Modified Bilateral Pi Craniectomy Technique for Reduction Cranioplasty: Novel Technique

Objective: Severe hydrocephalic macrocephaly can cause significant morbidity in infants due to positioning difficulties, skin breakdown, and poor cosmesis. Many surgeons over the past decades have described a variety of surgical techniques of reduction cranioplasty. In this article, the authors describe a novel technique for skull reduction cranioplasty with modified bilateral Pi craniectomy. Methods: Anterior coronal and posterior lambdoid bone cuts are performed to extend inferiorly toward the sqamous bone. Last bone cuts are made connecting the parasagittal burr holes bilaterally, thus isolating and de-roofing of the sagittal suture. Bilateral peninsular bone flaps are reduced medially aiming to approximate the upper borders of both flaps. Edges of frontal and occipital bone can be resected and shaved to achieve smooth round contour of the reconstruct. The final reconstruct can be fixated with metal meshes. Results: In our technique, modified bilateral Pi craniectomy is simple and effective reduction cranioplasty technique, as the technique does not require bone graft resection and reconstruction of the grafts making the time of the surgery short with decreased possible complications. Also, the amount of bone resection, bone bending, and shaving of the bone edges can be controlled and adjusted during the. An important issue is that this technique avoids posterior skull reconstruction which is more risky, as many patients are bed ridden with secondary compressed and flat occiput. Conclusions: Modified bilateral Pi craniectomy is a simple and effective technique for cranial vault reduction, especially in flat-occiput cases. Good understanding of the structural abnormality and the pathophysiological mechanisms of the possible complications is very important for performing proper surgical reconstruction.