A systematic review of endoscopic versus open treatment of craniosynostosis. Part 2: the nonsagittal single sutures

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OBJECTIVE

Despite increasing adoption of endoscopic techniques for repair of nonsagittal single-suture craniosynostosis, the efficacy and safety of the procedure relative to established open approaches are unknown. In this systematic review the authors aimed to directly compare open surgical and endoscope-assisted techniques for the treatment of metopic, unilateral coronal, and lambdoid craniosynostosis, with an emphasis on quantitative reported outcomes.

METHODS

A literature search was performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant articles were identified from 3 electronic databases (MEDLINE, EMBASE, and CENTRAL [Cochrane Central Register of Controlled Trials]) from their inception to August 2017. The quality of methodology and bias risk were assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies.

RESULTS

Of 316 screened records, 7 studies were included in a qualitative synthesis of the evidence, of which none were eligible for meta-analysis. These reported on 111 unique patients with metopic, 65 with unilateral coronal, and 12 with lambdoid craniosynostosis. For all suture types, 100 (53%) children underwent endoscope-assisted craniosynostosis surgery and 32 (47%) patients underwent open repair. These studies all suggest that blood loss, transfusion rate, operating time, and length of hospital stay were superior for endoscopically treated children. Although potentially comparable or better cosmetic outcomes are reported, the paucity of evidence and considerable variability in outcomes preclude meaningful conclusions.

CONCLUSIONS

Limited data comparing open and endoscopic treatments for metopic, unilateral coronal, and lambdoid synostosis suggest a benefit for endoscopic techniques with respect to blood loss, transfusion, length of stay, and operating time. This report highlights shortcomings in evidence and gaps in knowledge regarding endoscopic repair of nonsagittal single-suture craniosynostosis, emphasizing the need for further matched-control studies.

ABBREVIATIONS EBL = estimated blood loss; EPHPP = Effective Public Health Practice Project; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

OBJECTIVE

Despite increasing adoption of endoscopic techniques for repair of nonsagittal single-suture craniosynostosis, the efficacy and safety of the procedure relative to established open approaches are unknown. In this systematic review the authors aimed to directly compare open surgical and endoscope-assisted techniques for the treatment of metopic, unilateral coronal, and lambdoid craniosynostosis, with an emphasis on quantitative reported outcomes.

METHODS

A literature search was performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant articles were identified from 3 electronic databases (MEDLINE, EMBASE, and CENTRAL [Cochrane Central Register of Controlled Trials]) from their inception to August 2017. The quality of methodology and bias risk were assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies.

RESULTS

Of 316 screened records, 7 studies were included in a qualitative synthesis of the evidence, of which none were eligible for meta-analysis. These reported on 111 unique patients with metopic, 65 with unilateral coronal, and 12 with lambdoid craniosynostosis. For all suture types, 100 (53%) children underwent endoscope-assisted craniosynostosis surgery and 32 (47%) patients underwent open repair. These studies all suggest that blood loss, transfusion rate, operating time, and length of hospital stay were superior for endoscopically treated children. Although potentially comparable or better cosmetic outcomes are reported, the paucity of evidence and considerable variability in outcomes preclude meaningful conclusions.

CONCLUSIONS

Limited data comparing open and endoscopic treatments for metopic, unilateral coronal, and lambdoid synostosis suggest a benefit for endoscopic techniques with respect to blood loss, transfusion, length of stay, and operating time. This report highlights shortcomings in evidence and gaps in knowledge regarding endoscopic repair of nonsagittal single-suture craniosynostosis, emphasizing the need for further matched-control studies.

ABBREVIATIONS EBL = estimated blood loss; EPHPP = Effective Public Health Practice Project; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Although emerging data from the endoscopic treatment of sagittal synostosis suggest more favorable perioperative outcomes, there is substantially less data to inform decisions for the surgical treatment of nonsagittal single-suture craniosynostosis. Metopic craniosynostosis, or trigonocephaly, is often characterized by a triangular anterior cranial vault, bitemporal narrowing with biparietal expansion, or midline forehead ridging. The incidence of metopic synostosis has been estimated to be as high as 1 in 5000 births,23 and accounts for 10% of all craniosynostoses.15 Unilateral coronal craniosynostosis is the most common cause of synostotic frontal plagiocephaly. It is characterized by frontal and superior orbital retrusion on the fused side, sometimes resulting in strabismus.26 The incidence is estimated to be approximately 66 in 1 million live births.31 Lambdoid craniosynostosis is characterized by flattening of the occipital bone, leading to potential cranial vault deformity. Lambdoid suture synostosis is rare, representing 1% to 4% of all cases of craniosynostosis, and occurs once in every 40,000 live births.39

