Jesse's Op Report

CFS Op Report: My notes are in bold

The patient was identified. The presence of informed consent was noted to be in the chart. The patient was taken back to the operating room and placed supine face up on the operating table. Administration of general anesthesia was conducted uneventfully by Anesthesia. IV antibiotics were administered as well as mannitol this is used for Reduction of intracranial pressure and brain mass and Decadron (dexamethasone) is a corticosteroid, is similar to a natural hormone produced by the adrenal glands and is used to treat arthritis, skin, blood, kidney, eye, thyroid, intestinal disorders, severe allergies, and asthma. Decadron is also used to treat certain types of cancer and occasionally, cerebral edema per Neurosurgery's request. The hair was clipped in a 1.5-cm strip from ear to ear and a stealth bicoronal wavy, ear to ear incision was designed over the cranium. This was injected with 0.25% Marcaine with 1:100,000 epinephrine solution local or regional anesthesia for a total of 5 mL. An incision was made in the skin using electrocautery cauterizing instrument heated by electricity.

Dissection of the bicoronal flap was performed with a combination of blunt and sharp dissection in a subgaleal plane to the level of the superior orbital rim. The temporalis muscle was elevated bilaterally from the cranium. The subperiosteal plane was then entered at the level of the supraorbital rim, and subperiosteal dissection was conducted around the medial and lateral orbit and down to the nasofrontal junction. This paragraph describes how they pulled down the skin from the skull

Methylene blue was then used to mark out a frontal bone flap, and Dr. M elevated the flap. His dictation will be recorded separately. They marked the skull where the cuts were to be made

After obtaining the coronal flap frontal bone, forehead, the metopic ridge was burred down on the back table and the bone was transected divide by cutting at a right angle to the long axis in the midline with incomplete wedge osteotomies this is a triangular cut that does not completely go through the bone shown as triangular cuts in the diagram made to allow greenstick fracture bone fractures that don't go all the way through because the bone is still soft in infants and expansion. Some widening of the front of the forehead region was performed to a distance of approximately 1.5 cm. The new configuration of the bone was secured with KLS absorbable plates and screws. Used plates and screws to keep the forehead in the shape he created

The orbital bandeau top of the eye sockets was then incised from lateral to medial from the side to the middle at the zygomaticofrontal junction and at the zygomaticosphenoid junction describing exactly where the cuts were made. This was carried transversely medially across the middle through the nasal bones and an osteotomy bone was cut was used to complete the cuts with maintenance of the medial canthi attachments where the medial canthus ligaments attach. The orbital bandeau top of the eye sockets was then split longitudinally down the midline cut in half and expanded by about 1 cm move about 1 cm apart and secured using KLS absorbable plates. The lateral aspects that were expanded explained in previous sentence of the frontal bandeau were then all similarly secured to the temporalis bone using KLS absorbable plates. The temporalis muscle was resuspended using 3-0 Vicryl sutures and the frontal plate, which had been recontoured talking about the frontal bone that had already be recontructed, was similarly replaced onto the cranium and secured using KLS absorbable plates. Bones scraps from the turned frontal bone flap were used to fill in bony defects.

The scalp was reduced and contour was found to be satisfactory they replaced the skin flap and were happy with the results. Copious irrigation was then performed, and the galea was closed using interrupted 3-0 Vicryl sutures followed by 3-0 chromic gut in the skin. Explaining closure of the incision No drain was placed in this procedure. Bacitracin and Telfa were then used to cover the incision and a sterile head wrap was applied. Patient tolerated the procedure well and was transferred to the recovery room in stable condition.

NS Op Report:

PROCEDURE PERFORMED:
Multiple flap craniotomy for craniosynostosis repair with bone autograft and barrel stave-type procedure under general anesthesia.

Patient is supine in the operating room. He received intravenous antibiotics and glucocorticoids prior to the skin incision. The patient's anterior cranial vault and craniofacial region were clipped/prepped and draped in the usual sterile fashion.

I made an ear-to-ear incision with electrocautery dissecting through the subcutaneous tissue and galea aponeurotica with electrocautery. We turned the subgaleal dissection down the frontal orbital region bilaterally with electrocautery. After that was performed, we then dissected out the lateral temporalis fascia bilaterally using electrocautery. Dr. C performed a frontal orbital dissection, dictated by him as a separate dictation.

