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In the initial report describing the fronto-orbital distraction technique, bone segments were advanced preserving their attachments with the dura. This approach does not allow for the remodeling of the frontal segment. However, in the technique described herein, the fronto-orbital segment is separated from dura, remodeled, and advanced as a bone graft using distractors. Twenty-seven craniosynostosis patients that underwent fronto-orbital advancement and remodeling using distraction osteogenesis were retrospectively reviewed. The mean age at the time of surgery was 19.03 ± 9.19 months; the mean follow-up was 86.04 ± 34.98 months. The mean distraction amount was over 19 mm. No significant difference was found between frontal and occipital bone density measurements at the cortex and medulla. The mean total defect area was 4.79 ± 4.43 cm 2 and the mean number of bone defects was 4.8 ± 2.2. The cephalic index decreased from 98.56 ± 6.39 to 87.63 ± 4.54, and 59.3% of the patients reached the normal range in the late postoperative period. Fronto-orbital advancement and remodeling using distraction osteogenesis appears to be safe and effective. Distraction of the frontal bone as a graft does not lead to bone resorption, and new bone formation and improvements in head shape can be achieved., Competing Interests: Declaration of conflicting interests The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: With the increasing demand for facial feminization surgery, there is a growing need for reliable and reproducible techniques to enhance outcomes. The authors aimed to evaluate the effectiveness of single-stage nasoorbitofrontal (NOF) complex reshaping in facial feminization surgery. Effectiveness was gauged by computed tomographic assessments and an unvalidated patient satisfaction survey at 6 months postoperatively., Methods: The study included 155 transfeminine patients undergoing surgery of the upper third of the face. Outcomes were compared in patients receiving either orbitofrontal (OF) surgery or combined NOF surgery. A comparative analysis of preoperative and postoperative standardized computed tomography sections was performed, focusing on multiple anatomic angles in 2 dimensions. A self-administered satisfaction questionnaire based on 6 FACE-Q items was completed at 6 months., Results: Among the 155 patients, 65 underwent OF surgery and 90 underwent NOF surgery. The follow-up period ranged from 6 to 36 months, with an average follow-up of 18 months. Significant changes in craniometric measurements were observed. In the OF group, average changes in nasofrontal, frontal tilt, and metopion angles were +12.3 ± 0.2 degrees, -8.5 ± 2.2 degrees, and +20.0 ± 0.1 degrees, respectively ( P < 0.001); in the NOF group, they were +28.5 ± 0.3 degrees, -9.3 ± 2.4 degrees, and +23.9 ± 0.1 degrees, respectively ( P < 0.001). The NOF group demonstrated higher overall satisfaction (median, 4 of 5) compared with the OF group (median, 3 of 5). No early complications were reported., Conclusion: The NOF complex surgery is an effective approach in gender-affirming surgery of the upper third of the face, yielding predictable results and higher patient satisfaction., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Objective: Isolated craniosynostosis of the sagittal suture results in scaphocephaly characterized by a long, narrow skull. Surgical correction of this condition remains debated, particularly regarding the necessity of directly addressing frontal bossing. This study aimed to assess the effectiveness of extended strip craniectomy combined with bilateral barrel staving in improving cranial morphology without direct intervention on the forehead., Methods: This retrospective study included 81 patients diagnosed with isolated sagittal synostosis, treated surgically at an average age of 5.3 months. Three-dimensional photogrammetric scans were obtained 1 day before surgery and 14 days, 3 months, and 12 months postoperatively. The bossing angle, nasofrontal angle, cephalic index, and vertex ratio were analyzed. A control group of age-matched healthy children was used for comparison., Results: Significant reductions in the bossing angle were observed from preoperatively to 12 months postoperatively, indicating that the intervention contributed to a more normalized cranial shape. The cephalic index increased significantly postoperatively, although it remained lower than that of the control group. The nasofrontal angle remained stable across all time points, with minimal differences between the study and control groups. The vertex ratio decreased significantly over time, suggesting a balanced cranial shape. However, persistent differences between the study and control groups suggest that the intervention did not fully normalize cranial morphology in the short to midterm., Conclusions: Extended strip craniectomy with bilateral barrel staving, while effective in improving certain aspects of cranial morphology, may not fully equalize cranial shape within the short to midterm. The use of 3D photogrammetry as a noninvasive method for assessing cranial changes is validated in this study and holds promise for broader applications in craniofacial surgery.

Background: Frontoorbital distraction osteogenesis (FODO) is an established surgical technique for patients with unicoronal craniosynostosis. The authors' institution has used an endoscope-assisted technique (endo-FODO) in recent years to decrease cutaneous scarring and lessen the impact on the functional growth matrix. This study compared perioperative outcomes in patients undergoing endo-FODO to those in patients undergoing the traditional coronal approach., Methods: Patients with unicoronal craniosynostosis undergoing FODO from 2013 to 2023 were included, and grouped by whether they underwent endo-FODO or a traditional coronal incision. Operative time, estimated blood loss, transfusion volume, and length of hospitalization were compared. Cutaneous scarring at 1 year postoperatively was assessed with the Scar Cosmesis Assessment and Rating (SCAR) scale., Results: A total of 27 patients (18 traditional and 9 endoscope-assisted) with an average age of 5.6 months (interquartile range [IQR], 5.1 to 6.3 months) at surgery were included, with no difference between groups (P = 0.999). Operative time was 114 minutes (IQR, 92 to 122 minutes) for traditional FODO and 104 minutes (IQR, 95 to 112 minutes) for endo-FODO (P = 0.607). Time under anesthesia was shorter for endo-FODO (traditional, 243 minutes [IQR, 218 to 264 minutes]; endo-FODO, 210 minutes [IQR, 191 to 224 minutes]; P = 0.029). Transfusion volume was 12.2 mL/kg lower for endo-FODO compared with traditional FODO (P = 0.001). Length of stay was similar between groups (P = 0.678). SCAR ratings were 1.83 (IQR, 1.1 to 4.47) in traditional FODO compared with 1.00 (IQR, 0.58 to 1.67) in the endo-FODO (P = 0.036)., Conclusions: Endo-FODO was associated with reduced time under anesthesia, reduced transfusion requirements, and improved SCAR scores, with no change in duration of surgery, perioperative complications, or length of stay. Future work will compare functional and aesthetic outcomes between techniques., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Craniofacial fibrous dysplasia (CFD) is a benign bone condition that presents unique challenges due to its proximity to vital organs, esthetic significance, and variability in each case. Consequently, a meticulous and personalized surgical approach becomes imperative. Diverse techniques and technologies have been employed sporadically to tackle various aspects of CFD. Our approach includes a comprehensive integration of emerging methods and technologies, encompassing presurgical strategizing, three-dimensional computer-aided manufacturing (3D-CAM), intraoperative navigation systems, and a prefabricated drilling guide in a fronto-orbito-sphenoidal CFD case. This combined strategy is aimed at effectively addressing the complexities of this demanding ailment. Moreover, a collaborative team consisting of plastic surgeons, neurosurgeons, and oculoplastic surgeons cooperates to orchestrate the procedure. Embracing a multidisciplinary team and a holistic technological strategy appears to be the key to addressing the multifaceted challenges posed by intricate conditions like CFD., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

We present a novel case of intraosseous venous malformation of the frontal bone with dehiscence of the inner table of the frontal calvarium and extension into the frontal sinus and orbit. This case report discusses the surgical management of this intraosseous lesion achieved with a multidisciplinary approach involving otolaryngology and neurosurgical teams. We also present a review of the literature of the pathophysiology of venous malformations, the imaging modalities that aid in diagnosis of these lesions and the management options.

