Alexey Markelov MD, Renata Maricevich MD, Liliana Camison MD, Wei Wei Lee BS, Jesse Goldstein MD. Children's Hospital of Pittsburgh, University of ...
Alexey Markelov MD, Renata Maricevich MD, Liliana Camison MD, Wei Wei Lee BS, Jesse Goldstein MD Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
Purpose: Introduction: Fronto-‐orbital advancement (FOA) is the gold standard for surgical correction of both metopic and coronal synostosis. However, incredible variability exists in the description of surgical techniques for performing FOA. These variations and modifications in techniques might significantly impact short and long-‐ term patient outcomes. The authors performed a systematic review of medical literature in order to analyze the degree and significance of these differences in surgical techniques.
Initial Pubmed Search
15
24
• 467 Articles
English • 394 language Articles only Human studies ony
51 • 345 Articles
Full text • 294 available Articles for review
Level III
Level IV
Level V
Figure 3. Distribution of articles by study type
Abstract/ • 191 Title Review Articles for relevance Contains
Case reports
description • 51 Articles of surgical technique
20
Description of technique Case series
Figure 2. Articles selection process for final review
Cohor study 11
Figure 1. FOA with ‘en bloc’ frontal bone craniectomy
Methods: A systematic review was conducted of English articles evaluating variations in surgical technique for performing fronto-‐orbital advancement. Relevant articles were identified in PubMed/MEDLINE database (1966-‐2014). After pre-‐determined inclusion/exclusion criteria, articles were analyzed for design, demographics, level of evidence, and details of outcomes metrics employed.
Results: Fifty papers met final inclusion criteria and were included in the analysis. 75% of articles represented case reports and case series with lower levels of evidence (level IV and V on ASPS evidence rating scale). The majority of papers were published in 2012 -‐2014 (46%), with 42% of papers published in a single journal. 37% of papers described new techniques for FOA, while 13% described modifications to current surgical techniques. Only 17% of papers had control groups. Out of 1142 patients treated with various modifications of FOA, 68% had follow up after 12 months, 31% had follow up within on year of surgery. While 48% of papers used absorbable plates in surgery, over half used other materials or combinations of materials. Estimated blood loss (mean=218, SD=139) and operation duration (mean=240, SD=83) were also highly variable. Use of bandeau bone graft was split 50% to 50%, while 67% of papers reported using various techniques for frontal bone flap reshaping.
8
8 4
Number of articles
Figure 4. Distribution of articles by ASPS level of evidence (%)
Conclusions: There is no single widely used and accepted surgical approach for performing fronto-‐orbital advancement. Numerous variations in surgical technique obscure objective assessment of clinical results and make it difficult to perform prospective multicenter outcome based studies. The high prevalence of case reports and case series emphasizes the lack of scientific evidence in guiding selection of optimal technique for FOA.
