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David F. Jimenez and Constance M. Barone

Object

The objective of this study was to present the authors' 16-year experience treating coronal craniosynostosis in infants using endoscopy-assisted techniques and postoperative cranial orthoses.

Methods

A total of 128 synostosed coronal sutures in 115 patients were treated between 1996 and 2012 by endoscopically resecting a strip of bone containing the stenosed suture via a 2–3 cm incision made at the ipsilateral stephanion. Data were obtained from a prospective database. Following surgery, patients were fitted with custom cranial orthoses to help correct preoperative craniofacial deformities. All patients were followed closely with cranial anthropometric measurements and photographs.

Results

The estimated mean blood loss was 20 ml (range 5–120 ml) and the estimated mean strip size was 0.6 cm × 10.7 cm. The mean surgical duration was 55 minutes (range 22–150 minutes). One patient underwent an intraoperative blood transfusion and 1 had a postoperative blood transfusion, for a total transfusion rate of 1.7%. Ninety-seven percent of patients were discharged on the first postoperative day. There were no deaths. Vertical dystopia correction of more than 80% from baseline was obtained in almost two-thirds of patients, with 51% achieving 100% correction. Nasal and sagittal craniofacial deviation (vertex-nasion-gnathion) correction greater than 80% was achieved in 80% of patients, with 77% achieving 100% correction. Supraorbital rim advancement of the ipsilateral eye was obtained in 98% of cases, with correction of frontal plagiocephaly the last deformity to achieve correction.

Conclusions

Early treatment of coronal synostosis with endoscopy-assisted craniectomy and postoperative molding helmets leads to significant correction of craniofacial abnormalities, including vertical dystopia, nasal deviation, sagittal misalignment, and ipsilateral proptosis. This treatment method is associated with minimal trauma, blood loss, and transfusion rates, and typically only requires 1 overnight stay. This surgical approach is safe, effective, and associated with excellent results.

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David F. Jimenez and Constance M. Barone

Object

The authors present the results of treating infants with multiple-suture nonsyndromic craniosynostosis in whom the authors used minimally invasive endoscopy-assisted techniques and postoperative cranial molding over an 11-year period.

Methods

A total of 21 patients who presented with multiple-suture (nonsyndromic) craniosynostosis were treated using minimally invasive endoscopy-assisted craniectomies. Surgery was followed by treatment with custommade cranial orthoses for up to 12 months. A total of 48 sutures were treated. The most common was the coronal suture (38 cases) and this was followed by the sagittal (11 cases), metopic (6 cases), and lambdoid (3 cases) sutures. There were 13 male and 8 female pediatric patients. Their ages ranged between 3 weeks and 9 months (mean 3.2 months, median 2.5 months). The sagittal suture was treated with a wide vertex craniotomy via 2 incisions located behind the anterior fontanel and in front of the lambda. The metopic suture underwent a suturectomy as did the coronal and lambdoid sutures.

Results

The mean follow-up duration was 61 months (range 3–135 months). There were no deaths. In patients with bicoronal synostosis, brachycephaly was corrected. Patients presenting with vertical dystopia or nasal deviation had these deformities corrected as well. The mean blood loss was 42 ml (range 10–120 ml). The mean hospital length of stay was 1 day. The intraoperative transfusion rate was 0%. The results indicate that nonsyndromic multiple-suture synostosis can be safely and effectively treated using endoscopic techniques.

Conclusions

Early treatment of complex multiple-suture synostosis with endoscopic techniques provides an excellent surgical alternative. The results of the present study indicate marked correction of skull base and craniofacial deformities. Endoscopy provides a safe and effective way to treat these patients.

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David F. Jimenez and Constance M. Barone

Object. The authors sought to minimize scalp incisions, blood loss, and operative time by using endoscopically assisted strip craniectomies and barrel-stave osteotomies to treat infants with sagittal suture synostosis.

Methods. Four patients, aged 2, 4, 9, and 12 weeks, who presented with scaphocephaly underwent endoscopic midline craniectomies through small midline scalp incisions. The mean operative time for the procedure was 1.68 hours (range 1.15–2.8 hours); the mean blood loss was 54.2 ml (range 12–150 ml). Three patients did not require blood transfusions and were discharged within 24 hours. Postoperatively, all patients were fitted with custom cranial molding helmets. Follow-up evaluation ranged between 8 and 15 months. All patients had successful correction of their scaphocephaly with no mortalities, morbidities, or complications.

Conclusions. The use of endoscopic techniques for early correction of sagittal synostosis is safe; decreases blood loss, operative time, and hospitalization costs; and provides excellent early surgical results.

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David F. Jimenez and Constance M. Barone

Object

The purpose of this study was to assess the efficacy, safety, associated complications, and outcome in patients with sagittal suture craniosynostosis in whom endoscopy-assisted wide-vertex craniotomy and “barrel-stave” osteotomy were performed.

