The "adorability" of the ipsilateral oblique view in unicoronal craniosynostosis: a silver lining for families.

Abstract

Sir: Infants with unicoronal craniosynostosis demonstrate classic phenotypic findings of the anterior cranium and facial skeleton. These include ipsilateral forehead retrusion, brow elevation, and peaking of the lateral orbit. The palpebral fissure is rounded and shortened transversely on the affected side. The nasal root deviates toward the synostotic half, whereas the contralateral forehead and midface demonstrate increased compensatory projection (Fig. 1).1,2 Modern ultrasonography now identifies premature in utero fusion of the coronal suture with increasing reliability.3 Although this permits obstetricians and pediatricians to direct families to multidisciplinary craniofacial centers for prenatal and neonatal counseling, it can induce parental anxiety during an otherwise joyous time.Fig. 1: Anterior (left) and superior (right) views of an infant with left unicoronal craniosynostosis demonstrate classic craniofacial asymmetries. Note mild superior oblique palsy and contralateral head tilt.At our institution, every attempt is made to educate and reassure families about all available treatment options. With this in mind, parents meet our craniofacial surgeon, pediatric neurosurgeon, pediatric anesthesiologist, pediatric ophthalmologist, geneticist, pediatric nurse practitioner, social worker, and psychologist. However, before meeting any of these health professionals, parents first meet our full-time expert medical photographer (M.S.). Using a combination of automated stuffed animals and state-of-the-art cameras, two- and three-dimensional images of the infant’s head and face are taken in all standard views: anterior, lateral, oblique, posterior, superior, and submental. In reviewing these photographs—with parents and the surgical team—one consistent finding has been, for lack of a better word, the “adorability” of the ipsilateral oblique view. This view does more than simply mask inherent craniofacial asymmetries. The retruded forehead and elevated brow create the illusion of an engaged and inquisitive child (Fig. 2). The ipsilateral nasal root deviation and contralateral midfacial projection provide rare facial fullness for an oblique view and can suggest a “half-smiling” infant. Children with unicoronal craniosynostosis also often demonstrate ipsilateral strabismus (superior oblique palsy) with contralateral head tilt (Fig. 1).4,5 At the very least, the lateral oblique view hides these asymmetries; in our opinion, these ocular and positional findings actually increase the viewer’s perception of an engaged, playful infant (Fig. 2).Fig. 2: Contralateral (left) and ipsilateral (right) oblique views of the same infant. Ipsilateral oblique view masks craniofacial asymmetries, highlights “adorable” skeletal and soft-tissue differences, and creates the illusion of a playful, engaged infant.As owners of their child’s medical records, parents receive digitized copies of all professional photographs taken at our institution. In keeping with our team’s mission to educate, reassure, and guide anxious parents of children with unicoronal craniosynostosis, we find that it is useful to specifically share with young families the adorability of their child’s ipsilateral oblique image. While awaiting definitive reconstruction, anxious parents can enjoy a light-hearted moment with their new craniofacial team and selectively share their child’s ipsilateral oblique photograph with supportive friends and family. PATIENT CONSENT Parents or guardians provided written consent of use of the patient’s images. DISCLOSURE The authors have no financial interests or commercial associations to disclose. Raj M. Vyas, M.D. Michael Alperovich, M.D. Mary Spano David A. Staffenberg, M.D. Institute of Reconstructive Plastic Surgery New York University School of Medicine New York, N.Y.