Multidisciplinary approach for improved outcomes in secondary cranial reconstruction: Introducing the pericranial-onlay cranioplasty technique

Chad R. Gordon, Mark Fisher, Jason Liauw, Ioan Lina, Varun Puvanesarajah, Srinivas Susarla, Alexander Coon, Michael Lim, Alfredo Quinones-Hinojosa, Jon Weingart, Geoffrey Colby, Alessandro Olivi, Judy Huang

Research output: Contribution to journalArticlepeer-review

54 Scopus citations


Background: Although materials for secondary cranial reconstruction have evolved with time, the overall approach in terms of bone flap/implant reconstruction after necessary delay has remained constant. Objective: To present our cases series of 50 consecutive secondary cranial reconstruction patients and to describe a multidisciplinary cranioplasty approach developed to reduce morbidity, to minimize infection, and to improve aesthetic appearance. Methods: Standard technique teaches us to place the bone flap and/or alloplastic implant directly over the dura or dural protectant after scalp flap re-elevation. However, this procedure is fraught with high complication rates, including infection. While raising the previously incised scalp flap overlying the full-thickness calvarial defect, the dissection is performed within the loose areolar tissue plane beneath the galea aponeurosis, thus leaving vascularized pericranium intact over the dura. Results: A total of 50 consecutive patients were treated by the senior author encompassing 46 cranioplasties using the pericranial-onlay approach, along with 4 isolated temporal soft tissue reconstructions with liquid poly-methyl-methacrylate. Of the 46 cranioplasties (> 5 cm2), only 1 autologous bone flap developed deep infection necessitating bone flap removal (1 of 46, 2.17%; 95% confidence interval, 0.003-11.3). None of the alloplastic custom implants placed have developed any infection requiring removal. Conclusion: This multidisciplinary approach illustrated in our case series, including our "pericranial-onlay" technique described here for the first time, has the potential to improve patient outcomes, to decrease perioperative morbidity, and to minimize costs associated with postoperative infections after secondary cranial reconstruction.

Original languageEnglish (US)
Pages (from-to)179-189
Number of pages11
StatePublished - 1982


  • Cranial reconstruction
  • Craniofacial surgery
  • Cranioplasty
  • Pericranial onlay
  • Pterional custom cranial implant
  • Skull defect
  • Temporal soft tissue reconstruction

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology


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