Endoscopic-Assisted Correction of Metopic Synostosis Barbu Gociman, MD, PhD,* Mouchammed Agko, MD,Þ Ross Blagg, MD,* Jared Garlick, BS,þ John R.W. Kestle, MD, MSc,§ and Faizi Siddiqi, MD* Abstract: Our 6-year experience with correction of metopic syn- ostosis using a minimally invasive endoscopic-assisted technique followed by postoperative cranial vault helmet molding is pre- sented. In addition, a simple, objective method for quantification of the frontal vault contour is described. A total of 16 patients, 13 males and 3 females, with nonsyn- dromic, single-suture synostosis were included in the study. Patient age at operation averaged 2.9 months and the mean weight was 6 kg. The mean operative time was 79 minutes. The estimated blood loss during the procedure was 82.8 mL. Three patients required blood transfusions (18.7%). There were no significant postopera- tive complications. The mean hospitalization was 1.6 days. The average surgical cost, including the helmets, was $12,400, in con- trast to $33,000 charged for the equivalent open procedure. Very good esthetic results, judged by physical examination and photograph comparison, were obtained in all patients. No relapses were noted. Objectively, the outcome of the operative repair was evaluated using laser scanning. For quantification of the distortion and the postoperative level of correction, the metopic angle was defined and used. This angle changed from preoperative value of 104.9 degrees to 111.3 degrees at 3 months (P = 1.59Ej06) and to 114.9 degrees at 1 year postoperatively (P = 2.51Ej09). Due to its promising attributes, minimally invasive strip crani- ectomy emerges as an ideal modality for correction of metopic synostosis. Furthermore, the metopic angle should provide clinicians with an objective measure of the frontal cranial vault deformity and its correction. Key Words: Metopic synostosis, trigonocephaly, metopic angle, endoscopic-assisted, laser data acquisition system (J Craniofac Surg 2013;24: 763Y768) W ith an estimated incidence of 0.4Y1/1000, 1 craniosynostoses represent a common cause of cranial vault deformity. Metopic synostosis accounts for approximately 10% of cases, although recent increase in this incidence has been reported. 2Y4 Its presence is easily detected on physical examination. The premature fusion of the metopic suture leads to changes that phenotypically can vary sig- nificantly. In the mildest forms, the only abnormality present is a subtle midline vertical frontal ridge. The more severe cases present with bilateral retrusion of the frontal bones and the orbital rims that give the characteristic triangular forehead shape known as trigono- cephaly. In addition, the patients present antimongoloid orbital slants, hypotelorism, and a prominent keel-shaped frontal ridge. Over time, it was realized that only a minority of patients have associated increase in intracranial pressure 5 and therefore would benefit from a decompressive craniectomy. It is currently very well established that the goal of the treatment for the majority of patients with single-suture synostosis, including metopic synostosis, is remodeling of the vault to a normal shape to facilitate peer accep- tance and allow easier social integration. 6 Surgical correction of cranial vault deformity secondary to synostosis was first attempted for sagittal synostosis at the end of the nineteenth century. 7 The initial attempts to correct the cranial vault deformities were limited to strip craniectomies. The assumption was that the reshaping would progressively occur secondary to the pressure exerted, on the unrestricted vault, by the rapid brain growth present in the first 2 years of life. 8 Despite some reported successes, this approach did not yield consistently good results 9 leading to the development of more radical procedures. 10Y14 As craniofacial surgeons became comfortable with progressively more extensive procedures, techniques that allowed complete cranial vault remodeling 10Y14 were developed with excellent results. Nevertheless, these procedures are restricted to infants over 6 months old, are more expensive, and require prolonged hospitalization and recovery. 15 The most commonly employed treatment modality currently used for isolated metopic synostosis is an open procedure performed through an anterior bicoronal approach. It consists of orbital bandeau advancement and remodeling and anterior vault repositioning and reshaping. 16 After recently showing that the endoscopically assisted strip craniectomy followed by postoperative helmet molding is a very effective modality for the treatment of sagittal synostosis, we present here the experience at our institution obtained using the same method in the setting of trigonocephaly. 17 METHODS Since 2006, when the first endoscopic-assisted strip crani- ectomy was performed at our university medical center, 141 patients underwent the procedure for single-suture sagittal, metopic, coronal, or lambdoid synostosis. Charts were retrospectively reviewed and 24 patients were found to have been operated on for trigonocephaly. For the first 16 patients, 13 males and 3 females, there was at least 1 year postoperative follow-up available, and these patients were included in the current study. It is this group that all the subsequent analyses were conducted on. ORIGINAL ARTICLE The Journal of Craniofacial Surgery & Volume 24, Number 3, May 2013 763 What Is This Box? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code links to the online version of the article. From the *Division of Plastic Surgery, University of Utah Health Sciences Center, Salt Lake City, Utah; †Division of Plastic Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California; ‡University of Utah Health Sciences Center, Salt Lake City, Utah; and §Division of Pediatric Neurosurgery, Primary Children’s Medical Center, Salt Lake City, Utah. Received September 17, 2012. Accepted for publication December 23, 2012. Address correspondence and reprint requests to Dr. Barbu Gociman, Division of Plastic Surgery, University of Utah Health Sciences Center, 30 North 1900 East, 3B400, Salt Lake City, UT 84132; E-mail: barbu.gociman@hsc.utah.edu The authors report no conflicts of interest. Copyright * 2013 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e31828696a5 Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.