Supraorbital Bar Research Articles

Facial Fat Graft Injection Reduces Asymmetry and Improves Forehead Contour in Early Infancy Apert Syndrome Patients.

The objective of this study is to report the outcomes of a modified comprehensive Apert syndrome surgical protocol in which fat injection was performed during early infancy concurrent with postposterior vault distraction osteogenesis (PVDO) distractor removal. A retrospective study was performed on 40 consecutive young patients with Apert syndrome who underwent PVDO and subsequent distractor removal between 2012 and 2022. Of these 40 patients, 12 patients underwent facial fat injection concurrent with distractor removal to treat residual supraorbital bar recession as part of a modified comprehensive Apert syndrome surgical protocol. Preoperative and postoperative severity of recession and irregularity was graded from 1 to 3, with 1 being less severe and 3 being the most severe. Recession severity was correlated with the number and type of suture fusion. The complication rate was stratified via a Clavien-Dindo scale. The average patient age was 14.3±5 months, with 5 males (41.6%) and 7 females (48.3%). The average hospital stay was 1.08 days. The average volume of free fat graft injection was 8.29±5mL. According to the Likert scale, forehead morphology improved in 91.67% of the patients. Complete resolution of supraorbital bar recession was achieved in seven patients (58.33%), all of whom presenting a single suture synostosis. One patient with a cloverleaf skull presented a type IIIB complication. Facial fat grafting markedly reduces forehead asymmetry and improves forehead contour in Apert syndrome patients following PVDO. Total resolution of forehead recession directly correlated with a single suture fusion.

Improving Cranial Vault Remodeling for Unilateral Coronal Craniosynostosis-Introducing Automated Surgical Planning.

Cranial vault remodeling (CVR) for unicoronal synostosis is challenging due to the asymmetric nature of the deformity. Computer-automated surgical planning has demonstrated success in reducing the subjectivity of decision making in CVR in symmetric subtypes. This proof of concept study presents a novel method using Boolean functions and image registration to automatically suggest surgical steps in asymmetric craniosynostosis. The objective of this study is to introduce automated surgical planning into a CVR virtual workflow for an asymmetric craniosynostosis subtype. Virtual workflows were developed using Geomagic Freeform Plus software. Hausdorff distances and color maps were used to compare reconstruction models to the preoperative model and a control skull. Reconstruction models were rated as high or low performing based on similarity to the normal skull and the amount of advancement of the frontal bone (FB) and supra-orbital bar (SOB). Fifteen partially and fully automated workflow iterations were carried out. FB and SOB advancement ranged from 3.08 to 10.48mm, and -1.75 to 7.78mm, respectively. Regarding distance from a normal skull, models ranged from .85 to 5.49mm at the FB and 5.40 to 10.84mm at the SOB. An advancement of 8.43mm at the FB and 7.73mm at the SOB was achieved in the highest performing model, and it differed to a comparative normal skull by .02mm at the FB and .48mm at the SOB. This is the first known attempt at developing an automated virtual surgical workflow for CVR in asymmetric craniosynostosis. Key regions of interest were outlined using Boolean operations, and surgical steps were suggested using image registration. These techniques improved post-operative skull morphology.

Craniofacial Encephalocele: Updates on Management.

Craniofacial encephaloceles are rare, yet highly debilitating neuroanatomical abnormalities that result from herniation of neural tissue through a bony defect and can lead to death, cognitive delay, seizures, and issues integrating socially. The etiology of encephaloceles is still being investigated, with evidence pointing towards the Sonic Hedgehog pathway, Wnt signaling, glioma-associated oncogene (GLI) transcription factors, and G protein-coupled receptors within primary cilia as some of the major genetic regulators that can contribute to improper mesenchymal migration and neural tube closure. Consensus on the proper approach to treating craniofacial encephaloceles is confounded by the abundance of surgical techniques and parameters to consider when determining the optimal timing and course of intervention. Minimally invasive approaches to encephalocele and temporal seizure treatment have increasingly shown evidence of successful intervention. Recent evidence suggests that a single, two-stage operation utilizing neurosurgeons to remove the encephalocele and plastic surgeons to reconstruct the surrounding tissue can be successful in many patients. The HULA procedure (H = hard-tissue sealant, U = undermine and excise encephalocele, L = lower supraorbital bar, A = augment nasal dorsum) and endoscopic endonasal surgery using vascularized nasoseptal flaps have surfaced as less invasive and equally successful approaches to surgical correction, compared to traditional craniotomies. Temporal encephaloceles can be a causative factor in drug-resistant temporal seizures and there has been success in curing patients of these seizures by temporal lobectomy and amygdalohippocampectomy, but magnetic resonance-guided laser interstitial thermal therapy has been introduced as a minimally invasive method that has shown success as well. Some of the major concerns postoperatively include infection, cerebrospinal fluid (CSF) leakage, infringement of craniofacial development, elevated intracranial pressure, wound dehiscence, and developmental delay. Depending on the severity of encephalocele prior to surgery, the surgical approach taken, any postoperative complications, and the age of the patient, rehabilitation approaches may vary.

