COSMETIC RESULTS OF RECONSTRUCTIVE NEUROSURGICAL INTERVENTIONS ON THE SKULL Koporushko N. A., Mishinov S.V., Kangel'diev A.E., Stupak V.V.
Tsivyan Research Institute of Traumatology and Orthopedics, Novosibirsk, Russia
Acquired deformations and post-trepanation artificial defects of cranial bones are mostly caused by severe head injuries and also by previous craniectomy for brain tumors, aneurysm rupture, cervical perfusion disorders with cerebral edema and dislocation syndrome [1-7]. The increase in amount of decompressive trepanations during the last decade is determined by their efficiency in adequate correction of brain edema in the above mentioned conditions. These interventions cause extensive defects of cranial bones which affect two, three and even more cranial fields.
Reconstructive surgery (cranioplasty for closing cranial defects) is not difficult in technical realization, but it has not only the technical component for restoration of protective function of cranial bones, but also the significant esthetic aspect, which is related to patient's satisfaction with cosmetic result [3, 8]. Particularly, defects in frontotemporal lobe often cause esthetic problems due to their visible location. Postsurgical atrophy of the temporal muscle worsens a poor cosmetic result in this region.
Another important component in treatment of patients of such category is optimization of reconstructive intervention since persistence of an extensive defect of cranial bones leads to development and persistent preservation of trepanation syndrome, which is one of the key causes of decreasing working capability in young people without intense neurologic deficiency [1].
The increase in the rate of extensive decompressive trepanations causes the increasing incidence of use of individual implants since they allow closing the extensive defects with sizes exceeding the standard titanium mesh, and, from other side, achieving desirable cosmetic results since these items are produced with preliminary computer modeling and with consideration of anatomic features of patient's skull [13, 14].
One should note that review of domestic literature shows that authors accentuate their attention to such conditions as trophic disturbances of skin aponeurotic flap, incidence of purulent, surgical and neurological complications, and they almost do not say about cosmetic outcomes, although, as known, improvement in life quality and satisfaction with medical care are the trends of the modern medicine. As result, the study objective was set.
Objective – to estimate the cosmetic results of reconstructive interventions in patients with skull bone defects using individual plates made using three-dimensional printing, and standard titanium implants.
MATERIALS AND METHODS
The clinical materials included 161 patients with cranial defects. They were treated in Tsivyan Research Institute of Traumatology and Orthopedics. The prospective analysis (2017-2019) with historical control capture (2009-2016) included reconstructive surgeries for closure of bone defects. The study was conducted in two groups: 1) patients (80 persons) with individual titanium implants (3D printing) for replacement of a bone defect (the study group); 20 patients (81 persons) who received cranioplasty with standard titanium implants (the control group). The table 1 shows the general features of the groups.
Table 1
General characteristics of patients with acquired cranial defects, n (%)
|
Characteristics of patients |
Groups |
Total |
|
|
Study |
Comparison |
||
|
Total amount of patients |
80 (49.69 %) |
81 (50.31 %) |
161 (100 %) |
|
Mean age (years), Ì |
43.6 |
41.2 |
42.4 |
|
Men |
44 (55 %) |
48 (59.26 %) |
92 (57.14 %) |
|
PÒÌÔ > 0.05 / PFET > 0.05 |
|||
|
Women |
36 (45 %) |
33 (40.74 %) |
69 (42.86 %) |
|
PÒÌÔ > 0.05 / PFET > 0.05 |
|||
|
Terms of postsurgical follow-up (months), M ± m |
24.66 ± 1.43 |
53.44 ± 3.82 |
39.14 ± 2.34 |
|
PU < 0.001 |
|||
There were not any statistically significant intergroup differences in amount of patients, mean age, gender distribution, ratio of patients according to their number, sizes and location of available bone defects.
According to the classification accepted in Burdenko Neurosurgery Institute, the patients were distributed according to causes of defects, location in relation to the roof and base of the skull, lateralization, location, sizes and condition of soft tissue in region defect [15].
