See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/276341401

Fronto-orbital advancement: Revisited

Article in Journal of Cleft Lip Palate and Craniofacial Anomalies · January 2015
DOI: 10.4103/2348-2125.150739

CITATIONS READS

7 449

3 authors, including:

Derick A Mendonca
Al Jalila Children's Specialty Hospital
40 PUBLICATIONS 685 CITATIONS

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Endoscopic versus open cranial surgery for anterior craniosynostosis: Experience from South East Asia View project

All content following this page was uploaded by Derick A Mendonca on 16 April 2020.

The user has requested enhancement of the downloaded file.

Volume 2 / Issue 1 / January-June 2015
Volume 2 Issue 1 January-June 2015 Pages 1-***

Original Article
Fronto-orbital advancement: Revisited
Derick Mendonca, Somashekar Gejje, Nitin Kaladagi
ABSTRACT
Introduction: Craniosynostosis is a pathologic
condition resulting from the premature fusion of cranial
vault sutures, resulting in craniofacial deformities.
Anterior craniosynostosis can involve a combination
of metopic/unicoronal or bicoronal sutures. Aims and
Objectives: Fronto-orbital advancement (FOA) is the
standard surgical treatment. This article attempts to
highlight the importance of modifying the osteotomies
and reshaping of the cranial vault based on individual
requirements to achieve the best possible result.
Method and Results: Three consecutive cases of
anterior craniosynostosis (metopic with unicoronal,
unicoronal with sphenoethmoidal, bicoronal) with
individual modifications of the technique used in each
case are presented. Conclusion: FOA has to be
tailored for each variant of anterior craniosynostosis
and its requirements. The Technical variations can be
applied to any combination of anterior craniosynostosis.
Key words: Calvarial vault reconstruction,
craniosynostosis, fronto-orbital advancement
INTRODUCTION
Craniosynostosis is defined as the premature fusion of
one or more cranial sutures, resulting in predictable
changes in the shape of the cranial vault. Any cranial
suture can ossify prematurely, but fusion is most common
in the sagittal suture (40-55%), followed by the coronal
(20-25%), metopic (5-15%), and lambdoid (1-5%) sutures.
[1]
According to Indian data, coronal synostosis was the
commonest variety among the nonsyndromic patients,
followed by metopic synostosis.[2]
Premature closure of the metopic suture results in a
“keel” shaped deformity, termed trigonocephaly, and
Department of Plastic Surgery, Sakra World Hospital,
Bangalore, India
Address for correspondence:
Dr. Derick A. Mendonca, FRCS (Plast),
Consultant Craniofacial Plastic Surgeon, Sakra World Hospital,
Bangalore, 560 103, India.
E-mail: derickmen@yahoo.com
20 January-June 2015 / Vol 2 / Issue 1
Access this article online
Website:
www.jclpca.org
DOI:
10.4103/2348-2125.150739
Quick Response Code:
includes hypotelorism, strabismus with upslanting
palpebral fissures. Premature fusion of one of the
coronal sutures results in frontal plagiocephaly (A Greek
term meaning oblique skull). The “harlequin” orbit seen
on anterior-posterior radiographs is pathognomonic
for unilateral coronal synostosis and is secondary to
the lack of descent of the greater wing of the sphenoid
during development. Compensatory bulge in the
ipsilateral squamous portion of the temporal bone,
contralateral frontal and parietal bones is seen.
Coronal ring[3] is formed due to articulations between
the human frontal, sphenoid, and ethmoid bones.
This sutural component of the ring is C-shaped with
a cartilaginous bridge between the optic foramina
completing the ring. The extent of synostosis along the
coronal sutural ring contributes to the dysmorphology of
the orbit and the endocranial base deflection in patients
whose clinical phenotypic diagnosis is unilateral
coronal synostosis.[4]
Anterior craniosynostosis includes metopic, uni-coronal
and bi-coronal suture involvement. The standard
surgical treatment is a fronto-orbital advancement
(FOA).
Fronto-orbital advancement
The surgical goals of FOA are threefold:
a. To release the synostosed suture and decompress
the cranial vault,
b. To reshape the cranial vault and advance the frontal
bone, and
c. To advance the retruded supraorbital bar, providing
improved globe protection and an improved
aesthetic appearance.
The objective of this paper is to demonstrate that no two
