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The decision about which metopic synostosis patients should undergo surgery remains controversial. Multiple measures for radiographic severity have been developed in order to determine the optimal criteria for treatment. The aim of this study was to perform an extensive craniomorphometric analysis of patients who underwent surgery for metopic synostosis to validate and compare the various severity scales developed for this non-syndromic craniosynostosis. A comparative morphometric analysis was performed using computed tomography scans of preoperative metopic synostosis patients (n=167) and normal controls (n=44). Measurements included previous and newly developed metopic severity indices. Volumetric and area analyses were used to determine the degree of anterior cranial area and potential volume restrictions. Of the severity indices measured, the frontal angle, endocranial bifrontal angle (EBF), adjusted EBF (aEBF), anterior cranial fossa angle, horizontal cone angle, and bitemporal/biparietal distance ratio were significantly different in the metopic subjects relative to controls overall. However, metopic index, orbital rim angle, foramen ovale distance, and cranial volume exhibited no significant difference from controls. Only the frontal angle and aEBF correlated with the changes in anterior cranial dimensions observed in metopic synostosis. In conclusion, the frontal angle and aEBF provide the most accurate measures of severity in metopic synostosis., (Copyright © 2020 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Summary: Metopic craniosynostosis results in trigonocephaly, characterized by a triangular forehead with metopic ridge, bitemporal pinching, and narrow-set eyes with recessed lateral orbital rims. Surgical management is controversial but may include open expansion and vault remodeling, to enhance neurocognitive and aesthetic outcomes. This article and video vignette depict the diagnosis and treatment of metopic craniosynostosis, demonstrating the senior author's open approach, three-dimensional virtual surgical planning, and technical steps., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: Unilateral lambdoid synostosis (ULS) represents the rarest form of single suture nonsyndromic craniosynostosis. Differentiating between posterior deformational plagiocephaly (DP) and ULS has been difficult due to overlapping clinical findings. Past analyses have been limited by sample size. This study was undertaken to clarify anatomical features of ULS., Methods: A multiinstitution study was undertaken, analyzing CT imaging from patients with documented ULS to determine clinical and pathological characteristics. Similar analyses were performed on DP patients to differentiate the 2 conditions., Results: Twenty-seven ULS patient scans and 10 DP scans were included. For ULS patients mean age was 6.6 months, majority male (75%), and majority left-sided ULS (71%). The synostosed side ear was anteriorly displaced in 100% of ULS patients, mean difference of 9.6° (P < 0.001), and inferiorly in 96.3% of patients, mean difference of 4.4 mm, relative to the nonsynostosed side. The posterior fossa deflection (PFD) was deviated 5.9° toward the synostosed side relative to the anterior midline. In DP, there was no significant difference between sides in EAC measurements. The PFD and EAC displacements were significantly smaller in DP relative to ULS (P < 0.001 for each). An ipsilateral mastoid bulge was found in 100% of ULS and 0% of DP on CT imaging., Conclusion: Contrary to some previously published findings, the ear is more anteriorly displaced ipsilateral to the fused lambdoid suture in 100% of ULS patients. Ear position alone is not a reliable indicator to differentiate between DP and ULS. A mastoid bulge is a more reliable indicator of ULS., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 by Mutaz B. Habal, MD.)

Background: The purpose of this study was to evaluate the utility of a previously validated interfrontal angle for classification of severity of metopic synostosis and as an aid to operative decision-making., Methods: An expert panel was asked to study 30 cases ranging from minor to severe metopic synostosis. Based on computed tomographic images of the skull and clinical photographs, they classified the severity of trigonocephaly (1 = normal, 2 = mild, 3 = moderate, and 4 = severe) and management (0 = nonoperative and 1 = operative). The severity scores and management reported by experts were then pooled and matched with the interfrontal angle computed from each respective computed tomographic scan. A threshold was identified at which most experts agree on operative management., Results: Expert severity scores were higher for more acute interfrontal angles. There was a high concordance at the extremes of classifications, severe (4) and normal (1) (p < 0.0001); however, between interfrontal angles of 114.3 and 136.1 degrees, there exists a "gray zone," with severe discordance in expert rankings. An operative threshold of 118.2 degrees was identified, with the interfrontal angle able to predict the expert panel's decision to proceed with surgery 87.6 percent of the time., Conclusions: The interfrontal angle has been previously validated as a simple, accurate, and reproducible means for diagnosing trigonocephaly, but must be obtained from computed tomographic data. In this article, the authors demonstrate that the interfrontal angle can be used to further characterize the severity of trigonocephaly. It also correlated with expert decision-making for operative versus nonoperative management. This tool may be used as an adjunct to clinical decision-making when the decision to proceed with surgery may not be straightforward., Clinical Question/level of Evidence: Diagnostic, V.