Gradual Distraction Fronto-orbital Advancement With 'Floating Forehead' for Patients With Syndromic Craniosynostosis

Differences in Scalp Tension Associated With Craniosynostosis Among Patients of Different Races

BACKGROUND

Fronto-orbital advancement (FOA) is the gold standard treatment for craniosynostosis. Although FOA by gradual distraction has been practiced in Asia, it has not yet been accepted in Western countries. This may be attributable to differences in scalp tension among patients.

PATIENTS AND METHODS

The extent of skin advancement was intraoperatively measured as skin tension among 12 European (France) and 16 Asian (Japan) patients older than 6 months (age, 9.63±3.78 y) who underwent cranioplasty. Skin tension was measured at 3 points (left, right, and middle) after a zigzag bicoronal incision was made.

RESULTS

The skin tension measurements of European patients were as follows: left, 23.1±6.37 mm; middle, 18.5±3.85 mm; and right, 23.3±6.31 mm. Tension in the middle was significantly lower than that on the left and right (P<0.05). In contrast, the skin tension measurements of Asian patients were as follows: left, 12.8±1.49 mm; middle, 14.4±3.60 mm; and right, 13.0±1.74 mm. Tension in the middle was significantly higher than that on the left and right (P<0.05). In addition, skin tension was higher among European patients than among Asian patients.

CONCLUSIONS

Scalp tension differed according to race. This should be considered when selecting appropriate treatment.

Utilization of a Simple Surgical Guide for Multidirectional Cranial Distraction Osteogenesis in Craniosynostosis

Background:

Multidirectional cranial distraction osteogenesis (MCDO) can achieve a desired shape for deformities of the cranium. In the past, visual estimation was used to reflect on the actual skull, but it was time-consuming and inaccurate. Here we demonstrate an effective osteotomy navigation method using surgical guides made from a dental impression silicone.

Methods:

Seven patients who underwent MCDO between August 2013 and September 2016 were included in the study. Five cases involved utilization of the surgical guide for osteotomy. Three-dimensional (3D) printed cranium models were made using 3D computed tomography (3DCT) imaging data and dental impression silicone sheets were molded using the printed cranium models. These surgical guides were sterilized and used for intraoperative osteotomy design. Vertical distance between nasion/porion and osteotomy lines were calculated using 3D printed cranial models and postoperative 3DCT images to assess reproducibility.

Results:

The average surgical time/design time was 535/37.0 minutes for the nonsurgical guide group and 486.8/11.8 minutes for the surgical guide group (SG).Treatment using the surgical guide was significantly shorter in terms of operative time and time required for design. For the vertical distance comparison, the average distance was 5.7mm (SD = 0.3) in the non-SG and 2.5mm (SD = 0.44) in the SG, and SG was more accurate.

Conclusions:

Shorter operative times and higher reproducibility rates could be achieved by using the proposed surgical guide, which is accurate, low-cost, and easily accessible.

Experience with resorbable sonic pins for the attachment of distraction devices in posterior cranial vault distraction operations

BACKGROUND

Distraction techniques are effective methods for the treatment of craniosynostoses when a significant gain of an intracranial volume is required. However, this technique raises some challenges at different stages of the treatment. While installing the distractors in patients with thin calvarial bone, there is a risk of dural damage from the titanium screws. The need for wide exposure of the devices and the screws during removal causes soft tissue damage and bleeding.

OBJECTIVE

This study aimed to evaluate sonic pin use in the distraction procedures.

METHODS

Resorbable sonic pins were used in 11 consecutive posterior cranial vault distraction procedures to attach distraction devices to the calvarial bone.

RESULTS

This method allowed for a less traumatic and faster removal of the devices without the risk of leaving foreign bodies in the wound. In three out of 11 cases on follow-up, displacement of proximal distractor footplate and partial relapse of distraction were detected. Though there was a smaller volume increase in these patients, all of them benefited clinically from the PCVD and did not require reoperations.

CONCLUSIONS

This method allows a strong and stable attachment of the distractor devices to the cranial vault bones with a reduced risk of dural tears due to the screws. It also allows for easier and less traumatic device removal.

