Outcomes of Cranioplasty Reconstructions: Review of Cranioplasty Implants and Free Flap Coverage Variables that Affect Implant Exposure

Background: Complex scalp wounds with cranial/dural involvement are challenging to reconstruct. Successful reconstruction can be achieved with cranial implants/hardware and free flap coverage. Wounds can breakdown and require revision procedures. We addressed reconstructive outcomes of different implants requiring free flaps. Objective: To determine the factors associated with implant exposure. Design: Multi-institutional retrospective review of 82 patients, 2000–2020, repaired with cranial implants and free flap coverage. Results: Implant exposure occurred in 13/82 (16%) reconstructions. Flap atrophy or thinning leading to implant exposure occurred in 11/82 (13%) reconstructions, including partial flap atrophy OR 0.05 (95% CI 0.0–0.35) and total flap atrophy OR 0.34 (95% CI 0.02–19.66). Revision surgeries that occurred subsequent to flap reconstruction were also associated with implant exposure (OR 0.02 (95% CI 0.0–0.19)). Implant exposure was not associated with radiation therapy, patient health history, implant type, flap type, or postoperative complications. Conclusions: Implant exposure is associated with free flap atrophy, leading to inadequate implant coverage and the need for revision surgeries. Completing reconstruction with adequate soft tissue bulk and coverage and avoiding revision surgery may decrease the risk for implant exposure over time. Level of Evidence: 4 Laryngoscope, 133:2954–2958, 2023.