FOA are the same. The deformity has to be carefully
analyzed along with accurate preoperative planning,
to devise relevant osteotomies and bone contouring in
order to obtain the desired result. Three cases of anterior
Journal of Cleft Lip Palate and Craniofacial Anomalies
 Mendonca, et al.: Fronto-orbital advancement
craniosynostoses are described with modifications in
the surgical technique of FOA shown.
Standard surgical technique
Thorough preoperative evaluation should be done
by the pediatric anesthetist, with blood available for
a blood transfusion. Close communication with the
anesthetist is vital to the safety of the procedure.
The patient is positioned supine on a Mayfield head
rest with head up at 20-30°. A bicoronal incision is
made in a zig-zag manner for better scar outcome.
Water tight draping is done with separation of the nasal
areas and a collection drape to measure blood loss.
Local anesthetic with adrenaline is infiltrated prior
to the incision to reduce blood loss, and meticulous
hemostasis is obtained as the flaps are raised, and bone
exposed. Extensive subperiosteal dissection is done to
expose the entire frontal bone, down to the naso-frontal
junction, lateral orbital wall beyond the Zygomatico-
frontal (Z-F) suture and squamous temporal bones. A
supra-orbital foramen osteotomy may be necessary
to allow the bicoronal flap to reflect downward. The
osteotomy lines are marked as shown in Figure 1. Note
the bifrontal craniotomy supra orbital bandeau with
a tongue in groove extension and barrel staves on the
parietal segments. The bifrontal craniotomy is done by
a neurosurgeon and care is taken to avoid dural injury.
This is followed by the fronto-orbital bandeau segment,
which is carefully osteotomized and removed. Back
table contouring, reshaping and cutting is done with
a combination of Tessier bone benders, saw drills, and
the bones held in place by resorbable plating system
[Figure 2]. The senior author’s preference is to use the
Stryker Delta resorbable plating system (Kalamazoo,
Michigan).
Figure 1: Intraoperative osteotomy markings for bifrontal craniotomy and
supraorbital bandeau
Journal of Cleft Lip Palate and Craniofacial Anomalies
The recontoured fronto-orbital bandeau is replaced
in an advanced/tilted position, at least 1-1.5 cm
anterior to the frontal lobe [Figure 3]. A combination
of advancement and tilt is used to obtain the desired
result. The bandeau is secured laterally with rigid
resorbable plates. The reshaped frontal component
is then placed on top of the advanced bandeau and
secured rigidly [Figure 4]. The entire calvarial vault
is barrel staved and opened like a box. It is the senior
author’s preference to cover all large gaps with
Osteomesh scaffold. Long-term studies would need
to be done to demonstrate osteogenesis secondary to
the scaffold.
Meticulous skin closure is done in two layers with a
suction drain. Postoperative monitoring is done in the
pediatric intensive care under the close supervision of
an intensivist.
MATERIALS AND METHODS
Three consecutive children diagnosed with anterior
craniosynostosis were studied. Each case is individually
described to highlight technical variations in FOA. The
age of these patients ranged from 11 to 14 months. Out
of the three cases, one was a male child. The distribution
of synostoses was:
a. Metopic with left unicoronal synostosis,
b. Bicoronal synostosis and
c. M e t o p i c w i t h r i g h t u n i c o r o n a l a n d l e f t
sphenoethmoidal synostosis.
The mean age at surgery was 12.34 months. The mean
advancement obtained at the level of the frontal lobe was
1.5 cm and the mean increase in head circumference
was 3.17 cm. There were no postoperative complications
except for one patient who developed a cerebrospinal
Figure 2: Intraoperative bone segments after osteotomies, contouring
and fixation
January-June 2015 / Vol 2 / Issue 1 21
 Mendonca, et al.: Fronto-orbital advancement
fluid (CSF) leak, which settled with conservative
management.
RESULTS
Individual cases are described to highlight the technical
variations in the standard FOA to suit individual
anterior craniosynostosis.
Case 1
Baby “A” is a 14-month-old male who presented with a
craniofacial deformity along with delayed milestones
[Figures 5 and 6]. Computed tomography (CT) scan
confirmed a metopic and left unicoronal synostosis, along
