Unilateral Coronal Synostosis (Plagiocephaly)

Unilateral coronal craniosynostosis causes about 15% of all cases of isolated craniosynostosis. Unlike sagittal and metopic craniosynostosis that cause symmetric changes in the shape of the head, closure of one coronal suture causes a very uneven appearance to the skull and face. These patients have flat foreheads and raised eye sockets on the side of the closed coronal suture. On the side with the open coronal suture, the forehead is pushed forward and the upper part of the eye socket is pushed downward. Additional findings include deviation of the nasal bridge toward the side of the closed coronal suture and deviation of the chin away from the closed suture. This uneven appearance of the skull and face is the result of decreased (constricted) growth on the side of the closed suture and compensatory overgrowth on the side of the open suture. This compensatory growth occurs because the brain continues to grow at the same rate, whether all of the cranial sutures are open or not. If the left coronal suture is closed, the neighboring sutures including the right coronal suture must grow faster to make space for the brain. This is what causes the abnormal shape of the head.

The image above shows the front view of a normal skull and a left coronal craniosynostosis with the red arrow pointing to the closed coronal suture on the left side of the skull. Note that the forehead is flattened and the upper portion of the eye socket (orbit) is raised and pushed back on the side of the closed suture.

The image above shows the front view of a normal skull and a left coronal craniosynostosis with the red arrow pointing to the closed coronal suture on the left side of the skull. Note that the forehead is flattened and the upper portion of the eye socket (orbit) is raised and pushed back on the side of the closed suture.

The image above shows the top down view of a normal skull and a left coronal craniosynostosis with the red arrow pointing to the closed coronal suture on the left side of the skull. Note that the forehead is flattened on the left and pushed forward on the right. The left side of the skull is shorter than the right side because of the restricted growth on the side of the closed suture (left) and compensatory overgrowth on the right side of the skull.

The image above shows the top down view of a normal skull and a left coronal craniosynostosis with the red arrow pointing to the closed coronal suture on the left side of the skull. Note that the forehead is flattened on the left and pushed forward on the right. The left side of the skull is shorter than the right side because of the restricted growth on the side of the closed suture (left) and compensatory overgrowth on the right side of the skull.

The image above shows an infant with left coronal craniosynostosis. Note that the infant's left forehead is flattened and the upper portion of his left eye socket (orbit) is raised and pushed back on the side of the closed suture. This causes the left eyebrow to also become raised and be pushed back.

The image above shows an infant with left coronal craniosynostosis. Note that the infant's left forehead is flattened and the upper portion of his left eye socket (orbit) is raised and pushed back on the side of the closed suture. This causes the left eyebrow to also become raised and be pushed back.

The image above shows the top down view of the same infant with left coronal craniosynostosis. Note that the forehead is flattened on the left and pushed forward on the right. 

The image above shows the top down view of the same infant with left coronal craniosynostosis. Note that the forehead is flattened on the left and pushed forward on the right. 

The images above show the left and right side views of the same infant with left coronal craniosynostosis. Note that the forehead is flattened on the left and pushed forward on the right. The upper portion of the left eye socket sits behind the cornea. The right side sits farther in front of the cornea because of the compensatory overgrowth on the right side of the skull.

The images above show the left and right side views of the same infant with left coronal craniosynostosis. Note that the forehead is flattened on the left and pushed forward on the right. The upper portion of the left eye socket sits behind the cornea. The right side sits farther in front of the cornea because of the compensatory overgrowth on the right side of the skull.

Unilateral synostosis is treated with a fronto-orbital advancement at age 9-12 months of age. The goal of this procedure is to correct the position of the upper portion of the eye socket and forehead. Read more about fronto-orbital advancement. In order to have an even appearance when fully grown, we must overcorrect the forehead and eye socket position in a more forward position than the unaffected side. The children grow into the overcorrection in 1-2 years. If the forehead and upper eye socket are not overcorrected, the face and skull will have an uneven appearance when the child is fully grown. See before and after photos of patients with unicoronal craniosynostosis who were treated with fronto-orbital advancement.

Bilateral Coronal Synostosis (Brachycephaly)

Non-syndromic bilateral coronal craniosynostosis is rare, making up only 5-10% of all isolated craniosynostosis. In these patients both coronal sutures are closed which creates a symmetric change in the shape of the skull, unlike unilateral coronal synostosis which causes a very uneven appearance of the skull. Because the coronal sutures normally grow forward and are now closed the skull is shorter from front to back. The remaining open sutures must make up for the loss of growth at the closed coronal sutures. The compensatory overgrowth at the remaining open sutures causes the skull to be abnormally tall and wide. This skull shape that is tall, wide and short from front to back is called brachycephaly. The back of the head is also flattened. Note that the upper portion of the eye sockets (orbits) are abnormally raised and push back. The forehead is very flat and wide.

The red arrows indicate the location of the closed coronal sutures. Note the increased height and width of the skull from compensatory growth in the remaining open sutures. The upper portion of the eye socket (orbit) is raised and pushed back. The forehead is very flat, tall and wide.

The red arrows indicate the location of the closed coronal sutures. Note the increased height and width of the skull from compensatory growth in the remaining open sutures. The upper portion of the eye socket (orbit) is raised and pushed back. The forehead is very flat, tall and wide.