Distraction Osteogenesis Update: Introduction of Multidirectional Cranial Distraction Osteogenesis

In this review, we discuss in detail our current procedure for treating craniosynostosis using multidirectional cranial distraction osteogenesis (MCDO). The MCDO method allows all phenotypes of skull deformity to be reshaped by distraction osteogenesis, except in patients who are 5 months of age or younger and patients with posterior cranial vault problems. We report the results of clinical data of 36 children with craniosynostosis who underwent MCDO between 2005 and 2014 in our institute. This method has the following benefits, such as a high flexibility of reshaping, shorter treatment period and less invasive secondary intervention. We also discuss the other distraction osteogenesis techniques that are used to treat craniosynostosis and compare them with MCDO. The preferred procedure for correction of craniosynostosis may depend on the patient's age, the extent of deformity, and the extent of correction achievable by surgery. We can arrange the combinations of various methods according to the advantage and disadvantage of each technique.

Transsutural distraction osteogenesis for 285 children with craniosynostosis: a single-institution experience

OBJECT Although distraction osteogenesis (DO) requires a secondary procedure in the surgical correction of craniosynostosis, it is relatively simple, requires less transfusion, results in a shorter intensive care unit stay, and is quite safe. Because of these positive factors, various DO techniques have been developed. However, there is disagreement regarding the superiority of DO. The authors reported on a new DO technique, transsutural DO (TSDO), 6 years ago that was performed in 23 patients over a period of 6 months, and it continues to be used at the present time. In this paper the authors report the results of TSDO performed in 285 patients with craniosynostosis over a period of 6 years at a single institution. METHODS TSDO consists of a simple suturectomy of the pathological suture followed by direct distraction of the suturectomy site only. Types of TSDO conducted included sagittal TSDO in 95 patients, bicoronal in 14, unilateral coronal in 57, lambdoid in 26, metopic in 13, multiple in 19, syndromic in 33, and secondary in 28. The mean age (± SD) of the patients was 19.4 ± 23.0 months, and mean follow-up was 39.5 ± 21.0 months. RESULTS The mean operating time was 115 ± 43 minutes, and mean anesthesia time was 218 ± 56 minutes. The mean transfusion volume of red blood cell components was 48 ± 58 ml, and mean transfusion volume of fresh-frozen plasma was 19 ± 35 ml. Total transfusion volume was significantly less in infants younger than 12 months of age and in children with lower lumbar puncture pressures (p < 0.05). Complications included 1 (0.4%) death from postoperative acute pneumonia after a distractor removal operation and 23 (8%) surgical morbidities comprising 10 revisions (3.5%) and 13 early removals of distracters (4.6%). CONCLUSIONS TSDO is a simple, effective, and safe method to use for treating all types of craniosynostosis. Some morbidity was experienced in this study, but it may be attributed to the learning curve of the technique.

Relaxed pericranial flap for distraction osteogenesis to treat craniosynostosis: a technique for wound reinforcement--technical note

PURPOSE

Although distraction osteogenesis has been widely accepted to treat craniosynostosis, it occasionally results in wound complications. Positing that they are attributable to the tense pericranium under the scalp, we developed a simple technique to relax the pericranial flap.

METHODS

In 12- to 15-month-old infants (mean 13 months), we placed a coronal skin incision and dissected the scalp at the subgaleal layer. Then, we peeled the intact pericranium away from the skull along the planned osteotomy to obtain flaps with pedicles on the caudal part. After osteotomy and setting of the distraction device, the pericranial flaps freed from the scalp flap were repositioned to fit the osteotomy line, dura, and distraction device. The galea and skin were approximated layer by layer.

RESULTS

The shape of the skull was successfully corrected, and the bone defect created by expansion was filled by osteogenesis in all patients. During a mean follow-up period of 42.2 months, we encountered no wound complications.

CONCLUSIONS

The replaced relaxed pericranium closely adhered to the osteotomy, and the distraction device facilitated vascular growth and bone restoration. Bone resorption was prevented and skin expansion promoted. In patients with iatrogenic dural injury, the pericranium over the injured dura serves as a barrier to prevent cerebrospinal fluid leakage.

