Successful cases depend on continued intraoperative communication between the anesthetist, the craniofacial surgeon, and the neurosurgeon. Below are general principles for open or minimally invasive surgeries.
- Hemostatic scalp incision and reflection: Several steps can be taken to minimize blood loss during opening. The injection of normal saline into the marked incision will compress scalp vessels. The most superficial dermal layer can be opened with unipolar “Colorado” or insulated needle tip cautery (setting on cut, 2-15 W) to decrease blood loss. This is a simple and quick skin incision that does not extend into the deep layer. It is followed by coagulation of the galea (15W) and the blood vessels that run through it. The galea should be opened from the inside out, thereby coagulating vessels prior to their bleeding.
- Attention to bone bleeding to minimize: Bone bleeding is quickly stopped with large pieces of thrombin-soaked hemostatic sponge aggressively pressed into the bone edges and along the surface. If a pediatric cell saver is used, hemostatic gelatin sponges or similar agent cannot be used.
- Suction electrocautery: Suction electrocautery may be used to stop bone bleeding in the endoscopic method. If the diamond drill bit is not used in the minimally invasive method, the bone is cut with scissors. There may be bleeding from these edges that cannot be reached. A tonsillar suction electrocautery used with caution and dural coverage will stop this small hemorrhage.
- Drill usage: The author uses diamond drill bits to make the bur holes and troughs in the minimally invasive procedure. This decreases blood loss.
- Avoidance of fluid loss: The exposed dura can be covered with moist lap pads as the bone reconstruction is underway on the back table to minimize insensible fluid losses.
- All dural tears repaired: Any dural tears are sutured with absorbable 4.0/5.0 suture.
- Drains not required: Drains are not required, as the child’s face and scalp will swell from hematoma and skin retraction during surgery. Hematoma will be reabsorbed and swelling resolved over the first 4 days after surgery.
- Endoscopic treatment before 3–5 months of age: Reshaping is performed prior to 3 months of age. Some pediatric neurosurgeons have achieved good results in infants younger than 5 months of age if the appearance is mild. It is theorized that the bone is more malleable at the younger ages, thereby permitting the achiement of an improved cosmetic result with the helmet.
- Performed early in infancy: Reshaping is usually preformed prior to 3 months of age with 5 months of age being the upper limit.
- Limited scalp incisions: Scalp incisions provide access to calvarium for burr hole placement and introduction of tools for craniotomy.
- Synostosis cut out under scalp: The intended craniotomy is done under the scalp by elevation of the scalp and development of an epidural plane along the intended cut. Instruments are introduced via small incisions at bur holes to work under the scalp to perform craniotomy.
- Helmet recommended after surgery: Advocates of this technique commonly use helmets for variable periods after the surgery to define the final head shape.
- Performed after 4 months of age: Open craniotomy for reshaping of the cranial vault is performed from the ages of 4 to 12 months depending on the surgical team.
- Variety of techniques: Various techniques have been advocated for remodeling a cranium distorted by a prematurely fused suture. They span a spectrum from simple suture resection to complex craniotomies for extensive remodeling of the calvarium.
- Many involve multidisciplinary surgical teams: The more complex remodeling procedures will typically be performed by multidisciplinary craniofacial teams of neurosurgeons, plastic surgeons, and possibly others.