Dennis C. Nguyen

Are endoscopic and open treatments of metopic synostosis equivalent in treating trigonocephaly and hypotelorism

BackgroundPatients with metopic craniosynostosis are traditionally treated with fronto-orbital advancement to correct hypotelorism and trigonocephaly. Alternatively, endoscopic-assisted treatment comprises narrow ostectomy of the fused suture followed by postoperative helmet therapy. Here we compare the preoperative and 1-year postoperative results in open versus endoscopic repairs. MethodsWe reviewed preoperative and 1-year postoperative three-dimensional reconstructed computed tomography scans of patients treated for nonsyndromic metopic craniosynostosis by either open (n = 15) or endoscopic (n = 13) technique. Hypotelorism was assessed by interzygomaticofrontal distance and intercanthal distance. Trigonocephaly was assessed by 2 independent angles: first, an axial-plane two-dimensional angle between zygomaticofrontal suture bilaterally and the glabella (ZFR-G-ZFL); second, an interfrontal angle (IFA) between the most anterior point from a reconstructed midsagittal plane and supraorbital notch bilaterally. Age-matched scans of unaffected patients (n = 28) served as controls for each postoperative scan. ResultsPatients with open repair (9.5 ± 1.8 months) were older at time of surgery than patients with endoscopic repairs (3.3 ± 0.4 months) (P = 0.004). Male-to-female ratios were equivalent at roughly 7:3 in both groups. Preoperatively, the endoscopic group had worse hypotelorism and ZFR-G-ZFL than the open group (P ⩽ 0.04). After accounting for preoperative differences, all of the postoperative measurements (ie, interzygomaticofrontal distance, intercanthal distance, ZFR-G-ZFL angle, IFA) of the 2 groups were statistically equivalent (P ≥ 0.135). Trigonocephaly was significantly improved after repair in both the open (8 degrees [ZFR-G-ZFL] and 18 degrees [IFA]) and endoscopic (13 degrees [ZFR-G-ZFL] and 16 degrees [IFA]) groups (P < 0.001). Postoperative measures in both groups were equivalent to controls (0.12 < P < 0.89). Intrarater reliability ranged from 0.93 to 0.99 for all measurements. ConclusionOur retrospective series shows that endoscopic and open repairs of metopic craniosynostosis are equivalent in improving hypotelorism and trigonocephaly at 1-year follow-up. Additional studies are necessary to better define minor differences in morphology, which may result from the different techniques.

Comparison of Traditional versus Normative Cephalic Index in Patients with Sagittal Synostosis: Measure of Scaphocephaly and Postoperative Outcome.

Background: Preoperative severity and postoperative success for patients with sagittal synostosis are measured by cephalic index, but this metric does not describe the appropriateness of euryon location. The authors hypothesize that cephalic index in patients with sagittal synostosis is an inaccurate measure of scaphocephaly. Methods: Preoperative and 1-year postoperative cranial computed tomographic scans of children with sagittal synostosis treated before 6 months of age by either total calvarial reconstruction or endoscope-assisted craniectomy and helmet therapy (n = 10 for each) were reviewed retrospectively. The location of euryons in age-matched controls was measured as a fraction of the glabella-opisthocranion distance (horizontal point of maximum width) and as the fraction of the nasion-vertex vertical distance (vertical point of maximum width). Cephalic index at this ideal location (normative cephalic index) and traditional cephalic index were determined in all patients. Results: Ideal euryon location from preoperative controls was 56 percent by the horizontal point of maximum width and 56 percent by the vertical point of maximum width. Normative cephalic index (0.60) was significantly less than traditional cephalic index (0.66) in patients preoperatively (p < 0.001) and remained smaller postoperatively (0.68 versus 0.73) for patients who underwent open reconstruction (p < 0.001). Patients treated endoscopically also had a smaller normative cephalic index (0.71) than traditional cephalic index (0.76) postoperatively (p < 0.001). Conclusions: Anterocaudal displacement of euryon in patients with sagittal synostosis influences cephalic index. Normative cephalic index, assessed at ideal euryon location, is a more accurate measure of preoperative severity and postoperative outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, III.

