Advancement-onlay: an improved technique of fronto-orbital remodeling in craniosynostosis

Non-Surgical Touch-Up with Hyaluronic Acid Fillers Following Facial Reconstructive Surgery

The use of hyaluronic acid (HA) injectable fillers has become increasingly widespread in facial recontouring and rejuvenation. We report our experiences to emphasize the role of HA fillers as tools beyond aesthetic treatments in cases of post-surgical facial sequelae. HA fillers are generally used for aesthetic rejuvenation, but one potential new horizon could be their application in trauma, reconstructive, and craniofacial surgery. This study was conducted retrospectively, evaluating medical reports of patients treated at the Maxillofacial Surgery Unit, University of Campania “Luigi Vanvitelli”, Naples, for lip incompetence, trauma, oncological, reconstructive, and craniosynostosis surgery sequelae. Visual analog scale (VAS) evaluation was performed to assess patient satisfaction. No major complications (i.e., impending necrosis or visual loss) were reported. Bruising and swelling was reported for 48 h after lip injection. At the immediate VAS evaluation, 67% of the patients were “extremely satisfied” and 33% “satisfied”. In those 33%, VAS scores changed to “extremely satisfied” at 6–9 weeks and 3–6 months of VAS evaluation (contextually to improvement in tissue flexibility, elasticity, and aesthetic appearance). Results indicate that this minimally invasive approach achieves a high level of aesthetic enhancement, improving patient satisfaction. The concept of HA filler applications could be a frontier that may be applicable to other areas of reconstructive facial plastic surgery.

Is reverse frontal cranioplasty eligible for the correction of both the forehead deformities and the intracranial hypertension in craniosynostosis? Comparison of the preoperative and postoperative intracranial volumes

BACKGROUND

This study aimed to describe the surgical technique of reverse frontal cranioplasty (RFC), the aesthetical modification as well as the modification of intracranial volume (ICV) to assess its potential eligibility for the treatment of the intracranial hypertension (IH).

MATERIALS AND METHODS

A retrospective monocentric study included the patients with a history of craniosynostosis with a forehead deformity who underwent RFC. A subjective outcome questionnaire (SOQ) was conducted with each patient or their parent to determine their level of satisfaction after RFC. Pre- and postoperative computed tomography (CT) scans were analyzed and compared to investigate the ICV change and fronto-nasal angle.

RESULTS

Eleven patients were included in the study (6 female and 5 male) with a mean age of 10.9 years old (range 3-23 years) and an average follow-up of 4.5 years (1-11 years). All patients responded to the questionnaire with a high level of overall satisfaction (mean 9.1/10). The mean preoperative FNA was 134° ± 5° while the mean postoperative angle was 126.4° ± 6, corresponding to an average decrease of 7.6° (95% CI, 4.0-11.2°; p < 0.001). One patient with preoperative IH had a clinical recurrence during the follow-up. The ICV was significantly higher after the surgery (p < 0.0001), with an average increase of 3.2% (95% CI, 2.3-4.1%).

CONCLUSION

Reverse (RFC) is a useful technique for the correction of the frontal malformations related to craniosynostosis, such as a sloping forehead and/or a lack of the supraorbital projection. Regarding the limited gain of intracranial volume (ICV), it should not be used alone as primary cranial expansion surgery for craniosynostosis with intracranial hypertension (IH).

The Use of Finite Element Method Analysis for Modeling Different Osteotomy Patterns and Biomechanical Analysis of Craniosynostosis Correction

PURPOSE

Several post-processing algorithms for 3D visualization of the skull in craniosynostosis with their specific advantages and disadvantages have been already described. The Finite Element Method (FEM) described herein can also be used to evaluate the efficacy of the cutting patterns with respect to an increase in the projected surface area under assumed uniform loading of the manipulated and cut bone segments.

