2021 Treatment Guidelines for Craniosynostosis: Frontal Suture Management

Introduction to Craniosynostosis Treatment

This guide summarizes the latest evidence and recommendations from the 2021 treatment guidelines for craniosynostosis, published in the Journal of Craniofacial Surgery. The original text is available for free download at www.ncbi.nlm.nih.gov/pmc/articles/PMC7769187/. It focuses on managing premature closure of the frontal skull suture, a condition where the suture fuses too early, potentially affecting skull shape and brain development.

Categories of Frontal Skull Suture Severity

The frontal skull suture severity is classified into three main categories based on physical appearance:

• Severe: A clear protrusion in the center of the forehead is evident. From the top view, the brow bones on both sides are clearly visible.
• Moderate: The eyebrows are the most protruding feature. From the top view, the eyebrows on both sides may be visible.
• Mild: Does not meet the criteria for severe or moderate. The eyebrow bone is not visible from the top view.

Does Frontal Suture Premature Closure Require Surgery?

Recommendations vary by severity level:

• Severe: Surgery is advised to improve appearance.
• Moderate: No specific literature recommendations; decisions are based on expert opinions from different surgeons.
• Mild: The head shape may improve over time; expert opinions from surgeons guide the approach.

Comparing Endoscopic Surgery and Forehead Shaping Surgery

Endoscopic craniosynostosis surgery offers advantages such as less blood loss, fewer transfusions, shorter surgery time, and shorter hospital stays. Results may be comparable to forehead shaping surgery. However, endoscopic procedures have a higher reoperation rate (25%), while forehead shaping surgery requires reoperation in only 3.8% of cases. There is no unified conclusion on the best method; choices depend on the surgeon's professional experience.

Optimal Timing for Surgery

Studies indicate a low risk of optic disc edema (papilledema) before age one in cases of premature frontal suture closure, so early surgery is not necessary. Procedures are not recommended before six months of age. Timing decisions are based on the surgeon's professional experience, with no unified conclusion.

Monitoring Premature Frontal Suture Closure

Follow-up is essential both before and after surgery. Due to the low risk of optic disc edema, frequent fundoscopy is not required. Head circumference should be measured annually. If head growth stalls, fundoscopy or optical coherence tomography (OCT) may be needed.