PRS Journal Club: Craniofacial Symmetry Progression, Long-Term Cranial Vault Remodeling Outcomes, and Syndromic Risk Stratification

Craniosynostosis management has undergone substantial evolution, driven by advances in surgical technique, perioperative care, and longitudinal outcome assessment. Yet despite technical refinements, challenges remain, including the understanding of progressive changes with growth, preventing relapse and contour deformities, and objectively stratifying phenotypic severity to guide individualized treatment planning, particularly in syndromic disease. In the July of 2026 edition of PRS Journal Club, the 3 studies presented collectively address these gaps across the spectrum of craniosynostosis, from single-suture deformities to complex syndromic pathology, offering insights into the durability of correction, temporal patterns of craniofacial remodeling, and quantitative risk stratification. The 30-year single-surgeon retrospective review, “Long-Term Outcomes following Craniosynostosis Corrections: A 30-Year Retrospective,” by Coombs et al., represents one of the largest and longest follow-up series examining outcomes after remodeling procedures for single-suture craniosynostosis.1 The main strength of the study lies in its focus on skeletal maturity, a rare endpoint in the craniosynostosis literature.2 Among 924 procedures, including 752 primary procedures, the authors report low perioperative morbidity (0.7%), no deaths, a median hospital stay of 2 days, and a marked reduction in transfusion rates over time. Importantly, although the early secondary surgery rate was 3.4%, it increased to 20% among patients followed up for 15 years or more, underscoring the idea that early outcome reporting may underestimate long-term relapse or residual deformity.3 The observed decline in head circumference Z-scores over time further supports the concept of postoperative growth restriction following remodeling, reinforcing the authors’ rationale for overcorrection and delayed intervention.4 Their analysis suggests that each month of surgical delay is associated with a 15% reduction in the odds of secondary surgery. The temporal evolution in technique, toward operating at older ages and incorporating overcorrection, correlated with lower reoperation rates. The study by Harrison et al. in this issue, titled “Craniofacial Symmetry Progression following Strip Craniectomy in Unilateral Coronal Craniosynostosis,” provides a quantitative evaluation of craniofacial symmetry progression following strip craniectomy with helmet therapy for unilateral coronal craniosynostosis.5 Strip craniectomy offers an alternative to fronto-orbital advancement that has been associated with lower perioperative morbidity and a lower incidence of strabismus.6 Using serial 3-dimensional photogrammetry at standardized postoperative intervals over 2 years, the authors offer a depiction of how individual craniofacial features evolve. The most compelling finding is the rapid, statistically significant improvement in all measured asymmetries at 3 months postoperatively, with many parameters approaching or becoming similar to those of controls by 1 to 2 years. Composite imaging further enhances interpretability by visually demonstrating the correction’s tempo. Importantly, the study identifies persistent residual asymmetries in orbital width and midface projection at 2 years, offering a possible explanation from coronal ring involvement.7,8 The study advances our understanding of the temporal dynamics of correction after strip craniectomy in unilateral coronal craniosynostosis. It provides valuable data for surgical counseling, particularly with regard to which asymmetries normalize and which may persist. The final study, “The APERT Severity Scale: A Quantitative Tool for Risk Stratification in Apert Syndrome,” by Hu et al., introduces the APERT Severity Scale, a multidomain classification system designed specifically to stratify craniofacial severity in Apert syndrome.9 Drawing from a single-institution cohort of 37 genetically confirmed patients followed up to at least 11 years of age, the authors developed a 5-domain framework, including airway, pressure (intracranial), eyes, retrusion, and turribrachycephaly, that captures both morphologic and functional disease burden.10–12 A key strength of the work is its deliberate focus on preoperative phenotype, ensuring that scores reflect intrinsic severity rather than treatment effect. The scale is intuitive and grounded in observable findings, yet sufficiently discriminant to distinguish among mild, moderate, and severe phenotypes. Importantly, the total APERT score demonstrated a strong correlation with surgical burden (P < 0.001), and a cutoff score of 9 or higher predicted the need for 6 or more craniofacial operations with 100% sensitivity and 86.7% specificity. These findings provide compelling early evidence that the scale has meaningful prognostic utility. Together, these 3 studies underscore that durable outcomes in craniosynostosis depend not only on operative technique but also on an improved understanding of growth, relapse, and baseline phenotypic severity. Long-term follow-up after cranial vault remodeling demonstrates that early success may not equate to skeletal maturity stability, reinforcing the importance of timing, overcorrection strategies, and extended surveillance. Serial analysis of strip craniectomy outcomes in unilateral coronal craniosynostosis further refines our understanding of the tempo and pattern of symmetry restoration, distinguishing parameters that reliably normalize from those prone to residual asymmetry. Finally, the APERT Severity Scale advances the field toward objective, preoperative risk stratification in syndromic craniosynostosis, linking quantifiable phenotype to surgical burden. Collectively, these contributions emphasize a shift from short-term morphologic correction toward longitudinal, data-driven, and individualized care. DISCLOSURE The authors have no relevant financial disclosures to report.