The Use of Materials in the “First Modern Era"

A lth o u g h a so ca lle d “ M odern Era" of cra n io p la sty, is sa id to have sta rte d w ith th e in tro d u ctio n of a u to g e n o u s grafts by M errem (1810) and von W a lth e r (1821 ), little e vid e n ce of th is is ava ila b le . T h e e a rlie s t in fo rm a tio n in d ic a te s th a t d e fe c t clo su re w a s at first e ffe c te d by th e use of so ft sca lp tis s u e . T h e fla p tra n s p o s itio n , in tro d u ce d by M u lle r (1890) and K onig (1890) w a s p re d o m in a n t fo r m ost o f the first d e ca d e (Fig 1.5).

1.5.1. T h e U se o f D e rm a to p e rio -O s te a l Flaps

T h e M u lle r-K o n ig te c h n iq u e c o n s is ts of tra n s p o s in g a fla p of scalp, the u n d e rly in g p e rio s te u m , and th e o u te r b on e la ye r of th e skull. T w o a d ja c e n t skin fla p s h in g e d at o p p o site e n d s w e re o u tlin e d , one e n c lo s in g th e sca lp o v e r th e d e fe ct, th e o th e r e n c lo sin g the d o n o r scalp (Fig 1.5). U sing th is te c h n iq u e th e sca lp w a s strip p e d fro m the m a rg in s and b a se o f the d e fe ct, th e e d g e s o f th e b on e w e re fre e d , and th e n th e tw o fla p s in te rch a n g e d . If th e d o n o r a re a c o u ld not be c o m p le te ly co ve re d by th is m ethod, it w a s a llo w e d to g ra n u la te , o r a fu rth e r g ra ft w a s inserted. T h e p ro ce d u re w a s a e s th e tic a lly p o o r b e ca u se of th e tw iste d p ed icles, and w a s soon m o d ifie d by D u ra n te (1889 ), and von H a kke r (1890), w h o used a sin g le skin fla p and

a p e rio s te o -o s te a l g ra ft (Fig 1.5). S e ve ra l o th e r m o d ific a tio n s fo llo w e d , u sin g b on e w ith o r w ith o u t p e rio ste u m as a fre e graft. T h is m e th o d , w ith m o d ifica tio n s, pro ve d to be the o ld e st a nd firs t u n ive rsa lly p o p u la r c ra n io p la s ty te c h n iq u e and w as w id e ly used fo r th irty to fo rty years into th e 2 0 th century. T h e fla p tra n sp o sitio n , w a s in tro d u c e d by M u lle r (1890 ) and K o n ig (1890) and th e m o d ifica tio n by D u ra n te (1889) (Fig 1 5).

U sing th is te c h n iq u e th e scalp w as strip p e d fro m th e m a rg in s and b a se of th e d e fe ct, the e d g e s o f th e bon e w e re fre e d , and th e n th e tw o fla p s in te rch a n g e d . If th e d o n o r area cou ld n ot be c o m p le te ly co vered by th is m e th o d , it w a s a llo w e d to gra n u la te , o r a fu rth e r g ra ft w a s in se rte d (Fig 1 .5a, b, c, d). T h e p ro ce d u re w a s a e s th e tic a lly p o o r b e c a u s e o f the tw is te d p e d icle s, and w a s soon m o d ifie d by D u ra n te (1889 ), and vo n H a kke r (1890 ), w h o used a sin g le skin fla p and a p e rio s te o -o s te a l g ra ft (Fig 1.5e, f). S e ve ra l o th e r m o d ific a tio n s fo llo w e d , using b o n e w ith o r w ith o u t p e rio s te u m as a fre e graft. T h is m eth od, w ith m o d ific a tio n s , p roved to be th e o ld e s t and firs t u n ive rsa lly p o p u la r cra n io p la s ty te c h n iq u e an d w a s w id e ly used fo r th irty to fo rty ye a rs into th e 20'^^ century.

Fig 1.5. a, b, c, & d. The transposition type of cranioplasty, the M uller-Koenik procedure showing interchange of scalp and derm atoperio-osteal flaps; f. The Durante or von H acker m odification using a single scalp flap and hinged graft. (Redrawn; .A.Earl W alker. A History of Neurological Surgery. 1951).

D e fe c t O u t e r t a b l o f s k u ll. P e rio s tiu rn ' A l t e r n a t e a p p li c a t io n o f g r a ft,

1.5.2. B o ne C h ips

M a c e w e n (1885) and Keen (1905) th e n a p p a re n tly in tro d u c e d th e u s e of b o n e c h ip s alone.

1.5.3. E xtra C ra n ia l Bone

T h e firs t to use extra cra n ia l bone, o ste o -p e rio s te a l b o n e ta k e n fro m th e tib ia w a s S e yd e l (1889). Its use fro m m a n y site s b e ca m e w id e s p re a d a nd p o p u la r; sc a p u la b on e w as u se d by R o e p ke (1912 ), b o n e fro m th e iliu m by M a u c la ire (1914), and P ickerill (1921 ), rib b o n e by K a p p is (1915) a n d th e cu rv e d 12th Rib by W e b b e r (1916).

