Comparing Long-term Outcomes of Open Cranial Vault Reconstruction and Minimally Invasive Strip Craniectomy in Metopic Craniosynostosis

Abstract

PURPOSE: The gold-standard treatment for metopic craniosynostosis is open cranial vault reconstruction (OCVR) with fronto-orbital advancement. A recent alternative is minimally invasive strip craniectomy with orthotic helmet therapy (SCOT), which has perioperative outcomes superior to those of OCVR, though its long-term efficacy remains poorly defined.1 We sought to compare the long-term morphologic outcomes, patient satisfaction, and subjective appearance in patients with metopic synostosis who underwent OCVR versus SCOT. METHODS: Patients who underwent OCVR or SCOT between 2000 and 2017 for isolated metopic synostosis were identified at our institution. Inclusion criteria included (1) preoperative CT or laser scan imaging, (2) postoperative 3D photos, and (2) at least 3 years of follow-up. Interfrontal angle and interzygomaticofrontal distance measurements were taken from preoperative scans to assess baseline severity.2 Frontal width and intercanthal width, normalized by age and sex, and glabellar angle measurements were made on 3D photos at the latest follow up.2 Independent adolescents and craniofacial surgeons, blinded to the treatment of each patient, rated the appearance of postoperative photos. All patients’ parents completed satisfaction surveys at the latest follow up. RESULTS: Thirty-five patients were included (15 SCOT and 20 OCVR). Mean follow-up time was similar for both groups (SCOT 7.9 ± 3.2 years versus OCVR 9.2 ± 4.1 years, P = 0.33). Baseline severity between groups was similar in both interfrontal angle (SCOT 116.6 degrees ± 8.8 degrees versus OCVR 110.5 degrees ± 10.1 degrees, P = 0.07) and interzygomaticofrontal distance (SCOT 67.5 ± 6.8 mm versus OCVR 66.5 ± 8.6 mm, P = 0.75). Postoperatively, the glabellar angle was equal between groups (SCOT 122.2 degrees ± 4.2 degrees versus OCVR 123.9 degrees ± 6.0 degrees, P = 0.16), as were age- and sex-adjusted frontal width (SCOT Z-score −0.8 ± 1.5 versus OCVR −1.7 ± 1.5, P = 0.09) and intercanthal width (SCOT Z-score 1.2 ± 1.2 versus OCVR 0.5 ± 1.1, P = 0.11). Independent laypersons rated the overall appearance of SCOT patients as equal to that of normal controls (P = 0.31) and better than that of OCVR patients (P = 0.04). Craniofacial surgeons assigned Whitaker class I to a greater proportion of SCOT patients (75.6% ± 6.4%) compared with OCVR patients (43.3% ± 9.5%, P = 0.02), particularly among patients with moderate-severe synostosis (SCOT 72.2% ± 5.6% versus OCVR 33.3% ± 9.2%, P = 0.02). Parents of patients who underwent SCOT and OCVR reported equivalent levels of satisfaction with the appearance of their child’s forehead (93% versus 95%, P > 0.99) and with the overall results of the surgery (100% versus 95%, P > 0.99). Likewise, parents of children who underwent MISC were no more likely to report bullying (7% versus 15%, P = 0.82) or social exclusion (0% versus 15%, P = 0.34) due to their child’s appearance. CONCLUSION: Minimally invasive strip craniectomy with orthotic helmet therapy was associated with equivalent long-term morphologic outcomes and patient satisfaction, and superior subjective appearance, compared with open cranial vault reconstruction among patients with metopic craniosynostosis. REFERENCES: 1. Yan H, Abel TJ, Alotaibi NM, et al. A systematic review of endoscopic versus open treatment of craniosynostosis. Part 2: the nonsagittal single sutures. J Neurosurg Pediatr. 2018;22(4):361–368. 2. Nguyen DC, Patel KB, Skolnick GB, et al. Are endoscopic and open treatments of metopic synostosis equivalent in treating trigonocephaly and hypotelorism? J Craniofac Surg. 2015;26(1):129–134.