The Unfavorable Result in Plastic Surgery_ Avoidance and Treatment (2018, Thieme)

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
766
cial surgical procedures are interrelated and are commonly
performed in combination, operative complications are
best discussed in the following broad categories.
Airway Complications
Intraoperative airway control is critical; nasoendotracheal
intubation is necessary for surgical treatment of occlusion
with maxillary–mandibular fixation. Nasal intubation can
be difficult in patients with facial clefts who have previ­
ously undergone a pharyngeal flap procedure. Intubation
can be accomplished with fiberoptic guidance and/or ex­
change over a stent after oral intubation. Occasionally,
nasal intubation is not possible and, although less prefer­
able, the procedure can be performed in these cases with
orotracheal intubation and with the oral tube positioned
retromolar at the time of maxillary–mandibular fixation.
During the posterior aspect of the Le Fort I osteotomy, the
nasotracheal tube is particularly at risk at the times of sep­
tal–vomer dysjunction and with the osteotomy of the lat­
eral nasal wall on the side of the tube. The tube itself or the
access to the balloon cuff can be lacerated or transected by
the osteotome or by the reciprocating saw.24,25 In the case
of complete transection, immediate air leak or loss of air
exchange is evident by blood within the endotracheal tube.
To prevent endotracheal tube injury, I first perform the
septal dysjunction with a guarded osteotome; this facili­
tates placement of the reciprocating saw within the nasal
piriform, because the septum and nasotracheal tube are de­
flected to the opposite side, decreasing the risk of injury to
the tube. The maxillary osteotomy is made with a recipro­
cating saw and should be directed from medial to lateral,
away from the nasotracheal tube (Fig. 43.4). If injury to the
nasoendotracheal tube occurs, exchange of the tube is easier
before the maxillary osteotomy is initiated.25 In the case of
laceration of the tube or the balloon and a resulting mild
air leak when tube exchange would be difficult, posterior
oropharyngeal packing may be beneficial in controlling the
air loss.
There are several reasons for increased airway resis­
tance after completion of the maxillary–mandibular surgery.
­Intermaxillary fixation increases airway resistance, reducing
peak air flow, and patients who have undergone a Le Fort I
procedure in addition will necessarily have some degree of
nasal airway obstruction.26 For these reasons, many prefer
no maxillary–mandibular fixation or only guiding elastics
during the immediate recovery period. Coughing or strain­
ing with agitation can cause a fracture or an avulsion of the
internal fixation hardware. Avoiding maxillary–mandibu­
lar fixation may also reduce the risk of this complication.
I prefer not to use any maxillary–mandibular fixation during
the immediate recovery phase for patient comfort until the
first postoperative appointment, 1 to 2 weeks after surgery.
Hemorrhage
Any preexisting coagulopathy should be determined through
a history and physical examination. Patients should be
from an airway perspective, the orthodontic goal would be
to maximally decompensate the dentition to increase the
positive overjet. Failure to maximally decompensate the an­
terior dentition limits the surgeon’s ability to advance the
mandible and limits the orthodontist’s ability to achieve
class I buccal segments postsurgically. Maximal decompen­
sation may require extraction of either the first or second
mandibular premolars to allow retraction of the anterior
dentition into the extraction spaces. Additionally, proclining
the maxillary incisors adds additional overjet to the man­
dibular decompensation and improves the upper lip support.
As with the anterior-posterior compensations for skel­
etal discrepancies, there is transverse compensation that
needs to be addressed in the presurgical phase to prevent
postsurgical cross-bite and lingual-buccal inclinations. This
is best assessed by hand articulating dental study models in
a class I canine relationship. The decision that the orthodon­
tist and the surgeon must make is whether the transverse
width discrepancy can best be addressed by orthodontically
based expansion alone, surgically assisted orthodontic ex­
pansion, or multisegmental surgical maxillary expansion.
When the intercanine width is narrow, a two-segment max­
illary expansion is an option to correct the width discrep­
ancy. If the intercanine width is appropriate but there is a
posterior buccal cross-bite, a three-segment maxillary ex­
pansion can be considered. Thus there must be sufficient
interdental spacing and root divergence to allow the surgeon
to safely accomplish the interdental osteotomy to minimize
compromising adjacent tooth vitality.
For patients who present with apertognathia, a Le Fort
I osteotomy with posterior maxillary impaction will allow
skeletal closure of the open bite. In such patients the curve
of Spee may be excessive, and prior leveling of the curve
should be done with care. Mandibular incisors will typically
be overerupted and decompensated orthodontically. How­
ever, orthodontic leveling of the curve of Spee in the maxil­
lary dental arch may create a risk for postoperative relapse
and recurrence of the open bite, especially when the vertical
leveling must exceed 2 mm. Excessive maxillary incisor ex­
trusion before a single segment Le Fort I surgery is likely at
risk for relapse of an open bite of dental origin. In such cases
multisegmental orthodontic alignment and osteotomies are
a more stable treatment choice.
Managing Unfavorable
Results and Complications
in Orthognathic Surgery
and Maxillofacial Distraction
Surgery
Operative Complications
Operative complications of orthognathic and maxillofacial
distraction surgery can be categorized by the surgical tech­
nique (Box 43.1). However, because the various maxillofa­

767
Chapter 43 Orthognathic Surgery and Maxillofacial Distraction Surgery
Box 43.1
Maxillary Procedures (Le Fort I)
•• Avascular necrosis
•• Dental injury (segmental)
•• Fixation failure (plates, screws, and distraction
devices)
•• Gingival recession (segmental)
•• Hemorrhage
•• Infection
•• Injury to the internal maxillary artery
•• Injury to Stensen’s duct
•• Lacrimal duct injury
•• Malocclusion or relapse
•• Maxillary sinusitis
•• Nasal septal deviation or perforation
•• Traction injury of the infraorbital nerve
•• Transection of the descending palatine
neurovascular (inevitable)
•• Transection of nasopalatine artery
•• Unanticipated fractures
•• Vascular injuries (arteriovascular fistula, aneurysm)
•• Velopharyngeal insufficiency
•• Vision (blindness)
Mandibular Procedures (Bilateral Sagittal Split
Osteotomy, Intraoral Vertical Ramus Osteotomy)
•• Avascular necrosis
•• Condylar resorption
•• Fixation failure (plates, screws, and distraction
devices)
•• Hemorrhage
•• Infection
•• Traction injury of the inferior alveolar neurovascular
bundle
•• Traction injury of the lingual nerve
•• Transection of the inferior alveolar neurovascular
bundle
•• Malocclusion or relapse
•• Malpositioned proximal ramus
•• Unanticipated fractures
•• Vascular injuries (arteriovenous fistula, aneurysm)
Genioplasty
•• Gingival recession
•• Fixation failure (plates and screws)
•• Mental nerve injury
•• Mandibular border contour deformity
Intraoperative-Related Complications
Fig. 43.4 Endotracheal tube position after nasotracheal intubation. The balloon tubing and/or the endotracheal tube can be lacerated. The
endotracheal tube may be injured during osteotomy through the medial buttress. Directing the saw from medial to lateral will minimize
the risk of transecting the endotracheal tube. Separating the septum first will increase the intranasal space before the maxillary osteotomy
and facilitate placing the saw within the nasal cavity.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
768
ramus, vascular injury to the inferior alveolar neurovascular
bundle where it enters the mandible may occur with inad­
vertent supraperiosteal dissection. In dissecting the medial
ramus, it is helpful to start the dissection anterior to poste­
rior and superior to inferior. As the exposure continues in­
feriorly from the sigmoid notch, the inferior neuromuscular
bundles are reflected and protected by the elevator and/or
a medial ramus retractor. If bleeding occurs, epinephrine-
soaked cotton can be used temporarily to pack the medial
ramus to control the bleeding; however, the split may need
to be completed before bleeding from the posterior ramal
border can be controlled.
At the time of splitting of the mandibular ramus, the
inferior alveolar neuromuscular bundles are at risk. Using
a wedge-shaped osteotome and directing the split along
the lateral cortex can minimize the risk of injury, but the
risk cannot be fully eliminated because the bundles course
within a narrow width of the ramus. Bleeding along the
course of the artery resulting from injury at the time of the
split usually stops spontaneously. If it does not, the artery
can be dissected away from the inferior alveolar nerve and
carefully ligated. Cauterization poses a risk to the nerve and
should be avoided. In addition, at the time of the split, the
inferior and posterior border must be protected with a chan­
nel retractor to minimize risk to the facial artery and ret­
romandibular vasculature. For persistent bleeding, as may
occur when the masseteric or the facial artery is injured dur­
ing mandibular osteotomy, temporary packing with pressure
is sometimes helpful. Significant facial artery injuries require
isolation of the vessel and its ligation.37
Even with intraoperative control, patients will pres­
ent in the immediate postoperative period with bleeding
as they become normotensive. Any expanding hematoma
should of course be reexplored immediately. In most cases
the descending palatine artery is the primary source of post­
operative bleeding missed intraoperatively.38 It is preferable
to allow the patient to become normotensive after the oste­
otomies and downfracture to control any actively bleeding
vessels. It is important to note that intraoperative vascular
events that may be life-threatening may only become evi­
dent in the outpatient setting in the early recovery period
weeks after the surgery (Fig. 43.5). Uncontrolled epistaxis,
arteriovenous fistulae, false aneurysms, carotid cavernous
fistulae, and carotid artery thrombosis after either maxillary
or mandibular osteotomies have been reported as isolated
rare case reports.39–42 Suspicion must be high, and computed
tomography (CT) angiography and embolization are needed.
Vascular Compromise
Mucosal degloving, osteotomies, and repositioning of the
facial skeletal elements may reduce the blood supply to
the osteotomized segment significantly. This reduction
in blood supply can affect both the skeletal and soft tis­
sue elements (pulp, periodontium, and gingiva). Usually,
this vascular compromise is transient without significant
clinical impact on the outcome.31,43 Devitalization of the
teeth, periodontal defects, and segmental bone loss have
specifically asked about a history of excessive bleeding after
minor injuries or bleeding after previous procedures such
as third molar extractions. In addition, a careful medication
history should be taken, with particular attention to the use
of medications such as aspirin, other medications with anti­
coagulant properties, and herbal or nonformulary medica­
tions whose composition might not be clear. These should
be stopped long before surgery.
The use of local anesthetic with a vasoconstrictor and
controlled hypotensive anesthesia significantly reduces gen­
eralized bleeding and the need for blood transfusion while
greatly improving visualization of the operative field.27,28
One study demonstrated controlled operative hypotension
reduced blood loss by approximately 44%.29 Significant hem­
orrhage is uncommon, but it is more likely with maxillary
osteotomies.3,29 With maxillary osteotomy, the vessels at
risk include the greater palatine vessels, the maxillary ar­
tery, and the pterygoid plexus.30,31 Bleeding from the de­
scending palatine vessels occurs when the posterior aspect
of the lateral nasal wall osteotomy is made and, in most cir­
cumstances, spontaneously stops as it is retracted into the
bony canal. However, in such circumstances it is important
to carefully visualize the site of the descending palatine ves­
sels and coagulate with a flat-tip monopolar cautery pressed
against the bone. When bleeding persists and the vessels
can be visualized, it is easily controlled by vascular clips or
bipolar electrocautery once the maxilla is downfractured.
Such lacerations can be avoided by stopping the osteotomy
at the palatine bone and keeping it as low as possible near
the tuberosity as the maxilla is slowly downfractured and
the vessels identified. The descending palatine artery may
also be compromised during pterygomaxillary separation
and may require pterygopalatine fossa packing. Because the
separation of the pterygopalatine plate with an osteotome
is not directly visualized, placement of the osteotome at
its inferior aspect by palpation is critical to avoid injury to
the vessels within the pterygopalatine fossa. The margin of
safety is approximately 10 mm.32 Hemorrhage, when it does
occur, can be rapid and is best controlled by dense packing
of the fossa with cottonoid sponges soaked in an epineph­
rine solution. In most cases, bleeding, although significant,
is easily controlled by local measures. When bleeding cannot
be controlled by local measures, the operative site should be
packed with cotton, the maxilla returned to its original posi­
tion for compression and plated, and the patient transferred
to interventional radiology for vascular control via emboli­
zation. Carotid ligation is a means of last resort if interven­
tional radiology is unavailable and the bleeding cannot be
controlled by these maneuvers.
While significant hemorrhage with mandibular oste­
otomies (bilateral sagittal split osteotomy [BSSO], intraoral
vertical ramus osteotomy [IVO]) is uncommon, the vessels
at risk include the inferior alveolar, the maxillary, and the
facial arteries; the retromandibular vein; and the pterygoid
venous plexus.33–36 Careful subperiosteal dissection, retrac­
tion of soft tissues, and lateral splitting protected by ap­
propriate retractors help prevent vascular injuries in most
patients. During the exposure of the medial surface of the

769
Chapter 43 Orthognathic Surgery and Maxillofacial Distraction Surgery
As with maxillary surgery, avascular necrosis is uncom­
mon in mandibular procedures.46,47 The blood supply to the
mandible is derived from the inferior alveolar artery and
primarily from the nutrient vessels through the muscular at­
tachments of the masseter and the pterygoid muscles. When
performing sagittal split osteotomy (SSO) of the ramus, ex­
tensive stripping of the masseter muscle from the buccal
cortex may compromise the blood supply to the distal region
of the proximal segment, where the internal fixation hard­
ware is placed. Avascular necrosis, although uncommon, can
occur with a resulting loosening of the fixation (Fig. 43.7).
The blood supply to the distal element is derived from
the attachment of the pterygoid muscle to the lingual cortex.
been described after segmental Le Fort I osteotomies44,45
(Fig. 43.6). These complications often have been attrib­
uted to incisions, to excessive stripping of the periosteum,
to scars in the palatal mucosa (secondary to previous cleft
surgery), to interdental or segmental osteotomies with loss
of the attached gingiva, and to transverse expansion with
an excessive stripping of the palatal mucosa. When persis­
tent intraoperative gingival cyanosis is noted during the
surgery, the surgeon may consider returning the maxilla to
its original position and placement of midfacial distraction
appliances at the time of the procedure. An alternative is
readvancement 2 weeks after surgery when the mucosal
vascularity is improved as a delayed advancement.
Fig. 43.5 This patient presented 2 weeks after a Le Fort I and bilateral sagittal split osteotomy with right mandibular cervical swelling. The
patient was taken to the operating room and found to have a hematoma. The bleeding could not be controlled, so the patient underwent
emergent computed tomography angiography and selective embolization of a facial artery pseudoaneurysm. The bleed likely occurred at
the time the sagittal split was performed with an osteotome and not protected fully by the retractor at the posterior ramus.
Fig. 43.6 This patient presented 2 weeks after surgery with loss of the labial buccal gingiva and exposed alveolus resulting in avascular
necrosis. This required resurfacing the alveolus with a facial artery musculomucosal (FAMM) flap to revascularize the alveolus followed by
subsequent removal of the flap (the Crane principle) and split-thickness skin grafting with a stent to create a buccal sulcus. The dentition
was replaced with a temporary bridge followed by osseointegrated implants.
Fig. 43.7 This patient presented with external drainage a
month after a bilateral sagittal split osteotomy. Operative
exploration revealed loose hardware and avascular necrosis
of the distal segment of the proximal ramus.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
770
and buccal mucosa tend to resolve gradually over a 12- to
18-month period. Taste can be affected by involvement of
the greater superficial petrosal branch of the facial nerve
with a Le Fort I osteotomy, and recovery may take 6 to 9
months.48 Neurologic deficits of the second, third, fourth,
fifth, sixth, tenth, and twelfth cranial nerves have been re­
ported but are extremely rare.49,50 These injuries tend to oc­
cur as a result of unfavorable fractures ascending into the
cranial base.
In contrast to the Le Fort I osteotomy, sensory deficit
is a major concern during mandibular surgery, because the
nerve is not visualized, and the surgeon relies primarily on
anatomic data that are not specific for the individual pa­
tient.51 Even with the availability of the CBCT localization
of the nerve, the nerve remains at risk. The real value of the
patient-specific CBCT visualization of the nerve is to illus­
trate to the patient the difficulty of safely splitting the ramus
without injuring the nerve, even by experienced surgeons,
as part of the informed consent process. The patient should
expect some compromise to the nerve.
Of the mandibular procedures, the SSO of the ramus
carries the greatest risk of sensory loss.52 The inferior al­
veolar nerve is at risk at virtually every point during the
course of the SSO procedure: during exposure of the me­
dial ramus, horizontal osteotomy of the medial ramus, ver­
tical osteotomy of the buccal cortex, osteotomy along the
external oblique ridge, splitting of the ramus between the
The pterygomasseteric sling must be divided to allow ade­
quate mobilization through an osteotomy between the buc­
cal and lingual cortices. Although wide periosteal stripping
is necessary to allow visualization of the ramal osteotomies,
care should be given to expose only the necessary portion
of the mandible.
Excessive periosteal stripping of the chin during the
osseous genioplasty may cause avascular necrosis with a
subsequent bony resorption of the genioplasty segment.
Vascular compromise to the segment also may manifest as
gingival recession. The periosteum should be stripped only
to the degree necessary to perform the osteotomy.
Neurologic Complications
With the exception of the nasopalatine and superior alveo­
lar nerves that are inevitably transected with the Le Fort I
osteotomy, sensory loss in the infraorbital nerve distribu­
tion is temporary with nearly complete recovery, because
the infraorbital nerve is well visualized and most osteoto­
mies are inferior to the foramen. The long-term incidence
of sensory loss is approximately 1.5 to 2%.30 Permanent
anesthesia usually occurs as a result of extensive soft tis­
sue retraction or plate compression. The greater palatine
nerve is commonly transected with the posterior osteot­
omy but without apparent significant sensory disturbance
to the patient. Sensory deficits of the teeth, palatal mucosa,
Fig. 43.8 The course of the inferior alveolar nerve through the mandible. The proximity of the nerve to the buccal cortex makes it difficult
to split the ramus without injuring the nerve. Patients should be made aware that there is a real risk of permanent sensory loss.

