Wednesday, July 18, 2007

Cranioplasty with Insertion of Medpor

As I discussed last week during our weekly rendezvous, by far the coolest operation I have seen has been a craniofacial plastics-neuro tag team effort to reconstruct a man’s frontal skull bone after an unfortunate encounter with a baseball bat to the face. Poor guy. Anyway, to reiterate from last week, essentially this young man had very little frontal bone left and a shattered nasal bone due to said trauma.

So, now for some details…first, an incision was made from ear to ear across the crown of his head. The face was eventually peeled forward to reveal the defect and then the neurosurgeons, wearing super-geeky, thick double-lensed, black-rimmed glasses, started picking his brain…the not-so-fun, invasive way. I believe all they were doing was taking biopsies as very little tissue was removed, but I could very well be mistaken. It was so cool. There I was gawking at this guy’s brain pulsing to the rhythm of his blood flow. Awesome. It was actually quite curious, the location of the defect and extent of the face peel really looked like his eyeballs should have been starring back at me…yet, they weren’t…weird. I guess they were hidden under his face flapped over his nose. That sounds icky.

Anyway, tag team high five and plastic surgery’s on the scene. The procedure began by a leisurely drilling of his skull to isolate a portion of cranium destined for an autograft. Bone filings went EVERYWHERE…the surgeons’ faces, the floor, half of the observers - everywhere. Following this mess was a rather barbaric technology (if you ask me)…the hammer and chisel. Yes, we can put a man on the moon, genetically engineer all sorts of things, and yet, in order to take a simple graft we still use the age old, chisel to beat on someone’s skull until chips of bone fly into a nice warm, blue bowl of saline…there’s gotta be a better way to harvest bone grafts. This dude took a beating…again. So, just for a visual (since the pictures I took were on the fellow’s camera, and thus, gone forever), this guy’s face is peeled off, his parietal skull bone is drilled and chiseled away to remove a bone graft and blood is everywhere...and he's still missing most of the frontal bone.

Now for the cool innovations. First, a material developed by the medical device company, Stryker, provided us with a quick-drying (~30-40 seconds) cement of hydroxyapatite…a precursor to bone. This paste was spread over the donor site created on the parietal bone…and eventually along the interface of the implant and the skull. The next cool biomaterial used was Medpor (the implant), which is a custom made, perfectly contoured, porous sheet of high-density polyethylene microspheres sintered together...kinda like the small piece shown below.

Medpor is used instead of say, PMMA (polymethylmethacrylate), due to the lower risk of complications. Potential side effects of PMMA may include local tissue damage caused by its exothermic reaction, release of toxins, and the possibility for a high rate of infection. Medpor doesn’t have these. However, Medpor has several very enticing benefits, including its flexibility and ease of coverage, its biocompatibility, and its porous nature, allowing for the rapid ingrowth of vasculature and soft tissue. The latter is very important because it promotes wound healing and stabilizes the implant.

As an aside, one study I read about had zero post operative infections, zero wound breakdowns, and zero follow up surgeries after a period of 4 years in 611 procedures (Liu et al., Neurosurg. Focus 16, March 2004). Pretty cool stuff. I hope I invent something totally sweet like this.

Anyway, this sheet of Medpor flawlessly fit into the man’s cranial defect and was screwed into the skull for support with titanium (inert and biocompatible) screws. It looked something like this, but this is not from the actual case.

To finish the case, the man’s face was stapled and sewn back on…and despite the head bandage, he looked pretty normal. Amazing.

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