recommended, as
protective layer against infection, and avoids button hole defect.11 there is poor diploic differentiation. In cases of trauma and skull
As the button hole lies directly over the reconstruction material, the fracture the bone morphology and diploic architecture is disturbed
chances of infection are high. Direct suturing of skin fails to achieve because of scarring. An attempt to harvest split calvarial graft may
a hermitical seal. A pedicled connective tissue flap from the lead to patchy full thickness harvest (Fig. 1D). The diploic pattern
adjoining area helps to achieve 2-layered closure (Fig. 1C). can be assessed preoperatively by computed tomography scan.

DURAL TEAR AND CSF LEAK FRAGMENTATION

Dura is a thin and friable tissue. In case of repeated surgical The cortical bone is thick and brittle. Failure to achieve diploic
intervention, it is difficult to differentiate dura from pericranium. plane and wrong instrumentation may lead to fragmentation of the
During primary surgery, dura is hitched to margin of bony defect split calvarial graft. In elderly patients, the split calvarial graft is
with silk sutures to avoid hematoma. Dura is more prone to tear as more prone to fragmentation because of lack of elasticity. Suture
brain tissue tends to bulge out through the bony defect because of area should be avoided. In case of fragmentation, further attempt
postural increase in intracranial pressure during reconstruction. The should not be made to harvest split calvarial graft.
leakage of CSF is an indication of dural tear. Dural tear should be
repaired with 3–0 silk before reconstruction of the defect. Dural
defect can be repaired using pericranial graft, fascia lata, or DAMAGE TO DURA/BRAIN
synthetic dura patch. Damage to the dura, venous sinus, and brain may occur during
exposure of the defect and harvest of calvarial graft. Calvarial graft
harvesting should be restricted to parietal bone. In case of suspicion,
DAMAGE TO VENOUS SINUS neurosurgical opinion should be sought.
Venous sinus may be damaged during exposure of the defect,
harvesting of calvarial graft, and use of drill bits. Superior sagittal
sinus is more prone to damage because of its anatomical location. PLEURAL TEAR
Owing to negative pressure within venous sinus there is possibility It is a common complication associated with rib graft harvest. To
of air embolism. The damage should be identified and repaired confirm the pleural tear, normal saline is poured into the wound and
before reconstruction. It can be prevented by harvesting the calvar- the anesthetist is asked to inflate the lungs with positive pressure
ial graft at least 1 cm away from the suture. Shorter drill bits with ventilation. Escape of air bubbles suggests pleural tear. A chest tube
sleeve at 5 to 6 mm should be used while stabilizing the is placed for 48 to 72 hours.
reconstruction material.
HEMATOMA/CSF COLLECTION
FULL THICKNESS CALVARIAL HARVEST Hematoma can be prevented by achieving hemostasis before wound
There are different methods to harvest calvarial grafts. Some closure. Use of vacuum drain and pressure dressing helps in
surgeons prefer full-thickness harvest and split the graft. The outer adaptation of flap and minimizes the chances of hematoma. The
layer is returned to the donor site and inner layer is used for vacuum drain is removed after 48 hours when the collection is
reconstruction. Harvesting split calvarial graft is technically restricted to the tubing. CSF collection is suggestive of dural breach.

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The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2018 Complications of Cranioplasty

