Craniofacial surgery is a surgical subspecialty that deals with congenital and acquired deformities of the head, skull, face, neck, jaws and associated structures. Although craniofacial treatment often involves manipulation of bone, craniofacial surgery is not tissue-specific; craniofacial surgeons deal with bone, skin, nerve, muscle, teeth, and other related anatomy. [1] [2]
Defects typically treated by craniofacial surgeons include craniosynostosis (isolated and syndromic), rare craniofacial clefts, acute and chronic sequelae of facial fractures, cleft lip and palate, micrognathia, Treacher Collins Syndrome, Apert's Syndrome, Crouzon's Syndrome, Craniofacial microsomia, microtia and other congenital ear anomalies, and many others. Training in craniofacial surgery requires completion of a Craniofacial surgery fellowship. Such fellowships are available to individuals who have completed residency in oral and maxillofacial surgery, plastic and reconstructive surgery, or ear, nose, and throat surgery. Those who have completed residency in oral and maxillofacial surgery may be either single degree or dual-degree surgeons with no differences. There is no specific board for craniofacial surgery. In the US, cleft and craniofacial centers are found in many major academic centers.
The bones of the human skull are joined by cranial sutures (see figure 1). The anterior fontanelle is where the metopic, sagittal and coronal sutures meet. Normally the sutures gradually fuse within the first few years after birth. In infants where one or more of the sutures fuses too early the growth of the skull is restricted, resulting in compensation mechanisms which cause irregular growth patterns. Growth in the skull is perpendicular to the sutures. When a suture fuses too early, the growth perpendicular to that suture will be restricted, and the bone growth near the other sutures will be stimulated, causing an abnormal head shape. The expanding brain is the main stimulus for the rapid growth of the skull in the first years of life. Inhibited growth potential of the skull can restrict the volume, needed by the brain. In cases in which the compensation does not effectively provide enough space for the growing brain, craniosynostosis results in increased intracranial pressure. [3]
Craniosynostosis is called simple when one suture is involved, and complex when two or more sutures are involved. It can occur as part of a syndrome or as an isolated defect (nonsyndromic). [4]
In scaphocephaly the sagittal suture is prematurely fused. The sagittal suture runs from the front to the back of the head. The shape of this deformity is a long narrow head, formed like a boat (Greek skaphe, "light boat or skiff"). The compensatory head-growth forward at the coronal suture gives a prominent forehead, frontal bossing and a prominent back of the head, called coning. [5] The incidence of scaphocephaly is 2.8 per 10 000 births in the Netherlands and is therefore the most common form of craniosynostosis. [6] [7]
In trigonocephaly the metopic suture is prematurely fused. The metopic suture is situated in the medial line of the forehead. Premature fusion of this suture causes the forehead to become pointed, giving the head a triangular shape when viewed from above (Greek trigono, "triangle"). The incidence of trigonocephaly is 1 - 1.9 per 10 000 births in the Netherlands. [6]
In plagiocephaly one of the coronal sutures is prematurely fused. The coronal sutures run over the top of the head, just in front of the ears. The shape of this deformity is an asymmetrical distortion (flattening of one side of the head) as you can see in figure 2. The incidence is 1 in 10 000 births. [6] [8]
In brachycephaly both of the coronal sutures are prematurely fused. The shape of this deformity is a wide and high head. The incidence at birth is 1/20 000. [9]
Craniofacial surgery and follow-up care are usually conducted by a multidisclinary team of doctors, surgeons, nurses, and various therapists. [10] As of 2016, there is a new multidisciplinary care team of Neuroplastic Surgeons working with Neurosurgeons to prevent and/or correct neurosurgical-related deformities and to maximize outcomes in adult patients.
