I read with interest this follow-up study by Dr. Jimenez and Dr. Barone on their surgical treatment of coronal synostosis.1 The study reviews a 16-year experience with 115 patients who were surgically treated with an endoscopy-assisted craniectomy supplemented with postoperative cranial orthosis therapy (helmet-assisted recontouring of the skull deformity). I have been familiar with this work since its beginning and have participated in a number of panel discussions with Dr. Jimenez at national and international meetings over the years. As a result I am intimately familiar with the work of this team and have looked forward to seeing what their outcomes are in the long term. The authors nicely review the history of the strip craniectomy starting with ill-founded beginnings in the 1880s and 1890s by Lannelongue and Lane among a number of other not-so-insightful surgeons. Based on Rudolf Virchow’s paper on cretinism and microcephaly, the concept of the suture as the cause of craniosynostosis led a number of nineteenth-century general surgeons to remove fused sutures to treat “idiocy.” Thanks to a New York pediatrician by the name of Abraham Jacobi, who issued a scathing report detailing an enormously high mortality rate and poor results with this technique, suture craniectomy surgery came to a halt by the early 1900s. With the work of Ingraham and Matson the strip craniectomy came back into focus for neurosurgeons in the 1940s. Because the earlier procedures had not accomplished the desired goals, these surgeons decided to add silicone wrappers to the craniectomy edges and apply metal clips, with the intended effect of restricting rapid bone regrowth. Others supplemented the technique by adding Zenker’s solution to the dura among other things, only to find the morbidity rate to be excessively high. The strip technique, however, remained popular until well into the 1970s and 1980s, and was the technique I was trained to perform as a resident. With the work of Paul Tessier, Daniel Marchac, and Fernando Ortiz-Monestario among others, the cranial vault remodeling techniques, which are now widely used throughout the world, came to be adopted by both neurosurgeons and plastic surgeons. Cranial vault remodeling has remained popular, as the surgical teams performing these cranial vault remodeling procedures believe they are better able to achieve more favorable outcomes when compared with strip craniotomies. According to the detractors, the downside to cranial vault remodeling is the longer operating time, more blood loss, uneven surface contours, and greater hospital expense due to increased length of stay. In an effort to improve outcomes in strip craniectomy the authors added the orthotic helmet as an additional correction factor to prevent the relapse commonly observed in routine strip craniectomies; the question to ask is, have these technical changes improved this surgery, a thought that I will address later. One of the questions in dealing with any of the patients with craniosynostosis is, where are the biological factors coming from that lead to these multifocal deformations? To those who advocate the strip craniectomy, the suture is clearly the primary focus and the secondary changes noted in the craniofacial skeleton (such as orbital dystopia, facial scoliosis, and others) are secondary to the closed suture. Then there are those craniofacial surgeons who believe that the scalp, skull (and suture), muscle, and surrounding envelope of soft tissue all form a complex functional matrix with strong and important interactions driven by the skull base and the soft tissue matrix surrounding it. Although many investigators have researched this concept, the leader was Dr. Melvin Moss, who in the 1950s through the 1990s published a series of complex anatomical papers in which he detailed his views of the “functional matrix theory.” It is beyond the concept of a commentary to detail this work, but I will summarize his view with this quotation: “...the growth and development of the head, in both normal and pathological states, is primarily regulated by the development of the ‘soft’ nonskeletal parts, and cranial growth is a secondary phenomenon.”2,3 It is on the basis of this principle that I, and other craniofacial surgeons, have had a long and difficult time understanding why a strip craniectomy would work in such a complex biological interaction. I have had this discussion many times with Dr. Jimenez, and we clearly have differences in our views, but having said that, I was most Editorial
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Aug 16, 2023
Ze Liu + 1
Open Access