There is still controversy around the cosmetic and neurodevelopmental indications for surgical treatment of craniosynostosis.34,45,46 In milder forms, the diagnosis may be difficult and the natural course can be self-limited and self-correcting.8 However, because a fused suture may physically limit normal brain development, surgery is often offered to correct the deformity before the age of 1 year.1,6,37 Metopic synostosis has shown the greatest correlation with neurodevelopmental delay when compared to other single-suture synostoses,43 although it is yet unproven if corrective cranioplasty rectifies developmental problems.

The variety of synostosis presentation necessitates a variety of surgical techniques. The operative procedure is often tailored to the severity of the deformity. Open surgery techniques for metopic synostosis include synostectomy,3 the “floating head” cranial vault expansion,28 and fronto-orbital reshaping and expansion with bone grafts.2,18 Unilateral coronal synostosis has been treated with open surgical techniques that include forward advancement of the supraorbital bar and correction of the orbital asymmetry.2,32 Lambdoid synostosis requires open surgery to release the fused suture and correct the cranial vault. Endoscopic approaches to these 3 suture types include suturectomy, fronto-orbital advancement, or a combination, with helmet therapy to follow surgical treatment.48

Since its introduction in 2002, endoscopic treatment for craniosynostosis has been shown to be effective, safe, and inexpensive.15,19 This systematic literature review aims to directly compare open surgical techniques and endoscope-assisted techniques for the treatment of metopic, unilateral coronal, and lambdoid synostosis. A disproportionate number of studies have focused on sagittal synostosis. Given the encouraging outcomes reported, there is greater enthusiasm to further expand indications for endoscopic repair. This review presents the most comprehensive evidence for nonsagittal single-suture craniosynostosis. Given that the data for any one specific nonsagittal suture are limited and variable, the current report evaluates several suture types in the analysis of the newer endoscopic treatments compared to traditional open surgery. We highlight deficiencies in knowledge regarding safety and efficacy of the procedure relative to more established open approaches and discuss future studies to better assess outcomes in this heterogeneous patient population.

Methods

Search Strategy

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and recommendations.25,36 A literature search was performed on MEDLINE, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials) on August 17, 2017, by a librarian (M.A.). The database searches used keywords (individually and/or in combination) such as “craniosynostosis,” “endoscopic,” and “neuroendoscope” with the appropriate subject headings. The reference lists of retrieved articles were reviewed to identify additional relevant articles. Prior to submission, another search was conducted to include newly published studies.

Study Selection

Retrieved studies were systematically assessed using inclusion and exclusion criteria by 2 reviewers (H.Y. and T.J.A.). Inclusion criteria were 1) diagnosis of metopic, unilateral coronal, or lambdoid craniosynostosis by a plastics surgeon or neurosurgeon; 2) at least 50% of the patient population had isolated metopic, unilateral coronal, or lambdoid craniosynostosis; and 3) cohorts were divided into open surgery and endoscopically assisted surgery. Exclusion criteria for the meta-analysis included 1) lack of quantitative comparison between open surgery and endoscopically assisted surgery; 2) nonhuman subjects; 3) inclusion of patients with syndromic craniosynostosis; and 4) editorials, abstracts, review articles, case reports, and dissertations. When duplicate studies were found, only the most complete reports were included for quantitative assessment.

Data Extraction and Critical Appraisal

All data were extracted from article texts, tables, and figures. Each retrieved article was reviewed by 2 investigators independently (H.Y. and T.J.A.). Authors were contacted when there were missing or incomplete data. The quality of the methodology and the risk of bias across studies were assessed by 1 reviewer (H.Y.) using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies.41 Measured variables included selection bias, study design, confounders, blinding, data collection methods, withdrawals and dropouts, as well as a global rating, and the tool rates each as “strong,” “moderate,” or “weak.”

Results

Literature Search

The search strategy identified a total of 503 studies (Fig. 1). After removal of 187 duplicate studies, inclusion and exclusion criteria were applied to the titles of the remaining 316 articles. This yielded 28 studies that underwent full-text analysis (Table 1), of which 21 did not meet the inclusion criteria of 1) having more than 50% of patients present with metopic, unilateral coronal, or lambdoid synostosis; and 2) reporting on quantitative results. Two of the studies reported on the same cohort, although analyses were focused on different outcome metrics.11,29 Due to a dearth of studies with uniform quantitative data, a meta-analysis could not be conducted.

