Geoffrey 3 C. Gurtner, Peter C. Neligan, Daniel Z. Liu – Plastic Surgery-Craniofacial, Head and Neck Surgery-Pediatric Plastic Surgery. 3-Elsevier (2018)

197.e2
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CHAPTER 7 • Auricular construction
A
B
C
D
E
F
Fig. 7.42  Secondary auricular construction, after unsatisfactory tissue expander ear reconstruction. (A) Preoperative profile. (B) Size and shape of normal side are
confirmed with Type A-1 56-mm template. (C) Preoperative markings; proper location of the auricle, skin flaps for lower third of the auricle, and zig-zag temporal incision
for harvesting TPF. (D) Previous framework was removed. (E) Type A-1 3D framework. (F) Lower third of 3D framework is covered with local skin flaps. (G) Upper
two-thirds of framework was covered with TPF. (H) The fascia was covered with split scalp skin. (I) One year after surgery.
G
H
I

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CHAPTER 7 • Auricular construction
Constricted ear
Constricted ear is a concept proposed by Tanzer in 1975.65 In
constricted ear, helix and scapha fossa are hooded, and crura
of antihelix is flattened in various degrees. One gains an
impression that the rim of the helix has been tightened. Con-
stricted ear is often referred to as cup or lop ear. Tanzer clas-
sified constricted ear into three groups based on the severity
of defect/deformities.
Group 1
Group 1 constricted ear is defined by mild deformities of
the helix, often called lop ear (Fig. 7.43). The defect involves
helical cartilage with minimum skin defect. The Musgrave
(1966)66 technique is a useful method to expand the helix.
fascia flap with a long vascular pedicle, such as serratus
fascia54–56 may be an advantageous option, although it has the
disadvantage of creating a long scar at the lateral thoracic
donor site.
Role of deep temporal fascia (DTF)
Role of deep temporal fascia in complex ear reconstruction
has been advocated by Nagata, but still many surgeons believe
that the temporoparietal fascia flap is the last resort as a local
fascia flap. Deep fascia is based on the branch of the middle
temporal artery, which usually runs a similar course to the
STA, one layer underneath it (Fig. 7.37).64 If the TPF was
already used for anterior surface coverage of the ear frame-
work, then at the second stage of ear elevation, DTF can cover
the posterior aspect of the auricle (Fig. 7.9).
A
B
Fig. 7.41  (A) Preoperative view of a patient with microtia in Treacher–Collins syndrome. (B) Type B-2 template and 3D framework. (C) Immediate postoperative view, prior
to placing bolster suture. (D) Postoperative profile.
C
D

199
Secondary construction
A
a
b
c
B
Fig. 7.43  Constricted ear group 1 ear. (A) Preoperative view. (B) Musgrave technique for correction of cup ear: (a) The deformity, (b) the folded cartilage is exposed
through posterior incision, (c) cartilage fingers are elevated and fixed to a strut of conchal cartilage.
Continued
Through either an anterior or posterior skin incision, mul-
tiple cuts are made to the curled cartilage, fan upward and
backward, fixed to the curved strut made of concha cartilage
graft. The skin is then re-draped across the reconstructed
framework. For milder constricted ear (groups 1 and 2A),
focusing surgical correction to the constructed helical curve is
the reasonable option while keeping original elastic cartilage
framework and avoiding hard rib cartilage framework. When
superior crus is deficient, partial helix plus superior crus
frame from rib cartilage67 can normalize the deformity.
Group 2B
Constricted ear group 2B has both skin and cartilage defects
in the upper third of the auricle. The loss of folding may
involve antihelical crura, and hooding is more pronounced.
The height of the ear is sharply reduced. Park, in 2009,68
proposed a versatile solution for group 2B constricted ear. For
helical skin defect, Park modified the Grotting flap69 (post-
auricular flap), creating both skin flap and fascia flap with the
same pedicle. Since width of skin flap is limited by the hairline

200
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CHAPTER 7 • Auricular construction
The superior auriculocephalic sulcus is absent, but can be
demonstrated when you pull up the helical pole. Various
surgical corrections are reported from Japan, due to the high
prevalence of cryptotia as frequently as 1 : 400.73 Non-surgical,
ear molding treatment may be applied if the child is an early
neonate.73–75 The goal of surgical treatment is to create the ret-
roauricular sulcus by skin grafts, Z-plasty, V-Y advancement,
or rotation flap (Fig. 7.45)105. A common cartilage deformity
associated with cryptotia is helix-scapha adhesion, which
may be addressed by cartilage remodeling techniques.76
Stahl ear
In 1989, Binder77 described a rare congenital auricular defor-
mity as Stahl ear, named after Dr. Stahl. Stahl ear is character-
ized by the third crus extending toward the helical rim. Stahl
ear is classified into three types. Type 1 has obtuse-angled
bifurcation, and it looks like the superior crus is missing. Type
2 has trifurcation (Fig. 7.46). Type 3 has broad superior crus
and broad third crus (Fig. 7.47). Ear molding may work well
if in early infancy (Fig. 7.47). Surgical treatment is broadly
categorized into two types: cartilage/skin excision78,79 and
cartilage alteration.80 Cartilage/skin excision-type techniques
(Fig. 7.46) seem to work better than cartilage alteration tech-
niques in the literature. Type 1 Stahl ear needs special atten-
tion to reconstruct the missing superior crus by utilizing the
excised third crus78 or a rib cartilage graft.
(10–13 mm), a fascia flap can provide additional coverage of
the helix, if needed. The distal half of the skin flap can be
thinned to facilitate better definition of helix/scapha, with
proximal half of skin flap including a fascia layer to boost
blood supply. For helical cartilage defect, eighth rib cartilage
is harvested, the helix is fabricated, and the entire length of
the helix is constructed (Fig. 7.44). Bilateral constricted ear can
be operated with single eighth rib cartilage, split into two
strips for bilateral helical rim construction. Otoplasty tech-
niques such as the Mustardé sutures70,71 may be combined
with the Park technique to correct excessive ear projection.
Group 3
Tanzer defined group 3 as the most severe cupping: failure of
migration.
Brent recommends treating severe constricted ear as if it is
a form of microtia, when the construction is severe enough to
produce a height difference of 1.5 cm.6 Nagata recommends
treating severe constricted ear as a concha type microtia, to
replace the defective framework with a full rib cartilage
framework.72
Cryptotia
Cryptotia is a congenital ear deformity in which the upper
pole of the ear cartilage is buried underneath the scalp.
C
D
(C) Intra-operative view. Conchal cartilage strut was fixed to the cartilage fingers. (D) Postoperative view.
Fig. 7.43, cont’d

A
B
C
D
E
F
G
H
Fig. 7.44  Bilateral constricted ear group 2B. Cadaver cartilage was used at OSH with minimal improvement. Park method (2009) was used. (A) Preoperative frontal view.
(B) Preoperative view of right ear. (C) Preoperative view of left ear. (D) Evaluating the defect of right ear with 46-mm Type A-1 template. Upper helical pole skin and
cartilage are missing. (E) Left side has more defect than right side, based on evaluation with 46-mm Type A-1 template. (F) Right side surgical marking with modified
Grotting flap, combined skin flap and fascia flap based on the same pedicle. (G) Split eighth rib cartilage was fabricated for right helix construction. (H) Other half of split
eighth rib cartilage was used for left ear.
Continued

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SECTION II
CHAPTER 7 • Auricular construction
Hypoplasia of middle third of ear
Hypoplasia of the middle third of the auricle is a rare type of
ear deformity, classified as Tanzer Type 3.1 Literally, the middle
third is hypoplastic, but the upper and lower thirds have
normal anatomical architecture, although the width and the
ear dimensions (ratio) are abnormal. Tanzer used staged
Anotia
Anotia is classified as Tanzer Type 1 ear deformity. There is
no vestige skin present, and ear site is completely flat. Anotia
is frequently associated with hemifacial microsomia. Anotia
is a true reconstructive challenge, and it is extremely difficult
to achieve optimal outcomes.
I
J
K
L
M
(I) Grotting skin flap was used to cover the upper helix. (J) Park skin and fascia flap was used for helix cartilage coverage. (K) Postoperative frontal view.
(L) Postoperative view of right ear. (M) Postoperative view of left ear.
Fig. 7.44, cont’d

203
Trauma of the auricle
and reliable. Lop ear and Stahl’s ear respond well to nonsurgi-
cal correction only during the neonatal period, while protrud-
ing ears and cryptotia respond until approximately 6 months
of age (Fig. 7.47).73 It is widely believed that the early initiation
of molding is more effective, because maternal estrogen in the
neonate keeps ear cartilage soft and elastic. Although there
are a few reports with successful ear molding after 3 months
of age, most agree that if ear molding is started after 3 months
of age, the response tends to be poor.75 Helix–antihelix adhe-
sion responds poorly to ear molding treatment and may not
be an indication of ear molding (Fig. 7.48). There are minimal
complications reported in ear molding; skin irritation is prob-
ably the most frequent complication, possibly due to tape or
adhesive. Transient edema of helical skin is sometimes
observed during ear molding for unknown reasons.
Lobule reconstruction
The lobule is a unique anatomical component of the auricle:
there is no skeletal support in the lobule, and it is hanging
down from the ear framework. Because the lateral portion
of the lobule is composed of free margin, even small surgical
alterations can change its shape. In an elliptical excision of
a small tumor, if the long axis is perpendicular to the lobule
rim, or a piercing scar healed perpendicular to the lobule
margin, it may create a square-shape lobule (Fig. 7.49)82. If
you design the long axis of the ellipse parallel to the lobule
margin, the lobule deformity may be preventable. In cleft ear
cases, the author routinely uses six types of ear framework
templates36,37,81 as a guide to create a smooth transition of
the curve from helix to the lobule (Fig. 7.50). Construction of
earlobe is rarely required in congenital microtia, as the lobe
is formed by repositioning of auricular remnants. In total
auricular construction, the Nagata-type framework always
creates skeletal support in the lobule portion. By placing the
framework in the lobule, the transition from helix curve to
lobule curve becomes smooth. Brent, like Tanzer, switches
back full thickness vestige lobule, which allows ear-piercing
for children. For traumatic lobule defects, numerous effective
techniques have been introduced to repair earlobes with local
flap tissues.83–85
Trauma of the auricle
Assessing the extent of defect and tissue damage around the
auricle is the first step. Doppler ultrasound is a sensitive tool
to check the continuity of STA from the beginning to the
periphery of the temporal scalp. Because the cartilaginous
framework is difficult to produce, the salvage of amputated
auricular cartilage is recommended by numerous surgeons.
The skin may be removed and the cartilage is buried in an
abdominal pocket, in a cervical pocket, or in a retroauricular
area;86 Brent states that this procedure is futile, as the flimsy
ear cartilage almost invariably flattens beneath the snug. The
author prefers rib cartilage construction in traumatic ear
amputation. The amputated cartilage segment was buried
underneath a temporal skin pocket at another institution, and
it created poor auricular definition. Therefore, rib cartilage
framework was constructed and connected with existing
residue of frame, and a mastoid skin flap was coapted to the
framework. Fig. 7.51 shows a patient with total amputation
reconstruction,81 starting by dividing the superior and inferior
components, obtaining the normal vertical height, and the
resultant conchal defect is closed using a retroauricular flap.
Later, partial ear framework is transplanted to build up the
lower helix and posterior conchal wall. Nagata employs his
two-stage approach and treats it as if it is a concha type
microtia construction.
Ear molding
Matsuo, who first reported ear molding treatment for con-
genital ear deformities in 1984,74 states that when the ear
deformities are not hypoplastic, nonsurgical correction is easy
A
Fig. 7.45  (A) Preoperative marking for cryptotia (buried upper helix pole). V-Y
advancement method proposed by Yanai105 was used to correct the deformities.
(B) Postoperative view.
B

203.e1
Trauma of the auricle
A
B
C
D
E
F
Fig. 7.51  Total amputation of the
auricle associated with multiple injuries.
(A) View at the time of initial evaluation.
(B) STA and STV were reconnected, and
skin coverage was performed using
amputated skin. (C) Profile view prior to
total auricular construction. (D) Since
rib cartilage was partially calcified, helix
portion was harvested peripheral to the
base frame unit. (E) Completed 3D
framework with Nagata type paper
template. (F) Lower portion of 3D
framework was covered with skin flaps,
and upper two-thirds were covered with
temporoparietal fascia flap (STA/STV
was reconstructed at the initial surgery).
(G) Split scalp skin was placed over
TPF. (H) Postoperative view.
G
H

204
SECTION II
CHAPTER 7 • Auricular construction
A
B
Fig. 7.46  Surgical correction of Stahl ear. (A) Preoperative view of Type 2 Stahl ear. Extra crus connects between helix and superior crus. (B) Overlapped Type A-1
template demonstrated the curve change at third crus. (C) Wedge resection of skin/cartilage was planned, based on the helix curve analysis. (D) Immediate postoperative
view.
C
D

205
Partial ear reconstruction
of the left auricle with associated vascular injuries. Since the
amputated auricle was severely damaged, initial emergency
surgery was performed to restore the superficial temporal
artery/vein for future auricular construction.87 At the second
stage, total auricular construction was performed with rib
cartilage framework; the upper two-thirds of the frame were
covered with TPF flap, and the lower third was covered with
local skin flaps. To create a deep concha bowl, a Nagata-type
posterior lobule flap was transposed.
Burns
Burns may cause extensive injuries to the auricle and sur-
rounding tissues. In severe burn auricular defects, there have
been numerous debates on the choice between prosthesis
versus autogenous construction. In severe burns, local skin
usually does not provide an adequate skin envelope for the
entire ear framework. Expanding scarred skin also may not
work well. The temporoparietal fascia flap30 is a powerful tool
to cover the framework. Identifying the course of the STA
with Doppler ultrasound will determine if TPF will be avail-
able for coverage of the ear framework. If scalp hairs are
present in the entire temporal area, the STA is likely to be
present at the periphery. Fig. 7.9 shows an example of autog-
enous construction after severe burn amputation of the auricle.
A large TPF was used to cover the upper two-thirds of the
framework. The lower one-third of the frame was covered
with an anterior lobule flap, and a retroauricular island flap
was used to construct concha bowl.27
Partial ear reconstruction
The key to partial ear reconstruction is how you connect the
new parts smoothly to the existing anatomical architecture.
Defects involving the helical rim especially need careful
Fig. 7.47  Non-surgical correction of Stahl ear (A) Pretreatment view of Type 3 Stahl ear of a one-month-old female. (B) Ear splint was shaped according to Type A-2
template. Splint was fixed to the ear with tape. (C) View after 5 weeks of ear molding treatment.
A
B
C
Fig. 7.48  Helix-scapha adhesion causes pointed look of the auricle. This deformity
may not be a good indication for ear molding. Park reported effective surgical
correction.