Endoscope-assisted management of sagittal synostosis: wide vertex suturectomy and barrel stave osteotomies versus narrow vertex suturectomy

OBJECTIVE Endoscope-assisted methods for treatment of craniosynostosis have reported benefits over open calvarial vault reconstruction. In this paper, the authors evaluated 2 methods for endoscope-assisted correction of sagittal synostosis: wide vertex suturectomy and barrel stave osteotomies (WVS+BSO) and narrow vertex suturectomy (NVS). METHODS The authors evaluated patients with nonsyndromic sagittal synostosis treated with either wide vertex suturectomy (4–6 cm) and barrel stave osteotomies (WVS+BSO) or narrow vertex suturectomy (NVS) (approximately 2 cm) between October 2006 and July 2013. Prospectively collected data included patient age, sex, operative time, estimated blood loss (EBL), postoperative hemoglobin level, number of transfusions, complications, and cephalic index. Fourteen patients in the NVS group were age matched to 14 patients in the WVS+BSO group. Descriptive statistics were calculated, and Student t-tests were used to compare prospectively obtained data from the WVS+BSO group with t...

Comparison of Direct and Digital Measures of Cranial Vault Asymmetry for Assessment of Plagiocephaly.

Abstract Measurement of cranial vault asymmetry (CVA) is a common feature in the treatment of patients with deformational plagiocephaly (DP). In many cases, this measure is the primary marker of improvement. CVA is typically measured with calipers and is subject to interrater variability. There is little research comparing results of calipers with those of three-dimensional (3D) photogrammetry. Fifty nine visits were made by 51 children previously diagnosed with DP. Thirty eight were male and 13 were female. Thirty one of the visits included a 3D photograph. Direct measures were obtained by 2 experienced anthropometrists and included head length, width, circumference, and CVA. Their results were compared to digital measures including measures unobtainable with calipers, asymmetry of head circumference and global asymmetry. The interrater reliability of all caliper measures was excellent (intraclass correlation coefficients > 0.94). Caliper and digital measures of length, width, cephalic index, and circumference were strongly correlated (R 2 > 0.90). There was a consistent bias, caliper measures being 1 to 4 mm shorter than their digital analogues. Caliper measured CVA was highly correlated (R 2 > 0.90) with the directly corresponding digital measures. It was poorly correlated with measures of overall hemispheric asymmetry (R 2 < 0.10). The cranial measurements of children with DP taken independently by 2 experienced anthropometrists showed excellent interrater reliability. Caliper measures are consistently smaller than the digital measures, presumably due to pressure of the calipers and/or the use of skullcaps during photography. Like circumference and other assessments, cranial vault asymmetry measures correlate well with their analogous digital measurements.

Anthropometric Outcome Measures in Patients With Metopic Craniosynostosis.

PURPOSE Treatment of metopic craniosynostosis is performed by either fronto-orbital advancement (FOA) or endoscopic-assisted techniques. Interfrontal angle (IFA) is a validated measure of trigonocephaly, but requires a computed tomography scan. The most common direct measure to assess surgical outcome in patients with trigonocephaly is frontal width (ft-ft). The aim of this study is to determine if frontal width correlates with IFA and successful surgical correction 1 year after treatment. A review of current morphologic assessment techniques is also provided. METHODS Three-dimensional computed tomography scans (preoperative and 1 year postoperative) of patients who underwent FOA (n = 13) or endoscopic (n = 13) treatment of metopic craniosynostosis were reviewed. Age-matched scans of unaffected patients served as controls. Frontal width was measured by a straight line between the bilateral frontotemporal points. Measurements were performed by 2 experienced observers and compared to IFA. RESULTS Mean frontal width at preoperative scan for endoscopic and open patients was 55 ± 0.6 and 64 ± 0.7 mm, respectively (Z-score 1.6 and -3.7). Mean frontal width at postoperative scan for endoscopic and open patients was 80 ± 0.4 and 81 ± 0.7 mm (Z-score 0.0 for both groups). Frontal width for endoscopic correction significantly correlated with IFA (r = 0.536, P = 0.005), as well as for the open patients (r = 0.704, P < 0.001). CONCLUSION Frontal width normalizes 1 year after operation, regardless of technique. Advantage of frontal width is that it can be measured in the clinic using a spreading vernier caliper. It correlates well with IFA and can be used as a metric for morphologic outcome.Purpose: Treatment of metopic craniosynostosis is performed by either fronto-orbital advancement (FOA) or endoscopic-assisted techniques. Interfrontal angle (IFA) is a validated measure of trigonocephaly, but requires a computed tomography scan. The most common direct measure to assess surgical outcome in patients with trigonocephaly is frontal width (ft–ft). The aim of this study is to determine if frontal width correlates with IFA and successful surgical correction 1 year after treatment. A review of current morphologic assessment techniques is also provided. Methods: Three-dimensional computed tomography scans (preoperative and 1 year postoperative) of patients who underwent FOA (n = 13) or endoscopic (n = 13) treatment of metopic craniosynostosis were reviewed. Age-matched scans of unaffected patients served as controls. Frontal width was measured by a straight line between the bilateral frontotemporal points. Measurements were performed by 2 experienced observers and compared to IFA. Results: Mean frontal width at preoperative scan for endoscopic and open patients was 55 ± 0.6 and 64 ± 0.7 mm, respectively (Z-score 1.6 and −3.7). Mean frontal width at postoperative scan for endoscopic and open patients was 80 ± 0.4 and 81 ± 0.7 mm (Z-score 0.0 for both groups). Frontal width for endoscopic correction significantly correlated with IFA (r = 0.536, P = 0.005), as well as for the open patients (r = 0.704, P < 0.001). Conclusion: Frontal width normalizes 1 year after operation, regardless of technique. Advantage of frontal width is that it can be measured in the clinic using a spreading vernier caliper. It correlates well with IFA and can be used as a metric for morphologic outcome.

