Morphometric Outcomes of Late Presentation Nonsyndromic Sagittal Synostosis following Open Cranial Vault Reconstruction

Abstract

Background:

Sagittal craniosynostosis (SS) occasionally presents in a delayed manner. This study aims to quantify the change in cranial morphometrics for patients with late presentation SS (defined as cranial vault expansion after 1 y of age) at presentation, immediately postoperatively, and at 2-year follow-up.

Methods:

A retrospective chart review was performed of patients with a diagnosis of SS who underwent open cranial vault reconstruction at older than 1 year of age. Computed tomography scans were matched with controls. Vector analysis was performed to model the effect of open cranial vault reconstruction. Subgroup analyses were performed to determine if specific approach, or age at time of surgery resulted in an improved postoperative outcome.

Results:

Thirty-two patients met inclusion criteria. Craniomorphometric analysis demonstrated significant improvement in head shape which was maintained at 2 years postoperatively compared to preoperative scans. Vector analysis demonstrated an improvement in frontal morphology that is sustained at 2 years postoperatively with no significant difference relative to controls when examined from multiple vectors. Subgroup analyses demonstrated that specific surgical approach did affect the 2-year postoperative head shape, whereas older age at time of surgery (≥18 mo) did not consistently diminish the postoperative outcome.

Conclusions:

Open cranial vault reconstruction performed for late presentation SS is associated with improvement in head shape at 2 years postoperatively.

Takeaways

Question: Does open cranial vault expansion improve head shape in late-presenting (≥1 y) nonsyndromic sagittal craniosynostosis?

Findings: Open cranial vault expansion resulted in significant and sustained improvement in cranial morphology at 2 years, with normalization of frontal shape.

Meaning: Open cranial vault expansion is an effective treatment for late-presenting sagittal craniosynostosis, achieving durable improvement in head shape.

INTRODUCTION

Sagittal craniosynostosis (SS) is the most common form of craniosynostosis. Early surgical intervention (<1 y of age) is recommended to reduce the risk of elevated intracranial pressure and associated risk of neurological sequelae. The secondary surgical goal is normalization of head shape. Most cases are diagnosed at younger than 1 year of age. At our center, endoscopic strip craniectomy and open cranial vault expansion (CVE) are offered at less than 4 months and between 6 and 9 months, respectively. Regarding CVE, some argue that there is a recapitulation of the initial head shape abnormality over time and that an immediate postoperative correction that results in slight brachycephaly should be sought.¹

Occasionally, patients with SS present after 1 year of age, which may be attributable to a missed diagnosis, or a milder phenotype.² In the setting of delayed intervention, defined hereafter as surgery performed at older than 1 year of age (late presentation SS [LPSS]), the calvaria is thicker and less malleable, with less propensity for regeneration of cranial defects. Although there are theoretical risks of less favorable surgical outcomes following open CVE in children presenting with LPSS, there are no detailed craniomorphometric studies supporting this hypothesis.^3,4 Optimal treatment for delayed presentation scaphocephalic patients is widely debated.

Our purpose was to perform cross-sectional analysis of skull morphology before any surgical intervention in children with LPSS and to quantify the change in three-dimensional cranial morphometrics for patients with LPSS at presentation, immediately postoperatively, and at 2-year follow-up. To optimize postoperative outcomes following delayed presentation, it is crucial to understand which morphometrics are corrected and remain stable following open CVE in LPSS. Several key questions come to mind. After open remodeling in the delayed setting, is the head shape maintained postoperatively? Does the skull grow normally or does growth remain impaired despite open reconstruction? Does the associated frontal bossing need to be directly addressed at the time of this later presentation, or does it improve or worsen over time without anterior vault reconstruction?

METHODS

Cohort Selection

An institutional review board–approved retrospective study of infants treated for SS at a tertiary referral hospital from 2003 to 2023 was performed. Inclusion criteria were (1) diagnosis of SS from clinical and computed tomographic (CT) examination, and (2) open cranial vault reconstruction performed at older than 1 year of age. Exclusion criteria were patients with a syndromic diagnosis, inadequate quality imaging, or diagnosis of multi-suture craniosynostosis. Age-matched controls were derived from an institutional database without abnormal CT findings.

