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Zhang S, Fang C, Lan D, Wang Y, Dong C. Postoperative Orbital Morphology Observations Following Fronto-Orbital Advancement and Cranial Vault Remodeling in Patients With Unilateral Coronal Synostosis. J Craniofac Surg 2024:00001665-990000000-01883. [PMID: 39248645 DOI: 10.1097/scs.0000000000010493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 06/23/2024] [Indexed: 09/10/2024] Open
Abstract
OBJECT Observations of preoperative and postoperative orbital morphology following fronto-orbital advancement and cranial vault remodeling (FOA and CVR) in patients with unilateral coronal synostosis (UCS). METHODS This retrospective cohort included patients diagnosed with unilateral coronal synostosis and treated with fronto-orbital advancement and cranial vault remodeling at the Children's Hospital of Fudan University. The orbital height, orbital width, and orbital volume were obtained from head 3-dimensional computed tomography of preoperation and postoperation. The DICOM data of CT were then imported into mimics research version 21.0. The authors measured OH and OW according to the bony landmarks, then reset the parameters of the soft tissue window, and conducted a 3-dimensional reconstruction of the orbital soft tissue to get OV. The preoperative and postoperative measurements of the intact side were compared with the affected side, respectively. Statistical analysis was performed using SPSS version 25.0 (Ρ=0.05). RESULTS Twelve patients with UCS (5 male, 7 female) meeting criteria were included in the study. There were 4 patients with UCS on the left and 8 on the right. The average age at initial surgery was 19.50 months. Before the operation, the data of the intact side and the affected side were compared, respectively, and the difference was found to be significant in OH (Ρ=0.005) and OW (Ρ=0.005), while the OV (Ρ=0.106) was not statistically significant. After procedures of FOA and CVR, the data of the intact side and the affected side were compared, respectively, the significant difference was found in OV (Ρ=0.002), while not in OH (Ρ=0.060) or OW (Ρ=0.066). CONCLUSION After undergoing the operation of FOA and CVR, the OH and OW of the ipsilateral and contralateral sides of patients with UCS were basically symmetrical, while the volume of the affected orbit was still relatively smaller.
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Affiliation(s)
- Songchunyuan Zhang
- Department of Plastic Surgery, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai
| | - Cheng Fang
- Department of Neurosurgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Dongyi Lan
- Department of Plastic Surgery, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai
| | - Yueqing Wang
- Department of Plastic Surgery, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai
| | - Chenbin Dong
- Department of Plastic Surgery, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai
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Winnand P, Cevik E, Ooms M, Heitzer M, Bock A, Hölzle F, Modabber A, Raith S. Optimal untwisting of the orbital bandeau in unicoronal craniosynostosis correction: A finite element analysis. J Mech Behav Biomed Mater 2024; 157:106635. [PMID: 38943904 DOI: 10.1016/j.jmbbm.2024.106635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 05/27/2024] [Accepted: 06/18/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND Surgical correction of unicoronal craniosynostosis (UCS) is highly complex due to its asymmetric appearance. Although fronto-orbital advancement (FOA) is a versatile technique for craniosynostosis correction, harmonization of the orbital bandeau in UCS is difficult to predict. This study evaluates the biomechanics of the orbital bandeau using different patterns and varying characteristics of inner cortical bone layer osteotomies in a finite element (FE) analysis. METHOD An FE model was created using the computed tomography (CT) scan of a 6.5-month-old male infant with a right-sided UCS. The unaffected side of the orbital bandeau was virtually mirrored, and anatomical correction of the orbital bandeau was simulated. Different combinations of osteotomy patterns, numbers, depths, and widths were examined (n = 48) and compared to an uncut model. RESULTS Reaction forces and maximum stress values differed significantly (p < 0.01) among osteotomy patterns and between each osteotomy characteristic. Regardless of the osteotomy pattern, higher numbers of osteotomies significantly (p < 0.05) correlated with reductions in reaction force and maximum stress. An X-shaped configuration with three osteotomies deep and wide to the bone was biomechanically the most favorable model. CONCLUSION Inner cortical bone layer osteotomy might be an effective modification to the conventional FOA approach in terms of predictable shaping of the orbital bandeau.