206
SECTION II
CHAPTER 7 • Auricular construction
a posterior-based skin flap. Fig. 7.54 shows the partial ear
amputation of the middle portion due to trauma, for which
the author performed a one-stage partial ear construction. The
normal left auricle shape was Type A-1. A partial auricular
framework was constructed based on a Type A-1 template,
and the frame was sutured to the remaining frame and then
covered with a TPF. A split scalp skin graft was placed on top
of the TPF. Fig. 7.55 shows a three-year-old who is a victim of
a dog bite, and the amputated ear piece was lost. One-stage
auricular reconstruction was performed the next day, with the
rib cartilage framework covered with a temporoparietal fascia
flap and a scalp skin graft.
planning for a smooth curve transition between old and new.
Pure helical rim defects are best closed by advancing the helix
in both directions, as described by Antia and Buch (Fig. 7.52).88
These techniques may also be applied to correct asymmetry
of ear size (make a larger auricle small) for otoplasty.89 Major
middle-third auricular defects are classically repaired with a
cartilage graft which is either covered by an adjacent skin flap
(Fig. 7.7)16 or inserted via Converse’ tunnel procedure (Fig.
7.53).90 Pearl, in 2011,91 applied the two-stage total ear recon-
struction principle to the partial amputation of the auricle. He
created a partial ear framework made of rib cartilage, then
attached it to the remaining framework and covered it with
Fig. 7.49  (A) Square shape lobule deformity caused by wound closure perpendicular to the lobule margin. (B) Type A-2 template was used as a guide to correct square
shape lobule deformity. (C) Postoperative view.
A
B
C
Fig. 7.50  Cleft ear. (A) Preoperative view of cleft ear, with rectangular shape lobule. (B) Type A template was used as a guide to create smooth lobule curve.
(C) Postoperative view. (Reproduced with permission from Yamada A. Cosmetic surgery of the ear. In: Pu LLQ, Chen Y-R, Li Q-F, et al. Special Considerations in Cosmetic
Surgery of the Asian Ear. Aesthetic Plastic Surgery in Asians: Principles and Techniques. Boca Raton: CRC Press; 2015.)
A
B
C

207
Partial ear reconstruction
Fig. 7.52  Helical defect repaired by advancement of auricular skin cartilage. (A) Defect of the upper portion of the auricle. (B) Lines of incisions through skin and
cartilage. (C) The incisions completed: note the downward extension into the earlobe. (D) The skin–cartilage flaps mobilized. (E) The repair completed. (Modified from
Antia NH, Buch VI. Chondrocutaneous advancement of flap for the marginal defect of the ear. Plast Reconstr Surg. 1967;39:472.Copyright © 1967, The Williams & Wilkins
Company, Baltimore.)
A
B
C
D
E
A
B
C
D
E
F
G
H
Fig. 7.53  Repair of a defect of the middle third of the auricle: the tunnel procedure. (A) Carved costal cartilage graft. (B) The defect. (C) Incisions through the margins of
the defect. (D) Incisions through the edge of the defect are extended backward through the skin of the mastoid area. (E) The skin of the mastoid area is undermined between
the two incisions. (F) The medial edge of the incision at the border of the auricular defect is sutured to the edge of the postauricular incision. A similar type of suture is
placed at the lower edge of the defect. (G) The cartilage graft is placed under the skin of the mastoid area and anchored to the auricular cartilage with sutures. (H) Suture of
the skin incision. (Reproduced from Converse JM. Reconstruction of the auricle. Plast Reconstr Surg. 1958;22:150, 230.Copyright ©1958, The Williams & Wilkins
Company, Baltimore.)

208
SECTION II
CHAPTER 7 • Auricular construction
Surgeons carve the auricular framework from the potato
block, like a sculpture. This is the practice of pure carving to
grasp and understand the three dimensional structure of the
framework (Fig. 7.32).
Second step
Once surgeons become comfortable sculpting the framework
out of a potato, the next step is the carrot framework. The
carrot is a bit more solid and flexible than the potato, and it
is suitable for making each part of the framework, which are
then assembled together. Surgeons can create a base frame,
helix, antihelix, tragus, and concha cap. The ear parts model
developed by Wilkes may be used as a guide.9 The carrot has
a longitudinal fiber along the long axis in the inner cortex; it
allows surgeons to practice carving the helical portion. By
thinning the helical rim portion little by little, surgeons can
experience the moment when the helix suddenly becomes
flexible. The best portion for helix practice is just medial to
the outer skin. The outer skin itself is not the best portion,
since it has many creases, and it is easily fractured at a crease
when you try to bend it. The final portion of the practice is to
assemble each part of the frame with 38G double-armed stain-
less wires as surgeons do in clinical cases (Fig. 7.33).
Learning to create ear framework
Three-steps training method
Surgical simulation is not a new concept. Sushuruta (600 BC)
used vegetables for surgical simulation. Since microtia patients
have only one primary chance to obtain the best outcome,
surgeons must train well before they actually perform surgery
on patients, otherwise the surgeon may create an unsatisfac-
tory auricle. Although experienced surgeons can salvage a
difficult secondary auricular construction, the secondary
cases are still unlikely to be as good as the primary cases even
in expert hands. Since we cannot practice on patients, sur-
geons should perform hands-on training prior to become ear
makers.
First step
Brent uses vegetables for ear carving practice. The author uses
a potato as the first step in training. The potato is cheap, and
readily available.50 In step 1 training, acrylic 2D template and
3D framework models are used as a guide for curving practice;
a #15 scalpel and carving knife are the main instruments used.
Fig. 7.54  Traumatic partial amputation of the auricle. (A) Preoperative profile. (B) Preoperative
planning to identify the extent of cartilage defect. (C) Immediate postoperative view after one stage
of surgery. (D) Postoperative view.
C
A
B
D

209
Learning to create ear framework
A
Evaluating the defect
Normal side flip over
B
C
D
E
F
G
H
Fig. 7.55  A three-year-old male with partial amputation of the auricle due to dog bite. (A) Preoperative view. (B) Photographic analysis to identify the cartilage defect.
(C) Simulated cartilage defect. (D) Partial cartilage framework and Type A-1 46-mm template. (E) Temporoparietal fascia flap was tunneled to the ear defect. (F) Partial
cartilage framework was fixed to the remaining framework. (G) Continuation of helix curve was confirmed with Type A-1 template. (H) TPF was coated to the framework.
Continued

210
SECTION II
CHAPTER 7 • Auricular construction
Goal of otoplasty
As the author described in the microtia section, the auricle
should not be the anatomical part to draw attention of others.
A protruding auricle is more likely to draw attention. As for
the shape of the auricle, the goal is to restore soft, smooth, and
natural auricles. Therefore, surgeons must choose surgical
techniques that are simple, reliable, and least likely to cause
complications. Surgeons must delicately execute anterior
scoring technique because if surgeons did excessive scoring,
it may create sharp edges and an unnatural, unsmooth contour
of the auricle.
Timing of surgery
There is no absolute rule on timing of otoplasty.92–94 Otoplasty
may be performed in children or adults, although the proce-
dure is more common in children. Surgery is often recom-
mended near an age when ear growth is nearly complete,
such as 5–7, when a child’s ear cartilage is stable enough for
correction. At this point, the child can cooperate with their
care, and the social and psychological problems associated
with peer ridicule are avoided at a critical time in their social
development. Almost all young children require general
anesthesia for the procedure.
Surgical techniques
It is important to remember that symmetry is crucial in treat-
ing the prominent ear, because asymmetry is more likely to
draw attention. A unilateral case may be more difficult for
achieving symmetry. As part of the basic goals of otoplasty,
McDowell described the normal distance from skull to the
helix: the upper third of the helix, 10–12 mm; the middle third,
16–18 mm; and the lobule, 20–22 mm from the mastoid.95
Each case has a different combination of the deformities;
therefore, surgeons must combine the surgical options as well.
Surgeons should direct their efforts toward correcting the
specific problem areas of each individual ear rather than fol-
lowing a recipe. If the upper third of the ear protrudes because
Third step
The final step is to transform costal cartilage into an auricular
framework. Wilkes is the first to develop a rib cartilage model
from dental impression materials.51 The author modified the
shape, creating a more precise rib cartilage copy.49 With the
rib cartilage model, surgeons can simulate the framework
fabrication in a very realistic way. Exactly the same instru-
mentation as the clinical setting is used, and surgeons perform
carving, cutting, assembling, and adjusting of the cartilage
framework (Fig. 7.34).
Prominent ear
Background
Protruding ears are the most frequent congenital deformity of
the head and neck area, affecting 5% of the general public. Ear
deformities affect both genders equally and may be unilateral
or bilateral. In many cases protruding ears result in an abnor-
mal appearance. Although hearing may be normal, the indi-
vidual may suffer significantly from peer ridicule and lowered
self-esteem.
Evaluation
The first step in assessing the patient for otoplasty is deter-
mining the anatomic causes of protrusion of the ear. The most
common causes of protrusion of the external ear are (1) under-
development or effacement of the antihelix, (2) overdevelop-
ment of the deep concha, or (3) a combination of both of these
features.
Auricular protrusion may be one element of a more complex
auricular deformity such as a constricted ear, Stahl ear (third
crus), macrotia, or syndromic facial deformity. Chronic otitis
media, otitis externa, or conditions such as scalp infections or
acne must be treated well in advance of surgery. A simple
surgical wound infection can lead to an ear-threatening
chondritis.
I
J
(I) Split scalp skin was placed
over TPF. (J) Postoperative view.
Fig. 7.55, cont’d

211
Future direction
of an absent or weak antihelix, an antihelix must be formed.
If the middle third is too prominent, the concha must be
recessed by either cartilage excision or suture fixation. Lastly,
if the lobule protrudes, the surgeon should either resect or
retroposition the cauda helicis’ cartilaginous tail and/or
excise retrolobular skin.96
1.  Antihelical fold alteration
Scapha-conchal suture
Mustardé70,71 created the antihelix by inserting permanent
mattress sutures through the cartilage without using any
cartilage incisions. This technique is particularly useful in the
soft auricular cartilage of young children (Fig. 7.56), but it also
can be applied to adult patients (Fig. 7.57).
Anterior cartilage alteration
Chongchet97 scored the anterior scapha cartilage with multiple
cartilage cuts to roll it back and form an antihelix. While
Chongchet performed this technique under direct vision
using a scalpel, Stenstrom98 produced the same effect by using
a short-tined rasp instrument to score the antihelical region
through a posterior stab incision near the cauda helicis.
Restore antihelical fold by excision
Luckett99 restored the antihelical fold by excising a crescent of
anterior skin and cartilage. The majority of subsequent reports
have focused on creating a smoother antihelix than Luckett’s
sharp cartilage-breaking technique.
2.  Conchal alteration
Dieffenbach16 is credited with the first otoplastic attempt in
1845. This consisted of excising skin from the auriculocephalic
sulcus and then suturing conchal cartilage to the mastoid
periosteum. In addition to narrowing the auriculocephalic
sulcus, Ely17 and others excised a strip of conchal wall, a
procedure that is attributed to Morestin.100 This method of
tacking back the concha to the mastoid periosteum has been
revived through the years. The wide concha can be corrected
by excising a cartilaginous ellipse beneath the antihelix.
Future direction
As a part of a facial allotransplant, composite auricular
allotransplantation may be an option in the near future.
Tissue engineered-autogenous elastic cartilage has been in
progress99–101,104, but the issue of skin envelope deficiency has
not been completely solved yet.
Man-made skin flaps are not as thin as natural skin; cur-
rently only hard cartilage can create the definition of the
auricle. When both ear cartilage and thin skin regeneration
are achieved simultaneously, we will see the new era of
auricular construction.
A
Fig. 7.57  Free serratus fascia flap. (A) Elevation of fascia flap. (B) Fascia flap was
used to cover the posterior half of the auricle. Vascular pedicle was anastomosed to
neck vessels.
B

