Pediatric Outcomes following Cranial Vault Remodeling with Restricted Use of Postoperative Narcotics: A Retrospective Review.

BACKGROUND: The appropriate use of narcotics for postoperative pain control is controversial because of potential medication-induced complications. The authors sought to determine the effects of narcotics in the pediatric population following cranial vault remodeling operations. METHODS: A retrospective review was performed on 160 consecutive patients who underwent cranial vault remodeling for craniosynostosis. RESULTS: There was a statistically significant difference in total morphine equivalents in the group that experienced no emesis and those with at least one episode of emesis (0.97 morphine equivalents/kg versus 1.44 morphine equivalents/kg; p = 0.05). There was a statistically significant difference in hospital morphine equivalents in the group with documented respiratory events (average, 2.3 morphine equivalents/kg versus 1.3 morphine equivalents/kg in the nonevent group; p = 0.006). The patients who received dexmedetomidine had a trend toward a decrease in hospital narcotic administration with equivalent pain control (1.2 morphine equivalents/kg versus 1.9 morphine equivalents/kg; p = 0.09). There was a statistically significant positive correlation between total morphine equivalents for the hospitalization and hospital stay ( r = 0.27, p = 0.001). The amount of morphine equivalents used in the first 24 hours was also found to be an independent predictor of a respiratory event ( p = 0.002 by multivariate logistic regression). Independent positive predictors of hospital stay were age ( p < 0.001), intensive care unit time ( p < 0.001), and total morphine equivalents for the hospitalization ( p = 0.001) by multivariate analysis with linear regression. CONCLUSION: The authors' study demonstrates improvement in outcomes with decreased use of narcotics, which establishes that there is a need to further explore postsurgical recovery outcomes with multimodal pain control. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Evaluating Sensory Nerve Outcomes After Horizontal Osteotomy for Mandibular Distraction in Infant Robin Sequence Patients.

ABSTRACT: There has yet to be a consensus on the appropriate technique for mandibular distraction in the infant Pierre Robin population nor is their sufficient data on sensory nerve outcomes. The purpose of this study is to validate the safety of the horizontal osteotomy by: (1) determining mandibular foramen location in infant Pierre Robin patients relative to the dentoalveolar plane and (2) evaluate long-term function of the inferior alveolar nerve in previously distracted Pierre Robin patients. Preoperative 3D Computed tomography (CT) scans of Pierre Robin patients < 1 year old were reviewed. A line at the level of the mandibular dentoalveolar plane was drawn across the lingual surface of the ramus and the distance to the mandibular foramen was then measured. Semmes-Weinstein monofilaments of the lower lip and chin bilaterally was performed on mandibular distraction patients in clinic. Inclusion criteria was patients >6 years of age having undergone bilateral mandibular distraction at <1 year of age. Fifteen patients' CT studies were examined. The mandibular foramen was consistently below the level of the dentoalveolar plane at an average distance of 4.7 mm. Eight patients were included in the prospective arm. Average age was 12.2. All patients had normal sensation at 2.83 through all areas. The mandibular foramen reliably exists below the dentoalveolar plane. In addition, all patients reviewed postoperatively with >10 years of follow up demonstrated normative sensation. The horizontal corticotomy performed just above the mandibular dentoalveolar plane spares the inferior alveolar nerve in young Pierre Robin patients undergoing distraction.

Measuring the Position of the Mandibular Foramen in Relation to the Dentoalveolar Plane in Pierre Robin Patients: Establishing Safety of the Horizontal Osteotomy.

BACKGROUND: Mandibular distraction with horizontal osteotomy of the ramus and vertical distraction vector has successfully treated airway obstruction in young Pierre Robin patients. Placing the osteotomy just above the dentoalveolar plane can minimize damage to the inferior alveolar nerve. This study maps the position of the mandibular foramen relative to the height of the dentoalveolar plane to demonstrate the safety of this technique in Pierre Robin neonates. METHODS: Retrospective review of 3D CT scans of Pierre Robin patients was performed with inclusion criteria: ≤1 year of age, bilateral micrognathia requiring surgical intervention for airway (ie, tracheostomy versus mandibular distraction), no prior mandible surgery, and pre-operative 3D CT study. Demographic information collected included: age at CT scan, age at surgery, and genetic diagnosis. Using the 3D study of each patient's right mandible, a line at the level of the mandibular dentoalveolar plane was drawn across the lingual surface of the ramus and the distance to the mandibular foramen at a length perpendicular to the dentoalveolar plane line was then measured. RESULTS: Fifteen patients were included in the study (at least 9 Pierre Robin). Average age at time of CT scan was 71.4 days old. The mandibular foramen was below the level of the dentoalveolar plane in all cases at an average distance of 4.7 mm. Average ramus height 46.2±13.4 CONCLUSIONS:: The dentoalveolar plane was consistently above the mandibular foramen in all patients. Thus, the horizontal corticotomy at a level just above the mandibular dentoalveolar plane spares the inferior alveolar nerve in neonatal Pierre Robin patients undergoing vertical vector mandibular distraction.

