Operative Technique in Plastic Surgery – Kevin C.Chung

■ The head can be turned from side to side to access the lateral regions of the
donor area.
■ During longer FUE procedures, the patient’s position is changed multiple
times, including prone position, lateral positions, and even supine positions
with the head turned from side to side. This alleviates discomfort during the
FUE harvest.
■ Positioning in FUE procedures is very individual among surgeons and their
teams. It has become apparent that the FUE grafts are very fragile and even
short periods of desiccation or long periods without blood flow may be
detrimental.3 Thus, positioning is optimized to allow overlap of excision,
removal, and implantation phases.
FIG 10 • Positioning of patient in the prone pillow for
donor excision.
■ In most cases, the sites are created and the grafts are implanted with the
patients in a supine position.
■ If the vertex is the recipient area, however, the optimal position will be prone
for a portion of sites and implantation.
■ Some HRS perform the procedure with the patient in a sitting position for the
entire procedure—often in a special chair with a head rest to stabilize the head.
In the authors’ experience, patients tend to find this fairly uncomfortable for
long periods.
■ Anesthesia
■ All patients are given long-acting oral medication to start the day, including
an antianxiolytic (lorazepam 2 mg), a sedative (diazepam 10 to 20 mg), and

an analgesic (hydrocodone/acetaminophen 5/500 mg).
■ Just prior to injecting the local anesthesia, the patient is given fentanyl and
midazolam intravenously for immediate effect.
■ Anesthesia is typically performed as a field block with lidocaine 2% with
1/50 000 epinephrine. First wheals are placed at 2.5-cm intervals, and then
the block is completed by injecting laterally from within the anesthetized
areas. Occasionally, stronger anesthetics are used.
T E C H N I Q U E S
■ Donor Strip Harvest
■ Magnification is used to assist in excision and dissection under direct
visualization.
■ The transection rate in strip harvest varies depending on the surgeons’ and
technicians’ experience and is generally less than 1%.
■ The area to be harvested is tumesced in the subcutaneous layer with saline.
This helps separate the follicles, thus minimizing follicle transection. It also
lifts the tissue above the deeper and larger vasculature and nerves.
■ A single no. 15 blade is used to incise along the inferior edge of the donor
area followed by the superior edge.
■ The lateral ends of the strip are tapered before the tissue is removed.
■ Some HRS superficially score the surface with a blade to a depth of mid-
dermis and use skin hooks to allow for greater visualization or tissue
spreaders to bluntly separate the tissue and reduce transection rates further.
■ The strip is removed from the bed using a single blade, again under direct
visualization, to ensure dissection occurs in the relatively avascular plane just
deep to the follicular bulbs (TECH FIG 1).

TECH FIG 1 • Excision has been started. Note the
intact follicles and limited depth of incision.
■ Any significant bleeding vessels are cauterized, excepting those that are
immediately adjacent to follicular bulbs.
■ One very helpful pearl is to remove a strip from the occipital region first and
close that area with sutures before reassessing the scalp laxity in the adjacent
parietal and temporal regions and excising those strips. This is especially
beneficial when the donor area tension is somewhat unpredictable.
■ Donor Site Closure
■ Choosing the strip width and closing the donor wound in sections, as
described above, is helpful to avoid any unexpected areas of tension.
■ One region of the scalp can “borrow” laxity from another area and lead to
otherwise unanticipated increased tension.
■ Over the mastoid region, where tension is more often higher than expected,
wedge-shaped sutures may also help relieve tension.2
■ This technique eases the work (W) required for closure more effectively
than sutures placed perpendicular to the wound edge by increasing the
distribution of force (F) along the wound edge. With F and wound edge
displacement (d) being constant in the formula for work (W = Fdcos θ), the
magnitude of work is reduced as the angle (θ) increases (TECH FIG 2A).
■ The donor area may be closed in a single layer or double layer, depending on
the surgeon’s preference.
■ The double layer helps to decrease tension on the more superficial

epidermal layer, but it also carries the risk of worsening the scar in
individuals with hyper-reactive healing.
■ If the patient is undergoing a second surgery, the healing from the first
surgery can be a guide. If the scar spread after suture removal and there
was no hypertrophic healing, a double-layer closure nearly always results
in a finer scar compared to a single-layer closure.
■ If a double layer is used, the authors prefer PDSII 3-0 or Maxon 3-0.
■ Depending on the wound length, four to eight buried interrupted sutures
are placed deep to the level of the follicles, to approximate the base of the
wound (TECH FIG 2C).
TECH FIG 2 • A. Suture pattern in a wedge shape to
decrease tension on closure over the mastoid regions.
B. Deep sutures in place in double-layer closure. C.
Donor area after closure of the superficial layer. D. In
trichophytic closure, the epidermal layer being
trimmed is approximately 1 mm wide and 1 mm deep.

If the hair follicles are slightly further apart from one
another, the width may need to also be slightly larger.
E. Partially completed trichophytic closure. F. Final
appearance of scar in donor area.
■ The superficial epidermal layer is closed with 3-0 Supramid or 3-0 Prolene.
Usually, a running suture is utilized with stitches placed approximately 4 to 5
mm apart from one another, ensuring good approximation of the epidermal
edges.
■ The needle should pass through the dermis and exit just below the level of
the bulbs.
■ Beware sutures that are too close or too far from the wound edge.
■ Trichophytic closure can be used to help further camouflage the resultant
scar.
■ In this technique, prior to closure, a 1-mm section of epidermis is carefully
removed from the superior or inferior ledge of the wound, maintaining a
level superficial to the sebaceous gland (TECH FIG 2D).
■ The epidermal edges are then approximated and the wound is closed
(TECH FIG 2E,F).
■ FUE Harvest
■ FUE harvest can be accomplished by several methods: manual punch,
oscillating or rotating motorized punch (dull or sharp or even a modified
sharp punch), suction-assisted device, or robotic device.
■ Each of these methods has unique detailed requirements to produce ideal
results.
■ Originally involving the use of a sharp 1-mm “cookie cutter”–like punch,
hair follicles trimmed to 2 mm in length were extracted manually in a random
distribution so as to avoid overharvesting any particular area, which might
result in a “moth eaten” appearance.1
■ Gradually, powered instruments for FUE largely replaced manual punches
by demonstrating increased extraction speed and efficiency.6 Increased speed,
however, requires heightened attention to avoiding follicle transection or
follicle “decapitation” that may occur when a sharp punch is introduced at the
improper angle.8

■ Variable tissue and hair characteristics such as follicle curvature, angle of
exit from the skin, or splaying arrangement beneath the skin surface may
further increase the challenge of avoiding follicle transection.
■ To minimize follicle transection, nonsharp motorized punches have been
developed to perform “blunt” dissection of FUs from the skin. Rather than
cutting the deep segment of a follicle with an unforeseen curvature, a dull
punch can push the follicle within the cylinder and thereby reduce transection
rates.
■ Alternatively, a two-step manual process involving an initial “scoring
incision” at a 0.3- to 0.5-mm depth around the follicle followed by the
insertion of a blunt dissecting cylinder that reaches the full depth of the
follicle (approximately 4 to 5 mm) enables full separation of the intact
follicle from its native tissue prior to manual extraction using forceps.
■ A newer technique involves an oscillating motorized unit and a modified
blunted thin-walled punch. Limited reports indicate this may lower
transection rates dependably (below 3%) and allow removal of a graft with
limited mechanical traction and more tissue surrounding the FU, regardless
of patient’s tissue characteristics.
■ Larger punches alter the architecture of the donor area and may leave more
perceptible scars. In most cases, the punch should be smaller than 0.95 mm in
its external diameter.
■ A surgeon’s ability to properly position the punch according to the follicle’s
angle of exit from the skin surface requires proper (5× to 6.5×)
magnification.
■ The following step-by-step description applies to most techniques:
■ For large FUE cases, the donor areas are shaved.
■ Sterile saline tumescence injected at both a superficial and deeper depth
helps to increase the space between FU, increases the predictability of hair
follicle angle deep to the skin surface by making the follicles more erect,
and separates the follicle bulb from the underlying vascular and nerve
plexus.
• The tumescence can dissipate fairly quickly and therefore needs to be
repeated frequently as the surgeon progresses to subsequent areas.
■ The punch is centered over the FU and advanced.
• There is a tactile sensation that can be appreciated when the FU has been
“released.”

