Reoperative Aesthetic & Reconstructive Plastic Surgery

1126
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R EOPERATIVE SURGERY OF THE HEAD AND NECK
She is shown preoperatively and 6 months postoperatively.

At the time of a face lift several years previously, this woman had silicone malar im-
plants inserted in the subcutaneous plane.The asymmetry of the implants was quite
noticeable.The implants were removed during a secondary face lift. Postoperatively
the capsules that had formed around the implants are still noticeable. One might ask
in retrospect why the implants were indicated in the rst place.
1127
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This patient had a previous rhinoplasty and believed that her face was de cient in
the malar region. In addition to reduction genioplasty, lower lid blepharoplasties,
and a small calvarial bone graft to the nose, malar osteotomies were performed.
The axis of rotation of the malar bone after the osteotomy runs through the infra-
orbital rims, and the greatest advancement (almost 2 cm) can be achieved just be-
low the body of the malar bone inferiorly in the region of the zygomaticomaxil-
lary buttress.The osteotomized segments were maintained with miniplates, and the
relatively small gaps in the anterior maxillary wall were lled with calvarial bone
grafts.We think this method provides a much better result (as shown in this patient
1 year postoperatively) than either bone grafts or implants because the natural cur-
vature of the patient’s own malar bone is used for the advancement.

This man underwent extensive hair transplantation, and for some reason a 1 cm
wide area of scarring and hypopigmentation developed in front of the anterior
hairline. He presented seeking facial rejuvenation and in particular considered that
his cheekbones were “ at.” A prefollicular forehead lift was performed, removing
the hypopigmented area. Along with meloplasty, submental lipectomy, and genio-
plasty, outer-table calvarial grafts were harvested and placed as precisely and sym-
metrically as possible and af xed to the malar bones with miniscrews. A reasonable
result was achieved, but the malar augmentation appears to be unsatisfactory. The
subcutaneous tissue in the infraorbital region was very thin, and the outline of the
bone grafts is visible through the skin. This case led me to abandon onlay bone
grafts as a method of malar augmentation. Lest the advocates of alloplastic cheek
implants be encouraged, we think the result would have been just as bad with al-
loplastic implants.
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1130
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Four chin implants had been previously performed in this patient (three silicone,
one Proplast), all with poor results. The last implant had been placed at the lower
border of an already long chin, an error in aesthetic appreciation of the normal di-
mensions of the human face.
The implant was removed and a “jumping” genioplasty advanced the basilar seg-
ment at the same time that it shortened the chin. Onlay cranial bone grafts were
placed in the parasymphyseal regions to broaden the anterior mandible.The chin is
still somewhat recessive. Another genioplasty (sliding advancement) could easily be
performed through the old genioplasty to obtain another 6 to 8 mm of projection.

This man requested a face lift; he had had a previous chin implant, which was still
in place. He underwent a face lift, submental lipectomy, blepharoplasties, removal of
the methylmethacrylate chin implant, horizontal osteotomy of the mandibular sym-
physis, interpositional cranial bone graft, and advancement of the basilar segment
relative to the cranial bone graft (this type of bone carpentry was possible thanks to
plate xation). Note the improvement in the labiomental fold that comes with the
increase in the vertical dimension of the chin. Alloplastic chin implants can give
good results if used properly, but they should be avoided when abnormalities of
chin height are present, as was the case here.
1131
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1132
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
This man had previously undergone rhinoplasty and placement of silicone implants
in the malar regions and chin but remained dissatis ed with his facial appearance.
Speci cally, he believed that his eyes were too close together, and his face was too
long and narrow. Dental occlusion was satisfactory, and because he showed barely
enough of the central incisors with his mouth in the rest position, impaction of
the maxilla was ruled out.
After considerable discussion of risks versus bene ts, we proceeded with a trans-
cranial procedure that displaced both orbital cavities and the malar bones laterally.

The increase in the interorbital distance was 10 mm, and by hinging the malar
bones outward, a 20 mm increase in the bizygomatic width was obtained. The
malar implants and chin implant were removed, and a jumping genioplasty was
performed. A minor revision of the nose with a conchal cartilage graft was per-
formed, along with submental lipectomy.
1133
Chapter 31
Reoperative Craniomaxillofacial Surgery With Emphasis on Alloplastic Failure
The patient is shown about 8 months postoperatively, and he is quite pleased.There
is no diplopia, and his only concern is a palpable depression from one of the burr
holes for the craniotomy, which is behind the anterior hairline.
This is a fairly elaborate procedure for aesthetic reasons alone. In the risk-bene t
analysis, the surgeon must factor his own experience and feel fairly con dent that
he can provide the desired result without undue risk to the patient.

1134
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
References—With Key Annotated References
1. Gillies H, Millard DM Jr. The Principles and Art of Plastic Surgery. Boston: Little, Brown,
1957.
Historical publication on basic principles of plastic surgery written by two of the masters of the last cen-
tury. In this two-volume work, Gillies and Millard “outlined 16 principles which not only applied
to plastic surgery problems but had a basis in a more general way to a philosophy of life.”These
principles are the “result of personal lessons learned from both successes and failures, retained in mem-
ory and crystallized into proverbs of short sentences spawned from long experience.”
2. Millard DM Jr.The Principalization of Plastic Surgery. Boston: Little Brown, 1986.
The successor to The Principles and Art of Plastic Surgery, in which the original 16 principles
were modi ed and expanded into 33 general principles of basic plastic surgery, from local aps to bone
xation and bone substitution.A book with more than historic relevance, with attention directed to-
ward preparation, execution, innovation, contributions, and inspiration of surgical plans.
3. Tessier P, Hervouet F, Lekieffre M, et al. Plastic Surgery of the Orbit and Eyelids [translated by
SA Wolfe]. Paris: Masson, 1981, pp 49, 252-260.
Written by the recognized founder of craniofacial surgery, Dr. Paul Tessier, this textbook analyzes
and explains in detail the principles of plastic surgery of the orbit and eyelids. Unsurpassed results are
shown in the postoperative pictures.
4. Wolfe SA, Berkowitz S. Plastic Surgery of the Facial Skeleton. Boston: Little Brown, 1989.
This textbook deals in a systematic manner with the facial skeleton, beginning with the chin and pro-
gressing through the jaws, orbital cavities, and skull. Considerable attention is directed to the jaws and
orbital cavities, making this book of interest to the oral surgeon, maxillofacial surgeon, and ophthal-
mologist.
5. Yaremchuk M, Gruss J, Manson P, eds. Rigid Fixation of the Craniomaxillofacial Skeleton.
Boston: Butterworth-Heinemann, 1992.
This is the original textbook on management of the xation of craniomaxillofacial bones, with par-
ticular emphasis on the superior aesthetic results obtained by immediate extended open reduction
with primary bone grafting. A “must read.”
6. Pak MW, Chan ES, van Hasselt CA. Late complications of nasal augmentation using silicone
implants. J Laryngol Otol 112:1074-1077, 1998.
Although the silicones are bioinert, they have been implicated in a number of adverse reactions after
implantation.This study reports the experiences of three patients who presented with late complica-
tions after nasal augmentation using silicone implants.The mechanisms of implant failure are dis-
cussed.This material should only be used on an individual basis in carefully selected cases.
7. Baran CN,Tiftikcioglu YO, Baran NK.The use of alloplastic materials in secondary rhinoplas-
ties: 32 years of clinical experience. Plast Reconstr Surg 116:1502-1516, 2005.
8. Tessier P, Kawamoto H, Matthews D, et al. Autogenous bone grafts and bone substitutes—
tools and techniques: I. A 20,000-case experience in maxillofacial and craniofacial surgery.
Plast Reconstr Surg 116(5 Suppl):6S-24S; discussion 92S-94S, 2005.
Four short articles under the heading “Techniques and Tools”are presented addressing the harvesting
of (1) iliac, (2) costal, (3) tibial, and (4) calvarial grafts.These articles are based on the experience of
six surgeons using the same technique and instruments in more than 20,000 autogenous bone graft-
ing procedures.The senior surgeon’s experience of 9500 procedures spans a period of 50 years (from
1946 to 1996).
9. Cenzi R, Farina A, Zuccarino L, et al. Clinical outcome of 285 Medpor grafts used for cranio-
facial reconstruction. J Craniofac Surg 16:526-530, 2005.
10. Maas CS, Papel ID, Greene D, et al. Complications of injectable synthetic polymers in facial
augmentation. Dermatol Surg 23:871-877, 1997.

