Authors of section

Authors

Scott Bartlett, Michael Ehrenfeld, Gerson Mast, Adrian Sugar

Executive Editor

Edward Ellis III

General Editor

Daniel Buchbinder

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Anterior reshaping with widening

1. Introduction

Premature closure of the sagittal suture results in scaphocephaly (dolichocephaly) or a boat shaped head. There may be a great deal of variability in the head shape, likely depending upon whether the closure started posteriorly or anteriorly and at what age. Consequently the occiput may be more affected than the frontal region, or vice versa. Commonly both are affected. The general goal of surgery is to shorten the skull in a sagittal plane and widen it in a coronal plane.

definition

When the occipital region is significantly affected and the anterior is not, posterior vault reshaping alone may be all that is required.

Similarly if the deformity is mostly frontal, correction may be performed here only.

Most often both the anterior and the posterior skull need reshaping, and this can be done as a single stage or two separate stages.
Single stage total calvarial reshaping is usually confined to younger patients with less severe deformities.

When the deformity is more severe and one has to access the orbits anteriorly or the base of the occiput posteriorly, staged procedures are to be preferred.

anterior reshaping with widening

With an anterior deformity there is typically bitemporal narrowing and frontal bossing. If the bitemporal narrowing is severe, not only will the frontal bone need to be widened but the supraorbital bar will need expansion. This may involve an osteotomy of the bar and transverse expansion with interposition bone graft.

anterior reshaping with widening

2. Positioning and approach

With the patient in a supine position with a horseshoe head rest, the exposure of the anterior half of the skull is made via a coronal incision.

anterior reshaping with widening

3. Osteotomy

Craniotomy

After the exposure of the forehead and the orbits, a bifrontal craniotomy beginning 1 cm above the superior orbital rim and extending to behind the coronal sutures is outlined.

Burr holes are first placed at the vertex, avoiding the sagittal sinus, and nasal frontal region as well as temporally. An epidural dissection between these points is made.

The neurosurgeon then completes the osteotomies using a craniotome. This may be done as a single osteotomy or as two separate osteotomies if the exposure is difficult.

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Supraorbital bar osteotomy

After the bone flap is removed, the dura is freed from the anterior and middle fossae in the epidural plane.

The dura is protected with neurosurgical cottonoids.

anterior reshaping with widening

Malleable retractors are used intracranially to retract and protect the brain and intraorbitally to protect the orbital contents while performing the osteotomies.

anterior reshaping with widening

The supraorbital bar is then osteotomized.

A vertical osteotomy near the pterion (1) is followed by a horizontal osteotomy to the lateral orbital rim (2). An oblique osteotomy is then made through the orbital rim (3) and a transverse osteotomy is completed at the nasal frontal junction (4).

anterior reshaping with widening

With the brain carefully retracted, a right angle saw is then turned intracranially and the orbital roof is osteotomized beginning at pterion laterally and ending at the nasal frontal cut medially, joining the osteotomy made extra-cranially across the nasal frontal region.

anterior reshaping with widening

An osteotome is then inserted at the pterion and the lateral orbital wall cut completed on both sides, releasing the bandeau.

anterior reshaping with widening

4. Reshaping

Reshaping of the supraorbital bar

If a transverse expansion of the supraorbital bar is needed, then a standard osteotomy of the supraorbital bar is completed with long temporal extensions as illustrated. The bar is cut in the midline and a bone graft taken from the frontal or parietal bone flap is interposed. The bar is replaced in its now widened position and held in place with wires sutures or plates.

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Reshaping the frontal bone

The frontal bone, which is typically bossed is cut in the midline, bent and shaped with bone bending forceps to get the best possible fit and contour.

bilateral orbital advancement

The frontal bone is replaced in such a fashion to create a general curvature from anterior to posterior as in a normal forehead. This can be done by rotating and switching the two frontal bone halves with the addition of an interposition bone graft taken from the parietal segment removed to shorten the AP dimension of the skull. This serves to shorten the skull in an anterior posterior direction and widen it transversely.

anterior reshaping with widening

Reshaping the parietal bone

The shortened temporal/parietal bone is additionally expanded by interposition bone grafting and reshaped by an interposition bone graft and bending as required with bone shaping forceps.

anterior reshaping with widening

5. Fixation

All segments are then stabilized by absorbable plates and screws, wires or sutures. In an older child or an adult, titanium fixation may be used.

