Anterior Closure

When the anterior portion of the sagittal suture closes prematurely, the compensatory growth causes frontal bossing and an extensive craniotomy is required. The craniotomy must expand the narrowed skull, shorten the protracted anterior-posterior distance and attend to the bossing (Fig. 25.5a).

One option is to perform the so-called anterior n procedure. In the supine position, separate bi-parietal flaps are fashioned, whose anterior and posterior limits are the coronal and lambdoid sutures (Fig. 25.5a). The coronal suture and the bone overlying the temporal fossa are then rongeured, leaving a craniotomy in the shape of a n (Fig 25.5b). Notably, the pathological sagittal suture is not excised; the operation focuses on the compensations, and not the fused suture. The remaining elements are united, slanting the frontal bone posteriorly, thus correcting the skull length and the frontal bossing. Barrel-stave osteotomies are fashioned in the parietal and temporal bones and are then out-fractured so that when the remaining bony elements are brought together, the width of the skull can expand (Fig. 25.5c and d).

There are a number of variations in this procedure, depending on the degree of frontal bossing. When dramatic, the frontal bone must be removed and reshaped using radial osteotomies and careful infracturing of the frontal bone. At times, other techniques are used. The skull may be foreshortened by removing a narrow bi-parietal flap that contains the sagittal suture. This flap is then shortened and rotated 90° to increase the width of the skull. Skull on either side of the coronal and lambdoid sutures is rongeured and, after the remaining bone edges are united, the skull is shorter and rounder.

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The term vaginitis is one that is applied to any inflammation or infection of the vagina, and there are many different conditions that are categorized together under this ‘broad’ heading, including bacterial vaginosis, trichomoniasis and non-infectious vaginitis.

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