Bilateral Coronal Craniosynostosis Research Articles

Longitudinal analysis of cranial growth using comprehensive craniometric measurements after fronto-orbital advancement in coronal craniosynostosis.

The objective of this study was to investigate the longitudinal changes in cranial growth following fronto-orbital advancement (FOA) surgery in patients with unilateral and bilateral coronal craniosynostosis. This retrospective review analyzed head circumference (HC) and CT data during preoperative (T0), immediate postoperative (T1), and final follow-up (T2) visits in 40 patients (23 female, 17 male) who underwent FOA using either the open approach or distraction osteogenesis (DO) between 1987 and 2018. The mean follow-up period was 90.62 months. The z-scores of HC, CT-based intracranial volume, anteroposterior diameter (APD), biparietal diameter (BPD), and cranial height (CH) were calculated using sex- and age-specific standards. Logistic regression analysis was performed. While the z-scores of HC, intracranial volume, and BPD remained within the normal range, the z-scores of APD fluctuated between -2 and -1, and the z-scores of CH were > 2, indicating a substantial elevation compared with norms from T0 to T2. Age at surgery significantly influenced the z-scores of HC, BPD, and CH at T2 (all p < 0.05). Delayed surgical timing was correlated with increased BPD and CH z-scores from T1 to T2 (p = 0.007 and 0.019, respectively). The DO for FOA resulted in elevated HC z-scores at T2 and increased APD from T0 to T1, followed by a significant APD relapse from T1 to T2. These findings suggest that delayed surgical timing may support better cranial growth, as indicated by increased HC at long-term follow-up. However, delayed timing is also associated with worsening abnormally elevated CH. Despite the immediate APD expansion and long-term HC increase with DO, potential relapse warrants caution. While intentional overcorrection of APD is recommended, careful consideration of surgical timing and planning is essential.

The effect of minimally invasive suturectomy with postoperative cranial remolding orthotic treatment for an infant with bilateral coronal craniosynostosis

Key Clinical MessageMinimally invasive suturectomy has been reported to significantly decrease the economic cost of treating infants with craniosynostosis. Nonetheless, treatment should be accompanied by a cranial remolding orthosis to maintain the constant correction and reshaping of the skull throughout the infant's development.

One-piece fronto-orbital distraction osteogenesis without bandeau in patients with coronal craniosynostosis: A five-year follow-up retrospective study of 45 consecutive patients

This study aimed to review the surgical outcomes, complications, and long-term relapses in patients with unilateral or bilateral coronal craniosynostosis, who underwent one-piece fronto-orbital distraction osteogenesis (FODO) without bandeau.The cephalic index, frontal angle, and supraorbital symmetry ratio were measured on the initial and follow-up computed tomography images. Esthetic outcomes were evaluated using the Whitaker classification.45 patients were included in this study. The average follow-up interval was 5.4 ± 1.1 years (range 2.5–8.5 years). In patients with bilateral coronal craniosynostosis, the frontal angle decreased with a relapse ratio of −2.8 ± 4.3% during long-term follow-up compared with that during short-term follow-up (p = 0.028). In patients with unilateral coronal craniosynostosis, the supraorbital symmetry ratio decreased slightly, with a relapse ratio of −3.8 ± 2.6% during long-term follow-up (p = 0.017). Complications included dural tears during osteotomy (n = 2), early distractor removal (n = 2), and wound problems (n = 3).Within the limitations of the study it seems that one-piece fronto-orbital distraction osteogenesis (FODO) generates successful and sustainable results even in the long term. Therefore, this treatment option should be considered for patients with unilateral and bilateral coronal craniosynostoses whenever appropriate.

Comparison of the Relapse Ratio and Osteogenesis Between 1-Piece and 2-Piece Fronto-Orbital Distraction Osteogenesis Among Patients With Bilateral Craniosynostosis in Early Childhood.

