Forehead Remodeling Research Articles

Surgical Technique of Fronto-orbital Advancement And Strip Craniectomy for Correction of Oxycephaly With Towering of Bregma, a Case Report

Background: Craniosynostosis is a congenital problem of brain development that causes disfigurement of the head and face. Multiple synostoses is an abnormal development of head where fusion ofmany or all cranial sutures ’! oxycephaly (tower skull with undeveloped sinuses and shallow orbits). The most accepted surgical correction involves frontoorbital advancement and forehead remodeling. Aim of the Study: In this study, we described our experience and technique in surgical correction of multiple synostoses (Oxycephaly) in BSMMU,department of neurosurgery. Bang. J Neurosurgery 2022; 11(2): 134-137

Management of sagittal synostosis in the Synostosis Research Group: baseline data and early outcomes.

Sagittal synostosis is the most common form of isolated craniosynostosis. Although some centers have reported extensive experience with this condition, most reports have focused on a single center. In 2017, the Synostosis Research Group (SynRG), a multicenter collaborative network, was formed to study craniosynostosis. Here, the authors report their early experience with treating sagittal synostosis in the network. The goals were to describe practice patterns, identify variations, and generate hypotheses for future research. All patients with a clinical diagnosis of isolated sagittal synostosis who presented to a SynRG center between March 1, 2017, and October 31, 2019, were included. Follow-up information through October 31, 2020, was included. Data extracted from the prospectively maintained SynRG registry included baseline parameters, surgical adjuncts and techniques, complications prior to discharge, and indications for reoperation. Data analysis was descriptive, using frequencies for categorical variables and means and medians for continuous variables. Two hundred five patients had treatment for sagittal synostosis at 5 different sites. One hundred twenty-six patients were treated with strip craniectomy and 79 patients with total cranial vault remodeling. The most common strip craniectomy was wide craniectomy with parietal wedge osteotomies (44%), and the most common cranial vault remodeling procedure was total vault remodeling without forehead remodeling (63%). Preoperative mean cephalic indices (CIs) were similar between treatment groups: 0.69 for strip craniectomy and 0.68 for cranial vault remodeling. Thirteen percent of patients had other health problems. In the cranial vault cohort, 81% of patients who received tranexamic acid required a transfusion compared with 94% of patients who did not receive tranexamic acid. The rates of complication were low in all treatment groups. Five patients (2%) had an unintended reoperation. The mean change in CI was 0.09 for strip craniectomy and 0.06 for cranial vault remodeling; wide craniectomy resulted in a greater change in CI in the strip craniectomy group. The baseline severity of scaphocephaly was similar across procedures and sites. Treatment methods varied, but cranial vault remodeling and strip craniectomy both resulted in satisfactory postoperative CIs. Use of tranexamic acid may reduce the need for transfusion in cranial vault cases. The wide craniectomy technique for strip craniectomy seemed to be associated with change in CI. Both findings seem amenable to testing in a randomized controlled trial.

Forehead Widening in Nonsyndromic Scaphocephaly Operated After 12 Months of Age.

Our standard management is to operate isolated sagittal synostosis around 4 months of age because of morphological and cognitive outcomes. However, some patients present late and the likelihood of spontaneous remodeling is low in isolated sagittal craniosynostosis operated on after 12 months of age with a limited technique. The preliminary result of a modified technique for forehead remodeling and subtotal calvarial remodeling in nonsyndromic scaphocephalic children with late presentation is presented. All patients older than 1 with isolated sagittal synostosis assessed between 2011 and 2015, over 1 year of age at the time of surgery, with available pre and postoperative computed tomography-scans, were retrospectively included into the study. The following parameters were collected: (1) age at surgery, (2) duration of the procedure, (3) surgical technique, (4) fronto-nasal angle before and after surgery and (5) forehead width before and after surgery. Ten patients aged between 15 months and 6 years were retrospectively included. Delayed surgery was due to late presentation or initial parental reluctance. All patients presented with a transversal narrowing of the forehead and an anterior bulge. Mean age at surgery was 28 months and mean follow up was 23 months (1-4 years). Measurements showed significant improvement of both the fronto-nasal angle and the width of the forehead. Late-presenting scaphocephalic patients operated on after 12 months of age require forehead remodeling to achieve satisfactory aesthetic results. Modified forehead remodeling by splitting the forehead sagittally into 2 symmetrical halves and adding a midline bone strip is a safe and feasible way to widen the forehead. Long term follow-up is needed to assess this modified technique.