Surgical Approach

Echoing the study by Weinzweig et al,⁵ the surgical approach was chosen by the senior surgeon to target the specific phenotype present. Patients underwent one of the following procedures to address the specific craniofacial differences present: middle and posterior vault expansion (MPVE), MPVE with frontal barrelstaves (MPVE+FS), anterior and middle vault expansion (AMVE) which included fronto-orbital advancement or AMVE with supraorbital bandeau or pterional craniectomy dependent on whether the radiographic deformity was predominantly anterior or posterior. (Fig. 1). (See figure, Supplemental Digital Content 1, which displays the representative 3-dimensional reconstruction of operative techniques demonstrating approach to the posterior cranial vault, https://links.lww.com/PRSGO/F164.) For patients with severe frontal bossing and bitemporal constriction, frontal remodeling was performed with frontal barrel staves in younger patients, but direct remodeling was favored in older patients.

Fig. 1.

3D reconstruction of operative techniques. MPVE with (A) modified pi or (B) geometric expansion, MPVE + FS with (C) modified pi or (D) geometric expansion, AMVE with (E) supraorbital bandeau or (F) fronto-orbital advancement.

Regarding decision for approach to the middle and posterior cranial vault, the bone thickness, and thus malleability, is assessed intraoperatively. To do this, neurosurgery first performs the parasagittal osteotomies which allow determination of the thickness and malleability of the bone. If the bone is thick and, thus, not malleable, the parietal and occipital cuts are marked for geometric expansion. If the bone is malleable, the markings for a modified pi CVE are made. To avoid critical cranial defects, we minimize the size of these defects with geometric expansion and use particulate and split calvarial bone grafts for any defect created by the expansion. CVE is offered until age 2. After 2 years of age, symptoms of elevated intracranial pressure (headache, papilledema, and/or intracranial pressure on monitoring) determine the indication for CVE.

Clinical Variables

Clinical, operative, and postoperative variables were recorded by chart review. Clinical outcomes included estimated blood loss (in milliliters), duration of hospital stay (days), and postoperative complications.

Radiological Variables

CT scans were reconstructed in 3D using bone window in 3D Slicer.⁶ Craniofacial landmarks were annotated, and standardized measures of shape were calculated using custom software developed from open-source image analysis libraries (ITK and VTK).⁷ Study variables included linear measurements (cranial length [CL], width, height and bi-pterional distance), angles (frontal bossing angle and occipital incline angle), indices (CI and turricephalic index), and volumes (anterior, middle, posterior, and total vault volumes).^8–11

Vector analysis was performed at the axial plane at glabella-opisthocranion, coronal planes at pterion, sella, opisthion and inion, and sagittal planes at sella and zygomaticofrontal sutures. Average vector plots were plotted for both SS and control groups at three timepoints, and vector lengths were calculated at significant locations as previously described.^10,12,13

Statistical Analysis

At each timepoint (preoperative, postoperative, and 2-y postoperative) and for each measurement, the LPSS cohort was compared to controls using paired t test. Furthermore, to measure the effect of surgery and growth, each measurement was compared across three timepoints for the LPSS cohort using a paired Wilcoxon rank sum test. Significance was set at a P value less than < 0.05. Analysis was conducted in R.¹⁴

RESULTS

Thirty-two patients met inclusion criteria. Average age at surgery was 20 months (range 13–60 mo). Most patients were White (78%) (Table 1). All patients were referred to the craniofacial center due to abnormal head shape, but subsets also had headache (n = 3, 9%), developmental delay (n = 2, 6%), or papilledema (n = 2, 6%). Patients underwent targeted CVE by 6 different approaches to address their head shape phenotype (2 variations of MPVE, 2 variations of MPVE+FS, and 2 variations of AMVE). Specifically, patients most commonly underwent MPVE (n = 16, modified pi procedure [n = 14] and geometric expansion [n = 2]) with further subsets undergoing MPVE+FS (n = 8; for which geometric expansion [n = 4], modified pi [n = 4]) and AMVE (n = 8). The AMVE cohort can be broken down into AMVE (n = 4), AMVE + supraorbital bandeau (n = 2), fronto-orbital advancement (n = 2). MPVE alone is the procedure of choice for those presenting with sagittal craniosynostosis, with geometric expansion favored over a modified pi in cases where the bone was thicker on preoperative CT, with less propensity to contour the bone effectively. For patients with marked frontal bossing, frontal barrel staves were incorporated together with MPVE. Finally, for patients with severe anterior vault changes (frontal bossing and bitemporal constriction), AMVE was chosen. Patients were followed up for a mean of 55 months postoperatively, and 3 patients had significant postoperative cranial defects noted at 2-year postoperative CT for which cranioplasty was recommended.