211.e1
Future direction
A
B
Fig. 7.56  Unilateral protrusion of the auricle. (A) Preoperative frontal view. (B) Preoperative posterior view. (C) Postoperative frontal view. (D) Postoperative posterior view.
C
D

212
SECTION II
CHAPTER 7 • Auricular construction
Fig. 7.4 Development of the auricle in a 5-week human embryo: 1–6,
elevations (hillocks) on the mandibular and hyoid arches; ov, otic vesicle; af,
auricular fold. (Modified from Arey LB. Developmental Anatomy, 7th edn.
Philadelphia: WB Saunders; 1974.)
Fig. 7.6 Combined microtia/atresia surgery was performed as a first stage
reconstruction. Atresia surgery was performed by Dr. Shinichi Haginomori.  
(A) Preoperative view of a 10-year-old male with concha type microtia.
(B) Concha type skin incision was used both for microtia construction and
atresia surgery. (C) Canal wall up mastoidectomy was performed. The malleus
(M) and incus (I) formed the complex. EAC, external auditory canal; Ma,
mastoid cavity. (D) The malleus-incus complex was removed. Mobility of the
stapes (S) was good. MM, manubrium of the malleus; CT, chorda tympani
nerve; EAC, external auditory canal; Ma, mastoid cavity. (E) The columella
(3 mm in length) was made from the cortical bone. (F) The columella (C) was
inserted between the manubrium of the malleus (MM) and stapes (S).  
(G) Audiological finding, one year post; the patient is able to hear whisper
voice with affected side. (H) One year postoperative appearance.
Fig. 7.10 Microtia patient with hemifacial microsomia. First, mandibular
distraction osteogenesis was performed, then microtia reconstruction was done.
(A) Preoperative view. (B) 3D CT reconstruction demonstrates new bone
generation of the mandible between distraction pins. (C) Frontal view of the
patient after mandibular distraction osteogenesis. Tilt of the commissure is
corrected. (D) Profile view of the patient prior to total auricular construction.
(E) Type A-2 template and 3D framework (F) Immediate postoperative view.
(G) View of the patient 2 years after total auricular construction.
Fig. 7.11 Treacher–Collins patient with bilateral microtia. The patient had
bicoronal scar, and TPF was not available. (A) Preoperative view of the left side.
(B) Left side view after two-stage auricular construction. (C) Intraoperative view
of right microtia. Posterior pedicle fascia was used for ear elevation. Surgery
was performed with Dr. Satoru Nagata. (D) Immediate postoperative view of the
right side.
Fig. 7.12 (A) A seven-year-old male with small concha type microtia. (B) 30%
low hairline was demonstrated by ear positioning template.
Fig. 7.19 The ear positioning template is a tool to identify the tauricular
rectangle, within which the auricular framework will be placed.
Fig. 7.22 Type A-1 auricular construction was performed for lobule type
microtia. (A) Preoperative view. (B) Type A-1 rib cartilage framework.
(C) Postoperative view.
Fig. 7.24 First stage surgery for lobule type microtia (A) Skin incision outline
for anterior surface of the lobule. (B) W-shaped skin incision outline on the
posterior surface of the lobule and the mastoid surface. (C) Undermining the
mastoid area to create 2-mm thick skin flap, using straight blunt scissors. Skin
pocket extends 1 cm beyond the ear outline. (D) 3D frame is inserted from
tarsal portion by rotating around the subcutaneous pedicle. (E) Under
temporary suction, skin flap is coapted to 3D frame, and excessive skin is
trimmed.
Fig. 7.25 Lobule type microtia. (A) Preoperative profile. (B) One year after
surgery. (C) Eight years after surgery.
Fig. 7.26 Lobule type microtia. (A) Preoperative profile of an 11-year-old
female. (B) Topographic marking and skin incision outline (red). (C) 3D
framework and Nagata type template. (D) Intra-operative view; anterior lobule
flap and posterior W-shaped flap are seen.
Fig. 7.28 Concha type microtia for which W-shaped posterior incision was
used. (A) Preoperative profile. (B) Type A-1 52-mm template is overlapped
onto the normal ear to confirm the needed size and shape of template needed.
(C) W-shaped posterior lobule skin incision (red). (D) Type A-1 52-mm
template and 3D framework. (E) One year after surgery.
Fig. 7.32 The author’s training method of creating 3D framework: Step 1;
practice by using potato. (A) Type C-2 template was placed on a potato.
(B) Type C-2 template was printed on a flat potato surface. (C) Relief of 3D
framework carved out from potato. (D) Completed potato 3D frame.
Fig. 7.33 Step 2: practice on a carrot 3D framework (A) Type A-1 template was
printed on flat surface of carrot. (B) Five parts of 3D framework are created from
carrots. (C) Five parts are assembled to create a carrot Type A-1 3D framework.
Fig. 7.34 Step 3: practice to create a 3D framework from precise rib cartilage
copy. (A) Type A-2 template is placed on 6–7 rib cartilage model. (B) Five
parts of 3D framework are created from a rib cartilage model. (C) Completed 3D
framework from rib cartilage model; anterior surface. (D) Posterior surface of 3D
framework.
Fig. 7.36 Second stage of surgery (ear elevation). (A, B) Framework is
separated from head. (C, D) Fabricated cartilage is wedged, and then the entire
posterior surface is covered with temporoparietal fascia flap. (E) Split scalp is
harvested and grafted over TPF.
Fig. 7.37 The nutrient vessel for deep temporal fascia can be seen one layer
below temporoparietal fascia flap. The course of the branch of the middle
temporal artery (yellow arrows) is similar to the temporal branch of STA.
Fig. 7.38 Unsatisfactory auricular construction; poor definition, exposed
auditory canal, hairs on helix, and pubic hairs grow from groin skin graft.
Fig. 7.39 Ear separation by skin grafting without cartilage support; helix is
touching the head. The patient has difficulty cleaning the back of the auricle.
Fig. 7.40 (A) Preoperative view of a patient with microtia in Treacher–Collins
syndrome. (B) Postoperative view. Small ear was created to balance the face.
Fig. 7.42 Secondary auricular construction, after unsatisfactory tissue expander
ear reconstruction. (A) Preoperative profile. (B) Size and shape of normal side
are confirmed with Type A-1 56-mm template. (C) Preoperative markings;
proper location of the auricle, skin flaps for lower third of the auricle, and
zig-zag temporal incision for harvesting TPF. (D) Previous framework was
removed. (E) Type A-1 3D framework. (F) Lower third of 3D framework is
covered with local skin flaps. (G) Upper two-thirds of framework was covered
with TPF. (H) The fascia was covered with split scalp skin. (I) One year after
surgery.
Fig. 7.51 Total amputation of the auricle associated with multiple injuries.
(A) View at the time of initial evaluation. (B) STA and STV were reconnected,
and skin coverage was performed using amputated skin. (C) Profile view prior
to total auricular construction. (D) Since rib cartilage was partially calcified,
helix portion was harvested peripheral to the base frame unit. (E) Completed 3D
framework with Nagata type paper template. (F) Lower portion of 3D framework
was covered with skin flaps, and upper two-thirds were covered with
temporoparietal fascia flap (STA/STV was reconstructed at the initial surgery).
(G) Split scalp skin was placed over TPF. (H) Postoperative view.
Fig. 7.56 Unilateral protrusion of the auricle. (A) Preoperative frontal view.
(B) Preoperative posterior view. (C) Postoperative frontal view. (D) Postoperative
posterior view.
Bonus images for this chapter can be found in online at

213
Future direction
6. Brent BD. Reconstruction of the ear. In: Neligan PC, ed. Plastic
Surgery. 3rd ed. Philadelphia: Elsevier Saunders; 2013:187.
9. Wilkes GH, Wong JW, Guilfoyle R. Microtia reconstruction. Plast
Reconstr Surg. 2014;134(3):464e–479e.
46. Wallace CG, Mao HY, Wang CJ, et al. Three-dimensional computed
tomography reveals different donor-site deformities in adult and
growing microtia patients despite total subperichondrial costal
cartilage harvest and donor-site reconstruction. Plast Reconstr Surg.
2014;133(3):640–651.
63. Long X, Yu N, Huang J, Wang X. Complication rate of autologous
cartilage microtia reconstruction: a systematic review. Plast
Reconstr Surg Glob Open. 2013;1(7):e57.
64. Yano T, Okazaki M, Yamaguchi K, Akita K. Anatomy of the middle
temporal vein: implications for skull-base and craniofacial
reconstruction using free flaps. Plast Reconstr Surg.
2014;134(1):92e–101e.
67. Kon M, van Wijk MP. T-bar reconstruction of constricted ears and
a new classification. J Plast Reconstr Aesthet Surg.
2014;67(3):358–361.
75. Doft MA, Goodkind AB, Diamond S, et al. The newborn butterfly
project: a shortened treatment protocol for ear molding. Plast
Reconstr Surg. 2015;135(3):577e–583e.
81. Yamada A. Cosmetic surgery of the ear. In: Pu LLQ, Chen Y-R, Li
Q-F, eds. Special Considerations in Cosmetic Surgery of the Asian Ear:
Aesthetic Plastic Surgery in Asians: Principles and Techniques. Boca
Raton: CRC Press; 2015.
88. Sinno S, Chang JB, Thorne CH. Precision in otoplasty: combining
reduction otoplasty with traditional otoplasty. Plast Reconstr Surg.
2015;135(5):1342–1348.
104. Liao HT, Zheng R, Liu W, Zhang WJ, Cao Y, Zhou G.
Prefabricated, ear-shaped cartilage tissue engineering by scaffold-
free porcine chondrocyte membrane. Plast Reconstr Surg.
2015;135(2):313e–321e.
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213.e1
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SECTION II • Head and Neck Reconstruction
8 
Acquired cranial and facial  
bone deformities
Blake D. Murphy, Craig Rowin, and S. Anthony Wolfe
SYNOPSIS
■ Treatment of acquired cranial and facial bone deformities begins with a
thorough physical examination prior to radiologic studies.
■ Access incisions must allow visualization and exposure of the entire
defect.
■ Surgical treatment must follow Tessier’s principles of subperiosteal
exposure, judicious use of autogenous bone grafts, and rigid
fixation.
■ Alloplastic materials are to be avoided if possible.
■ Late presentation of acquired deformities may require an osteotomy
through the defect site prior to reduction.
■ Additional details regarding facial fractures can be found in Section 1,
Chapter 3: Facial injuries.
■ Additional details regarding mandibular and maxillary reconstruction
can be found in Section 2, Chapter 10.1: Midface reconstruction
introduction and Chapter 11: Oral cavity, tongue, and mandibular
reconstructions.
Introduction
The various causes of acquired deformities of the facial
skeleton include trauma, infection, and surgical or radio-
therapeutic treatment of neoplasia. The surgical treatment
of these acquired deformities has changed radically during
the past three decades as a result of advances in the
subspecialty of craniofacial surgery. Craniofacial surgery
developed almost entirely from the work of Paul Tessier,
who revolutionized facial skeletal surgery with his seminal
work regarding treatment of congenital malformations,
such as Crouzon disease,1 Apert syndrome,2 Treacher
Collins–Franceschetti syndrome, vertical orbital dystopias,
and orbital hypertelorism.3–8 The basic principles Tessier
stressed when operating on the facial skeleton include the
following:9
Key points
■ Complete subperiosteal exposure of the areas of interest
through coronal, lower eyelid, or intraoral incisions.
■ Repositioning misaligned segments of the craniofacial
skeleton with rigid fixation and interposed autogenous
bone grafts to provide consolidation of the structure.10
Onlay “camouflage” grafts are to be avoided because
they do not provide a three-dimensional (3D) correction
of the entire deformity.
■ Utilizing only fresh, autogenous bone grafts, obtainable
from the ribs, anterior and posterior ilium, tibia, and the
skull.11,12 There is little place for bone substitutes, whether
alloplastic materials or cadaver bone, in craniofacial
reconstruction.13
■ If a structure is not present to be repositioned, it can be
constructed in situ or constructed and then moved to the
proper location.
■ The once forbidden boundary zone between the cranial
cavity and the midface can safely be transgressed if
proper care is taken in its reconstruction. Regular and
frequent collaboration between the plastic surgical and
neurosurgical members of a craniofacial team decreases
the risks associated with a transcranial approach.
■ Other members of a craniofacial team, such as
ophthalmologists and orthodontists, will need to be
involved in the treatment of acquired deformities, just as
for congenital malformations.
Basic science/disease process
Access incisions
Access to the facial skeleton is provided through coronal,
lower eyelid, and intraoral incisions. The following para-
graphs describe the proper techniques to be used when
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215
Basic science/disease process
hemicoronal incision with an extension on to the forehead, are
relics of the past, and have no place in modern day craniofacial
surgery.
Lower eyelid incisions
The lower eyelid, inferior orbital rim, and orbital floor can be
accessed through either the conjunctiva or the lower eyelid. If
a cutaneous approach is used, it should be lower in the eyelid,
beneath the tarsal plate, rather than in the immediate subcili-
ary area in order to minimize postoperative ectropion.15,16
Intraoral incisions
Upper buccal sulcus incisions should have an adequate infe-
rior mucosal cuff for subsequent closure. The infraorbital
nerve should be protected and the buccal fat pad avoided
during dissection. The entire mandible up to the sigmoid
notch and 1 cm inferior to the coronoid process and condyle
are accessible through a lower buccal sulcus incision.17
Bone grafts
The key element to success in repositioning or replacing por-
tions of the facial skeleton lies in the liberal and exclusive use
of fresh autogenous bone grafts. Cranial bone is the preferred
donor site, given the ease of harvest, quality, and quantity of
the bone, and proximity to the operating field.
The preferred donor area for cranial grafts is the right
parietal area in right-handed patients.18 When large grafts are
required, the craniotomy can be extended anteriorly beyond
the coronal suture and posteriorly into the occipital region. If
additional bone is required, the opposite parietal region may
be utilized. The harvested bone should be slightly larger in
dimension than the area to be corrected. Each graft can be split
through the diploic space to give two segments of equal
dimensions. The inner table is replaced in the donor area with
one of the segments. A defect several millimeters in width will
be present, varying with the thickness of the craniotome
blade. This defect is placed posteriorly and filled in with small
bone chips, slivers, and bone dust and covered with a peri-
cranial flap.19 The bone graft for the defect is tailored exactly
to the defect (Fig. 8.2). On occasion, it is good to enlarge the
defect slightly by burring back to healthy bone. Fixation with
wires is preferred over miniplates for reasons of cost and ease
of use.
Although cranial bone is the preferential donor site in
craniofacial cases, iliac bone provides an excellent graft for the
orbital floor because of the thin cortical floor with malleable
cancellous bone that is rigid enough to support the globe.
Also, iliac bone is an excellent choice when large amounts of
cancellous bone are required, such as for obliterating a frontal
sinus (Fig. 8.3). Rib is often used when other donor sites are
not available or advisable and are best suited for areas of
the hair-bearing scalp when contour irregularities are less
conspicuous.
Soft-tissue cover
The success of free bone grafts depends on the intimate contact
of well-vascularized soft tissues both above and below the
grafts. This means that areas between bone grafts must be
filled in with other graft material and hematoma formation
making these incisions. Further detail regarding surgical
approaches to the craniofacial skeleton can be found else-
where.14 In addition, a thorough knowledge of the craniofacial
anatomy is essential and is detailed in Part 1, Chapter 1:
Anatomy of the head and neck in this volume.
Coronal incisions
Coronal incisions (not bicoronal as it is often mistakenly
referred to) should be made at least 3 cm behind the anterior
hairline, almost at the vertex. The incision is carried to a point
just above the anterior attachment of the ear, where a small
cutback of 8–10 mm is made in the direction of the lateral
canthus, allowing the coronal flap to be turned forward
without tension. Incisions close to or along the anterior hair-
line can be noticeable and difficult to improve in areas of
scarring alopecia. The dissection is carried out in a supraperi-
osteal plane to the level of the supraorbital ridge, where it
then becomes subperiosteal. The superficial temporal fascia
(STF) is generally divided, exposing the deeper temporal
fascia upon approaching the zygomatic arch and malar region.
The temporalis muscle should be elevated separately from the
scalp and re-sutured to the lateral orbital rim, anterior tempo-
ral crest, and posterior portion of the coronal incision, main-
taining its original tension upon closure of the incision. The
STF should also be resuspended at the time of closure. After
the temporal muscle has been sutured back into position
under proper tension, a suture is taken from near the lateral
canthal raphe and passed through the temporal aponeurosis
to reposition the lateral canthus properly (Fig. 8.1).
Once a coronal incision has been made, the same incision
should be used for any future surgeries, as a scalp with
multiple scars may greatly complicate later reconstruction.
Additionally, previously described incisions, such as the
Fig. 8.1  Coronal incision.