Unilateral Orticochea Pharyngoplasty for Unilateral Velopharyngeal Dysfunction: Long-Term Outcomes Data.

A unilateral deficit in velopharyngeal closure during speech production is an unusual presentation of velopharyngeal dysfunction (VPD) and few solutions have been described for this problem. This report details the long-term outcomes using this technique. We performed a retrospective chart review of all the patients who underwent a unilateral Orticochea pharyngoplasty for VPD. The authors identified 10 patients treated with 11 unilateral pharyngoplasty at a single tertiary care institutional setting. The mean age at repair was 8.6 years. The mean length of follow-up was 7.6 years. All the patients demonstrated improvement in velopharyngeal closure and speech resonance with 4 showing complete resolution of VPD. There were no revisions required or complications. One patient, after 10.7 years, required a unilateral procedure on the contralateral side which resulted in complete resolution of VPD postoperatively.

Improvement of Color Vision Following Posterior Cranial Vault Distraction for Crouzon Syndrome.

Crouzon syndrome (CS) is one of the craniosynostosis syndromes that leads to early fusion of cranial sutures and increased intracranial pressure. Intracranial hypertension is a serious complication that may lead to vision loss and cognitive impairment. Early detection and management are necessary to prevent complications. The authors present a patient with CS who underwent posterior cranial vault reconstruction with internal distraction after multiple episodes of headache and papilledema. The patient was unaware of any loss of color vision before the surgery; however, he noted an improvement in his color vision after the surgery. Color vision deficits may be an early sign of intracranial hypertension and finding these deficits using noninvasive testing methods may be an indication for early intervention.

Computer Simulation and Optimization of Cranial Vault Distraction.

OBJECTIVE: The objective of this study was to validate the proof of concept of a computer-simulated cranial distraction, demonstrating accurate shape and end volume. DESIGN: Detailed modeling was performed on pre- and postoperative computed tomographic (CT) scans to generate accurate measurements of intracranial volume. Additionally, digital distraction simulations were performed on the preoperative scan and the resultant intracranial volume and shape were evaluated. SETTING: Tertiary Children's Hospital. PATIENTS, PARTICIPANTS: Preoperative and postoperative CT images were used from 10 patients having undergone cranial distraction for cephalocranial disproportion. INTERVENTIONS: None; computer simulation. MAIN OUTCOME MEASURE: Computer simulation feasibility of cranial vault distraction was demonstrated through creation of digital osteotomies, simulating distraction through translating skull segments, followed by simulated consolidation. Accuracy of the model was evaluated through comparing the intracranial volumes of actual and simulated distracted skulls. RESULTS: The developed digital distraction simulation was performed on the CT images of 10 patients. Plotting the relationship between the actual and simulated postdistraction volumes for the 10 patients yielded a slope of 1.0 and a correlation coefficient of 0.99. The average actual resultant volume change from distraction was 77.0 mL, compared to a simulated volume change of 76.9 mL. CONCLUSIONS: Digital simulation of cranial distraction was demonstrated through manipulation of the CT images and confirmed by comparing the actual to simulated volume change. This process may provide objective data in designing an individual distraction plan to optimize volume expansion and resultant cranial shape as well as patient education.

Surgical Treatment of Nonsyndromic Craniosynostosis.

