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Suture between the two forehead bones had fused prematurely thus causing the cranio-facial deformity
India
healthysoch
New Delhi, February 10, 2021 :
A multi-disciplinary team of doctors at Fortis Hospital Shalimar Bagh treated an 18-month of infant suffering from Trigonocephaly. A rare condition in which the shape of front of the head is triangular, causing aesthetic and neuropsychological development defects. Such a case is not only surgically challenging, but it also requires meticulous planning. A cranio-facial surgery was performed to correct the deformity by a team of doctors led by Dr. Sonal Gupta, Director, Neuro and Spine Surgery and Dr. Richie Gupta, Additional Director, Plastic, Aesthetic and Reconstructive Surgery.
Dr Sonal Gupta said, “The infant presented with a triangular shaped appearance on the forehead and hypotelorism (a condition in which, the eyes appear closer together than normal). Normally, the bones forming the skull are separated by joints called sutures, which also serve as centres of growth. These sutures fuse at set times after birth, one of the earliest being the suture between frontal bones, the metopic suture which obliterates between 3-9 months of age. An early sutural fusion result in lack of skull growth in a direction perpendicular to the suture. However, the brain is still growing at a rapid rate during this period and needs space to do so. Therefore, the condition needed to be corrected, as it could hamper the neuro-psychological development of the child in addition to the obvious aesthetic defect.”
Dr Richie Gupta said, “A cranio- facial approach was needed to correct the deformity. We fed the digital data from patient’s 3DCT scan into the 3D printer to print two rapid protype skull and upper face models, which were exact replicas of patient’s skull. We worked on these to determine the exact site, dimensions, and angles of the osteotomies (bony cuts) on patient’s skull. There was no scope for even the smallest of deviations as it could cause the child to go blind, bleed profusely or even suffer from brain damage. To ensure that the actual surgery went off smoothly, we conducted the mock surgery on the 3D model of the skull a day prior.”
Dr Richie Gupta adds, “During the actual surgery, the next day, we transferred the measurements from 3D models to patient’s skull. We did an entire cranio-facial remodelling by removing the frontal bones (these form the forehead and front part of skull), as well as the orbital bandeau (which forms the lower part of forehead and the upper half of eyeball sockets) while simultaneously ensuring that the brain and eyeballs were protected. We recontoured these bones to the angles and dimensions as per the model surgery and replaced these in corrected position. We used absorbable sutures, miniplates and screws to avoid migration of implants to intracranial or inaccessible locations with later growth of this child. Our work with the two 3D models proved to be fruitful, enabling us to be meticulous in our execution, reducing the operative time and allowing the actual surgery to be precise.”
Dr Sonal Gupta adds, “It was a complex surgery which took seven hours. To put an infant under anaesthesia for that long is a challenge. It was an intensive and precise process which would not have been possible without the support of the anaesthesiology team led by Dr Umesh Deshmukh (Director and HOD anaesthesiology). There was a risk of significant blood loss during the surgery, so multiple blood products were arranged. After the surgery, we shifted the patient to the ICU, where he stayed for 3 days under the care of Dr Amit Singh (Consultant Paediatric Critical Care). Post this period, he was shifted to the ward for 2 days and on the 6th day he was discharged. Even though I had first met with this patient when he was only two months old, I chose not to the surgery immediately as it would not have yielded the desired results.”
Dr. Mahipal Bhanot, Zonal Director, Fortis Hospital Shalimar Bagh said, “Multiple specialities worked together to ensure that the best possible patient care was provided to the patient. I am very proud of our doctors, their co-ordinated efforts, and their commitment to their patient. Once again, Fortis Hospital Shalimar Bagh has proved that it is a premier hospital for patient care.”
Trigonocephaly (Greek trigonon, ‘triangle and kephale, ‘head’) is a congenital condition of premature fusion of the metopic suture (from Greek metopon, ‘forehead’). Premature merging of the two frontal bones leads to transverse growth restriction and parallel growth expansion leading to a triangular long and narrow forehead and anterior cranial fossa.
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