216
SECTION II
CHAPTER 8 • Acquired cranial and facial bone deformities
A
B
C
D
E
F
G
H
Fig. 8.2  This 12-year-old boy was in an automobile
accident in Cuba and sustained an open right frontal
fracture. The original laceration is apparently the
sweeping scar from near the midpoint of the anterior
hairline to a point above the right sideburn. A
subsequent neurosurgical procedure was performed
through an incision just along the right anterior
hairline, and yet another procedure was performed
through a more posterior incision (A,B). Through one
of these incisions, an attempt was made to correct the
cranial defect with an alloplastic material that had to
be removed because of infection. The cranial defect
was approached through an anterior hairline incision
that extended into a more posterior coronal incision
on the left side. A left parietal craniotomy of a slightly
larger dimension than the measurements of the right
frontal cranial defect was performed, and the cranial
flap was split (ex vivo) into two segments through the
diploic space. The outer table segment was used for
the frontal defect after precise trimming, and the inner
table segment was placed back in the donor area
(C,D). (E,F) A postoperative 3D computed
tomography scan displays the precise repair of  
the cranial defect with the split calvarial graft.  
(G,H) Healing was uneventful. There are two important
lessons to be learned from this patient. First, use a
posterior coronal incision, and use it for all
subsequent procedures. Second, use autogenous
cranial bone for cranioplasties whenever possible.

217
Treatment/surgical technique
children younger than 2 years of age, they often spontane-
ously ossify and do not require treatment. Cranial bone is the
material of choice for most cranioplasties due both to the
quality of bone and proximity to the field of operation (Figs.
8.2, 8.4, 8.5).20,21 In the authors’ experience, the youngest
patient with a cranial bone that can be successfully split ex
vivo is between 3 and 4 years of age. Good results can also be
obtained with split rib (Fig. 8.6). Rib grafts can be used from
the age of 4–5 years, depending on the size of the patient.
Alloplastic materials should not be used in children as a
primary reconstructive option. If the cranial defect has been
corrected with autogenous bone grafts and all reconstructive
work is complete, for minor surface irregularities present after
1 year, small amounts of alloplastic material such as Norian
(Synthes Inc., West Chester, PA, USA), BoneSource (Stryker
Inc., Kalamazoo, MI, USA), or hydroxyapatite may be utilized.
In adults, small defects remote from the frontal sinus may also
be primarily corrected with these materials.
Near the frontal sinus, only autogenous bone should be
used due to the proximity to the sinuses and elevated risk of
infection.22 If there is a full-thickness cranial defect near the
frontal sinus, the sinus should be cranialized; if the posterior
wall of the sinus is intact and the nasofrontal duct appears to
be blocked, all mucosa should be removed and the sinus filled
with autogenous cancellous grafts (Fig. 8.3).23, 24
prevented by fastidious hemostasis and adequate postopera-
tive drainage. When soft tissues are inadequate because of the
original trauma or radiotherapy, they must be replaced with
good soft tissue before bone grafts can survive. This includes
filling the dead space under planned autogenous cranioplasty
(Fig. 8.4). Given adequate exposure, an acceptable amount of
autogenous bone grafts, and the means to provide rigid fixa-
tion, the correction of deformities in various areas of the facial
skeleton should proceed smoothly.
Treatment/surgical technique
Treatment of specific defects
Acquired defects of the cranium and facial skeleton can be
divided into two groups: those resulting from displaced
fractures and those resulting from a loss of substance. We will
discuss each specific area of the cranial and facial bone defects
and their treatment.
Cranium
Cranial defects greater than half the thickness of the skull in
patients older than 2 years of age should be repaired. In
A
B
C
Fig. 8.3  This 25-year-old man had a chronic draining fistula communicating with a frontal sinus mucocele after
treatment of fronto-orbital fractures elsewhere (A). The fistula had been present for several years. The skin track
was excised transversely and exposed through a coronal incision in the large frontal sinus extending almost from
lateral orbital rim to lateral orbital rim. All mucosa was meticulously removed (outlined area) with a small burr,
sharp periosteal elevators, and small curets (B,C). The entire sinus cavity (outlined area) was then filled with fresh
autogenous iliac cancellous bone (D) and covered with a pericranial flap (arrows). The wound healed without
difficulty, and the patient is shown 5 years later (E) without having had any further surgery. Fresh, cancellous bone
is the best material to use for obliteration of the frontal sinus, even with chronic infection, as was the situation
here.
D
E

218
SECTION II
CHAPTER 8 • Acquired cranial and facial bone deformities
A
B
C
D
E
F
G
H
I
Fig. 8.4  A 28-year-old female who suffered a gunshot wound, resulting in loss of the right eye, right frontal, and supraorbital area. The patient was treated at an outside
institution with debridement and craniectomy, right orbital exenteration, and attempt at frontal sinus obliteration. She is seen at presentation with Penrose drain in place
(A,B,C). The patient underwent excision of draining fistula tract, dural patch (D), and obliteration of dead space with free latissimus dorsi flap (E). Photographs and CT
postoperatively (F,G). She then underwent reconstruction of the right supraorbital area with iliac bone graft (H) and is seen postoperatively in photographs (I) and CT (J).

219
Treatment/surgical technique
be repositioned and maintained with a percutaneous K-wire,
placed under local anesthesia, and maintained in position
until consolidation of the bone graft occurs (Fig. 8.7).
If substantial lengthening (>1 cm) of the nose is required,
such as in Binder syndrome29 or post-traumatic nasal fore-
shortening, dissection of the skin alone is not sufficient. The
lining needs to be lengthened as well. Tessier et al. have shown
that considerable lengthening can be obtained, even in con-
genitally short noses, by dissecting the lining from beneath
the nasal bones all the way back to the pharynx.30 Another
approach is purposely to section the lining (and bone) at the
nasofrontal area, as in a Le Fort III osteotomy (Fig. 8.8).31
The undersurface of the bone graft may be exposed to the
nasal cavity, but healing proceeds uneventfully, as it does in
a Le Fort III over bone grafts exposed to the maxillary sinus.
This type of procedure would not be applicable to the con-
tracted, foreshortened nose that is associated with sustained
Nose
This region involves the nasal bones, cartilaginous and bony
septum, and the upper lateral cartilages. Minimally displaced
fractures can often be treated with closed reduction and place-
ment of nasal splints. Comminuted fractures require an open
rhinoplasty approach and usually require placement of an
autogenous bone graft.25–28 This approach makes it possible to
separate the alar cartilages and then replace them over the
nasal bone graft. Bone grafts for a depressed dorsum are
simply placed into an appropriate pocket after dissection of
the skin alone. In general, the bone graft is not rigidly fixed
in place; care must be taken that the posterior portion of the
bone graft is flat to avoid shifting of the graft. Making bilateral
nasal vestibular incisions also helps provide an appropriate
pocket so that the graft will remain in the center of the nose.
If a graft does shift in the postoperative period, it can often
J
K
L
M
N
O
Subsequently, she underwent staged autologous cranioplasty with split calvarium (K) and later rib graft of donor site hidden under hair bearing scalp. She
is seen postoperatively in photographs (L) and CT (M). Current clinical photographs (N,O) with soft tissue revisions planned for right periorbital area surrounding her ocular
prosthesis.
Fig. 8.4, cont’d

219.e1
Treatment/surgical technique
C
Fig. 8.5  This 23-year-old was shot through the right frontal
region and has extensive debridement of the left frontal bone,
supraorbital ridge, and orbital roof (A,D,E). He is shown after
a split cranial bone cranioplasty (B,C), reconstruction of the
orbital roof and supraorbital ridge, and subsequent ptosis
correction by reattachment of the levator muscle to the tarsal
plate (F).
A
B
D
E
F

220
SECTION II
CHAPTER 8 • Acquired cranial and facial bone deformities
by definition, involves the orbit. Telecanthus, as a result of
lateral displacement of the medial orbital walls and nasal
foreshortening, is commonly seen after these fractures.
One must resist the temptation to treat this conservatively
with packing alone, as this pushes the structures further in,
adding to the nasal foreshortening. A coronal incision should
be used for adequate exposure unless a large facial lacera-
tion provides excellent exposure. Correction of telecanthus
secondary to displaced bone fragments with the medial
canthal tendons still attached can often be accomplished by
anatomic reduction of the bone segments, without having
cocaine use. Here, the lining is either altogether absent or
chronically granulating and infected. Before a nasal bone graft
can be added, nasal lining must be provided by local and
regional flaps such as nasolabial, forehead, or buccal sulcus
flaps. Alternatively, free flaps such as the radial forearm can
be utilized for severely deficient tissue.32
Nasoethmoid area
Fractures in this region are often referred to as naso-orbital–
ethmoid fractures, although the ethmoidal involvement,
Fig. 8.6  This 22-year-old man had multiple facial and cranial fractures
following a motor vehicle accident. He had a craniotomy for an acute
epidural hematoma and subsequently developed a retrofrontal mucopyocele,
necessitating removal of the infected frontal bone flap (A,B). Six months
later, the frontal defect was repaired with split-rib grafts (C–E). He is shown
8 months after surgery with improved contour of the previous defect (F,G).
A
B
C
D
E
F
G

