A bifrontal craniotomy is performed to remove the frontal bone. The supraorbital bar is advanced 10-15 mm and stabilized with wires or sutures. Bone grafts from the frontal bone flap are used to fill gaps in the temporal area and coronal bone. The frontal bone flap is reshaped and reattached with plates or sutures.

1. Frontoorbital Advancement

2. Bifrontal craniotomy is performed removing both the hypoplastic and protuberant frontal
bone. Further removal of the basal extension of the involved coronal suture (blue dashes)
into the cranial base is performed by rongeur

3. Positioning of the supraorbital bar
The supraorbital bar is then advanced 10-15 mm on the side of the fusion, hinging at the point
just behind the orbital rim on the uninvolved side. In infants an overcorrected advancement is
usually made, as there will be some recurrence of the deformity with growth.
In adults who have finished craniofacial growth, advancement is done so that the superior
orbital rim is approximately 12 mm anterior to the cornea, and equal or symmetric with the
uninvolved opposite side.
The key is to try to straighten the bandeau so that both sides are equal and symmetric,
employing osteotomies and fixation wherever required to make this possible.

4. Fixation of the supraorbital bar
The advanced bar is then stabilized. A wire or suture is placed between the
stable lateral orbital rim and the bandeau.

5. Pearl: To improve the stability of the advanced segment, a cranial bone graft may also
be wedged and placed in the orbital roof between the stable posterior segment and the
advanced anterior segment on the affected side.

6. Grafting of temporal bone gap
Bone graft harvested from the frontal bone flap is then inserted in the temporal gap and
held in position with a resorbable plate (infants and children)

7. If metallic or resorbable plate fixation is unavailable, self-retaining osteotomies may
be designed and utilized in conjunction with wire or suture fixation.

8. Replacement and fixation of the frontal bone
flap
The frontal bone flap is then typically split down the midline and reshaped with a bone
bending forceps (children) or with a partial osteotomies and plate fixation (adults).
Usually the right and left flaps are rotated, bent contoured and switched to get the optimal
symmetry.
The bone flaps are affixed to the supraorbital bar with resorbable plates or resorbable
sutures (infants), or titanium plates (adults).

9. Grafting of coronal bone gap
The coronal bone gap created from the advancement and harvesting of bone is then
filled with particulate bone shavings harvested with a manual hand-held burr-hole
instrument or commercial harvester (eg, Safe scraper) from the frontal bone flap or the
posterior skull.

10. Grafting of coronal bone gap
The coronal bone gap created from the advancement and harvesting of bone is then
filled with particulate bone shavings harvested with a manual hand-held burr-hole
instrument or commercial harvester (eg, Safe scraper) from the frontal bone flap or the
posterior skull.