SPECIAL ANNUAL ISSUE

Unicoronal synostotic plagiocephaly: surgical

correction: Lille's technique
Philippe Pellerin & Clotilde Calibre & Matthieu Vinchon &
Patrick Dhellemmes & Alexis Wolber & Pierre Guerreschi
Received: 10 April 2012 / Accepted: 26 April 2012
#Springer-Verlag 2012
Abstract
Introduction For 35 years, we have a tight neuro-plastic surgi-
cal cooperation for the surgical correction and long-term sys-
tematic follow-up of 125 cases of unicoronal synostotic
plagiocephaly.
Methods We have tried to understand why some patients
had kept an asymmetrical facial growth pattern in spite of a
good fronto orbital correction. Analysis in vestibular orien-
tation which was available from 1993 has demonstrated a
discrepancy between the ocular and the vestibular verticality
referential system. So we have designed a surgical proce-
dure to try to fix that problem.
Results and Conclusion Preliminary results in 27 cases op-
erated according to this procedure, for which we have pre-
and post-CT scan demonstrate significative improvements
of our results.
Keywords Unicoronal synostotic plagiocephally
.
Cranio
facial surgery
.
Vestibular orientation
Introduction
We started correcting unicoronal synostosis following cra-
niofacial techniques by a mixed neurosurgical and maxillo-
facial surgery team in 1977. Initially, techniques were based
on unilateral correction, but the results proved unsatisfacto-
ry, and we adopted bilateral fronto-orbital correction. Our
results improved; however, some cases presented asymmet-
rical growth leading to delayed morphological degradation.
In 1993, advances in CT scanner acquisition and reconstruc-
tion allowed us to perform vestibular reconstruction of the
skull. We found a discrepancy between the visual and vestib-
ular referentials in patients with UCS [1, 2]. We hypothesized
that this discrepancy between the horizontal and vertical refer-
entials could cause a postural imbalance causing tensions
responsible for asymmetrical craniofacial growth.
The surgical correction that we describe below aims not
just at correcting frontal deformation, but also at reposition-
ing the eye globes in the proper referential plane, perpen-
dicular to the vertical defined by the vestibules [3]. We
reviewed 28 observations for which pre- and postoperative
vestibule-oriented 3D-CT scanners were available, in order
to validate this hypothesis, and evaluate the long-term mor-
phological results with this technique.
Age of surgery
By trial and error on patients of different ages at the start of
our experience, we determined that the ideal age for surgery
was 10 months. From the anesthetist's point of view, the
risks were lower than in younger infants [4]. From the
surgeon's point of view, the facial skeleton, in particular
the fronto-malar and metopic sutures, is more ossified and
can be manipulated and fixated (which is a problem in
M. Vinchon
:
P. Dhellemmes
Department of Pediatric Neurosurgery,
Lille University Hospital,
Lille, France
P. Pellerin
:
C. Calibre
:
A. Wolber
:
P. Guerreschi
French National Center for Rare Craniomaxillofacial
Malformations, Lille University Hospital,
Lille, France
P. Pellerin (*)
French National Center for Rare Craniomaxillofacial
Malformations, Hpital Roger Salengro,
CHRU de Lille,
59037 Lille Cedex, France
e-mail: philippe.pellerin@chru-lille.fr
Childs Nerv Syst (2012) 28:14331438
DOI 10.1007/s00381-012-1793-x
younger infants); on the other hand, older children have a
more rigid bone which lends itself less to plastic procedures.
Although some authors have advocated surgery at a younger
age in order to prevent the constitution of oculomotor prob-
lems, we found that the benefit did not offset the increased
anesthetic risk and surgical difficulties, and we settled on ten
months as the ideal age for surgery.
Preoperative investigations, anesthetic,
and armamentarium
Evaluation of plagiocephaly
We consider CT-scanner mandatory for the preoperative
evaluation. This imaging may require some sedation in a
10-month baby. The CT should include interlaced slices
1 mm thick or less, and the volume studied should include
the jaw, skull base, and the whole calvaria. The raw data
in DICOM format are necessary in order to make the
surgical planning; we use the freeware Osirix for Mac-
intosh OS10 to perform reconstructions. The 3D-MPR
function allows non-orthogonal reslicing, parallel to the
plan of the vestibular lateral semi-circular canal. On this
oriented volume series, we can define landmarks allowing
3-dimensional reconstruction. This volume with landmarks
is exported as jpeg images under Adobe Photoshop and
used to outline the future osteotomies and measure pre-
cisely the tridimensional correction of the malformation
(Fig. 1a, b).