Sagittal suture craniosynostosis or craniosynostoses? The heterogeneity of the most common premature fusion of the cranial sutures

BackgroundScaphocephaly is usually defined as the deformation of the skull resulting from the premature fusion of the sagittal suture. It is the most common type of craniosynostosis, and can be easily recognized on simple clinical examination. Its pathophysiology is easy to understand and to confirm on neuroradiological examination. In contrast, surgical indications are still somewhat controversial, the dispute mainly concerning therapeutic versus esthetic objectives. In recent years, however, several studies have challenged these basic and relatively simplistic interpretations of the pathophysiology of the condition. Materials and methodsTo assess the heterogeneity of scaphocephaly, we reviewed cases of scaphocephaly operated on at the Hôpital Femme–Mère-Enfant, Lyon University Hospital, France during a 10-year period (2008–2017) and performed a review of the literature on scaphocephaly and sagittal suture closure. ResultsDuring the 10-year period, 401 children were operated on for a scaphocephaly at the Hôpital Femme Mère Enfant, Lyon University Hospital. Mean age at surgery was 1.14 years, for a median 0.7 years (range, 4 months to 8. 5 years). Several subtypes could be distinguished according to morphology, intracranial findings on imaging, patient age, and etiology associated to the sagittal synostosis. Two main surgical techniques were used to correct the malformation, depending on patient age, type of deformation and the surgeon's preference: cranial vault remodeling with occipital pole widening, with the patient in a prone position, and parietal enlargement with or without forehead remodeling, in dorsal decubitus. ConclusionsThe complexity and heterogeneous nature of sagittal synostoses depend on different pathogenic mechanisms leading to and interfering with the skull abnormalities: abnormalities of CSF dynamics, possibly associated with systemic alterations, accounting for the varied postoperative morphological and functional course, in terms of cognitive impairment and late complications (notably intra-cranial pressure elevation). However, the real impact of such heterogeneous clinical presentations on surgical indications and surgical results remains to be elucidated.

Frontoorbital Advancement and Forehead Remodeling for Correction of Anterior Calvarial Craniosynostosis, Surgical Technique and Results in Low Economic Facilities: Benha Experience

AbstractBackground: Craniosynostosis is a congenital problem that affects brain development and causes disfigurement of the head and face. Anterior calvarial craniosynostosis involves the metopic and/or coronal sutures. The most accepted surgical correction involves frontoorbital advancement and forehead remodeling. Lack of knowledge about craniosynostosis, the need for equipped facilities in addition to the fear of compli-cations from surgery led to delay in doing surgery at the optimum age, and with this delay more complex surgical techniques are needed, with a less favorable outcome.Aim of the Study: In this study, we described our experience and technique in surgical correction of anterior calvarial craniosynostosis at Benha University Hospital using the frontoorbital advancement technique without the use of any expensive miniplates or helmets compensating the low soci-oeconomic standard of the community.Study Design: This is a retrospective study case series of 15 patients, their ages ranged from 4 to 30 months. All patients have anterior calvarial craniosynostosis and were treated surgically using the frontoorbital advancement technique. Patients had been followed after surgery for a period of time ranged from 8 to 20 months during the years from March 2013 to December 2016.Patients and Methods: Fifteen patients were included; four with pure metopic craniosynostosis, five with combined metopic and coronal, four patients with bilateral coronal and two with unilateral coronal. Patients were clinically and radiologically evaluated using CT scan skull with 3D recon-struction. Pre and post-operative scans as well as patient photographs have been compared and evaluated for the degree of correction of the relationship between the supra orbital bar and the cornea as well as the degree of correction of the deformity in the face and forehead.Results: Out of 15 patients with craniosynostosis involved in this study, 11 (73.3%) patients had achieved very good cosmetic and functional outcome, two patients (13.3%) had an unsatisfactory cosmetic outcome in the form of irregularities in the shape of the skull that necessitated to do another surgery, one patient (6.67%) had a bad cosmetic outcome, and one patient died in the early post-operative period.Conclusion: Frontoorbital advancement with forehead remodeling is the best option for treating anterior calvarial craniosynostosis. For achieving better results surgery should be done at the optimum age and in well equipped medical center. Although using miniplates and helmets may help with the outcome, surgery can be performed with minimal resources in accordance with the economic state of the community with good results.

The cranial orbital buttress technique for nonsyndromic unicoronal and metopic craniosynostosis.

