decision making is no longer acceptable given the high costs of eachcranioplastyand led to the foundation of the German and UK Cranial Reconstruction Registry in 2014. 10 The aim is to gain valid data about eachcranioplasty. This study—the first prospective, randomized multicenter study conducted in Germany—of 2 common materials was planned back in 2009. The materials compared are porous hydroxyapatite [HA] (CustomBone [Finceramica]) andtitanium(DMD Dortmund). Both manufacturers produce implants on the basis of individual CT data sets and a virtual computer

biocompatibility and clinical reliability, 32 such as PMMA,titanium, numerous ceramics such as HA, carbon materials such as CFRP, and others ( Table 1 ). Nevertheless, it is unclear which material provides the best overall result. TABLE 1: Review of the literature regarding clinical studies dealing with alloplast graftcranioplastyAuthors & Year Study Design Material No. of Patients Mean Follow-Up Duration (mos) Complication Joffe et al., 1999 prospectivetitanium148 12 1 infection (0.6%) Blake et al., 1990

to compare the long-term aesthetic and functional outcomes and the cost-effectiveness of primary autologous bone versus primary prefabricatedtitaniumcranioplasty. Methods This prospective randomized controlled trial was approved by the human research ethics committees from the 2 hospitals that provide neurosurgical services in Western Australia and was registered with Australian and New Zealand Clinical Trials Registry (clinical trial registration no. ACTRN12612000353897, http://www.anzctr.org.au ). Sixty-four patients were enrolled and randomized to

decompressive craniectomies, such as freezer cryopreservation or subcutaneous abdominal implantation. 3 , 9 , 12 Computer-designed polyetheretherketone (PEEK) reconstruction has recently been proven as an effective and safecranioplastytechnique, but the price of each PEEK unit is expensive, particularly for uninsured patients in developing countries. 15 , 19 Therefore, metal implants, such astitaniumplates, are commonly used forcranioplastyin many countries, including mainland China. Previous epidemiological investigations have suggested that over 95% of patients

have mostly been abandoned due to their poor biocompatibility, high incidence of infection, and formation of subcutaneous fluid effusions. Autogenous bone is also less frequently used because of its limited availability and different degrees of postimplantation absorption. 9 From a variety of different repair materials,titaniummesh has become a popular material forcranioplastydue to its good compatibility with human tissue, light weight, thinness, hardness, and ability to be easily shaped. 1 , 10 , 13 In recent years, digital computer techniques have been

Staphylococcus epidermidis can form biofilms on metal implants that can prevent the penetration of antibiotics. 8 , 29 , 34 , 35 , 50 Perforations would also serve to decrease the surface area on which biofilms could form. Today, mosttitaniumcranioplastyimplants are either perforated or in a mesh-like pattern. The Demise of Tantalum and Rise of Acrylics Despite its widespread use forcranioplastyduring World War II, tantalum use incranioplastydeclined precipitously in the early 1950s. Acrylic (polymers based on acrylic acid) was the primary successor of tantalum

CSF leak following a suboccipital craniotomy for multiple etiologies has been reported in the literature to range from 1.5% to 14.5%. 3 , 6 , 8–11 To address this complication, various techniques in addition to creating a watertight dural closure have been developed. 1 , 12 Completecranioplastyis the replacement of the entire calvarial defect, using either the bone flap and a bone analog together or a bone analog alone to fill the entire defect. An incompletecranioplastyinvolves partial reconstruction of the calvarial defect, using only a bone flap, atitanium