Monobloc and facial bipartition osteotomies for reconstruction of craniofacial malformations: a study of extradural dead space and morbidity

An Elderly Patient With Crouzon Syndrome Treated With Monobloc Distraction

Monobloc advancement by distraction osteogenesis is the treatment of choice in patients with syndromic craniosynostosis. This procedure is usually performed at 18 to 24 months/5 to 10 years of age. Herein, we present the case of a male patient with Crouzon syndrome who underwent monobloc advancement at the age of 62 years. Although the patient lived a normal life (employed, married, and being a father of a daughter), he visited our hospital for surgical improvement in facial esthetics. The patient underwent monobloc advancement by distraction osteogenesis. He was satisfied with the postoperative esthetic improvement and did not experience any major complications. This case highlights the fact that patients with syndromic craniosynostosis desire esthetic improvement and suggests that multidisciplinary treatment involving both the neuro and plastic surgeons is important in such cases.

Anterior Skull Base and Pericranial Flap Ossification after Frontofacial Monobloc Advancement

BACKGROUND

Frontofacial monobloc advancement creates a communication between the anterior cranial fossa and nasal cavities. To tackle this issue, transorbital pericranial pedicled flaps are routinely performed in the authors' center. This study aimed to assess the postoperative ossification of the anterior skull base and pedicled flaps following frontofacial monobloc advancement, and to identify factors influencing this ossification.

METHODS

Measurements of the skull base only and of the ossified pedicled flaps together with the skull base were performed on computed tomographic scans at the nasofrontal and the nasoethmoid frontal junctions. The total thickness of the skull vault was measured and a qualitative defect score for the anterior skull base was computed.

RESULTS

Twenty-two patients who underwent frontofacial monobloc advancement at a median age of 3.1 years (range, 1.9 to 3.6 years) were included: 14 with Crouzon, five with Pfeiffer, and three with Apert syndrome. One year and 5 years after surgery, the distraction gap was completely ossified in the anterior skull base midline in all patients. Ossified pedicled flaps together with the skull base were thicker in patients than in controls at these two time points (p < 0.005 and p < 0.02). Patients with Pfeiffer syndrome had a significantly thicker skull base only and ossified pedicled flaps together with the skull base thicknesses (p = 0.01 and p = 0.03) and lower defect scores than patients with Crouzon or Apert syndrome (p = 0.03) 1 year postoperatively.

CONCLUSION

As ossification of the pedicled flaps and total reossification of the anterior skull base midline were observed in all patients, the authors indicate that performing pedicled flaps in frontofacial monobloc advancement surgery could promote the reossification of the anterior skull base.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Advances in the Treatment of Syndromic Midface Hypoplasia Using Monobloc and Facial Bipartition Distraction Osteogenesis

Midface hypoplasia or retrusion remains a persistent feature of syndromic craniosynostosis years after successful treatment of the cranium. Although expansion of the cranial vault in infancy by traditional fronto-orbital advancement, posterior expansion, or both, can treat the immediate intracranial constriction, midface hypoplasia and its stigmata of exorbitism, sleep apnea, central face concavity, and malocclusion remain suboptimally treated. Initial enthusiasm for the procedures was tempered due to a high rate of infectious complications; timing and indications for surgery continue to stir controversy. During the last decade renewed interest with the monobloc and facial bipartition procedure using distraction osteogenesis with either an internal or external distraction system has decreased morbidity significantly. These procedures have re-emerged as powerful and comprehensive tools in the treatment of syndromic midface hypoplasia.

The value of three-dimensional printing modelling for surgical correction of orbital hypertelorism

Orbital hypertelorism is defined as an increased distance between both medial and lateral sides of the orbits. Most common causes are frontonasal malformations, craniofacial fissures, encephalocele and a miscellaneous group of various syndromic or chromosomal disorders. Surgical correction of orbital hypertelorism is still challenging. The present report describes a case of severe orbital hypertelorism of an 11-year-old boy, where surgical correction was planned using three-dimensional printing modelling. This approach allowed reducing time of surgery, accurately planning the location of the osteotomies and precontouring the osteosynthesis material. Three-dimensional models are very helpful tools in planning complex craniofacial operative procedures.