Studies on the treatment of nonsyndromic craniosynostosis demonstrate decreasing morbidity and mortality; however, complication rates still range from 5% to 14%. Here, the authors present their last 10 years' experience treatment of nonsyndromic single suture craniosynostosis. A retrospective review was performed on patients who underwent open surgical treatment of nonsyndromic craniosynostosis over 10 years. Patient characteristics and clinical outcomes were reviewed. Radiological analysis of intracranial volumes was performed using Amira software. The authors' technique for treatment of sagittal synostosis was the Foreshortening and Lateral Expansion of the Cranium Activated by Gravity (FLAG) procedure. The authors identified 106 patients with a median age of 0.8 years. Sagittal synostosis was most common (n = 65, 61%). Seventeen percent underwent distraction of the cranial vault; the remainder underwent traditional remodeling procedures. The average operative time was 131 minutes, blood loss was 296 mL (30 mL/kg), and intraoperative transfusion was 332 mL (34 mL/kg). There were 2 postoperative complications. Six patients required an additional major operation years later, most commonly for increased intracranial pressure. The authors separately analyzed 50 patients with sagittal synostosis treated with the FLAG procedure. There were no postoperative complications, and only 4 patients required reoperation. The average operative time for the FLAG procedure was 97.3 minutes. Intracranial volume increased by 191.45 mL (28.3-427.5 mL) with 28% average relative cranial vault expansion (4.5%-93.2%). Surgical correction of craniosynostosis using the FLAG technique is safe and effective with minimal morbidity and long standing results. Treatment should involve a structured approach, which minimizes operative times and decreases complication rates.

Quantifying Craniometric Change Early After Fronto-Orbital Advancement in Metopic Synostosis.

Frontal orbital advancement (FOA) for metopic synostosis results in cranial vault expansion, supporting underlying growth of the developing brain and improving head shape. Previous studies have shown that FOA in younger infants leads to a greater incidence of long-term growth restriction of intracranial volume; however, it is still unknown as to whether this is due to undercorrection at the time of surgery versus primary suture pathology. The purpose of our study is to provide a method for objective analyses of intracranial volumes in the early post-FOA period. A retrospective chart review was conducted on patients who underwent FOA over a 10-year period by a single surgeon. Data collected included patient characteristics and clinical outcomes. Radiological analysis of intracranial volumes pre- and post-FOA was determined using Amira volume-rendering software. Average increase in intracranial volume at 6 weeks post-FOA was 139.27 mL (80.01-225.25 mL) with average relative cranial vault expansion of 18.1% (3.3-48%). Patients who underwent FOA older than 12 months of age had an average increase in intracranial volume of 8.5% (3.3-13.1%). Patients younger than 12 months had a statistically higher average increase of 25% (12.8-48%). Frontal orbital advancement effectively increases intracranial volume in patients with metopic synostosis. When compared with older patients, patients younger than 1 year of age have a greater relative increase in intracranial volume in the immediate postoperative period. Quantifying cranial vault expansion after FOA can assist surgeons in surgical planning as well as in measuring and monitoring clinical outcomes within and across craniofacial centers regardless of technique.

Advantages of Calvarial Vault Distraction for the Late Treatment of Cephalocranial Disproportion.

PURPOSE: Cephalocranial disproportion is a symptomatic condition related to a volume discrepancy between the calvarial vault and the brain. Traditional expansion techniques are unfavorable in older children due to inadequate dural ossification, lack of bone pliability, and limited future growth potential. The authors review their experience using distraction to close bone defects in this setting. METHODS: A retrospective analysis was performed of all patients treated using distraction in this setting by a single surgeon. Demographic and outcomes data were collected. The efficacy of ossification of bone defects after expansion by distraction was measured using volume analysis of three-dimensional computed tomography (CT) scans. This required a CT scan at the completion of device activation and a follow-up CT scan 6 months or more beyond activation. RESULTS: Sixteen patients (17 distractions) met the imaging-based inclusion criteria. The average age at surgery was 3.97 (2.14-6.89) years. The mean initial bone defect volume after asymmetric transverse distraction was 7.26 (5.45-13.73) mL. The mean final defect volume was 2.18 (0.00-5.90) mL with a mean change of 5.08 (1.21-12.79) mL and mean interval time of 27.85 (7.13-56.39) months. This represents a mean percent defect closure of 72.30 (20.38-100.00). CONCLUSION: Distraction osteogenesis is a very effective tool for treating the older child with cephalocranial disproportion. The ability to ossify the bone defects without a donor site provides a considerable advantage in these patients.

