Evolution of operative techniques for the treatment of single-suture metopic synostosis.

Purpose: Primary orbitocranioplasty for metopic craniosynostosis encompasses a variety of techniques, with variable long-term success. The authors present a series illustrating the evolution of surgical techniques and its impact on surgical outcomes.

Methods: All patients with single-suture metopic synostosis treated at the Children's Hospital of Philadelphia from 1975-2004 were included. Demographic information, preoperative clinical findings, operative technique, postoperative complications, postoperative clinical findings, and length of follow-up were all recorded. Five techniques are presented, reflecting a transition from mere reshaping with metallic fixation to the increased use of primary bone grafting and resorbable fixation to expand the frontal region. Preoperative covariates and technique type were analyzed for effect on outcomes.

Results: Eighty-six patients were identified. Mean follow-up was 50 months. In terms of esthetic outcome, patients with preoperative frontal irregularities had a higher incidence of postoperative deformities (P = 0.026). Patients with preoperative mean intercanthal distance <20 had a higher incidence of postoperative frontal irregularities (P = 0.045). Maximal expansion of the supraorbital bar via interpositional bone graft and stabilization of the construct with strategic bone grafting and resorbable fixation resulted in a lower incidence of postoperative temporal hollowing (P = 0.029). Patients with expansion and lateral reinforcement of the expanded bar had a lower incidence of reoperation (P = 0.026).

Conclusions: Undercorrection of metopic craniosynostosis is not an uncommon finding. To prevent long-term relapse, aggressive anterolateral expansion of the supraorbital bar via primary bone grafting and resorbable fixation with the overall goal of overcorrection may provide the best esthetic outcome.