Cranial Vault Reconstruction Research Articles

Wound Healing Complications After Cranial Vault Reconstruction for Craniosynostosis.

Craniosynostosis is a congenital cranial malformation involving premature fusion of cranial sutures. Indications for surgical repair of craniosynostosis include elevation of intracranial pressure, which can result in impaired vision and mental disability, as well as correction of abnormal skull shape. Resorbable plating systems have become the preferred technique for bony fixation in the repair of craniosynostosis. Multiple studies demonstrate the safety and low complication rate of resorbable plating systems.However, there is no consensus on which plating system is superior for patient outcomes. This study aims to investigate how the polymer composition of resorbable plating systems utilized in cranial vault reconstruction contributes to wound healing complications. A retrospective chart review was performed at the institution between January 1, 2005 and December 31, 2015. About 202 patients who underwent surgical repair of craniosynostosis were identified. The results showed that patients receiving the Biomet Lactosorb plating system were over twice as likely to have a wound complication within a year of surgery compared to other plating systems used at the institution. Wound complications continued to occur in the Biomet Lactosorb group at ≥180 days after surgery, whereas complications among the other plating systems occurred ≤80 days postoperatively. Half of all patients with wound complications had to undergo reoperation. These data demonstrate the effect of unique polymer compositions on wound healing, and will help to guide future clinical practice and industry development of resorbable plating systems.

Variation in the Utilization of Postoperative Computed Tomography for Patients With Nonsyndromic Craniosynostosis: A National Claims Analysis.

Routine postoperative computed tomography (CT) imaging in nonsyndromic craniosynostosis remains controversial due to the hazards of radiation exposure. The extent to which postoperative head CTs are performed remains unknown. Therefore, we sought to measure the use of postoperative CTs in this population. The authors reviewed insurance claims from OptumInsight, using Current Procedural Terminology codes to identify procedures and postoperative imaging. Multilevel logistic regression was used to describe the odds of undergoing postoperative CTs, adjusting for patient and provider covariates. Craniosynostosis patients who underwent reconstruction between 2001 and 2017 were reviewed. Patients older than 5 years at surgery, postoperative lengths of stay >15 days, syndromic diagnoses, operative complications within 30 days of surgery, and cranial bone grafting merited exclusion. Odds of postoperative head CTs after cranial vault reconstruction. In this cohort (n = 1150), 326 (28.4%) patients underwent postoperative head CTs. The number of CTs ranged from 0 to 14. Older age at surgery (odds ratio [OR]: 1.32, P = .002), increasing years of follow-up (OR: 1.12, P < .001), and increasing comorbidities (OR: 1.21, P = .017) were associated with postoperative CTs. After adjusting for patient factors, provider factors accounted for 31.3% of variation in imaging. Over a quarter of patients underwent head CTs following reconstruction, and provider factors accounted for a large percentage of the variation. Given the risks of radiation, neurosurgeons and craniofacial surgeons face a critical need to establish postoperative imaging protocols to reduce unnecessary imaging in these vulnerable patients.

Perioperative Management and Factors Associated With Transfusion in Cranial Vault Reconstruction.

Bleeding is the most common adverse event in patients undergoing cranial vault reconstruction. The authors compare the transfusion rates against a national sample to determine whether the patients experience lower transfusion rates. The authors queried the Pediatric National Surgical Quality Improvement Program (Peds-NSQIP) for patients who underwent cranial vault reconstruction (CPT 61559) and compared them to patients who underwent cranial vault reconstruction for sagittal craniosynostosis at Children's Hospital and Medical Center (CHMC) in Omaha, Nebraska. Patients over the age of 24 months were excluded. Binary logistic regression analysis was performed using IBM-SPSS v24.0 to determine factors associated with transfusion at CHMC. Patient demographics, preoperative hematocrit and platelet counts, readmission rates, and reoperation rates did not differ between CHMC (N = 54) and Peds-NSQIP (N = 1320) cohorts. Patients in the CHMC cohort had shorter preincision anesthesia times (47 versus 80 minutes, P < 0.001), shorter operative times (108 versus 175 minutes, P < 0.001), lower transfusion rates (50% versus 73%, P < 0.001), and smaller mean transfusion volumes (16 versus 33 mL/kg, P < 0.001); however mean length of stay was longer (4.1 versus 3.6 days, P < 0.001). Factors independently associated with transfusion at CHMC included preoperative hematocrit (odds ratio [OR] 0.423, P = 0.002), administration of an antifibrinolytic agent (OR 0.004, P = 0.001) and temperature at the time of incision (OR 0.020, P = 0.043). Patients at CHMC require less transfused blood and experience low transfusion rates. Preoperative hematocrit, administration of antifibrinolytic agents, and temperature at the time of incision are all modifiable factors associated with perioperative transfusion.