■ Initially, several of the grafts should be extracted to check if the depth is
sufficient to minimize trauma during the extraction phase.
• Once a depth has been determined, most physicians will incise up to a
hundred grafts or more and then extract using a two-handed method to
pull the grafts while simultaneously depressing the surrounding tissue to
assist in release.
• Depending on the position and region of harvest, occasionally, an assistant
can follow along and extract while the surgeon continues incisions.
■ Most physicians now employ a method of creating sites prior to the
extraction phase and alternating graft extraction and graft implantation
throughout the surgical day; thus, the more fragile FUE grafts do not remain
outside the body for long periods.
■ As noted earlier, the patient needs to be positioned and repositioned
throughout the day to facilitate harvesting the grafts and maintaining good
ergonomics for the surgeon.
■ Certain positions also enable the technicians to implant the grafts
simultaneously while the harvest continues.
■ It is worth repeating that the grafts need to be kept moist from the time of
extraction to implantation.
■ The robotic technique of harvesting FUE does make the process faster and
also has a faster “learning curve” for the physician. Nevertheless, some
patients complain of the discomfort of the positioning chair and prolonged
immobility.
■ The smallest punch size used with the robot has an internal diameter of 0.9
mm, but external diameter of 1.1 mm, so the punctuate scars are larger than
ideal.
■ The trend of “fractional harvesting of follicular groups”—removing only
some hairs within a follicular group—helps preserve donor architecture and
is not possible with the robotic punch.
■ Many physicians, including the authors, pack the donor sites with PRP and
ACell after the harvest is complete, to potentially minimize the visibility of
the scars and alteration of the subcutaneous tissue during healing.
Theoretically, this should facilitate a second FUE procedure.
■ Graft Preparation

■ Once a strip is removed (TECH FIG 3A), it is immediately transferred to a
dish with a chilled holding solution. The authors use HypoThermosol with
liposomal ATP (10:1 mL proportion). This solution has been shown to
improve survival of the grafts while outside the body, as compared to saline
or other solutions.
■ Akin to organ transplantation, factors of negative influence include
ischemia-induced hypoxemia and subsequent ATP depletion (resulting in
subsequent apoptosis) as well as ischemia-reperfusion injury.
■ Graft preparation takes place on ClearVue boards (translucent horizontal
cutting surfaces made of polyurethane), which allow backlighting to project
through the tissue. Lighting from above is provided by Meiji lights with
adjustable intensity.
■ Magnification requirements vary between technicians; some prefer
magnifying loupes, while others use microscopes.
■ The strip is initially “slivered” into “slices” that are one FU in width (TECH
FIG 3B).
■ The strip needs to be kept moist during this entire process with frequent
spraying of chilled saline.
■ One end of the strip is anchored with a 20-G needle, and countertension is
provided with Adson forceps. A single Personna blade held on a small
blade handle is gently pulled toward the technician to carefully dissect the
tissue between the follicles.
■ The slices thus produced are then turned on their sides and divided into the
individual grafts.
■ The grafts are sorted according to number of hairs and hair texture and
stored again in the chilled holding solution (TECH FIG 3C).
■ FUs are kept intact: they are not subdivided unless there is an insufficient
number of single hair grafts for the hairline.
■ The ideal “pear-shaped” graft (TECH FIG 3D) possesses little or no surplus
epidermis and retains an appropriate amount of protective dermis and
subcutaneous adipose tissue around the follicle, the intact sebaceous glands,
and the dermal papilla so as to reduce sensitivity to traumatic handling,
temperature changes, and graft desiccation (the main cause of poor graft
survival).
■ These characteristics are rarely achieved with FUE grafts, which are
mechanically pulled out of the skin with a combination of traction and

perifollicular pressure after a shallow circumferential incision and so are
more fragile. Some of the newer developments in blunt dissection with a
very thin-walled punch appear to improve the amount of surrounding tissue
in the FUE grafts.
■ FUE grafts rarely require much “preparation.” They are sorted according to
number and caliber of hairs.
TECH FIG 3 • A. A strip harvest after removal. B. A
“sliver” removed from the strip. C. FU grafts sorted in
the dishes filled with a storage solution
(HypoThermosol and liposomal ATP) and kept chilled.
D. FUE grafts on the left and FU grafts from strip on
the right.
■ Creation of Recipient Sites
■ The recipient site creation is arguably the most important step in producing
excellent cosmetic results.
■ The surgical plan should already include an estimate of how large an area
needs to be addressed, including current and future areas of alopecia.
■ Then, the physician needs to determine approximately how many grafts
will likely be harvested; this then guides the determination of the density of
sites to be created.
■ There should be micro- as well as macroirregularity to create a very natural
appearance. The density of the hairline should be lower than the density
created posterior to the hairline to produce a feathered effect.
■ The lateral hairline is formed by the anterior “temporal humps.” These
areas are re-created (at an angle very acute to the scalp) in patients who are
severely receded in these regions.
■ The angle and direction of recipient site incisions should in almost all cases
mimic those of any significant amount of pre-existing hair, regardless of its
location.
■ To do otherwise results in transection of those hairs, and every study on
follicle transection has demonstrated decreased number and/or hair caliber

of transected follicles.
■ Generally, the authors make sites parallel to the direction of the hair
(TECH FIG 4).
■ In the temporal regions and eyebrows or other areas requiring a very acute
angle, sites are made perpendicular to the hair direction.
■ If there is any movement of the FU within the site, it will not result in the
hair direction being less flush with the scalp.
■ The hairline zone should be completed with only single-hair FU, with the
finer one-haired and some two-haired FU placed anterior to the higher-caliber
ones.
■ The sites are made using a 20-G needle and follow the angle and direction
of existing hair.
■ The density of sites may vary between 25 and 35 FU/cm2 depending on the
effect being sought.
■ Behind the hairline zone, the sites are created using a 19-G needle for two-
haired and some three-haired FU, and the three- or four-haired FUs are
placed posterior to that in sites made with an 18-G needle or 1.3-mm blade
that is cut to size.
TECH FIG 4 • Recipient site pattern.
■ The density of these sites varies between 20 and 35 hairs, depending on the
distribution of the graft size, the area needing coverage, and the overall
density availability.
■ The three-haired FU and follicular families are concentrated in regions
where higher density is desired.