OBJECT Current craniosynostosis procedures can result in complications due to absorbable plates and screws or other specialized expensive hardware. The authors propose the cranial orbital buttress (COB) technique of frontoorbital remodeling for metopic and unicoronal synostoses, wherein no plates or screws are used. They hypothesize that, with this technique, aesthetically acceptable outcomes for unicoronal and metopic synostosis can be achieved. In this article, they present this technique and compare the results with current frontoorbital remodeling practices. METHODS The authors conducted a retrospective chart review of cases in which patients with nonsyndromic unicoronal or metopic synostosis underwent cranio-orbital surgery at their institution from 1985 through 2009. Operative parameters, surgical variations, and complications were analyzed. The COB technique uses a 1-piece switch, hemiforeheads, or multiple pieces for forehead remodeling. The supraorbital bar is reconstructed in patients with metopic synostosis using a double wedge or greenstick fracture technique, and in patients with unicoronal synostosis a hinge procedure based on a 1.5-orbital osteotomy is used. The supraorbital bar is advanced and supported in place by bone graft(s) inserted at the lateral aspect(s) of the orbit(s) to form a buttress, with fixation done using absorbable sutures. RESULTS A total of 79 cases met the criteria for inclusion in the study. Twenty-nine patients had metopic synostosis, 3 had combined metopic and sagittal synostoses, and 47 had unicoronal synostosis. The patients' mean age at surgery was 11.4 ± 10.1 months and the mean operative time was 183.4 ± 41.0 minutes. The mean length of hospital stay was 3.7 ± 1.2 days. The mean blood loss was 150.0 ± 125.6 ml, and 33% of patients required a blood transfusion (mean volume 206.9 ± 102.3 ml). In metopic synostosis, hemiforeheads were used most often (24/29, 83%), and the supraorbital bar was remodeled using a bilateral intracranial orbital osteotomy followed by a double wedge modification (23/29, 79%) or a greenstick fracture (4/29 14%) for milder cases. Forehead remodeling for unicoronal synostosis was by a forehead switch (39/47, 83%) and the supraorbital bar was remodeled using a 1.5-orbital intracranial orbital osteotomy (34/47, 72%) such that the bar was advanced on the abnormal side and hinged at the midline of the normal orbit. Perioperative complications occurred in 19% of cases and included dural tears (16%), inconsequential subdural hematoma (1.3%), and nasal greenstick fracture (1.3%). The total reoperation rate was 7.6% (cranioplasties for irregular contours, 6.3%; scar revision, 1.3%). CONCLUSIONS The COB remodeling technique is simple and efficient, gives acceptable outcomes, and is less resource intensive than previous techniques reported in the literature.

Intracranial Volume Before and After Surgical Treatment for Isolated Metopic Synostosis

Metopic synostosis results in a keel-shaped forehead, hypotelorism, and an increased interparietal width. This study aimed to measure the frontal and total intracranial volume in patients with metopic synostosis before and after surgery and to compare the effect of 2 different operation methods. All patients operated for isolated metopic synostosis between 2002 and 2008 at Sahlgrenska University Hospital who had undergone preoperative and/or postoperative computed tomographic examination (at 3 y of age) were included. The patients were grouped according to operation method: (1) forehead remodeling in combination with a bone graft or (2) forehead remodeling in combination with a spring. Sex- and age-matched controls were identified. A previously developed MATLAB computer program was used to measure the frontal and total intracranial volumes. Sixty patients and 198 controls were included. Preoperatively, the patients with metopic synostosis had significantly lower frontal volumes than those of the controls (P < 0.001) but equal total intracranial volumes. The operations redistributed the intracranial volume and resulted in an improved, frontal-total intracranial volume ratio. However, at 3 years of age, the frontal volume (P < 0.001), total intracranial volume (P ≤ 0.002), and ratio between the 2 (P < 0.001) were significantly lower in the patients than in the controls. The 2 operation methods were equally efficient in creating an improved frontal-total ratio. Surgery for metopic synostosis improves the distribution of the intracranial volume but does not result in normal total intracranial volume or frontal volume at 3 years of age.

Individualized Template-Guided Remodeling of the Fronto-Orbital Bandeau in Craniosynostosis Corrective Surgery

Reshaping of the forehead and fronto-orbitlal bandeau in the correction of craniosynostosis requires careful attention to the ideal craniofacial proportions. Osteotomies guided by standard templates have been described to correct deformities of the fronto-orbital bandeau and forehead. We have used an individualized template as a guide to correction by osteotomy and remolding, in cases of craniosynostosis affecting the anterior cranium. This is a prospective study examining the use of an individualized template to correct the forehead and facial shape in a consecutive series of 15 craniosynostosis cases over a 6-month period. No significant differences for the group were found between the ideal individual template measurements and those actually achieved at the completion of surgery. The use of individualized templates guiding meticulous forehead remodeling allows for the normalization of craniofacial appearance in the correction of craniosynostosis.

