From the Guidelines
Total cranial vault remodeling is a complex neurosurgical procedure that involves a series of precise steps to correct craniosynostosis, including patient positioning, coronal incision, scalp reflection, bone removal, reshaping, and reattachment with plates and screws. The operation begins with patient positioning and preparation under general anesthesia, followed by a coronal incision from ear to ear across the top of the head. The scalp is then reflected forward to expose the skull, allowing surgeons to remove the frontal bone, portions of the parietal bones, and sometimes parts of the temporal or occipital bones, depending on the specific deformity. These bone segments are reshaped outside the body using specialized instruments to create a more normal skull contour. Small plates and absorbable screws are used to secure the remodeled bone pieces back onto the skull in their new positions, as described in various neurosurgical procedures 1. The procedure creates additional space for brain growth while improving head shape. A surgical drain is typically placed before the scalp is closed in layers. Postoperatively, patients require close monitoring in the intensive care unit for 1-2 days, with attention to pain management, prevention of infection (using prophylactic antibiotics), and monitoring for complications such as bleeding or increased intracranial pressure, similar to the postoperative management of patients with pediatric central nervous system cancers 1. Key considerations in the postoperative period include:
- Monitoring for signs and symptoms of increased intracranial pressure
- Prophylaxis for seizures, infections, and venous thromboembolism
- Pain management and prevention of infection
- Monitoring for complications such as bleeding or increased intracranial pressure. Most children remain hospitalized for 3-5 days total, with significant swelling expected for several weeks after surgery. The procedure is typically performed between 6-12 months of age when the skull bones are still malleable but the child can better tolerate blood loss.
From the Research
Total Cranial Vault Remodeling Operation Steps
The steps involved in a total cranial vault remodeling operation can be outlined as follows:
- A frontal bandeau is performed, which is then followed by a 360-degree axial strip craniectomy 2
- The strip is rotated 90 degrees into a coronal orientation and interposed between fronto-parietal and parieto-occipital segments 2
- Modification for occipital widening can also be performed as needed 2
- Frontal release and pterional decompression are included to correct frontal bossing 3
- Calvarial bone is split to allow for redistribution and recontouring of the abnormal calvarium 4
Key Considerations
Some key considerations during the operation include:
- Operative time, which can range from 2 hours to 4 hours or more 2, 3
- Estimated blood loss and intraoperative transfusion volumes, which can vary depending on the patient and the procedure 4, 2
- Potential complications, such as surgical site infections, which can occur in a small percentage of cases 5
Patient Selection and Outcomes
The operation can be performed on patients of any age group, including those with nonsyndromic craniosynostosis 4