A Posterior Rotational Flap Technique Using Distraction Osteogenesis for Unilateral Lambdoid Craniosynostosis

Abstract

Introduction:The craniofacial asymmetry seen in unilateral lambdoid craniosynostosis may not be effectively treated by posterior cranial vault remodeling, endoscopic suturectomy, and helmet therapy, or suturectomy and distraction osteogenesis alone due to limitations in soft-tissue envelope expansion and relapse of the deformity. The authors report a series of unilateral lambdoid craniosynostosis patients treated with a posterior rotational cranial-flap technique using internal distraction osteogenesis. Methods: Posterior cranial vault reconstruction combined with internal distraction was used, aided by preoperative virtual surgical planning. An in situ posterior rotational flap osteotomy was utilized to maximize dural preservation. Primary outcome measures included age-adjusted volume change and age-adjusted percent volume change per mm distraction. Distraction characteristics and perioperative characteristics were also assessed. Results: A total of 5 patients were identified. Mean predistraction intracranial volume was 1087.5 cc (SD ¼ 202.3 cc) and mean postdistraction included intracranial volume was 1266.1cc (SD ¼ 131.8cc). Mean age-adjusted percent included intracranial volume change was 14.1% (SD ¼ 9.6%), and mean percent intracranial volume change per mm distraction was 0.43%/mm distraction (SD ¼ 0.37%/mm distraction). One patient developed a distractor site infection postoperatively that was treated successfully with oral antibiotics. All patients had a Whitaker score of 1 at one year follow up. Conclusions: Posterior cranial vault remodeling using osteogenesis and a rotational cranial flap technique with dural preservation can be effectively used to maximize bone flap viability and limit postoperative relapse in patients with unilateral lambdoid craniosynostosis. Long term analysis as well as comparison to open techniques will need to be interrogated.

Rotation Advancement Distraction Osteogenesis Technique is Attributed to Unilateral Lambdoid Synostosis and is Used to Correct Posterior Plagiocephaly

“…In addition, they showed that the posterior ration flap technique provides a sufficient increase in intracranial volume, and our method is comparable with their study. The bone flap in our method was slightly smaller than that in their study, and the location of the valve was localized near the occipital region 8. Barrel stave osteotomy (case 2 only) and back cutting were added to increase intracranial volume, and an absorbable plate was used to reinforce the hinge area.…”

“…Kamel et al8 reported the use of a posterior rotation flap technique during the distraction osteogenesis of ULS. The increase in intracranial volume was considered sufficient in this report.…”

Perioperative Comparison Between Open Cranial Vault Remodeling and Distraction Osteogenesis for Unilateral Lambdoid Craniosynostosis

“…(Fig. 4) Gradual, incremental expansion of the suture gap and preservation of dura-bone attachments with DO was hypothesized to more naturally simulate in-vivo cranial growth and minimize bone resorption, leading to improved long-term esthetic outcomes compared with traditional open approaches 6,15–19. (Fig.…”

“…More recently, DO utilizing a posterior rotational cranial flap has become the technique of choice for treating ULS. 6 This technique begins with the patient placed in a prone position. A bicoronal flap is first elevated in a subgaleal plane beyond the nuchal ridge.…”

“…4 Many techniques have been described for the treatment of patients with ULS, such as endoscopic suturectomy, distraction osteogenesis (DO), open posterior calvarial reconstruction, and bone-flap remodeling or switching. [1][2][3][4][5][6][7][8][9][10][11][12][13] At the time of this writing, the most common treatment for ULS was open posterior cranial vault remodeling (OCVR), however, reports on the effectiveness of this technique for treating this condition have been mixed. Zoller et al 12 indicated that OCVR resulted in the normalization of intracranial pressure and produced consistently favorable esthetic outcomes in patients with ULS.…”