771
Chapter 43 Orthognathic Surgery and Maxillofacial Distraction Surgery
the canal descends before exiting the foramen. The bone
below the foramen might be insufficient, however, to carry
out the osteotomy at this level safely. At times, extending
the mucosal incision or a second posterior exposure of the
inferior mandibular border facilitates visualization of the
osteotomy site. Despite these precautions, the incidence of
long-term sensory deficit has been reported to be as high
as 20%.55–57 When an osseous genioplasty is combined with
a BSSO, the incidence of a long-term sensory deficit signifi­
cantly increases, from approximately 10% with a genioplasty
and 30% with a sagittal split osteotomy alone to 70% (Video
43.1).55–57
Infection
Postoperative surgical infection is uncommon after or­
thognathic surgery. The reported incidence varies from
1.4 to 33.4%.53,58 Bacterial contamination is inevitable, and
the use of perioperative prophylactic antibiotics is com­
mon.59,60 There is evidence that preoperative antibiotic pro­
phylaxis is effective in reducing the postoperative infection
rate, but the length of continuing the antibiotic regimen
after surgery is not well established.60 Infections are more
common with mandibular procedures, likely because of the
poorer vascularity compared with the maxilla and the lack
of drainage that occurs naturally with the maxillary oste­
otomy and transnasal route. The serosanguinous fluid ac­
cumulates in the retromandibular space with a mandibular
procedure, allowing bacterial seeding and abscess forma­
tion (Fig. 43.10). Some surgeons advocate placing closed
suction drains overnight. Approximating the periosteum
with the mucosal closure assists with reducing the dead
space. Frank abscess is obvious and should be drained per­
cutaneously or intraorally; intraoperative drainage is indi­
cated when aspiration is inadequate and there is need for
irrigation.
proximal and distal segments, and finally during the fixation
(Fig. 43.8). A significant percentage of patients have sensory
loss with or without nerve transection. The incidence of a
complete transection, apparent at the time of the operation
(Fig. 43.9), is reported to be between 1.3 and 18%.36,51,54 Even
without visible transection, the long-term sensory loss of
the inferior alveolar nerve is reported to range from 24 to
85%.51,53–55 The correlation between the surgeon’s intraop­
erative assessment of the nerve injury and the postoperative
neurosensory deficit is poor; thus reacting to a perceived
nerve injury that does not include complete transection is,
in most circumstances, not indicated.37 When intraoperative
transection is identified, the nerve is repaired with standard
techniques.
Other neurologic deficits have been reported after SSO.
The lingual nerve may be affected during the osteotomy
of the inferior border, especially when the inferior border
saw is used. Taste function of the tongue is affected by im­
pairment of the chorda tympani and may take months to
recover.48 Seventh nerve palsy is uncommon, but with the
close proximity of the nerve to the posterior border of the
ramus, injury can occur; the incidence has been reported
to be between 0.4 and 1%.3,5 The risk of a nerve injury with
intraoral vertical osteotomy is less than with an SSO, but
the incidence of long-term sensory deficit is still between
2.3 and 14%.3,5 This deficit is attributed to the inability to
visualize the medially located foramen directly. Despite the
significant incidence of neurosensory loss, patients rarely
are bothered, and few, if any, mention it unless specifically
asked by the surgeon. Nonetheless, this complication should
be discussed frankly with the patient before surgery.
During osseous genioplasty, superficial distal fibers of
the mental nerve are transected with the mucosal incision,
and the mental nerve is at risk of transaction in proxim­
ity to the osteotomy site. Ideally, the osteotomy should be
placed 6 mm below the foramen, because the nerve within
Fig. 43.9 (a) Inferior alveolar nerve transection during bilateral sagittal split osteotomy. The distal nerve was then mobilized for repair.
(b) The contour of the osteotomy split in cross section. This unfavorable split wraps inferomedially, including the proximal segment, incor­
porating the nerve laterally and causing avulsion. A key to minimizing this unfavorable osteotomy is to completely section the inferior 3–5
mm of both cortices with a reciprocating saw or a fissure burr before splitting with an osteotome.
a
b

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
772
fracture may be difficult, and the surgeon should direct the
osteotomy of the posterior lateral maxillary wall toward
the pterygoid plate. Visualization is difficult, and the sur­
geon should have a three-dimensional understanding of
the skeletal anatomy.
The incidence of unfavorable fractures that occur dur­
ing SSO of the ramus may be as high as 3 to 23%.3,36 These
fractures include condylar neck, lingual plate, and buccal
plate fractures (Fig. 43.11; see also Fig. 43.9b). The ‘‘ideal’’
split may be technically difficult to achieve depending on
anatomic variations (e.g., variation in ramal width), and this
difficulty may affect the ability to place and to direct the
bony cuts with the osteotome. Condylar neck fractures occur
when the horizontal osteotomy is misdirected posteriorly
and superiorly instead of horizontal to the occlusal plane.
Buccal plate fractures typically occur when the vertical os­
teotomy at the inferior border is incomplete and a sagittal
split with the osteotome is attempted. The inferior border
should be cut fully before attempting the split. Lingual plate
fracture originates near the ascending ramus and may oc­
cur when the mandibular third molars have not been ex­
tracted before the surgery. For this reason, unerupted third
molars ideally are extracted 6 to 12 months before surgery
to avoid uncontrolled fractures and to allow internal fixa­
tion.1 When an unplanned fracture occurs, depending on
its pattern and on whether the distal segment advances or
sets back, the surgery may proceed after a prompt treatment
of the fracture that requires attention to the principles of
fracture management and a prolonged postoperative maxil­
lary–mandibular fixation. Alternatively, the procedure may
need to be abandoned and the fracture allowed to heal be­
fore further surgical intervention.
Unfavorable Osteotomies
With the Le Fort I osteotomy, uncontrolled fractures ex­
tending into the cranial base may occur when downfrac­
ture is attempted despite incomplete osteotomies or when
the osteotome is positioned improperly during the ptery­
gopalatine disjunction. Such fractures may result in one of
the rare but well-described vascular, neurologic, and oph­
thalmic complications.37,61,62 The downfracture should be
performed with digital pressure only, and Rowe disimpac­
tion forceps should be used only for the mobilization af­
ter the maxilla is completely separated from its base. With
digital pressure, sites of resistance can be identified. These
sites tend to occur at the posterior aspect of the lateral nasal
wall and at the posterior maxillary wall where the recipro­
cating saw was not positioned at its maximal depth. With
gentle downward pressure at the anterior maxillary piri­
form aperture, a thin osteotome can be introduced through
the osteotomy of the anterior wall until the resistance of
the intact posterior wall is felt. The osteotome should be
directed inferiorly, away from the orbital floor, and the pos­
terior wall should be sequentially perforated with steady
downward digital pressure until the maxilla easily frac­
tures. In patients who have developmental dentofacial de­
formities, the posterior maxillary wall is thin, and the max­
illa downfractures readily. In patients who have clefts and
craniofacial deformities, however, the posterior wall often
is excessively thick from bearing the greater loads, and in
such patients the osteotome may be needed to complete
the maxillary osteotomy. When the maxilla is sectioned at
a higher level, to include the body of the zygoma, the down­
Fig. 43.10 Postoperative infection. (a) This patient had a maxillary
advancement and mandibular setback procedure. Mandibular fixation
was through a transbuccal approach. (b,c) Computed tomography re­
vealed postoperative infection with an abscess originating in the left
angle region after the bilateral sagittal split osteotomy. The abscess
tracked inferiorly in the soft tissues of the neck. (d) Aspiration of puru­
lent fluid from the abscess. The patient was managed by surgical drain­
age and intravenous antibiotics.
d
a
b
c

773
Chapter 43 Orthognathic Surgery and Maxillofacial Distraction Surgery
arily with endodontic or prosthodontic techniques. The
attached gingiva and periodontal region should be closely
watched for recession.
Oronasal Lacerations and Fistulas
Oronasal fistula is an uncommon result of segmental max­
illary palatal osteotomies.5 Palatal expansion greater than 6
to 8 mm increases the risk of soft tissue breakdown.5 Care
should be taken to avoid tears in the palatal mucosa, and
any lacerations should be repaired in a tension-free man­
ner whenever possible. If primary repair is not possible be­
cause it would require elevation of palatal flaps that would
affect the blood supply to the maxilla, repair should be de­
layed and performed as a separate surgical procedure once
the maxilla is healed. Many smaller lacerations typically
close spontaneously. Tears can be best avoided by atten­
tion to detail when sectioning the hard palate. Hydrostatic
elevation of the palatal mucosa along the osteotomy line
just before sectioning is beneficial, and the use of a piezo­
electric saw can minimize the soft tissue injury. When sig­
nificant widening is needed, multiple parasagittal palatal
osteotomies should be made to distribute the distance of
the expansion required.
It is worthwhile noting that the sagittal split as de­
scribed by Obwegeser17 should be a complete split from the
oblique ridge to the mandible border. This does not always
occur where the split is more commonly incomplete; a sig­
nificant cortical component may remain on the proximal
segment, and this can be considered an unfavorable split.17,64
Without decorticating, bony interference can occur as the
distal segment is repositioned relative to the proximal seg­
ment, resulting in an unplanned torque on the condyle–
glenoid relationship.
Dental Injuries
The risk of dental injury is minimized with careful preoper­
ative planning and appropriate orthodontic management.
Tooth fracture or loss may occur from interdental osteoto­
mies. Presurgical orthodontics should provide adequate
space for anticipated osteotomies with displacement at the
crown and root divergence (Fig. 43.12). Interdental oste­
otomies should be performed with a thin mini–reciprocat­
ing saw blade or a 1-mm diameter fissure burr followed by
a thin spatula used as an osteotome. Postoperatively the
teeth adjacent to the osteotomy should be followed clini­
cally for their color.37 Tooth compromise is treated second­
Fig. 43.11 Horizontal corticotomy of a bilateral sagittal split osteotomy
that became a near-horizontal osteotomy, made with a Lindemann burr,
that resulted in an unfavorable osteotomy. This was managed by recogniz­
ing the technical error early and plating the segments before completing
the sagittal split. The remainder of the procedure went well and there was
no adverse outcome.
Fig. 43.12 (a) Root divergence by the orthodontist increases the margin of safety for an interdental osteotomy. (b) This oronasal fistula was
a result of traumatic laceration at the time of the palatal osteotomy for a segmental procedure to widen the palate. This was repaired as
a secondary procedure 2 months after the orthognathic surgery. A useful surgical technique to minimize laceration of the palatal mucosa
is to initially hydrostatically elevate the palatal mucosa with saline, then place a finger along the palatal surface as the palate is split with a
reciprocating saw and ideally a piezoelectric saw.
a
b

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
774
muscle forces would counter with a clockwise rotation. As
the linear distance for mandibular advancement increases,
soft tissue relapsing forces increase; the alternative to clas­
sic procedures is mandibular distractions. In rami that are
insufficient to split sagittally, as in patients with a craniofa­
cial microsomia Pruzansky class II mandible, or significant
vertical deficiency, as in Treacher Collins, the classic proce­
dures are replaced by skeletal distraction to allow gradual
expansion of the bony length and volume, the muscles, and
the soft tissue matrix in which they are embedded.
Early Relapse, Fixation Failure, and
Malocclusion
Postsurgical malocclusion is uncommon but can occur
and becomes readily evident in the early postoperative
period1,2,64 (Fig. 43.13). There is a tendency toward early
relapse; if it is minimal, it often can be managed by class
III or class II dental elastics and/or orthopedic appliances
(edge-to-edge incisor relation). More significant recurrence
of the initial preoperative occlusion necessitates a return
to the operating room. A postoperative anterior open bite
is perhaps the most common undesired outcome, a result
of insufficient posterior impaction. Immediate recurrence
of a class II relationship is commonly a result of improper
seating of the proximal ramus and condyle within the gle­
noid fossa. In most circumstances, early relapse occurs as a
result of one or more of the following: inadequate mobili­
zation of the repositioned jaws; bony interferences and in­
stability not appreciated during the repositioning; condyles
dislodged from the glenoid fossa at the time of fixation; and
failure of the internal plate and screw fixation systems65,66
(Fig. 43.14). Immediately after the operation the anesthe­
siology staff should take care to awaken the patient in a
gentle, relaxed fashion to avoid abnormal forces on the re­
positioned jaws and potential loosening or breakage of the
fixation by coughing, straining, and jaw clenching. Because
of the inability to control emergence from anesthesia, our
preference is to avoid maxillary–mandibular fixation.
Inadequate Mobilization
Relapse within the immediate surgical period is caused by
inadequate mobilization of the maxilla. The maxilla must
be mobilized fully so that it can be advanced passively into
the desired occlusion, guided by the surgical splint.17,62
Although mobilization can be achieved in most noncleft
cases, in patients with a cleft all soft tissue scars must be
released completely, including at times a pharyngeal flap. If
intraoperative advancement is not easily possible with pos­
itive overjet and overbite, gradual distraction of the maxilla
should be planned as an alternative. The general rule of us­
ing maxillary distraction for advancements greater than 10
mm at the occlusal level should be used as a guide and not
an absolute threshold. For most patients, conventional or­
thognathic surgery for patients with facial clefts produces a
stable result. Some patients can have stable advancements
greater than 10 mm, but for other patients mobilization is
difficult for advancements even significantly less than the
10-mm threshold. Perhaps the more pragmatic approach
is an intraoperative decision so the surgeon can determine
the difficulty in mobilization to the desired occlusion and
choose either placement of maxillary distraction devices
or the alternative mandibular setback. This should be
discussed with the patient and the family before surgery.
When presented with various alternatives and a complete
discussion in terms of the impact on recovery when dis­
traction will lengthen the overall surgical phase, patients
may opt for a combination maxillary advancement and
mandibular setback with understanding that mandibular
setback also has adverse consequences.
With mandibular surgery, it is critical that the proximal
ramus and the distal mandibular body can be positioned
independently to minimize the risk of relapse. The ptery­
gomasseteric muscular sling must be dissected off the pos­
terior mandibular body and angle after completion of the
split. This is especially important with any mandibular set­
back procedure in which the mandibular musculature would
anatomically limit the degree of setback. In addition, when
a counterclockwise mandibular rotation is planned, the
Fig. 43.13 Postoperative malocclusion with a significant anterior open bite after Le Fort I and bilateral sagittal split osteotomies. Condyles
were improperly positioned at the time of the fixation. The patient had another operation 3 weeks after surgery.

