Frontal Orbital Advancement Research Articles

Virtual Surgical Planning in Craniosynostosis Reduces Operative Time and Length of Stay for Cranial Vault Remodeling.

Cranial vault remodeling (CVR) with and without frontal orbital advancement remodels the skull in craniosynostosis. Virtual surgical planning (VSP) for preoperative planning has been previously shown to be effective in CVR. In this study, the authors aimed to evaluate the impact of VSP on operative and perioperative efficiency for craniosynostosis surgery. A retrospective chart review was conducted of patients with craniosynostosis who underwent CVR. Patient demographics, perioperative variables, use of VSP, and complications were obtained. Perioperative variables collected include operative time and length of stay. An independent t test was used to compare variables from patients who had surgery with VSP and patients who did not. Records were available for 126 patients with craniosynostosis who underwent CVR of whom 79 (62.7%) utilized VSP. There was no difference in average age at surgery (9.3±5.7mo versus 13.2±31.1mo, P =0.39). Surgeries planned using VSP demonstrated a decreased operative time of 1.3 hours (3.7±1.1 versus 5.0±1.1h, P <0.001) and a shorter length of stay (3.9±1.3 versus 4.6±1.7d, P =0.01). There were no differences in complication rates of dehiscence, infection, returns to the operating room, or 30-day readmission. These trends were similar among patients who underwent fronto-orbital advancement in addition to CVR. Virtual surgical planning was associated with decreased operative time and length of stay for patients with craniosynostosis and comparable complication rates. Virtual surgical planning is an effective tool for reducing anesthetic exposure time.

Perioperative Morbidity of Secondary Frontal Orbital Advancement After Initial Frontal Orbital Advancement.

Frontal orbital advancement (FOA) is frequently performed for patients with syndromic and/or multisuture craniosynostosis. A small proportion of patients who undergo FOA have unfavorable growth and subsequently require a second FOA later in life; however, the perioperative risks associated with this second procedure are not well studied. We report results from a retrospective review of FOAs conducted from 2007 to 2022 at a single site with the same craniofacial surgeon. A total of 33 patients were included. Perioperative outcomes were compared between primary and secondary FOA procedures. The two groups were similar in regard to suture involvement and diagnosis, although the secondary FOA group was older at the time of their FOA (1.23 versus 7.07y, P <0.001). There was no significant difference between groups in operating time, volume of blood transfusion by weight, or in the incidence of postoperative wound complications ( P >0.05). Primary FOA procedures had significantly higher weight-adjusted blood loss (28 versus 18mL/kg, P =0.014), with a higher proportion of patients receiving a blood transfusion (95% versus 62%, P =0.025). There was no significant difference between groups in the incidence of intraoperative dural injury (50% versus 84%, P =0.067). Our findings suggest that secondary procedures appear to impose less of a surgical risk relative to primary FOA traditionally performed in infancy, likely because of the advanced age at the time of secondary FOA.

Craniosynostosis With Preoperative Iron Supplementation Exposure: A Retrospective Cohort Study Examining Preoperative Iron Supplementation and Transfusion Practice in a National Paediatric Craniofacial Centre.

Blood loss and subsequent transfusion are key concerns in the surgical management of craniosynostosis, and have been associated with increased morbidity, requirement for intensive care admission and increased length of hospital stay. Patient blood management guidelines advocate treatment of anemia before elective surgical procedures where significant blood loss is anticipated. At present there is little evidence in the literature investigating the clinical value of this practice in pediatric craniofacial surgery. The authors examined the effect of preoperative oral iron supplementation on blood loss and transfusion rates in a national pediatric craniofacial unit. A total of 157 patients were included in a retrospective and prospective observational cohort study conducted between July 2011 and November 2016. Eighty-five (85) patients included in the preoperative iron supplementation group were prescribed oral ferrous fumarate before total cranial vault reconstruction, frontal-orbital advancement or extended strip cranial vault remodeling procedures. This cohort was retrospectively compared to seventy-two (72) consecutive patients who did not receive iron supplementation. Calculated blood loss was 51.3 mL/kg in the intervention group, and 56.65 mL/kg in the control group. Transfusion rate and mean volumes for the intervention group were 85.9% and 25 mL/kg. The control group had transfusion rate of 86.1% with mean transfused volume of 24.7 mL/kg. These differences were not statistically significant. Intraoperative tranexamic acid was associated with significantly reduced transfusion volumes overall. This study did not show a statistically significant benefit to preoperative iron supplementation. Secondary outcomes of this study showed a statistically significant difference in estimated versus calculated intraoperative blood loss. Further research in to specific iron supplementation protocols is indicated.

