Scaphocephaly correction with retrocoronal and prelambdoid craniotomies (Renier's "H" technique).

OBJECTIVE: The aim of this paper is to describe the surgical technique, originally devised by Dr. Renier which is currently used to treat children with scaphocephaly under 6 months of age at the Craniofacial Unit of Hopital Necker Enfants Malades (French National Referral Center for Faciocraniosynostosis), focusing on its advantages and limitations.

Anterior fronto-orbital remodeling for trigonocephay.

INTRODUCTION: Trigonocephaly secondary to the premature fusion of the metopic synostosis is associated to a risk of cerebral compression and several craniofacial morphological alterations. Numerous surgical techniques have been proposed. They all carry a risk of secondary temporal hollowing PURPOSE: The aim of this paper is to describe the surgical technique used for trigonocephaly at the craniofacial unit of Hopital Necker Enfants Malades (French National Referral Center for Faciocraniosynostosis) focusing on its advantages and limitations. Resorbable osteosynthesis should be part of the current techniques.

Hypertelorism correction: what happens with growth? Evaluation of a series of 95 surgical cases.

BACKGROUND: This report documents the authors' experience with 95 hypertelorism corrections performed since 1971. The authors note their findings regarding outcomes, preferred age at surgery, technique, and stability of results with growth. METHODS: Patients were classified into three groups: midline clefts (with or without nasal anomalies, Tessier 0 to 14); paramedian clefts (symmetric or asymmetric with or without nasal anomalies); and hypertelorism with craniosynostosis. The authors developed a hypertelorism index to measure longitudinal orbital position. RESULTS: A total of 70 box osteotomies were performed. Twelve of 95 patients had a bipartition. Six of 95 patients underwent a unilateral orbital box displacement or a three-wall mobilization, and seven of 95 had a medial wall osteotomy. Eighty patients were graded 1 to 4 using the Whitaker scale. Fifty-nine of 80 patients received a grade of 1, 15 patients received a grade of 2, five patients received a grade of three, four patients initially scored a 4, and three patients underwent reoperation and were rescored as 1. The authors developed a hypertelorism index to rate 28 patients with long-term follow-up. None showed deterioration of results over the long term. The complication rate was 4 percent. CONCLUSION: The most interesting finding was that an initially good result in terms of orbital correction, whatever the severity, remains good with time, and facial balance improves after completion of growth. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

[The plastic surgery for plagiocephaly].

OBJECTIVE: To sum up three types of plastic procedures for frontal plagiocephaly Based on the principle of floating forehead, the plagiocephaly (unilateral coronal synostosis). METHODS: was corrected and orbito-frontal reconstruction was performed by orbito-frontal advancement, 'or temporoparietal osteotomy, or fronto-parietal osteotomy. The absorbable plates and microscrews composed of From January 2008 to polylactide polymers, were used to immobilize calvarial segments. RESULTS: December 2010, 9 cases of plagiocephaly were treated with satisfactory result and no severe complication. The patients were followed up for 1-2 years with no recurrence of suture fusion and deformity. The brain development was not restricted. The absorbable plates were applied to avoid the metal fixation moving into The three types of plastic procedures, orbito-frontal advancement, or the cranial bone. CONCLUSIONS: temporo-parietal osteotomy, or fronto-parietal osteotomy, can correct the plagiocephaly with satisfactory orbito-frontal appearance. Long-term follow-up is needed to observe the long-term effect of the orbito-frontal reconstructive operation on mental and calvarial development as well as visual function.

Cloverleaf skull deformity and hydrocephalus.

OBJECTIVE: This article describes the clinical aspects for both operated and non-operated patients with a cloverleaf skull deformity treated in our service, focusing on hydrocephalus. METHODS: We describe 13 cases of cloverleaf skull deformity treated in our services between 1977 and 2008. Among them, ten were operated (9 out of 13 for the craniofacial stenosis and 7 out of 13 for hydrocephalus). RESULTS: Hydrocephalus was present in all patients with bilateral lambdoid stenosis. There was no case of hydrocephalus among the patients with unilateral or absent lambdoid stenosis. Associated malformations and severe faciostenosis were associated with higher mortality and morbidity. CONCLUSION: The development of hydrocephalus seems to be closely related to a bilateral lambdoid stenosis. The optimal treatment must be tailored individually considering the degree of the malformation and the presence of complications and comorbidities.

WITHDRAWN: Commentary about the hemi nasal flap.

