Role of Autologous Fat Injection in Neglected Patients With Anterior Plagiocephaly.

Anterior plagiocephaly is a type of non-syndromic craniosynostosis requiring surgery. In this study, the authors have presented 15 neglected patients with anterior plagiocephaly. Two of patients had moderate plagiocephaly whereas others had mild plagiocephaly. A total of 38 procedures (fat injections) were performed on these patients. Following procedures, 2 of patients were under corrected, 2 of who were over corrected, and others were adequate corrected. One of the patients developed fat necrosis. None of them showed persistent over correction. Authors believe that autologous fat transplantation is a safe and effective method, in patients with anterior plagiocephaly who have not been operated, to improve patients' appearance and, subsequently, their self-esteem as well as their social function.

Use of Navigation System in Craniofacial Surgery.

The use of navigated surgery in the treatment of craniofacial malformations can help obtain optimal results. In this article, the authors will discuss a case of anterior plagiocephaly, corrected with frontorbital bandeau remodeling. Navigation was used during the osteotomy and the reposition phase to ensure the correct positioning of the osteotomy instruments. It was also used to ensure that the bandeau was correctly repositioned in accordance with the surgical plan determined during the virtual simulation phase of the surgery.

Telescoping With Multiple Revolution Cranial Osteotomies in Patients With Simple Craniosynostosis.

Simple craniosynostosis is a cranial disease characterized by the premature closure of the cranial sutures, it develops during the first years of life and affects 1 in every 2000 to 2500 births worldwide (1). The cranial growth alteration occurs as parallel flattening to the compromised sutured with compensatory bulging in a perpendicular vector. Currently, The Suturectomy is the gold validated surgical treatment, that besides the dynamic Cranioplasties of multiples revolutions allows the design of bone flaps and therefore the correction of the secondary deformities caused by the synostosis. This multicenter descriptive study assessed a 20 series of cases (6 Plagiocephaly, 13 Scaphocephaly, 1 Brachycephaly) obtained in Cali, Colombia, that underwent surgery between January of 2014 and December of 2017, applying a Suturectomy surgery with additional telescoping of multiple revolution cranial osteotomies. The authors observe no clinical complications in the recruited patients regarding postoperative period of the described surgical technique (1, 90, and 180 days), thereby obtaining excellent outcomes on the maintained suture distraction focused on the assessment of the 3D reconstruction computed tomography scans.

Isolated Lambdoid Craniosynostosis.

INTRODUCTION: Lambdoid craniosynostosis is an extremely rare anomaly in which there is premature fusion of one or both lambdoid sutures. The mainstay of treatment is surgical intervention, for which various procedures have been described, but there is a paucity of data on long-term outcomes. This study examines the long-term outcomes in the surgical management of this challenging condition, showing that accurate diagnosis and careful planning can lead to safe and consistent results. MATERIALS AND METHODS: A retrospective chart review was performed looking at all cases of isolated lambdoid craniosynostosis treated with surgical intervention by the senior author from 1999 to 2016. Data collected included gender, age at diagnosis, age at surgery, length of follow up, method of diagnosis, side of affected suture, pre-operative and post-operative physical exam findings, surgical technique, complications, re-operation rate, and associated torticollis. RESULTS: Twenty-five patients (N = 25) were included in the study. All patients underwent posterior calvarial remodeling with/without barrel stave osteotomies and full thickness calvarial bone grafts. Mean length of follow up after operative intervention was 43.8 months (+/- 23.2 months). All patients were judged to have significantly improved head contour which was near-normal at conversational distance during post-operative follow up by the senior author. Residual plagiocephaly was present in 24% of patients. There were no major complications in this series. Reoperation rate was 8%. Seventy-six percent of patients also presented with torticollis, of which 37% had refractory torticollis that required sternocleidomastoid (SCM) release by the senior author. DISCUSSION: The authors present one of the largest series of operative cases of isolated lambdoid craniosynostosis to date. Our data show that with accurate diagnosis and careful planning, safe and consistent long-term results can be achieved with surgical intervention. A significant number of patients in our series also presented with concomitant torticollis. The authors recommend that all patients being evaluated for posterior plagiocephaly should also be evaluated for torticollis, because without recognition and intervention, patients may continue to have residual facial asymmetry and head shape abnormalities despite optimal surgical correction of the lambdoid synostosis.

