Posterior Cranial Vault Distraction Research Articles

Posterior cranial vault distraction in children with syndromic craniosynostosis: the era of biodegradable materials-a comprehensive review of the literature and proposed novel global application.

Distraction osteogenesis is utilized to increase intracranial volume in the treatment of restrictive pathologies, most commonly syndromic synostosis. Children too young for open calvarial vault expansion or other systemic or local contraindications to a direct reconstructive approach benefit greatly from distraction osteogenesis, typically addressing posterior vault expansion. Wound infection, cerebrospinal fluid (CSF) leak, device failure, need for a second surgery for removal, and cost, are issues that can limit the use of this approach. These challenges are more pronounced in low- and middle-income countries (LMICs) due to lack of access to the device, the financial burden of the need for a second surgery, and the severity of the implications of infection and CSF leak. Over the last five decades, there has been an increased acceptance of bioresorbable instrumentation in craniofacial surgery. Poly L-lactic acid, polyglycolic acid, and polydioxanone are the most commonly used polymers. New resorbable fixation tools such as ultrasound-activated pins and heat-activated pins are superior to conventional bioresorbable screws in allowing attachment to thinner bone plates. In this paper, we present a review of the literature on cranial vault distraction and the use of bioresorbable materials and propose a novel design of a fully absorbable cranial distractor system using external magnetic distraction control, eliminating the need for external activation ports and a second surgery to remove the hardware. The application of this technology in LMIC settings could advance access to care and treatment options for patients with syndromic synostosis.

Morphometric analysis and outcomes following posterior cranial vault distraction in syndromic and multisuture craniosynostosis

Turribrachycephaly is a common feature in many syndromic and multisuture craniosynostoses and is traditionally treated with total cranial vault reshaping and fronto-orbital advancement. A staged approach with posterior cranial vault distraction as a primary procedure followed by anterior cranial vault reshaping has the advantage of reducing the vertical dimension of the skull in a controlled and gradual manner while expanding the cranial volume. The purpose of this study was to evaluate outcomes following posterior cranial vault expansion using distraction osteogenesis at a single tertiary pediatric center. This retrospective review included all cases of posterior cranial vault distraction at a single institution from 2008 to 2022 performed by one surgeon. Morphometric outcomes such as Turricephaly Index (TI) and posterior cranial volume (PCV) were assessed from pre- and postoperative computerized tomography scans for patients who underwent posterior cranial vault distraction as a primary first-stage operation. Clinical outcomes and complications were collated. A total of 41 patients (25 females, 16 males; mean age 11 months) with syndromic craniosynostosis (n=32) and nonsyndromic craniosynostosis (n=9) were included. The main indication for posterior cranial vault distraction in this cohort was turricephaly (63%). The mean distraction distance was 25.9mm and the mean decrease in TI was 18%. The estimated increase in PCV from distraction in this cohort was 19.7%. In this cohort of patients, 13 patients (32%) experienced complications but there were no mortalities. Posterior cranial vault distraction osteogenesis is an effective surgical procedure to increase intracranial volume and correct turricephaly in children with syndromic and nonsyndromic craniosynostosis. This procedure is considered a safe and effective first-stage cranial operation in children with syndromic craniosynostosis with increased intracranial pressure and or turricephaly.

A Rare Case of Sagittal Sinus Obstruction Following Posterior Cranial Vault Distraction Osteogenesis.

Posterior cranial vault distraction osteogenesis (PCVDO) is a relatively new paradigm in the treatment of syndromic craniosynostosis, having first been introduced in 2009. PCVDO directly addresses the underdeveloped cranial vault and appears to allow for a larger increase in intracranial volume when compared to traditional techniques. Although reported as safe in the literature, critical appraisal is still required as PCVDO is a relatively uncommon procedure that may require greater numbers to detect true complication rates. The overall reported incidence of serious complications in PCVDO to date is low. This presentation highlights a rare case of sagittal sinus obstruction following posterior cranial vault distraction and raises questions as to the safest technical considerations when planning the operation.

