J Neurosurg 47:790-792,1977

A new method of eranioplasty

Technical note

TAKIS J. ASIMACOPOULOS, M.D., NIKOLAS PAPADAKIS, M.D.,

AND VERNON H. MARK, M.D.
Fifth Harvard Surgical Service (New England Deaconess Hospital), and Department
of Neurosurgery, Boston City Hospital, Boston, Massachusetts

v' A new method of cranioplasty is described. The skull defect is exposed, and an im-
pression is taken which is used for the construction of a plaster of Paris model of the
defect. Methyl methacrylate is molded to the model and thus an accurate reproduc-
tion of the skull defect is produced. The technique has the main advantage of good
cosmetic appearance and strength.

KEY WORDS cranioplasty

9 9 ,impression 9 plaster model
9 methyl methacrylate

E are presenting a new method of

W
cranioplasty. For impression materi-
al we use alginate hydrocolloid, gas
sterilized. For the construction of the skull
defect model, dental quality plaster of Paris is
used, also gas sterilized. The tray for the im-
pression is made of methyl methacrylate and
extensively perforated. Dental adhesive is
used to increase the anchoring capacity of the
tray. The skull plate is constructed from
methyl methacrylate.
Technique
The cranial defect is exposed and the peri-
cranium is incised 3 to 4 mm away from the
edge of the defect (Fig. 1). The incised peri-
cranium is then removed and the edges of the
defect are exposed and cleaned of scar tissue,
so that there is a clear demarcation between
the dura and the edge of the defect. At this
point, an impression tray is made as follows.
Methyl methacrylate is mixed to a doughy
consistency and fashioned in the shape of the
defect. After it hardens, it is perforated ex-
tensively and sprayed with sterile dental ad-
hesive to obtain anchoring capacity. A sterile
indelible pencil is then used to mark the edge
of the defect. Alginate hydrocolloid is mixed
with water to a thick cream, and placed in
generous amounts in the tray. The tray is then
immediately pressed against the skull defect
until it solidifieg (approximately 1 minute).
The impression is then removed from the
defect.
Plaster of Paris is mixed with water and a
generous amount of the mixture is used to
cover the impression. When the plaster
hardens (4 to 5 minutes), it is separated from
the impression. The resulting model is com-
pared with the impression and with the skull
defect for accuracy and its borders are deline-
ated with a sterile indelible pencil. Methyl
methacrylate is mixed to a doughy con-
sistency, placed in the model, and molded
into a replica of the missing bone. After the
plate hardens (approximately 10 minutes), it

790 J. Neurosurg. / Volume 47 / November, 1977

A new m e t h o d of cranioplasty
FIG. 1. Artist's drawing showing the steps in molding the model of the defect and placing the plate in
position.
is removed from the model and fitted into the
skull defect. Any minor irregularities may be
smoothed with a pneumatic drill. A few per-
forations are made in the plate and it is wired
to the skull in the usual manner. To this date,
we have performed 10 cranioplasties with this
method, producing good cosmetic results
even in cases with very large defects.
Discussion
The method described has several ad-
vantages. It provides the surgeon with a sys-
tem for work outside the operative field. The
plaster model is an accurate replica of the
skull defect, so the plate will both fit the
defect perfectly and have the same contour
with the missing bone. This is particularly im-
portant when the defect is in a visible area,
J. Neurosurg. / Volume 47 / November, 1977
such as in the supraorbital and frontal
regions. Also, no empty space exists to allow
accumulation of fluid inside or outside the
plate, with its attendant danger of infection.
The uniformity in thickness with the missing
bone contributes to the increased strength of
the plate, since unequal thickness results in
points of decreased strength.
There is one further advantage. The heat
release and consequent tissue irritation that
may result from the direct molding of methyl
methacrylate in the skull defect are elimin-
ated. In experiments with dogs, we found that
polymerization of methyl methacrylate
applied directly to a skull defect raises the
temperature of the epidural space from an ini-
tial level of 36 ~ to 64 ~ C despite continuous
irrigation with cold saline. This rise lasts for
approximately 3 minutes. Further experi-
791
 T. J. Asimaeopoulos, N. Papadakis and V. H. Mark
mental work by one of us has demonstrated
the deleterious effect of heat on cell via-
bility. 1
Reference
1. Asimacopoulos P J, McGrath J J, Cravalho EG:
The thermal sensitivity of the human fibroblast
HeLa S-3 as a model for thermal insult to the
neointima of a nuclear-fueled, blood-cooled,
792
left ventricular circulatory assist device, in Bell
AC, Nerem RM: 1975 Advances in Bio-
engineering. New York: American Society of
Mechanical Engineers, 1976, pp 28-31
Address reprint requests to: Nikolas Papadakis,
M.D., Department of Neurosurgery, Boston City
Hospital, 818 Harrison Avenue, Boston,
Massachusetts 02118.
J. Neurosurg. / Volume 47 / November, 1977