Turribrachycephaly: a technical note

We describe a technique for early correction of the so-called towering skull deformity, or turribrachycephaly. The technique makes use of the natural elasticity and plasticity of cranial bone, and it is best applied during the first year of life. Surgery consist of routine exposure of the cranial bone via a coronal incision. The frontal bone flap is elevated and removed. On either side, a bony osteotomy is then made, commencing low down in the temporal region and running posteriorly and superiorly toward the occiput. This approach leaves a superior bone flap, which may be left attached to the occipital bone via a flexible posterior hinge region, or completely detached by continuing the osteotomy across the midline. After the osteotomy, the bone flap is elevated up to the sagittal sinus on either side of the midline. The bone flap is not removed, but pushed down, compressing the brain along the craniocaudal axis. The lateral edge of the flap overlaps the temporal bone, and it can be fixed in the desired position by means of simple positional screws or Vicryl sutures. A standard fronto-orbital advancement is performed prior to lowering the skull vault, which permits the brain to be moved down and forward, filling the dead space in the anterior cranial fossa. The frontal bone flap is then shaped appropriately and fixed by means of plates and screws to the advanced fronto-orbital bar. Posteriorly, the frontal lobe is left "floating." To date, we have performed this technique on 5 patients, and we find it both faster and simpler than other techniques. Short-term results in terms of cranial shape are good. In older infants (> 2 years of age), this technique may not prove useful because of the loss of the loss of plasticity of the bone.