The shell technique: bilateral fronto-orbital reshaping in trigonocephaly
Fronto-orbital advancement is the procedure of choice for correction of fronto-orbital recession resulting from coronal synostosis in children. However, long-term follow-up evaluations often reveal "undercorrection" of the deformity with development of recurrent recession of lateral supraorbital regions. One factor that may contribute to this process is devascularization of the fronto-orbital bar during its reshaping and advancement. If subsequent revascularization is suboptimal, excessive resorption or inadequate growth of the bar may lead to supraorbital recession. On the basis of studies of temporal bone grafts, which have shown that vascularized grafts are superior to free bone grafts in terms of bone graft survival, we postulated that maintaining vascularization of the fronto-orbital bar would favor better healing and growth that would translate to more favorable aesthetic results. Herein, we review the vascular anatomy of the fronto-orbital region and report the application in six patients of a technique for fronto-orbital advancement that preserves a significant portion of this blood supply. Technical caveats involved in the successful application of this approach are discussed. The attachment of the periosteum to the lateral two thirds of the supraorbital bar allows additional stability. This prevented the use of plates and screws in these patients.