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Affiliation(s)
- Philipp Winnand
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074, Aachen, Germany.
| | - Ezgi Cevik
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074, Aachen, Germany.
| | - Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074, Aachen, Germany.
| | - Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074, Aachen, Germany.
| | - Anna Bock
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074, Aachen, Germany.
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074, Aachen, Germany.
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074, Aachen, Germany.
| | - Stefan Raith
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074, Aachen, Germany.
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Santiago G, Santiago C, Nguyen A, Choudhary A, Zhao L, Alkureishi LWT, Patel PK, Purnell CA. Alterations in Sphenoid Anatomy in Craniosynostosis: Implications for Fronto-Orbital Advancement. Cleft Palate Craniofac J 2024:10556656241245514. [PMID: 38567431 DOI: 10.1177/10556656241245514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVE Fronto-orbital advancement involves removal of the fronto-orbital bandeau. Visualization of the saw blade is lost as it passes through the fronto-orbital-sphenoid junction (FOSJ), placing the temporal lobe at risk of injury. We aim to provide a 3D analysis of the space surrounding this osteotomy to differentiate various types of craniosynostoses. DESIGN Retrospective cohort. SETTING Institutional. PATIENTS Thirty patients with isolated unicoronal synostosis, nonsyndromic bicoronal synostosis, metopic synostosis, Apert syndrome, Crouzon syndrome, and Muenke syndrome. INTERVENTIONS CT scans conducted between 2 months to 2 years of age were 3D reconstructed to compare craniometrics against normal controls. MAIN OUTCOME MEASURE(S) Craniometrics. RESULTS The mean bone thickness of the FOSJ at the level of the supraorbital rim was significantly small for the Apert, unicoronal and bicoronal groups. The mean vertical height of the middle cranial fossa from the lesser sphenoid wing was significantly greater in the unicoronal group. The mean vertical height of the tip of the temporal lobe from the lateral sphenoid ridge was greater in the unicoronal, isolated bicoronal, and Apert groups. The mean corneal protrusion beyond the lateral orbital rim was significantly greater in the Apert and unicoronal groups. The mean horizontal depth of the orbit was smallest in the Apert group. The mean vertical distance between the dacryon and the foramen cecum, and the mean volume of temporal lobe beneath the sphenoid shelf were the largest in the Apert group. CONCLUSIONS Patients with Apert syndrome have the most unfavorable morphology of the anterior and middle cranial fossae.
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Affiliation(s)
- Gaia Santiago
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
| | - Chiara Santiago
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
| | - Alvin Nguyen
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
| | - Akriti Choudhary
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
| | - Linping Zhao
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
| | - Lee W T Alkureishi
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
- Department of Plastic and Reconstructive Surgery, Shriners Children's Hospital, Chicago, IL, USA
| | - Pravin K Patel
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
- Department of Plastic and Reconstructive Surgery, Shriners Children's Hospital, Chicago, IL, USA
| | - Chad A Purnell
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
- Department of Plastic and Reconstructive Surgery, Shriners Children's Hospital, Chicago, IL, USA
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Sanati-Mehrizy P, Hopper RA, Susarla SM. Discussion: Improved Facial and Skull-Base Symmetry following Osteotomy and Distraction of Unilateral Coronal Synostosis. Plast Reconstr Surg 2024; 153:457-460. [PMID: 38266138 DOI: 10.1097/prs.0000000000010778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Affiliation(s)
- Paymon Sanati-Mehrizy
- From the Craniofacial Center, Divisions of Plastic and Craniofacial Surgery and Oral and Maxillofacial Surgery, Seattle Children's Hospital
| | - Richard A Hopper
- From the Craniofacial Center, Divisions of Plastic and Craniofacial Surgery and Oral and Maxillofacial Surgery, Seattle Children's Hospital
| | - Srinivas M Susarla
- From the Craniofacial Center, Divisions of Plastic and Craniofacial Surgery and Oral and Maxillofacial Surgery, Seattle Children's Hospital
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Choudhary A, Edgar M, Raman S, Alkureishi LW, Purnell CA. Craniometric and Aesthetic Outcomes in Craniosynostosis Surgery: A Systematic Review and Meta-Analysis. Cleft Palate Craniofac J 2023:10556656231204506. [PMID: 37859464 DOI: 10.1177/10556656231204506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023] Open
