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Grand Rounds-Endoscopic Management of Sagittal and Coronal Synostosis

David Jimenez and Cormac Maher

November 14, 2013


- Welcome to another edition of WNS Operative Grand Rounds. Today, we're going to interview Dr. David Jimenez from the University of Texas, San Antonio. Dr. Jimenez is the professor and chair of neurosurgery at University of Texas, San Antonio. And we're very fortunate to have him today because he has really developed and championed many of the procedures and many of the surgical techniques that we're going to be examining today. This will be the first of two parts for this presentation. The first part, we're going to look at sagittal and coronal craniosynostosis repairs. And then the next part, we'll look at metopic and lanoid synostosis repairs. So Dr. Jimenez, thank you for being with us today.

- Thank you very much, and thank you to Aaron for giving me this opportunity to present to you our experience, now for 17 years that I have done along with plastic surgeon that I work with, Dr. Constance Barone. And so far as the disclosures are concerned, I must say that we have no financial interest in either the helmet companies, the endoscopic companies or any of the companies associated with this instrumentation. So what are the treatments goals for craniosynostosis? Primarily, we wanna correct the abnormal forces that are applied on the brain by the synostosis, normalize cranial and facial morphology, minimize surgically related morbidities, decrease the need for secondary surgeries which has been an issue for us and to allow for normal frontal sinus development and to obtain results that are going to last long, long way. As we all know, this condition began to be treated back in the 1880s by Lennalougue. And then in the '40s, Matson and his group began doing a lot of the endoscopic strip craniectomy and then Tessier, Marchae, Ortiz-Monasterio brought in the concepts of calvary and morbid remodeling which has worked very well but over time. What are the indications to do endoscopic minimally assisted surgeries? Well, at this point, all sutures can be done in those manner. Also we have expanded our role into multiple sutures synostosis primarily the ones not associated with syndromes. And as of lately, we have been doing some syndromic cases. Indications, the younger the patient, the better. The concept here is simple. We want to use the fact that the brain is rapidly growing and allow the brain to do all the proper remodeling. So best results really come in children under three months of age. We still get good results between four and six months, moderate to good at seven to nine depending on how severe the deformity may be. One thing is for sure that children after 10 months of age, the results are probably not going to be that good. So what are the short-term goals of endoscopic surgery? To minimize surgical exposure, decrease operative time, decrease blood loss, decrease transfusion rates, and overall, decrease the number of complications. Also length of stay is another goal for us to minimize and the cost. Endoscopic glow long-term goals. Eliminate the need for secondary surgeries. As you all know that operating on children for the second or third time become very complicated. And correction of skull-based deformities which is something that can only be done if you operate in these kids at a very early age. Correction of facial deformities, and again, long-term results. And at the end of the process, what we want is the patients to look absolutely normal. Patients that nobody can tell that this child had craniosynostosis or had surgery. Briefly to review with you our experience, we started in 1996. And as of August, we had done a total of 519 patients. 268 of these have been sagittals, 125 coronal. So I will show you now what are experiences with sagittal synostosis.

- A couple of questions. You mentioned that obviously the younger the patient is, the better they are in terms of being candidates for this minimal endoscopic operation. In your own practice, What would you do when you see a patient that's a little bit older than the ideal age, say six months of age, eight months of age? Do you have a cut point where you say, they're too old for this operation or when you would start to recommend the more traditional operations?

- Well, and so far as sagittal synostosis is concerned, it depends on how severe the deformity is. But typically, a child or sagittal synostosis that is older than seven, eight months of age at that point, we won't do it because the helmets and all of the treatment will not correct the deformity to the degree that we would want. Older kids, then we proceed with the more traditional calvarial vault remodeling. For coronal synostosis, in a similar fashion, the younger, the better. But we have done patients up to the age of about six to seven months. After that, we won't do it because again, the results won't be excellent.

- Did you find that that requires some amount of training and the part of your referring physicians to get the patients in at much younger age than it was the case in the past?