11. Deva AK, Merten S, Chang L. Silicone in nasal augmentation rhinoplasty: A decade of clini-
cal experience. Plast Reconstr Surg 102:1230-1237, 1998.
Alloplastic materials, silicone in particular, have been associated in the literature with extrusion and
infection, but have the advantages of being affordable and easy to reshape with no requirement for har-
vesting autografts. A long experience with silicone nasal augmentation documenting clinical experi-
ence, acute and long-term complications, and patient satisfaction was reviewed in this article.
12. Ahn MS, Monhian N, Maas CS,et al.Total nasal reconstruction with alloplastic and autogenous
grafts. Facial Plast Surg 14:145-150, 1998.
The basic principles of successful total nasal reconstruction include providing a suf cient amount of tis-
sue coverage, creating an adequate structural framework, and fashioning a viable inner lining. A vari-
ety of options exist regarding the type of material used for nasal framework. Alloplastic metals, such
as vitallium or titanium mesh, combined with autogenous soft tissue coverage, are reliable alternatives
for use in total nasal reconstruction.
13. Kuttenberger JJ, Hardt N. Long-term results following reconstruction of craniofacial defects
with titanium micro-mesh systems. J Craniomaxillofac Surg 29:75-81, 2001.
14. Raghavan U, Jones NS, Romo T III. Immediate autogenous cartilage grafts in rhinoplasty af-
ter alloplastic implant rejection. Arch Facial Plast Surg 6:192-196, 2004.
There is little guidance in the literature on how to deal with the cosmetic and/or functional problems
that follow alloplastic implant rejection.The conventional advice has been to remove the allograft and
place no graft.This article presents the authors’experience treating allograft rejection and immediately
repairing any structural defect with autografts.
15. Maas CS, Monhian N, Shah SB. Implants in rhinoplasty. Facial Plast Surg 13:279-290, 1997.
1135
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Reoperative Craniomaxillofacial Surgery With Emphasis on Alloplastic Failure

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PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
1. A 32-year-old man, 3 years after a motor vehicle accident in which he suffered
multiple cranial and orbital fractures, had the orbital oor and part of the frontal
bone reconstructed with a titanium plate and methylmethacrylate. Now he pre-
sents with enophthalmos, reduced cheek projection, and worsening erythema of
the zygomatic area.Which of the following is the most appropriate management?
a. Removal of methylmethacrylate and orbital reconstruction with autoge-
nous bone graft.
b. Oral antibiotics and monitoring.
c. Admission to the hospital, intravenous antibiotics, and monitoring.
d. Observation.
e. Exploration and reconstruction with allogenic material.
2. If the same patient had presented with methylmethacrylate exposure and extru-
sion, which of the following would have been the appropriate management?
a. Observation
b. Methylmethacrylate removal and delayed reconstruction with autogenous
bone graft
c. Intravenous antibiotics
d. Oral antibiotics and monitoring
e. Methylmethacrylate removal and immediate reconstruction with autoge-
nous bone graft
3. A 34-year-old woman had silicone prosthesis migration after a rhinoplasty.
Which of the following is the most appropriate management?
a. Observation
b. Oral antibiotics
c. Intravenous antibiotics
d. Removal of implant
e. Removal of implant and immediate reconstruction with autograft
4. Which of the following is the most likely complication of a genioplasty?
a. Chin ptosis
b. Numbness of the chin
c. Periodontal defects of the mandibular anterior teeth
d. Posterior relapse of the advanced segment
e. Tooth loss/damage
R EVIEW QUESTIONS

1137
Chapter 31
Reoperative Craniomaxillofacial Surgery With Emphasis on Alloplastic Failure
5. A 42-year-old woman develops decreased projection of the chin 6 years after
undergoing placement of a silicone chin implant.Which of the following is the
most likely cause?
a. Displacement of the implant
b. Progressive anterior drift of the dentition
c. Rupture of the implant
d. Bone erosion under the implant
e. Thinning of the soft tissue
6. Which of these will be the most acceptable candidate for an alloplastic implant?
a. Caucasian man during nasal reconstruction secondary to cocaine use
b. Caucasian man during secondary rhinoplasty
c. African-American woman during nasal reconstruction after squamous cell
carcinoma removal
d. Asian man during primary rhinoplasty
e. Asian woman with Wegener’s granulomatosis
7. A 30-year-old man has malocclusion, tenderness, and ecchymosis around the
orbits and bridge of the nose after sustaining facial injuries in a motor vehicle
accident. The patient undergoes open reduction and internal fixation of the
fractures.Which is the proper management of the lacrimal system?
a. Placement of silicone stent
b. Exploration of the lacrimal system
c. Primary repair
d. Observation
e. Dacryocystorhinostomy
8. A 23-year-old woman has been diagnosed with short chin, with vertical and
horizontal bony de ciency of the mandible. She has class I occlusion.Which of
the following is the most appropriate management?
a. Sagittal split osteotomy
b. Vertical osteotomy
c. Osseous genioplasty with interpositional graft
d. Distraction
e. Chin implant

(Trang không có chữ)