Troubleshooting distraction osteogenesis for craniosynostosis

PURPOSE

We previously reported that distraction osteogenesis is less invasive and gives greater skull advancement compared to conventional cranioplasty [Akai et al: Pediatr Neurosurg 2006;42:288-292]. In this study, we analyzed the distraction osteogenesis process and tried to identify and solve various technical problems.

PATIENTS AND RESULTS

We operated on 22 patients, 5 syndromic and 17 nonsyndromic. During treatment, we encountered several problems: (i) dural laceration during craniotomy (2 cases), solution: repair by suturing with fascia; (ii) skull fracture at sphenofrontal or coronal sutures (2 cases), solution: completed distraction; (iii) device dislocation during distraction (1 case), solution: the device was secured to the skull with stainless wire; (iv) wound issues around shaft and device (3 cases), solution: treated with antibiotic ointment.

DISCUSSION

(1) Extra caution is needed to avoid dural damage at frontal bottom burr holes. (2) Completion of craniotomy should be confirmed by checking if the bone flap moves in sync with brain pulsation. The craniotomy line should be placed forward of coronal sutures. (3) For patients younger than 2 years, employ clamp-type devices. (4) Shafts should be cut short enough to prevent their tips from exerting pressure or puncturing the scalp from beneath.

CONCLUSIONS

The distraction osteogenesis technique has complications that may not occur in conventional one-stage cranioplasty. In this study, neither age at operation nor distraction distance were significant causes of complications during distraction osteogenesis.

Cranial vault expansion by distraction osteogenesis

OBJECT

The object of this report is to present a conceptual and technical approach for expanding the cranial vault, by distraction osteogenesis, in patients with craniocephalic disproportion secondary to pancraniosynostosis and in patients with complex syndromic craniofaciosynostoses undergoing operations for aesthetic improvement.

METHODS

The clinical characteristics, techniques used, outcome and complications for all patients who underwent cranial vault expansions with distraction osteogenesis in Children's Hospital of Denver were reviewed.

RESULTS

Twenty-six cranial vault expansions were done in 24 patients. Nineteen patients presented with intracranial hypertension. Twelve of these had pancraniosynostosis and 8 had a syndromic diagnosis. Large segments of cranial bone were translated in a controlled manner for distances up to 30 mm. All but one of the patients with intracranial hypertension experienced complete resolution.

CONCLUSIONS

Cranial vault expansion by distraction osteogenesis has the great advantage, as the name implies, of generating new and vascularized autologous bone of the correct shape and in correct locations. The technique, although not simple and not risk free, is much less technically complicated and places patients at lower risk for the most serious complications than does single-stage vault expansion. Less soft tissue dissection and less devascularization of bone are required and there are no postoperative dead spaces. Distraction osteogenesis facilitates far greater vault expansions than do single-stage procedures and can be accomplished in any desired direction.

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

OBJECTIVE

To review the complications in the surgical treatment of craniosynostosis in 306 consecutive transcranial procedures between June 1999 and June 2007.

PATIENTS AND METHODS

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).

RESULTS

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.

CONCLUSIONS

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.

Monoblock craniofacial internal distraction in a child with Pfeiffer syndrome: a case report

A 7-yr-old boy visited our surgical center with Pfeiffer syndrome type 1, presenting with macrocrania, broad big toe and thumb, exophthalmos, tongue protrusion, malocclusion with midfacial retrusion, mild respiratory difficulty due to minor upper airway obstruction, and developmental delay. He also exhibited anthrophobia with a passive character. The patient was treated with internal monoblock distraction osteogenesis to increase the intracranial and intraorbital volumes, and the nasal and pharyngeal airway spaces using two modular mid-facial internal distractors. For distraction, the latency period was 1 week, the daily activation of 1.0 mm was 20 days (total advancement 20 mm at the midline), and the consolidation period was 3 months. The follow-up computed tomography 12 months after surgery showed expansion of the brain and proper ossification in the distracted area. The patient also showed aesthetically good cranial contours, improved tongue and eyeball protrusion, no respiratory difficulty, and improved learning. We suggest that the internal distraction may last longer than an external type, resulting in a better bone fusion rate and successful expansion of craniofacial bones.