Usefulness of fronto-orbital advancement using integrated osteotomy of the frontal bone and supraorbital bar for craniosynostosis

Usefulness of fronto-orbital advancement using integrated osteotomy of the frontal bone and supraorbital bar for craniosynostosis

Point of Care Virtual Surgical Planning and Three-Dimensional Printing for Feminizing Foreheadplasty.

Point of Care Virtual Surgical Planning and Three-Dimensional Printing for Feminizing Foreheadplasty.

Anatomical Variations in the Location of Veins Draining Into the Anterior Superior Sagittal Sinus: Implications for the Transbasal Approach.

Many approaches are used for midline anterior cranial fossa meningioma resection. In the subfrontal approach, the anterior superior sagittal sinus (SSS) is commonly ligated to release the anterior falx. The transbasal approach allows access to the origin of the anterior SSS, allowing for maximum venous preservation. To investigate variations in the first and second veins draining into the SSS. We performed stepwise dissections for a transbasal level 1 approach on 8 anatomic specimens. We visualized the first and second veins draining into the sinus and measured the distance from the foramen cecum to these veins. We also measured the orbital bar height to determine the length of sagittal sinus that could be preserved with orbital bar removal. The distance between the foramen cecum and the first vein ranged from 4 to 36 mm while the distance to the second vein ranged from 6 to 48 mm. The mean orbital bar height was 26.4 mm. Based on these measurements, with a traditional bicoronal craniotomy without orbital bar removal, 81% of first veins and 58% of second veins would be sacrificed. A supraorbital bar or nasofrontal osteotomy, part of the transbasal skull base approach, is helpful to preserve the first and second veins when ligating the anterior SSS. Based on this study, it may be difficult to preserve these veins without orbital bar removal. Preservation of these veins may be of clinical importance when approaching midline anterior fossa pathologies.

Excessive ossification of the bandeau in Crouzon and Apert syndromes

BackgroundThe study aimed at assessing the variations in thickness of the supra-orbital bar in Crouzon (CS) and Apert syndromes (AS) before and after fronto-facial monobloc advancement (FFMBA) using CT-scan data. MethodsAll CS or AS patients who underwent FFMBA between 2008 and 2018 with available clinical and CT-scan data were included. Frontal bone thickness was assessed at five locations of the supra-orbital bar using the Half-Maximum-Height protocol and plotted over the bone surface. ResultsWe included 210 CT-scans from 25 CS to 10 AS patients and 25 controls. Before FFMBA, CS children only had a significantly thicker frontal bone (+0.772 mm ± 0.312, p = 0.017). After FFMBA, a significant increase in frontal bone thickness was reported for CS at 3 months (+0.637 mm ± 0.141, p < 0.001), 6 months (+0.910 mm ± 0.120, p < 0.001) and 12 months (+1.099 mm ± 0.124, p < 0.001) post-operatively as well as in AS at 1 month (+2.069 mm ± 0.441, p < 0.001), 6 months (+1.247 mm ± 0.406, p = 0.003) and 12 months (+2.360 mm ± 0.284, p < 0.001) post-operatively. For both syndromes, age at FFMBA and specific FGFR2 mutations significantly influenced post-operative frontal bone thickness. ConclusionsCraniofacial surgeons should be aware of the potential need for secondary surgery of the supra-orbital after FFMBA in CS and AS. Furthermore, a thicker supra-orbital bar is part of the CS phenotype, illustrating the role of FGFR2 in craniofacial growth.

