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Introduction: In an effort to maximize benefit and minimize morbidity when performing fronto-orbital distraction osteogenesis (FODO) for unilateral coronal synostosis (UCS), we have transitioned to an endoscopic-assisted approach (“endo-FODO”). This study compares photogrammetric outcomes of patients who underwent FODO via an endoscopic-assisted versus open approach. Methods: We retrospectively reviewed patients treated for UCS from 2013 to 2023. Photogrammetric outcomes at one to three years postoperatively were compared between patients who underwent endo-FODO and age- and sex-matched controls who underwent open FODO. Differences between pre- and postoperative periorbital symmetry ratios, canthal tilt symmetry, and orbital dystopia angle (ODA) were calculated. Results: Twenty patients (ten per group) underwent surgery at a mean age of 6.1 ± 1.8 and 5.4 ± 1.1 months (p = 0.426) and were photographed at 1.6 ± 0.9 and 1.8 ± 0.9 years (p = 0.597) postoperatively in the endo-FODO and open FODO groups, respectively. Patients who underwent endo-FODO demonstrated significant improvements in margin-reflex distance 1 (MRD1) symmetry ratio (p = 0.004), palpebral height symmetry ratio (p = 0.004), canthal tilt symmetry (p = 0.020), and ODA (p = 0.009). Patients who underwent open FODO likewise demonstrated significant improvements in MRD1 symmetry ratio (p = 0.004), palpebral height symmetry ratio (p = 0.033), and ODA (p = 0.004). All postoperative measurements as well as degrees of improvement were similar between groups (p > 0.05). Conclusions: Endo- and open FODO were associated with significant and comparable improvements in soft tissue periorbital symmetry and orbital dystopia at nearly two years postoperatively. While continued follow-up until cranial maturity is needed to assess the durability of aesthetic results, these data support a minimally invasive, endoscopic alternative to fronto-orbital distraction. [ABSTRACT FROM AUTHOR]

Background: The aesthetic goals of midface surgery in Apert syndrome are to correct the multi-planar midface deficiency and normalize facial ratios. This study characterizes the long-term photogrammetric outcomes of midface advancement in Apert syndrome. Methods: Patients with Apert syndrome who underwent midface distraction from 2000 to 2023 were retrospectively reviewed. Soft tissue measurements were applied to preoperative (T0), short-term postoperative (T1), and long-term postoperative (T2) photographs. Long-term changes were compared between subcranial and transcranial procedures, segmental and non-segmental osteotomies, and individual techniques. Frontal facial dimensions at time T2 were compared to age- and sex-matched normal controls from the NIMH-ChEFS face database. Results: Twenty patients had postoperative follow-up of T1 = 0.6 ± 0.4 and T2 = 4.7 ± 1.1 years and were compared to 40 normal controls. From time T0 to T2, middle facial third height increased (26.1 ± 3.0% to 27.8 ± 2.6%, p = 0.026), canthal tilt improved (− 7.6° ± 3.7° to − 3.9° ± 4.4°, p < 0.001), and facial convexity increased (182.9° ± 6.2° to 167.9° ± 8.6°, p < 0.001). From time T1 to T2, facial convexity flattened (159.4° ± 10.1° to 167.9° ± 8.6°, p < 0.001). Compared to controls, patients at time T2 had shorter middle facial third height (27.8 ± 2.6% vs. 32.0 ± 1.9%, p < 0.001) and reverse canthal tilt (− 3.9° ± 4.4° vs. 5.4° ± 2.6°, p < 0.001). Conclusions: A tailored treatment approach to the Apert midface yields varying degrees of resolution of central midfacial shortening, canthal tilt, and facial concavity at 5 years postoperatively. A slight reduction in facial convexity over time, likely reflecting pseudorelapse in the setting of sagittal overcorrection, should be anticipated. Greater utilization of segmental osteotomies may bring facial third ratios and canthal tilt closer to normal morphometric values. [ABSTRACT FROM AUTHOR]

Purpose: We examined differences in long-term morphometric outcomes of spring-mediated cranioplasty (SMC) for various forms of isolated nonsyndromic sagittal craniosynostosis. Methods: A retrospective review was performed of children who underwent SMC from 2011 to 2020 at the Children's Hospital of Philadelphia. Cephalic indices (CI), Whitaker grades, parietal bone thickness, and degree of suture fusion were assessed. Frontal bossing and vertex-nasion-opisthocranion (VNO) angles were compared to a normal control group. Results: Fifty-four subjects underwent surgery at age 3.6 ± 1.0 months with follow-up of 6.3 ± 1.8 years. Mean CI was 75.2 ± 4.1 at 5.9 ± 2.0 years postoperatively. Mean CI were 75.8 ± 4.1 (n = 32), 76.4 ± 4.0 (n = 22), and 77.1 ± 4.8 (n = 11) at 5, 7, and 9+ years postoperatively, respectively. Three (5.6%) required reoperation for persistent scaphocephalic cranial deformity. Fifty-one (94.4%) were Whitaker Grade I. On physical examination, 12 (22.2%) demonstrated craniofacial abnormalities. At long-term follow-up, there were no differences in frontal bossing angle (102.7 ± 5.2 degrees versus 100.7 ± 5.6 degrees, p =.052) and VNO angle (44.9 ± 3.3 degrees versus 43.9 ± 2.2 degrees, p =.063) between study and control groups. Younger age at surgery predicted a lower Whitaker grade, more normalized VNO angle, and greater change in CI during active expansion. Increased percentage fused of the posterior sagittal suture predicted a higher Whitaker grade, while decreased anterior fusion was associated with frontal bossing and temporal hollowing. Conclusions: Overall, children undergoing spring-mediated cranioplasty for sagittal craniosynostosis demonstrated maintenance of CI, favorable cosmetic outcomes, and a low reoperation rate at mid-term follow-up. Early intervention is associated with improved aesthetic outcomes, and regional fusion patterns may influence long-term craniofacial dysmorphology. [ABSTRACT FROM AUTHOR]

