Craniosynostosis

Surgical Treatment Options

Cranial Vault Remodelling

Cranial vault remodelling is a traditional, open surgical approach used for many types of craniosynostosis. It reshapes and repositions sections of the skull to achieve a normal contour and ensure space for brain growth. These procedures are generally carried out around 9-15 months of age.

The type of cranial vault remodelling depends on the suture involved:

• Total or Subtotal Cranial Vault Remodelling: Used for sagittal synostosis. A bicoronal incision across the top of the scalp is made. Four bone plates of the skull are removed and remodelled to widen the skull side-to-side and reduce frontal and occipital prominence. The remodelled bone is secured with dissolving plates.
• Bifrontal Orbital Advancement: Used for metopic or coronal synostosis. A bicoronal incision is made. The frontal bone and upper orbits are dissected, the supra-orbital bar is widened and advanced, correcting forehead flattening, widening temples, and deepening the upper orbit. The frontal bone is advanced.

Spring-Assisted Cranioplasty

This is generally used for sagittal synostosis.

Spring-assisted cranioplasty is a minimally invasive option for selected infants with sagittal synostosis. This needs to be carried out at a younger age, ideally around 3-4 months. Through a smaller incision, a cut in the bone is made either side of the fused sagittal suture. A small amount of bone is removed from the midline to allow the skull to shorten. Once this is done, two flexible metal springs are then inserted to gradually widen the skull over several months. The springs are removed at a second, short procedure three months later once adequate expansion has occurred.

This approach generally has a shorter surgical time, less blood loss, and a quicker recovery, however, it is done at a younger age and may not be suitable for every patient, for example, those with significant frontal bossing.

Cranial Distraction

Cranial distraction is a technique used for children with multisuture craniosynostosis, including cases involving both coronal sutures (bicoronal synostosis) or more complex patterns where the skull is significantly restricted. Instead of reshaping the skull in a single operation, distraction gradually expands the skull over time, allowing for a controlled increase in intracranial volume. Via a bicoronal incision, a cut in the bone is made around the back of the skull and two or small distraction devices are attached to the skull. These devices have a turning arm that protrudes through the skin. Over the following weeks, caregivers turn the devices slightly each day, slowly separating the bone segments. This gradual movement encourages new bone formation in the gap and increases space for the growing brain. Cranial distraction can achieve substantial volume expansion with less blood loss and a shorter operative time compared with extensive open reconstructions. It is particularly helpful in children with raised intracranial pressure or those who need significant expansion beyond what can be achieved safely with a single operation. Once the desired expansion is reached and the new bone has consolidated, the distractors are removed during a second, smaller procedure.

Note: Strip Craniectomy and Helmet Therapy

Strip craniectomy is a minimally invasive surgery sometimes used for single suture craniosynostosis. It involves removing a narrow strip of bone along the fused suture and correcting head shape gradually using a custom-moulded helmet. The helmet must be worn continuously for several months. This approach is not currently offered in Queensland due to less predictable correction.

What to Expect After Surgery

Children typically spend one night in the Paediatric Intensive Care Unit (PICU) so they can be kept comfortable and can be closely monitored. Patients can feed as soon as they are able to.

Generally, the next morning, they move to the ward, where they usually stay for three to four days. During this time, the team focuses on pain control, feeding, and wound care. Swelling is very common, especially around the eyes, and usually peaks between 48 and 72 hours after the operation. Many children will have swollen eyelids that may even close completely for a day or two. Although this can be distressing for parents, it is normal and temporary, and the eyes gradually reopen as the swelling settles.

A head bandage is worn for the first few days to protect the incision and reduce swelling. Most children also have surgical drains, which help remove fluid from under the scalp and are typically removed on day two or three. Parents will be shown how to gently clean the incision line after the bandages are removed. An ointment such as soft paraffin is used along the incision line. Note that all sutures used will dissolve by themselves.

A follow-up appointment at one week after surgery is arranged to check how the incision is healing, ensure swelling is improving, and answer any questions before the child resumes normal activities. Generally, at the six-week mark, most of the swelling has settled and children can return to daycare without the need to any extra precautions.

Potential Risks

All craniofacial surgeries carry some risks, and families are carefully counselled before surgery. Although these procedures are performed by highly specialised teams and complications are uncommon, it is important to understand what may occur.

• Blood loss and transfusion: Craniosynostosis surgery involves operating on highly vascular skull bones, so almost all patients will receive a blood transfusion during or after the procedure. This is planned and safely managed.
• Infection and wound healing issues: There is a small risk delayed healing along the scalp incision. Careful wound care helps minimise this. Infections can also occur, ranging from simple wound infections that settle with antibiotics to deeper collections that require washout.
• Dural tears: Occasionally the membrane over the brain (dura) may tear, causing a cerebrospinal fluid (CSF) leak. These are usually repaired during surgery and heal without long-term problems.
• Contour irregularities: Mild unevenness in skull shape may occur as healing progresses. This often improves over time as the bone remodels, though a small number of children may need later contouring.
• Bony defects or persistent soft spots: some children may have small gaps or soft areas in the skull for a period after surgery. These typically improve as the skull grows.

Secondary Procedures That May Be Required in Later Childhood

Some children require further procedures as they grow, depending on their original suture involvement and bone development.

A.    Anterior Cranioplasty and Correction of Temporal Hollowing

This may be needed in 10-20% of patients, typically from 10-12 years of age onward, to refine forehead contour or address temporal hollowing that may develop over time. Options for correction include alloplastic implants such as porous polyethylene or PEEK or a bone substitute like hydroxyapatite. These techniques help restore symmetrical contour and are tailored to the child’s anatomy.

B.    Corrective Jaw Surgery

In some children, particularly those with syndromic craniosynostosis, the upper or lower jaw may grow abnormally. Orthognathic surgery in adolescence can help improve jaw alignment, dental occlusion, airway function, and facial balance. Often this involves advancing the midface by a process of distraction.

Specialised Team Approach Craniosynostosis

Surgery is performed by a coordinated team involving both a plastic surgeon and a neurosurgeon, ensuring safe, comprehensive care. At Terrace Plastic Surgery, we work closely with Dr Robert Campbell and Dr Amelia Jardim to provide collaborative craniofacial care.

Even if surgery is performed in the private sector, we strongly recommend ongoing follow-up with the Queensland Children’s Hospital Craniofacial Multidisciplinary Team (MDT). We can arrange referrals to ensure each child’s long-term development, vision, dental care, and growth are appropriately monitored. All patients who had have surgery for craniosynostosis are follow up through the Queensland Children’s Hospital Craniofacial Clinic with clinical reviews every one to two years combined with regular ophthalmic assessments.