We have read with great interest the article by Natghian et al. in a recent issue of the Journal entitled “Long-Term Results in Isolated Metopic Synostosis: The Oxford Experience over 22 Years.”1 The authors performed a retrospective study of 245 patients with isolated metopic synostosis; about 82.4 percent of patients underwent fronto-orbital advancement and remodeling, and 18.3 percent of patients had subsequent procedures during the follow-up period. We appreciate that the authors provide us with some valuable experience (e.g., the aesthetic deformity of craniosynostosis improves or disappears over time) for patients and their parents. In this communication, we would like to propose some opinions to the authors.
The first is that the Oxford group prefers stainless steel wire for fixation. In our department, this technique is replaced by a titanium plate for its stability (Fig. 1). Since late 1980, a titanium rigid internal fixation system has been used for stabilization of bone fragments. As technology has advanced, the titanium implant material has received special attention and continuous refinement. Nowadays, titanium implants are easily applied and are at a high grade of reliability in terms of stability, ductility, and biocompatibility.2 Despite the drawbacks of using titanium plates reported in previous literature,3 adverse events have rarely been observed in our department since we started using titanium internal fixation in 1995. What’s more, as we know, titanium is an inert metal. Its metallic characteristics mean that it is acceptable for use with magnetic resonance imaging. However, the patients who have been fixed using stainless steel cannot be checked via magnetic resonance imaging. Finally, the cost for the titanium system we use amounts to $123 to $288 U.S. for one set (includes one plate and several screws). This cost is acceptable by patients and their parents. So we would appreciate if the authors would give us more details on why they prefer stainless steel wire for fixation instead of titanium plates.
In addition, the authors report that some patients would require another operation for re-expansion for recurrent elevated intracranial pressure. From the intraoperative figure the authors provided in the article, we have found that when the authors refined a neoforehead, they preferred to wire the cranium closely. If so, this procedure may increase the risk of raised intracranial pressure postoperatively. Most patients with craniosynostosis also have gene mutations,4,5 which accelerate osteoblast proliferation and differentiation and promote premature cranial suture fusion. Therefore, we would appreciate if the authors would give us more intraoperative details for further surgical understanding.
In conclusion, it is helpful that the authors have provided us with such complete long-term data. Although they have left us with many questions to explore, they have provided worthy experience for us to carry out clinical work. We expect further data that will allow us to assess and improve our techniques with the goal of providing better outcomes for our patients.
The authors have no financial disclosures to report.
Chenzhi Lai, M.D.
Xiaolei Jin, M.D.
Department of Sixteen
Plastic Surgery Hospital
Chinese Academy of Medical Sciences
Peking Union Medical College
1. Natghian H, Song M, Jayamohan J, et al. Long-term results in isolated metopic synostosis: The Oxford experience over 22 years. Plast Reconstr Surg. 2018;142:509e–515e.
2. Branch LG, Crantford C, Cunningham T, et al. Long-term outcomes of pediatric cranial reconstruction using resorbable plating systems for the treatment of craniosynostosis. J Craniofac Surg. 2017;28:26–29.
3. Kreppel M, Kauke M, Grandoch A, Safi AF, Nickenig HJ, Zöller J. Evaluation of fronto-orbital advancement using titanium-based internal fixation for corrective pediatric craniofacial surgery. J Craniofac Surg. 2018;29:1542–1545.
4. Rijken BF, Lequin MH, de Rooi JJ, van Veelen ML, Mathijssen IM. Foramen magnum size and involvement of its intraoccipital synchondroses in Crouzon syndrome. Plast Reconstr Surg. 2013;132:993e–1000e.
5. Timberlake AT, Persing JA. Genetics of nonsyndromic craniosynostosis. Plast Reconstr Surg. 2018;141:1508–1516.
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