ORIGINAL ARTICLE
Endoscopic Versus Open Total Vault Reconstruction of
Sagittal Craniosynostosis
Sultan Z. Al-Shaqsi, MBChB, PhD, Nicole Wing Lam, Hon,y
Christopher R. Forrest, MD, MSc, FRCS(C), FACS,y and John H. Phillips, BSc, MA, MD, FRCSCy
Sagittal craniosynostosis is the most common form of congenital
cranial deformity. Surgical interventions are performed either open
or endoscopic. Advancements in minimally invasive surgery have
enabled the development of the endoscopic suturectomy technique.
This is contrasted to the traditional open cranial vault reconstruc-
tion. There is a paucity of data comparing the head shape changes
from both techniques. This study aims to compare the morphologi-
cal outcome of endoscopic suturectomy versus total cranial vault
reconstruction.
Methods: This is a retrospective comparative study involving 55
cases of sagittal craniosynostosis, 37 of which has open total cranial
vault reconstruction and 18 had endoscopic suturectomy procedure.
Preoperative and postoperative 3D photographs of both groups were
analyzed and compared. The change in correction between
preoperative and postoperative state was measured against a
crowd-driven standard for acceptable head shape.
Results: Total cranial vault had higher percentage change between
pre and postoperative cranial index than endoscopic suturectomy
(14.7% versus 7.7%, P ¼ 0.003). However, both techniques were
able to achieve the minimum standard of 70% correction (TCV
107.5%, ES 100.4%, P ¼ 0.02).
Conclusion: Total cranial vault and endoscopic suturectomy are
effective in correcting scaphocephaly among children with sagittal
craniosynostosis. Additionally, both techniques are able to achieve
a percentage correction that exceeds the 70% benchmark
established by the lay public.
Key Words: 3D, cranial vault, craniosynostosis, endoscopic,
outcome, reconstruction, sagittal, scaphocephaly
(J Craniofac Surg 2021;32: 915–919)
From the Plastic and Reconstructive Surgery, University of Toronto, The
Hospital for Sick Children, Ontario; and yThe Hospital for Sick Children,
Toronto, Canada.
Received May 17, 2020.
Accepted for publication October 27, 2020.
Address correspondence and reprint requests to Sultan Z. Al-Shaqsi,
MBChB, PhD, Plastic and Reconstructive Surgery, University of
Toronto, The Hospital for Sick Children, 555 University Avenue, ON
M5G 1X8, Canada; E-mail: sultan.al-shaqsi@mail.utoronto.ca
The authors report no conflicts of interest.
Supplemental digital contents are available for this article. Direct URL
citations appear in the printed text and are provided in the HTML and
PDF versions of this article on the journal’s Web site (www.jcraniofa-
cialsurgery.com).
Copyright # 2020 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000007307
The Journal of Craniofacial Surgery  Volume 32, Number 3, May 2021
Copyright © 2021 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
C raniosynostosis is a spectrum of cranial deformities caused by
variable premature ossification of cranial sutures leading to
restriction in skull growth that could cause functional abnormali-
1,2
ties. Cranial development is a complex process and any disrup-
tion could lead to complex deformities. Surgical correction of such
deformities is indicated for functional or aesthetic concerns. There
is a predictable pattern of head shape deformity depending on the
suture involved. Sagittal craniosynostosis is an abnormal elongated
shape of the skull secondary to premature fusion of sagittal suture.3
It is the commonest form of nonsyndromic craniosynostosis. It is
estimated to occur in 1 in 5000 live births with a 3 to 1 ratio of male
to female predilection.3,4
For children with a confirmed diagnosis of isolated sagittal
craniosynostosis, surgical correction is indicated for functional or
morphological concerns.5 The surgical intervention involves
removing the abnormally fused suture and allowing the cranium
to expand in order to accommodate the growing brain.6 Hence,
cranial vault reshaping procedures have shown to have an impact on
the neurodevelopmental outcome including speech and language,
visuospatial skills, memory, and attention.7–9 The optimal timing
and extent of suture release continues to be controversial.10,11
Traditionally, surgeons have thought that a wide suture release
and a total cranial vault reshaping was required to allow the growing
brain to expand and minimize restriction. Since the introduction of
minimally invasive endoscopic suturectomies at an early age,
limited and targeted suturectomies have been shown to be as
effective as total extensive release in terms of brain growth vol-
ume.12 Therefore, the 2 broad categories of surgical intervention are
either endoscopic suturectomy or total vault reshaping depending
on the age of diagnosis.
