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Year : 2015  |  Volume : 2  |  Issue : 1  |  Page : 20-26

Fronto-orbital advancement: Revisited

Department of Plastic Surgery, Sakra World Hospital, Bangalore, India

Date of Web Publication4-Feb-2015

Correspondence Address:
Dr. Derick Mendonca
FRCS (Plast), Consultant Craniofacial Plastic Surgeon, Sakra World Hospital, Bangalore, 560 103
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Source of Support: No financial benefits from the publication of this manuscript by Stryker Company and Osteogenics Biomedical., Conflict of Interest: None

DOI: 10.4103/2348-2125.150739

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Introduction: Craniosynostosis is a pathologic condition resulting from the premature fusion of cranial vault sutures, resulting in craniofacial deformities. Anterior craniosynostosis can involve a combination of metopic/unicoronal or bicoronal sutures. Aims and Objectives: Fronto-orbital advancement (FOA) is the standard surgical treatment. This article attempts to highlight the importance of modifying the osteotomies and reshaping of the cranial vault based on individual requirements to achieve the best possible result. Method and Results: Three consecutive cases of anterior craniosynostosis (metopic with unicoronal, unicoronal with sphenoethmoidal, bicoronal) with individual modifications of the technique used in each case are presented. Conclusion : FOA has to be tailored for each variant of anterior craniosynostosis and its requirements. The Technical variations can be applied to any combination of anterior craniosynostosis.

Keywords: Calvarial vault reconstruction, craniosynostosis, fronto-orbital advancement

How to cite this article:
Mendonca D, Gejje S, Kaladagi N. Fronto-orbital advancement: Revisited. J Cleft Lip Palate Craniofac Anomal 2015;2:20-6

How to cite this URL:
Mendonca D, Gejje S, Kaladagi N. Fronto-orbital advancement: Revisited. J Cleft Lip Palate Craniofac Anomal [serial online] 2015 [cited 2021 Oct 16];2:20-6. Available from: https://www.jclpca.org/text.asp?2015/2/1/20/150739

  Introduction Top

Craniosynostosis is defined as the premature fusion of one or more cranial sutures, resulting in predictable changes in the shape of the cranial vault. Any cranial suture can ossify prematurely, but fusion is most common in the sagittal suture (40-55%), followed by the coronal (20-25%), metopic (5-15%), and lambdoid (1-5%) sutures. [1] According to Indian data, coronal synostosis was the commonest variety among the nonsyndromic patients, followed by metopic synostosis. [2]

Premature closure of the metopic suture results in a "keel" shaped deformity, termed trigonocephaly, and includes hypotelorism, strabismus with upslanting palpebral fissures. Premature fusion of one of the coronal sutures results in frontal plagiocephaly (A Greek term meaning oblique skull). The "harlequin" orbit seen on anterior-posterior radiographs is pathognomonic for unilateral coronal synostosis and is secondary to the lack of descent of the greater wing of the sphenoid during development. Compensatory bulge in the ipsilateral squamous portion of the temporal bone, contralateral frontal and parietal bones is seen.

Coronal ring [3] is formed due to articulations between the human frontal, sphenoid, and ethmoid bones. This sutural component of the ring is C-shaped with a cartilaginous bridge between the optic foramina completing the ring. The extent of synostosis along the coronal sutural ring contributes to the dysmorphology of the orbit and the endocranial base deflection in patients whose clinical phenotypic diagnosis is unilateral coronal synostosis. [4]

Anterior craniosynostosis includes metopic, uni-coronal and bi-coronal suture involvement. The standard surgical treatment is a fronto-orbital advancement (FOA).

Fronto-orbital advancement

The surgical goals of FOA are threefold:

  1. To release the synostosed suture and decompress the cranial vault,
  2. To reshape the cranial vault and advance the frontal bone, and
  3. To advance the retruded supraorbital bar, providing improved globe protection and an improved aesthetic appearance.

The objective of this paper is to demonstrate that no two FOA are the same. The deformity has to be carefully analyzed along with accurate preoperative planning, to devise relevant osteotomies and bone contouring in order to obtain the desired result. Three cases of anterior craniosynostoses are described with modifications in the surgical technique of FOA shown.

