The “clamshell” craniotomy technique in treating sagittal craniosynostosis in older children

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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.


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 ~ 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.


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.

Abbreviations used in this paper:CT = computed tomography; 3D = three-dimensional.

Article Information

Address reprint requests to: Matthew D. Smyth, M.D., Department of Neurosurgery, St. Louis Children’s Hospital, One Childrens Place, Suite 4S20, St. Louis, Missouri 63110. email:

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Intraoperative photographs showing patient positioning and scalp preparation. A: Care is taken to avoid kinking of the endotracheal tube. B: Note the access to the occipital bullet with the molded vacuum bean bag. C: An ear-to-ear band of hair is shaved in preparation for the coronal incision, which is marked out in a zig-zag fashion posterior to the coronal suture.

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    Intraoperative photographs. A: After the cranial vault is exposed, planned osteotomies are marked on the surface. B: Bur holes are placed bridging the sagittal sinus near the coronal and lambdoid sutures, as well as the frontotemporal region just above the lesser wing of the sphenoid bone bilaterally. C: After the bifrontal craniotomy is performed 1 cm above the orbital rim, the frontal bone is removed and taken for recontouring.

  • View in gallery

    Intraoperative photographs (A and C) and 3D reconstructed CT scans (B and D) showing the midline and occipital reconstruction. A: Occipital osteotomies. B: Image obtained immediately postoperatively, showing the occipital reconstruction. C: Midline osteotomies. D: Image obtained immediately postoperatively showing the midline reconstruction.

  • View in gallery

    Frontal reconstruction. A and B: Intraoperative photographs showing frontal bone inversion to correct frontal bossing. C: In some cases, patients had a split frontal craniotomy to correct bossing as can be seen in this postoperative 3D CT reconstruction.

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    Preoperative, immediately postoperative, and 1-year follow-up 3D reconstructed CT scans obtained in all eight patients. Two patients have not yet undergone 1-year follow-up CT scanning.

  • View in gallery

    Preoperative and postoperative frontal, lateral, and vertex photographs obtained in all eight patients. The age at which each operation was performed is shown in the left-hand column.



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