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Transatlantic Innovations: a new approach to international ideas and technology.

BACKGROUND: In April of this past year, Transatlantic Innovations brought a variety of organizations and industry together for an international exchange of ideas, new technology, and current trends in plastic surgery. METHODS: The meeting was highly interactive and included audience response devices. The focus was on 10 major areas: (1) new surgical techniques; (2) composite allografts versus conventional techniques, facing the future; (3) interspecialty collaboration versus competition; (4) the business of plastic surgery, best practices; (5) the image of the plastic surgeon, branding yourself; (6) medical tourism; (7) publicity; (8) the regulation of innovation, U.S. Food and Drug Administration and European Medicines Agency perspective; (9) the future of plastic surgery, cutting edge technologies; and (10) applications and controversies in fat grafting. The meeting concluded with the 8th International Committee for Quality Assurance, Medical Technologies and Devices in Plastic Surgery Consensus Conference with the development of a consensus statement. RESULTS: Through an interactive audience response system, additional questions and attitudes were asked of the audience and, in real time, international differences were identified, which led to further discussions from panelists. Responses were identified in three major groups: European Union, North America, and the Rest of the World. Responses and data are included in this article. CONCLUSIONS: The meeting brought participants, industry, regulators, and educators from both sides of the Atlantic. The interaction of these groups in these outlined topics brought a unique perspective to the meeting and, in the end, volumes of data. We have more in common than we believe. It is our anticipation that as we as plastic surgeons move forward, we can use these interactions to help our own practices but more specifically the specialty as a whole.

A horizontal V-Y advancement lower eyelid flap.

BACKGROUND: The authors were surprised to realize that the horizontal V-Y advancement flap of the lower eyelid is not even mentioned in the textbooks about eyelid repair, and they wanted to report their very positive experience with this subcutaneous pedicled flap. METHODS: Between 2000 and 2006, 21 patients were operated on, 13 women and eight men, aged 37 to 98 years, with a mean age of 67.5 years. The diagnosis was basal cell carcinoma in 20 cases and melanoma in one case. The size of the defect ranged from 10 to 30 mm, with a mean of 20 mm. RESULTS: All flaps survived and the aesthetic quality of the repair was excellent in 17 of 21 cases. Postoperative recovery was usually very fast. CONCLUSIONS: The lower eyelid is covered with remarkably thin skin, and for the repair of defects, especially after removal of basal cell carcinomas, it is preferable to avoid using tissues coming from another facial area (e.g., forehead, nose, or cheek), which has a different thickness and texture, or a full-thickness skin graft, which can leave a patch-like appearance. The ideal is to use the adjacent eyelid skin. For many years, the authors have used a horizontal large V-Y advancement flap on a muscular pedicle for the repair of lower eyelid defects, mostly after basocellular carcinoma excision, with very satisfactory results and often nearly invisible repairs.

Scaphocephaly: Part I: indices for scaphocephalic frontal and occipital morphology evaluation: long-term results.

UNLABELLED: Scaphocephaly is the most frequent craniosynostosis. Many correction techniques have been proposed. Their relevance is not completely appreciated by means of the Cranial Index, which cannot differentiate specifically the anterior and posterior modifications.The aim of this study was to propose a new fronto-occipital morphologic evaluation technique and its validation in normal and scaphocephalic patients, operated or nonoperated. PATIENTS AND METHODS: Two evaluation measures (indices) were developed for frontal and occipital deformities, traced over a standard skull radiograph. It was initially applied in 16 normal skull radiographs. Forty-two scaphocephalies were evaluated before and after linear perisutural craniectomy technique. Short- and long-term evaluations were performed in the 42 operated cases, with a follow-up period of 10 or more years.The created indices were named Frontal Sagittal Index (FSI) and Occipital Sagittal Index (OSI). They are proportional measures between 2 cranial lengths. RESULTS: A significant difference was found for the FSI and the OSI between scaphocephalies and normal skulls. A significant difference was also found between indices before and after surgery, whether it was short- or long-term follow-up. No significant differences were found between the indices for the short- and long-term follow-up. CONCLUSIONS: The FSI and the OSI were more precise measuring methods than the Cranial Index for the scaphocephaly anterior posterior morphologic evaluation and follow-up. There was also a stability of the results in the long-term follow-up with the technique used. We recommend these indices for the presurgical and result evaluation rather than the Cephalic Index.

