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Plastic and reconstructive surgery 09/2011; 128(3):827-8; author reply 828-9. · 2.74 Impact Factor
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ABSTRACT: Craniofrontal reshaping (CR) for the treatment of craniosynostosis results in a temporary cranial defect due to the advancement and/or expansion of the supraorbital and frontal bones. The goal of the present study was to determine whether the incidence traumatic brain injury (TBI) was increased in patients after CR as a result of this breach in skull integrity.
We performed a retrospective chart review of all patients with a diagnosis of craniosynostosis who underwent CR between 1997 and 2007 at our institution. The incidence of TBI (defined as a computed tomography-documented brain or skull injury or loss of consciousness) was determined during a 2-year postoperative follow-up period. Patients older than 1 year at the time of surgery, or those with less than 2 years of follow-up after surgery, were excluded.
A total of 396 patients met the inclusion criteria. The incidence of TBI was zero (95% confidence interval, 0-760/100,000).
The estimated incidence of TBI after CR surgery is between 0 and 760 per 100,000 patients in our clinic population. These data indicate that although CR may be associated with a slightly increased risk of TBI while the skull is healing, the absolute incidence of such injury remains extremely rare.
The Journal of craniofacial surgery 07/2011; 22(4):1284-6. · 0.81 Impact Factor
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ABSTRACT: We report on the novel association of trigonocephaly and polysyndactyly in two unrelated patients due to mutations within the last third (exon 14) and first third (exon 6) of the GLI3 gene, respectively. GLI3 acts as a downstream mediator of the Sonic hedgehog signal-transduction pathway which is essential for early development; and plays a role in cell growth, specialization, and patterning of structures such as the brain and limbs. GLI3 mutations have been identified in patients with Pallister-Hall, Grieg cephalopolysyndactyly syndrome (GCPS), postaxial polydactyly type A1, preaxial polydactyly type IV, and in one patient with acrocallosal syndrome (ACLS). Furthermore, deletions including the GLI3 gene have been reported in patients with features of GCPS and ACLS. To date, trigonocephaly has not been associated with abnormalities of GLI3 and craniosynostosis is not a feature of GCPS. However, Hootnick and Holmes reported on a father with polysyndactyly and son with trigonocephaly, polysyndactyly, and agenesis of the corpus callosum, considered GCPS thereafter. Guzzetta et al. subsequently described a patient with trigonocephaly, polysyndactyly, and agenesis of the corpus callosum postulating a diagnosis of GCPS, later considered ACLS. In retrospect, these two patients, evaluated prior to mutational analysis, and our patients, with confirmed mutations, likely fall within the GLI3 morphopathy spectrum and may provide a bridge to better understanding those patients with overlapping features of GCPS and ACLS. Based on this observation, we suggest GLI3 studies in patients presenting with this constellation of findings, specifically metopic craniosynostosis with polysyndactyly, in order to provide appropriate medical management and genetic counseling.
American Journal of Medical Genetics Part A 07/2010; 152A(7):1654-60. · 2.39 Impact Factor
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ABSTRACT: Pancraniosynostosis presents with premature fusion of three or more major cranial sutures. The four presentations of primary pancraniosynostosis are kleeblattschädel, complex, progressive, and normocephalic. This study compares the clinical presentation and treatment course of patients with normocephalic presentation against the other pancraniosynostosis groups.
The authors conducted a retrospective chart review of patients who presented to the craniofacial clinic at The Children's Hospital of Philadelphia with primary pancraniosynostosis born between January 1, 2000, and February 1, 2009. Patients with secondary causes of pancraniosynostosis were excluded. Data extracted included presenting symptoms, head shape, cranial sutures involved, and presence of clinical and radiologic evidence of elevated intracranial pressure. Surgical intervention(s) and the subsequent clinical course were noted. The between-group difference in the initial age of presentation and age at first cranial vault surgery were compared using the Mann-Whitney U test.
There were 17 patients with primary pancraniosynostosis: four kleeblattschädel, eight complex, one progressive, and four normocephalic. The average age at presentation and length of follow-up were 1.1 years and 3.8 years, respectively. Patients with normocephalic pancraniosynostosis presented at an average age of 3.5 years compared with 2 months in the other three groups (p = 0.01). The age at first cranial vault remodeling surgery for the normocephalic pancraniosynostosis group was 4 years 8 months compared with 11 months in the other three groups (p = 0.01).
