Pediatric Neurosurgeon Dr. Peter Sun and Nurse Practitioner Rebecca Silvers review what normal infant skull anatomy and biology looks like, and discuss the characteristic and causes of abnormal headshape.
mm head shape us. This is our small and mighty 18 and just what I really wanted you guys to have on this first slide is our phone number. Um We realize that you guys are out in the community managing so much and we have expertise and can be of support to you. So um Dr Sun's phone, personal phone number um and our email addresses will also be at the end of the presentation. But I wanted you guys to have this um in case you can come up with clinical questions. You have newborns, you're concerned about older patients call us. We're here today. We're gonna do is we're going to begin by a discussion of normal infant skull anatomy biology. We're gonna work on defining uh play succesfully positional, play beautifully and creamy assist assists. Talk about the common characteristics associated with those things. We're gonna examine appropriate evaluation and treatment measures and kind of help you guys understand what we do when we're working patients up for these. And dr sun's going to provide us with a brief but in depth surgical discussion on some of our options for Crimea since doses repair. So the anatomy of the infant skull. So here's I think you guys can all see this. Um So when we're born our skull is made up of five separate bone plates. It's not yet fused. It's actually quite thin. It's about four thicknesses of your nail. When we're born. So soft. Malleable not one bone yet. You've got these two frontal bones when we're looking from me from above. Got two parietal bones and an occipital bone. You obviously as pediatricians are super familiar with the anterior and the post here font nails which are openings there. And then we also have the openings in between these bone plates. They're called futures and those are the growth plates of the skull. They are what allow as our brain grows and expand for bone to fill in. We'll talk about a little bit of that in the, in the in a minute. Excuse me. So this I really like this diagram that doctor studies is and on the right you can see the arrows are pointing to bring growth and brain growth is really what drives our school growth. And we always need to remember that, especially in our first year of life when our brain exponentially grows and we'll talk more about that in a minute. But you've got the two bone plates in black there, you've got the brain pushing up and you can see how the bones will then go up and out. Open more open space will be in here and bone lays in perpendicular to the future lines and fills in those places. As I mentioned, we've got a huge brain growth in our first two years of life and by two we're at 87% of our adult size. So all that matters and that will all come together as we continue to discuss positional play joseph Pilates in creating a synthesis. So what is positional play joseph early? This is what we're talking about. We're talking about a flatness of the head and this is looking from above, looking down at the skull, a flatness to the head, secondary to prolong positioning in one area. The bone, as I mentioned, is quite thin and malleable when we're born. So if we spend one more time on one particular area of the skull as we grow things flatten out. High risk patients for this, our patients with Nicholas. So patients that have a fixation and of their neck on one side. So they continuously lay on that 11 side. Children that are born with a preference to one side. Perhaps they laid in utero in one way. And so if they have a choice, they will choose to always lay on one side patients that have spent time in the nicu and they're positioned from various in various positions for illness related reasons or secondary to treatment measures. And then of course our patients that come from multiple pregnancy, so you're twins or triplets um those all have a higher risk of this positional play joseph lee. So we loved excuse me when we have patients in our in our office, we really talk about the growth chart a lot. This is actually the growth chart of a patient currently in our nick you and creative synthesis and we're following his growth along the curve. But We really talk to families a lot about this and understanding that this is our skull when we're born our skull. And we explained that to them when they're if you're laying on one particular ways on your back or on the side. And as you can see on the curve in the first two months of life, let's say we were at the 50 per cent tile. We grow from 34 cm to 38cm We're laying were sleeping 16 to 20 hours a day. Were laying on one side on the mattress as their brain grows and expands. You can imagine that it's hard for that soft skull to push against our mattress. So our brain will push out in the skull and other directions and we'll end up with a flatness on one side. Really important to also think about is that play joseph lee doesn't just result in flatness of the back of the head. So for this patient here, he was laying on the right side and as his brain grew and expanded it has opened future lines so it can do so all over and it will push up in the front because it can't push back here and then because this is flat, the ear will also move forward. So we don't just see one change in the head shape, but we see multiple