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Cranioplasty remains a difficult procedure for all craniofacial surgeons, particularly when concerning the reconstruction of large lacunae in the skull. Considering the significant clinical and economic impact of the procedure, the search for materials and strategies to provide more comfortable and reliable surgical procedures is one of the most important challenges faced by modern craniofacial medicine.The purpose of this study was to compare the available data regarding the safety and clinical efficacy of materials and techniques currently used for the reconstruction of the skull. Accordingly, the scientific databases were searched for the following keywords autologous bone, biomaterials, cranial reconstruction, cranioplasty, hydroxyapatite, polyetheretherketone, polymethylmethacrylate, and titanium. This literature review emphasizes the benefits and weaknesses of each considered material commonly used for cranioplasty, especially in terms of infectious complications, fractures, and morphological outcomes.As regards the latter, this appears to be very similar among the different materials when custom three-dimensional modeling is used for implant development, suggesting that this criterion is strongly influenced by implant design. However, the overall infection rate can vary from 0% to 30%, apparently dependent on the type of material used, likely in virtue of the wide variation in their chemico-physical composition. Among the different materials used for cranioplasty implants, synthetics such as polyetheretherketone, polymethylmethacrylate, and titanium show a higher primary tear resistance, whereas hydroxyapatite and autologous bone display good biomimetic properties, although the latter has been ascribed a variable reabsorption rate of between 3% and 50%.In short, all cranioplasty procedures and materials have their advantages and disadvantages, and none of the currently available materials meet the criteria required for an ideal implant. Hence, the choice of cranioplasty materials is still essentially reliant on the surgeon's preference.

Purpose: Cranioplasty is a surgical intervention aimed at reestablishing the integrity of skull defects. Autologous bone is still considered the treatment of choice for cranioplasty. The aims of this study were to characterize and evaluate the efficacy of porous hydroxyapatite (HA) to fill skull defects based on its biomimetic characteristics., Methods: The authors analyzed the postmarketing data of all patients treated with custom-made porous HA prostheses (CustomBone Service). Characterization data in terms of physicochemical analysis and mechanical performance of the porous HA prostheses were also reported., Results: The low incidence of adverse events (5.72%) due to the use of HA porous custom-made prostheses for cranioplasty is related to the biomimetic performance of the prostheses. The composition and morphology of the porosity enable it to be a useful biomimetic prosthesis for the reconstruction of large and complex skull defects, also able to promote osteointegration., Conclusions: These collected and analyzed data demonstrate that porous HA is a suitable material to produce custom-made prostheses to repair craniolacunia. It is a biomimetic implant well-tolerated in both adult and pediatric patients and has been shown to be an effective and good alternative for cranial reconstruction.

Background: Although the porous hydroxyapatite (PHA) used in custom-made cranioplasty implants is a material appreciated for its biomimetic properties, before osteointegration it is initially very fragile. Nevertheless, we wondered whether this primary fragility is entirely due to brittleness or whether the surgeon's actions may influence the behavior of the material., Methods: To study the influence of the surgeon's behavior, we made a virtual model of a custom-made PHA cranioplasty implant and submitted it to three implant procedural variables using finite element methods. In the first test, a scenario in which the surgeon's design, validation, and positioning techniques are impeccable, the edges of the implant adhered well to the craniectomy margins. In the second test, a discrepancy between a portion of the perimeter of the craniectomy and the profile of the prosthesis was modeled, and in the third test, several gaps were simulated between the implant and the craniectomy margins., Results: Our mathematical model showed that when local and general discontinuities were included in the test scenarios, there was an increase in the load coming to bear on the cranioplasty implant, which amounted to 80 and 50 %, respectively., Conclusions: The fragility of custom-made PHA cranioplasty implants increases if the surgeon fails to achieve a precise design and validation, and/or an accurate surgical procedure. Nevertheless, careful attention during these phases helps to maintain the strength of the implant, given the more favorable mechanical conditions, without interfering with its biomimetic capacity.

Background: Scalp reconstruction has always been a challenging task. In our case, we report the use of INTEGRA Dermal Regeneration Flap, together with a cranioplasty for complex scalp defect. We have obtained not only an appropriate coverage of the cranial bone, but also an optimal aesthetic result., Method: We present a 24-year-old patient with a history of severe cranial trauma with sinking of the frontal bone with dural laceration and large bilateral frontal lacerocontusive focus. First, he had undergone reconstruction with the aid of autologous bone, metallic mesh, and titanium plates at a different clinical center. He arrived to our attention with exposure of the fixation devices, as well as part of the titanium plate used for the primary reconstruction. His general conditions could not allow a complex reconstructive procedure such as microsurgical flaps. The use of INTEGRA allowed us to reach the goal of a good and appropriate reconstruction, without exposing the patient to a higher-risk procedure. After the creation of a custom-made cranial implant in porous hydroxyapatite, the patient has undergone cranial bone remodeling to reach a homogeneous contour of the forehead profile. After the positioning of the implant, a single-layer INTEGRA regeneration template has been placed between the implant itself and the hypotrophic and thinned skin layer., Conclusions: The postoperative result after 16 months allowed us to observe a normal forehead profile with a normal thickness, good skin texture, and well-hidden scars.

Attempts have been made to overcome the limited visibility of anatomic structures on axial CT by direct multiplanar sections or multiplanar reformatted views. So as not to be restricted by "planar cuts," we have used curved coronal reformatting to investigate some of the cranial structures, whose tortuous anatomy cannot be visualized entirely with standard CT. In fact, we have provided a "flattened" presentation of the optic nerve and chiasma, facial nerve canal, and jugular foramen, showing them in their entire extension. Despite the geometrical deformation produced by this technique, its potential to depict the anatomy of some structures is noteworthy.