Intracranial pressure in craniostenosis

In this study, intracranial pressure (ICP) was recorded with an epidural sensor for periods of 12 to 24 hours in 92 cases of craniosynostosis. Pre- and postoperative recordings were performed in 23 patients, and 55 children underwent preoperative psychometric testing. The ICP was found to be normal in one-third of the cases, was obviously elevated in one-third, and was borderline in one-third. Waves of increased ICP were recorded during rapid eye movement (REM) sleep. After surgery, ICP decreased progressively and returned to normal in several weeks. A significant statistical relationship was found between the patients' ICP and their mental level: the higher the ICP the lower the mental level. The regression curve of ICP as a function of age shows that ICP is maximal at the age of 6 years and decreases later. The significance of these results is discussed. The authors recommend that ICP be recorded in cases of craniosynostosis since it is of some help in deciding whether patients should undergo surgery.

Genetic study of nonsyndromic coronal craniosynostosis

From a series of 1265 individuals with different craniosynostoses hospitalized between 1976 and 1993, 260 probands with nonsyndromic unilateral (181) or bilateral (79) coronal synostosis were analysed. The prevalence of craniosynostoses was estimated as 1 in 2100 children. In the group of coronal synostosis, family history was obtained on 192 probands in 180 pedigrees. The male:female ratio was 1:2. The average paternal age was 32.7 +/- 6.4 years, which is significantly higher than normal. In 26 of the 180 pedigrees, a high degree of familial aggregation was observed, giving a 14.4% figure of familial cases. The bicoronal synostoses were significantly more often familial than the unicoronal synostoses. Segregation analysis of these families leads to the conclusion that coronal synostosis is transmitted as a dominant disorder with 0.60 penetrance and 61% of sporadic cases.

Management of craniosynostoses

Although it is currently thought that surgery is indicated mainly for cosmetic reasons in isolated craniosynostoses, the functional aspects of the treatment must not be underestimated. Prospective studies on intracranial pressure and mental evolution of these children have shown that there were functional consequences in a significant proportion of cases even of single suture fusion. The frequency of increased intracranial hypertension and the risk of mental impairment depend on the age of the child and the type of craniosynostosis. In nonsyndromic cases, the higher risks are observed in multisutural craniosynostoses (brachycephaly, oxycephaly). In syndromic cases, the risk of intracranial hypertension is higher in Crouzon syndrome, and Apert syndrome carries the higher risk of mental retardation. The study of a personal series of 2,137 craniosynostoses shows that the functional and the cosmetic results are better after early surgery, and that the operative risks are not higher in infants than in older children.

Intracranial pressure and intracranial volume in children with craniosynostosis

Intracranial volume and intracranial pressure have been measured in 66 children with craniosynostosis, 48 boys and 18 girls. The premature fusion of skull sutures is assumed to restrict skull growth and predispose to elevated intracranial pressure. Thirteen children (20 percent) had raised intracranial pressure and demonstrated a significant restriction of skull growth. In this series, volume measurement alone, however, did not serve as a reliable predictor that the intracranial pressure was raised.

Combined report of problems and complications in 793 craniofacial operations

We report the experiences in 6 major craniofacial centers, with similar teams but in different parts of the world, in a total of 793 craniofacial operations. The mortality rate was 1.6%. Complications developed in 16.5% of the cases (including infections in 4.4%). This surgery has many potential advantages, not least of which is its psychosocial effects on previously disfigured patients. Certain problems seem inherent, however, for there are not yet any satisfactory solutions to them. Some of the factors that reduce morbidity and improve results include the use of hypotensive anesthesia, a reduction in operating time, rigid stabilization of the mobilized bones at the end of the operation, a diminution in the number of incisions, and extensive antibiotic therapy.

Genetic study of scaphocephaly

From a series of 1,408 patients with craniosynostosis hospitalized between 1976 and 1994, 561 probands with non-syndromal isolated sagittal synostosis were analyzed. The prevalence of sagittal synostosis was estimated in the order of 1 in 5,000 children. Family information was obtained from 373 probands distributed among 366 families. The male:female ratio was 3.5:1. There was no maternal or paternal age effect. In 22 of the 366 pedigrees, a high degree of familial aggregation was observed, giving a 6% figure of familial cases. Segregation analysis of 253 families indicates that sagittal synostosis is transmitted as a dominant disorder with 38% penetrance and 72% of sporadic cases. The frequency of twinning was 4.8% with only 1 concordance for sagittal synostosis in a monozygotic twin pair. The possibility of a mechanical pathogenesis in sporadic cases is discussed.