with signs of raised intra-cranial pressure (punched out
appearance). Preoperative head circumference placed
the child along the 20th percentile. A FOA was done with
a tilt technique and bone graft placed in the midline, in
order to expand the bandeau. Bone graft and Osteomesh
Figure 3: Supraorbital bandeau placed in the advanced position (1.5 cm
advancement). Note the increased calvarial space following parietal barrel
staving
Figure 5: Preoperative appearance of baby A showing metopic and left
unicoronal synostosis. Note harlequin deformity on the left side (arrow)
22 January-June 2015 / Vol 2 / Issue 1
scaffold (Osteogenics Biomedicals, Lubbock, Texas) was
created as an onlay on the left supraorbit to provide
supra-orbit projection. Frontal bone was osteotomized
in the midline and closed wedge osteotomies done to
open up the convexity. Midfrontal segments were bent
with Tessier bone benders. Barrel staving was done on
the restricted parietal bones to create a round shape
skull. An advancement of 1.5 cm was obtained on
the bandeau. Postoperatively, a smooth symmetrical
head, normal looking forehead and supra orbit is seen
with no harlequin sign and a normal brow position
[Figures 7 and 8]. Head circumference was increased
by 2 cm and no complications were seen.
Case 2
Baby “B” is an 11 months female presenting with
a flat forehead and an obvious brachycephaly
deformity [Figure 9]. Head circumference was placed
at the 2 nd percentile. Gross milestones were normal,
Figure 4: Final intra operative appearance of supraorbital bandeau and
frontal bone before skin closure. Note the bilateral onlay bone grafts with
Osteomesh scaffold
Figure 6: Preoperative appearance of baby A showing the asymmetric head
shape with flattening of left forehead (arrow)
Journal of Cleft Lip Palate and Craniofacial Anomalies
 Mendonca, et al.: Fronto-orbital advancement
but baby was extremely irritable. CT confirmed
a bicoronal synostosis with signs of raised intra
cranial pressure [Figures 10 and 11]. FOA with a
tilt technique was done. No midline bone graft was
placed as the width of the bandeau was deemed
adequate. Extensive onlay bone grafts were done
bilaterally with bone and Osteomesh scaffolds to
create adequate supraorbit projection. Frontal piece
was split in the midline bilaterally and opened like
a fan. Midfrontal segments bent with Tessier bone
benders to create midfrontal bulge and convexity. The
bandeau was advanced by 1 cm. Bones were secured
with delta resorbable plates. Parietal segments
were barrel staved bilaterally and outfractured to
create round head shape. Postoperative views show
adequate supra orbit projection and smooth forehead
[Figure 12]. Postoperative head circumference
increased by 4.5 cm, and no postoperative
complications were seen [Figure 13].
Figure 7: Postoperative appearance of baby A demonstrating a smooth
symmetrical forehead with a complete absence of the harlequin deformity
Figure 9: Preoperative appearance of baby B showing evidence of bicoronal
synostosis. Note the flat retruded forehead with brachycephaly
Journal of Cleft Lip Palate and Craniofacial Anomalies
Case 3
Baby “C” is a 12-month-old female presenting with
bilateral proptosis and a craniofacial deformity with
bulging anterior fontanelle. Gross milestones were
normal, but head deformity was grossly abnormal. CT
scan showed a partial metopic, right coronal and left
sphenoethmoidal synostosis, with raised intra cranial
pressure signs [Figure 14]. No evidence of obstructive
hydrocephalus was seen. Head circumference placed
the child at the 50th percentile. Genetic testing was not
done. FOA was done along with a midline bone graft
to widen the bandeau. Supra orbit advancement of 1.5
cm was obtained and secured with plates. Midfrontal
bending was done with Tessier bone benders, split
in the midline and secured. The large fontanelle was
closed with Osteomesh scaffold. Barrel staving was
done extensively to open up the cranium and create
a round head with increased space. Closed wedge
osteotomies were done (bilateral) on the sphenoid
Figure 8: Postoperative appearance of baby A showing complete correction
of head shape and well-rounded calvarium
Figure 10: Preoperative three-dimensional computed tomography of baby
B showing the brachycephaly deformity with imprinting on endocortical
surface
January-June 2015 / Vol 2 / Issue 1 23
 Mendonca, et al.: Fronto-orbital advancement

