Volume 7, Issue 1 | Research Article | Open Access
Hector H1*, Nohelia P1 , Leober M1 and Rubén M1,2
1Department of Oral and Maxillofacial Surgery, University of Carabobo Maxillofacial Residency Program, Dr. Ángel Larralde University Hospital, Venezuela 2Department of Craniofacial Surgery, Palmer Childrens Hospital, Maryland, USA
*Correspondance to: Hector Herrera
Fulltext PDFPurpose: To describe the management of patients with syndromic craniosynostosis using the monobloc frontofacial advancement technique currently used in Venezuela. To analyze the morphometric changes in patients with syndromic craniosynostosis, who underwent monobloc with facial bipartition advancement with internal osteogenic distraction devices and quantification of the vectors of movement by pre- and post-surgery CT scan and radiograph analysis. Materials and Methods: A retrospective study of cases diagnosed with syndromic craniosynostosis who underwent for surgery correction at the Dr. Ángel Larralde University Hospital in Valencia, Carabobo, Venezuela from 2018 to the present year, without distinction of gender, age, type of syndrome, was carried out. Describing the protocol currently used in our country and in the same way, evaluating the morphometric changes in patients with syndromic craniosynostosis, who underwent monobloc and/or facial bipartition advancement with internal osteogenic distraction devices by pre and postsurgery cephalometric analysis. Results: A total of 3 patients were studied, where the combination of monobloc osteotomy, Le Fort III, bipartition and fasciotomy was performed with the use of 4 internal distractors, with an angulation of 35º between two parieto-frontal distractors and two temporozygomatic distractors, these patients were between the ages of between 8 and 11 years old, 2 female and 1 male, all diagnosed with Crouzon Syndrome. In these cases, cephalometry was performed on preoperative (T1) and same postoperative analysis at the end of the consolidation phase of distraction osteogenesis (T2), where each craniometric point was quantified and compared to establish the resulting movement vector in CT scan and radiograph analysis. Other changes can be seen in a sagittal plane, which reflect advancement of the upper and middle third, 17.33 mm ± 1.26 for the middle third and 13.33 mm ± 1.15 in the upper third. Similarly, a decrease of up to 3.00 mm ± 0.50 in the infraorbital region can be seen in the middle third, however, in the upper third there is a rise in the Gb point of 0.5 mm ± 1.50 and a decrease in the N point of just 0.50 mm ± 0.50. In relation to these values, divergent distraction vectors are expressed, with a linear advancing distraction vector in the upper third and a simultaneously advancing and descending distraction vector in the middle third. Distraction vectors indicate an average of 13.83 mm advance for the upper third and 17.67 mm forward and downward for the middle third. In a coronal plane, transversal dimension changes were obtained with a decrease in the interorbital distance, which is evidenced with a mean of -7.50 mm ± 0.50 between the frontozygomatic sutures (Z) and -6.67mm ± 0.76 between both. Medial walls at Dacryon’s point level (Dc). However, at the level of the zygomatic arches, an increase of transverse width is shown with a mean of 1.33 mm ± 0.76 and expansion in the maxillary region at the level of the point (J) of 3.50 mm ± 0.50. Thus, obtaining in this study a transversal decrease in the orbital region and slight increase in the most inferior area of the middle third. Hector H1 *, Nohelia P1 , Leober M1 and Rubén M1,2 1 Department of Oral and Maxillofacial Surgery, University of Carabobo Maxillofacial Residency Program, Dr. Ángel Larralde University Hospital, Venezuela 2 Department of Craniofacial Surgery, Palmer Childrens Hospital, Maryland, USA Hector H, et al., Journal of Surgical Techniques and Procedures Remedy Publications LLC. 2 2023 | Volume 7 | Issue 1 | Article 1056 Introduction Craniofacial surgeons use a variety of surgical techniques for the correction of craniofacial deformities of syndromic etiology, such as Crouzon, Pfeiffer, Apert, Saethre Chotzen syndrome, and non-syndromic etiology such as midline clefts or isolated orbital hypertelorism. Tessier was a pioneer in describing techniques in which the fronto-orbital band is advanced independently in conjunction with a Le Fort III osteotomy, to produce frontofacial advancement [1]. Later, in 1978, Ortiz Monasterios et al. advanced the orbital component, the middle facial third, and the replacement of the frontal bone as a single unit, which he called Monobloc, for the correction of Crouzon syndrome [2,3]. One year later, Van der Meulen et al. performed the correction of facial clefts in the midline with a procedure that he called "median fasciotomy" by vertically splitting the monobloc in a half and removing the ethmoid bone in order to correct orbital hypertelorism [4]. Tessier later changes the shape of this vertical osteotomy, for correction of the deformity in three planes, to what he describes as facial bipartition [1]. A variety of techniques for correction of craniosynostosis syndromes has been described, however the main objective is to correct the intracranial hypertension, ocular proptosis and sleep obstructive apnea syndrome. For children and young adults there are special considerations in the protocol. The purpose of this study was to describe the protocols currently used at the Dr. Ángel Larralde University Hospital in Valencia, Carabobo, Venezuela. And to clinically evaluate the improvement of function, aesthetics and psychosocial development of patients with syndromic craniosynostosis operated on at the institution. Materials and Methods A retrospective study of cases diagnosed with syndromic craniosynostosis who underwent for surgery correction at the Dr. Ángel Larralde University Hospital in Valencia, Carabobo, Venezuela from 2018 to the present year. Describing the protocol currently Respect to orbital advancement, rotation counterclockwise of the orbital cone for diopter correction is crucial for visual field Improvement in patients with syndromic craniosynostosis. A mayor objective is to eliminate the dependence of a tracheostome in these patients and to correct the obstructive apnea syndrome due to middle third deficiency, by anteroposterior advance of the airway. Whenever is possible, the use of endoscopic surgery is a gold standard to correct craniosynostosis from 6 months of age. Allowing rapid brain expansion and a recovery time of 2 days, without the need for pediatric Intensive Care Unit. Frontofacial advancement through osteogenic distraction allows us to make great anteroposterior advancement, superior to rigid internal fixation technique and in turn allow a correct adaptation of the soft tissue, improving function and aesthetics. Conclusions: The fundamental keys to success are reflected in the experience and preparation of the surgical team. Optimization of intraoperative time to minimize excessive blood loss is a crucial factor in the outcome. Correction of intracranial hypertension, obstructive sleep apnea syndrome, the visual field in these patients. Aesthetics changes to allow their rapid psychological and social integration at the school and the society as soon as possible to avoid bullying. The preparation of the surgical team is essential to avoid intraoperative complications, both a trained anesthesiology team and a team of surgeons with surgical training in craniofacial surgery.
Hector H, Nohelia P, Leober M, Rubén M. Venezuelan Protocol for Management of Patients with Syndromic Craniosynostosis and Morphometric Craniofacial Changes with Frontofacial Monobloc Advancement Procedure Using Internal Osteogenic Distraction. J Surg Tech Proced. 2023;7(1):1056..