Rigid fixation and osteotomy design in frontal orbital advancement osteotomies

The advantages rendered by corrective osteotomies that mobilize large segments of the craniofacial complex, including the forehead, orbits, and maxillae, exceed those of any partial correction in this particular region. This fact has been fully demonstrated in recent years by different authors. An inconvenience of early correction of major craniofacial deformities is relapse at the maxillary level, mainly because of the lack of adequate dental occlusion. Rigid fixation methods have been used in surgical correction of Crouzon's disease and Apert's syndrome in order to preserve the position of the mobilized segments. In Crouzon's cases conventional monoblock advancements were performed, using anchor wire osteosynthesis at the frontal region and two metal plates attached to the temporal bone to support the middle third of the face. In Apert's syndrome cases, a monoblock advancement modified by the facial bipartition concept was the selected procedure to obtain a three-dimensional correction. Because a midfacial vertical elongation was necessary, a third plate joins the hemi faces, fixing them to the intermediate frontal bar. Advantages of this method have been demonstrated over the past 2 years. Sixteen children had a one-stage reconstruction by multiple osteotomies and extensive, combined mobilizations of the craniofacial complex. Successful long-lasting corrections attest to the efficacy of this fixation method.     

Airway obstruction in severe syndromic craniosynostosis.

Airway obstruction is frequent in patients with severe syndromic craniosynostosis, and must be treated for successful, complete care. The purpose of this study was to evaluate the incidence and the management of airway obstruction in patients with severe craniosynostosis. All patients with complex syndromic craniosynostosis at Chang Gung Craniofacial Center were evaluated retrospectively. Criteria for inclusion of patients were the presence of adequate follow-up and documentation. A total of 40 patients were included, of whom 13 had Apert's syndrome and 27 had Crouzon's disease. Clinical symptoms and signs related to airway obstruction and its treatment were evaluated carefully, and were verified further by telephone inquiry. The status of the airway was categorized into one of three groups: no obstruction; mild obstruction, for which positioning and medical treatment were needed; and severe obstruction, for which surgical intervention was needed. The results showed that 24 patients (60%) did not have airway obstruction, 11 patients (27.5%) had mild obstruction, and 5 patients (12.5%) had severe obstruction. There was no significant difference in the distribution of airway status between patients with Apert's syndrome and Crouzon's disease. Causes for the 5 patients with severe obstruction were midface hypoplasia, lower airway obstruction, tonsillar and adenoid hypertrophy, and choanal atresia. Tracheostomy was performed to control airway in 3 patients, and 1 patient died. Midface anterior distraction helped to decannulate 1 patient. In conclusion, airway obstruction was observed in 40% of patients with severe craniosynostotic syndromes. Most of them could be managed successfully with conservative or medical treatment, and surgical intervention should be considered on the basis of each patient's individual condition.     

MacroPore resorbable devices in craniofacial surgery

Resorbable polymer implants have become a compelling option in the treatment of acquired and congenital craniofacial deformities. The resorbable polylactide (PLa) and polyglycolide (PGa) polymers in particular have demonstrated excellent safety profile sin multiple in vitro, animal, and clinical studies and are currently being used in a wide variety of craniofacial applications. In this article, the authors discuss the biomaterial properties of PLa and PGa resorbable implants and provide an overview of the use of these polymers in craniofacial surgery. They conclude by relating their experience with an ongoing clinical series using MacroPore PLDLa and FRP implants for various applications,including Le Fort osteotomies, midface/monobloc internal distraction, and craniosynostosis reconstruction.     