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.

S6A-07 SESSION 6A: CORONAL SYNOSTOSIS SEVERITY OF ORBITAL DYSMORPHOLOGY CORRELATES WITH STRABISMUS IN UNICORONAL CRANIOSYNOSTOSIS PATIENTS UNDERGOING FRONTAL ORBITAL ADVANCEMENT

Introduction: The purpose of this study is to determine what craniometric changes occur to both orbits of unicoronal craniosynostosis (UCS) undergoing frontal orbital advancement and remodeling (FOAR) and which of these changes are associated with new onset of postoperative strabismus. Methods: A retrospective analysis of pre and postoperative 24 UCS orbits and 24 control orbits were analyzed, totaling 144 orbits. Eight parameters were evaluated utilizing multivariate logistic regression analysis: orbital volume, horizontal and vertical cone angles, orbital depth, corneal projection, orbital rim height and width, as well as modified orbital index (MOI). MOI is an indicator of severity of Harlequin deformity. Results: Significant differences in orbital dimensions and angles were present bilaterally in UCS orbits when compared to controls. FOAR increased the ipsilateral UCS orbital volume from 13,183.93 ± 2,003.45mm to 16,220.43 ± 2,322.54mm (p<0.001). Ipsilateral horizontal cone angles were increased from 48.49 ± 5.24° to 53.50 ± 6.51° (p=0.004). Ipsilateral vertical cone angles were decreased from 73.27 ± 8.00° to 66.23 ± 9.62° (p=0.003). Ipsilateral MOI improved from 0.83 ± 0.06 to 0.88 ± 0.06 (p=0.003). Contralaterally, orbital volume also improved to 15,670.33 ± 1,988.17mm (p<0.001), a 13.4% increase. Three of the nineteen UCS patients (15%) developed transient postoperative strabismus, which resolved with eye patching. The majority of patients developed postoperative strabismus with an MOI change of greater than 20%. Logistic regression analysis displayed a significant association between new-onset strabismus and a change in MOI with a coefficient of 30.84 ±14.51 (p<0.05). Conclusion: This is the first craniometric study evaluating the association between three dimensional changes incurred by UCS orbits undergoing FOAR and strabismus. The orbital dysmorphology in UCS is bilateral in nature, and it is not wholly treated with conventional FOAR. Severity of ipsilateral orbital dysmorphology is correlated with incidence of postoperative strabismus following conventional FOAR. An ipsilateral MIO change of greater than 20% would seem to suggest that the greater the correction of Harlequin deformity may be associated with FOAR-induced strabismus. We can hypothesize those who require more radical correction, i.e. had a more severe preoperative orbital dysmorphology, are at increased risk for developing strabismus. Our methodology precludes determination of causality, but the correlation is strong. Future research is needed to develop strategies to mitigate risk of development of strabismus in this group of patients.

Quantitative Analysis of Change in Intracranial Volume After Posterior Cranial Vault Distraction and Frontal Orbital Advancement/Remodeling.

