Advancing Cranioplasty Techniques Through Exoscopic Magnification: A Case-Series and Single-Center Experience

The pericranial-onlay technique for alloplastic cranioplasties creates a new plane within the loose areolar tissue that lies beneath the galeal fascia and above the pericranium. This retrospective consecutive case series aims to assess and report on the feasibility and applicability of performing the pericranial-onlay technique under exoscopic magnification (EM) for elective cranioplasties.

Patients included were: (1) 18 years and older; (2) underwent elective alloplastic cranioplasty to treat acquired skull defects; (3) the cranioplasty was performed using the pericranial-onlay technique; and (4) the pericranial-onlay dissection was performed under EM.

Eleven patients (23-68 years; 8 women, 3 men) were included. All patients underwent successful cranioplasty using the pericranial-onlay technique under EM. Seven patients (63.6%) had at least 2 previous surgeries involving the scalp and skull in the affected area, and all patients had undergone at least one previous surgical manipulation. In addition, 7 patients (63.6%) had existing hardware requiring removal before the current cranioplasty. Five patients (45.5%) presented with scalp infections related to previous cranioplasty failure. Eight patients had defect sizes equal to or greater than 15 × 10 cm. The mean operative duration was 145.4 ± 9.1 minutes, and the mean follow-up period was 13.1 ± 5.7 months. Only one patient (9%) developed a complication during the entire follow-up, an epidural hematoma which was not attributed to the surgical technique.

For the first time, this study introduces and reports on the feasibility of pericranial-onlay execution through 3-dimensional EM. In our experience, this approach facilitates meticulous dissection and allows for a safe and successful dissection (ie, no dura, galea or pericranium violation), particularly in challenging cases. We believe that the addition of EM to the soft tissue and pericranial-onlay dissection offers a novel and deeper perspective on how we view and approach the scalp, thereby pushing the boundaries of surgical management of cranial reconstructions.