Endoscopic intracranial craniofacial and monobloc osteotomies with the aid of a malleable high-speed pneumatic drill: a cadaveric and clinical study

Endoscopic techniques are now an accepted part of the surgical armamentarium and are used routinely in a number of aesthetic and reconstructive procedures. Endoscopic techniques are now being used commonly by plastic surgeons in forehead and face lifts. In both craniofacial surgery and in neurosurgery, the application of endoscopy potentially allows the surgical team to perform wide dissection of the dura mater in a minimally invasive fashion, thereby potentially reducing the risk of dural and brain injury. Also reduced by this surgical approach is potential injury to the major venous structures, such as the sagittal sinus, along with overall reduced bleeding. After an extensive laboratory study of 10 cadaveric dissections, the authors have refined a new endoscopic technique for completing an endoscopic intracranial craniofacial osteotomy. This study was conducted in the Department of Pathology at the University of Brno (Czech Republic), and was performed as a cooperative multicenter project between the University of Palermo, the Albert Einstein College of Medicine/ Montefiore Medical Center, the Hospital Infantil de Mexico, "Federico Gomez," and the Medtronic Midas Rex Institute, (Fort Worth, TX). During this cadaveric anatomic study and using small trephinations and skin incisions the authors were able to develop several different craniofacial and endoscopic monobloc procedures. To accomplish intracranial and facial osteotomies, a new malleable high-speed drill was designed for use in the endoscopic craniofacial approach. Using these newly developed cadaveric techniques and instrumentation, the authors performed two intracranial craniofacial procedures on children with congenital craniofacial anomalies. There would appear to be several significant advantages for the craniofacial patient as result of these new techniques: reduced surgical trauma, operative bleeding, surgical time, and hospitalization, along with a reduced risk of infection. It became quickly apparent, as a result of these cadaveric studies, that the learning curve for this endoscopic procedure is quite steep. Tutino M, Chico F, Tutino M, Goodrich JT, Ortiz Monasterio F. Endoscopic intracranial craniofacial and monobloc osteotomies with the aid of a malleable high-speed pneumatic drill: a cadaveric and clinical study.     

Craniofacial surgery in children: concepts and questions.

Craniofacial surgery is an exciting new subspecialty of medicine. It is strictly a team project that will function well only in a tertiary medical center. Particular coordination is needed among the plastic surgeon, neurosurgeon, anesthesiologist, and pediatrician. This article considers many of the potential advantages and some of the disadvantages of performing craniofacial surgery on infants. It is difficult or impossible, based on current knowledge, to predict the ultimate limits of such new techniques. The history of surgical evolution, however, continues to demonstrate that what "at first observation" was thought to be impossible or undesirable often evolves, with more understanding, to be the desired course of action. It was entirely appropriate that the initial craniofacial surgical efforts be generally confined to adult-type patients, but the currently available technical refinements have developed such procedures to the point where they now have a definite place in infant surgery as well. Continued clinical investigative research will provide further information regarding the eventual benefits and perhaps will lead to surgical techniques in neonates that will actually prevent the development of certain predictable deformities.     

Traumatisches intrakranielles Aneurysma der Arteria carotis interna bei longitudinaler Fraktur des Orbitadaches

A case of traumatic supraclinoidal aneurysm of the internal carotid artery is presented. The patient with adventitious multiple lesions of the midface was successfully treated by a team consisting of a neurosurgeon, a traumatologist, and a dental surgeon. As an example, this case presents the diagnostic problems, and the operative treatment. Problems of post-traumatic intracranial vasospasm are discussed.     

Evaluation of craniofacial surgery in the treatment of facial deformities.

Surgical access to the cranial, orbital, and facial areas, as developed by Tessier, has produced not only definitive repair of previously uncorrectable congenital deformities such as orbital hypertelorism and facial stenosis (e.g., Crouzon's, Apert's syndromes) but also has improved markedly the treatment of traumatic and neoplastic defects. The surgical approach allows complete dissection of facial soft tisses including the orbits from the underlying bones followed by corrective osteotomies and fixation. Mobilization of the frontal lobes through a frontal bone flap exposure may be required. The ramifications of this latest intrusion by surgeons into a previously inviolate anatomic area have involved neurosurgeons, ophthalmologists, anesthesiologists, and dental and psycho-social disciplines. The disciplines of genetics and embryology are being influenced by this new field of surgery, much as the study of immunology was influenced by transplantation surgery two decades ago. This report analyzes a 10 year experience with over 100 patients with emphasis on patient selection by disease, age, intellectual status, morbidity, complications, and the psycho-social reactions of patient and family. Procedures initially planned to correct dental and aesthetic defects are proving beneficial for other functions including hearing, taste and smell, articulation and tongue movement, respiratory function, vision, and possibly bone growth. The development of self image, a normal process always in operation, is also strikingly altered. These operations may last as long as 14 to 16 hours. We have had no deaths or postoperative blindness. One postoperative cerebrospinal fluid leak was successfully repaired. Three partial losses of bone grafts and four instances of late cellulitis have occurred. Prevention of infection seems related to avoidance of dead spaces and primary closure of all mucosal, dural, conjunctival and skin surfaces.     

