A Modified Approach to Surgical Correction of Anterior Plagiocephaly

Abstract

The gold standard for surgical correction of both uni- and bilateral coronal synostosis remains to this day, the "standardised bilateral fronoto-orbital advancement and reshaping" based on the "tongue in groove" technique developed by Tessier. It consists of bilateral frontal craniotomy for suture release and decompression, combined with creation of a "supraorbital bar" as a bilateral orbital complex by osteotomising the orbital roof (anterior cranial base), supraorbital ridge and upper lateral orbital rims bilaterally. This is followed by a bilateral advancement and remodelling of the frontal region as well as the orbital region bilaterally which is then rigidly fixed in position, the supraorbital bar to the face (at the fronto-zygomatic region and the fronto-nasal region) and the reconstructed forehead to the supraorbital bar. In this study, a slightly modified procedure was employed for correction of the right sided unilateral coronal synostosis, using a bifrontal craniotomy combined with unilateral orbital osteotomy (creating a unilateral supraorbital bar/bandeau), followed by radial osteotomies/kerfing, reshaping and advancement of the bifrontal calvarial segment. This was followed by the "tongue in groove" advancement of the right orbital segment (unilaterally). We preferred to spare osteotomising the contralateral (that is, the left) orbital region as it was not involved by compensatory growth deformity, and the frontal bossing/bulging was restricted to the upper forehead region alone. A gratifying aesthetic outcome and perfect symmetry was achieved using this technique. There were also no complications like wound infection or dehiscence, CSF leak, bone loss from resorption, damage to orbital contents or brain, recurrence of the dysmorphology or residual deformities or asymmetrics of the orbital region or forehead. Gratifying cosmetic results were seen using this modified technique and it was found that bilateral frontal reshaping and unilateral orbital advancement together with kerfing the frontal segment followed by fixation using resorbable implants is an effective strategy to not only permit remodelling of the skull and face thus correcting the cosmetic deformity, but also to increase the intracranial volume within the anterior cranial vault, without the need for any graft placement.

Evaluation and management of nonsyndromic craniosynostosis

“…Jeyaraj modified the technique of “bilateral frontal-unilateral orbital advancement” spares osteotomy of the contralateral unaffected orbit. [ 17 ] Pellerin et al [ 18 ] have suggested asymmetrical harvesting of the frontoorbital bandeau. The bandeau bone cut in the lateral orbital rim is extended to the frontozygomatic suture on the synostotic side and is shorter on the unaffected side.…”

Anteriorna plagiocefalija – Prikaz primera in opis kirurške tehnike

“…Važno je, da se diagnoza postavi v prvih mesecih življe-nja in da se otrok operira v prvih 12 mesecih (9). Tudi pri našem bolniku smo s kirurškim posegom počakali do ugodne starosti sedmih mesecev, saj je takrat izid zdravljenja najboljši (10,11). Optimalni čas operacije je sicer po opisih v literaturi še vedno vir razprav.…”

“…Optimalni čas operacije je sicer po opisih v literaturi še vedno vir razprav. Po mnenju večine avtorjev je poseg najbolje opraviti med šestim in dvanajstim mesecem starosti (10)(11)(12)(13). Poseg pred to starostjo je nevaren zaradi možne velike izgube krvi ter zaradi večje možnosti recidiva kraniosinostoze (11,13).…”

“…Ti omogočajo čvrsto pritrditev kostnih fragmentov, dokler se ti ne zarastejo. Dokončno se ta osteosintetski material resorbira po dvanajstih mesecih (10).…”

“…Jeyaraj je opisal korekcijo anteriorne plagiocefalije izključno na podlagi enostranske orbitalne osteotomije, torej oblikovanja frontoorbitalnega bandeauja samo na prizadeti strani (10). Tak tip posega je možen le v primerih, ko nasprotna stran čela ni izrazito prizadeta.…”