Considering the fact that 4 patients of each group received two post-trepanation defects, the study group included 82 bone defects, the comparison group − 83. Among all cases with 161 patients, 94 (58.4 %) were operated for traumatic brain injury; 98 (59.4 %) posttrepanation defects appeared. 49 (29.7 %) bone defects were closed with individual implants, 49 (29.7 %) − with use of standard implants. Among 67 (41.6 %) patients (33 (20 %) and 34 (20.6 %) in the study group and in the comparison group, correspondingly), with neurooncologic pathology as the cause of bone defects, 21 patients (31.3 %) received the individual implant, and 30 (44.8 %) − standard one. Among 11 (16.4 %) surgical patients with cerebrovascular pathology, 8 (11.9 %) defects were in the study group and 3 (4.5 %) in the comparison group. 5 (7.5 %) patients had some defects caused by neuroinfectious processes: 4 defects (6 %) in the study group, 1 (1.5 %) − in the comparison group.
Depending on lateralization, bone defects in 82 (50.9 %) patients (41 (25.5 %) in the study group), 41 (25.45 %) in the comparison group) were located to the left, in 62 (38.5 %) − to the right (32 (19.9 %) and 30 (18.6 %) in the study group and in the comparison group, correspondingly). 17 (10.6 %) patients had some cranial defects on both sides: 7 (4.4 %) patients in the study group, 10 (6.2 %) − in the comparison group. The jugal-orbital-facial region was involved by postcranioectomy defects in 17 (10.6 %) operated patients, 5 patients (3.1 %) with individual implants, and 12 (7.5 %) patients with standard implants.
Totally, bone defects were in 330 cranial regions in 161 operated patients. The highest amount of bone defects was in parietal (n = 123, 41 %) and temporal (n = 117, 39 %) regions. There were 84 (28 %) bone defects in the frontal region, and 6 ones (2 %) in the occipital region.
According to condition of soft tissues, 64 (38.8 %) patients had no changes, 5 (3 %) patients had scar processes, and 96 (58.2 %) − intense tissue deformations with depression over the jugal bone in the temporal region due to atrophy of the temporal muscle. Among them, 66 defects (41 %) were extensive, 27 (16.8 %) − big, 3 (3.1 %) − small and average. The study group had 44 (55 %) extensive and 9 (11.3 %) big defects, the comparison group − 22 (27.2 %) and 18 (22.2 %) such defects, correspondingly (Fig. 1).
Figure 1
A face photo of the patient with extensive defect in left parietotemporal region with rough atrophy of musculus temporalis
According to the recommendations for reconstructive surgery of skull defects (2015) from Russian Association of Neurosurgeons [16], posttrepanation defects were distributed into small (up to 10 cm2), average (10-30 cm2), big (30-60 cm2) and extensive (> 60 cm2) cranial defects. The table 2 shows the distribution of patients according to square of defects.
Table 2
Distribution of cranial defects in groups in dependence on square and number of defects, n (%)
|
Main feature of defects |
Bone defects distributed into groups |
Small (number, %) |
Mean (number, %) |
Big (number, %) |
Extensive (number, %) |
|
Number of defects |
Study group |
- |
5 (3.0 %) |
20 (12.1 %) |
57 (34.5 %) |
|
Comparison group |
5 (3.0%) |
25 (15.2 %) |
28 (17.0 %) |
25 (15.2 %) |
|
|
Total number of defects |
5 (3.0%) |
30 (18.2 %) |
48 (29.1 %) |
82 (49.7 %) |
|
|
Mean square of defect (cm2) |
Study group |
- |
19.4 ± 2.7 |
47.3 ± 2.2 |
105.9 ± 5.7 |
|
Comparison group |
7.2 ± 0.9 |
20.85 ± 1.1 |
42.25 ± 1.4 |
105.3 ± 8.3 |
|
|
Mean square of all defects |
7.2 ± 0.9 |
20.6 ± 0.9 |
44.4 ± 1.3 |
105.7 ± 4.7 |
|
|
Minimal square of defect (cm2) |
Study group |
- |
12.6 |
32.9 |
62.8 |
|
Comparison group |
3.53 |
13.7 |
30.2 |
62.8 |
|
|
Maximal square of defect (cm2) |
Study group |
- |
27.5 |
56.5 |
245.0 |
|
Comparison group |
9.42 |
28.3 |
56.7 |
219.9 |
Among all patients, the minimal size of a cranial defect was 3.53 cm2, maximal size − 24.5 cm2.