On-site CAD templates reduce surgery time for complex craniostenosis repair in infants: a new method.

The surgical correction of craniostenosis in children is a time-consuming and taxing procedure. To facilitate this procedure, especially in infants with complex craniostenosis, we refined the computer-aided design and manufacturing technique (CAD/CAM) based on computed tomography (CT)-generated DICOM data. We used cutting guides and molding templates, which allowed the surgeon to reshape and fixate the supraorbital bar extracorporeally on a side table and to control the intracorporal fit without removing the template. To compare our traditional concept with the possibility of preoperative virtual planning (PVP) technique, the surgical treatment and courses of 16 infants with complex craniostenosis following fronto-orbital advancement (FOA) (age range 8-15months) were analyzed in two groups (group 1: traditional, control group n = 8, group 2: CAD/CAM planned, n = 8). While in both groups, the head accurately reshaped postoperatively during the follow-up; the CAD group 2 showed a significantly shorter operating time with a mean of 4h 25min compared with group 1 with a mean of 5h 37min (p = 0.038). Additionally, the CAD group 2 had a significantly lower volume of blood loss (380ml vs. 575ml mean, p = 0.047), lower blood transfusion volume (285ml vs. 400ml mean, p = 0.108), lower fresh frozen plasma (FFP) volume (140ml vs. 275ml mean, p = 0.019), shorter stay in the pediatric intensive care unit (PICU) (3 vs. 5days mean (p = 0.002), and shorter total length of hospital stay (6days vs. 8days mean, p = 0.002). CAD/CAM cutting guides and templates offer optimizing operative efficiency, precision, and accuracy in craniostenosis surgery in infants. As shown in this single-center observational study, the use of on-site templates significantly accelerates the reconstruction of the bandeau. The virtual 3D planning technique increases surgical precision without discernible detrimental effects.

Craniosynostosis surgery: workflow based on virtual surgical planning, intraoperative navigation and 3D printed patient-specific guides and templates

Craniosynostosis must often be corrected using surgery, by which the affected bone tissue is remodeled. Nowadays, surgical reconstruction relies mostly on the subjective judgement of the surgeon to best restore normal skull shape, since remodeled bone is manually placed and fixed. Slight variations can compromise the cosmetic outcome. The objective of this study was to describe and evaluate a novel workflow for patient-specific correction of craniosynostosis based on intraoperative navigation and 3D printing. The workflow was followed in five patients with craniosynostosis. Virtual surgical planning was performed, and patient-specific cutting guides and templates were designed and manufactured. These guides and templates were used to control osteotomies and bone remodeling. An intraoperative navigation system based on optical tracking made it possible to follow preoperative virtual planning in the operating room through real-time positioning and 3D visualization. Navigation accuracy was estimated using intraoperative surface scanning as the gold-standard. An average error of 0.62 mm and 0.64 mm was obtained in the remodeled frontal region and supraorbital bar, respectively. Intraoperative navigation is an accurate and reproducible technique for correction of craniosynostosis that enables optimal translation of the preoperative plan to the operating room.

Craniofacial Approaches to Pediatric Orbital Tumors.

Primary pediatric orbital tumors requiring surgery are uncommon and often require multidisciplinary management. Commonly used surgical approaches to the orbit include transconjunctival, transcutaneous (eyelid), transcranial, or extracranial osteotomies. This paper reviews a 10-year experience of cases that required a transcranial or extracranial surgical approach at the Birmingham Children's Hospital. A total of 9 patients were identified between the years 2008 to 2017. Pathologies included rhabdomyosarcoma, juvenile ossifying fibroma, optic nerve glioma, and retinoblastoma. Surgical approaches to the orbit included supraorbital bar osteotomy (transcranial) or lateral orbitotomy (extracranial). Surgical team members included neurosurgery, craniofacial surgery, and ophthalmology. This study aims to review the role of surgery in management as well as the specific indications for performing transcranial or extracranial osteotomies. It also highlights the excellent access achieved with the use of these osteotomies in certain cases, especially when compared with transconjunctival or transcutaneous approaches.