775
Chapter 43 Orthognathic Surgery and Maxillofacial Distraction Surgery
pneumomediastinum, pneumocephalus, orbital compart­
ment syndrome, blindness, and death50 (Fig. 43.15). All are
rare events, and none could be predicted. Discussion with
patients and their families regarding such events are best
worded in terms of common analogies. Automobile crashes
and plane crashes are rare events, are not predictable, but
do occur, and despite the devastating outcome no one plans
their day based on the unlikely possibility.
Rare Complications
There are numerous reports of rare complications associ­
ated with orthognathic surgery. These are often presented
as isolated case reports, and the etiology and pathology is
often unclear or speculative. Among the complications re­
ported in the literature include nasolacrimal injury, severe
hemorrhage, various vascular anomalies, facial nerve palsy,
Fig. 43.14 (a) Failure of internal fixation after a Le Fort I osteotomy with fatigue of the plate and loss of the screw fixation. This occurred as
a result of an oral airway that was placed at the time of the extubation because of emergence delirium. The force of the jaws on the oral air­
way displaced and fatigued the fixation and caused an immediate malocclusion. (b) Failure of the external distraction device. This occurred
because of an incomplete mandibular osteotomy and the force of the activation arm that fatigued at the joint.
a
b
Fig. 43.15 Radiographic studies of an 11-year-old patient with bilateral cleft lip and palate who underwent a Le Fort I osteotomy for maxil­
lary hypoplasia and developed perioperative right monocular blindness and temporary numbness in the right upper and lower extremities.
(a) Computed tomography (CT) on postoperative day 2, demonstrating hematoma behind the posterior clinoid process. (b) CT demon­
strating a dissecting aneurysm of the basilar artery. (c) An oblique angiogram demonstrating a basilar artery aneurysm near the junction
of the right posterior cerebral artery. (d) A different oblique angiogram view of the aneurysm with a stalk on the ophthalmic segment of
the left internal carotid artery. (Reproduced from Lo LJ, Hung KF, Chen YR. Blindness as a complication of LeFort I osteotomy for maxillary
distraction. Plast Reconstr Surg 2002;109(2):688–698; discussion, 699–700.)
a
b
c
d

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
776
there can be an uncalculated outcome. Class II dental elas­
tics (see Fig. 43.16a) have not only a horizontal vector but
also a downward vertical vector with a resulting clockwise
rotation of the maxillary–mandibular complex. There is a
rotation of the occlusal plane with extrusion of the maxil­
lary anterior dentition with simultaneous extrusion of the
posterior mandibular dentition. The result is relapse with
increased dental display and gingival show. A class II trian­
gular elastic can help alleviate this secondary effect (see Fig.
43.16b). In addition, the posterior mandibular dental extru­
sion will result in clockwise mandibular rotation with loss of
chin projection and open bite. Similarly, care should be taken
in the routine use of class III dental elastics to maintain max­
illary advancement (see Fig. 43.16c). Posterior molar maxil­
lary extrusion can result in premature posterior contact and
an inadvertent resulting anterior open bite. Anterior vertical
elastics at the canine level may be considered in combina­
tion with the class III elastic to counter the vertical vector
(see Fig. 43.16d).
With this caveat in mind, the use of postoperative guid­
ing dental elastics can greatly optimize the coordination of
the dental arches, especially in the weeks to early months
immediately after surgery when there is rapid dental move­
ment and the opportunity exists to shorten the postsurgical
phase. If orthodontic assessment and intervention is delayed
long after skeletal healing (6–8 weeks after surgery), then
the opportunity may be missed to take advantage of the mo­
bility of the osteotomies and the accelerated dental move­
ment that occurs with surgery.67
Operative Orthodontic Management
It would be ideal if all surgical outcomes were perfectly
accurate, but the practical surgeon and orthodontist are
aware that this is impossible given the complexity of the
three-dimensional vectors of each of the skeletal elements
that need to be repositioned to achieve the desired occlu­
sal and aesthetic outcome. At best it is an approximation,
and how close the surgeon comes to achieving the surgical
goals influences the postoperative orthodontic mechanics.
Teamwork and communication are critical to achieve a de­
sired outcome and a satisfied patient.
When managing a postoperative occlusion, the ortho­
dontist and the surgeon should have an understanding of
the vectors involved with the use of guiding dental elastics
to coordinate the dental arches13,42 (Fig. 43.16). Dental elas­
tics after surgery help patients to know where their new
bite is because of initial loss of proprioception and to main­
tain the vector of the skeletal movement. In general class III
dental elastics are used in patients who undergo maxillary
advancement, and class II dental elastics are used in man­
dibular advancement. However, guiding dental elastics can
also worsen the occlusion, resulting in skeletal relapse when
the various components of the resulting vectors are not care­
fully thought out. An illustrative example is a patient who
undergoes maxillary impaction and mandibular advance­
ment for a vertical maxillary excess and a steep mandibular
plane angle. If in the postoperative period there is concern
of mandibular relapse and class II dental elastics are used,
Fig. 43.16 Postoperative management of occlusion using vector guided dental elastics. (a) Class II dental elastics will maintain the mandibu­
lar advancement, but can result in an adverse outcome with a clockwise rotation and an open bite. (b) A class II triangular elastic pattern
will assist in preventing an anterior open bite. (c) class III dental elastic will maintain maxillary advancement and/or mandibular setback but
can result in an anterior open bite. (d) Class III triangular elastic pattern will assist in preventing an anterior open bite. (e) A box pattern is
typically used to close a posterior open bite. (f) Anterior cross elastic is used to correct a postoperative midline dental discrepancy but can
result in not coinciding with the facial midline.
a
b
c
d
e
f

777
Chapter 43 Orthognathic Surgery and Maxillofacial Distraction Surgery
transnasally as the healthy sinus mucosa forms with ossi­
fication of the maxillary walls. However, some will develop
acute maxillary sinusitis, especially in the first 12 months
after surgery, that may become chronic in nature. If mucosal
disease is discovered at the time of the Le Fort I osteotomy,
I remove any polyps and débride inflamed sinus mucosa.
After surgery the ostia may become blocked, and bone graft
at the osteotomy may become a sequestrum. I insist on na­
sal saline irrigation as a routine postoperative regimen for
a minimum of 6 months after surgery in all patients under­
going a maxillary osteotomy procedure. If maxillary sinus­
itis symptoms occur, I use short courses of antibiotics; if
symptoms persist beyond a year, then I may suggest opera­
tive exploration, removal of hardware, and sinus irrigation
(Video 43.2).
The literature is replete with studies involving the im­
pact of orthognathic surgery on TMJ dysfunction (TMJD).74–77
Notable among the studies is the series of publications by
Abrahamsson. In a prospective, controlled, age-matched
study, patients with a significant degree of dental facial skel­
etal deformity requiring orthognathic surgery had a higher
incidence of having TMJD as a coexisting condition than the
control population with a baseline TMJD, but this difference
in frequency becomes comparable after orthognathic sur­
gery.76 Thus there is a favorable response with physiologi­
cal adaptive bone remodeling. However, the outcome is not
necessarily consistent; adverse unfavorable outcomes have
included worsening of preoperative TMJD symptoms, irre­
versible complications, limiting range of motion, condylar
torque, and condylar resorption. An adverse effect on the
TMJ is unpredictable, and the patient should be cautioned
that restoration of the normal anatomic relationship does
not necessarily follow elimination of TMJD. The internal
TMJ mechanism must be separated from the external max­
illary–mandibular skeletal alignment that orthognathic sur­
gery achieves. An illustrative example is the impact of the
condyle–glenoid relationship when an asymmetrical rota­
tion of the mandible is performed.
Although the focus is primarily on improving the dento­
skeletal relationship, patients should be made aware of both
the benefits and the unfavorable functional consequences
that can occur with orthognathic surgery.
Unfavorable Aesthetic Outcome
The final aesthetic appearance after skeletal surgery is a com­
posite of skeletal, soft tissue, and dental changes. Whereas
some aesthetic shortcomings are best treated with additional
skeletal surgery, others can be treated with soft tissue proce­
dures.
After maxillary surgery, the overimpacted and the
overretruded maxilla are the two most common skeletal
base disproportions; both give the patient an aged appear­
ance.10,78 The typical patient is a woman who underwent
maxillary impaction surgery in adolescence for vertical
maxillary excess, but now in her 30s is concerned about fa­
cial aging, including a retruded smile with progressive loss
As soon as surgery is over, patients typically place de­
mands on the orthodontist in removal of orthodontic ap­
pliances. Many of these patients have been in treatment for
years and are impatient for a definitive end. However, suf­
ficient time must be given to allow for maximal intercus­
pal coordination of the dental arches for stability, control of
tongue posture to limit relapse, and physiologic adaptation
to a new equilibrium of the stomatognathic system.
Outcome
Unfavorable Functional Outcome
Anatomic repositioning the maxillary–mandibular rela­
tionship to each other and relative to the cranial base in­
evitably alters the oromotor, speech, and airway functional
components.
Among the unintended consequences is velopharyngeal
insufficiency. With maxillary advancement in patients with
a cleft, there is an increased risk of deterioration in speech
with nasal airway escape. The soft palate that could pre­
viously close the velopharyngeal port can no longer con­
sistently do so with the advancement of the hard palate.
Whether the soft palate can functionally accommodate the
new velopharyngeal anatomy after surgery depends on a
number of factors that cannot be controlled preoperatively
but can be predicted to some extent. A significant percent­
age of cleft patients who have borderline or inadequate
closure developed VPI postoperatively, in contrast to those
patients without preoperative evidence of velopharyngeal
insufficiency.68,69 Even with patients who do not have VPI
before the surgery, many will have speech disturbance in
the early recovery period until preoperative competence is
regained that may take months to abate. It is best to inform
all cleft patients of the potential need for velopharyngeal
surgery after cleft orthognathic surgery and the need to in­
volve a speech pathologist well before the surgery.
Airway can be adversely affected with mandibular
setback surgery and lead to obstructive sleep apnea.70–72
Mandibular setback will result in retrodisplacement of the
tongue base and decrease the pharyngeal airway space. Even
a small decrease in the diameter will have a significant ef­
fect on the airflow. Historically mandibular setback was
performed for many patients, especially cleft patients, who
would have benefited instead from maxillary advancement
procedures and who would later in life experience obstruc­
tive sleep apnea. Maxillary advancement and maxillary–
mandibular advancement are preferable today both for aes­
thetic and functional reasons. However, maxillary impaction
can significantly affect nasal breathing with buckling of the
septum and a decrease in the intranasal volume because of
turbinates. Ideally both should be addressed at the time of
surgery or, if not, should be addressed postsurgically when
they become evident.
Nasal and sinus congestion can become problematic for
some patients months after a Le Fort I osteotomy.73 For most
patients the blood within the maxillary sinuses will drain

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
778
ceptable, the patient may benefit from a subsequent rhino­
plasty or lip augmentation. Patients should be forewarned of
these possible adverse changes and the need for corrective
surgery at a later stage.
Mandibular osteotomy and genioplasty result in changes
in lower facial skeletal contours. Poorly designed osteoto­
mies and/or poor soft tissue handling can be associated with
undesirable aesthetics of the lower face. Mandibular setback
results in less well-defined cervicomental contour and a
need for soft tissue procedures to improve the appearance
of the neck. With genioplasty, chin ptosis may result from
an excessive soft tissue dissection and an improper reattach­
ment of the mentalis muscle after the genioplasty. Patients
who have lip incompetence and mentalis strain during lip
closure may require revision surgery with vertical shorten­
ing. Many patients who have long-standing mentalis strain
continue to exhibit this characteristic even with adequate
skeletal correction. In women, chin advancement should be
done conservatively and should not extend beyond the lower
lip vermilion; the labial–mental sulcus should not be overly
deep. Asymmetry after osseous genioplasty should be as­
sessed with particular attention at the time of surgery. After
fixation of the genioplasty segment, the chin should be as­
sessed for symmetry from multiple viewpoints and should
be repositioned if indicated. In addition, the discontinuity
at the inferior mandibular border at the osteotomy may be­
come concerning to a patient with an hourglass deformity.
Patients with retrogenia who are narrow in width may not
be pleased with a simple osseous genioplasty advancement,
because the width only becomes narrower. For such patients
either a two-segment widening osseous genioplasty or an
alloplastic implant that can address the width and volume
should be considered (Video 43.3).
Dentoskeletal Instability and Relapse
With any skeletal movement, the surgeon must always be
aware of the potential for relapse, even under ideal condi­
tions, despite the use of a rigid internal fixation. The stabil­
ity of the repositioned maxilla and mandible is the subject
of numerous publications. Many factors come into play,
such as distance and vector of repositioning, the specif­
ics of the internal fixation, the use of bone grafts, the pe­
riod of postoperative occlusal stabilization, and retention
mechanics.
Delayed union and nonunion can occur after primarily
maxillary osteotomies as a result of constant micromotion
from the use of dental elastics, forces of mastication, failure
to bone graft for sufficiently large bony discontinuities, fixa­
tion failure, and chronic maxillary sinusitis.57 My preference
is to not apply any distracting forces for the first 2 to 3 weeks
after surgery to allow union to occur. If mobility remains
at 6 months despite an initial conservative approach of 2
to 3 weeks of either maxillary–mandibular elastic fixation
or return to a soft diet, a secondary procedure is necessary.
This involves curettage of the fibrous union, bone grafting,
and rigid fixation.
of dental display. Adequate correction often requires second­
ary skeletal surgery to vertically lengthen and increase the
dental display or to advance the maxilla to better support
the soft tissue for a more youthful appearance. The alter­
native to skeletal surgery would be upper lip shortening to
improve the dental display. It is better to undercorrect the
vertical impaction and leave an adolescent with a slightly
excess dental display knowing that with aging the upper
lip lengthens.
The curvatures of the arcs of the lips and their relation­
ships to the dentition play an important role in aesthet­
ics.52,78–81 The smile arc is the relationship between a curve
drawn along the edges of the maxillary anterior teeth and
the inner contour of the lower lip in the posed smile. The re­
lationship between the orthodontic dental movement, the
surgical dentoalveolar movement en bloc, and the soft tissue
lip dynamics is complex, and despite careful planning it is
difficult to achieve the desired smile. With ability of the sur­
geon to alter the occlusal plane and the incisor angulation,
the smile arc can be affected. If the maxillary occlusal plane
is canted excessively upward anteriorly, the incisal edges will
move away from the lower lip, resulting in a less attractive
smile arc and a reduced dental display. Conversely, if the oc­
clusal plane has an excessive clockwise rotation, the upper
lip will uncover the upper incisal edges, resulting in a less
attractive smile and an increased dental display. Maxillary
advancement along the classic Le Fort I lines will improve
perialar deficiency and upper lip support but may worsen
the zygomatic projection in patients who have midfacial
deficiency extending to the zygomatic region. Patients may
seek alloplastic malar implants as the zygomatic deficiency
becomes even more evident after maxillary advancement.
Consideration should be given to modifying the classic Le
Fort I osteotomy to include a component of the zygoma at
the initial procedure.
Maxillary repositioning alters the position of the ante­
rior nasal spine, the septal cartilage, and the vomer and may
result in septal deviation, septal buckling, and nasal airway
obstruction.82,83 After maxillary repositioning, the new lo­
cation of these structures should be assessed. When they
are deviated from the midline, especially in cases of maxil­
lary impaction, the septum should be trimmed to prevent
buckling and to allow return to the midline. In addition, the
inferior turbinates should be assessed as a potential source
of postoperative nasal airway obstruction in cases of maxil­
lary impaction. Ideally these secondary causes are addressed
at the time of the initial maxillary impaction.
Secondary nasal changes with maxillary advancement
surgery can be advantageous, with nasal tip elevation and an
increase in the nasolabial angle when desired. However, in
patients whose nasolabial angle is appropriate, it is better to
leave the anterior nasal spine attached to the nasal septum
and advance the maxilla below this plane. An adverse effect
of maxillary advancement for many patients is widening of
the alar base and thinning of the upper lip; many surgeons
routinely place an alar cinch suture and a V-Y vestibular
closure. If the appearance of the nose or lip remains unac­

