SPECIAL EDITORIAL
Current Concepts in Deformational Plagiocephaly
Wojciech Dec, MD, and Stephen M. Warren, MD
T
he term plagiocephaly describes an asymmetric cranium.
The word is derived from the Greek words Bplagios[
meaning slanted and Bkephale[ meaning head. A multitude
of etiologic factors can result in plagiocephaly, including
premature cranial suture fusion and in utero or postnatal mechanical
deforming forces.1 The term deformational plagiocephaly specifi-
cally refers to a cranial asymmetry due to external compression.
These deformational changes are thought to originate in utero and to
be exacerbated by sleeping in a supine position. Torticollis is a
common associated finding, and it is hypothesized to exacerbate
posterior deformational plagiocephaly.2 Other factors associated
with deformational plagiocephaly include multiple births, small
maternal pelvis, breech position, oligohydramnios, male sex of the
fetus, gestational diabetes, nulliparity of the mother, high birth
weight, large neonatal head size, vaginal delivery, prolonged length
of postdelivery hospital stay (94 days), and prolonged duration of
stage II labor.3 Collectively, these factors suggest that a larger fetal
head (eg, male sex or gestational diabetes) in a smaller maternal
uterus (eg, oligohydramnios or nulliparity) tends to limit fetal move-
ment, increasing the likelihood that the fetus’s skull will be exposed
to deforming forces. Interestingly, posterior deformational plagio-
cephaly tends to affect the right occiput more commonly than the
left occiput, highlighting the importance of late gestational fetal po-
sitioning in the uterus (ie, neonates are most commonly delivered left
occiput anterior).
The incidence of deformational plagiocephaly increased, fol-
lowing the recommendations by the American Academy of Pediat-
rics in 1992 to place infants in a supine sleep position.4 Before the
American Academy of Pediatrics recommendations, the incidence
of posterior deformational plagiocephaly was estimated at 0.3%.
Today, the incidence has been reported to be as high as 48%, de-
pending on the diagnostic criteria.5Y8 Although the Back to Sleep
Campaign has been successful in reducing the rate of sudden infant
death, supine positioning promotes a persistent deforming force on
the malleable neonatal skull. If the infant preferentially lays on one
side, the weight of the head exacerbates a unilateral occipital flatten-
ing and anterior displacement of the ipsilateral craniofacial skeleton
(ie, unilateral posterior deformational plagiocephaly). In cases where
the infant lies evenly on the occiput, this results in bilateral efface-
ment of the occipital bones and a compensatory increase in the verti-
cal height of the skull known as bilateral posterior deformational
plagiocephaly or positional brachycephaly.9 Correct diagnosis and
treatment are essential.
From the Institute of Reconstructive Plastic Surgery, New York University
Medical Center, New York, New York.
Received November 2, 2010.
Accepted for publication November 17, 2010.
Address correspondence and reprint requests to Stephen M. Warren, MD,
New York University, Institute of Reconstructive Plastic Surgery, 550
First Ave, New York, NY 10016; E-mail: stephen.warren.md@gmail.com
The authors report no conflicts of interest.
Copyright * 2011 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0b013e3182074e04
6 The Journal of Craniofacial Surgery
Copyright © 2011 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
DIAGNOSIS
The key to the diagnosis of deformational plagiocephaly is
to distinguish it from synostotic plagiocephaly because the 2 con-
ditions are treated differently. Differentiating deformational and
synostotic plagiocephaly can sometimes be challenging, but begins
with physical examination and an understanding of the natural his-
tory of the condition.10 Computed tomography scan can be used
selectively to make the diagnosis in complex cases. In addition,
ultrasound is a relatively inexpensive and safe tool for distinguishing
deformational and synostotic plagiocephaly.11
Facial evaluation of a child with unilateral posterior defor-
mational plagiocephaly reveals an ipsilateral vertically elongated
palpebral fissure and an inferiorly positioned ipsilateral ear (Fig. 1).
