Persistent Cranial Defects After Endoscopic Sagittal Synostosis Surgery.

INTRODUCTION: Incomplete cranial ossification is a rare complication of calvarial-vault remodeling for sagittal synostosis often requiring reoperation. Studies show an incidence ranging from 0.5% to 18%. METHODS: Infants with sagittal synostosis who underwent endoscopic sagittal synostectomy and barrel stave osteotomies with postoperative orthotic helmeting between 2003 and 2021 were included with minimum follow-up until the completion of helmeting. RESULTS: Of 90 patients, 86 met inclusion; 3 had defects (3.5%). Patients with and without cranial defects had no difference in age of surgery (113 versus 131 d), duration helmeting (6.6 versus 7.0 mo), or perioperative/postoperative complications. Two underwent reoperation for recurrence. Patients with cranial defects manifested the evidence of developmental concerns more than patients without (100% versus 16.9%).The average cranial defect size was 19.33 cm 2 and age at surgery 4.29 years. All were managed with cranial particulate bone grafting with addition of bone matrix and SonicWeld plate. The first had 6×6 cm posterior defect requiring cranioplasty at 4.86 years with excellent healing. The second had a 3×6 cm posterior and 1×1 cm anterior defect, underwent cranioplasty at 4.14 years with persistent 4×6 defect, requiring repeat cranioplasty at 5.3 years. The third had a 3×5 cm posterior defect and underwent cranioplasty at 3.88 years with continued defect, planning for repeat intervention. CONCLUSIONS: This is the largest documented series of reoperations for incomplete ossification after endoscopic sagittal synostectomy with postoperative helmet treatment. The authors report a 3.5% rate of cranial defects, managed with bone grafting, bone matrix, and absorbable plates. Patients with poor ossification may have a propensity toward developmental concerns.

Endoscopic Spring-Mediated Distraction for Unilambdoid Craniosynostosis.

BACKGROUND: Craniosynostosis treatment modalities have changed over time. These have included open calvarial remodeling, suturectomy with helmet molding, hand-powered distraction devices, and spring-mediated distraction. Implantable springs were first described for their use in treatment of craniosynostosis in 1998 (Lauritzen et al, Plast Reconstr Surg 121;2008:545-554). They have been used for the correction of craniosynostosis involving single and multiple sutures and have been placed through both endoscopic and open approaches. Their use for correction of lambdoid synostosis has been previously only described using an open approach (Arnaud et al, Child Nerv Syst 28;2012:1545-1549). The senior author has performed spring-mediated distraction for treating unilambdoid craniosynostosis using an endoscopic approach, which is described below and has not previously been reported by other authors. METHODS: A retrospective analysis of our series of endoscopic unilambdoid synostosis repairs is included in this article. Patients were analyzed based on patient characteristics, operative details, and outcomes. The operation commences by approaching the lambdoid suture endoscopically through a 2- to 3-cm incision lateral to the lambdoid suture. Burr holes are placed on either side of the suture and a suturectomy is performed. Springs are bent preoperatively to a predetermined force. Two springs are placed across the suturectomy defect and the skin is closed. The patient is monitored for improvement in head shape and cranial X-rays are performed to measure the degree of distraction. RESULTS: Seven patients underwent endoscopic spring-mediated distraction for unilambdoid craniosynostosis. The average age at the time of operation was 9.4 months. The median force of each spring placed was 7.0 N. The median length of hospital stay after spring placement was 2 days. Springs were removed at 5.6 months on average. Five patients had X-rays immediately after placement and prior to removal. Each spring expanded an average distance of 15.3 mm. There were no surgical complications. Three patients had both preoperative and postoperative computed tomography scans available. The angle of the cranial base, calculated by comparing foramen magnum to cribriform plate angles, improved 5.8° (12.3 preoperatively to 6.6 postoperatively). CONCLUSION: Endoscopic spring-mediated distraction is a safe and effective method of treatment for unilambdoid craniosynostosis. The series represents the largest experience with this technique. The approach can be considered in all patients with unilambdoid synostosis given the efficacious improvement in vault remodeling, low patient morbidity, short operating time, and minimal inpatient stay.

Isolated Intraorbital Frontosphenoidal Synostosis.

Unilateral anterior plagiocephaly is most commonly the result of deformational plagiocephaly or unilateral coronal synostosis, a premature fusion of the frontoparietal suture. However, other sutures within the coronal ring have been implicated in producing anterior cranial asymmetries. These fusions can occur in isolation or in concert with adjacent sutures. The frontosphenoidal suture is one such suture within the coronal ring that has been involved both concomitantly with and independently of frontoparietal suture fusion. Although isolated frontosphenoidal synostosis has been presented previously in the literature, these reports include patients with fusion of the extraorbital portion of the frontosphenoidal suture. This clinical report presents the first clearly documented patient of isolated frontosphenoidal synostosis that occurs entirely within the intraorbital region.The patient presented to Plastic Surgery Clinic at 3 months of age with left frontal flattening, supraorbital rim retrusion, and temporal bulging that was noted soon after birth. Computed tomography analysis revealed an isolated fusion of the greater and lesser wings of the sphenoid bone to the frontal bone on the left side. The patient had no family history of cranial anomalies and genetic testing was negative for mutations. The infant was treated with a cranial orthotic for 3 months, underwent open fronto-orbital advancement and cranial vault remodeling at 6 months, and continued wearing a cranial orthotic for another 4.5 months. Following surgical and orthotic treatment, the patient achieved a satisfactory result.

CO2-based tissue expansion: a study of initial performance in ovine subjects.

