Assuntos
Tronco Encefálico/anormalidades , Fissura Palatina , Anormalidades Craniofaciais , Malformações do Sistema Nervoso , Procedimentos de Cirurgia Plástica , Anormalidades da Pele , Criança , Humanos , Anormalidades da Pele/cirurgia , Anormalidades Craniofaciais/cirurgia , Fissura Palatina/cirurgiaRESUMO
It concerns three siblings (two 28 year old twin boys and a 25 year old woman) who presented a previous history of rupture of eyeball in one eye and very poor vision in the other. At the first ophthalmoscopic and instrumental evaluation, three patients presented with bluish sclera and keratoglobus in the intact eye. A genetic analysis with whole exome sequencing was then performed on the three siblings, identifying a biallelic variant of the PRDM5 gene that led to the diagnosis of Brittle Cornea Syndrome (BCS), a rare autosomal recessive disorder characterized by corneal thinning and blue sclera. To preserve the only intact eye from possible breakage, the three siblings were trained in using protective measures (polycarbonate goggles etc.) to carry out close monitoring of symptoms and were asked to continue with follow-up visits for ocular and systemic diseases associated with BCS. Given the poor best corrected visual acuity achievable with glasses and contact lenses, penetrating keratoplasty was performed, achieving good visual acuity maintained in the 2-year follow-up in two of the three patients. Knowledge of this pathology and its clinical manifestations is essential for early diagnosis and correct management of this rare but very debilitating pathology. To our knowledge, this is the first case series of BCS reported in an Albanian population.
Assuntos
Anormalidades do Olho , Instabilidade Articular , Anormalidades da Pele , Masculino , Feminino , Humanos , Adulto , Ceratoplastia Penetrante , Anormalidades da Pele/diagnóstico , Anormalidades da Pele/genética , Anormalidades da Pele/cirurgia , Anormalidades do Olho/diagnóstico , Anormalidades do Olho/genética , Anormalidades do Olho/cirurgia , Instabilidade Articular/diagnóstico , Instabilidade Articular/genética , Instabilidade Articular/cirurgia , Córnea/patologiaRESUMO
INTRODUCTION: Congenital midline cervical cleft is a rare condition and is frequently misdiagnosed as thyroglossal duct cyst. Otherwise, the combination of congenital midline cervical cleft and thyroglossal duct fibrosis in the same patient is as rare as important to be registered with the intention to inform and offer specific managements details for the literature. CASE PRESENTATION: Eight-year-old boy with simultaneous congenital midline cervical cleft and a thyroglossal duct fibrosis. The anatomic, clinical, radiologic, and pathologic characteristics of the congenital midline cervical cleft are described as well as surgical technique for removal and repair with Z-plasty. CONCLUSION: Congenital midline cervical cleft is a rare condition and when diagnosed must be surgically treated as early as possible. Its differential diagnosis is a clinical challenge.
Assuntos
Anormalidades Craniofaciais , Procedimentos de Cirurgia Plástica , Anormalidades da Pele , Cisto Tireoglosso , Masculino , Humanos , Criança , Pescoço/cirurgia , Anormalidades da Pele/cirurgia , Anormalidades Craniofaciais/cirurgia , Cisto Tireoglosso/diagnóstico , Cisto Tireoglosso/cirurgiaRESUMO
Purpose: To compare the anatomical, morphological, and functional outcomes of the conventional internal limiting membrane (ILM) peeling versus temporal inverted ILM flap technique for large full-thickness macular holes (FTMHs). Methods: Sixty eyes of 60 patients with a minimum base diameter >600 µm were included in this retrospective interventional study. Patients were divided into conventional ILM peeling (Group 1) and temporal inverted ILM flap (Group 2) groups. The hole closure rate, best-corrected visual acuity (BCVA), ellipsoid zone (EZ), and external limiting membrane (ELM) defects were analyzed at baseline and 6 months after surgery. Results: Hole closure was achieved in 24/32 (75.0%) cases of Group 1 and 27/28 (96.4%) cases of Group 2 (P = 0.029). The mean BCVA (logMAR) changed from 1.23 ± 0.47 to 0.70 ± 0.29 logMAR in Group 1 and from 1.03 ± 0.36 to 0.49 ± 0.24 logMAR in Group 2 at 6 months (P < 0.001 in both cases). U-shaped closure was observed in 5 (15.6%) eyes in Group 1 and 19 (67.9%) eyes in Group 2 (P < 0.001). The total restoration rates of ELM and EZ were significantly higher in the temporal inverted ILM flap group (P = 0.002, P = 0.001, respectively). Conclusion: The study results suggested that the FTMH closure rate, recovery of the outer retinal layers, and, consequently, the post-operative BCVA were better with the temporal inverted ILM flap technique than with the conventional ILM peeling for larger than 600 µm macular holes.