Introduction: In an effort to maximize benefit and minimize morbidity when performing fronto-orbital distraction osteogenesis (FODO) for unilateral coronal synostosis (UCS), we have transitioned to an endoscopic-assisted approach ("endo-FODO"). This study compares photogrammetric outcomes of patients who underwent FODO via an endoscopic-assisted versus open approach., Methods: We retrospectively reviewed patients treated for UCS from 2013 to 2023. Photogrammetric outcomes at one to three years postoperatively were compared between patients who underwent endo-FODO and age- and sex-matched controls who underwent open FODO. Differences between pre- and postoperative periorbital symmetry ratios, canthal tilt symmetry, and orbital dystopia angle (ODA) were calculated., Results: Twenty patients (ten per group) underwent surgery at a mean age of 6.1 ± 1.8 and 5.4 ± 1.1 months (p = 0.426) and were photographed at 1.6 ± 0.9 and 1.8 ± 0.9 years (p = 0.597) postoperatively in the endo-FODO and open FODO groups, respectively. Patients who underwent endo-FODO demonstrated significant improvements in margin-reflex distance 1 (MRD1) symmetry ratio (p = 0.004), palpebral height symmetry ratio (p = 0.004), canthal tilt symmetry (p = 0.020), and ODA (p = 0.009). Patients who underwent open FODO likewise demonstrated significant improvements in MRD1 symmetry ratio (p = 0.004), palpebral height symmetry ratio (p = 0.033), and ODA (p = 0.004). All postoperative measurements as well as degrees of improvement were similar between groups (p > 0.05)., Conclusions: Endo- and open FODO were associated with significant and comparable improvements in soft tissue periorbital symmetry and orbital dystopia at nearly two years postoperatively. While continued follow-up until cranial maturity is needed to assess the durability of aesthetic results, these data support a minimally invasive, endoscopic alternative to fronto-orbital distraction., Competing Interests: Declarations. Competing interest: The authors declare no competing interests., (© 2024. The Author(s).)

Cranial vault remodelling for craniosynostosis aims to increase intracranial volume to facilitate brain growth, avoid the development of raised intracranial pressure and address cosmesis. The extent of vault expansion is predominantly limited by scalp closure and reconstruction technique. Virtual surgical planning tools have been developed to predict post-operative changes and guide expansion. We present a validation study of a novel 'Dura-based Automated Vault Expansion-Remodeling' (DAVE-R) model to guide pre-operative planning for fronto-orbital advancement and remodelling (FOAR)., Methods: Patients with trigonocephaly who underwent FOAR with pre- and post-operative imaging from 2018 to 2020 were identified from a prospectively maintained database. Post-operative scans, normative atlas and whole brain parcellation were registered to the pre-operative images to quantify the change in intracranial volume and morphology (utilising measurement of fronto-orbital advancement and bifrontozygomatic distance) compared to that predicted by the DAVE-R model., Results: Ten patients were included. The DAVE-R model predicted bifrontozygomatic distances of 92.0 + / - 5.14 mm (mean + /SD), which closely matched the post-operative results of 92.7 + / - 6.02 mm (mean + / - SD); (t(d.f. 9) = -0.306, p = 0.77). The fronto-orbital advancement predicted by the DAVE-R method was 11.5 + / - 1.96 mm (mean + / - SD) which was significantly greater than 8.6 + / - 2.94 mm (mean ± SD); (t(d.f. 9) = 3.137, p = 0.01) achieved post-operatively., Conclusions: We demonstrate that the DAVE-R model provides an objective means of extracting realistic surgical goals in patients undergoing FOAR for trigonocephaly that closely correlates with post-operative outcomes. The normative dural model warrants further study and validation for other forms of craniosynostosis correction., Competing Interests: Declarations. Conflict of interest: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Reconstruction of skin defects after oncological surgery for a cutaneous squamous cell carcinoma is often mandatory to facilitate adjuvant treatment and/or to prevent chronic wound problems. Some of the most challenging regions to reconstruct after resection of a skin tumor are the frontal and parietal parts of the skull., Methods: This article describes three patients with large skin defects after oncological surgery that were reconstructed with the use of a (hemi) visor flap., Results: The (hemi) visor flap is easy to harvest, resulting in a concise procedure and short hospitalization with maximum wound control., Conclusion: The (hemi) visor flap is a safe and reliable option for the closure of large skin defects on the skull. Especially in the older and frail patient group., (© 2024 The Author(s). Head & Neck published by Wiley Periodicals LLC.)

Background: Feminizing fronto-orbital reconstruction involves one of four possibilities with the Ousterhout Type III anterior table frontal sinus osteotomy and setback performed in most patients while the Type I reduction recontouring is reserved for patients without frontal sinuses or thick anterior tables. However, patients with frontal sinuses and either a moderately thick anterior table or a shallow frontal sinus in the sagittal plane represent an intermediate morphology. For such morphologies, we introduce the novel Type I+ fronto-orbital reconstruction technique, consisting of frontal bone recontouring supplemented with anterior table reconstruction and split cranial bone graft., Methods: Transgender and gender non-conforming patients who underwent Type I+ or Type III feminizing fronto-orbital reconstruction (2019-2023) were included for retrospective review and comparison of techniques., Results: In the 123 patients (mean age 32.2 ± 9.5 years) included, 6.5% underwent Type I+ and 94.5% underwent Type III feminizing fronto-orbital reconstruction. Morphologically, Type I+ patients displayed a shallower frontal sinus compared to Type III patients (median anterior to posterior table depth 4.1[interquartile range, IQR, 1.1-5.0] versus 9.8[IQR 7.5-12.0]mm, p<0.001). At the maximum prominence, Type I+ patients also demonstrated thicker anterior tables compared to Type III patients (median 6.6[IQR 5.0-8.8] versus 2.2[IQR 0.4-4.7]mm, p=0.001). Patients receiving Type I+ procedures underwent an anterior table reduction of 2.7±1.2mm versus 4.2 ± 1.2mm for Type III procedures in the sagittal plane (p=0.002)., Conclusions: The current work introduces a novel solution to an intermediate frontal sinus phenotype for gender-affirming facial feminization surgery., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ., Competing Interests: Declarations. Conflict of interest: All authors have no financial interests, including products, devices, or drugs associated with this manuscript. The authors declare that they have no conflicts of interest to disclose aside from the senior author being a medical education consultant for Stryker. All sources of funds supporting the completion of this manuscript are under the auspices of our affiliated academic institution. Informed Consent: Informed consent is not required for this type of study. Statement of Human and Animal Rights, or Ethical Approval: This article does not contain any studies with human participants or animals performed by any of the authors., (© 2024. The Author(s).)

