Edward F. Joganic

Treatment of positional plagiocephaly with dynamic orthotic cranioplasty

Dynamic orthotic cranioplasty (DOC) was developed to treat asymmetrical head shape of a nonsynostotic origin, which is defined by the term positional plagiocephaly. These positional deformations have been found to correlate with a number of environmental factors. Infants with positional plagiocephal

Treatment of craniofacial asymmetry with dynamic orthotic cranioplasty

Dynamic Orthotic Cranioplasty (DOC) was developed to treat craniofacial deformities associated with positional plagiocephaly. This investigation describes the treatment of more than 750 patients with the DOC Band since 1988. All patients undergoing DOC treatment were fit with a custom fabricated orthosis made from a plaster impression taken from the infants head. When the orthosis was applied, the corrective pressure was directed to hold growth at the calvarial prominences and redirect symmetrical growth. A detailed medical history was obtained and anthropometric measurements were taken at start, exit, 12, 18, and 24 months follow-up. This information was recorded in a database created in Microsoft Excel. Mean length of treatment was 4.3 months with an average entrance age of 6.9 months. Analysis of anthropometric data showed significant reduction in mean cranial vault, skull base, and facial asymmetries. Correction of the more difficult skull base was documented with computed tomography. Our anthropometric and clinical observations document complete or near complete correction of asymmetry for a wide variety of head shapes. Based on the results of this investigation, we are able to support the earlier claims of our pilot study, which concluded that DOC is effective in the treatment of positional plagiocephaly.

Proposed Classification for the Transbasal Approach and Its Modifications

The transbasal approach offers extradural exposure of the anterior midline skull base transcranially. It can be used to treat a variety of conditions, including trauma, craniofacial deformity, and tumors. This approach has been modified to enhance basal access. This article reviews the principle differences among modifications to the transbasal approach and introduces a new classification scheme. The rationale is to offer a uniform nomenclature to facilitate discussion of these approaches, their indications, and related issues.

Preserving Olfactory Function in Anterior Craniofacial Surgery through Cribriform Plate Osteotomy Applied in Selected Patients

OBJECTIVE: Olfaction is often sacrificed to gain access to the cranial base in anterior craniofacial surgery. We describe the long-term results of olfactory function in patients who underwent anterior craniofacial surgery and a cribriform plate osteotomy to preserve olfaction. METHODS: Between 1992 and 2004, 28 patients underwent 29 cribriform plate osteotomies in an attempt to preserve olfaction during anterior craniofacial surgery performed through modified extended transbasal approaches. Patients’ charts and office notes were reviewed retrospectively. Formal olfactory testing was available in 5 patients, but most data were based on patients’ subjective reports of olfaction. Olfactory preservation was defined by the subjective ability to detect fumes such as coffee, chocolate, roses, and orange juice regardless of the intensity of the sensation. Follow-up was based on phone calls to patients. RESULTS: Four patients were lost to follow-up and excluded. Therefore, follow-up was available in 24 patients after 25 procedures. On the basis of patients’ subjective reports, olfaction was spared in 22 patients after 23 procedures (92%) and was confirmed objectively in the five patients formally tested. After surgery, only two patients were anosmic. CONCLUSION: Olfaction can be preserved in selected patients undergoing anterior craniofacial surgery. At least 1 cm of nasal mucosa should remain attached to the cribriform plate, which can be achieved by including the nasal bone in the osteotomy of the orbital bar. A medial orbital canthopexy is therefore necessary after these procedures.