Patients with craniosynostosis with shortened occipitofrontal diameter are mainly treated with posterior cranial vault distraction osteogenesis (PVDO) in our institution. If further intracranial volume (ICV) expansion is needed, additional treatment with frontal orbital advancement (FOA) is done. On the contrary, frontal orbital remodeling (FOR) is done for better aesthetic results. In this study, post-treatment ICV changes in patients with craniosynostosis treated with these methods have been investigated. Patients who underwent FOA or FOR in addition to PVDO at Juntendo University Hospital between 2011 and 2017 were reviewed for patient characteristics and pre/postoperative ICV measurements using 3-dimensional computed tomography scans. Nine patients aged from 5 months to 6 years 8 months at the time of PVDO were included. For PVDO, the ICV change was 113 to 328 mL, and the enlargement ratio of ICV was 109% to 152%. Two patients were further operated with FOA while the remaining 7 with FOR. With FOA, ICV change was 73 to 138 mL, while enlargement ratio of ICV was 107% to 114%. With FOR, ICV change was 3 to 45 mL (mean 20 mL), while enlargement ratio of ICV was 100% to 103%. The PVDO is our first line of treatment for ICV expansion and posterior cranial fossa decompression in patients with severe craniosynostosis. The FOA is performed if extra ICV increase is necessary. This approach seems to enable larger ICV expansions compared with other conventional methods. The FOR should be reserved for patients in whom adequate ICV levels are achieved with PVDO yet additional frontal reshaping is necessary.

Perioperative Blood Loss and Transfusion in Craniosynostosis Surgery.

Craniosynostosis has an incidence of 1 in 2000 to 2500 live births and may be corrected through several methods including total calvarial remodeling and frontal orbital advancement remodeling. Blood loss during craniosynostosis surgery can be substantial, ranging from 20% to 500% of total circulating volume with a high associated risk of transfusion-related adverse events. The authors performed a retrospective analysis of all patients undergoing surgery for craniosynostosis at a tertiary pediatric craniofacial center with a focus on blood loss and subsequent transfusion.The authors reviewed 40 patients with craniosynostosis >16 years at a single-center. Data on perioperative blood loss and transfusion were obtained, including pre-, intra-, and postoperative hemoglobin, hematocrit, and use of tranexamic acid. The authors calculated estimated percentage of circulating red cell volume lost and transfused.The majority of patients had sagittal synostosis and underwent total calvarial remodeling (n = 20); the rest underwent frontal orbital advancement remodeling (n = 19) or lambdoid correction (n = 1). The average estimated volume red cell loss was 77% of circulating volume and 90% of patients received blood transfusion with an average 88.3% transfusion of circulating red cell volume. Longer operative time, younger age, and lower weight predisposed to >50% blood volume transfusion (P = 0.032, <0.005, <0.005 respectively).This single-center observational study reports red cell volume loss and volume of transfusion in children undergoing surgical correction of craniosynostosis. Red cell volume loss was comparative to that in the literature and in this cohort longer operative time, younger age, and lower weight predisposed to >50% blood volume transfusion.

The Directive Growth Approach for Nonsyndromic, Unicoronal Craniosynostosis: Patient and Clinical Outcomes.

Deformities of the cranium in patients with nonsyndromic single-suture synostosis occur because of growth restriction at fused sutures and growth over compensation at normal sutures. Traditional surgery includes ostectomies of the synostotic suture to release these restricted areas and osteotomies to enable immediate cranial remodeling. In the process of reshaping the cranium, traditional approaches usually involve obliteration of both the normal functioning suture and the pathologic suture. The directive growth approach (DGA) is a new, simpler, more natural way to repair deformities caused by single-suture cranial synostosis. The DGA works by reversing the original deforming forces by temporarily restricting growth in areas of over compensation and forcing growth in areas of previous synostotic restriction. Most importantly, it preserves a normal functioning suture to allow for improved future cranial growth. Eighteen consecutive nonsyndromic patients with unilateral coronal synostosis were used to illustrate the efficacy of the DGA. Ten patients who underwent DGA treatment were compared with a control group of 8 patients treated with traditional frontal orbital advancement. Postoperative three-dimensional computed tomography (CT) comparison measurements were taken, including bilateral vertical and transverse orbital dimensions, lateral orbital rim to external auditory canal, and forehead measurements from the superior aspect of the orbital rim to the pituitary fossa. The traditional treatment group showed absence of the coronal sutures bilaterally on long-term CT scans. The DGA group showed normal coronal sutures on the unaffected sides. Postoperative CT measurements showed no statistical difference between the 2 techniques (P < 0.05).

Quantifying Craniometric Change Early After Fronto-Orbital Advancement in Metopic Synostosis.