Craniofacial surgery for craniosynostosis improves facial growth: a personal case review

An evaluation of 220 cases of frontocranial remodeling for craniosynostosis is reported. The follow-up period was 10 years for children, 7 years for infants. The principles of the craniofacial techniques described in 1974 [4] and 1978 [3] were not modified; only variations were added. The floating forehead [5] concept has also remained basically unchanged. Intracranial pressure recordings have been used continually to help evaluate borderline indications and to assess results [9]. Our results show that 14% of cases of craniosynostosis affecting only one suture, usually considered as merely aesthetic problems, in fact were accompanied by increased intracranial pressure. The postoperative recordings have shown a return to normal pressures. Growth has not deteriorated the initially satisfactory results at the level of the forehead. At the midface level, improvement has been observed after surgery, especially for plagiocephalics. Their orbitonasal asymmetry has nearly completely disappeared. Patients with bilateral faciocraniosynostosis show an improvement of midface development compared with non-operated patients, but in severe cases an inverted bite still develops and further facial osteotomies remain necessary. The Apert's patients remain the most difficult to improve.     

Endoscopically assisted fronto-orbitary correction in trigonocephaly

The development of multidisciplinar Units for Craneofacial Surgery has led to a considerable decrease in morbidity even in the cases of more complex craniofacial syndromes. The use of minimally invasive techniques for the correction of some of these malformations allows the surgeon to minimize the incidence of complications by means of a decrease in the surgical time, blood salvage and shortening of postoperative hospitalization in comparison to conventional craniofacial techniques. Simple and milder craniosynostosis are best approached by these techniques and render the best results. Different osteotomies resembling standard fronto-orbital remodelling besides simple suturectomies and the use of postoperative cranial orthesis may improve the final aesthetic appearence. In endoscopic treatment of trigonocephaly the use of preauricular incisions achieves complete pterional resection, lower lateral orbital osteotomies and successful precoronal frontal osteotomies to obtain long lasting and satisfactory outcomes.     

Adjuvant techniques for the management of large carotid body tumors. A case report and review

Although the first successful resection of a carotid body tumor was reported over 100 years ago this operation remains technically challenging with many potential pitfalls. The case of a man with a large (8 cm) carotid body tumor will be presented in order to identify key issues that pertain to effective diagnostic and therapeutic modalities. A multidisciplinary team (vascular surgeon, neurosurgeon, neuroradiologist, interventional radiologist and oromaxillofacial surgeon) provided specific expertise on each aspect of the patient's evaluation and treatment. Adjuvant techniques employed in this case included angiographic tumor embolization, jaw subluxation, strap muscle division, nasotracheal intubation, carotid resection and saphenous vein interposition grafting.     

Neurosurgical considerations in cranio-orbital surgery

The neurosurgeon is an integral member of the craniofacial team. The role of the neurosurgeon in the preoperative planning, intraoperative management, and postoperative follow-up of patients with craniofacial malformations is reviewed.     

Simultaneous multiple vector distraction for craniosynostosis syndromes.

Syndromic craniosynostoses are commonly treated conditions in craniofacial units. The features of the common syndromes (Apert, Pfeiffer and Crouzon) all include craniosynostosis, mid-face hypoplasia and ocular proptosis. The craniofacial management of a child with these syndromes through to adulthood may require a number of surgical interventions to allow brain development, to provide an adequate airway, to prevent corneal ulceration and to provide a functional dental occlusion. The management of these different priorities into timed interventions in our unit is determined by established protocols. We report two cases that underwent simultaneous mid-face (Le Fort III) and fronto-orbital osteotomies followed by distraction but using different vectors to advance the upper and mid-face regions (to achieve all treatment goals) in a 12-year-old boy and a 16-year-old girl.     