FIG. 1.
FIG. 1.

PRISMA flowchart for systematic review. Figure is available in color online only.

TABLE 1.

Exclusion of eligible studies

Authors & YearExcludedExplanations & Comments
Abbott et al., 2012YesPts w/ sagittal craniosynostosis only
Arts et al., 2018NoAnalyzed pts w/ metopic craniosynostosis separately
Bonfield et al., 2016YesPts w/ sagittal craniosynostosis only
Chan et al., 2013YesIncludes pts w/ syndromic craniosynostosis; pts w/ metopic craniosynostosis represent 21% of cohort
Dvoracek et al., 2015YesPts w/ sagittal craniosynostosis only; overlapping pt population suspected
Esparza & Hinojosa, 2008YesPts w/ sagittal craniosynostosis only
Farber et al., 2017NoNA
Garber et al., 2017YesPts w/ sagittal craniosynostosis only
Ghenbot et al., 2015YesPts w/ sagittal craniosynostosis only
Ghosh et al., 2014YesPts w/ sagittal craniosynostosis only
Han et al., 2016YesPts w/ metopic craniosynostosis represent <17% of cohort
Hashim et al., 2014YesAnalysis of neuropsychological outcomes only
Keshavarzi et al., 2009NoNA
Keshavarzi et al., 2010YesPts w/ metopic craniosynostosis represent 27% of cohort
Kohan et al., 2008YesCase studies of twin pts
Le et al., 2014YesPts w/ sagittal craniosynostosis only; overlapping pt population suspected
MacKinnon et al., 2009YesOverlapping pt population & data suspected
MacKinnon et al., 2013NoNA
Nguyen et al., 2015NoNA
Nowaková et al., 2015YesTranslated from Czech; nonquantitative data
Rogers et al., 2015YesMeasured outcome is hand preference
Shah et al., 2011YesPts w/ sagittal craniosynostosis only
Siu et al., 2014YesCase studies of 2 pts w/ unilat coronal craniosynostosis & Down syndrome
Tan et al., 2013NoNA
Thompson et al., 2018YesPts w/ metopic craniosynostosis represent 18% of cohort
Vogel et al., 2014YesPts w/ unilat coronal craniosynostosis only
Yarbrough et al., 2014YesCase series of 5 pts w/ mixed suture types
Zubovic et al., 2015NoNA
NA = not applicable; pts = patients.

Cohort Description

The cohort size of the literature review included 111 unique patients with metopic craniosynostosis, 65 patients with unilateral coronal craniosynostosis, and 12 patients with lambdoid craniosynostosis. Of the 7 studies included, only the patients in the Farber et al.11 cohort were considered non-unique patients because of notable similarities with the cohort in Nguyen et al.29 If these 26 patients, 13 in each group, are not counted separately from the patients in the Nguyen et al. cohort, then 100 (53%) children underwent endoscope-assisted craniosynostosis surgery and 88 (47%) patients underwent open repair (Table 2). The age of the endoscopically treated cohort was generally younger than that of the open cohort (range 2.0–5.5 months and 9.3–29.5 months, respectively).

TABLE 2.

Demographic characteristics of patients in literature review studies

Authors & YearCity & State or CountryEPHPP RatingSuture TypeStudy DesignNo. of PtsNo. of Pts TreatedMean Age (mos)% MaleFU (mos)
EndoOpenEndoOpenEndoOpenEndoOpen      
Arts et al., 2018Nijmegen, NetherlandsStrongMetopicR OS5035153.6 ± 1.110 ± 2.9NR12
Farber et al., 2017St. Louis, MOWeakMetopicR OS26*13*13*NRNR12
Keshavarzi et al., 2009San Diego, CAModerateMetopicR OS3316174.929.58865>36
Nguyen et al., 2015St. Louis, MOWeakMetopicR OS2813153.3 ± 0.49.5 ± 1.8707012
MacKinnon et al., 2013Boston, MAWeakUnilat coronalR OS4321224.09.3NR23.521.5
Tan et al., 2013Boston, MAModerateUnilat coronalR OS221111212NR34.545.9
Zubovic et al., 2015St. Louis, MOWeakLambdoidR OS12485.512.8NRNR
Endo = endoscopically assisted surgery; FU = follow-up; NR = not recorded; OS = observational study; R = retrospective.The mean values are expressed ± SD in studies in which SD was reported.

These patients considered non-unique because of notable similarities with the Nguyen et al. cohort.