Fronto-orbital distraction osteogenesis (FODO), used to correct bilateral coronal craniosynostosis (BCS), is grossly classified into 1-piece and 2-piece FODO. One-piece FODO osteomizes the frontal and supraorbital bones as one block by preserving the attachment between the dura mater and bone, whereas the 2-piece FODO detaches bone segments from the underlying dura mater and reshapes them. This study aimed to determine whether separating the bone-dura attachment would affect osteogenesis and the relapse of the deformity and to compare the surgical outcomes between 1-piece and 2-piece FODO. Patients with BCS who underwent either 1-piece or 2-piece FODO between May 2008 and November 2016 were retrospectively reviewed. Patients older than 12 months who were diagnosed with syndromic or nonsyndromic craniosynostosis were included. The CT images were taken at initial presentation (T0), 1-3 years postoperatively (T1), and >4 years postoperatively (T2). These images were used to measure the frontal angle, anterior skull base ratio, and bone defect area. This study included 11 patients in the 1-piece group and 9 patients in the 2-piece group. The relapse ratios of the frontal angle were -2.3% ± 0.6% and -4.9% ± 2.1% in the 1-piece and 2-piece groups, respectively, showing that the 2-piece group had a significantly higher relapse ratio ( P = 0.002). At the T2 period, the 1-piece group had a significantly higher anterior skull base ratio (0.80 ± 0.10) than that in the 2-piece group (0.69 ± 0.08, P = 0.046). In addition, the bone defect area was significantly lower in the 1-piece group (T1: 4.90 ± 2.32 cm 2 , T2: 2.55 ± 1.57 cm 2 ) than in the 2-piece group (T1: 10.74 ± 5.89 cm 2 , T2: 5.35 ± 2.74 cm 2 ) both at the T1 ( P = 0.037) and T2 ( P = 0.025) periods. One-piece FODO can result in the preservation of the bone segments' vascularity and the enhancement of osteogenesis in the distraction gap. Moreover, 1-piece FODO is associated with lower rates of relapse of deformity and bone defects compared with 2-piece FODO. Lastly, 1-piece FODO can be performed to maximize the advantages of distraction osteogenesis and improve surgical outcomes, especially among early childhood patients with BCS.

Endoscopic strip craniectomy with orthotic helmeting for safe improvement of head growth in children with Apert syndrome.

Bilateral coronal craniosynostosis in Apert syndrome is traditionally managed with open cranial vault remodeling procedures like fronto-orbital advancement (FOA). However, as minimally invasive procedures gain popularity, limited data exist to determine their efficacy in this syndromic population. This study examines whether endoscopic strip craniectomy (ESC) is inferior to FOA in correcting head growth in patients with Apert syndrome. The authors conducted a retrospective review of children with Apert syndrome over a 23-year period. Postoperative head circumferences until 24 months of age were compared for patients treated with ESC versus FOA by using normative growth curves. Intraoperative and postoperative morbidity was compared between groups. The median postoperative follow-up for the FOA (n = 14) and ESC (n = 16) groups was 40 and 28.5 months, the median age at operation was 12.8 and 2.7 months, and the median operative time was 285 and 65 minutes, respectively (p < 0.001). The FOA group had significantly higher rates of blood transfusion, ICU admission, and longer hospital length of stay (p < 0.01). There were no statistically significant differences in premature reossification rates, complications, need for further procedures, or complaints of asymmetry. Compared to normative growth curves, all patients in both groups had head circumferences comparable to or above the 85th percentile at last follow-up. Children with Apert syndrome and bilateral coronal craniosynostosis treated with ESC experience early normalization of head growth and cephalic index that is not inferior to those treated with FOA. Longer-term assessments are needed to determine long-term aesthetic results and the correlation between head growth and neurocognitive development in this population.

Endoscopic surgical treatment of bilateral coronal craniosynostosis.

Endoscopic surgery for single-suture synostosis has been widely adopted since its introduction over 2 decades ago. Its role in syndromic synostosis is emerging, both as a primary treatment and as the first stage in a multimodal treatment paradigm aimed at preventing the vexing turribrachycephaly seen in these children. In this video, the authors review the technique for endoscopic treatment of bilateral coronal craniosynostosis and discuss both the benefits and some of the concerns to look out for over time. They also review the long-term outcomes in a consecutive series of patients treated in this fashion.The video can be found here: https://vimeo.com/516351348.

Quantification of Bilateral Coronal Synostosis: Anterior Brachycephaly.