221
Treatment/surgical technique
Orbitozygomatic fractures vary considerably in their pre-
sentation, depending on the vector and force of the causative
injury. Lesser injuries may result in nondisplaced fractures of
the zygoma with minimal disruption of the orbital floor. In
this instance, no treatment other than follow-up observation
is necessary. If one has underappreciated the extent of the
orbital floor fracture, late enophthalmos is a possible sequela;36
however, one certainly does not have to operate on question-
able fractures simply because of this possibility. Some advo-
cated this approach when it was thought that enophthalmos
could not be corrected.37,38
Greater forces cause greater disruption, and because of the
elastic nature of bone, the extent of bone displacement during
the injury may be much greater than the displacement seen
when the patient first presents. Again, late enophthalmos may
develop if these injuries are not repaired properly (Fig. 8.11).
If one puts the orbital framework into proper position with
rigid fixation and repairs the internal orbital defects with
autogenous bone grafts, enophthalmos will not result. Exami-
nation of the orbital floor and globe position must be reas-
sessed after reduction, followed by a forced duction test to
ensure unrestricted movement of the globe.
Reduction of an orbitozygomatic fracture in which the
zygomatic body has been displaced away from the globe can
usually be accomplished in the first week after the fracture
simply by removing callus in the fracture lines and grasping
solid segments of bone with bone clamps. When the zygoma
has been displaced by the injury toward the globe, proptosis
or at least lack of enophthalmos may be present when the
patient is first seen. In some instances, it may not be possible
to reduce the fracture. In these instances, one must be pre-
pared to perform an osteotomy through the fracture lines in
order to reduce the fracture adequately.
Most fractures that are seen after a delay of 3 weeks or
more will have consolidated and will require osteotomy and
to detach the tendons and perform a transnasal medial
canthopexy.33,34
If the medial canthal tendon has been detached, a transna-
sal canthopexy must be performed. Some overcorrection of
the medial wall segments is desirable, as in the correction of
orbital hypertelorism. If there is significant loss of substance
in the medial orbital wall, it may be necessary to perform a
primary bone graft and medial canthopexy. The nasal dorsum
will usually require a bone graft to repair the foreshortening
resulting from the fracture (Fig. 8.9).
Late reconstructions may pose an even greater challenge
if the bones have consolidated in malposition. In such cases,
the dissection must be extensive, often involving coronal,
lower eyelid, and buccal sulcus incisions. The displaced
segments must be delineated and osteotomized in order to
return to their proper position. Plate and screw fixation is
used to stabilize the segments.35 A nasal bone graft is fre-
quently necessary for dorsal support and soft tissue may be
needed to keep in conjunction with the principle of aesthetic
subunits.
Orbitozygomatic region (Video 8.1 )
Acute, isolated fractures of the zygomatic arch require an
open approach if they cannot be reduced percutaneously. A
coronal incision gives access for reduction and plating of the
fracture or harvesting of bone grafts, if necessary.
Isolated orbital floor fractures are seen more commonly in
younger patients, where the infraorbital rim is more elastic in
comparison to adult patients (Fig. 8.10). It appears that the
causative force strikes the rim, which bends and then springs
back to its original position. These actions can cause a fracture
in the thin orbital floor. These injuries have the highest inci-
dence of entrapment, diplopia, and inferior rectus damage
which requires prompt intraoperative release.
Fig. 8.7  This 42-year-old man presented 2 months after
trauma to his nose resulting in a severe saddle-nose
deformity, bilateral nasal bone fractures, and a
significantly deviated septum, resulting in significant
difficulty breathing through his nose (A–C). He underwent
cranial bone graft reconstruction of his dorsum (D) with
columellar strut grafts, spreader grafts, and septoplasty.
The patient is shown 1 month after surgery with
resolution of both his functional and aesthetic concerns
(E–G).
A
B
C
D
E
F
G

222
SECTION II
CHAPTER 8 • Acquired cranial and facial bone deformities
should be fairly straight, and not bowed, in order to provide
proper projection of the midface.
Post-traumatic enophthalmos
Post-traumatic enophthalmos can result either from isolated
defects of the orbital floor and medial orbital wall, in which
there is herniation of orbital contents into the maxillary and
ethmoidal sinuses, or from displaced orbitozygomatic frac-
tures, in which there is herniation of orbital contents into the
paranasal sinuses.40 If there is even a slight displacement of
the zygoma from its proper position, it should be osteoto-
mized and properly positioned. Autogenous bone grafts are
used to replace missing or displaced portions of the internal
orbit.41,42 In the presence of a seeing eye, post-traumatic
enophthalmos can be completely corrected in most instances
if the bony orbit is completely reconstructed and all of the
repositioning. Coronal, lower eyelid, and buccal sulcus inci-
sions are used in most of these patients to provide good access
for the osteotomies and also to allow the surgeon to appreciate
the internal orbital anatomy fully, both of the medial orbital
wall and of the lateral orbital wall. The sphenoidal portion
of the lateral orbital wall should be perfectly aligned and is
an excellent starting point to ensure proper reduction and
correction of rotational deformity. A positioning wire is then
placed through the frontozygomatic suture, and finally the
inferior orbital rim is aligned. A wire is usually all that is
needed for the frontozygomatic suture, and a small plate is
placed to stabilize the inferior orbital rim. The zygomatic but-
tresses39 should be checked through the upper sulcus incision
and fixed in proper position with a larger plate. Finally, the
zygomatic arch is plated, and one should have exposure of the
normal side to check the exact shape of the normal zygomatic
arch. If the arches are fractured on both sides, recall that they
Fig. 8.8  This 17-year-old female was involved in a vehicular
accident in South America. She was treated with wire traction
from the zygomas to a head cap of some sort. Both globes
were severely damaged, and she was blind (A,B). She is
shown 6 months after a complete subperiosteal dissection of
the orbital cavities and midface through coronal, intraorbital,
and lower eyelid incisions, with mobilization of all
malpositioned segments, extensive bone grafting with both
iliac and cranial bone, and rigid fixation. The nasal lengthening
was accomplished by sectioning of the contracted lining at the
Le Fort III level and placement of an iliac bone graft in the
created gap and as a dorsal graft along with a conchal
cartilage graft to the nasal tip. This also corrected her class III
malocclusion. In the postoperative photographs (C,D), she has
ocular prostheses. The computer-generated overlay of her
preoperative and postoperative photographs shows the degree
of true nasal lengthening (E).
A
B
C
D
E

223
Treatment/surgical technique
Fig. 8.9  This 13-year-old boy, living in Haiti, was struck by a pipe protruding from a car while he was on his bicycle. He presented 2 days after the injury with prolapse of
the right globe and loss of vision, even though some extraocular motions were still present (A–C). Additionally, avulsion of the right medial rectus was noted. Fractures of
the right orbit and nasoethmoid region were present, as well as right telecanthus (A). Treatment consisted of exposure of the fractures through coronal, right lower eyelid,
and upper buccal sulcus incisions. Fractures were reduced and wire osteosynthesis placed. Replacement of the right globe into the orbital cavity required making multiple
scoring incisions of the periorbitum. Iliac bone grafts to the nose, orbital floor, medial orbital wall, and anterior maxilla were placed, and a transnasal medial canthopexy
through the medial orbital wall bone graft was performed (D). He is shown 5 years postoperatively with a cosmetic cover shell over the right eye and good maintenance of
nasal contour with the bone graft (E,F).
A
B
C
D
E
F
orbital contents are returned to the orbital cavity.43 Overcor-
rection by several millimeters in both the vertical and sagittal
directions should be performed to compensate for operative
swelling.
In patients with inadequate late correction of enophthal-
mos, even if it is mild, a coronal and sagittal computed
tomographic (CT) scan will show a few areas where further
bone grafting can provide a complete correction. When one is
performing secondary bone grafting such as this, it is impor-
tant to bear in mind that the orbital cavity may not have any
areas of egress because all of the communications into
paranasal sinuses have been closed off with bone grafts.
Bringing a small drain (such as a TLS drain) from the orbital
floor out through the sideburn area will lessen the possibility
of a volume and pressure increase due to hematoma (Figs.
8.12 & 8.13).44
The irradiated orbit
Irradiation of the orbit in early childhood, such as for
retinoblastoma, will result in a small orbit and often restric-
tion of growth of the temporal fossa. If a seeing eye is still

224
SECTION II
CHAPTER 8 • Acquired cranial and facial bone deformities
prolapsed into the maxillary sinus through defects in the
anterior maxillary wall, and these must be completely
retrieved. Autogenous bone grafts are used to recreate the
anterior maxillary wall and to keep the soft tissues in their
proper place. As noted previously, the dissected midfacial
tissues are suspended to the temporal aponeurosis, and a
lateral canthopexy is performed.
Maxillary fractures
When evaluating fractures of the maxilla, one must remember
the importance of the maxillary buttresses, as described by
Gruss and Mackinnon46 and Manson et al.39 These thickenings
of bone conduct masticatory and other forces through the
midface to the thicker bones of the skull and are divided into
four categories:
1. Central: septo-vomerine-ethmoidal-frontal
2. Medial/paracentral: maxillo-naso-frontal
3. Lateral: maxillo-malar-frontal
4. Posterior: maxillo-pterygoid.
present, one can deal with the temporal fossa defect with a
soft-tissue flap, most efficiently by composite tissue trans-
plantation. The orbit itself should not be altered. If the eye
is absent and the orbit small, an orbital expansion can be
performed to give an orbit of normal dimensions.45 This
is followed by socket reconstruction and placement of an
ocular prosthesis.
Primary and secondary facial bones
reconstruction
The overall approach for secondary correction of displaced
facial bone segments is the same as for primary correction:
obtain adequate exposure, place the segments into proper
position, utilize rigid fixation, and liberally use autogenous
bone grafts for any residual bone defects. The main difference
is that the soft-tissue dissection is often much more difficult
because of scarring and contraction of the soft-tissue envelope
over the malpositioned facial bone segments. The buccal fat
pad and other soft-tissue elements of the midface may have
A
B
C
Fig. 8.10  This 9-year-old boy was kicked in the face by a horse. Ophthalmologic examination showed no damage to the eye itself. There was considerable ecchymosis and
swelling of the eyelids, and, even with that, some enophthalmos was present (A). There was a palpable depression of the infraorbital rim. A computed tomography scan
showed comminution of the infraorbital rim and anterior maxilla with a large defect of the orbital floor. The malar bone, however, was not otherwise displaced. Treatment
consisted of a lower lid incision, removal of multiple small comminuted bone fragments of the infraorbital rim, exploration of the orbital floor, with retrieval of orbital
contents from the antrum, and placement of cranial bone grafts on the orbital floor and infraorbital rim/anterior maxilla (C–E). His postoperative appearance at 1 year shows
no evidence of enophthalmos (B).
D
E

225
Treatment/surgical technique
of autogenous bone grafts are essential to the consolidation of
the maxilla in its new position.
Maxillary reconstruction
The same dissection previously described for traumatic defor-
mities can be employed for either primary or secondary
reconstruction of maxillary defects subsequent to removal of
maxillary tumors, including use of the temporalis muscle.50 A
portion of the temporalis is mobilized through the coronal
incision and the arch of the zygoma is removed to allow
passage to the oral cavity. A hemimaxillary defect can easily
be closed with this muscle flap. The muscle does not need to
be covered by mucosa or skin grafted because it is rapidly
covered by mucosa naturally. An alveolar defect, either lateral
or anterior, must be present to bring in the muscle flap easily.
If the alveolar ridge is intact, it is difficult to bring in a muscle
flap because it involves making a hole through the anterior
maxillary wall or bringing the muscle behind the maxillary
tuberosity (Fig. 8.14). For large central palatal defects that
cannot be closed by local palatal flaps, a microsurgical solu-
tion is preferred with preference for the radial forearm flap.51
After complete healing of the soft-tissue palatal repair, a bony
alveolar ridge can be reconstructed with iliac bone grafts or
When any of the maxillary buttresses is fractured trans-
versely in only one place, but is otherwise intact, treatment
consists of reducing the fracture to a proper occlusal relation-
ship with the mandible, followed by rigid fixation across the
fracture line. The use of intermaxillary fixation depends on
the stability of the osteosynthesis. If the buttresses are com-
minuted with a loss of facial height, treatment must include
reconstitution of the bony deficiencies with primary bone
grafts. It is not uncommon for a Le Fort I fracture to be treated
by intermaxillary fixation with a satisfactory occlusal result
but a shortened midface. This occurs if the maxillary but-
tresses have all been fractured and the maxilla is displaced
upward until bone contact occurs.47 This deformity can be
prevented if a primary reconstruction of the buttresses is
carried out at the initial repair.48,49
If maxillary fractures have not been adequately reduced in
the primary operation, they may require late treatment. This
requires sectioning of the maxilla at the Le Fort I level,
mobilization of the maxilla, and intermaxillary fixation. If
the maxilla–mandible complex in intermaxillary fixation is
allowed to find its own position in the lightly anesthetized,
unparalyzed patient, this position represents the degree of
lengthening desired. The two sides of the sectioned maxilla
can now be plated in this position. Again, adequate amounts
A
B
C
Fig. 8.11  This woman was 32 years old when an
osteotomy and repositioning of the right zygoma were
performed along with an iliac bone graft (A). An
undercorrection was noted 6 years later (B). A computed
tomographic evaluation showed a persistent small defect
in the posteromedial orbital wall as well as an
enlargement of the inferior orbital fissure; the addition of
a small amount of cranial bone corrected the persistent
enophthalmos completely, as seen in her photo 4 years
after her second surgery (C). (D) Illustration showing the
repositioning of the right zygoma.
D