■ This includes a region behind the hairline transition zone and within a
larger oval-shaped region in the frontal forelock.
■ There is much debate regarding the ideal density of sites within the field of
hair restoration surgery.
■ The authors believe the ideal density depends on many factors, including
hair characteristics, final expected pattern of alopecia, donor availability,
and patient objectives.
■ The ideal density achieves the greatest cosmetic impact over the largest
area of the future pattern of alopecia; it is not a predetermined number.
■ Creation of recipient sites in the midscalp and vertex follows a similar
surgical plan, in that, nearly always, current and future areas are treated.
■ The site density again depends on the size of area that has to be treated and
the donor hair available over the patient’s lifetime.
■ The vertex should ideally not be surgically treated until the frontal two-thirds
of the area of MPB are satisfactorily completed.
■ This area responds best to medical treatment and is generally least
cosmetically important to patients.
■ Pre-existing hair should be protected during site creation, and grafts should
be placed in the future areas of loss to be certain that the transplanted area
remains “connected” to the fringe hair.
■ Hair Transplantation in Women
■ The most important aspect in hair transplantation in women is the planning
stage.
■ FIG 9 shows the most important cosmetic regions to treat in women to
make the greatest impact in a single surgery.
■ Unlike male patients, who are totally alopecic in the areas of concern, most
females’ scalp hair is getting progressively sparser.
■ The recipient area is fairly diffuse and the donor area is generally smaller
and more inferior in females. Density needs to be created very strategically.
■ The hairline zone should be more feathered in women than in men. If
preauricular hair is being transplanted, the patient should be instructed that
trimming the hair to make it more wisplike after surgery may be helpful.
■ Sites for FU are usually made with 20-G or 19-G needles, depending on the
size and caliber of the grafts following the exact angle and direction of the

existing hair.
■ In women, the coarser hairs are more likely to be terminal hairs that will
last over many years; these should be considered when choosing exactly
where to place a transplanted hair.
■ One of the authors makes some sites with a blade cut to size for DFU; grafts
that contain two FUs.
■ After several samples of DFU are produced, the grafts are tested in the
sites to ensure a good fit. The size is usually between 1.2 and 1.3 mm.
■ These grafts seem to produce more volume in the area in which they are
placed and potentially reduce the postoperative telogen effluvium
frequently seen in women.
■ Hair Transplantation into Scars From Cicatricial
Alopecia, Trauma, or Postrhytidoplasty
■ The major pearl for hair transplantation into scar tissue is related to the real-
time evaluation of the vascular supply. No epinephrine should be used in the
area prior to starting. This allows the surgeon to evaluate blood flow
throughout the area.
■ Sites are created using either a 20-G or 19-G needle, and the site should be
made deeper than usual, to try to access the vascular bed beneath the scar
tissue.
■ Site density should be between 10 and 20 FU/cm2 in the first pass.
■ If the blood supply seems quite good, density can be used adjacent to the
scar (eg, anterior to a postrhytidoplasty scar).
■ Patients should expect that at least a second surgery will be necessary to
create acceptable hair density. Often, neovascularization after the first surgery
has occurred and the density of sites can be higher.
■ Sometimes, the tissue has poor recoil and the grafts tend to slide out.
■ In such cases, tissue glue can help hold the grafts in place.
■ Facial Hair Transplantation
■ Scalp hair can be transplanted into the eyebrow, beard, mustache, and
eyelash areas.

■ The techniques involved in these procedures are very similar to those used
to treat areas of patterned hair loss with a few exceptions.
■ The sites are created almost exclusively with the 20-G needle, and almost all
grafts are one- or two-haired grafts.
■ The grafts should be cherry-picked from regions of the donor area with
matching texture.
■ The angles of the sites need to be particularly acute on the face, and the hair
needs to be oriented so it does not curl in the wrong direction.
■ Eyelash transplantation is particularly difficult to perform and produce
natural results. The hairs at the nape of the neck are well suited for this
purpose.
■ A curved needle is used to make sites in the lid margin and the hair is
threaded through and directed to follow natural lash curvature.
■ Some surgeons used scalp hairs threaded onto a crescent needle, which is
then threaded through the lid.
■ Trichiasis (misdirection of the eyelash) can be a significant complication.
■ Implantation of Grafts
■ Graft implantation requires very skilled technicians with excellent hand-eye
coordination and a gentle touch.9,10
■ In our office, the grafts are bathed in PRP + ACell in small dental rings prior
to implantation. The dental rings allow the grafts to remain moist while
limiting the need for constant change of field of focus to retrieve more grafts.
■ The graft is grasped by the fat at the proximal portion of the follicle and
gently placed with jeweler’s forceps into the recipient site.
■ Implanters have been gaining in popularity, especially in FUE cases. They
reduce graft handling and potential damage. They also reduce the need for
highly trained technicians.
■ The graft is threaded onto an implanter by holding it by the hair.
■ The implanter is then inserted into the site and atraumatically delivered.
PEARLS AND PITFALLS

Planning
■ The surgical plan should take into consideration the long-term
pattern.
■ The patient should be well informed and well educated about the
probable outcome and the possible complications accompanying
each technique.
■ Unrealistic long-term goals should be discouraged during the
consult and the day of surgery.
Anesthesia
■ A thorough evaluation of the patient’s overall health status should
be obtained by good history and P.E. and coordinating with the
patient’s primary care physician for other health issues.
■ The physician should be knowledgeable of the medication’s
pharmacodynamics, side effects, toxic levels, and drug interaction
and their corresponding management.
■ When indicated, it is best to get an anesthesiologist for the patient’s
overall safety.
Donor
harvest
■ The surgeon should only take an optimally sized donor area to
permit closure without tension to avoid the development of wide
scars.
■ Using monofilament absorbable sutures in the subcutaneous layer
helps eliminate “dead space” and lessen tension for good wound
closure.
■ Hemostasis should always be employed to avoid blood clot
formation in the donor area.
■ A solution of 3.33 mg/mL of triamcinolone (10 mg/mL) + 0.5%
Marcaine can be injected into the donor area to lessen postoperative
swelling.
Grafts
■ Avoid transections by making one follicle wide slivers to easily
divide the grafts into its natural groupings.
■ Leave enough tissue around the grafts for protection during
placement.
■ Eliminate the epidermis during graft cutting leaving a tear-shaped
graft.
■ Always keep the grafts moist by frequently spraying with normal
saline during cutting and storing them into normal saline solution or
HypoThermosol + ATP solution.
Recipient
sites
■ Create irregularities along the hairline to provide a natural look.
■ Meticulously follow the hair direction to minimize trauma and
shock loss to the surrounding follicles.
■ The hair transplant surgeon should address the “future areas” of loss
when making the recipient sites.