changes, especially as we get into the more severe cases. Mhm. I really like this slide because it's also helpful to explain to everybody that we don't just have one different one type of play joseph lee, I love I love visuals. So this is our normal baby. Just look from the top, looking down and I encourage you guys when you're assessing your patients and you're looking at their schools to not just look from the front but to really look from the top down, have the parents hold them below you look at their school and see what you see. Um And if you see a lot very most common I guess is the play joseph lee with the one sided for preference to one side. But we also see pretty significant amount of break especially which is if patients are laying on the back of their skull like this and their brain grows and expands, it pushes out to the side because that's easier than pushing you know back to the back. So we've got that wide skull base. Um And then with our donkey Stephanie patients are escape, especially patients, they're the patients that have slept on one side or the other so their brain pushes their skull out in the front words and backwards directions. How do how do we diagnose similar neurosurgery office? We have an orthodontist who does digital live scans a result of that scan or print out of what we receive when we get a scan is here on the right for you. Um So we get a digitalized scan and we look at multiple objective measures to kind of delineate how severe and what are we looking at. Um We're able to get a two D. Image on the right here. The red um was the first line of first image that we got of this patient in the blue is the follow up after some directed therapies and you can see some improvement there. He's coming out on that flat side and not really expanding in the other areas which is what we want to see. And patients with pledges definitely must have no signs or symptoms of cranial synthesis which we'll talk about in a minute. Um and then most importantly we let parents know that the brain is able to fully grow and expand so this does not affect bring growth or development. So really important to direct therapy and to understand things. We were scientists were northern neurosurgery. Um so we use those objective measures, as I mentioned from that scan. So we use a safe alec ratio, which is the ratio between the front and the back of the head. And we also look at the asem tree from one side to another and we put into three categories miles as you can see here. Just a mile, flattening moderate and severe and the severity is really important because it helps us determine the course of treatment. Treatment for play, joseph lee is really just back to the growth chart for a second treatments really based on utilizing skull growth to kind of correct things. This is just a cosmetic thing. We want to optimize things, but we don't want to have to get in and do nitty gritty surgery to to fix something that's just cosmetic and and especially because they have usually growth to go and we can use that growth and guide it into a productive place. So if the kids fall into the mild or moderate category, research has shown that repositioning measures measures alone will optimize their head shape. And when we talk about repositioning, we mean getting off that flat side as much as possible, whether it's the back of the head or one particular side. We encourage families and we guide them to do a lot of directed therapies of um tummy time, maybe even changing the crib direction in a room so that they're facing something to turn towards the other side, putting music. Um Children were told to call us really benefit from physical therapy exercises for the neck to kind of improve that. And a lot of families come to our office and ask us about the play joseph lee pillows. Um And I, you know, I just wanted to point out that there's not a lot of data um on the effectiveness of these pillows. Um and repositioning measures should really be encouraged right at the beginning and then our patients that fall in the severe category of play joseph lee. Research shows that cranium molding helmets will get you the best outcomes in terms of head shape. We the helmets are kind of amazing, families are really concerned about them when they first arrive, I put the picture of Mila on her belly in here just to show you these helmets are lightweight, patients can have normal activity, but they do um where them 24 hours a day, 3-6 months in length. And how the helmets work is they don't, they're not like braces. They don't attach and try to move anything. But what they do is they create area, they create kind of like the mattress did contact in the areas where we don't want it to grow. And then they provide nice open places and areas we do want it to grow. So as our brain continues to push our skull out, it goes into that mold and that nice round shape that we've created with the helmet. Um, one custom helmet for the duration of treatment. Um, so you guys know insurance really likes them to have already done repositioning measures for about two months before the, they will improve the helmet. So, um, that's a thing for you guys to know. And it does take us about 2 to 4 weeks to get the helmet pending insurance and the time to make this custom helmet. Families get to choose a fabulous design. Um And well we really like to support them through this process. Mhm. So