Perioperative Outcomes

Two studies4,20 were able to calculate the mean estimated blood loss (EBL) for patients with metopic craniosynostosis treated with endoscopic (range 39–57 ml) and open surgery (range 190–218 ml); endoscopic procedures were favored (Table 3). Similarly, patients with metopic craniosynostosis benefitted from lower transfusion rates when surgery was done endoscopically (range 17%–62%) compared to open (range 71%–100%) procedures. For patients with metopic craniosynostosis, only Keshavarzi et al.20 demonstrated lower transfusion volumes (91.9 ml vs 184 ml), shorter operating time (1.7 hours vs 2.21 hours), and shorter length of stay in hospital (2.46 days vs 2.76 days) for endoscopic procedures compared to open surgery, although no statistical analysis was performed.

TABLE 3.

Perioperative outcomes of patients in literature review studies

Authors & YearNo. of PtsSuture TypeMean EBL (ml)Mean Transfusion Vol (ml)% TransfusedOp Time (hrs)LOS (days)
EndoOpenEndoOpenEndoOpenEndoOpenEndoOpen   
Arts et al., 201850Metopic39 ± 25218 ± 167NR17100NRNR
3Coronal10110 ± 85NR0100NRNR 
26Plagiocephaly33 ± 25194 ± 124NR0100NRNR 
6Multisuture65 ± 36207 ± 90NR33100NRNR 
Keshavarzi et al., 200933Metopic56.819091.918462711.682.212.462.76
Zubovic et al., 201512Lambdoid15350NR01000.985.0NR
LOS = length of stay.

Arts et al.4 analyzed patients with coronal sutures, plagiocephaly, and multisutures, and Zubovic et al.49 analyzed 12 patients with lambdoid craniosynostosis. Consistently across suture types, endoscopically treated patients had lower mean EBL (range 10–65 ml) compared to patients with open surgery (range 110–350 ml). Analogously, the transfusion rate was consistently lower for endoscopically treated patients (range 0%–33%) compared to patients treated with open surgery (100%). Zubovic et al. also demonstrated that the operating time for endoscopic lambdoid procedures was lower, at 0.98 hours, compared to 5.0 hours for open lambdoid surgery.

Cosmetic Outcomes

Two studies11,29 reported on cosmetic outcomes for patients with metopic craniosynostosis (Table 4). The postoperative outcomes do not show a difference with regard to mean frontal width (80 mm vs 81 mm), mean interzygomaticofrontal distance (77.0 mm vs 76.2 mm, p = 0.68), mean intercanthal distance (30.3 mm vs 31.0 mm, p = 0.61), interfrontal angle (112.5° vs 112.6°, p = 0.98), or interzygomaticofrontal distance (109.0° vs 109.8°, p = 0.73). These cosmetic outcomes were measured at a minimum of 12 months after the operation.

TABLE 4.

Reported cosmetic outcomes comparing endoscopic and open treatment

Authors & YearNo. of PtsSuture TypeOutcomesTreatmentp Value
EndoOpenEndoOpen  
Farber et al., 20171313MetopicMean frontal width (mm)80 ± 0.481 ± 0.7
Z-score0.00.0   
Nguyen et al., 20151315MetopicMean ZF-ZF (mm)77.0 ± 0.876.2 ± 1.80.68
Mean ID (mm)30.3 ± 0.731.0 ± 1.00.61   
ZFr-G-ZFl109.0° ± 1.6°109.8° ± 2.0°0.73   
IFA112.5° ± 1.9°112.6° ± 2.8°0.98   
Tan et al., 20131111Unilat coronalNasal tip deviation2.3° ± 1.8°5.6° ± 3.0°0.006
Facial midline deviation1.4° ± 1.1°3.6° ± 2.4°0.018   
Difference btwn lt & rt brow projection (mm)1.7 ± 0.91.0 ± 0.60.054   
Zubovic et al., 201548LambdoidPFA6.4°6.6°0.691
PRA9.5°7.9°0.551   
MCA3.2°4.0°0.967   
Vertical EAM displacement (mm)−2.3−2.30.359   
Anterior-posterior EAM displacement (mm)7.86.80.459   
EAM = external acoustic meatus; ID = intercanthal distance; IFA = interfrontal angle; MCA = mastoid cant angle; PFA = posterior fossa deflection angle; PRA = petrous ridge angle; ZF = zygomaticofrontal; ZF-ZF = inter-ZF distance; ZFr-G-ZFl = right ZF–glabella–left ZF angle (i.e., axial bilateral zygomaticofrontal-glabella angle).

