Piezosurgery in endoscopic-assisted trigonocephaly correction: a technical note.

PURPOSE: This study aims to evaluate the effectiveness of the Piezosurgery® device in endoscopic-assisted correction of trigonocephaly. Trigonocephaly is a type of craniosynostosis characterized by a triangular-shaped forehead due to the premature fusion of the metopic suture. Traditional open cranial vault reconstruction, although common, is invasive and poses risks. The study explores a less invasive alternative using ultrasonic microvibrations for bone cutting, potentially reducing soft tissue damage and improving surgical outcomes. METHODS: The Piezosurgery® device was employed in endoscopic trigonocephaly correction surgeries performed on patients under 4 months old at the French Referral Center for Craniosynostosis in Lyon. The technique involves making a small skin incision and performing osteotomies from the anterior fontanel to the glabella. A rigid 0° endoscope provides visibility, and the Piezosurgery® device enables precise bone cutting while preserving the dura mater. Post-surgery, patients were discharged within 3 days and required to wear a remodeling helmet for 6-8 months. RESULTS: The use of Piezosurgery® device allowed precise osteotomies with minimal soft tissue damage. No dura mater injuries occurred in the patient series. The procedure was efficient, with an average duration of 80 min, and blood loss was minimal, reducing the need for blood transfusions. The endoscopic approach facilitated shorter surgical times and reduced postoperative infection risks. Enhanced visibility during surgery, due to cavitation effects, improved the accuracy of bone cuts. The technique demonstrated promising safety and esthetic outcomes, although it incurred higher costs compared to traditional methods. CONCLUSION: Piezosurgery® device provides a safe and effective method for minimally invasive endoscopic correction of trigonocephaly. The device's ability to selectively cut bone while preserving soft tissues offers significant advantages, despite longer surgical times and higher costs. This technique represents a viable alternative to traditional open surgery, promoting better clinical outcomes and reduced recovery times.

Initial UK series of endoscopic suturectomy with postoperative helmeting for craniosynostosis: early report of perioperative experience.

BACKGROUND: Endoscopic suturectomy with postoperative helmeting (ESCH) has emerged as a successful treatment for craniosynostosis, initially in North America. We report early outcomes from the first cohort of ESCH patients treated in the United Kingdom (UK). METHODS: Retrospective cohort study with electronic chart review. RESULTS: 18 consecutive patients from the first ESCH procedure in UK (May 2017) until January 2020 identified. 12 male and 6 female infantsd, with a mean age of 4.6 months (range 2.5-7.8 months) and weight of 6.8 kg (range 4.8-9.8 kg). Diagnoses were metopic (n = 8), unicoronal (n = 7), sagittal (n = 2) and multi-sutural (n = 1) synostoses. Median incision length was 3 cm (range 2-10 cm). 16/18 received no blood products, with 2 (both metopics) requiring transfusion (1 donor exposure). Mean operative time (including anaesthesia) was 96 min (range 40-127 min). Median length of hospital stay was 1 night. 1 surgical complication (superficial infection). All patients are currently undergoing helmet orthosis therapy. So far, no patients have required revisional or squint surgery. CONCLUSION: Early experience from the first UK cohort of ESCH suggests that this is a safe and well tolerated technique with low morbidity, transfusion and short hospital stay. Long-term results in terms of shape, cosmetic and developmental outcome are awaited.

Endoscopic treatment of sagittal suture synostosis - a critical analysis of current management strategies.

While many centers nowadays offer minimally invasive techniques for the treatment of single suture synostosis, surgical techniques and patient management vary significantly. We provide an overview of how scaphocephaly treated with endoscopic techniques is managed in the reported series and analyze the crucial steps that need to be dealt with during the management process. We performed a review of the published literature including all articles that examined sagittal-suture synostosis treated with endoscopic techniques as part of single- or multicenter studies. Fourteen studies reporting results of 885 patients were included. We identified 5 key steps in the management of patients. A total of 188 patients were female and 537 male (sex was only specified in 10 articles, for 725 included patients, respectively). Median age at surgery was between 2.6 and 3.9 months with a total range from 1.5 to 7.0 months. Preoperative diagnostics included clinical and ophthalmologic examinations as well as neuropsychological and genetic consultations if needed. In 5 publications, a CT scan was routinely performed. Several groups used anthropometric measurements, mostly the cephalic index. All groups analyzed equally recommended to perform endoscopically assisted craniosynostosis surgery with postoperative helmet therapy in children < 3 months of age, at least for non-syndromic cases. There exist significant variations in surgical techniques and patient management for children treated endoscopically for single suture sagittal synostosis. This heterogeneity constitutes a major problem in terms of comparability between different strategies.