1139
Patients who present with craniofacial problems for secondary surgery may be
children brought by their parents or adults who come of their own accord. The
problems may be minor, possibly part of an ongoing reconstructive requirement, or
major, resulting from relapse or a complication.The patient in the former situation
may require only a small procedure, and the decision-making process is not partic-
ularly dif cult for the surgeon. However, the patient in the latter situation may re-
quire another major operation with its attendant possible complications. In this
case, the decision-making process is more dif cult for the surgeon and parent or pa-
tient. For patients in the second group the surgeon must be secure with his or her
decision. Can the patient’s condition be improved? Is the procedure justi ed? These
Reoperative
Craniomaxillofacial Surgery
Ian T. Jackson
C ha pter 3 2
Reoperative Problems
Scarring
Undercorrection
Shortage of local tissue
Relapse of advancement
Persistent dead space
Temporomandibular joint ankylosis
Bone resorption
Anterior open bite
A man nds room in the few square inches
of the face for the traits of all his ancestors;
for the expression of all his history, and his wants.
Ralph Waldo Emerson

1140
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
are particularly cogent questions because the surgery is usually more dif cult and
complications more likely to occur for patients with major problems.The surgeon’s
experience is an extremely important factor in terms of both decision making and
the surgical procedure. The inexperienced surgeon should refer the patient to
someone with more experience.This action can bring only respect to the referring
surgeon and better treatment for the patient.
In the craniofacial area, as in other anatomic regions, reoperation may pose several
problems. Bleeding can be signi cant in young children. Any surgeon who has car-
ried out a repeat frontal advancement in a young patient with Apert’s syndrome
knows that such bleeding may be profuse.The presence of scar tissue resulting from
previous surgery will increase the chance of tissue loss and will always work against
any repositioning procedure. Thus xation must be ultrasecure. Shortage of local
material occurs with atrophic or absent bone and results in the need to import
more bone from elsewhere.There are many other problems that either alone or in
combination with others may make this surgery dif cult and somewhat hazardous.
If possible, secondary corrections, unless they are part of a planned se-
ries, should never be performed until 1 year to 18 months have passed
since the previous procedure.
It would be bene cial if all major reoperations could be left until the facial growth
phase has ended to ensure that any positional correction would be stable and last-
ing. Unfortunately this is not possible. Different areas of the face reach maturity at
different times during an individual’s development. At 21⁄2 years of age the frontal
supraorbital region will show little further change.The maxilla and mandible con-
tinue to develop and grow until late adolescence (16 to 17 years in girls, 17 to 18
years in boys). Other factors also affect the decision-making process. For example,
if the frontal area is not growing and the brain is becoming constricted, this is an in-
dication to perform frontal advancement. The brain’s opportunity to expand de-
creases the longer advancement is delayed, resulting in intracranial dead space and
the probable development of further complications.
Early repeat maxillary surgery, such as LeFort III, in patients with Apert’s syndrome
should be considered if breathing problems recur in a patient who has already un-
dergone advancement. Repeat mandibular surgery may have to be considered when
previous advancement for sleep apnea has been performed, with initial improve-
ment. In the latter situation, dental occlusion and facial pro le need to be carefully
considered.
In all of these cases, overcorrection is performed in the child to allow
growth that is inherently absent. In the adult, however, all planning
should be accurate.

RADIOLOGIC STUDIES
Standard radiologic studies are performed with all patients who will undergo reop-
erative craniomaxillofacial surgery. For patients with cranial problems, a CT scan is
mandatory. When maxillomandibular disproportions are present, dental models,
Panorex lms, and cephalograms form the basis of all planning.Three-dimensional
CT scanning, particularly interactive CT, is extremely useful. This type of scan
shows the deformity very accurately and in a way that the patient can understand.
With interactive programs such as ANALYZE (Mayo Foundation, Biomedical
Imaging Resources, Rochester, MN), which our team uses, soft tissue and hard tis-
sue measurements can be made;performance of osteotomies and bone grafting can
be simulated; images of de cient anatomic areas such as the mandible can be re-
moved;and a mandible sized for age, sex, and other factors can be substituted to see
what is required to provide an accurate reconstruction.1,2
PATIENT EXAMPLE
1141
Chapter 32
Reoperative Craniomaxillofacial Surgery
The value of three-dimensional CT scanning is demonstrated in the preoperative
planning for this 5-year-old child with glaucoma, an enlarged orbit, and an en-
larged eye with proptosis.

1142
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The deformity was analyzed using three-dimensional CT scanning with the
ANALYZE system.
The surgical plan was formulated based on the three-dimensional CT scan and in-
volved expansion of the posterior orbit and reduction of the anterior orbit by or-
bitozygomatic osteotomy. Although this type of investigation and planning has been
a considerable advance over what was available previously, the technology is rapidly
becoming more sophisticated.

The patient is shown 6 weeks postoperatively; the ptosis will gradually improve.
When available, holography and laser scans may also be used in this type of assess-
ment. Photographic records can also be helpful in planning. Speech, hearing, and
vision must be assessed.
One treatment goal for the patient who is to undergo reoperative craniomaxillo-
facial surgery is to have the patient progress toward a normal appearance without
compromising function. If possible, any de ciencies of function should also be cor-
rected. Although not always possible, an attempt should be made to perform all as-
pects of reconstructive surgery in one procedure because the component parts of
a deformity are usually interrelated developmentally, anatomically, and frequently,
functionally. Multiple procedures result in more scarring which, in turn, affects
growth of the young face adversely.
When reoperative surgery is discussed with the patient or parents, every effort
should be made to make them understand the problem and how dif cult the cor-
rection will be; it is very helpful to have three-dimensional imaging available at
this stage. In addition, a realistic appraisal of what can be reasonably expected from
the procedure should be provided. If this situation is explained properly, there will
be less disappointment with results.
1143
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Reoperative Craniomaxillofacial Surgery

1144
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
STAGED PROCEDURES
Staged procedures are to be avoided if possible;however, it is sometimes easier and
results in the potential for fewer complications. In older patients with Apert’s syn-
drome and Crouzon’s syndrome in whom frontoorbitomaxillary and mandibular
advancement is indicated, signi cant complications can occur when surgery is per-
formed in one procedure. In addition, a two-stage correction allows adjustments to
be made in regions previously operated on.
Although in my own practice I have performed monobloc advance-
ment for many years,3,4 I tend to reserve this procedure for the child
whose brain is still growing and will rapidly ll any intracranial dead
space.
In the older patient this dead space may persist and there is a connection into the
nasopharynx after the maxilla and supraorbital areas are advanced. In this patient
signi cant intracranial infection may result.5 The frontal bone ap may lose viabil-
ity and have to be removed, resulting in a signi cant frontal deformity.
The risk of infection can be avoided by closing this connection securely with a
galeofrontalis myofascial ap or with a free omental transfer.6 The method of using
the former ap is very important; it is not simply a case of bringing the ap down
and covering the skull base defect with it. Before raising the ap, drill holes are
made around the defect.When the ap has been mobilized it is sutured securely to
the edges of the defect in an overlapping fashion. When the frontal lobes come
back into position with this arrangement in place, there is a secure and watertight
closure of the anterior cranial base defect. Using this technique, the problem of in-
tracranial infection has been eliminated. Should a patient present with the latter
situation, exploration, irrigation, and the use of a galeofrontalis ap in the manner
described above is the recommended treatment.

