Fronto-orbital advancement using an en bloc frontal bone craniectomy.

BACKGROUND: Fronto-orbital advancement is a procedure commonly performed in craniofacial centers for coronal and metopic suture synostosis. Several variations of the technique have been reported. OBJECTIVE: To describe our modifications to the anterior cranioplasty procedure and the results of our surgical series. METHODS: Using our craniofacial database, we retrospectively analyzed the records of all patients undergoing fronto-orbital advancement for craniosynostosis. The same team of neurosurgeons and plastic surgeons performed all procedures. Demographic data, operative time, blood loss, length of stay, and clinical outcome were analyzed. RESULTS: Of 248 patients treated for craniosynostosis, a total of 70 patients underwent fronto-orbital advancement. Nineteen presented with metopic, 26 with unilateral coronal, 17 with bilateral coronal, and 8 with multiple synostosis. Median age at surgery was 6.5 months. Mean operative time was 210 minutes; mean blood loss was 167 mL; and length of stay was 4.5 days. A positive correlation was found between operative time and blood loss (r = 0.1, P < .01) and age at surgery and blood loss (r = 0.3, P < .0001). There was a minor morbidity rate of 2.9%. A good reconstruction was obtained in all patients using our en bloc fronto-orbital advancement without any midline osteotomies at a mean follow-up of 15 months. CONCLUSION: A team approach and the application of a standardized surgical technique should make it safer to operate in young children, shorten the surgical time, and lead to a reduction in blood loss. Reconstructing the frontal bone as an entire unit yielded excellent correction for coronal and metopic synostosis.

Airway analysis: with bilateral distraction of the infant mandible.

BACKGROUND: Mandibular distraction was proven to be a valuable tool for lengthening the hypoplastic mandible and relieving airway obstruction in infants. However, analysis of presurgical and postsurgical three-dimensional computed tomography and polysomnogram studies is lacking. The aim of this study was to describe the effect of distraction on the airway by evaluating the clinical, three-dimensional radiographic and polysomnogram studies before and after distraction. METHODS: Seventeen infants with micrognathia who underwent internal curvilinear mandibular distraction from April 2005 through April 2008 at Lucile Packard Children's Hospital were included. Preoperative and postoperative computed tomography, polysomnograms, and feeding evaluations were obtained and compared after distraction. RESULTS: The mean patient age before surgery was 105 days. All patients tolerated the distraction process with a mean mandibular advancement of 18.1 mm. One patient experienced a temporary marginal mandibular nerve palsy that resolved, and 1 postoperative wound infection was encountered. Preoperatively, the mean retroglossal oropharyngeal cross-sectional area was 41.53 mm. This was associated with a mean preoperative apnea-hypopnea index (AHI) of 10.57 and a minimum oxygen desaturation of 83%. After distraction, the mean airway increased to 127.77 mm. All patients had clinical improvement of their respiratory status; the mean postoperative AHI was 2.21, and the minimum oxygen desaturation was 90%. The result was a 209% cross-sectional airway increase. All patients progressed to oral feeds by 3.5 months postoperatively. CONCLUSIONS: Mandibular distraction is effective at relieving anatomic airway obstruction in infants with micrognathia and obstructive sleep apnea while avoiding some previously reported associated complications.