Chẩn Đoán Và Điều Trị Phẫu Thuật Tái Tạo Hiện Đại (CURRENT Reconstructive Surgery)

HEMIFACIAL MICROSOMIA • 183
In grade II-A HFM, mandibular elongation has ranged
from 14 to 22 mm (mean 19 mm). The dental occlusion
is disrupted, creating a contralateral crossbite and a poste-
rior open bite of 1 to 3 mm in half of the patients treated.
Posterior bite blocks, worn on the mandibular dentition
and dynamic orthodontic appliances are used to maintain
the space in order to allow the vertical growth of the con-
stricted maxillae into the open bite. In the following 2 to
3 months, the bite block is serially reduced in size to allow
the entire maxillary occlusal plane to become level and
maintain the elongation and occlusion ( Figure 17-8 A–F).
In patients younger than 4 years of age, the maxillary teeth
quickly fi ll the space and the above orthodontic maneuver
is often not necessary. The aesthetic results are excellent
with restoration of facial symmetry and horizontalization
of the chin and the buccal commissure.
The group of patients with grade II-B HFM character-
istically have a stable but incorrect dental occlusion with
marked deviation of the mandibular midline teeth to the
affected side. During the vertical distraction of the man-
dibular ramus, bite blocks are required to maintain the
posterior open bite and are gradually reduced to allow ver-
tical maxillary growth. Dynamic orthodontic appliances
are also used in all patients at an early stage. After the dis-
traction, the initial occlusion is reproduced in the opposite
direction on the contralateral side as a result of overcorrec-
tion. The maxilla has to be expanded to correct the cross-
bite with a classical palatal expansion device. The aesthetic
FIGURE 17-6. (A) An 8-year-old boy using an unidirectional external device. This
is made of two hollow plates with a central perforation to allow the entrance of the
mandibular pins. When it is activated, the distance between the plates is increased or
decreased. The resistance of the distractor device is softer than the pins; this produces a
fl exible device that can bend under the masticatory muscle action and externally refl ects
the shape of the elongated bone area. (B) Posteroanterior cephalogram showing the
mandibular changes during bone elongation.
A
B

184 • CHAPTER 17
D
E
F
FIGURE 17-7. (A) Preoperative frontal view of a 5-year-
old girl with hemifacial microsomia grade I. Despite the
minimal mandibular hypoplasia, a notorious facial asymmetry
is observed. (B) Postoperative view after a mandibular
elongation of 16 mm. Facial symmetry has been recovered.
(C) Long-term control at age 17 years. Facial symmetry is
stable and the soft tissue changes remain. (D) Preoperative
dental occlusion. Notice the inferior incisors midline deviation
to the affected side. (E) Postdistraction dental occlusion.
Maxillary transversal expansion, the use of posterior bite
blocks and myofunctional intraoral devices are the most
common orthodontics maneuvers to achieve occlusal stability.
(F) The occlusion at age 17 years.
C
A
B
improvement and the restoration of symmetry have also
been impressive in these patients ( Figure 17-9 A–D).
An important benefi t of bone distraction is the simulta-
neous expansion of the soft tissues of the face (skin, mus-
cles, fascia, vessels, and nerves). In fact, we were surprised
to see the rapid descent of the buccal commissure to a
normal position, the horizontalization of the chin, the
increase in the distance between the buccal commissure
and the external canthus-inferior orbital rim, and the
remarkable improvement in facial symmetry in all the

HEMIFACIAL MICROSOMIA • 185
FIGURE 17-8. (A) Preoperative view of a 6-year-old
boy with left hemifacial microsomia. The macrostomia was
repaired at age 8 months. (B) Postdistraction view at age
9 years. Notice the level of both oral commissures. To improve
the left cheek soft tissue defi ciency, a dermal fat graft has
been added. Also a macrostomia scar revision has been
performed. (C) Postdistraction frontal view control at age
20 years. Clinical stability of facial symmetry is maintained.
(D) Preoperative occlusal view. (E) Postdistraction occlusal
view showing a horizontal occlusal plane and a good
relationship between superior and inferior teeth. (F) Long-term
occlusal view at age 20 years.
A
B
C
D
E
F
unilateral cases. The secondary expansive effect on the soft
tissues and muscles is also refl ected in the fact that there is
minimal, if any, evidence of clinical relapse; in contrast to
the dental-skeletal relapse observed following traditional
orthognathic advancements procedures to reconstruct the
ramus in HFM patients.

186 • CHAPTER 17
B
A
D
C
FIGURE 17-9. (A) Preoperative view of a 3-year-old girl presenting with hemifacial
microsomia grade II-B. A severe facial asymmetry and inferior lip palsy is observed.
(B) Postdistraction view showing the obtained facial symmetry after a mandible
elongation of 38 mm of the right ascending ramus. (C) Long-term control at age
11 years. Notice the slight chin deviation to the affected side. (D) Long-term control at
age 16 years. Bone changes at the mandible and at soft tissue remain stable. For a fi nal
perfect facial symmetry an asymmetrical menton osteotomy will be added.

HEMIFACIAL MICROSOMIA • 187
Minimal to moderate soft tissue defi ciencies may not
require treatment until after puberty, at which time fat
aspirated from the lower abdomen or thighs may be used
for soft tissue augmentation. Large soft tissue defects may
require transfer of dermal fat grafts. More volume should be
added around the mandible angle. Since secondary fat reab-
sorption has been shown to approach 40%, usually observed
after the dermal fat graft insertion, two to three sessions of
fat injection should be necessary to obtain a fi nal aesthetic
contour of the cheek and a very good facial symmetry.
REFERENCES
1. Gorlin RJ, Pindborg JJ, Cohen MM Jr. Syndromes of the Head
and Neck . New York: McGraw-Hill; 1976:546–552.
2. Mellor DH, Richardson JE, Douglas DM. Goldernhar’s syn-
drome: oculo-auriculo-vertebral dysplasia. Arch Dis Child .
1973;48:537–541.
3. Goldernhar M. Associations malformatives-fi stula auris con-
genial et ses relations avec la dysostose mandibulo-faciale
[French]. J Genet Hum . 1952;1:243–282.
4. David DJ, Mahatumarat C, Cooter RD. Hemifacial mi-
crosomia: a multisystem classifi cation. Plast Reconstr Surg .
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5. Kaye CI, Rollnick BR, Hauck WW, Martin AO, Richtsmeier
JT, Nagatoshi K. Microtia and associated anomalies: statisti-
cal analysis. Am J Med Genet . 1989:34(4):574–578.
6. Poswillo D. The pathogenesis of the fi rst and second bran-
chial arch syndrome. Oral Surg Oral Med Oral Pathol . 1973;
35:302–328.
7. Lammer EJ, Chen DT, Hoar RM, et al. Retinoic acid embri-
opathy. N Engl J Med . 1985;313(2):837–841.
8. Sulik KK, Johnston MC, Smiley SJ, Speight HS, Jarvis BE.
Mandibulofacial dysostosis (Treacher Collins syndrome):
a new proposal for its pathogenesis. Am J Med Genet.
1987;27(2):359–372.
9. Pruzansky S. Not all dwarfed mandibles are alike. Birth De-
fects . 1969;1:120.
10. Murray JE, Mulliken JB, Kaban LB, Belfer M. Twenty-year
experience in maxillocraniofacial surgery: An evaluation of
early surgery on growth, function and body image. Ann Surg .
1979;190(3):320.
11. Vento AR, LaBrie RA, Mulliken JB. The O.M.E.N.S. classifi -
cation of hemifacial microsomia. Cleft and Palate Craniofac J.
1991;28(1):68–71.
12. Horgan JE, Padwa BL, LaBrie RA, Mulliken JB. OMENS-
plus: analysis of craniofacial and extracranial anomalies in
hemifacial microsomia. Cleft Palate Craniofac J . 1995;32(5):
405–412.
13. Björk A, Skieller V. Normal and abnormal growth of the
mandible. A synthesis of longitudinal cephalometric im-
plant studies over a period of 25 years. Eur J Orthod. 1983;5:
1–46.
14. McCarthy JG, Schreider J, Karp N, Thorne CH, Grayson
BH. Lengthening the human mandible by gradual distrac-
tion. Plast Reconstr Surg. 1992;89(1):1–8.
15. McCormick SU, Grayson BH, McCarthy JG, Staffenberg
D. Effect of mandibular distraction on the temporoman-
dibular joint. Part 2, Clinical study. J Craniofac Surg . 1995;
6:364–367.
16. Molina F, Ortiz Monasterio F. Extended indications for man-
dibular distraction: unilateral, bilateral and bidirectional.
In: Ortiz Monasterio F, ed. Craniofacial Surgery 5 . Bologna,
Italy: Monduzzi Editore; 1993.
17. Molina F, Ortiz Monasterio F. Mandibular elongation and
remodeling by distraction: A farewell to major osteoto-
mies. Plast Reconstr Surg. 1995;96(4):825–840; discussion
841–842.

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PATIENT EVALUATION AND SELECTION
Facial clefting is the most common facial birth defect, yet
craniofacial clefts are one of the least frequently seen cran-
iofacial anomalies. What constitutes a craniofacial cleft?
Basically, all facial clefts, aside from the commonly seen
cleft lip and palate, comprise the spectrum of craniofacial
clefts. These clefts may occur unilaterally or bilaterally, and
just about anywhere on the face. Clefting can be barely
discernible, limited just to the soft tissues as a forme fruste,
or may involve the deeper underlying bone. Some clefts
may affect the bone primarily and have only minimal over-
lying soft tissue involvement. Adding to the confusion as
to what exactly constitutes a craniofacial cleft has been the
previous inclusion by some authors of facial hyperplasias,
hypoplasias, and aplasias.
Epidemiology
Determining the true incidence of craniofacial clefts
re mains a daunting challenge, and the inclusion of syn-
dromes such as hemifacial microsomia and Treacher Collins
within the craniofacial clefting spectrum has further mud-
died these waters. Moreover, clefts may present with a wide
phenotypic variability with some clefts going unrecognized
for years. Kawamoto estimated that the incidence for cran-
iofacial clefts is somewhere between 1.4 and 4.9:100,000
births. 1 Another way of calculating the incidence of these
rare anomalies is to consider their proportion to the more
commonly seen cleft lip and palate. Cleft lip and palate
is often quoted as occurring as frequently as 1:550 births
(varying with family history, race, socioeconomic status, etc).
At the Craniofacial Center in Dallas, excluding the hyper-
and hypoplasias (eg, frontonasal dysplasia, Treacher Collins,
hemifacial microsomia), craniofacial clefts comprise about
10% of all facial clefts treated. The Australian Craniofacial
Unit has reported a similar proportion of treated craniofacial
clefts to cleft lip and palate of about 9%. 2 These proportions
suggest an incidence for the rare craniofacial clefts as com-
mon as 1:5500 births. However, it is likely that this estimate
is signifi cantly infl uenced by the nature of referral patterns
to major craniofacial centers (complicated clefts being
more likely to be referred, and simple cleft lip and palate
less likely to be referred), and that the true incidence of
craniofacial clefts is actually much lower. Ortiz Monasterio
et al. reviewed their cleft experience in Mexico City and
noted that during the same time period they had treated
174 craniofacial clefts and 5412 cleft lip and palates (a ratio
of 1:31, yielding an incidence of .1:17,000 births). 3 Finally,
the Texas Birth Registry, from 1996 to 2003 reported
36 cases of facial clefts for 2,419,928 births for an incidence
of 1.5:100,000 births. Suffi ce it to say, craniofacial clefts are
exceedingly uncommon.
Etiology
The most commonly cited theory explaining the anom-
alous embryological development resulting in a cleft lip
implicates a failure of mesodermal penetration. During the
fi rst 2 months of fetal development, supporting mesoder-
mal tissue migrates underneath an intact facial ectoder-
mal layer. Failure of this migration results in an overlying
ectodermal loss, resulting in a cleft. Much of the craniofa-
cial skeleton is believed to originate from migrating neural
crest cells. Facial skeletal hypoplasia results by interrupting
neural crest cell migration in the chick embryo, supporting
the theory that craniofacial clefts might arise from an inhi-
bition of normal migration, or cell death, during embryo-
genesis. Also, a correlation between limb ring constrictions
and craniofacial clefting has been noted, and craniofacial
clefts have also been artifi cially induced in an in utero
animal model using a suture constriction band technique.
Finally, craniofacial clefts also may occur in conjunc-
tion with midline encephaloceles, raising the question:
Which came fi rst? Currently, given the wide variability in
18
Craniofacial Clefts
Jeffrey A. Fearon, MD, FACS, FAAP
c h a p t e r

190 • CHAPTER 18
the presentation of rare craniofacial clefts, their etiology
appears to be multifactorial.
Classifi cation
A number of classifi cations for craniofacial clefts had been
proposed prior to Tessier’s landmark publication describing a
new schema that was based on his own considerable personal
experience. 4 His classifi cation assigns a specifi c number to
each craniofacial cleft, depending on the anatomic location
( Figure 18-1 ), and partially relies on a horizontal axis through
the center of the orbits. The fi rst cleft is designated #0, and
describes a vertical cleft occurring in the maxillary midline
(and central upper lip) up to the midorbital horizontal line.
A midline craniofacial cleft arising above this horizontal line
is given a separate number, #14. A full-length midline cleft,
extending both above and below the orbital horizontal, is
designated as a #0-14 cleft (however, the bony hyperpla-
sia associated with frontonasal dysplasia has also been con-
sidered a #0-14 “cleft”). As the location of the lower clefts
shifts laterally, a higher number is assigned. A single number
is used to describe each cleft, unless the cleft crosses the
midorbital horizontal line, at which point a second number
is added. For continuous clefts, extending above and below
the orbital horizontal, their combined numbers will add up
to 14. For example: a #1 cleft below the orbit becomes a #13
above the orbit, similarly a #2 below becomes a #12 above,
etc. The vertical facial clefts (becoming more oblique as they
occur lateral to the midline) include #0-14, #1-13, #2-12,
#3-11, #4-10, and #5-9. However, clefts do not always occur
in a continuous line. Tessier opined that the facial clefts
falling medial to the infraorbital foramen (#0-14 through
#4-10) are more likely to present with overlying soft tissue
defi ciencies, and those falling lateral to the infraorbital nerve
are more likely to have signifi cant bony clefting (others have
questioned this relationship). Tessier also observed that
clefts affecting the bony skeleton did not necessarily imply
the absence of principle neurovascular structures, and that
clefts of the soft tissues and bone do not always coincide.
The lateral facial clefts, assigned the numbers, #6, #7, and
#8, are used to describe Treacher Collins syndrome, as well
as auriculo-oculo-vertebral spectrum anomalies, including
hemifacial microsomia and the Goldenhar variant (with and
without true bony clefting). An isolated lateral facial cleft,
0
1
2
3
4
5
6
7
8
9
10
11
12 13
14
FIGURE 18-1. The Tessier Classifi cation for Rare Craniofacial Clefts.

