Scaphocephaly and cranial vault reconstruction: Renier's 'H' technique

Complex Craniosynostosis in Pitt-Hopkins Syndrome: Case Report in Twins

INTRODUCTION

Pitt-Hopkins syndrome (PTHS) is a rare genetic syndrome associated with neurodevelopmental disorders and craniofacial dysmorphisms caused by variations in the TCF4 transition factor. The aim of this article was to report the case of two twin infants diagnosed with PTHS, confirmed by the identification of a heterozygous pathogenic variant in the TCF4 gene through DNA extracted from a buccal swab.

CASE PRESENTATION

Both infants presented with craniofacial asymmetry with a metopic crest and cranial deformity. During the diagnostic investigation, computed tomography with three-dimensional reconstruction of the skull showed premature fusion of the left coronal and metopic sutures in both twins. They underwent craniofacial reconstruction at the 9th month of age using a combination of techniques. The postoperative outcomes were satisfactory in both cases.

CONCLUSION

To the best of our knowledge, this is the first case report to describe the occurrence of complex craniosynostosis (CCS) in children with PTHS. Further studies are needed to determine whether the co-occurrence of PTHS and CCS described here indicates an association or is explained by chance.

Aesthetic results in children with single suture craniosynostosis: proposal for a modified Whitaker classification

OBJECTIVE

Aesthetic assessment after surgery for non-syndromic single suture craniosynostosis (SSC) is crucial. Surgeons' evaluation is generally based on Whitaker classification, while parental impression is generally neglected. The aim of this paper is to compare aesthetic perceptions of parents and surgeons after surgery for SSC, expressed by a 10-item questionnaire that complement Whitaker's classification.

METHODS

The authors submitted a 10-item questionnaire integrating Whitaker's classification in order to evaluate the degree of satisfaction, the detailed aesthetics results and the need for surgical revision, to surgeons and parents of a consecutive series of patients operated for SSC between January 2007 and December 2018. The results were collected blindly.

RESULTS

A total of 70 patients were included in the study. Scaphocephaly and trigonocephaly were the two most frequent craniosynostosis. Parents and surgeons general aesthetics evaluation and average rating for Whitaker's classification were 1.86 vs 1.67 (p = 0.69) and 1.19 vs 1.1 (p = 0.45) respectively. Parents' evaluation for scar perception and alopecia (p < 0.00001), the presence of bony crest (0.002), bony bump (p < 0.00001), or other bone irregularities (p = 0.02) are significantly worse when compared to surgeons' perception.

CONCLUSIONS

Parents seem to be more sensitive to the detection of some aesthetic anomalies and their opinion should not be neglected. The authors propose a modified Whitaker classification based on their results to better stratify the aesthetic outcome after surgery for SSC.

Novel Method of Lateral Vault Modification in Scaphocephaly

BACKGROUND

Scaphocephaly is the commonest from of craniosynostosis. There are several surgical methods to correct this and is influenced by the areas affected. A common thread in any of these corrections is an attempt to increase the biparietal diameter by modifying the lateral vault panel (LVP). A simple and novel method is proposed.

MATERIALS AND METHOD

The records of all patients undergoing scaphocephaly correction in the craniofacial unit at the institution were reviewed from 2003 to 2019. There were 106 patients, 57 males, and 49 females. The age ranged from 6 months to 5 years with a mean of 11 months. The method of vault remodeling was LVP only in 36 (34%), subtotal vault remodeling in 59 (56%), and total vault remodeling in 11 (10%). All 106 patients underwent LVP remodeling as part of the procedure. One or 2 wedge excisions was performed to increase the curvature of the LVP and this panel was fixed on the outside of the temporal squame bone.

RESULTS

The patients were followed up for a minimum of 1 year. Satisfactory results were obtained. The mean preoperative cephalic index was 64% and the mean postoperative index was 75%. There were minor complications such as screw visibility in a few patients.

CONCLUSIONS

Wedge excisions of the LVP is a simple and effective maneuver that can be used as strategy when performing scaphocephaly correction.

A Technique for Minimizing the Need for Hemotransfusion in Non-Syndromic Craniosynostosis Surgery

ABSTRACT

Surgery for craniosynostosis is associated with excessive blood loss, as well as morbidity and mortality risks. This study investigated the effectiveness of a surgical technique for nonsyndromic craniosynostosis intervention in controlling bleeding, assessed based on the volume of blood transfused. The cohort included 73 children who underwent nonsyndromic craniosynostosis surgery during a 3-year period. Retrospective evaluation of patient parameters included sex, weight, and age at the time of surgery; type of craniosynostosis; duration of surgery; hemoglobin concentration before and after surgery; rate of transfusion; and volume of transfused blood (mL/kg). The surgical technique involved skin incision and subgaleal dissection using electrocautery with a Colorado needle tip. The pericranium was not removed but instead kept in situ, and orbiectomy was performed using piezosurgery. Of the 73 children in the cohort, 75.3% underwent fronto-orbital advancement and were included in the analysis. The average age was 10.9 months (range: 4-96 months), with 68.5% boys and 31.5% girls (P < 0.001). The most common type of craniosynostosis was trigonocephaly (57.5%), followed by scaphocephaly (19.2%). The mean duration of the surgery was 2 hours and 55 minutes. Blood transfusion was needed in 56.2% of patients, with a mean volume of 8.7 mL/kg body weight transfused intraoperatively. No complications or fatalities were observed. These results suggested that meticulous, continuous control of homeostasis is paramount in minimizing blood loss during surgical repair of nonsyndromic craniosynostosis.

Triple square extended osteotomies for treatment of scaphocephaly (Renier's "H" technique modification)

Scaphocephaly is the most common single suture craniosynostosis. Surgical technique has evolved from simple strip craniectomy over π-procedures and vertex craniectomies to extensive cranial remodeling which is preferred procedure nowadays. The purpose of this paper is to present our modification of Renier's standard "H" technique and its preliminary results in detail. Eleven patients with scaphocephaly were surgically treated from January 2011 until January 2014. Only children with isolated sagittal synostosis were included in the study. Our modified Renier's technique reduces the possibility of lesion of superior sagittal sinus, dividing parietal bone in three bone fragments, thus achieving shortening of the scull in AP diameter without detaching the bone from the superior sagittal sinus. The possibility for potential secondary stenosis is minimized using extended V-shaped osteotomies with rounding of the bone edges, as well as making wide neocoronal and neolambdoid sutures. Cosmetic results were estimated as very pleasing immediately after surgery by both the parents and the surgeons in all cases. The majority of patients presented in our study were categorized as Sloan Class 1. Improvement or normalization of the cranial index was accomplished in all patients. No revision surgeries were required during the follow-up. Triple square extended osteotomies technique is a fast, simple, and efficient surgical option for children with sagittal synostosis and can be safely applied in the first months of life in children even under weight of 6 kilos. Preliminary results are encouraging and deserve a longer follow-up and comparative surgical analysis to verify its usefulness in the future.