Reply: Autogenous Bone Cranioplasty: Review of a 42-Year Experience by a Single Surgeon

Sir: I thank Dr. Mitchell et al. for their comments on our article.1 First, I look forward to a comprehensive long-term examination of the long-term results of their series of 437 implants, mostly alloplastic, where they cited an 11 percent complication rate. As stated in our article, alloplastic implants, particularly methylmethacrylate, can become extruded 10 to 20 or more years after implantation. An 11 percent complication rate (most likely higher in the long term) compares with our 0 percent rate of implant loss in the period 1975 to 2018, and we would find this unacceptable. If we can extrapolate from their data using our outcome, that is 48 patients having a complication, which is avoidable. To view a preliminary latissimus free flap as something that could be avoided with a one-stage alloplastic implant I believe is folly. The success of either autogenous or alloplastic reconstruction depends completely on the condition of the overlying scalp, and when it is radiodystrophic and breaking down, failure with a one-stage procedure of any type is virtually guaranteed. Removing a substantial segment of full-thickness skull to replace it with a shunt-valve–containing alloplastic construct (as presented at the recent International Society of Craniofacial Surgery meeting in Paris) to avoid pressure from the shunt valve on overlying scalp could also be criticized, because the solution to this problem in our experience would be initial placement of the shunt valve in the occipital area beneath thick soft tissue. However, a larger percentage of our patients were in the pediatric age group compared with the Johns Hopkins group, but again, we had no complications in adult patients, and there was a substantial number of them. There are of course patients where an alloplastic solution is acceptable: ones in the geriatric age group with defects well away from the orbit and paranasal sinuses, and who will not be likely to require further reconstructive procedures in the area. We tend to use procedures that we have become comfortable with, and I suspect that in many of the cases where alloplastic materials were used it was because of the lack of comfort in working with autogenous bone on the part of the surgical team. Paul Tessier showed plastic surgeons how to work with the craniofacial skeleton, moving portions of it, and replacing others, and for the replacement, his advice to me over the years was to strictly adhere to the use of autogenous bone. We have followed his advice over the years, and our article documents the results. DISCLOSURE The author has no financial interest to declare in relation to the content of this communication or of the article being discussed.