- Well, yes. The challenge that we have is to get the pediatricians to send the kids at an early age. So it took quite a bit of training going to meetings and letting them know that if they send the patients to us at a very early age, they were going to end up with an operation that was well tolerated by the children, and consequently they've learned and that's how they do it now.

- In terms of the indications for the operation, you mentioned, I think in one of your first slides that getting pressure off the brain is at least sometimes a surgical indication for these cases. What do you counsel parents in terms of the risk of say ICP problems associated with craniosynostosis single suture and multi suture craniosynostosis. And do you use that as a justification for surgery or something that you mentioned that can occasionally go along with the craniosynostosis?

- Well, the concept of increased intracranial pressure for single suture synostosis is significantly less than multiple sutures synostosis perhaps in the range of 25% or so. So it is not the main goal of doing the surgery obviously, although it does plays some effect. In multiple sutures synostosis. then of course, we do have to take that into account. Then in some of the cases, you can see that there is significant effect on the brain and from the multiple suture synostosis, and that plays a bigger role in helping the parents decide to proceed with the surgery early on.

- In a simple single suture synostosis, do you think that it's something that we see very, very rarely or what would you say the percentage of children that would have ICP problems from a simple single suture craniosynostosis is?

- Well, it has been reported to be as high as I believe, 25% or so. I really haven't noticed that to be a significant part of our patient population. Since we operate on these kids when they're so young, it hasn't been an issue for us.

- But in your experience, you would say that number would be lower than what sometimes call it 25%. I understand we have a surgical video to look at now.