Methods

During a 4-year period, 59 patients with sagittal suture synostosis underwent endoscopy-assisted wide-vertex craniectomies, barrel stave–like osteotomies, and postoperatively were fitted with custom-made molding helmets. Data on operative time, blood loss, transfusion rates, hospital length of stay, complications, and hospital charges were collected prospectively. The mean patient age at the time of surgery was 3.7 months. The average blood loss was 31.8 ml; and only one patient required an intraoperative blood transfusion. Nine patients received transfusions of donor blood postoperatively. The mean operative time was 50 minutes, and all but three patients were discharged from the hospital the morning following surgery. There were no intraoperative complications. Normocephaly as well as normal cephalic indices were observed at latest follow up.

Conclusions

The authors conclude that early treatment of infants with sagittal suture craniosynostosis by using minimally invasive, endoscopy-assisted wide-vertex craniectomies provides excellent results and a significantly lower morbidity rate than traditional calvarial vault reconstructive procedures.

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David F. Jimenez and Constance M. Barone

Patients with Apert syndrome commonly present with ocular proptosis due to bilateral coronal craniosynostosis and midfacial hypoplasia. Severe proptosis can cause visual compromise and damage, which is most commonly treated with bilateral orbital frontal advancement. The authors present the case of a patient who was treated at 8 weeks of age with endoscope-assisted bilateral coronal craniectomies followed by treatment with a custom-made postoperative cranial orthosis. The patient underwent the procedure without any complications. Over the ensuing months, the patient's proptosis corrected, the forehead and orbital rims advanced without the need for an orbital frontal advancement and craniotomies. This approach may provide an alternative treatment modality for these patients.

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David F. Jimenez, Michael J. McGinity and Constance M. Barone

OBJECTIVE

The objective of this study was to present the authors’ 19-year experience treating metopic craniosynostosis by using an endoscopy-assisted technique and postoperative cranial orthotic therapy. The authors also aimed to provide a comprehensive, comparative statistical analysis of minimally invasive surgery (MIS) versus open surgery in reports previously published in the literature (through 2014) regarding only patients with metopic synostosis.

METHODS

A total of 141 patients with single-suture metopic nonsyndromic craniosynostosis sutures were treated between 1998 and 2017 by endoscopically resecting the synostosed bone followed by postoperative custom cranial orthosis use. All data used in the case series were collected prospectively and stored in a secure database. A comprehensive literature review was performed that included all previous case series reporting common surgical performance measures. A statistical comparison of traditional open methods versus MIS techniques was performed with regard to age, length of hospital stay (LOS), surgical time, estimated blood loss (EBL), and transfusion rate.

RESULTS

The mean age at the time of surgery in the current series was 4.1 months. The mean EBL was 33 ml (range 5–250 ml). One patient underwent an intraoperative blood transfusion and 5 underwent postoperative blood transfusion for a total transfusion rate of 4.3%. The mean operating time was 56 minutes. Ninety-eight percent of patients were discharged on the 1st postoperative day. The median size of the removed synostosed bone was 0.6 cm × 10 cm. The primary goal of achieving correction of the forehead deformity was obtained in 94% of the patients. One hundred eight patients presented with hypotelorism (76.6%). Those with a minimum 1-year follow-up achieved 99% correction (n = 97). Six patients younger than 1 year had not achieved correction at the time of follow-up (6%). There were no intra- or postoperative deaths. One patient had a temporary contact dermatitis to the helmet materials and 2 patients developed pseudomeningoceles, which were successfully treated with a lumbar drain and/or spinal tap. No patient required nor underwent a second surgical procedure. Regarding the previously published literature through 2014, the reported EBL in patients who underwent MIS versus traditional open methods was 54.7 ml versus 224 ml, respectively. The reported average age for patients undergoing MIS versus traditional open methods was 3.8 months versus 11.5 months. The average LOS for patients undergoing MIS versus traditional open methods was 1.7 days versus 3.7 days. The average reported surgical time for those undergoing MIS versus traditional open methods was 66.7 minutes versus 223.7 minutes. The transfusion rate for patients undergoing MIS versus traditional open methods was 22% versus 77%. All of the above differences demonstrated statistical significance.

CONCLUSIONS

The authors’ team has safely and effectively performed 141 metopic craniosynostosis corrections over the past 19 years, with excellent outcomes. Literature review comparing metrics such as LOS, EBL, operating time, and transfusion rate demonstrates a statistically significant improvement in all commonly reported measurements. MIS techniques are safe and effective and should be offered to parents and patients as an option at craniofacial centers treating this condition.