779
Chapter 43 Orthognathic Surgery and Maxillofacial Distraction Surgery
Box 43.2
• The surgeon and the orthodontist present a uni­
fied discussion of the options and overall treat­
ment plan. It is equally important to involve the
speech pathologist, the psychologist, and sleep
medicine specialists. Most cases occur in adoles­
cence and in young adulthood when self-image
and the impact of surgery can have an undesired
outcome.
• The decision as to where to optimally place the
skeletal bases (maxilla and mandible) and the
coordination of the dental arches to achieve the
optimal outcome must be determined in concert
by the surgeon and the orthodontist. This discus­
sion should occur early in the treatment-planning
phase and not late in the course of orthodontic
treatment. Reversal and lengthening of the treat­
ment time or compromise of the outcome will
otherwise occur.
• Model surgery and/or virtual surgical planning
should be done not only at the time of surgery, but
also at the time of initial consultation and record
taking. The ability to visualize the dentofacial
skeletal anatomy and to virtually carry out various
surgical procedures and orthodontic movement
allows the surgeon and the orthodontist to devel­
op a detailed blueprint at the outset. In addition,
the three-dimensional visualization of the plan
improves the communication with the patient and
the family.
• The dentition should be maximally decompen­
sated to allow for appropriate repositioning of
the maxilla and the mandible. This may require
premolar extractions to increase the difference
in the incisor distance (overjet) to parallel the
desired skeletal movement. Significant orthodontic
leveling of the open bite can lead to relapse, and
a segmental surgical alternative should be consid­
ered.
• To maximize stability and minimize relapse,
correction of the transverse width should be ad­
dressed initially either by orthodontic approach
alone or, if not possible, with surgically assisted
palatal expansion by segmental osteotomies. Once
the transverse width is corrected, sagittal and ver­
tical corrections can be achieved with a nonseg­
mental Le Fort I procedure.
• Although treatment planning in developmental
dentofacial skeletal cases can be straightforward,
congenital cases require an understanding of the
context of the soft tissue matrix. My preference
for cleft orthognathic surgery is to correct the
transverse width and ensure that the alveolus is
grafted before correcting the sagittal and vertical
components. Distraction should be within the sur­
geon’s armamentarium in severe cleft cases and
in craniofacial microsomia. Distraction should be
considered staged, and conventional orthognathic
surgery should always be discussed to optimize
final three-dimensional control.
• Virtual surgical planning allows the surgeon an
unprecedented detailed intraoperative map that
can minimize intraoperative complications by
predicting problem areas, bony interferences and
collisions, and osteotomy gaps. Reviewing this
with the patient and family visually helps with
communication of the complexity of the proce­
dure and the risks involved. The proximity of the
osteotomy along the course of the inferior alveolar
nerve can be shown.
• Initial recovery should focus on airway and patient
comfort. I prefer to not use maxillary–mandibular
fixation. At 2 to 3 weeks, guiding dental elastics
and active orthodontic mechanics optimize the
coordination of dental arches by taking advantage
of accelerated dental movement that occurs as a
natural response to surgery.
• In the early postoperative phase, both the or­
thodontist and the surgeon ideally should see
the patient together. This allows the surgeon to
assess the immediate outcome of surgery and the
orthodontic management to correct any unantici­
pated occlusal discrepancy. This team approach
after surgery facilitates communication with the
patient.
• Complications and unfavorable outcomes are
inevitable but provide an opportunity for honest
assessment. The complications are obvious, but
the unfavorable outcome is more elusive. Once
patients are debanded, many will fade away, and
the outcome remains unknown, unless com­
pleted cases are reviewed annually. However, the
outcome can only be measured when well-docu­
mented records and the initial treatment plan are
maintained. Regrettably, in a busy clinical practice,
the outcome review is rarely performed, and criti­
cal records commonly are missing.
Lessons Learned

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
780
reestablishing a new occlusal equilibrium and remodeling
of the facial skeleton. Ultimately, long-term skeletal stability
in a dynamic environment requires neuromuscular adapta­
tion.84 Although surgeons and orthodontists have the ability
to change anatomic boundaries, ultimately it is the patient’s
biology that determines the final position of equilibrium,
balancing the various applied forces to optimize functional
load. It would indeed be surprising that the bones remain
indefinitely where the surgeon places them and the teeth
where the orthodontist places them. Gradual skeletal dis­
traction can overcome the immediate recoiling soft tissue
forces; however, whether it can provide the long-term skel­
etal and occlusal stability remains to be shown. Newton’s
second and third laws will inevitably overcome the inertia
of Newton’s first law.
Conclusion
Orthognathic surgery provides a means of effectively cor­
recting dental malocclusions and facial disharmonies.
During this process, complications may arise at any one
or multiple stages of care: orthodontic and surgical plan­
ning, intraoperative, or perioperative orthodontic care.
Complications and unfavorable outcomes are inevitable
even in the most capable hands. When they do occur, the
theoretical or the potential becomes a reality and provides
an opportunity for honest assessment of the events lead­
ing to the undesired outcome or complication (Box 43.2).
The surgeon and the orthodontist as a unified team must
continually reconsider how to provide safer, more effective
care to patients. Seemingly small technical issues in orth­
odontic management and in the operating room can sig­
nificantly affect the outcome, resulting in reoperation and/
or additional months of orthodontics (Fig. 43.17).
Acknowledgments
The author would like to thank the colleagues who kindly
shared their unfavorable cases for this discussion.
As a general rule, the most stable moves are superior
maxillary impaction, followed by mandibular advance­
ment.84,85 In contrast, maxillary vertical lengthening, fol­
lowed by mandibular setback, are less predictably stable
procedures. The least stable is transverse maxillary wid­
ening. With maxillary impaction, the forces from the man­
dibular elevator muscles are favorable for maintaining the
vector of movement, in contrast to maxillary vertical length­
ening. Similarly, compensatory repositioning of the tongue
to maintain the airway is more favorable with advancement
than with setback.
These guidelines not only apply to the more common
developmental cases but equally apply to patients whose
dentofacial deformities are of congenital origin, such as facial
clefts, craniofacial microsomia, and other conditions. In such
patients, orthognathic surgery is a more complex undertak­
ing, because not only do such patients present with skeletal
considerations, but the soft tissue component also plays a
significant role in the management and outcome. Although
the goal of orthognathic surgery in all patients is to achieve
ideal occlusion, in patients with clefts, this often requires
performing multiple-segment osteotomies and overcoming
the restricting forces of the soft tissue and scar tissue imped­
iment to maxillary advancement. Furthermore, the surgeon
must take into account poor bone stock and the vascularity.
All these factors must be carefully considered and accurately
evaluated during the preoperative planning stages. A com­
prehensive strategy that addresses each of these variables is
important to optimize outcome. The surgical armamentar­
ium includes both distraction osteogenesis and conventional
orthognathic procedures supported by bone graft along with
orthodontic support with the understanding that both may
need to be used for a successful outcome.
Although it may seem reasonable that morphologic
stability and physiological adaptation should be complete
1 year after surgery, experience has shown that skeletal
and dental changes continue for years.86 Skeletal and oc­
clusal relapse can occur late, long after the initial surgery
and long after the patient is debanded.87,88 It is a result of a
complex interplay of functional dental and muscular forces

781
Chapter 43 Orthognathic Surgery and Maxillofacial Distraction Surgery
Fig. 43.17 This patient underwent presurgical orthodontic alignment and coordination (left), followed by a maxillary advancement
(Le Fort I, single segment) procedure that improved facial aesthetics in the profile view. However, when the outcome was reviewed (right),
the transverse width was not adequately corrected; the postoperative orthodontic detailing was countered by the relapsing force of the
scarred palatal mucosa. Moreover, there was progressive loss of correction in the transverse width over time. The use of canine substitution
in the left lateral incisor position contributed to the left posterior cross-bite. An alternative would have been to plan for an osseointegrated
implant for the missing left lateral incisor. Staging the correction with a left segmental osteotomy with transpalatal expansion followed by a
subsequent maxillary advancement would have given the patient a fuller canine-to-canine smile (minimizing the buccal corridor space) and
an improved posterior occlusion. The resulting occlusion is functional but not ideal. A more favorable outcome could have been achieved
with an alternative treatment plan.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
782
22. Grubb J, Evans C. Orthodontic management of dentofacial
skeletal deformities. Clin Plast Surg 2007;34(3):403–415
23. Patel PK. Maxillary osteotomies. In: Taub P, Patel PK, Bu­
chman SR, Cohen MN, eds. Ferraro’s Fundamentals of
Maxillofacial Surgery. New York: Springer; 2015
24. Mosby EL, Messer EJ, Nealis MF, Golden DP. Intraoperative
damage to nasotracheal tubes during maxillary surgery:
report of cases. J Oral Surg 1978;36(12):963–964
25. Peskin RM, Sachs SA. Intraoperative management of a
partially severed endotracheal tube during orthognathic
surgery. Anesth Prog 1986;33(5):247–251
26. Kohno M, Nakajima T, Someya G. Effects of maxilloman­
dibular fixation on respiration. J Oral Maxillofac Surg 1993;
51(9):992–996
27. Schaberg SJ, Kelly JF, Terry BC, Posner MA, Anderson EF.
Blood loss and hypotensive anesthesia in oral-facial cor­
rective surgery. J Oral Surg 1976;34(2):147–156
28. Fromme GA, MacKenzie RA, Gould AB Jr, Lund BA, Of­
ford KP. Controlled hypotension for orthognathic surgery.
Anesth Analg 1986;65(6):683–686
29. Lanigan DT, Hey JH, West RA. Major vascular compli­
cations of orthognathic surgery: hemorrhage associ­
ated with Le Fort I osteotomies. J Oral Maxillofac Surg
1990;48(6):561–573
30. Tung TC, Chen YR, Bendor-Samuel R. Surgical complica­
tions of the Le Fort I osteotomy—a retrospective review of
146 cases. Changge-ng Yi-xue Zazhi 1995;18(2):102–107
31. Epker BN. Vascular considerations in orthognathic sur­
gery. II. Maxillary osteotomies. Oral Surg Oral Med Oral
Pathol 1984;57(5):473–478
32. Turvey TA, Fonseca RJ. The anatomy of the internal maxil­
lary artery in the pterygopalatine fossa: its relationship to
maxillary surgery. J Oral Surg 1980;38(2):92–95
33. Teltzrow T, Kramer FJ, Schulze A, Baethge C, Brachvogel P.
Perioperative complications following sagittal split osteot­
omy of the mandible. J Craniomaxillofac Surg 2005;33(5):
307–313
34. Hwang K, Nam YS, Han SH. Vulnerable structures during
intraoral sagittal split ramus osteotomy. J Craniofac Surg
2009;20(1):229–232
35. Fujimura K, Segami N, Kobayashi S. Anatomical study of
the complications of intraoral vertico-sagittal ramus os­
teotomy. J Oral Maxillofac Surg 2006;64(3):384–389
36. Turvey TA. Intraoperative complications of sagittal oste­
otomy of the mandibular ramus: incidence and manage­
ment. J Oral Maxillofac Surg 1985;43(7):504–509
37. Bays RA. Complications of orthognathic surgery. In: Ka­
ban LB, Pogrel MA, Perrott DH, eds. Complications in Oral
and Maxillofacial Surgery. Philadelphia: WB Saunders
Company; 1997:193–221
38. Lanigan DT, West RA. Management of postoperative hem­
orrhage following the Le Fort I maxillary osteotomy. J Oral
Maxillofac Surg 1984;42(6):367–375
39. Lai JP, Hsieh CH, Chen YR, Liang CC. Unusual late vascular
complications of sagittal split osteotomy of the mandibu­
lar ramus. J Craniofac Surg 2005;16(4):664–668
40. Kim YW, Baek MJ, Kim HD, Cho KS. Massive epistaxis due
to pseudoaneurysm of the sphenopalatine artery: a rare
post-operative complication of orthognathic surgery. J
Laryngol Otol 2013;127(6):610–613
41. Chepla KJ, Totonchi A, Hsu DP, Gosain AK. Maxillary artery
pseudoaneurysm after Le Fort I osteotomy: treatment
References
1. el Deeb M, Wolford L, Bevis R. Complications of orthogna­
thic surgery. Clin Plast Surg 1989;16(4):825–840
2. Panula K, Finne K, Oikarinen K. Incidence of complications
and problems related to orthognathic surgery: a review of
655 patients. J Oral Maxillofac Surg 2001;59(10):1128–
1136, discussion 1137
3. Bays RA, Bouloux GF. Complications of orthognathic sur­
gery. Oral Maxillofac Surg Clin North Am 2003;15(2):229–
242
4. Kim SG, Park SS. Incidence of complications and problems
related to orthognathic surgery. J Oral Maxillofac Surg
2007;65(12):2438–2444
5. Morris DE, Lo LJ, Margulis A. Pitfalls in orthognathic sur­
gery: avoidance and management of complications. Clin
Plast Surg 2007;34(3):e17–e29
6. Sarver DM, Sample LB. How to avoid surgical failures. Se­
min Orthod 1999;5(4):257–274
7. Pahkala RH, Kellokoski JK. Surgical-orthodontic treatment
and patients’ functional and psychosocial well-being. Am
J Orthod Dentofacial Orthop 2007;132(2):158–164
8. Meade EA, Inglehart MR. Young patients’ treatment
motivation and satisfaction with orthognathic surgery
outcomes: the role of “possible selves”. Am J Orthod
­Dentofacial Orthop 2010;137(1):26–34
9. Rustemeyer J, Gregersen J. Quality of life in orthognathic
surgery patients: post-surgical improvements in aesthetics
and self-confidence. J Craniomaxillofac Surg 2012;40(5):
400–404
10. Sharifi A, Jones R, Ayoub A, et al. How accurate is model
planning for orthognathic surgery? Int J Oral Maxillofac
Surg 2008;37(12):1089–1093
11. Barbenel JC, Paul PE, Khambay BS, Walker FS, Moos KF,
Ayoub AF. Errors in orthognathic surgery planning: the
effect of inaccurate study model orientation. Int J Oral
Maxillofac Surg 2010;39(11):1103–1108
12. Mah J, Sachdeva R. Computer-assisted orthodontic treat­
ment: the SureSmile process. Am J Orthod Dentofacial Or­
thop 2001;120(1):85–87
13. Hatcher DC, Aboudara CL. Diagnosis goes digital. Am J Or­
thod Dentofacial Orthop 2004;125(4):512–515
14. Swennen GR, Mollemans W, Schutyser F. Three-dimen­
sional treatment planning of orthognathic surgery in the
era of virtual imaging. J Oral Maxillofac Surg 2009;67(10):
2080–2092
15. Hsu SS, Gateno J, Bell RB, et al. Accuracy of a computer-
aided surgical simulation protocol for orthognathic sur­
gery: a prospective multicenter study. J Oral Maxillofac
Surg 2013;71(1):128–142
16. Larson BE, Vaubel CJ, Grünheid T. Effectiveness of computer-
assisted orthodontic treatment technology to achieve
predicted outcomes. Angle Orthod 2013;83(4):557–562
17. Obwegeser HL. Mandibular growth anomalies. Berlin
Heidelberg: Springer-Verlag; 2001
18. Sabri R. Orthodontic objectives in orthognathic surgery:
state of the art today. World J Orthod 2006;7(2):177–191
19. Arnett GW, Gunson MJ. Esthetic treatment planning for
orthognathic surgery. J Clin Orthod 2010;44(3):196–200
20. Rosen HM. Facial skeletal expansion: treatment strategies
and rationale. Plast Reconstr Surg 1992;89(5):798–808
21. Rosen H. Aesthetics in facial skeletal surgery. Perspect
Plast Surg 1993;6:1

