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Introduction: When a child walks in the clinic with a unilateral frontal flattening, it is usually associated in our minds with unilateral coronal synostosis. While the latter might be the most common cause of anterior plagiocephaly, it is not the only one. A patent coronal suture will force us to consider other etiologies, such as deformational plagiocephaly, or synostosis of another suture. To understand the mechanisms underlying this malformation, the development and growth of the skull base must be considered., Materials and Methods: There have been few reports in the literature of isolated frontosphenoidal suture fusion, and we would like to report a series of five cases, as the recognition of this entity is important for its treatment., Conclusion: Frontosphenoidal synostosis must be searched in the absence of a coronal synostosis in a child with anterior unilateral plagiocephaly, and treated surgically.

Background: Premature closure of the metopic suture results in deformation of the anterior portion of the calvarium, which can vary from mild to severe. In mild forms, there is only prominent ridging of the metopic suture; more severe forms result in a marked narrowing of the frontal and temporal regions that in turn affects the supraorbital rims and produces hypotelorism., Methods: The authors retrospectively reviewed 39 consecutive cases of metopic synostosis treated over a 12-year period., Results: The average age at referral was 5 months, with surgery performed at an average age of 7.5 months. Fifteen infants had other congenital anomalies, with eight having synostosis of other sutures. Follow-up ranged from 7 months to 6 years, with an average of 29 months. In three mild cases, burring of the metopic ridge was performed with excellent aesthetic results in all cases. The other 36 patients had significant deformity of the supraorbital ridges and temporal regions, with obvious hypotelorism for over 50% of the time. In these cases, the patients underwent craniofacial reconstruction to normalize their appearance. In addition, the lateral aspect of the sphenoid ridges, including the orbital roof and lateral orbital wall to the infraorbital fissure, was removed to free the cranial base. The average blood loss was under 400 ml and the average hospital stay was 3.6 days. Results were considered good to excellent in all except three cases, which had recurrence of a prominent metopic ridge; two required a second operation after 6 months for burring of this ridge, whereas the third was treated conservatively with an orthotic headband., Conclusion: Mild forms of metopic synostosis can be successfully treated with burring of the metopic ridge alone. Severe forms require craniofacial reconstruction and may be associated with other congenital abnormalities, additional synostosis, and developmental delay. In all cases, the operative procedure must be tailored to the nature and severity of the deformity.

An operative series of 45 patients with anterior synostotic plagiocephaly is analyzed. In the cases of six children it was not possible to visualize synostosis of the cranial sutures on plain X-ray films or three-dimensional CT. Primary procedures were performed at an average age of 14 months with an average postoperative follow-up of 47.5 months. Children were operated on either with lateral canthal advancement (5 cases), unilateral orbital advancement with "tongue in groove" (12 cases), or bilateral orbital advancement (28 cases). Excellent results were obtained in 33/45 patients, while 8/45 children required secondary minor revisions. Of the three different surgical techniques, the results achieved by the bilateral approach were considered better than those attained with the unilateral techniques. Osteotomies of the nasal bones are recommended in the cases of older children with severe nasal deviation associated with dislocation of the nasoethmoidal complex.