PATIENT EXAMPLE
1145
Chapter 32
Reoperative Craniomaxillofacial Surgery
Following advancement there was a defect in the oor of the anterior cranial fossa
and a lack of frontal lobe expansion. An omental free ap was anastomosed to the
external jugular vein and the external carotid artery was used to ll the defect.
When the omental transfer is used to close the connection, it is revascularized from
neck vessels and it is packed into the frontal defect.7 The forward pressure of the
brain establishes a seal in the cranial base.
This Crouzon’s patient presented for frontosupraorbital advancement and under-
went a free tissue transfer for anterior skull base closure.The frontal dead space in-
dicates an initial extracranial connection.

1146
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The omentum is shown in position with a microvascular anastomosis with an ex-
ternal carotid artery branch.
Because of potential swelling, closure of the coronal incision was delayed to prevent
pressure on the omentum and its supplying vessels.

The patient is shown 2 years postoperatively with an acceptable correction of the
frontosupraorbital retrusion.
An additional method that can be of value in such a case is the irrigation suction
technique.The solution used is a combination of neomycin, polymixin B, and baci-
tracin, and the infusion continues over a period of 2 to 3 days.The uid is instilled
superiorly and suctioned out inferiorly. It is important that this ow be maintained;
thus observation is extremely important. However, if there is a persistent dead space,
this technique will not work.The defect must be lled with vascularized tissue.
The use of other aps such as latissimus dorsi muscle transferred as a free tissue
transfer has also been reported for lling dead space.8
The introduction of vascularized tissue will prevent infections or de-
feat established infections and will provide a more effective conduit for
antibiotic delivery.
When a staged procedure is employed, frontosupraorbital advancement is per-
formed and 6 months later the maxilla is advanced at the LeFort III level. Any re-
quired mandibular and nasal surgery is carried out at this time. If necessary, any
residual frontosupraorbital irregularities can be corrected.The exposure of the in-
tracranial contents to the nasopharynx is minimal, if at all.There have been no sig-
ni cant complications when this approach is used.
1147
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1148
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
PATIENT EXAMPLE
The protocol for the staged correction of a severe craniofacial deformity is demon-
strated by this patient with Crouzon’s syndrome. She had signi cant retrusion of the
frontosupraorbital area and maxilla with a degree of mandibular protrusion (den-
tal occlusion class III). She also had moderate exorbitism. The patient underwent
an initial frontosupraorbital advancement. Six months later, LeFort III advance-
ment, mandibular setback, and cranial bone graft to the nose were performed.The
patient is shown 2 years after the staged procedure.

HEMIFACIAL MICROSOMIA
In this condition there may be a complex deformity of frontal constriction, orbital
deformity, maxillary hypoplasia, a small or absent ascending ramus and zygomatic
arch, and soft tissue de ciency on the affected side.
Correction of hemifacial microsomia is frequently staged depending on the sever-
ity of the condition.When the ascending ramus of the mandible is absent or de -
cient with vertical facial shortening, this condition is corrected at an early stage. In
severe cases this pattern will often mean (1) cranial expansion anteriorly and later-
ally, (2) advancement of the lateral orbital wall, lateral part of the supraorbital rim,
and zygoma, and (3) reconstruction of the zygomatic arch and glenoid fossa. The
mandible is reconstructed with a costochondral graft and the zygomatic arch with
rib. The operative site is approached via a coronal ap and a neck incision at the
mandibular angle. In this way the costochondral graft can always be placed in its
correct anatomic position, with a portion of deep temporal fascia interposed be-
tween the cartilage and the new glenoid fossa to maintain joint mobility. Fixation
of the rib to the mandible is accomplished by the application of three lag screws.
Later, when indicated and possible, a bimaxillary procedure is performed to de n-
itively level the occlusion. Any additional onlay bone grafting of the zygoma is also
performed at this time.The latter is achieved using full- or partial-thickness cranial
bone that is introduced using a coronal approach;the grafts are always xed with lag
screws. If present, soft tissue de ciencies can be reconstructed with a combination
of occipital and temporal galea used as a vascularized ap, or with free tissue trans-
fer in more severe cases.To determine which technique to use, the volume de cit
is assessed using three-dimensional CT scans and a mirror-imaging technique.9 Any
defect under 25 cm3 can be improved with temporal and occipital galea;for volume
defects greater than 25 cm3, free tissue transfer is necessary.10 Very severe de cien-
cies may be totally corrected early, but the long-term results with this approach are
somewhat unknown in terms of growth of the transferred soft tissue. Our impres-
sion of this technique is that free tissue transfer volume is maintained. However, lo-
cal tissue transfer, such as galea, shows a varying reduction of tissue volume.
1149
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Reoperative Craniomaxillofacial Surgery

1150
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Early correction of right-sided hemifacial microsomia and a transverse cleft was
performed on this 3-year-old child. Three-dimensional CT scanning was used to
assess the defect.
A partial orbital osteotomy was per-
formed to correct retrusion of the or-
bit (top). The zygomatic arch and gle-
noid fossa were reconstructed with the
placement of a rib graft for the zygo-
matic arch and costochondral graft for
the ascending ramus (bottom).
PATIENT EXAMPLE
The child is shown 18 months postoperatively.

FAILED PRIMARY SURGERY
PATIENT EXAMPLE
1151
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Reoperative Craniomaxillofacial Surgery
This patient had previously undergone surgery elsewhere to treat bilateral microso-
mia and transverse facial clefts.The result was poor. Zygomatic arch reconstruction
with full-thickness cranial bone grafts was performed, together with mandibular ad-
vancement and rhinoplasty.The nal result was good at the 9-month follow-up.
Malar augmentation and zygomatic
arch reconstruction can be achieved
by harvesting full-thickness skull of
the required shape. A small metal
plate is placed on one side, and by
partial anterior osteotomics the re-
quired curve can be achieved by
bending the bone plate.