Objectives:Very few studies focus on the quantification of severity of synostotic anterior brachycephaly. Aim of this study is to implement Utrecht Cranial Shape Quantifier (UCSQ) in brachycephaly patients to objectively quantify severity for both clinical and research purposes.Design:Retrospective study.Setting:Primary craniofacial center.Patients and Participants:Fifteen preoperative patients with bilateral coronal craniosynostosis (age <1.5 years).Intervention:Utrecht Cranial Shape Quantifier was used to quantify severity using the variables: width of frontal peak ratio, difference forehead peak and occiput peak, and width between sides of the head.Main Outcome Measure(s):The UCSQ variables were combined and related to Argenta clinical classification and cephalic index (CI) using 1-way analysis of variance (ANOVA). All parameters were derived from computed tomography scans.Results:Statistically significant differences were found between group means of UCSQ in the 3 categories of Argenta (ANOVA; F(2,12) = 22.461; P < .01). Tukey post hoc test showed a significant difference between Argenta types 1 and 2, types 1 and 3, and types 2 and 3 (all P < .01). Statistically significant differences were found between traditional CI and Argenta types (F(2,12) = 4.956; P = .03). Tukey post hoc test showed significantly difference between Argenta type 1 and 3 (P = .02). No differences were found between other types. Low correlation was found between UCSQ and CI (r = 0.47).Conclusions:Utrecht Cranial Shape Quantifier objectively captures and quantifies the shape of synostotic brachycephaly, and we therefore developed a suitable method to put severity of synostotic (anterior) brachycephaly into numbers.

S12-15 SESSION 12: FACIOCRANIOSYNOSTOSIS – PART II ENDOSCOPIC STRIP CRANIECTOMY IN CHILDREN WITH APERT SYNDROME

Introduction: Apert syndrome is a unique craniofacial disorder that is associated with bilateral coronal craniosynostosis. Due to its rarity, little data exist to demonstrate superiority of surgical technique in treating the associated craniosynostosis. Minimally-invasive endoscopic strip craniectomy (ESC) has been used as a primary treatment in some children, but clinical efficacy to open procedures has not been demonstrated in this population. We present a series of 36 patients with Apert syndrome who underwent open correction (Group 1, n=17) or ESC with helmeting (Group 2, n=19) to determine whether ESC is comparable to open procedures in correcting head growth. Methods: We conducted a retrospective cohort study of children with Apert syndrome treated at Boston Children’s Hospital over a 24-year period. Median (IQR) post-operative follow-up was 185 (70, 208) and 12 (7, 25) months, for Groups 1 and 2, respectively. Postoperative head circumference and growth until 24 months of age were compared between groups using generalized estimating equations (GEE) to account for serial measurements within the same patient and WHO normative growth curves.Wilcoxon rank sum test and Fisher’s exact test were used to compare incidence of morbidity between groups. Results: For groups 1 and 2, Median (IQR) age at operation was 11 (9, 14) and 3 (2, 3) months, respectively. Median operative time was 248 minutes (IQR: 162, 311) and 64 minutes (IQR: 59, 75), respectively (P<0.001). Group 1 had significantly higher rates of blood transfusion, ICU admission, and longer hospital length of stay (all P<0.01). There was no statistically significant difference in refusion rates, complications, need for further procedures, complaints of asymmetry, or postoperative head circumference growth rates between the two groups. Overall, children in Group 1 had larger head circumferences at 2 years of age (P<0.001). Compared to WHO age- and gender-based normative growth curves, all patients in both groups were above the 50thpercentile for head circumference at last follow-up. Conclusion: Children with Apert syndrome and bilateral coronal craniosynostosis treated with ESC and helmeting have rates of head growth parallel to children treated with open correction. Following either intervention, children with Apert syndrome adopt similar head circumferences relative to their age and gender matched peers. The increased head size seen in Group 1 may be attributed to the advancement of the bandeau that is more easily achieved in open procedures compared to ESC. Longer-term assessments are needed to determine the natural history of head growth and its correlation with neurocognitive development in this population.

Craniometric Analysis of Endoscopic Suturectomy for Bilateral Coronal Craniosynostosis