Surgical Management of Craniosynostosis—Between the Past and the Future: A Comprehensive Review of the Literature

AbstractCranial sutures are fibrous joints between the bones of the cranial vault, acting as centers of osteogenesis of the embryonic mesenchyme. Skull growth is a strictly regulated process, controlled by several genetic pathways. A minor perturbation of these pathways may lead to premature fusion of the cranial sutures. Craniosynostosis occurs as a result of the premature fusion of the cranial sutures. The incidence of craniosynostosis is approximately 1 in 2,500 live births. Syndromic craniosynostoses such as Apert, Crouzon, and Pfeiffer comprise 15% of patients, while nonsyndromic craniosynostosis represents 85% of all patients. By the late 1800s, Lannelongue (Paris, 1890) and Lane (San Francisco, 1892) attempted the first surgical intervention (strip craniectomy) for the management of craniosynostosis. The inadequacy of simple suturectomies and strip craniectomies in the management of craniosynostosis led to the innovation of more complex procedures such as fronto-orbital advancement and posterior cranial vault distraction. However, these extensive surgical interventions are lengthy procedures and associated with more blood volume loss which requires blood transfusion. These limitations led to the modern era of minimally invasive endoscopic techniques. In this paper, we reviewed the body of the literature on the evolution of surgical management of craniosynostosis over the last century and the possible future directions.

Posterior Cranial Retraction Combined With Bilateral Parietal Distraction for Children With Nonsyndromic Craniosynostosis.

The nonsyndromic craniosynostosis is the most common of craniosynostoses in childhood. There are many treatments. We aim to treat 12 cases of nonsyndromic craniosynostosis via posterior cranial vault distraction osteogenesis combined with bilateral parietal distraction. Data of a total of 12 patients (7 boys and 5 girls) with nonsyndromic sagittal synostosis who underwent distraction osteogenesis between January 2015 and August 2020 were retrospectively analyzed. Bilateral parietal bone flaps and posterior occipital flaps were designed and cut. Then, distraction device was placed, which was distracted at 5 days after surgery (twice per day, 0.4-0.6 mm/d, and lasting for 10-15 days). After 6 months of fixation, the secondary surgery was performed to remove the device. The scaphocephaly was corrected, and the appearance was satisfactory. Postoperative follow-up time was 6 to 14 months, with an average of 10 months, and the mean CI was 63.2 and 78.25 before and after surgery, respectively; the mean anterior-posterior skull diameter was shortened (12.63 ± 3.47) mm, the transverse diameter of both temporal regions was lengthened (15.4 ± 4.18) mm, and the scaphocephalic deformity was significantly improved. There was no detachment or rupture of the extender postoperatively. No severe complications, such as radiation necrosis or intracranial infection, were observed. Posterior cranial retraction combined with bilateral parietal distraction in children with nonsyndromic craniosynostosis, in which the proposed technique did not exhibit severe complications, and it is worthy of further promotion and application in clinical practice.

Posterior Cranial Vault Distraction for Treating Syndromic Brachyturricephaly: A 2-Dimensional Operative Video.

De Schlichting, Emmanuel MD*; Pech-Gourg, Grégoire MD‡; Jecko, Vincent MD§,‖; Lechanoine, François MD¶; Gimbert, Edouard MD§; Zaldivar-Jolissaint, Julien Francisco MD*; Coll, Guillaume MD, PhD# Author Information

Posterior cranial vault distraction osteogenesis: A systematic review.

Posterior cranial vault distraction osteogenesis (PCVDO) has become the treatment of choice in specific indications within 12 years since its introduction in 2009. It is used to treat or prevent Intracranial hypertension secondary to craniosynostosis. However, there is still a lack of evidence describing this procedure's safety concerning the osteotomy line being close to the torcula. This systematic review aims to generate evidence regarding the safety of this new technique. A systematic search of Pubmed and Embase database were done without any time limit until the last search date of July 31, 2021. Articles focused on posterior cranial vault distraction osteogenesis were shortlisted using defined inclusion criteria. In addition, complications, volume gain, and distraction protocols in patients with craniosynostosis were assessed. The review included 11 articles from 11 different centres. Of the Total 241 patients, 51 were non-syndromic patients, and 190 were syndromic patients. There were 242 procedures done on 241 patients. The proportion of patients with complications was 30%. Wound infection was the most commonly reported complication. PCVDO resulted in 20-25% volume gain and successfully prevented increased intracranial pressure (ICP). The systematic review has significantly identified a 30.606% incidence of complications in PCVDO. No mortality was linked directly to the Posterior cranial vault distraction osteogenesis procedure (PCVDO). The authors identified the evolution of many unique vectors and osteotomy designs customized for patients and practices for safe surgery. The effects of PCVDO on the anterior cranial fossa remain a topic of interest and require observational studies for better understanding.

Comparing the Increased Intracranial Volume From Different Surgical Methods for Syndromic Craniosynostosis.