1152
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R EOPERATIVE SURGERY OF THE HEAD AND NECK
PATIENT EXAMPLE
This patient’s condition was more asymmetrical than the patient presented in the
previous example. Costochondral grafts were harvested and used to reconstruct the
ascending ramus of the mandible bilaterally and the temporomandibular joint. A
good result after LeFort I surgery and genioplasty was obtained in the long term.
The costochondral graft does not always provide a functional temporomandibular
joint.There may be ankylosis or limited movement resulting from periarticular -
brous tissue or bony fusion. If this limitation is left uncorrected, facial deformity,
speech problems, and dif culty with solid food will result.
This functional limitation presents a considerable reconstructive challenge and fail-
ure to obtain a satisfactory result is not uncommon.
Excision of the scarred tissue in and around the reconstructed joint should be per-
formed and a ap of soft tissue consisting of temporalis fascia or muscle can be in-
terposed between the joint surfaces. Active exercises must be performed after this
Temporomandibular
joint reconstruction
Graft xed to
angle of mandible
Age 10
Age 16

procedure. If they are available, condylar prostheses or silicone sheeting can be used,
but these techniques are frequently unsuccessful. Pain on movement and dislocation
or fragmentation of the implant are often problems. Fortunately, the former prob-
lem is infrequent and many patients are pleased to have movement, no matter how
restricted it may be, especially if the aesthetic result is satisfactory.
PATIENT EXAMPLE
1153
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When the soft tissue is de cient, as in this case of failed primary surgery, free tissue
transfer may be necessary.This 25-year-old patient had a combination of hypopla-
sia of the whole right side of his face. Bimaxillary osteotomy and free tissue trans-
fer were performed.
The nal result, seen 2 years postoperatively, was
excellent.
In addition to functional limitations, inadequate
growth of the bone graft is the other complica-
tion that may occur.This used to be a very con-
siderable problem, but it can now be solved by
osteotomy and distraction osteogenesis.Two con-
cerns associated with these procedures are the
volume of bone in the graft and facial scars. For-
tunately, when a bone graft is placed under me-
chanical stress, as in this case, it becomes thicker,
making distraction a possibility.The scars are indeed a problem but these can be re-
vised at a later date when they have matured.

1154
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TREACHER COLLINS SYNDROME
Treacher Collins syndrome consists of bilateral bimaxillary hypoplasia with under-
developed or absent zygomatic arches, vertical de ciency of the lower eyelids, and
hypoplasia or absence of the ears.
Similar to that of hemifacial microsomia, treatment of Treacher Collins syndrome
requires staged reconstruction. Early on, the zygomatic arches may be replaced with
rib or cranial bone grafts.These grafts extend to and over the zygoma to augment
the cheeks and are xed with lag screws.The inferolateral area of the inner aspect
of the orbit is built up with bone grafts, and the lateral area of the supraorbital rim
is contoured. This repair is designed to reverse the downward axis of the orbit,
which gives an antemongoloid slant to the palpebral ssures. To address this con-
formation, the lateral canthi are overelevated in a cranial direction and are securely
xed with nonabsorbable sutures taken through drill holes on the lateral orbital
rim.The clefts of the lower lid (lateral coloboma) may be reconstructed using ex-
cision and repair in layers, or by transferring a full-thickness ap that may be of
the island variety from the excess of the upper lid to the lower lid.11 Often there
may be some degree of resorption of the bone grafts, and further grafting may be
necessary.
PATIENT EXAMPLE
Early treatment was undertaken for this 3-year-old child with moderate Treacher
Collins syndrome.

Osteotomy of the supraorbital area was performed with repositioning of the re-
sected supraorbital rim to a new location on the supraorbital region. Full-thickness
vascularized cranium based on the temporalis muscle was used to reconstruct the
zygomatic arch.This technique is no longer used because vascularization is consid-
ered to be unnecessary, but it is something to bear in mind when vascularized bone
is required in this area for other reasons.
1155
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The patient is shown preoperatively and 3 years postoperatively.

1156
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Correction of signi cant maxillary and nasal deformity is delayed until adolescence,
if possible, when growth has been completed. At this time a bimaxillary procedure
with genioplasty and rhinoplasty is performed in a single procedure. Further bony
augmentation of the de cient zygoma is often indicated.
In patients with microtia,ear reconstruction is performed at age 4 using a carved rib car-
tilage framework;when an external prosthesis mounted on osteointegrated implants
is the chosen method, reconstruction is delayed for a few years to allow the bone of
the mastoid area to become somewhat thicker.This postponement allows safer and
more secure placement of the framework on which to place the ear prostheses.
PATIENT EXAMPLE
Late correction was performed in this 15-year-old girl who had a moderate defor-
mity resulting from Treacher Collins syndrome.This condition consisted of a zygo-
matic arch de ciency, an asymmetrical and retruded mandible, and a large, long,
humped nose with airway blockage. The patient is shown 1 year after one-stage
correction using cranial bone grafts for zygoma augmentation, rhinoplasty, septo-
plasty, and a bimaxillary procedure with an additional advancement genioplasty.

As with any bone grafting, there may be infection or resorption. If infection occurs
the bone graft is removed and a later attempt at grafting is performed. It is advis-
able to wait until complete resolution has occurred and the cheek area has returned
to its soft and supple condition. Again, cranial bone stabilized with lag screws would
be the chosen method.This technique is performed using a coronal approach.
An alternative technique that can be attractive to both the patient and the surgeon
is the use of hydroxyapatite granules (Interpore International, Irvine, CA). A small
incision is made in the upper buccal sulcus and the periosteum over the de cient
bony area is elevated until the defect appears to be corrected.The cavity should not
be overenlarged.The hydroxyapatite granules are introduced using the manufacturer-
supplied container, which is somewhat similar to a syringe.There should be no at-
tempt at overcorrection.What you see at this point is the nal result.This technique
has been used to augment bone in many facial areas and has been consistently suc-
cessful.The only problems,which have been few,are related to some degree of over-
correction or undercorrection when the anterior aspect of the maxilla is being aug-
mented. Closure of mucosa and submucosal tissue in the upper buccal sulcus should
be carried out with care to prevent any signi cant amount of granules from accumu-
lating under the buccal mucosa.The advantages of this type of reconstruction are that
it is quick, permanent, and can be modi ed, if necessary. In an adult patient, it is
usually performed as an outpatient procedure, using a local anesthetic, and with the
patient sedated.12
HYPERTELORISM
In hypertelorism the orbits are displaced laterally,and there may be central nasal cleft-
ing.The intercanthal distance is increased,as is the interlateral orbital wall distance.At
the initial correction the central intraorbital bone excess is removed, mobilized, and
brought together.The orbits are osteotomized, and the nose may be boned grafted.
Patients with hypertelorism frequently require secondary procedures, even with sat-
isfactory initial correction. Secondary correction usually relates to the nose because
the main problem in hypertelorism is a short, broad nose. In many cases the patient
may have a central cleft deformity.When the shortening is minimal or moderate, it
may be possible to achieve suf cient length with relatively conservative measures
(for example, subperiosteal mobilization of the facial mask, from the piriform aper-
ture and the inner aspect of the nasal bones).The periosteum over the nasal bones
is incised as far cranially as possible to allow advancement. Once mobilization is
achieved, a cranial bone graft is inserted from a vertical frontonasal incision and sta-
bilized in the glabellar area with a lag screw or a wire. It is often necessary to pre-
pare a recipient site in the glabella and/or nasal bridge line by contouring the area
with a drill.The operative site may also be approached via a coronal ap if there is
maxillary hypoplasia.The upper buccal sulcus incision is used to elevate the perios-
teum from the lower face and piriform aperture. At this time, bone grafting of the
zygoma and contouring may be performed. Occasionally it may be necessary to
perform an osteotomy around the piriform aperture and advance both the skeletal
support and the soft tissue of the nose.13
1157
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PATIENT EXAMPLE
The diagnosis in hypertelorism is of considerable importance. In some cases, the
correction does not consist of simply bringing the orbits together transversely. In
these cases, the orbits, together with the maxilla, are rotated outward. As a result, the
excess bone is V-shaped and the center of the maxilla is vertically short, causing a
disordered occlusion. To correct this problem or postsurgical disasters when the
true deformity has not been appreciated requires a facial bipartition.
This situation is well illustrated in the patient example shown here. This patient
shows a moderate degree of hypertelorism, more superiorly than inferiorly. The