Fronto-facial monobloc distraction in syndromic craniosynostosis. Three-dimensional evaluation of treatment outcome and facial growth

The objectives of this study were to investigate the treatment effect and stability of fronto-facial monobloc distraction osteogenesis. Five consecutive patients who underwent monobloc distraction were included (aged 4.8-18.4 years). Three patients had Crouzon syndrome, one had Apert syndrome, and one had Pfeiffer syndrome. The evaluation included clinical records, serial cephalograms for at least 1-year follow up (average 24.6 months). The treatment and post-treatment changes were measured. The intracranial volume, upper airway volume and globe protrusion were calculated from CT before and after treatment. After distraction, the supraorbital region was advanced 15.3mm forward, the midface demonstrated forward advancement of 17.7 mm, 22.1mm and 23.1mm at orbitale, anterior nasal spine and A point, respectively. The downward movement was 2-3mm at maxillary level. The intracranial volume increased 11%; the upper airway volume increased 85% on average. Globe protrusion reduced 3.7 mm on average, which was 20% of underlying skeletal movement. Facial growth demonstrated forward remodelling of the supraorbital region, mild downward but no further forward growth of the midface. Monobloc distraction is effective for relieving related symptoms and signs through differential external distraction at different vertical levels of the face.

Evaluation of cephalometric points in midface bone lengthening with the use of a rigid external device in syndromic craniosynostosis patients

Distraction osteogenesis has been extensively used to correct severe midface hypoplasia in syndromic craniosynostosis patients. However few studies have reported midface distraction outcomes through cephalometric evaluation.

Aim

The purpose of the present study was to evaluate outcomes with midface distraction rigid external device (RED) in patients with syndromic craniosynostosis, in terms of quantity of bone lengthening, skeletal stability and facial growth.

Materials and methods

Eleven patients were retrospectively evaluated in this study. Cephalometrics was carried out through three teleradiographies from each patient (T1 -before surgery; T2- immediate postop, rigth after distractor removal; T3 - late postop, obtained with a minimal interval of 12 months after surgery).

Results

Significant midface advancement was achieved with the procedure. The rate of horizontal relapse was minimal. We noticed a clear vertical facial growth, contrary to what was seen in the horizontal aspect, when there was a mild posterior relapse and no growth evidence.

Conclusion

Cephalometric evaluation showed adequate results in midface bone lengthening with rigid external distractor.

Reduction of Morbidity of the Frontofacial Monobloc Advancement in Children by the Use of Internal Distraction

BACKGROUND

Surgical treatment of faciocraniosynostosis is a complex problem that includes both function and aesthetics. Treatment goals are to prevent further neurologic disorders and to correct the morphologic impairment.

METHODS

Thirty-six patients with faciocraniosynostosis (mean age, 5.2 years) were evaluated prospectively after frontofacial monobloc advancement and quadruple internal distraction. Four distractors were used in combination with a frontofacial monobloc advancement osteotomy. Complications and advancement were evaluated clinically and radiographically. Respiratory status was evaluated by polysomnography. Relapse was evaluated by comparing results at the time of distractor removal to 6-month values. The mean follow-up was 30 months.

RESULTS

Distraction was completed in 35 patients. Twenty-eight patients (80 percent) completed their distraction uneventfully in the initial period. In seven patients, a problem related to the distraction devices required revision surgery, and subsequently six of them completed the distraction. One patient died the day after surgery from acute brain tonsillar herniation before distraction was begun. The exorbitism was corrected clinically in all patients in whom distraction was completed (n = 34). A class I occlusal relationship was obtained in 28 of 35 patients (80 percent). When respiratory impairment was present, it was corrected in all but two cases (14 of 16). A septic frontal osteonecrosis occurred in one patient 2 months after distraction was completed (frontal bone loss in one of 35 patients). Reossification at time of distractor removal was limited. Relapse has been observed predominantly at the occlusal level (six of 35) and more frequently in Pfeiffer syndrome.

CONCLUSIONS

Internal distraction allows for early correction of respiratory impairment and exorbitism of faciocraniosynostosis, and limits the major risks of frontofacial monobloc advancement. Previous operations performed before the frontofacial monobloc advancement increased its morbidity.