Craniofacial Distraction in the Management of Anterior Plagiocephaly: A Novel Idea and a Systematic Review of the Literature.

BACKGROUND: The objective of this work is to present a review of all reports involving the management of unicoronal synostosis with distraction osteogenesis (DO). Also, we have innovated a new method in the treatment of cases of anterior plagiocephaly at a young age using DO. METHODS: We present a case in which anterior plagiocephaly was treated by DO of both metopic and hemicoronal sutures in a 4-month-old female patient. A comprehensive systematic literature review was completed using the search terms "distraction osteogenesis," "unicoronal synostosis," "anterior plagiocephaly," and "craniosynostosis." We excluded all experimental articles and reviewed clinical reports detailing the use of DO in the management of unicoronal synostosis. RESULTS: The study sample of this review consisted of 16 reports published over a period of 17 years that were analyzed in detail. The total number of patients treated by DO was 120, and the mean age at operation was 12 months. In the case presented, successful correction of the unicoronal synostosis was achieved. CONCLUSION: Hemicoronal and metopic suture distraction in anterior plagiocephaly achieves considerable improvement in the midline shift of the anterior cranial base and naso-orbital complex.

A New Operative One-Wing Technique to Correct Fronto-Orbital Region in Unilateral Nonsyndromic Plagiocephaly.

Anterior plagiocephaly is a premature closing of unilateral coronal suture. This premature suture fusion causes a series of cranial asymmetry and alteration of the fronto-orbital region.The authors described a new surgical technique to correct the facial asymmetry that reduces the operative time and the possible complications.In a period between 2013and 2016, 12 children affected by nonsyndromic anterior plagiocephaly were treated with this new procedure.Clinical, cranial development, and absence of postoperative complication demonstrated that one-wing surgical bone correction is a useful and innovative technique.

Squamosal Suture Synostosis: Incidence, Associations, and Implications for Treatment.

Squamosal suture craniosynostosis is thought to be a relatively rare entity. In the authors' experience, it is underreported in imaging examinations and the existing literature. The authors sought to determine the incidence of squamosal synostosis, whether it is increasing in frequency, and its relationship with synostosis of the major calvarial sutures.Patients undergoing computed tomography imaging for suspected craniosynostosis over a 15-year period were reviewed by a plastic surgeon and pediatric neuroradiologist. Patients with synostosis of the squamosal sutures were identified and involvement of additional sutures, gender, and the presence of a known syndromic diagnosis were recorded. Patients greater than 4 years of age or those with prior craniofacial surgery were excluded.One hundred twenty-five patients met inclusion criteria, 26 of whom had squamosal suture synostosis (26/125, 20.8%). Squamosal synostosis was found in isolation in 3 patients (3/26, 11.5%), with 1 additional major suture in 10 patients (10/26, 38.5%), and ≥2 major sutures in 13 patients (13/26, 50%). Squamosal synostosis was more common in patients with a syndromic diagnosis (11/26 syndromic, 15/99 nonsyndromic, P < 0.001). Eleven of 26 patients with squamosal synostosis were identified in the radiology report (42.3%).Craniosynostosis of the squamosal suture is much more common than previously reported and can contribute to abnormal head shape in isolation, or in combination with major sutures. Squamosal suture synostosis is underdiagnosed clinically and radiologically, although insufficient evidence exists to determine if its true incidence is increasing.

Long-Term Assessment of Suturectomy in Trigonocephaly and Anterior Plagiocephaly.