planned correction is shown in the diagrams.The osteotomies were performed and
the central bone excess was removed.The two halves of the facial skeleton can be
rotated into their correct position. Note the change in the orbital axis.
After a central wedge excision, the two halves of the maxilla were rotated into a
normal position and stabilized. Nasal augmentation was performed with the use of
a cranial bone graft. Note the patient’s postoperative appearance. A rhinoplasty will
be performed when she is older.
In unique cases of severe shortening and/or deformity it may be bene cial to sac-
ri ce the skin of the nose and reconstruct the nose completely with a forehead
ap. It is best to plan total nasal reconstruction from the outset so that both the
patient and the surgeon understand the option being contemplated.
As mentioned with other intracranial procedures, the two signi cant problems that
may occur with hypertelorism correction are cerebrospinal uid leakage and infec-
tion. Dural repair must be meticulous. If there is a tear in the dura it must be re-
paired carefully. If there is a defect, fascia can be harvested from the abdomen and
placed on the inner aspect of the dura. It is then held in place with sutures taken
through the dura and onto the graft. In this way the brain gives compression to
the graft, and there is a CSF leak-proof repair.
1159
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1160
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R EOPERATIVE SURGERY OF THE HEAD AND NECK
In a large proportion of patients with hypertelorism, nasal reconstruction is neces-
sary.This procedure may be carried out at the time of surgery or at a later date.The
timing depends on many factors including operating time, the condition of the pa-
tient, and the available nasal tissue. A similar situation applies to the medial canthal
region. Although a medial canthopexy is performed at the time of the initial cor-
rection, it is frequently insufficient. This situation is closely related to the nasal
bridgeline position. This complicated relationship will be discussed later in this
chapter.
Sacri cing skin in the frontonasal area is common requirement in many patients
with hypertelorism. It is best at the initial correction to excise it as a vertical ellipse
taking in the center of the forehead and the nasal dorsum. It is recommended to al-
low this to heal and then, if necessary, make any adjustments (for example, Z-plasty
at the bridgeline). In this way, a more accurate correction can be accomplished.
Occasionally, positional symmetry of the eyes is a problem.The patient usually has
vertical or anteroposterior dystopia.
VERTICAL DYSTOPIA
Patients with vertical dystopia are assessed clinically and radiologically.The differ-
ence in eye position is then corrected using a transconjunctival approach through
the lower lid and the insertion of a thin bone graft or silicone sheet under the peri-
osteum of the orbital oor. A cranial bone graft is preferred because it can be ac-
curately contoured to t into any oor defect that may be present and it is not for-
eign material.
ANTEROPOSTERIOR DYSTOPIA
In a patient with anteroposterior dystopia, the enophthalmic eye needs to come
forward;a coronal ap approach is preferred. After mobilization of the orbital con-
tents at the subperiosteal level the eye is advanced. A circumferential strip of soft sil-
icone sheeting or Gore-Tex is placed around the orbital contents posteriorly.This
material is adjusted until the correct globe position is obtained. If necessary, any
scarring of the periorbita that prevents advancement is divided until the anteropos-
terior eye position is correct.
FRONTONASAL ENCEPHALOCELE
Frontonasal encephalocele is a midline deformity that usually results in a long nose
telecanthus. On some occasions there may be true hypertelorism. Reconstruction
is frequently staged. In the rst stage the encephalocele is excised and repaired. In
the second stage a more acceptable nose is constructed. This repair may involve
nasal shortening and support with a bone graft, preferably from the skull.

PATIENT EXAMPLE
1161
Chapter 32
Reoperative Craniomaxillofacial Surgery
This child was born with a large frontonasal encephalocele.
In the rst stage of correction, the encephalocele was excised (top). In a secondary
procedure, medial orbital shift was performed and a cranial bone graft was placed
in the nose (bottom).

1162
PART III
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SECONDARY PROCEDURES
CRANIOSYNOSTOSIS
Caniosynostosis results from premature closure of a cranial suture or several su-
tures, resulting in a typical cranial deformity. If performed correctly, correction of
craniosynostosis will usually provide a good permanent result. However, when cra-
niosynostosis is associated with a syndrome (for example, Apert’s syndrome or some
cases of Crouzon’s syndrome), a further frontoorbital advancement is frequently
necessary.This secondary correction can be performed any time after the age of 21⁄2
years because by this time the frontosupraorbital area is fully developed.14 When the
advancement is performed at this stage, it is stabilized securely with bone grafts and
interosseous wires, or plates and screws. It should be understood that the quality of
bone to be advanced is frequently poor as a result of the previous surgery. The
bone may be thinned or have defects in it; these de ciencies can be lled with
bone fragments, bone dust, or both. If the defects lie under the temporalis muscle,
they are not reconstructed.
The posterior cranial defects resulting from the advancement are again lled with
bone fragments and dust. Surgicel is placed as a sling overlapping both edges of the
defect and the bone material is laid on top.The reconstruction is covered with an-
other layer of Surgicel. A repeat frontosupraorbital advancement may be necessary
in the future.
It is unusual to have to reoperate on other types of craniosynostosis as long as the
operation was initially performed correctly. In my own series there was a case of
considerable interest. A child with bicoronal craniosynostosis underwent a fronto-
supraorbital advancement at 3 months of age. Postoperatively antibiotics were ad-
ministered overenthusiastically and an infection developed with Serratia organisms.
As a result, the frontosupraorbital segment had to be removed; recovery was un-
eventful. Six months later, the patient presented with the frontosupraorbital area
fully reconstituted—spontaneously and in exactly the same position as before. An-
other uneventful frontosupraorbital advancement was performed. At surgery it was
impossible to determine from examination of the skull and orbits that the patient
had undergone a previous procedure.
APERT’S SYNDROME
The cranial deformity of Apert’s syndrome is frequently caused by coronal cra-
niosynostosis.There is midface retrusion and syndactyly of the hands and feet. Most
children with Apert’s syndrome have degrees of learning disability, frequently se-
vere. Reoperation on patients with Apert’s syndrome is not infrequent.When reop-
eration involves an intracranial and extracranial procedure, there is a risk of infec-

