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Titanium mesh is a popular material for cranioplasty. However, long-term outcomes of these reconstructions remain unknown. We aimed to compare long-term outcomes between patients undergoing both (1) skull reconstruction with titanium mesh and other commonly used cranioplasty materials and (2) scalp reconstructions with locoregional flaps and free tissue transfers.
A retrospective review of patients treated with 466 cranioplasties (401 patients) between 2002 and 2014 was performed.
Materials used for reconstructions included nontitanium alloplast (52.0%), titanium mesh (38%), and autologous bone (10%). Median cranial defect size was 58.4 cm2. Eighty-three reconstructions (18%) included full-thickness scalp defect with a median area of 155.4 cm2. Median follow-up was 3.9 years. Retention rate for isolated cranioplasty was 90%, 89.9%, and 77.1% for titanium mesh, nontitanium alloplast, and autologous bone, respectively (P > 0.05). In composite defect cases, retention rate for autologous bone was comparable, 81.8% (P > 0.05), whereas for titanium mesh and nontitanium alloplast it was significantly lower, 46.8% and 72.0%, respectively (P < 0.05). The retention rate of titanium mesh cranioplasty with free fascio- and myocutaneous flaps was higher when compared with locoregional and free muscle flaps (P < 0.05).
Titanium mesh offers a durable repair of isolated bone defects. However, in high-risk patients with soft-tissue defect, the outcomes are significantly worse. In these cases, free tissue transfer for soft-tissue coverage tends to be more successful, especially when using a myocutaneous or fasciocutaneous free flap. This is the first study to identify a high complication rate of this popular material, especially when it is combined with a locoregional scalp flap or free muscle flap. Therefore, in these cases, titanium mesh should be used with caution.

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