Table 1.

Demographics and Surgical Variables

	Sagittal	Control Preoperative	Control Postoperative	Control Late Postoperative
Race	32	30	32	23
White	25 (78%)	21 (70%)	24 (75%)	17 (74%)
Asian	2 (6%)	2 (7%)	1 (3%)	2 (9%)
Black or African American	1 (3%)	0 (0%)	1 (3%)	1 (4%)
American Indian or Alaska Native	2 (6%)	0 (0%)	0 (0%)	0 (0%)
Native Hawaiian and other Pacific Islander	0 (0%)	1 (3%)	0 (0%)	0 (0%)
Other	2 (6%)	6 (20%)	5 (16%)	2 (9%)
Patient refused	0 (0%)	0 (0%)	1 (3%)	1 (4%)
Ethnicity
Hispanic	6 (18%)	7 (23%)	6 (18%)	3 (13%)
Non-Hispanic	26 (82%)	22 (74%)	25 (78%)	19 (83%)
Patient refused	0 (0%)	1 (3%)	1 (3%)	1 (4%)
Sex
Female	10 (31%)	9 (30%)	10 (31%)	7 (30%)
Male	22 (69%)	21 (70%)	22 (69%)	16 (70%)
Age, mo, mean ± SD (range)
Age at Surgery	20.0 ± 10.7	—	—	—
Preoperative CT age	18.1 ± 11.3	18.2 ± 11.3	—	—
Postoperative CT age	20.0 ± 10.7	—	20.1 ± 10.7	-
2-y CT age	49.3 ± 15.6	—	—	46.4 ± 8.1
Surgical approach
MPVE	16 (50%)	—	—	—
MPVE + FS	8 (25%)	—	—	—
AMVE	8 (25%)	—	—	—
Perioperative variables
Estimated blood loss (mL)	352 ± 174	—	—	—
Length of stay (nights)	3.5 ± 0.9	—	—	—

CEPHALIC LINEAR MEASUREMENTS

Preoperatively, the CI of the LPSS was significantly lower than the age-matched controls. (See figure, Supplemental Digital Content 2, which displays the anthropometric measurements [mean ± standard error] of patients with sagittal synostosis and age-matched normal controls preoperatively, immediately postoperatively, and 2 years postoperatively, https://links.lww.com/PRSGO/F165.) CI increased significantly in LPSS immediately following CVE and was maintained at 2 years postoperatively. Anthropometric analysis demonstrated that although CL was significantly reduced in the immediate postoperative LPSS cohort relative to preoperative measurement, this was not sustained at 2 years (Supplemental Digital Content 2, https://links.lww.com/PRSGO/F165). However, cranial width and height both increased significantly relative to the preoperative measurements immediately post CVE and at 2 years postoperatively (Supplemental Digital Content 2, https://links.lww.com/PRSGO/F165).

SAGITTAL VECTOR ANALYSIS

On mid-sagittal analysis through the sella, we observed the characteristic scaphocephalic head shape in the LPSS group. At 2 years postoperatively, we observed an improvement in the vector length in the anterior and middle cranium with no significant differences in LPSS relative to age-matched controls. However, we noted a persistently increased posterior CL immediately post CVE, which continued to be present at 2 years postoperatively and which significantly increased relative to age-matched controls (Fig. 2A). (See figure, Supplemental Digital Content 3, which displays the vector lengths [mean ± standard error] of patients with sagittal synostosis and age-matched normal controls preoperatively, immediately postoperatively, and 2 years postoperatively, https://links.lww.com/PRSGO/F166.)

Fig. 2.

Preoperative, immediate postoperative, and 2-year postoperative vector plots for LPSS and relative age-matched controls. Preoperative images shown on the left, immediate postoperative images shown in the middle, and 2-year postoperative images shown on the right. A, Mid-sagittal plane and parasagittal plane. B, Coronal at opisthion. C, Axial.

