Severity of trigonocephaly varies and potentially affects intracranial volume (ICV) and intracranial pressure (ICP). The aim of this study is to measure ICV in trigonocephaly patients and compare it to normative data and correlate ICV with the severity of the skull deformity according to UCSQ (Utrecht Cranial Shape Quantifier).Retrospective study.Primary craniofacial center.Nineteen preoperative patients with nonsyndromic trigonocephaly (age ≤12 months).Intracranial volume was measured on preoperative computed tomography (CT) scans by manual segmentation (OsiriX Fondation). Utrecht Cranial Shape Quantifier was used to quantify the severity of the skull deformity. When present, papilledema as sign of elevated ICP was noted.Measured ICV was compared to Lichtenberg normative cranial volume growth curves, and Pearson correlation coefficient was used to correlate UCSQ with the ICV.Mean age at CT scan was 6 months (2-11). Mean measured ICV was 842 mL (579-1124). Thirteen of h19 patients (11/15 boys and 2/4 girls) had an ICV between ±2 SD curves of Lichtenberg, 2 of 19 (1/15 boys and 1/4 girls) had an ICV less than -2 SD and 4 of 19 (3/15 boys and 1/4 girls) had an ICV greater than +2 SD. Mean UCSQ severity of trigonocephaly was 2.40 (-622.65 to 1279.75). Correlation between severity and ICV was negligible (r = -0.11). No papilledema was reported.Measured ICV was within normal ranges for trigonocephaly patients, in both mild and severe cases. No correlation was found between severity of trigonocephaly and ICV.
Significant treatment variation exists in the Netherlands between teams treating patients with cleft lip, alveolus, and/or palate, resulting in a confusing and undesirable situation for patients, parents, and practitioners. Therefore, to optimize cleft care, clinical practice guidelines (CPGs) were developed. The aim of this report is to describe CPG development, share the main recommendations, and indicate knowledge gaps regarding cleft care. Together with patients and parents, a multidisciplinary working group of representatives from all relevant disciplines assisted by two experienced epidemiologists identified the topics to be addressed in the CPGs. Searching the Medline, Embase, and Cochrane Library databases identified 5157 articles, 60 of which remained after applying inclusion and exclusion criteria. We rated the quality of the evidence from moderate to very low. The working group formulated 71 recommendations regarding genetic testing, feeding, lip and palate closure, hearing, hypernasality, bone grafting, orthodontics, psychosocial guidance, dentistry, osteotomy versus distraction, and rhinoplasty. The final CPGs were obtained after review by all stakeholders and allow cleft teams to base their treatment on current knowledge. With high-quality evidence lacking, the need for additional high-quality studies has become apparent.
To collect normative data on the development of fetal skull base, maxilla, mandible and facial depth by three-dimensional ultrasound (3DUS). 3DUS recording was performed four times at 18–34 week gestational age at 3–5 week intervals. In 126 normal singleton pregnancies anterior (ASBL) and posterior skull base length (PSBL), maxillary (MXCL) and mandibular corpus length (MNCL), maxillary (MXC) and mandibular curvature (MNC) and mid (MFD) and lower facial depth (LFD) were measured using the 3D View program on a personal computer. Best fit equation, 5th, 50th and 95th percentiles were calculated. The intraobserver variability was determined. Regression analysis showed a significant quadratic relation for ASBL, MXCL, MNCL, MXC and LFD relative to gestational age (p < 0.05). A significant linear relation was found for PSBL, MNC and LFD relative to gestational age (p = 0.0001). Acceptable intraobserver variability was established for all measurements. PSBL showed a stronger increment than ASBL, resulting in a significant negative relation between ASBL/PSBL log ratio and gestational age (weekly decrease: 11%, p = 0.0001). Analysis of MXCL/MNCL, MXC/MNC and MFD/LFD log ratio showed a stronger increment in mandibular growth than in maxillary growth (weekly ratio decrease 1.4–2.4%, p < 0.02). 3DUS can be used as a reliable method for determining fetal craniofacial development. The reference values on normative skull base, maxilla, mandible and facial depth may be employed as a potential method for detecting fetal craniofacial abnormalities.
Reliable postoperative monitoring in microvascular surgery is necessary to improve the low success rate of reexploration after vascular compromise. The use of laser Doppler flowmetry has been evaluated in this study. From November 1985 to January 1988, 79 microvascular operations were monitored postoperatively. These consisted of 45 replants and revascularizations in 34 patients, as well as 34 free vascularized tissue transfers. In the replant and revascularization group, a statistically significant difference in laser Doppler flowmetry readings has been demonstrated between well-vascularized and circulatory impaired patients (p < 0.001). In this study a reliable critical (alarm) value could be defined for replants and revascularizations with a sensitivity of 93% and a specificity of 94%. This critical alarm value can be adjusted according to the individual surgeon's attitude toward reexploration. Similar laser Doppler flowmetry characteristics were seen in patients with free vascularized tissue transfers; however, the numbers in this part of the study were too small to define reliable critical alarm values. The laser Doppler flowmeter is recommended for the postoperative evaluation of tissue after microvascular anastomoses, as it indicates vascular occlusion at an early stage where reexploration is worthwhile.