just just a quick note about referrals for play, joe just because I want you guys to think about this and how we can help optimize our patients outcomes if you have admiral head shape and you're like, I think this play jail but I don't know how severe or um if you have any questions at all send them to us. We are happy to see everybody we're working on, we get everybody in within two weeks. Um and we love to evaluate your patients and time matters with play joseph because when we looked at that growth curve, we saw that the highest growth velocity for Children's head head shape or had growth rather is in the first six months of life. So if we can get them in that helmet before six months, that's great. And they get that great growth spurt to kind of improve their head shape within that helmet or with tummy time etcetera. And as I mentioned earlier, you guys can be a big part of this by helping um in advising on repositioning measures early for these families. So we'll take a quick move over. You know, this is a lot in a short period of time, but we want you guys to really understand what we do in our practice. Um And so why do you guys refer to neurosurgery from a normal head shape? And I think the answer is pretty simple and it's crazy synthesis previous anastomosis is another cause of abnormal head shape and often it can look really similar to play joseph early. And that's our job is to really differentiate between the two and support their families and whatever treatment that they need. So the definition of creamy sinus thrombosis is a premature closure of a sutra line. So in the picture on the top, right within the blue box, you can see all those futures that we talked about earlier. We've got them the topics future, we have a corona, all future here saddle coming between the anterior and post your font nails. And then we have lamb died futures coming down the back between the occipital bone and the parietal bone. So if any of these futures has closed in utero before they were born, which is when this occurs, then their head shape will become abnormal because, as we know from our earlier discussion, our brain grows and these futures allow bone to fill in and expand and maintain that nice round shape. This is something that has that isn't just we put them in a helmet. This requires surgical correction in our hospital doctor. Some will discuss, but we can do to different surgeries. We try to do a minimally invasive technique early in life. And then if not, we have to go in and do more of an open surgery. And that's because early in life. As I mentioned, our bones are nice and thin and when we get bigger they're thicker and require a lot more work on our part. So we'll go through a few of these previous associates in terms of what we see and what the characteristics are. Um for the unilateral corona screen Asus Asus. So we know this is a normal skull here. We've got all open futures. This is a C three D reconstruction CT scan um Up on this side, you can see that this is missing a corona future. So this patient was born and has a missing future. So as their brain has grown and expand, their head has developed an abnormal shape. What we see in these patients is receive frontal flattening the brain is growing, but we can't expand bone at that place so that bone becomes flats. We also see that this on this side, the orbit gets pulled up with that because, as I mentioned, this can expand so the eye goes up because the brain is still pushing on this bone. We also see contra lateral nasal deviation. And that's because this bone, similar to where the eye is, the nose gets pulled up as well. So we see a nose deviation rather to this side. And then these are patients where we will also cease your business. So an important thing to look out for This is not known to be familial incidence is one in 10,000. Um and when we look at the patient themselves, you can these are some pictures for you. This is a little girl with just flatness and you can see this frontal gladness from that future not being open and her eye on this side pulled back and up compared to the eye on that side. Same thing with this baby on this side and this is following surgical correction. We have a nice contour of the forehead versus this right here. Unilateral land oid synthesis is far more rare actually. Um But it's important for us to think about it's only a three and 100,000. But because this future here on the back is closed, we have a poster of flatness and secondary to that because we still have brain growth happening. We get a bulge here and um asteroid and a bulge on the other side of the parietal bone. You can also appreciate that on the frontal view where you can see the bulge right here. And I'm sorry the Master bulge down here in the parietal bulge up here. We also see here movement. Um and we'll talk more about that in a minute. I think these pictures really help you guys understand why it might be hard to differentiate cranial synthesis from play joseph lee because on first glance even for me, I'm like oh that's you know, this kid has been laying on the side of his head. But when you get everything together, the history and the exam etcetera. And you look further at his exam, you'll think about other things because you'll see the Master a bulge here, you'll see um the parietal bulge here and then you'll see his ears actually pulled back instead of push forward, which