Frontal orbital advancement (FOA) for metopic synostosis results in cranial vault expansion, supporting underlying growth of the developing brain and improving head shape. Previous studies have shown that FOA in younger infants leads to a greater incidence of long-term growth restriction of intracranial volume; however, it is still unknown as to whether this is due to undercorrection at the time of surgery versus primary suture pathology. The purpose of our study is to provide a method for objective analyses of intracranial volumes in the early post-FOA period. A retrospective chart review was conducted on patients who underwent FOA over a 10-year period by a single surgeon. Data collected included patient characteristics and clinical outcomes. Radiological analysis of intracranial volumes pre- and post-FOA was determined using Amira volume-rendering software. Average increase in intracranial volume at 6 weeks post-FOA was 139.27 mL (80.01-225.25 mL) with average relative cranial vault expansion of 18.1% (3.3-48%). Patients who underwent FOA older than 12 months of age had an average increase in intracranial volume of 8.5% (3.3-13.1%). Patients younger than 12 months had a statistically higher average increase of 25% (12.8-48%). Frontal orbital advancement effectively increases intracranial volume in patients with metopic synostosis. When compared with older patients, patients younger than 1 year of age have a greater relative increase in intracranial volume in the immediate postoperative period. Quantifying cranial vault expansion after FOA can assist surgeons in surgical planning as well as in measuring and monitoring clinical outcomes within and across craniofacial centers regardless of technique.

Classification and Management of Metopic Craniosynostosis.

In the craniofacial surgery literature, there is a wide disparity of opinions regarding the management of nonsyndromic metopic synostosis. With the lack of level I evidence to support a particular regimen, we aimed to elucidate the current state of practice among craniofacial surgeons with the hope of establishing a standard of care. A survey was sent to 102 craniofacial surgeons. The survey featured 2 parts: clinical scenarios and questions regarding the following: primary indication for surgery, preference of timing, and choice of operative intervention for patients presenting with nonsyndromic isolated metopic synostosis. Surgeons were also queried regarding preoperative, intraoperative, and postoperative protocols. The total response rate was 72% (73/102) for the clinical scenarios and 63% (64/102) for the complete survey. There was a large discrepancy when classifying and managing mild metopic synostosis, with between 16% and 35% of surgeons electing to operate on a mild case. All surgeons agreed to operate on moderate and severe cases. For 95% of respondents, skull deformity was the primary indication for treatment of craniosynostosis. Open surgical management was most commonly performed at 6 months (29%) of age. Open frontal orbital advancement was the most commonly performed procedure in mild (27%), moderate (77%), and severe (89%) cases. Endoscopic approaches were more likely to be used in milder cases by 19% of surgeons. Our survey demonstrates that there is a wide disparity of opinion among craniofacial surgeons regarding the diagnosis and management of mild nonsyndromic metopic synostosis. Diagnostic, level 5.

Analysis of the Long-term Growth of the Mandible in Apert Syndrome

Apert syndrome carries a characteristic phenotype of midface hypoplasia, syndactyly, craniosynostosis, and developmental delay. These patients frequently require a large number of surgical procedures to produce a functional and aesthetically pleasing correction of their facial deformities. Although most of the focus for surgical planning is allocated to the cranial vault and the midface, controversy exists as to whether the mandible is intrinsically abnormal in this population.A retrospective chart review was performed to identify patients with Apert syndrome cared for at The Children's Hospital of Philadelphia. Patients with available craniofacial computed tomographic scans after skeletal maturity were examined using cephalometric and three-dimensional volumetric techniques. A comparison was made to age- and demographically matched controls, and statistical significance was determined using the Student t test (P < 0.05).Thirty-eight patients, in total, were identified, 9 of which had available three-dimensional computed tomographic scans. Most patients underwent frontal-orbital advancement in their infancy and at least 1 midface procedure later in life. Three-dimensional volumetric analysis identified a decreased maxillary volume (P = 0.03) in the population with Apert syndrome but found no difference in the mandibular volume (P = 0.59). Cephalometric analysis demonstrated that the patients with Apert syndrome have normal ramal height but a statistically significant decreased mandibular length.The mandible with Apert syndrome seems to be intrinsically normal on the basis of our three-dimensional analysis, and differences in appreciated mandibular length are likely related to the interrelationship with the maxilla. Patients can therefore be instructed that improving the midface position may likely also reduce the compensatory mandibular deformity.