Standard surgical technique

Thorough preoperative evaluation should be done by the pediatric anesthetist, with blood available for a blood transfusion. Close communication with the anesthetist is vital to the safety of the procedure.

The patient is positioned supine on a Mayfield head rest with head up at 20-30°. A bicoronal incision is made in a zig-zag manner for better scar outcome. Water tight draping is done with separation of the nasal areas and a collection drape to measure blood loss. Local anesthetic with adrenaline is infiltrated prior to the incision to reduce blood loss, and meticulous hemostasis is obtained as the flaps are raised, and bone exposed. Extensive subperiosteal dissection is done to expose the entire frontal bone, down to the naso-frontal junction, lateral orbital wall beyond the Zygomatico-frontal (Z-F) suture and squamous temporal bones. A supra-orbital foramen osteotomy may be necessary to allow the bicoronal flap to reflect downward. The osteotomy lines are marked as shown in [Figure 1]. Note the bifrontal craniotomy supra orbital bandeau with a tongue in groove extension and barrel staves on the parietal segments. The bifrontal craniotomy is done by a neurosurgeon and care is taken to avoid dural injury. This is followed by the fronto-orbital bandeau segment, which is carefully osteotomized and removed. Back table contouring, reshaping and cutting is done with a combination of Tessier bone benders, saw drills, and the bones held in place by resorbable plating system [Figure 2]. The senior author's preference is to use the Stryker Delta resorbable plating system (Kalamazoo, Michigan).
Figure 1: Intraoperative osteotomy markings for bifrontal craniotomy and supraorbital bandeau

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Figure 2: Intraoperative bone segments after osteotomies, contouring and fixation

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The recontoured fronto-orbital bandeau is replaced in an advanced/tilted position, at least 1-1.5 cm anterior to the frontal lobe [Figure 3]. A combination of advancement and tilt is used to obtain the desired result. The bandeau is secured laterally with rigid resorbable plates. The reshaped frontal component is then placed on top of the advanced bandeau and secured rigidly [Figure 4]. The entire calvarial vault is barrel staved and opened like a box. It is the senior author's preference to cover all large gaps with Osteomesh scaffold. Long-term studies would need to be done to demonstrate osteogenesis secondary to the scaffold.
Figure 3: Supraorbital bandeau placed in the advanced position (1.5 cm advancement). Note the increased calvarial space following parietal barrel staving

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Figure 4: Final intra operative appearance of supraorbital bandeau and frontal bone before skin closure. Note the bilateral onlay bone grafts with Osteomesh scaffold

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Meticulous skin closure is done in two layers with a suction drain. Postoperative monitoring is done in the pediatric intensive care under the close supervision of an intensivist.

  Materials and Methods Top

Three consecutive children diagnosed with anterior craniosynostosis were studied. Each case is individually described to highlight technical variations in FOA. The age of these patients ranged from 11 to 14 months. Out of the three cases, one was a male child. The distribution of synostoses was:

  1. Metopic with left unicoronal synostosis,
  2. Bicoronal synostosis and
  3. Metopic with right unicoronal and left sphenoethmoidal synostosis.

The mean age at surgery was 12.34 months. The mean advancement obtained at the level of the frontal lobe was 1.5 cm and the mean increase in head circumference was 3.17 cm. There were no postoperative complications except for one patient who developed a cerebrospinal fluid (CSF) leak, which settled with conservative management.

  Results Top

Individual cases are described to highlight the technical variations in the standard FOA to suit individual anterior craniosynostosis.