Unlike in synostotic plagiocephaly, there is no deviation of the nasal
root. When evaluating from the superior (ie, vertex) view, the child’s
head has a parallelogram shape, with unilateral occipital flatten-
ing, contralateral occipital bossing, anterior displacement of the ip-
silateral ear, and ipsilateral frontal bossing (Fig. 2).12,13 In contrast,
positional brachycephaly is commonly associated with a normal
facial appearance and bilateral occipital flattening with increased
vertical cranial height.9
Transcranial anthropometry can be measured with calipers
to assess vault asymmetry (Fig. 3).14,15 To accomplish this, a sliding
caliper is used to measure 2 oblique transverse cranial diameters,
from the midpoint of the supraorbital rim to the midpoint of the
contralateral parieto-occipital scalp. The difference between the
lengths of these 2 diagonals is calculated and recorded; a larger
value indicates a greater degree of asymmetry. Calipers can also be
used to measure cephalic index for patients with positional brachy-
cephaly. These numbers can be followed as an objective measure of
the results of treatment, which will in turn influence the decision to
implement additional therapies.
TREATMENT
Growth of the brain tends to restore symmetry of the cra-
niofacial skeleton when the compressive forces are eliminated.
Recognizing that supine positioning contributes to deformational
plagiocephaly has prompted primary care providers to educate
parents about the importance of supervised prone positioning and
alternating head position from left to right during supine sleep.16
In cases where muscular torticollis is diagnosed, physical therapy
to stretch the sternocleidomastoid and trapezius muscles is pre-
scribed. Infants are monitored on a monthly basis for signs of im-
provement. Those children who present early with mild or moderate
deformity and signs of improvement can be treated with positional
therapy. For example, when a child presents at 3 months of age with
a transcranial difference of 12 mm, we will often recommend posi-
tional therapy and reevaluate the child in 6 to 8 weeks. At this age,
the child’s head circumference will typically increase in size by 1 to
2 cm between visits, and if the occipital pressure is relieved, then
the transcranial difference will typically decrease by 1 to 2 mm be-
tween visits. Infants who present with severe deformity (transcra-
nial difference 920 mm), signs of significant anterior craniofacial
deformities, and developmental delay and those infants who do not
& Volume 22, Number 1, January 2011
The Journal of Craniofacial Surgery & Volume 22, Number 1, January 2011
FIGURE 1. Frontal view of a child with right-sided posterior
deformational plagiocephaly demonstrates ipsilateral
vertically elongated palpebral fissure and an inferiorly
positioned ipsilateral ear.
improve with conservative therapy can be candidates for external
cranioplasty with a molding helmet.17
Helmet molding therapy takes advantage of the infant’s pli-
able skull and rapid brain growth.9,18 By restricting growth in one
direction, the helmet encourages the skull to preferentially expand
in the desired direction to improve symmetry. The challenge with
helmet therapy is that it requires strict compliance with wearing the
helmet 23 hours per day, carries an additional financial cost, and
requires frequent modifications of the helmet to accommodate for
head growth and correction of the deformity over a period of 4 to
5 months of therapy.
Successful treatment outcomes are associated with several
variables. Correction of deformational plagiocephaly whether by
repositioning strategies or helmet therapy is linked to brain volume
expansion. For example, the brain doubles in volume in the first
9 months of life and achieves 80% of its final size by the age of
2 years.19 Therefore, the age at which positional or molding helmet
therapy is initiated is an important variable in determining how
much correction can be achieved; younger patients can achieve
better correction.20 Making a distinction between unilateral poste-
rior deformational plagiocephaly and bilateral positional brachy-
FIGURE 2. Vertex view of right-sided posterior deformational
plagiocephaly with characteristic ipsilateral occipital flattening
and anterior displacement of the forehead and ipsilateral
anterior ear displacement.
* 2011 Mutaz B. Habal, MD
Copyright © 2011 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Special Editorial
FIGURE 3. Transcranial anthropometry compares diagonal
transverse cranial diameters. Note that anthropometric
measurements are being demonstrated on a volunteer; this
patient does not have posterior deformational plagiocephaly.
cephaly is another important variable in determining outcome.
Unilateral deformities can often be normalized with helmet ther-
apy; however, the deformity in patients with bilateral brachycephaly
can often be improved, but complete normalization is rare.9 Unlike
in synostotic craniofacial deformities, surgical correction does not
play a role in the management of deformational plagiocephaly.
