From 1973 to 1986, 50 infants with sagittal synostosis have been operated by three different methods of craniectomy (linear craniectomy and extended craniectomies, as proposed by Schut and Epstein et al.). Preoperatively, the mean cephalic index was 67 +/- 4, 35.5% had clinical findings as cerebral palsy, psychomotor retardation and/or neurological signs, and intraoperatively the epidural pressure was more than 200 mm H2O in 60% (recorded in the last 20 patients). The mean follow-up time was 4.7 (1-10.6) years. Postoperatively, only 14.5% had minor clinical signs, which were mostly not in relation to the former scaphocephaly. Half of the patients with increased ICP had clinical signs preoperatively, and none of the 20 patients had distinct findings postoperatively. Out of the 20 children operated on by linear craniectomy or by Schut's method up to 1980, two-thirds had no school problems and one-third some school problems; one-third had occasionally headaches and one-quarter ametropia. Concerning the aesthetic results, Epstein's method and, somewhat less Schut's method, were superior to linear craniectomy, as verified by craniometry and by the tracings of the outlines of the neurocranium 0.4-0.7 and 1.6-2.0 years postoperatively: mean cephalic indices 73 +/- 5 (normal in one-fourth), 74 +/- 7 (normal in half) and 79 +/- 4 (normal in nearly all patients). Epstein's method is superior to the other two methods because it renders it possible to increase the breadth the greatest during the period of greatest postnatal brain growth. In addition to the effect on the neurocranium, the extended craniectomies add to normalization of the base of the skull (in contrast to the natural history of scaphocephaly). In the long run, the results obtained remain the same. The disadvantage of residual skull defects (approximately 11% of the patients with extended craniectomies) can be avoided by performing surgery prior to 4-6 months of age or by preserving the removed bone in a deep-freeze for a limited time.

Methods: In order to assess intermediate-term speech outcome after pharyngeal flap surgery for velopharyngeal dysfunction in children with cleft palate between 1980 and 1998, their pre- and postoperative speech performance was analyzed in a blinded fashion by speech pathologists and adult lay people. Speech was evaluated on the basis of tape recordings with regard to resonance, intelligibility, articulation, voice and secondary speech disorders. Results: Twenty-three patients could be evaluated. Both lay assessors and speech pathologists noted a significant improvement in speech performance after pharyngeal flap surgery. The percentage of children who improved was 83% (19/23, 95% confidence interval: 0.68–0.98, p = 0.002) when rated by lay people, and 87% (20/23, CI 0.73–1.01, p < 0.0001) when rated by professionals. Rated on a 5-point scale, the mean improvement per speech characteristic was 0.52 ± 0.32 scale points when judged by lay people, and 0.75 ± 0.8 points when judged by experts. Experts considered none of the children to have normal speech after surgery. Agreement with regard to outcome between lay people and speech pathologists occurred in 87% of the patients. Conclusion: The cranially based pharyngeal flap can improve speech performance in cleft palate children with chronic velopharyngeal insufficiency. However, it cannot be expected that this type of surgery will result in normal speech.

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