Craniofacial Anomalies, Part 2 - Plastic Surgery Internal

tomical correction of the deformitiy at the time of
surgery, with less reliance on passive correction
postoperatively, although many authors still advocate
vertex craniectomy for young infants with sagittal
synostosis. 394
In 1971 Tessier 275 mobilized the lower part of the
frontal bone in one piece while performing maxillary
advancement in adult patients with Crouzon or Apert
syndromes. Hoffmann and Mohr 395 adapted Tessier’s
supraorbital advancement techniques to infants, performing
a unilateral coronal supraorbital advancement.
Marchac 396 later devised a technique that involved
(1) rocking and advancement of the supraorbital bar
with a lateral temporal spur in the form of a Z-plasty
for stability and retention—the floating forehead—
and (2) mobilization and rearrangement of the anterior
cranial vault by means of bone grafts. Marchac
originally used the floating forehead technique with
frontocranial remodeling in the treatment of
brachycephaly, Crouzon or Apert syndromes, and
oxycephaly. 397 Marchac had originally hoped that
the floating forehead technique would allow normalization
of midfacial growth, but unfortunately this
did not materialize.
Other techniques utilize the mathematics of projection,
geometry, and stress relief to produce an
appropriate forehead contour. 398 Other methods
treat the forehead as a totally misshapen unit that
must be adjusted in all three dimensions with multiple
osteotomies and cranial bone grafts to recreate
the forehead/bandeau unit in jigsaw-puzzle fashion
(Fig 22). 399
Munro and coworkers 400 advocate 180° reversal
of the entire upper cranium, while Jackson, Hide,
and Barker 401 prefer frontal transposition cranioplasty
for correction of frontal contour. Ortiz Monasterio
and colleagues 402 combine frontal mobilization with
a one-piece orbitofacial advancement in Crouzon
syndrome.
Operations for frontocranial remodeling have
facilitated the approach to cranial as well as facial
deformities and have considerably improved the overall
surgical results. The vast number and variety of
methods to reshape the orbital rim and cranial vault
are proof that no technique is ideal in all cases. The
basic concept should be to reshape all bone that is
abnormal and to rearrange bone to arrive at the
SRPS Volume 10, Number 17, Part 2
Fig 22. Bilateral coronal synostosis and its surgical correction. A,
site of anterior cranial vault and three-quarter orbital osteotomies.
B, after osteotomies and reshaping and fixation of the
cranioorbital region. (Reprinted with permission from Posnick
JC: Craniosynostosis: Surgical Management in Infancy. In: Bell
WH (ed), Orthognathic and Reconstructive Surgery. Philadelphia,
WB Saunders, 1992; vol 3, p 1859.)
most aesthetic contour, and the degree to which
each of these maneuvers is applied differs among
patients. For example, at times it may be preferable
to shape the forehead by recontouring the existing
frontal bone, while at other times this goal is best
accomplished by replacing the frontal bone with
parietal bone. Early frontal remodeling is facilitated
by easy malleability of bone; rapid reossification;
outward push by the growing brain; and the beneficial
effect on adjacent structures of releasing the
stenosed areas. 136,199 On the other hand, the earlier
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