Fronto-orbital advancement (FOA) is the traditional surgical method used to increase intracranial volume, but posterior cranial vault distraction osteogenesis (PVDO) has been gaining popularity as an initial treatment option. This study aimed to compare the effects of FOA and PVDO on intracranial volume. Sixteen patients with multiple-suture synostosis and severe intracranial volume restriction were treated with FOA or PVDO at Children's Hospital of Fudan University between January 2016 and December 2019. Data on age at surgery, sex, preoperative intracranial volume, and postoperative intracranial volume were collected. Seven patients underwent FOA and 9 underwent PVDO. All patients underwent surgery for the first time, and the surgeries were performed by the same physician. There was no statistically significant difference in age at surgery or in the intracranial volumes before and after surgery between the 2 groups ( P >0.05). There was a statistically significant difference in the intracranial volume changes between the 2 groups before and after surgery ( P =0.028). Posterior cranial vault distraction osteogenesis provided statistically greater intracranial volume expansion than FOA.

Changes in venous drainage after posterior cranial vault distraction and foramen magnum decompression in syndromic craniosynostosis.

The authors' objective was to measure the effect of posterior cranial vault distraction (PCVD) plus foramen magnum decompression (FMD) on dural sinus volume and venous flow in patients with syndromic craniosynostosis. The volumes of the sagittal, straight, transverse, and sigmoid sinuses of 5 consecutive patients with syndromic craniosynostosis who underwent PCVD+FMD were calculated in cubic centimeters with T2-weighted volumetric MRI sequences before surgery, immediately after surgery, and after the end of the distraction process. Tridimensional reconstructions of phase-contrast magnetic resonance angiography (PC-MRA) images were obtained with multiplanar reconstruction (MPR). The average total volume of all dural sinuses increased immediately after surgery (from 10.06 cm3 to 12.64 cm3) and continued to increase throughout the 30-day distraction period (from 12.64 cm3 to 14.71 cm3) (p = 0.04), except that the right sigmoid sinus remained stable after the initial increase. The most important increases were observed for the left transverse sinus (+113.2%), right transverse sinus (+104.3%), left sigmoid sinus (+91.3%), and sagittal sinus (+41.8%). Less important modifications were evident for the right sigmoid sinus (+33.7%) and straight sinus (+23.4%). Significant improvements in venous flow were noted on the tridimensional reconstructions of the PC-MRA images. Venous obstruction grading score improved in 4 patients (average [range] 2.4 [ 2-5]) (p = 0.023) and remained stable in 1 patient. All patients had chronic tonsillar herniation (CTH) (mean [range] 16.6 [8-26] mm), and 3 had syringomyelia. CTH showed improvement on the last follow-up MRI evaluation in 4 patients (mean [range] 10.5 [0-25] mm) and worsened from 15 mm to 19 mm in 1 patient. Syringomyelia improved in 2 patients and remained unchanged in 1. This study has provided the first radiological evidence of the impact of craniofacial surgery on dural sinus anatomy and venous drainage. The venous anomalies described in patients with syndromic craniosynostosis are not static, and PCVD+FMD triggers a dynamic process that can lead to significant modifications of intracranial venous drainage. The traction exerted by the distracted bone flap onto the occipitoparietal dura mater adherent to the inner calvaria may account for the enlargement of the dural sinus throughout the distraction period. The impact of these modifications on venous pressure, intracranial pressure, CTH, and hydrocephalus remains to be determined.

Behavioral, Learning Skills, and Visual Improvement in Crouzon Syndrome Patient Following Late Posterior Vault Distraction Osteogenesis.

It is well accepted among craniofacial surgeons that surgery does not improve mental status but does prevent worsening or deterioration of cognitive and mental function. In this report, we describe significant improvement in behavioral, learning skills and visual acuity for a Crouzon patient who underwent late posteriorvault distraction osteogenesis. A 9-year-old Crouzon patient was referred to our hospital, presenting severe intracranial hypertension. The patient had previously undergone a strip craniectomy in early infancy at another medical institution, but there was no subsequent follow-up. Magnetic resonance imaging showed Chiari type I malformation and fundoscopy revealed papilledema. At the time of referral, the patient was not attending a regular school, had not acquired reading skills, was unable to concentrate, and could not accomplish school-related tasks that were standard for children in his age group. The patient underwent posterior vault distraction osteogenesis and showed concentration improvement and acquisition of fluent reading skills. Chiari type I malformation resolved as well as papilledema. visual acuity improved at Snellen test preoperatively from 20/200 to 20/60 at postoperative test. Ventricle size remained unchanged subsequent to performance of the posterior cranial vault distraction. The occipital veins were less visible upon clinical examination and less pronounced when palpated, and the bruit had completely disappeared. Late posterior vault distraction osteogenesis can improve behavioral, learning skills and visual acuity as shown in this 9-year-old Crouzon patient.