Case 1

Baby "A" is a 14-month-old male who presented with a craniofacial deformity along with delayed milestones [Figure 5] and [Figure 6]. Computed tomography (CT) scan confirmed a metopic and left unicoronal synostosis, along with signs of raised intra-cranial pressure (punched out appearance). Preoperative head circumference placed the child along the 20 th percentile. A FOA was done with a tilt technique and bone graft placed in the midline, in order to expand the bandeau. Bone graft and Osteomesh scaffold (Osteogenics Biomedicals, Lubbock, Texas) was created as an onlay on the left supraorbit to provide supra-orbit projection. Frontal bone was osteotomized in the midline and closed wedge osteotomies done to open up the convexity. Midfrontal segments were bent with Tessier bone benders. Barrel staving was done on the restricted parietal bones to create a round shape skull. An advancement of 1.5 cm was obtained on the bandeau. Postoperatively, a smooth symmetrical head, normal looking forehead and supra orbit is seen with no harlequin sign and a normal brow position [Figure 7] and [Figure 8]. Head circumference was increased by 2 cm and no complications were seen.
Figure 5: Preoperative appearance of baby A showing metopic and left unicoronal synostosis. Note harlequin deformity on the left side (arrow)

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Figure 6: Preoperative appearance of baby A showing the asymmetric head shape with flattening of left forehead (arrow)

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Figure 7: Postoperative appearance of baby A demonstrating a smooth symmetrical forehead with a complete absence of the harlequin deformity

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Figure 8: Postoperative appearance of baby A showing complete correction of head shape and well-rounded calvarium

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Case 2

Baby "B" is an 11 months female presenting with a flat forehead and an obvious brachycephaly deformity [Figure 9]. Head circumference was placed at the 2 nd percentile. Gross milestones were normal, but baby was extremely irritable. CT confirmed a bicoronal synostosis with signs of raised intra cranial pressure [Figure 10] and [Figure 11]. FOA with a tilt technique was done. No midline bone graft was placed as the width of the bandeau was deemed adequate. Extensive onlay bone grafts were done bilaterally with bone and Osteomesh scaffolds to create adequate supraorbit projection. Frontal piece was split in the midline bilaterally and opened like a fan. Midfrontal segments bent with Tessier bone benders to create midfrontal bulge and convexity. The bandeau was advanced by 1 cm. Bones were secured with delta resorbable plates. Parietal segments were barrel staved bilaterally and outfractured to create round head shape. Postoperative views show adequate supra orbit projection and smooth forehead [Figure 12]. Postoperative head circumference increased by 4.5 cm, and no postoperative complications were seen [Figure 13].
Figure 9: Preoperative appearance of baby B showing evidence of bicoronal synostosis. Note the flat retruded forehead with brachycephaly

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Figure 10: Preoperative three-dimensional computed tomography of baby B showing the brachycephaly deformity with imprinting on endocortical surface

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Figure 11: Preoperative lateral view of three-dimensional computed tomography demonstrating bicoronal synostosis

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Figure 12: Postoperative appearance of baby B showing complete correction of the forehead and brow deformity. Note the smooth well rounded forehead with normal brow aesthetics

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Figure 13: Postoperative three-dimensional computed tomography frontal view showing frontal osteotomies, supraorbital bandeau and onlay bone grafts

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Case 3

Baby "C" is a 12-month-old female presenting with bilateral proptosis and a craniofacial deformity with bulging anterior fontanelle. Gross milestones were normal, but head deformity was grossly abnormal. CT scan showed a partial metopic, right coronal and left sphenoethmoidal synostosis, with raised intra cranial pressure signs [Figure 14]. No evidence of obstructive hydrocephalus was seen. Head circumference placed the child at the 50 th percentile. Genetic testing was not done. FOA was done along with a midline bone graft to widen the bandeau. Supra orbit advancement of 1.5 cm was obtained and secured with plates. Midfrontal bending was done with Tessier bone benders, split in the midline and secured. The large fontanelle was closed with Osteomesh scaffold. Barrel staving was done extensively to open up the cranium and create a round head with increased space. Closed wedge osteotomies were done (bilateral) on the sphenoid ridges along endocortical surface of the frontal bandeau. Postoperatively excellent advancement is seen on the CT with head circumference increased by 3 cm [Figure 15] and [Figure 16]. Intra operatively a dural tear was seen with CSF leakage. This settled with conservative management.
Figure 14: Preoperative lateral three-dimensional computed tomography of baby C showing copper beaten appearance (raised intracranial pressure) and right coronal synostosis