Abstract
OBJECTIVE To systematically review the published comparative aesthetic outcomes, and its determinants, for craniosynostoses surgically treated by minimally-invasive cranial procedures and open cranial vault remodeling (CVR). DESIGN PRISMA-compliant systematic review. SETTING Not-applicable. PATIENTS/PARTICIPANTS Articles were included if they compared spring cranioplasty, strip minimally-invasive craniectomy or CVR for outcomes related to aesthetics or head shape. Forty-two studies were included, comprising 2402 patients. INTERVENTIONS None. MAIN OUTCOME MEASURE(S) The craniometric and PROM used to determine surgical outcomes. RESULTS Twenty-five studies (59%) evaluated sagittal craniosynostosis, with metopic (7;17%) and unicoronal (4;10%) the next most prevalent. Thirty-eight studies (90%) included CVR, 24 (57%) included strip craniectomy with helmeting, 9 (22%) included strip craniectomy without helmeting, 11 (26%) included spring cranioplasty, and 3 (7%) included vault distraction. A majority of studies only used 1 (43%) or 2 (14%) craniometric measures to compare techniques. In sagittal synostosis, 13 (59%) studies showed no difference in craniometric outcomes, 5 (23%) showed better results with CVR, 3 (14%) with strip craniectomy, and 1 (5%) with springs. In studies describing other synostoses, 10/14 (71%) were equivocal. Subjective outcome measures followed similar trends. Meta-analysis shows no significant difference in cranial index (CI) outcomes between CVR and less invasive procedures in patients with sagittal synostosis. CONCLUSIONS There is no difference in CI outcomes between CVR and less invasive procedures. The majority of literature comparing craniometric and aesthetic outcomes between CVR and less invasive procedures shows equivocal results for sagittal synostosis. However, the heterogeneity of data for other craniosynostoses did not allow meta-analysis.
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Affiliation(s)
- Akriti Choudhary
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
| | - Michael Edgar
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
| | - Shreya Raman
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
| | - Lee W Alkureishi
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
- Department of Plastic Surgery, Shriners Children's Hospital, Chicago, IL, USA
| | - Chad A Purnell
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
- Department of Plastic Surgery, Shriners Children's Hospital, Chicago, IL, USA
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Pfaff MJ, Bruce MK, Erpenbeck S, Mittal A, Beiriger JW, Zhu X, Dvoracek L, Goldstein JA. A Three-Dimensional-Based Morphometric Analysis of a Standardized Overcorrection Technique for Fronto-Orbital Advancement in Metopic Craniosynostosis. Cleft Palate Craniofac J 2023; 60:268-273. [PMID: 34870484 DOI: 10.1177/10556656211062843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION The concept of "overcorrection" for trigonocephaly has been reported to achieve both anterior cranial fossa expansion and normalization of craniofacial form. The purpose of this study is to describe in detail a standardized technique to fronto-orbital advancement utilizing the concept of "overcorrection" and objectively evaluate intermediate results. METHODS This retrospective study included patients with isolated metopic synostosis who underwent surgery via the proposed surgical technique and age and sex-matched unaffected controls. Craniofacial morphometric analysis was performed on pre-, immediate post-, and intermediate postoperative (>2 years) three-dimensional (3D)-rendered computed tomographic (CT) scans and photographs. Key CT-based measurements included interzygomaticofrontal suture distance (IZFS), endocranial bifrontal angle (ECA), and temporal expansion. 3D photogrammetry was performed using established measurements and associated Z-scores converted. A Paired t-test and analysis of variance were performed when appropriate. RESULTS Forty-one patients were included. A comparison of pre- and immediate postoperative CT scans demonstrated statistically significant increases in all measurements. Subset analysis of 12 patients with intermediate follow-up (age: 39.6 ± 3.6 months) demonstrated significant differences from preoperative values except for IZFS, which decreased from immediate postoperative values and was smaller than age- and sex-matched controls. 3D photogrammetry demonstrated a mean Z-score above the norm for frontal breath. 3D photogrammetry is also positively correlated with CT-based measurements. CONCLUSIONS This standardized "overcorrection" approach for trigonocephaly can provide the appropriate changes to maintain a normal ECA despite a reduction in bifrontal width over time. 3D photogrammetry positively correlated with CT-based measurements and may provide useful information when following patients clinically. Long-term follow-up assessment to determine the necessary degree of overcorrection at skeletal mature is needed.