783
Chapter 43 Orthognathic Surgery and Maxillofacial Distraction Surgery
59. Baqain ZH, Hyde N, Patrikidou A, Harris M. Antibiotic
prophylaxis for orthognathic surgery: a prospective, ran­
domised clinical trial. Br J Oral Maxillofac Surg 2004;42(6):
506–510
60. Danda AK, Ravi P. Effectiveness of postoperative antibiot­
ics in orthognathic surgery: a meta-analysis. J Oral Maxil­
lofac Surg 2011;69(10):2650–2656
61. Precious DS, Goodday RH, Bourget L, Skulsky FG. Pterygoid
plate fracture in Le Fort I osteotomy with and ­without
pterygoid chisel: a computed tomography scan ­evaluation
of 58 patients. J Oral Maxillofac Surg 1993;51(2):
151–153
62. Renick BM, Symington JM. Postoperative computed tomog­
raphy study of pterygomaxillary separation during the Le
Fort I osteotomy. J Oral Maxillofac Surg 1991;49(10):1061–
1065, discussion 1065–1066
63. Posnick JC. LeFort I osteotomy, sagittal splitting of the
mandible and genioplasty: historical perspective and step-
by-step approach. In: Posnick JC, ed. Craniofacial and
Maxillofacial Surgery in Children and Young 17 Adults, Vol 2.
Philadelphia: WB Saunders; 2000
64. Patel PK, Novia MV. The surgical tools: the LeFort I, bilat­
eral sagittal split osteotomy of the mandible, and the os­
seous genioplasty. Clin Plast Surg 2007;34(3):447–475
65. Moenning JE, Garrison BT, Lapp TH, Bussard DA. Early
screw removal for correction of occlusal discrepancies
following rigid internal fixation in orthognathic surgery.
Int J Adult Orthodon Orthognath Surg 1990;5(4):225–232
66. O’Connell J, Murphy C, Ikeagwuani O, Adley C, Kearns G.
The fate of titanium miniplates and screws used in maxil­
lofacial surgery: a 10 year retrospective study. Int J Oral
Maxillofac Surg 2009;38(7):731–735
67. Liou EJ, Chen PH, Wang YC, Yu CC, Huang CS, Chen YR.
Surgery-first accelerated orthognathic surgery: postop­
erative rapid orthodontic tooth movement. J Oral Maxil­
lofac Surg 2011;69(3):781–785
68. Janulewicz J, Costello BJ, Buckley MJ, Ford MD, Close J,
Gassner R. The effects of Le Fort I osteotomies on velo­
pharyngeal and speech functions in cleft patients. J Oral
Maxillofac Surg 2004;62(3):308–314
69. Phillips JH, Klaiman P, Delorey R, MacDonald DB. Predic­
tors of velopharyngeal insufficiency in cleft palate orthog­
nathic surgery. Plast Reconstr Surg 2005;115(3):681–686
70. Ramesh BV, Vinod N, Murugesan K. Pharyngeal airway
changes following mandibular setback surgery. Indian J
Dent Res 2005;16(4):147–150
71. Chen F, Terada K, Hua Y, Saito I. Effects of bimaxillary sur­
gery and mandibular setback surgery on pharyngeal air­
way measurements in patients with Class III skeletal de­
formities. Am J Orthod Dentofacial Orthop 2007;131(3):
372–377
72. Fernández-Ferrer L, Montiel-Company JM, Pinho T,
Almerich-Silla JM, Bellot-Arcís C. Effects of mandibular
­setback surgery on upper airway dimensions and their
influence on obstructive sleep apnoea—a systematic
­review. J Craniomaxillofac Surg 2015;43(2):248–253
73. Moses JJ, Lange CR, Arredondo A. Endoscopic treatment of
sinonasal disease in patients who have had orthognathic
surgery. Br J Oral Maxillofac Surg 2000;38(3):177–184
74. Dujoncquoy JP, Ferri J, Raoul G, Kleinheinz J. Temporo­
mandibular joint dysfunction and orthognathic surgery:
a retrospective study. Head Face Med 2010;6:27
75. Wolford LM, Reiche-Fischel O, Mehra P. Changes in tem­
poromandibular joint dysfunction after orthognathic
using transcatheter arterial embolization. J Craniofac Surg
2010;21(4):1079–1081
42. Silva AC, O’Ryan F, Beckley ML, Young HY, Poor D. Pseu­
doaneurysm of a branch of the maxillary artery following
mandibular sagittal split ramus osteotomy: case report
and review of the literature. J Oral Maxillofac Surg 2007;
65(9):1807–1816
43. Bell WH, You ZH, Finn RA, Fields RT. Wound healing af­
ter multisegmental Le Fort I osteotomy and transection
of the descending palatine vessels. J Oral Maxillofac Surg
1995;53(12):1425–1433, discussion 1433–1434
44. Lanigan DT, Hey JH, West RA. Aseptic necrosis following
maxillary osteotomies: report of 36 cases. J Oral Maxil­
lofac Surg 1990;48(2):142–156
45. de Mol van Otterloo JJ, Greebe RB, Tuinzing DB, van der
Kwast WA. Intra- and early postoperative complications
of the Le Fort I osteotomy. A retrospective study on 410
cases. J Craniomaxillofac Surg 1991;19(5):217–222
46. Epker BN. Vascular considerations in orthognathic sur­
gery. I. Mandibular osteotomies. Oral Surg Oral Med Oral
Pathol 1984;57(5):467–472
47. Lanigan DT, West RA. Aseptic necrosis of the mandible:
report of two cases. J Oral Maxillofac Surg 1990;48(3):
296–300
48. Gent JF, Shafer DM, Frank ME. The effect of orthognathic
surgery on taste function on the palate and tongue. J Oral
Maxillofac Surg 2003;61(7):766–773
49. Carr RJ, Gilbert P. Isolated partial third nerve palsy fol­
lowing Le Fort I maxillary osteotomy in a patient with
cleft lip and palate. Br J Oral Maxillofac Surg 1986;24(3):
206–211
50. Lo LJ, Hung KF, Chen YR. Blindness as a complication of Le
Fort I osteotomy for maxillary distraction. Plast Reconstr
Surg 2002;109(2):688–698, discussion 699–700
51. Guernsey LH, DeChamplain RW. Sequelae and com­
plications of the intraoral sagittal osteotomy in the
­mandibular rami. Oral Surg Oral Med Oral Pathol 1971;32(2):
176–192
52. Moore T, Southard KA, Casko JS, Qian F, Southard TE. Buc­
cal corridors and smile esthetics. Am J Orthod Dentofacial
Orthop 2005;127(2):208–213, quiz 261
53. Zaytoun HS Jr, Phillips C, Terry BC. Long-term neurosen­
sory deficits following transoral vertical ramus and sagit­
tal split osteotomies for mandibular prognathism. J Oral
Maxillofac Surg 1986;44(3):193–196
54. Van de Perre JP, Stoelinga PJ, Blijdorp PA, Brouns JJ, Hop­
penreijs TJ. Perioperative morbidity in maxillofacial
­orthopaedic surgery: a retrospective study. J Craniomax­
illofac Surg 1996;24(5):263–270
55. Posnick JC, Al-Qattan MM, Stepner NM. Alteration in fa­
cial sensibility in adolescents following sagittal split and
chin osteotomies of the mandible. Plast Reconstr Surg
1996;97(5):920–927
56. Lindquist CC, Obeid G. Complications of genioplasty done
alone or in combination with sagittal split-ramus oste­
otomy. Oral Surg Oral Med Oral Pathol 1988;66(1):13–16
57. Nishioka GJ, Mason M, Van Sickels JE. Neurosen­
sory ­disturbance associated with the anterior man­
dibular horizontal osteotomy. J Oral Maxillofac Surg
1988;46(2): 107–110
58. Kramer FJ, Baethge C, Swennen G, et al. Intra- and periop­
erative complications of the LeFort I osteotomy: a prospec­
tive evaluation of 1000 patients. J Craniofac Surg 2004;
15(6):971–977, discussion 978–979

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
784
82. O’Ryan F, Schendel S. Nasal anatomy and maxillary surgery.
II. Unfavorable nasolabial esthetics following the Le Fort I
osteotomy. Int J Adult Orthodon Orthognath Surg 1989;
4(2):75–84
83. Kawamoto HJ Jr. Simplification of the Le Fort I osteotomy.
Clin Plast Surg 1989;16(4):777–784
84. Proffit WR, Turvey TA, Phillips C. Orthognathic surgery:
a hierarchy of stability. Int J Adult Orthodon Orthognath
Surg 1996;11(3):191–204
85. Bailey L, Cevidanes LH, Proffit WR. Stability and predict­
ability of orthognathic surgery. Am J Orthod Dentofacial
Orthop 2004;126(3):273–277
86. De Clercq CA, Neyt LF, Mommaerts MY, Abeloos JV, De
Mot BM. Condylar resorption in orthognathic surgery: a
retrospective study. Int J Adult Orthodon Orthognath Surg
1994;9(3):233–240
87. Eggensperger N, Smolka K, Luder J, Iizuka T. Short- and
long-term skeletal relapse after mandibular advancement
surgery. Int J Oral Maxillofac Surg 2006;35(1):36–42
88. Wagner S, Reyneke JP. The Le Fort I downsliding osteoto­
my: a study of long-term hard tissue stability. Int J Adult
Orthodon Orthognath Surg 2000;15(1):37–49
surgery. J Oral Maxillofac Surg 2003;61(6):655–660,
discussion 661
76. Abrahamsson C, Henrikson T, Nilner M, Sunzel B, Bond­
emark L, Ekberg EC. TMD before and after correction of
dentofacial deformities by orthodontic and orthognathic
treatment. Int J Oral Maxillofac Surg 2013;42(6):752–758
77. Nadershah M, Mehra P. Orthognathic surgery in the pres­
ence of temporomandibular dysfunction: what happens
next? Oral Maxillofac Surg Clin North Am 2015;27(1):
11–26
78. Schendel SA, Mason ME. Adverse outcomes in orthogna­
thic surgery and management of residual problems. Clin
Plast Surg 1997;24(3):489–505
79. Sarver DM. The importance of incisor positioning in the
esthetic smile: the smile arc. Am J Orthod Dentofacial Or­
thop 2001;120(2):98–111
80. Desai S, Upadhyay M, Nanda R. Dynamic smile analysis:
changes with age. Am J Orthod Dentofacial Orthop 2009;
136(3):310.e1–310.e10, discussion 310–311
81. Parekh S, Fields HW, Beck FM, Rosenstiel SF. The accept­
ability of variations in smile arc and buccal corridor space.
Orthod Craniofac Res 2007;10(1):15–21
Discussion by Joseph G. McCarthy
Although I have used the expression “orthognathic sur­
gery” for more than 4 decades, I find the term ill-suited
and inaccurately descriptive of this type of specialized
surgery. As for so many medical terms, it is derived from
the Greek (ortho, a Greek prefix meaning “straight,”
and gnathic, from gnathos, meaning “jaw”).  It implies
purely skeletal surgery limited to the upper and lower
jaws and, as the chapter shows, the deformities have
soft tissue components often requiring soft tissue sur­
gical procedures. As the field evolved and the scope of
the specialty enlarged, surgeon unhappiness with the
term was reflected in subsequent name changes:
•• Maxillofacial, especially popular in Europe during
and after World War I.
•• Craniofacial, a 1960s term to encompass the fact
that surgeons were now operating on the orbits and
cranium with the aid of a craniotomy. However, such
procedures often involved surgical modification of
the maxilla or upper jaw.
•• Composite microvascular, a reflection of the
introduction of microsurgical reconstruction of the
jaws by microvascular anastomosis of composite
segments of skeletal and soft tissue from remote
donor sites. The recent introduction of facial
allotransplantation has demonstrated the capability
of incorporating components of the upper and lower
jaws in the composite transplant.
One can then ask, “What is the ideal term?” There is no
perfect one, but we do know the ideal term would be
one that reflects the expansion of the anatomic realm
and encompasses all of the clinical extensions of this
surgical specialty. Possible suggestions include the
­following:
•• Reconstructive facial surgery
•• Reconstructive plastic surgery of the face
•• Reconstructive craniofacial surgery
As George Santayana famously wrote: “Those who do
not remember the past are condemned to repeat it.” As
surgeons involved in facial reconstruction, it is incum­
bent on us to know our historic roots. An appreciation
and understanding of history illuminates the present
and can guide us to a path to move into the future.
One cannot definitively state when orthognathic
surgery began, but the following case report is usu­
ally cited as our beginning: In 1849, Simon Hullihen, a
frontier physician practicing in Wheeling, Virginia (now
West Virginia), reported an anterior mandibular dento­
alveolar osteotomy for the correction of an anterior open
bite. His motivation and surgical experience remain a
mystery. One can, however, assume he was motivated
by a desire to help the patient.
By the time of the 1870s, all of surgery was pro­
pelled by the introduction of anesthesia and the ­concept

785
Chapter 43 Orthognathic Surgery and Maxillofacial Distraction Surgery
of antisepsis. It was an era of incredible surgical firsts
and, more importantly, of the introduction of the con­
cept of surgery departments in research universities,
especially in Germany.
In the early 20th century, the city of St. Louis, Mis­
souri, saw the organization of the first facial reconstruc­
tive team in the unique collaboration of Vilray Blair, a
general surgeon, and Edward H. Angle, an orthodontist.
The former is considered the father of American plastic
surgery and the latter the father of American orthodon­
tics. They published papers on mandibular osteotomies,
and it is noteworthy that they were also involved in cel­
ebrated professional feuds. In 1912 Blair went on to au­
thor the first textbook, Surgery and Diseases of the Mouth
and Jaws. This became the surgical manual of the U.S.
Army during World War I. With trench warfare and an
inordinate number of maxillofacial injuries, World War
I was the defining event in the evolution of maxillofa­
cial surgery. Future leaders, such as Harold Gillies, V.H.
Kazanjian, Robert Ivy, and August Lindemann (German),
became internationally famous for their contributions
to this small surgical specialty. They became skilled in
treating facial fractures, developing innovative meth­
ods of stabilizing osseous segments, introducing autog­
enous bone grafts, and pioneering the extensive use of
soft tissue flaps (tube). Gillies went on to publish the
classic textbook Plastic Surgery of the Face in 1920. It
is noteworthy that he did not use the term “maxillofa­
cial” or “orthognathic” in the book title. In 1920, the first
professional organization of this nascent specialty was
founded, and the surgeons chose the name American
Association of Oral Surgeons. It was not until 1942 that
the name was changed to the American Association of
Plastic Surgeons.
During the interwar years, the professional activ­
ity switched to the continent of Europe, where there
were three kieferchirurgie schools. Georg Axhausen and
Martin Wassmund were chiefs of individual programs
in Berlin, and Hans Pichler led a school in Vienna. The
name “maxillofacial” was stressed, and most European
leaders in this field in the post-World War II era could
trace their training lineage to one of the three schools.
It was the era of dentoalveolar and mandibular osteoto­
mies, as well as intraoral tumor ablations. However, Ax­
hausen and Wassmund individually published case re­
ports of the Le Fort I osteotomy (but it was not until the
1970s that the procedure was practiced on a wide scale).
World War II presented an entirely different surgi­
cal experience, mainly the treatment of burns and rela­
tively little exposure to maxillofacial injuries. The facial
surgical experience paled in comparison to that of the
first world war.
Hugo Obwegeser, an Austrian who practiced at the
University of Zurich, dominated the field in the 1950s
and 1960s. He popularized the term maxillofacial sur­
gery and stressed the importance of the double degree
in the training of the “maxillofacial surgeon.” He wrote
extensively on the osseous genioplasty, and he intro­
duced the concept of the sagittal split osteotomy of the
mandible in 1953. He popularized the Le Fort I oste­
otomy, which, combined with the sagittal split oste­
otomy, introduced the era of two-jaw surgery. He was
skilled at preoperative planning using cephalograms and
dental models. Overall, he had an enormous impact on
this field and almost singlehandedly established it on a
strong professional footing.
In the late 1960s a major paradigm shift in this dis­
cipline was led by Paul Tessier of Paris. He revolution­
ized the field in his 1967 presentation in Rome of the
craniofacial correction of previously untreated mon­
strous facial deformities. He enlarged the clinical team
by bringing in a neurosurgeon. With an anterior crani­
otomy, he eliminated the dreaded fear of brain or ocular
injury. He refined and defined the Le Fort III osteotomy
(originally described by Gillies) and was a master at or­
bital translocation surgery, as in the correction of orbital
hypertelorism and orbital diplopia.
The 1970s witnessed the introduction of infant and
pediatric craniofacial surgery because of associated ad­
vances in pediatric anesthesia and pediatric critical care.
The 1980s saw the introduction of rigid skeletal fixation
and improved imaging, which eventually led to the in­
troduction of three-dimensional cone beam computed
tomography in outpatient clinics and virtual surgical
planning.
By the 1980s, craniofacial or maxillofacial surgery
had made giant strides and advances, but there were
multiple unsolved problems. The complication and in­
fection rates were relatively high; blood replacement of
large volume was often required, and successful recon­
struction depended on multiple operations or stages.
Bone graft harvest was often necessary, and many of the
procedures had become physiologically overwhelming.
Based on the principles of Ilizarov, as developed for the
long bones of the extremities, distraction osteogenesis
was introduced by the New York University team as an
entirely new type of reconstruction of the bones of the
craniofacial skeleton.
Distraction has now become the procedure of
choice; the indications for distraction are listed in Box
43D.1.
In this brief historical review, one should ask, “What
are the essential or critical requirements in achieving
favorable results?”

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
786
Box 43D.1
Mandible
Pediatric
•• Mandibular micrognathia with obstructive sleep
apnea (retroglossal)
•• Mandibular micrognathia and severe
dysmorphism, as in unilateral craniofacial
microsomia
Adult
•• History of unsuccessful or failed mandibular
advancement
•• Need for large mandibular advancements
(greater than 12 mm)
Maxilla (Le Fort I)
Pediatric
•• Cleft patient with severe class III malocclusion
Adult
•• Cleft patient requiring Le Fort I advancement in
excess of 12 mm
Midface
Pediatric
•• Le Fort III and monobloc advancement
because of respiratory obstruction or severe
dysmorphism
Adult
•• Large midface advancements in excess of 12 mm
•• Monobloc advancements to reduce the incidence
of postoperative infection
•• Previous unsuccessful midface advancement
surgery
Indications for Distraction
Team Organization
Team organization means not only having the neces­
sary specialties (orthodontics, anesthesiology, neuro­
surgery, etc.) represented but also participating fully in
joint sessions on a regular basis.
Communication
It is important that the surgeon and team members
communicate openly with the patient and family and
also with each other. Today, there are many available
educational aids, such as brochures, video clips, and
applications, that are particularly helpful in patient and
family communication.
Asking the Appropriate Questions
Asking the appropriate questions is especially impor­
tant at the initial consultation and the visits that follow:
•• What is it? This is the diagnosis. Is it a maxillary
hypoplasia or a true mandibular prognathism or a
combination? Is facial asymmetry a result of right-
side hyperplasia or hypoplasia on the left side, or is
it a combination of both?
•• What to do? Treatment obviously depends on
whether it is correction of a skeletal deformity alone
(mandibular micrognathia), a soft tissue deformity
alone, or a combination (unilateral craniofacial
microsomia). More and more, the surgeon must ask
whether the patient is a candidate for a traditional
or acute (orthognathic) advancement or a candidate
for distraction osteogenesis as discussed previously.
•• How to do it? The surgeon must have the requisite
skill and experience and must have a functioning
relationship with the specialists or team members,
especially the orthodontist. The procedure must
never be undertaken by a surgeon with limited
training or experience. The same requirements hold
for all team members.
•• When to do it? This is probably the most challenging
question. With the introduction of distraction
osteogenesis, surgical reconstructions, such as
those for the hypoplastic mandible or midface
in craniofacial synostosis, can be undertaken in
a growing child. As noted earlier in this chapter,
if surgical reconstruction is to be delayed until
adulthood or craniofacial maturity, orthodontic
therapy should not be undertaken that is at odds
with the proposed surgical correction.