Endoscopic suturectomy and helmeting represents a successful first-line surgical treatment for bilateral coronal craniosynostosis. Its effect on cranial morphology has not been previously described. Patients were identified who had bilateral coronal craniosynostosis treated with endoscopic suturectomy and postoperative helmeting at Boston Children's Hospital between 2005 and 2013 and who underwent preoperative and postoperative computed tomography. Two normative patient populations were identified from our trauma registry with computed tomographic scans completed at the same age as our pretreatment and posttreatment scans. Craniometric indices were used to quantify the effect of treatment. Twenty-seven patients were identified who underwent bilateral coronal suturectomy. Twelve patients had preoperative and postoperative computed tomographic studies. Eight patients (66.7 percent) were syndromic. The average ages for preoperative and postoperative computed tomographic scan were 1.1 months (range, 0.03 to 2.6 months) and 19.6 months (range, 10.8 to 37.5 months). Thirteen patients with an average age of 1.1 months (range, 0.5 to 1.6 months) were identified as a preoperative control group. Fourteen patients with an average age of 18.5 months (range, 15.5 to 22.9 months) were identified as a postoperative control group. The anterior cranial height stabilized with treatment and the anterior cranial base length increased. The anterior cranial height-to-anterior cranial base length ratio significantly decreased with treatment (p = 0.128). Frontal bossing normalized with endoscopic suturectomy (craniosynostosis versus control: preoperatively, p = 0.001; postoperatively, p = 0.8). Cephalic indices also normalized with treatment (craniosynostosis versus control: preoperatively, p = 0.02; postoperatively, p = 0.13). No cases of hydrocephalus were observed. Endoscopic suturectomy and helmeting improves anterior turricephaly and corrects frontal bossing and brachycephaly in patients with bilateral coronal craniosynostosis. Therapeutic, IV.

Outcomes of endoscopic suturectomy with postoperative helmet therapy in bilateral coronal craniosynostosis.

OBJECTIVE Historically, bilateral frontoorbital advancement (FOA) has been the keystone for treatment of turribrachycephaly caused by bilateral coronal synostosis. Early endoscopic suturectomy has become a popular technique for treatment of single-suture synostosis, with acceptable results and minimal perioperative morbidity. Boston Children's Hospital has adopted this method of treating early-presenting cases of bilateral coronal synostosis. METHODS A retrospective review of patients with bilateral coronal craniosynostosis who were treated with endoscopic suturectomy between 2005 and 2012 was completed. Patients were operated on between 1 and 4 months of age. Hospital records were reviewed for perioperative morbidity, length of stay, head circumference and cephalic indices, and the need for further surgery. RESULTS Eighteen patients were identified, 8 males and 10 females, with a mean age at surgery of 2.6 months (range 1-4 months). Nine patients had syndromic craniosynostosis. The mean duration of surgery was 73.3 minutes (range 50-93 minutes). The mean blood loss was 40 ml (range 20-100 ml), and 2 patients needed a blood transfusion. The mean duration of hospital stay was 1.2 days (range 1-2 days). There was 1 major complication in the form of a CSF leak. The mean follow-up was 37 months (range 6-102 months). Eleven percent of nonsyndromic patients required a subsequent FOA; 55.6% of syndromic patients underwent FOA. The head circumference percentiles and cephalic indices improved significantly. CONCLUSIONS Early endoscopic suturectomy successfully treats the majority of patients with bilateral coronal synostosis, and affords a short procedure time, a brief hospital stay, and an expedited recovery. Close follow-up is needed to detect patients who will require a secondary FOA due to progressive suture fusion or resynostosis of the released coronal sutures.

Molding of top skull in the treatment of Apert syndrome.

Patients with Apert syndrome have bilateral coronal craniosynostosis, along with a distinguishing feature of their many deformity, called tower skull. Surgical correction of this deformity is the mainstay of treatment. We describe 3 patients molded top skull after front bone osteotomy orbital bar advancement. This successfully restricted growth of their top skull while allowing growth in other dimensions. Utilization of top-skull molding after cranial surgery shows promise of satisfaction in this setting.

Respiratory and Cranial Complications during Anaesthesia in Pfeiffer Syndrome

Pfeiffer syndrome (PS) is rarely encountered, even at major craniofacial centers. Published reports indicate high mortality rates (25-85%) for severely affected subtypes. PS is characterized by bilateral coronal craniosynostosis, midface hypoplasia, beaked nasal tip, broad and medially deviated thumbs and great toes. We present a case of a 12-monthsold male infant with PS type 2 who underwent a craniosynostosis and advancing a supraorbital bar operations during general anesthesia. For simple procedures, a safe anesthetic plan can be formulated if the anatomic factors affecting the airway are carefully considered. More extensive and prolonged patient diagnosed to have PS require more monitoring and include all the problems associated with difficult intubation, hazardous airway management, massive blood loss and fluid shift, shunt-dependent hydrocephalus, and long anesthetic times. This case is presented since anaesthesiologists should be aware of the high incidence of respiratory and cranial complications in PS.

