Roman Arch, Keystone Fixation for Facial Bipartition with Monobloc Distraction:

Apert Syndrome: Selection Rationale for Midface Advancement Technique

Apert syndrome is characterized by a wide spectrum of craniofacial clinical features that have been successfully addressed via a variety of midface advancement techniques. Although surgeons have individual preferences as to which specific procedures should be performed to best treat Apert patients, craniofacial plastic surgeons, working in tandem with pediatric neurosurgeons, can identify and evaluate functional limitations and facial morphologic disproportions, and establish appropriate criteria for effective midface advancement technique indication and selection. The purpose of this review article is to present and discuss our rationale for midface advancement technique selection based upon the most common craniofacial characteristics presented by Apert syndrome patients. The present article also provides a grading system that stratifies as major, moderate, and mild, the effect of each midface advancement technique on the different types of Apert syndrome facial features. Surgeons should take into consideration the maximum effect and benefit of each craniofacial osteotomy and how these procedures will alter the craniofacial skeleton. By understanding the long-term effect of each osteotomy on the most common craniofacial characteristics of Apert syndrome patients, craniofacial plastic surgeons and neurosurgeons will be able to customize the surgical procedures they perform in order to achieve the best possible outcomes.

Hypertelorbitism Corrected by Facial Bipartition Improves Exotropia

BACKGROUND

The purpose of this study was to detail perioperative ophthalmologic evaluations to characterize functional ocular outcomes after facial bipartition surgery.

METHODS

Patients with hypertelorbitism who underwent facial bipartition surgery were studied specifically for eye motility disorders by separating patients into rare craniofacial clefts (midline and paramedian) (n = 34) and craniofacial dysostosis (Apert, Crouzon, and Pfeiffer) (n = 74). Preoperative and postoperative (12 months) ophthalmologic examinations (with depth perception tests), computed tomography scans, and magnetic resonance imaging scans were analyzed.

RESULTS

Among craniofacial cleft patients, mean interdacryon distance was reduced from 39 ± 4 mm to 17 ± 2 mm, with strabismus improved from 88 percent (exotropia 82 percent) preoperatively to only 29 percent postoperatively. Depth perception improved to a lesser degree, with abnormal tests at a rate of 79 percent preoperatively to 56 percent postoperatively. Wider hypertelorbitism had a higher degree of strabismus. Among craniofacial dysostotic patients, mean interdacryon distance was reduced from 37 ± 3 mm to 17 ± 2 mm, and strabismus improved from 55 percent to only 14 percent. Depth perception improved to a lesser degree, with 68 percent abnormal tests preoperatively and 46 percent postoperatively. Apert patients had more V-pattern strabismus and exotropia (79 percent) than did other craniofacial dysostosis patients (42 percent).

CONCLUSIONS

The authors' data indicate that facial bipartition for hypertelorbitism-known to improve periorbital aesthetics-also improves eye motility disturbances. Thus, vision problems related to exotropia should be considered a functional indication for facial bipartition surgery in patients with hypertelorbitism.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Treating Syndromic Craniosynostosis with Monobloc Facial Bipartition and Internal Distractor Devices: Destigmatizing the Syndromic Face

Monobloc and facial bipartition combined with distraction osteogenesis (MFBDO) has gained popularity over the past several years as a treatment of syndromic craniosynostosis, in part because this surgical technique effectively removes many stigmatic clinical features associated with the syndromic face. The objective of this study is to detail the surgical planning used to achieve medialization of the orbits and describe the authors' experience using MFBDO to destigmatize the syndromic face. By using MFBDO, hypertelorism, vertical orbital dystopia, and downslanting of the palpebral fissure were surgically corrected in all patients, thereby destigmatizing the syndromic face.

Midface Morphology and Growth in Syndromic Craniosynostosis Patients Following Frontofacial Monobloc Distraction

BACKGROUND

Facial advancement represents the essence of the surgical treatment of syndromic craniosynostosis. Frontofacial monobloc distraction is an effective surgical approach to correct midface retrusion although someone consider it very hazardous procedure. The authors evaluated a group of patients who underwent frontofacial monobloc distraction with the aim to identify the advancement results performed in immature skeletal regarding the midface morphologic characteristics and its effects on growth.

METHODS

Sixteen patients who underwent frontofacial monobloc distraction with pre- and postsurgical computed tomography (CT) scans were evaluated and compared to a control group of 9 nonsyndromic children with CT scans at 1-year intervals during craniofacial growth. Three-dimensional measurements and superimposition of the CT scans were used to evaluate midface morphologic features and longitudinal changes during the craniofacial growth and following the advancement. Presurgical growth was evaluated in 4 patients and postsurgical growth was evaluated in 9 patients.

RESULTS

Syndromic maxillary width and length were reduced and the most obtuse facial angles showed a lack in forward projection of the central portion in these patients. Three-dimensional distances and images superimposition demonstrated the age did not influence the course of abnormal midface growth.

CONCLUSION

The syndromic midface is hypoplastic and the sagittal deficiency is associated to axial facial concavity. The advancement performed in mixed dentition stages allowed the normalization of facial position comparable to nonsyndromic group. However, the procedure was not able to change the abnormal midface architecture and craniofacial growth.