Objective: Frontal and naso-orbito-ethmoidal (NOE) fractures are rare but important injuries due to their anatomical complexity and proximity to vital structures. This study aims to describe the patient factors, procedural factors, and postoperative outcomes in the surgical management of these fractures., Study Design: Retrospective review of patients aged 18 years or older who were surgically treated for these fractures at two Australian tertiary hospitals (2014-2020). Patient factors (demographics, mechanism of injury, fracture pattern, concomitant injuries); procedural factors (operation timing, surgical approach); and postoperative outcomes (complications, revision surgeries) were recorded., Results: 60 cases were included (41 frontal; 29 NOE; 10 combined). Mean age was 37 (frontal) and 39 years (NOE). Most cases were male (87.8%; 75.9%). The most common mechanism was traffic accidents (29.3%; 34.5%). The most common associated facial fractures were Le Fort fractures (46.3%; 89.7%). The most common associated systemic injuries were brain injuries (36.6%; 34.5%). Mean operation timing was 13 days (frontal) and 11 days (NOE). Coronal flap was most commonly used (68.3%; 82.8%). Postoperative complication rates were 39.0% (frontal) and 37.9% (NOE). Three cases required revision surgeries., Conclusion: Further larger longitudinal studies are required to build knowledge and improve patient outcomes., Competing Interests: Declaration of Interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: Anterior plagiocephaly ( AP), secondary to isolated frontosphenoidal synostosis (IFS), represents one of the rarest forms of craniosynostosis documented in medical literature. Therefore, there is a lack of comprehensive understanding regarding the long-term (> 2 years) postoperative outcomes of this minor suture synostosis., Methods: This study presents the long-term outcomes of two patients previously treated for IFS, detailing their clinical, imaging, and postoperative characteristics. Additionally, a systematic review was conducted following PRISMA criteria to summarize existing literature on the topic. The review specifically focuses on long-term aesthetic outcomes, reoperation rates, and complications following surgical intervention for IFS., Results: Four articles encompassing 12 patients were included in the systematic review. The review highlights clinical features, postoperative complications, reoperation rates, and long-term aesthetic outcomes. The mean age at surgery was 17.5 months (range 9.5-24 months), with an average age at diagnosis of 9.3 months (range 6-10 months). Fronto-orbital advancement was the predominant surgical approach described across all cases. The reoperation rate among patients was 16.6%, with only two cases reporting postoperative complications. In one of our cases, an intraoperative CT scan was utilized to illustrate real-time improvement in frontal bone alignment according to the surgical plan, which significantly contributed to positive long-term clinical outcomes observed during a follow-up period exceeding 24 months., Conclusion: IFS, is a rare minor suture synostosis, significantly affects the aesthetic appearance of the forehead and necessitates consideration in the management of AP cases. Surgical intervention has shown minimal reoperation rates and excellent long-term prognosis. These findings are reinforced by recent institutional data and a comprehensive systematic review of the current literature., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Sincipital meningoencephaloceles (MECs) are rare congenital malformations characterized by the herniation of brain or meningeal tissue through an opening in the anterior floor of the skull base. These malformations always affect the frontal bone, specifically the glabellar region and the naso-frontal angle. A collaboration between Médecins du Monde and the Children's Surgical Center in Phnom Penh has enabled the treatment of over four hundred cases over twenty years. Patients typically have not undergone radiological examinations, with surgical strategies based on clinical and intraoperative observations. There are several clinical forms of MECs: naso-frontal, naso-ethmoidal, and naso-orbital. The 1972 classification by Suwanwela remains the most relevant. Naso-frontal MECs are often associated with significant skin expansion without major bone deformity, unlike naso-ethmoidal MECs, which lead to significant deformities and are the most common. Naso-orbital MECs, being rarer, most frequently result in an increased orbital volume. The nature of the herniated tissue and the volume of the hernia are critical in determining the surgical strategy. Canthopexy, a key element of reconstruction, must be precise and adhere to strict rules to ensure an aesthetic result. The fronto-nasal remodeling completes the repair. The surgery for MECs follows well-codified principles. The humanitarian context influences management, with an emphasis on surgical safety and skill transmission. Treatment relies more on clinical assessment than radiological, although imaging advancements are now available in Cambodia. Long-term follow-up, especially in children, remains a challenge to document in order to evaluate the impacts on growth and the stability of surgical outcomes., (Copyright © 2024. Published by Elsevier Masson SAS.)

Superior orbital frontal clefts are one of the rare craniofacial clefts described by Tessier in 1976, and occur most often sporadically. They are numbered 9, 10 and 11 in this classification, and are located respectively laterally, in the middle and medially to the upper part of the orbit. Their clinical expression is variable on soft tissue and bone, with possible dissociation of involvement. They range from a simple aesthetic defect to an eyes functional prognosis. CT scans are systematically required in this context. Their management must be adapted to the polymorphism of the damage, and is based on multidisciplinary approach. In case of ocular risk, the eyelid reconstruction is an emergency. In all other cases, treatment is deferred, but must be carried out at an early stage to ensure the child's healthy development., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Background: Forehead feminization cranioplasty (FFC) risks entering the frontal sinus to achieve the desired contour. To date, no study has investigated long-term FFC complications. Objective: Determine if long-term sinus and headache symptoms worsen secondary to frontal sinus mucosal violation, measured by patient-reported outcomes. Methods: Single database retrospective chart review of patients who underwent forehead contouring between August 2012 and August 2019 was conducted. Two cohorts-frontal sinus mucosal violation versus mucosal preservation-were surveyed postprocedurely for postprocedure SNOT (Sinonasal Outcome Test)-22 scores and pre- and postprocedure sinus and headache symptoms. Results: Frontal sinus violation, mean time between surgery and response was 4.16 ± 1.88 years (range: 1-8). Without violation, mean time between surgery and response was 2.5 ± 1.10 years (range: 1-5). Postoperative SNOT-22 severity scores were not different (12.55 vs. 8.6, p  = 0.20). Postoperative SNOT-22 scores were equivalent to a control nonrhinosinusitis population. No difference was found between violation of the frontal sinus with worse postoperative sinus (22 vs. 5, p  = 0.60) or headache symptoms. Conclusion: Our data did not detect a difference in sinus or headache outcomes in patients who experienced violation of the anterior frontal table compared with a similar population with preservation of the frontal sinus, over an 8-year follow-up.

Frontal bone fractures are amongst the most common facial fractures and surgical management, which has traditionally involved access via a coronal flap, can result in unsightly scarring, alopecia, paraesthesia, facial nerve weakness and temporal hollowing. Alternative approaches include use of endoscopically-assisted surgery, often through the eyebrow, which minimises the risk of unsightly scarring but may also sacrifice access in the process. In this technical note, we discuss a surgical technique for open reduction and internal fixation of fractures of the bone overlying the frontal sinus and supra-orbital rim, which the authors have not found in the literature, which involves the making of a "zig-zag" incision through the eyebrow in a trichophytic manner which reduces the risk of unsightly scarring whilst simultaneously allowing for sufficient surgical access to the fracture site., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Parasinusal osteoma complicated by intracranial and orbit extension, cranial vault hyperostosis, intracranial mucocele, and inflammatory pseudotumor is exceptional. A 68-year-old man presented with a long history of progressive proptosis and recurrent episodes of keratoconjunctivitis in the left eye, with restriction in upward gaze. Contrast-enhanced magnetic resonance imaging revealed a frontal sinus lesion extending to the left anterior fossa and orbit, featuring an intracranial cystic component and heterogeneous contrast enhancement. Head computed tomography confirmed the double calcific-cystic nature of the lesion. A left supraorbital-pterional approach allowed complete resection of mucocele and drilling of intracranial and orbital osteoma, including the intrasinusal component. The frontal sinus was cranialized, and a flap of pericranium, reinforced by Gelfoam sponge, was reflected on the anterior cranial base/orbital roof. The postoperative course was uneventful; magnetic resonance imaging depicted resolution of proptosis. Histological examination favored parasinusal osteoma associated with intracranial mucocele, frontal bone hyperostosis, and inflammatory pseudotumor., (Copyright © 2024 Elsevier Inc. All rights reserved.)