Tan et al.40 analyzed the cosmetic outcomes for unilateral coronal synostosis (Table 4). They determined that there was no difference between endoscopic and open procedures with regard to supraorbital symmetry (p = 0.054). The endoscopically treated patients exhibited better facial symmetry in midline deviation (p = 0.018) and nasal tip deviation (p = 0.006). Zubovic et al.49 studied the cosmetic outcomes for unilateral lambdoid synostosis. At 1 year postoperatively, open and endoscopically treated patients were statistically equivalent in all measures (range, p = 0.359 to p = 0.967), and mean volume asymmetry was significantly improved in both groups.

MacKinnon et al.26 specifically studied the ophthalmic outcomes in children with unilateral coronal synostosis, showing that children treated with fronto-orbital advancement open surgery were more likely to develop amblyopia (p = 0.0015) and to receive surgery to correct their strabismus.

These retrospective observational studies were assessed by the EPHPP Quality Assessment Tool to include 4 weak, 2 moderate, and 1 strong study (Table 5). Blinding was either not possible or neglected in the methodology. The data collection and statistical analyses of these studies were rigorous, although the small patient population causes difficulty in finding and adjusting for confounders.

TABLE 5.

Results of quality assessment of methodology

Authors & YearSelection BiasStudy DesignConfoundersBlindingData Collection MethodsAnalysesGlobal Rating
Arts et al., 2018StrongModerateModerateModerateModerateModerateStrong
Farber et al., 2017WeakModerateWeakModerateModerateModerateWeak
Keshavarzi et al., 2009StrongModerateWeakModerateModerateModerateModerate
Nguyen et al., 2015StrongModerateWeakModerateWeakModerateWeak
MacKinnon et al., 2013ModerateModerateWeakModerateWeakModerateWeak
Tan et al., 2013StrongModerateWeakModerateStrongModerateModerate
Zubovic et al., 2015ModerateModerateWeakModerateWeakModerateWeak

Discussion

In this literature review, we found 4 studies4,11,20,29 that support the surgical treatment of metopic synostosis by endoscope-assisted surgery compared with open surgery. Two studies26,40 examined unilateral coronal surgery outcomes, and 1 study49 evaluated lambdoid synostosis. Based on limited data, endoscopic techniques were associated with better perioperative outcomes. Given the heterogeneity in presentations and procedures, strong conclusions cannot be formulated regarding cosmetic results, although objective indicators of cosmesis were equivocal in the few studies reporting these outcomes.

Two studies4,20 demonstrated that endoscopic procedures for patients with metopic craniosynostosis have a lower EBL and lower transfusion volumes, shorter operating time, and shorter hospital stay. These results highlighted, however, the fact that the lower blood loss may only be possible with the availability of appropriate instruments, such as a bone scalpel. Similar trends were reported for unilateral coronal synostosis and lambdoid synostosis.4,49

Cosmetic outcomes were only reported in 26 patients with metopic craniosynostosis on 1-year postoperative CT scans.11,29 Measurements of mean frontal width and interfrontal angle show no significant cosmetic difference between endoscopic and open treatment. Patients with unilateral coronal craniosynostosis seem to benefit more from endoscopic treatment, with better postoperative facial symmetry40 and a smaller risk for developing amblyopia or strabismus.26 The analysis of aesthetics is only as rigorous as the metrics available for measurement, which significantly limits the conclusions that could be derived from the literature. Ultimately, how the cosmetic outcomes of endoscopic craniosynostosis repair compare to those of open techniques remains an open question.

In larger studies in which several suture types were studied,7,16 the perioperative outcomes also seem to favor endoscopic procedures. Han et al.16 performed a detailed comparison between endoscopic and open procedures, with only 18.6% of their patients having metopic synostosis. They report similar results for endoscopic surgery: lower EBL (p < 0.001), lower transfusion rates (p < 0.001), shorter procedure time (p < 0.001), and shorter course in hospital (p < 0.001). These 4 significant differences are also supported by Chan et al.,7 whose cohort included patients with syndromic craniosynostosis, with 19% of their patients having metopic involvement. No studies were found specific to metopic, unilateral coronal, or lambdoid surgical correction that analyzed costs or rates of complication between endoscopic and open procedures.

Given the complex indications for surgery surrounding fused metopic sutures, and the variability of the degree of the deformity, minimally invasive endoscopic approaches may be a preferred option in the future. Although the early literature demonstrates safety and efficacy, a survey of 102 craniofacial surgeons demonstrates that only 19% of surgeons performed endoscopic procedures on mild cases of metopic synostosis.48 There has not yet been any analysis of the satisfaction of parents and patients with an extended length of helmet therapy. Furthermore, it is unclear at what ages children are most likely to benefit from one treatment versus another.