CONCLUSIONS
Supine positioning of infants during sleep has decreased the
incidence of sudden infant death syndrome, but it has also signifi-
cantly increased the occurrence of deformational plagiocephaly. Pri-
mary care providers must educate parents about supervised prone
positioning and adjusting head position during supine sleep to reduce
the incidence and severity of skull deformities. Diagnosis is usually
based on history and physical examination by an expert clinician,
but computed tomography and ultrasound can be used selectively to
confirm the diagnosis. Treatment includes altering the head position
during sleep and molding helmets for selected cases. Surgery does not
play a role in the treatment of deformational plagiocephaly.
REFERENCES
1. McKinney CM, Cunningham ML, Holt VL, et al. A case-control
study of infant, maternal and perinatal characteristics associated with
deformational plagiocephaly. Paediatr Perinat Epidemiol 2009;23:
332Y345
2. Losee JE, Mason AC, Dudas J, et al. Nonsynostotic occipital
plagiocephaly: factors impacting onset, treatment, and outcomes.
Plast Reconstr Surg 2007;119:1866Y1873
3. Bialocerkowski AE, Vladusic SL, Wei Ng C. Prevalence, risk factors,
and natural history of positional plagiocephaly: a systematic review.
Dev Med Child Neurol 2008;50:577Y586
4. American Academy of Pediatrics AAP Task Force on Infant Positioning
and SIDS: positioning and SIDS. Pediatrics 1992;89:1120Y1126
5. Dunn PM. Congenital postural deformities. Br Med Bull 1976;32:71Y76
6. Hutchison BL, Hutchison LA, Thompson JM, et al. Plagiocephaly
and brachycephaly in the first two years of life: a prospective cohort
study. Pediatrics 2004;114:970Y980
7. Kane AA, Mitchell LE, Craven KP, et al. Observations on a recent
increase in plagiocephaly without synostosis. Pediatrics 1996;97:
877Y885
8. Argenta LC, David LR, Wilson JA, et al. An increase in infant
cranial deformity with supine sleeping position. J Craniofac Surg
1996;7:5Y11
9. Teichgraeber JF, Seymour-Dempsey K, Baumgartner JE, et al. Molding
helmet therapy in the treatment of brachycephaly and plagiocephaly.
J Craniofac Surg 2004;15:118Y123
7
Special Editorial The Journal of Craniofacial Surgery & Volume 22, Number 1, January 2011

10. Cunningham ML, Heike CL. Evaluation of the infant with an
abnormal skull shape. Curr Opin Pediatr 2007;19:645Y651
11. Regelsberger J, Delling G, Tsokos M, et al. High-frequency ultrasound
confirmation of positional plagiocephaly. J Neurosurg 2006;105:
413Y417
12. Hutchison BL, Thompson JM, Mitchell EA. Determinants of
nonsynostotic plagiocephaly: a case-control study. Pediatrics 2003;
112:e316
13. Huang MH, Gruss JS, Clarren SK, et al. The differential diagnosis
of posterior plagiocephaly: true lambdoid synostosis versus positional
molding. Plast Reconstr Surg 1996;98:765Y774
14. Mulliken JB, Vander Woude DL, Hansen M, et al. Analysis of posterior
plagiocephaly: deformational versus synostotic. Plast Reconstr Surg
1999;103:371Y380
15. Farkas LG. Accuracy of anthropometric measurements: past, present,
and future. Cleft Palate Craniofac J 1996;33:10Y18; discussion 19Y22
16. Persing J, James H, Swanson J, et al. Prevention and management of
positional skull deformities in infants. American Academy of Pediatrics
Committee on Practice and Ambulatory Medicine, Section on Plastic
Surgery and Section on Neurological Surgery. Pediatrics 2003;112:
199Y202
17. Losee JE, Mason AC. Deformational plagiocephaly: diagnosis,
prevention, and treatment. Clin Plast Surg 2005;32:53Y64
18. Vles JS, Colla C, Weber JW, et al. Helmet versus nonhelmet treatment
in nonsynostotic positional posterior plagiocephaly. J Craniofac Surg
2000;11:572Y574
19. Kamdar MR, Gomez RA, Ascherman JA. Intracranial volumes in a
large series of healthy children. Plast Reconstr Surg 2009;124:
2072Y2075
20. Kelly KM, Littlefield TR, Pomatto JK, et al. Importance of early
recognition and treatment of deformational plagiocephaly with orthotic
cranioplasty. Cleft Palate Craniofac J 1999;36:127Y130

8 * 2011 Mutaz B. Habal, MD

Copyright © 2011 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.