Ophthalmological evaluation is mandatory because ocu-
lar dystopia can cause functional amblyopia, which if
neglected can become durable.
Genetic evaluation is necessary, since many apparently
sporadic coronal synostoses are the only manifestation of a
genetic disease.
Surgical equipment
In addition to standard instruments for soft tissue and bone
exposition, we use an electric burr with a high-speed cra-
niotome, a transverse oscillating saw, Tessier's bone cutting
forceps and bone-bending pliers. We avoid plates and use
instead steel wires which we found unmatched for precise
application of tension between bone parts.
Anesthesia and installation
General anesthesia is induced intravenously under strict
monitoring of the heart rate, blood pressure by an arm cuff,
urine output by bladder catheterization, central temperature
by a rectal probe, exhaled CO
2
by a capnometer and blood
oxygen by a finger pulse oxymeter. The patient is positioned
supine with the head elevated (in order to lower venous
pressure) on a vacuum mattress and covered with a warm
pulsed air blanket.
Fig. 1 a, b Pre-op surgical planning on C.T. scan orientated according
to vestibular orientation
1434 Childs Nerv Syst (2012) 28:14331438
Surgical technique
Skin and soft tissues
The hair is shampooed with povidone scrub the day before
and on the morning of surgery, and again in the OR (Fig. 2).
Minimal shaving is done along the incision line by the
surgeon then the skin is prepared with povidone. The sub-
cutaneous tissues are infiltrated with 1 % adrenalinated
xylocain in order to minimize bleeding. The draping expo-
ses only the scalp because of concerns about infection. Skin
incision using a cold blade runs from one tragus to the other
following a zigzag pattern (as much as possible at right
angle with the direction of hair), with a curve encompassing
the whole temporalis muscle. Skin sections are covered with
povidone-impregnated gauze stitched on the edges, reduc-
ing blood loss and avoiding contact with skin bacteria. The
pericranium is incised using a sharp Obwegeser elevator,
behind the limit of the temporalis muscle; the scalp, peri-
cranium, and muscle are then elevated together from the
bone [5]. The scalp is retracted down to the face, and
dissection is continued down to the nasal bones, around
the orbital rim medially down to the lacrymal fossa and
laterally down to the orbital floor. Whenever necessary, the
supraorbital nerve is freed from its bony canal and pre-
served. Careful dissection of the lateral orbital pillar is
required, in order not to damage the fronto-malar suture.
Soft tissue dissection ends with exposition of the medial,
superior, and lateral walls of the orbit and sphenoidal and
sphenomaxillary fissures.
Fig. 2 a, d Drawing of the osteotomies on the patient's 3D C.T. scan reconstruction
Childs Nerv Syst (2012) 28:14331438 1435
Craniotomy
The donor site for the projected forehead is chosen for its
size and shape, sometimes using a template cut out of
cotonoids and outlined using surgical ink. It has to be wide
enough, reproduce credible frontal eminences and be as
symmetrical as possible (Fig. 3). Generally, the ideal donor
site is frontal, its lower limit oblique about 1 cm above the
orbital bandeau on the synostotic side; however, the best
site may be parietal or temporo-parietal. Osteotomy is
prepared with two burr-holes and the dura is elevated
carefully before cutting the bone with the craniotome.
The flap is immersed in diluted povidone until use at the
end of surgery.
Having gained access to the inner cranium, the dura
mater is dissected from the frontal bandeau, sphenoid ridge,
and temporal pole, more widely on the synostotic side, with
great care to avoid tearing of the dura and bleeding from the
middle meningeal artery. Resection of the sphenoid ridge
gives access to the temporal fossa, which is necessary in
order to shield the dura from the oscillating saw during
osteotomy of the bandeau.
Cut of the bandeau
The bandeau is then outlined using surgical ink, according
to the preoperative plan. This bandeau is asymmetrical: on
the non-synostotic side, it ends at the fronto-malar suture; on
the synostotic side, it includes the lateral orbital process of
the malar bone. Osteotomies are performed using the oscil-
lating saw under constant irrigation with saline to avoid
heating. Osteotomy on the orbital pillar runs close to the
greater wing of the sphenoid, down to the spheno-maxillary
fissure. At this point, it joins a sagittal osteotomy through
the lateral pillar: this osteotomy is cut obliquely inferiorly
and posteriorly, so that, by replacing the bone flap anteriorly
to it, an osseous Z plasty will be created. On the non-
synostotic side, the bandeau is cut through the orbital pillar
at the level of the fronto-malar suture. On both sides, the
osteotomies are continued on the orbital roof medially,
where they join a horizontal cut through the nasion and
the bandeau is removed in one piece.