the aim of this paper, is to propose a new reference line: the Frontozygomatic-Infraorbital Line (FZ-IOL). This reference line can guide the surgical team planning mandibular angle harmonization, based on the patient's skeletal proportion. The Frontozygomatic-Infraorbital Line has been adopted for symmetrization surgery, masculinization surgery, and in unsatisfactory results of previous orthognathic surgery. From March 2021 to December 2022, 3 patients were treated for severe facial asymmetry affecting mainly the lower third of the face. All cases were planned with the reference FZ-IOL. Patients were treated in the same center, at the Orthognathic Surgery Department of the Instituto Portugues da Face, Lisbon, Portugal. The Frontozygomatic-Infraorbital Line is designed virtually using software to reconstruct a 3D image from a digital imaging and communications in medicine (DICOM) file obtained from a cone beam computer tomography (CBCT). , connecting the two orbital rims. Then, a vertical line, the frontozygomatic line perpendicular to the IOL and passing through the outmost lateral portion of the frontozygomatic suture is drawn. The proposed line demonstrated how establishing appropriate reference lines is crucial for the success of the surgery. The selection of reference lines should be based on the patient's anatomy, the symmetrization process's complexity, and the surgery's desired outcome. The Frontozygomatic-Infraorbital Line represents an adequate reference line for managing mandibular angle lateral projection, improving lower third of the face symmetrization., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

The aim of this study was to compare a traditional fronto-orbital remodeling and advancement (FORA) with the dynamic cranioplasty for trigonocephaly (DCT). The authors analyzed patients who underwent surgery for trigonocephaly. Perioperative data were compared. Parents were asked to use a visual analog scale to evaluate the pre- and postoperative distance between the eyes, the forehead shape, and the global appearance of the face. A panel of observers was asked to grade pre- and postoperative photographs using a similar visual analog scale. Pre- and postoperative anthropometric data were collected and analyzed in a subset of the study population aged 9 years or older. The total sample size was 51 patients (DCT n = 39; FORA n = 12). Durations of surgery and anesthesia were shorter in the DCT group (115 vs 194 min, p = 0.001; 226 vs 289 min, p = 0.001). Patients in the DCT group received similar preoperative ratings to those in the FORA group, but significantly higher postoperative ratings by parents for all three questions. There were no significant differences in postoperative ratings by the panel or postoperative anthropometric data. DCT is safe and effective. It is preferred over FORA because it is associated with shorter durations of surgery and anesthesia, while providing higher degrees of parental satisfaction and similar aesthetic and anthropometric outcomes., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to declare in relation to the content of this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: The objective of this study was to investigate the longitudinal changes in cranial growth following fronto-orbital advancement (FOA) surgery in patients with unilateral and bilateral coronal craniosynostosis., Methods: This retrospective review analyzed head circumference (HC) and CT data during preoperative (T0), immediate postoperative (T1), and final follow-up (T2) visits in 40 patients (23 female, 17 male) who underwent FOA using either the open approach or distraction osteogenesis (DO) between 1987 and 2018. The mean follow-up period was 90.62 months. The z-scores of HC, CT-based intracranial volume, anteroposterior diameter (APD), biparietal diameter (BPD), and cranial height (CH) were calculated using sex- and age-specific standards. Logistic regression analysis was performed., Results: While the z-scores of HC, intracranial volume, and BPD remained within the normal range, the z-scores of APD fluctuated between -2 and -1, and the z-scores of CH were > 2, indicating a substantial elevation compared with norms from T0 to T2. Age at surgery significantly influenced the z-scores of HC, BPD, and CH at T2 (all p < 0.05). Delayed surgical timing was correlated with increased BPD and CH z-scores from T1 to T2 (p = 0.007 and 0.019, respectively). The DO for FOA resulted in elevated HC z-scores at T2 and increased APD from T0 to T1, followed by a significant APD relapse from T1 to T2., Conclusions: These findings suggest that delayed surgical timing may support better cranial growth, as indicated by increased HC at long-term follow-up. However, delayed timing is also associated with worsening abnormally elevated CH. Despite the immediate APD expansion and long-term HC increase with DO, potential relapse warrants caution. While intentional overcorrection of APD is recommended, careful consideration of surgical timing and planning is essential.

Background: The fronto-temporo-orbito-zygomatic (FTOZ) craniotomy is a commonly utilized surgical approach for many complex skull base lesions, especially lesions traversing skull base compartments. This craniotomy has evolved over multiple stages, originating from the classic pterional craniotomy and many variations that have emerged over time., Methods: Few clinical and anatomic studies have both shaped these craniotomies as well as provided immense information about instances in which they are most useful. We review the origin and history of the one-piece and two-piece fronto-temporo-orbito-zygomatic craniotomy and deliberate their advantages and disadvantages., Results: The FTOZ craniotomy provides access to the orbit as well as to multiple compartments in the cranium (anterior, middle and upper third posterior cranial fossae); thus, offering a multi-corridor approach to complex skull base lesions. The one-piece and two-piece fronto-temporo-orbitozygomatic craniotomies are two particularly notable variations that have stood the test of time. Selection between the two variations is mostly surgeon preference and comfort with the technique; however, there are certain indications that specifically suit each approach. Additionally, a pictorial review has been crafted to clearly illustrate the cuts to be made in both methods., Conclusion: Understanding the evolution of this craniotomy and surgical approach provides an insight into accessing complex skull base pathologies with minimal brain retraction via safe and viable corridors., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: To investigate the locations of the anterior, middle, and posterior ethmoidal foramina and their relationships to the frontoethmoidal suture., Methods: One hundred twenty sides from sixty adult human skulls were used. Specimens with significant damage to the medial orbit wall were excluded. The number of ethmoidal foramina (anterior, middle, and posterior) on the medial orbital wall and the relationship of each foramen to the frontoethmoidal suture were recorded and classified as follows: Type I: superior to the frontoethmoidal suture; Type II: on the frontoethmoidal suture; Type III: inferior to the frontoethmoidal suture., Results: Of the ninety-four sides, fourteen (14.9%) had one foramen, sixty-two (66.0%) had two , and eighteen (19.1%) had three. In total, 192 ethmoidal foramina were observed. Among the fourteen sides with one foramen, eight foramina were anterior and six were posterior. Among the 192 ethmoidal foramina, 162 were eligible for fur ther classification (74 anterior, 14 middle, and 74 posterior). Types I, II, and III ethmoidal foramina were found in 38.3% (62/162), 61.7% (100/162), and 0% (0/162), respectively., Conclusions: Our current study found a higher incidence of type I than previously reported. It is important to be aware of the significant incidence of foramen variations when the medial orbit wall is manipulated during surgery. Unless caution is observed, an inadvertent surgical injury can occur and lead to life-threatening complications. Therefore, a good understanding of orbital anatomy and its potential variations is critical for improving patient out comes.

