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

Abstract

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.

Fig. 1.

Patient flowchart.

Fig. 2.

Representative patient photographs. Preoperative CT scans (left panels), preoperative photographs (center panels), and postoperative photographs (right panels) of one patient each who underwent SCOT (A) and OCVR (B) are shown. Both presented with moderate-to-severe synostosis and have 7 years of follow-up.

Fig. 3.

Patient-reported outcomes. Parents of all patients completed surveys assessing (A) postoperative satisfaction or (B) quality of their child’s social life. A, Each domain was assessed on a five-point Likert scale, from “very unsatisfied” to “very satisfied.” B, Each domain was assessed on a five-point Likert scale, from “never” to “always.” The proportion of parents reporting a frequency greater than “never” is displayed.

Fig. 4.

Independent layperson and surgeon assessment of postoperative appearance. Two-dimensional projections of 3D patient photographs were shown to independent (A) adolescents (n = 151) and (B) surgeons (n = 3), who were blinded to the identity and treatment of each patient. Bar height represents mean; error bars represent standard error. *Significant difference between groups, P < 0.05. A, Demonstrates the proportion of patients rated as “normal” or predicted not to have been born with a skull deformity by raters. B, Demonstrates the proportion of patients assigned to each Whitaker class, stratified by baseline severity.