Additional bone cuts
Resection of the thickened pterional bone on the synostotic
side, which we consider responsible for locking the regional
bone growth, is performed with a rongeur down to the floor
of the temporal fossa. The orbital fissure is opened by
resection of a small bone triangle, allowing reshaping of
the orbital walls with Tessier's bone bending pliers.
Reconstruction
Repositioning of the bandeau is tri-dimensional: on the
synostotic side, has to be lowered and rotated forward and
Fig. 3 a, c Dissection: same patient intra-operating views
1436 Childs Nerv Syst (2012) 28:14331438
translated to the non-synostotic side (Fig. 4). These move-
ments have been previously measured on the oriented tri-
dimensional model of the patient and calculated in order to
bring the midline of the anterior skull base in concordance
with the midline of the vestibules. Translation is generally
10 to 15 mm toward the non-synostotic side, measured
between the middle of the nasal bones and of the glabella;
generally, the glabella thus translated falls just in the axis of
the sagittal suture. Advancement of the bandeau on the
synostotic side is achieved and maintained by overriding
of the Z osseous plasty of the orbital pillar; to this move-
ment is associated lowering of the bandeau as calculated
preoperatively. Finally, a rotation movement around an axis
defined by the inferolateral angle of the synostotic orbit and
the superolateral angle of the other orbit brings the supero-
lateral angle of the orbit forward, in order to advance the
upper part of the synostotic orbit more than its lower part.
The bandeau is fixed by two semi-rigid wire sutures (Rocky
Mountain) on the orbital pillars.
The positioning of the bone flap requires some adjust-
ment on the non-synostotic side, in order to provide slight
overcorrection and create a rigid construct, on which the
bandeau will then be shaped and fixed rigidly. The aim is to
create an asymmetrical floating forehead fixated on the non-
synostotic side, preventing displacement under pressure
from the skin during closure, and allowing further advance-
ment with brain growth. After cutting the fronto-temporal
bone on the non-synostotic side at the shape of the frontal
bone flap in order to obtain a perfect fit, both are fixed
together with 23 wire sutures. The frontal bone flap is left
loose on the synostotic side. The bandeau is then fixed to the
frontal flap by four wire sutures, progressively bending the
bandeau into the desired shape (Figs. 5, 6).
The temporo-parietal bone on the synostotic side can be
reshaped by horizontal bone cuts using the craniotome then
remodeled using Tessier's bone bending pliers. Final correc-
tions include drilling of the nasal bone on the synostotic side
in order to correct the axis of the nose and of the glabella on
the non-synostotic side in order to avoid compression of the
eye globe.
Closing and postoperative care
After careful hemostasis, two non-aspirating silicone drains
are placed subcutaneously; the skin flap is basculated and its
edges are approximated with strong temporary sutures. The
Fig. 4 a, d Reconstruction:
same patient, intra-operating
views
Childs Nerv Syst (2012) 28:14331438 1437
skin is closed in two layers of fast-absorbing 2/0 sutures.
Blood transfusion is constantly needed, its volume
based on hemoglobin assays during and after surgery;
we consider transfusion inherent to this surgery. The
child is awaken initially in the OR, then transferred to
the intensive care, where he stays until the next morn-
ing, then back to the pediatric neurosurgery ward.
Drains are removed by day 2; postoperative edema of
the face is maximal on days 23 then subsides about
day 5. The child is discharged on day 6, with dry
dressing being renewed at home by a nurse every sec-
ond day until the sutures shed. We advise that the child
should not wear a helmet when he will learn walking
because the skull will by then be of normal resistance
and helmets can lead to exclusion. The first postopera-
tive control in craniofacial clinic occurs at 3 months,
then the child is seen gain after 18 months, then every
third year until aged 18. Regular ophthalmological eval-
uations and reeducation are often necessary, as well as
physical therapy for associated torticollis. In our expe-
rience, scoliosis of the lower face improved spontane-
ously whenever the craniocephalic posture was straight,
that is, when the ocular and the vestibular referentials
were correctly co-axed. No patient has presented with
recurrence of plagiocephaly requiring large reoperation
since we adopted correction based on vestibular orien-
tation. Minor imperfection could require some time lipo-
filling [6].
References
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Vestibular orientation for craniofacial surgery: application to the
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craniosynostosis surgery. Ann Chir Plast Esthet 51(6):5126 Fig. 5 a, b Pre-op same patient
Fig. 6 a, b Postop same patient
1438 Childs Nerv Syst (2012) 28:14331438