Long-term experience with methylmethacrylate cranioplasty in craniofacial surgery

Cranioplasty is a procedure commonly performed by plastic surgeons involved in craniofacial surgery, in which it is generally accepted that the ideal reconstructive material is autogenous bone. When this is not available or when its use is inappropriate, alloplastic materials are the next best option. A retrospective analysis was carried out to review the senior author's experience of 98 cranioplasties with methylmethacrylate (MM) from 1980 to 2001. The site and size of the implant and complications thereof were recorded and an assessment of the quality of the final result made. The patients were divided into two groups: Group 1: Methylmethacrylate as a full thickness inlay. Group 2: Methylmethacrylate as an onlay only. In group 1 there were 32 patients for whom the average follow up was 8.2 years (range 2-16 years). In group 2 there were 66 patients with an average follow up of 7.1 years (range 2-20 years). After a minimum follow up of 2 years, 89 out of 98 of the patients retained their implants. Nine implants in total were removed. Of the 89 patients retaining their implants, 85 had excellent or good results at long-term follow up. The infection and implant removal rate was very high if nasal or frontal sinus tissue was in direct contact with the implant during the operative procedure. The keys to the successful use of methylmethacrylate are discussed and representative case examples are presented. There is increasing evidence that the long term results of newer alternatives to methylmethacrylate for cranioplasty such as hydroxyapatite cement are disappointing and do not justify their expense. Methylmethacrylate is cheap, readily available and easy to use and it remains the alloplastic material of choice for cranioplasty in our hands.

Prognosis for mental function in scaphocephaly

Three hundred ninety-six children with scaphocephalies were prospectively studied to analyze the correlation between age, intracranial pressure (ICP), and mental function outcome. The ICP measurements and the early and late psychometric assessments were compared. The influence of surgery, when performed, was analyzed. In most cases, the mental function outcome of the patients was good whether or not they had undergone surgery. The mental level and the frequency of increased ICP both correlated with patient age. A correlation was found between the early and late psychometric assessments in all patients. Thus, the main predictive factor of mental function outcome appears to be the initial developmental level.

Hydrocephalus and craniosynostosis

OBJECT

A retrospective study of 1727 cases of craniosynostosis was undertaken to determine the interrelationship between abnormal cerebrospinal fluid (CSF) hydrodynamics and craniosynostosis.

METHODS

The patients were divided into two groups: nonsyndromic craniosynostosis and syndromic craniosynostosis. Cases of occipital plagiocephaly without suture synostosis and cases of shunt-induced craniosynostosis were excluded from the study. The majority of patients (1297) were treated surgically for their cranial deformity; 95% of these patients had a postoperative follow-up review period lasting 5 years. Clinical and radiographic charts covering the time from presentation through the follow-up period were reviewed.

CONCLUSIONS

Abnormal intracranial CSF hydrodynamics was found in 8.1% of the patients (3.4% of whom had received shunts and 4.5% of whom had not). Three types of CSF hydrodynamic disturbance were observed: progressive hydrocephalus with ventricular dilation, nonprogressive ventriculomegaly, and dilation of the subarachnoid spaces. Hydrocephalus occurred much more frequently in patients with syndromic craniosynostosis (12.1%) than in those with isolated craniosynostosis (0.3%). In fact, patients with kleeblattschädel exhibited hydrocephalus as a constant feature and patients with Crouzon's syndrome were far more likely to have hydrocephalus than those with other syndromes. In Apert's syndrome, ventricular dilation occurred very frequently, but it was almost always nonprogressive in nature. In most cases of syndromic craniosynostosis, venous sinus obstruction and/or chronic tonsillar herniation were found. Their role in the pathophysiology of hydrocephalus in craniosynostosis is discussed.

Prognosis for mental function in Apert's syndrome

The factors involved in the mental development of patients with Apert's syndrome were studied by the authors, focusing on the age of the patient at operation, associated brain malformations, and the quality of the family environment. Overall, 32% of patients with significant follow-up review had an intelligence quotient (IQ) greater than 70. Age at operation appeared to be the main factor associated with changes in mental development: final IQ was greater than 70 in 50% of patients operated on before 1 year of age versus only 7.1% in patients operated on later in life (p = 0.01). Malformations of the corpus callosum and size of the ventricles played no role in the final IQ, whereas anomalies of the septum pellucidum had a significant effect, with the proportion of patients with an IQ over 70 increasing more than twofold in patients with a normal septum compared with patients with septal anomalies (p < 0.04). Quality of the family environment was the third factor involved in intellectual achievement: only 12.5% of institutionalized children reached a normal IQ level compared to 39.3% of children from a normal family background.

