Craniofacial Anomalies, Part 2 - Plastic Surgery Internal

traces the patients’ course over a maximum of 12
years of recurrence-free follow-up.
V — UNCLASSIFIED
A few rare anomalies do not fit into the first four
categories and are best placed in this last category.
They should be described based an the organ or
organs involved. Examples include aglossia or macroglossia,
anotia,and ocular anomalies such as
epicanthal folds. 10
CRANIOMAXILLOFACIAL SURGERY
HISTORY
The origin of craniofacial surgery can be traced as
far back as 1890, when Lannelongue and Lane performed
the first craniotomies, 362,363 but it was not
until the First and Second World Wars that numerous
battle casualties stimulated the development of
techniques for the replacement of missing bone and
soft-tissue of the face, and set the stage for attempts
in the 1940s and ’50s to correct congenital facial
deformities.
Waterhouse 364 reviews the history of craniofacial
surgery with particular emphasis on the contributions
by Le Fort, Virchow, Gillies, and Tessier. In
1951 Gillies and Harrison 365 reported the first successful
Le Fort III advancement osteotomy for correction
of midfacial retrusion in a patient with
Crouzon syndrome. The operation was technically
very complex and only partially successful in correcting
the exorbitism, because it carried the osteotomy
in front of the orbital rim, lacrimal sac, and medial
canthal ligament. In 1962 Converse and Smith 366
described an operation to correct hypertelorism based
on their experience with malunited nasoorbital fractures
with telecanthus.
Paul Tessier is regarded by most clinicians as the
father of craniofacial surgery. After years of careful
study with many of the most innovative maxillofacial
surgeons of his time and numerous hours spent in
the laboratory doing cadaver dissections, Tessier proposed
a novel method of facial osteotomies and
wholesale mobilization of bone for operating on
patients with deformities of the craniofacial skeleton.
Tessier pioneered the intracranial approach for the
correction of hypertelorism, worked closely with
neurosurgeons to resect difficult craniofacial tumors,
SRPS Volume 10, Number 17, Part 2
was first to manipulate cranial bones in the treatment
of patients with craniosynostoses, and performed
successful Le Fort III operations in difficult
cases of Apert and Crouzon syndrome. In 1967
Tessier 367 presented this work at the Fourth International
Congress of Plastic and Reconstructive Surgery
in Rome, and the new field of craniofacial surgery
was launched.
Two principles fundamental to the practice of
craniomaxillofacial surgery emerged from his discussion:
(1) large segments of the facial and cranial skeleton
can be completely denuded of their blood supply,
repositioned, and yet survive completely; and
(2) the eyes can be translocated horizontally or vertically
over a considerable distance without impairing
the vision.
Tessier’s results in the late ’60s and early ’70s
proved conclusively that most skeletal deformities of
the face and calvarium can be corrected or at least
significantly improved by appropriate surgical
maneuvers. The importance of his work to the
intracranial correction of hypertelorism 368–370 cannot
be overemphasized. Along with Converse’s onestage
procedure, it is the backbone of present-day
techniques for hypertelorism correction.
Basing his approach on Le Fort’s anatomic research
with cadaver skulls, 371 Tessier developed the Le Fort
III osteotomy for facial advancement and presented
his results in 1971. His experience encompassed
151 patients representing almost 500 individual malformations
of the cranial and facial region. Tessier’s
contributions to craniofacial surgery were reviewed
in Rome in 1982 on the occasion of the 15th anniversary
of Tessier’s original presentation. 372
The advent of plate-and-screw fixation after
maxillary and mandibular osteotomies has been
of tremendous benefit to the management of congenital
as well as traumatic cases of craniomaxillofacial
deformity. Rigid fixation has dramatically
enhanced the stability of bony fragments,
improved primary bone healing, and eliminated
the need for prolonged maxillomandibular fixation
in the older patient. 373–378
The fate of microfixation hardware during rapid
calvarial growth in infants and young children has
been questioned. Munro and colleagues 379 acknowledge
intracranial “migration” of microplates and
screws. Goldberg and colleagues 380 report cases of
children undergoing revisional surgery who were
found to have microscrews and plates lying beneath
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