Computer-Assisted Design and Manufacturing Assists Less Experienced Surgeons in Achieving Equivalent Outcomes in Cranial Vault Reconstruction.

The purpose of this study was to assess whether long-term outcomes were equivalent between computer-assisted design and manufacturing (CAD/CAM) -assisted cranial vault reconstruction performed by an inexperienced surgeon, with fewer years of surgical experience, and traditional reconstruction performed by senior surgeons with many decades of experience. An Institutional Review Board-approved retrospective cohort study was performed for all patients with nonsyndromic craniosynostosis between the ages of 1 month to 18 years who received primary, open calvarial vault reconstruction at the Johns Hopkins Hospital between 1990 and 2017. The primary outcome variable was the Whitaker category (I-IV) for level of required revision at the 2-year follow-up visit. Secondary outcomes included estimated blood loss, length of stay, operative time, and postoperative complications. CAD/CAM-assisted surgery was considered noninferior if the proportion of cases requiring any revision (Whitaker II, III, or IV) was no more than 10% greater than the proportion in the traditional surgery group with multivariate logistic regression analysis. t tests and fisher exact tests were used for secondary outcomes. A total of 335 patients were included, with 35 CAD/CAM-assisted reconstructions. CAD/CAM-assisted reconstruction was noninferior to traditional after accounting for patient demographics, type of surgery, and experience level of the plastic surgeon. The traditional group required revision more frequently at 29.0% compared to CAD/CAM at 14.3%. Secondary outcomes were not significantly different between groups, but CAD/CAM had significantly longer average operative times (5.7 hours for CAD/CAM, 4.3 hours for traditional, P < 0.01). CAD/CAM technology may lower the learning curve and assist less experienced plastic surgeons in achieving equivalent long-term outcomes in craniofacial reconstruction.

Spotlight in Plastic Surgery: October 2019

Spotlight in Plastic Surgery: October 2019

Developing a 3D composite training model for cranial remodeling.

Craniosynostosis correction, including cranial vault remodeling, fronto-orbital advancement (FOA), and endoscopic suturectomy, requires practical experience with complex anatomy and tools. The infrequent exposure to complex neurosurgical procedures such as these during residency limits extraoperative training. Lack of cadaveric teaching tools given the pediatric nature of synostosis compounds this challenge. The authors sought to create lifelike 3D printed models based on actual cases of craniosynostosis in infants and incorporate them into a practical course for endoscopic and open correction. The authors hypothesized that this training tool would increase extraoperative facility and familiarity with cranial vault reconstruction to better prepare surgeons for in vivo procedures. The authors utilized representative craniosynostosis patient scans to create 3D printed models of the calvaria, soft tissues, and cranial contents. Two annual courses implementing these models were held, and surveys were completed by participants (n = 18, 5 attending physicians, 4 fellows, 9 residents) on the day of the course. These participants were surveyed during the course and 1 year later to assess the impact of this training tool. A comparable cohort of trainees who did not participate in the course (n = 11) was also surveyed at the time of the 1-year follow-up to assess their preparation and confidence with performing craniosynostosis surgeries. An iterative process using multiple materials and the various printing parameters was used to create representative models. Participants performed all major surgical steps, and we quantified the fidelity and utility of the model through surveys. All attendees reported that the model was a valuable training tool for open reconstruction (n = 18/18 [100%]) and endoscopic suturectomy (n = 17/18 [94%]). In the first year, 83% of course participants (n = 14/17) agreed or strongly agreed that the skin and bone materials were realistic and appropriately detailed; the second year, 100% (n = 16/16) agreed or strongly agreed that the skin material was realistic and appropriately detailed, and 88% (n = 14/16) agreed or strongly agreed that the bone material was realistic and appropriately detailed. All participants responded that they would use the models for their own personal training and the training of residents and fellows in their programs. The authors have developed realistic 3D printed models of craniosynostosis including soft tissues that allow for surgical practice simulation. The use of these models in surgical simulation provides a level of preparedness that exceeds what currently exists through traditional resident training experience. Employing practical modules using such models as part of a standardized resident curriculum is a logical evolution in neurosurgical education and training.

