Craniofacial Anomalies, Part 2 - Plastic Surgery Internal

TABLE 7
Brain Growth During the First 20 Years of Life
(Data from Blinkov SM, Glezer II: The Human Brain in Figures
and Tables: A Quantitative Handbook. New York, Plenum
Press, 1968. Reprinted with permission from Marchac D, Renier
D: Craniofacial Surgery for Craniosynostosis. Boston, Little
Brown, 1982, p 36.)
metrical deformities to lessen the need for major
revisions at a later date. 404
Certainly unilateral cases can be expected to
achieve better results than bilateral cases. McCarthy
demonstrated good to excellent results in 86% of
patients undergoing unilateral procedures and in 49–
70% of bilateral procedures. 418,419
SURGERY FOR COMBINED CRANIOSYNOSTOSIS AND
HYPOPLASIA OF THE MIDFACE
There have been few changes in the treatment of
Crouzon disease since Tessier first described his classic
facial osteotomy technique. 275,288,367,420,421 Modifications
have progressed from the Tessier I—a
subcranial Le Fort III—in 1958, through the more
radical Tessier VIII of 1976, which split and bent a
frontofacial monobloc segment, derotated the orbits,
and brought the maxilla forward. In Tessier’s hands
this extensive procedure yielded nearly normal results.
In 1976 and again in 1979, Van der Meulen 422,423
described a similar operation that involves simultaneous
total osteotomy of the two halves of the face
and correction of the orbitofrontal and maxillary
deformities. The coronal approach to osteotomy of
SRPS Volume 10, Number 17, Part 2
the pterygomaxillary fissure obviates intraoral surgery
with its potential contamination.
Ortiz Monasterio and associates 402 first advocated
monobloc advancement of the entire forehead and
face (Fig 23) in 1977. Anderl and coworkers 424 proposed
a modification of the frontoorbital bar with
preservation of an intact anterior cranial base to separate
the cranial and nasal spaces when indicated for
relief of respiratory or orbital distress accompanying
severe craniosynostosis. Although many surgeons
believe that monobloc advancements are hazardous
because of the high number of associated infectious
sequelae, the authors feel their technique is safe even
at a young age.
Fig 23. Cranial vault reshaping for correction of Crouzon
syndrome with bilateral coronal synostosis. The procedure
involves osteotomies of the anterior cranial vault, monobloc, Le
Fort I, and chin. (Reprinted with permission from Posnick JC:
Craniosynostosis: Surgical Management of the Midface Deformity.
In: Bell WH (ed), Orthognathic and Reconstructive
Surgery. Philadelphia, WB Saunders, 1992; vol 3, p 1888.)
Wolfe 425 reviewed his experience with 32 patients
who underwent transcranial monobloc frontofacial
advancement +/– simultaneous facial bipartition.
The author cautions that the procedure “carries with
it substantial risks, [but] with careful consideration of
airway control, the anterior cranial base dura, and
retrofrontal dead space, the procedure is recommended
for carefully selected patients.” Wolfe lists
his indications and contraindications for the procedure
in various age groups.
Treatment for combined deformities from craniosynostosis
of the anterior cranial vault and
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