A Protocol for the Management of Frontal Sinus Fractures Emphasizing Sinus Preservation

PURPOSE

The purpose of this retrospective study is to review the incidence and etiology of frontal sinus fractures at an urban trauma center and validate a treatment protocol by assessing the outcome of a consecutive series of patients treated over a 10-year period.

PATIENTS AND METHODS

All patients with frontal sinus fractures admitted to our trauma service from 1995 to 2005 were managed by the same surgeons using similar treatment philosophies based on the amount of displacement or comminution of the anterior and/or posterior table, the integrity of the nasofrontal duct, and the neurologic status of the patient as determined by clinical and radiographic examination. Using information obtained from the Trauma Registry and from individual physician chart notes, a database was created for the purpose of assessing outcome, defined as complications, length of hospital stay, and death. Demographics, injury severity score, fracture pattern, mechanism of injury, length of hospital stay, the number of operations, concomitant maxillofacial injuries, treatment, follow-up, and complications were statistically described. Outcome measures were evaluated by Student's t test using continuous variables.

RESULTS

One thousand two hundred seventy-five patients with facial fractures were identified during the study period, of which 144 patients (11.3%) carried the diagnosis of frontal sinus fracture; 28 patients had inadequate records, leaving a study group of 116 patients. The majority of patients were male, had a mean age of 33.7 years, and presented with significant injuries demonstrated by a mean injury severity score of 23.7 and mean length of hospital stay of 8.9 days. The most common mechanisms of injury were blunt trauma resulting from a motor vehicle collision, fall, assault, or other accidents. Sixty-six patients presented with nondisplaced frontal sinus fractures that were managed nonoperatively; 50 patients had frontal sinus injuries that required surgical repair consisting of: 1) open reduction and internal fixation of the anterior table alone, with preservation of the sinus membrane (n = 29); 2) removal of all sinus mucosa, obliteration of the frontal sinus with autogenous abdominal fat, and reconstruction of the anterior table (n = 5); and 3) removal of all sinus mucosa, cranialization of the frontal sinus, and lining of the nasofrontal recess with a pericranial flap (n = 16). Six patients died of concomitant injuries. With follow-up ranging between 0 and 90 weeks, there were no known complications in the patients treated nonoperatively; 82% of the patients maintained normal sinus function and anatomy and the overall complication rate was 6.9%. Complications occurred in 16% of those patients treated surgically: including brain abscess, contour deformity, osteomyelitis, hematoma, meningitis, and mucocele. There was no statistically significant association between complications and other patient variables (P > .05), other than the test for injury severity score, which was different between survivors and nonsurvivors (P < .01).

CONCLUSION

Application of the management protocol described in this report results in functional sinus preservation for the majority of patients, with relatively few significant perioperative complications.

Monobloc Advancement by Distraction Osteogenesis Decreases Morbidity and Relapse

BACKGROUND

Treatment of midface hypoplasia and forehead retrusion with monobloc advancement is associated with significant complications, including meningitis, prolonged intubation, and frontal bone flap necrosis. To see whether distraction of the monobloc segment offered decreased morbidity, the authors compared clinical outcomes of patients who underwent conventional monobloc advancement with those of patients who underwent monobloc distraction.

METHODS

Group 1 (conventional monobloc; n = 12) underwent traditional monobloc advancement with bone grafting. Group 2 (modified monobloc; n = 11) did not receive ventriculoperitoneal shunts and underwent the above procedures with placement of a pericranial flap and fibrin glue over the midline defect. Group 3 (monobloc distraction; n = 24) underwent advancement of the monobloc segment by distraction osteogenesis using internal distraction devices. Complications included meningitis, cerebrospinal fluid leak, frontal bone flap loss, and wound infection. Preoperative, postoperative, and follow-up lateral cephalograms were used to assess horizontal changes of the forehead, midface, and maxilla.

RESULTS

Group 3 (distraction monobloc) had the lowest complication rate (8 percent), followed by groups 2 (modified monobloc; 43 percent) and 1 (conventional monobloc; 61 percent) (p < 0.05). Group 3 achieved greater advancement (12.6 mm) than did group 2 (9.4 mm) or group 1 (9.1 mm) (p < 0.05). Relapse was least in group 3 (8 percent) compared with groups 2 (67 percent) and 1 (45 percent).