Assuntos
Membrana Epirretiniana , Perfurações Retinianas , Anormalidades da Pele , Humanos , Perfurações Retinianas/diagnóstico , Perfurações Retinianas/cirurgia , Vitrectomia/métodos , Estudos Retrospectivos , Membrana Epirretiniana/cirurgia , Membrana Basal/cirurgia , Tomografia de Coerência Óptica , Acuidade Visual , Retina , Anormalidades da Pele/cirurgiaRESUMO
Congenital midline cervical cleft (CMCC) is a rare congenital difference. Accurate diagnosis is important to ensure appropriate treatment. CMCC results in both functional and esthetic concerns addressed by surgical management. While the majority of reported CMCC cases have been treated with a z-plasty, the best method of repair has been debated in the literature. The authors present a case of CMCC and review of the literature.
Assuntos
Procedimentos de Cirurgia Plástica , Anormalidades da Pele , Humanos , Estética Dentária , Pescoço/cirurgia , Pescoço/anormalidades , Anormalidades da Pele/cirurgiaRESUMO
Webbed neck is a rare condition characterized by bilateral subcutaneous bands, which extend from approximately the mastoid to the acromion. Given its rarity, the literature lacks a review of the techniques used in the repair of this condition. We performed a scoping review to define and summarize the surgical techniques been used in the treatment of webbed neck, with the goal of better equipping the surgeons' armamentarium. Two databases, PubMed and Scopus, were searched from inception through December 27, 2021. Studies were considered for inclusion if they (1) described the webbed neck condition and (2) reported results of surgical correction of this condition. Surgical outcomes and follow-up durations were reported as available. Twenty-two manuscripts were analyzed and included data on 60 patients. The most common syndrome associated with webbed neck was Turner syndrome (48 patients). The most frequently documented procedure technique was a Z-Plasty (38 patients). Other procedures described included: butterfly correction, V-Y Plasty, posterior cervical lift, skin excision, tissue expansion plus skin excision, T to M rearrangement, and subcutaneous fascial excision. Documented complications included hypertrophy of procedure scars or webbed neck recurrence. In summary, we present the first full literature review of the surgical techniques used in the repair of webbed neck. When selecting the technique for repair of the webbed neck, function and cosmesis are important considerations. Future studies should collect standardized outcomes data to appropriately assess and compare the described procedures.
Assuntos
Anormalidades da Pele , Síndrome de Turner , Humanos , Pescoço/cirurgia , Anormalidades da Pele/cirurgia , Orelha/cirurgia , Síndrome de Turner/cirurgia , Expansão de TecidoRESUMO
BACKGROUND/AIMS: To evaluate the clinical outcomes of deep anterior lamellar keratoplasty performed by stromal peeling in eyes that have previously undergone penetrating keratoplasty (PK) for keratoconus. METHODS: Standardised stromal exchange included (1) 9 mm trephination of the recipient bed outside the old PK wound, (2) creation of a partial anterior corneal flap through lamellar dissection across the PK wound, (3) opening the stromal component of the old PK wound using blunt-tipped Vannas scissors until a plane of separation is reached, (4) severing the attachment of the PK surgical scar from the recipient host, (5) peeling the stroma of the PK graft from the underlying tissue and (6) suturing the donor anterior corneal lamella prepared by microkeratome dissection (450 µm depth, 9 mm diameter). Main outcome measures were success rate, best spectacle-corrected visual acuity (BSCVA) and endothelial cell loss (ECL). RESULTS: Of 21 post-PK eyes, stromal exchange succeeded in all but three cases, which were converted to a two-piece mushroom PK. After complete suture removal, mean BSCVA significantly improved from 0.95±0.39 logMAR preoperatively to 0.23±0.17 logMAR (p<0.001). Mean ECL was 5.4±23.2%. Double anterior chamber formation occurred in eight cases (44%), which all resolved after a single re-bubbling. CONCLUSION: In post-PK eyes, stromal exchange can be performed by means of simple peeling without deep anterior lamellar dissection of the previous PK graft. Large-diameter (9 mm) repeat keratoplasty through stromal peeling yields excellent visual outcomes and minimal ECL. Double anterior chamber formation may complicate the postoperative course, but prompt intervention allows successful management.