Use of Acellular Dermal Matrix in Craniosynostosis.

In craniofacial surgery, a wide spectrum of pathological conditions are usually treated. The aetiology of these could be congenital, traumatic, infective, post-tumor resection, postradiation, autoimmune, iatrogenic, or other miscellaneous conditions. The surgical approach for the procedures is usually via a coronal incision. In a large proportion of the patients, the frontal bone is removed to obtain intracranial access. The frontal bone is then replaced either in its original form or in a remodeled state. In congenital conditions the supraorbital bar and frontal bone is often also removed, remodeled, and replaced. One of the common late sequelae following craniofacial surgery is contour irregularities of the frontal region. These irregularities can vary in their extent. They are invariably palpable and often visible. Surgeons have attempted various methods to improve the contour irregularities. Despite these measures contour irregularities can still ensue. In the authors' unit, the authors have been using acellular dermal matrix in an attempt to diminish the contour irregularities in the frontal region following craniofacial reconstruction for craniosynostosis. This has been used in 35 patients undergoing craniosynostosis correction. Of the 35 patients, 12 were for plagiocephaly, 7 for brachycephaly, 10 for scaphocephaly, 4 for trigonocephaly, and 2 for combined coronal and metopic synostosis. The age of the patients ranged from 5 months to 12 years (mean 20.5 months). There were 21 males and 14 females. The follow-up ranged from 10 to 48 months (mean 23 months).

Distraction of Fronto-Orbital Segment as a Nonvascularized Bone Graft in Craniosynostotic Patients.

Fronto-orbital advancement using distraction techniques involves the dura left attached to the osteotomized bone segment to avoid dead space formation and dural injury, whereas it is impossible to reshape the supraorbital bar and the frontal bone complex, when necessary. Our approach combines advantageous parts of conventional and distraction osteogenesis techniques as remodel and distract the supraorbital bar and frontal bone complex as a free bone graft. Twenty-seven patients either being syndromic and nonsyndromic craniosynostosis, with at least 3 years of follow-up were reviewed in this study. Mean age of the patients at the time of the operation was 23.44 ± 18.42 months and mean operative time was 4.96 ± 0.97 hours. Blood transfusion was required in all patients, with an average of 112.04 ± 44.60 mL. Amount of the distraction ranged 10 to 30 mm, a mean of 17.26 ± 4.71 mm for the right side and 18.15 ± 4.69 mm for the left side. Mean duration of consolidation was 98.26 ± 12.98 days and mean follow-up was 41.33 ± 22.92 months. In this study, result of internal distraction of fronto-orbital segment as a nonvascularized bone graft in craniosynostotic patients is reviewed to emphasize the efficacy of the nonvascularized bone graft distraction in management of craniosynostosis. Graft distraction after fronto-orbital and cranial vault remodeling appears to be safe and effective approach in correcting severe craniosynostosis deformities especially necessitating asymmetrical advancement.

Cortical bridging venous segment protruding into the inner skull depression: a potential site of hemorrhage at external ventriculostomy.

The cortical bridging venous segment protruding into the inner skull depression (CBVISD), a distinctive structure found in the calvarial convexity, may be a potential risk factor for hemorrhagic complications resulting from trephination. However, this subject has not been documented. In the present study, we explore the CBVISD using magnetic resonance imaging (MRI). A total of 94 patients underwent contrast-enhanced MRI. Distributions of the CBVISDs were recorded in two symmetrical regions of the frontal calvarial convexity. The lateral dimensions on both hemispheres were defined to range between 25 and 35mm from the midsagittal section. The anteroposterior axis was delimited anteriorly by the supraorbital bar and posteriorly by the coronal suture, which was further divided into four parts: the forehead (FH), anterior frontal (AF), FH-AF junctional, and posterior frontal (PF) regions. Analysis of the delineations revealed that the CBVISDs had variable shapes and sizes. They were identified on the right side in 40% of the 94 patients and in 41% on the left side. Among the 91 identified CBVISDs, 5.5% of the CBVISDs were located in the FH, 17.6% in the FH-AF, 34.1% in the AF, and 42.9% in the PF. The CBVISDs are most frequently located at the common trephination site of external ventriculostomy. Trephination performed in the FH and FH-AF junctional regions may be safer than that in more posterior frontal areas.