ridges along endocortical surface of the frontal bandeau. the CT with head circumference increased by 3 cm
Postoperatively excellent advancement is seen on [Figures 15 and 16]. Intra operatively a dural tear was

Figure 11: Preoperative lateral view of three-dimensional computed Figure 12: Postoperative appearance of baby B showing complete
tomography demonstrating bicoronal synostosis correction of the forehead and brow deformity. Note the smooth well
rounded forehead with normal brow aesthetics

Figure 13: Postoperative three-dimensional computed tomography frontal

Figure 14: Preoperative lateral three-dimensional computed tomography of
view showing frontal osteotomies, supraorbital bandeau and onlay bone
baby C showing copper beaten appearance (raised intracranial pressure)
grafts
and right coronal synostosis

Figure 15: Postoperative three-dimensional computed tomography of Figure 16: Postoperative three-dimensional computed tomography of
baby C showing advanced supraorbital bandeau and frontal bone. Note baby C showing advanced supraorbital bandeau and frontal bone. Note
the increased calvarial space and advancement (1.5 cm) the increased calvarial space and advancement

24 January-June 2015 / Vol 2 / Issue 1 Journal of Cleft Lip Palate and Craniofacial Anomalies
 Mendonca, et al.: Fronto-orbital advancement
seen with CSF leakage. This settled with conservative
management.
DISCUSSION
The FOA is the standard procedure for the correction
of anterior craniosynostosis. Although the technique
is well established since Tessier introduced the FOA
as the key procedure to correct forehead dysplasia,[5]
technical variations exist. The authors wish to
highlight the importance of tailoring the osteotomies
and contouring to fit individual patient needs. The
main goals of surgery are to advance the superolateral
orbit, expand the temporal dimensions, and round the
forehead. Evolution and modification of this original
technique has been reported with excellent results.[6] In
spite of technical modifications, hollowing and contour
irregularities are seen, requiring revision surgery.[7] An
effective strategy to minimize secondary procedures
is to over-expand and overcorrect the superolateral
dimensions. An ideal technique achieves both near
anatomical correction and overcorrected dimensions
to account for future growth impairment.[8]
Long term follow up has shown traditional expansion
techniques tending to revert back to the original
deformity.[7] This is due to diminished intrinsic growth,
inadequate surgical expansion, and devascularization
of segments at the time of advancement or some
combination.[9] Vascular preservation of the fronto-
orbital bar preserves long-term growth potential, and
this aspect has to be borne in mind while contouring.[10]
A strategy suggested is to maintain a vascularized
pedicle to the advanced bandeau while “tilting” the
segment forward.[6]
The fronto-orbital bandeau is typically positioned
about 12-13 mm anterior to the cornea. An 8-15-mm
magnitude of bandeau advancement is usually required
on the affected side. Simultaneous to repositioning the
orbital rim, the ipsilateral forehead is advanced, the
orbital height may be reduced, and the contralateral
forehead is recessed or contoured as necessary. A
canthopexy may be performed to resuspend the canthus
following dissection. Some advocate including the
nasal bones in continuity with the frontal bar and
uprighting the nasal radix deviation by closing wedge
osteotomy. Others feel the nasal root deviance corrects
by adolescence with the lack of continued “pull” toward
the fused suture.[11]
In bicoronal synostosis, correcting bilateral forehead and
supraorbital rim width and retrusion (brachycephaly)
Journal of Cleft Lip Palate and Craniofacial Anomalies
is necessary to normalize fronto-facial balance and to
afford orbital protection. Current techniques involve
a bifrontal craniotomy and creation of a bilateral
frontal bandeau with a plan to advance liberally. Note
the technical variation of placing onlay bone grafts
to improve projection. The anterior dimension is
advanced, creating greater forehead prominence. Bone
benders are used to create the midfrontal bulge in the
frontal segments. In bicoronal synostosis, the height of
the skull may also be increased (turribrachycephaly).
This can be addressed by barrel staves and greenstick
fracture of the posterior parietal bones or occipital
plates.
Metopic synostosis correction involves anterior cranial
vault expansion, thereby alleviating the bitemporal
constriction and triangular head appearance.[12] The
intent is to round the forehead shape and also to
improve hypotelorism. An endoscopic strip craniectomy
procedure has been reported.[13] This technique may
have some utility in young infants, but it is not effective
in all patients and not appropriate for older infants
more than 6 months age. Several more comprehensive
techniques have been described in an attempt to correct
the morphologic sequelae seen in metopic synostosis.[14]
The current strategy entails splitting the fronto-orbital
bar in the midline and interposing a bone segment
to increase the bitemporal and inter-orbital distance.
The new construct exhibits a more obtuse endocranial
angle, witnessed by advancement and expansion of
the lateral rims and temporal region. The sphenoid