tion. It is thus essential to prevent this occurrence. The preventive measures taken
are the same as those that would apply to any case involving an intracranial na-
sopharyngeal connection. The intracranial and nasopharyngeal areas are separated
by a well-vascularized ap (for example, a galeofrontalis ap) with a secure skull
base seal.This maneuver is achieved by overlapping the skull base defect and sutur-
ing the galeofrontalis ap through drill holes on the edge of the defect (see p. 1144).
Forward advancement of the frontal lobes provides secure closure.
Because of the lack of frontoorbital facial growth potential, it may be necessary to
readvance the whole frontofacial block. In this situation advancement is often per-
formed in a patient whose brain can no longer expand. Thus advancement of the
frontal area and the maxilla leaves a connection into the nasopharynx just in front
of the cribriform plate.This connection can be especially signi cant because the in-
ner aspect of the skull is irregular, the result of brain pressure.Therefore dissection
of the dura is difficult and dural tears may occur, placing the patient at risk for
meningitis.
To prevent this situation, the galeofrontalis myofasciopericranial ap is passed into
the anterior cranial fossa bone to form a vascularized barrier between the nasophar-
ynx and the cranial cavity as described above. A slit in the frontal bone allows pas-
sage of the ap without compression of the pedicle. If a ap has been used previ-
ously, a more lateral ap can be used. This ap can be taken through any available
defect. Defects are plentiful because the cranium over the temporal lobes is re-
moved and barrel-staved to allow attening to be achieved, and the frontosupraor-
bital area is contoured and advanced. As the brain expands it xes the galeal aps
into position.This movement ensures that the size and shape of the anterior cranial
fossa are correct, and minimizes the possibility of ascending infection. A CT scan
is performed 72 hours postoperatively to ensure that the brain is expanding.
Correction of Apert’s syndrome or hypertelorism may result in incorrect reposition-
ing of the orbits.This latter deformity is particularly dif cult to correct if the me-
dial shift has been excessive, producing hypotelorism. Three-dimensional interac-
tive CT planning is valuable because all aspects of the deformity must be considered.
The dental occlusion must be observed, cephalograms examined, and orthodontic
advice sought. A comprehensive plan is devised.This process frequently involves or-
thodontic preparation and surgical manipulation of the three-dimensional views
of the facial skeleton on the computer workstation. A composite correction is ad-
vised: skull advancement and widening, orbital widening, maxilla advancement,
and mandibular advancement or genioplasty.The nose frequently requires length-
ening by extensive soft tissue mobilization and cranial bone grafting.The results of
this type of treatment are satisfactory, but often minor soft tissue procedures (for ex-
ample, canthopexy) are later indicated.
1163
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1164
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R EOPERATIVE SURGERY OF THE HEAD AND NECK
PATIENT EXAMPLE
As the result of an earlier surgical correction, this patient with Apert’s syndrome dis-
played postsurgical deformities including hypotelorism.
Three-dimensional imaging clearly demonstrates the skeletal problems (left). The
reformatted axial scan based on the three-dimensional images shows the hy-
potelorism (right).

The supraorbital and orbital areas were expanded
with an interpositional bone graft. The supraorbital
rim position was advanced, and the middle cranial
fossa was expanded.
1165
Chapter 32
Reoperative Craniomaxillofacial Surgery
The patient is shown preoperatively
and 2 months postoperatively.

1166
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
HEMIFACIAL MICROSOMIA (LATE EFFECTS)
This condition was described on p. 1149, but Goldenhar’s syndrome tends to be a
more severe form, with signi cant orbital and eye problems.When hemifacial mi-
crosomia or Goldenhar’s syndrome is severe, early correction may be unsatisfac-
tory.The results are frequently poor because of either the lack of growth on the af-
fected side or inadequately planned or poorly executed surgery.
Undertreatment may result from of a lack of understanding of the deformity. In
moderate to severe cases the involvement is widespread. Soft tissue is de cient in
the temporal fossa, orbit, and cheek; it is a three-level problem. The skeletal de -
ciency involves the skull, orbit, maxilla, and mandible;it is a four-level problem. In
addition, the deformity exists in three dimensions: transverse, anteroposterior, and
vertical. Growth is another factor in uencing the severity of the deformity. Fre-
quently, older patients present with exceedingly complex problems showing all of
the above defects together with abnormalities resulting from previous surgery (for
example, temporomandibular joint ankylosis, scarring, the reconstructed ear in the
wrong position in all dimensions, and anterior open bite).These patients need to be
very carefully assessed using cephalometry, Panorex film, and three-dimensional
imaging. Orthodontic advice, planning, and treatment are essential.When the den-
tition is in the ideal position, a total correction is performed.Tissue expansion may
be performed as an initial procedure to provide normal skin for cover if soft tissue
is to be transferred microsurgically.
The facial correction involves skull expansion anteriorly and laterally; expansion
of the temporal fossa is particularly important because this process establishes the fa-
cial width.The orbit is expanded and advanced, the zygomatic arch is reconstructed
if necessary, the maxilla is advanced and leveled, and the mandible is advanced and
leveled with or without a costochondral graft. A genioplasty procedure is frequently
indicated.
If soft tissue augmentation is required,the volume required will have been calculated
beforehand as described earlier, and a combined temporal and occipital galeal ap or
free tissue transfer is performed. It is particularly important to place the soft tissue
under the ear area because this region is usually de cient and may be neglected. If
indicated, rhinoplasty and septoplasty are performed.
A malpositioned ear is repositioned at a later date. If the reconstruction is poor, it
may be repeated or removed and replaced by a prosthesis.15
In patients who have undergone previous and somewhat conservative operations,
this radical one-stage treatment has produced much better results than the staged
procedures used previously. Minor soft tissue corrections or onlay bone graft place-
ment may be necessary at a later date.

PATIENT EXAMPLE
1167
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Reoperative Craniomaxillofacial Surgery
This child with Goldenhar’s syndrome of the left side of the face was previously
treated elsewhere with poor results.Three-dimensional CT analysis with preoper-
ative scanning was performed.
The zygomatic arch was reconstructed with vascularized bone based on the tem-
poralis muscle. A costochondral graft was placed, and a scapular free ap was har-
vested for soft tissue augmen-tation.

1168
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R EOPERATIVE SURGERY OF THE HEAD AND NECK
The patient is shown 3 years preoperatively and after composite correction that
included LeFort I osteotomy, eyelid surgery, and placement of a cosmetic lens in the
left eye.
The complications in this condition are related to its initial severity. Again, poor
scars, hematoma, and infection can occur, as with any other facial deformity. The
most signi cant complication that occurs with time is the tendency for the involved
side of the face to lag behind in growth.The material has been augmented but the
growth stimulus is reduced or lacking, and further correction by bony augmenta-
tion or osteotomy may be required. If soft tissue growth is signi cantly decreased,
a further free tissue transfer may be necessary. It remains to be seen whether the at-
tempt to use vascularized soft tissue and bone will be successful in the long term.
As mentioned earlier, volume increase of the mandible and maxilla can be pro-
vided using hydroxyapatite granules inserted subperiosteally.This material has been
very effective in these cases, and virtually complication-free. Perhaps the greatest ad-
vantage of this material is that procedures in which it is used can be performed
quickly and safely.
HEMIFACIAL ATROPHY
Hemifacial atrophy is characterized by shrinkage of the skin and underlying fat
with related bony hypoplasia. Etiologic factors are not known. Patients with hemi-
facial atrophy usually require secondary correction because of poorly planned and
executed surgery resulting from a lack of appreciation of the total deformity. The
bony de ciency is frequently underestimated, particularly when the cause is irradi-
ation in infancy.The assessment and treatment are exactly as described for hemifa-
cial microsomia. In these cases free tissue transfer is mandatory. Neck skin can be
expanded to provide cheek resurfacing as necessary.