Total cranial vault remodeling (TCVR) is a well-established
surgical technique for the management of craniosynostosis.9,10
The critical steps include removing the cranial bone with the affected
suture, reshaping the bone grafts and reorganizing the reshaped grafts
in a way that ensures expansion of the cranial dimension in the most
constricted regions. The reshaped bony segments are stabilized by
means of internal fixation. Small areas of excess space are created by
this re-organizing procedure and the growing brain fills such space.13
Despite significant advances in surgical technique, fixation methods
and anesthesia, total cranial vault reconstruction has a well-docu-
mented relatively high rate of blood loss requiring transfusion,
prolonged hospital, and intensive care stay.14–17
Endoscopic suturectomy, first reported in the literature in 1998,
as advances in minimally invasive surgery continues to evolve.12,16
It provides a minimally invasive correction of craniosynostosis. It
relies on the malleability of skull bones to expand and remodel after
the procedure and therefore usually recommended for children
before the age of 6 months.18
The 2 techniques have been extensively compared and con-
trasted in the literature. Although total cranial vault reshaping is
effective in correcting head shape deformity in sagittal craniosyn-
ostosis, it is associated with increased blood transfusion rates,
length of operative time, and length of stay in hospital compared
915
Al-Shaqsi et al The Journal of Craniofacial Surgery
to endoscopic interventions such as endoscopic suturec-
tomies.14,15,19,20 Hence it is usually associated with higher overall
cost than endoscopic procedures. Studies have estimated the aver-
age cost difference between endoscopic and total vault to be
between CD $11,603 to $31,744 per case.21,22 Endoscopic proce-
dures are shown to be less invasive, as they are associated with
lower complication rate, shorter hospital stay, and have a faster
recovery time than total cranial vault reshaping.19 However, for
endoscopic release to be effective, it has to be performed while skull
bones are still malleable, which is before 6 months of age.9,10,23 If
performed after 6 months, the effectiveness of endoscopic release is
reduced, and total vault reshaping is usually required.
Public perception of head shape is an essential outcome measure
that is usually underestimated.24 Studies have shown that children
with cranial deformities are perceived ‘‘differently’’ by the public.25
Such issues are important to investigate to mitigate and reduce
social stigma associated with cranial deformities. A recent crowd
sourcing study has shown that the public considers at least 70%
correction in sagittal craniosynostosis is needed in order for the
public to consider the head shape as ‘‘normal.’’24 Studies have
focused on comparing the perioperative differences and outcomes
between the 2 techniques. There is currently a paucity in evidence
comparing the long-term outcome of the 2 techniques (ie, endo-
scopic versus open total vault reconstruction). A study by Le et in
2014 looked at the long-term head shape correction between 13
patients who underwent open vault reconstruction compared to 6
cases of endoscopic suturectomy indicated equivalence head shape
correction.20 This study is limited by small numbers of cases and
lack of benchmark in which the outcome was measured against.
Therefore, this article presents a relatively larger sample of patients
and presents a validated benchmark correction percentage in which
the two techniques can be measured against.
METHODOLOGY
Clinical Materials and Methods
A retrospective review was performed on all children diagnosed
with sagittal craniosynostosis and underwent either endoscopic
suturectomy or total cranial vault reconstruction at the Hospital
for Sick Children, Toronto, Canada between 2009 and 2019.
Patients for this study were recruited from a departmental database
that collects clinical and 3D photographs of all craniofacial patients.
The inclusion criteria for this study group was defined as
patients who were clinically diagnosed with sagittal craniosynos-
tosis and had 3D photographs taken to document their preoperative
and postoperative head shape following either endoscopic suture-
ctomy or total cranial vault reconstruction performed by craniofa-
cial surgeons at the Hospital for Sick Children. Children without pre
or postoperative 3D photographs were excluded. There were 55
identified patients who met the study inclusion criteria of which 18
patients had undergone endoscopic craniectomy and 37 patients had
undergone total cranial vault reconstruction.