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Affiliation(s)
- Miles J Pfaff
- 6619Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pediatric Plastic Surgery, Pittsburgh, PA, USA
| | - Madeleine K Bruce
- 6619Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pediatric Plastic Surgery, Pittsburgh, PA, USA
| | - Sarah Erpenbeck
- 6619Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pediatric Plastic Surgery, Pittsburgh, PA, USA
| | - Aditya Mittal
- 6619Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pediatric Plastic Surgery, Pittsburgh, PA, USA
| | - Justin W Beiriger
- 6619Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pediatric Plastic Surgery, Pittsburgh, PA, USA
| | - Xiao Zhu
- 6619Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pediatric Plastic Surgery, Pittsburgh, PA, USA
| | - Lucas Dvoracek
- 6619Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pediatric Plastic Surgery, Pittsburgh, PA, USA
| | - Jesse A Goldstein
- 6619Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pediatric Plastic Surgery, Pittsburgh, PA, USA
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Patient-Specific Implants and Fat Grafting for Contour Deformities Post Craniosynostosis Reconstruction: A Therapeutic Approach. J Craniofac Surg 2023; 34:959-963. [PMID: 36727933 DOI: 10.1097/scs.0000000000009178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/10/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Contour deformities after fronto-orbital advancement for craniosynostosis reconstruction are commonly encountered. There is a paucity of literature describing secondary procedures to correct such deformities with reported outcomes. An approach to defect analysis and procedure selection is lacking. The authors present our experience utilizing fat grafting (FG) and patient-specific implant (PSI) reconstruction as management strategies for this population. METHODS A retrospective analysis of consecutive patients who underwent secondary onlay PSI or FG for contour deformities after primary craniosynostosis reconstruction was carried out. Patient demographics, defect analysis, surgical approach, postoperative complications, and esthetic outcomes were recorded. Data were pooled across the entire cohort and presented in a descriptive manner. RESULTS Fourteen patients (36% syndromic and 64% isolated) were identified that either underwent PSI (n = 7) with a mean follow-up of 56.3 weeks, FG (n = 5) with a mean follow-up of 36 weeks or a combination of both (n = 2) for deformities postcraniosynostis surgery. Supraorbital retrusion and bitemporal hollowing were the most common deformities. There were no intraoperative or postoperative complications. All patients achieved Whitaker class I esthetic outcomes and there were no additional revisions during the defined study period. The presence of a significant structural component or large (>5 mm) depression typically necessitated a PSI. CONCLUSIONS Contour deformities after fronto-orbital advancement reconstruction can be successfully managed using FG and PSI either as a combination procedure or in isolation. The authors have proposed anatomical criteria based on our experience to help guide procedure selection. Future prospective studies would be beneficial in providing more objective assessment criteria.
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One-piece fronto-orbital distraction osteogenesis without bandeau in patients with coronal craniosynostosis: A five-year follow-up retrospective study of 45 consecutive patients. J Craniomaxillofac Surg 2022; 50:884-893. [PMID: 36635150 DOI: 10.1016/j.jcms.2023.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 01/01/2023] [Accepted: 01/02/2023] [Indexed: 01/06/2023] Open
Abstract
This study aimed to review the surgical outcomes, complications, and long-term relapses in patients with unilateral or bilateral coronal craniosynostosis, who underwent one-piece fronto-orbital distraction osteogenesis (FODO) without bandeau. The cephalic index, frontal angle, and supraorbital symmetry ratio were measured on the initial and follow-up computed tomography images. Esthetic outcomes were evaluated using the Whitaker classification. 45 patients were included in this study. The average follow-up interval was 5.4 ± 1.1 years (range 2.5-8.5 years). In patients with bilateral coronal craniosynostosis, the frontal angle decreased with a relapse ratio of -2.8 ± 4.3% during long-term follow-up compared with that during short-term follow-up (p = 0.028). In patients with unilateral coronal craniosynostosis, the supraorbital symmetry ratio decreased slightly, with a relapse ratio of -3.8 ± 2.6% during long-term follow-up (p = 0.017). Complications included dural tears during osteotomy (n = 2), early distractor removal (n = 2), and wound problems (n = 3). Within the limitations of the study it seems that one-piece fronto-orbital distraction osteogenesis (FODO) generates successful and sustainable results even in the long term. Therefore, this treatment option should be considered for patients with unilateral and bilateral coronal craniosynostoses whenever appropriate.