These side views show the closed coronal suture indicated with a red arrow. Note the increased height of the skull and decreased length of the skull from front to back. The forehead is taller and flatter than normal.

These side views show the closed coronal suture indicated with a red arrow. Note the increased height of the skull and decreased length of the skull from front to back. The forehead is taller and flatter than normal.

This top down view shows the closed coronal sutures indicated with red arrows. Note the increased width of the skull and decreased length of the skull from front to back. The forehead is wider and flatter than normal.

This top down view shows the closed coronal sutures indicated with red arrows. Note the increased width of the skull and decreased length of the skull from front to back. The forehead is wider and flatter than normal.

Similar to unilateral coronal synostosis, these patients will eventually require a fronto-orbital advancement (FOA) in order to achieve a normal appearance to the forehead and eye sockets. In bilateral coronal synostosis there are two sutures involved. Since two sutures are involved the changes in the skull shape are more profound than unilateral synostosis. The shape of both the front and back of the skull are severely affected. Read more about front-orbital advancement.

Recently, posterior cranial vault distraction osteogenesis (PVDO) has emerged as a powerful procedure in these patients. Distraction osteogenesis (DO) is a technique in which cuts are made in the facial or skull bones and specialized devices (distractors) move the cut bones slowly over time. This creates new bone and allows for repositioning of the bones also. PVDO uses specialized devices called cranial distractors to move the bones of the back of the skull very slowly. PVDO allows for reshaping and enlargement of the back of the skull, generation of new bone and also slowly stretches the scalp as the bones move. The scalp is usually what limits how much we can correct the head shape in a single operation. Cranial distraction allows for more significant reshaping of the skull than single stage procedures can provide. Expanding the back of the head creates space for the growing brain and allows us to delay the reshaping of the forehead and eye sockets with FOA to an age closer to the completion of skull growth. If the FOA procedure can be delayed to a later age the long-term appearance of the patients is better. 

I have published several articles on PVDO and presented my research on PVDO at both national and international meetings (see my publications). Before and after photos of one of my patient can be seen below. The photos show the changes in the head shape achieved with PVDO performed at age 6 months and FOA performed at age 3 years old. 

These photos show my patient who has bicoronal synostosis immediately before posterior cranial vault distraction osteogenesis (PVDO) at age 6 months on the left and immediately after removal of the distractor devices at age 9 months on the right.

These photos show my patient who has bicoronal synostosis immediately before posterior cranial vault distraction osteogenesis (PVDO) at age 6 months on the left and immediately after removal of the distractor devices at age 9 months on the right.

Note that the preoperative photos on the left show that the skull is vertically taller while the skull is short from front to back and flat at the back of the head. After PVDO on the right, back of the head is much more rounded and normal appearing. The front of the skull also tends to look better even though no surgery was performed there.

Note that the preoperative photos on the left show that the skull is vertically taller while the skull is short from front to back and flat at the back of the head. After PVDO on the right, back of the head is much more rounded and normal appearing. The front of the skull also tends to look better even though no surgery was performed there.

These pictures show the changes in the patient's appearance between the time of her PVDO (age 9 months) and the reshaping of her forehead and upper eye sockets (orbits) with fronto-orbital advacement (FOA) age 3 years old.

These pictures show the changes in the patient's appearance between the time of her PVDO (age 9 months) and the reshaping of her forehead and upper eye sockets (orbits) with fronto-orbital advacement (FOA) age 3 years old.

These pictures show the changes in the patient's appearance between the time of her PVDO (age 9 months) and the reshaping of her forehead and upper eye sockets (orbits) with fronto-orbital advacement (FOA) age 3 years old.

These pictures show the changes in the patient's appearance between the time of her PVDO (age 9 months) and the reshaping of her forehead and upper eye sockets (orbits) with fronto-orbital advacement (FOA) age 3 years old.

The pictures on the left above show the patient's appearance 2 years after her PVDO, just before her FOA. The images on the right are 6 months after the reshaping of her forehead and upper eye sockets (orbits) with fronto-orbital advancement (FOA) performed at age 3 years old. Note the improved contour of the forehead from broad and flat to narrower and more rounded. The upper portion of the eye sockets have been moved forward and downward.

The pictures on the left above show the patient's appearance 2 years after her PVDO, just before her FOA. The images on the right are 6 months after the reshaping of her forehead and upper eye sockets (orbits) with fronto-orbital advancement (FOA) performed at age 3 years old. Note the improved contour of the forehead from broad and flat to narrower and more rounded. The upper portion of the eye sockets have been moved forward and downward.

The pictures above show the patient's appearance 2 years after her PVDO on the left, just before her FOA. The images on the right are 6 months after the reshaping of her forehead and upper eye sockets (orbits) with fronto-orbital advancement (FOA) performed at age 3 years old. Note the improved contour of the forehead from broad and flat to more rounded. The upper portion of the eye sockets have been moved forward and downward. They now site in front of the eyes in a more normal position.

The pictures above show the patient's appearance 2 years after her PVDO on the left, just before her FOA. The images on the right are 6 months after the reshaping of her forehead and upper eye sockets (orbits) with fronto-orbital advancement (FOA) performed at age 3 years old. Note the improved contour of the forehead from broad and flat to more rounded. The upper portion of the eye sockets have been moved forward and downward. They now site in front of the eyes in a more normal position.