Chart review of all cases was conducted, and variables were
extracted. Variables including demographics, clinical presentation,
timing of surgical intervention, surgical technique, date of 3D
photographs, and medical and surgical history were extracted from
medical records.
For each case a detailed analysis of the preoperative and
postoperative 3D photographs was done using a standardized
method which was previously published.33 All 3D photographs
were captured by a trained technician using 3dMD Face System
(3dMD; Atlanta, GA). A single tightly fitted nylon swimming cap
was used on the subject’s head to flatten the hair to provide better
resolution of the cranial vault shape. After technical refinement of
916
Copyright © 2021 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 32, Number 3, May 2021
the 3D photos, the head surface was selected and transferred as the
Wavefront Object (.obj) file extension format into the Canfield
Mirror database (Canfield; Fairfield, NJ). All 3D photographs were
then oriented in the Frankfort horizontal plane by rotating and
translating it such that the right tragion and right lower orbitale were
situated on the horizontal plane, eyes leveled, and the cranium
bisected on the sagittal plane. Once orientation is established,
standard anthropometric lengths which include glabella to opistho-
cranion (g-op), most anterior point on the cranium to the opistho-
cranion (ap-op), left to right euryon (eu-eu) were calculated. All
measurements were executed by the same investigator. Cranial
Index was calculated from the (eu-eu) divided by (ap-op)  100.26
Statistical Analysis
Anonymous extracted data variables were entered into a pre-
populated Microsoft Excel (Microsoft Corporation, Redmond,
WA). Descriptive analysis was used to present the study results
and patient demographics. Subsequently, the main outcome mea-
sure (change in head shape) was analyzed by comparing the
percentage change and absolute change in Cranial Index between
the preoperative and postoperative 3D photographs through a
Pearson Student t test analysis. A percentage correction to normal
cranial index was determined for each patient, adjusting for age and
sex. An alpha of 0.05 was used to determine statistical significance.
All data were de-identified and Statistical analysis was performed
using Statistical Package for the Social Sciences (SPS, IBM Corp,
Armonk, NY). Approval for this study was obtained from the
Hospital for Sick Children ethics board. This study was conducted
in accordance with Helsinki principles of medical research.27
RESULTS
There were 55 sagittal craniosynostosis patients that were identified
for this study. Eighteen patients had undergone endoscopic suture-
ctomy and 37 patients had undergone total cranial vault reconstruc-
tion. Males constituted 81.5% (n ¼ 44) of the total sample size. In the
endoscopic group, males constituted 82.4% (n ¼ 14) and in the total
cranial vault reconstruction group, males constituted 81.1% (n ¼ 30).
The mean age of presentation was 10.0 ( 16.3) months, 2.9 ( 2.8)
months for endoscopic and 13.4 ( 19.2) months for total cranial
vault reconstruction (P ¼ 0.01). The mean age of operation was 12.3
( 16.9) months, 3.6 ( 2.7) months for the endoscopic group, and
16.6 ( 19.2) months for the total cranial vault group (P ¼ 0.02). The
mean age for follow-up in the endoscopic group was 5.5 ( 3.7)
months, whereas in the total cranial vault reconstruction group the
mean age of follow up was 20.7 ( 20.3) months. Despite corrected
cranial index values following surgery in our patient group, in the
total cranial vault reconstruction group, 10.8% (n ¼ 4) of patients had
to undergo titanium mesh addition to compensate for soft spots and
2.7% (n ¼ 1) underwent secondary surgical intervention. From our
patient group, 7.2% (n ¼ 4) of patients were syndromic. This
included Jacobsen syndrome, Xia-Gibbs Syndrome, and FGFR2
Mutation from the total cranial vault reconstruction cohort and
Xp22.33p22.32 deletion from the endoscopic craniectomy group.
All patients were clinically diagnosed with isolated sagittal cranio-
synostosis through the use of computed topography.