■ The surgeon should always balance between “dense packing”
especially the hairline and frontal area and doing a lower number of
FU/cm2 for wider recipient areas especially for patients with limited
donors.
■ The angle of the recipient site should be determined before
attempting to plant a graft.
Graft
implantation
■ Avoid overhandling and unnecessary manipulation of the grafts to
minimize traumatic injury.
■ Keep the grafts moist and store them in appropriate storage
solutions such as normal saline or HypoThermosol with or without
ATP. PRP can also be used to store the grafts right before
implantation.
■ Always use “ring containers” when placing grafts to avoid drying
and graft death.
■ In experienced hands, the use of implanters can be a safe and fast
method of planting the grafts.
■ The grafts should ideally be at the same level of the original hairs.
Buried grafts can cause ingrown hairs and skin dimpling of the
recipient sites when healed.
■ Elevated grafts can be prone to getting dislodged during the postop
period and hair washing.
■ Assistants should be comfortably positioned when planting the
grafts. This would improve their technique and would minimize
traumatic handling of the grafts.
■ The recipient area should be thoroughly cleaned and the implanted
grafts checked one more time before bandaging.
POSTOPERATIVE CARE
■ Immediately after the procedure is finished, an antibiotic ointment is applied to
the recipient and donor areas, and the head is bandaged overnight.
■ This practice has been continued by the authors because the occlusion
provides a moist environment that is beneficial for healing and also acts as a
physical barrier to microbial invasion.
■ The bandage is removed the first day after surgery and nurses wash the
recipient and donor areas.
■ Our patients are encouraged to continue soaking and cleaning twice daily to
help dissolve any crusts that have formed and keep the surgical areas clean.
■ Patients also apply lubricant to the surgical areas to keep them moist and use
minoxidil 3.5% for its vasodilatory effect and potential for decreasing telogen

effluvium.
■ Postoperative pain after strip harvest is usually minimal.
■ Patients complain of a “tight” feeling in the donor area.
■ After FUE, patients report very little discomfort, likened sometimes to a bad
razor burn (FIG 11).
■ In addition to analgesic use (acetaminophen or narcotics), patients are
instructed to apply ice for 10- to 15-minute intervals along the nape of the neck
to help decrease edema, which may add to the tension along the suture line.
■ The authors generally remove sutures between 8 and 10 days after surgery.
■ In cases of an increased risk of wound dehiscence (eg, multiple donor area
scars and marked tension upon donor wound closure) or instances of
excessive scalp laxity upon donor site closure, sutures should be left in place
for a longer period of time, usually 10 to 14 days.
■ 4 to 5 weeks after surgery, patients are encouraged to return for evaluation.
FIG 11 • Donor area after FUE harvest.
■ On occasion, there is excessive erythema or hyperesthesia in the donor area;
this may be treated with intralesional triamcinolone acetonide (3.33 mg/mL).
■ Patients should be alerted to possible postoperative sequelae:
■ Tissue edema may become most evident 3 to 5 days postoperatively in the
forehead and temple areas.
• Patients are encouraged to ice these areas and maintain a supine or lateral
position as much as possible for the initial 72-hour postoperative period. It
is generally mild, but in 1 out of approximately 50 patients, it may be severe
enough to cause ecchymosis around the eyes.

■ Scalp hypoesthesia resulting from severed sensory nerves during the
processes of both donor harvest and recipient site creation
• This generally resolves in 3 to 6 months however, depending on the size and
location of the nerve, may take up to 18 months to return to normal.
■ Telogen effluvium, or temporary hair loss sometimes referred to as “shock
loss,” may be experienced by approximately 10% to 20% of male patients and
40% to 50% of females.
• The temporary nature of this effluvium, which may affect 10% to 25% of
the pre-existing recipient area hair, is emphasized during the consultation. It
resolves in 2 to 3 months, but if a patient is not emotionally prepared for this
likelihood, he or she should not undergo HRS.
OUTCOMES
■ Although patients may vary considerably, the general timeline for hair growth
after a session is as follows:
■ Newly transplanted vellus hairs begin to appear around the 3rd or 4th
postoperative month, although the addition of PRP to our surgical procedures
seems to result in some hairs being retained and growing without a dormant
phase.
■ The number and caliber of transplanted hairs continue to increase until full
growth can be appreciated approximately 18 to 24 months after a session.
■ One surgery can create a cosmetically excellent result in any one region of the
recipient area (FIGS 12 to 14).
■ The hair transplanted will last as long in its new area as it would have lasted
in the donor area.
■ The results become less dense over time because pre-existing hair is lost over
time and some donor area hair, even in the SDA, is lost with the passage of
time.

FIG 12 • A. Patient with limited donor hair available and
a large alopecic area. B. Two lower-density hair
transplants, covering both current and future areas of
loss, provided the greatest cosmetic benefit for this
patient. C. His limited donor area after two strip
harvests. The scar is not visible, and all grafts were
harvested from the safest donor area composed of hair
that will last for the majority of his life.

FIG 13 • A,B. This patient has a very dense donor
region. Given his age and objectives, a higher-density
surgical plan was chosen. C,D. Appearance after one
surgery.
FIG 14 • A. Patient postrhytidoplasty. B. Patient after
one hair transplant to camouflage scars and thicken
hairline.
■ Medical therapy in conjunction with surgery will help mitigate this effect.
■ One of the most important questions regarding FUE is whether the graft

survival is comparable to the survival of grafts obtained from a strip harvest.
■ Limited studies performed to date suggest that survival is considerably lower.
■ One study involving four patients and 3560 hairs/follicles, which was
presented at the ISHRS annual meeting 2015, showed at 14 months only
61.4% of the FUE grafts had regrown, while 86% of the strip harvest–derived
FU had regrown. More studies are required.
COMPLICATIONS
■ Beyond focal neuralgia, uncommon donor area complications include wound
dehiscence and arteriovenous fistulas as well as aesthetic complications of
visible scarring, keloid or hypertrophic scarring, or donor hair effluvium.
■ Within the recipient area, the uncommon, but most serious complication of
central recipient area necrosis results from vascular compromise and is more
likely in smokers, diabetics, and patients having undergone prior scalp
surgeries.
■ Folliculitis or ingrown hairs. These are uncommon and less severe
complications that can occur in up to 20% of patients in a very mild form or a
much smaller percentage in a more severe presentation. This may be treated
with either warm compresses or a course of a first-generation cephalosporin,
such as cephalexin, depending on the severity.
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androgenetic alopecia. Dermatol Surg. 2016;42(4):491-497.
7. Uebel CO, da Silva JB, Cantarelli D, Martins P. The role of platelet plasma
growth factors in male pattern baldness surgery. Plast Reconstr Surg.

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8. Cooley J. Bio-enhanced hair restoration. Hair Transpl Forum Int.
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9. Speranzini M. FUE graft placement with dull needle implanters into premade
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10. Unger R. Female hair restoration. Facial Plast Surg Clin North Am.
2013;21(3):407-419.