Combined unilateral coronal-lambdoid suture synostosis: surgical outcome of suturectomy and postoperative helmet therapy.

INTRODUCTION: Nonsyndromic, multi-suture craniosynostosis is not common, especially those involving unilateral coronal and lambdoid sutures. Based on the experience on 6 cases, we analyzed the skull morphology of combined unilateral coronal-lambdoid suture synostosis and evaluated the surgical outcome of suturectomy. METHODS: Patients who underwent an operation for craniosynostosis in Seoul National University Children's Hospital from 2010 to 2018 were reviewed. For qualitative analysis of the surgical outcome, five typical morphologic characteristics (ipsilateral superior orbital rim deviation, deviation of the nasal ridge, ipsilateral frontal flattening, contralateral parietal bulging, ipsilateral occipitomastoid bulging) in unilateral coronal-lambdoid suture synostosis were evaluated based on medical photos, plain skull radiographs, and CT scans. For quantitative analysis, three parameters (nasal root deviation, orbital asymmetry, posterior skull base deviation) were measured. RESULTS: Among 316 patients with craniosynostosis, 41 patients had nonsyndromic, multi-suture synostosis. There were 6 unilateral coronal-lambdoid suture synostosis patients who were all treated with suturectomy. Qualitative evaluation of the postoperative outcome revealed that the nasal root and orbital rim deviations and the contralateral occipitomastoid bulging showed satisfactory improvements. However, ipsilateral frontal flattening and contralateral parietal bulging were improved but still present in most cases. Quantitative, craniometric analysis supported the qualitative outcomes. The nasal ridge deviation angle was corrected from 7.04 to 1.79 degrees. The posterior skull base deviation angle improved from 6.29 to 3.55 degrees. CONCLUSION: Unilateral coronal-lambdoid suture synostosis suturectomy followed by helmet therapy resulted in favorable outcomes, although the correction of frontal flattening was less satisfactory than the other measures. Considering the minimal invasiveness of the treatment, suturectomy may be a viable option for these patients.

Partial suturectomy for phenotypical craniosynostosis caused by incomplete fusion of cranial sutures: a novel surgical solution.

OBJECTIVE: Patients presenting with head shape changes phenotypical for craniosynostosis may have incomplete fusion of the involved sutures. The surgical literature is lacking in appropriate management strategies for these patients. In this paper, the authors evaluate their experience with a novel treatment strategy: suturectomy of only the fused portion followed by helmeting therapy in patients with skull deformity secondary to incomplete suture synostosis. METHODS: Patients with craniosynostosis with incomplete suture fusion requiring operative intervention between 2018 and 2020 were included for evaluation. Patients were selected for partial suturectomy if the patent portion of the suture had a normal appearance. All patients underwent craniectomy of the involved portion of the synostosed suture. Intraoperative ultrasound was used to reassess the degree of fusion at the time of surgery and incision planning. A 2- to 3-cm strip craniectomy was performed under direct visualization through a single minimal access incision. Postoperative helmeting was utilized for all patients. Demographic and perioperative data were collected, including laser scan data in the form of cranial index (CI) and cranial vault asymmetry (CVA), defined as the difference between two diagonal measurements, from the frontozygomaticus to the opposite eurion. RESULTS: Four males and 1 female with a mean age of 2.8 months (range 1.1-3.9 months) at presentation were included. All patients had incomplete sagittal synostosis (one patient also had an incomplete left lambdoid synostosis and another had an incomplete left coronal synostosis). The mean age at surgery was 3.5 months (range 2.0-4.7 months) without any major complications. All patients were compliant with postoperative helmeting. The average age at the last follow-up was 12.8 months (range 5.3-23.7 months) with a mean follow-up duration of 9.3 months (range 0.5-19.6 months). Final laser scan evaluations were available for 3 patients and showed an improvement of the CI from an average of 71.3 (range 70-73) to 84.3 (range 82-86). The CVA improved from an average of 9.67 mm (range 2-22 mm) to 1.67 mm (range 1-2 mm). CONCLUSIONS: Minimally invasive direct excision of the involved portion of fused cranial sutures followed by helmet therapy for phenotypical craniosynostosis is a safe and effective treatment strategy. This technique is suitable for very young patients and appears to offer similar outcomes to complete suturectomy. Further studies are required to see if this approach reduces the deformity severity for patients requiring vault remodeling later in life.