Supplemental Table, http://links.lww.com/SCS/C133 one
describes the main outcome measured in this article. Cranial index
was compared between the 2 treatment groups pre- and postopera-
tively. This study found a significant difference (P ¼ 0.02) in
measured cranial index between endoscopic suturectomy
(74.1  4.4) and total vault reconstruction group (79.3  10.0)
postoperatively. Both surgical groups displayed successful surgical
expansion as an increase in cranial index was observed among both
surgical groups. However, on average total vault reconstruction
# 2021 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery  Volume 32, Number 3, May 2021Which Technique Leads to Greater Change in Head Shape?
FIGURE 1. Preoperative photos of a female child with sagittal craniosynostosis
at 6 months of age.
technique has significantly higher percentage change in calculated
CI compared to the endoscopic group (TCVR ¼ 14.72  14.95,
ES ¼ 7.75  5.99, P ¼ 0.03). This study found that both procedures
meet and exceed the benchmark correction of 70% in that on
average the endoscopic provides about 100.4% correction in cranial
deformity and open total vault provides on average 107.5%. There-
fore, the mean difference in percentage correction between open
total cranial vault reconstruction and endoscopic suturectomy is
estimated to be 7% (P ¼ 0.02). (Supplemental Table 1, http://
links.lww.com/SCS/C133)
An example of sagittal craniosynostosis in a female child is
shown in Figure 1. This has been surgically corrected by total
cranial vault reconstruction at the age of 10 months and the
immediate postoperative results at the age of 12 months are shown
in Figure 2. In contrast an example of a female child with sagittal
craniosynostosis is shown in Figure 3. This patient underwent an
endoscopic suturectomy at the age of 5 months and helmet therapy
thereafter. The postoperative results at the age of 12 months are
shown in Figure 4.
DISCUSSION
Sagittal craniosynostosis is arguably the most common cranial vault
deformity that craniofacial surgeons deal with.28 Indications for
surgical intervention in sagittal craniosynostosis children are based
on whether any functional deficits have been detected and whether the
aesthetic deformity warrants a surgical correction. Both endoscopic
suturectomy with subsequent molding helmeting or open total vault
reconstruction have been shown to be equally effective.29 Despite
their effectiveness, both techniques incur a significant health care cost
and have well documented complications such as bleeding requiring
blood transfusion leading to prolonged hospital and intensive care
FIGURE 2. Postoperative photos of the child in Figure 1 at age 12 months after
undergoing total cranial vault reconstruction.
# 2021 Mutaz B. Habal, MD
Copyright © 2021 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
FIGURE 3. Preoperative photos of a female child with sagittal craniosynostosis
at 4 months of age.
unit (ICU) stay.14,30 However, the degree of correction and the subtle
differences in head shape between the 2 techniques have not been
investigated against a standardized outcome in studies and hence the
objective of this project. Hence, this study is unique in that it measures
the effectiveness of TCVR versus ES against a publicly generated
crowds standard that reflects the acceptability of head shape by
laypersons.24
As expected, this series showed that children with sagittal cra-
niosynostosis who undergo TCVR are older than those who undergo
ES. This is similar to other published literature and reflects an
inherent selection bias as the 2 procedures are indicated for different
age-groups of children. Endoscopic repair can only be performed,
whereas the skull bones are still amenable to molding likely within
4 months of age.9 A recent study by Melin et al found that of 88 cases,
ES were generally younger than those who underwent TCVR (3.8
versus 14.0 months).17 Although our study represents endoscopic
cases for sagittal craniosynostosis, the study by Melin et al represents
all types of synostosis and found that type of craniosynostosis is not a
factor in average age at the time of the procedure.17
The main finding from our study is that endoscopic suturectomy
and open total vault reconstruction were both effective in correcting
the preoperative cranial deformity accounted for by cranial index
measures (P < 0.05). This finding is consistent with published
literature. A study by Le et al reviewed 46 cases of sagittal
craniosynostosis, 13 open total vault reconstruction, and 33 endo-
scopic with a mean follow-up of 97 months.20 The average age at
surgery for the open group was 5.1 months compared to 3.3 for the
endoscopic group.20 They found no significant difference in post-
operative length, width, Cranial Index, and cranial volume mea-
surements between the 2 groups reinforcing that both procedures
seem to be equally effective in correcting the cranial deformity of
FIGURE 4. Postoperative photos of the child in Figure 3 at age 12 months after
undergoing endoscopic suturectomy and helmet therapy.
