Achieving differential facial changes with Le Fort III distraction osteogenesis: the use of nasal passenger grafts, cerclage hinges, and segmental movements

Simultaneous Lefort 2 Distraction and Fronto-Orbito-Malar Advancement: Correcting Severe Upper and Midface Retrusion in a Patient With Crouzon Syndrome

Craniofacial syndromes present with exorbitism and airway obstruction as a result of upper and middle facial hypoplasia. Classical subcranial Lefort III (LF III) or monobloc distraction osteogenesis (DO) using an external craniofacial device is used to treat these deformities. These procedures are done during mixed dentition, in most cases, advancing an abnormal face, to a more normal position. In patients with a severe midface retrusion, to achieve differential facial changes, Hopper and colleagues have proposed a combination of LF II distraction with simultaneous zigomatic repositioning. The aim of this presentation is to show a 3-year follow-up of a patient with Crouzon syndrome with severe upper and midface retrusion, who underwent an LF II DO combined with a fronto-malar advancement to achieve cranial and midface expansion and facial ratio normalization. The authors present a variation of technique by Hopper and colleagues;​ a combined intra and extracranial procedure, performing simultaneously a fronto-orbital-malar advancement and LF II DO. The authors performed photographs and craniofacial computed tomography scans to evaluate the patient's appearance and shape of the cranial base. Authors found an important expansion of the middle third of the face with improved facial rations due to differential movement of the bony segments. Lefort II distraction in combination with fronto-orbito-malar advancement is an excellent option for the treatment of patients with severe upper and middle face retrusion. It provides eye globe protection enabling maximal midfacial expansion, resulting in a better functional and esthetic outcome. Results have remained stable after 3 years.

Skeletal and Soft Tissue Surgeries in the Long-term Management of Patients With Syndromic Craniosynostosis: A 20-Year Review

BACKGROUND

Soft tissue procedures are often crucial for normalizing the long-term facial appearance in patients with syndromic craniosynostosis, yet they are underrepresented in the literature and existing treatment algorithms. This study evaluated secondary soft tissue surgeries in relation to skeletal operations in patients with syndromic craniosynostosis.

METHODS

A retrospective review evaluated patients with syndromic craniosynostosis treated at a tertiary children's hospital from 2003 to 2023. Craniofacial skeletal and soft tissue procedures were assessed for timing and frequency. Skeletal surgeries included redo fronto-orbital advancements, monobloc advancement/distraction ± facial bipartition, and LeFort III or III/I advancement/distraction. Soft tissue surgeries encompassed oculoplastic procedures, scalp reconstruction, fat grafting, and septorhinoplasty.

RESULTS

Of 106 patients with syndromic craniosynostosis, 57 (57.8%) underwent ≥1 secondary skeletal operation, and 101 (95.3%) underwent ≥1 soft tissue procedures, averaging 3.7 ± 3.3 soft tissue procedures per patient. Patients who underwent secondary forehead advancement had significantly higher rates of subsequent lateral canthopexy (71.4% vs 25.6, P < 0.001), ptosis reconstruction (17.9% vs 7.7%, P = 0.025), and frontotemporal fat grafting (50.0% vs 15.4%, P < 0.001) than those who did not. Patients who underwent midface advancement surgery had significantly higher rates of subsequent lateral canthopexy (65.4% vs 11.1%, P < 0.001), medial canthopexy (7.7% vs 0.0%, P = 0.038), scalp reconstruction (36.5% vs 16.7%, P = 0.020), frontotemporal fat grafting (34.6% vs 14.8%, P = 0.018), malar fat grafting (11.5% vs 0.0%, P = 0.010), and septorhinoplasty (26.9% vs 1.9%, P < 0.001) than those who did not. Specifically, LeFort III or III/I advancement/distractions were significantly associated with higher rates of subsequent septorhinoplasties (33.3% vs 1.6%, P < 0.001). The mean follow-up was 10.2 ± 7.0 years.

CONCLUSIONS

This study revealed an intricate interplay between skeletal and soft tissue surgery in patients with syndromic craniosynostosis. Exploring techniques to reduce the need for further corrective surgery and anticipating necessary secondary interventions may improve patient counseling and outcomes.

Practical Considerations in Computerized Surgical Planning for Frontofacial Surgery

The field of frontofacial surgery has advanced considerably, building on the pioneering techniques of Paul Tessier, with computerized surgical planning (CSP) emerging as a critical component. CSP has enhanced the precision and efficiency of surgeries for craniofacial dysostoses and hypertelorism, resulting in improved outcomes. This review delves into the importance of understanding orbital anatomy and the crucial bony and soft tissue landmarks essential to the application of CSP in frontofacial procedures, encompassing Le Fort III and monobloc advancements, as well as the correction of hypertelorism.

