Can we "overcorrect" our way to normal appearance in metopic craniosynostosis? A single-center's 33 year odyssey

To better expand the anterior cranial fossa and account for growth and relapse after traditional fronto-orbital advancement (FOA), an intentional "overcorrection" technique was adopted by our institution in 2012. This study compared long-term clinical and aesthetic outcomes between traditional (T-FOA) and overcorrection (O-FOA) approaches.

A retrospective review was performed of all children who underwent FOA for isolated metopic craniosynostosis from 1987 to 2020. Patients with ≥4 years follow-up were included.

Among the 270 patients who underwent FOA, 166 (61.5%) patients met the inclusion criteria (n=100 (60.2%) T-FOA and n=66 (39.8%) O-FOA). Mean age at surgery was 10.9±6.3 months with follow-up of 9.5±4.1 years. There were 13 (7.8%) surgical complications, and 40 (24.1%) patients underwent at least one secondary surgery, more commonly in the T-FOA cohort (35.0% vs. 7.6%, p<0.001). In the intermediate term, T-FOA patients had higher Whitaker scores (2.2±1.0 vs. 1.5±0.8, p<0.001) and were more likely to have palpable bony irregularities (64.0% vs. 21.2%, p<0.001), visible irregularity (68.0% vs 48.5%, p=0.012), and lateral orbital retrusion (48.0% vs. 15.2%, p<0.001) compared to O-FOA. However, in subgroup analysis of patients ≥10 years old postoperatively (n=85), aesthetic outcomes (Whitaker 2.1±1.0 vs. 2.4±1.0, p=0.167) and revisions (48.6 vs. 26.7%, p=0.122) were comparable between the cohorts.

FOA with overcorrection is a safe and effective approach for improving aesthetic outcomes in the intermediate term. Its association with aesthetic decline over time highlights the importance of long-term follow-up until skeletal maturity. Further research is needed to better understand the underlying causes of relapse.