Surgical treatment of trigonocephaly: technique and long-term results in 48 cases

Clinical article

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Object

The authors present their experience in the surgical treatment of metopic synostosis by orbital bandeau remodeling and frontal bone rotation. The pitfalls and advantages of the surgical technique are discussed, along with the long-term clinical results in 48 consecutive cases.

Methods

Forty-eight consecutive patients in whom trigonocephaly was diagnosed between 1990 and 2009 were treated with frontal bone rotation and frontoorbital bandeau remodeling. Of these patients, 38 (79%) were boys and 10 (21%) were girls. The age at the time of surgical treatment ranged between 4 and 42 months (mean ± SD 11.4 ± 8.7 months). The average follow-up period was 5.5 ± 4.2 years (range 5 months–19 years). The preoperative and latest postoperative photographs of the patients were evaluated for the following features: 1) shape of the forehead; 2) hypotelorism; and 3) temporal depression. Scores of 0, 1, or 2 were assigned for each item: 0 was normal, 1 meant moderate deformity, and 2 denoted severe deformity.

Results

In the early postoperative period, no complications were documented. The average hospitalization period was 4 days. Follow-up radiographs or 3D CT scans were obtained at regular intervals. The mean preoperative scores for the evaluated items were 1.38 ± 0.49 for the shape of the forehead, 1.33 ± 0.48 for hypotelorism, and 1.7 ± 0.46 for the temporal depression. The mean postoperative scores were 0.06 ± 0.24 for the shape of the forehead, 0.21 ± 0.4 for hypotelorism, and 0.67 ± 0.48 for the temporal depression. Overall, the total preoperative score dropped from 4.4 to 0.93 postoperatively (p < 0.05). All the patients were contented with the cosmetic results.

Conclusions

Early detection and treatment of metopic suture synostosis has a significant, favorable influence on the outcomes. Good understanding of the structural abnormality and the pathophysiological mechanisms of the possible complications is very important for performing proper surgical reconstruction.

Article Information

Address correspondence to: Pamir Erdincler, M.D., Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey. email: pam@istanbul.edu.tr.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Intraoperative photographs showing the position of the patient (A), the site of the skin incision related to the anterior fontanel (B), the dural exposure after frontal craniotomy (C), and the exposure of the frontoorbital bandeau (D and E). AF = site of the anterior fontanel; BC = the planned bone cut; SI = the planned skin incision.

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    Intraoperative photographs taken after removal of the frontoorbital bandeau and exposure of the superior (A) and lateral (B) periorbit. Anterior (C) and superior (D) views of the resected frontal bone and bandeau.

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    Intraoperative photographs showing superior (A) and inferior (B) views of the bandeau before remodeling, and some remodeling techniques of the bandeau, such as fixation of the midline fractured bandeau with surgical sutures (C); midline grooving and fixation of both the bandeau and the nasofrontal suture with a single square miniplate (D); midline grooving and 2-miniplate fixation (E–G); posterior support of the bandeau with bone graft (H–J); and with addition of a square miniplate (K).

  • View in gallery

    Intraoperative photographs showing fixation of the midline of the bandeau to the nasal bone with surgical sutures (A) and miniplate (B). Schematic drawings demonstrating the final position of the frontoorbital bandeau after firm fixation to the nasal bone (C), and the loose fixation of the frontal bone to create the mobile frontoorbital joint (floating forehead [D]).

  • View in gallery

    A: The frontal bone is rotated 180°, with the anterior fontanel becoming located anteriorly and the midline frontal ridge becoming located posteriorly. B: Multiple cuts are performed toward the center of the bone, forming fingerlike projections of the bone. C: View of the frontal bone after its fixation with surgical sutures to the bandeau. Prominent parts of the frontal bone are drilled, thus creating a smoothly convex bone. D: An intact periosteal surgical suturing of the lateral parts (temporal muscles) and at the interface area between the frontal bone flap and the frontoorbital bandeau, without placement of surgical sutures in the posterior part of the periosteum.

  • View in gallery

    An illustrative case with preoperative (A–D), 5 months postoperative (E–I), and 2.5 years postoperative (J–M) photographs and images.

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    An illustrative case with preoperative (A–E), 6 months postoperative (F–I), and 2 years postoperative (J–M) photographs and images.

  • View in gallery

    An illustrative case with preoperative (A–E), 6 months postoperative (F–J), and 2.5 years postoperative (K–O) photographs and images.

  • View in gallery

    An illustrative case with preoperative (A–E), 4 months postoperative (F–I), and 2 years postoperative (J and K) photographs and images.

  • View in gallery

    A drawing demonstrating the basic surgical technique used in the treatment of trigonocepahly in our series, consisting of orbital bandeau remodeling, 180° rotation of the frontal bone flap, and the floating forehead model.

  • View in gallery

    A case of trigonocephaly surgically treated with firm fixation of the frontal bone to the bandeau, resulting in limited anterior expansion of the head, with compensatory vertical growth. A 3D CT scan showing the frontal fixation (A), and a lateral skull plain radiographic study (B). Photographs showing anterior (C) and lateral (D) views of the patient.

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