PART 2
Craniofacial

(Trang không có chữ)

1
CHAPTER
Section I: Craniosynostosis
Fronto-Orbital Advancement
Rajendra Sawh-Martinez and John A. Persing
DEFINITION
■ Fronto-orbital advancement is a series of adjustments to modifications of
anatomy in coronal and metopic synostosis.
■ Fronto-orbital advancement strives to approximate normality of deficient
supraorbital rim and adjacent frontal and temporal bone deformities.
■ Unilateral coronal synostosis (UCS), bilateral coronal synostosis, and metopic
synostosis have unique fronto-orbital deformities, which require individualized
treatment for optimal results.
ANATOMY
■ Unilateral coronal synostosis
■ Periorbital deformities are characterized by flattening of the frontal bone
ipsilateral to the fused half of the coronal suture.1,2
■ Recession of the ipsilateral supraorbital rim
■ Overprojection anteriorly of the ipsilateral zygoma
■ Convex deformity of the squamous temporal bone
■ Diminished mediolateral dimension of the orbit compared to normal
■ Increased vertical height of the ipsilateral orbit
■ Enlarged and more superiorly positioned ipsilateral orbital roof and
accompanying greater wing of the sphenoid (harlequin deformity)
■ Depression of contralateral orbital roof/supraorbital rim
■ Ipsilateral nasal radix deviation
■ Contralateral chin point deviation
■ Bilateral coronal synostosis
■ Characterized by premature fusion of the coronal sutures bilaterally and

brachycephaly (shortening) of the anteroposterior dimension of the skull, to
include the anterior cranial fossa with compensatory widening of the skull3
■ The frontal bones bilaterally, and the supraorbital rim adjacent to them, are
hypoplastic and retrusive, relative to normal frontal bone development.
■ Squamous temporal bone is more convex in form than normal.
■ The zygomas are deficient in the anteroposterior projection.
■ The malar area, as well as the midface, may be more significantly retruded in
patients with syndromic forms of bilateral coronal synostosis.
■ Metopic synostosis
■ Fusion of the metopic suture, associated with ridging of the midline frontal
bone structure, and symmetric retrusion of the lateral frontal bones bilaterally4
■ Retrusion of the supraorbital rims bilaterally and flaring of the parietal bones
as a form of compensation for continuing brain growth bilaterally
■ The orbits are symmetrical in appearance.
■ The squamous temporal bones are not convex, but flattened in profile and
retrusive.
■ Hypotelorism
PATHOGENESIS
■ Craniosynostosis occurs as nonsyndromic forms and as part of a varied
number of syndromic patterns.
■ Metopic and coronal synostoses are believed to have a positive family history
in approximately 10% of cases.
■ Ephrin-A4 has been implicated in nonsyndromic craniosynostosis, whereas
FGFR3 and TWIST gene mutations may be linked to familial inheritance of
craniosynostosis.5
■ Syndromic craniosynostosis cases are linked to varied genetic mutations
corresponding to the underlying syndrome.
■ Multiple environmental factors have been suggested as promoters or risk
factors for synostosis, including abnormal intrauterine position, multiple
gestation, antenatal head compression, and infants large for their gestational
age.
■ Additionally, maternal smoking, advanced maternal age, gestation at high
altitude, fertility treatments, and endocrine abnormalities have also been
associated with the development of craniosynostosis.
■ The natural history of all forms of craniosynostosis is that they are, at the very
least, stable, if not progressive during early childhood due to the expanding

brain. Compensatory abnormalities increase the discrepancy between the fused
bones and the remainder of the skull.
■ The main theories of pathogenesis of premature fusion relate to timing of the
fusion as either a primary event or a secondary occurrence as the effect of a yet
undetermined cause.
■ Despite ongoing research on the underlying mechanisms, general principles
dominate the resultant morphology.1,6,7
■ Prematurely fused bones act as a single bone plate with limited growth
potential.
■ Asymmetrical, increased bone deposition occurs at perimeter sutures directed
away from the affected bone plate.
■ Unaffected, adjacent perimeter sutures compensate more in growth than do
distant unaffected sutures.
PATIENT HISTORY AND PHYSICAL FINDINGS
Metopic craniosynostosis4,6,8
■ Premature fusion of the metopic suture.
■ Key relevant anatomic features include the following:
■ Central ridging/bulged metopic suture
■ Characteristic triangular-shaped forehead (bilateral fronto-orbital hypoplasia)
occurs to varying degrees, with classification schemes related to the severity
of angulation
■ Hypotelorism
■ Lateral orbital rim posteriorly displaced and hypoplastic
■ Flattened profile of the squamosal bone
■ Biparietal widening of the skull
Unilateral coronal craniosynostosis6,9,10
■ Premature bony bridging of the coronal suture, typically in the approximate
midpoint of the course of the coronal suture
■ Patent sagittal suture is displaced away from the fused suture posteriorly and
toward it anteriorly.
■ Key features:
■ Flattened ipsilateral forehead
■ Contralateral forehead bossing
■ Intrinsic orbital changes (pathognomonic harlequin deformity)

• Ipsilateral flattened supraorbital rim and vertically taller/narrower orbit with
steep superior orbital fissure and greater/lesser sphenoid wings
• Depression (inferior displacement) of contralateral supraorbital rim
■ Squamosal-temporal bone convexity
■ Depression of the free border of the superolateral orbital rim
■ Protrusive zygoma, ipsilateral to the coronal fusion
■ Raised eyebrow and widened palpebral opening ipsilateral to the fused suture
■ Root of nose deviation toward the affected (fused) side and nasal tip towards
the contralateral (open) side
■ Ear displacement anteriorly/superiorly, ipsilateral to fused suture
■ Contralateral chin point deviation
■ Base of skull deformity
• Severity can be determined by evaluating the sphenopetrosal angle and the
degree of angulation from midline structures (cribriform plate) ipsilateral to
fusion2,6,9
Bilateral coronal craniosynostosis2
■ Bilateral premature fusion of the coronal suture with symmetric foreshortened
anterior cranial base
■ Key features:
■ Bilateral retrusion of frontal bone and supraorbital rims
■ Bilateral lateral bulge of squamous temporal bones
■ Increased biparietal diameter
■ Syndromic vs nonsyndromic features include midface hypoplasia and
mandibular deformity in syndromic cases
■ Frontosphenoidal synostosis11–13
■ Rare case of anterior plagiocephaly
■ Often misdiagnosed
■ Requires 3D CT reconstruction to identify in isolated cases
■ Angulation of the anterior cranial base
■ Deflection of the anterior cranial fossa opposite to fused suture
■ Altered relationship between cranial vault and facial skeleton, resulting in a
phenotype similar to UCS
■ Contralateral bossing and ipsilateral brow depression
■ Nasal tip deviation reported in 50% of cases
■ Harlequin deformity may not be present or be minimally evident.

■ Key orbital/ophthalmologic evaluation
■ Orbital size/shape
■ Globe position/prominence
■ Corneal inflammation (exposure)
■ Distinct structural differences between ipsilateral and contralateral orbits
■ Extraocular movement (strabismus), particularly superior oblique dysfunction
■ Visual acuity
■ Lid margin and levator function (anterior plagiocephaly)
■ Supratarsal crease reduction (anterior plagiocephaly)
■ Hypertelorism (brachycephaly) in some syndromic cases
■ Malar recession in syndromic cases
IMAGING
■ The definitive diagnostic study for craniosynostosis is a CT scan
demonstrating fusion of a cranial vault suture.
■ However, imaging of cranial anatomy has been used less frequently, as the
typical clinical structure in the individual forms of craniosynostosis is more
recognized.
■ This has been highlighted by concerns related to exposure of infants to
ionizing radiation by CT scan and for sedation and anesthetics often required
to obtain MR scans.
■ Ultrasound examinations, except in the very young, are not accurate enough
to serve as a definitive diagnostic source and therefore used infrequently.
■ Occasional cases of craniosynostosis are best examined using CT scan, with
3D reconstruction, which may help in certain forms of craniosynostosis for
planning of surgery (FIG 1).
SURGICAL MANAGEMENT
■ With a typical clinical exam, or confirmatory CT scan, cranioplasty is typically
performed early in life to take advantage of the potential for better intellectual
development (up to 6 months of age).4,7
■ The counterargument to earlier surgery is the potential increase in the number
of cases requiring revision surgery, as structurally it is more difficult to account
for continuing growth when surgery is performed at earlier stages of life.
■ Bone manipulation and stabilities are enhanced in older-age children beyond 6
months of age, but the issue of deleterious impact on brain development is now

creating more concern, leading to promoting delayed surgery.14,15
■ An advantage of earlier surgery is better malleability of bone.
■ Larger bone defects may fill in secondarily by subsequent growth of the brain
and dura.
■ Potentially improved neurologic outcome
■ Disadvantages of early surgery include the following:
■ Increased risk for proportionate blood loss with smaller amounts of volume
lost
■ A potential increased requirement for repeat surgeries in the future
■ Advantages of later surgery (delayed to 1 year of age):
■ More mature brain and bone systems to be operated on
■ Blood loss is not as strong a concern due to increased body weight and
proportionate circulating blood volume.
■ Structures may be fixed in place more securely with lesser concern about
growth restriction.