Exposure of midline cranial base without a facial incision through a combined craniofacial-transfacial procedure

OBJECTIVE: A single-stage combined craniofacial-transfacial approach that exposes the midline cranial base without visible facial incisions is described. METHODS: Between 1992 and 1998, eight patients underwent surgery for five different anterior cranial base pathological findings: four angiofibromas, one mesenchymal chondrosarcoma, one esthesioneuroblastoma, one odontogenic myxoma, and one encephalocele. In all cases, the surgical exposure consisted of a bicoronal scalp incision with a bifrontal craniotomy and fronto-orbitonasal osteotomy, and then a sublabial incision for transmaxillary exposure. RESULTS: Gross total resection was achieved in five cases. The encephalocele was resected with complete reconstruction of the bony defect. Seven patients developed complications, primarily wound infections, cerebrospinal fluid leaks, and anemia. Postoperative Karnofsky Performance Scale scores ranged between 80 and 100 (mean, 92.5). Long-term follow-up information (mean, 56 mo; median, 59.5 mo; range, 5–108 mo) was available for all patients. CONCLUSION: Large anterior cranial base lesions can be resected and excellent cosmetic outcomes can be achieved with a single-stage combined transfacial-craniofacial approach that exposes the entire midline cranial base and requires no facial incisions.

The transfacial approaches to midline skull base lesions: A classification scheme

A variety of transfacial surgical approaches to midline skull base lesions can be organized in a simple classification scheme of six techniques or levels. Three intracranial approaches use a subfrontal trajectory and variable amounts of transfacial exposure through the nasal and orbital bones. Surgical exposure increases with the amount of bone removed with the facial fragment: supraorbial bar (level 1), supraorbitonasal bar (level II), and orbitonasal bar (level III). Three extracranial approaches use a more inferior trajectory and variable amounts of transfacial exposure through the maxilla. The transnasomaxillary approach (level IV) requires a Le Fort II osteotomy with splitting of the maxillary fragment. The transmaxillary approach (level V) requires a Le Fort l osteotomy with splitting of the palate. The transpalatal approach (level VI) requires circumferential osteotomy and removal of the hard palate. These versatile transfacial approaches, used alone or in combination, have a distinct role in the armamentarium of the skull base surgeon who develops individualized treatment strategies for curative resection of midline skull base lesions.

Pediatric Cranial Vault Defects: Early Experience With β-Tricalcium Phosphate Bone Graft Substitute

Pediatric calvarial defects may result from numerous causes. Availability of bone is often limited because of the childs age, and bone substitutes may be needed to reconstruct the defects. A bone substitute composed of ultraporous &bgr;-tricalcium phosphate (Orthovita, Malvern, PA) is an osteoconductive product successfully used in orthopedic surgery. However, its application in cranial vault reconstruction is largely unstudied. The purpose of this investigation was to determine the healing rate of bone defects with the use of this product.A retrospective review was performed of patients in whom &bgr;-tricalcium phosphate was used. Patient population consisted of 23 patients. Mean surgical age was 35 months. Reconstructions consisted of 20 craniosynostosis corrections and 3 posttraumatic repairs. The average defect size was 37 cm2 (range, 4.6-210 cm2). Average follow-up was 12.7 months.At 2 months, 19 (79%) of 23 patients achieved healing of their defect, defined as the absence of persistent bone gaps. Persistent areas of bone weakness occurred in 3 patients at 4 months and 2 patients at 6 months. By 9 months, only 1 patient had not healed. This patient had the largest original defect of 210 cm2. Defects taking longer than 2 months to heal measured 83 cm2, whereas healed defects were 32 cm2. No patients required treatment for graft-related problems such as infection or exposure.Early experience with &bgr;-tricalcium phosphate bone substitute shows good healing of pediatric calvarial vault defects by 2 months, with no graft-associated complications. It seems most effective in the repair of smaller defects less than 40 cm2.