Versatility of Distraction Osteogenesis for the Craniofacial Skeleton.

Malformations of the craniofacial skeleton are common. Restoration of anatomic shape, size, and position has been traditionally accomplished using autologous bone grafting to fill gaps created by surgery and segmental movement. The authors present their practice using distraction in many different ages and settings over 20 years. A retrospective review was performed of all craniofacial patients treated using distraction osteogenesis for mandible, midface, and calvarium. The authors identified 205 patient. Mandible: 112 patients were treated at an average age of 3.4 years. 18.8% of patients required repeat distraction. There was no difference in the neonatal versus older group (P = 0.71). There were significantly higher reoperation rates in syndromic children (P < 0.01). Midface: 58 patients underwent Lefort III distraction at an average age of 13.6 years. One (1.7%) required repeat distraction (Miller syndrome). Five (8.6%) patients underwent subsequent Lefort I advancement for occlusal changes. Calvarium: 33 patients were treated at an average age of 4.7 years. No repeat distractions were performed. One patient required an additional advancement procedure. Distraction demonstrates successful long-term correction of defects in the craniofacial skeleton with the versatility and control needed to treat the wide spectrum of deformity.

Reformatted 3D airway imaging in patients with airway obstruction and micrognathia.

PURPOSE: Mandibular distraction osteogenesis (MDO) is an effective treatment for patients with micrognathia and severe recurrent airway obstruction (Denny, 2004; Denny and Amm, 2005; Denny, 2009; Cicchetti et al., 2012; Flores et al., 2014). However the efficacy of the procedure is based on selecting the appropriate patient. Presence of central apnea or airway obstruction anywhere other than the tongue base will make MDO futile. The availability of three dimensional reformatting of the airway has greatly improved the accuracy of correct patient selection, providing a powerful tool to further characterize the pathology in these patients. METHODS: We conducted a retrospective review of the last thirty patients with micrognathia and severe recurrent airway obstruction seen in consult by the senior author for potential role of surgery in their management. RESULTS: Twenty-one patients met our inclusion criteria, with fourteen treated appropriately with MDO. The remaining patients had findings on the 3D airway CT scans with other anatomic causes of obstruction making them inappropriate candidates for mandibular distraction osteogenesis. CONCLUSIONS: The use of three dimensional formatting of the airway from CT scans obtained using low dose protocols has improved the accuracy of evaluation and treatment of Pierre Robin patients. Most valuable is the non-invasive identification of airway abnormalities that would make mandibular distraction osteogenesis ineffective in correcting the airway obstruction.

Imaging neonates and children with Pierre Robin sequence before and after mandibular distraction osteogenesis: what the craniofacial surgeon wants to know.

Pierre Robin sequence is characterized by micrognathia and glossoptosis causing upper airway obstruction. Mandibular distraction osteogenesis is a mandibular lengthening procedure performed in neonates and children with Pierre Robin sequence to alleviate airway compromise. This pictorial review demonstrates the role of imaging in the preoperative and postoperative assessment of these children. It is important for pediatric radiologists to know what information about the mandible and airway the craniofacial surgeon needs from preoperative imaging and to identify any complications these children may encounter after surgery.

Mandibular lengthening by distraction osteogenesis in the setting of osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is an inherited disorder characterized by bone fragility and deformity. The craniofacial skeleton may be involved either primarily or by result of a concomitant diagnosis. Distraction osteogenesis has emerged as a versatile reconstructive option for many craniofacial deformities. Mandibular lengthening by distraction has not been reported in a patient with OI. We present a patient in whom mandibular lengthening was successfully performed twice for hemifacial microsomia. Bilateral lengthening was initially performed with successful airway improvement. This was followed by transport distraction on the more severely affected side for condylar reconstruction. Successful mandibular lengthening by distraction is possible in the setting of OI.

Cranial bone grafting for alveolar clefts: a 25-year review of outcomes.

