The Directive Growth Approach for Nonsyndromic, Unicoronal Craniosynostosis: Patient and Clinical Outcomes

Abstract

Deformities of the cranium in patients with nonsyndromic single-suture synostosis occur because of growth restriction at fused sutures and growth over compensation at normal sutures. Traditional surgery includes ostectomies of the synostotic suture to release these restricted areas and osteotomies to enable immediate cranial remodeling. In the process of reshaping the cranium, traditional approaches usually involve obliteration of both the normal functioning suture and the pathologic suture. The directive growth approach (DGA) is a new, simpler, more natural way to repair deformities caused by single-suture cranial synostosis. The DGA works by reversing the original deforming forces by temporarily restricting growth in areas of over compensation and forcing growth in areas of previous synostotic restriction. Most importantly, it preserves a normal functioning suture to allow for improved future cranial growth. Eighteen consecutive nonsyndromic patients with unilateral coronal synostosis were used to illustrate the efficacy of the DGA. Ten patients who underwent DGA treatment were compared with a control group of 8 patients treated with traditional frontal orbital advancement. Postoperative three-dimensional computed tomography (CT) comparison measurements were taken, including bilateral vertical and transverse orbital dimensions, lateral orbital rim to external auditory canal, and forehead measurements from the superior aspect of the orbital rim to the pituitary fossa. The traditional treatment group showed absence of the coronal sutures bilaterally on long-term CT scans. The DGA group showed normal coronal sutures on the unaffected sides. Postoperative CT measurements showed no statistical difference between the 2 techniques (P < 0.05).

Cranial growth in isolated sagittal craniosynostosis compared with normal growth in the first 6 months of age

“…; Persing, ; Mann et al. ). An increased understanding of the shape changes and suture closure patterns that occur in SCS compared with normal children in the first 6 months of age would provide valuable information in pursuit of this goal.…”

“…The increased duration of anesthesia and the larger volume of blood transfusion during any type of craniofacial surgery have been associated with potentially poor neurodevelopmental outcomes in patients later in life (Tunc ßbilek et al 2005;Stricker & Fiadjoe, 2014;Bonfield et al 2016). Since these surgeries are typically performed in the first 6 months of age, it is important to identify the optimal time to intervene for best surgical outcome while having the least detrimental impact to the patient (Yarbrough et al 2014;Sivakumar et al 2015;Bergquist et al 2016;Persing, 2016;Mann et al 2017). An increased understanding of the shape changes and suture closure patterns that occur in SCS compared with normal children in the first 6 months of age would provide valuable information in pursuit of this goal.…”

Comparison of Head Shape Outcomes in Metopic Synostosis Using Limited Strip Craniectomy and Open Vault Reconstruction Techniques

“…A potential limitation of the LISC technique is compliance with helmet therapy (Kung et al, 2016; Mann et al, 2017), which has been described as a major factor for a successful LISC (Barone and Jimenez, 1999; Jimenez et al, 2018). Some surgeons challenge the LISC technique due to the potential need for subsequent OCVR repair if treatment fails.…”

“…Surgeons may criticize LISC by describing anecdotal treatment failures that have come to them for second opinions (Kung et al, 2016). Others might be negatively influenced by the length of time LISC takes to achieve normalization of shape compared to OCVR, or the need to wear an orthotic helmet (Kung et al, 2016; Mann et al, 2017; Jimenez et al, 2018). Proponents of LISC may prefer the relative simplicity of the procedure; with lower blood loss, shorter operative times, less scarring, and their belief that long-term shape outcomes are equivalent or even superior (Shah et al, 2011; Gociman et al, 2013; Le et al, 2014; Nguyen et al, 2015; Han et al, 2016; Goyal et al, 2018; Jimenez et al, 2018; Ha et al, 2020).…”