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Al-Shaqsi et al The Journal of Craniofacial Surgery
sagittal craniosynostosis.20 Moreover, this study highlights that
unlike some reports that suggest surgery causes diminished cranial
growth by inducing synostosis in other cranial sutures, in this series
the cranial volume is within normal limits for age and sex.15,20
The protocol for helmet therapy at our institution entails use for
4 to 6 months or until the patient is 12 months of age. The helmet is
worn for 23 hours of the day and adjustments are made every 3 to 4
weeks. Despite concerns regarding patient tolerance and skin
irritation as complications of helmet therapy, this study indicates
that helmet therapy following endoscopic suturectomy enables
comparable corrective results to TCVR methods.31–33 Until further
studies are conducted to indicate the inefficacy of helmet therapy,
our institution recommends the use of orthotic helmets following
ES among sagittal synostosis patients.
Based on a recent study which showed that a percentage correction
of 70% in sagittal craniosynostosis is required in order for the public
to consider the head shape to be normal then both techniques (TCVR
and ES) were able to achieve this benchmark (ES 100.42%  5.96%,
CVR 107.5%  13.5%). It is interesting to note that there is a
tendency for overcorrection among the CVR patient group (CVR
107.5%, SD  13.5%) more than that of E (100.4%  5.96. The CVR
patient group displayed a greater percentage change in cranial index
when compared to the ES patient group despite similar severity levels
as indicated by insignificant differences in preoperative cranial index
values among both groups (E 68.8  2.6, CVR 69.2  3.9,
P ¼ 0.3111). This reflects the fact that greater anatomical exposure
can be achieved with an open approach which could possibly translate
to the ability to overcorrect the deformity much more than limited
endoscopic approach. Theoretically, some degree of over correction
is required to counteract potential regression as the child grows.
Furthermore, it would be interesting to assess whether overcorrection
of cranial index translates to any noticeable esthetic deformity that
can be detected by lay persons.
Despite this study been the first to measure the effectiveness of
TCVR and ES against a crowdsourcing standard, there were several
limitations to be noted. First this study is not able to elaborate as to
why what is the main criteria for TCVR versus ES other than the age
of presentation. It is conceivable that factors such as surgeon’s
experience with one technique over another determined the clinical
decision. Other limitations included the inherent risk of missing
data in clinical charts. Other limitations are inherent errors in 3-
dimensional photography studies which include image distortion
due to movement or hair interference. This has been mitigated by
performing all 3D photographs under consistent standards by
having the children wear tightly fitting swimming caps. Addition-
ally, this study used cranial index solely as a measurement of
surgical outcome among sagittal synostosis patients. The protocol
for this study involved the use of an adjusted cranial index (aCI)
developed to enable better anatomical accounting of frontal and
occipital bossing. This is proven to prevent underestimation of
severity in scaphocephaly derived from the use of traditional CI
measurements.26 However, the sole use of aCI to account for cranial
deformity may still be lacking in documenting alternative morpho-
logical abnormalities that may persist among patients. Nevertheless,
a major strength of this study beyond the relatively large size and
long follow-up is the ability of this study to adjust for sex and age
cranial normative values to provide accurate estimates of cranial
index corrective changes. Despite such limitations this study was
able to highlight significant finding measurable against a crowd-
driven benchmark correction.
CONCLUSIONS
Sagittal craniosynostosis is a common presentation to craniofacial
surgeons. Current total cranial vault reconstruction and endoscopic
918
Copyright © 2021 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 32, Number 3, May 2021
surgical techniques are offered to children with sagittal craniosyn-
ostosis. This study showed that both techniques are effective in
correcting the head shape. More importantly, both techniques
confer significant improvement in head shape that is considered
‘‘normal’’ and meets the benchmark correction set by lay people.
Based on current available evidence, endoscopic repair seems more
cost-effective and as equivalent to total cranial vault reconstruction.
It is still important to appreciate that total vault reconstruction is
indicated for older children or where the deformity mandates a
wider surgical exposure to correct the deformity or where mallea-
bility of the skull bones cannot be harnessed with endoscopic repair.
Future research could address whether lay people are able to
distinguish between the outcome of the 2 techniques.
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