Management of a Large Frontal Encephalocoele With Supraorbital Bar Remodeling and Advancement

Of all the craniofacial abnormalities, facial clefts are the most disfiguring. Facial clefts are classified according to the affected anatomical area as described by Tessier. Through this classification, the location and extent of the cleft can be designated numerically.A 2-month-old male infant was referred to authors' craniofacial unit, from a hospital in a rural province of South Africa, with a problem of a supranasal encephalocoele. Bilateral raised eyebrows were noted as was a right-sided upper lid central third coloboma. Computed tomography and magnetic resonance imaging scans confirmed the presence of a supranasal encephalocoele with a large frontal bone defect and splayed nasal bones. Bilateral enlarged orbits were noted with tented orbital roofs that we classified as Tessier number 10 facial clefts. The child was booked for an encephalocoele excision and calvarial reconstruction at 4 months of age.As a result of the encephalocoele, the supraorbital bar with its adjacent nasal bones was cleaved in 2, resulting in a significant frontal bone defect. Osteotomies were performed to remove the supraorbital bar and nasal bones from the calvarium. The supraorbital bar segment was remodeled and plated with absorbable poly-L-lactic acid plates. Osteotomies of the nasal bones allowed them to be united centrally, also with absorbable plates. This entire construct was transferred and secured to the calvarium, but in a more caudal position thereby obliterating the frontal bone and Tessier number 10 facial cleft defects with a naturally contoured construct.