Analysis of Cosmetic Results of Metopic Synostosis

Trigonocephaly is caused by premature fusion of the metopic suture of the calvarium. The resultant facial and skull deformities place a newborn at a higher risk of cerebral impairment. Frontal orbital advancement and remodeling is the accepted surgical management. An analysis was undertaken to assess the cosmetic results for nonsyndromic metopic synostosis following frontal orbital advancement and remodeling and to determine whether the observer technique used had validity.The photographs of 20 consecutive patients with metopic synostosis were assessed preoperatively, postoperatively, and at 3 and 5 years of age. Each photograph was analyzed by 2 pairs of trained rotating observers. The findings were compared and reviewed by the fifth member, who acted as a "referee." Where there were disagreements between the findings, the referee came to a final decision. The presence and severity of trigonocephaly, temporal hollowing, hypotelorism, orbital asymmetry, epicanthic folds, and scarring were assessed. κ Analysis was used to determine the validity of observer concordance when using photographic material.There was a significant overall trend in craniofacial aesthetic improvement with time. However, 12% had some persistence of trigonocephaly. Temporal hollowing was usually persistent. κ Statistics varied among attributes and time period assessed. The greatest concordance was for improvement of epicanthic folds and trigonocephaly, with observers agreeing 84.1% and 82.6% of the time, respectively. There was least concordance for severity of hypotelorism and scarring.This study suggests that observer analysis of photographic records is a valid outcome measure for cosmesis, although it yields variable interobserver concordance according to the feature assessed. Surgery corrected most but not all the features of trigonocephaly. The prognostic indicators for good cosmetic outcome are presented.

Frontal–orbital advancement for the management of anterior plagiocephaly

The main purposes of this manuscript are to provide an overview of various modalities of surgical correction of anterior plagiocephaly and to emphasize their differences with the classic open frontal-orbital advancement. Advancement of technology provides development of many other ways to achieve the same results. The authors describe the classic open frontal-orbital advancement and compare with other proposed techniques for correction of frontal plagiocephaly. The main limitation of the use of new forms of treatment of the anterior plagiocephaly is the age of the patient. There is still no consensus on criteria for quantitative evaluation of surgical results, and new forms of treatment do not present results with long follow-up. Frontal-orbital advancement is the preferred procedure to correct unicoronal synostosis due to its universal indication regardless of the age and degree of deformation of the anterior plagiocephaly.

Serial Head Circumference and Neurodevelopmental Screening after Surgical Correction for Single- and Multiple-Suture Craniosynostosis

To evaluate serial head circumference (HC) measurements and neurodevelopmental (ND) screening before and after surgical revision for craniosynostosis. Retrospective assessment. Tertiary institutional. All children treated with single-stage frontal-orbital advancement or total calvarial expansion for single-suture (SS) or multiple-suture (MS) craniosynostosis over a 7-year period. Changes in ND and HC were measured over postoperative visits after the primary surgery. More importantly, ND and HC changes were measured prerevision and postrevision. Of 183 patients undergoing primary surgery, complete records and adequate follow-up were available for 112 patients. The overall revision rate was 21% (n = 23). Postrevision follow-up was adequate for 18 of the 23 revisions. After primary surgery, but prior to revision, children demonstrated a larger decline in HC (z-score, median = -1) along with higher ND findings (median = 2) from one postoperative visit to the next than those who did not go on revision (HC z-score median = 0, ND median = 0). After revision, patients demonstrated a significant improvement in ND screening findings (median ΔND findings = -2) compared with prerevision ND (p < .001). Head circumference also significantly increased by a z-score of +1 postrevision (p = .001). Patients chosen for revision surgery display not only a larger decline in HC but also more ND findings prior to revision. Furthermore, surgical revision has a significant association with both improved ND screening and HC.

