PATIENTS AND METHODS: In a retrospective review, four patients presented with large calvarial defects from trauma. Each of these patients had absent underlying brain in addition to the missing segment of bone. All patients were well healed from the original injury and were neurologically stable, although all patients had a neurologic deficit. The defects were studied by three-dimensional computed tomography (CT) and the volume deficit measured. All patients underwent first stage free tissue transfer and at a second hospitalization, cranioplasty was performed. The volume was filled largely by the free tissue transfer and an alloplastic material was used to re-create the rigid surface contour.

RESULTS: Preoperative and postoperative CT scans were performed on all patients. There were no healing problems and the flaps were viable at the time of cranioplasty. The volume deficit was measured preoperatively and then reviewed on the postoperative CT scan. The resultant volume fill by the free tissue transfer and the surface area of the alloplast were measured. All patients left the hospital without neurologic change and remained in the preoperative, post-morbid state.

CONCLUSION: Large volume calvarial defects can be very challenging to repair. Cranioplasties can be performed using alloplastic, cadavaric or autologous materials. The extent of the volume can only partially be addressed with the materials used for the cranioplasty. In this small series of patients, free tissue transfers were safely used to fill the large volume defects followed by a secondary cranioplasty. With this experience, we will present an algorithm for large volume calvarial defects.