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Massenburg BB, Tolley PD, Lee A, Susarla SM. Fronto-Orbital Advancement for Metopic and Unilateral Coronal Craniosynostoses. Oral Maxillofac Surg Clin North Am 2022; 34:367-380. [PMID: 35787824 DOI: 10.1016/j.coms.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Fronto-orbital advancement remains a powerful technique for the correction of anterior cranial vault differences related to metopic (trigonocephaly) or unilateral coronal (anterior plagiocephaly) craniosynostoses. Traditional fronto-orbital advancement requires access to the forehead and superior 2/3 of the orbit via a coronal incision. The frontal bone and orbital segment (bandeau) are then separated from the skull and reshaped. In patients with metopic craniosynostosis, the bandeau and frontal bone will need to be advanced and widened. In patients with unilateral coronal craniosynostosis, the bandeau will need to be "untwisted" to address the supraorbital retrusion on the affected side, the affected orbit will need to be shortened and widened, and the frontal bone flap will need to be proportionately advanced on the affected side. Overcorrection of the affected dimension should be undertaken to account for growth and relapse.
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Affiliation(s)
- Benjamin B Massenburg
- Craniofacial Center, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, WA, USA
| | - Philip D Tolley
- Craniofacial Center, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, WA, USA
| | - Amy Lee
- Craniofacial Center, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, WA, USA
| | - Srinivas M Susarla
- Craniofacial Center, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, WA, USA.
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Wong A, Lance SH, Gosman AA. Treatment of Unicoronal Craniosynostosis by Rotational Flap Technique Preserves Blood Supply to the Frontal Bone Flap. Ann Plast Surg 2022; 88:S348-S350. [PMID: 35180749 DOI: 10.1097/sap.0000000000003080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Surgical correction of unicoronal craniosynostosis (UCS) remains a challenging problem. Long-term results are often unsatisfactory secondary to recurrence of the original deformity, requiring secondary operations such as fat grafting or complete revision of the calvarial remodeling. Distraction osteogenesis (DO) has recently emerged as a new modality for treatment of UCS, with promising results and decreased rates of reoperation compared with open cranial vault remodeling. A theoretical benefit of DO is preservation of blood supply to the frontal bone following osteotomy, as the frontal bone can be retained in situ compared with the complete removal and reshaping of the frontal bone during traditional fronto-orbital advancement. Preservation of blood supply to the frontal bone may allow for more robust bony healing and preservation of long-term growth potential; however, the vascularity of the frontal bone flap in DO has not previously been demonstrated. Here, we demonstrate unequivocally that blood supply to the frontal bone is preserved after creation of a rotational bone flap in DO management of UCS. METHODS Frontal bone flap creation via osteotomy for DO treatment of UCS was performed via previously reported technique. Indocyanine green was injected intravenously, and bone perfusion was assessed with a fluorescence imaging system. RESULTS Four patients underwent three cranial remodeling and three distractor removal procedures. After frontal bone flap creation via osteotomy for DO, perfusion to the osteotomized portion of the frontal bone flap is preserved. Blood flow is seen crossing the midline of the frontal bone. After removal of the distractor, perfusion in the osteoid consolidate is also observed. CONCLUSIONS Preservation of blood supply has not been previously demonstrated empirically in the setting of DO treatment of UCS. We show for the first time that during frontal bone flap creation, blood flow to the osteotomized portion of the frontal bone flap is maintained. Robust blood flow to the osteoid consolidate is also demonstrated. These data support the use of DO in treatment of UCS, as preserved blood supply to the bone is more likely to support improved healing and long-term results.