Inferiorly Directed Posterior Cranial Vault Distraction for Treatment of Chiari Malformations.

The authors present a case series of patients with Chiari I malformations treated with distraction osteogenesis of the posterior cranial vault, utilizing a vertical distraction vector for appropriate cranial vault expansion while mitigating the risks of scaphocephaly and cerebellar ptosis. Patients with syndromic and nonsyndromic Chiari I malformations treated with vertical-vector distraction osteogenesis of the posterior cranial vault were identified from 2008 to 2014. Demographics, preoperative and postoperative clinical symptoms, and perioperative details were assessed. Long-term esthetic outcomes, complications, and symptomatic improvement were evaluated in conjunction with neurosurgery. Nine patients were identified. Five had known syndromes, 2 likely had unidentified syndromes, and 2 were nonsyndromic. Seven had prior Chiari-related surgeries. Most presented with hydrocephalus, motor symptoms, and developmental delay. Operatively, 2 to 3 internal distraction fixators were applied such that the vector of distraction was along a cephalad-caudad axis. Devices were activated on postoperative day 5 and distracted 1mm per day. Three postoperative complications were found within the first 3 months which included a dislodged distraction arm, a device extrusion, and a local cellulitis. No complications affected the clinical outcome. Radiographic follow-up showed good bone formation, decompression of the posterior fossa, improved cerebrospinal fluid flow, and no cerebellar ptosis. Neurological surveillance showed improvement in intracranial pressure, hydrocephalus, motor symptoms, and behavioral problems. The authors have presented 9 patients with Chiari I malformations treated with distraction osteogenesis, along with a novel technique to safely and effectively expand the posterior fossa while minimizing the risk of cerebellar ptosis. Level II (prognostic/risk studies).

Posterior Vault Distraction for Multi-Suture Craniosynostosis in a Patient with Craniometaphyseal Dysplasia: A Case Report

Study Design Case report Objective Syndromic multi-suture craniosynostosis can result in complex dysmorphology and increased intracranial pressure. We present a case report of a child with craniometaphyseal dysplasia and syndromic multi-suture craniosynostosis who presented with increased intracranial pressure, ventriculomegaly and Chiari deformity Type 1. Methods The child underwent a posterior vault distraction to increase the intracranial volume. Results The posterior cranial expansion was successful in correcting the craniocerebral disproportion caused by multi-suture synostosis, and resolved the high intracranial pressure and papilloedema. There were no post-operative complications. Conclusions Posterior cranial vault distraction was an effective method of addressing increased intracranial pressure by correcting craniocerebral disproportion by increasing intracranial volume and also addressing the Chiari Type I deformity that resulted from syndromic multi-suture craniosynostosis in a child with craniometaphyseal dysplasia.

Posterior vault distraction technique: how I do it

Posterior cranial vault distraction is an effective technique when a significant increase in the intracranial volume is required in patients with craniosynostoses. This technique has been proven to be safe and time saving and usually is associated with low perioperative morbidity as well as low intraoperative bleeding. Herein a technique is presented starting from the preoperative planning, describing the surgical steps of the operation and the postoperative distraction protocol used by the authors. The authors present important tips and tricks aiming to minimise complications and undesired events.

Posterior Cranial Vault Distraction Osteogenesis Utilizing a Posterior-Superior Distraction Vector in the Treatment of Mercedes Benz Pattern Craniosynostosis.