787
Chapter 43 Orthognathic Surgery and Maxillofacial Distraction Surgery
The Future
In my lifetime, I have observed that all surgical disci­
plines have witnessed technical advances that have
minimalized the physiological stress of individual
surgical procedures, and the latter have become less
invasive.
In this mode, I would prophesy that the surgeon of
the future will have nonsurgical means of promoting
growth in the jaws of children born with anomalies.
Osteotomies will be performed endoscopically with
limited surgical incisions; there will be bone graft sub­
stitutes. The surgeon will have the ability to “spot weld”
or accelerate bony healing, obviating the need for fixa­
tion devices. Distraction devices will be miniaturized
and will be capable of multivector movement of the os­
teotomized segments.
Innovation will ensure that the field will not remain
stagnant. The surgeon of the future will benefit from
associated technological and laboratory developments,
making the practice of surgery more exciting and, more
importantly, improving surgical outcomes for the indi­
vidual patient.
This chapter guides us into the future to reduce
complication rates and to make the surgical experience
less traumatic for the patient and also for the surgeon.

CHAPTER
44
788

Auricular Reconstruction
Françoise Firmin and Alexandre Marchac
Neither myself nor anyone else has anything to learn
from success, but only from failures and complica­
tions … Success always leads to self-satisfaction and
therefore not to improvement … We should live in
a world of complications … and have the courage
to investigate the causes that are not always flat­
tering: poor indications, disorganization, ignorance
and haste.

— The World of Complications

  Translation of a text written by Dr. Paul Tessier
Auricular reconstruction can probably claim the award for
the longest learning curve in plastic surgery, and surgeons
who simply “give it a try” usually end up with very unsatis­
factory results. Indeed, it takes time to learn how to sculpt
a harmonious framework from costal cartilage, and, despite
a sound knowledge of flaps, probably just as much to learn
how to safely cover it with a thin layer of skin.
Until three-dimensional printing of bioengineered frame­
works becomes a reality, an ear still has to be reconstructed
using a support from autologous rib cartilage or synthetic ma­
terial. We strongly prefer to use costal cartilage for its ability
to be precisely shaped into the form of the contralateral ear,
its resistance in case of exposure, and its longevity.
Over three decades, I (F.F.) have reconstructed more
than 2,400 ears1,2 and have systematically applied the prin­
ciples of my mentor, Paul Tessier, to critically analyze com­
plications, to treat them, and to try to avoid them.
The goal of this chapter is to highlight the hurdles along
the path of ear reconstruction and to provide guidelines to
avoid them.
Avoiding Unfavorable Results
and Complications in Auricular
Reconstruction
Summary Box
The Most Common Problems Related to Ear
Reconstruction
•• Skin necrosis (the most common
complication)
•• Inaccurate design of the framework
•• Poor projection of the framework
•• Malposition of the framework
•• Infection (the most severe complication, because it
induces resorption of the cartilage)

789
Chapter 44 Auricular Reconstruction
projection (MIP) reconstruction of the ribs to recognize os­
sifications of the cartilage, which will dictate which ribs to
harvest (Fig. 44.1).
Preoperative Drawings
Learning to correctly place the reconstructed ear is essen­
tial and relies on selecting landmarks from the normal side,
which are drawn and used on the affected side. We com­
monly see patients for a secondary reconstruction in whom
the axis of the ear has been placed too vertical, the ear too
anterior and too low.
To avoid malposition of the newly reconstructed ear,
landmarks are drawn on the auricular area:
•• Axis of the nasal dorsum and axis of the normal ear
•• Level of the lobule and of the root of the helix
•• Distance from the lobule to the corner of the mouth, and
distance for the root of the helix and lateral canthus
•• Contours of the framework
During the skin preparation with povidone iodine, these
landmarks tend to fade, and we recommend incising the
key points with a 25-gauge needle.
The course of the superficial temporal artery is marked
using a handheld short-depth Doppler probe. Ectopic
courses are common in syndromic microtia. The superficial
temporal fascial flap is the workhorse of secondary recon­
structions and must be preserved at all cost (Fig. 44.2).
Intraoperative Considerations
The shape of the framework is directly seen under the thin
skin covering it, and the quality of the result is directly
­dependent on the harmonious contours of this framework.
Preoperative Planning and Patient
Selection
Patients referred for an ear reconstruction can be sorted in
two very different categories:
1. Children with a congenital anomaly who have never
had an operation.
2. Posttraumatic cases, mostly in adults. The presence of
scars stresses how the analysis of the skin potential is
essential.
Planning the cartilage skin coverage is the most challenging
part of an ear reconstruction, and incorrect planning is the
most common source of unfavorable results and complica­
tions.
Each case is different, but understanding the different
possible skin approaches makes it possible to select the most
appropriate one for each case.
Evaluating the expectations of an adult patient or those
of a child’s parents is important, particularly when local con­
ditions are not ideal. During the first consultation, and after
drawing the contours of the ear on a template and placing
it on the ideal position, the surgical planning (contours to
reproduce and skin approach to use) is established.
Contours to Reproduce
It is essential to draw the contours of the nondeformed
ear to determine those that must be removed from the
deformed ear and those that must be reproduced when
carving the cartilaginous framework. This analysis will also
predict the amount of cartilage needed.
Preoperative planning includes computed tomography
of the thorax and three-dimensional maximum intensity
Fig. 44.1 Computed tomography of the thorax and three-dimensional maximum intensity projection reconstruction of the ribs to discover
ossifications of the cartilage, which will dictate which ribs to harvest. In this case, the right eighth rib is less ossified than the left one and
will make a better helix.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
790
The antihelix has two very different roots. The anterior
one is sharp, whereas the posterior one has a smooth curve
which blends into the scapha. We have begun to carve our
posterior root much smoother.
Because the framework is made of costal cartilage, it is
much thicker than an original ear, made out of “fibrocarti­
lage” (which is actually elastic cartilage). The posterior edge
must be thinned before implantation; otherwise the frame­
work will be very bulky after the second stage when seen
from behind.
Taking these mistakes, which became evident when fol­
lowing our patients and critically observing our results, into
Several typical mistakes must be avoided when sculpting
the framework (Fig. 44.3):
•• The concha should not be too small.
•• The posterior root of the antihelix should not be too
prominent.
•• The posterior edge of the framework must not be too
thick.
A small concha is a very common mistake. A harmonious
ear has a large concha and a very narrow groove between
the helix and the antihelix.
a
b
Fig. 44.2 (a) Landmarks are drawn to avoid malposition of the new ear: (1) axis of the normal ear relative to the nasal dorsum; (2) level of
the lobule and of the root of the helix; (3) distance from the lobule to the corner of the mouth, and distance for the root of the helix and
lateral canthus. The course of the superficial temporal artery is marked using Doppler mapping. Ectopic courses occur in syndromic microtia
framework. (b) Contours of the framework are drawn in the ideal position. Because a limited operating field is prepared to avoid infection
from nasal or oral cavities, it is essential to keep all these landmarks until the end when placing the framework.
a
b
c
Fig. 44.3 Typical mistakes can be found in the design of the framework. (a) The concha is too small. (b) The posterior root of the antihelix
is too prominent. (c) The posterior edge of the framework is too thick.

791
Chapter 44 Auricular Reconstruction
Skin Necrosis
The most common complication is skin necrosis. When
performing the first dressing change on day 3 after surgery,
the skin blood supply is appreciated. If the surgeon has any
doubt regarding vascularity, he or she must wait until at
least the eighth postoperative day to clinically confirm the
presence of skin necrosis.
Rib cartilage is resistant to exposure and can stay ex­
posed for several days, covered by a moist dressing with pe­
troleum jelly and fucidic acid. When the exposure affects a
small area in a hollow (i.e., the concha, the scapha, or the in­
tertragal notch), it should be left to heal secondarily, because
it will not be visible if the cartilage resorbs. Nevertheless,
when it affects a hill (i.e., the helix, antihelix, or antitragus),
it should be covered by a skin flap or a fascial flap to prevent
cartilage resorption.
Careful planning of the skin incision decreases the risk
for skin necrosis. We follow the principles outlined in our
classification of skin incisions3 (Fig. 44.6).
account, we began to carve our framework differently (Fig.
44.4).
Evolution in carving is evident when comparing a frame­
work carved as a beginner 30 years ago and a recent one
(Fig. 44.5).
Avoiding Postoperative Complications
Infection
The worst complication in ear reconstruction is infection,
although it is not common. In our experience, infection oc­
curs when there is an unclean external auditory canal, and
the bacteria is usually Pseudomonas aeruginosa. To prevent
infection, patients with an external auditory canal are sys­
tematically sent for a preoperative cleaning under micro­
scope, and we prescribe daily ciprofloxacin droplets in the
ear for 5 days before the surgery.
a
b
Fig. 44.4 Our current typical complete framework. (a) The framework includes a base, a helix, an antihelix, a tragus–antitragus, a projec­
tion piece (P1), and a projection piece (P2). (b) A segment of cartilage is kept under the thoracic skin for the second stage. Note the wide
concha with a very narrow groove between the helix and the antihelix, the smooth edge of the posterior root of the antihelix, and the
thinned posterior edge of the base.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
792
a
b
Fig. 44.5 (a) This framework was one of our first. It was made out of two pieces, a base and a helix. Retrospectively, it has little to no projec­
tion, and the result was very disappointing. (b) Now our typical framework has many hills and valleys, with multiple pieces and extra projec­
tion. Besides adding the antihelix in the anterior surface of the base, we routinely add projections behind the base. Good three-dimensional
reproduction of the contours and correct positioning of the framework are evident.
Type 3a
Enough skin to perform a
single-stage reconstruction
Type 3
Skin-only incision
Type 1
Traditional z-plasty to transpose the
lobule
Type 2
Transfixion incision through the
remnants to place part of the
framework into a skin pocket; the
other part is buried and elevated
secondarily
Type 3a
Enough skin to perform a
single-stage reconstruction
FIRMIN’S CLASSIFICATION OF SKIN APPROACH
Fig. 44.6 The classification of skin approach. Choosing the type of skin approach depends on the remnants. Type 1 is the traditional z-
plasty described by Burt Brent4 and modified by Satoru Nagata,5 which we no longer use. We prefer type 2 or type 3, which have less risk
of skin necrosis.

793
Chapter 44 Auricular Reconstruction
analysis of the result is critical before planning the second
stage.
Some revision of the contours may be determined nec­
essary; this can be performed when elevating the ear (Fig.
44.7).
If the contours are deceiving because of a resorption
of the cartilage, generally because of an infection that may
have occurred secondarily after a trauma or extrusion of
wire sutures or another cause and was not efficiently cured,
it is essential to start the reconstruction from scratch and to
help the patient to accept this solution, even if the patient
must travel far for the second stage (Fig. 44.8).
Managing Unfavorable Results
and Complications in Auricular
Reconstruction
Personal Unfavorable Result
When a surgeon becomes an expert, patients are referred
to the surgeon from far away. Nonetheless, the follow-up
is essential after both stages, and patients must be fol­
lowed by the operating surgeon for at least 2 weeks. At the
follow-up several months after the first stage, a critical
a
b
c
d
e
f
Fig. 44.7 (a) Conchal-type microtia. A type 2 skin approach is performed. (b) A critical analysis of the result after the first stage showed that
the ear was a little bigger than the other (not shown), that the meatus was too visible, the concha had too sharp an anterior border, and the
root of the helix was lacking projection. When performing the reconstruction of the retroauricular sulcus (c), a direct approach of the inferior
extremity of the framework (d) makes possible its reduction (e). (f) This little piece of cartilage will be placed in a tunnel behind the root of
the helix to improve the projection of the upper part of the ear at the end of the second stage, after skin grafting to reconstruct the sulcus.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
794
patients for prolonged administration of IV antibiotics.
Daily dressing changes with topical treatment are per­
formed, and the patient is seen once or twice a week in
the office.
The patient and family should be told that once the
infection resolves, the site must be monitored for resorp­
tion and a complementary stage may be indicated. We wait
at least 6 months to perform this complementary stage.
All signs of inflammation must have subsided, and the
Infection
When an infection occurs, samples are taken to bacteriol­
ogy and appropriate oral antibiotics are prescribed. Anti­
biotics diffuse poorly in the cartilage, and bacteriologists
typically recommend high doses of intravenous (IV) anti­
biotics over the span of 2 weeks. Unfortunately, we have
not found this to make any difference in terms of cartilage
resorption. Therefore we do not recommend hospitalizing
a
b
c
d
e
f
Fig. 44.8 (a) This patient with lobular-type microtia presented with good skin quality. (b) When the patient left to go back to his home coun­
try, which was far away, a very good result was expected. (c) Two months later, a picture was sent by the patient that showed an inflamma­
tory process. Antibiotics were prescribed by a local doctor, and the inflammatory process disappeared. (d) However, when the patient was
seen by the surgeon 6 months later, loss of contours was evident and a new reconstruction was elected. (e) Cartilage was harvested from the
other thoracic side for the new framework. (f) There was great improvement when the patient returned 6 months later for the second stage.

795
Chapter 44 Auricular Reconstruction
1. The skin potential needed to avoid excessive tension on
the skin
2. The skin approaches used to insert the framework and
to avoid poorly vascularized flaps
As mentioned, when skin necrosis occurs, it usually causes
cartilage exposure. Skin flaps from the auricular area are
rarely usable to cover the defect, but around the ear are
multiple fascia layers that can be used with an axial vas­
cularization (e.g., the superficial temporal artery, the pos­
terior auricular artery, or the occipital artery),6 or random
fascial flaps can be used (Fig. 44.10).
­remaining contours should be stable. A new reconstruction
may be indicated (Fig. 44.9).
Primary infection has never occurred in a patient with­
out an auditory canal; thus our assumption is that infecting
agents come from the auditory canal. As mentioned previ­
ously, preoperative cleaning is essential.
Skin Necrosis
An autologous rib cartilage framework is a three-­dimen­
sional structure placed under the thin skin of the auricular
area. Two very important factors must be considered:
Fig. 44.9 (a) Conchal-type microtia with good skin quality. (b) The framework does not include the tragus and antitragus, which are present
surrounding the auditory canal. (c) One week after the reconstruction, infection is evident, evidently coming from the canal. Pseudomonas
aeruginosa was the infecting agent. (d) Intensive local and general treatment did not prevent resorption of the cartilage. (e) One year later,
a new costal cartilage framework was sculpted from the contralateral side of the thorax. (f) Five years later, the patient is happy with the
result despite an extrusion of wire suture on the antihelix, which can be easily removed.
a
b
c
d
e
f

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
796
Fig. 44.10 (a) This patient had lobular-type microtia. (b) After the first stage of reconstruction he developed skin necrosis over the anti­
helix. He returned home with instructions to allow spontaneous healing. (c) The patient returned 2 months later with a persistent open
wound and resorption of the antihelix. (d) We used a random mastoid fascial flap to cover the defect and reconstructed the antihelix using
the costal cartilage banked under the thoracic skin for the second stage. (e) The fascial flap was then covered by a split-thickness skin graft
harvested from the scalp. (f) The final result 1 year after the elevation of the ear.
a
b
c
d
e
f

797
Chapter 44 Auricular Reconstruction
of the concha. This decreased the blood supply to the skin
covering the concha. We should have placed a transfixion
stitch at the base of this skin excess and removed it during
the second stage.
Secondary Cases
One third of my (F.F.) patients are secondary cases with un­
favorable results who often have already had several opera­
tions. It is essential to analyze not only the local conditions
but also the motivations of the patient, because anxiety is
compounded in these patients.
Retrospectively, the mistake made with the patient in
Fig. 44.10 was to opt to allow secondary healing on the an­
tihelix. We should have performed a fascial flap a week after
his exposure became apparent (Fig. 44.11).
Retrospectively, the superior part of the remnants in the
patient in Fig. 44.11 was too narrow to perform the recon­
struction in one stage, and we should not have used a simple
transverse skin incision but instead should have used a type
2 skin approach and performed this reconstruction in two
stages (Fig. 44.12).
Retrospectively, the mistake with the patient in Fig.
44.12 was in excising some skin excess in the upper part
a
b
c
d
e
f
Fig. 44.11 Skin necrosis. (a) This patient has a conchal-type microtia. (b) A single-stage reconstruction with a transverse approach (type 3a)
was selected. (c) Excessive tension led to skin necrosis. (d) One week later, the necrosis was excised and the cartilage was covered by a ran­
dom mastoid fascia flap and a split-thickness skin graft. (e) Ten days after the salvage procedure. (f) The final result after elevation of the ear.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
798
There are two very different presentations:
1. The patient is referred after the first stage because of
some problem (infection, resorption, poor design of the
framework), and the contours are poorly defined.
2. The reconstructed ear has been elevated. The new
sulcus has created scars behind the ear and interrupted
the vascularization of the skin covering the framework.
It is usually difficult to make secondary patients under­
stand that even if a better result can be expected, the pres­
ence of scars may interfere with the result, and that costal
cartilage must be harvested again, sometimes on the other
thoracic side. The chance of having a very good result is
lower in secondary cases than in primary reconstruction,
and the surgeon should always discuss the prosthetic solu­
tion as an alternative or as a safety plan in case of failure.
a
b
c
d
e
f
Fig. 44.12 Lobular-type microtia on a 50-year-old patient. (a) Complete framework, including the tragus and antitragus (type 1 framework).
This adult cartilage has a yellow color but it is not ossified and is easy to carve. (b) After insertion of the inferior part of the framework into
the lobule and coverage of the upper part with the local skin (type 2 skin approach). (c) Two weeks later, skin necrosis exposed the concha
and the antihelix. (d) Salvage with a temporoparietal fascial flap based on the posterior branch of the superficial temporal vessels. (e) The
flap was covered by a split-thickness skin graft from the scalp to avoid a color mismatch. (f) The result after elevation of the ear is satisfac­
tory, except for the tragus, which could be more prominent.