It is self-limiting. No attempt should be made to aspirate, as it may of calvarial and rib graft leads to irregular webby surface. Loss of
get infected. contour is because of resorption of the graft. Calvarial graft is
resistant to resorption, whereas rib graft is more prone to resorption.
WOUND DEHISCENCE AND FLAP NECROSIS
Designing of flap depends upon the size of the defect, previous STEP DEFORMITY
suture line, arterial supply, presence of soft and hard tissue graft, It is a donor site deformity following harvest of split outer calvarial
and requirement of calvarial graft. Usually in craniectomy, the graft. The step can be minimized by reducing the margins with a rotary
suture line is on the margin of the defect. For cranioplasty, the bone trimmer. Remodeling takes place over a period of time. Except
incision line is extended beyond the previous scar tissue to the for the patient’s awareness, it has hardly any clinical significance.
healthy bone to avoid the suture line directly over the reconstruction
material and zone of transition of graft and host. The strip of soft LOSS OF FIXATION
tissue parallel to the previous suture line has compromised vascu- The reconstruction material is stabilized by wiring or bone plates
larity. In case of avulsive scalp injury, the exposed calvarial bone is and screws. Loss of fixation may be seen because of resorption of
covered with split skin graft or reconstructed with local flaps. bone graft. In case of implants, loss of fixation is at bony end rather
Necrosis of the flap is seen when extended to these areas than at implant end. Use of appropriate size of drill bit and coolant
(Fig. 1E). Use of resorbable suture material should be minimal, to avoid thermal necrosis is the vital step to avoid loss of fixation.
as it is more prone to infection and suture breakdown. Loose and palpable fixation device causes pressure effect and
irritation (Fig. 1H). Thermal sensitivity, skin discoloration, palpa-
GRAFT AND IMPLANT INFECTION bility, migration, and tissue reaction are problems related to allo-
Bone grafts preserved inside the body and harvested autogenous plastic reconstruction material. Large metallic implants and
grafts do not require any sterilization. After harvesting, it should be inadequate scalp thickness may lead to thermal sensitivity and
used as early as possible. In case of delay, it can be preserved in discoloration. CCI manufactured by computer-aided designing
blood-soaked gauze piece or in normal saline. Sterility of bone graft and computer-aided manufacturing (CAD/CAM) technique are
preserved in bone bank should be ascertained before use. In case of of high precision and margins are hardly palpable. Migration of
any doubt, the graft may be cleaned and autoclaved before use. alloplastic material may occur because of loss of fixation and
Sterilization of implant is a critical factor to avoid infection. growth of skull. Hence, alloplastic material is not preferred in
Implants are either customized or adapted directly over the defect growing skull. Stability of implant is improved by making multiple
during reconstruction. Ready to use customized implants are steril- holes to permit in growth of fibers. Titanium is biocompatible and
ized by the manufacturer and supplied in sealed pouches. The extensively used for fracture fixation and reconstruction. PMMA
metallic implants can be sterilized by autoclaving. The nonmetallic without coloring agents and additives processed as per manufac-
implants are sterilized by cold sterilization. Adaptation of noncus- turers direction has minimal residual monomer and causes no
tomised implants is difficult and time-consuming, thereby exposing tissue reaction.
the implant for longer duration.
The patients undergoing cranioplasty are placed under appro- TEMPORAL HOLLOWING
priate antibiotic cover at least 2 to 3 hours before surgery and Postoperative temporal hollowing is related to atrophy of the
continued for 3 to 5 days postoperatively. Special attention is given temporalis muscle and fat following neurosurgical intervention.
to the patient having history of diabetes mellitus. In case of CCI is slightly over contoured to compensate the hallowing effect.
persistent infection there is no other option except removal of Bony defects of the temporal fosse are exposed by dissecting under
the graft or implant. the temporalis muscle. The muscle is transfixed to the reconstruc-
tion material with 2–0 silk to minimize the hollowing effect
DRAINING SINUS (Fig. 1I).
It may be associated with local causes like skin infection, folliculi-
tis, wick effect of buried suture material, and infection of fixation ALOPECIA
and reconstruction material. Sinus healing takes place following Loss of hair is seen in the scar tissue and along the line of incision.
local wound care, removal of infected suture, and fixation device. Alopecia within the hair line is of least clinical significance.
Use of appropriate antibiotic is considered following sensitivity Electrocautery should be judiciously used to minimize damage
test. Removal of the reconstruction material may be considered as to the hair follicles.
the last resort.
DISCUSSION
EXPOSURE OF RECONSTRUCTION MATERIAL Complications in any reconstructive surgery are multi-factorial.
Wound dehiscence, flap necrosis, and infection of graft/implant are Complications in cranioplasty have been broadly attributed to the
the causes of exposure of reconstruction material. Sharp margins of nature of the initial underlying pathology, type of the reconstruction
metallic mesh may puncture through the soft tissue and get exposed material, and the technique of the cranioplasty procedure.1,2,10,12–22
(Fig. 1F). Reconstruction material is removed to avoid spread Complications related to anesthesia, medications, and transfusion
of infection. are beyond the scope of the subject. Both the systemic condition of
the patient and status of recipient site are the host factors. According
to Gooch et al,7 3 major factors for complication are medical
CONTOUR DEFECT AND RESORPTION condition of the patient, recipient site, and selection of reconstruc-
OF GRAFT tion material. Immunity of the host is compromised in illness like
Irregular contour, loss of contour, and over contour are 3 different diabetes, asthma, chronic infection, blood dyscresia, and malig-
types of contour defects. It is rarely encountered in customized nancy. Patients suffering from coronary artery disease and on
cranial implants (CCIs). Irregular contour and loss of contour are anticoagulant therapy are at high surgical risk. Any preexisting
associated with bone grafts (Fig. 1G). Space between multiple strips medical condition may significantly increase the surgical

