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Nonsyndromic Unicoronal Craniosynostosis: Analysis of Long-Term Aesthetic Outcomes
Christopher L. Kalmar, MD MBA, Laura S. Humphries, MD, Carrie E. Zimmerman, BS, Giap H. Vu, BA, Jordan W. Swanson, MD, Scott P. Bartlett, MD, Jesse A. Taylor, MD.
Children's Hospital of Philadelphia, Philadelphia, PA, USA.

BACKGROUND: Although fronto-orbital advancement and cranial vault remodeling mitigate risk of intracranial pressure, it has been demonstrated that these techniques may lead to worsening aesthetic outcomes as patients mature with age. The purpose of this study was to evaluate long-term aesthetic outcomes in patients with isolated unilateral coronal synostosis utilizing contemporary reconstructive techniques.
METHODS: Retrospective review was performed on patients with isolated unicoronal synostosis since the adoption of our contemporary standardized reconstructive techniques implemented in 2004, namely overcorrection in the anteroposterior and lateral dimensions, supraorbital strut grafts, temporal bandeau reshaping, temporalis muscle repositioning, and particulate bone grafting. Patient demographics, preoperative indications, and postoperative aesthetic outcomes were compared using appropriate statistics.
RESULTS: Since the adoption of contemporary reconstructive techniques fifteen years ago, 63 patients underwent surgical correction for unilateral craniosynostosis, of which 26 patients met inclusion criteria having at least five years of follow-up imaging and without interim cranioplasty. Long-term aeshestic outcomes were classified as 15.4% (n=4) Whitaker I, 76.9% (n=20) Whitaker II, 7.7% (n=2) Whitaker III, and 0% (n=0 of 26) Whitaker IV at most recent follow up. There were 61.5% (n=16) with supraorbital retrusion, and 26.9% (n=7) patients with temporal hollowing, and 15.4% (n=4) with neither. Previously, it was demonstrated with historical techniques that patients with nasal root deviation (p=.011, OR 4.4) and occipital bossing (p=.049, OR 2.6) were more likely to have Whitaker III/IV outcomes; however, utilizing contemporary techniques, nasal root deviation (p=1.00) and occipital bossing (p=1.00) are no longer implicated in developing Whitaker III/IV outcomes. Utilizing contemporary techniques, implementation of resorbable hardware was significantly protective of developing supraorbital retrusion (p=.037, OR 0.1). Follow up of 6 years or more (p=.004, OR 15), 7 years or more (p=.004, OR 15), 8 years or more (p=.011, OR 10.5), and 9 years or more (p=.040, OR 8.8) demonstrated increased development of temporal hollowing. Interestingly, utilizing contemporary techniques, extended follow-up through ten years did not increase risk of supraorbital retrusion (p all >.508).
CONCLUSIONS: Utilization of contemporary techniques for unicoronal synostosis, such as overcorrection and temporalis muscle repositioning, may mitigate occurrence of Whitaker III/IV outcomes as children mature with age. There is no longer an increased risk of supraorbital retrusion with advanced follow up through ten years. Temporal hollowing continues to manifest as children grow older, and further research is needed to elucidate surgical techniques that independently or in combination may help mitigate recurrence of this asymmetry with older age.


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