- Yes we do. This is an animation of the concept of what we're trying to do here. This is the location of the incisions in the scalp. Burr holes are made at each incision side. Anterior and posterior osteotomies are made. And once the dura is removed and freed from the overlying bone, a large section of bone is receipted. This is followed by an anterior wedge osteotomy to the anterior fontanelle, and then followed by bilateral wedge osteotomies temporal and parietal bones. The surgery is then followed by a custom-made arthrosis, which will allow the head to expand out on the lateral biparietal area. Notice again, this is not a strip craniectomy, but rather a wide vertex craniectomy and bilateral barrel craniectomies. Okay, this is a another demonstration that shows how the helmet works. The red arrows indicate the areas where we're holding the growths of brain and the yellow arrows indicate how the brain expands out laterally. We continue to change the helmets over time molding the shape of the head to the size of one. The first face of the helmet therapy really is to get a normal head shape, the second phase of the therapy is to over-correct the patients and the third phase is to maintain the shape exactly what we wanted because we know that typically in these patients, the head will elongate and then go back to a scaphocephalic shape. The next slide here demonstrates approximately where the incisions are made. One is going to be behind the anterior fontanelle. At the beginning, we made it right over the fontanelle but we found out that distance was put very far. And the next incision is immediately anterior to the lambda. Now, I would like to go through an actual surgical video to demonstrate for you what the surgery is like. So here we have an instrument that we designed that has been very helpful to us. This is what we call a JMB retractor. What this allows us to do is to protect the dura in the process of cauterizing. This allows a endoscope to go through this port. This maneuver allows the blades to open in this direction. And then the endoscope gets placed on locked in place right at this area. This is an exit. The endoscope goes right through this port and is exactly what we ended up seeing. We see the blades in front. Typically this blade is going to elevate the scalp, keep it from getting burned. And then the lower blade is going to protect the dura. And then we're able to then with single handedly, one surgeon can take care of entire coagulation process in order. Instrumentation is very simple, minimal. This is a rhinoplasty lighter retractile. It's very useful. Simple set of brain ribbons. This is a suction tube that has been insulated, and we use this also to cauterize and also use it as a dissector. The next set of instruments that we use are simple retractors. We use a lot of surgery flow as far as how the incisions are made. Again, you can see the monopolar electrocautery is used said at 1515 blend 1. And incision is made again behind the anterior fontanelle as you can see there. This can be done in a completely bloodless fashion. The section is taken in through the galea. Care however, is taken not to do a sub-periosteal deception because this will lead to a significant amount of blood loss. We then move on to do the second incision in the back. This is anterior through the anterior to the lambda. Again, as you can see in a bloodless fashion, this is done very well. Since it's set at 15 Watts, the scalp heals very well. Now we're developing the subgaleal plane anteriorly towards the anterior fontanelle which is to the right of your image. As you can see, this can be done in a very bloodless fashion. We are now looking back. This is the anterior incision, here is the rhinoplasty retractor, the monopolar electrocautery, and you can see very well and the direct visualization how in a very bloodless fashion, we can develop this plane. People wonder how you can see this. You can see the visualization is excellent. All these little perforating vessels cauterize maintaining the blood loss to a minimum. Again, the key concept is to leave the periosteum in place. Otherwise significant bloodletting will take place. We now go back from the back and we bring this two incisions together. We have now fully elevated the galea from the of pericranium below. And this doesn't need to be a really wide opening as opposed to incision back there. Our next attention is placed to creating the burr holes and the osteotomies. A pediatric craniotome is used to create a burr hole on the lateral aspect of each incision. Once this is done, a little bit of gel foam is placed. Now we're doing it in the back incision the same way. You can see so far, we have lost no blood. Little piece of gel foam is placed with a cottonoid. Then the key is to begin freeing the bone from the underlying dura. We use this number one penfield. And to do the anterior osteotomy across here, a five millimeter Kerrison is done in a quick fashion we come across. This kid that we're operating on here was approximately six months of age. So you can see the bone is somewhat thicker. I chose this patient for that reason so you can see an older patients, you can get a little more bleeding, but it still can be easily controlled. We now go in the back and again, we continue to expand that osteotomy which can be done also with Leksell rongeurs. The number one penfield is then taken and with the left hand and with the right hand, we're palpating the anterior fontanelle. Once we have that area of freed, Kyron Mayo scissors or bone cutting scissors are used to cut the wedge osteotomy all the way to the front. Piece of bone is removed. This maneuver then will allow us to place the endoscope and push down in the dura so we can get under the bone which you can see here. Here's the dura below, the sagittal sinus is in this area. We get underneath the bone. Again, you can see the tenosuture here. And now we're going all the way back through the poster osteotomy. The paramedian osteotomies are performed. We now know that the scalp has been freed, the dura has been freed and the bone is now just hanging free. So it's very simple to take a pair of scissors. We designed these as well to cut thick bone. And we can go in a stepwise fashion going all the way back doing the paramedian osteotomies. In this case, the bone is fairly thick. When you operate on a kid who's barely a few weeks old or a month, it's really like almost like cutting a piece of paper, easy and with minimal blood loss. The osteotomy on the opposite side is being done. We cut through and through. As far as how why the osteotomy is made, it really depends on the age of the patient, Inversely proportional to the age of the child, the younger the child, the more removed. You can see here the section has been taken out. And we are about to demonstrate that this bone, this is the tenosuture. You can see the sagittal sinus, the pericranium is still intact and you can see this is a fairly thick piece of bone. And still overall, you can see the blood loss is not that much. In this case, the bone was about three millimeters thick. Now we need to pay attention to widening and curving out the osteotomy, the wedge osteotomies. Here we are cutting the edges, removing no more bone. We can do that on both sides. The idea is not to lead sharp pieces of bone, but rather smooth the osteotomies from side-to-side. The key again here is to feel with your fingers and that in the right plane of pieces. Pieces of bone are removed in this fashion. And I would say that this is about the major bloodletting part of the operation. Once this is done, the large piece of gel foam can be placed underneath in there to cover any dural bleeders that may be in place. A lap punch is placed, you put a little pressure on the overall area. And that typically takes care of most of the bleeding. These are important because these allow the skull to expand out laterally. So the simple thing to do here is to take a brain ribbon, we place it underneath and slide it all the way to a squamosal suture say on the right frontal area behind the coronal suture. We take the pair of scissors, develop a subgaleal plane. And from that corner, we're able to take a wedge of bone and a strip of bone that gets cut down almost as close to squamosal as we can. After we do that, we place a little bit of gel surgery flow in the area to keep in bleeding from taking place. And we do this in a stepwise fashion. We now do it posterially. Again, we're aiming to the lateral aspect. Now, the lambda suture is going to go in this direction. So we have to be careful not to cut this way. We're gonna do a dural tear. The idea is to take away just the osteotomies leaning towards the front of the patient. And you can see now the wedge of bone being removed from that side. So we go around circumferentially obtaining cuts in all four corners. Now this is what I believe is the key to minimize some blood loss. Once you cut here, sub-dura, we're opening the dural retractor, we're elevating the scalp. This is the paramedian osteotomy. You can see that the fusion from the thrombic space. Now this little instrument is fantastic. We've got this from the plastic surgery tray. It's suctioning electrocautery attaches to a Bovie set about 60 Watts. And we basically go to town cauterizing the edge of the diploid space to the point that is basically black. And it doesn't really cause any problems with infection. We haven't had any issues at all in any of the patients. So we keep going back and forth, back and forth until all the bleeding really stops from the deployed space. This is part of the reason why I think when we do the surgery, patients have postoperative hematoma is 'cause this continues to ooze. But we tried using bone wax, we tried using another other things. This is the best thing to use. And we go all the way around circumferentially making sure that the bone is completely cauterized. You can see that the retractor is very helpful in keeping us from burning the dura or from burning the overlying scalp. This is showing now how we can also obtain cauterization of a wedge osteotomy. You can see the edges of the bone posteriorly on the right side. And on the frontal area, you can see the wedge and we continue to go further down. We move our retractor down. And this retractor again is elevating the scalp. And this retractor below is pushing the dura away, protecting it. And we're just simply going back and forth cauterizing the bone until there's no more bleeding. And you can see this was the end of the wedge osteotomy. And there is another cut that goes down to squamosal suture as you can see right there. The goal at the end of this operation is to have no bleeding whatsoever from the osteotomies. You can see that we can do that safely by pushing the dura away. So people question oftentimes, well, can you see what you're doing? And the answer is absolutely. And here we are, great view. You can see the dura, you can see all of it. Because in craniosynostosis, the fibers are not attached to the sagittal sinus, the section of the sinuses is done in a totally a traumatic fashion. Here at the end, we take the 30 degree endoscope. We flip it upside down, we get a bird eye view. You can see the sagittal sinus right here is intact. This is the post paramedian osteotomies. We can see underneath gently pushing the dura down. There's some surgery flow there, and we can see that the operation has been done. And typically again, this can be done in a fairly bloodless fashion. The younger the patient, the better it is.