225.e1
Treatment/surgical technique
A
B
C
D
Fig. 8.14  This 29-year-old woman had undergone a hemimaxillectomy and postoperative irradiation for a neuroesthesioblastoma (A). She was left with a large palatal
defect (B), as shown in her post-resection computed tomography scans (C,D). Shortly after the initial preoperative photograph was taken, her right eye spontaneously
perforated and she underwent an evisceration (removal of all of the orbital contents down to periosteum). Reconstruction of her maxilla was performed using a temporalis
muscle flap to close the palatal defect (E). The radiation-damaged skin of the lower eyelid and cheek was resected and a skin graft placed over the temporalis muscle. At a
subsequent operation, an iliac bone graft was placed from alveolar ridge to pterygoid region (F), well nourished by the underlying temporalis muscle; the lower eyelid was
reconstructed with a forehead flap. Osseointegrated implants have been placed in the maxillary bone graft, and this portion of her reconstruction has been completed (G). A
second forehead flap was required for the lower eyelid reconstruction and her final postoperative result is shown (H).
E
F
G
H

226
SECTION II
CHAPTER 8 • Acquired cranial and facial bone deformities
Fig. 8.12  This 23-year-old man had suffered major right orbitocranial fractures several years previously in a vehicular accident. A defect of most of the right frontal bone
had been reconstructed with methyl methylmethacrylate. There was profound enophthalmos and hypoglobus of the right eye, which still retained some vision (A). In the
initial operation, the alloplastic material was removed, and the frontal defect was reconstructed with split cranial bone (B). Major reconstructive orbital surgery is not
recommended if there is any alloplastic material in the region of the periorbital sinuses. At the same time, refracture and repositioning of the right zygoma were performed
along with cranial bone grafting of the medial orbital wall and orbital floor defects. This corrected the enophthalmos, but the patient was left with a considerable persistent
hypoglobus. This was treated as a true vertical orbital dystopia, with an intracranial elevation of the entire – now intact – orbital cavity (C). The medial canthal tendon was
left attached to bone and was elevated with the orbit. The patient is shown 3 years after the second operation (D).
Methacrylate
Outer
Inner
B
A
C
D
Fig. 8.13  In this post-trauma patient, one can see a hypoglobus without enophthalmos (A). The orbital roof had been pushed into the orbital cavity, resulting in a slight
proptosis. The globe was elevated by an osteotomy and repositioning of the zygoma, elevation of the orbital roof, and bone grafting of the orbital floor along with a
transnasal medial canthopexy (B). The canthopexy shows that the canthal tendon is brought through a drill hole in the medial orbital wall just above and posterior to the
lacrimal fossa and tied over a toggle on the contralateral side. He is shown operatively with correction of his hypoglobus (C).
A
B
C

227
Postoperative care
microvascular osseous flaps (fibula or parascapular flaps are
the most common).52 After the bone repair is well consoli-
dated, osseointegrated implants can be placed to accept a
denture and finish the reconstruction.
Mandible fractures
When evaluating a patient with a suspected mandibular
fracture, the diagnosis can often be made by physical exami-
nation alone. Common findings include malocclusion, a step
in the occlusal plane, a change in the axial inclination of the
teeth, mental nerve paresthesias, ecchymosis or a tear in the
buccal mucosa overlying the fracture, and localized pain on
palpation and movement at the fracture site. To locate the
fracture and any associated fractures precisely, a Panorex or
CT scan should be performed.53
Treatment of nondisplaced mandibular fractures in compli-
ant patients may consist of a soft diet and careful observation
alone with repeat radiological studies over 4–6 weeks. If the
patient is noncompliant, he or she may be best served with
4–6 weeks of intermaxillary fixation.
Displaced fractures of the mandibular symphysis, body, or
ascending angle are usually associated with malocclusion and
require treatment with open reduction and internal fixation.
In 1976, Spiessl54 described the concept of the “tension band”
in the treatment of displaced mandibular fractures. He
described the use of one fixed point of osteosynthesis as a
fulcrum in order to achieve greater compression of the bone
fragments and, therefore, more stability and primary bone
healing. Two levels of fixation, along the upper and lower
border of the mandible, are required. In the non-tooth-bearing
regions (ascending ramus and angle), two plates may be used.
In the tooth-bearing regions, an arch bar will provide stability
for the upper border and a plate may be used along the lower
border. In the symphysis and parasymphyseal regions, two
plates can be placed in the space below the roots of the inci-
sors and the lower border. Miniplates can be used with this
approach, unless there have been significant comminution
and fragmentation of the mandible.55 In such cases involving
comminution of the fracture, larger mandibular plates are
required. When significant loss of mandibular substance
occurs, a large reconstruction plate is necessary.
The edentulous state results in loss of alveolar bone, leaving
a mandible that can be 1 cm or less in vertical height along
the body. The thickness of the symphysis and structure of the
vertical ramus change little, which accounts for the majority
of fractures in edentulous mandibles occurring at the para-
symphyseal area and body. These patients may have difficulty
with fracture healing even with the use of rigid fixation, due
to lack of bone stock. In select cases, primary bone grafting
should be done to reinforce the fracture site.
Much debate remains as to the treatment of condylar
fractures. In children under 12 years of age, no operative
treatment is almost always indicated due to the tremendous
potential of the condyle to remodel and regenerate.56 In teen-
agers and adults, definite indications for operative treatment
include the following: displacement of the condyle in the
middle cranial fossa, bilateral fractures with an anterior open
bite, multiple other maxillary and mandibular fractures where
mandibular stability is important to maintaining facial height,
and the situation in which the patient cannot be brought into
occlusion with less invasive measures.57 If the patient has
sustained a subcondylar fracture with the condyle in the
glenoid fossa and no malocclusion, treatment consists of
application of arch bars with elastics or wire fixation, soft diet,
and occlusal splint for 4–6 weeks, followed by aggressive
physical therapy. If, however, the condyle is out of the fossa,
the debate continues as to whether open or closed treatment
is best.58
Mandibular reconstruction
Incontinuity defects of the mandible less than 3–4 cm in
length covered by healthy soft tissue can be corrected with
free bone grafts (iliac and cranial represent the bone grafts of
choice) and rigid fixation with miniplates.59,60 An adequate
amount should be present (20 mm or more) in the vertical
dimension in tooth-bearing areas for placement of osseointe-
grated implants. If defects involve the alveolus alone, either
in the maxilla or in the mandible, getting enough bone for
implants to take as a free graft may be difficult. If enough bone
is present to permit a horizontal osteotomy, distraction osteo-
genesis will provide the best result because the gingiva will
come up with the distracted bone and one can easily overcor-
rect the bone defect. Overcorrection may cause premature
contact at the apex of the (now overcorrected) deficiency, with
overeruption of the posterior molar teeth.
Although incontinuity defects of the mandible longer than
5 cm can be dealt with by free non-vascularized bone grafts,
these larger defects are better corrected with microvascular
transplantation of osseous flaps, particularly when the overly-
ing soft tissues are less than optimal in condition or have been
irradiated.59 The fibular free flap is ideal for longer defects
because it can be repeatedly osteotomized and fabricated to
any desired shape, while the iliac free flap is well suited for
anterior defects. The lesser amount of bone available in the
radial forearm and scapular free flaps makes them less desir-
able choices.61
Chin
The most common reason for osseous procedures on the chin
for acquired deformities has been an unfortunate outcome
from a chin implant. Many of the patients have indeed had a
number of chin implants, with removal, replacement, and
often removal again, for reasons of infection and displace-
ment.62 Under these circumstances, an osseous genioplasty63
should be performed, rather than trying again with an allo-
plastic material.64 The capsule that forms around the implant
should be removed to allow the osseous expansion to keep
the soft-tissue envelope properly stretched. In some patients,
a proper diagnosis had not been made in the first place, and
the corrective procedure may need to provide proper correc-
tion of the original deformity, such as lengthening the chin for
a congenital shortness (Fig. 8.15). Rarely, if the chin has had
many previous operations and there is not adequate bone
stock for an osseous genioplasty, a microvascular osteocutane-
ous free flap may provide the only solution (Fig. 8.16).
Postoperative care
With the exception of isolated orbital or nasal bone fractures,
all patients will be placed on a liquid or soft diet for 2 weeks
after surgery. Nasal splints can be removed after 1 week, and

227.e1
Postoperative care
Fig. 8.15  This 30-year-old man had had five different chin implants (A,B),
the last one being a long “wrap-around” model placed below the lower
border of his mandible. As with the others, he was displeased with the result
of this one. He is shown after removal of the implant and a “jumping
genioplasty” (C,D). If he wished further projection of the chin, after an
interval of 6 months or so, a sliding advancement genioplasty could be done
through the previous genioplasty. Chin implants are appropriate for mild
degrees of retrogenia, but severe retrogenia, chins requiring vertical or lateral
alteration, and failures of previous chin implants should be treated with
osseous genioplasties.
A
B
C
D

227.e2
SECTION II
CHAPTER 8 • Acquired cranial and facial bone deformities
Fig. 8.16  This 67-year-old woman stated that she had undergone some
sort of jaw injury as a child (perhaps condylar fractures) and had been
treated, among others, by Dr. Robert Ivy in Philadelphia and Dr. Varaztad
Kazanjian in Boston. In total, she had undergone more than 26
operations in attempts to construct a chin. Segments of block
hydroxyapatite had been successfully placed along the mandibular body,
but all of the chin implants had to be removed because of infection or
intraoral exposure (A,B). She had only a thin segment of bone
connecting the parasymphyseal areas, and the intraoral soft tissues were
thin and scarred; it was thought that they would not provide adequate
coverage for any type of conventional genioplasty. After considerable
explanation to the patient and her husband, the decision was made to go
ahead with the only method that could most likely provide her with a
chin: microsurgical reconstruction with use of an iliac osteocutaneous
free flap. The U-shaped segment of iliac bone was attached to the
inferior border of what remained of her native symphysis and a skin
paddle and soft-tissue attachments were transferred with the bone
segment (C). She is shown a month after the operation, with the skin
paddle in place (D), and a year after the original operation, following
defatting of the pedicle and removal of the skin island (E,F).
A
B
C
D
Artery
Vein
E
F

228
SECTION II
CHAPTER 8 • Acquired cranial and facial bone deformities
of the defects. Inadequacy of reduction of facial fractures can
lead to enophthalmos, malocclusion, and loss of proper facial
proportions.
Secondary procedures
If a secondary operation is required more than 1 week after
the initial operation, it is best to perform osteotomies to recre-
ate the defect. This is almost certainly to be followed by the
use of bone grafts to restore facial harmony.
interdental fixation is usually removed within 4–6 weeks. All
suture material on the face should be removed within 7 days.
Outcomes, prognosis, and
complications
It is advisable to obtain postoperative radiographic images to
assess the adequacy of reduction achieved. If the fractures are
not adequately reduced on imaging, the surgeon must plan to
return the patient to the operating room for proper correction
Fig. 8.5 This 23-year-old was shot through the right frontal region and has
extensive debridement of the left frontal bone, supraorbital ridge, and orbital
roof (A,D,E). He is shown after a split cranial bone cranioplasty (B,C),
reconstruction of the orbital roof and supraorbital ridge, and subsequent ptosis
correction by reattachment of the levator muscle to the tarsal plate (F).
Fig. 8.14 This 29-year-old woman had undergone a hemimaxillectomy and
postoperative irradiation for a neuroesthesioblastoma (A). She was left with a
large palatal defect (B), as shown in her post-resection computed tomography
scans (C,D). Shortly after the initial preoperative photograph was taken, her
right eye spontaneously perforated and she underwent an evisceration (removal
of all of the orbital contents down to periosteum). Reconstruction of her maxilla
was performed using a temporalis muscle flap to close the palatal defect (E).
The radiation-damaged skin of the lower eyelid and cheek was resected and a
skin graft placed over the temporalis muscle. At a subsequent operation, an
iliac bone graft was placed from alveolar ridge to pterygoid region (F), well
nourished by the underlying temporalis muscle; the lower eyelid was
reconstructed with a forehead flap. Osseointegrated implants have been placed
in the maxillary bone graft, and this portion of her reconstruction has been
completed (G). A second forehead flap was required for the lower eyelid
reconstruction and her final postoperative result is shown (H).
Fig. 8.15 This 30-year-old man had had five different chin implants (A,B), the
last one being a long “wrap-around” model placed below the lower border of
his mandible. As with the others, he was displeased with the result of this one.
He is shown after removal of the implant and a “jumping genioplasty” (C,D). If
he wished further projection of the chin, after an interval of 6 months or so, a
sliding advancement genioplasty could be done through the previous
genioplasty. Chin implants are appropriate for mild degrees of retrogenia, but
severe retrogenia, chins requiring vertical or lateral alteration, and failures of
previous chin implants should be treated with osseous genioplasties.
Fig. 8.16 This 67-year-old woman stated that she had undergone some sort of
jaw injury as a child (perhaps condylar fractures) and had been treated, among
others, by Dr. Robert Ivy in Philadelphia and Dr. Varaztad Kazanjian in Boston. In
total, she had undergone more than 26 operations in attempts to construct a
chin. Segments of block hydroxyapatite had been successfully placed along the
mandibular body, but all of the chin implants had to be removed because of
infection or intraoral exposure (A,B). She had only a thin segment of bone
connecting the parasymphyseal areas, and the intraoral soft tissues were thin
and scarred; it was thought that they would not provide adequate coverage for
any type of conventional genioplasty. After considerable explanation to the
patient and her husband, the decision was made to go ahead with the only
method that could most likely provide her with a chin: microsurgical
reconstruction with use of an iliac osteocutaneous free flap. The U-shaped
segment of iliac bone was attached to the inferior border of what remained of
her native symphysis and a skin paddle and soft-tissue attachments were
transferred with the bone segment (C). She is shown a month after the
operation, with the skin paddle in place (D), and a year after the original
operation, following defatting of the pedicle and removal of the skin island
(E,F).
Bonus images for this chapter can be found online at