How I do it. 3D endoscopic treatment of metopic craniosynostosis through a single incision.

BACKGROUND: Endoscopic approaches for craniosynostosis are a growing field in pediatric neurosurgery. In metopic synostosis, previous reports for complete fronto-orbital remodeling have proposed an intervention with multiple incisions (bregmatic, tarsal, and preauricular) to open frontonasal and frontoethmoidal synostotic sutures, and orbital roof. METHODS: We propose a technique to complete all these osteotomies with a unique incision anterior to the bregmatic fontanel under 3D endoscopic vision, and review possible complications, limits, and pitfalls. CONCLUSIONS: Under endoscopic assistance, a complete fronto-orbital remodeling could be completed with a unique incision without mayor drawbacks.

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

Minimally 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.

Racial differences in the care of pediatric sagittal craniosynostosis: a single-institution cohort study affecting state Medicaid policy.

OBJECTIVE: Although research has shown the cost-effectiveness of endoscopic versus open repair of sagittal synostosis, few studies have shown how race, insurance status, and area deprivation impact care for these patients. The authors analyzed data from children evaluated for sagittal synostosis at a single institution to assess how socioeconomic factors, race, and insurance status affect the surgical treatment of this population. They hypothesized that race and indicators of disadvantage negatively impact workup and surgical timing for craniosynostosis surgery. METHODS: Medical records of patients treated for sagittal synostosis between 2010 and 2019 were reviewed. Area deprivation index (ADI) and rural-urban commuting area codes, as well as median income by zip code, were used to measure neighborhood disadvantage. Black and White patients were compared as well as patients using Medicaid versus private insurance. RESULTS: Fifty patients were prospectively included in the study. Thirty-one underwent open repair; 19 had endoscopic repair. All 8 (100%) Black patients had open repair, compared to 54.8% of White patients (p = 0.018). Black patients were more likely to use Medicaid compared to White patients (75.0% vs 28.6%, p = 0.019). White patients were younger at surgery (5.5 vs 10.0 months, p = 0.001), and Black patients had longer surgeries (147.5 minutes vs 110.0 minutes, p = 0.021). The median household income by zip code was similar for the two groups. Black patients were generally from areas of greater disadvantage compared to White patients, based on both state and national ADI scores (state: 7.5 vs 4.0, p = 0.013; national: 83.5 vs 60.0, p = 0.013). All (94.7%) but 1 patient undergoing endoscopic repair used private insurance compared to 14 (45.2%) patients in the open repair group (p = 0.001). Patients using Medicaid were from areas of greater disadvantage compared to those using private insurance by both state and national ADI scores (state: 6.0 vs 3.0, p = 0.001; national: 75.0 vs 52.0, p = 0.001). CONCLUSIONS: Because Medicaid in the geographic region of this study did not cover helmeting after endoscopic repair of sagittal synostosis, these patients usually had open repair, resulting in significant racial and socioeconomic disparities in treatment of sagittal synostosis. This research has led to a change in Alabama Medicaid policy to now cover the cost of postoperative helmeting.

Is endoscope-assisted strip craniectomy the future of metopic suture craniosynostosis treatment? An 11-year experience with 62 patients.