BACKGROUND: Cranial bone grafting for an alveolar cleft obtains membranous bone from a low-morbidity donor site. Although iliac crest bone is the favored donor site, there are no objective analyses of three-dimensional radiologic outcomes with cranial bone grafting and no studies evaluating complications and long-term outcomes in a large series of patients undergoing cranial bone grafting. METHODS: A retrospective chart review was conducted on patients who underwent alveolar bone grafting from the cranium over a 25-year period performed by a single surgeon. Data collected included patient characteristics, complications, and clinical outcomes. Radiologic analysis of graft outcomes was determined using Amira volume-rendering software on the most recent 10 consecutive patients. RESULTS: The authors' study cohort included 308 patients, with an average age of 11.5 years. Complications involved harvesting the graft in 3.5 percent, the donor site in 1 percent, and the recipient site in 17.2 percent. Regrafting was required in 7.1 percent, with a clinical success rate of 92.9 percent. The average alveolar defect was 1.19 ml preoperatively and 0.19 ml postoperatively, with 85 percent fill of the cleft defect by radiologic analysis. CONCLUSIONS: Cranial bone grafting for the alveolar cleft is a low-morbidity operation and has success similar to that of iliac crest bone grafting. It should be considered more often as a viable option for the alveolar cleft patient. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Le Fort III distraction using rotation advancement of the midface in patients with cleft lip and palate.

BACKGROUND: Patients with cleft lip and palate demonstrate a spectrum of maxillary growth deficiencies. The purpose of this study was to review the authors' experience in the treatment of midface hypoplasia in nonsyndromic cleft lip-cleft palate patients using rotation advancement of the midface with Le Fort III distraction. METHODS: A retrospective chart review was conducted to include all patients with nonsyndromic cleft lip and/or cleft palate who underwent Le Fort III rotation advancement of the midface from 1999 to 2011. Along with standard outcome measures, Amira imaging software was used to perform surface analysis on the last five consecutive patients in this series. RESULTS: Forty-three consecutive patients met inclusion criteria. Diagnoses included unilateral complete cleft lip and palate (n = 25) and bilateral complete cleft lip and palate (n = 18). Average distraction distance measured 10.1 mm at the level of the zygoma (range, 6 to 15 mm). Preoperative and 6-month postoperative sella, nasion, A point angles measured 76.3 and 81.8 degrees; whereas sella, nasion, B point angles measured 79.9 and 78.7 degrees, respectively. Preoperative and 6-month postoperative overjet measured -5.4 and 3.2 mm, whereas overbite measured 1.9 and 1.1 mm, respectively. Six patients (13 percent) developed pseudorelapse, with five patients going on to have subsequent Le Fort I advancement at an average of 7 years after distraction (range, 2 to 11 years). CONCLUSIONS: Le Fort III rotation advancement of the midface addresses severe midface deficiencies in select patients. Whereas older techniques target occlusal correction alone, extending osteotomies to the Le Fort III level allows occlusal correction along with improvements in malar and nasal projection required to achieve facial harmony in this group of patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Safety and efficacy of recombinant human bone morphogenetic protein 2 on cranial defect closure in the pediatric population.

BACKGROUND: Traditional reconstructive options for cranial defects include autogenous bone graft, bone substitutes, and synthetic materials. The established standard for repairing cranial defects is autogenous bone. However, young children do not have abundant donor sites for bone harvest, which leads to challenges in closing calvarial defects. Synthetic materials are not ideal alternatives because they require subsequent retrieval and are prone to infection. Their long-term effects on growth of the skull are also not well studied. Bone morphogenetic protein 2 (BMP-2), are shown to positively affect closure of cranial defects in animal models. We present a study comparing the efficacy and safety of closure of cranial defect with bone graft augmented with recombinant human BMP-2 (rhBMP-2) and compared with a series of patients treated with bone graft alone. METHODS: This study is a retrospective multicenter evaluation of 36 patients spanning 5 years. Twenty-one patients undergoing cranial defect closure augmented with rhBMP-2 were compared with 15 patients who underwent cranial defect closure using cranial bone shavings alone. We measured preoperative and postoperative defect size on volumetric computed tomographic scan reconstructions to compare defect sizes. RESULTS: The rhBMP-2 group had slightly increased proportional closure compared with the control group, 86% versus 76% (P < 0.018), respectively. Two patients in the rhBMP-2 group had postoperative fusion of a suture that was known to be patent at the time of cranial defect closure. No instances of brain edema, herniation, airway compromise, or other adverse effects directly attributable to rhBMP-2 were observed. CONCLUSIONS: Bone morphogenetic protein 2 may increase the amplitude and uptake of cranial bone grafts in cranial defect closure. This study shows that defect sizes of up to 16 cm can be reliably closed using this technique. Postoperative fusion of uninvolved sutures in 2 patients indicates that rhBMP-2 may have unreported adverse effects; consideration of this finding should be weighed against the benefit of improved closure of calvarial defects.