9. Wolfe SA. The influence of Paul Tessier on our current treatment of
facial trauma, both in primary care and in the management of late
sequelae. Clin Plast Surg. 1997;24:515–518. This article reviews the
principles of facial skeletal surgery taught by Paul Tessier, the father of
craniofacial surgery. His principles, such as obtaining complete
subperiosteal exposure and the use of autogenous bone grafts, have
withstood the test of time and remain critical for the education of all
craniofacial surgeons.
11. Wolfe SA. Autogenous bone grafts versus alloplastic materials. In:
Wolfe SA, Berkowitz S, eds. Plastic Surgery of the Facial Skeleton.
Boston: Little, Brown; 1989:25–38.
14. Ellis IIIE, Zide MF. Surgical approaches to the facial skeleton. 2nd ed.
Baltimore: Lippincott Williams & Wilkins; 2006.
23. Rodriguez ED, Stanwix MG, Nam AJ, et al. Twenty-six-
year experience treating frontal sinus fractures: a novel
algorithm based on anatomical fracture pattern and failure of
conventional techniques. Plast Reconstr Surg. 2008;122(6):
1850–1866.
31. Wolfe SA. Lengthening the nose: a lesson from craniofacial surgery
applied to post-traumatic and congenital deformities. Plast Reconstr
Surg. 1994;94:78. This article describes a variety of causes of nasal
hypoplasias, from traumatic to congenital and the author’s treatment
strategies. The article stresses the liberal use of bone and cartilage grafts
in rebuilding the nose.
36. Wolfe SA. Application of craniofacial surgical precepts in orbital
reconstruction following trauma and tumor removal. J Maxillofac
Surg. 1982;10:212. This article describes the principles of craniofacial
surgery, as described by Paul Tessier, in working with the orbit and their
application to management of the reconstructive or trauma patient. These
include the use of subperiosteal exposure and liberal use of autogenous
bone grafts when reconstruction of the floor is necessary to prevent
enopthalmos.
39. Manson PN, Hoopes JE, Su CT. Structural pillars of the facial
skeleton: an approach to the management of Le Fort fractures. Plast
Reconstr Surg. 1980;66:54. This landmark article describes the facial
buttresses and their relationship to facial structure. It describes the
importance of these relationships in treating Le Fort fractures.
46. Gruss JS, Mackinnon SE. Complex maxillary fractures: role of
buttress reconstruction and immediate bone grafts. Plast Reconstr
Surg. 1986;78:9.
47. Wolfe SA, Baker S. Fractures of the Maxilla. In: Wolfe SA, Baker S,
eds. Operative Techniques in Plastic Surgery: Facial Fractures. New
York: Thieme Medical Publishers; 1993:61–71.
64. Cohen SR, Mardach OL, Kawamoto HK Jr. Chin disfigurement
following removal of alloplastic chin implants. Plast Reconstr Surg.
1991;88:62, discussion 67. This article describes the risks involved with
the use of alloplastic chin implants, particularly the associated changes in
the mandible. It advocates the use of the osseous genioplasty.
Access the complete reference list online at

228.e1
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228.e2
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CHAPTER 8 • Acquired cranial and facial bone deformities
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51. Hanasono MM, Matros E, Disa JJ. Important aspects of head and
neck reconstruction. Plast Reconstr Surg. 2014;134(6):968e–980e.
52. Neligan PC. Head and neck reconstruction. Plast Reconstr Surg.
2013;131(2):260e–269e.
53. Morrow BT, Samson TD, Schubert W, Mackay DR. Evidence-based
medicine: mandible fractures. Plast Reconstr Surg. 2014;134(6):
1381–1390.
54. Spiessl B. New Concepts in Maxillofacial Bone Surgery. New York:
Springer; 1976.
55. Champy M, Loddé JP, Schmitt R, Jaeger JH, Muster D. Mandibular
osteosynthesis by miniature screwed plates via a buccal approach. J
Maxillofac Surg. 1978;6:14–21.
56. Bruckmoser E, Undt G. Management and outcome of condylar
fractures in children and adolescents: a review of the literature. Oral
Surg Oral Med Oral Pathol Oral Radiol. 2012;114(5 suppl):S86–S106.
57. Zide MF, Kent JN. Indications for open reduction of mandibular
condyle fractures. J Oral Maxillofac Surg. 1983;41(2):89–98.
58. Sharif MO, Fedorowicz Z, Drews P, et al. Interventions for the
treatment of fractures of the mandibular condyle. Cochrane Database
Syst Rev. 2010;(4):CD006538.
59. Foster RD, Anthony JP, Sharma A, et al. Vascularized bone flaps
versus nonvascularized bone grafts for mandibular reconstruction:
an outcome analysis of primary bony union and endosseous
implant success. Head Neck. 1999;21:66.
60. Wolfe SA, Berkowitz S. The use of cranial bone grafts in the closure
of alveolar and anterior palatal clefts. Plast Reconstr Surg.
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61. Fernandes RP, Yetzer JG. Reconstruction of acquired oromandibular
defects. Oral Maxillofac Surg Clin North Am. 2013;25(2):241–249.
62. Hoffman S. Loss of a Silastic chin implant following a dental
infection. Ann Plast Surg. 1981;7:484.
63. Ward JL, Garri JI, Wolfe SA. The osseous genioplasty. Clin Plast
Surg. 2007;34(3):485–500.
64. Cohen SR, Mardach OL, Kawamoto HK Jr. Chin disfigurement
following removal of alloplastic chin implants. Plast Reconstr Surg.
1991;88:62, discussion 67. This article describes the risks involved with
the use of alloplastic chin implants, particularly the associated changes in
the mandible. It advocates the use of the osseous genioplasty.

SECTION II • Head and Neck Reconstruction
9.1 
Computerized surgical  
planning: Introduction
Introduction to computerized
surgical planning
In an era of exponential technological progress, it is fitting
that, for the first time in Plastic Surgery, two chapters on the
topic of computerized surgical planning have been selected
for publication. The first chapter is the perspective of the
craniofacial orthodontist, an inseparable collaborator of the
multidisciplinary craniofacial team. Outlining the transition
from traditional two-dimensional (2D) craniofacial planning
to current three-dimensional (3D) techniques, a step-by-step
guide details the process of digital component creation for
synthesis of an operative orthognathic surgical plan. State of
the art software has enhanced our understanding of 3D cra-
niofacial deformities, allowing for more meticulous design of
pre-surgical guides, ultimately fashioning osteotomies with
more precision and ease in reproducibility while minimizing
errors. This technology is undeniably here to stay, and famil-
iarizing oneself with the concepts is essential for today’s
modern reconstructive surgeon.
The second chapter describes a handful of computerized
surgical planning applications in head and neck reconstruc-
tion. The authors chronicle their evolving experience and
emphasize important considerations based on anatomical
location and mechanism of injury. A summary of the planning
process – from imaging studies and web meetings with
engineers to the design and 3D printing of patient-specific
anatomical models and positioning and osteotomy guides –
provides a complete overview of the resources available to
reconstructive surgeons. Redefining the true sense of the
surgeon’s armamentarium, this chapter details the planning
and streamlined execution of increasingly complex recon-
structions with reduced operative times and consistent out-
comes. The future of Plastic Surgery is rooted in the discovery
of techniques for tomorrow.
Both installments embody the collaborative spirit of plastic
surgeons: a multidisciplinary approach that involves engi-
neers, orthodontists, and ablative surgeons. This has led to
remarkable synergy and unprecedented outcomes. The early
adoption of these advances reminds us of the dynamic and
innovative nature of our specialty. In an age of mobile smart-
phones, tablets, and 3D printers, one can only imagine how
rapidly this will be available when evaluating the patient at
the bedside. Far from a path to stagnation, new technologies
seem to spark our creativity and inspire us to push the enve-
lope even further.
Eduardo D. Rodriguez

SECTION II • Head and Neck Reconstruction
9.2 
Computerized surgical planning in
orthognathic surgery
Pradip R. Shetye
SYNOPSIS
■ Recent advances in imaging technology have significantly changed the
practice of surgical treatment planning for patients undergoing
orthognathic surgery. With improvements in imaging technology, such
as computed tomography (CT), cone beam computed tomography
(CBCT), 3D photography, and 3D intraoral dental scanners, the ability
of the clinician to evaluate and treat facial dysmorphology has been
revolutionized.
■ Advancements in 3D surgical planning software, 3D printing of
stereolithography models, cutting guides, positioning guides, and
surgical splints using computer-aided design/computer-aided
manufacturing (CAD/CAM) technology enable surgeons to significantly
improve surgical treatment planning in terms of accuracy, efficiency,
and time.
■ This chapter will focus on the step-by-step process of computerized
surgical planning in orthognathic surgery, from image acquisition to
surgical plan execution in the operating room, using this 3D
technology.
Introduction
A well-planned and executed orthognathic surgical treat-
ment plan can consistently deliver predictable and successful
clinical results. Over the past few years, efforts have been
made to better identify and understand patient expecta-
tions of orthognathic surgery and to consistently deliver the
planned skeletal correction in the most efficient and predict-
able manner possible. Traditionally, orthognathic surgical
treatment planning was based on the two-dimensional (2D)
records of patients, i.e., photographs and radiographs (lateral
and postero-anterior cephalograms). The surgical splints
used to position the maxilla or mandible was fabricated by
performing model surgery in a laboratory on plaster dental
study models mounted on a semi-adjustable articulator. This
process did not allow the surgeon to visualize the direct
changes in the skeleton in real time or the secondary changes
to the unoperated jaw when the position of one jaw was
altered. This traditional technique of surgical planning also
has several opportunities for error.1 There could be error
in obtaining accurate facebow registration and transferring
the patient’s maxillary and mandibular jaw relationship to
the semi-adjustable articulator through a facebow transfer.
Patients with facial asymmetry may also have postero-anterior
and vertical discrepancy with the position of the ears and
eyes, and achieving a facebow transfer in these patients is
difficult (Fig. 9.2.1). Planning surgery on plaster dental study
models, constructing surgical splints, and then transferring
the plan to the operating room can all lead to inaccuracies
if there was an error in recording the facebow transfer. This
process is also time-consuming in both the clinical setting and
the laboratory.
3D imaging and computer-aided design/computer-aided
manufacturing (CAD/CAM) have revolutionized the surgical
treatment planning process for patients undergoing orthog-
nathic surgery. The advent of computed tomography (CT and
CBCT), 3D photography, 3D dental model scanners, 3D surgi-
cal planning software, and 3D printing of models allow for
clinically significant improvements in surgical treatment
planning, leading to greater accuracy and efficiency.2 3D
technology and surgical planning software enable the ortho-
dontist and the surgeons to develop a virtual treatment plan
and simulate complex orthognathic surgeries on a personal
computer with the visualization necessary to deliver predict-
able and optimal end results.
3D imaging not only helps the surgeon to better understand
the complex craniofacial deformity and plan the surgery but
also helps to generate patient-specific cutting guides, position
guides, and surgical splint for orthognathic surgery. CAD/
CAM technology allows 3D designing and printing of cutting
guides, positioning guides, intermediate and final splints, and
templates to harvest bone grafts, if needed. This technology
also eliminates the need for facebow transfer to register the
maxillary and mandibular jaw relationships and for mounting
dental study models on an articulator for model surgery and
splint construction.

