Microscopic minimally invasive approach to nonsyndromic craniosynostosis.

PURPOSE: The purpose of this retrospective study was to present the results of the authors' microscopic minimally invasive approach in the treatment of nonsyndromic craniosynostosis. METHODS: From 2001 to 2007, the authors treated a cohort of 67 infants with nonsyndromic sagittal, unicoronal, bicoronal, and metopic craniosynostosis, either with the microscopic (n = 40) or the open (n = 27) approach. In the microscopic approach, incisions were placed over the premature suture, and using a surgical microscope, the appropriate synostectomy was performed. The open approach used a traditional coronal incision with cranial vault reconstruction. Both groups of patients had postoperative molding helmet therapy. Finally, anthropometric measurements were used to evaluate the treatment results. The measurement used for the patients with sagittal and bicoronal craniosynostoses was the divergence from the norm of the age-adjusted cephalic index. The (FZr-EUl/FZl-EUr) and (FZr-EUr)/(FZl-EUl) were used for the patients with unicoronal craniosynostosis. The divergence from the norm of age-adjusted (FTr-FTl)/(Tr-Tl) was used for the patients with metopic craniosynostosis. (FZr = right frontozygomaticus, EUl = left eurion, FZl = left frontozygomaticus, Eur = right eurion, FTr = right frontotemporale, FTl = left frontotemporale, Tr = tragion, Tl = left tragion). RESULTS: The median surgical times for microscopic and open approaches were 108 and 210 minutes, the volumes of blood loss were 75 and 220 mL, the durations of hospital stay were 2 and 4 days, the numbers of helmet were 2 and 1, and the durations of helmet therapy were 10.5 and 8 weeks, respectively. The analysis of variance for repeated measures showed that there was no statistically significant difference between the 2 groups in any of the craniosynostoses. CONCLUSIONS: The treatment outcomes from the microscopic minimally invasive approach to craniosynostosis are equal to those seen with the open approach. The microscopic approach results in less operative time, blood loss, and hospitalization.

Long-term treatment effectiveness of molding helmet therapy in the correction of posterior deformational plagiocephaly: a five-year follow-up.

OBJECTIVE: To evaluate the long-term effectiveness of helmet therapy in the correction of deformational plagiocephaly and to assess the early occlusal abnormalities seen in these patients. DESIGN: A prospective study with blinded measurements. PATIENTS: Twenty-eight patients with deformational plagiocephaly who were treated with molding helmet therapy with at least 5 years of follow-up. INTERVENTIONS: The average length of molding helmet treatment was 6.2 months. At the time of this follow-up evaluation, the mean interval since completing the molding helmet therapy was 5.6 years. MAIN OUTCOME MEASURES: Anthropometric measurements of cranial asymmetry included cranial vault asymmetry (CVA), orbitotragial depth asymmetry (OTDA), and cranial base asymmetry (CBA). A dental examination was also performed. RESULTS: At the completion of therapy, the most improvement was seen in the measurement of CBA, followed by CVA and OTDA. However, in evaluating the long-term stability of molding treatment, OTDA tended to continue improving after the initial treatment, while CBA and CVA appeared to regress, although none of the changes reached statistically significant levels. In dental measurements, all the dental midline and chin deviations were toward the unaffected side with respect to occipital deformation. CONCLUSION: This study demonstrated that helmet remodeling with the dynamic orthotic cranioplasty band is effective in the correction of cranial asymmetry, with some nonstatistically significant changes in long-term cranial vault symmetry. Dental observations indicated the possibility of occlusal abnormalities that may affect dental, especially orthodontic, diagnosis and treatment planning.

Microscopic approach to craniosynostosis.

The purpose of this study is to describe a minimally invasive approach using a microscope and the subsequent helmet therapy. The authors have treated 14 patients with the microscopic technique between May 2001 and November 2003. In this group of patients, there were 3 females and 11 males with an average age of 10.5 weeks and a range of 4 to 28 weeks. The study included 8 patients with sagittal synostosis and 6 patients with other synostoses. In the latter group, there were 3 patients with metopic, one with unicoronal, one with bicoronal, and one with lambdoidal. The approach used limited incisions over the affected sutures. The craniotomy/craniectomy was completed using a 5-mm burr. Postoperative helmet therapy was begun within 2 weeks after surgery. In patients with sagittal synostosis, a mean of 1.5 helmets for a duration of 11.4 weeks was used. In the other groups of patients with craniosynostosis, a mean of 2.3 helmets for a duration of 13.5 weeks was used. A microscopic variation to the "minimally invasive" approach to craniosynostosis is presented. It provides excellent visualization, illumination, and control of the surgical field. When compared with traditional surgery, it results in shorter hospitalization and operative time and decreased blood loss. The authors note that critical to this approach is the postoperative helmet therapy. Early results are encouraging.