CRANIOFACIAL CLEFTS • 191
extending through the soft tissues of the oral commissure is
designated a #7 cleft (as is a vertical cleft of the zygomatic
arch). Finally, a separate number, #30, was used by Tessier to
describe a cleft occurring through the midline of the lower
lip and mandible. A number of years ago I had the occasion
to ask Tessier why he had assigned the #30 to the lower lip,
instead of #15, or even a #-14? He replied: “I simply wanted
a very different number.” Detractors of Tessier’s classifi ca-
tion note that it does not take embryological development
into account, while supporters point out that most cranio-
facial clefts do not occur along lines that correspond to the
fusion planes for the various facial processes. One aspect
of the Tessier classifi cation, which has somewhat obscured
exactly what constitutes a rare craniofacial cleft, is the broad
net that has been cast over multiple different conditions.
Telorbitism, with intervening bony hyperplasia, has been
considered a #14 cleft. The bony and soft tissue hypopla-
sias associated with milder Treacher Collins and hemifa-
cial microsomia fall under the lateral facial “clefts” #6, #7,
and #8. Should the hyperplasias, hypoplasias, and aplasias
all be included under the moniker “cleft”? Moreover, how
necessary is it to differentiate between clefts that arise in
such close anatomic proximity, and does the treatment of
craniofacial clefts differ suffi ciently to require a classifi ca-
tion that includes 16 different clefts, with multiple possible
combinations? Published reviews that include all craniofa-
cial clefts tend to be protean in length. Finally, few physi-
cians are able to classify craniofacial clefts, or conjure up
a visualization of a cleft when given a descriptive number,
without fi rst consulting a diagram. Instead of attempting to
split facial clefts along fairly minutely spaced anatomic loca-
tions, which are not always germane to treatment paradigms,
clefts can be classifi ed more regionally based on variations in
surgical planning. 5 Using the aforementioned criteria, it is
possible to categorize all craniofacial clefts, using a surgical
classifi cation , into one of four primary types ( Figure 18-2 ):
• Type I, midline facial clefts (#0-14, and #30)
• Type II, paramedian facial clefts (#1-13, #2-12)
• Type III, orbital facial clefts (#3-11, #4-10, #5-9)
• Type IV, lateral facial clefts (#6, #7, and #8, excluding
hypoplasias)
Orbital
Paramedian
Median
FIGURE 18-2. The Surgical Classifi cation for Rare Craniofacial Clefts.

192 • CHAPTER 18
Each cleft type could be further subclassifi ed as frontal,
maxillary, or mandibular, if necessary. This simplifi ed classi-
fi cation system would enable surgeons to quickly describe
an observed cleft, have a basic treatment paradigm appli-
cable to each location, and permit others to easily under-
stand the location of the cleft.
PATIENT PREPARATION
Infants born with craniofacial clefts require an expeditious
initial evaluation. The common refl exive action is to order
a CT scan, but almost all preliminary decision making
is based on factors identifi able on physical examination;
in fact, arguments can be made for delaying a CT scan
evaluation, not only because the results of this test almost
never impact treatment decisions in the newborn, but also
because of concerns, which some have raised concerning
radiation exposure on the growing brain in the fi rst few
years of life. Furthermore, bone grafting of clefts is typi-
cally not indicated in infancy, unless the cranial vault is
involved. Therefore, a physical examination remains the
primary evaluation for the majority of rare craniofacial
clefts presenting during infancy, and a surprising amount
of information can be ascertained by a thorough examina-
tion. However, in older children a 3D CT scan may provide
invaluable insight into the extent of underlying skeletal
defects, providing considerable assistance in the planning
of the surgical reconstruction. 6
Type I, Midline Facial Clefts
In midline craniofacial clefts, an absence of bone run-
ning vertically down the central forehead almost always
results in an encephalocele. A “widow’s peak,” or V-shaped
midline frontal projection of hair, may be a marker for an
underlying bony cleft. A careful evaluation of vision, and
interpupillary distance is important (ie, Is vision stereo-
scopic?). Patency of the nares may be determined simply
by placing an unraveled cotton swab under each naris in
order to ascertain air movement. The palate should be
carefully evaluated for clefting; the presence of a soft tissue
mass herniating through a split palate is a basal encepha-
locele until proven otherwise. Often, palatal clefting will
be accompanied by a central upswing of the horizontal
occlusal plane. An MRI evaluation is very useful for the
midline craniofacial clefts, in order to evaluate brain paren-
chymal for possible midline defects, as well as to deter-
mine the presence and extent of a basal encephalocele.
An endocrine workup can also be of great benefi t for the
midline facial clefts in order to evaluate basic pituitary and
hypothalamic function.
The midline clefts, arising below the mouth, may or
not involve the underlying mandible (which can be easily
assessed by physical examination). The tongue is evaluated
for clefts and ankyloglossia, and the neck is extended to
look for fi brotic contractures. Although these clefts may
extend down into the sternum, treatment of the chest is
typically never required. Up to 10% of these rare clefts
may be associated with congenital heart anomalies.
Type II, Paramedian Facial Clefts
Clefts occurring lateral to the midline, but sparing the
majority of the orbit, are most likely to affect the fron-
tal bone, hemi-nose, and maxilla. These clefts may be as
simple as a notch in the alar rim, or can result in hemi-
nasal agenesis or a lateral proboscis. Often the nasolacrimal
drainage system is compromised. The patency of the ipsi-
lateral naris, if in doubt, should again be determined with
a cotton swab as described above.
Type III, Orbital Facial Clefts
The majority of oblique clefts involve the orbit; there-
fore, evaluation of the globe for exposure is of paramount
importance. Often, clefts involving the orbit may affect
eyelid coverage, which can quickly lead to an exposure
injury of the globe. The oblique clefts may be associated
with a normal globe, a hypoplastic globe (microphthal-
mia), or complete anophthalmia. Intraoral examination of
the alveolus and palate are performed, and palpation can
provide clues to underlying bony clefts of the maxilla, as
well as the supraorbit. The lateral oblique clefts may rarely
involve maxillary-mandibular fusion, which can be eas-
ily ascertained by examining jaw opening for extent and
symmetry.
Type IV, Lateral Facial Clefts
The lateral facial clefts primarily involve the oral commis-
sure and adjacent soft tissues. An assessment can be made
of the size of the hemi-mandible, ascending ramus, and
temporomandibular joint on the affected side by clinical
examination. Observing the chin point in relation to the
midfacial plane, and palpating the ascending ramus, may
provide clues to the size of the lower jaw. Rocking the
body of the mandible on each side allows comparison of
the joint spaces, and can assist in determining if the tem-
poral mandibular joints are fully formed.
TECHNIQUE
The primary goals of surgery vary signifi cantly with both
the type of cleft as well as the age of the patient, permit-
ting few generalizations. In the newborn, the adage often
attributed to Pichler, “fi rst the bone, then the soft tissue,”
should be ignored for the exact opposite is typically the
more prudent course. Soft tissue coverage is fi rst considered
in order to protect exposed structures, such as the globe,
and to assist with feeding if the cleft extends intraorally. As
children grow older, and the facial skeleton matures, bony
osteotomies and grafting are considered. These osteoto-
mies include, but are not limited to, facial bipartitions for
the midline clefts, bone grafting of alveolar clefts prior to
dental eruption, and cranial bone graft reconstruction of
maxillary defects. The volume of bone graft necessary to
correct the cleft defects is easy to underestimate and may
be surprisingly large. The following descriptions provide
general principles and treatment approaches, depending
on the anatomic location of the cleft.

CRANIOFACIAL CLEFTS • 193
Type I, Midline Facial Clefts
The surgical treatment of midline facial clefts can be
extremely challenging, even for the most experienced
craniofacial surgeons. Exceptions to the aforementioned
admonishment to avoid early bony reconstructive surgery
would include the midline clefts that involve the frontal
bone. For these cases, early bone grafting prior to a year of
age not only reconstructs the skull and protects the brain,
but it is also facilitated by the ability of the dura to regen-
erate bone, which eliminates the need to reconstruct the
donor site. The focus of the surgery for clefts that include
frontal bone defects is the correction of the encepha-
locele. In the absence of a frontal bone defect and corre-
sponding encephalocele, it is best to avoid the correction
of any associated hypertelorism during infancy because
these early procedures always need to be repeated and
any small achievable gains are rarely suffi cient to justify
the risks. An additional caveat to this reproach might be
cases of extreme telorbitism, with impairment of stereo-
scopic vision; for these individuals, the risks and benefi ts
of early hypertelorism corrections must be carefully bal-
anced. In older children, it is better to undercorrect than
overcorrect telorbitism, because mild hypertelorism is
generally considered more attractive than mild hypotelor-
ism. It is also prudent to delay, or avoid, the treatment of
any intraoral brain herniations in order to avert signifi cant
endocrine dysfunction. The author is aware of attempts,
at other institutions, to treat basal encephaloceles in chil-
dren that resulted in complete loss of pituitary function.
Reconstruction of the nose may be equally as challenging
as an intracranial hypertelorism correction, and may be the
crucial step in normalizing facial appearance. These midline
nasal reconstructions frequently entail a central skin resec-
tion as a component to bringing the hemi-nasal structures
together in the midline; however, it is always aesthetically
preferable to avoid a nasal scar when possible. For minor
central vertical facial clefting, an MRI or CT scan evalua-
tion should be undertaken prior to performing a primary
rhinoplasty to rule out an occult encephalocele, which may
split the nasal septum ( Figure 18-3 ) potentially leading to
dire consequences for the unsuspecting surgeon.
Upper central lip clefts present unique challenges. These
midline clefts may include a complete absence of the cen-
tral lip elements (philtrum and Cupid’s bow) that will
A
B
FIGURE 18-3. (A, B) Patients with a “simple” bifi d nose need to be evaluated for a
possible encephalocele, such as in this patient, which splits the nasal septum.

194 • CHAPTER 18
negatively infl uence postrepair aesthetics. The superior
extension of these clefts through the columella requires
careful planning, prior to surgical closure, in order to avoid
postoperative nasal airway compromise ( Figure 18-4 ).
Staged reconstruction with Abbe cross-lip fl aps can help
to establish normal upper lip dimensions through the cre-
ation of a philtrum and central lip tubercle.
The midline lower clefts are usually handled similar
to the upper lip clefts. During a primary closure, fi brous
union of the lateral mandibular halves may be appreciated.
It is best to delay any bony repair until mixed dentition in
order to prevent injuring permanent dentition with bone
fi xation that can damage unerupted tooth follicles.
Type II, Paramedian Facial Clefts
Procedures designed to correct nasal defects, and associ-
ated choanal atresia, are best left until a child is about
to enter school. Early corrections of choanal atresia have
signifi cant failure rates; moreover, there is little truth to
the dictum that infants are obligate nasal breathers, as any
physician who has treated congenital arhinia can attest. It
is probably best to not to even attempt to create a nasal
airway for children who have a unilateral functioning nasal
airway, as the functional results typically do not justify the
surgical efforts. 2 Isolated clefting of the ala can be often
addressed with an excision and a z-plasty repair. As the
clefts become more extensive, local fl aps and full recon-
struction with a forehead fl ap may be required. The gen-
eral tenet of nasal repair, “replace like with like,” should be
applied to the treatment of congenital clefts of the nose as
well. Nasal repair may be coordinated with palatal repair,
when the clefts involve both structures. Reconstruction of
the nasolacrimal apparatus is also better delayed until chil-
dren are bigger, and a larger stent can be used.
Type III, Orbital Facial Clefts
Primary corrections for clefts that involve the orbit are
focused on the protection of the globe. Additional con-
sideration is given to reestablishing the oral sphincter, if
affected, and providing general soft tissue closure. Orbital
clefts typically involve some degree of vertical defi ciency,
and multiple different repairs have been described using
multiple z-plastys, variations on nasolabial fl aps, and even
rotation fl aps. As in any cleft repair, length may be accom-
plished in one of two ways: wider lateral paring of the cleft
with recruitment of tissues medially and laterally, resulting
in a straight line scar; or, limited lateral paring of the cleft
with the use of z-plastys, or other fl aps that recruit tissue
laterally and reorient it to increase vertical length. Millard
argued, with the presentation of his technique for cleft lip
repair, that when fl aps are required to provide length, they
should used in such a way as to avoid crossing discrete ana-
tomic landmarks. Similar principles should be applied to the
treatment of craniofacial clefts, and the author would argue
for a restraint in the use of any large facial fl aps, whenever
possible. If fl aps must be used, their design should be kept
as small as possible, striving to keep scars along junctions of
facial aesthetic units, and tissue discarding should be kept
to a minimum. 7 This principle requires greater undermin-
ing of the lateral facial mass in closing large clefts. After
primary closure is achieved, and early scar contracture has
relaxed, the judicious use of carefully placed small z-plastys
can be considered. Protection of the globe can be particu-
larly challenging with signifi cant clefting involving the eye-
lids. Once again, minimizing the use of larger transposition
fl aps will result in a better aesthetic outcome in the major-
ity of cases. The use of tissue expanders may assist with the
closure of extremely wide clefts. Coloboma-type defects
can be closed with a small z-plasty, and segmental eyelid
B
A
FIGURE 18-4. (A, B) Treatment of the lower midline facial clefts requires the
recruitment of as much local tissue as possible to reconstruct the nasal fl oor, and
lengthening of the anterior abortive columella/septum, to achieve as much nasal height
as possible in order to not signifi cantly diminish the nasal airway.