Assuntos
Transplante de Córnea , Ceratocone , Anormalidades da Pele , Córnea/cirurgia , Humanos , Ceratocone/cirurgia , Ceratoplastia Penetrante , Estudos Retrospectivos , Anormalidades da Pele/cirurgia , Resultado do Tratamento , Acuidade VisualRESUMO
Cutaneous head and neck reconstruction following Mohs micrographic surgery frequently presents the surgical dilemma of dog-ear formation during wound closure. Z-plasty corrects a dog-ear deformity without skin excision by recruiting tissue from the axis of the standing cone and redistributing it along another. We describe dog-ear correction using the Z-plasty technique.
Assuntos
Cirurgia de Mohs/métodos , Procedimentos de Cirurgia Plástica/métodos , Retalhos Cirúrgicos , Humanos , Masculino , Anormalidades da Pele/cirurgiaRESUMO
Beare-Stevenson syndrome (BSS) is an extremely rare genetic disorder characterized by a broad range of congenital malformations including craniosynostosis, cutis gyrata, facial deformities, and abnormal genitalia. The authors report a case of a 7 month old female who developed a mechanical ptosis secondary to dermatochalasis as a complication of fronto-orbital advancement and remodeling (FOAR) surgery which subsequently required multiple lid surgeries to reverse ptosis. This is the first report of blepharoptosis correction in a child with BSS as a complication of FOAR.
Assuntos
Acantose Nigricans/cirurgia , Blefaroptose/cirurgia , Craniossinostoses/cirurgia , Orelha/anormalidades , Dermatoses do Couro Cabeludo/cirurgia , Anormalidades da Pele/cirurgia , Acantose Nigricans/complicações , Blefaroptose/complicações , Craniossinostoses/complicações , Orelha/cirurgia , Feminino , Humanos , Lactente , Órbita , Dermatoses do Couro Cabeludo/complicações , Anormalidades da Pele/complicaçõesRESUMO
Laser surgery is becoming an increasingly efficacious and customizable treatment modality for the management of pediatric vascular lesions. Proper use requires a thorough understanding of the scientific principles of laser surgery and knowledge of the various lasers available. Moreover, each laser has a multitude of settings that can be employed to properly target the lesion at hand. Each patient will present with unique challenges and variations in the presentation of their vascular lesion. This requires understanding of the most effective laser to use for each lesion and the factors that may alter the desired device settings. Using key search terms, a literature search was conducted on laser surgery for pediatric vascular lesions using PubMed/MEDLINE and Embase for articles published in English or French. Ultimately, 52 articles met our search criteria. The laser indications, limitations, and settings utilized for each type of vascular lesion were compiled for the purposes of this summative review. Laser surgery is an effective and appropriate option for the treatment of certain pediatric vascular lesions. Knowledge of optimal device parameters in every setting is essential to good clinical practice.
Assuntos
Terapia a Laser/instrumentação , Anormalidades da Pele/cirurgia , Pele/irrigação sanguínea , Pele/patologia , Criança , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Pele/efeitos da radiaçãoRESUMO
BACKGROUND: Limited dorsal myeloschisis (LDM) is postulated to be a result of incomplete dysjunction in primary neurulation. However, clinical experience of LDM located below the first-second sacral (S1-S2) vertebral level, which is formed from secondary neurulation (S2-coccyx), suggested that LDM may not be entirely explained as an error of primary neurulation. OBJECTIVE: To elucidate the location and characteristics of LDM to investigate the possible relation of its pathoembryogenesis to secondary neurulation. METHODS: Twenty-eight patients were surgically treated for LDM from 2010 to 2015. Since the level where the LDM stalk penetrates the interspinous ligament is most clearly defined on the preoperative MRI and operative field, this level was assessed to find out whether the lesions can occur in the region of secondary neurulation. RESULTS: Eleven patients (39%) with typical morphology of the stalk had interspinous defect levels lower than S1-S2. These patients were not different from 17 patients with classic LDMs at a level above or at S1-S2. This result shows that other than the low level of the interspinous level, 11 patients had lesions that could be defined as LDMs. CONCLUSION: By elucidating the location of LDM lesions (in particular, the interspinous level), we propose that LDM may be caused by errors of secondary neurulation. The hypothesis seems more plausible due to the supportive fact that the process of separation between the cutaneous and neural ectoderm is present during secondary neurulation. Hence, incomplete disjunction of the two ectoderms during secondary neurulation may result in LDM, similar to the pathomechanism proposed during primary neurulation.
