Advances in the Treatment of Facial Deformities
Larry A. Sargent, M.D.

Introduction

Craniofacial surgery encompasses a broad spectrum of reconstructive procedures of the cranium and face. Paul Tessier, of Paris, is considered the father of modern craniofacial surgery techniques and the originator of a new specialty. Tessier, a French plastic surgeon, concentrated initially on traumatic problems of the orbits. He developed techniques to extensively dissect the facial soft tissue from its respective bones with simultaneous intracranial exposure and circumferential mobilization of the orbits to allow radical repositioning of the eyes and skull. The main principle from which his treatment evolved is that the skeletal defects and abnormalities of craniofacial deformities must be either repositioned or reconstructed with bone grafts prior to soft tissue repair (see reference 1). By pioneering these radical concepts, he was able to correct major facial deformities previously thought untreatable.

In the past 10 or 15 years, regional centers have evolved, offering a multidiscipline team approach, as well as innovative surgical techniques to provide effective comprehensive care for these patients. evaluation and treatment of these complex problems in a regional center is essential because of the necessary multidiscipline approach and supraspecialization. The center provides a coordinated comprehensive care program for the treatment of their multifactorial physical deformities and psychosocial problems. In general, these patients are unique, and without centralization, it is not possible to maintain the necessary expertise for proper treatment. Craniofacial procedures performed on an irregular or occasional basis invite disaster and are not in the best interest of the patient. We adhere to Tessier's principles that craniofacial surgery should be performed only by surgeons who have that as their main interest, and only where they have the support facilities of a major pediatric medical center to provide safety in care and planning (see reference 2).

Case Presentations
The Tennessee Craniofacial Center at T.C. Thompson Children's Hospital and Erlanger Medical Center specializes in the evaluation and treatment of patients of all ages with facial deformities. The techniques and principles of craniofacial surgery can be applied to facial deformities from a variety of etiologies ranging from congenital problems to acute craniofacial trauma. The following examples illustrate current reconstructive techniques.

Case 1. A baby girl, referred at one week of age, was born with a large midline nasal mass that was increasing in size (Fig. 1). The visual field of the right eye was completely obscured. The distal half of the nose was flattened and the medial canthi widely separated. A CT scan confirmed the mass to be an encephalocele with a large defect located at the nasofrontal suture. The communicating nasofrontal encephalocele caused a marked widening of the medial orbital walls.

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Figure 1. (Left) Photograph of the patient at 1 week of age showing large nasofrontal encephalocele. (Right) Postoperative photographs of the patient eight months after definitive one-stage reconstruction (case 1).

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Figure 2. The nasofrontal encephalocele bone defect is shown with osteotomies for mobilization of the medial orbital walls illustrated. The orbital walls are centrally mobilized and then stabilized, and the remaining defects bone grafted (case 1).

An intracranial approach was used to excise the encephalocele and repair the defect in the dura; osteotomies were performed on the medial orbital walls with central mobilization to correct the orbital hypertelorism (Fig. 2). The nasal bones and defects were reconstructed with bone grafts. The postoperative course was uneventful. At one-year follow-up examination, the patient has maintained the anatomical correction (Fig. 1). Case 2. A 12 year old girl with facial features characteristic of Crouzon's disease (Fig. 3) had severe midface hypoplasia and retrusion with a class III malocclusion. The patient also had a moderate degree of orbital hypertelorism. A facial bipartition procedure was performed to correct the orbital hypertelorism and midface retrusion in one operation (Fig. 4). The improvement in profile is seen after orbital-maxillary advancement with forehead remodeling (Fig. 3).

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Figure 3. (Left) A 12-year-old girl with severe midface hypoplasia and retrusion. (Right) Postoperative result after facial advancement with facial bipartition procedure (case 2).

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Figure 4. The osteotomies and resections are illustrated in a frontofacial monobloc advancement with correction of hypertelorism (facial bipartition procedure). The frontofacial complex is stabilized with miniplates (case 2). 

Case 3. This 15-year-old boy had severe orbital hypertelorism due to craniostenosis (Fig. 5). He had a broad flat nasal dorsum with an interorbital distance of 52 mm. Operative correction consisted of an intracranial and extracranial approach with four wall block osteotomies of the entire orbit and mobilization centrally (Fig. 6). The interorbital distance was decreased to 20 mm and the nasal bone reconstructed with calvarial bone grafts. Fig. 5 shows the postoperative appearance at one year.

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Figure 5. (Left) A 15-year-old boy with severe orbital hypertelorism. (Right) Postoperative results one year after intracranial/extracranial correction of hypertelorism with forehead and skull remodeling (case 3). 

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Figure 6. Four wall block osteotomies illustrated. Central bony section removed and orbits mobilized medially (case 3). 

Case 4. A 30-year-old man involved in a high speed motorcycle accident sustained severe facial trauma. He sustained extensive midline facial lacerations and severely comminuted panfacial fractures (Fig. 7)

Operative treatment consisted of open reduction and rigid fixation of all facial fractures utilizing craniofacial techniques. Bone grafts were further utilized to reconstruct missing bone. Postoperative recovery was uneventful and the patient's preinjury appearance has been restored (Fig. 7).

