The surgical goal is to expand the calvarium to allow room for normal brain growth as well as to create a symmetrical and aesthetic alignment. To achieve that goal the craniofacial team has to deal with tight restrictive sutures, uneven skull bossing, and a shallow orbital bandeau, to name only a few complexities. Surgical techniques have evolved during the past years, and most craniofacial units have now adopted the fronto-orbital bandeau technique as advocated by Marchac and Renier with a floating forehead (or back of head), the use of barrel-staving, and split-thickness bone grafts (40).
As a general rule, priority is always given to the orbito-cranial level, and once the upper midface and the cranium have stabilized, it becomes the foundation for reconstruction of the nose, maxilla, and mandible. See child page on timing of procedures.
Before a craniotomy is carried out, the team makes a decision on the placement of the bone flaps, which are then marked in methylene blue or pencil.
Posterior reconstruction and/or advancement are indicated if the occipital area is most severely affected with a flattened appearance and obvious growth restriction in that area. In growing infants with elevated ICP, a posterior expansion can allow brain growth prior to the optimum time for definitive front-orbital surgery.
An alternative to skull vault reconstruction techniques is that of distraction.
A monobloc procedure is usually carried out after the permanent dentition in the upper jaw has occurred since it would otherwise destroy the tooth buds. In a monobloc procedure, the frontal bone and midface are simultaneously advanced in two segments.