Patients with normocephalic pancraniosynostosis have an insidious clinical course. Because of their indistinct cranial morphology, they present late with significant symptoms of elevated intracranial pressure requiring urgent surgical decompression.
Plastic and reconstructive surgery 05/2010; 125(5):1493-502. · 2.74 Impact Factor
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ABSTRACT: Patients with Saethre-Chotzen syndrome have a heterogeneous phenotype. The purpose of this study was to use the genotypic diagnosis of the authors' series of patients with TWIST1-confirmed Saethre-Chotzen syndrome to describe their natural history and long-term surgical outcomes.
A retrospective chart review was performed on patients treated at The Children's Hospital of Philadelphia with TWIST1-confirmed Saethre-Chotzen syndrome (n = 22) over 23 years (1985 to 2008). Their phenotype, need for primary cranial vault remodeling surgery, and subsequent need for reoperation were recorded. Genetic records were reviewed to identify each patient's TWIST1 mutation.
There were nine female patients and 13 male patients. Ten had bicoronal (45 percent), six had unicoronal (27 percent), and four had multisuture (18 percent) craniosynostosis. One had metopic and another had sagittal craniosynostosis. Average follow-up was 7.6 years (range, birth to 19.6 years). Seventeen (77 percent) underwent initial cranial vault remodeling and 10 (59 percent) required repeat intracranial vault remodeling (Whitaker class IV). One patient required major reoperation with bone grafting (Whitaker class III). Three patients needed minor revision procedures (Whitaker class II). Three patients needed no further intervention (Whitaker class I). The locations of the TWIST1 gene mutations in this study did not correlate to a specific surgical outcome.
TWIST1-confirmed Saethre-Chotzen syndrome is heterogeneous and manifests as either mild or severe craniofacial deformities. Our patients with TWIST1-confirmed Saethre-Chotzen syndrome had a reoperation rate of 65 percent for Whitaker class III and IV surgical outcome, and 59 percent required a secondary intracranial procedure for recurrent supraorbital retrusion.
Plastic and reconstructive surgery 12/2009; 124(6):2085-95. · 2.74 Impact Factor
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ABSTRACT: Craniofacial microsomia is one of the most common and well-characterized craniofacial anomalies. Tongue dysmorphism, however, has been neither thoroughly investigated nor reported in the context of this disease. This review focuses on the true prevalence of tongue dysmorphology in craniofacial microsomia and its relation to the deformities seen in this condition.
A 20-year retrospective study was performed to determine the number of patients who had a documented tongue anomaly and any relation to the development of abnormal speech. In recognition of the limitations of this approach, a 1-year prospective study was also performed to see the true prevalence of tongue dysmorphology in these patients.
Eight of 167 patients (4.8 percent) in the retrospective study were found to have tongue dysmorphologies, as opposed to 24 of 55 (43.6 percent) in the prospective study. The majority of tongue anomalies were mild. Of the eight retrospective patients, seven currently have intelligible speech with a combination of intensive speech therapy and/or surgical correction. The eighth patient is without intelligible speech. Tongue dysmorphology was positively correlated with the degree of hard- and soft-tissue deformity.
Tongue dysmorphologies in craniofacial microsomia, although usually mild, are frequently overlooked. The correlation of the tongue, soft tissue, and mandible anomalies may point to a common error early in gestation or an interdependence of adjacent growth centers.
Plastic and reconstructive surgery 09/2009; 124(2):583-9. · 2.74 Impact Factor
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ABSTRACT: Posterior vault reconstruction involves exposure, craniotomy, and reconstruction of the occipital cranium. Although it is commonly performed, the safety and complications associated with posterior vault reconstruction have not been specifically or thoroughly examined.
A retrospective chart review was performed for all patients undergoing posterior vault reconstruction at the Children's Hospital of Philadelphia between 1996 and 2006. Diagnosis, operative indication, age and weight at time of surgery, procedure type, intraoperative and postoperative complications, estimated blood loss, blood transfusion volume, and length of surgery and admission were recorded.
