Fronto-orbital Advancement (FOA)

What is a Fronto-orbital advancement (FOA)?

Fronto-orbital advancement (FOA) is a surgical procedure used to reshape and reposition the bones of the forehead and the eye sockets (orbits). Fronto-orbital advancement is commonly used to treat unilateral coronal synostosis, bilateral coronal synostosis and metopic synostosis, because these forms of craniosynostosis all cause changes in the shape of the forehead and upper portion of the eye socket (orbit) that result in an abnormal appearance.

How is Fronto-orbital advancement (FOA) Performed?

Fronto-orbital advancement is usually performed between 9-12 months of age. A bicoronal incision is made across the top of the head, from ear-to-ear, to provide access to the bones of the skull and eye socket for reshaping. The bicoronal incision is typically made in a wavy or zigzag pattern to help make the resulting scar less conspicuous. The deformity of the forehead and eye sockets varies based upon which cranial sutures have closed prematurely, but the ultimate goal of the fronto-orbital advancement is the same in all cases – to restore normal contour to the affected areas. 

The skull bones requiring reshaping are removed with a neurosurgeon. The contour of the skull bones and the upper portion of the eye socket(s) are made by hand. In order to have a normal appearance when the child's skull is fully grown we must account for the continued growth of the skull. This requires that we place the bones of the forehead and eye socket position in a more forward position for coronal synostosis and wider position for metopic synostosis. After reshaping the skull bones are reattached to the skull with dissolvable sutures and plates. The incision is closed in layers with dissolvable sutures.

The infant's appearance immediately after surgery does not look completely normal for their age, but the children grow into the overcorrection in next 1-2 years after surgery. If the forehead and upper eye socket are not overcorrected, the child will outgrow the correction and will have an abnormal appearance (similar to the original head shape) when they are fully grown. Below are some examples of patients before and after fronto-orbital advancement.

 This baby has left coronal synostosis. Note the flattening of the left forehead and upper portion of the eye socket (orbit). He underwent FOA at 10 months of age.

This baby has left coronal synostosis. Note the flattening of the left forehead and upper portion of the eye socket (orbit). He underwent FOA at 10 months of age.

 This is the same child 4 months after his FOA. Note that the left forehead and upper eye socket have been moved much farther forward than the right side. This is because the closed coronal suture on the left side will not provide the forward growth that the right open coronal suture will.

This is the same child 4 months after his FOA. Note that the left forehead and upper eye socket have been moved much farther forward than the right side. This is because the closed coronal suture on the left side will not provide the forward growth that the right open coronal suture will.

 This is the same patient at age 2 years old. He is more than a year out from his FOA. Note that he is still slightly overcorrected, but he has largely grown into his overcorrection already. There is a balanced look to the position and shape of both the forehead and upper eye socket. 

This is the same patient at age 2 years old. He is more than a year out from his FOA. Note that he is still slightly overcorrected, but he has largely grown into his overcorrection already. There is a balanced look to the position and shape of both the forehead and upper eye socket. 

 These are side views of the patient above before FOA. Note the the forehead and upper eye socket are much farther forward on the child's right side, while the left side is much flatter. Note that the upper eye socket on the left is abnormally positioned behind the eye.

These are side views of the patient above before FOA. Note the the forehead and upper eye socket are much farther forward on the child's right side, while the left side is much flatter. Note that the upper eye socket on the left is abnormally positioned behind the eye.

  These are side views of the patient above 14 months after FOA. Note the symmetric shape and position of the forehead and upper eye socket.

These are side views of the patient above 14 months after FOA. Note the symmetric shape and position of the forehead and upper eye socket.

What is the Recovery for Fronto-orbital advancement (FOA)?

The procedure takes 5-6 hours depending on the type and severity of craniosynostosis. The primary risks of this procedure are bleeding, infection and scarring and the possible need for further surgery. The amount of blood loss is not dangerous, however the small size of the patients requires a blood transfusion to be given in almost all cases. Patients recover in the intensive care unit (ICU) for the first night after surgery to have a higher level of nursing attention than a regular room would afford. IV pain medication is used to control pain in the first 24 hours after which oral pain medicine is effective in controlling pain. The remainder of the recovery in the hospital is in a regular hospital room for 3-4 days. The eyes will typically swell shut between the first and second day after surgery and reopen as the swelling subsides at 3-4 days after surgery. The average time to discharge from the hospital is 4-5 days after surgery. I see my patients at 3 weeks, 3-4 months and 1 year after surgery, and then yearly until age 14 years.

Skull growth after FOA is unpredictable, but the typical patient does not require another large scale skull reshaping. In a minority of patients some form of a contouring procedure is needed to address minor shape irregularities. 

  The pictures on the left above show a patient with bilateral coronal synostosis 2 years after posterior cranial vault distraction, just before her FOA at age 3 years old. The images on the right are 6 months after the reshaping of her forehead and upper eye sockets (orbits) with fronto-orbital advancement (FOA) performed at age 3 years old. Note the improved contour of the forehead from broad and flat to narrower and more rounded. The upper portion of the eye sockets have been moved forward and downward.

The pictures on the left above show a patient with bilateral coronal synostosis 2 years after posterior cranial vault distraction, just before her FOA at age 3 years old. The images on the right are 6 months after the reshaping of her forehead and upper eye sockets (orbits) with fronto-orbital advancement (FOA) performed at age 3 years old. Note the improved contour of the forehead from broad and flat to narrower and more rounded. The upper portion of the eye sockets have been moved forward and downward.

  The pi  ctures above show the   side views of the same patient before and after her FOA. The images on   the right are 6 months after the r  eshaping of her forehead and upper eye sockets (orbits) with fronto-orbital advancement (FOA) performed at age 3 years old. Note the improved contour of the forehead from broad and flat to more rounded. The upper portion of the eye sockets have been moved forward and downward. The upper portion of the orbit now sits in front of the eyes in a more normal position.

The pictures above show the side views of the same patient before and after her FOA. The images on the right are 6 months after the reshaping of her forehead and upper eye sockets (orbits) with fronto-orbital advancement (FOA) performed at age 3 years old. Note the improved contour of the forehead from broad and flat to more rounded. The upper portion of the eye sockets have been moved forward and downward. The upper portion of the orbit now sits in front of the eyes in a more normal position.