METHODS

The FEM analysis was performed. Starting with the classic cranial osteotomies for bifrontal craniotomy and orbital bandeau a virtually mirroring of the unaffected triangular shaped frontal bone was performed to achieve a cup-shaped sphere of constant thickness of 2.5 mm with a radius of 65 mm. Mechanical properties required for the analysis were Young's modulus of 340 MPa and Poisson's ratio of 0.22. Four different cutting patterns from straight to curved geometries have been projected onto the inner surface of the sphere with a cutting depth set to 2/3rds of the shell thickness. The necessary force for the deformation, the resulting tensions and the volume loss due to the osteotomy pattern were measured.

RESULTS

Better outcomes were realized with pattern D. The necessary force was 73.6% smaller than the control group with 66N. Best stress distribution was achieved. Curved cutting patterns led to the highest peak of stress and thus to a higher risk of fracture. Straight bone cuts parallel to the corners or to the thighs of the sphere provided a better distribution of stresses with a small area with high stress. Additionally, also with pattern D a surface increase of 20.7% higher than reference was registered.

CONCLUSION

As a proof of concept for different cutting geometries for skull molding in the correction of craniosynostosis, this computational model shows that depending of the cutting pattern different biomechanical behavior is achieved.

Bite force and electromyography evaluation after cranioplasty in patients with craniosynostosis

OBJECTIVE

This long-term follow-up investigation aimed to assess masticatory muscle function in 15 patients with craniosynostosis with detachment of the temporal muscle during fronto-orbital advancement 6 years after cranioplasty compared with a non-operative stomatognathic healthy cohort in the same age group (n = 25).

STUDY DESIGN

The follow-up assessment for the operated children occurred on average 5.2 ± 1.7 years after surgery at the age of 7 ± 1.6 years. The maximum bite force was assessed, in addition to the bilateral function of both temporal and masseter muscles, which were analyzed using superficial electromyography.

RESULTS

The maximum bite force was 257 ± 89 N 255 ± 88 N (right/left), respectively, in the group of operated children and 212 ± 61 N and 203 ± 57 N (right/left), respectively, in the control group, without clinical relevant difference between groups. The surface electromyography signal of the temporal muscle correlated positively with the bite force and showed a slightly lower average resting tone activity in the control group, whereas muscle fatigue occurred slightly faster in the operated children in both muscles without statistically significant difference between the 2 groups.

CONCLUSIONS

There was no measurable dysfunction in the temporal muscle after the operative correction of craniosynostosis compared with a healthy population of children.

Fronto-orbital advancement using an en bloc frontal bone craniectomy

BACKGROUND

Fronto-orbital advancement is a procedure commonly performed in craniofacial centers for coronal and metopic suture synostosis. Several variations of the technique have been reported.

OBJECTIVE

To describe our modifications to the anterior cranioplasty procedure and the results of our surgical series.

METHODS

Using our craniofacial database, we retrospectively analyzed the records of all patients undergoing fronto-orbital advancement for craniosynostosis. The same team of neurosurgeons and plastic surgeons performed all procedures. Demographic data, operative time, blood loss, length of stay, and clinical outcome were analyzed.

RESULTS

Of 248 patients treated for craniosynostosis, a total of 70 patients underwent fronto-orbital advancement. Nineteen presented with metopic, 26 with unilateral coronal, 17 with bilateral coronal, and 8 with multiple synostosis. Median age at surgery was 6.5 months. Mean operative time was 210 minutes; mean blood loss was 167 mL; and length of stay was 4.5 days. A positive correlation was found between operative time and blood loss (r = 0.1, P < .01) and age at surgery and blood loss (r = 0.3, P < .0001). There was a minor morbidity rate of 2.9%. A good reconstruction was obtained in all patients using our en bloc fronto-orbital advancement without any midline osteotomies at a mean follow-up of 15 months.

CONCLUSION

A team approach and the application of a standardized surgical technique should make it safer to operate in young children, shorten the surgical time, and lead to a reduction in blood loss. Reconstructing the frontal bone as an entire unit yielded excellent correction for coronal and metopic synostosis.