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6. Aftercare following transcranial and Le Fort III procedures in infants and children

Intraoperatively

Most surgeons favors placement of a bulb suction drain under the scalp for 3-5 days. Resorbable skin sutures are often used.

Postoperatively

A circumferential head dressing is utilized for 48 hours. The neurosurgeon may request placement of a lumbar drain if significant dural tears have occurred during surgery. Patients should spend at least 1-2 days in an intensive care unit for neurological monitoring.

Postoperative positioning

Keeping the patient’s head in an upright position postoperatively may significantly improve periorbital edema and pain. Some surgeons use injectable corticosteroids during surgery to reduce periorbital swelling.

Nose-blowing

To prevent orbital emphysema, nose-blowing should be avoided for at least 10 days.

Medication

The following perioperative medications are controversial. There is little evidence to make strong recommendations for postoperative care.

  • Avoidance of aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) for 7 days.
  • Analgesia as necessary.
  • Antibiotics (many surgeons use perioperative antibiotics. There is no clear advantage of any one antibiotic, and the recommended duration of treatment is debatable.).
  • Nasal decongestant may be helpful for symptomatic improvement in some patients.
  • Steroids may help with postoperative edema. Some surgeons have noted increased complications with perioperative steroids.
  • Ophthalmic ointment should follow local and approved hospital protocol. This is not generally required in case of periorbital edema. Some surgeons prefer it. Some ointments have been found to cause significant conjunctival irritation.
  • Regular perioral and oral wound care has to include disinfectant mouth rinse, lip care if intraoral incision has been used.

Ophthalmological examination

Postoperative examination by an ophthalmologist may be requested, although sever periorbital edema may prevent useful assessment. The following signs and symptoms are usually evaluated:

  • Vision
  • Extraocular motion
  • Diplopia
  • Globe position
  • Lid position

Postoperative imaging

Postoperative imaging has to be performed within the first days after surgery to verify accuracy of surgery. 3-D imaging (CT, cone beam) is recommended.

Wound care

Remove sutures from skin after approximately 7-10 days if nonresorbable sutures have been used.
Apply ice packs for the first 12 postoperative hours as able although infants and young children do not tolerate this well (may be effective in a short term to minimize edema).
Avoid sun exposure and tanning to skin incisions for several months.

Diet

Soft diet can be taken as tolerated until there has been adequate healing of any maxillary vestibular incision. In children and infants age appropriate diets are then prescribed.
Patients in MMF will remain on a liquid diet until such time the MMF is released.

Clinical follow-up

Clinical follow-up depends on the complexity of the surgery, and whether the patient has any postoperative problems. Most patients are discharged at postoperative day 3-5 and seen again in 2-3 weeks.

  • In patients undergoing monoblock or Le Fort III distraction, distraction typically begins at day five at 1 mm/day and is assessed weekly with plane radiographs and clinical examination until the desired position is reached. After advancement a period of consolidation of 1-3 months is recommended before the retractors are removed.
  • In patients undergoing conventional advancement with intermaxillary fixation, MMF is kept in place for 4-6 weeks. Routine oral hygiene is prescribed. Patients with arch bars and/or intraoral incisions and/or wounds must be instructed in appropriate oral hygiene procedures. The presence of the arch bars or elastics makes this a more difficult procedure. A soft toothbrush (dipped in warm water to make it softer) should be used to clean the surfaces of the teeth and arch bars. Elastics are removed for oral hygiene procedures. Chlorhexidine oral rinses should be prescribed and used at least 3 times a day to help sanitize the mouth.
    For larger debris, a 1:1 mixture of hydrogen peroxide/chlorhexidine can be used. The bubbling action of the hydrogen peroxide helps remove debris. A Waterpik® is a very useful tool to help remove debris from the wires. If a Waterpik is used, care should be taken not to direct the jet stream directly over intraoral incisions as this may lead to wound dehiscence.

Follow-up

The patient needs to be examined and reassessed regularly and often. Additionally, ophthalmological, ENT, and neurological/neurosurgical examination may be necessary. If any clinical signs for meningitis or mental disturbances develop, professional help has to be sought. Due to the young age of many patients, routing CT-scans are performed only if clinically indicated to avoid excessive radiation exposure.