In cases where the forehead is involved (trigonocephaly and plagiocephaly), a technique called fronto-supraorbital advancement is used to correct the shape of the head. The procedure is performed at a young age in order to provide the brain with enough space to grow and prevent further abnormal growth of the skull. Fronto-orbital advancement literally means moving the front of the skull including the eye sockets forward. A section of the skull, ranging from the coronal sutures to the eye sockets is cut loose in order to correct the shape of the skull. The incision is cut in a zigzag shape from ear to ear so that the hair will cover the scar and make it less visible. The incision is made to the bone only, leaving the underlying meninges intact. The top half of the eye sockets is cut loose. Once the eye socket section has been cut loose, a vertical incision is made in the midline, and the whole section of the eye socket is bent outwards in order to correct the pointed shape of the forehead. Because the section is now too wide, a wedge needs to be cut on either side to allow the section to fit into the skull. Figure 4 shows the sections that are loosened and adjusted, and Figure 3 shows the location of the vertical incision (arrow A) and the two wedges (arrow B).[ citation needed ]
In scaphocephaly, the sagittal suture is prematurely fused, preventing the skull from growing perpendicular to the suture. Thus, the head becomes very narrow and long. If a scaphocephaly is diagnosed within 4 to 5 months after birth, it can be corrected with a relatively simple procedure whereby the sagittal suture is surgically reopened. Once the suture has been opened the bone segments will be able to grow again, and the head can regain its normal shape. This operation is only performed on patients younger than five months old with a scaphocephaly. This is due to the fact that the bone segments only have the ability to adapt so severely when the operation is performed at this young age. A scaphocephaly that is diagnosed and treated later in life requires a more extensive secondary operation than one that is treated before five months.[ citation needed ]
A major focus in craniosynostosis reconstruction is maintaining normalized aesthetics of temporal region, and avoiding temporal hollowing. Despite using overcorrection methods, autologous fat transfer, and bone grafts to prevent temporal hollowing, up to 50% of patients still experience post-operative depression in the temporal fossa.
Cranioplasty, or skull reconstruction, is the main concentration of a new field for adult neurosurgical patients known as Neuroplastic Surgery. There are now several centers around the world, including the United States and Israel. The first center of Neuroplastic Surgery was started at Johns Hopkins by Dr. Chad Gordon and the Department of Neurosurgery, which is where this new craniofacial subspecialty was born (c. 2016). [11]
Some of the surgical complications in craniofacial surgery may include Death, Shock, Haemorrhage, visual loss, Intracranial collection of air/fluid, Epileptic seizures, Unexpected respiratory complications, etc. [12]
Say–Meyer syndrome is a rare X-linked genetic disorder that is mostly characterized as developmental delay. It is one of the rare causes of short stature. It is closely related with trigonocephaly. People with Say–Meyer syndrome have impaired growth, deficits in motor skills development and mental state.
Brachycephaly is the shape of a skull shorter than average in its species. It is perceived as a cosmetically desirable trait in some domesticated dog and cat breeds, notably the pug and Persian, and can be normal or abnormal in other animal species.
Plagiocephaly, also known as flat head syndrome, is a condition characterized by an asymmetrical distortion of the skull. A mild and widespread form is characterized by a flat spot on the back or one side of the head caused by remaining in a supine position for prolonged periods.
Scaphocephaly, or sagittal craniosynostosis, is a type of cephalic disorder which occurs when there is a premature fusion of the sagittal suture. Premature closure results in limited lateral expansion of the skull resulting in a characteristic long, narrow head. The skull base is typically spared.
Trigonocephaly is a congenital condition due to premature fusion of the metopic suture, leading to a triangular forehead. The premature merging of the two frontal bones leads to transverse growth restriction and parallel growth expansion. It may occur as one component of a syndrome together with other abnormalities, or in isolated form. The term is from the Greek trigonon, "triangle", and kephale, "head".
Crouzon syndrome is an autosomal dominant genetic disorder known as a branchial arch syndrome. Specifically, this syndrome affects the first branchial arch, which is the precursor of the maxilla and mandible. Since the branchial arches are important developmental features in a growing embryo, disturbances in their development create lasting and widespread effects.
Apert syndrome is a form of acrocephalosyndactyly, a congenital disorder characterized by malformations of the skull, face, hands and feet. It is classified as a branchial arch syndrome, affecting the first branchial arch, the precursor of the maxilla and mandible. Disturbances in the development of the branchial arches in fetal development create lasting and widespread effects.
Craniosynostosis is a condition in which one or more of the fibrous sutures in a young infant's skull prematurely fuses by turning into bone (ossification), thereby changing the growth pattern of the skull. Because the skull cannot expand perpendicular to the fused suture, it compensates by growing more in the direction parallel to the closed sutures. Sometimes the resulting growth pattern provides the necessary space for the growing brain, but results in an abnormal head shape and abnormal facial features. In cases in which the compensation does not effectively provide enough space for the growing brain, craniosynostosis results in increased intracranial pressure leading possibly to visual impairment, sleeping impairment, eating difficulties, or an impairment of mental development combined with a significant reduction in IQ.