is what we see um in place successfully. And just to reiterate that point, here's the difference. Just on a sketching this is play, joseph lee were also future lines are open, so if we lay on the flat side everything will grow. And so we've got a little bulge up here and bulge back here and the air moves forward. But when we have sinus toe sis we have the parietal, the parietal bulge, the master eyeballs and ears pulled back. So it's just a little bit different. And that's that's why we're happy to see these kids. The topic Crane Arsonist Asus is 10-20% of all of our patients with us syndrome. They range in severity pretty significantly. Some kids clothes a little bit early and have a ridge up front and other kids have very severe case where they end up with Trigana succesfully. So if you look at their head from above, like this picture here, you see this really Trigana front shape. These are kids that definitely would require surgery and correction in order to optimize their contour here on the front and for their eyes as well. Sagittal cranial synthesis as they mentioned, the saddle future runs from the enter to the post here fontanel. So right along here, these are kids that their heads can't expand wide so they grow front to back. They end up with frontal bossing and an occipital keel. These patients are known to have elevated intracranial pressure if they're uncorrected um and higher rates of development to delay without correction. So this is somebody who is really important that we correct early and as soon as we are aware these are some patients with sagittal Crimea synthesis. We've got that really big keel here in frontal bossing, narrow top and again saying with this little one. So pretty significant. This was a lot I realized. But I want you guys to kind of take a minute and think about it just one more time. This is the same picture from my first cranial synthesis slide. It's important to remember that these needs surgical correction. Children with fused futures because the brain is always growing and if they can't expand in a round way, then the brain and the skull rather will not be able to expand in certain places and become deformed and can cause issues with intracranial pressure and needs to be corrected. How we diagnose these patients is through a few different ways. We start with a history. Usually the flatness or abnormal shape is present at birth or shortly after birth. We talk about shape as we kind of earlier discussed and then we palpate sutras for separation. So we always do like a really deep feel of the head and then especially the midline futures will feel a ridge over there if they fused early. So those are all really indicative of Chronos anastomosis. But for confirmatory sake, we use X rays. I know I've gone over a lot of cts with you guys today through this lecture and three D reconstruction. And those are really helpful in cases where we can't um the rare cases where we can't see it on on an X ray, but cts have so much more radiation that we try to avoid them and you know 80 to 90% I think dr sun uh percent of the time we can diagnose this with confirm things with an X ray. So just a quick little case that for you guys just to point out how important it is for us to do through exams um and thorough evaluations of all these patients. This is a kid who came in um and had this abnormal head shape. He had this flattening of the back and then at first you think, okay, this kid's got played geo and then you look a little bit closer and you're like, hey, but maybe also something up here, what could this be? You know, um you know, you guys take a minute to think about it. But um when we looked a little bit further and we did the full ct with reconstruction, it was pretty interesting outcome. This is the side of the head and we had the flattening on the back that was so severe you were like, But then we had the flattening in the front and you're like, what is causing what? This kid ended up having to things. This kid did have a very nice open lamb died future. So that wasn't fused, that wasn't causing the flatness, but missing a corona future. So we had the frontal flattening, had the I pulled up had that, but also had pretty severe play, joseph lee. So sometimes they can have not one but two. Um and we're happy to help you guys navigate these things with your patients, Help you understand them. Um and dr sun take it away. Great. Thanks so much. Um Rebecca. That was excellent. So, um before I go to the surgical correction, I just wanted to uh, there is this question here and I think we should go ahead and answer it. Rebecca, do you want to show us that's your skull model again? Yeah. Sure. Hold on to me, son. I can't see the question. But if you can tell me what it is. Questions about the topic future. So I just one thing about the topics future, topics future is present at birth, but this is the only future. If you look at an adult skull that goes away. So the topic future actually fuses between six and 18 months of life. If it had fused in Utero, we come out with the Tribunal Stephanie that we need to fix if it actually feels very close to when it normally fused a lot of times, a patient would just have a ridge on the forehead. So so it's a matter of of of of um when it fused relative to to its normal closure time. So usually discloses when um when um when the fontanel closes. So we can have a spectrum