CORONAL VECTOR ANALYSIS

At the pterion, the coronal plane vectors were significantly reduced at 30 degrees and significantly longer at 90 degrees relative to the control group, demonstrating the presence of frontal bossing and narrow head shape. Immediately postoperatively, CVE resulted in significant improvement at 30 degrees from the sella relative to the preoperative scan. This expansion was maintained at 2 years postoperatively and was not significantly different to age-matched controls (Supplemental Digital Content 3, https://links.lww.com/PRSGO/F166). (See figure, Supplemental Digital Content 4, which displays the vector graphs. A, Coronal at sella. B, Coronal at pterion. C, Axial at superior orbit, parallel to sella-nasion plane, https://links.lww.com/PRSGO/F167.) At the sella, the coronal plane vector lengths at 0, 30, and 60 degrees to the sella were significantly lower than control preoperatively, whereas the vector at 90 degrees was longer relative to control. At the opisthion, there was no significant difference at 0 and 90 degrees between the LPSS and control groups at baseline, but significantly shorter vector lengths at 30/60 degrees, which improved immediately post CVE. However, at 2 years postoperatively, there was a significant difference at 30/60 degrees between LPSS and controls, representing a postoperative regression of head shape morphology (Fig. 2B; Supplemental Digital Content 3, https://links.lww.com/PRSGO/F166).

AXIAL VECTOR ANALYSIS

Axial vector analysis demonstrated that the preoperative and postoperative head shapes were markedly different. Here, in the preoperative cohort, the vector lengths were relatively longer in the anterior and posterior cranial vault (at 0, 30, and 180 degrees, respectively), but significantly narrower at 60, 90, and 120 degrees. Immediately following CVE, there was significant improvement in transverse expansion/width, but the vector lengths remained significantly longer relative to age-matched controls in the anterior and posterior cranium. Interestingly, however, the anterior cranial vector lengths (0 and 30 degrees) improved at the 2-year postoperative CT with no significant difference seen relative to control at this timepoint (Fig. 2C, Supplemental Digital Content 3 and 4, https://links.lww.com/PRSGO/F166; https://links.lww.com/PRSGO/F167). The posterior fossa length significantly improved relative to baseline preoperative head shape but not relative to control at 2 years postoperatively (Fig. 2C, Supplemental Digital Content 3, https://links.lww.com/PRSGO/F166). This pattern was also seen axially at the superior orbit, parallel to the sella-nasion plane (Supplemental Digital Content 4, https://links.lww.com/PRSGO/F167).

In summary, our pertinent findings of postoperative outcomes following open CVE for LPSS reveal (1) an improvement in frontal morphology that is sustained at 2 years postoperatively with no significant difference relative to age-matched controls when examined from axial, and sagittal vectors; (2) increased transverse width through the anterior and middle vault relative to preoperative baseline CT imaging, which, however, remains significantly less relative to age-matched controls; and (3) increased posterior CL relative to age-matched controls, which is most marked in the mid-sagittal plane.

SUBGROUP: TECHNIQUE

To determine if a specific approach was associated with improved postoperative outcomes, we performed a subgroup analysis of MPVE (n = 8), MPVE+FS (n = 9), and AMVE (n = 5). On vector analysis, reflective of the deformity targeted approach, the patients who underwent MPVE alone had less severe morphology in comparison to patients undergoing MPVE+FS or AMVE, which is also reflected in their respective cranial indices (Figs. 3–5 left panels). (See figure, Supplemental Digital Content 5, which displays the demographics per technique, https://links.lww.com/PRSGO/F168.) (See figure, Supplemental Digital Content 6, which displays the technique subgroup morphometrics: anthropometric measurements [mean ± standard error] of patients with sagittal synostosis and age-matched normal controls preoperatively, immediately postoperatively, and 2 years postoperatively, https://links.lww.com/PRSGO/F169.) (See figure, Supplemental Digital Content 7, which displays the technique subgroup vector lengths [top to bottom: MPVE, MPVE + FS, and AMVE], https://links.lww.com/PRSGO/F170.)

Fig. 3.

Preoperative, immediate postoperative, and 2-year postoperative sagittal vector plots for LPSS stratified per procedure. Preoperative images shown on the left, immediate postoperative images shown in the middle, and 2-year postoperative images shown on the right. A, MPVE. B, MPVE+FS. C, AMVE.

Fig. 5.

Preoperative, immediate postoperative, and 2-year postoperative axial vector plots for LPSS stratified per procedure. Preoperative images shown on the left, immediate postoperative images shown in the middle, 2-year postoperative images shown on the right. A, MPVE. B, MPVE+FS. C, AMVE.