OBJECTIVE: Endoscopic mini-invasive treatment for sporadic trigonocephaly is becoming a widely accepted surgical treatment. In most centers this treatment is performed in association with postoperative helmeting. The aim of the present study was to review and report the authors' 11-year experience of endoscope-assisted metopic suturectomy for treatment of 62 trigonocephaly patients without helmet use. METHODS: For this retrospective study, clinical data of 62 consecutive pediatric patients (age 3-8 months) were obtained from the data bank of the "Anna Meyer" Children Hospital. These patients had been diagnosed with trigonocephaly (type II and III) and undergone surgery performed with a mini-invasive endoscopic technique during the period from January 2011 to January 2022. No helmet was used postoperatively in these patients, and they were evaluated through craniometric measurements, pre-/postoperative photographs, and parents' impressions, as well as thorough clinical examinations during follow-up appointments. RESULTS: The mean patient follow-up period was 6 ± 1.3 years. The female/male ratio was 1:2; 52% of the patients presented with type II trigonocephaly and the remaining patients with type III. The mean age at surgery was 153 ± 44 days (5 ± 1.5 months, range 3-8 months). In 92% of the patients the surgical outcome was defined as good to excellent. However, 4 patients presented with an unsatisfactory outcome, including 1 patient with a CSF collection requiring surgical repair 2 months after the first surgery and 1 patient who developed infection of the surgical wound and needed a second surgery. In the latter patient the outcome was evaluated as satisfactory, and no sequelae regarding the infection were encountered during follow-up. CONCLUSIONS: According to the authors' experience, endoscopic metopic suturectomy alone, without the use of a helmet, is a valid surgical option for trigonocephaly treatment, and its application can be considered in patients of older age groups (up to 8 months). Thus, in the right patient selection context, this technique represents the treatment of choice.

Flexible endoscope-assisted suture release and barrel stave osteotomy for the correction of sagittal synostosis.

OBJECTIVE: Early suturectomy with a rigid endoscope followed by orthotic cranial helmet therapy is an accepted treatment option for single-suture craniosynostosis. To the authors' knowledge, flexible endoscope-assisted suture release (FEASR) has not been previously described. Presented herein is their experience with FEASR for the treatment of isolated sagittal craniosynostosis. METHODS: A retrospective analysis of the health records of patients who had undergone FEASR between March 2018 and December 2020 was performed. Patients under the age of 6 months who had been diagnosed with isolated sagittal synostosis were considered eligible for FEASR. Exclusion criteria included syndromic synostosis or multiple-suture synostosis. The cephalic index, the primary measure of the cosmetic endpoint, was calculated at prespecified intervals: immediately preoperatively and 6 weeks and 12 months postoperatively. Parental satisfaction with the cosmetic outcome was determined throughout the clinical follow-up and documented according to a structured questionnaire for the first 12 months. RESULTS: A total of 18 consecutive patients met the criteria for study inclusion. The mean patient age at the time of surgery was 3.4 months (range 2-6 months). All patients underwent a wide craniectomy with no need to convert to an open procedure. The mean craniectomy width was 3.61 cm. Estimated blood loss ranged from 5 to 30 ml. The mean operative time was 75 minutes. No intraoperative complications were observed. The average length of stay was 2.6 days. The mean cephalic index was 67.7 preoperatively, 77.1 at 6 weeks postoperatively, and 76.3 at 1 year postoperatively. The mean percentage change in the cephalic index from preoperatively to the 12-month follow-up was 10.44 (p < 0.001). The mean follow-up was 17 months (range 12-28 months). All parents were satisfied with the cosmetic outcome of the procedure. No patients developed symptoms of raised intracranial pressure (ICP) or needed invasive ICP monitoring during the follow-up period. No patients required reoperation. CONCLUSIONS: In this modest single-hospital series, the authors demonstrated the feasibility of FEASR in treating sagittal synostosis with favorable cosmetic outcomes. The morbidity profile and resource utilization of the procedure appear similar to those of procedures conducted via traditional rigid endoscopy.

Endoscopy in Craniosynostosis Surgery: Evolution and Current Trends.