Syndromal and nonsyndromal primary trigonocephaly: analysis of a series of 237 patients

From a series of 1,713 patients with craniosynostosis hospitalized between 1976 and 1996, 237 propositi with metopic synostosis were analyzed. The prevalence of metopic synostosis was estimated in the order of 1 in 15,000 children. Family information was obtained from 184 propositi from 179 families. The male-to-female ratio was 3.3:1. There was no maternal or paternal age effect. A family history was obtained in 10 of the 179 families, giving a 5.6% figure of familial cases. The frequency of twinning was 7.8% with two concordances for metopic synostosis in two monozygotic twin pairs. The male-to-female ratio, the twinning frequency, and the proportion of familial cases in trigonocephaly are very similar to those observed in scaphocephaly, which also involves the longitudinal sutural system. Fetal exposure to valproic acid was noticed in eight cases. The series was divided into two groups: nonsyndromal trigonocephaly (n = 184) and trigonocephaly associated with other malformations (n = 53). The second group included 13 cases of well-delineated syndromes and 40 cases of trigonocephaly associated with one or more malformations, but without any known syndrome, that could be undelineated syndromes. These groups differed significantly in their mental prognosis.

Timing of treatment for craniosynostosis and facio-craniosynostosis: a 20-year experience

The timing of surgery for craniosynostosis is still controversial. Having used the same basic techniques since 1973, and having done follow-up on the growth of our 983 operated patients, we thought it useful to report our protocol. Early frontocranial remodelling is performed between 2 and 4 months for brachycephalies, but the other craniosynostoses are operated on between 6 and 12 months of age. When diagnosis is made later, we perform the same operations until 4 years of age, with some modifications, such as a tongue in groove advancement for brachycephalies, and a complete closure of the bony defects after 2 years of age. Later on, facial distortion and frontal sinus development complicate the surgery. For syndromal craniofacial synostosis, we prefer to perform a two-step operation: forehead advancement first, facial advancement later, to avoid the risk of frontal osteitis. The frontofacial monobloc is indicated, in our opinion, for severe exorbitism in infancy but otherwise we prefer a two-stage procedure. Facial bipartition is necessary to narrow the upper face and widen the maxilla in Apert's syndrome.

Face lifts and sprayed fibrin glue: an outcome analysis of 200 patients

The use of aerosolised fibrin glue has been evaluated in a group of 100 consecutive patients undergoing face lift procedures and compared to a similar group of 100 consecutive patients who had face lifts but received no fibrin glue. There was a statistically significant decrease in the rate of major haematoma formation and presentation of ecchymosis associated with the use of fibrin glue. The incidence of total complications was unchanged between the two groups, despite the fact that there were no drains or postoperative dressings used in the fibrin glue treated group. Patients found the omission of drains and dressings to be most convenient.

Experience with the "floating forehead"

The effectiveness of the "floating forehead" operation for treating brachycephaly in infants has been assessed. All children who had undergone this procedure at the Hôpital des Enfants Malades between 1977 and 1984 were reviewed retrospectively by an independent observer. Particular attention was paid to the effects on cranial growth, facial growth and morphology.

The axial frontonasal flap revisited

After 15 years of experience and 50 cases, we think that the axial frontonasal flap is of great value for the repair of large skin defects of the nose. This flap mobilizes all the skin cover of the nose located above the defect and the adjacent frontal skin and rotates it on a vascular pedicle existing at the level of the inner canthi. The excess of skin of the glabella is then transferred to the nose, and this large flap allows coverage of the defect without tension or distortion. The long-term results are very good, with a hardly visible repair in 26 of 50 patients, the long scar being very well hidden at the periphery of the nose.