- Thank you, Dr. Jimenez. In the worst case scenario say where you're stripping the bone away from the dura in the midline and in some of these kids especially if it's a multi-suture case with dura that's very stuck from the ICP problems. I'm sure you've seen it where there's substantial venous bleeding around the sinus. Do you have any tips or pointers for how to deal with that eventuality?

- Been shown in this video, but I have other videos that oftentimes you do have perforating veins particularly towards the lambda. Some of them are fairly sizeable. Though when you push down on the dura, they pull away from the bone and they do bleed. All that simply needs to be done is under direct visualization, with the suction on the one hand and with the endoscope on another, we can then take the endoscopic bipolar forceps and under direct visualization, cauterize those veins and immediately take control. We have not had in all the cases that we've done any tears of the sinus. But I could imagine that if something like that was to happen, we could use the same principle. You have the visualization, you're right on top of it. You just take your suction, take a cottonoid, put pressure, and either put a suture or just wading through a cauterizes. But it really has not been an issue. I would say that that would be, I'm now more concerned about how we used to free the sinus when we're doing the CVRs where you're blindly taking penfields without really seeing where you're going and getting the dural tear here because you're seeing exactly every step of the way what you're doing. The likelihood of tearing the dura or the sinus really is minimized.

- That makes sense. What sort of vascular access do you have for these cases on a routine basis?

- That's a great question. Vascular access really comprises of only two peripheral IVs. We do not use arterial lines, we do not use central lines, we do not use Foley catheters in any of our patients. Because the surgeries are done in such a rapid fashion, and because the blood losses tend to be fairly minimal, our anesthesiologists have over the years learned that there's no need to put all those central lines in A lines and all that. So simply to peripheral work and IVs is all that's necessary.

