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The Effects of Whole-Vault Cranioplasty versus Strip Craniectomy on Long-Term Neuropsychological Outcomes in Sagittal Craniosynostosis

Persing, John A. M.D.; Brooks, Eric YMS; Hashim, Peter M.D.; Patel, Anup M.D.; Yang, Jenny YMS

Plastic and Reconstructive Surgery: May 2015 - Volume 135 - Issue 5 - p 926e–927e
doi: 10.1097/PRS.0000000000001179

Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, Conn.

Correspondence to Dr. Persing, Yale Plastic Surgery, Yale University School of Medicine, 330 Cedar Street, Third Floor, New Haven, Conn. 06520,

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We appreciate the commentary of Drs. Wood, Proctor, and Rogers related to our recently published study.1 Data were presented in that article documenting a better neurocognitive outcome following whole-vault cranioplasty in patients with sagittal synostosis compared with endoscopic craniectomy. The question asked in the commentary was whether our study1 was designed to condemn the use of an endoscope and the pi procedure.2 In short, no, it was not. The study was designed to provide a comparison of neurologic function between patients who had undergone an acute comprehensive release (whole-vault) cranioplasty procedure versus a minimally invasive endoscopic procedure (endoscopic craniectomy). It is well recognized that some cranial expansion occurs acutely with both approaches. At issue is which approach has been more effective in developing maximal improvement in brain function. The data strongly support that a more extensive procedure performed early in life is associated with better neurologic outcomes compared with an approach with less extensive correction.

The concern was also raised related to more extensive procedures being associated with longer operative time, thus exposing patients to potentially more negative influence on neurologic outcomes. This statement has some support. We all agree that shortening operative time is an appropriate goal for all patients. However, performing a procedure in a shorter period, yet not correcting the irregularity fully, also has potentially deleterious effects. In the recent study,1 even with the longer operative time associated with whole-vault cranioplasty, the net result was a better neurologic outcome than the shorter endoscopic craniectomy procedure. Why? This has yet to be determined fully, but it may be more critical to release the skull extensively, earlier in childhood during the most rapid growth rates of the brain, than to allow reshaping to occur more gradually over the course of many months.

The senior author (J.A.P.) previously examined the neurologic outcome in sagittal synostosis patients undergoing strip craniectomy alone,3 because of repeated observations by the patients’ parents that their children were having significant problems with achievement and with behavioral problems/learning disability. With this information in hand, it is unlikely that the more limited release of the craniosynostosis skull deformity by strip craniectomy alone, described by Ridgway et al.,4 would yield an improved outcome compared with more comprehensive procedures. It is even plausible that the neurologic outcomes could be worse, as the added lateral parietal “barrel staves” to the strip craniectomy performed at the University of Pittsburgh are more likely to have allowed even more immediate expansion of skull volume (with or without a cinching stitch) than the strip craniectomy procedure alone.

Finally, although we have confidence in the findings of the comparison-of-technique study, no study is perfect. There should be follow-up studies to examine the questions raised by Drs. Wood, Proctor, and Rogers. In fact, shortly after this material was presented at an international craniofacial society meeting 1 year ago, the senior author approached Dr. Proctor about performing additional comparisons of the whole-vault technique versus the isolated strip craniotomy approach, which Dr. Proctor and colleagues preferred. By mutual agreement, we set about to get this done. A formal proposal was passed through human investigation committees at both Harvard and Yale. The data collection is set to begin in November of 2014.

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The authors have no financial interest to declare in relation to the content of this communication.

John A. Persing, M.D.

Eric Brooks, YMS

Peter Hashim, M.D.

Anup Patel, M.D.

Jenny Yang, YMS

Section of Plastic and Reconstructive Surgery

Yale University School of Medicine

New Haven, Conn.

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1. Hashim P, Patel A, Yang JF, et al. The effects of whole-vault cranioplasty versus strip craniectomy on long-term neuropsychological outcomes in sagittal craniosynostosis. Plast Reconstr Surg. 2014;134:491–503
2. Jane JA, Edgerton MT, Futrell JW, Park TS.. Immediate correction of sagittal synostosis. J Neurosurg. 1978;49:705–710
3. Magge S, Westerveld M, Pruzinsky T, Persing JA.. Long term neuropsychological effects of single-suture craniosynostosis on child development. J Craniofac Surg. 2002;13:99–104
4. Ridgway EB, Berry-Candelario J, Grondin RT, Rogers GF, Proctor MR.. The management of sagittal synostosis using endoscopic suturectomy and postoperative helmet therapy. J Neurosurg Pediatr. 2011;7:620–626
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