Current Management of Zygomaticomaxillary Complex Fractures: A Multidisciplinary Survey and Literature Review.

Despite the prevalence of zygomaticomaxillary complex (ZMC) fractures, there is no consensus regarding the best approach to management. The aim of this study is to determine differences in ZMC fracture treatment among various surgical specialties. A survey was conducted regarding treatment of patients with different ZMC fractures that included a minimally displaced fracture (Case 1), a displaced fracture without diplopia (Case 2), a displaced fracture with diplopia (Case 3), and a complex comminuted fracture (Case 4). The survey was distributed to members of plastic surgery, oral maxillofacial surgery, and otolaryngology societies. The rates of surgical treatment, exploration of the orbital floor, and plating three or more buttresses were analyzed among the specialties. A total of 173 surgeons participated (46 plastic and reconstructive surgeons, 25 oral and maxillofacial surgeons, and 102 otolaryngologists). In Case 1, a significantly higher percentage of plastic surgeons recommend an operation (p < 0.01) compared with other specialties. More than 90% of surgeons would perform an operation on Case 2. Plastic surgeons explored the orbital floor (p < 0.01) and also fixated three or more buttresses more frequently (p < 0.01). More than 93% of surgeons would operate on Case 3, with plastic surgeons having the greatest proportion who fixed three or more buttresses (p < 0.01). In Case 4, there was no difference in treatment patterns between specialties. Across the specialties, more fixation was placed by surgeons with fewer years in practice (<10 years). Conclusion There is no consensus on standard treatment of ZMC fractures, as made evident by the survey. Significant variability in fracture type warrants an individualized approach to management. A thorough review on ZMC fracture management is provided.

Calvarial thickness and diploic space development in children with sagittal synostosis as assessed by computed tomography.

AbstractFollowing surgical management of craniosynostosis, residual calvarial defects may require reconstruction, frequently with the use of cranial bone grafts. Knowledge of optimal sites for harvest would be beneficial in such situations. The goal of this study is to compare calvarial thickness (CALV) and diploic thickness (DIPL) in children with corrected sagittal synostosis to normal controls (n = 47) using postoperative CT scans.We also compare the results from children who had undergone open (OPEN) (n = 26) and endoscopic (ENDO) (n = 26) surgery.On each skull, CALV and DIPL were measured at 44 points over 5 regions. Multiple regression analysis was used to compare CALV and DIPL controlling for gender and age.Children who had undergone previous craniosynostosis correction tended to have thinner CALV compared to controls in operated regions but thicker CALV in unoperated regions (P < 0.001). Adjusted mean CALV was thinner overall in ENDO compared to OPEN (P = 0.020). Children with corrected sagittal synostosis have thinner DIPL than controls (P = 0.002). No difference was found in DIPL comparing OPEN and ENDO (P = 0.977) approaches.Children who had undergone previous craniosynostosis correction tended to have thinner CALV when compared to controls in operated regions but thicker CALV in unoperated regions. ENDO calvaria were thinner than OPEN calvaria. Children with corrected sagittal synostosis have thinner DIPL than controls; no difference was found in DIPL comparing OPEN and ENDO approaches. Due to irregularities in bone development among children who had previously undergone calvarial reconstruction, individualized preoperative CT assessment is recommended in all patients undergoing secondary split calvarial bone grafting procedures.

An Alternative Method of Intermaxillary Fixation for Simple Pediatric Mandible Fractures.