Background: Fibrous dysplasia (FD) is a benign developmental disorder of the bone that causes normal skeletal tissue to be replaced by excess fibrous tissue and poorly differentiated osteoblasts. Intraosseous xanthomas are benign intraosseous tumor growths characterized microscopically by the presence of lipid-laden foamy histiocytes, often with cortical expansion or disruption. Although FD commonly occurs in craniofacial bones, primary intraosseous xanthomas of the skull or facial skeleton are extremely rare. Although 2 distinct conditions, each may be difficult to differentiate on CT imaging when occurring in the facial skeleton., Methods: We report a case of an incidental finding on craniofacial CT of a frontal bone lesion originally thought to be FD. The finding was in a 55-year-old transgender woman who was assigned male at birth before receiving multiprocedural facial feminization surgery., Results: The clinical features, radiological findings, and treatment are discussed. Postoperatively, the patient had no sequelae secondary to facial feminization surgery or to the orbital lesion biopsy procedure. Bone graft appeared stable on CT imaging, although FD did not appear to resolve completely., Conclusions: Diagnosis of such lesions is challenging and may require both radiographic and histopathologic assessment. As in the case of this patient, intraosseous xanthomas may also be misdiagnosed as other benign lesions such as FD. In most known cases, surgical intervention leads to complete resolution without recurrence of the lesion., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

A frontoorbitozygomaticomaxillary fracture, also known as a complex midface fracture or "quadripod fracture," is a type of facial fracture involving multiple midface region bones. This includes the frontal bone (forehead), orbitozygomatic complex (which includes the zygomatic bone or cheekbone and the orbital bones around the eye), and the maxillary bone (upper jaw). These complex midface fractures associated with temporoparietal bone fractures can occur in clinical practice. However, a single-piece fracture of these has not been reported before. This study reports a 44-year-old male patient with a significant frontoorbitozygomaticomaxillary fracture associated with a temporoparietal bone fracture combined with epidural hematoma at the superior aspect of unilateral frontoparietotemporal convexity. Surgical treatment was performed 3 weeks after the traumatic event. Despite craniotomy of the parietal bone fragment, the reduction was not possible. The facial bone reduction was finally achieved following an additional single osteotomy at the unilateral zygomaticomaxillary buttress. The follow-up CT scan taken immediately and 3 weeks postoperatively showed successful realignment of craniofacial bone fracture. In conclusion, a single-piece fracture of frontoorbitozygomaticomaxillary bone connected to a temporoparietal bone can require additional osteotomy to achieve successful outcomes in an acute setting., Competing Interests: The authors declare no conflicts of interests., (Copyright © 2023 by Mutaz B. Habal, MD.)

Traditionally forehead bony lesion is approached directly through the forehead skin or invasive coronal incision resulting prominent scar. An endoscopic approach through mini hairline incisions may provide a unique way to achieve the best esthetic results, but often time the authors encounter potential soft tissue injury from the high-speed burr. The authors present a case with multiple frontal bone osteoma lesions which were successfully removed through 2 small hairline incisions with the help of an otorhinolaryngological system and an innovative mini-trocar. Significant improvement in forehead shape with minimal scars was observed at an 18-month follow-up. This innovative and easily manipulating technique may help surgeons achieve better outcomes when treating frontal bone osteoma endoscopically., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Background: Osteomas are the most common primary bone tumors of the calvaria, with an incidence of less than 0.5%. In skull vault osteomas, the exostotic form that grows from the outer table is more common than the enostotic ones which arise from the inner table and grow intracranially. Osteomas of the forehead are very noticeable and disfiguring; patients usually seek medical advice for cosmetic reasons. Forehead osteomas were traditionally excised via either a direct incision over the lesion using the naturally occurring creases or a conventional bicoronal flap. More recently, endoscopic approaches for excision of forehead osteomas were introduced. The results were very encouraging and the technique was adopted by many groups worldwide yet with many technical variations. In this chapter we elaborate on the surgical technique and nuances of the fully endoscopic resection of frontal osteomas., Methods: From a prospective database of endoscopic procedures maintained by the senior author, clinical data, imaging studies, operative charts, and videos of cases of forehead osteomas were retrieved and analyzed. The pertinent literature was also reviewed., Results: The surgical technique of the fully endoscopic resection of frontal osteomas was formulated., Conclusion: The endoscopic technique has many advantages over the conventional procedures. In our hands, the technique has proven to be less time-consuming, efficient, and minimally invasive with excellent cosmetic results., (© 2024. The Author(s), under exclusive license to Springer Nature Switzerland AG.)

Background: Forehead contouring can be a component of facial feminization surgery (FFS). Its complications have been rarely reported on and are often described as "hypothetical." Methods: A case report of complications from forehead contouring resulting in frontal osteomyelitis and sinusitis. Results: A female patient presented with frontal osteomyelitis, sinusitis, and forehead contour deformity after a type III forehead contouring surgery. She had failed prior treatment including oral antibiotics, IV antibiotics, revision sinus surgery, and revision nasal surgery. For definitive treatment, she underwent an anterior table resection, sinus obliteration with bony contouring, and pericranial flap. Conclusions: Forehead contouring represents a recent significant advancement in FFS and gender-affirming therapy. Descriptions of complications and their management are important when novel therapies such as FFS are introduced. This case demonstrates complications from type III forehead contouring including osteomyelitis, frontal sinusitis, and forehead deformity.

Background: The prevalence of trigonocephaly has increased worldwide over the past 2 decades. Early identification and appropriate treatment are critical. The aim of this study is to evaluate the outcomes and the effect of metopic suture excision, perisutural frontal bone shave, and bilateral pericranial flap method on the shape of the forehead after surgical correction in infants with moderate trigonocephaly., Methods: The present study was performed as a cross-sectional study on 40 infants of 3 to 12 months old with trigonocephalus who underwent metopic suture excision and pericardial flap surgery in Mofid Pediatric Hospital from 2016 to 2022. The definitive diagnosis of patients' trigonocephaly was made based on clinical signs and computed tomography scan findings by a plastic surgeon., Results: Overall in 40 patients operated by this technique, 23 (57.5%) of cases were males, and 17 (42.5%) were females. The mean age of patients was 7.86 ± 2.22 months. Hospital stay was 2 to 4 days (mean: 3 d), intensive care unit admission was in 33 cases for 24 hours, and no intensive care unit admission for 7 cases. Blood was transfused during surgery for 25 patients, and 15 patients did not require blood transfusion use. Results were evaluated in 6 to 12 months after surgery by 3 independent plastic surgeons, with pre and postoperative photos. Satisfaction with the results of forehead shape was excellent for 60% of patients, good for 37.5%, and moderate for 2.5%. Only one female patient had a recurrence after the surgery., Conclusion: This study showed that the pericranial flap method after full metopic suture excision and frontal shave was very effective in the treatment of infants with moderate trigonocephaly., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Complications after craniosynostosis surgery occur in 11% to 36% of cases and may be precipitated by poor soft tissue coverage and concomitant exposure of non-sterile regions; sequelae may result in infection, osteomyelitis, and bone loss requiring complex reconstruction. In the pediatric population, autologous cranioplasty remains the gold standard due to growth potential and a more favorable complication profile than synthetic cranioplasty. Virtual surgery planning (VSP) and computer-assisted design (CAD)/computer-assisted manufacturing (CAM) technology can be utilized to create innovative, patient-specific autologous solutions, similar to the approach with synthetic cranioplasty. A novel surgical approach using VSP was used for an 18-month-old female with near total bifrontal bone loss. Surface area measurements were used to determine the amount of bone available to replace the infected frontal bone. VSP was utilized to determine the most efficient construct configuration possible to achieve maximal coverage via calculation of cranial bone surface area measurements. Surgical reconstruction of the defect was planned as a Modified Visor Bone Flap with Posterior Brain Cage. A construct was fashioned from available cranial bone struts to obtain widespread coverage. 3D Recon images from before and after surgery demonstrate almost complete re-ossification of the cranial vault with significant resulting clinical improvement. Reconstruction of total frontal bone loss is possible by utilizing this technique. VSP can improve the safety and efficiency of complex autologous cranial bone reconstructions. We propose a treatment algorithm to address the problem of near total frontal bone loss in young children for whom alloplastic implants are not suitable., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

We present a complementary report of a 38-year-old XY intersex female with frontal mucopyocele developing 5 years after frontal setback for gender-affirming surgery to supplement recent report by Brown et al: Frontal Osteomyelitis and Sinusitis Complication After Type III Frontal Bone Cranioplasty for Facial Feminization by Brown et al.