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Affiliation(s)
- Alvin Wong
- From the Division of Plastic Surgery, Department of Surgery, University of California San Diego; and Rady Children's Hospital, San Diego, CA
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Virtual Coordinate System in Unicoronal Synostosis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3616. [PMID: 34422508 PMCID: PMC8376362 DOI: 10.1097/gox.0000000000003616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 03/26/2021] [Indexed: 11/26/2022]
Abstract
We propose a landmark-based, virtual coordinate system, specifically designed for assessment of asymmetrical craniofacial anatomy associated with unicoronal synostosis. Method CT scans of 33 patients with nonsyndromic unicoronal synostosis were included. Proposed mid-sagittal plane was compared with commonly used sagittal planes: (1) nasion, sella, and basion (N-S-BA); (2) midplane of bilateral frontozygomatic sutures (midFZ); and (3) the skull gravity center plane, to evaluate reliability and validity in the assessments of the anterior and posterior skull base. Results The proposed midplane is similar to the midFZ plane in describing the direction of the anterior skull base. However, it has less bias than the N-S-BA (P < 0.001), and the gravity center planes (P < 0.001). The proposed midplane measures the direction of the posterior skull base plane, similar to the midFZ and gravity center planes, but it has less measurement deviation than the N-S-BA plane (P < 0.001). The most protrusive point on the frontal bone in unicoronal patients is contralateral to the fused suture and distant from the mid-sagittal plane by 13.93 ± 4.01 mm. In addition, it is more anteriorly positioned, by 5.32 mm (P < 0.001), when compared with the corresponding point on the synostotic side. The uppermost point of the supraorbital rim on the synostotic side is cephalic to that of the contralateral side by 4.09 mm (P < 0.001). Conclusions Prioritized orientation of an averaged Frankfort horizontal plane, followed by the location of the mid-sagittal and coronal planes, can generate a reliable and valid coordinate framework for the assessment of asymmetric skull shape in unicoronal synostosis.
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12
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Adidharma W, Mercan E, Purnell C, Birgfeld CB, Lee A, Ellenbogen RG, Hopper RA. Evolution of Cranioorbital Shape in Nonsyndromic, Muenke, and Saethre-Chotzen Bilateral Coronal Synostosis: A Case-Control Study of 2-Year Outcomes. Plast Reconstr Surg 2021; 147:148-159. [PMID: 33370058 DOI: 10.1097/prs.0000000000007494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this study was to quantify change in cranioorbital morphology from presentation, after fronto-orbital advancement, and at 2-year follow-up. METHODS Volumetric, linear, and angular analyses were performed on computed tomographic scans of consecutive bilateral coronal synostosis patients. Comparisons were made across three time points, between syndromic and nonsyndromic cases, and against normal controls. Significance was set at p < 0.05. RESULTS Twenty-five patients were included: 11 were nonsyndromic, eight had Saethre-Chotzen syndrome, and six had Muenke syndrome. Total cranial volume was comparable to normal, age-matched control subjects before and 2 years after surgery despite an expansion during surgery. Axial and sagittal vector analyses showed advancement and widening of the lower forehead beyond control values with surgery and comparable anterior position, but increased width compared to controls at 2 years. Frontal bossing decreased with a drop in anterior cranial height and advanced lower forehead position. Middle vault height was not normalized and turricephaly persisted at follow-up. Posterior fossa volume remained lower at all three time points compared to control subjects. Supraorbital retrusion relative to anterior corneal position was overcorrected by surgery, with values comparable to those of control subjects at 2 years because of differential growth. There was no difference at 2 years between syndromic and nonsyndromic groups. CONCLUSIONS Open fronto-orbital advancement successfully remodels the anterior forehead but requires overcorrection to be comparable to normal at 2 years. Although there are differences in syndromic cases at presentation, they do not result in significant morphometric differences on follow-up. Posterior fossa volume remains lower at all time points. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Widya Adidharma
- From the Craniofacial Image Analysis Lab, Craniofacial Center, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Neurological Surgery, University of Washington
| | - Ezgi Mercan
- From the Craniofacial Image Analysis Lab, Craniofacial Center, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Neurological Surgery, University of Washington
| | - Chad Purnell
- From the Craniofacial Image Analysis Lab, Craniofacial Center, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Neurological Surgery, University of Washington
| | - Craig B Birgfeld
- From the Craniofacial Image Analysis Lab, Craniofacial Center, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Neurological Surgery, University of Washington
| | - Amy Lee
- From the Craniofacial Image Analysis Lab, Craniofacial Center, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Neurological Surgery, University of Washington
| | - Richard G Ellenbogen
- From the Craniofacial Image Analysis Lab, Craniofacial Center, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Neurological Surgery, University of Washington
| | - Richard A Hopper
- From the Craniofacial Image Analysis Lab, Craniofacial Center, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Neurological Surgery, University of Washington
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13
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Ferry AM, Dibbs RP, Sarrami SM, Abu-Ghname A, Beh HZ, Maricevich RS, Buchanan EP. Pediatric Fronto-Orbital Skull Reconstruction. Facial Plast Surg 2021; 37:771-780. [PMID: 33525031 DOI: 10.1055/s-0041-1722920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Craniofacial surgery in children is a highly challenging discipline that requires extensive knowledge of craniofacial anatomy and pathology. Insults to the fronto-orbital skeleton have the potential to inflict significant morbidity and even mortality in patients due to its proximity to the central nervous system. In addition, significant aesthetic and ophthalmologic disturbances frequently accompany these insults. Craniosynostosis, facial trauma, and craniofacial tumors are all pathologies that frequently affect the fronto-orbital region of the craniofacial skeleton in children. While the mechanisms of these pathologies vary greatly, the underlying principles of reconstruction remain the same. Despite the limited data in certain areas of fronto-orbital reconstruction in children, significant innovations have greatly improved its safety and efficacy. It is imperative that further investigations of fronto-orbital reconstruction are undertaken so that craniofacial surgeons may provide optimal care for these patients.