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Neurulação/fisiologia , Anormalidades da Pele/diagnóstico por imagem , Anormalidades da Pele/cirurgia , Disrafismo Espinal/diagnóstico por imagem , Disrafismo Espinal/cirurgia , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Ligamentos Articulares/diagnóstico por imagem , Ligamentos Articulares/embriologia , Ligamentos Articulares/cirurgia , Imageamento por Ressonância Magnética/métodos , Masculino , Sacro/diagnóstico por imagem , Sacro/embriologia , Sacro/cirurgiaRESUMO
Introducción y objetivo: El colgajo submentoniano ha sido descrito como alternativa para la cobertura de defectos cutáneos en tercio medio e inferior de la cara y como colgajo microquirúrgico para tratamiento del linfedema secundaria de extremidades, al incorporar en su diseño nódulos linfáticos vascularizados. El presente estudio pretende justificar el uso del colgajo submentoniano en sus distintas variantes con la incorporación tradicional de músculo digástrico, perforante de arteria submentoniana, de flujo reverso o microquirúrgico, y con mínima morbilidad del sitio donador. Material y método: Presentamos una serie de 8 pacientes en los que realizamos un colgajo submentoniano para cobertura de defectos en tercio medio e inferior de cara y de linfedema secundario de extremidad superior. Los colgajos tuvieron dimensiones de 40 a 84 cm2 (media de 62 cm2). Los colgajos fueron pediculados con base en la arteria submentoniana en 4 casos (50%), con preservación del músculo digástrico basado en un vaso perforante de la arteria submentoniana en 2 casos, como colgajo submentoniano de flujo reverso en 1 caso, y como colgajo submental linfático vascularizado en 1 caso. Resultados: Recogimos como complicación una necrosis parcial distal de un 20% en un colgajo submentoniano de flujo reverso, que fue tratada con cicatrización dirigida a segunda intención. La zona donadora se trató en todos los casos con cierre primario. Conclusiones: En nuestra opinión, el colgajo submentoniano es una herramienta útil en la reconstrucción de tejidos blandos del tercio medio e inferior de la zona facial, con un grosor, textura y coloración similares, así como una alternativa en el tratamiento del linfedema secundaria de la extremidad superior
Background and objective: The submental flap has been previously described as an alternative for the coverage of cutaneous defects or the middle and lower thirds of the face, as well as a vascularized lymph node flap for the treatment of secondary lymphedema of the extremities. Our goal is to justify its clinical application, and the use of the variants of the components of the flap and design, either with the inclusion of the digastric muscle, submental perforator, reverse flow or microvascular flap, with minimal complications. Methods: We present a series of 8 patients in which a submental flap was performed to restore cutaneous defects of the middle and lower thirds of the face, and the treatment of secondary lymphedema of the upper extremity. Flaps dimensions were between 40 to 84 cm2 (average of 62 cm2). The flap was designed as submental pedicled flap in 4 cases (50%), with preservation of digastric muscle based on a submental perforator in 2 cases, reverse flow submental flap in 1 case, and as a vascularized submental lymph node transfer flap y 1 case. Results: Complications occurred in 1 of the cases, presented as a partial necrosis of a 30% of a submental reverse flow flap, which healed by secondary intention. Donor site was closed primarily in all the cases. Conclusions: In our opinion, the submental flap is a good choice for the coverage of cutaneous defects of the middle and lower face, providing a thickness, texture and color similar to neighboring tissues, as well as an alternative for the treatment of secondary lymphedema of the upper extremity
