title: The "clamshell" craniotomy technique in treating sagittal craniosynostosis in older children.
abstract: OBJECTIVE
  Although most patients with sagittal craniosynostosis are recognized and treated in infancy, some children are not referred to craniofacial centers until later in childhood. In this paper the authors describe a novel operative technique for calvarial reconstruction in older children with previously untreated sagittal craniosynostosis.
  
  
  METHODS
  The authors report a clinical series of eight patients who were treated using novel single-stage calvarial reconstruction, and they assess the complications and outcomes. The patient is placed supine for the procedure, which consists of a coronal incision, bifrontal craniotomy without orbital osteotomy, and multiple interlocking midline parietooccipital osteotomies and recontouring. Fixation is achieved using a bioabsorbable plate system. Cranial indices were calculated from measurements obtained before and after the reconstructive procedures. Preoperative, intraoperative, and postoperative photographs and three-dimensional computed tomography scans are presented for review. Between November 2003 and April 2005, the authors treated seven boys (age range approximately 1-10 years, mean age 4.2 years) with uncorrected sagittal craniosynostosis and one with bicoronal and sagittal synostosis. The mean operating time was 5.13 hours (range 4.3-8 hours), with a mean blood loss of 425 ml (range 200-800 ml). As a percentage of the estimated circulating blood volume, the mean operative blood loss was 33.5% (range 17-57%). The mean hospital stay was 4.9 days. The cranial index significantly improved from a mean of 65.6 to 71.3% (p = 0.001). No acute or delayed complications have been noted. Follow-up examinations performed at an average of 12 months (range 1-17 months) have confirmed early patient and family satisfaction.
  
  
  CONCLUSIONS
  An approach of aggressive calvarial reconstruction with multiple interleaving osteotomies crossing the midline achieves improvements in biparietal narrowing. Combined with a bifrontal reconstruction, early outcomes are excellent, with an acceptable amount of intraoperative blood loss and no significant complications.
authors.affiliation: Department of Neurological Surgery and Division of Plastic Surgery, St. Louis Children's Hospital, Washington University, St. Louis, Missouri 63110, USA. smythm@nsurg.wustl.edu
authors.forename: Matthew D
authors.initials: MD
authors.lastname: Smyth
authors.forename: Marissa J
authors.initials: MJ
authors.lastname: Tenenbaum
authors.forename: Christian B
authors.initials: CB
authors.lastname: Kaufman
authors.forename: Alex A
authors.initials: AA
authors.lastname: Kane
mesh_terms: D016063:Blood Loss, Surgical; D002648:Child; D002675:Child, Preschool; D003398:Craniosynostoses / Q000000981:diagnostic imaging / Q000601:surgery*; D003399:Craniotomy / Q000379:methods*; D005500:Follow-Up Studies; D006801:Humans; D007091:Image Processing, Computer-Assisted; D021621:Imaging, Three-Dimensional; D007223:Infant; D007902:Length of Stay; D008297:Male; D017060:Patient Satisfaction; D011184:Postoperative Period; D013997:Time Factors; D014057:Tomography, X-Ray Computed