Reossification of cranium and zygomatic arch after monobloc frontofacial distraction advancement for syndromic craniosynostosis.

Monobloc frontofacial advancement with distraction is becoming more routinely used within craniofacial surgery for faciocraniosynostosis, because of the simultaneous correction obtained on the exorbitism and of the respiratory impairment. Reossification of the cranium and zygomatic bone in monobloc frontofacial advancement with distraction has not been assessed previously on long series. In this study, 40 patients, 22 Crouzon, 11 Apert, and 7 Pfeiffer syndrome who underwent a frontofacial monobloc advancement by distraction osteogenesis, were retrospectively reviewed, after a mean of 2.1 years of follow-up. The bone linkage between both margin of the coronal and zygomatic osteotomy gap was evaluated on three-dimensional computed tomographic scan postoperatively. The correlations between reossification and some clinical situations (diagnosis, existence of previous anterior craniofacial procedure, use of bone paste, and the age at operation) were studied to determine factors that influence on reossification. "Good" or "fair" reossification on coronal gap was demonstrated by 68.2% of those with Crouzon and 54.5% of those with Apert syndrome. In contrast, 85.7% of those with Pfeiffer syndrome had "poor" or "absent" reossification. Rebridging of the zygomatic arch in Pfeiffer was also the poorest among 3 syndromes. Previous operations performed before the frontofacial monobloc advancement decreased reossification of distraction gap. In the group of patients in whom autologous bone paste on coronal osteotomy gap was applied, the bone formation was improved in all syndromes significantly. The reossification of the coronal osteotomy gap in patients with Pfeiffer syndrome is poor compared with those with Crouzon and Apert syndromes. Bone paste is extremely effective on increasing osteogenesis even in patients with Pfeiffer syndrome or the patients with previous surgery.

Fraciocraniosynostosis treatment strategy: one or two stages?

O tratamento cirúrgico da craniossinostose envolve técnicas complexas para prevenir danos cerebrais secundários e corrigir a retrusão facial, incluindo suas conseqüências (exorbitismo e danos às vias aéreas superiores). O avanço fronto-orbital convencional (antes de um ano de idade) pode corrigir problemas associados em um único procedimento na grande maioria dos casos apesar do crescimento cerebral estar completo aos três anos, a retrusão facial pode ser corrigida posteriormente, sabendo-se que o crescimento facial está completo oa redor de 16-18 anos. Uma osteotomia Le Fort III definitiva realizada tardiamente poderia não necessitar de distração. Pacientes com indicação de correção precoce, como crianças que apresentam malformações mais graves como risco de sequelas psicológicas importantes, podem ser operados antes, assim, considerando-se que o distúrbio genético de crescimento irá permanecer, cirurgia futura seá necessária. Os autores apresentam uma discussão sobre a realização do procedimento em um ou dois estágios para tratar esta desafiadora malformação, apresentando sua experência com milhares de casos já operados.

Against the "visible" short scar face lift.

According to the author, the short scar face lift seeks to eliminate the retroauricular scar by exerting a vertical pull on the cheek, but residual excess skin frequently remains below the ear lobe. More importantly, this vertical elevation of the cheek creates significant skin excess at the temporal level. To eliminate this excess, a precapillary temporal skin excision is usually performed. A potentially obvious temporal scar is thus created in a very visible part of the face. In this article, the author outlines his views on the drawbacks of the short scar face lift and advocates a different technique, using a vertical retroauricular incision, with the goal of avoiding the disadvantages of the short scar approach.

Unoperated craniosynostosis patients: correction in adulthood.

BACKGROUND: The purpose of this project was to determine whether adult patients with frontal deformities caused by untreated craniosynostosis can undergo successful surgical correction. METHODS: Thirteen unoperated adult craniosynostosis patients are reported: seven women and six men, with a mean age of 24 years. There were four plagiocephalies, four scaphocephalies, three oxycephalies, and two brachycephalies. Computed tomographic scans with cerebral contrast were obtained, and the projected computerized correction was discussed with the patients. Frontocranial remodeling with an intracranial approach was used in 11 cases, and a frontal implant plus nasal en bloc realignment was used in two. RESULTS: No significant perioperative complications occurred in this series. There were two late revisions for bony irregularities, through a limited approach. The morphologic correction was very satisfactory, emphasizing how important correct anatomy of the forehead and upper cranial vault is for the equilibrium of the face. CONCLUSIONS: Unoperated craniosynostosis creates a significant to severe disfigurement because of the frontal deformation. Therefore, only in mild cases can one propose a limited operation or an implant, avoiding an intracranial approach. In most cases, a radical intracranial approach is the only effective operation. Risks must be discussed with the patient, but the psychological impact of the disfigurement is so great that these young adults are usually willing to undergo a radical approach. Early operation in infancy is of course preferable, but if this was not performed for various reasons, it is still possible to correct the deformity, despite it being a much more complicated operation.