CRANIOFACIAL CLEFTS • 195
defects can be closed with serial advancement or switch
fl aps. Once soft tissue closure has been accomplished, sec-
ondary cranial bone grafting of the underlying facial skel-
eton can be considered. Ideally, bone grafting is performed
at skeletal maturity (avoiding fi xation injuries to unerupted
teeth), but any signifi cant aesthetic deformities should be
addressed around ages 5 to 7 years, before they lead to any
permanent psychosocial issues.
Micro-ophthalmia may best be treated with serial con-
formers fi tted over the globe. Complete anophthalmia
may be best treated with orbital expansion. Although
the author has used both saline-fi lled and osmotic orbital
expanders; currently, the use of serial static orbital implants
is preferred. This involves early placement of an orbital
prosthesis, followed by an exchange for a larger prosthesis
a few years later. This slower “expansion” needs to be coor-
dinated with a prosthetist, who can serially exchange the
appropriate conformers to maintain the sulci for the fi nal
eye prosthesis.
Type IV, Lateral Facial Clefts
The key to correcting a lateral facial cleft, or macrostomia,
is the repair of the underlying muscle. Multiple variations
on the use of w-plastys and z-plastys have been described
for repairing the lateral clefts. Macrostomia repairs may be
undertaken at any age, but they are typically performed
within the fi rst year of life. As with the oblique clefts, the
author prefers a straight-line closure, minimizing the use
of fl aps ( Figure 18-5 ). It is clearly better to undercorrect
than to overcorrect these clefts; slight macrostomia is a far
more attractive trait than the appearance of an overcor-
rected macrostomia, which can resemble an electrical burn
injury of the oral commissure. Lateral facial clefts may also
occur in conjunction with bimaxillary fusion.
COMPLICATIONS
Very little has been published regarding complications
related to rare craniofacial cleft repair, and the discussion
of complications is made more problematic by the wide
variety of procedures that are used to repair these clefts.
Nevertheless, a failure to achieve a reasonable postopera-
tive appearance may be the most common complication
following the treatment of these clefts. As a result of the
rarity of such clefts, few surgeons have experience levels
that are commensurate with achieving a good result with a
minimal risk for complications.
For midline clefts, achieving a satisfactory correction
of any associated telorbitism will be more likely in older
children, with any procedures performed during infancy or
early childhood certain to require subsequent repeat pro-
cedures. Infection rates are probably higher in the facial
bipartition type procedures than for isolated cranial vault
reconstructions that do not breach sinuses. The author is
aware of two unpublished cases of panhypopituitarism
following surgical procedures performed at other centers
intended to treat midline facial clefts by placing bone grafts
above palatal defects, which likely resulted in injury to the
hypothalamic pituitary axis.
Paramedian clefts are diffi cult to correct at a young
age, and multiple procedures that accomplish little must
be considered a complication. It is also extremely unlikely
that a permanently patent nasal passage can be satisfacto-
rily accomplished for cases involving congenital atresia.
With orbital facial clefts, unsightly scarring has been
reported following the use of large facial z-plastys in treat-
ing the oblique facial clefts, emphasizing the need for
restraint in using fl aps to assist with the closure of facial
clefts. In addition, the treatment of congenital anophthal-
mia with expanders is also prone to potential complica-
tions, including expander displacement outside the orbit,
expander exposure, and conjunctival scarring. Avoidance
of these complications may be possible by instead placing
static orbital implants that are serially exchanged two or
three times, prior to skeletal maturity.
OUTCOME ASSESSMENTS
Although the literature is replete with case reports of cran-
iofacial clefts, there are only a few reports describing series
of patients with these rare clefts, and none have examined
B
A
FIGURE 18-5. (A, B) Lateral facial clefts are best corrected with a straight-line
closure, and undercorrection is preferable to overcorrection.

196 • CHAPTER 18
outcomes in any meaningful way. It is reasonable to assume
that better outcomes are accomplished in the milder
clefts that are treated by the more experienced surgeons.
Whenever possible, patients with the more severe cran-
iofacial clefts should be referred to regional centers with
particular expertise with these anomalies.
REFERENCES
1. Kawamoto HK Jr. The kaleidoscopic world of rare cranio-
facial clefts: order out of chaos (Tessier classifi cation). Clin
Plast Surg. 1976;3:529.
2. Coady MSE, Moore MH, Wallis K. Amniotic band syn-
drome: the association between rare craniofacial clefts and
limb ring constrictions. Plast Reconstr Surg. 1998;101(3):
640.
3. Ortiz Monasterio F, Fuente Del Campo A, Dimopulos A.
Nasal clefts. Ann Plast Surg . 1987;18(5):377.
4. Tessier P. Anatomical classifi cation of facial, cranio-facial and
laterofacial clefts. J Maxillofac Surg . 1976;4:69.
5. Fearon JA. Rare craniofacial clefts: a surgical classifi cation.
J Craniofac Surg . 2008;19:110.
6. David DJ, Moore MH, Cooter RD. Tessier clefts revisited
with a third dimension. Cleft Palate J . 1989;26:163.
7. Longaker MT, Lipshutz GS, Kawamoto HK. Reconstruc-
tion of Tessier no. 4 clefts revisited. Plast Reconstr Surg .
1997;99:1501.

19
c h a p t e r
Orthognathic Surgery and
Cephalometric Analysis
Jesse A. Goldstein, MD / Stephen B. Baker, MD, DDS, FACS
INTRODUCTION
Orthognathic surgery is the term used to describe surgi-
cal movement of the tooth-bearing segments of the max-
illa and mandible. Candidates for orthognathic surgery
have dentofacial deformities that cannot be adequately
treated with orthodontic therapy alone. Children with
cleft lip and palate as well as certain craniofacial anoma-
lies are especially prone to develop malocclusion. Indeed,
where approximately 2.5% of the general population have
occlusal discrepancies that warrant surgical correction,
25% to 30% of patients who undergo surgical correction of
cleft lip and palate in infancy will have severe enough mid-
face retrusion to require orthognathic surgery.1 Maxillary
hypoplasia resulting in class III malocclusion is the typi-
cal deformity seen in patients with cleft and craniofacial
deformities, but class II malocclusion, anterior open bites,
occlusal cants, and many other dentofacial deformities can
also occur. Regardless of the etiology, patient examination
and treatment planning principles remain the same. The
goal of orthognathic surgery, therefore, is to establish ideal
dental occlusion with the jaws in a position that optimizes
facial form and function.
HISTORY AND PATIENT SELECTION
It is important to obtain a thorough medical, dental, and
surgical history from every patient. Systemic diseases such
as juvenile rheumatoid arthritis, diabetes, and scleroderma
can affect treatment planning. With jaw asymmetries, a
history of hyperplasia or hypoplasia from syndromic, trau-
matic, postsurgical, or neoplastic etiologies affects treat-
ment considerations. Each patient should be questioned
regarding symptoms of temporomandibular joint (TMJ)
disease or myofascial pain syndrome. Motivation and real-
istic expectations are important for an optimal outcome.
It is likewise important for patients to have a clear under-
standing of the procedure, the recovery, and anticipated
result. In younger patients, a family discussion in terms
they can understand helps to alleviate preoperative anxi-
ety. Orthognathic surgery is a major undertaking, and the
patient and family must be appropriately motivated to
undergo necessary preoperative and postoperative orth-
odontic treatment in addition to the surgery itself.
A complete physical examination should be performed
on every patient prior to surgery. The frontal facial evalua-
tion begins with the assessment of the vertical facial thirds
(trichion to glabella, glabella to subnasale, and subnasale
to menton) and the horizontal facial fi fths (zygoma to
lateral canthus, lateral to medial canthi, and intracanthal
segment). The most important factor in assessing the verti-
cal height of the maxilla is the degree of incisor showing
while the patient’s lips are in repose. Males should show at
least 2 to 3 mm, whereas as much as 5 to 6 mm is consid-
ered attractive in females. If the patient shows the correct
degree of incisor in repose, but shows excessive gingival in
full smile, the maxilla should not be impacted. It is more
important to have correct incisor show in repose than in
full smile. If lip incompetence or mentalis strain is present,
it is usually an indicator of vertical maxillary excess.
The inferior orbital rims, malar eminence, and piriform
areas are evaluated for the degree of projection. These
regions often appear defi cient in cleft patients; maxillary
advancement is indicated. If they are prominent, posterior
repositioning may be necessary. The alar base width should
also be assessed prior to surgery since orthognathic sur-
gery may alter this width which, in turn, may accentuate

198 • CHAPTER 19
any asymmetries associated with a cleft nasal deformity.
Asymmetries of the maxilla and mandible should be docu-
mented on physical examination, and the degree of devia-
tion from the facial midline noted.
The profi le evaluation focuses on the projection of the
forehead, malar region, the maxilla and mandible, the
nose, the chin, and the neck. An experienced clinician can
usually determine whether the deformity is caused by
the maxilla, the mandible, or both simply by looking at
the patient. This assessment is made clinically and veri-
fi ed at the time of cephalometric analysis. The intraoral
exam should begin with an assessment of oral hygiene and
periodontal health. These factors are critical for successful
orthodontic treatment and surgery. Any retained decidu-
ous teeth or unerupted adult teeth are noted. The occlusal
classifi cation is determined, and the degrees of incisor over-
lap and overjet are quantifi ed. The surgeon should assess
the transverse dimension of the maxilla as prior cleft pal-
ate repair will often result in transverse growth restriction.
If the mandibular third molars are present, they must be
extracted 6 months prior to sagittal split osteotomy. Any
missing teeth or periapical pathology should be noted, as
should any signs or symptoms of TMJ dysfunction. These
issues should be addressed prior to proceeding with orthog-
nathic surgery. The term “dental compensation” is used to
describe the tendency of teeth to tilt in a direction that
minimizes dental malocclusion. For example, in a patient
with an overbite (Angle class II malocclusion), lingual ret-
roclination of the upper incisors and labial proclination of
the lower incisors minimize the malocclusion. The oppo-
site occurs in a patient who has dental compensation for
an underbite (Angle class III malocclusion). Thus, dental
compensation, which is often the result of orthodontic
treatment, will mask the true degree of skeletal discrep-
ancy. Precise analysis of the dental compensation is done
on the lateral cephalometric radiographs.
If the patient desires surgical correction of the deformity,
presurgical orthodontics will upright and decompesate the
occlusion, thereby reversing the compensation that has
occurred. This has the effect of exaggerating the maloc-
clusion, but it also allows the surgeon to maximize skeletal
movements. If the patient is ambivalent or not interested
in surgery, mild cases of malocclusion may be treated by
further dental compensation, which will camoufl age the
deformity and restore proper overjet and overlap. The
importance of a commitment to surgery prior to orthodon-
tics lies in the fact that dental movements for decompensa-
tion and compensation are in opposite directions, so this
decision needs to be made prior to orthodontic therapy.2
CEPHALOMETRIC
AND DENTAL EVALUATION
Identifying the proper patient for orthognathic surgery is
a key step to ensure satisfaction and successful outcomes.
This includes amassing considerable data beyond a simple
history and physical exam and should be coordinated with
other members of the care team.
ANS
A
B
OP
Me
MP
Gn
Go
Ar
Pog
Pg
Ba
PNS
Ptm
S
Or
FIGURE 19-1. The cephalometric radiograph is used to
identify skeletal landmarks used in determining the lines and
angles that refl ect facial development. These measurements
aid in determining the extent to which each jaw contributes to
the dentofacial deformity. (S, sellaturcica, the midpoint of the
sellaturcica; N, nasion, the anterior point of the intersection
between the nasal and frontal bones; A, A point, the innermost
point in the depth of the concavity of the maxillary alveolar
process; B, B point, the innermost point on the contour of the
mandible between the incisor tooth and the bony chin; Pg,
pogonion, the most anterior point on the contour of the chin;
Go, gonion, the most inferior and posterior point at the angle
formed by the ramus and body of the mandible; Po, porion,
the uppermost lateral point on the roof of the external auditory
meatus; Or, orbitale, the lowest point on the inferior margin of
the orbit; Gn, gnathion, the center of the inferior contour of the
chin; Me, menton, the most inferior point on the mandibular
symphysis.)
A cephalometric analysis and comparison to normative
values can help the surgeon plan the degree of skeletal
movement needed to achieve both an optimal occlusion
and an optimal aesthetic result. A lateral cephalometric
radiograph is performed under reproducible conditions so
that serial images can be compared. This fi lm is usually
taken at the orthodontist’s offi ce using a cephalostat, an
apparatus specifi cally designed for this purpose, and a head
frame to maintain consistent head position. It is impor-
tant to be certain the surgeon can visualize both the bony
and soft tissue features in order to facilitate tracing every
landmark. Once the normal structures are traced, several
planes and angles are determined ( Figure 19-1 ).
The sella-nasion-subspinale (SNA) and sella-nasion-
supramentale (SNB) are the two most important angles in
determining the positions of the maxilla and mandible rela-
tive to each other as well as the cranial base. These angles
are determined by drawing lines from sella to nasion to
A point or B point , respectively. By forming an angle with
the sella and nasion, this position is referenced to the cranial