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Figure 15: Postoperative three-dimensional computed tomography of baby C showing advanced supraorbital bandeau and frontal bone. Note the increased calvarial space and advancement (1.5 cm)

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Figure 16: Postoperative three-dimensional computed tomography of baby C showing advanced supraorbital bandeau and frontal bone. Note the increased calvarial space and advancement

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  Discussion Top

The FOA is the standard procedure for the correction of anterior craniosynostosis. Although the technique is well established since Tessier introduced the FOA as the key procedure to correct forehead dysplasia, [5] technical variations exist. The authors wish to highlight the importance of tailoring the osteotomies and contouring to fit individual patient needs. The main goals of surgery are to advance the superolateral orbit, expand the temporal dimensions, and round the forehead. Evolution and modification of this original technique has been reported with excellent results. [6] In spite of technical modifications, hollowing and contour irregularities are seen, requiring revision surgery. [7] An effective strategy to minimize secondary procedures is to over-expand and overcorrect the superolateral dimensions. An ideal technique achieves both near anatomical correction and overcorrected dimensions to account for future growth impairment. [8]

Long term follow up has shown traditional expansion techniques tending to revert back to the original deformity. [7] This is due to diminished intrinsic growth, inadequate surgical expansion, and devascularization of segments at the time of advancement or some combination. [9] Vascular preservation of the fronto-orbital bar preserves long-term growth potential, and this aspect has to be borne in mind while contouring. [10] A strategy suggested is to maintain a vascularized pedicle to the advanced bandeau while "tilting" the segment forward. [6]

The fronto-orbital bandeau is typically positioned about 12-13 mm anterior to the cornea. An 8-15-mm magnitude of bandeau advancement is usually required on the affected side. Simultaneous to repositioning the orbital rim, the ipsilateral forehead is advanced, the orbital height may be reduced, and the contralateral forehead is recessed or contoured as necessary. A canthopexy may be performed to resuspend the canthus following dissection. Some advocate including the nasal bones in continuity with the frontal bar and uprighting the nasal radix deviation by closing wedge osteotomy. Others feel the nasal root deviance corrects by adolescence with the lack of continued "pull" toward the fused suture. [11]

In bicoronal synostosis, correcting bilateral forehead and supraorbital rim width and retrusion (brachycephaly) is necessary to normalize fronto-facial balance and to afford orbital protection. Current techniques involve a bifrontal craniotomy and creation of a bilateral frontal bandeau with a plan to advance liberally. Note the technical variation of placing onlay bone grafts to improve projection. The anterior dimension is advanced, creating greater forehead prominence. Bone benders are used to create the midfrontal bulge in the frontal segments. In bicoronal synostosis, the height of the skull may also be increased (turribrachycephaly). This can be addressed by barrel staves and greenstick fracture of the posterior parietal bones or occipital plates.

Metopic synostosis correction involves anterior cranial vault expansion, thereby alleviating the bitemporal constriction and triangular head appearance. [12] The intent is to round the forehead shape and also to improve hypotelorism. An endoscopic strip craniectomy procedure has been reported. [13] This technique may have some utility in young infants, but it is not effective in all patients and not appropriate for older infants more than 6 months age. Several more comprehensive techniques have been described in an attempt to correct the morphologic sequelae seen in metopic synostosis. [14] The current strategy entails splitting the fronto-orbital bar in the midline and interposing a bone segment to increase the bitemporal and inter-orbital distance. The new construct exhibits a more obtuse endocranial angle, witnessed by advancement and expansion of the lateral rims and temporal region. The sphenoid wings are burred to create more space, and the lateral orbit bent inward to create a lateral orbit curvature. This bandeau is then held in place by sutures at the Z-F region and temporally with resorbable plates. An intervening bone graft is often utilized at the temporal gap created from the advancement of the fronto-orbital construct to prevent relapse. The frontal segments are split in the midline and opened up as described in the three cases. Occasionally the frontal segments would need to be completely contoured like a cone to create the midfrontal bulge. The goal is to overcorrect the hypoplastic bone segments, especially the temporal and lateral orbital regions, which are most prone to regress toward the original deformity (secondary to impaired growth potential).