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Affiliation(s)
- Andrew M Ferry
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Rami P Dibbs
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Shayan M Sarrami
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Han Zhuang Beh
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Renata S Maricevich
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Edward P Buchanan
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
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14
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Technical Strategy Using Piezosurgery to Correct Flattened Supraorbital Rim in Unilateral Coronal Craniosynostosis. J Craniofac Surg 2020; 32:97-100. [PMID: 33156179 DOI: 10.1097/scs.0000000000007017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
ABSTRACT The surgical correction of orbital deformities in patients with unilateral coronal craniosynostosis is challenging. Traditional techniques have shown the persistence of orbital flattening. This study presents a new strategy for remodeling the compromised orbit, using the piezosurgery technique, which improves the orbital curvature.
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15
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Robertson E, Kwan P, Louie G, Boulanger P, Aalto D. Test-retest validation of a cranial deformity index in unilateral coronal craniosynostosis. Comput Methods Biomech Biomed Engin 2020; 23:1247-1259. [PMID: 32691624 DOI: 10.1080/10255842.2020.1795143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Unilateral coronal craniosynostosis (UCS) affects many infants resulting in abnormalities affecting the forehead and orbits. As a result, the deformity caused by UCS is very noticeable and there are several surgical treatment options available to normalize the head shape. However, there is a lack of consistently used outcome measures, resulting in difficulty assessing surgical outcomes and on-going debate over optimal treatments. Current techniques to quantify deformity in UCS are cumbersome, provide limited information, or are based on subjective assessments. In this study, a cranial deformity index was developed to quantify abnormality at the frontal bones for UCS that is accessible, user-friendly, and generates objective surface distance measurements. The cranial deformity index is defined as the Euclidean distance at the point of the largest deviation between the deformed skull compared to a reference skull. In addition, the index was successfully used to quantify post-operative changes in a single case of UCS that underwent corrective surgery. The reproducibility of the index was assessed using test-retest reliability and was demonstrated to be highly reproducible (ICC = 0.93). A user-friendly measurement index that is based on open-source software may be a valuable tool for surgical teams. In addition, this information can augment the consultation experience for patients and their families.
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Affiliation(s)
- Emilie Robertson
- Division of Plastic and Reconstructive Surgery, University of Alberta, Edmonton, Canada.,Faculty of Rehabilitation Medicine, Department of Communication Sciences and Disorders, University of Alberta, Edmonton, Canada.,Institute for Reconstructive Sciences in Medicine, Misericordia Community Hospital, Edmonton, Canada
| | - Peter Kwan
- Division of Plastic and Reconstructive Surgery, University of Alberta, Edmonton, Canada
| | - Gorman Louie
- Division of Plastic and Reconstructive Surgery, University of Alberta, Edmonton, Canada
| | - Pierre Boulanger
- Department of Computing Sciences, University of Alberta, Edmonton, Canada
| | - Daniel Aalto
- Faculty of Rehabilitation Medicine, Department of Communication Sciences and Disorders, University of Alberta, Edmonton, Canada.,Institute for Reconstructive Sciences in Medicine, Misericordia Community Hospital, Edmonton, Canada
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