Split Rib Cranioplasty for Aplasia Cutis Congenita and Traumatic Skull Defects

The potential role of mechanotransduction in the management of pediatric calvarial bone flap repair

Pediatric patients suffering traumatic brain injuries may require a decompressive craniectomy to accommodate brain swelling by removing a portion of the skull. Once the brain swelling subsides, the preserved calvarial bone flap is ideally replaced as an autograft during a cranioplasty to restore protection of the brain, as it can reintegrate and grow with the patient during immature skeletal development. However, pediatric patients exhibit a high prevalence of calvarial bone flap resorption post-cranioplasty, causing functional and cosmetic morbidity. This review examines possible solutions for mitigating pediatric calvarial bone flap resorption by delineating methods of stimulating mechanosensitive cell populations with mechanical forces. Mechanotransduction plays a critical role in three main cell types involved with calvarial bone repair, including mesenchymal stem cells, osteoblasts, and dural cells, through mechanisms that could be exploited to promote osteogenesis. In particular, physiologically relevant mechanical forces, including substrate deformation, external forces, and ultrasound, can be used as tools to stimulate bone repair in both in vitro and in vivo systems. Ultimately, combating pediatric calvarial flap resorption may require a combinatorial approach using both cell therapy and bioengineering strategies.

Three dimensional custom-made PEEK cranioplasty

BACKGROUND

An optimal reconstruction of calvarial skull defects is a challenge for neurosurgeons, and the strategy used to achieve the best result remains debatable. Therefore, we conducted this study to compare the esthetic and functional outcome of custom-made three-dimensional (3D) cranioprostheses to handmade bone cement in reconstructing calvarial skull defects.

METHODS

We included 66 patients above 10 years of age with calvarial skull defects and undergoing reconstruction: 33 were enrolled in the custom-made 3D implants group and 33 in the handmade implants group in the period from August 2017 to December 2020 in the neurosurgery department of Fayoum University Hospital.

RESULTS

Complete success of the esthetic end-point was insignificantly higher in the custom-made 3D prostheses group based on the doctor's and patients' assessment (60.6% vs. 42.4%; 33.3% vs. 9.1%, P > 0.05), respectively. Complete success of the functional end-point was significantly higher in the custom-made 3D group compared to the handmade cement bone group according to the doctor's and patients' assessment (60.6% vs. 0%; 21.2% vs. 0%, P < 0.05). There were no late complications noted in the custom-made 3D prosthesis group, whereas 50% of the handmade bone group had late complications (P < 0.05). Full improvement of the symptoms of the "syndrome of trephined" was achieved in the 3D custom-made group compared to the handmade bone cement group (20% vs. 0%).

CONCLUSION

Cranioplasty using three dimensional customs made PEEK prosthesis is a reliable method which saves operative time, lowers cost and provides less complications if compared with other cranioplasty techniques. Custom-made 3D cranioprostheses are better than handmade bone cement in reconstructing calvarial defects in terms of esthetic and functional outcome as well as complications.

Use of an epidermal growth factor-infused foam dressing in a complicated case of Adams-Oliver syndrome

Adams-Oliver syndrome is a rare disorder with varying degrees of scalp and cranial bone defects as well as limb anomalies, which can range from mild to more pronounced manifestations. In mild cases, closure of these defects can be achieved with a conservative approach. However, surgical closure is recommended in cases where the defect is extensive and includes cranial involvement. Several complicated cases of Adams-Oliver syndrome have been reported, in which flap failures were encountered and other alternatives had to be used to close critical scalp defects. Here, the case of a 4-year-old child with Adams-Oliver syndrome and a complex cranial defect with exposed titanium mesh is described. The patient was successfully treated with epidermal growth factor (EGF) infused foam dressings and subsequent split-thickness skin grafting. The EGF has been highlighted for its essential role in dermal wound repair through the stimulation of the proliferation and migration of keratinocytes, and showed accelerated wound healing when used in partial or full-thickness skin wounds.

Classification of the Residual Cranial Defects and Selection of Reconstruction Materials

The cranial defects are complex in nature and are due to various causes. Therefore, there is a need for a common term of reference to these defects. This requirement stood as a prime reason for proposing a classification system for cranial defects. The classification is based on 2 decades of experience in cranioplasty. This efficient and simple way of representation would fill the existing lacunae for a systematic communication on cranial defects. Over the ages the evolution of reconstruction and grafting had undergone a massive progress. Therefore, it is essential to enumerate all available graft and bio-materials for restoring the cranial defects. The aetiology for these defects, age and sex of the patient, site and size of the defect, associated systemic conditions, cost factor, and operator's choice are the factors that play key role in the selection of the reconstructive material. This article discusses on these factors in cranioplasty. High success rate with excellent function and cosmetic outcome in using a variety of materials, as shared in this article. The advantages of autografts cannot be matched by any existing alloplast. However, in case of larger defects, for a better cosmetic outcome and to reduce the donor site morbidity, alloplasts are the most widely preferred material of choice.