Primary aesthetic correction of nasal anomaly with costal graft in treating orbital hypertelorism

Orbital hypertelorism is a common congenital craniofacial anomaly in Asians. As Tessier pointed out, the correction of hypertelorism is effectively the correction of the nasal deformity, which is characterized by a broad, flat nose accompanying an increased interorbital distance and a lack of nasal projection.

OBJECTIVES

To measure the changes in the orbital and nasal parameters after Tessier box osteotomy and primary aesthetic rhinoplasty, performed concurrently with otogenous costochondral graft.

METHODS

From 2009 to 2013, 49 hypertelorism patients were treated in our craniofacial unit. Correction involved a classic Tessier box osteotomy combined with aesthetic augmentation and reconstruction of the nasal dorsum using a costochondral graft. All patients underwent photographic and tomographic documentation both before and 12 months after surgery. Patients underwent morphometric analysis to document the change in interorbital distance, IOD, hypertelorism index, and aesthetic nasal parameters, including the nasal dorsum and alar width, the nasal dorsal height, and the index of nasal apex protrusion versus nasal length.

RESULTS

All patients were satisfied with the outcome of the combined orbital and nasal repair. Morphometric analysis indicated that the IOD, hypertelorism index, and aesthetic nasal parameters all improved following surgery. The resorption rate of the costochondral graft was 16-19%, and graft warpage was nearly absent. Although complications included infection, cerebrospinal fluid leak, and hyposomia, no severe or life-threatening complications occurred.

CONCLUSION

Tessier box osteotomy with primary aesthetic rhinoplasty using costochondral grafts has shown to be efficacious in the treatment of patients with hypertelorism.

Family of Crouzon Syndrome Represents the Evolution of the Frontofacial Monobloc Advancement Technique: From Immediate Movement to Monobloc Distraction to Monobloc Bipartition Distraction

Crouzon syndrome (CS) is an autosomal dominant disorder characterized by premature fusion of cranial sutures, midface and supraorbital ridge retrusion, exorbitism, and in some clinical scenarios strabismus, parrot-beaked nose, short upper lip and hypertelorbitism. Treatment of CS is overlapped with the beginning of craniofacial surgery and is grounded on morphologic and functional objectives. The authors reported on the outcomes and complications of family members (mother and 2 siblings) with CS, who were operated on by different techniques of frontofacial advancement and have attained skeletal maturity. Operations were performed in different moments throughout the last 3 decades of craniofacial surgery history. A 10-year-old Crouzon progenitor underwent a monobloc osteotomy with acute advancement, using rigid fixation and bone grafting in the osteotomy sites. An 8-year-old Crouzon daughter underwent gradual lengthening of a monobloc segment, using an external, institutionally made distracter device. In addition, a 10-year-old Crouzon son underwent gradual lengthening of a monobloc segment associated to facial bipartition, using an internal distracter device. After 30 years, the mother presented a mild relapse on the orbit level, but her children had satisfactory stable outcomes. The family members with CS have undergone different modifications of the monobloc approach based on different chronological momentum, from acute monobloc advancement, to monobloc distraction, to monobloc facial bipartition distraction.

Advances in the Treatment of Syndromic Midface Hypoplasia Using Monobloc and Facial Bipartition Distraction Osteogenesis

Midface hypoplasia or retrusion remains a persistent feature of syndromic craniosynostosis years after successful treatment of the cranium. Although expansion of the cranial vault in infancy by traditional fronto-orbital advancement, posterior expansion, or both, can treat the immediate intracranial constriction, midface hypoplasia and its stigmata of exorbitism, sleep apnea, central face concavity, and malocclusion remain suboptimally treated. Initial enthusiasm for the procedures was tempered due to a high rate of infectious complications; timing and indications for surgery continue to stir controversy. During the last decade renewed interest with the monobloc and facial bipartition procedure using distraction osteogenesis with either an internal or external distraction system has decreased morbidity significantly. These procedures have re-emerged as powerful and comprehensive tools in the treatment of syndromic midface hypoplasia.

45 Years of Simultaneous Le Fort III and Le Fort I Osteotomies: A Systematic Literature Review

Objective

To review and collectively summarize our knowledge of simultaneous Le Fort III and Le Fort I osteotomies.

Design

A PubMed search using “Le Fort III,” “simultaneous Le Fort III and Le Fort I,” “combined Le Fort III and Le Fort I,” “dual midface,” and “segmental midface” was performed. Articles with relevant abstracts were obtained for formal review. A new case of simultaneous Le Fort III and Le Fort I is presented to describe and discuss specific operative indications and surgical decisions.

Results

There were 14 articles that met inclusion criteria with reports of simultaneous Le Fort III and Le Fort I osteotomies. A total of 20 cases were present in the literature. No major complications were reported. We performed combined Le Fort III with Le Fort I osteotomies in a 25-year-old patient with Crouzon syndrome who had undergone a previous Le Fort III at the age of 4 years. The patient tolerated the procedure well, and postoperatively, her exophthalmos and class III malocclusion were corrected.

Conclusions

Simultaneous Le Fort III and Le Fort I can correct differential upper and lower midface hypoplasia and is a well-tolerated procedure in the mature facial skeleton. This systematic review improves our understanding of the surgical technique and indications for a procedure that can correct complex midfacial deformities.