of Trigano succesfully um between very frank uh you know, triangular head. That just obviously it's not right. Obviously needs to be fixed to sometimes family would just point to, you know what? My child has a ridge here. And technically that is my topic quino synthesis. Um But we don't fix the minor ridges because they even out over time and it doesn't cost a significant deformity and just um. Yeah, I think. Should we go on on the surgical slides? Yes. Yeah. So this is just once again a reiteration of of what Rebecca has gone through I think um you know when we evaluate a child or baby newborn with head shape issues as long as we keep in mind of the orientation of the futures and the fact that new bones lay down perpendicular tourist orientation. You really could predict um You know what the head shape is going to be for Kronos and Associates. So for example, like Rebecca said, if you don't have the saddle future, can you guys see that? People see my screen, they can't release in my school. Um, so, uh, the satchel switches down in the middle is fused and can't grow sideways so we can protect the head shape. And I strongly, uh, yeah, uh, based on, you know, the compensatory changes of a future being fused. So for example, like Robeco saying the corona future is fused here, then we can grow from the back here and then we rely on X rays and even sometimes CT scans to establish the diagnosis, but we don't just, you know, I think a lot we can just figure out in, in, in clinic on physical exam and one, let's just go back to 11 more thing. Another thing I commonly see or have parents ask about is whether um uh bridging of a particular future is a problem. Um So there's actually normal region of lateral future. So we actually palpate the chrome future to make appropriate burr hole. So that's anatomical landmark. The lateral blandois future is also palpable in terms that you can get a bunch bump but you really shouldn't have a very big prominence over the saddle future in terms of um how it's pal painting, If you have a big bump over the saddle future and then you have elongated head shape, then we suspect cranial synthesis. And same with the topic like we mentioned, so whether it's a tribunal Stephanie or just a bump there. Yeah. Okay, so here's again or has a conference card after surgery. Okay, nelson associates, we always want to see them back to make sure you're still growing appropriately. We talked about how brain growth drives head growth. It's not like long bones that will just grow. We do need to brain growth. Brain push so microcephaly, we mostly think of bringing issues rather than cranial synthesis. Again, this picture we talked about important to keep in mind and just go back one second, just wanting to point out that as the fontanel close, the topic goes away. Right? So yeah, and these are just again reiteration of how we can predict the different head shapes based on which future is closed. So, you know, lambda way, that's really, really rare. Um we maybe see it maybe once or twice a year. So the vast majority of the posterior play joseph lees that we see are going to be positional play joseph lee. And I think if there's any question at the end, we should go back to Rebecca slides and just to go over a couple of points about a posterior played rochefort versus land voice and associates. It's really you can figure it out, you know, on the on the on the on the on the exam. Mhm. So this is a child with the unilateral corona synthesis. We can see the large I. And sometimes this is why we get a referral that the eye is large or the ophthalmologist gets to see the patient. But this is in fact from the future being fused on that side. Pulling up the eye socket, as shown by the C. T. Scan. Again, saddles and associates, we get to the compensatory frontal bossing and exhibit it'll kill. I think this is what differentiates the door. Microcephaly patients perhaps, you know, laying in uh occupation, being on the side of the head versus truce and associates is where we see this compensatory frontal bossing and exhibit Tokyo. And we can see the ct scan shows no future there. So this is a child with Trigano succesfully where we can see that forehead is quite triangular. And correction will be based on, you know, the psychosocial effects of this deformity going forward. And we can see the intra operative picture of of the scalp peel back. And now we're taking this bone down um to fix it. So this is a child with a lambda synthesis that Rebecca has shown. So really the hallmark is not just the saddest flat is that this year is pulled back towards you. You get the master a bulge and you get the private bulge. You really don't really see that. You don't see that on the positional play doh Stephanie where they're flat on this side. So this is the key difference. And this is again showing that we don't have to future. Here. We have the future on the other side and this future grows perpendicular to its orientation, right? So that's where we get the mastery bulge, and that's where we get the parietal bulge. And we have the lack of growth along the hips, bilateral parietal bulge in the contra lateral mastoi. Because this future is growing to lay down more bone to compensate for the contra lateral closure. Yeah. And we've seen this. So so Queen of Sun Associates treatment. The paradigm really is based on the deformity. We don't have great evidence that