Intracranial Volume in 15 Children with Bilateral Coronal Craniosynostosis

Background:Intracranial volume (ICV) growth in patients with bilateral coronal craniosynostosis (BCS) is not well described. It is therefore important to evaluate the consequences of cranial surgery in children with this condition. The aim of the present study was to evaluate ICVs in patients operated on for BCS.Methods:A consecutive series of patients with BCS were operated on using spring-assisted cranioplasty, with computed tomography scans in 0.6-mm slices, were included. A MATLAB-based computer program capable of measuring ICV was used. Patients were compared with an age- and gender-matched control group of healthy children. Student’s t test was used for statistical analysis.Results:Fifteen patients (7 girls and 8 boys) with 43 computed tomography scans were identified. The diagnoses were 13 syndromic BCS (3 Apert, 1 Crouzon, 6 Muenke, and 3 Saethre-Chotzen) and 2 nonsyndromic BCS. The mean preoperative volume at the age of 5 months (n = 15) was 887 mL (range, 687–1082). Mean volume at follow-up at the age of 3 years (n = 13) was 1369 mL (range, 1196–1616). In comparison, the mean ICVs for controls at the ages of 5 months (n = 30) and 3 years (n = 26) were 854 mL and 1358 mL, respectively. The differences were not statistically significant (P > 0.05).Conclusions:Patients with BCS were operated on with spring-assisted cranioplasty seem to maintain their age-related ICV at 3 years of age when compared to normal children.

Craniosynostosis and radial ray defect: A rare presentation of 22q11.2 deletion syndrome

A newborn with bilateral coronal craniosynostosis, hypoplastic thumbs, imperforate anus, and prenatal growth restriction was evaluated and given the clinical diagnosis of Baller-Gerold syndrome (BGS). While confirmatory testing of RECQL4 was pending, the infant developed unexplained hypocalcemia, prompting testing for a 22q11.2 deletion. Subsequently, the infant was found to have a 22q11.2 deletion, and was negative for an RECQL4 mutation. We therefore conclude that 22q11.2 deletion syndrome can present with findings resembling the BGS phenotype.

Prenatal ultrasound and molecular diagnosis elucidate the prognosis of Pfeiffer syndrome1)

AbstractPfeiffer syndrome (PS) is one of several related craniosynostosis and occurs in 1 out of every 100,000 births. The diagnosis has historically been based on the clinical neonatal findings of bilateral coronal craniosynostosis, midface hypoplasia, with broad thumbs and great toes.A craniosynostosis suggestive of PS was identified on prenatal ultrasound at 34+3 weeks gestation by findings of polyhydramnios, a cloverleaf skull, ventriculomegaly, hypertelorism, marked orbital proptosis, short limbs, broad digits, and an abnormality of the spine. Prenatal molecular testing of thePS can now be diagnosed prenatally. In our case, the specific mutation was associated with an especially severe phenotype. The ultrasonographic findings in conjunction with the molecular diagnosis allowed us to better inform the patient and medical staff about the diagnosis and prognosis.

Epilepsy in Muenke Syndrome: FGFR3-Related Craniosynostosis

Epilepsy, a neurologic disorder characterized by the predisposition to recurrent unprovoked seizures, is reported in more than 300 genetic syndromes. Muenke syndrome is an autosomal-dominant craniosynostosis syndrome characterized by unilateral or bilateral coronal craniosynostosis, hearing loss, intellectual disability, and relatively subtle limb findings such as carpal bone fusion and tarsal bone fusion. Muenke syndrome is caused by a single defining point mutation in the fibroblast growth factor receptor 3 (FGFR3) gene. Epilepsy rarely occurs in individuals with Muenke syndrome, and little detail is reported on types of epilepsy, patient characteristics, and long-term outcomes. We present seven patients with Muenke syndrome and seizures. A review of 789 published cases of Muenke syndrome, with a focus on epilepsy and intracranial anomalies in Muenke syndrome, revealed epilepsy in six patients, with intracranial anomalies in five. The occurrence of epilepsy in Muenke syndrome within our cohort of 58 patients, of whom seven manifested epilepsy, and the intracranial anomalies and epilepsy reported in the literature, suggest that patients with Muenke syndrome may be at risk for epilepsy and intracranial anomalies. Furthermore, the impact of Muenke syndrome on the central nervous system may be greater than previously thought.