799
Chapter 44 Auricular Reconstruction
ricular area and usually skin graft behind the reconstructed
ear. It is crucial to check whether the temporal artery has
been preserved. A Doppler is performed during the consul­
tation to map the course of the superficial temporal artery
(STA). If the STA has been preserved, a new reconstruction
can be safely performed.
If the STA has been severed, the remaining options are
to use the local skin or the occipital fascia. The prosthetic
solution should always be discussed at this stage, because
complications are more common with use of the occipital
fascia (Figs. 44.14–44.16).
Secondary Cases Referred After the First
Stage
In the case of unsatisfactory contours after the first stage,
the second stage should not be considered without correct­
ing the contours partially or totally (Fig. 44.13). The surgeon
should never elevate an ear when the contours are unsatis­
factory after the first stage.
Secondary Cases That Present After the
Second Stage
Patients who present after the second stage has been com­
pleted are challenging, because there are scars in the au­
Fig. 44.13 A 12-year-old patient who had a deceiving aesthetic result after the first stage performed elsewhere. (a) Poor framework design,
infection, and resorption of the cartilage are possible causes of a poor result. The patient was very motivated and accepted a new costal
harvest. (b) Local skin quality was good. The skin approach was planned to use the former scars. (c) The first framework was removed.
The helix and antihelix had totally disappeared. (d) Not only was skin preserved, but it even had been expanded by the first framework.
(e) A new framework was inserted under the skin. (f) The final result.
a
b
c
d
e
f

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
800
a
b
c
d
Fig. 44.14 (a) This patient had a partial reconstruction of an amputated ear performed elsewhere, covered by a superficial temporal fascial
flap. (b) The helix and scapha were poorly defined, but the fascial could be reused. (c) The new framework. (d) The final result 1 year later.

801
Chapter 44 Auricular Reconstruction
a
b
c
d
e
f
Fig. 44.15 This patient had a total ear amputation reconstructed elsewhere in two stages. (a) The local skin in the superior portion was too
thick to be reused. The superficial temporal artery was present. (b) A new framework was sculpted from the contralateral side. (c) Projec­
tion pieces were added on the posterior side. (d) A superficial temporal fascial flap was used. (e) The flap was long enough to extend all the
way to the sulcus. (f) The result 1 year after a single operation.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
802
Fig. 44.16 This patient had six operations elsewhere, including elevation of the reconstructed ear. (a) The anterior and posterior sides of
the ear were scarred. (b) The superficial temporal artery had been severed, but the occipital artery was identified using Doppler imaging
on a shaved scalp area. A large Y incision (green dotted line) would allow a dissection of the fascia with the understanding that the temporal
part of the fascia would be used to cover the framework (black dashed line). (c) The new framework. (d) The fascia covered the framework;
some native skin was used for the lobular part. (e) The fascia was covered with a split-thickness skin graft from the scalp. (e) One year later,
the edema of the fascia has decreased and the patient is finally ready for the elevation of the ear.

803
Chapter 44 Auricular Reconstruction
Conclusion
Ear reconstruction is a very challenging field, and compli­
cations are common. With experience, severe complica­
tions are exceedingly rare, and minor complications are
treated easily. This chapter explored a methodology to
treat complications in auricular reconstruction, illustrat­
ing how constant self-criticism helps in perfecting one’s
results.
Auricular Prosthesis
When no viable options are left to reconstruct the ear, a
bone-anchored ear prosthesis should be offered to the pa­
tient. Bone-anchored pillars are placed in a single surgery
in an ambulatory setting, and the prosthesis is then custom
made in 2 weeks. The prosthesis must be removed at night,
and it needs to be replaced every 2 or 3 years.7 Nevertheless,
the aesthetic result is usually far superior than what can be
achieved with local skin and costal cartilage (Fig. 44.17).
a
b
c
Fig. 44.17 This patient had three stages for repair of a lobular-type microtia. (a) Despite poor definition after the first stage, the ear was el­
evated, grafting the retroauricular area and cutting the superficial temporal artery. (b) The remnants were excised, and two bone-anchored
pillars were placed in the retroauricular area. A tragus was reconstructed using the cartilage found in the remnants. (c) The prosthesis looks
exactly like the contralateral ear (not shown), and the presence of a tragus makes it even more natural looking.
References
1. Firmin F. State-of-the-art autogenous ear reconstruction in
cases of microtia. Adv Otorhinolaryngol 2010;68:25–52
2. Firmin F. Ear reconstruction in cases of typical microtia.
Personal experience based on 352 microtic ear corrections.
Scand J Plast Reconstr Surg Hand Surg 1998;32(1):35–47
3. Firmin F, Marchac A. A novel algorithm for autologous ear
reconstruction. Semin Plast Surg 2011;25(4):257–264
4. Brent B. Microtia repair with rib cartilage grafts: a review of
personal experience with 1000 cases. Clin Plast Surg
5. Nagata S. Modification of the stages in total reconstruction
of the auricle: Part I. Grafting the three-dimensional costal
cartilage framework for lobule-type microtia. Plast Recon­
str Surg 1994;93(2):221–230, discussion 267–268
6. Nagata S. Secondary reconstruction for unfavorable micro­
tia results utilizing temporoparietal and innominate fascia
flaps. Plast Reconstr Surg 1994;94(2):254–265, discussion
266–267
7. Korus LJ, Wong JN, Wilkes GH. Long-term follow-up of os­
seointegrated auricular reconstruction. Plast Reconstr Surg
2011;127(2):630–636

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
804
Discussion by David J. Reisberg
A missing or malformed ear may be the result of a con­
genital condition, ablative surgery, or trauma. Although
surgery is the most natural and preferred way to re­
store function and appearance, it is not always possible.
In cases of tumor surgery or trauma, the ear may be
impossible to surgically reconstruct because of soft tis­
sue loss or scarring. When a surgical reconstruction is
performed, complications may arise. The aesthetic out­
come may not be ideal, or a dehiscence or infection may
occur, with the result that the reconstruction cannot be
salvaged and must be revised or removed. It may not
be possible to reattempt a reconstruction. At the very
least, another attempt at surgical reconstruction may
have to be delayed. In any of these circumstances, an
auricular prosthesis should be considered (Fig. 44D.1).
Prosthesis Fabrication
Prosthetic rehabilitation has been available for hun­
dreds of years. Current techniques are well established.
With advances in digital technology, an auricular pros­
thesis may be fabricated in less time and with better
aesthetics than in the past.1–4
Complications Associated With a
Prosthesis
The Very Nature of a Prosthesis
The most obvious shortcoming of a prosthesis is its
artificial nature; it cannot be permanently attached.
Beyond all other prosthetic considerations and com­
promises, this lack of permanency contributes to all
other potential prosthetic problems. The prosthesis
must also be removed daily to clean, and the skin
covered by the prosthesis must also be cared for on
a daily basis. For most patients, this daily regimen of
prosthesis removal and skin and prosthesis hygiene
can become part of their daily routine, but for some
it may be psychologically unacceptable and/or physi­
cally challenging.
Tissue Remnants
The presence of soft tissue remnants at the auricular
site may compromise the prosthetic outcome. Whether
these are native tissues or the result of a previous
a
b
Fig. 44D.1 (a) Surgical reconstruction. (b) Reconstruction removed and replaced by an auricular prosthesis.

805
Chapter 44 Auricular Reconstruction
­reconstruction, the presence of portions of the helix,
concha, or lobule may obstruct the ideal prosthetic
form (Fig. 44D.2). If a future surgical reconstruction is
planned, these remnants may be a useful part of this
later surgery and need to be retained. In this case, the
prosthesis has to either circumvent or overlay them.
In either case, the shape and aesthetic outcome may be
compromised. If no further reconstruction is planned,
these tissue remnants should be removed to achieve
an optimal prosthetic outcome. This is a decision to
be made between the surgeon and the patient before
a prosthesis is considered. The most ideal site for a
prosthesis is a flat skin surface with thin, immobile
soft tissue. The presence of an external meatus, tragus,
and normal hairline are helpful to orient the prosthesis
when positioning it and to camouflage its edges where
it meets the skin.
Wear and Tear
Although the prosthesis will appear lifelike when first
made, over time the prosthetic material will discolor
and degrade. The thin edges that are required to blend
with the surrounding natural skin for an aesthetic
appearance are subject to tearing (Fig. 44D.3). These
problems are inherent in the nature of the currently
used materials and occur in varying degrees with daily
wear and care. Recoloring and repairing of a prosthe­
sis are reasonable options, but a new one is usually
needed every 12 to 18 months simply because of the
limitations of the silicone elastomers and pigments.
As long as there have been no soft tissue changes and
the fit of the prosthesis is satisfactory, a new prosthe­
sis may be made from an existing mold and skin color
formula.
Retaining the Prosthesis: Adhesive
Versus Implant
Auricular prostheses may attach to the patient with
skin adhesives or osseointegrated implants.5,6
Adhesive-Retained
Adhesive is used to retain an interim prosthesis, be­
cause it is impractical to place implants at a site where
future soft tissue reconstructive surgery is planned. Al­
ternatively, the patient may decide not to have the sur­
gery required for implant placement, in which case the
adhesive will be used to retain a definitive prosthesis.
The adhesives are silicone or acrylic polymer–based
and are applied to the intaglio surface of the prosthe­
sis before placing it on the skin. Although these have
been used for many years as a relatively reliable means
of retaining an auricular prosthesis, they are not with­
out shortcomings.
Application of the adhesive and precise position­
ing of the prosthesis are time-consuming and may be
a challenge to those with compromised visual acuity or
manual dexterity. The adhesive must be cleaned off the
skin and prosthesis after wearing. This not only adds
additional steps to the daily regimen but leads to ad­
ditional handling of the prosthesis and more wear and
tear on the prosthetic material.
The reliability of the adhesive is also a concern.
­Depending upon the oiliness of the patient’s skin and per­
spiration factors, adhesiveness may be compromised, and
the prosthesis may unintentionally loosen or detach—a
serious problem if this occurs in a public place. There are
several types of adhesives with increasing levels of ad­
hesion, but each comes with an increasing difficulty in
Fig. 44D.2 Native soft tissue. This presents an obstruction for a
prosthesis but may be useful for surgical reconstruction.
Fig. 44D.3 Torn margin of a facial prosthesis.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
806
removal from the prosthesis and skin. If the patient has
undergone radiation therapy in the area of the prosthesis,
any adhesive may prove too irritating to the skin.
Implant-Retained
The use of osseointegrated implants to retain an au­
ricular prosthesis has several significant advantages
over adhesives. The increased strength of implant ver­
sus adhesive retention has been documented.7 It is also
much easier to position the prosthesis correctly and
easier to remove it, even for those with visual or dex­
terity issues. The edges of the prosthesis may be made
thinner to blend in with the surrounding skin because
there is no need to apply or clean off adhesive from
these tear-prone areas and thus less handling and wear
of the prosthetic material. Patients also report that the
implant-retained prosthesis feels much more “a natu­
ral part of them.”8,9 Two or three implants are placed,
typically in the helix area so as not to interfere with the
aesthetic contours of the prosthesis.
The actual surgery to place the implants is rela­
tively straightforward and is performed on an outpa­
tient basis. Presurgical planning is required by the sur­
gical and prosthetics team to ensure proper position of
the implants. The use of some type of template is criti­
cal for success. There are a wide range of techniques to
develop such a surgical template. If a well-integrated
implant has been placed beyond the perimeter of the
prosthesis, it cannot be used or the aesthetic outcome
of the prosthesis will be compromised. If this does oc­
cur, a cover screw may be placed on the implant and
soft tissue allowed to grow over it. In a case where
closure of the soft tissue is not complete, a minor sur­
gical procedure is required to refresh the tissue for
complete healing.
Implants placed in the auricular region are the most
successful of any craniofacial location. However, it is still
possible for an implant to fail; even after the prosthesis
has been made. To be retentive and stable, an auricu­
lar prosthesis must have at least two implants. In many
cases, a third implant is placed as a reserve, or it may be
used outright with the other two. However, should one
implant fail, the remaining two are adequate to retain
the prosthesis.
The retention mechanism is either reciprocating
magnets on the implants and prosthesis or a bar con­
necting the implants with clips within the prosthesis.
It is possible that either of these retentive mechanisms
may require repair or replacement periodically or may
become detached from the prosthesis and require recon­
nection (Fig. 44D.4). The bar or magnets are threaded
into the implants. Occasionally these may loosen, but
they are easily retightened. They should be seated with
a torque driver to prevent loosening.
Fig. 44D.4 A retentive mechanism separated from a silicone
elastomer prosthesis.
Fig. 44D.5 Site of a failed implant.
Fig. 44D.6 Spontaneous healing.

