Related Experiment Video
Updated: May 3, 2026
Coronoid-Temporalis Pedicled Flap for Orbital Floor Defect Reconstruction
Published on: December 5, 2025
Multidisciplinary approach for improved outcomes in secondary cranial reconstruction: introducing the
Chad R Gordon1, Mark Fisher, Jason Liauw
1*Department of Plastic and Reconstructive Surgery and §Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; ‡Johns Hopkins University School of Medicine, Baltimore, Maryland.
Background:
Although materials for secondary cranial reconstruction have evolved with time, the overall approach in terms of bone flap/implant reconstruction after necessary delay has remained constant.
Objective:
To present our cases series of 50 consecutive secondary cranial reconstruction patients and to describe a multidisciplinary cranioplasty approach developed to reduce morbidity, to minimize infection, and to improve aesthetic appearance.
Methods:
Standard technique teaches us to place the bone flap and/or alloplastic implant directly over the dura or dural protectant after scalp flap re-elevation. However, this procedure is fraught with high complication rates, including infection. While raising the previously incised scalp flap overlying the full-thickness calvarial defect, the dissection is performed within the loose areolar tissue plane beneath the galea aponeurosis, thus leaving vascularized pericranium intact over the dura.
Results:
A total of 50 consecutive patients were treated by the senior author encompassing 46 cranioplasties using the pericranial-onlay approach, along with 4 isolated temporal soft tissue reconstructions with liquid poly-methyl-methacrylate. Of the 46 cranioplasties (> 5 cm), only 1 autologous bone flap developed deep infection necessitating bone flap removal (1 of 46, 2.17%; 95% confidence interval, 0.003-11.3). None of the alloplastic custom implants placed have developed any infection requiring removal.
Conclusion:
This multidisciplinary approach illustrated in our case series, including our "pericranial-onlay" technique described here for the first time, has the potential to improve patient outcomes, to decrease perioperative morbidity, and to minimize costs associated with postoperative infections after secondary cranial reconstruction.
