Computer-Guided In-House Cranioplasty: Establishing a Novel Standard for Cranial Reconstruction and Proposal of an Updated Protocol

Background: Restoring the ideal geometry of the skull vault can be a challenging task. This is especially true for complex cases when cranial reconstruction is associated with concomitant cranial resection in a one-stage procedure. Oftentimes, cranioplasty designing and production are delegated to external companies, with a significant increase in time and cost to fabricate an alloplastic implant. This case series collects and critically examines previous experiences in the field of in-house cranial reconstruction providing an updated protocol to establish a novel standard for cranial reconstruction with a substantial reduction of costs. Materials and Methods: A virtual craniotomy was digitally designed by the surgeon and transferred in the operating room using navigation and a surgical guide. Cranial reconstruction was planned using interpolation functions, recreating the ideal shape of the skull vault. Molds were designed, and 3D printed to intra-operatively shape polymethyl methacrylate (PMMA) according to the pre-operative plan. For validating the accuracy of reconstruction, as well as the restoration of the appropriate skull thickness, software-encoded color maps and root-mean-square error (RMSE), were calculated. Results: All surgeries were uneventful. No adverse reactions to PMMA were observed. Accuracy of the procedure was validated, showing a submillimetric deviation from the original planning and a plate thickness value similar to the adjoining bone. All steps of design and production were performed by the surgical team, and costs were seven to ten times less than the past. Conclusion: We discussed and improved previous reports in the field of computer-guided in-house cranioplasty, particularly when complex one-stage resective and reconstructive procedures are planned. The use of three-dimensional analyses provides a validation of the accuracy of the resulting cranial reconstruction. The authors hope that the results might inspire other colleagues to consider computer-guided in-house cranioplasty, giving surgeons the mastery of each planning phase with a substantial decrease in costs