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Retalhos Cirúrgicos/cirurgia , Queixo/cirurgia , Carcinoma Basocelular/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Queixo/patologia , Anormalidades da Pele/cirurgia , Neoplasias de Tecidos Moles/cirurgia , Linfedema/cirurgia , Neoplasias da Mama/secundário , Extremidade Superior/patologia , Extremidade Superior/cirurgia , Estudos RetrospectivosRESUMO
No disponible
Assuntos
Humanos , Masculino , Feminino , Lactente , Pescoço/anormalidades , Procedimentos de Cirurgia Plástica/métodos , Anormalidades da Pele/cirurgia , Pescoço/cirurgiaRESUMO
PURPOSE: There are different techniques for medial canthoplasty in blepharophimosis syndrome where individuals have epicanthus inversus and telecanthus leading to typical facial appearances. These methods have potential problems with scarring, epistaxis, and extrusion of metal plates. METHODS: The authors describe a novel technique of medial canthal reconstruction using titanium microplates with microscrew fixation to the anterior lacrimal crest, with effective, safe, and reproducible results. RESULTS: Seven children with blepharophimosis syndrome underwent medial canthus reconstruction surgery at a single center with the collaboration of a pediatric oculoplastic surgeon and craniofacial plastic surgeon to improve eye opening through correction of the lid contours and telecanthus. CONCLUSIONS: This is a safe, effective, and reproducible technique, with minimal morbidity and rapid postoperative recovery in children. It produces cosmetically acceptable scars and a strong stable reconstruction of the medial canthal insertion.
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Blefarofimose/cirurgia , Blefaroplastia/métodos , Aparelho Lacrimal/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Anormalidades da Pele/cirurgia , Anormalidades Urogenitais/cirurgia , Criança , Pré-Escolar , Feminino , Humanos , MasculinoRESUMO
No disponible
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Humanos , Anormalidades da Pele/cirurgia , Retalhos Cirúrgicos/cirurgia , Nariz/cirurgiaRESUMO
BACKGROUND: The aims of this study were to characterize the spinal deformity of patients with Escobar syndrome, describe results of growth-friendly treatments, and compare these results with those of an idiopathic early-onset scoliosis (EOS) cohort to determine whether the axial stiffness in Escobar syndrome limited correction. METHODS: We used 2 multicenter databases to review the records of 8 patients with EOS associated with Escobar syndrome who had at least 2-year follow-up after initiation of growth-friendly treatment from 1990 to 2016. An idiopathic EOS cohort of 16 patients matched for age at surgery (±1 y), postoperative follow-up (±1 y), and initial curve magnitude (±10 degrees) was identified. A randomized 1:2 matching algorithm was applied (α=0.05). RESULTS: In the Escobar group, spinal deformity involved 7 to 13 vertebrae and ranged from no vertebral anomalies in 3 patients to multiple segmentation defects in 6 patients. Mean age at first surgery was 5 years (range, 1.4 to 7.8 y) with a mean follow-up of 7.5 years (range, 4.0 to 10 y). Mean major curve improved from 76 degrees at initial presentation, to 43 degrees at first instrumentation, to 37 degrees at final follow-up (both P<0.001). Mean pelvic obliquity improved from 16 degrees (range, 5 to 31 degrees) preoperatively to 4 degrees (range, 0 to 8 degrees) at final follow-up (P=0.005). There were no differences in the mean percentage of major curve correction between the idiopathic EOS and Escobar groups at the immediate postoperative visit (P=0.743) or final follow-up (P=0.511). There were no differences between the cohorts in T1-S1 height at initial presentation (P=0.129) or in growth per month (P=0.211). CONCLUSIONS: Multiple congenital fusions and spinal curve deformity are common in Escobar syndrome. Despite large areas of congenital fusion, growth-friendly constructs facilitate spinal growth and improve curve correction. These results are comparable to those in idiopathic EOS. LEVEL OF EVIDENCE: Level III-case-control study.
