Reconstruction of Large Calvarial Defects Using Titanium Mesh Versus Autologous Split Thickness Calvarial Bone Grafts: A Comprehensive Comparative Evaluation of the Two Major Cranioplasty Techniques.

Background: Both alloplastic 3-D dynamic titanium mesh implants and Autogenous split calvarial cortico-cancellous bone grafts have been extensively used for cranial defect reconstruction. Whether either method is procedurally, cosmetically or therapeutically superior to the other, has rarely been studied or evaluated.

Aim: The aim of the study was to objectively examine, assess, evaluate and compare the procedural ease, convenience, safety and versatility of cranioplasty performed using titanium mesh implants versus split calvarial grafts and to compare the intra- and post-operative complications encountered, and the cosmetic and therapeutic outcomes achieved using these two cranioplasty techniques.

Material and Methods: A retrospective analysis was carried out on 40 patients with large post-craniectomy defects, who underwent cranioplasty between 2012 and 2016. Twenty patients underwent cranioplasty with titanium mesh implants and 20 with split calvarial cortico-cancellous bone grafts. Post-operative follow-up ranged from 1 to 5 years and the patients were observed (clinically as well as by means of radiographs and CT scans) for cosmetic, functional and neurological improvements.

Results: Titanium mesh cranioplasty afforded more benefits, such as a shorter operating time, ease in manipulation, absence of donor-site morbidity, usefulness in previously infected or compromised recipient sites, absence of the risk of graft resorption or rejection, and a ready means to aspirate any post-operative epidural collection through its mesh structure. It also compared favorably when the cranial defects were large, owing to its, so to speak, limitless supply viz a viz, the relative paucity of harvestable split calvarial bone autograft.

Conclusion: Both modalities have their pros and cons. Split calvarial grafting is the more physiologic and less expensive option, useful for small- to medium-sized defects, while titanium mesh is the safer, more versatile, reliable and often preferred option, particularly when the cranial defects are large and also in severe head injury patients in whom harvesting calvarial bone could further compromise the already traumatized calvarium with possible stress fractures, further endangering its vital contents.