ORTHOGNATHIC SURGERY AND CEPHALOMETRIC ANALYSIS • 199
base. A point provides information about the anteroposte-
rior position of the maxilla. If the SNA angle is excessive,
the maxilla exhibits an abnormal anterior position relative
to the cranium. If SNA is less than normal, the maxilla is
posteriorly positioned relative to the cranial base. The same
principle applies to the mandible: B point is used to relate
the mandibular position to the cranial base. The importance
of the cranial base as a reference is that it allows the clini-
cian to determine if one or both jaws contribute to a noted
deformity. For example, a patient’s class III malocclusion
(underbite) could develop from several different etiologies:
a retrognathic maxilla and a normal mandible as is com-
mon in cleft patients, a normal maxilla and a prognathic
mandible, a retrognathic mandible and a more severely
retrognathic maxilla, or a prognathic maxilla and a more
severely prognathic mandible. All of these conditions yield
a class III malocclusion, yet each requires a different treat-
ment approach. The surgeon can delineate the true etiology
of the deformity by the fact that the maxilla and mandible
can be independently related to a stable reference, the cra-
nial base. Next, cephalometric tracings are performed.
Cephalometric tracings give the surgeon an idea of how
skeletal movements will affect one another as well as the
soft tissue profi le. They also allow the surgeon to deter-
mine the distances the bones will be moved to achieve
the goals of specifi c procedure. Different tracing methods
using acetate paper are used for isolated maxillary, isolated
mandibular, or two-jaw surgeries. Much of the traditional
hand cephalometric tracing, however, has given way to
computer-aided cephalometric analysis which allows the
surgeon to electronically position the maxilla and man-
dible on the cephalogram while recording the soft tissue
changes and measuring the degree of repositioning.
Complete dental records, including mounted dental
casts, are needed to execute preoperative model surgery
and fabricate surgical splints. Casts allow the surgeon to
evaluate the occlusion both before and after articulation
into proper positions. Analysis of new occlusion gives the
clinician an idea of how intensive the presurgical orthodon-
tic treatment plan will be. Casts also allow the clinician to
distinguish between absolute and relative transverse max-
illary defi ciency. Absolute transverse maxillary defi ciency
presents as a posterior crossbite with the jaws in class I
relationship. A relative maxillary transverse defi ciency is
commonly seen in a patient with a class III malocclusion.
A posterior crossbite is observed in this type of patient,
raising suspicions of inadequate maxillary width. However,
as the maxilla is advanced or the mandible retruded, the
crossbite is eliminated. Articulation of the casts into a class
I occlusion allows the surgeon to easily distinguish between
relative and absolute maxillary constriction.
Using the cephalometric tracings as a guide, the next
step is to reproduce the maxillary and/or mandibular
movements on articulated dental models. This allows for
the fabrication of occlusal splints to be used intraopera-
tively to guide jaw repositioning in preparation for osteo-
synthesis. Model surgery begins by obtaining accurate casts
of the patient’s occlusion. If the surgeon does not have a
dental laboratory, the orthodontist will obtain the casts.
The success of the technical portion of orthognathic sur-
gery correlates directly with the accuracy of the model sur-
gery and splint fabrication.
It should be noted that if isolated mandibular surgery
is being performed, the casts can be hand articulated into
the desired occlusion. The Galetti articulator is a useful
tool that allows securing of casts with a screw mount. A
universal joint allows the casts to be set in the desired rela-
tionship. Surgical splints can then be made from the artic-
ulator. If the maximum intercuspal position is the desired
postoperative occlusion, a splint is unnecessary. The sur-
geon can osteotomize the mandible and secure it into its
new position using the maximum intercuspal position as
a guide to the new position. The surgeon should always
verify the desired postoperative occlusion with the othro-
dontist prior to surgery.
A face bow is a device that is used to accurately relate
the maxillary model to the cranium on an articulator. If a
maxillary osteotomy is being performed, one set of models
should be mounted on an articulator using the face bow. Two
other sets of models are used in treatment planning. Next,
an Erickson model block is sued to measure the current
position of the maxillary central incisors, cuspids, and the
mesiobuccal cusp of the fi rst molar. The face bow-mounted
maxillary cast is placed on the model block. The maxillary
model is then measured to the tenth of a millimeter ver-
tically, anteroposteriorly, and end-on. By having numerical
records in three dimensions, the surgeon can reproduce the
maxillary cast’s exact location, as well as determine a new
location. Reference lines are circumferentially inscribed
every 5 mm around the maxillary cast mounting. The dis-
tances the maxillar will move in anteroposterior, lateral, and
vertical directions have been determined from the previ-
ous cephalometric exam. These numbers are added or sub-
tracted from the current values measured on the model
block to determine the new three-dimensional position of
the maxillary cast. The occlusal portion of the maxillary
cast is removed from its base using a saw. As much plaster is
removed from the cast as is necessary to accommodate the
new position of the maxilla. Once the model block verifi es
the maxilla is in its new position, the cast is secured with
sticky wax or plaster to the mounting ring. Now it can be
placed on the articulator. At this point, the surgeon has a
mounting of the postoperative maxilla related to the pre-
operative mandible. An acrylic splint is made at this point.
This splint is called the intermediate splint and is used in the
operating room to index the new position of the maxilla to
the preoperative position of the mandible. A second mount-
ing with the casts in the occlusion desired by the orthodon-
tist is used to make a fi nal splint that represents the new
position of the mandible to the repositioned maxilla. This is
fabricated in a manner similar to the splint for isolated man-
dibular surgery. If the occlusion is good, intercuspal position
can be used to position the mandible without the splint.
Several computer-assisted design (CAD) and computer-
aided manufacturing (CAM) programs are commercially
available that can assist the surgeon with some or all of the

200 • CHAPTER 19
preoperative patient preparation. A CT scan is obtained
with the patient wearing a bite jig that correlates natural
head position to the 3D CT image of the patient’s face.
Although conventional helical CT scans with fi ne cuts
through the face are ideal, cone beam CT scans offer a
comparable image quality with considerably less cost and
radiation exposure (50 μSv compared to 2000 μSv). A
cephalometric analysis can then be performed as well as
simulated movements of the jaws and chin in any dimen-
sion. Once the osteotomy movements are verifi ed by the
surgeon, CAD/CAM technology is used to fabricate surgi-
cal splints for the patient. If necessary, 3D models of the
patient can be made showing the exact proposed move-
ment ( Figure 19-2 A–E). Some systems can actually “wrap”
a 2D digital image around the soft tissue envelope of the
3D CT image, thus replicating a 3D image of the patient’s
actual face in color.
In our experience, the 3D CT modeling has demon-
strated improved accuracy in diagnosis and treatment. The
elimination of traditional model surgery saves the surgeon
time in patient preparation. Finally, the 3D aspect of this
treatment planning approach enhances the surgeons abil-
ity to predict how osteotomies may affect soft tissue of the
face. These advantages facilitate the ability of the plastic
surgeon to provide optimal care for these patients.
DEVELOPING A TREATMENT PLAN
Once the data are obtained, the surgeon can determine
which abnormalities the patient exhibits and the extent
to which these features deviate from the norm. The treat-
ment plan is the application of these data to provide the
best aesthetic result while establishing a class I occlusion.
The goal is not to “treat the numbers” in an attempt to
FIGURE 19-2. (A–E) A 3D CT reconstruction of patient with class III malocclusion
and anterior open bite. (A) Lateral preoperative view. (B) Front pre-operative view.
(C) Lateral view after LeFort I osteotomy has been simulated with intermediate splint in
place. (D) Lateral postoperative view after LeFort I and bilateral sagittal split osteotomies
have been simulated with correction of class III malocclusion and anterior open bite.
(E) Close-up view of predicted postoperative occlusion.
D
E
A
B
C

ORTHOGNATHIC SURGERY AND CEPHALOMETRIC ANALYSIS • 201
normalize every patient. The appearance of the soft tissue
envelope surrounding the facial skeleton is the most cru-
cial factor in determining the aesthetic success of orthog-
nathic procedures, and the jaws should be positioned so
they provide optimal soft tissue support.
Historically, skeletal movements that expanded the soft
tissue of the face were less stable, so posterior and superior
movements were preferred. Although these movements
were more stable, they resulted in contraction of the facial
skeleton with the associated soft tissue features of prema-
ture aging. Since the introduction of rigid fi xation systems,
osteotomies that result in skeletal expansion have been
achieved with a great degree of predictability. An attempt
is made to develop a treatment plan that will expand or
maintain the preoperative volume of the face. If a superior
or posterior (contraction) movement of one of the jaws is
planned, an attempt should be made to neutralize the skel-
etal contraction with an advancement or inferior move-
ment of the other jaw or the chin. It is important to avoid
a net contraction of the facial skeleton, as this may result
in a prematurely aged appearance.3
As skeletal expansion is increased, soft tissue laxity
is reduced and facial creases are softened. These effects
increase the defi nition of the face, creating a more attractive
appearance. It has been shown that skeletal expansion is aes-
thetically pleasing, even if facial disproportion is necessary
to achieve the expansion. Women with successful careers
as fashion models often exhibit slight degrees of facial dis-
proportion and are considered beautiful. The aesthetic ben-
efi ts the patient receives by expanding the facial envelope
frequently justify the small degree of disproportion neces-
sary to achieve them. Even in young adolescent patients
who do not show signs of aging, one must not ignore these
principles. A successful surgeon will incorporate these prin-
ciples into the treatment plan of every patient so that as
the patient ages, the signs of aging will be minimized and a
youthful appearance will be maintained as long as possible.
A class I occlusion can be achieve with the jaws in a
variety of positions. The goal in treatment planning is to
use the data from the patient’s examination to predict the
location of the jaws that will optimize the soft-tissue fea-
tures of the face. By reducing the emphasis on normal val-
ues and increasing the awareness of the soft tissue effects
of skeletal movements, preserving skeletal disproportion
can often lead to a more favorable result.7
GENERAL PRINCIPLES
AND PERTINENT ANATOMY
Several principles have broad application to jaw surgery.
Blood loss can be substantial in maxillofacial surgery and
even small volumes can have signifi cant clinical implica-
tions in the pediatric population. Standard techniques of
head elevation, hypotensive anesthesia, blood donation,
and administration of erythropoietin are useful adjuncts
to reduce blood loss, especially in the younger population.
Before incisions are made, an antimicrobial rinse is helpful
to minimize the intraoral bacterial count. A topical steroid
is applied to the lips to reduce pain and swelling associated
with prolonged retraction. Intravenous steroids may also
be useful to reduce postoperative edema.
The occlusion desired may not be the same as maxi-
mum intercuspal position. The splint is useful in maintain-
ing the occlusion in the desired location when it does not
correspond to maximal intercuspal position. It is easy for
the orthodontist to close a posterior open bite, but very
diffi cult to close an anterior open bite with orthodontic
treatment. At the end of the case, it is important to have
the anterior teeth and the canines in a class I relationship
without an open bite.
Guiding elastics are useful postoperatively to control the
bite. Class II elastics are placed in a vector to correct a class
II relationship (maxillary lug is anterior to the mandibular
lug). Class III elastics are applied to correct a class III dis-
crepancy. With rigid fi xation, the elastics will not correct
malpositioned jaws. They serve only to help the patient
adapt to his new occlusion. Minor malocclusions can be
corrected with postoperative orthodontic treatment.
Certain skeletal movements are inherently more sta-
ble than others. Stable movements include mandibular
advancement and superior positioning of the maxilla.
Movements with intermediate stability include maxil-
lary impaction combined with mandibular advancement,
maxillary advancement combined with mandibular set-
back, and correction of mandibular asymmetry. The
unstable movements include posterior positioning of the
mandible and inferior positioning of the maxilla. The least
stable movement is transverse expansion of the maxilla.
Long-term relapse with rigid fi xation has not been dem-
onstrated to be clearly superior to nonrigid fi xation in
single-jaw surgery. However, in two-jaw surgery, rigid fi x-
ation results in less relapse. The judgment of the surgeon
will dictate the extent to which the facial skeleton can be
expanded without resulting in unacceptable relapse.
The maxilla is associated with the descending palatine
artery, the intraorbital nerve, the tooth roots, and the inter-
nal maxillary artery. The internal maxillary artery runs
about 25 mm from the pterygomaxillary junction, and the
descending palatal artery descends into the posteromedial
maxillary sinus. The infraorbital nerve exits the intraorbital
foramen below the infraorbital rim along the midpupillary
line. The maxillary tooth roots extend within the maxilla
in a superior direction. The canine has the longest root and
is usually visible through the maxillary cortical bone.
The patient who presents with a cleft lip and/or palatal
anomaly will have several anatomic differences when com-
pared with an unaffected patient. The maxilla is typically
defi cient in both the anteroposterior and vertical dimen-
sions. Because the midface retrusion can be signifi cant, it
frequently appears that the mandible is prognathic, but it is
rare that the mandible demonstrates a true prognathia. It is a
relative prognathia secondary to the maxillary defi ciency.
LEFORT I OSTEOTOMY
The fi rst step in any facial osteotomy is satisfactorily secur-
ing the nasal endotracheal tube; our preference is a nasal
Ring–Adair–Elwin (RAE) endotracheal tube. The vertical

202 • CHAPTER 19
position of the maxilla is recorded by measuring the dis-
tance between the medial canthus and the orthodontic arch
wire. These vertical measurements are absolutely critical.
The maxillary vestibule is injected with epinephrine prior
to patient preparation. An incision is made with needle
tip electrocautery 5 mm above the mucogingival junction
from fi rst molar to fi rst molar. A periosteal elevator is then
used to expose the maxilla around the piriform rim and
infraorbital nerve. Obwegeser toe-in retractors are held by
the assistant at the head of the operating table. As the dis-
section extends laterally, it is important to remain subpe-
riosteal to avoid exposure of the buccal fat pad. A Woodson
elevator is used to initiate refl ection of the nasal mucosa,
and a periosteal elevator is used to complete the dissection
of the nasal fl oor and lateral nasal wall. A double-balled
osteotome is used to release the septum from the maxilla
and an uniballed osteotome is used to release the lateral
nasal wall. The surgeon can insert a fi nger on the posterior
palate to help feel when the cut is complete. A periosteal
elevator is used to protect the nasal mucosa and then a
reciprocating saw is used to make a transverse osteotomy
from the piriform aperture laterally until the cote descends
just posteriorly to the last maxillary molar and drops
through the maxillary tuberosity. The cut should be made
at least 5 mm above the tooth apices. This distance is deter-
mined from preoperative Panorex radiographs. If cuts are
complete, the maxilla is downfractured with manual pres-
sure. An alternative is to use Rowe disimpaction forceps.
These fi t into the piriform aperture and on the palate to
provide increased leverage for the downfracture. Pressure
should be applied in a slow steady, controlled fashion,
not in a serious of quick movements. If the maxilla is not
mobilized with relative ease, the cuts are likely not com-
plete and should be reevaluated. Once the downfracture
is complete, a bone hook can be used by the assistant to
hold the maxilla down while any remaining bony interfer-
ences are removed. The descending palatine arteries will be
seen near the posteromedial maxillary sinus. These can be
clipped prophylactically without compromising the blood
supply to the maxilla ( Figure 19-3 ). The splint is then used
to place the maxilla in its proper position in occlusion with
the mandible. Mandibulomaxillary fi xation (MMF) is then
applied with 26-gauge wires around the surgical lugs. The
amount the maxilla will be impacted or elongated was
determined in the treatment plan. This distance is added
or subtracted from the medial canthal-incisor distance to
determine the new vertical position of the maxilla. Four
2-mm plates, usually L shaped can be used to secure the
maxilla. The MMF is released and occlusion verifi ed prior
to closure. If the alar base is wise, an alar cinch can be per-
formed to normalize the width. Lip shortening may also
result from closure. A V-Y closure at the central incisor can
help alleviate this effect.
In patients who require increased cheek projection, a high
LeFort I osteotomy can be performed. This differs in that
the transverse osteotomy is made as high as the infraorbital
nerve will allow. If further cheek projection is necessary,
bode grafts can be added. In the case of inferior or anterior
positioning, gaps between the segments greater than 3 mm
should be grafted with autogenous bone, cadaveric bone, or
Descending palatine artery
Lesser palatine artery
Maxillary
artery
LeFort downfracture
Ascending pharyngeal artery
External carotid artery
Ascending palatine artery
Facial artery
Greater palatine artery
Nasopalatine artery
FIGURE 19-3. Blood supply to maxilla before and after LeFort I osteotomy and
downfracture. After the nasopalatine and descending palatine arteries are transected,
perfusion of the maxillary segment occurs via the lesser palatine artery.

