On September 22, pediatric neurosurgeon Ramin Eskandari and plastic surgeon Jason P. Ulm of the Medical University of South Carolina (MUSC) hosted a Grand Rounds on Figure 1, a global case-sharing network of healthcare professionals.
Grand rounds are a mainstay of medical education. Unlike traditional rounds — in which a physician will lead a small group of residents, interns and medical students from patient to patient — grand rounds typically involve a single significant case presented to a larger group of healthcare professionals. Figure 1 Grand Rounds offer these insights to the largest possible audience, as all of global healthcare can follow along in the free Figure 1 mobile app.
The Grand Rounds hosted by Dr. Eskandari and Dr. Ulm walked through a surgical correction of nonsyndromal craniosynostosis, one of nearly 40 such surgeries performed every year at MUSC. Craniosynostosis is the premature fusion of one or more of the brain’s sutures in an infant. Surgical correction is used to prevent symptoms like headaches, learning disabilities, and vision issues.
Here are some highlights of the one-hour event:
Preparing for brain surgery
Precise measurements were taken and were used along with preoperative imaging and 3D models to plan this surgery. The image below shows 3D-printed models of the patient’s skull before this surgery and before a surgery the patient already had. The smaller model was created at three months of age. The larger model was created one year later.
On MUSC’s 3D-printing capabilities, Dr. Ulm says, “Our medical center has two 3D printers that are capable of producing these models. For the past 18 months we have been routinely using this technology in our complex craniofacial/craniosynostosis cases.”
How to open a skull
A wave-like incision was made from above one ear to above the other, making sure to stay within the hairline. The doctors explained why: “The incision is typically dictated by the extent and location of the areas that need to be exposed. We use a wavy or zigzag design to help conceal the scar within the hair.” As Dr. Ulm added, “it may also have a secondary beneficial effect to disperse tension”.
A registered nurse responded, “Concealing an incision as best as possible will have an enormous positive impact on these kids lives as they grow and develop. Great work.”
Removing a piece of the skull
A skin incision was made with a sharp, sterile blade, which only goes through the outer layer of the skin in order to minimize bleeding. The second layer was cut using an electrocautery device, which coagulates small skin blood vessels as it cuts. This is done to help prevent blood loss and a blood transfusion. The scalp was cleared away from the skull, so the bulging skull on the anterior frontal region could be removed and reconstructed. The photo below shows one of the surgeons holding the piece of bone taken from the anterior frontal region.
After removing the bone, Dr. Ulm split it into two pieces of thinner bone to be used for filling gaps. These pieces could be bent into the appropriate position, preventing the need for implanting foreign material for bone replacement. The surgeons drilled into the anterior frontal bone in order to secure the rotated skull piece in place with sutures and absorbable fasteners (plates and screws). After the anterior cranial vault expansion and orbital reconstruction, several areas of open defects remained secondary to creation of more room in the skull. These areas will grow in over time.
How to recover from neurosurgery
The recovery from this surgery is surprisingly short considering its complexity. Dr. Ulm explained, “The patient spends the first night being monitored in the ICU. On post-op day 1 they are usually transferred to a lower level of care bed and discharged on POD 2–5, depending on the extent of surgery. The skin incision will heal within a couple of weeks and the bone gaps in the next few months. The child typically returns to pre-operative behavior within 1–2 weeks.”
An occupational therapist replied, “20 years ago when I had my 1st surgery, I was in the hospital for a week and couldn’t participate in sports for a while until I healed. Even now if someone accidentally hits me in the head or face I’m hypersensitive. The surgeries have come a long way in 20 years!”
Dr. Eskandari and Dr. Ulm share more about surgical correction of nonsyndromal craniosynostosis in the video below.
You can find all of the cases from this Grand Rounds on the Figure 1 app. Interested in learning more about Figure 1? Email us at communications@figure1.com
(Faces and other information that could identify a patient are strictly prohibited on Figure 1. Because of the educational value and public nature of this case, an exception was made with the consent of the patient and the agreement of all parties.)