Pfeiffer Syndrome Twins

Twins with Pfeiffer syndrome (or acrocephalosyndactyly) had a similar phenotypic appearance with findings of classic or type 1 Pfeiffer syndrome, including bicoronal and sagittal craniosynostoses, midface hypoplasia, and broad thumbs/toes. We document their treatment with 2 monobloc advancements and discuss growth disturbances in craniofacial dysostosis. At 6 months, both twins underwent release of multisuture (bilateral coronal and sagittal) fusions for improvement of scaphocephalic shape and multisuture release; however, one twin had a more aggressive procedure with advancement of the frontal-orbital region. Despite improved initial correction by one twin, at 5 years of age, both twins presented with midface hypoplasia and exorbitism and underwent a monobloc distraction procedure with similar 20-mm advancements. Comparative analysis by our craniofacial multidisciplinary team included perioperative reports, computed tomographic scans, cephalograms, parent questionnaires, and physician surveys. Both twins had an improved confidence interval scores from 84 to 68 and 82 to 69 postoperatively. In 6-month follow-up, the Whitaker score of the first twin was 2.8, whereas that for the second twin with the frontal-orbital advancement was 1.2. Preschool expressive and receptive tests yielded 97 and 95, and 97 and 98, and developmental testing was similar between the twins. Global evaluations were equivalent to age-matched controls, and memory and attention skills were within normal limits. Parental surveys showed a high level of satisfaction after all procedures in both twins. Our study demonstrates that the phenotypic outcome for both twins remained unchanged when comparing a more aggressive surgery to less aggressive surgery as an infant. The genetic mutation may have overridden the different surgical interventions. Both twins ultimately required 2 subsequent monobloc corrections.

Endoscopic Release of Unicoronal Craniosynostosis

We demonstrate a novel method of endoscopic frontal-orbital advancement for the treatment of unicoronal craniosynostosis. The evolution of this cranioplasty modality burrows from an established precedent of safety and technical experience in strip craniectomies and endoscopic brow surgery. The procedure facilitates osteotomies similar to open frontal-orbital advancement and uses reabsorbable materials to achieve immediate intraoperative correction of unicoronal craniosynostosis through smaller incisions. The patients in the study underwent endoscopic frontal-orbital advancement and cranial vault remodeling. This was made possible with the use of a novel ultrasonic bone saw that permits osteotomies to be made with minimal disruption to the dura matter. After full frontal-orbital advancement, immediate reabsorbable fixation was used to stabilize the advancement as in the open technique. There were no major complications. All patients demonstrated improvement in plagiocephaly due to unilateral coronal synostosis. Patients and their families reported a 100% patient satisfaction and an improvement in cranial asymmetry from 10 to 2 mm (P < 0.5). This is a new endoscopic cranial vault remolding technique that achieves state-of-the-art correction of unicoronal craniosynostosis with less morbidity and mortality.

Is There a Relationship Between the Severity of Metopic Synostosis and Speech and Language Impairments?

The occurrence of cognitive impairment and behavioral problems in patients with metopic synostosis has been described. The relationship between the severity of metopic synostosis and the incidence of speech and language delays has not been established. Twenty patients with nonsyndromic isolated metopic synostosis were evaluated. Five different preoperative measurements (metopic angle at the roof of the orbit, angle of lateral orbital wall at the sella, cranial indices, and distances between medial orbital walls and lateral orbital walls) were taken from computed tomography and compared with results from postoperative speech and language assessments. Frontal orbital advancement and remodeling were carried out by the same surgical team at a mean age of 1 year 4 months. Speech and language were assessed at 3 and 5 years. Six of the 20 patients had delayed speech and language developments. No consistent trend was observed linking the severity of frontal stenosis using the measured parameters with speech and language delays. Speech and language impairments in these patients cannot be explained by a physical concept, causing mechanical compression of the frontal lobes.