FIG 1 • 3D CT reconstruction of craniosynostosis
subtypes. Metopic craniosynostosis (trigonocephaly) in
frontal view (A), oblique view (B), and top-down view

(C). Unilateral coronal craniosynostosis (anterior
plagiocephaly) in frontal view (D), oblique view (E), top-
down view (F). Bilateral coronal craniosynostosis
(brachycephaly) in frontal view (G), right lateral view
(H), left lateral view (I), and top-down view (J).
■ Disadvantages:
■ Bone defects are more difficult to “fill in” nonoperatively.
■ Bone is more difficult to remodel at approximately 1 year of age.
■ Potential reduction in brain function related to delay
Preoperative Planning
■ Generally, once the decision to perform surgery has been made, and with
confirmatory clinical and/or CT exam, preparation includes appropriate
supports from blood loss to include monitoring, review of current status of
blood count, preparation for blood replacement, monitoring for air emboli
(Doppler, end-tidal CO2, mean arterial pressure, CVP), and, in selected cases,
coagulation studies to support reduction in blood.
■ Plan for admission to a postoperative care setting consistent with potential
need for urgent care.
Positioning
■ Typically, the patient is placed supine for optimal supraorbital rim
advancement regardless of etiology of the nonsyndromic craniosynostosis.
Approach
■ Fronto-orbital advancement via the tilt procedure is the authors’ preferred
approach.16–19
■ It has the main advantage of potentially greater preservation of baseline blood
supply to the osteotomy segments.
■ This procedure also addresses the issues of reducing the likelihood of
postoperative depressions in the anterior temporal fossa and adds forward,
stable projection of the supraorbital rim, without the added potential for
restricting postoperative growth due to rigid fixation.

T E C H N I Q U E S
■ Incisions for the Tilt Procedure
■ Incision line is posteriorly inclined from the region just anterior to the ear, to
the occiput below the level of the hair whorl to minimize scar visibility and
ease of the visualization of the skull20 (TECH FIG 1A,B).
■ For the posteriorly inclined coronal incision, care must be taken to preserve
the ascending branch of the superficial temporal artery to maintain
appropriate vascularity for the scalp (TECH FIG 1C).
■ An alternative to this incision is to do either a straight coronal incision that
is slightly posteriorly inclined or a stealth incision.
■ These alternatives, however, have more potential visible scarring and take
longer to both incise and close.
■ All incisions should include injection of local anesthetic with epinephrine
and intraoperative use of clotting agents (such as aminocaproic acid and
tranexamic acid).
■ Exposure of the frontal and periorbital regions bilaterally is appropriate for
both coronal synostosis and metopic synostosis to assess symmetry (TECH
FIG 1D).
■ Intraoperative confirmation of fused sutures is made.
■ Subperiosteal dissection is performed at the level of the orbital rims to
expose the deficient projection of the rims (TECH FIG 1E).
■ General and specific operative steps and modifications are given below
based on the individual sutural pathology.

A Frontal branch of superficial temporal artery and vein Superficial temporal artery and vein Posterior auricular artery and vein B Parietal branch of the superficial temporal artery and vein Occipital artery and vein

TECH FIG 1 • A, B. Preferred incision line is placed
posteriorly toward the occiput below hair whorl to
maximize skull exposure and minimize scar visibility
postoperatively. C. Elevation of scalp flap in subgaleal
plane with preservation of superficial temporal
vessels. D. Subperiosteal dissection 1 cm above the
orbital rim border to preserve neurovascular bundle of
supraorbital and supratrochlear vessels. E. Temporalis
reflected to the level of pterion (arrow).
■ Unilateral Coronal Synostosis
Exposure and Bur Hole Placement
■ Exposure of the frontal/parietal bones in the supraperiosteal plane (less
blood loss)
■ Bifrontal craniotomy is performed with exposure of bilateral supraorbital

rims, in a subperiosteal plane.
■ Ipsilateral to the fused suture, the periorbita and anterior temporalis muscle
(approximately the superior 50% of the origin of the muscle) is dissected
from the underlying bone.
■ Bur hole placement for the bifrontal craniotomy is placed more cephalad and
posteriorly, so as to reduce the likelihood of depression in the frontal bone
profile postoperatively.
■ Bur hole placed on the fused side, as the coronal suture is displaced
anteriorly.
■ Measurement is made of the distance from the normal coronal suture,
contralateral to the fused suture, to the midline. This distance is transferred
to the side ipsilateral to the fused suture to define the position of the
osteotomy line, to get a symmetrical bifrontal bone segment for remodeling
the frontal region (TECH FIG 2).
Supraorbital Rim Osteotomy and Advancement
■ An orbital roof osteotomy is performed in situ, with a side-cutting bur and
osteotomes from the lateral orbit to the anterior cribriform plate region
(TECH FIG 3A–D).
■ Care is taken to avoid extensive dissection around the frontozygomatic
suture to prevent disruption of the frontozygomatic suture soft tissue with
advancement of the orbital rim.
■ Advancement of the orbital rim is performed in situ with as minimal as
possible disruption of the metopic-frontonasal suture tissue junction medially
and the frontozygomatic suture laterally (TECH FIG 3E):
■ Angulation forward can be up to 1 to 1.5 cm (usually 1–1.2 cm), depending
on the degree of deformity.

TECH FIG 2 • Location of bur holes relative to fused
suture (temporalis muscle). Placement of bur hole
posterior to coronal suture (arrow) is to prevent
worsened temporal hollowness.