Bilateral lambdoid and sagittal synostosis, or Mercedes Benz Syndrome, is a rare complex craniosynostosis resulting in frontal bossing, a tapered posterior fossa, and an anteriorly displaced cranial vertex. Its ideal surgical correction must result in posterior expansion, skull elongation, and caudal repositioning of the vertex. We present a craniometric analysis of skull changes with posterior-superior distraction and introduce a novel craniometric measure: vertex position. In this study, a retrospective review was performed to analyze outcomes of posterior cranial vault distraction osteogenesis (PVDO) using a posterior-superior distraction vector from 2016 to 2019. Cranial vertex position was measured as a fraction of the occipitofrontal diameter from rostral to caudal (0-1.0). Four patients underwent PVDO at mean age 10.61 ± 3.16 months utilizing a posterior-superior distraction vector. Linear distraction distance averaged 30.30 ± 0.90 mm with a mean consolidation period of 3.98 ± 0.72 months. Mean corrected change in intra-cranial volume was 236.30 ± 3.71 mL, at an average rate of 7.81 ± 2.00 mL/mm of distraction. Increases in anterior cranial height (7.83 ± 2.51 mm), middle cranial height (8.43 ± 4.21 mm), posterior cranial height (13.15 ± 7.45 mm), and posterior cranial fossa height (21.99 ± 8.55 mm) were observed. Cranial vertex demonstrated a mean posterior movement of 0.18 ± 0.13. PVDO utilizing a posterior-superior distraction vector for management of nonsyndromic bilateral lambdoid and sagittal synostosis effectively increases intracranial volume and height and provides an esthetic outcome with posterior movement of the cranial vertex.

Posterior vault distraction osteogenesis: indications and expectations.

Cranial vault remodeling (CVR) in patients with craniosynostosis serves to correct abnormal skull morphology and increase intracranial volume to prevent or treat pathologic increases in intracranial pressure (Taylor and Bartlett, Plast Reconstr Surg 140: 82e-93e, 2017). Distraction osteogenesis is a well-established technique for bony repositioning and growth stimulation in the facial and long bones, in which the gradual separation of bony segments at an osteotomy site results in generation of new bone and subsequent bone lengthening (Greene, 2018). While initially described in the orthopedic literature, the relevance and applicability of distraction osteogenesis to craniofacial surgery has been well-studied and is now well-established (Steinbacher et al., Plast Reconstr Surg 127: 792-801, 2011). Posterior cranial vault distraction osteogenesis (PVDO) was introduced as a treatment option for cranial vault expansion in patients with craniosynostosis in 2009 by White et al., based upon the premise that posterior vault distraction could provide greater intracranial volume expansion than fronto-orbital advancement and remodeling (FOAR), but that acute posterior cranial vault expansions were limited by the soft tissue envelope of the infant scalp and prone to relapse related to the supine positioning typical of infants (White et al., Childs Nerv Syst 25: 231-236, 2009). Since this introduction, significant evidence has accrued regarding the safety of, and outcomes after, PVDO. PVDO is now known to provide larger increases in intracranial volume in comparison to anterior cranial vault remodeling procedures (Derderian et al., Plast Reconstr Surg 135:1665-1672, 2015) and to provide morphologic improvements in both the posterior and anterior cranial vaults (Goldstein et al., Plast Reconstr Surg 131:1367-1375, 2013). Perioperative major morbidity is comparable to conventional vault remodeling (Taylor et al., Plast Reconstr Surg 129:674e-680e, 2012) and the procedure has been safely applied to patients of various ages with syndromic and non-syndromic craniosynostosis (Zhang et al., J Craniofac Surg 29:566-571, 2018; Li et al., J Craniofac Surg 27:1165-1169, 2016). Many high-volume craniofacial centers now consider PVDO the preferred first operation in infants with syndromic craniosynostosis, and indications for this procedure continue to expand as evidence accrues regarding its utility and safety (Steinbacher et al., Plast Reconstr Surg 127: 792-801, 2011; Swanson et al., Plast Reconstr Surg 137:829e-841e, 2016).

A Review on Variability in Treatment Protocols With Posterior Cranial Vault Distraction.

Prior studies have confirmed the ability of posterior cranial vault distraction osteogenesis (PVDO) to expand the intracranial volume in patients with craniosynostosis. To date, there is scant literature on the optimal distraction protocol for PVDO. The authors sought to review the literature and define a common protocol for posterior cranial vault distraction. The authors performed a systematic review for published PVDO protocols. The data collected from these studies included age at the time of PVDO, number of distraction devices placed, time for latency, rate and rhythm of distraction, distraction length, time for consolidation, and surgical outcomes. A total of 286 patients were identified within 24 studies from 2011 to 2019. The mean age of patients identified was 25.34 months. After application of distractors, latency period ranged between 1 and 7 days, with most patients undergoing 5 to 7 days of latency. Once distraction was begun, the majority of patients (77.4%) underwent 1 mm of distraction daily. Total lengths of distraction ranged between 13 and 35 mm, with the largest cohort of patients undergoing 26 to 30 mm of total distraction. A total of 60 complications were reported for a total of 212 patients, yielding an overall complication rate of 28.3%. Although there is variability in reported PVDO protocols, the majority are similar to distraction osteogenesis protocols described for long bone sites. Increased patient age correlates with selection of a greater latency period and total distraction length, while frequency of complications is also increased.