CONCLUSIONS

Monobloc advancement by distraction osteogenesis had less morbidity and achieved greater advancement with less relapse compared with conventional methods of acute monobloc advancement with bone grafting. Monobloc distraction is superior to conventional methods of acute monobloc advancement and is an alternative to staged fronto-orbital advancement followed by Le Fort III advancement.

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.

How to make the blockage between the nasal cavity and intracranial space using a four-layer sealing technique

BACKGROUND

Craniofacial surgery for facial advancement or correction of severe craniofacial malformations such as orbital hypertelorism, Crouzon's disease, and Apert's syndrome may carry great risk. Postoperative infection after craniofacial surgery is a life-threatening complication. Ascending infection via nasofrontal communication in frontofacial monobloc advancement, intracranial Le Fort III osteotomy, correction of hypertelorism (intracranial approach), and acute trauma of cribriform plate can lead to life-threatening meningitis and meningoencephalitis.

METHODS

A four-layer sealing technique for the closure of nasofrontal communication using Gelfoam, galeopericranial flap, rib bone graft, and Tissel is a very effective method. Until the rib bone graft is taken up, Gelfoam is used to temporarily block bony defects and prevents displacement of the rib bone graft. The authors used galeoperiosteal flap for the sufficient blood supply to the rib bone graft. Tissel is used as a biologic adhesive and for blockage of the surrounding gaps.

RESULTS

There were no cases of cerebrospinal fluid rhinorrhea, epidural abscesses due to nasofrontal ascending infection, or meningitis, and no cases underwent débridement due to necrosis of the frontal bone flap. This indicated that the blockage of nasofrontal communication was successful in this series. Moreover, postoperative cosmetic outcomes were satisfactory.

CONCLUSION

This study indicated that the blockage using the Gelfoam, galeopericranial flap, rib bone graft, and Tissel application was effective for the thorough management of nasofrontal fistula and the prevention of recurrent episodes.

Prevention of halo pin complications in post-cranioplasty patients

INTRODUCTION

Distraction Osteogenesis has been successfully implemented in the treatment of maxillary hypoplasia. By using the Rigid External Distraction device (RED) the maxilla can be advanced without the need for bone grafts, providing more stability to the repositioned maxilla.

BACKGROUND

The introduction of the RED system in craniofacial surgery has given rise to previously unseen problems.

AIM

To provide a set of protocol improvements that might prevent the intracranial pin migration seen at the removal of a RED-II in one patient.

CONCLUSIONS

Although the RED device has been shown to achieve good clinical results, there are some disadvantages to the system. There is a high incidence of pin tract infections - leading to loosening of the pins and loss of rigidity. Also, the external ring is prone to traumatic injury. Furthermore, the positioning of the pins can be difficult in thin bone. The improvements used in our protocol might prevent this complication.

Monobloc Distraction Osteogenesis in Pediatric Patients With Severe Syndromal Craniosynostosis

The management of the hypoplastic midface in syndromic craniosynostosis remains a great challenge. Frequently, patients have to be operated on numerous times to achieve a satisfactory end result, partially because of the limited skeletal advancement possible when using traditional surgical techniques. During the last decade, however, methods for gradual midfacial distraction have been presented, whereby greater advancements can be obtained. We present four children aged 17 months to 15 years with severe syndromal craniosynostosis in need of midface advancements because of severe respiratory obstruction or severe exophthalmos. These patients were complex cases with several previous craniofacial surgeries (mean of three times, range of two to six times) that yielded insufficient skeletal advancements. They were operated on with gradual monobloc advancements using the Modular Internal Distraction System. The mean length of operations was 370 minutes (range: 240-455 minutes), and the mean amount of perioperative blood transfusion needed was 1,300 ml (range: 280-2,700 ml) or 66.9 ml/kg (range: 31.1-94.9 ml/kg). The patient with the greatest number of previous operations also had the longest operation time as well as the most blood loss. The average midface advancement obtained was 25 mm (range: 20-30 mm), resulting in cessation or a significant decrease of preoperative respiratory problems, reduced exophthalmos, and improved facial profile. Apart from a local infection in one patient with a connective tissue disorder and several previous wound infections, no major postoperative complications were recorded. Distraction osteogenesis has become a versatile and safe technique that allows for large advancements of the midface.