Complications in the surgical treatment of craniosynostosis and craniofacial syndromes: apropos of 306 transcranial procedures

To review the complications in the surgical treatment of craniosynostosis in 306 consecutive transcranial procedures between June 1999 and June 2007. Surgical series consist of 306 procedures done in 268 patients: 155 scaphocephalies, 50 trigonocephalies, 28 anterior plagiocephalies, one occipital plagiocephaly, 20 non-syndromic multisutural synostosis and 32 craniofacial syndromes (11 Crouzon, 12 Apert, seven Pfeiffer and two Saethre-Chotzen) Complications and time of hospitalisation were reckoned. Surgical procedures were classified in 12 different types according to the technique: Type I: frontal-orbital distraction (26 cases); Type II: endoscopic assisted osteotomies in sagittal synostosis (39 cases); Type III: sagittal suturectomy and expansive osteotomies (44 cases); Type IV: same as type III, but including frontal dismantling or frontal osteotomies in scaphocephalies (59 cases); Type V: complete cranial vault remodelling (holocranial dismantling) in scaphocephalies (13 cases); Type VI: frontal-orbital remodelling without frontal-orbital bandeau in trigonocephaly (50 cases); Type VII: frontal-orbital remodelling without frontal-orbital bandeau in plagiocephaly (14 cases); Type VIII: frontal-orbital remodelling with frontal-orbital bandeau in plagiocephaly (14 cases); Type IX: Occipital advancement in posterior plagiocephaly (one case); Type X: Standard bilateral front-orbital advancement with expansive osteotomies (28 cases); Type XI: holocranial dismantling (complete cranial vault remodelling) in multisutural craniosynostosis (12 cases); Type XII: occipital and suboccipital craniectomies in multiple suture craniosynostosis (six cases). There was no mortality and all complications resolved without permanent deficit. Mean age at surgery was 6.75 months. Most frequent complication was non-filiated postoperative hyperthermia (13.17% of the cases) followed by infection (8.10%), subcutaneous haematoma (6.08%), dural tears (5.06%) and cerebrospinal fluid (CSF) leakage (2.7%). Number and type of complications was higher among the group of reoperated patients (12.8% of all): 62.5% of all the series infections, 93% of all dural tears and 75% of all CSF leaks. In relation to surgical procedures, endoscopic assisted osteotomies reported the lowest rate of complications, followed by standard frontal-orbital advancement in multiple synostosis, trigonocephalies and plagiocephalies. Highest number of complications was related to complete cranial vault remodelling (holocranial dismantling) in scaphocephalies and multiple synostoses and after the use of internal osteogenic distractors. Special consideration deserves two cases of iatrogenic basal encephaloceles after combined frontal-facial distraction. Finally, we establish considerations based on the complications related to every specific technique. Percentage and severity of complications relates to the surgical procedure and is higher among patients going for re-operation. Mean time of hospitalization is also modified by these issues.

Age-Dependent Closure of Bony Defects after Frontal Orbital Advancement

Age-Dependent Closure of Bony Defects after Frontal Orbital Advancement

Age-Dependent Closure of Bony Defects after Frontal Orbital Advancement

The ability of the immature skull to spontaneously heal large bony defects created after craniofacial procedures was examined over a 25-year period of craniofacial surgery at the Children's Hospital of Philadelphia. Only patients who underwent frontal orbital advancement and reconstruction, had at least 1 year of documented follow-up, and had the presence or absence of a bony defect documented on clinical examination were included. The sex, age at operation, diagnosis, history of a prior craniectomy, and presence or absence of a postoperative infection were determined for each patient. A variety of statistics were applied to the data. Eighty-one patients met the inclusion criteria. A statistically significant association between age at operation and closure of bony defect was demonstrated. Children who closed a bony defect after frontal orbital advancement and reconstruction were significantly younger than those children who had a persistent bony defect. Iterative regression analyses demonstrated that a transition point between closure and the inability to close bony defects occurred between 9 and 11 months of age. Closure of bony defects was not statistically associated with sex, prior craniectomy, an FGFR mutation, or a postoperative infection in the regression analysis. Healing of bony defects after frontal orbital advancement and reconstruction is significantly related to age at initial operation, with a mean age for closure of less than 12 months. Between 9 and 11 months of age, a change occurs that results in an increasingly lower probability of bony defect closure; thus, all other considerations being equal, initial frontal orbital advancement and reconstruction would ideally take place before this occurs.