Fifty posterior vault reconstruction cases were included in the study (17 syndromic and 33 nonsyndromic). Mean estimated blood loss was 53.6 percent (range, 15.9 to 142.9 percent) of total blood volume and was statistically greater in syndromic patients (60.6 percent versus 50.0 percent; p = 0.038). Transfusion volume averaged 66.1 percent of total blood volume but was not statistically significant. Length of surgery and number of intraoperative complications were significantly elevated in the syndromic cohort (p = 0.007 and p = 0.037, respectively), whereas length of admission and number of postoperative complications were not. Complications were intraoperative in seven patients (14 percent) and postoperative in seven (14 percent), for an overall complication rate of 28 percent.
This is the largest series to date addressing the safety and complications of posterior vault reconstruction. In the authors' experience, posterior vault reconstruction carries a higher risk of intraoperative complications and blood loss compared with that reported in the literature for other types of cranial vault reconstruction. In addition, syndromic patients were more likely than nonsyndromic patients to encounter intraoperative problems.
Plastic and reconstructive surgery 04/2009; 123(3):995-1001. · 2.74 Impact Factor
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ABSTRACT: Slit ventricle syndrome and postshunt craniosynostosis are uncommon complications after shunting procedures for congenital hydrocephalus. Slit ventricle syndrome occurs as a complication in 1 to 5 percent of patients after shunting procedures for hydrocephalus during infancy. These patients usually have had a shunt in place for years, with overdrainage of cerebrospinal fluid resulting in very small ventricles. Excessive intracranial decompression may result in ventricular collapse with the formation of slit-like ventricles and cranial vault collapse with secondary craniosynostosis.
A retrospective review of 12 patients who had undergone cranial vault expansion for management of postshunt craniosynostosis and slit ventricle syndrome refractory to other treatment modalities was performed. All patients had initially been shunted for congenital hydrocephalus and subsequently underwent a mean of 4.9 shunt revisions before cranial vault expansion.
All 12 patients demonstrated decreased ventricular volume, with noncompliant slit-like ventricles in nine of these patients. Five patients demonstrated pancraniosynostosis, three patients demonstrated multiple sutural fusion, and isolated sagittal synostosis occurred in two patients. Two patients appeared to have "functional" synostoses with narrowed, overlapping sutures that were not actually fused. Eleven patients underwent bilateral fronto-orbital advancement with frontotemporoparietal expansion; one patient underwent only posterior vault expansion. Seven of the 12 patients required a mean of 2.3 shunt revisions after cranial vault expansion; five patients did not require subsequent revisions. Improvement in cranial vault shape was achieved in all 12 patients, as was improvement of neurologic symptoms in nine of the 12 patients.
Cranial vault expansion is a useful approach in the management of the restricted cranium associated with slit ventricle syndrome and postshunt craniosynostosis. This approach resulted in a decreased need for shunt revisions and improvement of neurologic symptoms and cranial vault shape.
Plastic and reconstructive surgery 11/2008; 122(4):1171-80. · 2.74 Impact Factor
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ABSTRACT: Classic literature indicates an infrequency of metopic craniosynostosis (3 to 10 percent) compared to other single-suture craniosynostosis. Recent observation challenges these conceptions, warranting long-term demographic analysis.
Syndromic craniofacial dysostoses and multiple suture involvement were exclusion criteria, leaving only single suture synostoses treated between 1975 and 2004. A chart review was performed and patient information recorded. Chi square analysis and Fisher's exact were used to determine differences in patient characteristics. A Moran's I statistic was used to determine differences in spatial means and whether changes in incidence of single-suture synostoses over time are a function of regional phenomena.
Over 800 patients presented to The Children's Hospital of Philadelphia with a diagnosis of single-suture synostosis. There was an outpacing of sagittal suture involvement over other sutures. Data demonstrate a decrease in unicoronal synostosis and an increase in metopic synostosis (p = 0.011). Geostatistical analysis reveals increasing separation between populations over the study period: 9.8 miles in the first 5 years to 20.8 miles in the last 5 years. Metopic maternal age increased between 1975-1989 and 1990-2004 (p = 0.002, 0.0002), while unicoronal maternal age did not. The proportion of male patients increased considerably in the metopic group compared to unicoronals from 1990-2004 (p = 0.0001), as did the proportion of syndromic metopic patients (p = 0.02). Plausible etiologies for these epidemiological shifts are discussed.
Metopic synostosis is on the rise. Changing demographic bases and increasing proportions of syndromic patients may be clues to the etiology of this epidemiologic event.
