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Background: Fronto-orbital reconstruction is the standard of care for repair of unilateral coronal synostosis. This study examined the relationship between age at initial surgery and need for secondary surgery, to determine the optimal age for reconstruction., Methods: The series comprised 81 patients with unicoronal synostosis who underwent reconstruction over a 30-year period by a single surgeon. Measured outcomes included reoperation rate, relapse/defect rate, relapse interval, and problem rate., Results: Average age at surgery was 11.3 months (range, 1.5 to 71 months). The problem rate was 27.2 percent. Mean follow-up was 69 months (range, 6 to 234 months). The postoperative defect rate was 73 percent. Sixteen patients (20 percent) underwent reoperation to correct secondary deformities. Whitaker category I or II results were achieved in 90.1 percent. Problem rates for patients aged 0 to 6 months, 6 to 12 months, and older than 12 months were 13.3, 28, and 35, respectively. Secondary surgery was performed in 40 percent of patients whose first surgery was at 0 to 6 months, 7 percent aged 6 to 12 months, and 30.4 percent older than 12 months. After surgery, 87 percent of patients aged 0 to 6 months, 95 percent aged 6 to 12 months, and 87 percent older than 12 months had Whitaker category I or II results., Conclusions: Fronto-orbital advancement at younger than 6 months had the highest incidence of readvancement. Patients treated at 6 to 12 months had the least need for any secondary surgery; however, patients older than 12 months had the lowest incidence of readvancement. These results indicate that fronto-orbital advancement should be delayed until at least age 6 months to avoid relapse.

Background: The ability of the immature skull to spontaneously heal large bony defects created after craniofacial procedures was examined over a 25-year period of craniofacial surgery at the Children's Hospital of Philadelphia., Methods: Only patients who underwent frontal orbital advancement and reconstruction, had at least 1 year of documented follow-up, and had the presence or absence of a bony defect documented on clinical examination were included. The sex, age at operation, diagnosis, history of a prior craniectomy, and presence or absence of a postoperative infection were determined for each patient. A variety of statistics were applied to the data., Results: Eighty-one patients met the inclusion criteria. A statistically significant association between age at operation and closure of bony defect was demonstrated. Children who closed a bony defect after frontal orbital advancement and reconstruction were significantly younger than those children who had a persistent bony defect. Iterative regression analyses demonstrated that a transition point between closure and the inability to close bony defects occurred between 9 and 11 months of age. Closure of bony defects was not statistically associated with sex, prior craniectomy, an FGFR mutation, or a postoperative infection in the regression analysis., Conclusions: Healing of bony defects after frontal orbital advancement and reconstruction is significantly related to age at initial operation, with a mean age for closure of less than 12 months. Between 9 and 11 months of age, a change occurs that results in an increasingly lower probability of bony defect closure; thus, all other considerations being equal, initial frontal orbital advancement and reconstruction would ideally take place before this occurs.

A retrospective statistical analysis of orbital hypertelorism correction was performed by comparing the preoperative and postoperative intercanthal distances of these patients with published age-matched normal values. Forty-five patients who had undergone surgery over a 15-year period with an average follow-up of 5 years (6 months to 14 years) were evaluated. Comparison of age-normalized preoperative and postoperative intercanthal distances revealed a significant difference for orbital hypertelorism patients as a group (p < 0.0001), patients with clefts (p < 0.0001), patients with nasoencephalocele (p < 0.01), and patients with frontonasal dysplasia (p < 0.05), but not for those patients with craniofacial dysostosis (p < 0.20). Multiple analyses of variance revealed a significant interaction existing between the extent of preoperative deformity and the cause of hypertelorism for both the postoperative deformity and the total amount of correction achieved, but not for the type of surgery or for the age at which the surgery was performed.

Orbital hypertelorism, strictly defined as an increase in bony interorbital distance, is not itself an isolated syndrome, but is instead an anomaly that may occur as either part of a syndrome or malformation sequence. Evaluation of orbital hypertelorism and the various anomalies that accompany it is best performed by a multidisciplinary craniofacial team. The timing of surgery involves considerations of multiple variables, but when performed can offer marked cosmetic improvements. Equally important as the skeletal surgery is correction of the associated soft-tissue problems.

