Cranioplasty for Metopic Craniosynostosis

Overview This video demonstrates an open anterior cranial vault reconstruction for metopic craniosynostosis on a 5-month-old female. Related External Links https://www.childrenshospitalvanderbilt.org/medical-conditions/craniosynostosis Editor Recruited By N/A Tags Craniofacial, cranial vault, calvarium, resorbable, open Procedure Metopic craniosynostosis has historically been treated with open cranial vault reconstruction. A landmark study by Marsh and Vannier in 1986 demonstrated improvement in cranial base abnormalities following cranioplasty for craniosynostosis.1 In patients younger than 4 months, some surgeons perform endoscopic strip craniectomy followed by helmeting as a less invasive alternative. Indications The main indications for this procedure are two-fold. The first goal is alleviation or prevention of increased intra-cranial pressure. The second is to correct the trigonocephaly deformity and restore a normal head shape. Contraindications Contraindications include bleeding diatheses or comorbid medical conditions in which the risk of surgery outweighs the benefit. Instrumentation SonicWeld RxÒ resorbable implant system by KLS Martin Group Stryker TPX handpieces – reciprocating saw, pineapple burr, footed router Setup The patient is positioned supine in a neurosurgical horseshoe headrest. It is helpful to have two mono-polar and bi-polar cauteries connected to separate machines to facilitate concomitant use by two surgeons, as operative time and hemostasis are of the utmost importance. A back table is set up with space and instrumentation for bone cutting, contouring, and plating. A sterile warm water bath is necessary, as the plates require significant heat to bend. It is helpful to keep Mayo scissors in the bath as warmed scissors facilitate cutting the plates to the desired length.  For two-team efficiency, our back table setup is replicated over the foot of the bed using two Mayo stands. Bair huggers and a warm ambient room temperature are necessary to prevent hypothermia. Blood products should be in the room at the start of the case. Preoperative Workup Though it is debated within the craniofacial community, our protocol is to obtain a low-dose protocol CT of the head to confirm diagnosis. If there is multi-suture involvement or the patient has dysfunction of another organ system, a syndromic work-up is performed and the patient is referred to genetics. In more complex cases, the patient receives pre-operative workup from the anesthesia and pediatric ICU teams. All patients are typed and crossed for blood transfusion which is required in approximately 50 percent of our cases. Anatomy and Landmarks A wavy coronal incision is designed just above the ears bilaterally. Dissection anteriorly is sub-periosteal, whereas posteriorly a subgaleal dissection is performed to decrease blood loss. As the coronal flap is elevated anteriorly, periorbital dissection proceeds from just below the zygomaticofrontal suture, superiorly over the globe and medially to just below the nasofrontal junction. If the supra-orbital nerve is in an enclosed foramen, it must be freed with an osteotome to allow anterior mobilization of the coronal flap. The upper extent of the bandeau is marked approximately 1cm above the supraorbital rim. This is facilitated by placing a ruler along the supraorbital rim and using it as a marking guide. The inferior extent of the bandeau is at approximately the level of the zygomaticofrontal junction. Advantages/Disadvantages The primary advantage of open cranial vault reconstruction, when compared to endoscopic approaches, is the ability to perform a fronto-orbital advancement and reshape the fronto-orbital bandeau. The disadvantages include increased operative duration, increased blood loss, and increased recovery time. Complications/Risks The most significant intraoperative complication is surgical bleeding, which can result in death. This is mitigated by meticulous surgical hemostasis, close intra-operative monitoring of hemodynamic stability and hematocrit, and transfusion when needed. Acute post-operative complications include infection, hematoma, seroma, and CSF leak. These risks are increased in syndromic patients. Longer term complications include residual deformity, osseous defects, and recurrent elevated intra-cranial pressure.2 Correction often requires re-operation. Disclosure or Conflicts No authors have financial, consultant, institutional or other relationships that might lead to bias or a conflict of interest. Acknowledgements N/A References Marsh JL, Vannier MW. Cranial base changes following surgical treatment of craniosynostosis. Cleft Palate J. 1986;23(Suppl 1):9–18. Tahiri, Youssef M.D., C.M., M.Sc.; Bartlett, Scott P. M.D.; Gilardino, Mirko S. M.D., M.Sc. Evidence-Based Medicine: Nonsyndromic Craniosynostosis, Plastic and Reconstructive Surgery: July 2017 - Volume 140 - Issue 1 - p 177e-191e doi: 10.1097/PRS.0000000000003473

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The authors have no conflicts of interest to disclose, financial or otherwise.

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