The operative treatment of isolated craniofacial dysostosis (plagiocephaly): a comparison of the unilateral and bilateral techniques

Both the safety and efficacy of the treatment of isolated craniofacial dysostosis (plagiocephaly) in infancy have been demonstrated. Opinions remain divided, however, as to the optimal type of procedure to be undertaken. In an attempt to answer this question, we have retrospectively evaluated a study population of 48 children operated on in infancy by either a unilateral or bilateral approach. Results of treatment at a minimal follow-up of 3 years were assessed based on preoperative and postoperative photographs and direct patient examination. Based on this retrospective comparison of the unilateral and bilateral approaches to the treatment of isolated craniofacial dysostosis, we conclude that (1) either approach as specifically outlined will give excellent results in the majority of patients, (2) there is no statistically significant difference in the results obtained by using either procedure, (3) in the majority of instances, less than ideal correction was manifested by contour irregularities evident in the temporal and/or lateral forehead region, and strict attention should be given to these areas in an attempt to further improve results, and (4) in those cases where significant protrusion is observed on the "normal side," a bilateral approach is preferable.

Classification of previously unclassified cases of craniosynostosis

Cases of craniosynostosis usually fall into well-demarcated categories: those related to a syndrome or those identified by a combination of suture involvement and morphological appearance. Between 1976 and 1995, 53 (3.6%) of 1474 cases in the craniofacial databank were assessed and designated as nonsyndromic but unclassifiable. The records and radiological studies obtained in these patients were retrospectively analyzed and comparisons were made with patients classified in the databank as having simple craniosynostoses. It proved possible to divide the formerly unclassifiable cases into two groups: those with "two-suture disease" (Group A) and a "complex" group (Group B) in which more than two sutures were affected. Group A consisted of 36 cases (68%) of patients presenting with clear evidence of simultaneous involvement of two sutures but with no progression over time to suggest a more diffuse pansynostosis. Suture involvement was as follows: 17 of 36 sagittal plus one coronal; seven of 36 sagittal and metopic; six of 36 sagittal plus one lambdoid; and six of 36 metopic plus one coronal. The only significant difference between the Group A cases and the cases of simple craniosynostoses was in the percentage requiring a second operation (24% vs. 5%, p < 0.0001). Group B consisted of 17 cases in which the patients presented at a slightly earlier age (mean 1 year) with severe morphological changes and multiple suture involvement. At the time of surgery, six of 17 patients showed large areas of lacunae within the cranial vault, making craniectomy the only option. In Group B, 10 of 17 patients displayed bilateral lambdoid plus sagittal suture involvement resulting in marked occipital recession posteriorly, whereas anteriorly in six of these 10 patients there was a massive frontal bone associated with posteriorly located coronal sutures. In contrast, there were also four patients in Group B with bilateral coronal plus metopic involvement resulting in a small frontal bone. There was a trend toward a lower intelligence quotient and a worse morphological outcome in the patients in Group B, but again the only result attaining statistical significance when compared to the databank was the rate of second operation (37.5 vs. 5%, p < 0.0001). "Two-suture synostosis" is a relatively straightforward condition and is treatable with standard craniosynostosis techniques. However, possibly as a result of surgical compromise when two sutures are involved, the rate of reoperation is far higher than in simple suture cases. In contrast, patients in the "complex" group presenting with severe multisuture involvement require a more tailor-made approach to their management that often entails a second procedure.

Intracranial volume in children with craniosynostosis

The intracranial volume of 104 children with craniosynostosis was measured. Premature fusion of skull sutures is thought to deny the growing brain room to expand, but contrary to traditional teaching the intracranial volume of such children is often within normal limits.

Fibrin glue fixation in forehead endoscopy: evaluation of our experience with 206 cases

The endoscopic approach has totally replaced the bicoronal approach for the treatment of forehead aging in our practice since November of 1993. The fixation in proper position is obtained with fibrin glue. Results of a series of 206 procedures performed in 196 patients are presented. Eyebrow positioning and muscle weakening were rated on a scale of 1 to 4. The evaluation has been made at a minimal follow-up time of 6 months. The comparison of the results between the first series of 28 patients during the first 6 months of our experience and the second series of 69 patients during the following period showed a significant increase in the number of excellent results (from 47 to 78 percent). Altogether, the satisfactory results (rated excellent or good) increased from 71 to 86 percent. Fibrin glue provides a stable fixation with the possibility of displacement in several directions, including transversal expansion. Complications have been minimal. Secondary procedures and association with other facial operations have been analyzed.