Utility of Postoperative Fever Workup After Craniosynostosis Repair

Craniosynostosis is the premature fusion of ≥1 cranial sutures. Surgical management involves early cranial vault reconstruction. Postoperative management of these patients is often complicated by fever of unknown origin and results in additional laboratory studies, extended hospital intensive care unit stays, and increased cost to the patient. A retrospective analysis of 70 consecutive patients who underwent cranial vault reconstruction were included. Postoperative fever (Tmax), length of stay, transfusions, estimated blood loss, and white blood cell counts were obtained, as well as blood, urine, and other culture data. Mean age at surgery was 1.1 years. Sixty (86%) patients had idiopathic postoperative fevers >38°C. Of those, 20% underwent fever workups, none of which returned a positive culture or concern for pneumonia. Length of stay was significantly increased in patients who had fever workups (6.1 days vs. 4.7, P < 0.001). There was no significant difference in age, estimated blood loss, Tmax, white blood cell count, and day of postoperative fever between groups. The average estimated cost of a fever workup at our institution is $1288 (U.S. dollars). Fever of unknown origin is a common finding after craniosynostosis repair. Workup for fever of unknown did not result in the identification of an infection and added significantly to the cost and patient's length of stay.

S4A-01SESSION 4A: GENERALITIES IN CRANIOSYNOSTOSIS – PART I CLINICAL AND GENETIC CHARACTERIZATION OF CRANIOSYNOSTOSIS; A RETROSPECTIVE COHORT STUDY AT KING SAUD UNIVERSITY MEDICAL CITY

Introduction: Craniosynostosis (CS) is defined as premature fusion of one or more of the cranial sutures and is classified to either simple or complex.CS can present as a part of a syndrome or as isolated finding.The aim of this study was to evaluate the clinical and genetic pattern of CS among Saudi population. Methods: A retrospective cohort study has been conducted from February 2015 till February 2019 at King Saud University Medical City among patients diagnosed with CS. Results: A total of 31 patients with CS has been identified in our center, of which 26 patients were operated, 4 patients refused surgery, and 1 was operated outside. 58 % (18 cases) of patients were male and 42% (13 cases) were female. Mean age at surgery among the 26 patients was 16 months. Simple CS was observed in 19 cases and complex CS in 12 cases. In our population, the most common simple skull suture fusion was unilateral coronal (plageocephaly) followed by metopic (trigonocephaly). Raised intracranial pressure was detected in 35.4% of the patients especially among syndromic cases and the most common grade of Papilledema were grade I and grade II preoperatively. The Most common procedure done was cranial vault reconstruction with fronto-orbital advancement, followed by posterior vault distraction. Post-operatively, Papilledema resolved in all but one patient who had improvement and is still being followed up. Furthermore, we found that 77.4% of patients had normal development and 22.6% presented with developmental delay. Developmental delay was observed commonly among complex suture fusion patients followed by metopic suture fusion. Genetics etiology was identified either by whole exome sequencing, single gene testing or microarray. Testing revealed; FGFR2 (5 cases), TWIST1 (4 cases), ALPL (2 cases), FREM1 (1 case), TGFBR2 (1 case), TCF12 (1 case), MAN2B1 (1 case), SETD2 (1 case), Interstitial deletion of the short arm of chromosome 7 in one case, and dual genetic diagnoses in one patient with ALDOB and ADAT3 gene mutations. Genetic testing for the remaining 9 cases is still not finalized. Parental consanguinity presented in 25.8% of the patients. Conclusion: Worldwide, Sagittal suture is the most commonly affected suture in simple craniosynostosis, but in our population coronal suture fusion was observed to be affected the most. This is the first study conducted about this topic in Saudi Arabia and further studies needed to investigate the characteristics of CS in our population.