Strengths of this study include an extensive search of the current literature, strict adherence to PRISMA guidelines, and quality of evidence analysis by EPHPP protocol. Currently, there is a dearth of literature that directly compares endoscopic and open techniques for the treatment of metopic, unilateral coronal, or lambdoid synostosis. The greatest limitation of this study is the inclusion of several suture types, although the analysis suggests similar findings. Most of the studies included in this analysis were of weak or moderate quality, consisting of retrospective observational studies; one study was found to be strong. Longitudinal studies with extensive follow-up are required to be able to analyze the long-term cost, neurological sequelae, and cosmetic results.

Conclusions

Endoscope-assisted correction of metopic, unilateral coronal, or lambdoid synostosis shows early benefits over open surgical repair. In 7 studies that directly compared endoscopic and open procedures, there were comparable postoperative cosmetic results and better perioperative outcomes such as less blood loss, shorter operations, and shorter hospital stays. Current evidence in the literature comparing endoscopic and open craniosynostosis repair is mostly of weak to moderate quality. Future large prospective registries or randomized controlled trials are required to study long-term outcomes and to explore multiple sources of heterogeneity.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Yan, Ibrahim. Acquisition of data: Abel, Yan, Anderson. Analysis and interpretation of data: Abel, Yan. Drafting the article: Abel, Yan. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Statistical analysis: Alotaibi. Administrative/technical/material support: Ibrahim. Study supervision: Yan, Ibrahim.

Supplemental Information

Companion Papers

Yan H, Abel TJ, Alotaibi NM, Anderson M, Niazi TN, Weil AG, et al: A systematic review and meta-analysis of endoscopic versus open treatment of craniosynostosis. Part 1: the sagittal suture. DOI: 10.3171/2018.4.PEDS17729.

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  • 25

    Liberati AAltman DGTetzlaff JMulrow CGøtzsche PCIoannidis JP: The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 6:e10001002009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    MacKinnon SProctor MRRogers GFMeara JGWhitecross SDagi LR: Improving ophthalmic outcomes in children with unilateral coronal synostosis by treatment with endoscopic strip craniectomy and helmet therapy rather than fronto-orbital advancement. J AAPOS 17:2592652013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    MacKinnon SRogers GFGregas MProctor MRMulliken JBDagi LR: Treatment of unilateral coronal synostosis by endoscopic strip craniectomy or fronto-orbital advancement: Ophthalmologic findings. J AAPOS 13:1551602009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Marchac DRenier DJones BM: Experience with the “floating forehead”. Br J Plast Surg 41:1151988

  • 29

    Nguyen DCPatel KBSkolnick GBNaidoo SDHuang AHSmyth MD: Are endoscopic and open treatments of metopic synostosis equivalent in treating trigonocephaly and hypotelorism? J Craniofac Surg 26:1291342015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Nowaková MKordoš PHladík MMedřická HRosický JKaleta E : Endoskopické operační řešení kraniosynostóz z pohledu dětského intenzivisty. Přehledové články 16:3083112015

    • Search Google Scholar
    • Export Citation
  • 31

    Oh AKWong JOhta ERogers GFDeutsch CKMulliken JB: Facial asymmetry in unilateral coronal synostosis: long-term results after fronto-orbital advancement. Plast Reconstr Surg 121:5455622008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Panchal JUttchin V: Management of craniosynostosis. Plast Reconstr Surg 111:203220492003

  • 33

    Rogers GFWood BCAmdur RLJeelani YReddy SProctor MR: Treatment type is associated with population hand preferences in patients with unilateral coronal synostosis: implications for functional cerebral lateralization. Plast Reconstr Surg 136:782e788e2015

    • Search Google Scholar
    • Export Citation
  • 34

    Selber JReid RRGershman BSonnad SSSutton LNWhitaker LA: Evolution of operative techniques for the treatment of single-suture metopic synostosis. Ann Plast Surg 59:6132007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Shah MNKane AAPetersen JDWoo ASNaidoo SDSmyth MD: Endoscopically assisted versus open repair of sagittal craniosynostosis: the St. Louis Children’s Hospital experience. J Neurosurg Pediatr 8:1651702011