- In your practice, are the patients cross-matched prior to the operation?

- No, we don't. We do not cross match anyone. So in terms of some basic results, I'll go over some of these with you here. The craniectomy sizes range from as little as a half a centimeter to as wide as 13 with a mean of about 5.7 and the length between one and 15 centimeters, Again, inversely proportional to the child's age because we have so much time to go. If the child's only a couple of weeks old, then we take more bone. Additionally, I can tell you that our estimated blood loss is minimal, a mean of about say 30 CC. It's range as little as five CC which is hard to believe to 150, and these has been multiple sutures synostosis patients and most of these at the beginning of our series. We've only had to do two inter-operative blood transfusions for the sagittal synostosis, 15 post-operative. None of these were fatal type transfusions critically low. So we transfused them for a total of 17 which really translates to about a 7% transfusion rate overall. Surgical time. The majority of the patients, 60% of the patients were done within an hour. Some of his longer patients here are multiple suture synostosis. So the average time of surgery is 57 minutes. And as you can see, 95% of the children stayed overnight and were discharged the next morning. Some of these kids here were premies and we kept a couple of days old. And one of these patients had cardiac issues from another issue. So I would say that since we don't have time to go through all of the outcomes, I would refer you to if you want to look at the photographs of long-term followup of our patients. Thank you.

- Thank you very much, Dr. Jimenez for that presentation on sagittal synostosis. And with that, we'll segue right into the next topic which is the next most common synostosis type and coronal synostosis.

- Well, thank you. Now, coronal synostosis is I think an area where we really have made a significant difference in the treatment of these patients because coronal synostosis as you know is a very complicated synostosis. Although simple in nature, it causes a lot of problems. You can see your classical frontal plagiocephaly nasal deviation. The incision is made right here, and that's about the size of the incision. It's very small.

- So now we have a video of Dr. Jimenez performing a endoscopic coronal repair.

- Yes, exactly. Here's a child, a three month old female vertical dystopia on the right side. Nasal deviations on proptosis. The incision is made. In this case, we made it with a 15 blade, but you can also do it with a monopolar electrocautery needle set at 15 as you can see here. The incision is made at the level of the Stephania which is approximately halfway between the anterior fontanelle and the pterion. In a similar fashion, the section is taken through the galea, but not through the periosteum. Here is taken not to disrupt the periosteum 'cause bleeding will take place. This doesn't really need to be any bigger than that. Usually measures about a centimeter and a half max. Then in the similar fashion, a subgaleal, the section is undertaken. The aid of a rhinoplasty lighter retractor can be used to help visualize or even simple with sand retractor. You can see underneath the subgaleal the section gets to take place. First, we begin towards the anterior fontanelle then we go to the pterion. This rhinoplasty lighter retractor is very useful to see the dissection since distance is not that far. We don't need to go any further than that. We go towards the anterior fontanelle and you can see how quickly is reached. You could do this again with an endoscope or if you have perfect visualization, you can do it with your eyes directly. You can see we've reached that area. We can palpate the fontanelle. Next, the texon is placed to doing the exact same thing down towards pterion. Now, originally we started doing this by resecting the entire coronal suture down to the frontal end of the pterion. Later on, we found really was not necessary to do that. And now our osteotomies basically go from the anterior fontanelle and then go posteriorly behind the pterion. As we found that oftentimes the coronal suture is opened down closer here, and we didn't wanna risk cutting the dura as it happened to us twice. The dural closure again, was able to be performed by extending the incision a little bit more and under direct racialization, putting a couple of frontal lines with no long lasting effects. You can use a brain ribbon to finish the dissection of the galea all the way down to the pterion as you can see here. So the overall amount of dissection that needs to be done is minimal. All we're trying to do is simply do a suturectomy. This is literally a linear strip craniectomy that we'll perform in here. A little bit of thrombin this placed just in case any bleeding start.

- Given the associated skull base anomalies, eye anomalies, face anomalies, I know you like to do these operations at a young age. Is your ideal candidate for this younger than the sagittals or does that make any difference for you?