Comparing the Use of 3D Photogrammetry and Computed Tomography in Assessing the Severity of Single-Suture Nonsyndromic Craniosynostosis.

Single-suture nonsyndromic craniosynostosis is diagnosed using clinical assessment and computed tomography (CT). With increasing awareness of the associated risks of radiation exposure, the use of CT is particularly concerning in patients with craniosynostosis since they are exposed at a younger age and more frequently than the average child. Three-dimensional (3D) photogrammetry is advantageous-it involves no radiation, is conveniently obtainable within clinic, and does not require general anaesthesia. This study aims to assess how 3D photogrammetry compares to CT in the assessment of craniosynostosis severity, to quantify surgical outcomes, and analyze the validity of 3D photogrammetry in craniosynostosis. Computed tomography images and 3D photographs of patients who underwent craniosynostosis surgery were assessed and aligned to best fit. The intervening area between the CT and 3D photogrammetry curves at the supraorbital bar (bandeau) level in axial view was calculated. Statistical analysis was performed using Student t test. Ninety-five percent confidence intervals were determined and equivalence margins were applied. In total, 41 pairs of CTs and 3D photographs were analyzed. The 95% confidence interval was 198.16 to 264.18 mm2 and the mean was 231.17 mm2. When comparisons were made in the same bandeau region omitting the temporalis muscle, the 95% confidence interval was 108.94 to 147.38 mm2, and the mean was 128.16 mm2. Although statistically significant difference between the modalities was found, they can be attributable to the dampening effect of soft tissue. Within certain error margins, 3D photogrammetry is comparable to CT in assessing the severity of single-suture nonsyndromic craniosynostosis. However, a dampening effect can be attributable to the soft tissue. Three-dimensional photogrammetry may be more applicable for severe cases of craniosynostosis but not milder deformity. It may also be beneficial for assessing the overall appearance and aesthetics but not for determining underlying bony severity.

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.

Respiratory and Cranial Complications during Anaesthesia in Pfeiffer Syndrome

Pfeiffer syndrome (PS) is rarely encountered, even at major craniofacial centers. Published reports indicate high mortality rates (25-85%) for severely affected subtypes. PS is characterized by bilateral coronal craniosynostosis, midface hypoplasia, beaked nasal tip, broad and medially deviated thumbs and great toes. We present a case of a 12-monthsold male infant with PS type 2 who underwent a craniosynostosis and advancing a supraorbital bar operations during general anesthesia. For simple procedures, a safe anesthetic plan can be formulated if the anatomic factors affecting the airway are carefully considered. More extensive and prolonged patient diagnosed to have PS require more monitoring and include all the problems associated with difficult intubation, hazardous airway management, massive blood loss and fluid shift, shunt-dependent hydrocephalus, and long anesthetic times. This case is presented since anaesthesiologists should be aware of the high incidence of respiratory and cranial complications in PS.

A new operative “open-wind” technique to correct the fronto-forehead unit in the metopic synostosis

Patient with trigonocephaly may present a prominent “keel”, forehead accompanied by recession of the lateral orbit rims, hipotelorism and constriction of the anterior frontal fossa. In a period between 2007 and 2011, in the “Child Salesi Hospital”, were treated for nonsyndromic variety of metopic synostosis eleven children; the age of ranges from 6 months to 9 months. The most important aims of our new surgical technique is the achievement of symmetry and normal proportion and reconstruction of the fronto-forehead unit but remaining in a very conservative treatment. The morphology and position of supraorbital ridge-lateral orbital rim region are key elements of upper facial aesthetics. This new “open-wind” technique for the reconfiguration of the bilateral supraorbital bar requires a medial incomplete osteotomy that involve only the internal cortex of the fronto-nasal region. So both lateral orbital walls are bent inwardly and tilting forward, as CT scan planning, with a greenstick fracture pivoting on the preserved medial fronto-nasal region. This “open-wind” conservative technique allow to avoid the most important complication that may result with traditional way such as dead space in the anterior cranial fossa, infections, blood loss but with an achievement of satisfactory craniofacial form.

