PURPOSE: Surgery to correct primary craniosynostosis, either a simple or a complex pattern, is well described in the literature.  This surgery usually occurs in the first year of life and results in an improvement of cranial growth and head shape.  However, the long term sequel of cranial vault surgery and the resulting deformities, as well as their corrections, is not well described.

METHOD: We describe our approach to the management of four patients that represent examples of typical secondary deformities occurring after cranial vault surgery in infancy.  The aesthetic defects become evident with differential/abnormal growth and development of the fronto-orbital regions during skeletal maturation.  The deformities can be divided into temporal hollowing, fronto-orbital deficiencies, and central forehead hollowing.  We review our protocols used to diagnose, image, and surgically correct the deformities for these patients.
Successful correction of these deformities requires the use of different surgical modalities to address different tissue components and regional morphologic differences.  We rely on fat grafting to resurface the areas of the cranio-orbital region primarily in the glabella region and at the junction of the temporalis muscle and the cranium.   When there is significant bony contour irregularity along the orbital rim, we use a solid hard tissue replacement (HTR) polymer based on a 3-D anatomic model. 
RESULTS: The patients were assessed for aesthetic improvement.  This was done both clinically and by the comparisons of preoperative and post operative digital photography. 

CONCLUSION: Secondary management of residual craniosynostosis deformities at skeletal maturity can be managed based on sound principles.  Successful correction of these deformities requires the use of different surgical modalities to address different tissue component and regional morphological differences.  When soft tissue deficiencies occur we use fat grafting.  When there are bony deficiencies we use synthetic polymers.