LAUSR

1109e Reply: Autogenous Bone Cranioplasty: Review of a 42-Year Experience by a Single Surgeon Sir: I thank Dr. Mitchell et al. for their comments on our article.1 First, I look forward to a comprehensive long-term examination of the long-term results of their series of 437 implants, mostly alloplastic, where they cited an 11 percent complication rate. As stated in our article, alloplastic implants, particularly methylmethacrylate, can become extruded 10 to 20 or more years after implantation. An 11 percent complication rate (most likely higher in the long term) compares with our 0 percent rate of implant loss in the period 1975 to 2018, and we would find this unacceptable. If we can extrapolate from their data using our outcome, that is 48 patients having a complication, which is avoidable. To view a preliminary latissimus free flap as something that could be avoided with a one-stage alloplastic implant I believe is folly. The success of either autogenous or alloplastic reconstruction depends completely on the condition of the overlying scalp, and when it is radiodystrophic and breaking down, failure with a one-stage procedure of any type is virtually guaranteed. Removing a substantial segment of full-thickness skull to replace it with a shunt-valve–containing alloplastic construct (as presented at the recent International Society of Craniofacial Surgery meeting in Paris) to avoid pressure from the shunt valve on overlying scalp could also be criticized, because the solution to this problem in our experience would be initial placement of the shunt valve in the occipital area beneath thick soft tissue. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.