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.
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.