A retrospective analysis of our experience, techniques, and concepts for the secondary reconstruction of orbital injuries to 78 patients over a 15-year period is presented. Secondary orbital reconstruction has the following four basic steps: (1) freeing of the overlying soft tissues by extensive subperiosteal dissection; (2) skeletal reconstruction, usually with onlay bone grafting and contour osteoplasty; (3) restoration of palpebral shape and position by medial and lateral canthopexy; and (4) soft-tissue refinement. Reconstruction required an average of at least two operations. In this series, there were no mortalities, three infections, and no reoperations for bleeding. Thirty patients required a second operation to an area previously addressed reflecting inadequacies in technique, the unpredictability of bone grafts, and soft-tissue scarring. Distortion of the skeletal infrastructure is most amenable to secondary reconstruction. Soft-tissue distortions that accompany bone malposition are less well corrected. Soft-tissue contraction is the limiting factor in successful reconstruction dictating separate movement of the overlying soft tissues and ligaments, their overcorrection, and subsequent revisional surgery. Secondary orbital reconstruction, although providing significant improvement, usually fails to restore the preinjury appearance, and usually falls short of properly performed acute reconstruction.

A physical anthropologic basis for aesthetic evaluation of the supraorbital ridges and forehead is described. The structures included for evaluation and possible treatment are the supraorbital ridges, relation of the orbital walls to the eyes, the temporal ridges, and slope of the forehead. All can be altered by reduction contouring or augmentation using methods described. Twenty-one patients are presented having procedures for purely aesthetic reasons. If more than 5 to 6 mm of augmentation or reduction is desired, the deformity is more than aesthetic and should be treated by a craniofacial team. The aesthetic restructuring procedures described are done using tissue localized to the cranium and have proven to be safe and free of complications in the patients treated. Physical anthropology helps to put the aesthetics of these procedures on a firmer basis and to determine which patients may require more than an extracranial aesthetic procedure.

Four geographically widely separated medical centres with a primary interest in cranio-facial surgery present their combined complications to illustrate the dangers and unsolved problems of this surgery. There wre 149 cases with 2 deaths and 3 other life threatening situations (infections). Approximately 60% of the patients had no complications (90/149). Secondary corrections are often necessary to obtain the desired result or correct problems produced by the surgery. The complexity and rarity of the surgery and supporting disciplines is such that in the interest of the patient and the speciality concentration of this surgery in a few centres is desirable.

We have treated 12 patients with severe oculo-orbital trauma during the past 3 years. The structural problems, produced by disruption or displacement of the orbital cone, were treated effectively (and, on occasion, preferentially) with onlay bone grafts. For an effective correction, we advise radical mobilization of the soft tissue and simultaneous correction on the ocular adnexal deformities. Ocular muscle problems are produced by direct injury to the extraocular muscles, or oculomotor nerve, and were possible these should be corrected early. The structural damage to the eye and orbit falls into certain patterns, related to weak points about the orbit. These have been described.

Orbital hypertelorism as defined by increased bony interorbital distance is a complex manifestation of many congenital anomalies. As such, it is associated with a multitude of orbital, adnexal, and surrounding soft-tissue deformities. Treatment of these problems requires extensive experience and a comprehensive team, permitting adequate preoperative evaluation, diagnosis, and treatment. The results obtained may be dramatic. The overall safety of the procedures has been demonstrated. Continued refinements and long-term follow-up will undoubtedly continue to make significant improvements.

Strabismus, ptosis, lateral canthal dystopia, nasolacrimal obstruction, and cranial nerve palsy were noted preoperatively in 32%, 21%, 14%, 12%, and 9% of 34 patients, respectively, undergoing ophthalmologic evaluation prior to unilateral orbital advancement for plagiocephaly. Thirty-two percent of the patients had normal preoperative ocular and adnexal examination results. Ptosis, strabismus, and amblyopia were frequently acquired postoperative abnormalities in 29%, 18%, and 18% of the patients, respectively. Forty-four percent of the patients had no new abnormalities following craniofacial surgery.