Functional and aesthetic evaluation after cranial reconstruction with polymethyl methacrylate prostheses using low-cost 3D printing templates in patients with cranial defects secondary to decompressive craniectomies: A prospective study
- Department of Plastic Surgery, Hospital da Restauração, Recife, Pernambuco, Brazil
- Department of Neurosurgery, Hospital da Restauração, Recife, Pernambuco, Brazil
- Information Technology Center Renato Archer (Ministry of Science and Technology of Brazil), Campinas, Sao Paulo, Brazil
- Process Engineering and Materials Engineering. Works at Information Technology Center Renato Archer (Ministry of Science and Technology of Brazil), Campinas, Sao Paulo, Brazil
Juan Pablo Borges Rodrigues Maricevich
Department of Neurosurgery, Hospital da Restauração, Recife, Pernambuco, Brazil
DOI:10.4103/sni.sni_149_18Copyright: © 2019 Surgical Neurology International This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
How to cite this article: Juan Pablo Borges Rodrigues Maricevich, Auricelio B. Cezar-Junior, Edilson Xavier de Oliveira-Junior, Jose Arthur Morais Veras e Silva, Jorge Vicente Lopes da Silva, Amanda Amorin Nunes, Nivaldo S. Almeida, Hildo Rocha Cirne Azevedo-Filho. Functional and aesthetic evaluation after cranial reconstruction with polymethyl methacrylate prostheses using low-cost 3D printing templates in patients with cranial defects secondary to decompressive craniectomies: A prospective study. 15-Jan-2019;10:1
How to cite this URL: Juan Pablo Borges Rodrigues Maricevich, Auricelio B. Cezar-Junior, Edilson Xavier de Oliveira-Junior, Jose Arthur Morais Veras e Silva, Jorge Vicente Lopes da Silva, Amanda Amorin Nunes, Nivaldo S. Almeida, Hildo Rocha Cirne Azevedo-Filho. Functional and aesthetic evaluation after cranial reconstruction with polymethyl methacrylate prostheses using low-cost 3D printing templates in patients with cranial defects secondary to decompressive craniectomies: A prospective study. 15-Jan-2019;10:1. Available from: http://surgicalneurologyint.com/surgicalint-articles/9161/
Background:Cranial reconstruction surgery is a procedure used as an attempt to reestablish the cranial bone anatomy. This study evaluates the symptomatic and aesthetic improvement of patients with cranial defects secondary to decompressive craniectomies after cranial reconstruction with customized polymethyl methacrylate (PMMA) prostheses. Secondly, we aim to divide our experience in the production of these prostheses with a low-cost method.
Methods:A prospective study was carried out with patients submitted to cranioplasty at the Hospital da Restauração between 2014 and 2017. A total of 63 cranioplasties were performed using customized PMMA prosthesis produced by 3D impression molds. All patients underwent a functional and aesthetic evaluation questionnaire in the preoperative period and in the sixth postoperative month.
Results:Sixty-three patients underwent cranioplasty with a mean age of 33 years, ranging from 13 to 58 years, 55 males and 8 females. The mean area of the defect was 147 cm2. The mean postoperative follow-up of the patients was 21 months, ranging from 6 to 33 months. Fifty-five patients attended the 6-month postoperative consultation. All patients presented symptomatic improvement after reconstruction of the skull. The infection rate was 3.2%, 4.8% of extrusion, 1.6% of prosthesis fracture, 7.9% of extradural hematoma, 17.4% of reoperation, 5% of wound dehiscence, and 4.8% of removal of the prosthesis.
Conclusion:Cranioplasty, with a customized PMMA prosthesis, improved the symptoms and aesthetic appearance of all operated patients. The use of prototypes to customize cranial prostheses facilitated the operative technique and allowed the recovery of a cranial contour very close to normal.
Keywords: Cranial defects, cranial reconstruction, cranioplasty, decompressive craniectomies, methyl methacrylate
Decompressive craniectomy is a surgical procedure indicated for the treatment of severe and refractory intracranial hypertension related to conditions such as traumatic brain injury, subarachnoid hemorrhage, intracranial hemorrhage, and ischemic stroke.[
Cranial reconstruction aims to reacquire cerebral protection against trauma, to recover the cranial contour, and to improve neurological symptoms with the reestablishment of intracranial physiological pressure.[
Cranioplasty is performed with autologous bone or with alloplastic materials.[
PMMA molds can be performed preoperatively or intraoperatively. During surgery, it can be molded manually or with molds built with 3D printing (additive manufacturing). Through a partnership with the Renato Archer Information Technology Center in Campinas, São Paulo, we sent CT scan of the patients who would undergo cranial reconstruction to make 3D models, which allow the molding of a personalized cranial prosthesis with PMMA.
This study demonstrates the improvement of neurological symptoms and the aesthetic aspect of patients submitted to cranial reconstruction, with customized PMMA prosthesis through 3D printing after decompressive craniectomy. Second, we share our experience with a low-cost method of manufacturing these prostheses.