Plastic and reconstructive surgery 08/2008; 122(2):527-33. · 2.74 Impact Factor
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ABSTRACT: Fronto-orbital reconstruction is the standard of care for repair of unilateral coronal synostosis. This study examined the relationship between age at initial surgery and need for secondary surgery, to determine the optimal age for reconstruction.
The series comprised 81 patients with unicoronal synostosis who underwent reconstruction over a 30-year period by a single surgeon. Measured outcomes included reoperation rate, relapse/defect rate, relapse interval, and problem rate.
Average age at surgery was 11.3 months (range, 1.5 to 71 months). The problem rate was 27.2 percent. Mean follow-up was 69 months (range, 6 to 234 months). The postoperative defect rate was 73 percent. Sixteen patients (20 percent) underwent reoperation to correct secondary deformities. Whitaker category I or II results were achieved in 90.1 percent. Problem rates for patients aged 0 to 6 months, 6 to 12 months, and older than 12 months were 13.3, 28, and 35, respectively. Secondary surgery was performed in 40 percent of patients whose first surgery was at 0 to 6 months, 7 percent aged 6 to 12 months, and 30.4 percent older than 12 months. After surgery, 87 percent of patients aged 0 to 6 months, 95 percent aged 6 to 12 months, and 87 percent older than 12 months had Whitaker category I or II results.
Fronto-orbital advancement at younger than 6 months had the highest incidence of readvancement. Patients treated at 6 to 12 months had the least need for any secondary surgery; however, patients older than 12 months had the lowest incidence of readvancement. These results indicate that fronto-orbital advancement should be delayed until at least age 6 months to avoid relapse.
Plastic and reconstructive surgery 06/2008; 121(5):251e-260e. · 2.74 Impact Factor
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ABSTRACT: Primary orbitocranioplasty for metopic craniosynostosis encompasses a variety of techniques, with variable long-term success. The authors present a series illustrating the evolution of surgical techniques and its impact on surgical outcomes.
All patients with single-suture metopic synostosis treated at the Children's Hospital of Philadelphia from 1975-2004 were included. Demographic information, preoperative clinical findings, operative technique, postoperative complications, postoperative clinical findings, and length of follow-up were all recorded. Five techniques are presented, reflecting a transition from mere reshaping with metallic fixation to the increased use of primary bone grafting and resorbable fixation to expand the frontal region. Preoperative covariates and technique type were analyzed for effect on outcomes.
Eighty-six patients were identified. Mean follow-up was 50 months. In terms of esthetic outcome, patients with preoperative frontal irregularities had a higher incidence of postoperative deformities (P = 0.026). Patients with preoperative mean intercanthal distance <20 had a higher incidence of postoperative frontal irregularities (P = 0.045). Maximal expansion of the supraorbital bar via interpositional bone graft and stabilization of the construct with strategic bone grafting and resorbable fixation resulted in a lower incidence of postoperative temporal hollowing (P = 0.029). Patients with expansion and lateral reinforcement of the expanded bar had a lower incidence of reoperation (P = 0.026).
Undercorrection of metopic craniosynostosis is not an uncommon finding. To prevent long-term relapse, aggressive anterolateral expansion of the supraorbital bar via primary bone grafting and resorbable fixation with the overall goal of overcorrection may provide the best esthetic outcome.
Annals of Plastic Surgery 08/2007; 59(1):6-13. · 1.32 Impact Factor
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ABSTRACT: The ability of the immature skull to spontaneously heal large bony defects created after craniofacial procedures was examined over a 25-year period of craniofacial surgery at the Children's Hospital of Philadelphia.
Only patients who underwent frontal orbital advancement and reconstruction, had at least 1 year of documented follow-up, and had the presence or absence of a bony defect documented on clinical examination were included. The sex, age at operation, diagnosis, history of a prior craniectomy, and presence or absence of a postoperative infection were determined for each patient. A variety of statistics were applied to the data.
Eighty-one patients met the inclusion criteria. A statistically significant association between age at operation and closure of bony defect was demonstrated. Children who closed a bony defect after frontal orbital advancement and reconstruction were significantly younger than those children who had a persistent bony defect. Iterative regression analyses demonstrated that a transition point between closure and the inability to close bony defects occurred between 9 and 11 months of age. Closure of bony defects was not statistically associated with sex, prior craniectomy, an FGFR mutation, or a postoperative infection in the regression analysis.