Over the past 30 years, advances in endoscopic technology and advancing interest in the benefits of minimally invasive approaches for craniofacial surgery have resulted in these techniques becoming a part of the standard of care in the treatment of craniosynostosis. In this review, we discuss the evolution and adoption of endoscopic-assisted strip craniectomy procedures. In addition to reviewing the studies describing various nuances and modifications to minimally invasive strip craniectomy, attention to comparisons in outcomes between traditional or open cranial vault reconstructions and endoscopic-assisted techniques is highlighted for different craniosynostosis diagnoses.

Complications in craniosynostosis surgery in patients with rickets: illustrative case and systematic review of literature.

BACKGROUND: Craniosynostosis (CSS) is the premature fusion of calvarial sutures associated with identified genetic mutations or secondary to alterations in intracranial pressure, brain, or bone growth patterns. Of the metabolic etiologies implicated in CSS, X-linked hypophosphatemic rickets (XLHR) is the most common, with dysfunctional bone mineralization leading to progressive hyperostosis and delayed synostosis. There is a paucity of literature discussing the unique surgical considerations for XLHR-related CSS. OBSERVATIONS: A 26-month-old male with XLHR-related sagittal CSS underwent cranial vault remodeling (CVR). Surgery was complicated by the presence of diploic hypertrophy with significant intraoperative estimated blood loss (EBL). EBL greatly exceeded reference ranges for CVR in all-cause CSS. As a result, the surgical goals were modified and the complete planned procedure aborted. Subsequent review of preoperative imaging revealed multiple fine vascular lacunae within the bone. A systematic literature review was conducted to identify reported complications relating to surgical intervention for rickets-associated CSS. LESSONS: Future considerations for patients with XLHR-related CSS should emphasize awareness of metabolic risk factors with associated complications, and the need for selection of approach and operative management techniques to avoid EBL. Further research is required to elucidate underlying mechanisms and determine whether the encountered phenomenon is characteristic across this patient population and potentially minimized by preoperative medical therapy.

Trigonocephaly: Quantitative Comparison of the Complete Vault Reconstruction and Minimally Invasive Suturectomy.

OBJECTIVE: The objective of the study was to present and compare outcomes and complications of conventional open reconstruction and minimally invasive correction of metopic synostosis in patients who underwent treatment of trigonocephaly in our center between 2015 and 2019. METHODS: The hospital database was searched for hospitalization and surgical information, as well as imaging of individuals with trigonocephaly. Postoperative evaluation of the patients was performed during the follow-up sessions. The radiological evaluation was based on brain computed tomography scans taken 2 years following the operation. RESULTS: Sixty-four patients (19 females and 45 males) had their trigonocephaly corrected surgically. Thirty-five patients (9 females and 26 males) had complete vault reconstruction surgery, while 29 patients (10 females and 19 males) had minimally invasive suturectomy (MIS). The postoperative cephalic width/intercoronal distance ratio and interpupillary distance/interfrontozygomatic distance ratio assessment showed no differences in the outcome of both groups (P value > 0.05). Minimally invasive techniques resulted in less intraoperative bleeding, a shorter stay in the intensive care unit and hospital, and a shorter surgery and anesthesia duration (P value < 0.05). CONCLUSIONS: Surgical treatment of trigonocephaly can result in a satisfactory correction of the deformity. MIS delivers a comparable result to complete vault reconstruction with less invasiveness and hospitalization and can be considered a reasonable option for patients in their early months of life. Patients must, however, undergo long-term cosmetic, behavioral, and developmental evaluations.

Evaluation and Management of Nonsyndromic Craniosynostosis.

Nonsyndromic craniosynostosis (NSC) is more common than syndromic craniosynostosis and predominantly involves single suture. It affects sagittal, coronal, metopic, and lambdoid sutures in the decreasing order of frequency. A surgery for NSC is generally recommended to avoid potential neurodevelopmental delays and sequelae of raised intracranial pressure. Open calvarial vault reconstruction, strip craniectomy with/without the use of a postoperative molding helmet, strip craniectomy with spring implantations, endoscopic suture release, and cranial distraction osteogenesis are various surgical options used for NSC cases. The ideal age for intervention is 6-12 months for open procedures and 3-4 months for endoscopic approaches. The management is directed toward minimizing operative trauma and improving the neurocognitive outcome. The role of nonsurgical intervention by the use of genetic manipulation is still not a reality because of the nature of disease and time of presentation.