wings are burred to create more space, and the lateral
orbit bent inward to create a lateral orbit curvature.
This bandeau is then held in place by sutures at the
Z-F region and temporally with resorbable plates. An
intervening bone graft is often utilized at the temporal
gap created from the advancement of the fronto-orbital
construct to prevent relapse. The frontal segments are
split in the midline and opened up as described in the
three cases. Occasionally the frontal segments would
need to be completely contoured like a cone to create
the midfrontal bulge. The goal is to overcorrect the
hypoplastic bone segments, especially the temporal and
lateral orbital regions, which are most prone to regress
toward the original deformity (secondary to impaired
growth potential).
Bone gaps can be covered with alloplastic materials
such as acrylic implants or with Osteomesh scaffold, as
in the cases described. Long-term studies would need
to show the formation of new bone in the gaps covered
by Osteomesh.
January-June 2015 / Vol 2 / Issue 1 25
 Mendonca, et al.: Fronto-orbital advancement
A modification of the fronto-orbital bandeau advancement
is the tilt-procedure (TP) where osteotomy line is similar
to that of the above-mentioned technique, excluding
the fronto-zygomatic process. Furthermore, as a key
manoeuvre, the superolateral aspect of the supraorbital
rim is greensticked anteriorly maintaining the attachments
within the frontonasal and frontozygomatic suture,
allowing this segment to pivot without compromising
medial and lateral attachments. The superior and inferior
latero-orbital blood supply is maintained with periosteal
preservation and connections of the deep vessels. The
preserved vascularization of this fronto-orbital segment
may play a pivotal role in frontal sinus development and
function.[15] Cases 1 and 2 had a variation of the TP, with
a view to maintain long-term growth. Case 3 needed a
more radical advancement to correct orbital proptosis,
and hence the tilt technique was not done. Fronto-
orbital surgery has to be tailored to address individual
morphological variations in anterior craniosynostosis.
However, a balance has to be struck by obtaining
adequate intra-operative correction and maintaining
long term growth.
CONCLUSION
Technical variations in the technique of FOA for various
forms of anterior craniosynostosis are described.
Accurate preoperative planning of the deformity aids
in complete successful correction of the entire cranial
vault and restoration of forehead aesthetics.
REFERENCES
1. Rogers GF, Warren SM. Single suture craniosynostosis and
deformational plagiocephaly. In: Thorne CH, editor. Grabb and
Smith’s Plastic Surgery. 7th ed. Philadelphia: Lippincot William &
Wilkins; 2013. p. 221.
26 January-June 2015 / Vol 2 / Issue 1
View publication stats
2. Sharma RK. Craniofacial surgery in India. J Craniofac Surg
2014;25:5.
3. Burdi AR, Kusnetz AB, Venes JL, Gebarski SS. The natural history and
pathogenesis of the cranial coronal ring articulations: Implications
in understanding the pathogenesis of the Crouzon craniostenotic
defects. Cleft Palate J 1986;23:28-39.
4. Dundulis JA, Becker DB, Govier DP, Marsh JL, Kane AA. Coronal
ring involvement in patients treated for unilateral coronal
craniosynostosis. Plast Reconstr Surg 2004;114:1695-703.
5. Tessier P. Total facial osteotomy. Crouzon’s syndrome, Apert’s
syndrome: Oxycephaly, scaphocephaly, turricephaly. Ann Chir
Plast 1967;12:273-86.
6. Hoffman HJ, Mohr G. Lateral canthal advancement of the
supraorbital margin. A new corrective technique in the treatment
of coronal synostosis. J Neurosurg 1976;45:376-81.
7. Cohen SR, Kawamoto HK Jr, Burstein F, Peacock WJ. Advancement-
onlay: An improved technique of fronto-orbital remodeling in
craniosynostosis. Childs Nerv Syst 1991;7:264-71.
8. Fearon JA. Beyond the bandeau: 4 variations on fronto-orbital
advancements. J Craniofac Surg 2008;19:1180-2.
9. McCarthy JG, Karp NS, LaTrenta GS, Thorne CH. The effect of
early fronto-orbital advancement on frontal sinus development and
forehead aesthetics. Plast Reconstr Surg 1990;86:1078-84.
10. Cohen SR. Vascularized fronto-orbital advancement. J Craniofac
Surg 1996;7:228.
11. Anderson PJ, David DJ. Late results after unicoronal craniosynostosis
correction. J Craniofac Surg 2005;16:37-44.
12. Williams JK, Ellenbogen RG, Gruss JS. State of the art in craniofacial
surgery: Nonsyndromic craniosynostosis. Cleft Palate Craniofac J
1999;36:471-85.
13. Jimenez DF, Barone CM. Early treatment of anterior calvarial
craniosynostosis using endoscopic-assisted minimally invasive
techniques. Childs Nerv Syst 2007;23:1411-9.
14. Marchac D, Renier D, Jones BM. Experience with the “floating
forehead”. Br J Plast Surg 1988;41:1-15.
15. Patel A, Chang CC, Terner JS, Tuggle CT, Persing JA. Improved
correction of supraorbital rim deformity in craniosynostosis by the
“tilt” procedure. J Craniofac Surg 2012;23:370-3.
Cite this article as: Mendonca D, Gejje S, Kaladagi N. Fronto-orbital
advancement: Revisited. J Cleft Lip Palate Craniofac Anomal 2015;2:20-6.
Source of Support: No financial benefits from the publication of
this manuscript by Stryker Company and Osteogenics Biomedical.
Conflict of Interest: None declared.
Journal of Cleft Lip Palate and Craniofacial Anomalies