For examination of long term results of surgical treatment, we developed a score based on some plastic surgery estimation scores by Ramsey Alsarraf (2000) [17] for assessment of long term cosmetic results of surgical treatment after four common procedures of facial plasty surgery: rhinoplasty, rhytidectomy (facial lift), blepharoplasty and various procedures of dermabrasion (laser and chemical peeling).
Our score includes some questions and possible variants of answers for operated patients. The maximal number of points in one question was 4. The estimation was conducted according to sum of points. The points were interpreted as indicated below: 19-24 points − excellent cosmetic result, 13-18 points − good result, 7-12 points − satisfactory result, 0-6 points − poor result.
The score for estimation of cosmetic results after reconstructive surgery for closure of skull defects includes the following items:
1. Estimate your satisfaction with appearance of your head:
a) no changes;
b) to some degree;
c) moderate;
d) I am quite satisfied;
e) I am satisfied completely.
2. What about your anxiety concerning the current cosmetic changes in the surgery site:
a) very strong anxiety;
b) strong anxiety;
c) moderate anxiety;
d) to some degree;
e) no anxiety.
3. How other people estimate your appearance:
a) extremely mutilated;
b) very mutilated;
c) rather harmonic than mutilated;
d) quite harmonic;
e) no differences from other people.
4. Does your current appearance limit your social or professional activity:
a) it limits constantly;
b) it limits often;
c) it limits sometimes;
d) it limits rarely;
e) no limitations.
5. Do appearance and symmetry of your head present the best variant:
a) definitely no;
b) rather no than yes;
c) 50/50, may be it could be better;
d) rather yes than no;
e) definitely yes.
6. Would you like to change the appearance of your head in the surgery site with use of additional methods of treatment:
a) certainly;
b) with high probability;
c) probably;
d) rather no;
e) no.
Our score was analyzed for estimation of its reliability. Two methods were used: 10 split-half method (reliability was 0.9); 2) calculation of Cronbach's alpha (reliability was 0.9). The analysis showed the validation of the score, and possibility for its practical use for estimation of cosmetic results of treatment after realization of surgical interventions for closure of cranial defects.
All patients were operated with use of the modern microsurgical techniques. They received 169 operations. 157 (97.5 %) patients were operated in one step; 4 patients (2.5 %) received two-staged operations for 2 (1.2 %) cases of meningocele in region of bone defects and for 2 cases (1.2 %) with nasal liquorrhea. Therefore, 2 patients primarily received the surgical interventions for revision of epidural cavity and for realization of dura matter plasty. Two patients received skull hermetization by means of closure of frontal sinus with fat flap. After wound healing, one and a half month after surgery, the main stage for closure of cranial defect was conducted.
Statistical analysis. The statistical analysis was carried out with Statistica 10. Mann-Whitney test and Fisher's exact test were used for estimation of confidence. P ≤ 0.05 was considered as statistically significant.
The study corresponds to the ethical principles of Helsinki Declare (2013), and to the Rules for Clinical Practice in the Russian Federation (the Order by the Russian Health Ministry, June 19, 2003, No. 266). It was approved by the local ethical committee (the protocol No. 008/20, April 5, 2020).
RESULTS
On the basis of our scale, we analyzed the cosmetic results of surgical treatment in two groups of patients after closure of bone defects with use of standard and individual implants (the table 3). The mean sum of points was 23.9 ± 0.1 in the study group; the minimal one − 20, the maximal one − 24. In the comparison group, the mean sum of points was 21 ± 0.6; the minimal and maximal values − 4 and 24, correspondingly.