Background: Fronto-orbital advancement and remodeling (FOAR) is among the most common surgical approaches for unicoronal craniosynostosis (UCS), although some data demonstrate failure to achieve long-term aesthetic normalcy, leading some to seek alternative treatment paradigms such as fronto-orbital distraction osteogenesis (FODO). This study compares long-term aesthetic outcomes of patients with UCS treated with FOAR and FODO. Methods: Twenty patients (four males) with non-syndromic UCS presenting to our institution and undergoing distraction were compared to a matched cohort of 20 patients (six males) undergoing FOAR. Clinical photographs and ImageJ were used to quantify periorbital anatomy including palpebral fissures, pupil-to-brow distance (PTB), and margin-reflex distance (MRD1) in pixels. Whitaker classification was blindly assigned by craniofacial surgeons. Results: Photogrammetric analysis and Mann–Whitney U tests demonstrated significantly improved postoperative symmetry in distraction patients for palpebral width (p = 0.020), MRD1 (p = 0.045), and canthal tilt (p = 0.010). Average Whitaker classification scores between FOAR (1.94) and distraction (1.79) cohorts were similar (p = 0.374). Conclusions: UCS patients demonstrated significant postoperative improvements in periorbital symmetry, with distraction patients demonstrating superior results in palpebral width and canthal tilt. FOAR and FODO patients achieved similar Whitaker classification scores. These cohorts will be followed until craniofacial maturity prior to making any definitive conclusions. [ABSTRACT FROM AUTHOR]

Background: Variables interacting to predict outcomes following spring-mediated cranioplasty (SMC) for non-syndromic craniosynostosis, including spring parameters and calvarial thickness, are poorly understood. This study assessed interactions between spring parameters and calvarial thickness to predict changes in cephalic index (CI) following SMC. Methods: Patients undergoing SMC for non-syndromic sagittal craniosynostosis at our institution between 2014 and 2021 were included. Calvarial thickness was determined from patient preoperative CTs using Materalise Mimics at 27 points in relation to the sagittal suture. Linear mixed effects models were used to determine interactions between anterior, middle, and posterior calvarial thickness with spring force and length. Results: Sixty-nine patients undergoing surgery at mean age 3.7 months were included in this study. Stronger posterior spring force interacted with thinner posterior calvarial thickness to predict greater changes in CI at 3 months postoperatively (p = 0.022). When evaluating spring force and calvarial thickness set distances from the sagittal suture, stronger posterior spring force interacted with thinner posterior calvarial thickness 5 mm (p = 0.043) and 10 mm (p = 0.036) from the sagittal suture to predict changes in CI. Interactions between spring parameters and calvarial thickness in the anterior and middle positions did not significantly predict changes in CI. Conclusions: Stronger posterior spring force interacted with thinner posterior calvaria to predict greater changes in CI 3 months following SMC for non-syndromic sagittal craniosynostosis. These results suggest dynamic interactions between several variables may impact outcomes following SMC. [ABSTRACT FROM AUTHOR]

Introduction: This study assesses the diagnostic reliability of a novel photogrammetric measurement to distinguish sagittal craniosynostosis (SS) from control and false positive cases (SNS). Methods: Head CTs from 2014–2020 were reviewed for patients with sagittal synostosis (SS, n = 177), presumed sagittal synostosis with normal imaging (SNS, n = 30), and controls (n = 100). Using preoperative clinical photographs and CTs, a measurement reflecting the anterior–posterior location of the vertex was measured using an angle drawn between the cranial vertex, nasion, and opisthocranion (VNO) in profile view, with the head in a neutral position. Results: Mean age at pre-operative head CT was 9.5 months for the SS cohort, 4.2 months for the SNS cohort, and 8.9 months for controls (p =.327). Mean age at pre-operative clinical photograph was 9.5 months for the SS cohort and 4.2 months for the SNS cohort (p =.149). Pearson correlations revealed no significant association between age and VNO angle. The average VNO angle measured on clinical photographs was 54.7° ± 3.8° for the SS group, 43.1° ± 2.2° for the SNS group, and 41.1° ± 3.7° for controls (p <.001). Receiver operating characteristic (ROC) analysis yielded a cut-off of ≥ 50° to identify SS. Diagnostic sensitivity and specificity were 96.6% and 99.2%, respectively. Three-rater analysis yielded an average ICC of 0.742 (p =.004). Conclusions: Measurement of the VNO angle is a reliable screening tool to diagnose sagittal craniosynostosis, with an angle of 50° or more suggesting suture synostosis. This method relies on the relationship between the anterior displacement of the vertex and occipital bulleting to approach the diagnostic accuracy of CT imaging. [ABSTRACT FROM AUTHOR]