Comparison of Head Shape Outcomes in Metopic Synostosis Using Limited Strip Craniectomy and Open Vault Reconstruction Techniques

Minimally Invasive Versus Open Cranial Vault Remodeling Procedures for Single-Suture Craniosynostosis: What Do We Know?

Craniosynostosis is a congenital condition characterized by the premature fusion of cranial sutures, disrupting normal skull and potentially brain growth. The current gold standard for nonsyndromic single-suture craniosynostosis is open cranial vault remodeling, which was pioneered by surgeons like Tessier and Whitaker in the 1970s. Recent advances have led to minimally invasive techniques, such as endoscopic-assisted strip craniectomy with helmeting, spring-assisted cranioplasty, and distraction osteogenesis. These methods aim to minimize surgical trauma, reduce blood loss, and shorten recovery times. This review assesses the evidence comparing open and minimally invasive surgeries for nonsyndromic single-suture craniosynostosis.

Craniometric and Aesthetic Outcomes in Craniosynostosis Surgery: A Systematic Review and Meta-Analysis

ObjectiveTo systematically review the published comparative aesthetic outcomes, and its determinants, for craniosynostoses surgically treated by minimally-invasive cranial procedures and open cranial vault remodeling (CVR).DesignPRISMA-compliant systematic review.SettingNot-applicable.Patients/ParticipantsArticles were included if they compared spring cranioplasty, strip minimally-invasive craniectomy or CVR for outcomes related to aesthetics or head shape. Forty-two studies were included, comprising 2402 patients.InterventionsNone.Main Outcome Measure(s)The craniometric and PROM used to determine surgical outcomes.ResultsTwenty-five studies (59%) evaluated sagittal craniosynostosis, with metopic (7;17%) and unicoronal (4;10%) the next most prevalent. Thirty-eight studies (90%) included CVR, 24 (57%) included strip craniectomy with helmeting, 9 (22%) included strip craniectomy without helmeting, 11 (26%) included spring cranioplasty, and 3 (7%) included vault distraction. A majority of studies only used 1 (43%) or 2 (14%) craniometric measures to compare techniques. In sagittal synostosis, 13 (59%) studies showed no difference in craniometric outcomes, 5 (23%) showed better results with CVR, 3 (14%) with strip craniectomy, and 1 (5%) with springs. In studies describing other synostoses, 10/14 (71%) were equivocal. Subjective outcome measures followed similar trends. Meta-analysis shows no significant difference in cranial index (CI) outcomes between CVR and less invasive procedures in patients with sagittal synostosis.ConclusionsThere is no difference in CI outcomes between CVR and less invasive procedures. The majority of literature comparing craniometric and aesthetic outcomes between CVR and less invasive procedures shows equivocal results for sagittal synostosis. However, the heterogeneity of data for other craniosynostoses did not allow meta-analysis.

Comparative Analysis of Patient-reported Outcomes After Cranial Vault Remodeling and Strip Craniectomy With the FACE-Q Craniofacial Module

BACKGROUND

The debate continues among craniofacial surgeons regarding the effectiveness of strip craniectomy (SC) compared with cranial vault remodeling (CVR) in achieving optimal functional and aesthetic outcomes in patients with single-suture craniosynostosis. This study aimed to compare long-term patient-reported outcomes (PROs) between SC and CVR procedures at a single institution using the validated FACE-Q Craniofacial module.

METHODS

Patients older than or equal to 8 years of age and parents of patients younger than 8 years of age who underwent SC or CVR for single-suture craniosynostosis were eligible. Patients with <2 years of follow-up, lambdoid synostosis, and syndromes were excluded. Primary endpoints were PROs as measured by the FACE-Q, with higher scores indicating increased health-related quality of life. Linear regression was used to control for covariates.

RESULTS

Sixty-two participants completed the module (response rate 33.3%). SC was performed in 29 patients (46.8%), and CVR in 33 patients (53.2%). On unadjusted bivariate analysis, SC patients had higher eye (P=0.03) and forehead (P=0.05) scores. On regression analysis, controlling for sex, race, craniosynostosis type, and follow-up, there were no significant differences between operation types in any domain. Metopic and sagittal synostosis were associated with higher Eye (metopic: 17.61, P=0.049; sagittal: 41.44, P<0.001) and Head scores (metopic: 48.12, P=0.001; sagittal: 49.35, P<0.001), and sagittal synostosis was associated with higher Face (38.16, P<0.001), Forehead (55.93, P<0.001), and Nose scores (19.28, P=0.003).

CONCLUSIONS

From patients' and parents' perspectives at a single institution, SC and CVR were equivalent regarding aesthetics and health-related quality of life.