Split Rib Cranioplasty for Frontal Osteoma: A Case Report and Review of the Literature

INTRODUCTION

Osteomas are benign bone tumors. They generally lead to a local thickness on the frontal bone in calvarium. When they occur on the forehead, they often cause a cosmetic disorder without any neurological symptoms. The significant problem is the repair method of the cranium defect.

CASE PRESENTATION

The rib of a 34-year-old female was split and used for a small cranium defect of 3 × 3.5 cm. The preferred method and the obtained results were presented under the guidance of the literature.

CONCLUSIONS

Along with the technological advancement, different materials are employed according to the size of the cranium defect and the age of the case. The application of split costa cranioplasty for the small cranium defects in the region of patient's face is the method with the least possibility of complications, and its cosmetic and functional results are quite promising.

Dilemmas and challenges in the management of a neonate with Adams-Oliver syndrome with infected giant aplasia cutis lesion and exsanguination: a case-based update

BACKGROUND

Aplasia cutis is a rare developmental anomaly usually involving the calvarium, associated with a variable extent of defective formation of the scalp. Adams-Oliver syndrome is a condition mainly characterized by the congenital absence of skin, known as "aplasia cutis" which is usually limited to the vertex scalp and transverse limb defects.

CASE REPORT

A 17-day-old term female neonate was referred to us with an infected scalp lesion of the vertex. The lesion which is about 10 × 9 cm had signs of infection with necrotic eschar. We started the neonate on systemic parenteral antibiotics with local dressings. On day 3 of conservative management, the neonate had exsanguination due to bleeding from the midline with severe hemodynamic compromise requiring cardiopulmonary resuscitation. After controlling the bleeding with local tamponade and resuscitating the child, she was taken for early surgery. Debridement and bipedicled rotation flap of the scalp to cover the raw area was performed. On day 18, the flap started showing signs of necrosis. The neonate was taken up for debridement, and subsequently, maternal allograft of split-thickness skin was placed as a temporary wound cover. Meanwhile, the wound showed progressive epithelialization. At 1 year, the patient continued to have a non-healing area, which was later successfully covered with a split-thickness skin graft. We plan to revaluate the need for cranioplasty at around 3-4 years of age.

DISCUSSION

We discuss the dilemmas and challenges involved in the successful management of a neonate with Adams-Oliver syndrome with infected aplasia cutis and an episode of life-threatening exsanguination.

CONCLUSION

Aplasia cutis is a rare developmental anomaly usually involving the calvarium, associated with defective formation of the scalp to a varying extent and severity, requiring various timely strategies.

Two different management modalities in a two sibling case report of Adams Oliver syndrome

The authors report two-sibling case of Adams Oliver syndrome. One was managed with early surgical intervention after a period of failed conservative management and the other conservatively managed until reconstruction and surgical correction of alopecia. The goal of treatment is to achieve a complete closure of the defect without encountering any fatal complications such as haemorrhage and infection or causing any long-term neurological morbidity. Various papers have been published related to ACC, yet there is no consensus on the therapeutic approach. The management decision hinges upon balancing the risks of complications including spontaneous sagittal sinus haemorrhage and the risk of surgical intervention. Both treatment modalities proved successful in these cases.

Split-rib reconstruction of the frontal sinus: two cases and literature review

BACKGROUND

Large defects of the anterior wall of the frontal sinus require closure using either autologous or foreign material. In cases of osteomyelitis, the reconstruction must be resistant to bacterial infection. Split-rib osteoplasty can be used in different sites.

METHODS

Two patients with malignant sinonasal tumours underwent repeated treatment, and subsequently developed osteomyelitis of the frontal bone. After adequate therapy, a large defect of the anterior wall persisted. Reconstruction was performed using the split-rib method. The literature on this topic was reviewed.

RESULTS

Both patients' treatment were successful. No complications occurred. A PubMed search on the topic of rib reconstruction of the frontal sinus and skull was performed; 18 publications matched the inclusion criteria. From these sources, we noted that 182 reconstructions yielded good results with few complications.

CONCLUSION

Large defects of the anterior wall of the frontal sinus can be closed successfully using autologous split-rib grafting. Aesthetic outcome is good and donor site morbidity is minimal.

A case of extensive Aplasia Cutis Congenita with underlying skull defect and central nervous system malformation: discussion of large skin defects, complications, treatment and outcome

Aplasia Cutis Congenita (ACC) is a rare condition characterized by the absence of a portion of skin at birth. Skin defects are usually small (0.5 to 3 cm) and located on the scalp. Although there can be other physical or genetic abnormalities, ACC is most often a benign isolated condition. Rarely is an underlying bony defect present, and this association increases the rate of complications. We report a case of a newborn male with ACC of the entire crown and vertex scalp, non-ossified parietal skull and dysplastic corpus callosum. The patient's skull and skin defects were treated non-surgically, and he recovered well.