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James Tait Goodrich

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David F. Jimenez and Constance M. Barone

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David F. Jimenez, Constance M. Barone, Maria E. McGee, Cathy C. Cartwright and C. Lynette Baker

Object. Endoscopic techniques were introduced 7 years ago for the surgical management of patients with sagittal synostosis. In this study of 139 patients with sagittal synostosis, the authors assessed the efficacy, safety, complications, and outcomes after performing endoscopy-assisted wide-vertex craniectomies with bitemporal and biparietal barrel stave osteotomies.

Methods. The sample population consisted of a total of 99 boys and 40 girls who ranged in age from 0.4 to 9.2 months (mean 3.6 months). Two small incisions were made near the lambda and vertex. Using endoscopic visualization, wide-vertex craniectomies with bilateral temporal and parietal barrel stave osteotomies were performed. Postoperative treatment included custom-made surlyn cranial orthotic devices for cranial reshaping and maintenance.

The mean craniectomy width was 5.4 cm and the length was 10 cm. The overall blood transfusion rate was 9% (two intraoperative and 12 postoperative transfusions). The mean estimated blood loss was 29 ml (range 5–150 ml). The mean preoperative hematocrit was 32%, whereas the postoperative level was 27%. One hundred thirty-two patients were discharged the morning following surgery. The majority of patients did not experience facial swelling, and none suffered postoperative fevers. Anthropometric cephalic index measurements indicated that excellent results were obtained in 87% of the patients (cephalic index > 75); good results in 8.7% (cephalic index 70–75); and poor results in 4.3% (cephalic index > 70). There were no cases of intraoperative death, infection, hemorrhage, or venous sinus injury.

Conclusions. Analysis of the results indicates that use of the aforedescribed procedure in the early treatment of infants with sagittal synostosis provides excellent outcomes and that the morbidity rate is lower than that associated with traditional cranial vault reconstruction. Detailed anthropometric and radiographic analyses demonstrated that with adequate helmet therapy in our patients normocephaly was achieved and maintained without the need for secondary operations.

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David F. Jimenez, Michael J. McGinity and Constance M. Barone

OBJECTIVE

The objective of this study was to present the authors’ 19-year experience treating metopic craniosynostosis by using an endoscopy-assisted technique and postoperative cranial orthotic therapy. The authors also aimed to provide a comprehensive, comparative statistical analysis of minimally invasive surgery (MIS) versus open surgery in reports previously published in the literature (through 2014) regarding only patients with metopic synostosis.

METHODS

A total of 141 patients with single-suture metopic nonsyndromic craniosynostosis sutures were treated between 1998 and 2017 by endoscopically resecting the synostosed bone followed by postoperative custom cranial orthosis use. All data used in the case series were collected prospectively and stored in a secure database. A comprehensive literature review was performed that included all previous case series reporting common surgical performance measures. A statistical comparison of traditional open methods versus MIS techniques was performed with regard to age, length of hospital stay (LOS), surgical time, estimated blood loss (EBL), and transfusion rate.

RESULTS

The mean age at the time of surgery in the current series was 4.1 months. The mean EBL was 33 ml (range 5–250 ml). One patient underwent an intraoperative blood transfusion and 5 underwent postoperative blood transfusion for a total transfusion rate of 4.3%. The mean operating time was 56 minutes. Ninety-eight percent of patients were discharged on the 1st postoperative day. The median size of the removed synostosed bone was 0.6 cm × 10 cm. The primary goal of achieving correction of the forehead deformity was obtained in 94% of the patients. One hundred eight patients presented with hypotelorism (76.6%). Those with a minimum 1-year follow-up achieved 99% correction (n = 97). Six patients younger than 1 year had not achieved correction at the time of follow-up (6%). There were no intra- or postoperative deaths. One patient had a temporary contact dermatitis to the helmet materials and 2 patients developed pseudomeningoceles, which were successfully treated with a lumbar drain and/or spinal tap. No patient required nor underwent a second surgical procedure. Regarding the previously published literature through 2014, the reported EBL in patients who underwent MIS versus traditional open methods was 54.7 ml versus 224 ml, respectively. The reported average age for patients undergoing MIS versus traditional open methods was 3.8 months versus 11.5 months. The average LOS for patients undergoing MIS versus traditional open methods was 1.7 days versus 3.7 days. The average reported surgical time for those undergoing MIS versus traditional open methods was 66.7 minutes versus 223.7 minutes. The transfusion rate for patients undergoing MIS versus traditional open methods was 22% versus 77%. All of the above differences demonstrated statistical significance.

CONCLUSIONS

The authors’ team has safely and effectively performed 141 metopic craniosynostosis corrections over the past 19 years, with excellent outcomes. Literature review comparing metrics such as LOS, EBL, operating time, and transfusion rate demonstrates a statistically significant improvement in all commonly reported measurements. MIS techniques are safe and effective and should be offered to parents and patients as an option at craniofacial centers treating this condition.