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Surgical Outcomes in Craniosynostosis Reconstruction - The Use of Prefabricated Templates in Cranial Vault Remodeling
David Y. Khechoyan, MD1, Nikoo R. Saber, PhD2, Jonathan Burge, MBChB3, Adel Fattah, PhD4, James Drake, MD5, Christopher R. Forrest, MD, MSc6, John H. Phillips, MD6.
1Texas Children's Hospital, Houston, TX, USA, 2The Centre for Image Guided Innovation and Therapeutic Intervention (CIGITI), Toronto, ON, Canada, 3Department of Plastic & Reconstructive Surgery - University of Auckland, Auckland, Australia, 4St. Andrew's Centre for Plastic Surgery, Chelmsford, Essex, United Kingdom, 5Division of Neurosurgery - The Hospital for Sick Children, Toronto, ON, Canada, 6Division of Plastic & Reconstructive Surgery - Centre for Craniofacial Care and Research - The Hospital for Sick Children, Toronto, ON, Canada.

PURPOSE:
Cranio-orbital reshaping for anterior cranial vault deformities associated with craniosynostosis traditionally relies on the surgeon’s subjective estimate of the shape and appearance of a normal forehead. Patient-specific supra-orbital bar bandeau templates created with CAD/CAM (computer-aided design/computer-aided manufacture) were introduced in our center to eliminate this subjectivity and to effect more reproducible surgical results. The aim of this study was to compare two groups of patients (template, n = 14 vs. no template, n = 23) to examine surgical outcomes.
METHODS:
The virtual, computational version of the template was utilized as an outcome assessment tool. It was used to calculate an intervening area under the curve (AUC) between the normative template and the patient’s reconstructed supra-orbital bar on a representative CT axial section. In the subset of patients in the no template, control group who had a follow-up CT scan at one year post-operatively (15 of 23 patients), further analysis was performed to quantify the stability of the reconstruction and to note any relapse.
In the template group, the synostosis diagnoses included 7 metopic, 5 unilateral coronal, 1 bilateral coronal, and 1 fronto-sphenoidal. The mean age at time of operation was 11. 5 months; and mean weight was 9.6 kg. In the no template (control) group, there were 11 patients with metopic and 12 patients with unilateral coronal suture synostosis. The mean age at time of operation was 10.2 months; and mean weight was 9.7 kg. A comprehensive chart review of patients in both groups to examine the peri-operative variables was conducted.
RESULTS:
In the template group − as compared to the control, no template group − the use of the bandeau template led to a greater reduction in AUC (74% vs. 56%, p = 0.016), indicating a better post-operative conformity between the reconstructed supra-orbital bar and the ideal, normal bandeau shape. The duration of operation was significantly reduced with the use of the template (212 vs. 258 minutes, p < 0.001). For the no template, control group, at a follow-up period of one year, 7 of 10 patients with metopic and 2 of 5 patients with unilateral coronal synostosis had relapse of the original reconstruction. On average, approximately 41% relapse of the original AUC reduction was noted for the 7 patients in the metopic group.
CONCLUSION:
The application of pre-fabricated templates in cranio-orbital reshaping is highly useful for accurate pre-operative planning; reproducible and efficient intra-operative correction of dysmorphology; and for objective surgical outcomes assessment.


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