PURPOSE Mandibular fractures represent a substantial portion of facial fractures in the pediatric population. Pediatric mandibles differ from their adult counterparts in the presence of mixed dentition. Avoidance of injury to developing tooth follicles is critical. Simple mandibular fractures can be treated with intermaxillary fixation (IMF) using arch bars or bone screws. This report describes an alternative to these methods using silk sutures and an algorithm to assist in treating simple mandibular fractures in the pediatric population. PATIENTS AND METHODS A retrospective chart review was performed and the records of 1 surgeon were examined. Pediatric patients who underwent treatment for a mandibular fracture in the operating room from 2011 to 2015 were identified using Common Procedural Terminology codes. Data collected included age, gender, type of fracture, type of treatment used, duration of fixation, and presence of complications. RESULTS Five patients with a mean age of 6.8 years at presentation were identified. Fracture types were unilateral fractures of the condylar neck (n = 3), bilateral fractures of the condylar head (n = 1), and a unilateral fracture of the condylar head with an associated parasymphyseal fracture (n = 1). IMF was performed in 4 patients using silk sutures, and bone screw fixation was performed in the other patient. No post-treatment complications or malocclusion were reported. Average duration of IMF was 18.5 days. CONCLUSIONS An algorithm is presented to assist in the treatment of pediatric mandibular fractures. Silk suture fixation is a viable and safe alternative to arch bars or bone screws for routine mandibular fractures.

Anatomical Study of the Intraosseous Pathway of the Infraorbital Nerve.

Background:The infraorbital nerve (ION) is at risk for iatrogenic injury during orbital floor repair. The authors aim to anatomically characterize the intraosseous course of the ION between the inferior orbital fissure and infraorbital foramen. Methods:Ten cadaver heads (20 orbits) were dissected, with exposure of the orbital floor. The ION was identified from the infraorbital fissure to inferior orbital foramen. The presence and caliber of an osseous roof was noted. Distances measured were infraorbital foramen to infraorbital margin; length of the inferior orbital groove; length of the inferior orbital canal; length from the inferior orbital fissure to the infraorbital margin. Results:Three variations of the osseous anatomy around the ION were identified. Four cadavers had no identifiable groove (Type 1, 40%) and the ION was completely roofed throughout its course. Five specimens exhibited a thin, transparent osseous roof over the nerve before forming the true canal, which we describe as a “pseudocanal” (Type 2, 50%). A true groove was seen in both orbits from a single cadaver (Type 3, 10%). Each cadaver had an ION course of the same type on both sides. Mean ± SD intraorbital foramen to infraorbital margin distance was 7.1 ± 1.4 mm. Distance from the infraorbital fissure to the infraorbital margin was 28.5 ± 2.3 mm. Conclusions:The course of the infraorbital nerve can be described as Type 1 (true canal), Type 2 (pseudocanal), and Type 3 (groove and canal). The authors propose that this novel classification system will raise awareness of variations in orbital floor anatomy.

Transcaruncular Approach for Treatment of Medial Wall and Large Orbital Blowout Fractures

We evaluate the safety and efficacy of the transcaruncular approach for reconstruction of medial orbital wall fractures and the combined transcaruncular-transconjunctival approach for reconstruction of large orbital defects involving the medial wall and floor. A retrospective review of the clinical and radiographic data of patients who underwent either a transcaruncular or a combined transcaruncular-transconjunctival approach by a single surgeon for orbital fractures between June 2007 and June 2013 was undertaken. Seven patients with isolated medial wall fractures underwent a transcaruncular approach, and nine patients with combined medial wall and floor fractures underwent a transcaruncular-transconjunctival approach with a lateral canthotomy. Reconstruction was performed using a porous polyethylene implant. All patients with isolated medial wall fractures presented with enophthalmos. In the combined medial wall and floor group, five out of eight patients had enophthalmos with two also demonstrating hypoglobus. The size of the medial wall defect on preoperative computed tomography (CT) scan ranged from 2.6 to 4.6 cm2; the defect size of combined medial wall and floor fractures was 4.5 to 12.7 cm2. Of the 11 patients in whom postoperative CT scans were obtained, all were noted to have acceptable placement of the implant. All patients had correction of enophthalmos and hypoglobus. One complication was noted, with a retrobulbar hematoma having developed 2 days postoperatively. The transcaruncular approach is a safe and effective method for reconstruction of medial orbital floor fractures. Even large fractures involving the orbital medial wall and floor can be adequately exposed and reconstructed with a combined transcaruncular-transconjunctival-lateral canthotomy approach. The level of evidence of this study is IV (case series with pre/posttest).