title: Lessons learned in posterior cranial vault distraction.
abstract: BACKGROUND
  Posterior distraction (PD) is rapidly emerging as an important technique to increase the intracranial volume and correct calvarial morphology in patients with severe brachycephaly or turribrachycephaly.
  
  
  METHODS
  A retrospective review was performed of all 31 patients who underwent PD at the Oxford Craniofacial Unit between 2007 and 2012.
  
  
  RESULTS
  Twenty-three patients (74.2%) underwent PD as a primary procedure at a median age of 8 months. Eight patients (25.8%) had PD as a secondary transcranial procedure at a median age of 48 months. Full distraction to 20 mm was achieved in 28 patients (90.3%). Of these, all but 1 demonstrated a significant improvement in morphology, with a resolution of the symptoms and signs of raised intracranial pressure in all proven to have it preoperatively. Unanticipated events occurred in 61.3% of patients, with 19.4% undergoing one or more unplanned procedures. Wound infection (29.0%) and tissue necrosis (22.6%) were the commonest. Cerebrospinal fluid leaks were rarer (6.5%) but prevented full distraction. Nine patients (29.0%) had a consolidation period of less than 30 days without experiencing relapse. In 11 patients who had a later fronto-orbital advancement and remodeling, wound closure was tight, resulting in dehiscence in 3 cases (27.3%).
  
  
  CONCLUSIONS
  Posterior distraction is an effective procedure in the management of severe brachycephaly or turribrachycephaly but has associated risks. Our protocol has evolved with experience to favor a reduced latency period and consolidation phase and the use of 2 distractor devices.
authors.affiliation: From the Oxford Craniofacial Unit, Oxford University Hospitals NHS Trust, Oxford, UK.
authors.forename: Gregory P L
authors.initials: GP
authors.lastname: Thomas
authors.forename: Steven A
authors.initials: SA
authors.lastname: Wall
authors.forename: Jayaratnam
authors.initials: J
authors.lastname: Jayamohan
authors.forename: Shailendra A
authors.initials: SA
authors.lastname: Magdum
authors.forename: Peter G
authors.initials: PG
authors.lastname: Richards
authors.forename: Akira
authors.initials: A
authors.lastname: Wiberg
authors.forename: David
authors.initials: D
authors.lastname: Johnson
mesh_terms: D000168:Acrocephalosyndactylia / Q000601:surgery; D065634:Cerebrospinal Fluid Leak / Q000209:etiology; D002648:Child; D002675:Child, Preschool; D003394:Craniofacial Dysostosis / Q000601:surgery; D003398:Craniosynostoses / Q000601:surgery; D003399:Craniotomy / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D019586:Intracranial Hypertension / Q000601:surgery; D008297:Male; D009336:Necrosis; D019857:Osteogenesis, Distraction / Q000295:instrumentation / Q000379:methods*; D012189:Retrospective Studies; D012886:Skull / Q000601:surgery*; D013529:Surgical Wound Dehiscence / Q000209:etiology; D013530:Surgical Wound Infection / Q000209:etiology