ORTHOGNATHIC SURGERY AND CEPHALOMETRIC ANALYSIS • 203
block hydroxyapetite. Finally, if simultaneous expansion of
the maxilla is necessary, the maxilla can be split into two or
more pieces to allow concurrent expansion.
Surgically Assisted Rapid Palatal Expansion
Correction of transverse maxillary constriction are com-
mon in patients with repaired cleft palates or those with
craniofacial syndromes such as Apert or Cruzon syn-
drome. Such palatal constriction can be addressed in ado-
lescence with nonsurgical orthodontic appliances. As the
sutures begin to close during late adolescence, relapse rates
increase. A multiple LeFort I osteotomy can be performed
to provide simultaneous maxillary expansion, but the
degree of relapse is high. In the young adult, the preferred
procedure is the surgically assisted rapid palatal expansion
(SARPE) procedure.8 The orthodontist places a palatal
expander prior to the procedure. A LeFort I osteotomy is
performed to completely mobilize the maxilla from the
upper face. A small osteotome is used to make a thin cut
between the roots of the central incisors, and a midline
split is completed to the posterior nasal spine. Separation
is verifi ed by activating the device. The maxilla is widened
until the gingival blanches and then is relaxed several turns
to avoid ischemia. The SARPE procedure offers the best
stability for maxillary expansion in the young adult and
older patient. Transverse defi ciencies of the mandible can
be corrected with a similar technique, that of distraction
osteogenesis (see Chapter 14 ).
BILATERAL SAGITTAL
SPLIT OSTEOTOMY
The endotracheal tube placement and epinephrine injec-
tion are carried out in a similar fashion to the LeFort I
osteotomy. The cut is made with electrocautery about 10
mm from the lateral aspect of the molars and extends
from the midramus to the region of the second molar. If
insuffi cient tissue is left on the dental side of the incision,
closure is more diffi cult. A periosteal elevator is used to
expose the lateral mandible and the anterior coronoid
process in a subperiosteal plane. As the coronoid process
is exposed, placement of a notched coronoid retractor
may facilitate the dissection. A curved Kocher with a
chain can be clamped to the coronoid process and the
chain secured to the drapes. To optimize blood supply,
subperiosteal dissection is limited to those areas required
to complete the osteotomy. A J-stripper is used to release
the inferior border of the mandible from the attachments
of the pterygomasseteric sling. The eternal oblique ridge
and inferior border of the mandible should be exposed.
The medial aspect of the ramus is also dissected subpe-
riosteally. The mandibular nerve should be identifi ed. A
Seldin elevator is inserted medial to the ramus and pro-
tecting the nerve. A Lindemann side-cutting burr is used
to make a cut on the medial ramus that is parallel to
the occlusal plane and extends about two thirds of the
distance to the posterior ramus. The cut extends from
medial to lateral until the burr is in the cancellous por-
tion of the ramus. Mandibular body retractors are then
placed and a fi ssure burr or a reciprocating saw is used
to make a cut from the midramus down along the exter-
nal oblique ridge, gently curving to the inferior border of
the mandible. The cuts are verifi ed with an osteotome,
and then large osteotomes are inserted and rotated to
gently separate the segments. The tooth-baring segments
are referred to as the distal segment, and the condylar
portion as the proximal segment. The inferior alveolar
nerve should be identifi ed and found in the distal seg-
ment. If part of the nerve is located within the proxi-
mal segment, it should gently be released with a small
curette. After both osteotomies are complete, the distal
segment is placed into occlusion and secured by tighten-
ing 26-guage wire loops around the surgical lugs. If a sur-
gical splint is necessary to establish a required occlusion,
it is placed between the teeth before MMF wiring. The
proximal segments are then gently rotated to ensure they
are seated within the glenoid fossa. When each condyle is
comfortably seated within the fossa, it is rotated to align
the inferior borders of the two segments and secured into
position with a clamp. Three lag screws are placed at the
superior border of the overlapping segments on each side
of the mandible. To ensure that the transbuccal trocar
will be placed properly, a hemostat is placed at the pro-
posed screw location and pointed toward the cheek. A
small stab incision is made in the skin, and the trocar
is placed through the tissue bluntly until the tip enters
the oral incision. The trocar is then exchanged for a drill
guide, and the 2.0-mm and 1.5-mm drills are used in the
lag sequence to make three holes through the overlap-
ping portion of the proximal and distal segments. The
screw lengths are measured and the screws inserted. The
MMF is released, and the mandible is gently opened and
closed to verify the occlusion. If a malocclusion is noted,
the most likely etiology is that one or both condyles are
not seated properly during application of fi xation. The
screws should be removed and replaced until the correct
occlusion is established. The wounds are irrigated and
closed with interrupted 4-0 chromic sutures.
Intraoral Vertical Ramus Osteotomy
A second technique for correcting mandibular prognathism
or asymmetry is the intraoral vertical ramus osteotomy.
The incision is the same as described above. A subpe-
riosteal dissection is performed from the lateral ramus and
a LeVasseur-Merril retractor is used to hold this tissue lat-
erally. An oscillating saw is then used to make a vertical
cut from the sigmoid notch to the inferior border of the
mandible. The cut must be make posterior to the mandib-
ular foramen on the medial side. The antilingula is a use-
ful landmark. This is an elevation on the lateral mandible
that indicates the approximate location of the mandibular
foramen. After both sides are complete, the distal segment
is moved into occlusion, making sure that the proximal
segments remain lateral to the distal segments posteriorly.

204 • CHAPTER 19
Because rigid fi xation is diffi cult to apply, a single wire, or
no fi xation at all, is used, and the patient remains in MMF
for 6 weeks. This osteotomy can be done from an external
approach but this incision results in a scar on the neck.
Two-Jaw Surgery
Moving the maxilla and the mandible in one procedure
requires osteotomizing both jaws and precisely securing
them into position as determined by the treatment plan.
If proper treatment planning, model surgery, and splint
fabrication are performed, each jaw should be able to be
placed into its desired position with precision. The man-
dibular bony cuts are made fi rst but terminated prior to
osteotomy completion. The maxillary osteotomy is made,
and the maxilla is placed into its new position using the
intermediate splint. The splint is used to wire the teeth
into MMF, allowing for indexing the new position of the
maxilla to the preoperative (uncorrected) position of the
mandible. With the condyles gently seated, the maxil-
lomandibular complex is rotated so that the maxillary
incisal edge is at the correct vertical height. The maxilla
is plated into position, the MMF is released, and the inter-
mediate splint removed. Next the mandibular osteotomies
are completed, and the distal segment of the mandible is
placed into the desired occlusion using the fi nal splint.
If the teeth are in good occlusion without the splint, the
fi nal splint may not be necessary to establish the desired
occlusal relationship. Wire loops secure the occlusal rela-
tionship and the rigid fi xation is completed as previously
described.
GENIOPLASTY
Including a genioplasty in the treatment plan can be a
powerful adjunct to mandibular movements, either by off-
setting soft tissue collapse with posterior mandibular repo-
sitioning or augmenting anterior mandibular movement.
When performed asymmetrically, a genioplasty may also
correct for minor mandibular asymmetries.
After adequate local anesthetic infi ltration, the mucosa
is incised from canine to canine with needle tip electrocau-
tery 5 mm below the mucogingival junction. The mentalis
is transected, being sure to leave enough muscle cuff to
allow for reapproximation during closure. Failure to do so
can result in a ptotic soft tissue envelope, or “witch’s chin”
deformity. Next, the dissection is carried out in a subpe-
riosteal fashion identifying and protecting the mental
nerves bilaterally. Using a reciprocating saw, the mandibu-
lar midline is gently marked to aid is centric fi xation. The
transverse osteotomy is made approximately 3 mm below
the mental foramina in order to protect the intraosseus
course of the mental nerves and the canine tooth roots.
The trajectory of the osteotomy can be varied depending
on the type of correction required. The mobilized segment
is then fi xed into the desired position with plates and
screws, using the midline mark as a guide. The mentalis is
then repaired and the mucosa closed.
Finally, because of lesser segment collapse, the dental
midline is often deviated toward the cleft side.
Despite having had alveolar bone grafting performed,
many of these patients have defi cient or missing bone in
the region of the alveolus. Persistent palatal fi stulas may
be present as well. The lateral incisor is frequently missing
in these patients and closure of this space must be taken
into consideration at the time of treatment planning. If a
large fi stula is present in the alveolus, modifi cations of the
LeFort I procedure can be performed to facilitate a ten-
sion-free alveolar closure.
The important structures in the mandible that may be
injured in the mandibular osteotomy are the mental nerve,
the inferior alveolar nerve, and the tooth apices. The third
branch of the trigeminal nerve enters the mandibular fora-
men to become the inferior alveolar nerve. It runs below
the tooth roots and exits at the level of the fi rst and second
premolars through the mental foramen. The region where
it is most medial to the outer cortex is located near the
external oblique ridge. This is where the vertical portion
of the bilateral sagittal split osteotomy is made because it
affords the largest margin of error.
CLEFT SURGERY
Orthognathic surgery in cleft lip/palate patients is done
similar to noncleft patients with the exception of several
important modifi cations that are necessary to maintain
blood supply and assist in fi stula closure.
In a unilateral cleft lip patient, the standard maxillary
incision can be made with little jeopardy to the premaxil-
lary blood supply. Each side of the cleft has an incision
made similar to that of the alveolar bone graft incision.
This allows for a two-layer closure of the palatal and nasal
mucosa. If supplemental bone grafting needs to be done at
this time, harvested bone can be placed into the alveolar
gap after fi xation has been applied. If a wide fi stula is pres-
ent, the surgeon can compress the maxillary segments to
reduce the size of the alveolar space. This ensures the soft
tissue closure is under minimal tension and the chance of
fi stula closure is optimized. The canine may now be adja-
cent to the central incisor, but the restorative dentist can
fabricate a prosthetic crown for the canine to make it look
like a lateral incisor.
In the bilateral cleft patient, care must be taken not to
make the vestibular incision across the premaxilla. The
premaxillary blood supply originates from the vomer
and the buccal mucosa. Since the vomer will be split, the
majority of blood fl ow to the premaxilla must course from
the premaxillary buccal mucosa. A circumvestibular inci-
sion that violates this mucosa will severely jeopardize the
blood supply of the premaxillary segment. To minimize
the risk of complications, the incision is stopped just lateral
to the alveolar cleft on each side. One minimizes refl ection
of the mucosa from the premaxilla in order to preserve the
blood supply. The osteotomy of the premaxillary segment
is made from a posterior approach just anterior to the
incisive foramen. This allows mobilization of the segment
without violation of the buccal mucosa. Similar to the uni-
lateral cleft maxilla, residual fi stulae and inadequate alveo-
lar bone may be present. If either is identifi ed, it can be

ORTHOGNATHIC SURGERY AND CEPHALOMETRIC ANALYSIS • 205
corrected by a two-layer mucosal closure and bone graft-
ing into the alveolar defect. If large gaps are present that
may jeopardize fi stula closure, the segments can be com-
pressed at the alveolar gaps to reduce tension of the repair.
Postoperative orthodontics and prosthetic restorations of
the teeth can correct almost any postoperative dental aes-
thetic irregularities.
Once the incision is made, the mucosa is refl ected in a
subperiosteal plane to expose the piriform aperture, the
zygomatic buttress, and the posterolateral maxilla. A recip-
rocating saw is used to make a high LeFort I osteotomy in
most cases. A high LeFort I osteotomy is cut horizontally
in a lateral direct line from the piriform aperture to the
zygomatic buttress. One takes this line as high as possible
while staying at least 5 mm below the inferior orbital fora-
men. A vertical cut is now made from the lateral edge of
the horizontal cut and taken to an area about 5 mm above
the tooth root apices. The lateral nasal walls are cut with a
uniball osteotome and mallet. The vomer and septum can
be reached through the lateral maxillary osteotomies so
the mucosa remains preserved. The pterygomaxillary junc-
tion can be separated with a 10-mm curved osteotome or
the maxillary tuberosity can be cut posterior to the last
molar in the arch. The latter choice makes downfracture
easier and results in fewer complications. Downfracture
is now completed with either digital pressure or applica-
tion of the Rowe disimpaction forceps. If a wide alveo-
lar fi stula is present, the greater and lesser segments can
be compressed at the alveolus. The occlusion that would
result from segment compression would be evaluated on
the dental casts during preoperative model surgery. Any
defi ciency of alveolar bone can be corrected with supple-
mental bone grafts after application of fi xation, and fi stulas
can be corrected as well.
The surgical splint is then placed orient the new position
of the maxilla to the mandible. Twenty 6-gauge wire loops
are used to place the patient in maxillomandibular fi xa-
tion. It is extremely important to make sure the condyles
are seated as the maxillomandibular complex is rotated to
its new vertical dimension. Generally, cleft patients have
vertical maxillary defi ciency in addition to the sagittal
defi ciency. This requires the maxilla to be inferiorly posi-
tioned to its new position. If vertical lengthening greater
than 5 mm is required, bone grafts are placed between
the osteotomy segments to reduce relapse. Rigid fi xation is
now used to secure the maxilla into its new position. If any
instability remains across the maxillary segments, a small
plate can be placed across the segments to reduce mobil-
ity and maintain the bone graft. Because the osteotomized
cleft maxilla results in a multisegment maxilla, the surgical
splints are wired in place for 6 to 8 weeks in order to allow
for bone healing.
BASIC APPROACHES TO COMMONLY
ENCOUNTERED PROBLEMS
The following paragraphs outline basic treatment
approach es to commonly encountered dentofacial defor-
mities commonly seen in orthognathic patients.
Skeletal Class II Malocclusion
Class II malocclusion is almost always caused by mandibu-
lar retrognathia and is almost always best treated by man-
dibular advancement ( Figure 19-4 ). The mandible is small,
FIGURE 19-4. Mandibular sagittal split osteotomies dem-
onstrating mandibular advancement and mandibular setback.