Avoiding the operated on look in multiple face lifts.

AIM: Reviewing 43 patients of ours who have had three or more face lifts, we wanted to demonstrate that it is possible to avoid the multi-operated on look. MATERIAL AND METHODS: Forty-three patients have been operated on three times or more: 42 females and one male. Thirty-six patients had three face lifts, six had four face lifts, one patient had five face lifts. The mean age at time of surgery was 50.3 years for the first face lift, 56.7 for the second, and 64.2 for the third face lift. These patients were operated on by the same surgeon using a technique which has evolved over the years but with the same basic goal of hiding the scars and of minimising hairline displacement. General appearance, scars and hairline displacement were evaluated in patients who had had three or more face lifts. RESULTS: The results of the evaluation of our 43 multi-operated on face lift patients were as follows: 35 patients did not appear to have had face lifts, eight patients did appear to have had face lifts, but with satisfactory appearance, 30 patients had no visible scars at a conversational distance, 10 patients had slightly visible scars when their hair was lifted, five had obvious scars when the hair was lifted, 34 patients had a normal hairline, six patients had a slightly receding hairline at the temporal level and three had hair loss at the level of the temporal scar. CONCLUSIONS: New technical improvements allow the preservation of a natural appearance, with well-hidden scars and a well-placed hairline. The common opinion that several repeated face lifts should be avoided because they give an unnatural appearance and severe sequelae in terms of scars and hairline displacement has not been confirmed by our clinical experience with 43 patients having undergone at least three face lifts.

Palpebral fissure changes after monobloc frontofacial advancement in faciocraniosynostosis.

There is virtually no literature on the effect of correction of syndromal faciocraniosynostosis with monobloc advancement on the palpebral fissure shape. Using image processing software, we measured the effect of monobloc advancement on the position of the upper and lower eyelids as well as the palpebral fissure slant in a series of 18 patients with syndromal faciocraniosynostosis who had undergone surgery for correction of orbital and midface hypoplasia. For both eyes of each patient, 3 variables were measured on the pre- and postoperative photographs: the linear distances between the upper and lower eyelid margins, the pupil center and the angle between the inner and outer canthi. The globe protrusion was also measured on axial computed tomography scans before and after surgery. The results indicate that the exorbitism reduction induced by monobloc advancement is accompanied by a diminution of the distance between both eyelids and the pupil center. However, the downward slant of the palpebral fissure is increased after surgery. The data suggest that the lower and upper eyelid retraction seen preoperatively in the majority of patients with faciocraniosynostosis tend to be corrected when the frontofacial region is advanced by the monobloc. On the other hand, the surgery tends to lower the outer canthus, increasing the negative slant of the fissure. The postoperative changes induced by the frontofacial monobloc advancement need to be taken into account when the surgery is going to be performed.

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.

Exorbitism correction of faciocraniosynostoses by monobloc frontofacial advancement with distraction osteogenesis.

Monobloc frontofacial advancement with internal distraction osteogenesis is still a relatively new technique, and the literature on exorbitism correction of syndromal faciocraniosynostosis with monobloc advancement is scarce. Using a image processing software, we measured on axial computed tomographic scans the effect of monobloc advancement on the correction of exorbitism on a large series of patients (n=38) with syndromal faciocraniosynostosis who underwent surgery for correction of cranial and facial hypoplasia. A population reference of 23 patients without faciocraniosynostoses was also measured. For each orbit, globe protrusion was expressed as the ratio between the length of the globe that is above the interzygomatic line and eye size. The results indicate that monobloc has a symmetrical effect on both eyes that is correlated to the preoperative degree of exorbitism. Longitudinal data indicate that exorbitism correction changes with time. A mean preoperative globe protrusion of 0.86 dropped sharply to 0.54 at 6 months after distraction and increased to 0.61 at 16 months after distraction removal, a value that is not significantly different from the ratio of the control group (0.60). Overall, the data suggest that a certain degree of enophthalmos in the early postoperative period does not necessarily imply a sustained overcorrection.