This is a clinical trial performed by the Plastic Surgery and Neurosurgery Service of the Hospital da Restauração (HR) in Recife – PE, between 2014 and 2017. It included 63 patients, previously submitted to decompressive craniectomy as a consequence of severe traumatic brain injury, stroke, and neoplasia; and released by neurosurgery to perform a plastic surgery. These 63 patients underwent cranial reconstruction with PMMA prosthesis using 3D impression molds and followed up for at least 3 months postoperatively.
All patients were attended at the Neurosurgery and Plastic Surgery of the Hospital and were operated in the HR. Participants signed the free and informed consent term and the study was approved by the CAAE of HR under number 128551/2017. Patients with bone defects underwent CT scan (SOMATOM Definition AS 64 slice, Siemens®) with cuts ≤1 mm and the exams were recorded in DICOM format on a DVD. These files were sent via Dropbox® to the Renato Archer Information Technology Center (CTI RA) in Campinas – SP. Scanned images are handled in the software InVesalius® (open source software and developed by CTI Renato Archer) for the models to be developed and later printed by a 3D printer (SLS HiQ, 3D System®).
Three prototypes were developed:
The prototypes were printed by the Polyamide Plastic Material Sintering (PA12) technology, are not biocompatible, and cannot be implanted in humans. Thus, the prototype 3 allows the molding of the cranial prosthesis in biocompatible material during the surgery. All prototypes were sterilized by steam autoclave at 134°C for 5 min and sent to the operating room.
After anesthetic induction, the customized prosthesis is made with PMMA and it is inserted in solution with antibiotic and saline, until reaching the ambient temperature [
An evaluation of the signs and symptoms of the Syndrome of the trefinado was performed through a questionnaire, for all patients, in the pre- and sixth postoperative month. The reported complaints were local discomfort, headache, dizziness, tinnitus, insomnia, fatigue, irritability, depression, insecurity, intolerance to vibration, seizures, paresis, dysphasia, dyspraxia, attention deficit, memory deficit, and worsening symptoms in orthostatic position or with Valsalva maneuver. In the sixth postoperative month, the patients also answered about the aesthetic result of the surgery (excellent, very good, good, regular, and bad). We analyzed postoperative data and postoperative evolution. Complications within the follow-up period were assessed by the Landriel Ibanez classification system.[
The number of patients operated during the study period determined the sample size. The Chi-square test was used to calculate the proportions. The P value considered statistically significant was <0.05.
Sixty-three consecutive cranioplasties were performed between 2014 and 2017 in patients with a mean age of 33 years, ranging from 13 to 58 years, 55 males and 8 females. All of these patients were followed up until the third postoperative month and 55 (87.3%) attended the medical appointment in the sixth month to respond to the symptom questionnaire. We considered the N of 63 for evaluations of complications and N of 55 for evaluation of functional and aesthetic outcome. Mean postoperative follow-up was 21 months, ranging from 3 to 33 months. The mean area of the defect was 147 cm2. All patients showed improvement of symptoms after reconstruction of the skull bone [
All 55 reconstructions had a satisfactory aesthetic result. Forty-nine (89.09%) found the result excellent and six patients (10.90%) found the result very good. Five patients had extradural hematoma (7.9%): two asymptomatic extradura and three symptomatic hematomas. Forty-one patients (65.1%) had seroma and three (4.8%) had dehiscence. There were 11 reoperations (17.4%): five drainage of extradural hematoma, two successful closures of extrusions, two removals of prostheses by infection, one removal of prosthesis by refractory extrusion, and one replacement of prosthesis by fracture of the same. Six patients (9.5%) had a seizure in the first 12 h postoperatively. There was a neurological sequel in one of the patients (2%) of extradural hematoma [
Cranioplasty with the use of PMMA is a method that has been increasingly consolidated in neurosurgical practice.[
The use of customized prosthesis through 3D impression molds in cranial reconstruction has an advantage to facilitate the surgical technique and the excellent cranial contour [
In addition to PMMA, other materials can be modeled for cranioplasty with the aid of a 3D printer, such as titanium,[
Recent studies suggest that cranioplasty contributes to neurological recovery in craniectomized patients.[
We also compared our results to previous studies documenting secondary cranial reconstruction with PMMA. Zanaty et al.[
Therefore, this is a technique with functional gains where the aesthetic factor has a significant impact on the social reintegration of the patients. Although all patients in this study considered the new cranial contour as excellent or very good, there is often a variable asymmetry in the temporal region. This prosthesis achieves excellent bone symmetry, and we believe that it happens for two reasons: the lack of repositioning of the temporal muscle at the end of the decompressive surgery and the atrophy of this muscle by the time it remained disinserted from the temporal fossa. Consequently, the temporal muscle tends to become less bulky and “retract” caudally, creating a bulge above the zygomatic arch.
The cranial reconstruction with customized PMMA prosthesis promoted the improvement of the neurological symptoms and aesthetic appearance of all operated patients. Finally, by sharing our experience using a reliable and a low-cost method with the use of a 3D printer, we hope to make this surgical technique easily accessible and reproducible in any institution.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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