Healing of bony defects after frontal orbital advancement and reconstruction is significantly related to age at initial operation, with a mean age for closure of less than 12 months. Between 9 and 11 months of age, a change occurs that results in an increasingly lower probability of bony defect closure; thus, all other considerations being equal, initial frontal orbital advancement and reconstruction would ideally take place before this occurs.
Plastic and reconstructive surgery 10/2006; 118(4):977-84. · 2.74 Impact Factor
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Donna M McDonald-McGinn,
Karen W Gripp,
Richard E Kirschner,
Melissa K Maisenbacher,
Virginia Hustead,
Galen M Schauer,
Kim M Keppler-Noreuil,
Karen L Ciprero,
Patrick Pasquariello,
Don LaRossa,
Scott P Bartlett, Linton A Whitaker,
Elaine H Zackai
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ABSTRACT: We report on the presence of craniosynostosis in four patients with the 22q11.2 deletion. In light of previous reports of the association, we propose that the occurrence is higher than the general population incidence. Therefore, we suggest that craniosynostosis should be considered a manifestation of the 22q11.2 deletion and conversely that the 22q11.2 deletion should be considered in the differential diagnosis of craniosynostosis.
American Journal of Medical Genetics Part A 09/2005; 136A(4):358-62. · 2.39 Impact Factor
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ABSTRACT: A meeting entitled "The Art and Science of Anti-Aging Therapies: Convergence of Theory and Practice" took place on 18 and 19 March 2005 at the University of Pennsylvania School of Medicine. The symposium was held for health care professionals, researchers, and consumers to provide them with information about current trends in anti-aging therapies. The program, which combined medical, surgical, and nonpharmacological approaches to healthy successful aging, gave attendees the opportunity to make sense of the issues at hand and to sort out safe treatments from perilous quick fixes.
Science of Aging Knowledge Environment 05/2005; 2005(17):pe11.
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ABSTRACT: This retrospective chart review study examined the mental health histories and psychiatric medication usage of persons who sought cosmetic surgery. The medical records of 232 patients who had undergone a consultation for a cosmetic procedure were reviewed. The rates of self-reported psychiatric disorders and of psychiatric medication usage of these patients were compared with those of 200 patients who underwent noncosmetic procedures. Nineteen percent of cosmetic surgery patients reported a mental health history, significantly greater than the 4 percent of the noncosmetic patients who reported a psychiatric history. Eighteen percent of the cosmetic patients reported using a psychiatric medication at the time of their consultation, also significantly greater than the 5 percent of the noncosmetic patients who reported psychiatric medication usage. These results underscore the importance of collecting a psychiatric history from prospective cosmetic surgery patients. Recommendations for assessing patients' psychiatric history and status are provided.
Plastic and reconstructive surgery 01/2005; 114(7):1927-33; discussion 1934-5. · 2.74 Impact Factor
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ABSTRACT: The purpose of this work was to develop a simple yet comprehensive classification scheme dedicated to congenital nasal anomalies. To date, no such classification system has been proposed and widely used. A 22-year retrospective review was performed. Two hundred sixty-one patients with congenital nasal anomalies were identified. From this extensive database, a systematic morphogenic classification system was devised. Congenital nasal deformities were classified into four categories. Type I, hypoplasia and atrophy, represents paucity, atrophy, or underdevelopments of skin, subcutaneous tissue, muscle, cartilage, and/or bone. Type II, hyperplasia and duplications, representing anomalies of excess tissue, ranging from duplications of parts to complete multiples, are categorized here. In the type III category, clefts, the comprehensive and widely utilized Tessier classification of craniofacial clefts is applied. Type IV deformities consist of neoplasms and vascular anomalies. Both benign and malignant neoplasms are found in this category.
