Tái tạo khuyết hổng hộp sọ cá nhân hóa kết hợp phục hồi đường nét khuôn mặt Patient-specific cranioplasty with aesthetic restoration of temporal contour

Cranial defect reconstruction is not solely intended to restore the continuity and protective function of the skull. When the defect involves the temporal region or is associated with maxillofacial trauma, restoration of facial contour and symmetry becomes an important component of reconstruction.

This case illustrates a multidisciplinary approach combining neurosurgery, maxillofacial surgery, and patient-specific implant design to simultaneously address a cranial defect, temporal hollowing, and post-traumatic zygomatic deformity.

When the cranial defect has been reconstructed but facial asymmetry remains

The patient had sustained a severe traumatic brain injury abroad and underwent removal of a portion of the skull. The resulting cranial defect was subsequently reconstructed at another institution using titanium mesh.

Although the cranial defect itself had been adequately covered, the temporal region remained noticeably depressed compared with the contralateral side. In addition, an associated zygomatic fracture had not been fully reconstructed, resulting in flattening of the malar region and further contributing to facial asymmetry.

The problem was therefore no longer simply a defect of the skull. It represented a three-dimensional deformity involving the cranial skeleton, temporalis muscle, surrounding soft tissues, and zygomatic framework.

Temporal hollowing after cranial surgery

Temporal hollowing is a recognized deformity following trauma and surgery involving the temporal region.

The contour of the temple is determined not only by the underlying bone but also by the temporalis muscle and its surrounding soft-tissue layers. Following trauma and surgery, the temporalis muscle may undergo injury, atrophy, displacement, or loss of normal attachment. These changes can produce a visible depression of the temporal region even when the underlying cranial defect has already been reconstructed.

Consequently, an implant designed simply to reproduce the missing bony anatomy may not necessarily restore the external contour of the head and face.

For this patient, I therefore adopted a different strategy: the implant was designed not only to reconstruct the cranial defect, but also to compensate for part of the missing soft-tissue volume.

Using the unaffected side as a template

The first step was to reconstruct a three-dimensional model of the patient's skull together with the existing titanium mesh. Based on this anatomy, an initial patient-specific cranial implant was designed.

However, reproducing the bony contour alone would have left a residual temporal depression because of the associated soft-tissue deficiency.

I therefore reconstructed the volume of the temporalis muscle on the unaffected side and mirrored it to the side of the defect.

The unaffected side provided a patient-specific reference for the temporal contour that we aimed to reproduce.

Using this information, the initial implant design was modified and intentionally augmented in selected areas. The objective was not merely to reproduce the missing bone, but to create an implant capable of compensating for soft-tissue volume deficiency and restoring a more symmetrical temporal contour.

After the design had been finalized, the data were returned to the manufacturer and the customized cranial implant was produced in PEEK (polyetheretherketone).

Combining neurosurgical and maxillofacial reconstruction in a single operation

The procedure was performed through close collaboration between neurosurgery and maxillofacial surgery.

The neurosurgeon removed the previous titanium mesh and placed the patient-specific PEEK implant to reconstruct the cranial defect.

From the maxillofacial perspective, I simultaneously addressed the temporal contour and reconstructed the residual post-traumatic zygomatic deformity. A portion of the temporal soft tissue was adjusted to accommodate the augmented implant volume and prevent excessive fullness following reconstruction.

By performing these procedures during the same operation, the cranial, temporal, and zygomatic contours could be evaluated and reconstructed as a continuous aesthetic unit, rather than treating each defect independently.

Reconstruction is more than replacing missing bone

At three months after surgery, a substantial improvement in temporal and malar symmetry was achieved.

This case demonstrates an important principle in craniofacial reconstruction: restoring the skeletal anatomy does not necessarily restore the external facial contour.

In temporal defects, reconstruction of the bone alone may leave a significant residual deformity if changes in the temporalis muscle and surrounding soft tissues are not considered.

Patient-specific implant design allows us to go one step further. Instead of asking only “What bone is missing?”, we can also ask “What volume needs to be restored to recreate facial symmetry?”

For patients with combined cranial and maxillofacial injuries, multidisciplinary planning from the beginning of reconstruction is equally important. Rather than considering the cranial defect and facial deformity as two independent problems, an integrated reconstructive strategy may allow both to be addressed during the same surgical procedure.

At the Department of Plastic and Aesthetic Surgery, National Hospital of Odonto-Stomatology, Hanoi, patients with combined cranial and maxillofacial pathology are managed in collaboration with neurosurgery when indicated, with the objective of restoring structure, function, and facial contour as an integrated whole.