Use of hydroxyapatite cement in pediatric craniofacial reconstructive surgery: strategies for avoiding complications

The emergence of powdered hydroxyapatite (HA) has dramatically expanded the repertoire of reconstructive tools for craniofacial surgeons. Although several groups have reported mixed success using HA powder, to date there have been few large series retrospective reviews of HA use in an exclusively pediatric population. The purpose of our study was to assess the incidence of complications using a single surgeon's experience in an entirely pediatric cohort of patients. We present 78 pediatric patients (mean age, 9 [SD, 5.1] years; 26 girls, 52 boys) who have undergone craniofacial reconstruction with HA powder in the form of Mimix or BoneSource (mean, 57.3 [SD, 27.9] g). From this cohort, we discuss in detail 7 patients who experienced complications after their reconstruction with HA. These complications were related to trauma, infection, and exposure. Of these 7 patients with problems, 6 required eventual HA removal. In addition, all 7 patients who had complications after HA reported having a traumatic event with respect to their cranial reconstruction before presenting with a complication. Our series concludes that HA powder is a safe and effective material for use in pediatric craniofacial reconstruction. When certain principles are not violated, meticulous hemostasis and surgical planning are of paramount importance to reduce the incidence of seroma, exposure, and infection of the overlying HA placement. However, should these complications arise, prompt removal of HA is usually necessary.