Apert syndrome: craniofacial challenges and clinical implications

Apert syndrome is a rare acro-cephalo-syndactyly syndrome characterised by craniosynostosis, severe syndactyly of hands and feet, and dysmorphic facial features. It demonstrates autosomal dominant inheritance assigned to mutations in the fibroblast growth factor receptor gene, as a result of which signals are not received to produce necessary fibrous material necessary for normal cranial sutures. Deformities are generally cosmetic but can affect various functions such as hearing, visual abnormalities, swallowing, writing, etc, so a multidisciplinary approach is needed for their management.Presently described is a case of a male in his late adolescence who was medically diagnosed with Apert syndrome at birth. Physical appearance and dental examination of the patient included acrocephaly, prominent forehead, ocular hypertelorism, proptosis, short and broad nose, pseudo-prognathism, dental crowding and ectopia, maxillary hypoplasia, low hairline, webbed neck, pectus excavatum and severe bilateral syndactyly of hands and feet.

Crouzon Syndrome Spanning Three Generations: Advances in the Treatment of Syndromic Midface Deficiency

Background

Crouzon syndrome is an autosomal dominant genetic disorder characterized by craniosynostosis, midface retrusion, and exophthalmos. Over the past century, the treatment of craniofacial disorders like Crouzon syndrome has evolved significantly.

Methods

An institutional review board-approved retrospective study was conducted to ascertain the treatment of three individuals with Crouzon syndrome from one family, complemented with a series of literature searches to examine the evolution of craniofacial surgical history.

Results

Dr. David Williams Cheever developed the Le Fort I level to correct malocclusion, maxillomandibular malformations, and midface hypoplasia. Later, Dr. Paul Tessier introduced the Le Fort II and III osteotomies to treat syndromic midface hypoplasia. In 1978, Dr. Fernando Ortiz-Monasterio and Dr. Antonio Fuente del Campo published the first series of monobloc osteotomies, allowing for simultaneous correction of supraorbital and midface malformations, although complicated by blood loss and high infection rates. In 1992, McCarthy et al introduced the concept of gradual distraction to the craniofacial skeleton. In 1995, Polley et al performed the first monobloc advancement using external distraction. Subsequently, in 1997, Polley and Figueroa introduced a rigid external distraction device with multiple vector control to manage severe cleft maxillary hypoplasia. The technique was further refined and applied to treat syndromic midface hypoplasia, reducing complication rates. Currently, either external or internal distraction approaches are used to safely treat this challenging group of patients.

Conclusion

The treatment of syndromic midface deficiency has significantly evolved over the past 50 years, as evidenced by this report of three generations of Crouzon syndrome.

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.

Subcranial Midface Advancement in Patients with Syndromic Craniosynostosis

Patients with syndromic craniosynostosis can present with midface hypoplasia, abnormal facial ratios, and obstructive sleep apnea. These symptoms can all be improved with midface advancement, but it is essential to evaluate the specific morphologic characteristics of each patient's bony deficiencies before offering subcranial advancement. Midface hypoplasia in Crouzon syndrome is evenly distributed between the central and lateral midface and reliably corrected with Le Fort III distraction. In contrast, the midface hypoplasia in Apert/Pfeiffer syndromes occurs in both an axial and a sagittal plane, with significantly more nasomaxillary hypoplasia compared with the orbitozygomatic deficiency.

Influence of Nonsyndromic Bicoronal Synostosis and Syndromic Influences on Orbit and Periorbital Malformation

BACKGROUND

Oculoorbital disproportion in patients with craniosynostosis has similarities and dissimilarities between syndromic and nonsyndromic cases. The authors hypothesized that these two conditions have specific individual influences as they relate to development of the orbital and periorbital skeletons.

METHODS

A total of 133 preoperative computed tomography scans (nonsyndromic bicoronal synostosis, n = 38; Apert syndrome bicoronal synostosis subtype, n = 33; Crouzon syndrome bicoronal synostosis subtype, n = 10; controls, n = 52) were included. Craniometric and volumetric analyses related to the orbit and periorbital anatomy were performed.

RESULTS

Orbital cavity volume was mildly restricted in nonsyndromic bicoronal synostosis (7 percent, p = 0.147), but more so in Apert and Crouzon syndromes [17 percent (p = 0.002) and 21 percent (p = 0.005), respectively]. The sphenoid side angle in Apert syndrome was wider than when compared to Crouzon syndrome (p = 0.043). The ethmoid side angle in Apert patients, however, was narrower (p = 0.066) than that in Crouzon patients. Maxilla anteroposterior length was more restricted in Apert syndrome than Crouzon syndrome (21 percent, p = 0.003) and nonsyndromic cases (26 percent, p < 0.001). The posterior nasal spine position was retruded in Crouzon syndrome (39 percent, p < 0.001), yet the anterior nasal spine position was similar in Apert and Crouzon syndromes.