Early treatment of anterior calvarial craniosynostosis using endoscopic-assisted minimally invasive techniques

BACKGROUND

A total of 100 patients who presented with synostosis of the metopic or coronal suture were consecutively treated during a 6-year period using minimally invasive endoscopic-assisted suturectomies. After surgery, all patients were fitted with custom-made cranial helmets for up to 12 months.

MATERIALS AND METHODS

The coronal group consisted of 50 patients, 26 females and 23 males with a mean age of 3.78 months. Surgery was done through a single 2-mm incision at the ipsilateral stephanion. After endoscopic-assisted dissection, a craniectomy of the involved suture was done (mean width, 6 mm, and mean length, 10 cm). The metopic group consisted of 50 patients, 35 males and 16 females with a mean age of 4.1 months. A single 2- to 3-cm incision was placed on the midline behind the hairline. A suturectomy of the suture from anterior fontanelle to nasofrontal suture was performed (mean width, 7 mm, and mean length, 9.8 cm).

RESULTS

For the entire cohort, the mean estimated blood loss was 34 cc (5-250 cc). The mean estimated percent of blood volume lost was 5.2% (1-26%). There were no intraoperative blood transfusions and five postoperative for a total transfusion rate of 6.7%. The mean surgical time was 56 min. All but one patient (99%) was discharged on the first postoperative day. Complications included two dural tears and four pseudomeningoceles. There were two cases of incomplete reossification of the craniectomy. There were no infections, mortalities, hematomas, or visual injuries. There were no complications related to helmet therapy except three superficial skin breakdowns that cleared immediately with helmet non-use for 3-4 days. Using anthropometric measurements and extensive photographic and physical assessments, excellent results were obtained in 84%, good results in 9%, and poor results in 7% of patients.

CONCLUSIONS

Early treatment of infants with coronal or metopic craniosynostosis using endoscopic assisted minimally invasive suturectomies is a safe and efficacious treatment alternative associated with excellent results in a large portion of these patients.

3D visualization and simulation of frontoorbital advancement in metopic synostosis

OBJECTIVES

Current multislice computed tomography (CT) technology can be used for diagnosis and surgical planning applying computer-assisted three-dimensional (3D) visualization and surgical simulation. The usefulness of a technique for surgical simulation of frontoorbital advancement is demonstrated here in a child with metopic synostosis.

MATERIALS AND METHODS

Postprocessing of multi-slice CT data was performed using the software 3D slicer. 3D models were created for the purpose of surgical simulation. These allow planning the course of the osteotomies and individually placing the different bony fragments by an assigned matrix to simulate the surgical result. Photo documentation was obtained before and after surgery. Surgical simulation of the procedure allowed determination of the osteotomy course and assessment of the positioning of the individual bony fragments.

CONCLUSIONS

Computer-assisted postprocessing and simulation is a useful tool for surgical planning in craniosynostosis surgery. The time-effort for segmentation currently limits the routine clinical use of this technique.

Spring-Assisted Correction of Hypotelorism in Metopic Synostosis

BACKGROUND

Metopic synostosis, apart from the pointed forehead, typically is characterized by hypotelorism with egg-shaped orbits on cephalography and the frontoorbital axis parallel or even converging superiorly. The frontoorbital axis angle is a novel parameter for analyzing and describing the orientation of the orbits. Current methods of surgery often result in undercorrection of the almost ever-present hypotelorism. The present study was performed to analyze a new technique, capable in this respect, using steel wire springs in conjunction with a cranioplasty.

METHODS

A retrospective study of 23 metopic synostosis patients operated on between 1999 and 2004 was conducted. A strip midline craniectomy and frontal reshaping were combined with the insertion of a steel wire spring across the midline craniectomy, forcing lateral displacement of the orbits. Preoperative and postoperative follow-up cephalograms were obtained, and the bony medial interorbital distance was measured and compared with the bony medial interorbital distance of a control group. Perioperative data and complications were noted.