206 • CHAPTER 19
and forward positioning is an expansible movement that
enhances facial form. If the maxilla is also slightly defi -
cient or in a normal position, one may consider a bimax-
illary advancement to further enhance facial soft tissue
defi nition, especially in more mature patients. If the mal-
occlusion is minimal and there is little preexisting dental
compensation, one may choose to have the orthodontist
intentionally compensate the dentition to correct the
occlusion and avoid surgery. In contrast, if the malocclu-
sion appears minimal but there is dental compensation,
the skeletal discrepancy will be more signifi cant after the
orthodontist decompensates the dentition, and the patient
may be a good surgical candidate.
Skeletal Class III Malocclusion
A class III malocclusion may be treated by advancing the
maxilla, posteriorly positioning the mandible, or by combin-
ing these procedures. It is important to consider the contri-
butions of the mandible and the chin separately as each may
require different treatments to achieve aesthetic goals. If
some posterior positioning of the mandible is necessary, one
may advance the maxilla to counteract the skeletal contrac-
tion produced from posteriorly positioning the mandible.
Additionally, the patient may benefi t from an advancement
genioplasty, counteracting any skeletal contraction occur-
ring from a mandibular setback. As in the class II patient,
a minor malocclusion with minimal dental compensation
may be corrected with orthodontic treatment alone. In con-
trast, a minor malocclusion with dental compensation may
become a signifi cant malocclusion after dental decompen-
sation, and the patient will be a good surgical candidate.
Maxillary Constriction
Patients can present with a maxilla that is narrow in a
transverse dimension. Maxillary constriction may occur
as an isolated fi nding or as one of multiple abnormalities.
Up to about age 15 years, the orthodontist can usually
expand the maxilla nonsurgically with a palatal expander.
If orthopedic expansion cannot be done, the SARPE tech-
nique can be performed. If the maxilla requires movement
in other dimensions, a two-piece (or multipiece) LeFort
I osteotomy can be performed to place the maxilla in its
new position while simultaneously achieving transverse
expansion ( Figure 19-5 ).
Apertognathia
An anterior open bite is caused by a premature con-
tact of the posterior molars and is commonly seen in
patients with syndromic craniosynostoses such as Apert
or Crouzon syndrome. The recommended treatment is a
posterior impaction of the maxilla. By reducing the ver-
tical height of the posterior maxilla, the mandible can
come into occlusion with the remaining mandibular teeth.
Posterior maxillary impaction does not necessarily result in
incisor impaction; the posterior maxilla is simply rotated
clockwise and upward using the incisal tip as the axis of
rotation. Therefore, incisor show should not be affected.
If a change in incisor show is also desired, the posterior
impaction is performed, and then the whole maxilla can
be inferiorly positioned or impacted to its new position
( Figure 19-6 A–C).
A
B
D
E
C
FIGURE 19-5. LeFort I osteotomies demonstrating maxillary advancement,
impaction, setback, and multipiece LeFort.

ORTHOGNATHIC SURGERY AND CEPHALOMETRIC ANALYSIS • 207
FIGURE 19-6. (A) Anterior open bite. (B) The LeFort
osteotomy allows posterior impaction of the maxilla and
clockwise rotation. (C) Counterclockwise mandibular
autorotation closes the anterior open bite.
A
B
C

208 • CHAPTER 19
Vertical Maxillary Excess
Vertical maxillary excess is typically associated with lip
incompetence, mentalis strain, and an excessive degree
of gingival show (long face syndrome). The treatment
approach is to impact the maxilla to achieve the proper
incisor show with the lips in repose. Impaction, however,
may result in skeletal contraction, so the surgeon must
consider anterior repositioning of the jaws to neutralize
the associate adverse soft tissue effects. As the maxilla is
impacted, the mandible rotates counterclockwise (with
respect to a rightward facing patient) to maintain occlu-
sion. This rotation results in anterior positioning of the
chin and is called mandibular autorotation. The opposite
occurs if the maxilla is moved in an inferior direction. In
this case, the chin point rotates in a clockwise direction,
resulting in posterior positioning of the chin point. It is
important to note that these effects on the cephalometric
tracing during treatment planning because a genioplasty
may be required to reestablish proper chin position.
Short Lower Face
A short lower face is marked by insuffi cient incisor show
and/or a short distance between subnasale and pogon-
ion. Treatment is aimed at establishing a proper degree
of incisor show. The facial skeleton should be expanded
to the degree that provides optimal soft tissue esthetics.
As the maxilla is inferiorly positioned, resulting clock-
wise mandibular rotation leads to a posterior positioning
of the chin. The surgeon needs to preoperatively assess
the new chin position on the cephalometric prediction
tracing to determine if an advancement genioplasty will
be necessary to counter the effects of mandibular clock-
wise rotation.
OUTCOMES, PROGNOSIS,
AND COMPLICATIONS
Accurate assessment of orthognathic surgical outcomes is
essential to maintaining safe practices, maximizing patient
satisfaction, and effectively evaluating an ever-chang-
ing fi eld. Indeed, this importance is echoed in the wide
range of ways investigators have used to record postop-
erative results. These include measurement tools such as
three-dimensional CT scanning and volumetric analyses
to evaluate postoperative changes in bony and soft tis-
sues immediately and over time to questionnaires assess-
ing patient-reported satisfaction scales and quality of life.
While there is currently no universally accepted tool to
accurately and reliably demonstrate patient outcomes
after orthognathic surgery, with reasoned and reasonable
expectations on the part of the patient, family and surgeon
alike, orthognathic surgery can result in high levels of satis-
faction both from a functional and aesthetic level.4–6
REFERENCES
1. DeLuke DM, Marchand A, Robles EC, Fox P. Facial growth
and the need for orthognathic surgery after cleft pal-
ate repair: literature review and report of 28 cases. J Oral
Maxillofac Surg . 1997;55(7):694–697.
2. Tompach PC, Wheeler JJ, Fridrich KL. Orthodontic con-
siderations in orthognathic surgery. Int J Adult Orthodon
Orthognath Surg . 1995(10):97–107.
3. Selber JC, Rosen HM. Aesthetics of facial skeletal surgery.
Clin Plast Surg . 2007;34(3):437–445.
4. Janulewicz J, Costello BJ, Buckley MJ, et al. The effects
of Le Fort I osteotomies on velopharyngeal and speech
functions in cleft patients. J Oral Maxillofac Surg .
2004;62(3):308–314.
5. Posnick JC, Tompson B. Cleft-orthognathic surgery: com-
plications and long-term results. Plast Reconstr Surg .
1995;96(2):255–266.
6. Baker SB, Goldstein JA, Seiboth L, Weinzweig J. Posttrau-
matic maxillomandibular reconstruction: a treatment algo-
rithm for the partially edentulous patient. J Craniofac Surg.
2010;21(1):217–221.
7. Proffi t WR, Sarver DM. Treatment planning: optimizing ben-
efi t to the patient. In: Proffi t WR, White RP, Sarver DM, eds.
Contemporary Treatment of Dentofacial Deformity . St. Louis,
MO: Mosby; 2003:213–223.
8. Silverstein K, Quinn PD. Surgically assisted rapid palatal ex-
pansion for management of transverse maxillary defi ciency.
J Oral Maxillofac Surg . 1997;55:725–727.

20
Skull Base Surgery
Stephen P. Beals, MD, FACS, FAAP / Hahns Y. Kim, MD
PATIENT EVALUATION AND SELECTION
Based on the principles established by Tessier more than
40 years ago for the correction of congenital craniofacial
anomalies, development of advanced transfacial approaches
has made possible the curative resection of many skull base
lesions once considered inoperable. 1 – 8 A six-level classifi ca-
tion scheme ( Figure 20-1 ) has been developed to guide the
approach based on the location of the tumor. 1 , 9
A complete history and physical examination of a
patient can provide clues to the location and extent of
a tumor. Often, the clinical presentation is vague and
nonspecifi c until the tumor has grown to a large size. The
pathophysiology of the specifi c signs and symptoms may
depend on whether the tumor is benign or malignant. With
benign tumors, signs frequently result from compression of
adjacent tissues. For example, a patient with an angiofi -
broma may present with nasal obstruction and a patient
with fi brous dysplasia may present with proptosis. Signs of
malignant tumors are often changes in the function of the
tissues due to invasion by the lesion, such as headaches,
focal seizures, loss of cranial nerve function, altered facial
animation, and visual changes.
Once a thorough understanding of the patient’s clinical
presentation and defi cits related to the tumor is established,
further workup should include computed tomography with
true coronal cuts as well as magnetic resonance imaging.
Angiography may provide added benefi t in select patients.
Tissue diagnosis through biopsy, when feasible, is always
preferred, but surgical resection can proceed with open
biopsy and frozen section analysis before full exposure is
undertaken or critical structures are sacrifi ced.
An essential component of evaluating a patient is a
multidisciplinary team approach. The skills and training
from several surgical disciplines are required to manage
the complex needs of a patient with a skull base tumor.
A skull base team can establish a centralized center where
patients are referred for the treatment of these rare skull
base tumors. This allows for adequate volume to maintain
a high skill level, to conduct research in order to refi ne
surgical techniques, and to improve outcomes. Specialties
involved include the core specialties of neurosurgery, plas-
tic surgery, and head and neck surgery as well as neurol-
ogy, radiation oncology, endovascular radiology, oncology,
ophthalmology, and neurorehabilitation. Coordinated
care through a team approach improves communication
between physicians, facilitates development of a superior
treatment plan, and assists in follow-up and discussions of
morbidity and mortality, ultimately giving the patient the
best chance for a successful outcome.
PATIENT PREPARATION
A full discussion of the potential risks and complications
associated with the procedure is necessary, as well as ensur-
ing that the expectations of the patient and surgeon are
in congruity. The risks of craniotomy include neurologic
injury, bleeding, infection, cerebrospinal fl uid (CSF) leak.
Other possible risks include alteration of orbital adnexal
function, such as extraocular muscle imbalance, visual loss,
altered globe position, and alteration of blink dynamics,
tear production or drainage. There can be loss of olfaction,
temporary or permanent change of facial sensation, brow
weakness or paralysis, or change in orbital nasal confi gura-
tion. Soft tissue contour defects can result if temporalis
or forehead galeal muscle fl aps are used. With extracra-
nial approaches (levels I–III), there can be malocclusion
requiring secondary surgery or orthodontic correction or
loss of segmental circulation which may result in an orona-
sal fi stula and abnormal speech. In children, there may be
loss of secondary tooth buds.
Preparation for patients undergoing a level IV or V
approach requires additional workup. The maxillary-
mandibular relationship and occlusal relationship need
c h a p t e r

210 • CHAPTER 20
to be documented with life-size photographs, dental
models, and x-rays, including occlusal views, anteropos-
terior and lateral cephalometrograms as well as a pan-
oramic of the mandible. A presurgical acrylic splint is
fabricated, making sure it is deep enough to allow the
two palatal halves to snap into splint, reducing the need
for arch bars.
SURGICAL TECHNIQUE
Classifi cation of Transfacial Approaches
The transfacial approach can be divided into six levels
based on the anatomic location of the lesion and the pat-
tern of extension. The kyphotic shape of the skull base is
perpendicular to the vertical plane of the face and calls
for a more superior approach through the frontonasal
region for lesions with anterior extension, while posteri-
orly located lesions with superior extension would require
a more inferior or transmaxillary approach. The surgery
can be customized for each patient based on the best
angle of approach, combining intracranial and extracranial
approaches, if needed.
The upper three approaches (levels I– III) are derived
from the supraorbital bar ( Figure 20-2 ). By removing the
supraorbital bar, in continuity with the naso-orbital com-
plex, the approach is extended vertically to include the
entire midline skull base. Removal of the naso-orbital
complex increases the degree of horizontal extension, and
an even greater exposure can be obtained by combining
levels II and III with a circumferential cribriform plate
osteotomy, which allows brain retraction but preserves
olfaction. The lower three approaches (levels IV–VI) pro-
vide exposure to the skull base through the maxilla. The
level IV exposes the entire midline skull base, the level V
exposes the lower half, and the level VI exposes the lower
third ( Figure 20-3 ).
Intracranial Approaches (Levels I–III)
Patient Positioning . The patient in placed in the supine
position and general anesthesia is introduced through an
orotracheal tube. The tube can be secured to the lower
dentition with a 26-gauge wire to allow for unobstructed
access to the surgical fi eld. After monitoring lines and
intravenous lines are placed, prophylactic antibiotics are
A
B
FIGURE 20-1. (A) Region of tumor sites in the anterior skull base and clivus that
can be exposed by direct anterior transfacial routes. (B) Summation of the six levels
demonstrating that the anatomical site of the tumor and direction of growth determine the
level of the transfacial exposure. (With permission from Barrow Neurological Institute.)