Sagittal analysis revealed persistent improvement of head shape at 2 years postoperatively in all cohorts. In the MPVE cohort, there was less improvement seen at 45 degrees to sella when compared to MPVE+FS and AMVE cohorts in the mid-sagittal plane (Fig. 3, Supplemental Digital Content 7, https://links.lww.com/PRSGO/F170). In all cohorts, there was a persistently elevated vector length posteriorly at 165 degrees to sella relative to controls. At the level of the ZF suture, MPVE+FS and MPVE patients continued to have significantly reduced vector length at 120 degrees from sella relative to age matched controls, and this contrasts with the improvement seen in the AMVE cohort at 2 years postoperatively (Fig. 3, Supplemental Digital Content 7, https://links.lww.com/PRSGO/F170). Vertex height relapse was more notable at 2 years postoperatively in the MPVE+FS subgroup relative to AMVE versus MPVE (Fig. 3, Supplemental Digital Content 7, https://links.lww.com/PRSGO/F170).

Focusing on coronal vectors, there was less improvement in head shape seen in the MPVE+FS group relative to MPVE/AMVE cohorts at the sella, pterion, and opisthion (Fig. 4, Supplemental Digital Content 7, https://links.lww.com/PRSGO/F170). On analysis of the axial vector from the glabella to the opisthocranion, there were more significant changes in vector lengths in the MPVE and AMVE cohorts relative to the MPVE+FS at 2-year postoperative (Fig. 5, Supplemental Digital Content 7, https://links.lww.com/PRSGO/F170).

Fig. 4.

Preoperative, immediate postoperative, and 2-year postoperative coronal vector plots for LPSS stratified per procedure. Preoperative images shown on the left, immediate postoperative images shown in the middle, 2-year postoperative images shown on the right. A, MPVE. B, MPVE+FS. C, AMVE.

SUBGROUP: AGE

To determine if older age at time of surgery results in less favorable postoperative outcomes, we performed a subgroup analysis of patients who underwent surgery at 2 timepoints: 18 months or younger (n = 17) and older than 18 months (n = 15). Here, regarding their preoperative morphology, the older cohort had significantly greater vector lengths in the axial plane at 0 and 30 degrees and mid-sagittal vector at 45 and 75 degrees relative to younger patients. However, reviewing the immediate postoperative transverse expansion in the axial plane, the younger cohort did not maintain this as well as the older cohort, with a significant difference noted in the axial vector lengths relative to their age-matched controls at 2 years postoperatively seen in the younger group. (See figure, Supplemental Digital Content 8, which displays the craniomorphometric analysis stratified by age, https://links.lww.com/PRSGO/F171.) (See figure, Supplemental Digital Content 9, which displays the vector plots stratified by age, https://links.lww.com/PRSGO/F172.) (See figure, Supplemental Digital Content 10, which displays the vector lengths stratified by age [top table age <1.5 y, bottom table age ≥1.5 y], https://links.lww.com/PRSGO/F173.)

DISCUSSION

Patients who are diagnosed with SS in a delayed manner (>1 year of age) represent a clinical conundrum. The calvaria is thicker and less malleable, with less propensity for cranial regeneration, causing some to question if open CVE should be pursued. We demonstrated that our LPSS cohort did not have a mild phenotype or trend to clinocephaly, as previously described.^2,13,15,16 In addition, only 7 of 32 patients in our cohort had a concern for developmental delay or symptoms suggestive of elevated intracranial pressure.

In our study, CVE performed for LPSS is associated with improvement in head shape that is maintained at 2 years postoperatively. Three key findings are present: (1) an improvement in frontal morphology that is sustained at 2 years postoperatively, with no significant difference relative to age-matched controls when examined from axial and sagittal vectors; (2) increased transverse width through the anterior and middle vault relative to preoperative baseline CT; and (3) increased posterior CL at 2 years postoperatively relative to age-matched controls, which is most marked in the mid-sagittal plane.

Returning to our key questions: After open CVE in the delayed setting, is the head shape maintained postoperatively? Here, we can see that there is an improvement in head shape seen at 2 years postoperatively with increased cranial width and improvement in forehead shape. There is a persistent increase in CL seen relative to the preoperative phenotype, however, the length is significantly increased when compared to age-matched controls. Unlike patients younger than 1 year, older children are unlikely to lie on back of their heads, which may affect the persistent increase in posterior cranial vector lengths (or lack of remodeling) appreciated here, relative to data from younger patients.¹⁰ Or, this may be due to a technical issue. Does the skull grow normally or does growth remain impaired despite open reconstruction? Comparison of the vector lengths preoperatively, immediately postoperatively, and at 2 years postoperatively shows an increase in vector lengths, demonstrating that the skull continues to grow post open cranial vault reconstruction in the older patient cohort.

