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Original Article Plastic and Aesthetic Research

Surgical pitfalls with custom-made porous

hydroxyapatite cranial implants

Bruno Zanotti , Angela Verlicchi , Roberto Stefini , Attilio Carlo Salgarelli ,
2
3
4
1
Nicola Zingaretti , Pier Camillo Parodi , Casadei Matteo , Massimo Robiony 6
6
5
5
1 Department of Neurosurgery, University Hospital S. Maria della Misericordia, 33100 Udine, Italy.
2 Neurology Unit, Free University of Neuroscience “Anemos”, 42124 Reggio Emilia, Italy.
3 Department of Neuroscience, Neurosurgery Unit, University of Brescia, 25123 Brescia, Italy.
4 Department of Head and Neck Surgery, Unit of Maxillofacial Surgery, Modena and Reggio Emilia University, 41124 Modena, Italy.
5 Department of Plastic and Reconstructive Surgery, University Hospital S. Maria della Misericordia, 33100 Udine, Italy.
6 Department of Maxillo-Facial Surgery, University Hospital S. Maria della Misericordia, 33100 Udine, Italy.
Address for correspondence: Prof. Massimo Robiony, Department of Maxillo-Facial Surgery, University Hospital S. Maria della Misericordia,
33100 Udine, Italy. E-mail: massimo@robiony.it
ABSTRACT
Aim: Cranioplasty implants are used primarily in cases of surgical cranial decompression following
pathological elevations of intracranial pressure. Available bone substitutes include porous
hydroxyapatite (HA) and polymethylmethacrylate. Whichever material is used, however, prosthetic
cranial implants are susceptible to intra- and postsurgical complications and even failure. The aim
of this study was to investigate such occurrences in HA cranioplasty implants, seeking not only to
determine the likely causes (whether correlated or not with the device itself) but also, where possible,
to suggest countermeasures. Methods: We analyzed information regarding failures or complications
reported in postmarketing surveillance and clinical studies of patients treated worldwide with
custom-made HA cranial implants (Custom Bone Service Fin-Ceramica Faenza, Italy) in the period
1997-2013. Results: The two most common complications were implant fractures (84 cases, 2.9% of
the total fitted) and infections (51 cases, 1.77%). Conclusion: Although cranioplasties are superficial
and not difficult types of surgery, and use of custom-made implants are often considered the “easy”
option from a surgical perspective, these procedures are nonetheless plagued by potential pitfalls. If
performed well they yield more than satisfactory results from the points of view of both the patient
and surgeon, but lack of appropriate care can open the door to numerous potential sources of failure,
which can compromise-even irreparably-the ability to heal.
Key words:
Cranial, cranioplasty, custom-made, hydroxyapatite, implants

INTRODUCTION roles in restoring both function and aesthetics, and
thus, consideration of a custom‑made solution as a first
Cranioplasty implants, whether of autologous bone or choice is in the best interest of the patient. Available
biocompatible bone substitutes, are used primarily in cases bone substitutes include porous hydroxyapatite (HA),
of surgical cranial decompression following pathological which favors regeneration (biomimetism) as well as
elevations of intracranial pressure. These implants play reconstruction, and polymethylmethacrylate (PMMA),
which should be reserved for severe cases of psychiatric
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Quick Response Code: disturbance, violent institutionalized patients, epileptics
[1]
Website: with frequent falling episodes, and the terminally ill.
www.parjournal.net Whichever material is used, however, prosthetic cranial
implants are susceptible to intra‑ and postsurgical
complications and even failure. The aim of this study
DOI:
10.4103/2347-9264.149364 was to investigate such occurrences in HA cranioplasty
implants, seeking not only to determine the likely

Plast Aesthet Res || Vol 2 || Issue 1 || Jan 15, 2015 7