Clinical application of the classification scheme of transfacial approaches

Between 1990 and 1998, 63 patients (39 men and 24 women) underwent a transfacial approach. Based on the level I through level VI classification scheme developed by the Barrow Neurological Institute Skull Base Team, 83 transfacial procedures were performed: 49 procedures involved a single level, 8 involved a level III approach combined with a level V approach, and 3 involved a level I through III aoproach combined with either a pterional craniotomy or orbitozygomatic craniotomy. Eleven procedures were performed in a staged fashion. Thirty-five different pathologies were addressed: Chordomas (7), angiofibromas (7), and pituitary macroadenomas (5) were most common. One patient (1.6%) died postoperatively. Overall, 29 (46%) patients experienced complications after transfacial surgery. Six (9.5%) patients experienced major complications, and 23 (36.5%) patients experienced minor complications. The transfacial surgeries were without complications in 34 (54%) patients. This large series demonstrates the versatility of transfacial skull base approaches for treating benign and malignant lesions. The procedures are associated with good patient outcomes and an acceptable rate of complications.

Multivectored Superficial Muscular Aponeurotic System Suspension for Facial Paralysis

Purpose: Facial paralysis is a devastating condition that may cause severe cosmetic and functional deformities. In this study we describe our technique for superficial muscular aponeurotic system (SMAS) suspension using barbed suture and compare the vectors of suspension in relation to the underlying musculature. This study also quantifies the improvements in postoperative symmetry using traditional anthropologic landmarks. Methods: The efficacy of this procedure for improving facial paralysis was determined by comparing anthropometric indices and using Procrustes distance between 4 groupings of homologous landmarks plotted on each patients preoperative and postoperative photos. Geometric morphometrics was used to evaluate change in facial shape and improvement in symmetry postoperatively. To analyze the vector of suspension in relation to the underlying musculature, specific anthropologic landmarks were used to calculate the vector of the musculature in 3 facial hemispheres from cadaveric controls against the vector of repair in our patients. Results: Ten patients were included in our study. Subjectively, great improvement in functional status was achieved. Geometric morphometric analysis demonstrated a statistically significant improvement in facial symmetry. Cadaveric dissection demonstrated that the suture should be placed in the SMAS in vectors parallel to the underlying musculature to achieve these results. There were no complications in our study to date. Conclusion: In conclusion, multivectored SMAS suture suspension is an effective method for restoring static suspension of the face after facial paralysis. This method has the benefit of producing quick, reliable results with improved function, low cost, and low morbidity.

Outcomes of Titanium Mesh Cranioplasty in Pediatric Patients

Purpose: Cranial defects in children have been repaired with various materials ranging from autologous bone to synthetic materials. There is little published literature on the outcomes of titanium mesh cranioplasty (TMC) in calvarial reconstruction in the pediatric population. This study evaluates a pediatric cohort who underwent calvarial defect reconstruction with titanium mesh and assesses the efficacy and outcomes of TMC. Methods: An Institutional Review Board approved retrospective review of patients ⩽18 years of age who underwent cranioplasty from 1999 to 2014 at 2 centers was performed. The cohort undergoing TMC was studied. Results: A total of 159 cranioplasties were performed. Autologous reconstruction included 84 bone flap replacements and 36 split calvarial bone graft reconstructions. Six patients underwent PEEK implant reconstruction. Titanium mesh cranioplasty was performed on 33 patients. Two patients underwent 2 separate cranioplasties. The median age of patients was 6 years (19 months to 18 years). The most common underlying etiologies were congenital syndromes/craniosynostosis (13 patients), and trauma (11). The majority of patients had prior cranial surgeries (85%). Various types of titanium mesh were used with sizes ranging from 2×3 cm to 19×20 cm, with some patients requiring distinct areas of defect reconstruction. Perioperative complications were noted in 2 patients that subsequently improved. Two patients had late soft tissue problems with complications of wound infections requiring resection of a portion of the mesh. Patients were followed an average of 4 years (range 13 days to 6.8 years), with 2 patients lost to follow-up. Overall, all patients with follow-up achieved a cranial contour with good symmetry to the unaffected side, as well as effective protection to the brain. Conclusions: Titanium mesh cranioplasty is an effective option for correcting pediatric cranial defects when autologous bone availability is limited and soft tissue coverage allows placement of an implant. The interim outcome for these patients is favorable with few complications and no evidence of growth restriction in the authors’ series. Follow-up will be ongoing for these patients.