INTRODUCTION: Techniques for treating trigonocephaly and anterior plagiocephaly have evolved from the initial suturectomy technique to frontal cranioplasty. The authors evaluated the suturectomy technique in adolescent patients with these craniosynostoses, by carrying out a retrospective, long-term assessment at the end of growth. METHODS: Patients with anterior plagiocephaly or trigonocephaly were included. All had undergone coronal or metopic suturectomy with bilateral orbitofrontal bandeau resection between 1997 and 2005. The primary endpoint was the Whitaker classification. The secondary endpoints were anthropometric measurement, assessments of the bone defects on computed tomography scan, and the comments of patients and their relatives concerning the final skull outcome. Patients with anterior plagiocephaly also attended an ophthalmological consultation. RESULTS: Seventeen patients were included in the study: 8 with anterior plagiocephaly and 9 with trigonocephaly. Mean age at the time of surgery was 6.91 months. Mean age at the time of craniofacial consultation was 14 years. Fourteen patients (82%) were classified as Whitaker Class III and IV, corresponding to poor esthetic results and persistent bone defects. Seven patients requested further surgery. CONCLUSION: This study shows that suturectomy seems to yield poor esthetic results in the long term and patients should be followed up throughout adolescence to correct any craniofacial deformities.

The usage of the three-dimension distractor in the NAVID system for plagiocephaly-three case reports.

BACKGROUND: Distraction osteogenesis is a standard method for craniosynostosis. However, the technique using conventional devices still has some disadvantages, especially for anterior or posterior plagiocephaly with complex deformities. In the Nakajima's angle-variable internal distraction (NAVID) system originally for maxillary surgeries, the cranial three-dimension (D) distractor with three dimensionally movable joint at the anterior arm has been developed recently in order to prevent the interference in the distraction process and excessive force. CASE REPORTS: In this paper, we first reported two cases of anterior plagiocephaly, and one case of posterior plagiocephaly received distraction osteogenesis using new 3-D distractor in the NAVID system. In two cases of anterior plagiocephaly, the reshaping of supra-orbital bar in reference of simulating by the 3-D skull model was performed. In all cases, we fixed two paralleled 2-D distractors and a 3-D distractor in the upper frontal or parietal region. CONCLUSION: Within the limitations of this study, we believe that the NAVID system is suitable for infant plagiocephaly due to the simple and small joint arm. Furthermore, the usage of the 3-D distractor would reduce the interference with 2-D distractors and easily lead to attainment of targeted distracting distance.

Frontal cranial modeling using endocranial resorbable plate fixation in 27 consecutive plagiocephaly and trigonocephaly patients.

INTRODUCTION: Premature ossification of coronal and metopic sutures is treated by fronto-orbital remodeling. Such operations require stable fixation of the reshaped cranial bones. Currently, biodegradable plating systems are used to provide sufficient stability over the time that takes for the osteotomies to ossify. Plates that are placed traditionally on the outer surface of the cranium are often palpable and even visible through the thin overlying skin, compromising the cosmetic results of these operations. Improved aesthetics could be achieved by placing the plates endocranially. PURPOSE: This study aimed to evaluate endocranial resorbable plate fixation and its clinical and radiographic results in frontal remodeling cranioplasty for plagiocephaly and trigonocephaly patients with follow-up sufficiently long for the plates to have been completely resorbed. METHODS: A poly(lactide-co-glycolide) (PLGA) resorbable plating system was used on the inner aspect of frontal bone in 27 patients treated for coronal and metopic craniosynostoses. The outcome was evaluated at follow-up visits. The mean follow-up was 79.2 months. RESULTS: Three patients had complications that required reoperations. None of these complications were related to the endocranial location of the plates. There were no problems with ossification of the osteotomy sites. All but one patient's outcome was judged as good or excellent. CONCLUSION: Placement of resorbable fixation on the endocranial surface of the calvarial bones is safe, stable, and results in satisfactory aesthetics without interfering with the ossification of the cranial bones.

The assessment of relationship between the skull base development and the severity of frontal plagiocephaly after bilateral fronto-orbital advancement in the early life.

