gms | German Medical Science

Objective: In the first year of life the osteogenic potency of the dural layer accounts for fast reclosure of skull defects. Nevertheless we saw few children with persistent skull defects after decompressive craniectomy after trauma or median craniectomy for treatment of craniosynostosis. As the growing skull calls for autologous repair of these defects we demonstrate our concept of reclosure by autologous bone grafting from the opposite side of the skull.

Methods: Our concept is primarily based on the presence of a functioning dural layer. If the dura is deficient a restoration by rotated periosteum from another part of the skull is possible. As second step we harvest an appropriate bone graft from the opposite side and fix it with resorbable sutures to the recipient side, carefully creating long corresponding contact zones between donor and recipient. The donor site is packed with bone fragments between dural layer and periosteum. These bone fragments were either scratched from the inner skull layer of the transplanted bone segment or from the outer skull layer at other skull sites. Regular examinations were performed.

Results: Four children, aged 3–9 years with vast one-sided bony skull defects were treated in our department. A common denominator was the intraoperative observation that the dural layer was absent or severely damaged in large areas of the defect. In 3 cases we managed complete repair of the defect on the recipient side as well as complete reossification on the donor side. In a 9 year old boy we decided intraoperatively to harvest bone from the lamina externa of the bone on the opposite side due to a difficult anatomical situation. Here a partly closure of the defect was achieved, although a further attempt with whole skull graft is still planned.

Conclusion: Vast craniectomies for decompression of the brain or for treatment of craniosynostosis in children call for a deliberate strategy. Even in emergency-situations the dural layer should be handled with extreme care or restored by periosteum in order to create a basis for reossification afterwards. In the rare situation of a persistent bone defect the dural layer or autologous replacement by periosteum is a basic requirement for further strategy. The donor site needs very careful handling in order to allow reossification. We present a strategy for complete autologous skull repair that allows physiological skull growth in the years thereafter.