SKULL BASE SURGERY • 211
FIGURE 20-2. The three intracranial approaches
represent variations of the amount of bone resected with the
supraorbital bar. The shaded areas indicated by the numbers
1, 2, and 3 represent the amount of exposure for levels I, II,
and II, respectively. (With permission from Barrow Neurological
Institute.)
FIGURE 20-3. The extracranial approaches provide
increasing exposure as more of the maxilla is removed. The
shaded areas indicated by the numbers 4, 5, and 6 represent
the amount of exposure for levels IV, V, and VI, respectively.
(With permission from Barrow Neurological Institute.)
given and a lumbar drain is inserted, if indicated. Rigid
three-point fi xation is used to position the patient’s
head, placing the tongs posterior to the ears to allow for
a more posterior bicoronal incision. The ISG Frameless
Stereotactic Guidance System Wand is attached, and
fi duciary reference points are correlated with the MRI
and then registered. The patient’s face, scalp, and any
other anticipated donor sites for reconstruction are
prepped and draped. Temporary tarsorrhaphy sutures
using 5-0 cardiovascular silk are placed for corneal
protection.
Level I—Transfrontal Approach . This approach is indi-
cated for tumors of the anterior cranial fossa and the
superior orbital region ( Figure 20-4 A–C). A bicoronal
incision is placed posteriorly (in line with the preauricular
crease) to allow for potential pericranial and frontal gal-
eal fl aps of adequate length ( Figure 20-5 ). Dissection is
continued until the radix and superior orbits are exposed
and the temporalis muscles are refl ected. A bifrontal
craniotomy is performed and the dura is retracted from
the anterior cranial fossa. The supraorbital bar is removed
( Figure 20-4 C).
After tumor resection, a pericranial fl ap, cranial
autografts, and fi brin glue are used to reconstruct a water-
tight separation between the nasopharynx and the cra-
nial fossa. The supraorbital bar is fi xated with plates and
screws.
Level II—Transfrontal Nasal . This approach is indicated
for tumors of the anterior cranial fossa, nasopharynx, eth-
moidal and sphenoidal sinuses, clivus, and tumors that
extend anteriorly or into the superior, medial, and lateral
aspects of the orbit ( Figure 20-4 D–F). A bicoronal inci-
sion as in a level I approach is used. Dissection is con-
tinued until the radix, nasal bones, nasal process of the

212 • CHAPTER 20
FIGURE 20-4. Composite illustration showing the levels of exposure for the three intracranial approaches and the
osteotomies required for each. (A) Level I transfrontal exposure for anterior cranial fossa. (B, C) Level I exposure requires removal
of the supraorbital bar. (D) Level II transfrontal nasal exposure for anterior approach to the anterior cranial fossa and clivus. (E, F)
Level II exposure requires removal of the frontonasal fragment. (G) Level III transfrontal nasal-orbital exposure for larger lesions of
the anterior cranial fossa, nasopharynx, and clivus. This approach is similar to level II, except that it provides a wider exposure by
allowing lateral retraction of the globes (see Figure 20-4D). (H, I) Level III exposure requires inclusion of the lateral orbital walls on
the frontonasal fragment (frontal nasal-orbital unit). (With permission from Barrow Neurological Institute.)
A
B
C
D
E
F
G
H
I

SKULL BASE SURGERY • 213
maxilla, and the superior orbits are exposed. The perior-
bita is stripped, taking great care to preserve the nasolac-
rimal ducts. The medial canthal ligaments are taken down,
with a small fragment of bone if desired. The upper lat-
eral nasal cartilages are detached from beneath the caudal
margin of the nasal bones, and nasal mucosa dissected
off the nasal bones. The temporal muscles are refl ected
and a bifrontal craniotomy is performed as in a level I
approach. The supraorbital bar is removed in continuity
with the nasal complex and medial orbital walls to the
anterior ethmoid foramen ( Figure 20-4 F).
Level III—Transfrontal Nasal-Orbital . This approach is
indicated for large anterior cranial fossa or nasopharyn-
geal tumors or for clival tumors with anterior extensions
( Figure 20-4 G–I). The dissection proceeds as in the level II
approach, but when the osteotomies are made, the lateral
orbital walls are included with the supraorbital segment
from the level of the inferior orbital fi ssure. A majority
of the orbital roof can also be included. This allows for
lateral retraction of the globes to allow for greater mid-
line exposure when compared with the level II exposure
( Figure 20-4 I).
After tumor resection, skull base reconstruction is
achieved with a pericranial or temporalis fl ap and cranial
autografts as needed. The upper lateral cartilages are reat-
tached to the nasal bones and transnasal wiring is used to
repair the medial canthal ligaments. The frontonasal frag-
ment is secured with rigid fi xation.
Cribriform Plate Preservation . When performing a
level II or III approach, the integrity of the cribriform
plate and olfactory nerves can be preserved when they
are not involved with tumor. This is accomplished with a
circumferential osteotomy and allows for increased pos-
terior exposure, simplifi ed skull base reconstruction, and
reduced risk of CSF leak all while preserving olfaction. 10
After the craniotomy for the level II or III approach is
completed, the dura is separated from the anterior cranial
fossa as previously described. Osteotomies are performed
to remove the frontonasal or the frontonasal-orbital unit,
leaving the cribriform plate behind ( Figure 20-6 ). The
cribriform plate is osteotomized along its lateral margins
into the ethmoidal sinuses. The fi nal cut is made through
the planum sphenoidale ( Figure 20-6 C). While carefully
preserving a cuff of nasal mucosa and septum, attached
to the inferior side of the plate, the perpendicular plate
of the ethmoid is cut, freeing the cribriform plate and
allowing retraction with the dura ( Figure 20-6 D). After
resection of the tumor, reattachment of the plate is accom-
plished with stainless steel wires before reconstruction as
described for the intracranial procedures.
Extracranial Approaches
(Levels IV through VI)
Patient Positioning . The patient in placed in the supine
position and general anesthesia is introduced through
an orotracheal tube or a temporary tracheostomy. With
orotracheal intubation, the tube can be secured to the
lower dentition with a 26-gauge wire. After monitoring
lines and intravenous lines are placed, prophylactic
antibiotics are given and a lumbar drain is inserted, if
indicated. Rigid three-point fi xation is used to position
the patient’s head, placing the tongs posterior to the
ears to allow for a more posterior bicoronal incision. The
ISG Wand is attached, and fi duciary reference points
are correlated with the MRI and then registered. The
patient’s face, scalp, and any other anticipated donor sites
for reconstruction are prepped and draped. Temporary
tarsorrhaphy sutures using 5-0 cardiovascular silk are
placed for corneal protection. An epinephrine solution is
infi ltrated into the upper buccal sulcus and mucosa in the
anterior maxillary region.
Level IV—Transnasomaxillary . This approach is indi-
cated for large nasopharyngeal and clival tumors that
extend in any direction. It provides wide exposure to
the entire central skull base region ( Figure 20-7 A–D).
The transnasomaxillary approach is performed through a
modifi ed Weber-Ferguson incision. This is continued across
the radix and along the opposite subciliary margin of the
lower lid ( Figure 20-7 B). Plates are adapted that will be
used for fi xation, and then a LeFort II osteotomy is per-
formed. The nasal fragment is divided at the nasal process
of the maxilla on one side and at the midline of the palate
( Figure 20-7 C–D). The nasal soft tissue remains intact and
is retracted with the fragment.
FIGURE 20-5. Frontogaleal and pericranial fl aps must
be preserved during the initial dissection. (With permission from
Barrow Neurological Institute.)

214 • CHAPTER 20
After tumor resection, the skull base defect may require
a fat graft or bone graft before mucosal closure. Fibrin glue
can then be used to seal the margins and create a water-
tight closure. Reconstruction then proceeds with the pre-
registered plates and an acrylic splint (prepared ahead of
time from dental models). The facial incisions are closed
precisely to maximize the aesthetic result. The splint is left
in place for 7 to 10 days and a liquid diet is recommended
for 4 weeks.
Level V—Transmaxillary . This approach is indicated
for moderate-sized clival tumors with superior, poste-
rior, and inferior extensions and small to moderate-sized
nasopharyngeal tumors ( Figure 20-7 E–G). An upper labial
sulcus incision is used to expose the anterior maxilla. A
LeFort I osteotomy is performed after adapting plates
for later fi xation, and the segment is displaced inferiorly
providing adequate exposure. When more exposure is
required, a midline palatal split and soft palate division on
one side of the uvula is made. The two maxillary fragments
can then be rotated laterally to expose the clivus ( Figure
20-7 G). For additional exposure, the pterygoid plates can
be included on the fragments.
After tumor resection, a dermal fat graft or bone graft
and fi brin glue are used to reconstruct the skull base defect.
The preregistered plates and interdental splints are used
to complete the facial reconstruction. The splint is left in
place for 7 to 10 days and a liquid diet is recommended
for 4 weeks.
Level VI—Transpalatal . This approach is indicated
for small tumors of the lower clival and upper cervical
FIGURE 20-6. (A) Anterior cranial fossa demonstrating
the initial circumferential cribriform plate osteotomies.
(A) anterior osteotomy; (B, C) parasagittal osteotomy;
(D) posterior osteotomy through the planum sphenoidale.
The additional lines indicate osteotomy cuts for removal of
the fronto-nasal-orbital unit. (B) All osteotomy cuts, except
for the posterior cut, are performed to allow removal of the
fronto-nasal-orbital unit.
A
B

SKULL BASE SURGERY • 215
FIGURE 20-6. (continued) (C) The fi nal, posterior osteotomy through the planum
sphenoidale is performed with appropriate retraction of the frontal lobe dura and
paranasal soft tissues. (D) After the trabeculae are divided and a generous cuff of mucosa
is left intact, the intact cribriform plate unit is released from the skull base. (With permission
from Barrow Neurological Institute.)
C
D

216 • CHAPTER 20
A
D
G
B
E
H
J
I
C
F
FIGURE 20-7. Composite illustration showing the levels of exposure for the three extracranial transfacial approaches and
the osteotomies required for each. (A) Level IV transnasomaxillary approach yields a wide exposure of the entire central skull
base from the radix to the craniocervical junction. A similar degree of exposure can usually be obtained with a combination of
the level III and level V exposures. (B) Skin incisions for the transnasomaxillary approach. (C) Level IV exposure requires a LeFort
II osteotomy and then (D) splitting of the maxillary fragment. (E) Level V transmaxillary approach provides exposure of the clivus
and nasopharyngeal area. (F) Level V exposure requires a LeFort I osteotomy and (G) splitting of the palate for further exposure.
(H) Level VI transpalatal approach provides access to the lower clivus and upper cervical region. Level VI exposure requires an
(I) osteotomy and (J) removal of the hard palate. (With permission from Barrow Neurological Institute.)

SKULL BASE SURGERY • 217
regions ( Figure 20-7 H–J). An upper labial sulcus incision
is made and the nasal fl oor is exposed. The palatal mucosa
is incised in the midline and the soft palate is divided on
one side of the uvula. The mucoperiosteal fl aps are then
elevated, and the hard palate is osteotomized. The septum
and nasal groove are separated along the nasal fl oor, and
cuts are made in the lateral nasal wall into the antra with
an osteotome. The hard palate is removed and the soft pal-
ate is retracted laterally. When more exposure is required,
the vomer and perpendicular plate of the ethmoid can be
removed with a rongeur.
After tumor resection, a dermal fat graft or bone graft
and fi brin glue are used as indicated to reconstruct the
skull base defect. The hard palate is then secured with
microplates for rigid fi xation. The soft tissue is repaired
with absorbable sutures.
Combined Surgical Approaches
Any of the transfacial approaches may be combined to
provide an overlapping range of exposure for a lesion. The
combination of a level II or III and a level V approaches
achieves exposure to the entire anterior cranial fossa and
midline skull base. When intracranial and extracranial
approaches are combined, the intracranial approach is per-
formed fi rst. The tumor is resected from skull base and
dural integrity restored. Then the extracranial approach is
performed, removing the remaining portion of the tumor.
Facial reconstruction is then completed and the incisions
closed.
COMPLICATIONS
The most serious complications that are life-threatening
and result in lifelong functional defi cits are neurologic.
Wide exposure is essential to minimize brain retraction,
to allow good visualization for complete tumor resection,
and to provide enough space for reconstruction of the dura
with a watertight closure. While wide exposure may seem
radical, it actually speeds up surgery, thus making it safer.
The ISG localizing wand gives greater accuracy in localiz-
ing vital structures affected by tumor and allows the resec-
tion to be more complete.
Wound complications after skull base surgery are some
of the most challenging that plastic surgeons face. The
goals of reconstruction are to support the brain, contain
CSF, and provide a watertight sealing of the compartment
from contamination. Unfortunately, the area is often pre-
disposed to wound healing problems due to prior surgery,
irradiation, or dead space. Pericranial fl aps and tempora-
lis fl aps are the fi rst choice in helping to seal skull base
defects. The frontogaleal fl ap leaves the forehead skin
thin, predisposing it to break down, and should be used as
a last resort to seal midline defects. The risk of breaking
the reconstructive seal with a Valsalva maneuver is pres-
ent for at least 3 months after surgery, and possibly life-
long. A fl imsy reconstructive fl ap and granulation tissue
will not seal the defect effectively and hold up to forces
created by a Valsalva maneuver, often resulting in infec-
tious complications. Therefore, an adequate reconstruc-
tion is critical.
A CSF leak can doom any skull base reconstruction and
can occur despite ideal repair. During the early phase, a
lumbar drain is used routinely for 3 to 5 days along with
prophylactic antibiotic therapy. If the leak fails to resolve
after this time period, localization studies and exploration
of the wound is undertaken. Direct repair is preferred for
small defects if the adjacent tissues are of good quality.
Reinforcement with a fat or muscle graft or a local fl ap, if
available, and fi brin glue is ideal. If the defect is large, or
is due to necrosis or fl ap infection, debridement and sec-
ondary reconstruction is performed. Fastidious attention
to detail in the reconstruction of the skull base is essential
in prevention a CSF leak. Close postoperative surveillance
and early intervention are critical to successful manage-
ment of a postoperative CSF leak.
Malocclusion after level IV and V approaches is usu-
ally avoidable with precise technique and adequate preop-
erative preparation. In patients who undergo a two-piece
transmaxillary (level V) approach, a fi xation plate or lag
screw placed between the two fragments is essential. A
plate can be placed on the nasal fl oor anteriorly or across
the anterior nasal spine region. Postoperative intermaxil-
lary fi xation is not routinely used. If a postoperative mal-
occlusion occurs and is not correctable with orthodontic
treatment, secondary osteotomy at an appropriate time
postoperatively is necessary to correct it.
Speech abnormalities can occur not only because of
neurologic complications, but also due to a palatal split.
Spontaneous improvement is usually noted as the soft pal-
ate and nasopharynx heal. Velopharyngeal insuffi ciency
can result secondary to irregularities and concavity of the
clival and vertebral junction in the region of the nasophar-
ynx. Speech evaluation with nasoendoscopy can aid in
diagnosing the cause.
A palatal fi stula can occur after a palatal split and is usu-
ally related to surgical technique. Secondary repair may be
necessary using palatal fl aps to line the nasal and oral sides
of the fi stula.
Approaches that require an osteotomy near the nasolac-
rimal duct or require an actual transection of the duct may
result in epiphora postoperatively. The surgeon should
look for duct disruption during reconstruction and repair
and cannulate as indicated. When transection is required,
the duct can be repaired over tubes during reconstruction.
If postoperative epiphora is persistent, workup is indicated
and occasionally a dacryocystorhinostomy is needed.
Orbital volume must be restored to maintain symme-
try and globe position. This is accomplished with anatomic
reconstruction of the orbital walls. When a large portion
of the orbit is removed during resection of the tumor, this
reconstruction can prove diffi cult. If enophthalmos occurs
postoperatively, secondary reconstruction of the orbit with
autogenous bone grafts is indicated. Strabismus can occur
after orbital surgery and may require surgical correction.