After Dr. C completed his frontal orbital dissection, I then created a large bifrontal-type craniotomy. I made bur holes in the lateral temporal region bilaterally with the Midas Rex drill, then I exploited the still open anterior fontanelle by using electrocautery along the anterior margin of the anterior fontanelle and then carefully dissecting the dura away from it using the #1 Penfield dissector. After that was accomplished, I then created a large bifrontal craniotomy using the footplate attachment with the Midas Rex drill into the osteotomies laterally from the temporal bur holes to the bregm a, anterior fontanelle, and then anteriorly around the frontal orbital region down to the mid nasion region. After that was accomplished, I then carefully dissected the dura away from the overlying cranial bone with a #1 Penfield dissector. I then snapped the bone flap over on the nasion and handed this to Dr. C who performed reconstruction of it on the back table. This will be dictated by Dr. C as a separate dictation.

After that was accomplished, I then easily achieved hemostasis with bipolar electrocautery, and then placed Gelfoam fibrillar over the sagittal sinus to good hemostatic effect. I then carefully dissected in the anterior cranial fossa with the #1 Penfield dissector and bipolar electrocautery. I elevated the frontal lobes bilaterally. I dissected down to the region of the foramen cecum in the midline, and then laterally over to the lateral sphenoid wings and over the orbital roofs bilaterally. After that was accomplished, I then created 2 small craniectomies over the anterior parietal regions bilaterally at Dr. C's request to use for further bone autografting. I used the footplate attachment to make a small craniectomy first on the right and then on the left and handed the additional bone flaps over to Dr. C who used them for reconstruction on the back table. I achieved hemostasis easily with bone wax and the bipolar electrocautery. I also applied Surgicel over the exposed dura.

After that was accomplished, Dr. C then performed a frontal orbital advancement. This will be dictated by him as a separate dictation. We examined the floor of the anterior cranial fossa and there was no evidence of any dural tears or lacerations, cerebrospinal fluid leakage or untoward bleeding.

The bone autografts were then reconstructed on the back table using the resorbable cranial plate fixation set and were brought into the field and used for bone autografts, and the reconstructive result was excellent.

We then irrigated with antibiotic saline. Hemostasis was quite good. We resuspended the temporalis fascia bilaterally with 3-0 Vicryl stay strictures. The galea aponeurotica was closed with 3-0 Vicryl in an interrupted fashion, and the skin was closed in the second layer. We placed antibiotic ointment and sterile dressings. The patient was taken from the operating room in stable condition.

This report is just explaining exactly how the bone was removed and doesn't give any detail as to how the reconstruction was actually done.

I think he did something like this:

But I don't think the forehead was actually split apart as shown. It seems as though all he did was burr down the ridge and then made triangular cuts to flatten out the forehead, but the suture itself was left intact if I am reading the report correctly.

I don't think there was much reconstruction done. I think he just took the orbital bandeau off, cut it in half, moved it out a bit and then put it back on. The NS came out to talk to use right after he was finished. It was only about 30-40 minute later that the CFS was done. That still bugs me. I don't know how long this sort of thing should take, but 30-40 minutes just doesn't seem like enough time.

So here is what was done. I noted the incomplete wedge osteotomies as barrel staves, but I'm not sure on the correct terminology. I got the term barrel staves from the NS op report. If it is in fact barrel staves, then more of the triangular cuts would have been made, but there is no way to know from the report.

The fact that there was only about 1 cm of adjustment on the orbital bandeau just makes no sense to me at all. I know I'm not a surgeon, or even a doctor for that matter, but it's not very much. I've posted about this on a forum and another mother's son was corrected by 1.5 cm and her son was considered mild and at first it was thought he may not even need surgery. Jesse was considered upper moderate to severe and his correction was only 1 cm. He was under-corrected. And it doesn't appear as though they even released the suture! This makes no sense to me at all either. How do they expect the head to grow if the suture is still fused? Now it even makes more sense to me why they had the helmet removed when they found out the ortho was trying to correct the forehead as well as the plagio in the back. And it explains why he had indications of increased pressure with the helmet as well.

I will admit I am making some assumptions here based on the info from the operative report. The main assumption is that the suture wasn't released. Hopefully his next surgeon will request a CT Scan and we'll know exactly what was done.