Surgical approaches for the correction of metopic synostosis

Premature closure of the metopic suture results in a deformity ranging from a minor variation to a severe cosmetic deformity. The three principal abnormalities comprising metopic synostosis are trigonocephaly secondary to the restriction of growth of both frontal bones, deficient lateral supraorbital rims, and hypotelorism. Seventeen of 18 patients evaluated for metopic synostosis had surgical correction of their anomalies. For a minor degree of prominence at the metopic suture, a bicoronal flap followed by shaping at the suture with a shaping burr was sufficient and yielded favorable cosmetic results. A more extensive procedure for cosmetic resolution of trigonocephaly and hypotelorism was required for those patients with more pronounced deformities. In patients with moderate to severe metopic synostosis, the following procedures were important in achieving excellent cosmetic results: a bicoronal subgaleal flap down to the supraorbital rims with preservation of continuity of pericranium with an intact periorbita; bifrontal craniotomy with complete removal of the metopic suture; dural plication in midline to achieve an immediate aesthetically pleasing contour; removal or remodeling of the supraorbital rims and nasion with replacement of the remodeled frontal bone anteriorly in order to rebuild the orbital rim and release the supraorbital bar from the anterior cranial base; and securement of the bifrontal bones anteriorly and laterally, but not posteriorly, to allow further anterior and lateral displacement of the supralateral orbital margin.