you have frontal lobe dysfunction when you have tried unsuccessfully or its lateral frontal lobe dysfunction when you have frontal play joseph. So, so the queen of spain associate treatment is based on the deformity and that's why we work closely with our plastic surgeons. These patients all go to our craniofacial panel. The only future, the only single future queen of sources that we worry about brain is the satchel because it encompasses is such a large area of the skull. About 15 to 25% of patients that go uncorrected. They will have to struggle to support portion elevated I. C. P. Down the line. So saddle. We treat both from the deformity and because of bringing issues and the other single suit Ukrainian sources which treat based on the deformity. If you have two or three or more suitors fused, then that comes into play in terms of I. C. P. Down the line to because the sculptures can't grow. But we're focusing on single suit your opinions and sources uh today. So there has been an evolution and this is something I want to introduce everybody to start thinking about in terms of of our treatment paradigm. So when we first started to treat these at the turn of the century, you know, people did just cut out the future and and thought that was going to fix it, but it really didn't. So what happened happening in the 60s and 70s is that we did a much more extensive operation where we not only cut out the few future, but we reshape the host, skull. but now there's an actual further evolution over the past two decades. And that, you know, if we think about what really makes the skull and forehead rounds your brain, right? So, so if we can take a child who is diagnosed relatively early and we do just cut out the few future and then we put them in a helmet, we let to bring itself due to work to reshape the deformity and we're taking, going a little bit away from the mechanical operation back to a smaller, more minimally invasive strip craniectomy. And that has been popularized since the early uh, 2000s by a combination of happiness and Verona is a plastic surgeon and a neurosurgeon couple. So, um, yeah, so the vault remodeling is a huge operation, you know, and then because we do cut the bones extensively, what we tell the parents and sometimes is that, you know, we're gonna, during the surgery, we're going to make your child look great. It's gonna be perfect, right? We're not going to leave the operator operating room unless everything just looks great. But you know, it's so, it's kind of like wood shop. But unfortunately it's not with our cement. All the Aussie Allah means that we make on the forehead. Um, down the line can create lumps and bumps because you know it's life is life tissue. And then I know a lot of you are eating lunch right now but we are going to show some pictures of of of Kronos and Associates operations. Um So this is a child with a track anencephaly and then this is the interrupt operation. So I often think that we show these slides to all the pediatricians when they were getting another referral because I can't believe what we have to do to correct them. So this child had a bike final decision from the top of the year to the top of the year. We take off the forehead, we take off the orbit and then we reshape it right, it's a mechanical operation. We shape it along with the plastic surgeons and then we put it back on, we put it back on with a horrible place and screws and we make it nice and round and everything's great. So this is post operatively and then we're happy with the result. And also with cranial send social surgery with other extensive deformity. Sometimes we even planet out virtually so that once we get into the operating room we know exactly where to cut and how to put it back together. And we have tools in the operating room like we have a little skull that we want to reshape the forehead into a more normal contour we match it to to the particular skull age. And then this child was a patient of mine who Had long blond hair about four or 5, four years of age. Nobody could really realize that perhaps the headship is very elongated and narrow, went to go get a bike helmet. There was no bike helmet that could fit this child because he had been diagnosed statue of synthesis and the family decided to go ahead and correct it. And just, you know, it's a big operation like this mark that you see as a Bikram decision that I was talking about. Uh this is the narrowness that you can see from the sagittal sinus psychosis and this is the incision. And then we do take the skull off to reshape it and put it back on a more rounder fashion and a more expanded fashion to accommodate the brain. So this is an issue that I see with open open surgery. So this is a child with microcephaly. You can see that is quite narrow here. Yeah, nine months of age is typically where we do these open operations and we put them back on and everything looks great And your uh six months later everything looks good. But when we follow these Children out over years, okay, What happens with these big operations? That we see that we can see sometimes a little bit of high prosthesis or we just can't make the forehead big enough at nine months to accommodate the full facial feature of an older child or adult. And we see this kind of pinching on the side. So uh sometimes these patients do undergo additional touch up surgeries. Uh DR Pomeranz are