BACKGROUND: Tissue expanders are an essential reconstructive surgical tool commonly utilized in two-staged breast reconstruction. The current technology is limited primarily to saline expansion, which can be a long process requiring frequent office visits. Eliminating the need for percutaneous injections could potentially improve the psychological and physical discomfort associated with the expansion process as well as save time and resources for both the patient and surgeon. OBJECTIVES: The authors describe a novel system of gradual, controlled, needle-free expansion. The purpose of the study was to evaluate, prior to clinical use, the in vivo communication between CO(2)-based tissue expanders and their paired handheld dosage controllers and the ability of each expander to reach its intended volume. METHODS: Twelve expanders-three small (400 cm(3)), three medium (650 cm(3)), four large (850 cm(3)), and two full (1100 cm(3))-were implanted in two mature ovines and were expanded daily with CO(2) using 12 paired handheld dosage controllers. Device performance and expansion progress (cm(3)/d) to size-specified volumes were observed and recorded. An on-site veterinarian monitored the animals for signs of distress during and after inflations. After full expansion of the implants, the animals were euthanized and the implants were surgically removed and examined. RESULTS: All 12 paired devices performed to specification, achieving successful expansion, and measured volumes of explanted expanders confirmed expansion to the labeled volume. Expansion to full volume was achieved in all units in Ovine 1 within 13 days and in Ovine 2 within 11 days. Total implantation time was 21 days in Ovine 1 and 12 days in Ovine 2. No adverse events were encountered. CONCLUSIONS: This CO(2)-based tissue expansion system offers a novel and potentially valuable tool for reconstructive surgery. This study demonstrated the in vivo performance of a CO(2)-based tissue expander in an ovine model and merits future clinical research efforts. All tested devices accomplished needle-free expansion with the expanders responding to dosage-controller commands within programmed safety limitations. This system has the potential to expedite expansion through gradual, controlled distention of tissue and to simplify the process for both physician and patient.

Neosagittal Suture Formation after Endoscopic Sagittal Strip Craniectomy: A Case Report and Literature Review.

The fate of the excised synostotic suture in craniosynostosis remains relatively understudied. The purpose of this report is to describe a case of neosagittal suture formation following endoscopic excision of a pathology-proven synostotic suture, with CT demonstration of complete reossification in the areas adjacent to the neosagittal suture. We additionally review the existing literature on neosuture formation that has been published over the past 50 years. We conclude that continued investigation is warranted, both through histological comparison of normal and neosutures and through studies to determine clinical risk factors, as this may improve our understanding of the underlying mechanism of pathologic premature suture fusion in craniosynostosis.

The Pushback Pharyngeal Flap: An 18-Year Experience.

BACKGROUND: The pharyngeal flap is one of the oldest and most popular techniques for correction of velopharyngeal insufficiency. The authors describe a large series using a technique that combines a pharyngeal flap with a palate pushback to avoid common causes of operative failure while restoring the velopharyngeal mechanism. METHODS: A retrospective cohort study was performed of patients who underwent a pushback pharyngeal flap by a single surgeon from 2000 to 2017. All patients had a preoperative nasoendoscopy diagnostic of velopharyngeal insufficiency. Operative technique involved elevation of the hard palate mucosa through a retroalveolar incision, passage of the flap through the nasopharyngeal mucosa opening, and inset with sutures through the hard palate mucosa. RESULTS: There were 40 patients with a median age of 9.7 years. Preoperative closure patterns were predominately coronal (85.7 percent), with poor posterior wall motion and an average gap size of 27.5 mm. Postoperative complications included flap dehiscence (n = 1), transient dysphagia (n = 2), obstructive sleep apnea (n = 4), and a palatal fistula and/or persistent velopharyngeal insufficiency that required further surgery (n = 6). At an average of 2.5 years postoperatively, 91.7 percent of patients achieved adequate velopharyngeal function, with significant improvements in the majority of speech metrics (p < 0.001). CONCLUSIONS: The pushback pharyngeal flap is a safe and effective technique for treatment of velopharyngeal insufficiency. Advantages include high, secure inset with prevention of palatal scar contracture and shortening. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Single Stage Repair of #30 Facial Cleft with Bone Morphogenic Protein.

Tessier #30 clefts (median mandibular clefts) represent a spectrum of deformities ranging from a minor cleft in the lower lip to complete clefts of the mandible involving the tongue, lower lip, hyoid bone, thyroid cartilages, and manubrium. Various techniques have been used to address these problems; the most common procedure involving 2 stages: an initial correction of the soft tissue followed by closure of the mandibular cleft at a later date using bone grafting. This approach was subsequently reduced to a single operation, but still required harvesting of autologous bone graft. Here, we describe a modified single-stage operation using human recombinant bone morphogenic protein, avoiding bone graft harvest and allowing for simultaneous treatment of bone and soft tissue.

Vermilion Only Cross-lip Flap for Treating Whistle Deformity in Secondary Bilateral Cleft Lip Repair.

Bilateral cleft lip repairs can result in various secondary deformities. One more commonly seen deformity, the whistle deformity, is characterized by a reduced or absent tubercle, orbicularis muscle diastasis, and abnormalities of the philtrum with notched appearance of cupid's bow. Various techniques have been described to address these problems. One common procedure is the lip-switch flap originally described by Abbe in 1898, which has been modified by various surgeons. In these procedures, lower lip vermilion, mucosa, orbicularis, and lip skin are transposed to the upper lip on a pedicle that is later divided. In all these variations of the lip-switch procedure, the transposed tissue involves the entire lower lip skin-leaving large, unsightly, and unnecessary scars. It also brings abnormal tissue into the philtrum further distorting the upper lip. A modified cross-lip flap that is limited to the taking only mucosa, vermilion, and orbicularis is feasible and provides an optimal reconstruction without compromising additional tissue.