CONCLUSIONS

Orbit and periorbital malformation in syndromic craniosynostosis is likely the combined influence of syndromic influences and premature suture fusion. Apert syndrome expanded the anteriorly contoured lateral orbital wall associated with bicoronal synostosis, whereas Crouzon syndrome had more infraorbital rim retrusion, resulting in more severe exorbitism. Apert syndrome developed maxillary hypoplasia, in addition to the maxillary retrusion, observed in Crouzon syndrome and nonsyndromic bicoronal synostosis patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Le Fort II Distraction with Simultaneous Zygomatic Repositioning

Severe midface hypoplasia is often managed by Le Fort III distraction. Le Fort II distraction with zygomatic repositioning is a modification of the Le Fort III distraction operation aimed to correct abnormal facial ratios of patients with greater central than lateral midface deficiency. The operation starts with Le Fort III osteotomies and is followed by separation and fixation of bilateral zygomas. The central nasomaxillary Le Fort II segment is then distracted to achieve independent movements of the central and lateral midface. The Le Fort II zygomatic repositioning operation has become our procedure of choice for patients with Apert facial dysmorphology.

Lefort II distraction with zygomatic repositioning versus Lefort III distraction: A comparison of surgical outcomes and complications

The aim of the study was to determine if the additional surgical complexity of Lefort II distraction with zygomatic repositioning (LF2ZR) results in increased complications compared to Lefort III distraction (LF3). A retrospective review was performed of all LF3 and LF2ZR advancements performed by the senior author over 15 years. Demographic, operative, postoperative, and cephalometric data were collected from initial procedure through greater than 1 year postoperatively. Univariate and multivariate analyses were performed to compare procedures. 19 LF2ZR and 39 LF3 in 53 patients met inclusion criteria. Diagnoses differed between procedures, with more Crouzon Syndrome in LF3 and more Apert Syndrome in LF2ZR. Complication rate was 7/19 for LF2ZR and 12/39 for LF3 with no severe morbidity or mortality, and no difference between procedures (p = 0.56). The types of complications encountered differed between procedures. LF2ZR had a significantly longer operative time (506 ± 18 vs. 358 ± 24 min, p<0.001). However, a greater number of LF2ZR patients underwent concomitant procedures (15/19 vs. 13/39, p<0.001). Multivariate analysis revealed that Apert Syndrome and reoperative midface advancement were the most significant predictors of increased blood loss. LF2ZR has an equivalent complication rate to LF3. Therefore, it is our treatment of choice for cases requiring differential sagittal and vertical distraction of the central midface.

Le fort II distraction osteogenesis with a hybrid system for an Apert syndrome patient: A case report

Background

Le Fort II advancement is considered for normalizing the facial appearance in Apert syndrome. When these procedures are performed during growth, overcorrection of midface advancement is required. We developed a system that can control the distance and vector of movement for the central midface to create more normal facial proportions. This case report shows Le Fort II distraction osteogenesis with this hybrid system for an Apert syndrome patient.

Case

The patient was a girl with Apert syndrome with midfacial-nose hypoplasia and skeletal class III malocclusion. She was healthy without respiratory problems and had no learning disabilities. She underwent our Le Fort II distraction osteogenesis with the hybrid system at 10 years and 6 months of age. Her midface was elongated 22 mm at point Or forward and moved 5° downward to the Frankfort horizontal plane compared to the standard position of average Japanese adult women on the cephalogram. Examining the facial image, the midfacial depression was improved 4 years after the operation.

Discussion

Overcorrection of midface advancement is required for patients to reduce the number of procedures during growth. The system that we developed could control the distance and vector of movement steadily when the central midface was overcorrected to try to create normal adult facial proportions.

Surgical-Orthodontic Considerations in Subcranial and Frontofacial Distraction

Subcranial and frontofacial distraction osteogenesis have emerged as powerful tools for management of hypoplasia involving the upper two-thirds of the face. The primary goal of subcranial or frontofacial distraction is to improve the orientation of the upper face and midface structures (frontal bone, orbitozygomatic complex, maxilla, nasal complex) relative to the cranial base, globes, and mandible. The various techniques used are tailored for management of specific phenotypic differences in facial position and may include segmental osteotomies, differential vectors, or synchronous maxillomandibular rotation.

Syndromic Craniosynostosis

Management strategies for syndromic craniosynostosis patients require multidisciplinary subspecialty teams to provide optimal care for complex reconstructive approaches. The most common craniosynostosis syndromes include Apert (FGFR2), Crouzon (FGFR2), Muenke (FGFR3), Pfeiffer (FGFR1 and FGFR2), and Saethre-Chotzen (TWIST). Bicoronal craniosynostosis (turribrachycephaly) is most commonly associated with syndromic craniosynostosis. Disease presentation varies from mild sutural involvement to severe pansynostoses, with a spectrum of extracraniofacial dysmorphic manifestations. Understanding the multifaceted syndromic presentations while appreciating the panoply of variable presentations is central to delivering necessary individualized care. Cranial vault remodeling aims to relieve restriction of cranial development and elevated intracranial pressure and restore normal morphology.

