Operative Planning

• Repair of skull defect can be performed acutely in clean cases
  
• In cases of hemicraniectomy for control of elevated intracranial pressure, repair is performed following resolution of intracranial hypertension
  
• In contaminated cases, wait 3 to 6 months before repair is attempted
  
• Shunt may be placed preoperatively in those with external hydrocephalus

Equipment

• Major craniotomy tray
  
• Mayfield head holder
  
• High-speed drill
  
• Methyl methacrylate, hydroxyapetite cement, or substitute (Norian [Norian Corporation, Cupertino, CA], Bonesource [Stryker-Leibinger, Kalamazoo, MI], HydroSet [Stryker], etc.) (optional)
  
• Titanium microplates and screws (optional)
  
• Titanium mesh (optional)

Operating Room Set-up

• Headlight
  
• Loupes
  
• Bovie cautery and bipolar cautery

Anesthetic Issues

• Intravenous antibiotics (cefazolin 2 g) should be given 30 minutes prior to incision

Positioning

• Depends on location of defect
  
• Consider placing lumbar drain to remove cerebrospinal fluid, thus decreasing intracranial pressure and allowing more room for cranioplasty

Planning of Sterile Scrub and Prep

• As for craniotomy

Exposure

• Typically, previous incision is used and/or previous laceration is in part used
  
• Flap is carefully elevated from underlying scar and dura; use of blunt dissection and/or sharp dissection
  
• Brain may be adherent to scar and skin in cases of incompetent dura
  
• Edges of bone identified with a curette or periosteal elevator
  
• Dura covered with compressed Gelfoam or DuraGen