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 36

    Shamseer LMoher DClarke MGhersi DLiberati APetticrew M: Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ 350:g76472015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Sidoti EJ JrMarsh JLMarty-Grames LNoetzel MJ: Long-term studies of metopic synostosis: frequency of cognitive impairment and behavioral disturbances. Plast Reconstr Surg 97:2762811996

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Siu ARogers GFMyseros JSKhalsa SSKeating RFMagge SN: Unilateral coronal craniosynostosis and Down syndrome. J Neurosurg Pediatr 13:5685712014

  • 39

    Smartt JM JrReid RRSingh DJBartlett SP: True lambdoid craniosynostosis: long-term results of surgical and conservative therapy. Plast Reconstr Surg 120:99310032007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Tan SPProctor MRMulliken JBRogers GF: Early frontofacial symmetry after correction of unilateral coronal synostosis: frontoorbital advancement vs endoscopic strip craniectomy and helmet therapy. J Craniofac Surg 24:119011942013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Thomas BHCiliska DDobbins MMicucci S: A process for systematically reviewing the literature: providing the research evidence for public health nursing interventions. Worldviews Evid Based Nurs 1:1761842004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42

    Thompson DRZurakowski DHaberkern CMStricker PAMeier PMBannister C: Endoscopic versus open repair for craniosynostosis in infants using propensity score matching to compare outcomes: a multicenter study from the Pediatric Craniofacial Collaborative Group. Anesth Analg 126:9689752018

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 43

    van der Meulen J: Metopic synostosis. Childs Nerv Syst 28:135913672012

  • 44

    Vogel TWWoo ASKane AAPatel KBNaidoo SDSmyth MD: A comparison of costs associated with endoscope-assisted craniectomy versus open cranial vault repair for infants with sagittal synostosis. J Neurosurg Pediatr 13:3243312014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Warschausky SAngobaldo JKewman DBuchman SMuraszko KMAzengart A: Early development of infants with untreated metopic craniosynostosis. Plast Reconstr Surg 115:151815232005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    Wes AMPaliga JTGoldstein JAWhitaker LABartlett SPTaylor JA: An evaluation of complications, revisions, and long-term aesthetic outcomes in nonsyndromic metopic craniosynostosis. Plast Reconstr Surg 133:145314642014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47

    Yarbrough CKSmyth MDHolekamp TFRanalli NJHuang AHPatel KB: Delayed synostoses of uninvolved sutures after surgical treatment of nonsyndromic craniosynostosis. J Craniofac Surg 25:1191232014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48

    Yee STFearon JAGosain AKTimbang MRPapay FADoumit G: Classification and management of metopic craniosynostosis. J Craniofac Surg 26:181218172015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 49

    Zubovic EWoo ASSkolnick GBNaidoo SDSmyth MDPatel KB: Cranial base and posterior cranial vault asymmetry after open and endoscopic repair of isolated lambdoid craniosynostosis. J Craniofac Surg 26:156815732015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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Article Information

Contributor Notes

Correspondence Taylor J. Abel: The Hospital for Sick Children, Toronto, ON, Canada. taylor.abel@sickkids.ca.INCLUDE WHEN CITING Published online July 6, 2018; DOI: 10.3171/2018.4.PEDS17730.

H.Y. and T.J.A. contributed equally to this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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    PRISMA flowchart for systematic review. Figure is available in color online only.

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    Kohan EWexler ACahan LKawamoto HKKatchikian HBradley JP: Sagittal synostotic twins: reverse pi procedure for scaphocephaly correction gives superior result compared to endoscopic repair followed by helmet therapy. J Craniofac Surg 19:145314582008

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    Le MBPatel KSkolnick GNaidoo SSmyth MKane A: Assessing long-term outcomes of open and endoscopic sagittal synostosis reconstruction using three-dimensional photography. J Craniofac Surg 25:5735762014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Liberati AAltman DGTetzlaff JMulrow CGøtzsche PCIoannidis JP: The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 6:e10001002009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    MacKinnon SProctor MRRogers GFMeara JGWhitecross SDagi LR: Improving ophthalmic outcomes in children with unilateral coronal synostosis by treatment with endoscopic strip craniectomy and helmet therapy rather than fronto-orbital advancement. J AAPOS 17:2592652013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    MacKinnon SRogers GFGregas MProctor MRMulliken JBDagi LR: Treatment of unilateral coronal synostosis by endoscopic strip craniectomy or fronto-orbital advancement: Ophthalmologic findings. J AAPOS 13:1551602009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Marchac DRenier DJones BM: Experience with the “floating forehead”. Br J Plast Surg 41:1151988