Surgical outcomes in craniosynostosis reconstruction: The use of prefabricated templates in cranial vault remodelling

Cranio-orbital reshaping for anterior cranial-vault deformities associated with craniosynostosis traditionally relies on the surgeon's subjective estimate of the shape and appearance of a normal forehead. Computer-aided design/computer-aided manufacture (CAD/CAM) bandeau templates to guide reconstruction were introduced in our centre to eliminate this subjectivity and to effect more reproducible surgical results. The aim of this study was to compare two groups of patients (template, n = 14 vs. no template, n = 23) to measure surgical outcomes. The virtual, computational version of the template was used as an outcome assessment tool. It was used to calculate an intervening area under the curve (AUC) between the normative template and the patient's reconstructed supra-orbital bar on a representative computed tomography (CT) axial section. A comprehensive chart review was conducted of patients in both groups to examine the preoperative and postoperative variables. Based on the analysis performed on the immediate postoperative CT scans, in the template group - as compared to the control, no-template group - the use of the bandeau template led to a greater reduction in AUC (74% vs. 56%, p = 0.016), indicating a better conformity between the reconstructed supra-orbital bar and the ideal, normal bandeau shape. The duration of operation was significantly reduced with the use of the template (212 vs. 258 min, p < 0.001). The application of prefabricated templates in cranio-orbital reshaping is highly useful for accurate preoperative planning; reproducible and efficient intra-operative correction of dysmorphology; and objective surgical outcomes assessment.

Modified one-piece extended transbasal approach for translamina terminalis resection of retrochiasmatic third ventricular craniopharyngioma

Retrochiasmatic third ventricular craniopharyngiomas are formidable tumors to remove surgically. Access to the third ventricle can be achieved through the lamina terminalis corridor. A skull base approach to the lamina terminalis can be performed using either an anterolateral approach (orbitozygomatic, pterional, supraorbital) or a midline approach (extended transbasal, subfrontal). The major disadvantage of an anterolateral approach is the lack of visualization of the ipsilateral wall of the third ventricle and hypothalamus. However, a midline transbasal approach eliminates this blind spot thereby providing direct visualization of both ependymal walls for safe dissection of the tumor. In this operative video manuscript, the author demonstrates an illustrative step-by-step technique for translamina terminalis resection of a retrochiasmatic retroinfundibular craniopharyngioma within the third ventricle via a modified one-piece extended transbasal approach. This approach uses the standard bifrontal craniotomy and incorporates the anterior wall of the frontal sinus as a one-piece flap. The inferior limit of the osteotomy is based along the coronal contour of the anterior skull base which eliminates any bony overhang that can obstruct the line of sight to the lamina terminalis. Additional removal of the supraorbital bar is not necessary. The operative technique for this skull base approach and surgical nuances for craniopharyngioma resection are illustrated in this video atlas. The video can be found here: http://youtu.be/E3Bsp6dUdAE. (http://thejns.org/doi/abs/10.3171/2013.V1.FOCUS12354)

The shell technique: bilateral fronto-orbital reshaping in trigonocephaly

The shell technique, used in the Pediatric Neurosurgical Department at the Catholic University, Rome, since the 1990s for the correction of trigonocephaly, is associated to a significant reduction in surgical time and intraoperative blood loss as compared to other procedures, while allowing an adequate remodelling of the bifrontal bone by means of multiple radial osteotomies. The technique does not necessitate the creation of a supraorbital bar, as the supraorbital ridges are modified in situ, further reducing the operative blood loss. In spite of reduced surgical time and manipulation, this procedure ensures aesthetic and functional results comparable to more extensive and complex cranial vault reshaping procedures. The main limitation of this technique is related to the surgical timing, as better results are obtained between 3 and 9 months of age, when the skull bone is still ductile to work with, thus allowing it to be remodelled by greenstick fractures. Moreover, in this age group, the cranial defects that result from the enlargement of the frontal bone flap by means of radial cuts and from the anterior displacement of its lateral portions may benefit from the more effective bone regeneration which characterizes younger children as compared to their older counterparts. A small number of cases showing either persistent hypotelorism or temporal depression have been observed in the post-operative period, although these residual deformities probably depend on a more extensive involvement of the cranial base in the synostotic process in these patients than on the procedure itself.