New surgical techniques for children with craniofacial abnormalities are translating into better outcomes at Cincinnati Children’s, where pediatric neurosurgeons and plastic surgeons work side by side to achieve optimal results.

One technique involves using virtual surgical planning, or VSP, for children with craniofacial abnormalities. Surgery for these patients can involve removing up to 50 percent of the skull and rearranging the pieces to create the desired head shape. Traditionally, pediatric neurosurgeons and plastic surgeons went into each surgery with a “textbook plan” for where to cut and how to rearrange the pieces. But since every skull and deformity is different, they had to improvise during the surgery itself. VSP uses three-dimensional computer modeling so that surgeons can plan more aspects of the surgery in advance.

Creating a digital plan

“With VSP, we use a high-resolution computed tomography scan to create a three-dimensional bony map,” says Jesse Skoch, MD, a pediatric neurosurgeon at Cincinnati Children’s. “The neurosurgeon and plastic surgeon look at that together and decide where to make the initial cuts in the bone, and a technician simulates those cuts in the three-dimensional image. Then we take the virtual skull pieces and manipulate them on the computer until we are happy with the end result. We can shift pieces around, cut a piece in two, compare different approaches and so on. The technology allows us to be more creative and experimental in the planning phase.”

Once the surgical plan is finalized, the VSP software interfaces with a 3-D printer to create two different molds. One is a sterile cutting guide, and the other is a reconstruction guide. “We expose the skull in the operating room, then place the cutting guide on top of the skull and it shows us exactly where to make our cuts,” Skoch says. “After making the cuts, we position the pieces inside the reconstruction guide, which is a resorbable, negative mold of the child’s skull. Once everything is assembled according to the surgical plan, we plate the mold to the intact skull. This technology simplifies the reconstruction process, and can shorten surgery time by as much as one to two hours.”

The craniofacial surgery team has been using VSP for very challenging reconstructions since 2015, but in 2017 began utilizing it much more, even for somewhat routine cases. “We think VSP may be less invasive than the traditional surgical approach, and may be associated with less blood loss, swelling and shorter hospital stays,” Skoch says. “Most importantly, though, we feel VSP helps achieve a better cosmetic result and surgical outcome for these patients.”

Optimizing endoscopic craniosynostosis repair

Skoch has been using another, minimally invasive approach to craniosynostosis that combines endoscopic resection and helmet therapy to optimize the surgical result. “We make one small incision and advance an endoscope under the skin and bone to the site of the abnormal suture,” Skoch says. “The next step is to resect the thin strip of bone that represents the suture in order to create a normal gap. For the next three to 10 months, the child wears a customized helmet that helps guide bone growth to achieve a normal head shape.”

Local pediatricians, recognizing the need for early intervention, are referring families to Cincinnati Children’s for an evaluation in the early weeks and months of a child’s life when craniosynostosis is suspected. This timing allows patients to avoid a dramatic deformity and the need for major reconstructive surgery.