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.

A mild case of frontonasal dysplasia: the rhinologic perspective

Frontonasal dysplasia (FND) is a congenital malformation characterized by hypertelorism, broad nasion with a midline cleft in the bony dorsum, midline defect of the frontal bone, absence of the nasal tip, and deformities in the nasal alar region. The clinician should be aware of the mild forms of FND. We presented absence of crista galli in a mild case of FND. Computed tomography scanning should assess the facial bones, nose, and paranasal structures. If a surgical correction is planned, this complete work-up prevents unexpected complications and complements the evaluation of paranasal deformities.

Traumatic Cranial Injury Sustained From a Fall on the Rigid External Distraction Device

Distraction osteogenesis has become a popular treatment of congenital maxillocraniofacial anomalies. Many ingenious internal and external devices have been developed and used. The rigid external distraction system based on systems previously used in correction of maxillary retrusion offers postoperative adjustment in two dimensions. Figueroa and Polley reported the use of this device with minimal morbidity in children as young as 5 years of age. They reported no problems with infection, bleeding, pain, loosening of the intraoral splint, dental injury, or wear problems in a series of 14 consecutive cleft patients. Recent modification of the system, rigid external distraction II, has allowed it to be applied to more complex craniofacial deformities that require a LeFort III osteotomy. A review of the neurosurgery and orthopedic literature revealed that halo complications relate primarily to the skull pins. In most cases, these complications can be prevented if the device is carefully applied and monitored. Early recognition and prompt treatment of complications are important. After experience with this system for advancement at the LeFort III level, six patients with various syndromes involving the craniofacial skeleton have undergone LeFort III level distraction osteogenesis with the rigid external distraction device in combination with a planned and stabilized frontosupraorbital advancement. In one of these cases, a 7-year-old child fell on the device after discharge from the hospital and sustained a compound depressed skull fracture that required debridement and repair.

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.

Frontoorbital advancement by gradual distraction. Technical note

A substantial number of patients with coronal synostosis who undergo frontoorbital advancement still require additional surgical treatment to correct increased intracranial pressure or unsatisfactory craniofacial structure. However, frontoorbital advancement currently requires elevation of the frontal as well as the orbital bone, which can result in a fragile dura mater and partial resorption of the advanced bone. Thus the dura is easily torn by dissection and the advanced bone is further resorbed and deformed during repeated craniofacial operations. To avoid these drawbacks and to create an easier second surgical treatment via the intracranial approach, a new technique for frontoorbital advancement is presented. In this technique frontoorbital bone is advanced as a single unit, without elevation from the underlying dura, by means of gradual distraction. The details of the technique and an illustrative case are reported.

A comparison of single-stage versus gradual fronto-parietal advancement in terms of extradural dead space and bone deposition

This study was designed to investigate the differences between single-stage and gradual advancement of cranial vault in adult cats. Fifteen animals underwent fronto-parietal craniotomy including the roof of the frontal sinus. They were randomly assigned to three experimental groups; single-stage advancement (n = 5), gradual distraction with intact dura-bone attachments (n = 5), and gradual distraction after separation of the dura from the fronto-parietal bone segment (n = 5). Development of an extradural dead space and new bone formation were evaluated with CT scans at 1, 4 and 12 weeks. After sacrificing the animals at 12 weeks, midsagittal frozen sections and decalcified coronal sections of the heads were obtained. The single-stage advancement group developed an extradural dead space which communicated with the frontal sinus. The advanced bone segment, which was exposed to the air-filled dead space, showed bony resorption. Both groups of gradual advancement showed enlargement of the cranial cavity and frontal sinus. As the dura and brain were stretched superiorly, no extradural dead space was produced. Although the distraction gap demonstrated deposition of new bone in both gradual advancement groups, the bone formation was less pronounced in distraction after separating the dura from the bone segment. In conclusion, gradual distraction of a fronto-parietal bone prevents extradural dead space formation regardless of whether the dura is kept attached to or it is separated from the distracted bone segment. Devascularization of the bone segment by dissecting off the dura, however, decreases new bone formation, and thus may increase a risk of relapse.