S16-09 SESSION 16: PLANNING/IMAGING – PART II SEPARATING CRANIOPAGUS TWINS: A 4 STAGE APPROACH USING 3D IMAGING TECHNOLOGY

Introduction: Craniopagus twins are the most rare form of conjoined twins, and successful separation poses a significant challenge to both neurosurgical and plastic surgical teams. Total craniopagus twins share a unified calvarium that houses two fused brains with shared venous sinuses. Orientation of total craniopagus twins, as classified by Stone and Goodrich, may be angular or vertical. To overcome the neurosurgical challenge is to separate two fused brains rotated at different orientations and safely separating the share venous system. The plastic surgery team aims to plan the complex cranial vault reconstruction of two fused calvaria. 3D technology was used to assist in these endeavors. One of the senior authors has previously separated 11 cases of craniopagus twins, and the advantages of our most recent approach using 3D technology will be discussed relative to these cases. Methods: Two sets of total craniopagus twins were separated in 4 stages (n=4). 3D technology was used for pre-operative planning, intra-operative execution, and post-operative analysis of reconstructive outcomes. Virtual surgical planning with 3D printed jigs and guides, 3D surface analysis, and 3D printed models were used at each stage. A two-team approach with neurosurgery and plastic surgery was employed at each stage, and 3D-technology was used by each team. Results: Two sets of total craniopagus twins were successfully separated using a 4-stage, two-team approach supplemented by 3D-technology. The neurosurgical team used 3D-printed models of the brains and vasculature to plan and perform dissection. Plastic surgery used VSP to select tissue expanders and design templates for incisions and osteotomies. 3D printed models offered intraoperative reference to safely separate the brain and its vasculature. 3D printed jigs and guides were fit on the calvarium to guide osteotomies for cranial vault reconstruction, and onto the scalp to guide soft tissue reconstruction. Conclusion: Separation the brain and its vasculature was aided by pre-operative 3D printed anatomic models that were then used as freely rotational reference intra-operatively. Calvarial and scalp reconstruction was improved with virtual surgical planning and 3D printed guides at each stage to precisely plan type and placement of tissue expanders, osteotomies and scalp rotation flaps. 3D technology offers anatomic reference and surgical guidance in the multistage separation of total craniopagus twins, and its potential to further assist in such complex surgical endeavors is a topic of continued investigation.

S5A-03 SESSION 5A: GENERALITIES IN CRANIOSYNOSTOSIS – PART II THE MELBOURNE METHOD OF TOTAL CRANIAL VAULT RECONSTRUCTION - NEUROSURGICAL NUANCES

Introduction: The Melbourne method has been the surgical “work horse” technique for craniofacial surgery in our institution since 2000. As a single step correction this is a significant operation however experience over the past 2 decades reveals a pattern of the predictable pressure points for the operation and the surgical nuances to mitigate these. Whilst we have previously described the technique, safety and long-term outcomes, this is the first review of the neurosurgical aspects of the Melbourne method. Methods: From 2000-March 2019, 273 cases have been completed. Patient demographics, operative reports and complications are reviewed. The cases have been reviewed to identify the stages of the operation where complications may occur and potential techniques to avoid these. Results: Technical modifications can help mitigate a number of complications such as air embolism, dural tear and haemorrhage from emissaries. We will discuss and illustrate the safety points of sequential osteotomies, the “pressure points” where complications may occur and nuances such as safe manipulation of the head and neck throughout the procedure. Conclusion: Experience gained with the Melbourne method over almost 2 decades combined with review of the complications of the series provides knowledge of how to limit the complications and optimise the outcome of cranial vault reconstruction. These nuances contribute to the low complication rate in our series and are presented to compliment the established technique.

S4A-13 SESSION 4A: GENERALITIES IN CRANIOSYNOSTOSIS – PART I WOUND HEALING COMPLICATIONS AFTER SURGICAL REPAIR OF CRANIOSYNOSTOSIS: ARE ALL RESORBABLE PLATING SYSTEMS CREATED EQUAL?

Introduction: Although multiple resorbable plating systems are available for the repair of craniosynostosis, there is a no consensus on which plating system is associated with the lowest complication rates. In a previous retrospective study conducted at our institution, patients with craniosynostosis who underwent surgical repair with the Biomet Lactosorb plating system were over twice as likely to have a wound complication within a year of surgery. Our institution subsequently shifted its practice from the primary use of Biomet Lactosorb for repair of craniosynostosis to Stryker Delta and KLS Martin SonicWeld. The purpose of this study is to compare the incidence of wound complications and return to the operating room between the Stryker Delta and KLS Martin Sonic Weld resorbable plating systems. Methods: A retrospective review of institutional data was performed. Patients less than 18 years old with craniosynostosis who underwent cranial vault reconstruction or frontal orbital advancement with the Stryker Delta or KLS Martin SonicWeld resorbable plating systems between January 1, 2005 and December 31, 2018 were eligible for inclusion. The outcomes of interest were wound healing complications, defined as infection or dehiscence, and return to the operating room. Results: Overall, 242 patients underwent surgical repair of craniosynostosis at our institution between 2005 and 2018. The Stryker Delta or KLS Martin SonicWeld resorbable plating systems were used in a total of 76 patients. 41 patients had repair with Stryker Delta, while 35 patients underwent repair with KLS Martin SonicWeld. Patients who received the Stryker Delta plating system had higher rates of wound complications and return to the operating room. Conclusion: The Stryker Delta cohort had a higher wound healing complication rate (17.1%) compared to the wound complication rate of patients undergoing repair with KLS Martin SonicWeld (5.1%). Complication rates associated with resorbable plating systems should influence surgeon and institutional practice as well as industry development.