Plastic & Reconstructive Surgery 03/2004; 113(2):676-89. · 3.38 Impact Factor
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ABSTRACT: Only the metopic suture normally fuses during early childhood; all other cranial sutures normally fuse much later in life. Despite this, metopic synostosis is one of the least common forms of craniosynostosis. The temporal sequence of normal physiologic metopic suture fusion remains undefined and controversial. Therefore, diagnosis of metopic synostosis on the basis of computed tomography images alone can prove misleading. The present study sought to determine the normal sequence of metopic suture fusion and characterize both endocranial and ectocranial suture morphology. An analysis of computed tomography scans of 76 trauma patients, ranging in age from 10 days to 18 months, provided normative craniofacial data that could be compared to similar data obtained from the preoperative computed tomography scans of 30 patients who had undergone surgical treatment for metopic synostosis. Metopic suture fusion was complete by 6 to 8 months in all nonsynostotic patients, with initiation of suture fusion evident as early as 3 months of age. Fusion was found to commence at the nasion, proceed superiorly in progressive fashion, and conclude at the anterior fontanelle. Although an endocranial ridge was not commonly seen in synostotic patients, an endocranial metopic notch was virtually diagnostic of premature suture fusion and was seen in 93 percent of synostotic patients. A metopic notch was not seen in any nonsynostotic patient. The morphologic and normative craniofacial data presented permit diagnosis of metopic synostosis based on computed tomography images obtained beyond the normal fusion period.
Plastic & Reconstructive Surgery 11/2003; 112(5):1211-8. · 3.38 Impact Factor
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ABSTRACT: This study investigated the body image concerns of women who sought cosmetic breast augmentation. Thirty breast augmentation candidates completed several measures of body image before their initial surgical consultation. Thirty physically similar women who were not interested in breast augmentation were recruited from the medical center and university community and also completed the measures. Breast augmentation candidates, as compared with women not seeking augmentation, reported greater dissatisfaction with their breasts. Augmentation candidates rated their ideal breast size, as well as the breast size preferred by women, as significantly larger than did controls. In addition, women interested in breast augmentation reported greater investment in their appearance, greater distress about their appearance in a variety of situations, and more frequent teasing about their appearance. Finally, breast augmentation candidates also reported more frequent use of psychotherapy in the year before the operation as compared with women not seeking augmentation. These results replicate and extend previous studies of body image in cosmetic surgery patients.
Plastic & Reconstructive Surgery 08/2003; 112(1):83-90. · 3.38 Impact Factor
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Linton A Whitaker
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ABSTRACT: At the time of its founding in 1988, The Edwin and Fannie Gray Hall Center for Human Appearance at the University of Pennsylvania was the first such center in a major academic setting dedicated to the multispecialty serious study of problems of appearance. The concept was for five key specialties, originally, and now six, with primary interests in appearance, to meet regularly to present ideas and problems, and to approach the study and treatment of appearance in a comprehensive, scholarly, and multidisciplinary manner. The group has been cohesive, which has depended on frequent and regular personal interactions, as well as an adequate and supportive financial structure. With these factors in place, and a dedication to making it work, there have been publications, new ideas, and teamwork that has made it possible for competing specialties to effectively function together.
Facial Plastic Surgery 03/2003; 19(1):3-6. · 0.96 Impact Factor
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ABSTRACT: An algorithm for the management of sagittal synostosis in older children who underwent delayed cranial vault reconstruction is presented. This algorithm tailors the surgical approach to the specific craniofacial deformity present in each case. The scaphocephalic deformity characteristic of sagittal synostosis varies significantly when presentation is delayed beyond the first year of life, the time during which reconstruction is usually performed. Sixteen patients with sagittal synostosis who presented after 12 months of age, and were a mean of 3.2 years of age at the time of cranial vault reconstruction, were reviewed. Four patients demonstrated preoperative symptoms and objective findings indicative of increased intracranial pressure, including frequent headaches and emesis, papilledema, or digital markings on computed tomographic scan. Each of the 16 patients underwent either (1) single-stage total vault reconstruction with or without concomitant fronto-orbital expansion; (2) two-stage total vault reconstruction with anterior two-thirds vault expansion followed by transverse occipital expansion and recession a mean of 8.7 months later; or (3) anterior two-thirds vault reconstruction with or without fronto-orbital expansion. In each case, the extent of the scaphocephalic deformity determined the procedure used. The presence of severe frontal bossing associated with transverse restriction of the orbitotemporal region was an indication for fronto-orbital expansion in addition to vault reconstruction, whereas significant occipital protrusion was an indication for transverse posterior vault expansion and recession in addition to anterior two-thirds vault reconstruction. Excellent aesthetic results were obtained in all cases regardless of the type of reconstruction performed. However, it is essential that the extent of the deformity be carefully evaluated preoperatively to permit selection of the appropriate technique for reconstruction.
Plastic & Reconstructive Surgery 09/2002; 110(2):397-408. · 3.38 Impact Factor