Double stellate tongue reduction: a new method of treatment for macroglossia in patients with Beckwith-wiedemann syndrome.

BACKGROUND: Although multiple methods of tongue reduction have been described, recent literature suggests that the central reductions may be more favorable in patients with Beckwith-Wiedemann syndrome (BWS). In this case series, we review our experience with macroglossia associated with BWS, and we offer a new technique of central tongue reduction. METHODS: Between 1993 and 2007, a retrospective chart review was conducted to include all patients with a diagnosis of BWS who have undergone stellate or double stellate tongue reduction at the Children's Hospital of Wisconsin. RESULTS: A total of 7 patients met all inclusion criteria. All patients had good tongue mobility at 1-year follow-up. One patient required speech therapy for persistent articulation errors postoperatively. A total of 2 patients required secondary procedures for recurrent macroglossia. There were no complaints of abnormal taste or sensation. CONCLUSIONS: The stellate and double stellate tongue reductions provide effective treatment in macroglossia associated with BWS.

Volumetric analysis of cranial vault distraction for cephalocranial disproportion.

The purpose of this study was to provide an objective analysis and quantify the intracranial volume change produced by cranial vault distraction osteogenesis. We recently published a technique to expand the cranial vault by distraction in symptomatic patients with findings of cephalocranial disproportion. Resolution of symptoms was documented in that publication. In this current study, we analyzed postdistraction intracranial volume changes in 11 consecutive patients retrospectively from 10/2001 to 11/2010 with institutional review board approval. These 11 patients were treated by cranial vault distraction osteogenesis for symptomatic cephalocranial disproportion. Pre- and postoperative CT DICOM data were analyzed using specialized software to generate finite element models. Intracranial and ventricular volumes were calculated. Topographical surface maps were generated to document and quantify areas of change. Possible effects on brain physiology are discussed. Pre- and postoperative CT scans were obtained at an average of 3.5 months prior to, and 4.2 months following distraction, respectively. Average age at distraction was 55.72 months (range 26-104 months). Operative time averaged 2 h 44 min (range 127-198 min, SD = 30.6). Intracranial and ventricular volumes increased by an average of 77.01 and 4.85 ml, respectively. Nonventricular intracranial volumes increased by 5.91%, 71.67 ml following distraction. All postoperative volume changes were statistically significant (p ≤ 0.000025). The ability to use the same methodology to quantify ventricular volume changes was unexpected. The fact that all ventricles expanded after distraction at approximately 10% of the total intracranial volume increase indicates that compensatory mechanisms had been activated. We conclude that this occurs at the expense of cerebral blood flow.

Internal distraction osteogenesis to correct symptomatic cephalocranial disproportion.

BACKGROUND: Cephalocranial disproportion describes a state of volume mismatch between brain size and intracranial space. Nonsyndromic single-suture craniosynostosis patients can present with symptoms from elevated intracranial pressure because of inadequate or delayed treatment. The purpose of this study was to present five sagittal synostosis children with symptomatic cephalocranial disproportion treated with cranial vault distraction osteogenesis. METHODS: Asymmetric transverse internal distraction osteogenesis was performed to preferentially expand the posterior cranium. A wider base plate, pivot screw, anterior hinge plate, and flexible drive rod were applied to minimize device failure while accomplishing lateral rotation of parietal bones. A distraction protocol was developed and produced consistent results. RESULTS: Two girls and three boys underwent distraction for sagittal synostosis between 2002 and 2006. Average age at surgery was 5.8 years. All had resolution or amelioration of preoperative symptoms. Average operating room time for distractor placement was 2.5 hours (152 minutes) and average hospital stay was 2.8 days. The average distracted distance was 14.4 mm. Average operating room time for distractor removal was 1.1 hours (69 minutes) and average hospital stay was 1.6 days. No perioperative complications occurred. Average follow-up period was 4.2 years, with no recurrence of symptoms. CONCLUSIONS: Symptomatic cephalocranial disproportion can present in older children with craniosynostosis. Asymmetric transverse distraction of the posterior cranial vault is a safe and effective treatment modality for this population.