S4A-04 SESSION 4A: GENERALITIES IN CRANIOSYNOSTOSIS – PART I EVALUATING THE UTILITY OF POSTOPERATIVE COMPUTED TOMOGRAPHY SCANS FOLLOWING CRANIAL VAULT RECONSTRUCTION SURGERY FOR CRANIOSYNOSTOSIS

Introduction: To evaluate the utility of routine immediate post-operative computed tomography (CT) scans after cranial vault reconstruction surgery for craniosynostosis. Methods: We reviewed intraoperative events and post-operative CT scans for patients with craniosynostosis who underwent cranioplasty between October 2009 and June 2018 at our institution after implementing a standard treatment protocol. We categorized common CT findings and identified the reporting radiologists’ assessment of whether the post-operative CT findings were expected, indeterminate, or unexpected results, including communicated critical results Results: Over a 10-years period, 507 participants were found eligible for enrollment. 39 of these patients had two or more surgeries, resulting in a total number of 550 surgeries. 64.5% of these patients were male, most surgeries (40.2%) were performed between 7–12 months of age and ~90% of these patients had single suture craniosynostosis. Most (82.7%) CT scans (455/550) showed expected post-operative findings and include intracranial, extradural air and fluid as common findings. Unexpected findings were described by the radiologist in 8% (n=44/550) of CT scans. A pediatric neuroradiologist confirmed abnormal findings in 52.3% (n=23), and these included: subdural hemorrhages (21.7%, n=5), subarachnoid hemorrhages (17.4%, n=4), intraparenchymal hemorrhages (13%, n=3), dural venous injury (13%, n=3) and displaced bone fragments (13%, n=3). Two cases had CT reports that described findings concerning for cerebral infarct; however, no infarct was identified on follow-up imaging. Increasing ventriculomegaly was identified in 8.7% of these cases (2/23). Bone flap was reported in 1 case (4.3%). In 52.2% (12/23) of these cases a close observation leading to additional images was required. In one case (4.3%) an intervention with anti-thrombolytic agents was required. Return to the operation room (OR) was required for one case (4.3%). For the remainder 9 cases (39.1%) no clinical action was performed. Conclusion: Abnormal findings on post-operative CT scans following cranial vault reconstruction surgery are relatively uncommon, and unexpected findings were identified in 4.2% (23/550). Whereby only 2 of these cases led to a significant intervention, return to the OR and an anti-thrombolytic management. For the remaining 21 cases no intervention was required except for close observation leading in 12 cases to additional CT imaging.

Comparison of different dosage regimes of epsilon aminocaproic acid on blood loss in children undergoing craniosynostosis surgery.

Open cranial vault reconstruction is frequently performed for craniosynostosis. These procedures often involve high volume blood loss that requires blood transfusion. Antifibrinolytics have been shown to decrease blood loss during these procedures but the optimal dose that maximizes benefits is not known. The primary aim was to evaluate the differences in calculated blood loss between a high infusion rate (40mg/kg/h) and a low infusion rate (≤30mg/kg/h) of epsilon aminocaproic acid after a 100mg/kg loading dose. Secondary aims were to determine if a high infusion rate of epsilon aminocaproic acid was associated with decreased packed red cell transfusion volume and to determine the factors associated with blood loss. This was a retrospective study of children who underwent open cranial vault reconstruction. Using an electronic medical record, we identified patients that fit the inclusion criteria. Demographic, laboratory, transfusion, and perioperative data were collected and statistical analysis was performed. Fifty-three patients were included into the study with twenty-three receiving higher infusion rate (40mg/kg/h) epsilon aminocaproic acid. There was a 14.3mL/kg (95% CI 6.6-23.9) decrease in calculated blood loss in the high-dose cohort. An EACA bolus of 100mg/kg followed by an infusion of 40mg/kg was associated with a lower calculated blood loss compared to the group who received 100mg/kg EACA and≤30mg/kg infusion.

