Craniofacial Surgery at UPMC Children's Hospital of Pittsburgh

Open procedures are performed in children who need more extensive operations and who are most often 9 months old or older.

In an open procedure, your surgeon will:

• Open the skin from ear to ear so they can see the tissues and structures underneath.
• Remove and reshape your child's skull bones.
• Reattach the newly shaped bones to the skull using non-metal plates and screws. The body absorbs these plates and screws as the bones heal.

Each of these surgeries takes about 4 to 6 hours.

Your child will likely spend several days in the hospital after surgery including 1 day in the intensive care unit.

This surgery corrects the shape of the forehead — or front of the skull (fronto) — and the top of the eye sockets (orbital).

During the procedure, surgeons:

• Remove the forehead bone and the bone of the upper eye sockets.
• Reshape the forehead and eye socket bones.
• Place the bones in a better position that allows more room for the brain and the eyes.

Anterior refers to the front of the skull, and cranial vault refers to the skull itself.

This technique aims to make more space inside the front of the skull.

Surgeons remove the front part of the skull, reshaping it or adding bone grafts to make it larger without reshaping the top of the eye sockets.

Some types of craniosynostosis keep the skull from growing wide enough for the brain.

This surgery reshapes the middle part of the skull, right above the ears, to make enough room for the brain.

This surgery is often used for children who are older with close to normal head shapes but who still need extra space for their brains to function normally.

This surgery corrects the bones in the back part of the skull when it's too flat, or long and narrow.

Surgeons reshape the bones to make the back of the head rounder.

Doctors use this technique to treat patients with lambdoid sagittal craniosynostosis.

Surgeons often use this method for children with sagittal craniosynostosis.

In this procedure, surgeons make the skull more round by correcting several places at once. This makes the skull wider, taller, and less elongated in one surgery.

This procedure is most often performed in children 6 to 9 months of age.

The word “distraction" means to apply a device that separates bones over time. “Osteogenesis" means to make new bone.

Distraction techniques allow the skin to stretch as the bones expand and form over time. These procedures can expand the skull more than non-distraction techniques and are used for severe cases.

Surgeons need to open the skin from ear to ear so they can see the tissues and structures below.

During this surgery, the surgeon:

• Separates a part of the skull by making a cut and places two or more distraction device called distractors across this cut. The devices have arms that stick through the skin so that they can be turned after surgery.
• Turns the distractor a little every day, which causes it to open and move the separated part of the skull. The distractor creates a gap in which new bone grows to close the gap as the distractor moves the bones.
• Removes the arms when they determine the skull is in a more normal shape, and then removes the distractor in a separate procedure a few months after placement.

Types of cranial vault osteogenesis procedures:

• Anterior cranial vault distraction to expand the front part of the skull only.
• Posterior cranial vault distraction to expand the back part of the skull only.

In minimally invasive techniques, surgeons:

• Make smaller incisions in the scalp.
• Remove less bone than in open procedures.

In order to see everything through smaller incisions, surgeons will sometimes use an endoscope, so these procedures are often called “endoscopic-assisted" or “endo" surgery.

They rely on the natural growth of the brain to help reshape the skull, so children are younger who undergo this surgery. These surgeries most often require something to help reshape the skull, such as a helmet or springs.

This technique:

• Reduces the risk of blood loss during surgery.
• Allows your child to leave the hospital sooner, often without any time in the intensive care unit.

This minimally invasive surgery is most often used for children with sagittal craniosynostosis.

During this procedure, the surgeons:

• Remove bone along the fused suture.
• Insert two or three metal springs into the resulting space.
• The surgery usually takes less than 2 hours, and most children go home the next day.
• The springs will cause the bones to separate and widen the skull into a more normal shape and create more space. As the gaps widen, new bone grows in the gaps.

The springs are removed 4 months later in a short, same-day surgery.

Another minimally invasive method to treat patients with craniosynostosis involves removing the fused suture and using an orthotic helmet to help reshape the skull. This is sometimes referred to as “endo with helmet."

As with springs, the surgeon removes a small piece of bone from the suture that fused prematurely in a short 1 to 2 hour surgery. Children will typically go home the following day.

After surgery, your child will wear a helmet custom made for their head. The helmet will help the skull to form a more normal shape. Most helmets are worn for 6 to 12 months after surgery.

Frontofacial surgeries help correct abnormal facial features caused by syndromic forms of craniosynostosis or other craniofacial conditions. Their goals are to:

• Expand the eye sockets and face.
• Improve the bite.
• Help with breathing.

These are complex procedures that are either performed using distraction techniques or as an “all at once" movement.

The Lefort I moves the bones of the upper jaw and teeth. Surgeons use this to help improve the bite, the airway, and the relationship between the upper lip and teeth.

During Lefort I procedures, surgeons:

• Make an incision inside the mouth.
• Cut the bones above the upper teeth but below the nose to separate this part of the face.
• Reposition this section using plates and screws, and bone grafts.

The Lefort II procedure moves the nasal bones and upper jaw forward without moving the cheekbones or eye orbits.

During Lefort II, surgeons:

• Make incisions at the top of the head and inside the mouth.
• Cut the bones around the nose to separate this part of the face.
• Reposition this section using plates and screws, and bone grafts.

The purpose of a Lefort III procedure is to move the cheekbones, lower part of the eye sockets, and upper jaw into a better position.

Surgeons start this surgery by making incisions on the top of the head and inside the mouth. They then cut and separate the bones in this part of the facial bones from the skull.

Surgeons can perform Lefort III with or without distraction osteogenesis.

When distractors are used, a device will be fixed to the outside of the head with pins and attached to the face by wires. This is called a “halo distractor."

Your team will teach you how to tighten the wires over time and slowly pull the facial bones forward. Once the bones are in a good position, the halo distractor remains in place for a few months until the bones heal.

When this surgery is performed without distraction, bone grafts will be used to fill the spaces that result from moving the facial bones forward.

The Monobloc technique aims to move the forehead, eye sockets, cheekbones, and upper jaw into a better position.

Most often surgeons separate the bones and use distractors to move the bones into the final position.

In this procedure, a device will be fixed to the outside of the head with pins and attached to the face by wires. This is called a “halo distractor."

Your team will teach you how to tighten the wires over time and slowly pull the facial bones forward. Once the bones are in a good position, the halo distractor remains in place for a few months until the bones heal.

The Facial bipartition technique is similar to the monobloc technique but also involves separated the facial bones down the midline.

This allows the surgeon to adjust the position and shape of the eye sockets and upper jaw as well as moving the bones into a better position.

The Four wall box osteotomy is a technique that is used to change the position of the eye sockets without moving the upper jaw.

Similar to the other frontofacial procedures, surgeons use an incision in the scalp and in the mouth to access the bones around the orbits. The forehead bone is removed to find the tops of the eye sockets so that they can be moved into a better position. The bones are then reattached using plates and screws.