Advanced cranial reconstruction using intracranial free flaps and cranial bone grafts: An algorithmic approach developed from the modern battlefield

Background: The objective of this study was to report outcomes after initiation of an algorithmic approach (Bethesda protocol) using intracranial free flaps, cranial bone autografts, and dermal/fat grafts to treat warfare-related cranial frontofacial defects after war-related decompressive craniectomy. Methods: A retrospective review of personnel undergoing complex cranial defect reconstruction that required free flap interpositions for dead space obliteration, cranial bone grafting, or dermal/fat grafting for orbital defects was performed over a 52-month period. Results: From March of 2003 to July of 2011, 13 patients were identified who underwent complex craniofacial defect reconstruction. All patients were male (average age, 25 years). Average follow-up was 3.6 years. Glasgow Coma Scale score was 7 initially and 9 on arrival to the continental United States. Average evacuation time was 4.2 days. Forty-six percent of injuries were blast injuries. Nine patients (69 percent) underwent hemicraniectomies and four (31 percent) underwent bifrontal craniectomies. Two patients required free flaps and four required free flaps and cranial bone grafts for skull base reconstruction. Five patients required cranial bone grafts and two required cranial bone grafts with dermal fat grafts for reconstruction. All patients were complication free at conclusion of the study. The initial free flap success rate was 86 percent (six of seven flaps). Successful frontal bar/free flap reconstruction was present in 100 percent and the secondary cranioplasty rate was 77 percent. Conclusion: Decompressive craniectomy defects associated with orbital, sinus, and skull base defects can be successfully reconstructed using an algorithmic approach with low morbidity and high secondary cranioplasty retention rates.