Microsurgical tissue transfer and individual computer-aided designed and manufactured prefabricated titanium implants for complex craniofacial reconstruction

From 1994 to 2000 187 individual computer-aided designed and manufactured (CAD/CAM) prefabricated titanium skull implants were inserted at 37 clinical centres. Since the processing chain of construction and fabrication of implants has become routine the clinical success totally depends on the condition of the soft tissues at the recipient site. In three patients in our own department with a history of up to 18 surgical interventions, and additional previous irradiation in one case, these conditions were so bad that a microsurgical tissue transfer had to be made before insertion of the implant. A latissimus dorsi free flap with submandibular microsurgical anastomosis had to be used in all three cases. However, the aetiology of the soft tissue deficits differed, and they were at a different tissue level in each case: anterior skull base, subcutaneous temporal area, and frontoparietotemporal skin. This series of patients therefore demonstrates the variability of possible combinations, which also require special timetables and principles of construction of the CAD of the implant. In all cases the cranioplasties were done three to five months after the transfer of the flaps and fulfilled the criteria of greatest precision and the best possible aesthetic outcome with minimal stress for the patients. These applications are surgical strategies for extreme cases but also illustrate the elaborate interdisciplinary approach in Computer Assisted Surgery.