Occipital plagiocephaly.

The diagnosis of occipital plagiocephaly has remained a complex and controversial issue in the field of craniofacial surgery. Over the past 30 years, numerous studies have been published describing the management and treatment for 'posterior plagiocephaly', 'plagiocephaly without synostosis', 'deformational plagiocephaly' and 'occipital plagiocephaly', with surgical 'correction' being chosen as the primary modality of treatment irrespective of the patency status of the lambdoid sutures.Two hundred and four patients with unilateral occipital plagiocephaly have been seen at the Australian Craniofacial Unit over the past 16 years. Each patient was evaluated by a craniofacial surgeon, paediatric neurosurgeon and paediatric geneticist. All children underwent plain radiographs of the skull to define the sutural anatomy. In those patients where the sutural anatomy was equivocal, 2-D and 3-D CT scans were performed.Only two of the 204 patients (approximately 1%) manifested the clinical, radiographic and pathological features of true unilambdoid synostosis. There was radiographic evidence of sutural fusion on plain films, 2-D and 3-D CT scans. Pathology specimens showed bony sutural fusion.Two hundred and two patients presented with unilateral occipital deformities and patent sutures on radiography. These patients with occipital plagiocephaly in the absence of true synostosis were initially managed conservatively (head positioning, and physiotherapy in those patients with torticollis). Those patients who underwent surgical correction in infancy (21/204) included patients with severe plagiocephaly not responding to conservative therapy (19/204) and the two patients with true unilambdoid synostosis (2/204).One hundred and ninety-one of the total patients (94%) were noted by their parents to have acceptable improvement in their head shape. Thirteen patients were seen within the past year and are too early to assess. Two surgical patients (one fronto-orbital advancement, one occipital craniectomy) and one patient followed conservatively were judged by their parents to be without notable improvement. In our series it is apparent that the majority of cases of occipital plagiocephaly are not secondary to true synostosis and can be managed by conservative positional measures.     

The use of rapid prototyping in the preoperative planning of distraction osteogenesis of the cranio-maxillofacial skeleton.

OBJECTIVE: In cranio-maxillofacial surgery, the principle of distraction osteogenesis (DO) can be used for the reconstruction of the deformed skull, midface complex, mandible and alveolar ridge. Optimal results can only be obtained with accurate planning of the osteotomies and accurate positioning of the distraction device. In addition, the surgical planning must be transferred very precisely to the patient in the operating theater. The clinical accuracy and utility of stereolithographic models in cranio-maxillofacial distraction osteogenesis of the midface, mandible and alveolar ridge will be demonstrated. MATERIALS AND METHODS: Thirteen patients were treated by DO in the cranio-maxillofacial skeleton. Five patients suffered from midface retrusion and were treated by a LeFort III advancement. One patient suffered from an aseptic necrosis of the condylar process of the mandible and had a reconstruction of the condylar process by DO. Seven patients underwent an osteotomy of the alveolar ridge of the mandible with subsequent placement of distraction screws and implants because of advanced atrophy of the mandible. Following preoperative acquisition and conversion of the CT-scan data, a model was fabricated by stereolithography (SLA). Simulation of the osteotomies and placement of distraction devices was performed on these models, then surgical guides were used to transfer the surgical planning to the patient in the operating theater. Pre- and postoperative facial photographs and X-rays were compared to evaluate the accuracy of the transfer procedure. RESULTS: In all cases, matching of pre- and postoperative facial photographs and X-rays showed reconstruction of the bony structures to be as accurate as planned on the SLA models. Transfer of the surgical plan by means of custom-made surgical guides was optimal in all cases. CONCLUSION: Preoperative planning of distraction osteogenesis of the cranio-maxillofacial skeleton and transfer to the operating theater by custom-made surgical guides remains the standard procedure for the planning of complex distraction cases. However, improvements in surgical simulation software and accurate virtual-reality surgery will probably make the use of these models redundant in the future.     