RESULTS

Preoperative mean bony interorbital distance was 10.6 mm (range, 7.7 to 13.2 mm). It increased to 15.7 mm (range, 10.4 to 22 mm) at 1.5 months postoperatively and to 16.2 mm (range, 10.9 to 24.5 mm) 5 months postoperatively. Results as judged clinically ranged from little effect to a definitive overcorrection. The frontoorbital axis was improved in every case. Average frontoorbital axis was -4 degrees (range, -33 to 23 degrees) preoperatively and 28 degrees (range, 11 to 46 degrees) postoperatively.

CONCLUSION

It was concluded that a spring used together with a cranioplasty is a powerful tool for the correction of both hypotelorism and orbital shape in trigonocephaly.

Emotional and psychological impact of delayed craniosynostosis repair

INTRODUCTION

Among children with craniosynostosis, there exists an interesting dynamic involving parents' preconceptions of craniosynostosis and its repair, influenced in large part by differing cultural perspectives. In a time in which we are understanding how critical a child's early formative years are in influencing his/her emotional and psychological development, the authors describe one medical aspect involved in that dynamic process.

MATERIALS AND METHODS

The authors reviewed their cumulative experience at the Children's Hospital San Diego between January 2000 and June 2004 and identified nine children with significant craniofacial deformities and, for one reason or another, had delayed surgical repair.

DISCUSSION

The authors have found that by age 6, parents will often bring their children back to their physician and insist on surgical correction. The significant motivating factor in most of these cases stems from teasing by classmates with respect to head shape. In this manuscript, we report and discuss some of the emotional and psychological issues associated with delayed craniosynostosis repair. Often times, these issues are overlooked or underemphasized in the overall surgical care of such patients.

Prevention of Temporal Depression That Follows Fronto-orbital Advancement for Craniosynostosis

Contour abnormalities presenting after fronto-orbital advancement for craniosynostosis are common. Often there is bilateral temporal depression, the result of leaving a coronal bony gap posterior to the advanced segments. The authors present techniques to prevent this temporal depression by utilizing full-thickness bone grafts for structural support in the inferior coronal defects, and cortico-cancellous graft in the remaining superior coronal and parietal donor defects. Prior to contouring and repositioning the frontal elements, a hand-driven Hudson brace and D'Ericco bit is used to harvest cortico-cancellous bone "mush" from the endo- and ectocortical surfaces. The bandeau and frontal elements are advanced and secured, and the resultant coronal gap is measured. Full-thickness cranial bone grafts are harvested from the parietal regions (near the vertex) and secured in the coronal defect behind the frontal elements. The temporalis muscle is rotated, advanced, and secured to the bandeau. Bone mush is used to fill the remaining superior coronal and donor site defects. Representative case examples are presented.

Fronto-orbital and cranial osteotomies with resorbable fixation using an endoscopic approach

Over the past 3 years the authors have used modified minimally invasive endoscopic techniques in the surgical correction of craniosynostosis. For selected patients, these techniques offer an alternative to traditional techniques, minimizing postoperative morbidity and the need for cranial banding. Long-term follow-up will be needed to assess the ultimate efficacy of these techniques. Traditional techniques for repair of craniosynostosis have historically had a record of excellent aesthetic results with acceptable morbidity. Ultimately, each patient is best served by a customized plan, developed and implemented by a multidisciplinary team capable of the full range of techniques.

Predicting the risk of reoperation in metopic synostosis: a quantitative CT scan analysis