231
Presurgical orthodontics preparation
planning technology then becomes an invaluable tool for the
surgeon by allowing for more precise three-dimensional
control over the osteotomized segment. Another advantage of
3D technology is that the surgeon and the patient can visual-
ize the postsurgical treatment predicted changes in facial
appearance in 3D prior to surgery.
The 3D technology does not affect the importance of
detailed pre-surgical clinical examination findings of the
patient, which primarily drive the surgical treatment plan. 3D
technology has replaced the traditional 2D cephalometric
analysis and prediction, 2D photographic prediction, facebow
transfer, dental study model surgery, and laboratory surgical
splint construction. Surgical planning simulation software
efficiently integrates a patient’s 3D CT/CBCT data, 3D pho-
tograph, and dental occlusal relationship, and reconstructs a
virtual 3D patient. This allows for complete visualization of
the patient’s soft tissue surface contours, craniofacial skeletal
deformity, and dental occlusion as a reconstructed 3D image
on a personal computer. The surgeon can then use this data
to plan the orthognathic surgery and design various patient-
specific cutting and position guides and splints (intermediate
and/or final) to execute the orthognathic surgical treatment
plan.
Presurgical orthodontics preparation
Orthodontic treatment for a patient requiring orthognathic
surgery must be closely coordinated with the surgeon. The
orthodontic treatment can be divided into three phases: the
pre-surgical, perioperative, and post-surgical periods (Fig.
9.2.3). The pre-surgical orthodontic treatment plan to prepare
a patient for jaw surgery is to decompensate dental malocclu-
sion and coordinate the patient’s maxillary and mandibular
dentitions through orthodontic tooth movement with fixed
orthodontic appliances.3 In this phase of orthodontic treat-
ment, the maxillary and mandibular dental arches are coordi-
nated so they fit optimally in an occlusion after surgical
skeletal correction. Decompensation of the maxillary and
mandibular dentitions is necessary prior to orthognathic
surgery because dental compensation of skeletal malocclusion
can occur naturally with growth, and the position of the teeth
might have been compensated through orthodontic interven-
tion during the early teenage years (Fig. 9.2.4). Decompensa-
tion of malocclusion is also necessary to optimize the position
of the jaws with surgery and to achieve the best possible final
facial aesthetic results. This pre-surgical orthodontic phase
In orthognathic surgery, surgeons are often faced with
complex skeletal malformations in such syndromes as cranio-
facial microsomia, Treacher–Collins syndrome, syndromic
craniosynostosis, and hypertelorism, which have a variable
amount of skeletal and soft tissue deficiency. To correct these
skeletal deformities, surgical treatment often involves complex
osteotomies with intricate movements and repositioning of
multiple skeletal components in relation to one another. There
may also be a need for an autogenous bone graft to reconstruct
the deficient craniofacial skeleton. In patients with asymmet-
ric skeletal deformities, the osteotomized bony segments need
to be repositioned in all three spatial planes to correct the
anteroposterior, vertical, and transverse deformities and
re-establish facial symmetry. In addition to the linear move-
ment, the patient will need some angular change in the pitch,
roll, and yaw to correct occlusal plane, cant rotation, and
arch rotation, respectively (Fig. 9.2.2). The 3D pre-surgical
Fig. 9.2.1  A patient with significant facial asymmetry, including eye dystopia and
discrepancy with the position of her ears. This poses a challenge to obtain an
accurate facebow transfer and mount dental study models on an articulator to
accurately represent the orientation of the model to the craniofacial skeleton.
Fig. 9.2.2  In addition to AP, transverse and vertical changes in the osteotomized
bony segment may have to be corrected for yaw, pitch, and roll to change the
occlusal plane, cant rotation, and arch rotation, respectively, in patients with
craniofacial asymmetry.
Cant rotation
Occlusal plane
Arch rotation
Pitch
Roll
Yaw
Fig. 9.2.3  The coordination of orthodontic treatment pre-, peri- and post-
orthognathic surgery to achieve an optimal result.
• Diagnosis and
treatment plan
• Decompensate
malocclusion
• Arch width
coordination
• Stabilization
rigid arch wires
Pre-surgical
orthodontics
• 3D data
acquisition and
analysis
• Virtual surgical
planning
• Splint
fabrication
• Surgery
Orthognathic
surgical planning
• Finishing and
detailing of the
occlusion
• Appliance
removal
• Retention
• Follow-up
Post-surgical
orthodontics

232
SECTION II
CHAPTER 9.2 • Computerized surgical planning in orthognathic surgery
exhibits crowding of teeth, permanent premolars may
have to be extracted to correct this discrepancy.
2) Coordinating the anteroposterior inclination of the
maxillary and mandible anterior teeth. Correction of the
anteroposterior inclination of the maxillary and
mandibular dentitions will allow for optimal skeletal
jaw movement for the best facial aesthetic results. In a
Class III skeletal malocclusion, the dental compensation
occurs in the maxillary arch by proclination of the
maxillary teeth, and teeth in the mandibular arch tend
to be retroclined. By contrast, in a Class II skeletal
malocclusion, the mandibular dentition is compensated
by excess proclination.
3) Coordinating the transverse anteroposterior dental
relationship. The posterior arch width needs to be
coordinated so that when the maxillary and mandibular
dentitions are brought into the predicted final occlusion,
the teeth have the best intercuspation. This allows for
better dental function and long-term stability of the
occlusion.
4) Coordinating the vertical dental relationship. The
maxillary and mandibular arches need to be leveled by
either extrusion or intrusion of the anterior or posterior
teeth. This will allow better post-treatment occlusion
with little interference and greater stability of surgical
correction.
Progress toward the pre-surgical orthodontic treatment
goals must be closely monitored with periodic
orthodontic study models. These study models must be
hand articulated in the anticipated postsurgical
occlusion and checked for arch width coordination and
any premature interference with opposing teeth.
can take between 4 and 18 months depending on the severity
of the malocclusion. After surgery, the post-orthodontic treat-
ment phase can vary from 6 to 12 months. Recently, there has
been keen interest in performing surgery first and initiating
orthodontic treatment to decompensate for malocclusion after
the orthognathic surgery. It is believed that orthodontic tooth
movement immediately after surgery is accelerated due to
increasing cellular activity.4 This method may work very
well in patients with a simple, straightforward orthognathic
surgery treatment; however, a patient who requires complex
jaw correction in all the three spatial planes may have a better
outcome if pre-surgical orthodontic treatment goals are com-
pleted before surgery. Most patients with these types of cra-
niofacial conditions have multiple missing teeth, unerupted
teeth, or a significant transverse discrepancy and will have a
stable and predictable postsurgical dental occlusion if they
undergo pre-surgical orthodontic treatment. 3D technology
can also be applied in pre-surgical and post-surgical orth-
odontic treatments to accurately plan for the position of the
teeth. The orthodontic tooth position can be controlled using
3D technology and robotic wire bending created by Suresmile
Technology.5 This helps to achieve optimal pre-surgical dental
occlusion before orthognathic surgery.
Goals of pre-surgical orthodontics
The goals of pre-surgical orthodontic treatment in preparing
the patient for orthognathic surgery include:
1) Coordinating tooth size and dental alveolar arch length
discrepancy. If there is a significant discrepancy between
tooth size and dental arch length and the patient
Fig. 9.2.4  (A) Pre-orthodontic study
models. (B) Posterior transverse and
anterior midline discrepancies after hand
articulation of pre-orthodontic treatment
study models in the anticipated post-
surgical position. (C,D) After completion of
pre-surgical orthodontic treatment with the
extraction of the maxillary right and left first
premolars and decompensation of
malocclusion. Note the coordination of the
posterior dental arch width and the
maxillary and mandibular midlines.
A
B
C
D

233
Constructing a 3D virtual patient for virtual surgical planning
patient using virtual planning software are a clinical examina-
tion, 3D CT scan, intraoral dental scan, and 3D photographs
(Fig. 9.2.5).
The data that are usually acquired for 3D computerized
surgical planning include:
1)  A 3D image acquisition of
the craniofacial skeleton
A 3D skeletal image can be acquired using medical-grade 3D
CT or CBCT. The medical-grade CT is usually obtained with the
patient lying in the supine position. This position will require
an extra step to reposition the patient’s head in the virtual space
during computerized surgical planning. A CBCT is normally
obtained with the patient standing upright with a natural
head position. This position will not require an additional
step to reposition the patient’s head in the virtual space (Fig.
9.2.5). The most common CT file format is Digital Imaging
and Communications in Medicine (DICOM). This format is
the standard for handling, storing, printing, and transmitting
information in medical imaging. Individual DICOM files with
voxel orientation must be requested if the patient is referred
to an outside facility for imaging. The CT slices must be less
than 1 mm; CBCT slices must be less than 0.4 mm.
One important consideration before obtaining 3D images
is the patient’s dental occlusion relationship. If the patient
does not have any functional shift, it is acceptable to obtain a
scan with the teeth in maximum intercuspation. However, if
the patient has a significant functional shift from centric rela-
tion (CR) to centric occlusion (CO), the scan should be obtained
with the patient in centric relation (Fig. 9.2.6). This can be
Fig. 9.2.5.  A schematic diagram of 3D data acquisition to create a virtual patient
for virtual surgical planning and simulation.
Fig. 9.2.6  (A) A 3D cone beam computed tomography
(CBCT) image (DICOM file format). (B) Image taken with an
in-office CBCT machine with the patient in an upright
standing position with a natural head position. (Planmeca
Group.)
A
• 2D and 3D functionality
• Works natively in Mac OS environment
• 8 selectable, single scan fields of view
• Automatically adjusts volume sizes
for children
• More than 36 preprogrammed targets
• High resolution, flat panel technology
• Patented SCARA technology allows
limitless imaging possibilities
• Full view, open patient positioning for
standing, sitting, and wheelchair accessibility
• DICOM compatibility
Note: With high resolution scans confined to the
region of interest and respecting the radiographic
principle of ALARA (As Low As Reasonably Achievable),
the 3D image quality is improved while minimizing
exposure to the patient.
ProMax 3D Mid, pan/ceph
FEATURES
B
After the completion of pre-surgical tooth movement goals,
the orthodontist must fit the patient with heavy, rectangular,
stainless steel archwires with surgical hooks in preparation
for the pre-surgical evaluations. It is preferred that wires be
secured with stainless steel ties in all orthodontic brackets. If
any of the orthodontic brackets accidentally become debonded
in the operating room, the bracket will remain on the orth-
odontic archwire.
Constructing a 3D virtual patient for
virtual surgical planning
After the patient has completed the pre-surgical orthodontic
preparation, he or she will be ready for updated pre-surgical
evaluations to construct a 3D virtual patient for surgical plan-
ning. The data that are usually required to create a virtual

234
SECTION II
CHAPTER 9.2 • Computerized surgical planning in orthognathic surgery
splints from these 3D dental study models that will fit the
teeth accurately during surgery.
The typical file format for 3D dental scans is stereolithog-
raphy (STL). This file format is native to the stereolithography
CAD/CAM software used to create it. STL is also known as
standard tessellation language and is used for rapid prototyp-
ing and computer-aided manufacturing. STL files describe
only the surface geometry of a three-dimensional object
without any representation of color, texture, or other common
CAD model attributes.
3)  3D craniofacial photograph or
2D photographs
The 3D photograph is not absolutely necessary for virtual
surgical planning; however, it does help in evaluating the
post-surgical simulation changes (Fig. 9.2.8). As CT data does
not include skin color, superimposing the soft tissue with
surface skin color does give a better visualization of the surgi-
cal prediction. This also helps in patient education and in
understanding patient expectations.
The common file format for 3D photography is obj,
which holds 3D object files created with computer drawing
software. These files contain texture maps, 3D coordinates,
and other 3D object data (Fig. 9.2.9). Another file format is
BMP, also known as a bitmap image file, a device indepen-
dent bitmap (DIB) file, or simply a bitmap. This is a raster
graphics image file format that is used to store bitmap
digital images independent of the display device (such as a
graphics adapter).
4)  Patient interview and clinical exam
The patient’s primary complaints and the clinical examination
are important factors in making a decision on repositioning
the jaw to accomplish optimal functional and facial aesthetic
results. It is important to understand and discuss what the
patient expects from the surgery so that the surgeon is better
prepared to address the patient’s primary complaints at the
time of surgical planning.
The clinical exam should focus on capturing dynamic data
that are not easily captured on a patient’s static radiographic,
or photographic images. One of the important facial aesthetic
features is the amount of incisor show at rest and smiling. It
is important to maintain approximately 3.5–4 mm of incisor
show at rest after surgery. The mandibular rest position and
path closing from the rest position to habitual occlusion must
also be evaluated. These can be important considerations
when obtaining pre-surgical records and using the mandible
to reposition and fixate the maxilla after osteotomy with an
intermediate splint. If centric relation and centric occlusion
discrepancies are not detected, the post-surgical outcome may
be compromised. If the patient has a CR–CO discrepancy, it
is important that all pre-surgical records be obtained in CR.8
The path of opening and closing must also be assessed from
the rest position to maximum occlusion. Temporo-mandibular
joint (TMJ) pain and dysfunction, if observed, should be well
documented in the patient’s record. If the patient complains
of persistent TMJ pain or progressive condition, it is recom-
mended that the TMJ symptoms be addressed prior to
orthognathic surgery. It is important to remember that CT
scans, dental study models, and photographs are all static
achieved by using wax with the condyle in CR. This is impor-
tant in the operating room if the mandible is to be used as a
reference to reposition the maxilla during fixation with a split.
If there are significant CR and CO discrepancies, after surgery
the actual position of the maxilla can differ from the planned
position. To overcome this, mandibular surgery can be per-
formed first or position guides can be used to position the
maxilla independent of the mandible. This is discussed in
more detail later in this chapter.
2)  3D dental scan or dental study models
Currently, CT/CBCT imaging data do not provide enough
dentition detail to make precise CAD/CAM splints. CT/
CBCT data are volume data rather than surface data. The 3D
volume is reconstructed by registering and integrating mul-
tiple slices that are 1 mm or less apart with the help of software.
The details of the teeth and occlusion are not captured with
high accuracy in these slices. Therefore, acquiring 3D surface
data of the teeth with the help of a 3D surface dental scanner
is recommended (Fig. 9.2.7). This can be obtained directly
using an intraoral dental scanner or indirectly by making a
dental impression of the teeth and scanning the impression or
the dental stone models. This allows for the fabrication of
A
Fig. 9.2.7  (A) A patient in centric occlusion (maximum intercuspation). Note the
mandibular midline to the left of the maxillary midline. (B) A patient photograph
taken with the mandible in centric relation (condyles in centric relation in the
condylar fossa).
B