Background: Frontal sinus anterior wall defects occur because of various diseases, causing not only aesthetic problems, such as forehead bulging and upper eyelid ptosis, but also exerting physical pressure on the brain or optic nerve. Therefore, this study aimed to evaluate the prognosis of performing split-rib bone graft for frontal sinus anterior wall defects., Methods: This study included 30 patients who received a split-rib bone graft for a frontal sinus anterior wall defect. The sizes and volumes of the defects and grafts were measured using three-dimensional computed tomography before, after, and every 6 months for 2 years after the surgery. The Medical Imaging Interaction Toolkit was used for analysis., Results: The average size and volume of the grafts were 27.29 cm 2 and 5.88 cm 3 , whereas they were 23.76 cm 2 and 4.80 cm 3 at 24 months after surgery, respectively. In a graft size and volume of less than 27 cm 2 and 6 cm 3 , respectively, the rate of graft take was greater than 80% during long-term observation. The younger the age, the higher the rate of graft take. No difference was found in the defect causes. Absorption occurred for up to 18 months., Conclusions: Frontal bone defect reconstruction revealed the stable results of the split-rib bone graft over a long period when the size and volume were less than 27 cm 2 and 6 cm 3 , respectively. Furthermore, bone resorption was seen in more than 20% to 30% of the patients, and the rate of resorption increased with age; thus, it is appropriate to consider overcorrection and other reconstruction methods., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Introduction: Growing skull fracture (GSF) is a rare complication of head trauma in the pediatric population, commonly observed in children younger than 3 years., Discussion: In this report, the authors describe a case of a 3-year-old male child, with clinical features of Ehlers-Danlos syndrome (EDS), who developed a GSF in frontal bone after a crib fall, treated with duraplasty and cranioplasty with autologous craft. Here, pertinent literature was reviewed with an emphasis on surgical techniques, and correlation with the mentioned syndrome., Conclusion: This is the first case of GSF in association with EDS in the literature. The relevance of the case described concerns the rarity of the condition itself, the atypical presentation, and the intraoperative findings, which showed the important fragility of the dura mater, probably due to EDS. Therefore, this syndrome, besides having influenced the pathogenesis, was also a challenging factor in the surgical treatment., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

We report a nine-year-old male having malignant peripheral nerve sheath tumor (MPNST) of the frontal bone, represented with a twelve-month history of ptosis and proptosis in his right eye and enlarged rapidly in the last three months. Except for slight numbness at his one-third of the right forehead, he had no neurological deficit. The patient's both eyes were having normal eye movements, and he had no visual acuity or field loss. After surgery, we observed the patient with no recurrence for 4 years., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Forehead osteomas are benign bone tumors. They are frequently associated with exophytic growth in the outer table of the skull, causing cosmetic disfigurement of the face. 1-9 The objective of this study was to present the efficacy and feasibility of the endoscopic treatment of forehead osteomas by presenting a case report with details of the surgical technique. A 40-year-old female patient presented with aesthetic complains of a progressing bulge in the forehead. A computed tomography scan with 3-dimensional reconstruction showed bone lesions on the right side of the forehead. The patient underwent surgery under general anesthesia with no noticeable incision, which was planned 2 cm behind the hairline in the midline because the osteoma was close to the midline plane on the forehead (Video 1). A retractor coupled with a 4-mm channel for endoscopy and a 30-degree optic was used to dissect, elevate the pericranium, and locate the 2 bone lesions in the forehead. The lesions were removed using a chisel, endoscopic facelifting raspatory, and a 3-mm burr drill. The tumors were resected completely, resulting in good cosmetic outcomes. The endoscopic approach for treating forehead osteomas is less invasive and facilitates complete removal of tumors, which results in good cosmetic outcomes. Neurosurgeons should consider and add this feasible approach to enhance their surgical armamentarium., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Orbital schwannoma is an exceptionally rare cause of ptosis. Diagnosis may be elusive given its slow rate of growth and its various presentations depending on localization. Herein, we report the case of a 50-year-old male who presented to our clinic with a complaint of unilateral, recurrent ptosis of the left eye. He underwent levator palpebrae resection, which was unsuccessful at improving his ptosis. He later represented with acute-onset diplopia for which magnetic resonance imaging was obtained. Magnetic resonance imaging showed a lesion in the superior orbit with secondary bony dehiscence of the orbital roof. Through a vertical lid-split incision, the lesion was removed, and the frontal lobe was observed protruding through the defect in the orbital roof. This case highlights the importance of diagnostic skepticism in the face of recurrent ptosis and emphasizes the utility of the vertical lid-split approach for anterior lesions of the superior orbit., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Background: Historically, depressed skull fractures that warranted surgery were treated in 2 stages: the first stage involved debridement and craniectomy, followed by the second stage of delayed cranioplasty. More recently, single-stage autologous cranioplasty has been proven to be safe. However, there is a paucity of literature regarding single-stage titanium mesh cranioplasty when autologous repair is not possible., Methods: A retrospective review identified 22 patients who underwent single-stage titanium mesh cranioplasty for the acute treatment of comminuted depressed skull fractures. Fracture location, fracture etiology, timing of surgery, neurologic complications, infection, and cosmetic deformity were recorded. Average follow-up was 9 months., Results: The mean age of the patients was 34 years (range: 3-77); 83% were male. Seventeen (77%) involved the frontal bone, with 7 (32%) involving the frontal sinus. Eighteen (82%) had open defects at presentation. Sixteen (73%) were neurologically normal. Average time from presentation to repair was 11 hours (range: 1-28 hours). There were no neurologic worsening, seizures, or infections postoperatively. Antibiotic prophylaxis was prescribed in 13 cases (57%). One patient required revision surgery for persistent cosmetic deformity., Conclusions: Autologous cranioplasty for depressed skull fractures is not always possible especially in cases of significant comminution. From our case series, single-stage titanium mesh cranioplasty appears to be a safe option., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Fronto-orbital advancement and remodeling (FOAR) is among the most common surgical approaches for unicoronal craniosynostosis (UCS), although some data demonstrate failure to achieve long-term aesthetic normalcy, leading some to seek alternative treatment paradigms such as fronto-orbital distraction osteogenesis (FODO). This study compares long-term aesthetic outcomes of patients with UCS treated with FOAR and FODO., Methods: Twenty patients (four males) with non-syndromic UCS presenting to our institution and undergoing distraction were compared to a matched cohort of 20 patients (six males) undergoing FOAR. Clinical photographs and ImageJ were used to quantify periorbital anatomy including palpebral fissures, pupil-to-brow distance (PTB), and margin-reflex distance (MRD 1 ) in pixels. Whitaker classification was blindly assigned by craniofacial surgeons., Results: Photogrammetric analysis and Mann-Whitney U tests demonstrated significantly improved postoperative symmetry in distraction patients for palpebral width (p = 0.020), MRD 1 (p = 0.045), and canthal tilt (p = 0.010). Average Whitaker classification scores between FOAR (1.94) and distraction (1.79) cohorts were similar (p = 0.374)., Conclusions: UCS patients demonstrated significant postoperative improvements in periorbital symmetry, with distraction patients demonstrating superior results in palpebral width and canthal tilt. FOAR and FODO patients achieved similar Whitaker classification scores. These cohorts will be followed until craniofacial maturity prior to making any definitive conclusions., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