3D Analysis of the Cranial and Facial Shape in Craniosynostosis Patients: A Systematic Review

With increasing interest in 3D photogrammetry, diverse methods have been developed for craniofacial shape analysis in craniosynostosis patients. This review provides an overview of these methods and offers recommendations for future studies. A systematic literature search was used to identify publications on 3D photogrammetry analyses in craniosynostosis patients until August 2023. Inclusion criteria were original research reporting on 3D photogrammetry analyses in patients with craniosynostosis and written in English. Sixty-three publications that had reproducible methods for measuring cranial, forehead, or facial shape were included in the systematic review. Cranial shape changes were commonly assessed using heat maps and curvature analyses. Publications assessing the forehead utilized volumetric measurements, angles, ratios, and mirroring techniques. Mirroring techniques were frequently used to determine facial asymmetry. Although 3D photogrammetry shows promise, methods vary widely between standardized and less conventional measurements. A standardized protocol for the selection and documentation of landmarks, planes, and measurements across the cranium, forehead, and face is essential for consistent clinical and research applications.

Fronto-Orbital Advancement for Metopic and Unilateral Coronal Craniosynostoses

Fronto-orbital advancement remains a powerful technique for the correction of anterior cranial vault differences related to metopic (trigonocephaly) or unilateral coronal (anterior plagiocephaly) craniosynostoses. Traditional fronto-orbital advancement requires access to the forehead and superior 2/3 of the orbit via a coronal incision. The frontal bone and orbital segment (bandeau) are then separated from the skull and reshaped. In patients with metopic craniosynostosis, the bandeau and frontal bone will need to be advanced and widened. In patients with unilateral coronal craniosynostosis, the bandeau will need to be "untwisted" to address the supraorbital retrusion on the affected side, the affected orbit will need to be shortened and widened, and the frontal bone flap will need to be proportionately advanced on the affected side. Overcorrection of the affected dimension should be undertaken to account for growth and relapse.

Correction of trigonocephaly after endoscopic strip craniectomy with postoperative helmet orthosis therapy: a 3D stereophotogrammetric study

OBJECTIVE

Endoscopic strip craniectomy with postoperative helmet orthosis therapy (ESCH) has emerged as a less invasive alternative to fronto-orbital remodeling for correction of trigonocephaly. However, there is no standardized objective method for monitoring morphological changes following ESCH. Such a method should be reproducible and avoid the use of ionizing radiation and general anesthesia for diagnostic imaging. The authors analyzed a number of metrics measured using 3D stereophotogrammetry (3DSPG) following ESCH, an imaging alternative that is free of ionizing radiation and can be performed on awake children.

METHODS

3DSPG images obtained at two time points (perisurgical and 1-year follow-up [FU]) of children with metopic synostosis who had undergone ESCH were analyzed and compared to 3DSPG images of age-matched control children without craniofacial anomalies. In total, 9 parameters were measured, the frontal angle and anteroposterior volume in addition to 7 novel parameters: anteroposterior area ratio, anteroposterior width ratios 1 and 2, and right and left anteroposterior diagonal ratios 30 and 60.

RESULTS

Six eligible patients were identified in the operated group, and 15 children were in the control group. All 9 parameters differed significantly between perisurgical and age-matched controls, as well as from perisurgical to FU scans. Comparison of FU scans of metopic synostosis patients who underwent surgery to scans of age-matched controls without metopic synostosis revealed that all parameters were statistically identical, with the exception of the right anteroposterior diagonal ratio 30, which was not fully corrected in the treated patients. The left anterior part of the head showed the most change in surface area maps.

CONCLUSIONS

In this pilot study, ESCH showed satisfactory results at 1 year, with improvements in all measured parameters compared to perisurgical results and normalization of 8 of 9 parameters compared to an age-matched control group. The results indicate that these parameters may be useful for craniofacial units for monitoring changes in head shape after ESCH for trigonocephaly and that 3DSPG, which avoids the use of anesthesia and ionizing radiation, is a satisfactory monitoring method.

A new method for quantification of frontal retrusion and complex skull shape in metopic craniosynostosis: a pilot study of a new outcome measure for endoscopic strip craniectomy

OBJECTIVE

The objective of this study was to propose a new skull outline-based method to objectively quantify complex 3D skull shapes and frontal and supraorbital retrusion in metopic craniosynostosis using 3D photogrammetry.