PURPOSE: The deformation of the skull base in patients with unilateral frontal plagiocephaly (UFP) is well known, but the mechanism is not still clear. We analyzed the skull base in the patients with UFP who underwent fronto-orbital advancement (FOA) in the early life during the last decade. METHODS: We assessed the treatment results and outcome of FOA performed in six patients, four girls and two boys younger than 2 years, in the last decade. Also, the basal cranium's angles were measured by 3D reconstruction images on computed tomography (CT) scan. RESULTS: The mean patients' age at FOAs was 11 months. Two cases were classified as grade 2A, two cases as grade 2B, and two cases as grade 3 (the classification of Di Rocco and Velardi). The ethmoidal axis was deviated a mean of 8.2° to the affected side. The mean angle between the petrosal pyramids and the midline (anterior-petrosal-sagittal angle, APSA) was 75.3° on the affected side and 66.2° on the normal side. The mean difference of APSA was 9.2°. On the follow-up CT images 5 years after surgery, the deviations of the ethmoidal axis clearly decreased, 5.7°, but the differences of APSA did not change, 8.8°. CONCLUSIONS: The midline distortion of anterior skull base should be considered to be spontaneously corrected during the follow-up periods in patients with all types of UFP who underwent FOA, unlike posterior skull base in the patients with grades 2B and 3 classification.

Suitable indication for the application of distraction osteogenesis: occipital enlargement for lambdoid synostosis.

In recent years, cranial distraction osteogenesis (DOG) for craniosynostosis has often been performed in Japan. Since 1998, DOG has been conducted in more than 80 patients with craniosynostosis in our institution. It is now important to define the appropriate indications for the application of DOG for craniosynostosis. From the point of view of our more than 10 years of experience with the application of cranial DOG, posterior enlargement is one of the most appropriate applications. Bilateral posterior expansion is conducted for hypertension because of bilateral lambdoidal synostosis, whereas unilateral posterior expansion is conducted for asymmetry because of unilateral posterior plagiocephaly. Posterior expansion by gradual distraction was conducted for 12 cases. Eight cases of syndromic craniosynostosis and 4 of simple unilateral lambdoid synostosis were included. Clinical and radiological improvement was observed in all cases. Postdistraction computed tomography demonstrated a decrease in digital printing within a few months in all cases. Distraction osteogenesis is a useful procedure for posterior enlargement by gradual expansion and guarantees postdistraction rigidity without collapse in a supine position in bilateral and unilateral lambdoid synostosis.

Frontal-orbital advancement for the management of anterior plagiocephaly.

PURPOSES: The main purposes of this manuscript are to provide an overview of various modalities of surgical correction of anterior plagiocephaly and to emphasize their differences with the classic open frontal-orbital advancement. METHODS AND RESULTS: Advancement of technology provides development of many other ways to achieve the same results. The authors describe the classic open frontal-orbital advancement and compare with other proposed techniques for correction of frontal plagiocephaly. The main limitation of the use of new forms of treatment of the anterior plagiocephaly is the age of the patient. There is still no consensus on criteria for quantitative evaluation of surgical results, and new forms of treatment do not present results with long follow-up. CONCLUSION: Frontal-orbital advancement is the preferred procedure to correct unicoronal synostosis due to its universal indication regardless of the age and degree of deformation of the anterior plagiocephaly.

Posterior plagiocephaly.

INTRODUCTION: Asymmetrical cranial vaults resulting from external forces on an infant's head can be caused by abnormal sutural development (synostotic plagiocephaly) or abnormal external forces acting on an intrinsically normal, developing cranium (deformational plagiocephaly). DISCUSSION: The incidence of posterior plagiocephaly has increased dramatically since the initiation of the "Back to Sleep" campaign against sudden infant death syndrome. The majority of cases are due to deformational plagiocephaly, but rigorous diagnostic evaluation including physical examination and radiological imaging must be undertaken to rule out lambdoid synostosis in extreme or refractory cases. CONCLUSION: Unique clinical features and radiological examination using computed tomography technology are helpful in confirming the correct cause of posterior plagiocephaly. Plagiocephaly is considered a benign condition, but with the recent increase in cases, new studies have revealed developmental problems associated with cranial vault asymmetries. Treatment of positional/deformational plagiocephaly includes conservative measures, primarily behavior modification, and, in some cases, helmet therapy, whereas lambdoid synostotic plagiocephaly requires surgical intervention, making differentiation of the cause of the asymmetry critical.