A new method for cranial vault reconstruction: Augmented reality in synostotic plagiocephaly surgery

PurposeAugmented reality (AR) is considered to be a valuable tool in craniofacial surgery for preoperative design, intraoperative navigation, and postoperative assessment. Corrective surgery is necessary synostotic plagiocephaly for functional and aesthetic outcomes. Open calvarial reconstruction is a difficult classic surgical procedure with a high accuracy requirement. The purpose of this study was to introduce an AR system application in synostotic plagiocephaly surgery. Materials and methodsSeven plagiocephaly patients (ages 6 months–24 months, average 16.7 months) were enrolled. Preoperative design was accomplished based on three-dimensional computed tomography (CT) data for patients with synostotic plagiocephaly. We completed the registration with the predefined markers through an image registration process preoperatively. Then, we overlaid the registration results into the surgical field to assist surgeons intraoperatively. CT scans were performed postoperatively. Intracranial volume was measured to judge the surgical outcomes. We performed a quantitative craniometric analysis between the planning of the reconstruction and post-operative results, and the main evaluation indicator was the intracranial volume asymmetry. ResultsWe successfully applied the AR system in patients undergoing synostotic plagiocephaly, providing real-time navigational images of position and orientation information during open calvarial reconstruction surgery in 7 plagiocephaly patients within a span of 5 years. Good appearances were observed after the surgery. Cranial volume asymmetry was decreased from 27.87% to 16.57%, achieving precise intra-operative goals. No significant differences were found between planning and post-operative results. ConclusionsThe AR system can be applied to plagiocephaly procedures guiding to obtain reliable and accurate results via a precise osteotomy.

Long-Term Characterization of Cranial Defects After Surgical Correction for Single-Suture Craniosynostosis.

Craniosynostosis is typically corrected surgically within the first year of life through cranial vault reconstruction. These procedures often leave open calvarial defects at the time of surgery, which are anticipated to close over time in a large proportion of cases. However, residual calvarial defects may result as long-term sequelae from cranial vault remodeling. When larger defects are present, they may necessitate further reconstruction for closure.Better understanding of the calvarial osseous healing process may help to identify which defects will resolve or shrink to acceptable size and which will require further surgery. Our study aims to assess the long-term changes in defect size after cranial vault reconstruction for craniosynostosis. One-year postoperative and long-term computed tomography scans were retrieved from the craniofacial anomalies archive. Analysis used custom software. All defects above the size of 1 cm were analyzed and tracked for calvarial location, surface area, and circularity. Monte Carlo simulation was performed to model the effect of initial defect size on the rate of defect closure. We analyzed a total of 74 defects. The mean ± SD initial defect surface area was 3.27 ± 3.40 cm. The mean ± SD final defect surface area was 1.71 ± 2.54 cm. The mean ± SD percent decrease was 55.06% ± 28.99%. There was a significant difference in the percentage decrease of defects in the parietal and frontoparietal locations: 68.4% and 43.7%, respectively (P = 0.001). Monte Carlo simulation results suggest that less than 10% of defects above the size of 9 cm will close to the size of 2.5 cm or less. We describe and make available a novel validated method of measuring cranial defects. We find that the large majority of initial defects greater than 9 cm remain at least 1 in in size (2.5 cm) 1 year postoperatively. In addition, there appear to be regional differences in closure rates across the cranium, with frontoparietal defects closing more slowly than those in the parietal region. This information will aid surgeons in the decision-making process regarding cranioplasty after craniosynostosis correction.

PEEK-custom made implants for facial reconstruction of complex congenital malformations

Background: PEEK-custom made implants have been widely used for cranial vault reconstruction with constant good biomechanical and aesthetic results. Although autologous bone is preferred in many cases, its usefulness may be limited by difficulty with contouring, resorption, and donor site availability and morbidity.

Open cranial vault reconstruction in the surgical correction of craniosynostosis. A review of 100 cases

Background: Craniosynostosis, the premature fusion of one or more cranial sutures, occurs in approximately 3,5 to 4,5 out of 10.000 births worldwide. Surgical correction is recommended during infancy for those patients. Different surgical techniques have been employed in the treatment of this condition, ranging from minimally invasive approaches to conventional open procedures.