Bilateral endoscopic craniectomies in the treatment of an infant with Apert syndrome

Patients with Apert syndrome commonly present with ocular proptosis due to bilateral coronal craniosynostosis and midfacial hypoplasia. Severe proptosis can cause visual compromise and damage, which is most commonly treated with bilateral orbital frontal advancement. The authors present the case of a patient who was treated at 8 weeks of age with endoscope-assisted bilateral coronal craniectomies followed by treatment with a custom-made postoperative cranial orthosis. The patient underwent the procedure without any complications. Over the ensuing months, the patient's proptosis corrected, the forehead and orbital rims advanced without the need for an orbital frontal advancement and craniotomies. This approach may provide an alternative treatment modality for these patients.

Unilateral and bilateral expression of a quantitative trait: asymmetry and symmetry in coronal craniosynostosis

Bilateral symmetry in vertebrates is imperfect and mild asymmetries are found in normal growth and development. However, abnormal development is often characterized by strong asymmetries. Coronal craniosynostosis, defined here as consisting of premature suture closure and a characteristic skull shape, is a complex trait. The premature fusion of the coronal suture can occur unilaterally associated with skull asymmetry (anterior plagiocephaly) or bilaterally associated with a symmetric but brachycephalic skull. We investigated the relationship between coronal craniosynostosis and skull bilateral symmetry. Three-dimensional landmark coordinates were recorded on preoperative computed tomography images of children diagnosed with coronal nonsyndromic craniosynostosis (N = 40) and that of unaffected individuals (N = 20) and analyzed by geometric morphometrics. Our results showed that the fusion pattern of the coronal suture is similar across individuals and types of coronal craniosynostosis. Shape analysis showed that skulls of bilateral coronal craniosynostosis (BCS) and unaffected individuals display low degrees of asymmetry, whereas right and left unilateral coronal craniosynostosis (UCS) skulls are asymmetric and mirror images of one another. When premature fusion of the coronal suture (without taking into account cranial dysmorphology) is scored as a qualitative trait, the expected relationship between trait frequency and trait unilateral expression (i.e. negative correlation) is confirmed. Overall, we interpret our results as evidence that the same biological processes operate on the two sides in BCS skulls and on the affected side in UCS skulls, and that coronal craniosynostosis is a quantitative trait exhibiting a phenotypic continuum with BCS displaying more intense shape changes than UCS.

Improved Correction of Supraorbital Rim Deformity in Craniosynostosis by the “Tilt” Procedure

Orbital rim deficits are a feature of metopic, unilateral coronal, and bilateral coronal craniosynostosis. Several procedures have been developed to address this issue, but relapse to the preoperative hypoplastic deformity and stunted growth of the fronto-orbital region are common. The authors describe a technique modification of the conventional lateral canthal advancement referred to as the orbital rim "tilt" procedure, which aims to preserve inferior bony support for the orbital rim and create projection with optimal proclination of the fronto-orbital complex.

Effectiveness of skull models and surgical simulation: comparison of outcome between different surgical techniques in patients with isolated brachycephaly

The aim of this study was to emphasize the importance of preoperative surgical planning using 3D skull models in craniosynostosis surgery. By using 3D polymethyl methacrylate skull models manufactured using 3D tomography images, the authors previously showed that after fronto-parietal osteotomy, instead of fixing the fronto-parietal bone flap without rotation, angled advancement with horizontal osteotomy provides maximum increase in intracranial volume, in a bilateral coronal craniosynostosis model. After changing the operation technique using data gathered from previous studies, we reviewed two bilateral craniosynostosis patients operated with the new technique and compared it with two patients that were operated with the old technique. Comparing cranial indexes (CI), significant improvement was detected in both groups. The decrease in CI in the second group was slightly better than the first group. In the comparison of intracranial volume (ICV), there was an increase in ICV values in both groups. The percentage of increase between two groups was similar. The morphological outcome was satisfactory in all patients. There were no major or minor complications and morbidity. Current multislice tomography technology and stereolithographic procedures provide an excellent surgical simulation model to find new techniques and predict the outcome. These models should be used in all complex and syndromic craniosynostosis for both better results and reducing the operative time and associated blood loss.