METHODS

A standard section from 3D photogrammetry, which represents the trigonocephalic shape, was used in this study. From the midpoint of the area of this section, half diagonals were calculated to the skull outline at 5° increments in the anterior half of the head. These half diagonals were used to create a sinusoidal curve, and the area under the sinusoidal curve (AUC) was used to represent the mathematical expression of the trigonocephalic head shape. The AUC from 0° to 180° (90° from the midline to each side) was calculated and is referred to as AUC0→180. The AUC from 60° to 120° (30° from the midline to each side) was also calculated and is referred to as AUC60→120. A total of 24 patients who underwent endoscopic strip craniectomy and 13 age- and sex-matched controls were included in the study. The AUC values obtained in patients at different time points and controls were analyzed.

RESULTS

The mean preoperative AUC60→120 and AUC0→180 in the patients were significantly lower than those in control individuals. The increase in both AUC60→120 and AUC0→180 values is statistically significant at the discontinuation of helmet therapy and at final follow-up. Receiver operating characteristic curve analysis indicated that AUC60→120 is a more accurate classifier than AUC0→180.

CONCLUSIONS

The proposed method objectively quantifies complex head shape and frontal retrusion in patients with metopic craniosynostosis and provides a quantitative measure for follow-up after surgical treatment. It avoids ionizing radiation exposure.

Superior Long-term Appearance of Strip Craniectomy Compared with Cranial Vault Reconstruction in Metopic Craniosynostosis

Background:

Strip craniectomy with orthotic helmet therapy (SCOT) is an increasingly supported treatment for metopic craniosynostosis, although the long-term efficacy of deformity correction remains poorly defined. We compared the longterm outcomes of SCOT versus open cranial vault reconstruction (OCVR).

Methods:

Patients who underwent OCVR or SCOT for isolated metopic synostosis with at least 3 years of follow-up were identified at our institution. Anthropometric measurements were used to assess baseline severity and postoperative skull morphology. Independent laypersons and craniofacial surgeons rated the appearance of each patient’s 3D photographs, compared to normal controls.

Results:

Thirty-five patients were included (15 SCOT and 20 OCVR), with similar follow-up between groups (SCOT 7.9 ± 3.2 years, OCVR 9.2 ± 4.1 years). Baseline severity and postoperative anthropometric measurements were equivalent. Independent adolescent raters reported that the forehead, eye, and overall appearance of SCOT patients was better than OCVR patients (P < 0.05, all comparisons). Craniofacial surgeons assigned Whitaker class I to a greater proportion of SCOT patients with moderate-to-severe synostosis (72.2 ± 5.6%) compared with OCVR patients with the same severity (33.3 ± 9.2%, P = 0.02). Parents of children who underwent SCOT reported equivalent satisfaction with the results of surgery (100% versus 95%, P > 0.99), and were no more likely to report bullying (7% versus 15%, P = 0.82).

Conclusions:

SCOT was associated with superior long-term appearance and perioperative outcomes compared with OCVR. These findings suggest that SCOT should be the treatment of choice for patients with a timely diagnosis of metopic craniosynostosis.

Correction of Metopic Craniosynostosis Using Limited Incision Strip Craniectomy Versus Open Fronto-Orbital Reconstruction: An Assessment of Aesthetic Outcomes

BACKGROUND

Metopic craniosynostosis is traditionally repaired with fronto-orbital advancement (FOA) or, alternatively, limited short scar strip craniectomy (LSSSC) followed by helmet therapy. There is controversy among surgeons regarding resultant head shape outcomes between the 2 methods. This study aims to assess how surgeons perceive the postoperative aesthetic results of the 2 metopic craniosynostosis repair methods.

METHODS

A retrospective analysis was performed on 13 (n = 6 LSSSC; n = 7 FOA) patients who presented for surgical correction of isolated metopic craniosynostosis via either LSSSC (followed by helmet therapy) or FOA. Clinical photographs at 1 year postop were shown to 10 craniofacial surgeons who rated the aesthetic outcomes on a Likert scale of 1 (poor) to 5 (excellent) and guessed which surgical method was performed.

RESULTS

Mean age at the time of the procedure was younger in LSSSC than FOA (3.1 ± 1.0 versus 17.5 ± 8.5 months; P < 0.001). Mean blood loss was significantly lower with LSSSC versus FOA (202.0 ± 361.2 versus 371.43 ± 122.9 mL; P < 0.001), as was mean blood transfusion requirement (92.5 ± 49.9 versus 151.3 ± 51.2 mL; P < 0.001) and mean duration of the operation (3:06 ± 0:24 versus 7:53 ± 0:31 hours; P < 0.001). Mean surgeon scores of aesthetic outcomes were similar between groups: LSSSC, 3.27 ± 1.09; FOA, 3.51 ± 0.95 (P = 0.171). When asked to identify which procedure patients had received, only 63.8% of responses were correct.

CONCLUSIONS

Limited short scar strip craniectomy offers an important alternative to traditional open FOA and should be considered as an option for children diagnosed with metopic craniosynostosis.