Retroposition of the Globe After Le Fort III Midfacial Distraction

BACKGROUND

Patients with syndromic craniosynostosis exhibit exorbitism due to supraorbital and midfacial retrusion. This study documented the change in sagittal orbital-globe relationship following Le Fort III midfacial advancement.

METHODS

This retrospective case series comprised patients with syndromic craniosynostosis who underwent midfacial distraction from 1997 to 2016. Changes in sagittal globe position in relation to the orbital rims were measured by pre- and postoperative direct anthropometry, computed tomographic scans, or both methods. Descriptive statistics were calculated; significance was set at P < 0.05.

RESULTS

Anthropometry showed a significant increase from superior orbital rim-to-corneal apex (os-acor) (4.1 ± 4.0 mm, P < 0.001) and from inferior orbital rim-to-corneal apex (oi-acor) (4.5 ± 5.3 mm, P < 0.001). The lateral orbital rim to the corneal apex (ol-acor) dimension did not change significantly. Computed tomography measurements confirmed retropositioned globes relative to the anterior border of the orbital cavity (2.5 ± 6.4 mm, P = 0.036). The 2 analytic methods yielded statistically similar results.

CONCLUSION

The globes move posteriorly a mean of 2.5 to 4.5 mm following Le Fort III midfacial distraction in patients with syndromic craniosynostosis. This finding is useful in attaining euophthalmos when planning and executing this procedure.

Subcranial and orthognathic surgery for obstructive sleep apnea in achondroplasia

PURPOSE

Obstructive sleep apnea (OSA) is a common problem in patients with achondroplasia. The purpose of this study was to assess changes in airway volumes following various degrees of facial skeletal advancement.

METHODS

This was a retrospective evaluation of patients with achondroplasia who underwent facial skeletal advancement for obstructive sleep apnea. Patients were treated with either an isolated Le Fort III distraction (LF3) or Le Fort II distraction with or without subsequent Le Fort I and bilateral sagittal split osteotomies (LF2 ± LF1/BSSO). Demographic, cephalometric, volumetric, and polysomnographic variables were recorded pre- and postoperatively.

RESULTS

Six patients with achondroplasia underwent midface advancement for treatment of OSA (2 LF2 + LF1/BSSO, 2 LF2, 2 LF3). Patients undergoing LF2 + LF1/BSSO had consistent volumetric improvements at the nasopharyngeal and oropharyngeal levels (Δ ≥ +347% and ≥+253%, respectively). Patients undergoing LF2 alone had consistent improvement in the nasopharyngeal airway alone (Δ ≥ +214%). Patients undergoing LF3 alone had consistent, but less dramatic, changes in nasopharyngeal volume (Δ ≥ +97.1%). All patients undergoing LF2 distraction (with or without LF1/BSSO) had a ≥50% reduction in the apnea-hypopnea index (AHI) postoperatively; there was no improvement in AHI with LF3 alone.

CONCLUSION

In patients with achondroplasia-associated OSA there are variable improvements in airway volume. This preliminary report suggests that LF2 distraction, with or without subsequent LF1/BSSO, may provide consistent reductions in AHI relative to LF3 distraction.

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.

A osteogenesis distraction device enabling control of vertical direction for syndromic craniosynostosis

Background:

We have developed a hybrid facial osteogenesis distraction system that combines the advantages of external and internal distraction devices to enable control of both the distraction distance and vector. However, when the advanced maxilla has excessive clockwise rotation and shifts more downward vertically than planned, it might be impossible to pull it up to correct it. We invented devices attached to external distraction systems that can control the vertical vector of distraction to resolve this problem. The purpose of this article is to describe the result of utilizing the distraction system for syndromic craniosynostosis.

Methods:

In addition to a previously reported hybrid facial distraction system, the devices for controlling the vertical direction of the advanced maxilla were attached to the external distraction device. The vertical direction of the advanced maxilla can be controlled by adjustment of the spindle units. This system was used for 2 patients with Crouzon and Apert syndrome.

Results:

The system enabled control of the vertical distance, with no complications during the procedures. As a result, the maxilla could be advanced into the planned position including overcorrection without excessive clockwise rotation of distraction.

Conclusion:

Our system can alter the cases and bring them into the planned position, by controlling the vertical vector of distraction. We believe that this system might be effective in infants with syndromic craniosynostosis as it involves 2 osteotomies and horizontal and vertical direction of elongation can be controlled.