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Figure 7. (Left) A 30-year-old man involved in a motorcycle accident sustaining severe facial lacerations and panfacial fractures. (Right) Postoperative appearance after one-stage reconstruction using craniofacial techniques (case 4). 

Discussion
These examples illustrate the application of radical concepts to skeletal problems of the skull and facial bones in a wide age group of patients. A craniofacial team committed to this specialty requires expertise of super-specialized professionals from numerous health care fields (Table 1). No single surgeon can possess the expertise to evaluate and treat all the abnormalities of these patients. The goal of the team is to diagnose the physical and psychosocial problems and formulate a treatment plan. This is followed by execution of the treatment plan at the appropriate time, longitudinal follow-up, collection of data on the team's activities, and production of research on its results.

A number of advances have been made in surgical technique and technology as applied to craniofacial surgery. With the experimental evidence that membranous onlay bone grafts survive better than endochondral grafts, craniofacial surgeons, for the most part, have abandoned rib and iliac bone grafts and their associated morbidity for the longer surviving cranial bone grafts (see reference 3). This bone is available in an assortment of sizes and shapes, and can be harvested as dust or free grafts, or transposed as vascularized tissue. The techniques of harvesting and utilization of cranial bone have expanded from the field of congenital craniofacial surgery to correction of traumatic facial deformities or use in aesthetic procedures. As more experience is gained, the indications for cranial bone grafts will continue to expand rapidly.

In the past ten years, tremendous radiologic advancements have been made that have improved our understanding of craniofacial deformities (see reference 4). Improvements in diagnostic evaluation with the use of two and three-dimensional CT scans have drastically enhanced our ability to analyze these complex deformities. These scans have replaced the plain radiographs for evaluation of the upper face. The three-dimensional reconstructions have added a further dimension to facial bone analysis and provide valuable information for preoperative planning (Fig. 8).

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Figure 8. An example of a three-dimensional CT scan showing multiple facial fractures. 

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Figure 9. This plain radiograph illustrates the use of miniplates to rigidly fix severe facial fractures.

Another major advancement has been the application of rigid skeletal fixation to craniofacial surgery. The new techniques of rigid miniplate fixation combined with wide exposure have allowed the craniofacial surgeon to obtain much better stability and eliminate intermaxillary fixation in most cases (Fig. 9). This offers a significant advantage, particularly in children, and has both improved our overall quality of results and decreased morbidity.

TABLE 1.

The Craniofacial Team:

  • Plastic surgeon
  • Neurosurgeon
  • Anesthesiologist
  • Audiologist
  • Dentist
  • Geneticist
  • Ophthalmologist
  • Orthodontist
  • Otolaryngologist
  • Pediatrician
  • Psychiatrist/Psychologist
  • Speech pathologist
  • Social worker
  • Clinical coordinator

Perhaps the biggest contribution the techniques of craniofacial surgery have brought to an allied field are in the treatment of acute craniofacial trauma (see references 5 and 6). The complete exposure of the injury pattern followed by precise rigid fixation of the fractures (using bone grafts as needed) has improved our results both functionally and aesthetically. The results achieved with this craniofacial approach have minimized revisional surgery and brought us closer to reproducing exact preinjury facial bone architecture. These innovative techniques establish a higher standard of care for facial fracture treatment.

 

Summary and Conclusion
Craniofacial surgery encompasses the reconstruction of a broad spectrum of facial deformities. These techniques and principles have been used to improve the treatment and standard of care in congenital and acquired deformities. This field is in its early stages of development and is growing rapidly. The functions of a craniofacial team have been described and examples used to show the type of reconstructive procedures routinely performed at our center. These complex problems require a multidisciplinary team specializing in and dedicated to their care, thus permitting the maximum expertise to be applied to both treatment and development of innovations. Such a center offers great possibilities to many deformed patients. We hope this paper will inform physicians of the services available to their patients with craniofacial deformities.

 

References
1. Jackson IT, Munro IR, Sayler KE, et al: Atlas of Craniofacial Surgery. St. Louis, CV Mosby, 1982, pp XII-XIV. 2. Tessier P: The scope and principles--dangers and limitations--and the need for special training--in orbitocranial surgery, in Transactions of the Fifth International Congress on Plastic and Reconstructive Surgeons. Melbourne, Aust., Butterworth, 1971, pp 903-905. 3. Zins JE, Whitaker LA: Membranous versus endochondral bone: implications for craniofacial reconstruction. Plast Reconstr Surg 72:778-784, 1983. 4. Marsh JL, Vannier MW: The "third" dimension in craniofacial surgery. Plast Reconstr Surg 71:759-767, 1983. 5. Manson PN, Hoopes JE, Su CT: Structural pillars of the facial skeleton: an approach to the management of LeFort fractures. Plast Reconstr Surg 66:54-61, 1980. 6. Gruss JS, MacKinnon SE, Kassell EE, et al: The role of primary bone grafting in complex craniomaxillofacial trauma. Plast Reconstr Surg 75:17-24, 1985. Reprinted from the Journal of the Tennessee Medical Association, Vol 82, No 7, July 1989. Copyright 1989, Tennessee Medical Association


 

 

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