To compare standard biometry of the fetal head measured with two-dimensional ultrasound (2DUS) with three-dimensional ultrasound (3DUS) measurement. Standard biometry of the fetal head; biparietal distance (BPD), frontal occipiptal distance (FOD), head circumference (HC), intra ocular distance (IOD) and outer ocular distance (OOD) was performed in 126 normally developing fetuses. In each fetus 2DUS measurement, followed by 3DUS recording with off line measurement, was performed four times at 18–34 week gestational age at 3–5 week intervals. 3DUS measurements were made using a personal computer with the 3D View program. To determine reproducibility, the coefficient of variation for differences between repeated tests and between analyses of the same recorded volume, was calculated for every measurement with 3DUS. Good reproducibility was found for all 5 measurements with 3DUS. Good agreement was found for measurement of BPD, FOD, HC and OOD (intra-class correlation coefficient, ICC = 0.98–0.99). Acceptable agreement was found in measuring IOD (ICC = 0.89). Significant, but not relevant, differences between 2DUS and 3DUS of 0.3–5.4 mm were found for measurement of BPD, FOD, HC and OOD. Standard biometry can be measured with 3DUS at the same level of reliability as 2DUS.
Long-term results after cranioplasty for trigonocephaly often show bitemporal depressions and a residual hypotelorism. Both findings fuel the perception that the growth of the periorbital region and the forehead as a whole continues to be restricted, even after correction. The aim of this study is to evaluate the growth process of the periorbital region after correction for trigonocephaly in the long term. From 1986 to 2004, 123 patients underwent a cranioplasty for the correction of trigonocephaly. Cephalometric analysis was performed on the radiographs taken at presentation and on the last available radiograph before the age of 6 years (92 posteroanterior and 93 lateral cephalograms). Cephalic landmarks were used to analyze the growth of the forehead: Mo (medial orbital wall), Lo (lateral orbital wall), Losp (crosspoint between lateral orbital wall and sphenoid), and Eu (most lateral point of the skull). As a result of the lack of standardized cephalograms, growth ratios were used instead of absolute numbers. The Eu-Eu growth rate was higher than the Lo-Lo rate, which in its turn surpassed the Losp-Losp rate. An initial undercorrection of the hypotelorism was noted followed by an increased limited autocorrection. A higher Mo-Mo growth rate was noted in the group operated after 1 year of age. Increased interorbital growth accounts for an autocorrection of the residual hypotelorism. The growth rate of the anterotemporal area (Losp) was shown to be the lowest, which could explain the bitemporal depressions so often seen after a frontosupraorbital cranioplasty.
Long-term results after cranioplasty for trigonocephaly often show bitemporal hollowing and a residual hypotelorism. Both findings fuel the perception that the growth of the periorbital region and the forehead as a whole continues to be restricted, even after correction. The aim of this study was to evaluate the growth process of the periorbital region after correction for trigonocephaly in the long term.From 1972 to 2004, 184 patients underwent a cranioplasty for the correction of nonsyndromatic trigonocephaly. Cephalometric analysis was performed in 33 of these patients who had their radiographs taken on the same day as the photograph, at least 1 year postoperative and before the age of 6 years. Cephalic landmarks were used to analyze the growth of the forehead. Because of the lack of standardized cephalograms, growth ratios were used instead of absolute measurements. For visual analysis, normal anteroposterior photographs were used, which were taken on the same day as the radiograph. Two observers evaluated the anteroposterior photographs for the presence and level of temporal hollowing. A score of 0 (normal), 1 (moderate deformity), or 2 (severe deformity) was assigned to each of the photographs.A significant relation was found between a severe deformation seen at postoperative photographic evaluation and a lower growth ratio. The preoperative photo score was not of predicting value for the postoperative growth ratio and therefore, indirectly, for the postoperative photo score. The mean preoperative photo score dropped 5% after surgery. The age at operation had no influence on this postoperative photo score. The experience of the surgeon, however, was a significant contributing factor.Temporal hollowing seems to be of bony origin and can be explained by skeletal growth inhibition in the affected area. When present immediately after operation, they seem to persist through the years, which makes surgical skill another factor of importance.
