Craniosynostosis is a condition that is primarily managed by surgical intervention. Management aims to offer enough intracranial volume to facilitate brain growth and expansion, to decrease the adverse sequelae on cognitive function, and to create a cosmetically acceptable standard shape of the skull [19, 20]. The history of operative management of craniosynostosis involves “Strip Craniectomies” that was first performed by Lannelounge in 1890 and Lane in 1892. The idea behind strip craniectomies is that minimal release/ removal of the prematurely closed sutures was assumed to allow the head to grow naturally without the need for any significant cranial vault remodeling. Nevertheless, the end outcomes were unpredictable, and the aim of spontaneous normalization and self-correction of the head and fronto-orbital disfigurement was rarely achieved. In 1967, Tessier had implemented the concept of craniotomy for suture release together with skull reshaping using an intracranial and extracranial approach, ingenious osteotomy sites, 360° periorbital dissection, and autogenous bone grafting [21]. The same idea of prematurely closed suture release plus skull reshaping carried out in infancy was carried out by Hoffman and Mohr [22], Whitaker et al. [23], and Marchac and Renier [24]. In the early twentieth century, different surgical techniques were described in the literature to correct anterior craniosynostosis deformity. These procedures range from simple suturectomy to calvarial bone remodeling. Distraction osteogenesis, which is based on Elizavrov’s principle, is also performed [6,7,8,9,10,11,12,13,14,15,16,17,18]. Less invasive methods, such as endoscopic suturectomy, have also been mentioned in the literature [25,26,27,28]. In our technique, we address the cosmetic outcome in both patients with MS and UCS. The area most noticed by families is the child’s forehead. The authors believe proper attention to the bandeau advancement and symmetry and forehead curvature are key to a successful aesthetic outcome. In our technique, the vertex curve in both these deformities is nicely curved. Utilizing that curve to shape the forehead curve will give a superior aesthetic outcome, along with decreasing operative time and blood loss. We believe that this technique allows for quicker recovery time post-surgery and overall morbidity compared with the standard management
Craniosynostosis surgeries are often performed in the 1st year of life. They are frequently considered complex procedures and may cause significant intraoperative bleeding, ranging from 20 to 500% of the patient’s circulating blood volume [29]. It is well known that blood loss during open repair is significantly higher than other procedures. This may lead to the need for blood transfusion intraoperatively or immediately within the postoperative period. There is limited literature estimating intraoperative blood loss because of the inaccurate measurements of small circulating volumes and the operative logistics. Previously published articles have mentioned the estimated blood loss intraoperatively differs but have documented ranges between 50 and 100% of estimated red cell volume [30,31,32]. However, these are not objective measurements. Tuncbielk et al. retrospectively reviewed the charts of 30 patients who underwent craniosynostosis repair and reported an average of 566.8 ml blood loss [33]. Another study conducted by Shah et al. reported that the mean estimated intraoperative blood loss was 218 ml in patients undergoing isolated sagittal synostosis repair [34]. A recent study by Lopez et al. showed that the average surgeon estimated blood loss in primary open repair was 207.4 ml [35]. In comparison, our mean estimated intraoperative blood loss was 225 ml (range, 100–400 ml) for all our included patients. We predict that this variance in ranges of estimated blood loss in the literature is highly dependent on the type and complexity of the procedure, age of the patient, and surgeon estimation. Although the open surgical approach for repairing the cranial vault effectively manages craniosynostosis, extensive blood loss, often needing a blood transfusion, has been listed as the most significant risk of undergoing this procedure [30]. According to a 10-year single-center study conducted by Bonfield et al., PRBC transfusion was given to 24% of the patients, 17% were open sagittal, 7% endoscopic assisted sagittal, 6% in unicoronal, 21% bicoronal, 45% metopic, and 45% in patients with multisuture craniosynostosis [36]. Other centers stated that almost 83% of patients who underwent cranioplasty received blood transfusions. This percentage includes all patients (100%) who underwent cranial vault reconstruction, about 98% of patients underwent fronto-orbital advancement and only 32% of spring cranioplasty patients [37]. In comparison, in our study, all patients (100%) received an average of 329.166 ml packed red blood cell transfusion. It is routine to start the blood transfusion at the beginning of the procedure to prevent hemoglobin drop during or after the procedure.
As there are many types of surgical procedures for craniosynostosis, it is expected that operative time will vary with procedure type. Open cranial vault procedure time has been reported to range between 205 and 670 min with a mean of operative time of 342 min [38]. In another retrospective study by Keshavarzi et al., their mean open correction of metopic synostosis surgery was 132.6 min [39]. In our study, the mean operative time was 315 min (range, 263–368 min), which concurs with operative times of open cranial vault remodeling in other centers. In this retrospective study and description of the technique article, we demonstrated our novel technique to use a single-piece bone flap for cranial reshaping of the anterior mold in patients diagnosed with anterior craniosynostosis. As well as, to find the surgical correction results in the patients who have been managed with this new technique at our university hospital compared to similar international papers in comparison to the standard fronto-orbital reshaping for patients diagnosed with anterior craniosynostosis [38, 39], our technique showed better early results and normalization in head morphology. Furthermore, we have revealed a notable decrease in blood loss, recovery time post-surgery, and overall morbidity compared with standard management. The small number of patients may be considered a limiting factor for our series. This might be explained by the lack of early diagnosis or misdiagnosis of the available cases. We believe further studies are needed to modify the technique and assess further surgical outcomes.