Expression of transforming growth factor-ß1, -ß2, and -ß3 in plagiocephalic fused and patent coronal suture.

BACKGROUND: Craniosynostosis is a relatively rare disease. Recently, several studies have investigated the etiology of craniosynostosis using animal models; however, the etiology remains unknown. In this study, we examined transforming growth factor (TGF) ßs immunostaining from coronal sutures in patients with plagiocephaly. MATERIALS: The examined materials were obtained from 3 patients who had undergone surgery for plagiocephaly. The sections were obtained from the normal patent side and the abnormal fused side of the coronal suture. The subjects included 2 girls and 1 boy with ages ranging from 1 to 4 years. Osteoblasts and connective tissue were observed with hematoxylin and eosin stain. Immunohistochemistry of the TGF-ß isoforms was performed to investigate the difference between the patent and fused sutures. RESULTS: No connective tissue was observed in the fused suture. The osteoblasts in the patent suture were activated, whereas the osteoblasts in the fused suture were inactivated. The osteoblasts were positive for TGF-ß1, -ß2, and -ß3. The periosteum tended to be positive for TGF-ß2 and negative for TGF-ß1 and -ß3. There was no distinct difference between the patent and fused sutures in this study. DISCUSSION: In this study, all sutures had fused completely, and therefore, we may have missed the period when there are differences in protein manifestation. The modulation of the growth factor profile at the suture site may have a potential therapeutic value.

Long-term ophthalmological outcomes in patients with anterior plagiocephaly managed with a fronto-orbital advancement procedure.

BACKGROUND: Anterior plagiocephaly results from early fusion of a unilateral coronal cranial suture, which affects 1/10,000 infants at birth and can be associated with ophthalmological complications. The study aimed to evaluate the frequency of oculomotor disorders and refractive errors in children with non-syndromic anterior plagiocephaly. METHODS: Patients with anterior plagiocephaly undergoing surgery using a fronto-orbital advancement technique were included in this retrospective study between 2011 and 2017. The following data were collected: cycloplegic refraction in diopters (D), best-corrected visual acuity, manifest strabismus in primary position, ocular motility, head tilt in primary position, slit-lamp and fundus examination. The refractive errors were determined by autorefraction after cycloplegia with cyclopentolate. RESULTS: Among the sixteen patients included, hyperopia >2.5D was found in 10 patients, astigmatism >1D in 10 patients and anisometropia >1D in 7 patients. Astigmatism was contralateral to the synostosis in 7 cases. In total, significant refractive errors were found in 92.9%. Amblyopia was found in 33.3% patients. Strabismus was found in 11 patients, most frequently combined horizontal and vertical, of which 4 required strabismus surgery. The most frequent vertical deviation was ipsilateral hypertropia in 54.5%. We found superior oblique muscle limitation in 3 patients. Optic disc pallor was found in 2 patients. CONCLUSION: In the years following fronto-orbital advancement for non-syndromic anterior plagiocephaly, refractive errors and oculomotor disorders are frequently encountered, mainly contralateral astigmatism and strabismus with both horizontal deviation and ispilateral hypertropia.

Reconstruction of unicoronal plagiocephaly with a hypercorrection surgical technique.