A 19-year-old woman presented with swelling of the left forehead without pain. She did not have any relevant past or family history. Computed tomography showed destruction of the outer cortex of the frontal bone. A solitary mass lesion with a fluid collection was detected with magnetic resonance imaging. Because the swelling of the left forehead had enlarged rapidly with osteolytic changes, surgical removal of the lesion was performed. The lesion appeared to be enveloped in a fibrous capsule. The soft lesion was removed from the frontal bone. The outer frontal bone was absent, although the inner frontal bone was preserved. Then, the frontal bone was resected with margins from the edge of the erosion. The dura mater under the lesion was intact. A cranioplasty was performed using titanium mesh. On histological examination, the trabecular bones revealed irregular shapes and arrangements, indicating fibrous dysplasia. There was a continuous high-cell-concentration pathological lesion outside the fibrous dysplasia. There were numerous cells, such as mononuclear cells, osteoclast-like multinucleated giant cells, foam cells, and red blood cells. The osteoclast-like multinucleated giant cells and other cells did not show significant nuclear atypia. Immunostaining with H3.3G34W was negative, and the ubiquitin-specific peptidase 6/Tre-2 gene showed no rearrangements. The histopathological diagnosis was secondary aneurysmal bone cyst with fibrous dysplasia. Additional postsurgical therapy was not performed. There has been no evidence of recurrence of the lesion for two years., Competing Interests: The authors declare no conflicts of interest associated with this manuscript.

Fronto-orbital advancement and remodelling (FOAR) has undergone many modifications over the years, aimed at improving outcomes and reducing risks for patients. This work describes 2 techniques for remodelling the neoforehead used by the Oxford Craniofacial Unit since 1995: lateral remodelling and a central S-Osteotomy. Both methods adopt bone from the vertex as a neoforehead, but they differ in their techniques to adapt its shape to that of the newly remodelled orbital bandeau. The novel S-Osteotomy technique can be successfully applied to all FOAR procedures, irrespective of underlying synostosis and calvarial symmetry. It was originally developed for when 2 separate bony panels were required to create a neoforehead in asymmetrical cases, but was adopted for single panel neoforehead designs in metopic synostosis with the idea it may reduce temporal hollowing. An investigation of temporal hollowing in these patients who underwent either of the described methods was undertaken to assess this hypothesis with no statistically significant difference seen ( P =0.1111). Both techniques on average resulted in minimal hollowing that was not felt to require any revision, supporting the belief that temporal hollowing is a multifactorial issue. This work describes 2 successful methods of neoforehead remodelling and introduces the S-Osteotomy technique that can be applied in all FOAR procedures., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

This study aimed to review the surgical outcomes, complications, and long-term relapses in patients with unilateral or bilateral coronal craniosynostosis, who underwent one-piece fronto-orbital distraction osteogenesis (FODO) without bandeau. The cephalic index, frontal angle, and supraorbital symmetry ratio were measured on the initial and follow-up computed tomography images. Esthetic outcomes were evaluated using the Whitaker classification. 45 patients were included in this study. The average follow-up interval was 5.4 ± 1.1 years (range 2.5-8.5 years). In patients with bilateral coronal craniosynostosis, the frontal angle decreased with a relapse ratio of -2.8 ± 4.3% during long-term follow-up compared with that during short-term follow-up (p = 0.028). In patients with unilateral coronal craniosynostosis, the supraorbital symmetry ratio decreased slightly, with a relapse ratio of -3.8 ± 2.6% during long-term follow-up (p = 0.017). Complications included dural tears during osteotomy (n = 2), early distractor removal (n = 2), and wound problems (n = 3). Within the limitations of the study it seems that one-piece fronto-orbital distraction osteogenesis (FODO) generates successful and sustainable results even in the long term. Therefore, this treatment option should be considered for patients with unilateral and bilateral coronal craniosynostoses whenever appropriate., (Copyright © 2023 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Facial feminization surgery can include forehead feminizing cranioplasty (FFC). The reshaped bones are fixated together with titanium plates and screws. Objective: To define the authors' preferred plating patterns and measure complications of bony nonunion when less hardware is applied. Methods: A 7-year retrospective review of patients who underwent FFC was conducted. Data collection included cranioplasty technique, fixation patterns, and complications. Traditional fixation (≥2 screws on each side of the osteotomy) was compared with conservative fixation (<2 screws). Results: A total of 483 patients were identified with a median of 241 days of follow-up (interquartile range: 8-528 days). Most patients (77.8%) had frontal bone fixation with microplates and screws. The most common combination was placement of two plates with four screws in total, comprising two screws on each plate, with one screw on each side of the fracture line (305/483, 63.1%). No signs or symptoms of bone flap mobility were noted on examination. Conclusion: Conservative fixation of the anterior table does not appear to increase signs of nonunion in forehead reshaping gender-affirming surgery.

Background: Outside-in frontal drill out entails drilling the frontal sinus floor in the midline before identifying and dissecting the frontal recesses. It is a more direct approach, especially in revision surgery or cases with challenging anatomy., Objectives: The aim of this study was to highlight the anatomical and surgical concepts for easy and safe outside-in frontal drill out by a preclinical anatomic study on cadaveric heads. In addition, to review our experience with this approach over a 5-year period for challenging frontal sinus pathologies., Methods: The study included 2 sectors; a preclinical study, in which 5 cadaveric heads were dissected and studied to identify and standardize the anatomical landmarks of this approach. This was followed by a clinical case series which included 22 patients with challenging frontal sinus pathologies that were treated with this proposed approach., Results: We concluded from the anatomic study that the nasal spine of the frontal bone (NSFB) and its anatomical orientation in relation to the nasal branch of the anterior ethmoidal artery (NBAEA) is a consistent landmark that enables the surgeon to identify the correct coronal trajectory of drilling to avoid injury of the cribriform and the skull base. The clinical case series included 22 patients that were successfully treated with the proposed approach. No intraoperative nor postoperative complications were reported in this study. Long-term follow-up showed that the frontal neo-ostium was patent in all cases (n  =  22)., Conclusion: Outside-in frontal drill-out is a safe and easy approach; especially in challenging frontal sinus pathologies; using the NSFB and its anatomical coronal orientation to the NBAEA as a consistent landmark, anterior to the skull base. This approach offers early, safe, and direct bone removal without the need for initial identification and dissection of the frontal recess.