Comparison of aesthetic outcomes between open and endoscopically treated sagittal craniosynostosis.

OBJECTIVE: In the last several decades, there has been much debate regarding the ideal treatment for sagittal synostosis. The purpose of this study was to compare perioperative, anthropometric, and subjective assessments of cosmetic outcomes between open and endoscopic management of isolated sagittal synostosis. METHODS: At their routine postoperative follow-up, pediatric patients with sagittal craniosynostosis were recruited to undergo digital cranial measurement and standardized photography for objective and subjective assessments of perioperative outcomes. Age-normalized z-scores for cephalic index, head circumference, euryon-euryon diameter (Eu-Eu), and glabella-opisthocranion diameter (G-Op) were calculated for each patient. Faculty surgeons, surgical trainees, nurses, and laypersons were asked to rate the normalcy of craniofacial appearances using a 5-point Likert scale. Outcomes were compared between patients treated with endoscopic correction and those treated with open repair. RESULTS: A total of 50 patients were included in the study. Thirty-one had undergone open surgical correction, and 19 had undergone endoscopic treatment. Endoscopic repair involved significantly lower operative time, blood loss, transfusion rate, and hospital length of stay than those with open repair (p < 0.001). There was no significant difference between groups in terms of z-scores for head circumference (p = 0.22), cephalic index (p = 0.25), or Eu-Eu (p = 0.38). Endoscopic treatment was associated with a significantly lower G-Op (p = 0.009). Additionally, the average subjective rating of head shape was higher for endoscopic treatment when corrected for age, gender, and ethnicity (p = 0.02). CONCLUSIONS: The study findings suggest that patients who are treated endoscopically may have an overall more normal appearance in skull morphology and cosmesis, although these results are limited by poor reliability.

Analysis of clinical outcomes for treatment of sagittal craniosynostosis: a comparison of endoscopic suturectomy and cranial vault remodeling.

The authors compared the effectiveness of two main surgical techniques used for treating sagittal craniosynostosis (SC): endoscopic suturectomy (ES) and cranial vault remodeling (CVR). The safety, head growth, and aesthetic results following ES and CVR were compared by reviewing the charts of more than 200 patients. By comparing the effectiveness of these two treatments, this study will help guide selection of the optimal surgical treatment for patients with SC.

Incomplete reossification after craniosynostosis surgery-incidence and analysis of risk factors: a clinical-radiological assessment study.

OBJECTIVE One of the principles of the surgical treatment of craniosynostosis includes the release of fused bone plates to prevent recurrence. Such bone defects require a reossification process after surgery to prevent a cosmetic problem or brain vulnerability to damage. The objective of this study is to describe and analyze the radiological and clinical evolution of bone defects after craniosynostosis. METHODS From January 2005 to May 2016, 248 infants underwent surgical correction of craniosynostosis at HUiP La Fe Valencia; the authors analyzed data from 216 of these cases that met the inclusion criteria for this study. Various surgical techniques were used according to the age of the patient and severity of the case, including endoscopic-assisted suturectomy, open suturectomy, fronto-orbital advancement, and cranial vault remodeling. Clinical follow-up and radiological quantitative measurements in 2 periods-12-24 months and 2 years after surgery-were analyzed; 94 patients had a postoperative CT scan and were included in the radiological analysis. RESULTS At the end of the follow-up period, 92 of 216 patients (42.59%) showed complete closure of the bone defect, 112 patients (51.85%) had minor bone defects, and 12 patients (5.56%) had significant bone defects that required surgical intervention. In the multivariate analysis, age at first surgery was not significantly associated with incomplete reossification (p = 0.15), nor was surgical site infection (p = 0.75). Multivariate analysis identified area of cranial defect greater than 5 cm2 in the first CT scan as predictive of incomplete reossification (p = 0.04). The mean area of cranial defect in the first CT scan (12-24 months after surgery) was 3.69 cm2 in patients treated with open surgery and 7.13 cm2 in those treated with endoscopic-assisted procedures; in the multivariate analysis, type of procedure was not related to incomplete reossification (p = 0.46). The positive predictive value of palpation as evaluation of bone cranial defects was 50% for significant defects and 71% for minor defects. CONCLUSIONS The incidence of cranial defects due to incomplete reossification requiring cranioplasty was 5.56% in our series. Defects greater than 5 cm2 in the first postoperative CT scan showed a positive association with incomplete reossification. Patients treated with endoscope-assisted procedures had larger defects in the initial follow-up, but the final incidence of cranial defects was not significantly different in the endoscope-assisted surgery group from that in the open surgery group.