OBJECT Successful surgical repair of unicoronal plagiocephaly remains a challenge for craniofacial surgeons. Many of the surgical techniques directed at correcting the stigmata associated with this craniofacial deformity (for example, ipsilateral supraorbital rim elevation [vertical dystopia], ipsilateral temporal constriction, C-shaped deformity of the face, and so on) are not long lasting and often result in deficient correction and the need for secondary revision surgery. The authors posit that the cause of this relapse was intrinsic deficiencies of the current surgical techniques. The aim of this study was to determine if correction of unilateral coronal plagiocephaly with a novel hypercorrection surgical technique could prevent the relapse of the characteristics associated with unicoronal plagiocephaly. METHODS The authors performed a retrospective analysis of 40 consecutive patients who underwent surgical repair of unicoronal plagiocephaly at their institution between 1999 and 2009. In all cases, the senior author (S.R.B.) used a hypercorrection technique for surgical reconstruction. Hypercorrection consisted of significant overcorrection of the affected ipsilateral frontal and anterior temporal areas in the sagittal and coronal planes. Demographic, perioperative, and follow-up data were collected for comparison. The postsurgical appearance of the forehead was documented clinically and photographically and then evaluated and scored by 2 independent graders using the expanded Whitaker scoring system. A relapse was defined as a recurrence of preoperative features that required secondary surgical correction. RESULTS The mean age of the patients at the time of the operation was 13 months (range 8-28 months). The mean follow-up duration was 57 months (range 3 months to 9.8 years). The postsurgical hypercorrection appearance persisted on average 6-8 months but gradually dissipated and normalized. No patients exhibited a relapse of unicoronal plagiocephalic characteristics that required surgical correction. In all cases the aesthetic results were excellent. Only 3 patients required reoperation for the management of persistent calvarial bone defects (2 cases) and removal of a symptomatic granuloma (1 case). CONCLUSIONS Our study demonstrates that patients who undergo unicoronal plagiocephaly repair with a hypercorrection surgical technique avoid long-term relapse. Our results suggest that the surgical technique used in the correction of unilateral coronal synostosis is strongly associated with the prevention of postsurgical relapse and that the use of this novel method decreases the need for surgical revision.

V-Y advancement flaps for scalp closure after acute cranial volume expansion.

Sometimes the surgeon who contemplates a coronal incision for craniofacial surgery, such as fronto-orbital advancement, faces a situation in which closure by primary suture becomes impossible because of acute cranial volume expansion. To avoid such a situation, the authors invented V-Y advancement flap method. This flap was found to be highly effective in 6 craniofacial patients who were treated between March 2007 and March 2008. The method consists of an incision line that starts from the highest spot on the ear and proceeds in the direction of the hairline at 45 degrees, and then runs up to the vertex in a sawtooth manner. This line is used when acute cranial volume expansion is expected after surgery. Another incision line is symmetrically drawn on the opposite side of the head. These 2 lines are conjoined at the vertex. The lengths of the 2 sides of a single sawtooth are both about 2 to 3 cm. When the scalp of an expanded cranium is closed, some V-shaped scalp margins under normal tension can simply be sutured using a traditional V-V advancement flap. However, the others under increased tension need to be in a Y-shaped pattern. During the follow-up period (6 months on average), application of this V-Y advancement flap method led to good functional and aesthetic outcomes in all 6 cases. The authors attribute these results to scalp closure using a mixture of V-V and V-Y flaps.

Posterior calvarial augmentation in premature craniosynostosis: a technique avoiding foreign implants or free bone flaps.

BACKGROUND: A surgical technique of posterior calvarial augmentation without the use of plates or screws and avoiding the formation of free bone flaps is described. DISCUSSION: Three infants with strong occipital flattening successfully underwent the procedure in their first year of life. There were no intra- or postoperative complications; the amelioration of the head shape and the cosmetic results in all three cases were convincing also in the long term. CONCLUSION: The proposed surgical technique is both feasible and effective; it is recommended for infants with marked flat deformation of the posterior calvaria in the first year of life.

Craniosynostosis and oculomotor disorders.

Simple, complex or syndromic craniosynostosis may be responsible for ocular and especially oculomotor pathologies. Among simple craniosynostosis, anterior plagiocephaly is the most frequently associated with oculomotor disorders. Oculomotor disorders encountered in craniosynostosis are specific to this pathology. They may be related to orbital deformities or oculomotor muscle malformations. Early craniofacial surgery reduces the onset and severity of these oculomotor disorders which is very important for ophtalmological patient care. Indeed, these oculomotor disorders are difficult to treat for the ophthalmologist with most of the time several surgeries needed, and lead to amblyopia if neglected.