TECH FIG 3 • Supraorbital rim osteotomy. A. Orbital
roof osteotomy starts laterally, with adequate distance
(10–15 mm) from the rim to account for a potentially
thin supraorbital foramen. B. Lateral osteotomy
(dashed line) is carried medially sequentially along
orbital roof. Careful attention is paid so as to avoid

osteotomy beyond the frontozygomatic suture (arrow).
C. Medial orbital roof osteotomy (dashed line) is
carried out in midline anterior to the cribriform plate to
avoid CSF leak. D. Completed orbital roof osteotomy
demonstrating osteotomized segments, orbital
contents, and preservation of soft tissue at
frontozygomatic suture. E, F. Demonstration of the
degree of tilt achievable after orbital roof osteotomy
(arrow).
■ Correction of the lateral orbital roof and greater wing of the sphenoid
deformity (harlequin deformity) is performed with rongeur removal of
abnormally positioned bone, to a point approximately 1 to 2 cm lateral to the
superior orbital fissure.
■ This allows less impeded advancement of the anterior tip of the temporal
and frontal lobe into the area of hypoplasia in the frontal region,
consequently improving its contour.
■ The squamous temporal bone has a more convex outward profile in UCS, on
the fused suture side.
■ It is either removed by rongeur or remodeled in situ with the aid of barrel
stave osteotomies.
■ Stabilization of the advancement of the orbital rim is desirable to prevent
collapse with a reflection of the scalp flap later on, but “too rigid” fixation
may impede further growth of the fronto-orbital complex postoperatively
(if standard anterior and posterior rigid plate fixation is performed).
Bony Fixation
■ A resorbable orbital rim advancement plate (KLS) is used to angulate the
fronto-orbital bar anteriorly, which maintains its normal attachment point
(pivot point), at the level of the frontozygomatic suture laterally and the
metopic/frontal nasal sutures medially (TECH FIG 4A,B):
■ This angulated bone improves the potential for normal profile of the lateral
orbital rim and supports bone continuity in this region of remodeled frontal
bone later in development.
■ The absorbable plate is straight initially and should remain flat to diminish
the abnormal convexity noted preoperatively in this region.

■ The resorbable plate is remodeled anteriorly at the attachment point to the
orbital rim, with the use of warm water bath (TECH FIG 4C–E).
• Removal of the excess flare of the anterior footplate using an
ophthalmology cautery is common.
• Once released, the angle of the orbital rim is tilted forward as much as soft
tissues will allow (usually approximately 10–12 mm). The posterior cup
end of the plate is indexed to the anterior border of the cut squamous
temporal bone.
• This will be done in a series of approximations to be able to get the
maximum of tilt and also security of the plate posteriorly.
• This is typically done by leaving a “ledge” of bone at the superior border
of the squamous temporal bone to facilitate greater stabilization without
screw fixation.
• Although there are holes placed in the wings of the posterior cup of the
orbital rim plate for potential securing, we advise not to use them so as to
allow the fronto-orbital complex to grow anteriorly, without constraint
postoperatively.
■ Testing is performed to determine the maximum advancement that can be
achieved (TECH FIG 4F):
• This is done by successive steps of placing the cup (posterior) end of the
resorbable plate into a cut out segment of squamous temporal bone and
tilting the orbital rim forward manually yet still preserving the
zygomaticofrontal suture fibrovascular tissue.
Completion
■ Minimal contouring of the mediolateral dimension of the internal surface of
the fronto-orbital bar may be performed at this time, if there is a discrepancy
of more than 2 mm:
■ This is accomplished with a shaping bur, to approximate the normal
dimensions between the fused suture orbit and the nonfused suture orbit
contralaterally.
■ The frontal bone and the medial orbital rim are remodeled anteriorly with a
bur, to reduce any unusual prominence of the advanced orbital rim-temporal
bone complex.
■ The bone chips that had been harvested from the squamous temporal bone
and the greater wing of the sphenoid earlier in the operative procedure are
now placed in the pocket between the advanced orbital rim and remaining

squamous temporal bone, beneath the temporalis muscle.
■ The temporalis muscle is secured over the resorbable plate with a long-term
resorbable suture to the advanced orbital rim anteriorly (primarily) and is
released posteriorly, just anterior to the ear, to allow anterior rotation of that
segment with less tension.

TECH FIG 4 • A. Resorbable plate for anterior bony
fixation of FOA. B. The plates can be molded using a
hot water bath to the desired convexity as needed.
The top plate is convexed molded for metopic
craniosynostosis. The bottom plate remains straight
for coronal craniosynostosis. C. A bony ledge is
created by resection of squamous temporal bone with
a rongeur, creating a groove to interdigitate with the
posterior cup of the absorbable plate. D. Angling the
orbital rim forward, the cup of the plate is placed into
the notch to test length, curvature, and interdigitation
with supporting upper bony ledge (arrow). E. The plate
is remodeled as needed with water bath and high-
temperature cautery to ensure adequate fit of plate to
superolateral orbital rim. F. The plate is secured
anteriorly with resorbable screws. Determine tilt and
secure with maximal tilt with pivoting on
frontozygomatic suture. Drill holes, and place
resorbable screws into superolateral orbital rim.
■ Metopic Synostosis
■ Metopic synostosis is characterized by a triangular skull deformity, which is
addressed through a bifrontal craniotomy with contouring of the prominent
metopic ridge, and radial osteotomies to allow remodeling of the frontal bone
to assume a more normal contour pattern once the orbital rims have been
advanced.
■ The exposure of the orbital rims bilaterally is similar to that in the
unilateral/bilateral coronal synostosis patients; however, the differences
relate primarily to the revision of the tissues of the temporal region.
■ Orbital roof osteotomy is performed as in coronal synostosis.
■ The distinction between metopic and coronal synostoses is noted in that the
squamous temporal bone in metopic synostosis is “flatter” compared to the
convex profile in UCS patients.

■ The resorbable plate is made more convex to fit a more normal temporal
profile.
■ The plate is remodeled in a heated water bath to allow for a gentle curve
(more convex form) in the supporting bar.
■ The attachment to the advanced orbital rim and fixation or support through
the squamous temporal bone posteriorly is otherwise identical to the
coronal synostosis patients (TECH FIG 5).
■ The bone chips removed are morselized and placed in the space between
the temporalis muscle and the lateral temporal lobe/squamous temporal
bone. The temporalis muscle is placed over the convex bar of the plate to
expand the projection of the squamous temporal bone profile.
■ Bleeding from the base of the skull can be addressed through standard bone
wax, injectable collagen, and thrombin products.
TECH FIG 5 • The absorbable plate is fixed anteriorly
with a resorbable screw (arrow). The posterior plate is
cupped into bony groove created with overlying ledge
to support the posterior cup of the absorbable plate
(yellow line).
■ Bilateral Coronal Synostosis

■ Bilateral coronal synostosis is handled similar to UCS patients with
supraperiosteal dissection for bifrontal craniotomy, bilateral orbital rim
exposure in a subperiosteal plane, and bilateral elevation of the periorbital
tissue intraorbitally, to avoid injury during release of the orbital roof by side-
cutting burs and osteotomes.
■ Both orbital rims are tilted forward as described unilaterally in UCS, so as to
include release of the bone just anterior to the cribriform plate in the crista
galli, with an osteotome.
■ With this, there may be excess prominence of the orbital rims medially, and
if so, local contouring is performed in situ, as described for UCS.
■ There is no attempt to correct the hypoplasia of the zygomas bilaterally,
particularly in syndromic cases, as this will be later addressed through Le
Fort advancement procedures.
■ Early intervention risks possible injury to a developing malar region and
tooth structure by the C-shaped osteotomy into the zygoma.21
■ C-shaped orbital osteotomy extending into the zygoma is used only for a
limited number of cases to include minor degrees of depression of the
zygomas in nonsyndromic bilateral coronal synostosis patients who are
older than 1 year of age and who will not be undergoing Le Fort
advancement later in life.
■ However, the patent frontozygomatic suture does not allow enough support
to make substantial long-term advancement in the zygoma. Therefore, care
is taken to avoid dissection in this plane in the young child (less than 1 year
of age).
■ The squamous temporal bone advancement is handled much like it is in the
patient with UCS.
■ The exception being that in bilateral coronal synostosis, the greater
sphenoid wing is not typically as abnormal, and ordinarily, does not require
resection of this skull base segment.
■ The forehead remodeling and reshaping is also the same (radial osteotomies
in infants older than 1 year of age), as it is for UCS.
■ Alternate Methods
■ There are two general categories of alternate techniques to advance the
orbital rim.