Table 3
General distribution of patients in dependence on cosmetic results
|
Treatment outcomes |
Amount of patients |
|
|
Individual implants (number, %) |
Standard implants (number, %) |
|
|
Excellent (19-24 points) |
80 (100.0 %) |
62 (76.5 %) |
|
PFET < 0.01 |
||
|
Good (13-18 points) |
- |
8 (9.9 %) |
|
Satisfactory (7-12 points) |
- |
7 (8.6 %) |
|
Poor (0-6 points) |
- |
4 (5 %) |
|
Total |
80 (100 %) |
81 (100 %) |
The patients with individual titanium implants achieved 100 % of excellent cosmetic results. The patients with standard implants showed excellent results in 76.5 % (62) of cases, good results − in 8 (9.9 %), satisfactory results − in 7 (8.6 %), poor ones − in 4 (5 %).
The statistical analysis showed the dependence of the results on a type of the implant. The number of excellent results of surgical interventions was higher for individual implants as compared to standard ones (p < 0.05).
Also we conducted the analysis of cosmetic results depending on bone defects (the table 4). The size of a bone defect significantly influenced on cosmetic results. The highest percentage of excellent cosmetic results was in the group with individual implants: all 55 (100 %) patients or 76.2 % of the whole group of patients with excellent results. In this group, the minimal sum of points was 20, the maximal one − 24 (p < 0.05).
Table 4
Distribution of patients in dependence on sizes of defect and received cosmetic results
|
Treatment outcomes |
Number of patients with extensive defects (number, %) |
Number of patients with big defects (number, %) |
Number of patients with mean ad small defects (number, %) |
Total amount of patients (number, %) |
|||
|
Individual implant |
Standard implant |
Individual implant |
Standard implant |
Individual implant |
Standard implant |
||
|
Excellent (19-24 points) |
55 (100.0 %) |
17 (68.0 %) |
20 |
21 (77.8 %) |
5 (100.0 %) |
24 (82.8) |
142 (88.2 %) |
|
PÒÌÔ < 0.01 / PFET < 0.01 |
PÒÌÔ = 1.0 / PFET = 1.0 |
||||||
|
Good (13-18 points) |
- |
2 (8.0 %) |
- |
3 (11.1%) |
- |
3 (10.3 %) |
8 (5.0.%) |
|
Satisfactory (7-12 points) |
- |
4 (16.0 %) |
- |
2 (7.4 %) |
- |
1 (3.4 %) |
7 (4.3 %) |
|
Poor (0-6 points) |
- |
2 (8.0 %) |
- |
1 (3.7 %) |
- |
1 (3.4 %) |
4 (2.5 %) |
|
Total |
55 (100.0 %) |
25 (100.0 %) |
20 (100.0 %) |
27 (100.0 %) |
5 (100.0 %) |
29 (100.0 %) |
161 (100 %)
|
Among patients of the study group with big cranial defects, the excellent results were achieved in 100 % of cases (p < 0.05).The group with standard implants showed excellent results in 77.8 % (21 of 27 operated patients), good results − in 3 (11.1 %), satisfactory results − in 2 (7.4 %) and poor ones − in 1 (3.7 %).
The patients with average and small defects showed excellent cosmetic results in 100 % (5) and 82.8 % (24) of cases in the study group and in the comparison group, correspondingly. Patients with standard implants showed good cosmetic result in 3 (10.3 %) cases, satisfactory results − in 1 (3.4 %) case, and poor ones in 1 (3.4 %).
The most severe situations relating to satisfactory cosmetic results were some cases with big and extensive cranial defects in the frontal-parietal-temporal region with significant atrophy of the temporal muscle in patients with significant cosmetic defects. The table 5 shows the results of surgical treatment depending on sizes of a defect of the temporal bone.