Regarding the subgroup analysis, sagittal and axial vector analysis demonstrated that MPVE, MPVE+FS, and AMVE can all lead to persistent improvement in frontal bossing at 2 years postoperatively in comparison to preoperative baseline CT scans, which contrasts work from Paternoster et al suggesting that late-presenting scaphocephalic patients require forehead remodeling to achieve satisfactory aesthetic results.¹⁷ The LPSS head shape phenotype was varied, with more severe phenotypes seen in the AMVE and MPVE + FS cohorts and this, together with small cohort numbers, makes it difficult to make definitive conclusions. Our findings suggest that in the setting of older, less malleable bone, indirect frontal remodeling (eg, frontal barrel staves together with MPVE) may be less effective than formal anterior and middle CVE in addressing frontal morphology. This may be the result of thicker, less malleable bone and improved postoperative stability and/ or due to technical approach. Further comparative studies are required before making definitive conclusions.

Reflecting on our group’s previously published data on CVE in younger patients (6–9 mo of age¹⁰), we observed the same preoperative pattern, in that patients with LPSS had significantly larger anterior cranial vault volumes, significantly smaller middle vault volumes, and larger posterior vault volumes than seen in the younger cohort. However, in contrast to the younger cohort, there was less propensity for middle vault expansion at 2 years postoperatively. There was no significant difference in posterior vault volume in the LPSS patients relative to control, but the posterior vault volume was increased immediately postoperatively, and this was maintained at 2 years, similar to the younger cohort.¹⁰

Further subgroup analyses were performed to determine if increased age at the time of surgery portends a poor outcome. Here, we demonstrate that CVE can be performed at older than 18 months of age, with stability of head shape seen at 2 years postoperatively. In this cohort, more patients underwent AMVE relative to the group who underwent surgery at younger than 18 months of age. We noted that AMVE led to improved postoperative outcomes in many variables versus MPVE+FS.

In this cohort of LPSS, 3 patients (aged 12, 19, and 19 mo, respectively, at time of CVE) had persistent cranial defects for which cranioplasty was recommended. This is in keeping with previously published rates^2,18 and is helpful to discuss when counseling families regarding open CVE in older patients. Here, to ensure optimization of bone regeneration, particulate bone grafting was carried out in all procedures, and intraoperatively, if the bone felt thick (and thus, less malleable), geometric expansion was utilized to ensure optimal bone surface area coverage.

Finally, there are shortcomings of this retrospective study. Notably, 3 senior surgeons performed interventions and decided on a surgical approach based on their experience rather than an established algorithm. In addition, three techniques with 6 variations are implemented, thus making it difficult to make definitive conclusions, and we are not powered to do so. Despite this, our cohort represents, to our knowledge, the only study to date providing detailed craniomorphometric outcomes in patients undergoing open CVE beyond 1 year of age, demonstrating improvement in head shape at 2 years postoperatively. It is important, however, to contextualize these findings within the known phenomenon of partial recapitulation of the presenting deformity over time. Prior studies have suggested that cranial growth patterns may lead to regression toward the preoperative phenotype, and accordingly, some authors advocate for intentional overcorrection.^1,19 Although our data demonstrate sustained improvement at 2 years, we do not have sufficient long-term follow-up to determine whether similar regression occurs in this cohort or to assess the impact of overcorrection. This remains an important area for future investigation.

A further deficiency is the lack of patient-/parent-reported outcome measures.^20–22 Previous studies have demonstrated a lack of correlation between craniometric data and subjective assessment, further underlining the need for patient-reported outcomes as meaningful parameters in the perspective of patients and their parents undergoing open CVE.²³

In conclusion, vector analysis at 2 years postoperatively demonstrated an improvement in frontal morphology that is sustained at 2 years postoperatively with no significant difference relative to age-matched controls when examined from multiple vectors. Although transverse width and posterior CL are improved compared to baseline, these variables are significantly different relative to age-matched controls at 2 years postoperatively. Finally, further subgroup analysis of patients aged 18 months or younger versus older than 18 months at time of surgery demonstrate that it is feasible to produce and maintain improved head shape morphology on 2-year postoperative scans in patients older than 18 months at time of surgery.

DISCLOSURES

Dr. Hopper is an inventor of a patented nasal molding device (not discussed in this article) licensed to KLS Martin. Dr. Tevlin holds a Dean’s Scholars Award from the Washington University Division of Physician-Scientists, which is funded by a Burroughs Wellcome Fund Physician-Scientist Institutional Award. The other authors have no financial interest to declare in relation to the content of this article.