Surgical correction of trigonocephaly: theoretical basis and operative procedures.

Trigonocephaly involves premature fusion of both the metopic suture and the sutures in the skull base. Surgical treatment by opening of the prematurely fused metopic suture and expansion of the anterior cranial base by creating "neosutures" was used to treat three children with trigonocephaly. The combination of lateral canthal advancement and radical forehead remodeling achieved excellent results. These procedures can also prevent the development of midface hypoplasia such as hypotelorism. The two younger patients, aged 0 and 6 months, achieved rapid bone growth in the defects and normalization of intercanthal and interpupillary distances. The older patient, aged 8 years, retained some skull defects at follow-up. The optimal age for surgery is 3-6 months, which allows good cosmetic results and minimizes visual repercussions with relatively low perioperative risks.

Craniosynostosis.

Craniosynostosis affects approximately one infant out of one thousand. Increase of intracranial pressure and risks of functional problems are more frequent than previously thought, especially in single-suture synostosis. Frontocranial remodeling will correct both functional and esthetic consequences of craniosynostosis. The best time for surgery is the first year of life, 2-3 months of age for the brachycephalies, and 6-9 months of age for the other craniosynostoses. Not only does growth not deteriorate after forehead remodeling, but the adjacent orbitonasal areas improve with time. In Crouzon's disease and Apert's syndrome, early frontal advancement does not prevent the midface retrusion, and a radical frontofacial advancement may be occasionally indicated in very severe cases. Frontocranial remodeling is also indicated in children presenting with sequelae of classical neurosurgical treatment or those who have had no treatment.

Analysis of Intracranial Pressure and Operative Procedures for Craniosynostosis

The operative benefits and goals in the treatment of craniosynostosis were considered mainly from the cosmetic standpoint before the 1960s. In the last 25 years, two major clinically critical points have been added to the consideration of an operative method. One is the associated increased intracranial pressure (ICP) and the other is the newly recognized pathophysiology of associated premature closure of skull base sutures. Thus, classical linear craniectomy, which used to be the only accepted operative method for craniosynostosis, has been reconsidered with its unsuccessful and unsatisfactory results both for cosmetic and decompressive purposes. Twenty-five cases were analyzed in the light of operative procedures and discussed with the results of pre and postoperative ICP monitoring in treatments for craniosynostosis. Only 13 out of 25 children were treated before 1 year of age. Simple suture closure was seen in 13 patients, namely, six sagittal, four coronal, and three metopic. Multiple involvements were seen in the other 12 patients, namely, five Crouzon's disease, two Apert's syndrome, one cloverleaf skull, and four other multiple cranial suture closures. The signs and symptoms and radiological evidence of increased ICP with or without continuous ICP monitoring were checked in all cases. All children over 2 years of age or with multiple suture involvements revealed the evidence of increased ICP before the operation. All six patients over 3 years of age had one or more symptoms of decreased visual acuity, headaches, psychomotor developmental delay, or convulsion. Pre and postoperative pressure monitoring confirmed satisfactory improvement in ICP in advanced elderly cases treated with bilateral wide flap operations or in infantile craniofacial dysostosis, plagiocephaly, or trigonocephaly treated with lateral canthal advancement with radical forehead remodeling. This study strongly emphasizes that ICP is an extremely important factor in considering operative procedure for craniosynostosis.

Treatment of Craniosynostosis in Infancy

Craniosynotosis affects approximately one infant out of 1000. The increase of intracranial pressure and the risks of functional problems are more frequent than usually estimated, especially in monosutural synostosis. Frontocranial remodeling will correct both functional and aesthetic consequences of craniosynostosis. The best operative period is the first year of life, 2 to 3 months of age for the brachycephalies, and 6 to 9 months of age for the other craniosynostoses. Not only does growth not adversely affect the results of the forehead remodeling, but the adjacent orbitonasal areas improve with time. In Crouzon's disease and Apert's syndrome, early frontal advancement does not prevent the midface retrusion, and a radical frontofacial advancement may be indicated in very severe cases.

Radical forehead remodeling for craniostenosis: D. Marchac. Plast Reconstr Surg 61:823–835 (June), 1978

Radical forehead remodeling for craniostenosis: D. Marchac. Plast Reconstr Surg 61:823–835 (June), 1978