Lessons learned measuring peripheral venous pressure waveforms in an anesthetized pediatric population

Objectives: The purpose is to describe our institution’s experience with collecting peripheral venous pressure (PVP) waveforms using a standard peripheral intravenous catheter in a pediatric patient under general anesthesia. Approach: PVP waveforms, piezoelectric monitoring, arterial blood pressure recording, and electrocardiogram (EKG) tracings were collected from patients undergoing cranial vault reconstruction for craniosynostosis. Data was obtained prospectively in a continuous manner from time of patient final positioning to closure of incision. Description of the technical aspects are discussed. Main Results: The waveform data collection was affected by the following: use of electrocautery, location of electrocautery in relation to PVP monitor, and movement of the operating room table. Significance: PVP waveforms can be collected in a pediatric patient undergoing general anesthesia with accurate data acquisition. Additionally, the set-up used also allows for accurate collecting of piezoelectric monitoring, arterial blood pressure recording, and EKG tracings in real time.

Anterior Cranial Vault Reconstruction With Distraction for Primary and Secondary Craniosynostosis Repair.

Traditional fronto-orbital advancement continues to be a useful operation for correction of craniosynostosis involving the coronal or metopic sutures. Recently, distraction osteogenesis has been used to correct a variety of cranial deformities. Studies have mostly focused on posterior vault distraction due to its simplicity and greater volume gain when compared with anterior vault distraction. However, certain patients are not candidates for posterior distraction due to anterior deformity and need for expansion of the frontal skull. The authors have developed a technique that allows for both reshaping as well as distraction of the anterior cranial vault.This was a retrospective chart review performed between March 2012 and October 2016 at a single institution by a single plastic surgeon. Thirty-nine (39) patients were included in this study. The indications for surgical intervention were signs of increased intracranial pressure or severe anterior skull deformity in the setting of craniosynostosis. The authors reviewed patient characteristics, length of follow-up, number of previous and subsequent surgeries, complications, and rate of relapse.The average age of patients undergoing the procedure was 5.2 years (range 6 months-15 years). Twenty-four (24) patients had 1 previous surgery, 3 had 2 previous surgeries, 1 had 3 previous surgeries, and 11 had no previous surgeries. The average follow-up was 2.5 years (range 6 months-4 years). One patient had a broken activation wire requiring return to the operating room. Three (3) patients (2 Apert and 1 Crouzon) underwent subsequent posterior vault distraction surgery. All patients demonstrated significant improvement in forehead cosmesis.Anterior cranial vault reconstruction with distraction is a safe alternative to traditional cranial vault reconstruction. It can improve forehead shape and position in older children who have had previous surgery as well as patients with severe anterior skull deformity associated with craniosynostosis.

Evaluation of Long-term Outcomes of Facial Sensation following Cranial Vault Reconstruction for Craniosynostosis.

Cranial vault reshaping to correct craniosynostosis in infants may injure terminal branches of the trigeminal nerve, namely the supraorbital, supratrochlear, zygomaticofacial, and zygomaticotemporal nerves, especially if a fronto-orbital advancement is performed. Despite numerous studies demonstrating successful esthetic outcome after FOA, there are no long-term studies assessing facial sensation after possible damage to these nerves as the result of surgery. A cross-sectional case-control research design was used to evaluate facial sensory threshold in the trigeminal branches after cranial vault reconstruction in children with isolated, nonsyndromic metopic, and unicoronal craniosynostosis, compared with those with sagittal craniosynostosis and age-matched nonaffected controls. Study participants were recruited from the Hospital for Sick Children between the ages of 6 and 18 years. Sensory outcome was determined using the Weinstein Enhanced Sensory Test, the Ten Test, and self-reported facial sensibility function questionnaire. The sensory outcomes of 28 patients and 16 controls were examined at an average age of 9.6 years and 10.3 years, respectively. No subjective or objective sensory deficit was noted in supraorbital, supratrochlear, zygomaticofacial, or zygomaticotemporal nerve distributions between groups. Qualitative reports of facial sensibility function indicated no difference in subjective sensation, protective sensation, or motor behavior between groups. These results suggest that while sensory nerve injury during routine FOA may occur, it does not result in a quantifiable nor clinically significant long-term sensory deficit threshold. Patients do not develop long-term neuropathic pain following surgical intervention.