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complication23 and clearance should be obtained from treating fabrication of autologous, customized tissue-engineered graft. The
physician. Longer duration of surgery and autogenous bone grafting osteoconductive bioresorbable materials, tissue engineering,
unless preserved are better avoided in such cases. osteoinductive materials, growth factors, and gene therapy prom-
Complications of cranioplasty may be related to etiological ised to deliver integrated prosthesis of autogenous bone and com-
factors and size of calvarial defect. The etiological factors of bination of cells and scaffolds with much faster bony integration.
acquired calvarial defects are trauma, DC, tumour resection, and Preliminary clinical studies have shown promising results; how-
infection.24 The overall complication rates in cranioplasties after ever, issues of biocompatibility, bone apposition, mechanical integ-
decompressive craniotomies may be as high as 36.5%.25– 27 Cranial rity, and maintenance of skeletal function need to be addressed
defects owing to pathological conditions and in patients of older age before its application in large-scale clinical settings.35
group are more prone to infection.4 Larger the size of defect, the Postoperative complications that occur within 3 weeks of sur-
chances of complication are more. Local conditions like residual gery is early complication and beyond that is late complication.23
pathology, infection, draining sinus, severe scarring, existing recon- Infection and wound break down are the most common early
struction, irradiated tissue, thickness of scalp tissue, presence of postoperative complications. Gooch et al7 reported 34% incidence
flap, and skin graft should be carefully evaluated preoperatively. To of immediate postoperative complications like infection, wound
minimize the possibility of local contributory factors we prefer the breakdown, intracranial hemorrhage, bone resorption, and sunken
delayed cranioplasty by 4 to 6 months regardless of the etiology. cranioplasty. Duration of the surgery has also been attributed as a
Early cranioplasty within 1 month of trauma does not increase the cause for complication. Operating time <200 minutes is considered
risk of complication except in bifrontal cranioplasties.28 Chang et al as a prognostic factor for fewer surgery-associated infections.36
reported a significant reduction in the incidence of surgery associ- Scalp tissue has rich vascularity because of multiple feeder
ated complications in patients <40 years of age when operated for vessels. Vascularity is compromised because of scarring and when
reimplantation of bone flap within 3 months of DC.4 The overall scalp tissue is replaced with skin graft and flaps. Extension of
complication was 19.7% when factors like history of previous incision to these areas to expose the defect jeopardizes the vascu-
cranioplasty, size of defect, type of reconstruction material, and larity of the flap. We have come across few such cases with bluish
delayed cranioplasties were considered.6,29 discoloration of the flap in early postoperative phase that were
Intraoperative complications like damage to dura, brain, and managed by selective removal of sutures and topical application of
venous sinus warrant on the spot consultation with neurosurgeon heparin ointment (10,000 IU). However, 2 cases landed up with flap
before further intervention. Harvesting of the graft should be done necrosis along the margins exposing the bone graft. After a gap of
only after exposure of the defect. If procedure is required to be 12 weeks, the strip of exposed bone graft was removed and the area
discontinued because of intraoperative complication, at least the was grafted with split skin graft.
graft is not wasted. Premature discontinuation of the procedure has Autogenous grafts like rib, iliac crest, and calvarium have been
been reported because of intraoperative complications like hypo- popular for cranioplasty. This is so because of lower incidences of
tension and bradycardia.7 infection and exposure of graft material. Split rib is softer, less stiff,
Intraoperative complications may be associated with harvest- and thus better suited for pediatric patients. Furthermore, the intense
ing of autogenous bone graft. Retrieving the graft preserved in foreign body reaction associated with alloplasts is avoided alto-
anterior abdominal wall and lateral aspect of thigh is least gether. Thus, cranioplasty using autogenous split rib and calvarium
complicated. Harvesting of split calvarial graft is technique- has been universally accepted as the preferred option in adults and
sensitive and demands high level of surgical expertise. Frag- pediatric patients.37 Delayed complications like resorption and loss
mentations, bleeding from diploic veins, diploic harvest, and of contour are the drawbacks. Several studies support the advan-
damage to inner cortex are some of the expected complications tages of membranous bone over endochondral bone, the most
that can be safely managed. Pleural tear may be encountered accepted being lesser resorption as compared to endochondral
while harvesting rib graft. For large defects, split rib graft can be bone.38– 41 Ozaki and Buchman observed that the resorption rate
arranged across each other in a ‘‘baseball catcher’s mask’’ of the bone graft is determined by its microarchitecture rather than
fashion using minimal grafting material.30,31 Peritoneal perfora- its embryologic origin.42 High incidence of autogenous bone
tions have been reported during harvesting of iliac bone graft. resorption was seen in pediatric patients when reconstruction
Permanent gait disturbance, gluteal sag, and landslide hernias are was done following DC.8 It was related to the size of defect.
few of the postoperative complications. However, age, sex, anatomical location, number of fractures,
The undesirable exothermic reaction, residual monomer leach- presence of shunt, and time interval had no correlation. The donor
ing, tissue necrosis, and marginal fit of alloplastic cranial implants site complications are minor and do not have much clinical signifi-
are best addressed by CCIs fabricated by CAD/CAM 3-dimensional cance. CCIs are fabricated using PMMA or titanium. Titanium is
printing technology. These prefabricated patient-specific CCIs have biocompatible, well tolerated by the body, and extensively used in
best fit and contour and achieve symmetric skull reconstruction by the surgical field.
mirroring the contralateral cranium.32,33 If required, further cus- Besides these, certain other factors like age of the patient, size of
tomization of PMMA implants can be done intraoperatively to defect, time of cranioplasty, duration of preserved graft, method of
improve the fit, but same is not possible for metallic implants. Over fixation, and duration of surgery also contribute to the successful
riding, sharp margins and cut ends are better addressed intraopera- surgical outcome. However, serious complications like meningitis,
tively. At least 3-point fixation should be done for adequate stability air embolism, and death are rare.
and to avoid postoperative complications like implant mobility,
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# 2018 Mutaz B. Habal, MD 5

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