Children with metopic synostosis have a well-described clinical picture of trigonocephaly, often with hypotelorbitism. The craniofacial disorder itself is well recognized; however, objective prognostic factors for predicting the risk of reoperation are not well known. In 39 children with metopic synostosis, measurements of the cranial length, cranial width, anterior intercoronal distance, anterior interorbital distance (intercanthal distance), lateral orbital distance, and interzygomatic buttress distance were taken from preoperative computed tomographic (CT) scans and were normalized relative to each child's age. To separate overall facial hypoplasia from regional hypoplasia, a ratio of intercanthal distance to interzygomatic buttress distance was determined. These prognostic factors were analyzed with respect to reoperation rate. A stepwise logistic regression analysis was used to determine the interrelationships between the prognostic factors. Twenty-eight percent of the children underwent reoperation (N=11, 1 total reoperation and 10 minor recontouring). All of the reoperations occurred in children with a decreased intercanthal distance (p=0.30). The ratio of intercanthal distance to midfacial width was related to reoperation rate, with those children who had a ratio < or =0.80 having a reoperation rate of 44% (8 of 18 total children with an intercanthal-to-zygomatic ratio < or =0.8, p=0.07). This relationship was significant in children younger than the age of 12 months (6 of 13 total children with an intercanthal-to-zygomatic ratio < or =0.8, 46% reoperation rate, p=0.006). This study suggests that preoperative CT measurements can be used as a means of risk stratification in outcome analyses of the surgical treatment of craniosynostosis. In children treated for metopic suture synostosis, a foreshortened intercanthal distance compared with the interzygomatic buttress distance was related to reoperation rate, especially in children younger than 12 months of age.

Fronto-orbital remodeling without orbito-naso-frontal bandeau

INTRODUCTION

Fronto-orbital bilateral advance is the procedure of choice for the treatment of craniosynostosis affecting most of the anterior area of the skull and orbitomalar regions. The aim of the technique is to achieve a supra-orbital bilateral bar and a frontal bone. We have introduced a modification in order to simplify the technique.

PATIENTS AND METHODS

From November 1998 to January 2002, 18 patients with craniosynostosis have been surgically treated using our technique. The mean age when the treatment was performed was 6.93 months (range 3 to 22 months). Brain computed tomography (CT) scans and three-dimensional (3-D) reconstruction of CT scans were performed before and after treatment.

SURGICAL TECHNIQUE

A bifrontal craniotomy was performed taking the osteotomy up to the supraorbital rim. A new frontal bone was obtained from another region of the cranium creating new orbital edges. The osteosynthesis was conducted using absorbable materials.

RESULTS

The follow-up of the patients ranged from 3 months to 3 years. All patients were studied using CT scans and 3-D reconstruction of CT after treatment, which demonstrated the persistence of the fronto-orbital advance. No secondary complications related to the new technique were found in any of the patients.

CONCLUSIONS

The frontal-orbital advance obtained was stable. The technique was simplified by not creating a supraorbital bar and by reducing the bone fixation points. The manipulation of both frontal lobes and orbital globes was negligible. The aesthetic results were excellent.

Onlay bone graft augmentation for refined correction of coronal synostosis

OBJECTIVE

The primary purpose of this study was to evaluate the long-term result of an onlay bone graft augmentation of the supraorbital ridge at the time of primary correction of coronal suture synostosis.

DESIGN

The study is a retrospective review of 62 consecutive patients treated for coronal synostosis from June 1991 through February 1997. The surgical technique utilized involved a standard bilateral fronto-orbital advancement and calvarial reshaping with the addition of an onlay bone graft in the supraorbital region.

SETTING

All patients were treated at a tertiary care craniofacial center.

RESULTS AND CONCLUSION

A total of 62 patients were treated by this technique. Fifty patients underwent primary correction as infants (mean age 9.8 months). An additional 12 patients were older (mean age 8.2 years) and were treated for residual deformity having previously undergone correction by another technique. Results with follow-up as long as 7 years demonstrate stable forehead and orbital symmetry. Complications identified by chart review were minimal and not directly attributable to this modification in surgical technique.

Early management of craniosynostosis using endoscopic-assisted strip craniectomies and cranial orthotic molding therapy

OBJECTIVE

To assess the safety, efficacy, and results of the early treatment of infants with craniosynostosis using minimally invasive endoscopic strip craniectomies and postoperative helmet molding therapy.