Saethre–Chotzen syndrome (SCS), also known as acrocephalosyndactyly type III, is a rare congenital disorder associated with craniosynostosis. This affects the shape of the head and face, resulting in a cone-shaped head and an asymmetrical face. Individuals with SCS also have droopy eyelids (ptosis), widely spaced eyes (hypertelorism), and minor abnormalities of the hands and feet (syndactyly). Individuals with more severe cases of SCS may have mild to moderate intellectual or learning disabilities. Depending on the level of severity, some individuals with SCS may require some form of medical or surgical intervention. Most individuals with SCS live fairly normal lives, regardless of whether medical treatment is needed or not.
Carpenter syndrome, also called acrocephalopolysyndactyly type II, is an extremely rare autosomal recessive congenital disorder characterized by craniofacial malformations, obesity, syndactyly, and polydactyly. Acrocephalopolysyndactyly is a variation of acrocephalosyndactyly that presents with polydactyly.
The frontal suture is a fibrous joint that divides the two halves of the frontal bone of the skull in infants and children. Typically, it completely fuses between three and nine months of age, with the two halves of the frontal bone being fused together. It is also called the metopic suture, although this term may also refer specifically to a persistent frontal suture.
The sagittal suture, also known as the interparietal suture and the sutura interparietalis, is a dense, fibrous connective tissue joint between the two parietal bones of the skull. The term is derived from the Latin word sagitta, meaning arrow.
The coronal suture is a dense, fibrous connective tissue joint that separates the two parietal bones from the frontal bone of the skull.
Synostosis is fusion of two or more bones. It can be normal in puberty, fusion of the epiphyseal plate to become the epiphyseal line, or abnormal. When synostosis is abnormal it is a type of dysostosis. Examples of synostoses include:
Muenke syndrome, also known as FGFR3-related craniosynostosis, is a human specific condition characterized by the premature closure of certain bones of the skull during development, which affects the shape of the head and face. First described by Maximilian Muenke, the syndrome occurs in about 1 in 30,000 newborns. This condition accounts for an estimated 8 percent of all cases of craniosynostosis.
Pediatric plastic surgery is plastic surgery performed on children. Its procedures are most often conducted for reconstructive or cosmetic purposes. In children, this line is often blurred, as many congenital deformities impair physical function as well as aesthetics.
McGillivray syndrome is a rare syndrome characterized mainly by heart defects, skull and facial abnormalities and ambiguous genitalia. The symptoms of this syndrome are ventricular septal defect, patent ductus arteriosus, small jaw, undescended testes, and webbed fingers. Beside to these symptoms there are more symptoms which is related with bone structure and misshape.
Metopism is the condition of having a persistent metopic suture, or persistence of the frontal metopic suture in the adult human skull. Metopism is the opposite of craniosynostosis. The main factor of the metopic suture is to increase the volume of the anterior cranial fossa. The frontal bone includes the forehead, and the roofs of the orbits of the eyes. The frontal bone has vertical portion (squama) and horizontal portion. Some adults have a metopic or frontal suture in the vertical portion. In uterine period in right and left half of frontal region of the fetus there is a membrane tissue. On each half a primary ossification center appears about the end of the second month of the fetus. Primary ossification center extends to form the corresponding half of the vertical part (squama) and horizontal part of the frontal bone.
Craniosynostosis and dental anomalies is an autosomal recessive syndrome characterized by craniosynostosis, maxillary hypoplasia, and dental anomalies. Dental anomalies seen in this condition include malocclusion, delayed and ectopic tooth eruption, and/or supernumerary teeth. Syndactyly, clinodactyly, and other digit anomalies may also be present.
Leptocephaly is a rare form of complex craniosynostosis in which the sagittal and metopic suture simultaneously close. Leptocephaly is characterized by equal narrowing of the head and a tall and narrow head shape. Leptocephaly is usually nonsyndromic, but has been seen in individual cases such as Neu-Laxova syndrome.
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