The Use of Periorbital Steroids to Reduce Postoperative Swelling in Fronto-orbital Advancement: An Analysis of Outcomes

Abstract

PURPOSE: Marked facial swelling is a known consequence following fronto-orbital advancement (FOA), which can result in prolonged eye closure, patient discomfort, and postoperative hospitalization. There are limited reports on the efficacy and safety of periorbital steroids to help reduce facial swelling in craniofacial surgery, which has become standard practice at some centers. The purpose of this study is to compare outcomes with and without the use of periorbital steroids in patients undergoing FOA. METHODS: A retrospective chart review of patients who underwent FOA at Seattle Children’s Hospital between January 2012 and December 2019 was completed. All procedures were performed by 2 senior surgeons (R.A.H. and C.B.B.) in conjunction with a pediatric neurosurgeon. All patients received pre-, intra-, and postoperative care via a standardized clinical care pathway. In the periorbital steroid cohort, triamcinolone was administered as an injection into the subcutaneous tissues or soaked in gelfoam and placed in the frontal/periorbital region before closure of the scalp. Statistical significance between outcomes measures was determined using a 2-tailed unpaired Student’s t test or chi-square test as appropriate. RESULTS: A total of 167 patients were included in this study (80 control, 87 periorbital steroid). The majority of these patients underwent FOA for isolated metopic synostosis (52.1%) followed by multisuture synostosis (23.9%) and isolated unicoronal synostosis (18%). 15.6% of patients had craniosynostosis as part of a diagnosed craniofacial syndrome. The average postoperative length of stay following FOA was 4.3 ± 2.0 days. Criteria for discharge including adequate PO intake, appropriate pain control, removal of the surgical drain, and improvement in facial swelling with opening of at least 1 eye. The use of periorbital steroids resulted in a statistically significant decrease in the hospital length of stay (LOS) compared with controls for isolated metopic (12.5 hours; P = 0.031) and unicoronal (12 hours; P = 0.015) craniosynostosis; there was no statistically significant difference in LOS for multisuture craniosynostosis (5.2 hours; P = 0.329). There was a significantly higher rate of surgical site infection in patients who received periorbital steroids compared to controls (10.2% versus 2.5%; P = 0.041). All of these complications represented scalp wound infections requiring operative intervention. Ninety-one percent of patients required hospital readmission with an average LOS of 17.6 days and 36% required subsequent revision cranioplasty. There was no association between specific suture involvement, craniofacial syndrome, or age at FOA with infectious complications. CONCLUSIONS: The use of periorbital steroids has been reported in the literature to reduce facial swelling and shorten convalescence following FOA. This study demonstrates that there is a statistically significant decrease in hospital LOS with the use of periorbital steroids in isolated suture craniosynostosis. However, it is associated with a significantly higher rate of infectious complications requiring operative intervention, extended hospital readmissions, prolonged antibiotic therapy, and secondary reconstruction.