  • 29

    Nguyen DCPatel KBSkolnick GBNaidoo SDHuang AHSmyth MD: Are endoscopic and open treatments of metopic synostosis equivalent in treating trigonocephaly and hypotelorism? J Craniofac Surg 26:1291342015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Nowaková MKordoš PHladík MMedřická HRosický JKaleta E : Endoskopické operační řešení kraniosynostóz z pohledu dětského intenzivisty. Přehledové články 16:3083112015

    • Search Google Scholar
    • Export Citation
  • 31

    Oh AKWong JOhta ERogers GFDeutsch CKMulliken JB: Facial asymmetry in unilateral coronal synostosis: long-term results after fronto-orbital advancement. Plast Reconstr Surg 121:5455622008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Panchal JUttchin V: Management of craniosynostosis. Plast Reconstr Surg 111:203220492003

  • 33

    Rogers GFWood BCAmdur RLJeelani YReddy SProctor MR: Treatment type is associated with population hand preferences in patients with unilateral coronal synostosis: implications for functional cerebral lateralization. Plast Reconstr Surg 136:782e788e2015

    • Search Google Scholar
    • Export Citation
  • 34

    Selber JReid RRGershman BSonnad SSSutton LNWhitaker LA: Evolution of operative techniques for the treatment of single-suture metopic synostosis. Ann Plast Surg 59:6132007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Shah MNKane AAPetersen JDWoo ASNaidoo SDSmyth MD: Endoscopically assisted versus open repair of sagittal craniosynostosis: the St. Louis Children’s Hospital experience. J Neurosurg Pediatr 8:1651702011

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 36

    Shamseer LMoher DClarke MGhersi DLiberati APetticrew M: Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ 350:g76472015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Sidoti EJ JrMarsh JLMarty-Grames LNoetzel MJ: Long-term studies of metopic synostosis: frequency of cognitive impairment and behavioral disturbances. Plast Reconstr Surg 97:2762811996

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Siu ARogers GFMyseros JSKhalsa SSKeating RFMagge SN: Unilateral coronal craniosynostosis and Down syndrome. J Neurosurg Pediatr 13:5685712014

  • 39

    Smartt JM JrReid RRSingh DJBartlett SP: True lambdoid craniosynostosis: long-term results of surgical and conservative therapy. Plast Reconstr Surg 120:99310032007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Tan SPProctor MRMulliken JBRogers GF: Early frontofacial symmetry after correction of unilateral coronal synostosis: frontoorbital advancement vs endoscopic strip craniectomy and helmet therapy. J Craniofac Surg 24:119011942013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Thomas BHCiliska DDobbins MMicucci S: A process for systematically reviewing the literature: providing the research evidence for public health nursing interventions. Worldviews Evid Based Nurs 1:1761842004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42

    Thompson DRZurakowski DHaberkern CMStricker PAMeier PMBannister C: Endoscopic versus open repair for craniosynostosis in infants using propensity score matching to compare outcomes: a multicenter study from the Pediatric Craniofacial Collaborative Group. Anesth Analg 126:9689752018

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 43

    van der Meulen J: Metopic synostosis. Childs Nerv Syst 28:135913672012

  • 44

    Vogel TWWoo ASKane AAPatel KBNaidoo SDSmyth MD: A comparison of costs associated with endoscope-assisted craniectomy versus open cranial vault repair for infants with sagittal synostosis. J Neurosurg Pediatr 13:3243312014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Warschausky SAngobaldo JKewman DBuchman SMuraszko KMAzengart A: Early development of infants with untreated metopic craniosynostosis. Plast Reconstr Surg 115:151815232005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    Wes AMPaliga JTGoldstein JAWhitaker LABartlett SPTaylor JA: An evaluation of complications, revisions, and long-term aesthetic outcomes in nonsyndromic metopic craniosynostosis. Plast Reconstr Surg 133:145314642014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47

    Yarbrough CKSmyth MDHolekamp TFRanalli NJHuang AHPatel KB: Delayed synostoses of uninvolved sutures after surgical treatment of nonsyndromic craniosynostosis. J Craniofac Surg 25:1191232014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48

    Yee STFearon JAGosain AKTimbang MRPapay FADoumit G: Classification and management of metopic craniosynostosis. J Craniofac Surg 26:181218172015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 49

    Zubovic EWoo ASSkolnick GBNaidoo SDSmyth MDPatel KB: Cranial base and posterior cranial vault asymmetry after open and endoscopic repair of isolated lambdoid craniosynostosis. J Craniofac Surg 26:156815732015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
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