Anderson presented the results of 107 cases of metopic and coronal synostosis in 1981, advising “that craniofacial operations for synostosis should be as extensive as necessary” [
6]. After that, Freide et al. were one of the first to attempt an aesthetic evaluation of their treatment for metopic synostosis [
30]. Their retrospective review of 11 cases consisted of six operated and five non-operated children with metopic synostosis. Advancement and straightening of supraorbital bone contour was performed in all six cases. Three to four years after surgery, the osteotomy lines where hardly found on palpation except temporally where the tongue in groove advancement sometimes yielded slight bone irregularity. They concluded that, since minor characteristics were still present after such a long time, a modification seemed appropriate to enhance restitution of forehead width and morphology of the temporal regions. Cohen et al. noted none or minor irregularities in 9 of their 17 cases in which photographic analysis was done. Their reoperation rate was 18 % [
16]. Posnick et al. investigated structural improvements of the periorbital region following corrective surgery using CT data in ten patients, concluding that “anterior cranial vault and lateral orbital wall positions were corrected successfully and remained in good position despite subsequent growth. The orbital hypotelorism, although improved, remained undercorrected” [
75]. Havlik et al. adjusted their technique based on these same issues of correction of hypotelorism and prevention of temporal hollowing in ten cases with severe trigonocephaly, using a midline interposition bonegraft and temporal extension graft to reduce these problems [
37]. They later on follow-up on this and reviewed their 68 metopic synostosis patients, concluding that preoperative frontal irregularities and reduced preoperative intercanthal distance predisposed to inferior aesthetic outcome while interpositional bonegrafting reduced the postoperative rate of temporal hollowing [
37,
84]. In 2002, Hinojosa commented on their series of 28 cases, grading as high as 85 % good to excellent cosmetic results with an average follow-up of a little over 2 years (27 months) [
40]. Aryan et al. noticed a recurrence of the midline ridge in 3 out of their 39 cases, requiring a reoperation in two [
10]. Hilling et al. remarked that results were persistently good over the years if the operation managed to achieve good reposition of the forehead in the first place [
39]. Greenberg et al. recently found a 15 % reoperation rate in their 50 cases, again mainly for correction of temporal hollowing [
35].
An extensive radiological analysis of the largest series to date (92 cases, all operated according to the technique described above) revealed a tendency of auto-correction of the hypotelorism as a result of an increased postoperative interorbital growth rate. Temporal hollowing seemed to be the most commonly seen postoperative abnormality, which coincided with a notably reduced postoperative growth rate of the bony temporal region [
97]. A subsequent study confirmed that reduced bone growth (and not soft tissue factors) was the major contributor to this temporal hollowing [
99].