Optimal duration of postoperative helmet therapy following endoscopic strip craniectomy for sagittal craniosynostosis.

OBJECTIVEMany infants with sagittal craniosynostosis undergo effective surgical correction with endoscopic strip craniectomy (ESC) and postoperative helmet therapy (PHT). While PHT is essential to achieving optimal cosmesis following ESC, there has been little comprehensive analysis of the ideal PHT duration needed to attain this goal.METHODSThe authors retrospectively reviewed the charts of infants undergoing ESC and PHT for sagittal synostosis at our institution between 2008 and 2015. Data collected included age at surgery, follow-up duration, and PHT duration. Cephalic index (CI) was evaluated preoperatively (CIpre), at its peak level (CImax), at termination of helmet therapy (CIoff), and at last follow-up (CIfinal). A multivariate regression analysis was performed to determine factors influencing CIfinal.RESULTSThirty-one patients (27 male, 4 female) were treated in the studied time period. The median age at surgery was 2.7 months (range 1.6 to 3.2) and the median duration of PHT was 10.4 months (range 8.4 to 14.4). The mean CImax was 0.83 (SD 0.01), which was attained an average of 8.4 months (SD 1.2) following PHT initiation. At last follow-up, there was an average retraction of CIfinal among all patients to 0.78 (SD 0.01). Longer helmet duration after achieving CImax did not correlate with higher CIfinal values. While CImax was a significant predictor of CIfinal, neither age at surgery nor CIpre were found to be predictive of final outcome.CONCLUSIONSPatients undergoing ESC and PHT for sagittal synostosis reach a peak CI around 7 to 9 months after surgery. PHT beyond CImax does not improve final anthropometric outcomes. CIfinal is significantly dependent on CImax, but not on age, nor CIpre. These results imply that helmet removal at CImax may be appropriate for ESC patients, while helmeting beyond the peak does not change final outcome.

Review of Past Reports and Current Concepts of Surgical Management for Craniosynostosis.

The purposes of surgery for craniosynostosis are to release increased intracranial pressure and to normalize cranial shape. The procedure was developed from a simple strip craniectomy in practice which ranged from the removal of the fused suture before the 1960s to total calvarial remodeling after 1970s and later methods of the 1990s, such as distraction and its modifications. According to its history, craniofacial surgeons might be changing their procedures with more effective, than less invasive ways. Since the late 1990s, when the distraction was applied to the craniofacial surgery, the gradual expansion, in particular of the anterior cranium, common in Japan, has long been controversial until the Caucasians accepted its use for the posterior cranium. Currently, the method may revert to the old procedure because a more sophisticated and better morphological result can be obtained depending on the types of deformity, even if a little more invasive maneuver is required. In other words, if treatment can be performed in optimal time, the procedures that were developed in the last half a century should be altered to each condition.

Minimally Invasive Suturectomy and Postoperative Helmet Therapy : Advantages and Limitations.

Various operative techniques are available for the treatment of craniosynostosis. The patient's age at presentation is one of the most important factors in the determination of the surgical modality. Minimally invasive suturectomy and postoperative helmet therapy may be performed for relatively young infants, whose age is younger than 6 months. It relies upon the potential for rapid brain growth in this age group. Its minimal invasiveness is also advantageous. In this article, we review the advantages and limitations of minimally invasive suturectomy followed by helmet therapy for the treatment of craniosynostosis.