Page 153 - Clinical relevance of current materials for cranial implants

Virtual surgical planning for skincancer with cranial bone invasion
In the described case, there were multiple factors making this a high risk cSCC, including recurrent setting and size of the lesion. Local wound problems and pain had severe impact on the quality of life of the patient. Accommodated by shared surgical decision-making and not as much the inherent value of human life, a decision to intervene was made through a close dialogue of this frail and elderly patient, family and health care providers57. Non-operative alternatives were unattractive regarding the exposed bone with tumor invasion and history of prior radiotherapy. A one stage surgical treatment was decided upon with the aim to eradicate the tumor and affected tissues, to achieve stable tissue coverage of the defect and enable the patient to return to prior activities with protection of the intracranial content with a cranioplasty. The CAD-CAM produced resection templates allowed for an accurate resection with tumor free margins as planned and proper fit of the alloplastic cranioplasty. Unfortunately, this digital workflow did not prevent the occurrence of wound dehiscence and implant exposure, which is most feared in this type of surgery. However, it did lead to predictable margins, a more rapid and easy surgical procedure and accurate fast placement of the cranioplasty. Potentially, a delayed cranioplasty, would have prevented wound dehiscence problems, as described by Chao et al.40.
CONCLUSION: 7
Composite defects of the scalp and cranium resulting from invasive squamous cell carcinoma are known to be a reconstructive challenge and associated with a high rate of complications and morbidity. This first report of a one stage 3D virtual resection and reconstruction, demonstrates the advantages of an accurate and predictable resection and accurate fast placement of the designed cranioplasty. Unfortunately, this did not overcome the complication of wound dehiscence and implant exposure. The possible benefits and risks should always be assessed in relation to the patient’s diagnosis, co- morbidity and life-expectancy. For high risk cases and unfavorable local conditions such as previous infections, radiotherapy or exophytic tumors, a multiple staged approach seems to remain the most predictable treatment strategy.
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