Molding helmet therapy in the treatment of brachycephaly and plagiocephaly.

The purpose of this study was to compare the use of molding helmet therapy in the treatment of positional brachycephaly and posterior positional plagiocephaly. Four hundred twenty-eight children with positional brachycephaly or plagiocephaly were included in this study. In this group of patients, 132 (32%) were treated with positioning alone. Of the 292 (68%) patients who were treated with molding therapy, 64 (21.9%) were treated for positional brachycephaly and 248 (78.1%) were treated for posterior positional plagiocephaly. All children were evaluated by a craniofacial surgeon and a pediatric neurosurgeon. Anthropomorphic measurements were used to assess the efficacy of treatment. Measurements were made before initiation of therapy and at 2-month intervals until the completion of therapy. Results showed that statistically significant improvements (P < 0.01) were seen in all patients treated with molding helmet therapy. Overall, the children with posterior plagiocephaly normalized their head shapes; however, the head shapes of the children with positional brachycephaly did not normalize despite statistically significant improvements in their Cephalic Index. It is concluded that molding helmet therapy is an effective treatment of position-induced head shape abnormalities. Helmet therapy is more effective in children with posterior positional plagiocephaly than in children with positional brachycephaly.

Nonsynostotic scaphocephaly: the so-called sticky sagittal suture.

OBJECT: Scaphocephaly is a common craniofacial abnormality that results from craniosynostosis of the sagittal suture. The authors have treated a group of infants who presented with nonsynostotic scaphocephaly, or a so-called sticky sagittal suture. The purpose of this study was to describe these patients with nonsynostotic scaphocephaly, the natural history of the disease, and its treatment. METHODS: At the University of Texas-Houston Medical School between 1996 and 2002, nine patients presented with nonsynostotic scaphocephaly. When the abnormality in patients was diagnosed prior to 12 months of age, the majority (seven of eight) were successfully managed by molding helmet therapy. The only child in this group in whom this therapy failed to correct the deformity was noted on repeated computerized tomography scanning to have true sagittal synostosis, which required surgical correction. One child with nonsynostotic scaphocephaly, who presented after 1 year of age, required surgical correction followed by postoperative molding helmet therapy. CONCLUSIONS: Patients with nonsynostotic scaphocephaly appear to have sagittal synostosis. If treated early (at < 12 months of age), head shape in these patients can be normalized by molding helmet therapy. Surgery is reserved for older patients (> 12 months of age) or those with sagittal synostosis.

Molding helmet therapy in the management of sagittal synostosis.

The current surgical treatment of sagittal craniosynostosis often fails to produce a normal cephalic index; however, recent reports of early endoscopic suture release and postoperative helmet therapy promise improved cranial symmetry. The role of helmet therapy is critical in this approach, but there are few reports on the use of helmet therapy after craniosynostosis surgery. The authors present a retrospective review comparing the results of surgery alone versus surgery and postoperative banding in treating children diagnosed with sagittal synostosis. Cephalic index (CI) measurements and the divergence of the CI from the norm (DFN) were used to compare the banded and the non-banded groups. Included in the study were 21 children with sagittal craniosynostosis of whom 6 were treated with surgery alone and 15 were treated with surgery and postoperative banding. Preoperatively, both groups were significantly different from the norm (non-banded, P < 0.05; banded, P < 0.01), while postoperatively they were not significantly different from the norm. Statistically significant changes were present in the CIs of the banded group in the preoperative-follow-up interval (P < 0.01), while no significant changes occurred in the non-banded group during this same interval. Statistically significant changes in the DFN occurred in the preoperative-postoperative and preoperative-follow-up intervals of the banded group; however, these changes were not significant in the non-banded group during the same intervals. Correction toward a normal CI was seen in the banded group throughout the course of treatment, while this trend was not present in the non-banded group. Therefore, molding helmet therapy maintains the operative correction obtained and promotes more normal cranial growth patterns.