Craniofacial surgery: present and future.

The possibilities for radical craniofacial restructuring have increased dramatically in the past 6 years with the development of craniofacial surgery. The field developed from a background of patients with major craniofacial birth defects allowing orderly planning and expansion to correction of a multitude of other craniofacial structural problems. The procedures concentrate upon changing the skeletal structures using extensive subperiostial dissection of soft tissue, and adding bone to fill in areas of deficiency. There are three grades of complexity in craniofacial procedures. After extensive soft tissue sub-periostial stripping about the orbits and upper face, the simplest form consists of onlay bone grafts. The next most complicated involves osteotomies to shift the face into a more normal position. In its most complicated form, abnormal proportions of bone are removed and the orbits or cranium are shifted into a new or normal position. We have had experience with 69 patients since September, 1972. Thirty-six have had intracranial procedures. Infection has been the most serious problem, and there have been no instances of death or blindness. A number of lesser problems occur. Future applications of craniofacial surgery are appearing with great frequency as more experience is gained with its uses. It has particular application in acute and late reconstruction of patients with traumatic defects about the face. Preventive osteotomies are an area with great potential, by releasing stenotic areas of bone and allowing the developing brain to mold the upper face and orbits. There is also applicability in surgery of tumors about the craniofacial structure and in cosmetic surgery.     

Craniofacial surgery: the team approach.

Craniofacial surgery offers a new hope to some grossly deformed people. This complex surgery, which is based on a multidisciplinary team approach, needs to be carefully rationalized and regionalized to facilitate investigation, to improve planning, to reduce the number of complications, and to conserve financial resources. To date the Cranio-Facial Clinic at the Adelaide Children's Hospital and the Royal Adelaide Hospital has reviewed 37 cases and operated upon 13 of these. This work is presented together with a review of the team approach.     

Craniofacial surgery: airway problems and management

Airway problems are the greatest cause of morbidity and mortality during operations to repair craniofacial anomalies. These problems can be managed by awareness of the risks and prophylactic intervention rather than by desperate steps when acute problems occur in treatment. Airway obstruction is the major problem in managing patients with such deformities in the preoperative period, at the time of intubation, during the operation, and in the early postoperative period. Congenital craniofacial problems that may lead to airway difficulties are extremely rare, and for physicians to gain sufficient experience to prevent morbidity, these patients should be referred to regional centers, where at least two or three such operations are performed per week.     

Changing concepts of cancer surgery: surgery as immunotherapy.

Historically, the effectiveness of surgical therapy for cancer was thought to depend upon the successful removal of every last tumor cell from the patient's body. However, this view is not consistent with modern concepts of surgical oncology which suggest that successful cancer surgery depends upon how favorably it influences the patient's defenses against the cancer. Recent evidence suggests that the growing neoplasm is capable of evading immune attack by producing specific and nonspecific immunosuppression of the host's defenses to enhance tumor growth. The extent of the immunosuppression correlates with the tumor burden; immunosuppression is reversed by removing the neoplasm. Therefore, cancer surgery acts as immunotherapy because it removes the cancer cells that produce the immunodepression and allows the patient's immune response to recover.     

Craniofacial surgery and specific airway problems

Infants and children undergoing craniofacial surgery may present with a wide range of diseases and conditions posing an array of challenges to the anesthesiologist. Optimal perioperative care requires an understanding of these diseases and their impact on airway and anesthetic management. For those children with anomalies affecting airway anatomy, soft tissues of the head and neck, or skeletal mobility, advanced airway management techniques (ie, modalities other than direct laryngoscopy) may be required to secure the airway. Additionally, some craniofacial surgical procedures have direct implications on airway management, such as with Le Fort III midface advancement involving halo distractor application, where the distractor device precludes facemask ventilation. For all of these patients, the anesthetic and airway management plans must be tailored to the surgery being performed, the patient's specific conditions, and take into consideration all phases of perioperative care. In this review, we present some of the more commonly encountered craniofacial abnormalities affecting airway management.     