METHODS

A total of 100 patients with documented diagnosis of craniosynostosis were prospectively studied and treated with endoscopic strip craniectomies. A total of 106 stenosed sutures were operated on with the following distribution: 61 sagittal, 23 coronal, 18 metopic, and 4 lambdoid sutures. Sixty-three patients were treated under 16 weeks of age. After surgery, all patients were treated with custom-made molding helmets for up to 7 months. Follow-up ranged between 4 months and 50 months.

RESULTS

All patients underwent the surgical procedures successfully and without complications. The mean surgical operative time was 52.7 minutes. The mean estimated blood loss was 26.2 mL; only 1 patient underwent intraoperative blood transfusion, and 10 patients had a non- life-threatening postoperative blood transfusion. All but 3 patients were discharged on the first postoperative day. There were no infections, dural sinus tears, cerebrospinal fluid leaks, or neurologic injuries, and there were no significant complications related to the use of helmet therapy. Most patients have achieved or are in the process of reaching normalization of their craniofacial deformities.

CONCLUSIONS

The results indicate that the early treatment of craniosynostosis with minimally invasive endoscopic strip craniectomies is a safe, efficacious, and valuable therapeutic alternative to the current extensive surgical treatment modalities. The significantly less blood loss, need for blood transfusions, and length of stay and decreased costs make this procedure an excellent early option for treating infants who present with craniosynostosis.

The craniofacial dysostosis syndromes: current surgical thinking and future directions

Craniofacial dysostosis is the term applied to familial forms of craniosynostosis in which the sutural involvement generally includes the cranial vault, cranial base, and midfacial skeletal structures. The syndromic forms of craniofacial dysostosis were initially described by Carpenter, Apert, Crouzon, Saethre and Chotzen, Pfeiffer, and others. In addition to the dysmorphic cranial features, affected individuals may have profound alterations in facial skeletal development. Surgical reconstruction requires thoughtfully sequenced and staged procedures with consideration for the individual's specific malformations, craniofacial growth patterns, and psychosocial needs. Management of the craniofacial dysostosis syndromes is surgical, but the indications and the timing, type, and effectiveness of each stage of reconstruction have not been well evaluated and remains as much an art as a science. This article reviews the specific characteristic clinical features of the craniofacial dysostosis syndromes and presents current philosophy and rationale for the staging of reconstruction.

The Craniofacial Dysostosis Syndromes: Current Surgical Thinking and Future Directions

Craniofacial dysostosis is the term applied to familial forms of craniosynostosis in which the sutural involvement generally includes the cranial vault, cranial base, and midfacial skeletal structures. The syndromic forms of craniofacial dysostosis (CFD) were initially described by Carpenter, Apert, Crouzon, Saethre and Chotzen, Pfeiffer, and others. In addition to the dysmorphic cranial features, affected individuals may have profound alterations in facial skeletal development. Surgical reconstruction requires thoughtfully sequenced and staged procedures with consideration for the individual's specific malformations, craniofacial growth patterns, and psychosocial needs.

Management of the CFD syndromes is surgical, but the indications and the timing, type, and effectiveness of each stage of reconstruction have not been well evaluated and remains as much an art as a science. This article reviews the specific characteristic clinical features of the CFD syndromes and presents current philosophy and rationale for the staging of reconstruction.

Metopic synostosis: in favour of a "simplified" surgical treatment

Metopic synostosis is a relatively simple form of craniosynostosis, resulting from premature fusion of the metopic suture. In this pathology different degrees of dysmorphia of the anterior cranial fossa and the presence of associated anomalies of the skull might enable specific subgroups to be identified. Since most functional and cosmetic anomalies benefit from early surgical treatment, over the last few years neurosurgeons have been forced to elaborate less drastic, but nonetheless effective, surgical techniques. In the present report we analyze the surgical results obtained in a series of 62 infants with trigonocephaly operated on within their 1st year of life. Patients were subdivided into two groups (group I: 8 patients; group II: 54 patients) according to the specific dysmorphic characteristics of the frontal bone and anterior cranial fossa, and the presence of compensatory deformities affecting the anterior cranial base and temporo-parietal region. All the patients were treated using one of two relatively simple surgical techniques (procedure A: inversion of two hemifrontal bone flaps--48 cases; procedure B: the "shell" operation--14 cases). Both surgical procedures appeared to be effective, allowing adequate functional and cosmetic correction of the cranial deformity. In patients operated on following procedure B surgical time and blood loss were dramatically reduced. Long-term outcomes were satisfactory in all cases, irrespective of the surgical technique used. In the group II patients, however, progressive normalization of the interorbital distance was constantly observed, suggesting a different degree of stenotic involvement at the level of the anterior cranial base in these patients.

