2015 HSC Section 1 Book of Articles

Maxillofacial surgery

with syndromic craniosynostoses, but its role in cranial vault surgery is still limited. Steinbacher et al. [28] published a case series of eight syndromic patients who underwent posterior cranial vault dis- traction osteogenesis using mandibular distractors. They were successful in expanding the posterior cranial vault (mean advancement of 23mm) and state that the technique allows greater advancement due to the expansion of the constricting scalp. However, there are several limitations of distrac- tion osteogenesis for the cranial vault, including the absence of devices specific to the cranial vault, the need for a second surgery to remove the devices, and the inability to mould gross calvarial deformities. Rare cases of treating the adult patient with craniosynostosis have been reported. Marchac et al. [29] reported on a series of 13 patients (mean age 24 years); 11 underwent cranial vault remodel- ing and two had camouflage surgery with polyme- thylmethacrylate implant and correction of nasal deformities. Cranial vault remodeling for patients presenting later in life is primarily a cosmetic pro- cedure involving significant operative risk, as well as the risk of irregular contour deformities from their less malleable bone. The authors indicated the exception in one patient with intractable headaches and copper beating of the skull indicative of increased intracranial pressure. The patient’s head- aches resolved after surgery. The authors advocate avoiding radical cranial vault remodeling in the adult patient presenting with limited frontal asym- metry, reserving cranial vault remodeling for patients with neurological signs or symptoms or those with orbital dystopia. There is no consensus on the best operative procedure. Proponents of endoscopic suturectomy claim shorter operative time, less blood loss and transfusion requirements, and shorter hospital stay. Advocates of cranial vault remodeling argue that contemporary surgery is much safer and new bench- marks are necessary to compare the morbidity of each procedure [30 & ]. In 1979, Whitaker et al. [31] reported 2.2% mortality and 25.7% complication rate in a combined trial of 793 craniofacial oper- ations. In 2010, Seruya et al. [30 & ] found a compli- cation rate of 3.3% in 212 patients who underwent craniofacial operations (two cerebral contusions, two hematomas, one cerebrospinal fluid leak, one infection, and one wound breakdown). Improved outcomes can be attributed to specialized anesthesi- ology and the use of controlled intraoperative hypo- tension and improved critical care. The senior author feels that sagittal synostosis in patients under 6 months of age can be treated with craniectomy and barrel stave osteotomies followed by helmet

therapy with predictable outcomes. Other presenta- tions of nonsyndromic craniosynostosis are most predictably managed with cranial vault remodeling between ages 6 and 9 months, and rarely is helmet therapy of benefit following surgery. Timing of surgery is determined primarily by the choice of surgical procedure, as described above. Suture release procedures such as endoscopic suturectomy, spring-mediated distraction and the pi procedure are usually done earlier than 6 months of age. Cranial vault remodeling is performed between 4 and 13 months of age. We prefer to delay cranial vault remodeling until greater than 6months of age as before this time the bones are too malleable to retain their shape following surgical correction. In addition, delaying major cranial vault surgery until after 6 months provides a larger infant who can tolerate extended surgery better than the neonate. CONCLUSION The management of nonsyndromic craniosynosto- sis is rapidly evolving with the introduction of alternatives to cranial vault remodeling. Cranial vault remodeling remains the gold standard treat- ment and allows contouring without relying on the underlying expanding brain, but the technique is limited by significant morbidity. Newer mini- mally invasive techniques include strip craniectomy with helmet therapy, spring-assisted cranioplasty and distraction osteogenesis for posterior vault remodeling.

Acknowledgements None.

Conflicts of interest There are no conflicts of interest.

REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 342). 1. Knoll B, Persing JA. Craniosynostosis. In: Bentz ML, Bauer BS, Zuker RM, editors. Pediatric plastic surgery. 2nd ed. St Louis: Quality Medical Publish- ing; 2008. pp. 541–563. 2. Cohen MM Jr. Epidemiology of craniosynostosis. In: Cohen MM Jr, MacLean RE, editors. Craniosynostosis. 2nd ed. New York: Oxford University Press; 2000. pp. 112–118. 3. Persing JA, Knoff B, Duncan CC. Nonsyndromic craniosynostosis. In: Guyur- on B, Eriksson E, Persing JA, editors. Plastic surgery, indications and practice. Philadelphia: Saunders Elsevier; 2009. pp. 389–404. 4. Albright AI, Byrd BP. Suture pathology in craniosynostosis. J Neurosurg 1981; 54:384–387. 5. Sommering S. Of the human body [in German]. 2nd ed. Leipzig, Germany: Voss; 1839.

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