1.5.4. S to re d A u to g e n o u s B o ne

S to re d b o n e w a s firs t used by M a ce w e n (1 9 8 5 ). T h e b o n e w a s k e p t in a p re s e rv a tiv e fo r re im p la n ta tio n . K re id e r fo llo w e d , at an u n s p e c ific d a te b u t a t a b o u t th e sa m e tim e , storing cra n ia l b o n e in th e a b d o m in a l w all until it w a s to be re p la ce d in th e defect.

1.5.5. C a rtila g e

C a rtila g e w a s trie d and fo u n d to be to o fle x ib le b y M o re stin (1915).

1.5.6. H o m o g e n e o u s B o ne a n d G ra fts

D a m b rin (1919 ) re p o rte d on 107 d e fe c t re p a irs using a u to p s y sku ll b o n e p la ce d in xylol, and fo rm a lin , a n d s te rilis e d by m o ist hea t, durin g th e 1 9 1 4 - 1918 w ar. H e ro g e n o u s g ra fts w e re th e n u sed by m a n y su rg e o n s, in c lu d in g R icard (1893), w h o used th e ilium fro m a dog, and K u e ttn e r (1917 ) th e b o n e s fro m apes.

1.5.7. S o u p b o n e C ra n io p la s tv

c ra n io p la sty. T h e bon e cam e from m any s o u rce s, Ja k s c h (1889) u sed b o n e fro m eagles, G re k o ff (1898) used ca lf s c a p u la , and R e y n ie r (1915 ), b o n e fro m ra b b it sca p u la . T he n B a b co ck (1917) a n d V illa n d re (1 9 1 7 ) used s h e e p s ku ll an d oxen sca p u la .

1.5.8. K eratin G ra fts

H e n s c h e n (1916) used b u ffa lo horn, and th e n a p p a re n tly trie d th e u se of to rto is e shell. R ehn (1913) used ox horn, an d M a u cla ire (1916) tried th e use o f Ivory.

1.5.9. A llo p la stic M aterial

W a lk e r (1951), c ite s th e fo llo w in g v e g e ta b le an d m in e ra ls u sed to illu s tra te th e re m a rka b le to le ra n c e o f th e va rie ty o f fo re ig n b o d ie s u sed fo r c ra n ia l repair:

H ard rubber, G u tta percha . P la ste r o f P aris, S h e e t M ica, G u m C o rk, and C a lc iu m p h o s p h a te and C a rb o n a te in olive oil. A llo p la s tic g ra ftin g b e c a m e in c re a s in g ly p o p u la r. F ra e n ke l in (1890) in tro d u c e d C e llu lo id , w h ich w a s e n th u s ia s tic a lly rece ive d in first A u s tria and G e rm a n y and th e n fu rth e r a fie ld .

It w a s th e first use o f a “pla stic". Its use p ro ve d to be p ro b le m a tic, F ra e n k e l re p o rte d on flu id a c c u m u la tio n in th e 1st w e e k s , an d F un ke (1915) re p o rte d on its unsta b le n a tu re havin g a te n d e n c y to ch a n g e sh a p e . A lu m in iu m w a s in tro d u c e d by B o o th and C u rtis as e a rly as 1893, th e n at th e tim e of th e firs t w o rld w a r the use o f m e ta ls b e ca m e p o p u la r. E sto r (1917 ) re p a ire d 100 d e fe c ts using gold, w h ich w a s a p p a re n tly su c c e s s fu l, re su ltin g in o n ly 2 d e a th s and 2 in fe ctive re m o va ls. D a n zig e r (1 9 1 8 ) used lead an d trie d silve r, w h ich w a s b io -in e rt an d w e ll to le ra te d , b u t u n fo rtu n a te ly c a u se d m a rk e d u n a c c e p ta b le d is c o lo u ra tio n . P latinu m w a s used fo r a short tim e by C o rn io ly (1929).

S a cks (1947) an d W a lk e r (1 9 5 1 ) report th a t p o s s ib ly b e ca u se of th e cost, b u t m a in ly b e ca u s e of th e u n a c c e p ta b le n u m b e r of failure s, p re fe re n c e

re tu rn e d to th e use of m o d ific a tio n s of th e M u lle r-K o n ig te c h n iq u e (Fig 1.6). T h e y in d ica te th a t its use co n tin u e d until th e n in e te e n th irtie s , and w a s fo llo w e d by th e a d v e n t of th e n e w a llo p la s tic m a te ria ls, u se d fro m 1939, to th e p re s e n t day. T h is is now a ga in re fe rre d to as "T he M o d e rn Era " of cra n io p la s ty .