Table 5
Cosmetic results of treatment of patients in dependence on sizes of temporal bone defect with musculus temporalis atrophy
|
Treatment outcome |
Number of patients with extensive defects (number, %) |
Number of patients with big defects (number, %) |
Total number of patients (number, %) |
||
|
Individual implant |
Standard implant |
Individual implant |
Standard implant |
||
|
Excellent (19-24 points) |
44 (100.0 %) |
13 (59.1 %) |
9 (100.0 %) |
14 (77.7 %) |
80 (87 %) |
|
PÒÌÔ < 0.01 / PFET < 0.01 |
PÒÌÔ = 0.2 / PFET = 0.2 |
||||
|
Good (13-18 points) |
- |
2 (9.1 %) |
- |
2 (11.1 %) |
4 (4.3 %) |
|
Satisfactory (7-12 points) |
- |
5 (22.7 %) |
- |
1 (5.6 %) |
5 (5.4 %) |
|
Poor (0-6 points) |
- |
2 (9.1 %) |
- |
1 (5.6 %) |
3 (3.3 %) |
|
Total |
44 (100.0 %) |
22 (100.0 %) |
9 (100.0 %) |
18 (100.0 %) |
92 (100 %) |
On the basis of the data in the table 5, one can say that the use of individual implants during cranioplasty in patients with evident atrophy of the temporal muscle allows closure of extensive and big defects of cranial defects, and achievement of 100 % of excellent cosmetic results.
DISCUSSION
Since the patient's subjective estimation is the important component of surgical treatment in neurosurgery and any other reconstructive interventions, we, for the first time, analyzed degrees of satisfaction with cosmetic results of cranioplasty. Both groups of the respondents did not show any significant differences in causes of cranial defects, with 58.4 % of patients with consequences of traumatic brain injury as the main cause.
According to the literature data, the estimation of results of surgical intervention is conducted with special questionnaires, most of which are focused on general well-being and life quality. For esthetic surgery, some specific questionnaires for each section were developed: nasal plasty, facial lifting, mammoplasty etc. The questionnaire by Fischer C.M. et al. (2012) was offered for estimation of results of reconstructive neurosurgical interventions [18]. However, the authors did not present any data on point stratification and validation of the scale. As result, we developed the variant of the scale for estimation of cosmetic results of cranioplasty which gives the point estimation of each parameter.
The best surgical results were in patients with extensive and big cranial defects who received cranioplasty with individual implants produced with computer modeling and 3D printing. All these patients showed excellent cosmetic results. The patients with extensive defects treated with standard perforated titanium implants showed excellent results in 68 %, with bone defects − in 77.8 %.
Lower sizes (average and small) of bone defects gave lower dependence of cosmetic results on a type of the implant. It is explained by the fact that small sizes of a bone defect can be rapidly covered with titanium sheet without modeling for compliance with anatomic features of the skull. It is simply fixed to edges of a bone. Excellent cosmetic results are 82.8 %.
The literature analysis and our experience showed poor cosmetic results were more often in frontal and temporal regions since these regions are not covered with hair, and patients can see such defects in the mirror. As we mentioned, the temporal muscle atrophy makes additional influence. This atrophy worsens during recurrent surgical interventions [19-23]. This circumstance accentuates the necessity of use of individual implants during surgery for frontal and temporal regions, which are most significant for esthetic perspective. Considering the fact, that adequate decompressive trepanation should be extended to the basis of the middle cranial fossa, with resection of a part of the temporal bone, and separating the temporal muscle, one can make a logical conclusion that absolute amount of craniectomy procedures will give good cosmetic effects.
One should note that the use of individual implants do not warrant restoration of previous head symmetry since the shape of the implant considers only bone structures; soft tissues are not considered during modeling. Therefore, we developed a way for production of the individual implant with possibility of alternation of curvature in site of the atrophied temporal muscle for correction of atrophy-related cosmetic defects (the patent). We also developed the fixing elements, which are located inside the implant. They allow proper fixation of the temporal muscle, and prevents migration during mastication.
The conducted study showed that our method, which includes modification of the implant curvature in the temporal region, with fixation of the temporal muscle to the implant, gives good and excellent cosmetic results.
CONCLUSION
1. The use of the individual implant for big and extensive skull defects allows 100 % of excellent cosmetic results. The use of the standard implant for patients with extensive cranial defects gives 68 % of excellent results in the whole group, and in 77.8 % of patients with big defects.
2. The individual implant produced with 3D printing is a method of choice in reconstructive surgery for closure of extensive and big defects.
Information on financing and conflict of interest
The study was conducted without sponsorship.
The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.