Premature closure of skull sutures is associated with compensatory cranial and facial deformational changes that often require major reconstructive procedures. In the early years of synostosis surgery, releases at an early age were felt to be the standard of care for treating these patients. Strip craniectomy, a technique first reported in the late 1800s (19) that involves the removal of the fused suture, was for many years the preferred treatment for craniosynostosis, However, over time it was felt that the cosmetic results were often disappointing, and the surgeries required large incisions and frequent need for blood transfusion since extensive scalp mobilization was required for adequate exposure. In a child less than 2 mo of age, skull exposure alone can lead to significant blood loss. Furthermore, the failure to correct the skull shape adequately in a significant percentage of patients led to the evolution of cranial vault remodeling as the preferred technique for synostosis repair. Obviously, these procedures continue to use large bicoronal skin incisions and have an even greater likelihood of blood tranfusion.

The significant invasiveness of current procedures, combined with the advent of newer technologies, has recently brought about innovative approaches in craniosynostosis repair that combine the old and the new. Multiple authors, following the lead of Jimenez and Barone (20,21), have described combined techniques using small incisions, endocopic strip craniectomies, and postoperative orthotic cranial banding to correct synostosis. This allows for a minimally invasive, low blood loss way of doing strip craniectomies, with the orthosis leading to improved cosmetic outcomes compared with the stand-alone strip craniectomies. Endoscopic strip craniectomy is now commonly being used in children less than 2 mo of age to treat sagittal synostosis, with more recent use of the technique for coronal and metopic synostosis as well. The endoscope has minimized the scalp incision, decreased the blood loss, and shortened the operative and recovery time; the authors believe the clinical result is acceptable. The endoscopic technique does have the disadvantage of requiring the patient to wear a molding helmet postoperatively both to help reshape the cranium and to maintain head shapes in the long term. Jimenez advocates the use of the helmet until the child is 1 yr of age. Many consider this a significant drawback to the technique and would rather pursue a more aggressive surgical approach without the need for postoperative orthosis.

Some authors have combined open techniques with more minimally invasive techniques to try and take advantage of each. These newer procedures tend to involve multiple strategically located smaller incisions, along with use of the endoscope, to achieve results similar to those of open procedures in a mini mally invasive fashion, involving less blood loss. Although the newer procedures in craniofacial surgery seem to involve lower transfusion rates and shorter operative times than more conventional procedures, the ultimate outcome measures of function and appearance are harder to compare. Although the cephalic index data appear favorable in the correction of sagittal synostosis

(21), there are fewer well-accepted objective measurements for the comparison of coronal and metopic synostosis repairs.

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