Fast-track concepts in routine pediatric surgery: a prospective study in 436 infants and children

Background and aims  The aim of this study was to investigate fast-track concepts in routine pediatric surgery in a university clinic over 1 year. Patients/methods  Fast-track concepts were established for procedures requiring hospital admission in patients up to 15 years of age. Patients were studied prospectively from June 2006 to June 2007. Results  Out of a total of 436 potentially suitable patients, 155 (36%) were finally treated following the protocols. The mean intensity of pain in children younger than 4 years (CHIPPS, 0–10) was 1.3 ± 1.5 the evening of the operation day and decreased to <1 at all other time points. The initial postoperative mean pain intensity in older children (Smiley/VAS, 1–10) was 3.7 ± 2.2 and decreased constantly thereafter. The mean hospital stay of fast-track patients was significantly shorter compared with German diagnosis-related group data (4.6 ± 2.9 versus 9.7 ± 3.8, p < 0.01). There were four (3%) readmissions for minor complications. At follow-up after 2 weeks, 95% of patients and parents judged fast-track care as excellent. Conclusion  Fast-track concepts are feasible in one third of pediatric patients undergoing routine in-hospital surgery. Fast-track pediatric surgery achieves accelerated convalescence, minimal hospital stay, and high patient and parent satisfaction.     

Craniofacial necrotizing fasciitis: reconstruction after radical surgery

An otherwise healthy 47-year-old male is described, he developed craniofacial necrotizing fasciitis of the scalp and face after having undergone dental extraction. Escherichia coli and coagulase-negative staphylococci were isolated from his wound cultures. Multiple debridement operations were necessary, with subsequent loss of his left eye and which resulted in severe mutilation. Both magnetic resonance imaging and computed tomography scanning helped to demonstrate the retrobulbar infection of his left eye. These were thus helpful to determine the extent of the disease and plan the course of surgery. Although we recognize that free flap surgery is the method of choice to cover this type of defect, we describe an alternative method of reconstruction. We have made multiple burr holes in the skull and used a low vacuum device to create a significant and viable layer of granulation tissue which was then covered with split skin grafts.     

Craniofacial morphology in untreated and shunt-treated hydrocephalic children

Craniofacial morphology was studied in 45 shunt-treated hydrocephalic children and 7 untreated hydrocephalic patients. A sample of 74 normal children from northern Finland were used as controls. Following shunt treatment the sella turcica became shallow and J-shaped. The cranial base angles changed markedly during shunt treatment. The cranial base angles were more obtuse in untreated patients than in control subjects, whereas the opposite was the case in shunt treated patients. The Nasion-Sella-Basion angle was 143.4 degrees in untreated hydrocephalic patients, 132.6 degrees in normal subjects and 127.9 in shunt-treated hydrocephalics. The changes in cranial base angles appeared to be progressive during a two-year follow-up period.     

Rhinosurgery in children: basic concepts

In newborns, the main supporting structure of the nose is the dorsoseptal cartilage, a T-bar-formed complex of septum and upper lateral cartilages, which is essentially an external extension of the cartilage of the anterior cranial base. Later the anatomic situation gradually changes -- a potential pitfall for surgeons and radiologists. The vulnerability of various processes underlying postnatal development of the facial skeleton is discussed. The cartilaginous septum is the dominant growth center. Loss of septal cartilage at different ages leads to different facial syndromes involving nose, maxilla, and orbita. The septal cartilage in children demonstrates thinner fracture-prone areas next to thicker growth zones. Septum fractures have a preference for the thinner regions, corresponding with the most frequent septum deviations observed in growing children. The essential problem in pediatric rhinosurgery is not the age-specific anatomy but the poor wound-healing capacity: fractured or transected septum cartilage will not heal, and disconnected ends tend to overlap, resulting in increasing or recurrent deviations. Based on clinical and experimental evidence, indications and "safe" and "unsafe" techniques of rhinosurgery are presented for children of various age groups.