Bone gaps can be covered with alloplastic materials such as acrylic implants or with Osteomesh scaffold, as in the cases described. Long-term studies would need to show the formation of new bone in the gaps covered by Osteomesh.

A modification of the fronto-orbital bandeau advancement is the tilt-procedure (TP) where osteotomy line is similar to that of the above-mentioned technique, excluding the fronto-zygomatic process. Furthermore, as a key manoeuvre, the superolateral aspect of the supraorbital rim is greensticked anteriorly maintaining the attachments within the frontonasal and frontozygomatic suture, allowing this segment to pivot without compromising medial and lateral attachments. The superior and inferior latero-orbital blood supply is maintained with periosteal preservation and connections of the deep vessels. The preserved vascularization of this fronto-orbital segment may play a pivotal role in frontal sinus development and function. [15] Cases 1 and 2 had a variation of the TP, with a view to maintain long-term growth. Case 3 needed a more radical advancement to correct orbital proptosis, and hence the tilt technique was not done. Fronto-orbital surgery has to be tailored to address individual morphological variations in anterior craniosynostosis. However, a balance has to be struck by obtaining adequate intra-operative correction and maintaining long term growth.

  Conclusion Top

Technical variations in the technique of FOA for various forms of anterior craniosynostosis are described. Accurate preoperative planning of the deformity aids in complete successful correction of the entire cranial vault and restoration of forehead aesthetics.

  References Top

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Dundulis JA, Becker DB, Govier DP, Marsh JL, Kane AA. Coronal ring involvement in patients treated for unilateral coronal craniosynostosis. Plast Reconstr Surg 2004;114:1695-703.  Back to cited text no. 4
Tessier P. Total facial osteotomy. Crouzon's syndrome, Apert's syndrome: Oxycephaly, scaphocephaly, turricephaly. Ann Chir Plast 1967;12:273-86.  Back to cited text no. 5
Hoffman HJ, Mohr G. Lateral canthal advancement of the supraorbital margin. A new corrective technique in the treatment of coronal synostosis. J Neurosurg 1976;45:376-81.  Back to cited text no. 6
Cohen SR, Kawamoto HK Jr, Burstein F, Peacock WJ. Advancement-onlay: An improved technique of fronto-orbital remodeling in craniosynostosis. Childs Nerv Syst 1991;7:264-71.  Back to cited text no. 7
Fearon JA. Beyond the bandeau: 4 variations on fronto-orbital advancements. J Craniofac Surg 2008;19:1180-2.  Back to cited text no. 8
McCarthy JG, Karp NS, LaTrenta GS, Thorne CH. The effect of early fronto-orbital advancement on frontal sinus development and forehead aesthetics. Plast Reconstr Surg 1990;86:1078-84.  Back to cited text no. 9
Cohen SR. Vascularized fronto-orbital advancement. J Craniofac Surg 1996;7:228.  Back to cited text no. 10
Anderson PJ, David DJ. Late results after unicoronal craniosynostosis correction. J Craniofac Surg 2005;16:37-44.  Back to cited text no. 11
Williams JK, Ellenbogen RG, Gruss JS. State of the art in craniofacial surgery: Nonsyndromic craniosynostosis. Cleft Palate Craniofac J 1999;36:471-85.  Back to cited text no. 12
Jimenez DF, Barone CM. Early treatment of anterior calvarial craniosynostosis using endoscopic-assisted minimally invasive techniques. Childs Nerv Syst 2007;23:1411-9.  Back to cited text no. 13
Marchac D, Renier D, Jones BM. Experience with the "floating forehead". Br J Plast Surg 1988;41:1-15.  Back to cited text no. 14
Patel A, Chang CC, Terner JS, Tuggle CT, Persing JA. Improved correction of supraorbital rim deformity in craniosynostosis by the "tilt" procedure. J Craniofac Surg 2012;23:370-3.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]

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