- Ideally if we could do these babies as they come out of the womb, we would do them a little away. The younger, the better. Our best results are kids who've been couple of weeks old, a month old. And under three months of age, they get excellent results. Coronals again, not quite as good if you do them older. The idea is to allow the brain to do the reshaping of the face as I will show you in some pictures and in their recent paper that was published this month, Journal of Neurosurgery. You can see the long-term results really are very good in terms of correction of the vertical dystopia, the nasal deviation, the settling of the orbits, the straining of the skull base, 'cause literally the brain is the one that are doing all of the work. We now take a Bovie. We make a little mark on the pericranium in a similar fashion. A craniotome is used to create a seven millimeter burr hole. The size of the osteotomy literally doesn't have to be any more than six millimeters, just about the size of the instruments that we use, the Kerrison rogeurs. Because what happens is that when we do the traditional surgery, what are we doing? We're doing a bifrontal craniotomy, and we're doing a frontal orbital advancement which is what great efficient surgeons do well. In reality, when you do this kids at a very young age and you release the suture, although they we have to go all the way down to spormosal, but you now are able to do this to allow the brain to move the entire frontal bone including the orbital rim forward. And we've taken x-rays, plain x-rays of a lot of these kids and we follow them over time. And you can see them within three to six months, you can have osteotomies that we made at six millimeters can go up as much as 30 millimeters. So it's an incredible internal frontal advancement that takes place without having to take everything down. So making a big osteotomy is not necessary. We are now done the burr hole here as you can see. We can now take either a number one penfield or curate and free the bone in this fashion. The idea now since you have a small round hole is to elongate it. So there, it allows us to put the endoscope underneath in both directions, both internally towards the anterior fontanelle and laterally towards the pterion. So here we are removing, exposing the dura. And you can see the dura there. Kerrison rongeurs can be used. Here's instruments used to make sure that it's free. Then Kerrison rongeurs are used to expand the burr hole in this direction, in a linear fashion. You don't have to make it any bigger. I would say this is my favorite instrument of all time, so the number one penfield. You can in a easy fashion free, and either you can do it directly under direct visualization or you could just do it blindly right up to about this area. You don't wanna go too close. Kerrison rongeurs are now used to enlarge or elongate the burr hole because then we need to be able to put a rigid endoscope and you can't really get it under the bone if you just have a round hole. So by having an elongated burr hole, you can get underneath as you can see there. Now we're taking a zero degree rigid endoscope. We've done a little wedge osteotomy. We've under direct visualization prior to this. Now we're showing that the osteotomy that we've made literally goes all the way down to anterior fontanelle. And you know you're there because you will see the fibers of the anterior fontanelle, the dura going right up to that point. But you have to go up to that point. And you can see when we press it on the skull how that area is now completely free. Here is our dura which is intact. You can see the osteotomy medially.