Midface surgery from Tessier to distraction

The wall separating the face and the cranium was broken by Paul Tessier and Gérard Guiot in the 1960s, making it possible to perform a combined operation around the orbits and forehead, and opening up close cooperation between plastic surgeons and neurosurgeons, especially for treatment of the major malformations such as hypertelorism of major facial retrusions. The principles of mobilization of the orbits to correct teleorbitism or orbital dystopia are recalled with reference to the different variations and with clinical examples. Facial advancement to correct the retrusions created by faciocraniosynostosis is explained with the many possible variants, combined with a intracranial approach or not, with or without a bipartition. The indications are discussed as is the risk linked to combined advancement of face and forehead. The progressive bone elongation principle introduced by Ilizarov for the limbs has been applied to the face at the mandibular level by McCarthy, with great success. The distraction of bone structures is now also applied at the level of the midface and makes it possible to overcome the retraction of soft tissues and lower the risk of relapse of facial retrusion. Many technical problems have still to be solved, but the results are already very promising. Many other applications of the distraction principle will be developed for the midface level, with other technical improvements such as the use of absorbable mini-plates and screws.

Craniosynostosis

Craniosynostosis affects approximately one infant out of one thousand. Increase of intracranial pressure and risks of functional problems are more frequent than previously thought, especially in single-suture synostosis. Frontocranial remodeling will correct both functional and esthetic consequences of craniosynostosis. The best time for surgery is the first year of life, 2-3 months of age for the brachycephalies, and 6-9 months of age for the other craniosynostoses. Not only does growth not deteriorate after forehead remodeling, but the adjacent orbitonasal areas improve with time. In Crouzon's disease and Apert's syndrome, early frontal advancement does not prevent the midface retrusion, and a radical frontofacial advancement may be occasionally indicated in very severe cases. Frontocranial remodeling is also indicated in children presenting with sequelae of classical neurosurgical treatment or those who have had no treatment.

Intracranial enlargement of the orbital cavity and palpebral remodeling for orbitopalpebral neurofibromatosis

Exophthalmos with lowering of the globe, eyelid enlargement, and canthal displacement are the usual consequences of orbitopalpebral neurofibromatosis. A cerebral hernia into the orbit may be seen on CT scan. An intracranial approach allows for pushing back the brain with a bone graft to create an enlarged orbital cavity, lifting the globe with a graft on the orbital floor, and fixing the canthi in proper position. An eyelid radical resection is performed in the same stage or later. This approach is discussed in the treatment of 17 cases of orbitopalpebral neurofibromatosis.

Fibrin glue in craniofacial surgery

Fibrin glue has been utilized for the past 15 years in Europe in plastic surgery, especially at the beginning for nerve and skin grafts. For 4 years, we have utilized it in craniofacial surgery in over 72 cases. No adverse reaction has been observed, and the various applications are discussed.

[Distraction osteogenesis with double internal devices combined with early frontal facial advancement for the correction of facial craniosynostosis. Report of clinical cases]

Frontofacial monobloc advancement is a surgical procedure which corrects at the same time both frontal and facial retrusions in faciocraniosynostosis. The high risk morbidity limited its use to major exorbitism or severe breathing impairment. We report the results of a preliminary experience in five children with a mean age of 3.8 years. All patients presented with a Crouzon or Pfeiffer syndrome. The procedure performed was a frontofacial monobloc osteotomy with peroperative mobilization. Two pairs of distractors (Martin-Medizin) were implanted. The upper pair of frontal distractors was located behind the supraorbital bar. The pair of temporo-zygomatic distractors (a modification of the MicroFrance prototypes) was implanted behind the zygomatic bone. In one patient a transfacial pin was connected to the anterior part the lower distractors, to avoid facial bipartition. Distraction was performed according to classical protocols with a 1 mm advancement per day, until sufficient advancement was obtained. The correction of exorbitism and facial retrusion was obtained in all cases. An open-bite was created by the advancement in two out of the five patients. Minor infection occurred in one patient. This combination of distractors with frontofacial advancement seemed to increase the efficacy and reduce the morbidity. This might lead to a one stage strategy for faciocraniosynostosis treatment, even if minor additive procedures will be necessary when children get older and that insufficient facial growth still reoccurs.

Use of coral granules in the craniofacial skeleton

Solid coral blocks have been used as a bone graft substitute in clinical orthopedics for more than 12 years. In this study, 36 patients with 54 craniofacial osseous contour defects received subperiosteal augmentations with natural coral granules made chiefly of calcium carbonate. The patients were followed for 12 to 36 months. The postoperative results were satisfactory; there were only 5 sites of clinically evident resorption. There were 2 incidences of wound irritation and 1 instance of overt infection. Technical aspects of the procedure are discussed.