Fronto-Orbital Advancement and Cranial Vault Remodeling for Metopic Craniosynostosis

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Author: Akshay Krishnan
Published:
Specialties: Neurosurgery, Pediatric Surgery, Plastic Surgery
Schools: University of Arkansas for Medical Sciences
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Basic Info

Contributors:Michael Golinko, MD, MA, Eylem Ocal, MD and Kumar Patel, PA

Premature metopic suture fusion is corrected using fronto-orbital advancement and cranial vault remodeling to open the fused suture and allow for adequate brain growth.

DOI#: https://doi.org/10.17797/hg9xbuxoms

Advanced

Procedure

The patients hair is cleaned and then shaved along the midline of the skull from ear-to-ear so that a wavy coronal incision can be drawn. 0.5% Lidocaine with epinephrine is, then, injected into the area to anesthetize, ensure adequate hemostasis, and hydro-dissect.

The incision is made along the wavy coronal marking using a 15-blade, and a bovie knife is used to cut through the remaining skin layers and periosteum to expose the skull. The subperiosteal dissection is first extended to the orbital rims and nasofrontal junction, then extended laterally towards the zygomaticalfrontal suture. During this process, the surgical team must watch for 3 things: (1) avoiding damage to the supra-orbital nerve (2) sudden bradycardia due to the oculocardiac reflex (3) patient blood loss. Blood loss can be minimized using a cautery to stop tissue bleeds and gel-foam powder to stop cranial bone bleeds.

After the cranial dissection is completed, craniotomy cuts are drawn out in such a way as to leave the normal shaped skull behind. Prior to removing the skull after cuts with a reciprocating saw, neurosurgeons must carefully dissect the dura and retract the brain. Once the frontal bone is removed, the orbital bandeau can be excised as well. Care must be made to avoid damaging the globes.

Once both the frontal bone and orbital bandeau are removed, the bone flaps can be constructed. First, the frontal bone is split apart using an osteotome to guarantee there are sufficient bone grafts for the reconstruction. Next, the bandeau is expanded by placing precise cuts and molded using a special polymer. These newly modeled frontal bones and bandeau are re-attached to the patient; however, spaces still remain in the new skull construct. These gaps are filled using the remaining bone grafts, which are placed in a suture trellis (not directly attached) to allow optimal cranial expansion and brain growth. Prior to closure, the periorbita of the eyes are incised to allow soft tissue advancement to occur in conjunction with skeletal advancement.

Once adequate hemostasis is reached, closure beings by re-suspending the temporalis muscle with vicryl 2-0 sutures. Deep galeal and deep dermal sutures are, then, placed, followed by a running 4-0 plain gut on the skin. Drains are typically not used post-op, but a head wrap is applied for 2 days.

Indications

True synostosis with cerebral compression, hypotelorism, deformation of the orbital roof, intracranial hypertension, progressive exophthalmos with risk to vision, and risk of developmental delay. Children 9-12 months old are the best candidates for surgery.

Contraindications

Patient desire, cardiovascular or respiratory problems, and older or syndromic children (they may develop recurrent craniosynostosis).

Instrumentation

Setup

General anesthesia and a covering over the eyes. Shave along the midline of the skull to allow for a coronal incision. Plan out the incision by marking the scalp and prep the area with betadine. Inject lidocaine and epinephrine and allow time for vasoconstriction.

Preoperative Workup

History and physical exam, neurologic examination, pulmonary evaluation, radiographic imaging (3D CT), CBC, and electrolytes.

Anatomy and Landmarks

(1) Observation of the position of the forehead, eyebrows, nose, cheeks, mandibles, and ears
(2) Close-set eyes and triangular-shaped forehead indicate premature metopic suture fusion

Advantages/Disadvantages

Advantages: reduced intracranial pressure, proper skull shape to allow for brain growth
Disadvantages: there is substantial edema post-op, the surgery is highly invasive, risk of infection, risk of nerve damage during dissection

Complications/Risks

Significant post-op edema, bleeding, nerve damage, and infection

Disclosure of Conflicts

None.

Acknowledgements

N/A

References

Anantheswar YN, Venkataramana NK. Pediatric Craniofacial Surgery for Craniosynostosis: Our Experience and Current Concepts: Part-1. Journal of Pediatric Neurosciences. 2009;4(2):86-99. doi:10.4103/1817-1745.57327.

Lane JA, McKisic MS. Surgery for Craniosynostosis: Background, History of the ... Medscape. http://emedicine.medscape.com/article/248568-overview. Accessed October 12, 2016.

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