PATIENT EXAMPLE
1169
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This 16-year-old girl presented with atrophy of the lower face on the right side.
Previous soft tissue surgery had be unsuccessful. Three-dimensional CT scanning
was used to estimate soft tissue and bony deficiency volumes. Correction was
achieved using free ap reconstruction with a rectus abdominis free tissue transfer.
Further trimming will be necessary.
Enophthalmos is corrected by advancement of the orbital contents, followed by
the subperiosteal insertion of soft alloplastic material in the posterior aspect of the
orbit. This type of implant is chosen rather than bone to obviate later volume
changes resulting from bone graft resorption; if resorption occurs, an implant or a
further bone graft would be necessary.This implant can shrink if intraorbital pres-
sure increases; thus it functions as a safety valve.

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SPECIFIC TECHNIQUES
CORRECTION OF CRANIAL IRREGULARITY
Patients usually request correction of a cranial irregularity only if it is located in the
frontal area. If the deformity is caused by a bone defect, then split skull may be
taken either in situ or as a full-thickness graft, which is then split.The graft is then
contoured in shape and size, and xed with resorbable plates and screws.
Very large defects require split-rib grafts that are linked and xed with wire.16 These
grafts are covered with bone dust and Surgicel, which provides external cover, to
give a smooth surface to the reconstruction. Fixation of bone grafts is extremely
important to achieve satisfactory bony union and preservation of volume.
On occasion defects have been lled with craniotome bone dust harvested using a
craniotome with constant cooling. Surgicel is placed over the dura, overlapping the
bone defect. The craniotome bone dust, slightly in excess, is placed in position.
The area is then covered with another sheet of Surgicel. When surface irregulari-
ties are present, methylmethacrylate with a broad-spectrum antibiotic incorporated
can be used as long as these defects are not associated with the frontal or any other
sinus. As mentioned earlier, miniscrews inserted into the cranium are used to retain
the methylmethacrylate in position.Very cold water is used to control the exother-
mic reaction. If screws are not available, holes or grooves can be made with the
contouring drill to ensure fixation of the methylmethacrylate. The hardened
methylmethacrylate is then contoured.When there is a full-thickness defect to be
reconstructed, the brain is covered with several layers of Surgicel. Miniscrews are in-
serted transversely into the edges of the defect to hold the methylmethacrylate.
The latter is now inserted and ice cold water is used during the heating phase.
Smoothing with a contouring drill completes the reconstruction.17
It is recommended that hip cement be used. Other types of methylmethacrylate are
less satisfactory. If this regimen is adopted, the complication rate is extremely low.
The hydroxyapatite compounds are not recommended, they frequently cause skin
thinning and even skin defects.

PATIENT EXAMPLE
1171
Chapter 32
Reoperative Craniomaxillofacial Surgery
This patient underwent resection of a large squamous cell carcinoma involving the
anterior skull base, frontal sinus, ethmoid bones, and nose. At the time of the ini-
tial resection, the large communication between the anterior cranial fossa and the
nasal cavity was repaired using a turndown galeofrontalis ap with overlapping of
the bony defect. Stabilization was achieved with sutures taken through appropriately
positioned drill holes. Reconstruction of the frontal area was required.
At the time of surgery the extent of the frontosupraorbital defect was demon-
strated.

1172
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R EOPERATIVE SURGERY OF THE HEAD AND NECK
Split-rib grafts were placed. Cranial bone graft material provided by the craniotome
was used to reconstruct the skull.This technique could be used because of the per-
fect healing of the well-vascularized galeofrontalis ap that sealed off the nasal cav-
ity. It was possible at a later date to smooth off the frontal irregularities with methyl-
methacrylate.
The patient is shown 3 years postoperatively. He did not wish to undergo further
surgery, and the tumor has not recurred.

With growth, the asymmetry, even after early adequate correction, may recur to
some extent. On analysis this may be a combination of tight or insuf cient soft tis-
sue and bony underdevelopment. If possible, it is better to attempt correction of
both tissues by bony augmentation. If the soft tissue defect is too extensive, a ller
can be used. Fat from the abdomen harvested using the appropriate needle, in our
case a veterinary needle, can be used as soft tissue augmentation.18 This procedure
may need to be repeated on several occasions. If bony augmentation is required, hy-
droxyapatite granules would be used.
MEDIAL CANTHOPEXY
Medial canthopexy is often performed as a secondary procedure. In the past, recur-
rence of lateral drift has occasionally occurred. The canthus may be approached
from a coronal ap exposure or through a direct skin incision, which may be part
of a skin rearrangement procedure.With the coronal approach, the medial canthal
tendon may be seen to protrude from the periosteum. This tendon may also be
identi ed by placing a ne hemostat in the medial canthal area and observing its
periosteal protrusion. If the tendon cannot be moved relatively easily into its cor-
rect position, it may have to be mobilized by incising inferiorly.The area to be ex-
cised is located by feeling for a tension band with the index nger.
An 18-gauge wire is cut to a point to form a “needle” and is double-looped through
the tendon, with the loops placed at right angles to each other.The wire is pulled tight
on the tendon for secure xation.The two free ends are pulled medially to ensure that,
on external facial inspection, the canthus is indeed being moved and the position is
correct. Once this movement is con rmed, a hole is made in the medial orbital wall
at the same vertical level as the contralateral medial canthus, just behind the poste-
rior lacrimal crest. A common error is to place this hole too far anteriorly.The in-
sert for the tendon is made with a contouring burr.The classic transnasal canthopexy
is not recommended, because recurrence of drift is unacceptably frequent.
A stable portion of the nasoglabellar area is chosen. The position of the bony area
for wire-tightening is of no importance other than the thickness of the bone; this
should be enough to take the wire-tightening pressure. Two drill holes are made
from this point down to the hole for the tendon. When these holes have been
made, an 18-gauge hypodermic needle is placed through one of the drill tracks
and the wire is threaded up the needle.
The needle is withdrawn, and the maneuver is performed through the other drill
hole.The wire can then be tightened without fear of cutting through the bone.
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Drill holes
Hole for canthus
Medial canthal
ligament
Nasolacrimal
canal
Syringe
needle
Wire
Wire through
canthal ligament
An alternative wire-passing technique is to insert a Keith needle backward through
the track and to capture the wire in that fashion. With a medial canthal skin inci-
sion, the tendon is easily displayed by direct dissection from the anterior approach.
The area of wire tightening is approached from a small incision high on the con-
tralateral side of the nasal bridge line.19