Usefulness of 3D Fluoroscopic Composite Images of Cranial Bone and Cavernous Sinus in Posterior Cranial Vault Distraction Osteogenesis

Usefulness of 3D Fluoroscopic Composite Images of Cranial Bone and Cavernous Sinus in Posterior Cranial Vault Distraction Osteogenesis

Posterior Cranial Vault Distraction (PCVD): Common Complication Rates and Strategies of Prevention and Management.

Posterior cranial vault distraction (PCVD) is a well-established procedure to treat infants with craniosynostosis. Craniofacial surgeons have seen an evolution in the complications following PCVD. This report aims to demonstrate the rates of common complications from PCVD, and to identify strategies for prevention and management of these complications. A formal literature review of studies on postoperative complications from PCVD was conducted to identify the breadth of reported complications from PCVD and rates of occurrence. A total of 776 articles were captured by our search strategy. Nineteen original articles met inclusion criteria, with a total of 342 patients. The average rate of reported complications was 25%, range (0%-100%). The most commonly reported complication was postoperative infection (23.7%), followed by cerebrospinal fluid leak (20.3%) and device failure (15.3%). Postoperative infection, device exposure, iatrogenic vascular injury, cerebrospinal fluid leak, and other complications have the potential to disrupt distraction and increase morbidity and mortality. By continuing to identify and evaluate complications, prevention strategies can be determined and standardized to decrease complications from PCVD. These efforts uphold the ultimate goal for surgeons involved in the treatment of craniosynostosis: to provide safe, effective surgical care.

Serial Posterior Cranial Vault Distraction for the Treatment of Complex Craniosynostosis.

Posterior cranial vault distraction is an important modality in the management of craniosynostosis. This surgical technique increases intracranial volume and improves cranial aesthetics. A single procedure is often inadequate in patients with complex multisuture craniosynostosis, as some will go on to develop intracranial hypertension despite the operation. Considering the negative effects of intracranial hypertension, some patients may warrant 2 planned distractions to prevent this scenario from ever occurring. Three patients with complex multiple-suture synostosis and severe intracranial volume restriction (occipital frontal head circumferences [OFCs] <1st percentile) were treated with 2 planned serial posterior cranial vault distractions at the institution between 2013 and 2018. Demographics, intraoperative data, and postoperative distraction data were collected. The OFC was recorded pre- and postdistraction, at 3- and 6-month follow-up appointments. Patients had a corrected average age of 18 weeks at the time of their initial procedure. There was an average of 38 weeks between the end of consolidation and the time for their 2nd distraction procedure. There was an average age of 79 weeks at the time of the 2nd procedure. All patients had a substantial increase in OFC and improvement of the posterior calvarium shape. The average increase in OFC was 5.2 cm after first distraction and 4.3 cm after 2nd distraction. No postoperative complications were encountered. Planned serial posterior cranial vault distraction is a safe and effective strategy for increasing intracranial volume, improving aesthetic appearance, and preventing the consequences of intracranial hypertension in patients with multisuture craniosynostosis and severe intracranial volume restriction.

Management of Paronychia in Patients With Apert Syndrome.

Apert syndrome is a complex congenital syndrome that includes bicoronal craniosynostosis, craniofacial dysmorphologies, cleft palate, hearing loss, spina bifida occulta, cardiac anomalies, and affects the upper and lower extremities-producing complex syndactyly in these patients. Management of the hands yields several challenges and mandates close follow-up to balance repair of complex polysyndactyly with other pressing interventions, such as posterior cranial vault distraction and surgical management of the airway. Our goals of therapy for the hands are to preserve 10 digits, provide sufficient soft tissue coverage, optimize hand function, and minimize the number of surgical interventions. Ideally, surgical management of the hand differences occurs between the ages of 9 months and 2 years, to optimize neurocognitive development. In complex syndactyly observed in patients with Apert syndrome, there are broad, conjoined nail plates that overlie the fused digits, and paronychia occurs frequently. Suppurative infections can delay definitive surgical intervention for the patient's complex syndactyly, and resolution of paronychia is critical. This study aims to propose an effective and safe technique to manage paronychia when it occurs in patients with Apert complex syndactyly and to mitigate the length of delay to definitive polysyndactyly reconstruction. In the context of these patients' need for multiple surgical interventions within the first few years of life, this strategy for preventing or mitigating paronychia can play an important role in streamlining their complex surgical management while avoiding multiple cancellations.