We thank Drs. Lai and Jin for their interest in our retrospective study of 245 patients with isolated metopic synostosis who were treated at the Oxford Craniofacial Unit between February of 1995 and February of 2017.1 Since the establishment our department, stainless steel wires have been the preferred fixation method in craniosynostosis surgery. However, we are aware of the controversy that exists with regard to the ideal form of bone fixation and that the use of rigid internal fixation systems (titanium and bioabsorbable devices) predominate in most craniofacial units.2 At the Oxford Craniofacial Unit, we believe there is no ideal fixation method and that each system has its disadvantages, particularly with the concern related to internal translocation of plates and the difficulty in dealing with embedded/integrated plates if secondary surgery is required in terms of this letter.3 We prefer stainless steel wires because we have found them to be reliable, inexpensive, and easy and quick to use. A further retrospective study on the use of these wires over the past 22 years at the Oxford Craniofacial Unit has demonstrated that less than 1 percent of all inserted wires had to be removed. In addition, a cost-effectiveness analysis was performed to compare the primary use of stainless steel wires to the use of resorbable plates in craniosynostosis surgery, in the form of a projected estimated cost in our patients over a 22-year period. Although this is a specific comparison with resorbable plates as opposed to the comparison with a titanium system, we were able to demonstrate that use of stainless steel wires in craniosynostosis surgery remains 17.5 times cheaper. Specifically, the latter took into account the cost of additional surgical procedures performed for wire removal. The article, “A 22-Year Review of the Use of Stainless Wires in Craniosynostosis Surgery: A Single-Center Study,” has recently been published in the Journal of Craniofacial Surgery.4
We have found that very few (2.9 percent) of our patients experience recurrent elevated intracranial pressures necessitating secondary re-expansion procedures.1 Contrary to the comment in this letter, in our experience, genetic mutations associated with intrinsic bone biology along the lines of the FGFR-associated syndromes are rare in metopic synostosis and do not substantially contribute to the reoperation risks. The role of the recently described SMAD6 mutations, which are reported to occur in a small percentage of metopic synostosis patients, still needs to be fully clarified, but in our albeit brief review of available results in our study, these mutations do not as yet seem to be associated with a higher reoperative risk.5 Secure fixation of the neoforehead with wires is necessary to form a stable construct, therefore preventing early mechanical true forehead relapse. (The same technique is used in unicoronal and bicoronal synostosis related procedures.) Consequently, we do not believe that our surgical technique of secure wiring of the neoforehead construct increases the risk of raised intracranial pressure postoperatively.
The authors have no financial disclosure to report.
Hamidreza Natghian, M.D.
Marie Song, M.R.C.S.
Jayaratnam Jayamohan, F.R.C.S.
David Johnson, D.M., F.R.C.S.
Shailendra Magdum, F.R.C.S.
Peter Richards, F.R.C.S.
Steven Wall, F.C.S.(S.A.)Plast.
Oxford Craniofacial Unit
John Radcliffe Hospital
Oxford, United Kingdom
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. Goodrich JT, Sandler AL, Tepper O. A review of reconstructive materials for use in craniofacial surgery bone fixation materials, bone substitutes, and distractors. Childs Nerv Syst. 2012;28:1577–1588.
3. Rovati LC, Pricca M, Caronni EP, Granata G, Donati R, Gaini SM. A delayed complication with steel wire osteosynthesis. J Craniofac Surg. 1997;8:323–325.
4. Natghian H, Song M, Wall S, et al. Review of the use of stainless wires in craniosynostosis surgery. J Craniofac Surg. 2019;30:550–553.
5. Timberlake AT, Choi J, Zaidi S, et al. Two locus inheritance of non-syndromic midline craniosynostosis via rare SMAD6
and common BMP2
alleles. eLife 2016;5:e20125. DOI: 10.7554/eLife.20125.
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