plastic surgery, colleagues would inject a little bit of fat into these areas surrounded out. So because of how big these operations are, because the touch up that sometimes require them or philosophy of partners and Associates treatment has shifted more towards a minimally invasive operations. So, but this minimally invasive operation has to be done before Uh by three or 4 months of age whereby we released a few future. Okay. But because um we take advantage of the brain's ability to grow and round things out, it has to be done early. And then we uh put them in a helmet post operatively, like the helmets that we use for pleasure's definitely. So this is again a child with Cejudo synthesis. You can see the elongated head shape, but instead of a big by corona decision that you saw in the older child to take off the entire bone of the cranial vault to reshape it, we just make a small cut in the front and make a small cut in the back. We reach in with our light retractor and we take out the strip of bone. So this is the endoscopic view. This is a few future up top where the bonus coming off with the dura. Cool. And then we remove this ship of bone uh and also some of the side to release the futures. Previously we did make gaps on the side tube. Now we just take the few future off from the lambda confluence through the anterior fontanel. They wear a helmet afterwards and we can get this kind of correction right? So we go from a head shape on the left to head shape on the right, just by the minimally invasive operation by releasing the future with the aid of a helmet post opportunity, we can get really excellent uh shape correction. So here's another opera example of me topics future that we talked about. You saw the some of the uh deficiencies or the problem with a big open operation. Uh So this child was diagnosed early so we can utilize the minimally invasive approach. You can see the future issues so we can't grow sideways. So we have the tribunal's fellow ted shape. So in this operation we would take a strip of bone from the fontanel, uh down to the nasal frontal future. We don't make a big microphones exact decision take off the forehead or the orbital bar. We just released the future. So right afterwards you can see the cut where we release the future from. And then, you know, we took our endoscope or laterally tractor and worked all the way down. And this is this is the all we have is a tiny little cut here. Now the head shape right afterwards, of course, isn't that different. We removed the Trigano Stephanie, removed a bump but it's still narrow. But after a few months of helmet you can see down the line six months later, it looks better by one year, looks pretty much, you know, normal. And what we like about this operation is that years down the line, we don't see the lateral pinching as much because when the brain pushes out the skull, you know, it gives it a nice normal contour. You know, some physiologic, it's not um you know, mechanical or there's no Osti autumn is there? Yeah, So this is the evolution that we would see on the digital scanning. In the beginning, we have to try unsuccessfully. We've been in a helmet for a number of months and we can see how it rounds out. Here's another example of trying to most safely and you can see how it rounds out with the helmet over time. You know, they do have a little bit of pinching sometimes uh a few years later and it can take up to several years full of to fully round out. But we're beginning to see that um you know, we have a pretty large series now uh that there revision rate is less than the open operation in terms of needing it. Touch up shaving something down or injecting some fat laterally. Yeah. Okay so this came out back then. We fully embraced this uh approach to give us better results cosmetically and also smaller operations. Right? So these patients stay in the hospital for uh uh two days as opposed to five days. Only half of them get a blood transfusion. Where's the big operations? Almost all of them get a transfusion. Yeah. So um we talked about head shape. We talked about the surgical department and I just want to mention that all this is done in the setting of team care with our plastic surgery, colleagues and all the Children get. Uh we'll try to get everybody to see the craniofacial panel where there is an ophthalmologist throughout Papua Dema. Rebecca mentioned that when there is a frontal plato Stephanie from unilateral comments and associates because eye socket is short and a lot of them gets for business so or something gets through the business. So it's nice to have an ophthalmology at the premium facial panel of course is geneticists and go through some of the things with the parents and um so everybody uh criminal silicosis we treat through the craniofacial panel, yep. Yeah, great. So I think that covers head shape in terms of play doh Stephanie and cranial synthesis the treatment paradigm and how we um I would love to um lie on early diagnosis. So oftentimes of course we can't rely on you in the office to need the diagnosis, but if something doesn't look right, you know, we encourage, you know, early diagnosis. Um Either through Rebecca's a PP clinics or neurosurgeon clinics or plastic surgery office, uh, we're happy to see these patients early on to make sure that they don't have photosynthesis and then they do. They have a minimally invasive option mm mm.