Comprehensive correction of the craniofacial deformity in achondroplastic dwarfism.

The treatment of this patient serves to demonstrate a craniofacial team approach to a unique and moderately severe problem. By the modification and careful combination of standard techniques, i.e., frontofacial advancement, and Le Fort I and vertical mandibular osteotomy, a good correction has been obtained. Analysis of the problem clearly indicated the need for moving multiple components of the facial skeleton into new positions to provide correction. The upper and lower midface required simultaneous movements in exactly opposite directions to normalize the skeletal deformity. To address the excess forehead height and projection, a modification of the usual frontofacial advancement was necessary. Rotation of the frontofacial segment forward inferiorly allowed correction of the orbital deficiency while also allowing shortening of the vertical forehead dimension. This is a deviation from the straight linear advancement usually dissected. Simultaneous retroposition and rotation of the maxilla allowed correction of the plane of occlusion while lengthening the midface. The unique combination and application of standard techniques of craniofacial surgery in this patient allowed a very good result.     

General surgery and trauma.

While some degree of specialization is essential in surgery there remains a place for the general surgeon. The tendency to regard surgical intensive care as a specialty should be resisted. Similarly the surgery of trauma should remain in the field of the general surgeon in full co-operation with the orthopaedic surgeon and, in special circumstances, the neurosurgeon.     

Pitfalls of midface surgery

The endoscopic forehead midface lift is perhaps the most powerful tool has been made available to the facial aesthetic surgeon in the last 10 years. Although this technique can reap the greatest rewards, it is also fraught with the greatest peril. A difficult dissection, prolonged period of edema, and numerous other pitfalls have tempered enthusiasm among facial aesthetic surgeons for this powerful technique. Nonetheless, the midface lift can be performed both safely and effectively. Through careful analysis of the pitfalls of midface surgery, one can adopt principles that help prevent or minimize potential complications. Such an approach can maximize the surgical benefit to the patient and lessen the anxiety surrounding the procedure for the patient and surgeon alike.     

Distraction osteogenesis of the midface: a new implantable distraction device

This report describes the use of a new implantable device for distraction osteogenesis of the maxilla in treatment of midface hypoplasia seen in craniofacial syndromes. The technique of distraction osteogenesis is a recent advance in plastic surgery for treatment of bone growth disorders. The device is totally implantable except for the activating pin and can provide up to 30 mm of total advancement. We will describe our surgical technique and distraction protocol, illustrated by a case report of the device successfully used in a child with Crouzon syndrome.     

Orthopaedic surgery and rehabilitation in rheumatoid arthritis.

Orthopaedic surgical procedures are episodes in the continuing management and rehabilitation of the patient with rheumatoid arthritis. Well-chosen procedures give excellent relief of symptoms and deformity, and successful management is a prime example of rehabilitation requiring considerable team work from physician, surgeon, therapists, social workers and nursing staff. Team work enables the rheumatologist to be in charge of the overall management of the patient through the clinic with responsibility for general medical care, while the surgeon can take charge during periods in hospital for surgery and the immediate postoperative outpatient care. Cooperation between physician and surgeon eases each of some of the clinical burden that is at present provided by this disease.     

Infantile craniosynostosis: Clinical,radiological, and surgical considerations based on 100 surgically treated cases

Summary One hundred children affected by craniosynostosis were operated on from January 1952 to February 1977.Forty-six patients were operated on within the first year of life, and only 9 after six years of age.In 27 cases only one cranial suture was synostotic (mostly the coronal: 15 cases). In 36 cases two sutures were involved (mostly coronal plus sagittal: 25 cases). In 28 cases all the cranial sutures were involved. Also included in this series are seven cases of Crouzon's, one of Apert's, and one of Carpenter's syndromes. The clinical, radiological, and surgical features of this condition are discussed, and the long-term results are reported.