Fronto-orbital advancement remains a powerful technique for the correction of anterior cranial vault differences related to metopic (trigonocephaly) or unilateral coronal (anterior plagiocephaly) craniosynostoses. Traditional fronto-orbital advancement requires access to the forehead and superior 2/3 of the orbit via a coronal incision. The frontal bone and orbital segment (bandeau) are then separated from the skull and reshaped. In patients with metopic craniosynostosis, the bandeau and frontal bone will need to be advanced and widened. In patients with unilateral coronal craniosynostosis, the bandeau will need to be "untwisted" to address the supraorbital retrusion on the affected side, the affected orbit will need to be shortened and widened, and the frontal bone flap will need to be proportionately advanced on the affected side. Overcorrection of the affected dimension should be undertaken to account for growth and relapse., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to learn about the morphological characteristics of the supraorbital foramen and to determine its precise position in relation to the surrounding anatomical landmarks in the adult population of Bosnia and Herzegovina., Material and Methods: For this purpose, 60 skulls from the Bosnia and Herzegovina population of known sex (32 males and 28 females), taken from the osteological collection of the Department of Human Anatomy of the Medical Faculty in Sarajevo, were subjected to morphological and morphometric analysis. Morphometric measurements were performed using a digital vernier caliper (Mitutoyo Corporation, Japan)., Results: The study showed that most supraorbital nerves exit the orbit through the supraorbital notch (73.8%) and the rest through the foramen (26.2%). Of this number, bilateral supraorbital notches were recorded in 58.33% of cases, a bilateral supraorbital foramen in 18.34% of cases, while in 23.33% of cases a notch was recorded on one side and a foramen on the contralateral side. Morphometric measurements performed to determine the exact position of the supraorbital foramen relative to the surrounding landmarks showed different values in males and females. An accessory foramen was also observed on the examined skulls in 16.67% of cases., Conclusion: Detailed knowledge of anatomical variations of the supraorbital foramen is required for safe and successful administration of regional anesthesia, in order to avoid iatrogenic nerve injuries during orbitofacial region surgery., (Copyright © 2022 by Academy of Sciences and Arts of Bosnia and Herzegovina.)

Frontofacial surgery, encompassing the monobloc with or without facial bipartition and the box osteotomy, can treat the frontal bone and midface simultaneously, providing comprehensive improvement in facial balance. Complex pediatric patients with genetic syndromes and craniosynostosis are most optimized by an interdisciplinary team of surgeons, pediatricians, geneticists, speech pathologists, audiologists, dietitians, pediatric dentists, orthodontists, and psychosocial support staff to manage the myriad of challenges and complications throughout early childhood and beyond. Despite early treatment of the anterior and posterior cranial vault, these patients frequently have resultant frontal and/or midface hypoplasia and orbital abnormalities that are best managed with simultaneous surgical treatment., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Abstract: Theories for late-developing deformity (LDD) following fronto-orbital reconstructive surgery (FOR) for metopic synostosis (MS) must explain both its delayed onset and its physical characteristics. This study examined whether FOR-related interference with the normal childhood expansion of temporalis is responsible for its soft tissue component.Three-dimensional reformats of preoperative and postoperative computed tomography scans of MS patients were reviewed. Measurements of vertical and horizontal reach of temporalis against those of the underlying skull (to allow for normal skull growth) were compared with normal subjects. The thickness of temporalis and the development of the temporal crests were also assessed.Mean age at FOR was 17.1 months; interval between surgery and first report of LDD 4.7 years; mean age at computed tomography scan for post-FOR LDD patients 8.8 years. There was a significant difference between vertical and horizontal reach of temporalis in pre-FOR MS patients compared to normal subjects ( P < 0.0017 and P < 0.05, respectively). The vertical age-related reach of temporalis in post-FOR patients after allowing for underlying skull growth was significantly reduced ( P = 0.0045) compared to normal subjects but not its horizontal reach ( P = 0.25). Temporal crests in LDD patients were absent or aberrantly formed while muscle thickness was similar to normal subjects at the 2 levels measured.This study supports the theory that failure of the normal childhood expansion of temporalis is responsible for the soft tissue element of LDD, accounting for both its delayed onset and physical characteristics. Aberrant temporal crest development suggests FOR-related damage as the probable cause., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Background: Surgical correction of unicoronal craniosynostosis (UCS) remains a challenging problem. Long-term results are often unsatisfactory secondary to recurrence of the original deformity, requiring secondary operations such as fat grafting or complete revision of the calvarial remodeling. Distraction osteogenesis (DO) has recently emerged as a new modality for treatment of UCS, with promising results and decreased rates of reoperation compared with open cranial vault remodeling. A theoretical benefit of DO is preservation of blood supply to the frontal bone following osteotomy, as the frontal bone can be retained in situ compared with the complete removal and reshaping of the frontal bone during traditional fronto-orbital advancement. Preservation of blood supply to the frontal bone may allow for more robust bony healing and preservation of long-term growth potential; however, the vascularity of the frontal bone flap in DO has not previously been demonstrated. Here, we demonstrate unequivocally that blood supply to the frontal bone is preserved after creation of a rotational bone flap in DO management of UCS., Methods: Frontal bone flap creation via osteotomy for DO treatment of UCS was performed via previously reported technique. Indocyanine green was injected intravenously, and bone perfusion was assessed with a fluorescence imaging system., Results: Four patients underwent three cranial remodeling and three distractor removal procedures. After frontal bone flap creation via osteotomy for DO, perfusion to the osteotomized portion of the frontal bone flap is preserved. Blood flow is seen crossing the midline of the frontal bone. After removal of the distractor, perfusion in the osteoid consolidate is also observed., Conclusions: Preservation of blood supply has not been previously demonstrated empirically in the setting of DO treatment of UCS. We show for the first time that during frontal bone flap creation, blood flow to the osteotomized portion of the frontal bone flap is maintained. Robust blood flow to the osteoid consolidate is also demonstrated. These data support the use of DO in treatment of UCS, as preserved blood supply to the bone is more likely to support improved healing and long-term results., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Congenital meningoencephalocele is a herniation of brain and meninges through a skull base defect. It may result not only in neural defects, sensorimotor deficits, neurological morbidities, visual impairment, impaired nasal function, and a potential risk of intracranial infection. Goals of surgery include removal or repositioning of nonfunctional cerebral tissue, closure of the dura, and reconstruction of skeletal and cutaneous structures., Materials and Methods: The authors present the case of a 4-months-old infant who was found to have a frontoethmoidal encephalomeningocele that was only discovered after birth, the volume increased gradually. After multiple department discussions, the procedures were planned in 2-staged surgical protocol comprising of the first stage urgently performed by neurosurgeon and craniomaxillofacial surgeon, which aimed at removal or repositioning of nonfunctional cerebral tissue, closure of the dura, and reconstruction of skeletal; then second stage was performed by plastic surgeon to correct craniofacial hard and soft tissue deformities., Results and Conclusions: The surgical procedures for frontoethmoidal encephalomeningocele are complicated, particularly for the infant. In order to achieve the final surgical purpose, it needs multiple department cooperation to make the surgical plans., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of Mutaz B. Habal, MD.)

Abstract: Pott puffy tumor (PPT), first described by Sir Percivall Pott in 1760, is a rare clinical entity characterized by a subperiosteal abscess associated with osteomyelitis of the frontal bone caused by direct or hematogenous spread. Although rare in this modern age of antibiotics, this tumor usually occurs as a complication of sinusitis. Moreover, intracranial complications such as subdural abscess, meningitis, sinus thrombosis, or brain abscess can occur concomitantly with the underlying sinusitis, despite the administration of antibiotics. Herein, we present the case of a 48-year-old man who was diagnosed with PPT using computed tomography and treated medically and surgically. The infection remained uncontrollable after surgery and drain removal, owing to the persistence of the original dental focus of the infection. This case highlights the importance of treating the source of the infection in addition to the local area of inflammation, to facilitate complete infection control in PPT., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)