Assuntos
Anormalidades Múltiplas , Hipertermia Maligna , Procedimentos Ortopédicos/métodos , Pediatria/métodos , Anormalidades da Pele , Curvaturas da Coluna Vertebral , Anormalidades Múltiplas/cirurgia , Estudos de Casos e Controles , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Hipertermia Maligna/complicações , Hipertermia Maligna/cirurgia , Estudos Retrospectivos , Anormalidades da Pele/complicações , Anormalidades da Pele/cirurgia , Curvaturas da Coluna Vertebral/diagnóstico , Curvaturas da Coluna Vertebral/etiologia , Curvaturas da Coluna Vertebral/cirurgia , Resultado do TratamentoRESUMO
This case report intends to provide the facial characteristics of Escobar syndrome and to describe the orthodontic treatment of a 12-year-old female patient diagnosed with it. Escobar syndrome, a variant of the multiple pterygium syndrome, is a rare disorder with many systemic, facial, and oral manifestations.The patient presented with mixed dentition, severe dolichofacial pattern, increased lower facial height, convex profile, severe anterior open bite, maxillary hypoplasia, and mandibular retrognatism. The multidisciplinary approach included soft cleft palate repair, orthodontic treatment, orthognathic surgery, restorative cosmetic dentistry, speech therapy, and physiotherapy. Despite the limitations imposed by the syndrome, this report illustrates how the multidisciplinary treatment approach aided in the correction of occlusal function and facial esthetics and improvement in the quality of life of the patient with Escobar syndrome.
Assuntos
Anormalidades Múltiplas , Fissura Palatina , Hipertermia Maligna , Qualidade de Vida , Anormalidades da Pele , Anormalidades Múltiplas/cirurgia , Criança , Fissura Palatina/cirurgia , Estética Dentária , Feminino , Seguimentos , Humanos , Hipertermia Maligna/cirurgia , Aparelhos Ortodônticos , Anormalidades da Pele/cirurgiaRESUMO
Barber-Say syndrome is an unusual dysplasia caused by the mutation of the TWIST2 gene (2q37.3), which encodes a protein that acts at an epigenetic level. The case is presented of a 2-day-old male child in whom ectropion, hypertelorism, hypertrichosis and other dysmorphic features led to the clinical diagnosis of Barber-Say syndrome, which was later confirmed with genetic tests. Around 20 cases have been reported on this syndrome, of which less than half have described the surgical technique, as it represents a surgical challenge. The approach in this case included a lateral tarsorrhaphy and skin grafts taken from the volar surface of the forearm, retroauricular area and supraclavicular fossa, as well as autologous lipografts from the inner side of both thighs for palpebral reconstruction. This is the first case of Barber-Say syndrome in which the use of skin grafts are taken from supraclavicular fossa and forearms.
Assuntos
Blefaroplastia , Doenças Palpebrais/cirurgia , Hirsutismo/cirurgia , Hipertelorismo/cirurgia , Hipertricose/cirurgia , Macrostomia/cirurgia , Anormalidades da Pele/cirurgia , Humanos , Recém-Nascido , Masculino , Equipe de Assistência ao PacienteRESUMO
PURPOSE: Posterior calvarial vault expansion using distraction osteogenesis is performed for syndromic craniosynostosis as the first choice. This procedure allows far greater intracranial volume than fronto-orbital advancement (FOA). This study aimed to determine the most suitable timing of posterior distraction or FOA to sufficiently increase the intracranial volume and remodel the skull shape. PATIENTS AND METHODS: From 2014 to 2017, the authors performed posterior distraction in 13 patients with syndromic craniosynostosis. Data on premature suture fusion, age at first visit, age at surgery, skull thickness, and complications were collected. RESULTS: Five patients underwent posterior distraction at approximately 12 months of age and had no complications, including cerebrospinal fluid leakage or gull wing deformity. However, during the waiting period for the operation, the skull deformity continues to extend upward (turribrachycephaly). To prevent progress of the skull deformity, the authors performed the operation at approximately 6 months of age in 7 patients. However, in 3 of 7 patients whose lambdoid sutures were opening, gull wing deformity occurred. From these results, in a patient with severe Beare-Stevenson syndrome, the authors performed FOA first at 5 months of age, followed by posterior distraction at 12 months of age, and achieved favorable results. CONCLUSIONS: Treatment patterns are patient specific and should be tailored to premature suture fusion, specific skull deformity, and required intracranial volume of each patient.