■ The “free floating” orbital rim technique relies on osteotomy at the
frontozygomatic suture, orbital roof osteotomy, and greenstick fracture
advancement of the orbital rim.
■ This technique of advancement relies on the growing brain to propel the
orbital rim forward with subsequent development. This technique has the
advantage of being quick and easy, with in situ release of the orbital rim.
■ Disadvantages include the following:
• Short- and long-term scalp flap (soft tissue) restriction of the advancement
of the bony rim
• It does not correct the squamous temporal deformities (convex or planar)
associated with coronal and metopic synostosis.
• Detachment of the pivot point at the frontozygomatic suture results in
subsequent posterior tilting of the rim with growth, creating a frontal bone
depression locally, postoperatively.
■ The other approach is the “fixed plate” overcorrected position technique,
which has the advantage, in the immediate perioperative period, of
overcorrection and prevention of orbital rim collapse after rigid fixation in
the immediate postoperative period.
■ This avoids the constricting influence of the skin flap that is likely to occur
later on in the postoperative period from scalp replacement.
■ It is particularly important because most rigid advancement techniques
detach the zygomatic process to the frontal bone from the frontozygomatic
suture. If not stabilized, this will collapse inferiorly and rotate the
supraorbital rim posteriorly; this diminishes the profile of the frontal bone
in this region.
■ Advancements with fixation of larger distances (1.5–2 cm) have been used
in order to try to address this restriction.
• It remains to be seen if this is sufficient to be effective long term, as it also
potentially restricts the ability of anterior growth postoperatively.
■ Disadvantages:
• “Posterior” rigid fixation with plates and screws restricts long-term
forward growth of the supraorbital rims.
• Rigid fixation with ex vivo remodeling of the bone, such as the use of
templates, may contribute to longer-term devascularization and yield less
bone production over the longer term.
• Postoperative overcorrected “look” at the level of the orbital rims.

PEARLS AND PITFALLS
Technique
■ Reduce temporal hollowing with more posterior placement of bur
holes—just posterior to the coronal suture.
■ Maintain fibrous/bony attachment at the frontozygomatic suture to
have base support for pivoting of the orbital rim. This reduces the
likelihood of posterior rotation of the superolateral supraorbital rim
and adjacent frontal bone, leading to postoperative temporal
depression.
■ Resorbable, cupped plates prevent initial posterior collapse of the
advanced orbital rim, with later scalp closure.
■ Avoid growth-impeding, posterior rigid plate fixation.
■ Individualize technique to specific deformities of unilateral coronal,
bilateral coronal, and metopic synostosis.
POSTOPERATIVE CARE
■ The patient is placed in a lightly wrapped head dressing:
■ Supine position is recommended primarily for patient comfort.
■ Typically, helmets or further supports to the bone are not required for
metopic synostosis but may be for coronal synostosis.
■ If helmets are to be used, the decision is to be made 6 weeks postoperatively,
when initial postoperative swelling is reduced adequately.
■ Patients are often placed in the pediatric ICU for resuscitation (if needed) and
monitoring:
■ Hemodynamics, urine output, hemoglobin, hematocrit, and serum chemistries
are serially checked, and resuscitation is undertaken, until clinical stability is
ensured.
■ Blood loss is an important consideration, and transfusions should be given
for both laboratory and hemodynamic considerations.
■ Patients are transferred to pediatric floors and discharged once clinical
stability parameters are met.
■ Clinical monitoring for blood loss and visual responsiveness are carried out
throughout the postoperative period.
OUTCOMES

■ To date, there have been limited long-term assessments of fronto-orbital
advancement techniques with current techniques and sufficient numbers,
appropriately divided as to diagnosis, to state definitively “the” best method.
■ Reports have related to development of frontal sinuses and fronto-orbital
advancements.
■ The major concern about long-term outcomes is that orbital rim projection and
development will be diminished.
■ Reports often cite a lack of normal growth of the supraorbital rim and the
presence of frontotemporal hollowing in later postoperative reviews.
■ The role of genetics on outcomes has yet to be determined.
COMPLICATIONS
■ Complications are largely related to lack of growth with retained or new
deformity, in normal fronto-orbital rim region development. This may be
exaggerated by:
■ Loss of attachment of the temporalis muscle leading to a hollowing in the
region just posterior to the advanced rim. This may be addressed by complete
release of the temporalis muscle posteriorly and advancement of the muscle
attachment to the orbital rim anterolaterally.
■ Fracture of the advancing orbital rim at the point of the supraorbital nerve
foramen
• This is addressed prior to surgery by using a thicker segment of bone
superior to the foramen. Instead of 8 to 10 mm, use 10 to 12 mm in that
region and/or wider segment of orbital roof to be advanced adjacent to the
region of the supraorbital rim.
• If fracture does occur at the supraorbital rim at the time of surgery, stabilize
it with a resorbable plate.
■ Disruption of the frontozygomatic suture during the tilt procedure. If it
becomes detached, it should be reattached with long-lasting resorbable suture
through separate drill holes through the zygomatic process of the frontal bone,
and frontal process of the zygomatic bone, surrounding the frontozygomatic
suture.
■ Plate restriction of growth of orbital rims. Treatment is avoidance of
posterior fixation of support for orbital rim advancement.
■ Postoperative changes may arise from incomplete knowledge of mechanisms
of orbital rim growth, such as the role played by individual genetic factors,
and vascularity of advanced bone segments.

REFERENCES
1. Babler WJ, Persing JA, Persson KM, et al. Skull growth after coronal
suturectomy, periostectomy, and dural transection. J Neurosurg. 1982;56:529-
535.
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2
CHAPTERFronto-Orbital Distraction
Jesse A. Taylor and Wen Xu
DEFINITION
■ Craniosynostosis affects 1 in 2500 live births worldwide and is defined as the
premature fusion of one or more cranial sutures.
■ Craniosynostosis may affect a single suture or multiple sutures and may be
idiopathic or associated with an underlying syndrome.
■ The most frequently affected suture is the sagittal suture, followed by the
coronal suture, the metopic suture, and the lambdoid suture.
■ Cranial vault distraction allows for gradual expansion of bone and soft tissues
of the cranium without leaving behind any indwelling hardware in the growing
craniofacial skeleton.
ANATOMY
■ There are four major calvarial sutures (metopic, sagittal, coronal, and
lambdoid) that are patent at birth but close in a predictable and sequential
manner in the first few years of life.
■ The metopic suture divides the two halves of the frontal bone in the sagittal
plane.
■ The sagittal suture is located along the midline and divides the left and right
parietal bones.
■ The coronal suture is located between the frontal bone and the parietal bone
and can be divided into a left coronal suture and a right coronal suture.
■ The lambdoid suture is located between the parietal bone and the occipital
bone and is continuous inferiorly with the occipitomastoid suture.
■ The anterior fontanelle is a diamond-shaped membrane-filled space located at
the junction of the metopic, sagittal, and coronal sutures that is present in