Published On: Thu, Jan 31st, 2013

Pakistani Girl Malala Shot by Taliban to Get Skull Surgery

By Christine Hauser

The Pakistani teenager who was shot in the head by the Taliban last year for advocating for the education of girls will return to a British hospital for skull surgery and has asked to keep a fragment of bone from her skull as a souvenir, medical staff said on Wednesday.

The schoolgirl, Malala Yousafzai, was shot in October 2012 by a gunman who singled her out as she returned from school in Mingora, in the northwestern Swat Valley. Just 15 years old at the time of the shooting, she had already worked for several years to promote girls’ education and children’s rights.

She was initially treated at a Pakistani hospital before being flown to Britain for what medical experts said would be a long period of rehabilitation. When she was discharged from the Queen Elizabeth Hospital in Birmingham in early January, doctors said at the time that she would be staying with her family, who had joined her in Britain, before returning for further surgery to rebuild her skull. Video posted online showed her waving as she left the hospital.

On Wednesday, the hospital explained the surgery needed on her skull, which she will undergo in the next week or so. Dr. Dave Rosser, the medical director at the hospital, said Ms. Yousafzai’s skull would be fitted with a titanium plate that had been shaped to recreate the original contour of her skull and cover the piece that had been removed. Doctors had sewn that piece of skull bone under the skin in her abdomen; it had been removed in the initial surgery in Pakistan.

But after consultation with Ms. Yousafzai, the decision was made to fit her skull with the plate instead of trying to replant the bone, which might have been partly reabsorbed and therefore slightly smaller in size, Dr. Rosser said. The bone piece will be surgically removed from her abdomen, sterilized, and given to the girl “who wishes to keep it for, as a memory I guess,” he said in a video of the news conference posted by The Telegraph.

She will also be implanted with a cochlear implant since she is completely deaf in her left ear.

Her shooting brought global condemnation of the Taliban, who have vowed to try to attack her again.

Stefan Edmondson, the principal maxillofacial prosthetist, provided further details about the procedure, known as titanium cranioplasty, using a series of videos and animations based on her medical records released by the hospital. They show the making of the plate, the image of her CT scans when she was first admitted to the hospital, and the fitting of the plate and implant. A red line drawn diagonally down the skull shows the approximate journey of the bullet.

A hospital statement said:

Malala was shot at point blank range. The bullet hit her left brow and instead of penetrating her skull it traveled underneath the skin, the whole length of the side of her head and into her shoulder. The shock wave shattered the thinnest bone of the skull and the soft tissues at the base of her jaw/neck were damaged. The bullet and its fracture lines also destroyed her eardrum and the bones for hearing. She has no hearing in her left ear (right ear remains normal) however, the nerve of hearing is intact.

The titanium cranioplasty procedure is carried out first and will take between one and two hours. The head will be shaved at the wound location and the flap of skin covering it will be prepared and draped back. This will expose the dura – the tough fibrous membrane covering the brain. The 0.6mm metal plate that has been molded from a 3D model created through CT imaging from Malala’s own skull, will then be put in place. It is secured to the skull with screws placed in 2 mm countersunk holes. The flap of skin is then draped back over the plate and stitched into place.

The cochlear surgeon then takes over from the neurosurgeon. The surgeon will locate the cochlear and identify the structures of the inner ear. An incision will be made in the round window membrane and the implant is fed through it. A small well will be drilled in the skull behind the titanium plate to allow the electronics to be implanted. This part of the surgery will take approximately 90 minutes.

The surgery was similar to a procedure done on former Representative Gabrielle Giffords, who was shot in the head and was fitted with a custom-made piece of synthetic bone attached to cover for the portion of her skull that was removed to allow her brain to swell, as this CNN interview with the neurosurgeon who performed the operation showed. Ms. Giffords testified at a Senate hearing on gun violence on Wednesday.

In an interview on Wednesday, Ms. Giffords doctor, Dr. Dong H. Kim, the chairman of neurosurgery at Memorial Hermann and University of Texas Health Science Center, said the two operations were similar. Usually, he said, the layer of bone that is removed from the skull is better replaced with an artificial one rather than the original.

Both titanium and plastic are fairly similar and equivalent, it is a local choice. They can both be molded to size, so there is no cosmetic defect. If you are going to use the patient’s own bone there might be problems. Sometimes it shrinks over time and doesn’t fit the skull and cosmetically it is not as good. And when you remove the bone after trauma, especially from a laceration or bullet, you cannot be certain that the bone has not been contaminated with bacteria.

He added that the practice of inserting a piece of the skull in the abdomen was not an uncommon one. The abdomen is sterile and the fragment is portable, meaning it goes with the patient if at some point he or she might end up somewhere else. In the United States however, it is usually not done anymore because surgeons do not want to create another incision.

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