807
Chapter 44 Auricular Reconstruction
In a rare situation, an implant in the temporal
­region may fail. It is important to note that once an
implant ­becomes mobile, it cannot be stabilized and
must be ­removed or will exfoliate by itself (Fig. 44D.5).
The bone and skin at the site will usually heal spon­
taneously without any surgical or other intervention
(Fig. 44D.6).
If an implant does fail, the surgeon has several op­
tions. Additional implants may be placed, but these
must heal for a minimum of 3 months. If there are two
remaining stable implants, then the retention mecha­
nism may be modified and the prosthesis may continue
to be worn. If only one implant remains, this will re­
quire a modification of the existing prosthesis into an
adhesive-retained one to continue wear during implant
healing, or the patient may need to forego wearing a
prosthesis until the additional implants are ready to
be used. At that time, a new prosthesis will need to be
made. Alternatively, the patient may decline further sur­
gery, and an adhesive-retained prosthesis will be the
definitive solution.
References
1. Giot JP, Labbé D, Soubeyrand E, et al. Prosthetic re­
construction of the auricle: indications, techniques,
and results. Semin Plast Surg 2011;25(4):265–272
2. Jiao T, Zhang F, Huang X, Wang C. Design and fabrica­
tion of auricular prostheses by CAD/CAM system. Int J
Prosthodont 2004;17(4):460–463
3. Subburaj K, Nair C, Rajesh S, Meshram SM, Ravi B.
Rapid development of auricular prosthesis using CAD
and rapid prototyping technologies. Int J Oral Maxil­
lofac Surg 2007;36(10):938–943
4. Liacouras P, Garnes J, Roman N, Petrich A, Grant GT.
Designing and manufacturing an auricular prosthesis
using computed tomography, 3-dimensional photo­
graphic imaging, and additive manufacturing: a clini­
cal report. J Prosthet Dent 2011;105(2):78–82
5. Tjellström A, Yontchev E, Lindström J, Brånemark
PI. Five years’ experience with bone-anchored au­
ricular prostheses. Otolaryngol Head Neck Surg
1985;93(3):366–372
Soft Tissue Irritation
Whether adhesive- or implant-retained, skin irrita­
tion may be a complication of wearing an auricular
prosthesis. As noted previously, irradiated skin may be
more sensitive and reactive to the adhesive and may
demonstrate irritation that presents as varying de­
grees of inflammation. Even on nonirradiated skin, the
prosthetic material may cause irritation. This may be
a rare contact dermatitis but more often is a result of
failure of the patient to remove the prosthesis daily and
perform proper hygiene procedures. The silicone elas­
tomer is prone to fungal accumulation, and this may
cause inflammation, especially when the patient fails
to remove the prosthesis daily for cleaning. This may be
corrected by proper cleaning of both the skin and pros­
thesis but may require temporary discontinued use of
the prosthesis and occasionally an antifungal medica­
tion to resolve.
Surgical reconstruction of the ear is the preferred
method of restoration but may not always be possible.
Within the limitations of an artificial replacement, an
auricular prosthesis, whether adhesive- or implant-­
retained, can provide a reasonable alternative.10
6. Nishimura RD, Roumanas E, Sugai T, Moy PK. Auricu­
lar prostheses and osseointegrated implants: UCLA
experience. J Prosthet Dent 1995;73(6):553–558
7. Del Valle V, Faulkner G, Wolfaardt J, Rangert B, Tan
HK. Mechanical evaluation of craniofacial osseointe­
gration retention systems. Int J Oral Maxillofac Im­
plants 1995;10(4):491–498
8. Guo G, Schwedtner O, Klein M. A retrospective study
of implant-retained auricular prostheses. Int J Oral
Maxillofac Implants 2008;23(3):539–543
9. Chang TL, Garrett N, Roumanas E, Beumer J III. Treat­
ment satisfaction with facial prostheses. J Prosthet
Dent 2005;94(3):275–280
10. Markt JC, Lemon JC. Extraoral maxillofacial prosthetic
rehabilitation at the M. D. Anderson Cancer Center:
a survey of patient attitudes and opinions. J Prosthet
Dent 2001;85(6):608–613

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
808
Special Commentary by John Reinisch and Youssef Tahiri
Auricular Reconstruction:
Polyethylene Framework Technique
Using a Polyethylene Ear Framework
The use of an alloplastic framework is an alternative
approach to ear reconstruction. I (J.R.) developed the
procedure over a 26-year period and have performed
more than 1,500 ear reconstructions using a polyeth­
ylene implant covered by either a temporoparietal or
­occipitoparietal fascial flap. A large experience with
many years of follow-up has allowed modifications to
improve outcomes and reduce poor outcomes. A poly­
ethylene ear framework can provide an excellent and
long-lasting ear reconstruction. However, it is important
to understand the differences between an autologous
cartilage framework and a polyethylene ear framework.
Both cartilage and polyethylene frameworks are
passive skeletons that provide shape and projection
to the covering soft tissue. Cartilage has a low meta­
bolic requirement because it has relatively few active
cells within a large extracellular matrix. As a result, it
survives nicely as a graft and is well tolerated beneath
a thin skin flap. By contrast, when a porous polyethyl­
ene implant is placed beneath a thin skin flap, a signifi­
cant rate of exposure of the implant is seen over time.
A polyethylene implant should never be substituted for
a cartilage framework when performing the traditional
mastoid skin pocket soft tissue coverage.
A polyethylene framework requires a different type
of soft tissue coverage to avoid exposures. Early in my
series, I (J.R.) learned that covering the entire alloplastic
material with a temporoparietal or occipitoparietal fas­
cial flap reduces exposures to a very low rate. The cov­
ering fascia must be well vascularized, must include its
underlying loose areolar layer, and must be large enough
to envelop the entire implant without tension.1 With
cartilage reconstruction, the harvest and assembly of
the framework is the most time-consuming aspect of
the procedure. With a polyethylene reconstruction, the
soft tissue coverage of the framework becomes the larg­
est and most critical component of the surgery. Video
44SC.1 highlights some of the key steps in the process
of harvesting the temporoparietal fascial flap (TPF).
­Adequate color-matched full-thickness skin grafts are
then placed over the fascial flap.
In the rare instances in which the TPF has been used
or is damaged, a polyethylene implant ear reconstruc­
tion can be used by covering it with anterior transpo­
sition of an inferior-based occipitoparietal fascial flap
based on the occipital artery.
We prefer to use a porous polyethylene ear
­reconstruction, because, in our experience, it more
comprehensibly addresses the cosmetic, functional, and
psychological issues associated with microtia. Although
surgeon have modified Tanzer’s technique of ear recon­
struction to reduce the number of required operative
stages, these refinements require a larger amount of cos­
tal cartilage.2–6 To obtain a greater volume of cartilage,
surgeons have postponed the age of ear reconstruction
from the age originally recommended by Tanzer to 10
years and older. This delay in the age of reconstruction
with autologous cartilage is both psychologically and
socially difficult for children and their families.
The use of an alloplastic framework allows ear re­
construction before children start school and are ex­
posed to peer ridicule.7 Early ear reconstruction is pos­
sible because the growth of the normal ear reaches 85%
of adult size by 3.5 years.8 The use of a large fascial flap
provides enough soft tissue coverage so that the recon­
structed ear can match the projection of the opposite
ear. Therefore the use of an implant allows an early, sin­
gle-stage reconstruction. Furthermore, by eliminating
the discomfort of the costal cartilage harvest, an allo­
plastic implant reconstruction can be done as an out­
patient procedure with its obvious psychological and
economic advantages.
Hearing loss is an important issue associated with
microtia. This functional component of microtia has of­
ten been ignored by plastic surgeons. Although normal
hearing from the opposite ear in unilateral cases usually
allows acquisition of speech, there are a number of other
deficits with unilateral hearing loss (sound localization,
difficulty hearing in noise, lack of binaural summation,
compromised language acquisition) that become more
evident and significant in older children and adults.9–11
Furthermore, emerging data supporting amblyaudia as
a diagnostic entity highlights the importance of early
hearing management.12 Amblyaudia is a term used to
describe persistent hearing difficulty experienced by
individuals with a history of asymmetrical hearing loss
during a critical early window of brain development.
To avoid damaging the virgin mastoid skin needed
to cover a cartilage framework, an atresia repair is gen­
erally performed after the costal cartilage framework is
placed. On the other hand, because an alloplastic frame­
work must be covered by transposition of an adjacent
arterial fascial flap, the tissue needed to cover the al­
loplastic framework is not jeopardized by a prior, early
canal reconstruction. Thus an atresia repair can be per­
formed before, or even at the same time as, an alloplastic
ear reconstruction.

809
Chapter 44 Auricular Reconstruction
Furthermore, an autologous ear reconstruction re­
quires healthy and, ideally, non–hair-bearing mastoid
coverage, making reconstruction more challenging
in patients with very low hairlines (seen for example
in patients with Treacher Collins syndrome) or with a
traumatized or scarred auricular or temporal cutane­
ous area.
Fig. 44SC.1 shows the preoperative and the 3.5-
year postoperative photos of a 7-year-old boy with bi­
lateral microtia. After bilateral aural atresia repairs done
3 months apart at age 3 years, he had a single outpa­
tient procedure to reconstruct his left ear and a similar
surgery 3 months later for further reconstruction. The
patient wore bone conduction hearing aids before the
atresia repairs. This patient demonstrates that early ear
reconstruction and restoration of hearing is possible us­
ing the polyethylene implant technique.
Conclusion
We prefer the use of an alloplastic implant recon­
struction, because it provides a more holistic ap­
proach to ear reconstruction. Ear reconstruction with
a fascial-covered polyethylene implant can be done
before the patient starts school, in a single-stage,
outpatient surgery that is not adversely affected
by the early restoration of hearing by prior canal
reconstruction.
Fig. 44SC.1 A 7-year-old patient with bilateral microtia. At the age of 3 years, he underwent bilateral aural atresia repairs. At 7
years, he had a single outpatient procedure to reconstruct his left ear and a similar surgery 3 months later for further reconstruc­
tion using the polyethylene implant technique.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
810
References
1. Reinisch JF, Lewin S. Ear reconstruction using a po­
rous polyethylene framework and temporoparietal
fascia flap. Facial Plast Surg 2009;25(3):181–189
2. Tanzer RC. Total reconstruction of the external ear.
Plast Reconstr Surg Transplant Bull 1959;23(1):1–15
3. Brent B. The correction of mi-rotia with autogenous
cartilage grafts: I. The classic deformity.? Plast Recon­
str Surg 1980;66(1):1–12
4. Nagata S, Fukuda O. A new reconstruction for the
lobule type microtia. Jpn J Plast Reconstr Surg
1987;7:689
5. Firmin F. Ear reconstruction in cases of typical mi­
crotia. Personal experience based on 352 microtic ear
corrections. Scand J Plast Reconstr Surg Hand Surg
1998;32(1):35–47
6. Kasrai L, Snyder-Warwick AK, Fisher DM. Single-stage
autologous ear reconstruction for microtia. Plast Re­
constr Surg 2014;133(3):652–662
7. Reinisch J. Ear reconstruction in young children. Fa­
cial Plast Surg 2015;31(6):600–603
8. Adamson JE, Horton CE, Crawford HH. The growth
pattern of the external ear. Plast Reconstr Surg
1965;36(4):466–470
9. Jensen DR, Grames LM, Lieu JE. Effects of ­aural
atresia on speech development and learning:
­retrospective analysis from a multidisciplinary
­craniofacial clinic. JAMA Otolaryngol Head Neck Surg
2013;139(8):797–802
10. Klee TM, Davis-Dansky E. A comparison of unilater­
ally hearing-impaired children and normal-hearing
children on a battery of standardized language tests.
Ear Hear 1986;7(1):27–37
11. Lieu JE, Tye-Murray N, Karzon RK, Piccirillo JF.
Unilateral hearing loss is associated with worse
speech-language
scores
in
children.
Pediatrics
2010;125(6):e1348–e1355
12. Kaplan AB, Kozin ED, Remenschneider A, et al. Am­
blyaudia: review of pathophysiology, clinical presen­
tation, and treatment of a new diagnosis. Otolaryngol
Head Neck Surg 2016;154(2):247–255

811

Vascular Anomalies
Arin K. Greene
CHAPTER
45
Vascular anomalies are disorders of the endothelium that
usually present during childhood. Lesions affect all parts of
the vasculature: capillaries, veins, arteries, or lymphatics.
Although vascular anomalies are benign, they can cause lo­
cal destruction and systemic morbidity. The field is difficult
because (1) different lesions look similar and (2) terminol­
ogy is confusing (Fig. 45.1). The most important principle
in managing these conditions is to use correct terminology
and confirm the diagnosis before intervention (Tables 45.1
and 45.2).
Fig. 45.1 Vascular anomalies can look similar. These four patients each have an enlarged cheek caused by a different type of vascular anom­
aly. It is critical to accurately diagnose the patient, because each of the lesions has unique morbidity, prognosis, and treatment. (a) Infantile
hemangioma. (b) Capillary malformation. (c) Lymphatic malformation. (d) Arteriovenous malformation.
a
b
c
d

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
812
Error in Diagnosis
The most common cause of complications in the field of
vascular anomalies is misdiagnosis leading to incorrect
treatment (Figs. 45.2 and 45.3). Seventy percent of papers
published in 2009 used the term hemangioma erroneously
to describe another type of vascular anomaly.1 This is de­
spite peer review and authors who are more likely to be
familiar with this field. In practice, the diagnostic error rate
likely is even higher. In our Vascular Anomalies Center, 47%
of patients have an incorrect referral diagnosis; malforma­
tions are more likely to be mislabeled (54%) compared with
tumors (30%).2 Patients with misdiagnosed lesions are at
risk for receiving incorrect management (21% in the litera­
ture).2 For example, if a patient with a venous malforma­
tion is diagnosed with a cavernous hemangioma (this term
has been abandoned), then the individual is more likely to
be treated with propranolol or corticosteroid. These drugs
are used to treat infantile hemangioma and have no effi­
cacy for venous malformation.
Avoiding Unfavorable Results
and Complications in Vascular
Anomalies
Table 45.1 Classification of vascular anomalies
Tumors
Malformations
Slow flow
Fast flow
Overgrowth syndromes
Infantile hemangioma
Capillary malformation
Arteriovenous malformation
CLOVES
Congenital hemangioma
Venous malformation
Klippel-Trenaunay
Kaposiform
hemangioendothelioma
Lymphatic malformation
Parkes Weber
Pyogenic granuloma
Sturge-Weber
Table 45.2 Incorrect terminology commonly used to describe vascular anomalies
Tumors
Malformations
Biologic name
Incorrect term
Biologic name
Incorrect term
Infantile hemangioma
Strawberry hemangioma
Capillary hemangioma
Cavernous hemangioma
Capillary malformation
Port-wine stain
Capillary hemangioma
Congenital hemangioma
Infantile hemangioma
Lymphatic malformation
Cystic hygroma
Lymphangioma
Kaposiform
hemangioendothelioma
Capillary hemangioma
Venous malformation
Cavernous hemangioma
Pyogenic granuloma
Hemangioma
Arteriovenous malformation
Arteriovenous hemangioma
Summary Box
The Most Common Problems Associated with
Vascular Anomalies
•• Error in diagnosis
•• Overaggressive treatment
•• Managing complex patients outside of an
interdisciplinary vascular anomalies center
•• Failure to recognize potential comorbidities
associated with the vascular anomaly

813
Chapter 45 Vascular Anomalies
Ultrasound can determine whether the lesion is fast flow or
slow flow and does not require sedation in children. If the
diagnosis is unclear after ultrasound, the area is evaluated
using magnetic resonance imaging (MRI). Rarely, a vascular
anomaly cannot be diagnosed using imaging studies (less
than 1%) and a biopsy is necessary to identify the lesion.
Although numerous types of vascular anomalies exist,
if a physician can differentiate between the 8 major lesions,
he or she will be able to successfully manage at least 95% of
patients5 (Fig. 45.4, Table 45.3).
One method to reduce diagnostic errors is to man­
age  patients in an interdisciplinary vascular anomalies cen­
ter with providers who focus on these diseases. Treatment
errors resulting from misdiagnosis also can be minimized
by using the biologic classification of vascular anomalies
and avoiding outdated terms for these lesions.3,4 With this
framework 90% of vascular anomalies can be identified by
history and physical examination; 10% require radiographic
tests to confirm their diagnosis. Ultrasound usually is the
first imaging modality used to diagnose a vascular anomaly.
Fig. 45.2 Misdiagnosis of a vascular anomaly. (a–c) A female infant referred with a “hemangioma” of the upper lip. The patient has a ­venous
malformation. It was present at birth, enlarged slowly, and did not regress. (a) Early infancy. (b) At 1 year of age. (c) At 3 years of age.
(d–f) Infantile hemangioma. Rapid growth during infancy was followed by involution. (d) Early infancy. (e) At 1 year of age. (f) At 3 years of age.
a
b
c
d
e
f
Fig. 45.3 Patients erroneously diagnosed with a “hemangioma.” (a) A young child with a pyogenic granuloma of the cheek. (b) An adoles­
cent with a congenital hemangioma of the lower extremity.
a
b

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
814
Table 45.3 Differentiation of vascular anomalies
Main vascular tumor types
Characteristic
Infantile hemangioma
Has a unique growth phase: lesions enlarge rapidly over the first few months of life
and then regress in early childhood
Congenital hemangioma
Is fully-grown at birth and has a peripheral halo
Kaposiform
hemangioendothelioma
Is typically large, is present at birth, and causes severe thrombocytopenia, bruising,
and bleeding
Pyogenic granuloma
Small, red lesion that presents in childhood and bleeds
Vascular malformation types
(present at birth)
Characteristic
Capillary malformation
Becomes purple and thickens over time
Venous malformation
Is bluish, enlarges with dependent positioning, and causes pain from localized
thrombosis
Lymphatic malformation
Most commonly affects the neck and axilla and can leak lymphatic fluid
Arteriovenous malformation
Exhibits fast flow on handheld Doppler examination
a
b
c
d
e
f
Fig. 45.4 Major types of vascular anomalies (a)
Infantile hemangioma. (b) Congenital hemangi­
oma. (c) Kaposiform hemangioendothelioma. (d)
Pyogenic granuloma. (e) Capillary malformation.
(f) Venous malformation. (g) Lymphatic malfor­
mation. (h) Arteriovenous malformation.
g
h