Stability of fronto-orbital advancement in nonsyndromic bilateral coronal synostosis: a quantitative three-dimensional computed tomographic study

Fronto-orbital dysmorphology in nonsyndromic bilateral coronal synostosis includes frontal flattening, supraorbital recession, and ocular globe protrusion. Surgical advancement of the supraorbital region ("bandeau") is performed to correct these deformities. A retrospective analysis of 10 consecutive patients with nonsyndromic bilateral coronal synostosis was performed to assess the effect of two types of bandeau fixation at the nasion. The advanced bandeau was fixed medially at the nasion with a calvarial bone graft and polyglycolic acid sutures (bone graft/suture group, five patients) or with a microplate (plate group, five patients) and bilaterally at pterion with calvarial bone grafts and polyglycolic acid sutures (all patients). The cranio-orbital dysmorphology and the surgical results were studied using pre-, peri-, and post-operative three-dimensional computed tomographic (CT) data. Reformation, manipulation, editing, and quantitative measurements of the CT data were performed on a computer workstation and Analyze imaging program. Four measurements performed to evaluate the fronto-orbital morphology: the length:width ratio of anterior cranial fossa, ventral globe index, cornea position, and supraorbital rim lag. The ventral globe index assessed the degree of eyeball protrusion out of the orbit cavity. Measurements of the cornea position and supraorbital rim lag were performed on the longitudinal orbit projections of the CT data. Six normal skull CT scans were available for same measurement and comparison. Measurements of the preoperative fronto-orbital dysmorphology in bilateral coronal synostosis were significantly different from those of normal subjects. One year after the surgery, the length:width ratio of the anterior cranial fossa was normalized in both groups. The ventral globe index was improved but not normalized in both groups, whereas the cornea position and supraorbital rim lag were improved in the bone graft/suture group but were normalized in the plate group. Based on the quantitative data, the surgical outcomes in the plate group were significantly better than those in the bone graft/suture group. Major relapse of surgical advancement in the bone graft/suture group seemed to occur in perioperative period. In summary, at 1 year postoperatively, the bandeau advancement improved but did not entirely normalize the fronto-orbital dysmorphology of nonsyndromic bilateral coronal synostosis in either group. We conclude that plate rigid fixation at the nasion provides superior stability for bandeau advancement compared with bone graft/suture fixation.

Trigonocephaly-associated hypotelorism: is treatment necessary?

This study was designed to examine whether hypotelorism associated with trigonocephaly might be self-correcting. Only patients who required surgical treatment and had undergone preoperative and postoperative anthropometric measurements were included. In no case was any attempt made to correct the hypotelorism surgically. The study sample consisted of 16 patients, of whom 10 underwent preoperative and postoperative computed tomography in addition to anthropometric examinations. The results were compared with sex- and age-matched pooled normal standards, converted to standard Z scores, and analyzed by means of Student's t tests. Both intercanthal and interorbital widths increased significantly postoperatively, with improvements in delta Z scores of 0.445 (p < or = 0.01) and 0.638 (p < or = 0.05). These increases exceeded average growth increments by 1.6 mm for intercanthal width and 1.3 mm for interorbital width. Improvement in the intercanthal widths was significantly greater in the more severely affected children than in those whose conditions were less severe. A greater improvement in interorbital width also was noted in children treated at less than 6 months of age compared with those treated later. The younger the patient at surgery, the greater was the improvement, suggesting that early surgery may somehow release a constraint on interorbital growth.