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To Operate or Not?: Surgical Decision-making Concerning the Spectrum of Orbitofrontal Deformity Associated with Metopic Suture Closure
Min-Jeong Cho, M.D.1, Rami R. Hallac, Ph.D.1, Maleeh Effendi, B.S.2, James R. Seaward, M.D.1, Alex A. Kane, M.D.1.
1University of Texas Southwestern Medical Center, Dallas, TX, USA, 2Texas Tech University Health Science Center School of Medicine, Lubbock, TX, USA.

Purpose:
Metopic suture closure can manifest from benign metopic ridge, a benign variant of normal, to “true” metopic craniosynostosis (MCS), a severe trigonocephaly. Currently, there is no gold standard for how much associated orbitofrontal dysmorphology should trigger surgical intervention. In our study, we used a semi-automated three-dimensional (3D) curvature analysis to separate the phenotypes along the spectrum, and have employed it in conjunction with cluster analysis to compare surgeons¹ thresholds for operation at one tertiary care craniofacial center.
Methods:
Retrospective chart review was performed identifying patients who presented with an early metopic suture closure and underwent computed tomography (CT) or 3dMD scans in the interval 2010-2015. Curvature analysis were performed on these images using two user-defined regions of interest (mid-forehead and lateral orbit). K-means cluster analysis was performed to test the consistency of surgical intervention threshold among the different surgeons.
Results:
Three-dimensional curvature and cluster analyses were performed in 43 patients. The difference in average mean curvature between patients who underwent operation and conservative treatment was 11.3 m-1 and -16.1m-1 for mid-forehead strip and right/left lateral orbit, respectively. The average mean curvatures of three regions of interest were significantly different (p<0.0001). In addition, K-means clustering classified patients into two different severity groups, and there was 96% agreement between the algorithm classification and surgeons’ decisions except two patients.
Conclusions:
The described methods are effective in classifying severity and associated surgeon behavior, and offer the possibility for determining when surgical intervention may have been of questionable benefit.


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