- Well here, you can see that we're using a 30 degree endoscope to look at the under surface of the osteotomy as it joins the anterior fontanelle. The suction is used to push down on the dura and you can see the fibers of the dura in to fontanelle. And pushing on the bone on the scalp, you can see that the has been complete release of the frontal bone from the posterior bone. This then allows the forehead to move forward and to allow for correction of the deformity. Care is taken to make sure that the osseous bleeding is controlled as we spoke before. Here you can see now with a zero degree endoscope using the suction electrocautery set at 60 Watts, we carefully cauterize the bone both anteriorly and posteriorly. Obviously, lots of care must be taken not to cauterize the sagittal sinus. A coated brain ribbon is seen underneath protecting the dura. This maneuver continues until there's no longer any bleeding. Once again, I believe that this maneuver is really what has allowed us not to have any postoperative bleeds whatsoever. We have not required to take a patient back to surgery because of a bleed. And once again, you can see here that the bone has been freed. The endoscope view is towards the anterior fontanelle. In a similar fashion, the same as done towards the opposite side going to the pterion and the entire area is completely freed. Care is taken to make sure that the osteotomy is done all the way down to this squamosal suture. So I'll share with you a little bit of the results. We have seen that are mean with craniectomy is only really six millimeters. So it doesn't need to be any more than that because what happens is that as time goes on, the forehead gets pushed forward, and that osteotomy increases over time to 10 millimeters, 15 millimeters, 20, 25, sometimes 30. So in essence, what happens is that the distraction is done internally by the brain. We don't have to do a bifrontal, we don't have to do the osteotomies and do totally new approach. The brain does it all for us. And the length of the craniectomy side really is just the distance between the anterior fontanelle and the pterion which is about 10 or 11 millimeters. Next, we see that the estimated blood loss, it's literally just a over a tablespoon. We just did a case last night and literally was almost little, just barely five CC and it took me 20, 23 minutes. The range has gone from five CC to 120, and these are the patients that had multiple suture synostosis. We have not had the need to transfuse a single patient during the surgery, and only one postoperative blood transfusion. The bulk of the patients were discharged the following morning. Matter of fact, yesterday which is did six cases and all went home this morning. As far as the outcomes. Well, there was paper again written that was published this month in the Journal of Neurosurgery and it goes into great detail about the outcomes but in summary. The correction of the vertical dystopia, we consider it to be really the key in the fundamental aspect of the results that we have. And in over half of the patients, we have obtained 100% correction about 10% between 1999 and 5%, 80 to 90%. So those are compare very favorably to other operations. Let me show you some examples, clinical examples of these. Here's a young little girl who's two months of age. You can see the patient has significant vertical dystopia. One of the ways in which we measure this is we draw a line on the unevolved eye from the exothecium to the endothecium and draw it across the other eye. And then measure the distance in which the pupil is elevated over that line which should be along the same axis. For instance, this is a 10 millimeter elevation. At the end of the treatment, if it's down to five, we can say, we've gotten a 50% correction. If it's on the same line, it's 100% correction. You can see the child here at three and a half years. The a child has had almost complete correction of a bit and it's calmed down on its own. How about patients with sagittal deviation? 81% of them present like that. Again, we've had a significant correction of these patients. I'll show you some examples. This is a child who when we measure the angle, if you measure the angle between the nasian and the Nafion and the vertex, it should be a straight line. We measure that this angle right here, the deviation is about 19%. And over time in this case, for instance, four years later, this child is fairly straight and is fully corrected. So how does the correction take place? Primarily the first thing that begins to correct is the nose and begins to go back to the midline. Then the vertical dystopian takes place and the last thing to correct is a frontal plagiocephaly. That can take years. But as you know, the first thing that we look at in individual's their eyes. And as long as their eyes are perfectly aligned, literally symmetry of the forehead or whatnot can be camouflaged. So we figure that's a cosmetic deformity that could be careful later in life, if necessary yet we haven't had the need to do that. I'm gonna go through some examples real brief to show you. This is almost four months child. Operation took 44 minutes, 10 CC blood loss, the patient stayed overnight. You can see here before the patient has a right elevation of the orbit, notice that the right eye is looking away from us while the left eye is looking at us. At six weeks, you still see the semi-symmetry. But I had six and a half months, you already can see how the eyes are now looking at us both of them directly. And then three years, you can see that the vertical dystopia has fully corrected. Notice that there's still a little bit of plagiocephaly for it has somewhat recess, but that I think is minor compared to the effect that this operation has had on the face, on the orbits and on the nose. Next patient is a little girl just under two months of age. 50 minutes was the operation, 10 CC is blood loss, patient stayed overnight. And you can see again here that this is a pretty significant deformity with that dystopia. And over the ensuing months, you could see full correction so that when you look at the girl all the way three or so years later that you can't tell there was anything wrong with her. Another child, a female, little under three months. Surgery took 30 minutes, five CC blood loss and overnight stay. You can see that this is a little baby and the vertical dystopia, their left eye is elevated. And by the time she's six years of age, the totally normal beautiful looking child with no evidence of scarring anywhere. So I think that this overall wraps for us the concept of the treatment of coronal synostosis. Using endoscopic techniques provides long-term excellent results. Once the correction takes place, it does not go back like say, sagittal synostosis. This concludes this session. We'll continue with another one at another of that section. Thank you very much.

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