218 • CHAPTER 20
REFERENCES
1. Beals SP, Joganic EF. Transfacial exposure of anterior cranial
fossa and clival tumors. BNI Q. 1992;8(4):2–18.
2. Sandor GK, Charles DA, Lawson VG, et al. Tran-
soral approach to the nasopharynx and clivus using the
LeFort I osteotomy with midpalatal split. Int J Maxillofac
Surg. 1990;19(6):352–355.
3. Spetzler RF, Pappas CT. Management of anterior skull base
tumors. Clin Neurosurg. 1991;37:490–501.
4. Cocke EW Jr, Robertson JH, Robertson JT, et al. The exten-
ded maxillotomy and subtotal maxillectomy for excision
of skull base tumors. Arch Otolaryngol Head Neck Surg.
1990;116:92–104.
5. Brown AM, Lavery KM, Millar BG. The transfacial approach
to the postnasal space and retromaxillary structures. Br J
Oral Maxillofacial Surg. 1991;29:230–236.
6. Weissler MC. Transoral approaches to the skull base. Ear
Nose Throat J. 1991;70(9):587–592.
7. Osguthorpe JD, Patel S. Craniofacial approaches to tumors
of the anterior skull base. Otolaryngol Clin North Am.
2001;34(6):1123–1142,ix.
8. Beals SP, Joganic EF. In: Dickman C, Spetzler RF, Sonntag
VKH, et al. Surgery of the Craniovertebral Junction. New
York: Thieme; 1998:395–418.
9. Beals SP, Hamilton MG, Joganic EF, et al. Classifi ca-
tion of transfacial approaches in the treatment of tumors
of the anterior skull base and clivus. Plast Surg Forum.
1993;16:211–213.
10. Spetzler RF, Herman JM, Beals S, et al. Preservation of
olfaction in anterior craniofacial approaches. J Neurosurg.
1993;79(1):48–51.
11. Solares CA, Ong YK, SNyderman CH. Transnasal endoscopic
skull base surgery: what are the limits? Curr Opin Otolaryn-
gol Head Neck Surg. 2010;18:1–7.
OUTCOMES ASSESSMENT
Although skull base tumors remain challenging and have
been associated, in the past, with formidable morbidity and
mortality, the emergence of cranial facial disassembly has
provided an avenue of safe, wide exposure of this critical
region. The past several decades have shown progressively
improving survival rates with curative skull base resection.
Furthermore, the concomitant evolving techniques and
technology offered by a comprehensive skull base team
continues to offer profi cient management of such complex
cases. There has been some promise that transnasal endo-
scopic techniques may be successful in managing a subset
of patients in a minimally invasive manner. 11 Ultimately,
the skull base surgeon can often offer a versatile treatment
strategy, and thus the patient can face his or her treatment
with confi dence.

c h a p t e r
Overview of Facial Fractures
Alexandre Marchac, MD / Jeffrey D. Larson, MD / Stephen M. Warren, MD
INTRODUCTION
In the latter half of the twentieth century, radiologic and
implant advancements substantially improved the diag-
nosis, management, and treatment of facial fractures. In
addition, the widespread acceptance of the concept of
facial buttresses simplifi ed complex fracture management.
The bones of the face are lightened by pneumatic cavities
(sinuses) and reinforced by vertical and horizontal pillars
(ie, buttresses). These buttresses are linked to the cranial
base either directly or indirectly. The buttresses provide
support as well as projection for the overlying soft tissues.
The buttress concept does not change the classic anat-
omy of the face, but the concept is surgically important.
Buttresses not only represent areas of bony condensation
that conveniently hold screws and plates, but anatomic
reduction of fractured buttresses will restore facial con-
tour. Following Paul Mason’s work on the structural pil-
lars of the facial skeleton, Gruss and Mackinnon described
four paired vertical buttresses in the face: (1) anterior
medial or nasomaxillary, (2) anterior lateral or zygoma-
ticomaxillary, (3) posterior or pterygomaxillary buttress,
and (4) posterior vertical or mandibular ramus. Anatomic
reduction of these vertical buttresses restores facial
height. Of note, the posterior vertical maxillary buttress
can be ignored if the two anterior maxillary (medial and
lateral) and the vertical mandibular buttresses (ramus) are
restored. Four paired transverse buttresses maintain facial
profi le and width to the face: (1) upper transverse maxil-
lary (orbital fl oor), (2) lower transverse maxillary (palate),
(3) upper transverse mandibular, and (4) lower transversal
mandibular buttresses. Adequate anatomic reduction of
these buttresses restores facial width and provides func-
tional support for the globes and teeth.
PATIENT EVALUATION
Kelley 1 showed that in a level 1 urban trauma center, the
mechanism for facial fractures where largely dominated
by assault and interpersonal violence (50%), followed by
motor vehicle accidents (28%), gunshot wounds (13%),
fall (5%), automobile-pedestrian accidents (3%), contact
sports (2%), and stab wounds (2%). Drugs and/or alcohol
commonly fuel these traumatic events.
In a conscious patient, the examination begins with a
history of the event, with particular attention paid to loss
of consciousness, symptoms of intracranial trauma (head-
ache, confusion, etc), medications, and last meal. The
examination of the face begins with a general inspection
for obvious deformity or asymmetry. All bony surfaces
should be palpated: forehead, superior and inferior orbital
rims, nasal bones, cheek bones, and borders of the mandi-
ble (Figure 21-1). The auditory canals should be evaluated
for hemotympanum, which would indicate a skull base
fracture. Any face examination must include documen-
tation of vision and extraocular movements; this can be
done with a pocket Snellen chart in the awake patient and
response to light in the unconscious or sedated patient.
The surgeon should also inspect the nose and look for a
septal hematoma, which should be incised and drained to
prevent septal necrosis. The intraoral area must be exam-
ined for step-offs or lacerations, and the examiner must
take care to protect his or her hands during this examina-
tion, as the unconscious or combative patient may bite
down on an examiner’s fi nger (Figure 21-2). Occlusion is
to be assessed by asking the patient to clench his teeth and
describe any abnormalities. Maxillofacial instability, indi-
cating a possible LeFort injury, is evaluated by manipulat-
ing the upper dentition (Figure 21-3). Sensory function
21

220 • CHAPTER 21
(cranial nerve V) can be assessed by lightly touching the
patient on both sides of the face and assessing for sym-
metrical sensation. Motor function (cranial nerve VII) is
assessed by asking the patient to raise his eyebrows, smile
and frown, and observing for symmetry.
Most imaging requirements for diagnosing facial frac-
tures are met by the maxillofacial computed tomography
(CT) scan and should be obtained before contacting sub-
specialty services. Thanks to the technological advances of
modern imaging, there is little indication for plain fi lms,
although isolated mandible fractures can be adequately
imaged by low Townes and panorex x-rays. Nevertheless,
panorex requires the patient to sit during the examination,
and is commonly unavailable at night.
FIGURE 21-2. Injury sustained during intraoral
examination. Note right and left central incision marks on the
index fi nger eponychium.
A
B
C
FIGURE 21-3. Endoscopic treatment of depressed frontal sinus fracture. (A) Axial
CT image demonstrating depressed anterior table frontal sinus fracture; (B) dashed inner
line marks the borders of the fracture. The solid outer line marks the estimated size of
the titanium mesh. Note the right medial eyebrow incision used to allow elevation of the
fracture fragments. (C) Endoscopic image of titanium mesh in situ. Note a screw has
been placed transcutaneously to affi x the fracture fragments to the titanium mesh.
Computed tomography has become the gold standard
for imaging the craniofacial skeleton in facial trauma.
Panorex radiograph is useful in diagnosis of mandibu-
lar injuries, but it requires a cooperative patient. Two-
dimensional CT and three-dimensional reconstructions
allow precise diagnosis and valuable tools in preopera-
tive planning.
First developed for dental purposes, cone beam com-
puted tomography (CBCT), where a cone-shaped beam
captures a cylindrical volume much faster than conven-
tional slice CT (10–17 s), with a lower radiation exposure,
and with less metallic artifacts than CT, yields some very
promising applications in facial trauma, including intraop-
erative imaging. 2 Two-dimensional and three-dimensional
CT navigators are now available to the surgeon in the oper-
ating room. Software like Osirix, a free, open-source soft-
ware for navigating in multidimensional, DICOM (Digital
Imaging and Communications in Medicine) images, allows
A
B
C
FIGURE 21-1. Inspection and palpation of patient
with facial injuries. (A) Palpation of inferior orbital rim;
(B) determining stability of the nasal pyramid; (C) determining
stability of the midface.

OVERVIEW OF FACIAL FRACTURES • 221
the surgeon to do, on his laptop, most of the complex
3D maneuvers that radiologist perform on desktop com-
puters. 3 Overall, these technological improvements in
craniofacial imaging allow better preoperative planning
and intraoperative control over the reduction of the bone
fragments. This is particularly useful in panfacial “smashed”
fractures, when all anchor points have been displaced.
PATIENT PREPARATION
Treatment of facial fractures should be scheduled in the
days following injury (2–3 d) as early as possible. A team
approach is necessary in the case of multisystem injuries to
coordinate a long facial reconstruction before critical sys-
temic complications occur such as pulmonary, hepatic, or
renal dysfunction. Moreover, the surgeon should not wait
for the patient’s neurologic prognosis to be determined,
because doing so often results in untreated fractures and
secondary facial deformities. If thoracic or abdominal
surgery is required, facial reconstruction can be delayed.
Mandibulomaxillary fi xation (MMF), however, can easily
be combined with chest or abdominal surgery in order to
initiate the treatment of panfacial/midfacial injuries to
stabilize the fractures and reduce blood loss.
If spine injury has not been ruled out by physical
examination and MRI (ligamentous injuries cannot be
detected on CT scan), the cervical spine must be immo-
bilized during the operation. Nasotracheal intubation
facilitates MMF, but oronasal bleeding can cause fi berop-
tic intubation to be diffi cult. Tracheostomy may be neces-
sary for airway protection.
In addition to the initial eye examination, the surgeon
should make a careful assessment of the patient’s pupil
diameter and responsiveness prior to incision. This
will allow for comparison at the end of the operation.
Preoperative assessment of lower lid laxity and posi-
tion is important. Patients with lower lid laxity are best
treated with a lateral canthopexy and/or Frost stitch to
avoid ectropion and sclera show. When operating near
the orbit, it is important to document function of the
intraocular muscles. Rectus muscle entrapment should
be diagnosed by a forced duction test before and after
the procedure.
TREATMENT
Frontal Sinus Fractures
Frontal sinus fractures occur in 5% to 12% of all facial
fractures and are associated with 32% of panfacial/maxil-
lary fractures. Of the patients with frontal sinus fractures,
35% present with concomitant orbital fractures, 17%
with zygomatic fractures, and 15% with naso-orbitoeth-
moid (NOE) fractures. Frontal sinus fractures may be
considered in four categories: (1) isolated anterior table
fractures; (2) combined anterior and posterior table fac-
tures; (3) fractures with nasofrontal duct injury; and (4)
isolated posterior table fractures with or without dura
mater or brain injury.
Frontal sinus fracture patterns that include the ante-
rior table will induce a contour deformity of the forehead.
The subjective degree of comminution, depression, and
contour deformity will determine the treatment strategy.
Minor injuries may be observed. More modest injuries will
require bone fragment elevation. Traditionally, a coronal
incision has been used to gain access to the anterior table.
Recently, the endoscopic approach has become popular. 4
Isolated anterior wall fractures can be repaired using the
endoscope. Small scalp incisions (usually two) are placed
1cm behind the hairline and a third incision is sometimes
placed in the medial aspect of the eyebrow (Figure 21-3).
Dissecting in a subperiosteal plane, the fracture fragment
is repositioned using a threaded fragment manipulator
(a long, self-drilling, 2.0-mm screw inserted through a
small stab incision on the forehead) or using an elevator
inserted through the medial eyebrow incision. The frag-
ment is fi xed with a miniplate (titanium or resorbable)
and self-tapping screws. 4 If the fracture is severely commi-
nuted, endoscopic reduction and fi xation of the outer table
is unlikely to succeed and a coronal approach should be
used. In unrepaired fractures resulting in a contour defor-
mity of the forehead, Mueller proposes a delayed endo-
scopic approach (.3 months) to camoufl age the defect
with hydroxyapatite cement, porous polyethylene custom
implants or 0.85-mm porous polyethylene sheets inserted
endoscopically. 4 Caution should be exercised against plac-
ing alloplastic materials in or around open or potentially
communicating sinuses.
The importance of combined anterior/posterior table
factures as well as isolated posterior table fractures lies in
the presence or absence of concomitant nasofrontal duct
and/or dura mater injuries. The drainage to the frontal sinus
is provided by ostia which are located bilaterally in the
posteromedial aspect of the frontal sinus fl oor. These ostia
drain caudally into the nasal cavity by means of the fron-
tal recess or nasofrontal duct and empty into the middle
meatus. Determining whether the nasofrontal ducts have
been obstructed by the traumatic event can be diffi cult.
The surgeon should examine CT looking for comminution
in the superior portion of the uncinate process (anterior
border of the nasofrontal duct), the superior portion of
the bulla ethmoidalis (posterior border of the nasofron-
tal duct), the conchal plate (medial border of the nasof-
rontal duct), and the suprainfundibular plate (lateral border
of the nasofrontal duct). If the nasofrontal ducts appear to
be patent, then the anterior/posterior table fracture pat-
tern can be treated as an isolated anterior table fracture
(if there is no dural injury). If the nasofrontal ducts appear
to be patent, then the isolated posterior table fracture can
be observed, unless, again, there is a dural injury.
When the nasofrontal ducts are injured, the surgeon has
fi ve options: (1) ablation, (2) exenteration, (3) frontoeth-
moidectomy, (4) obliteration, or (5) cranialization. When
the anterior and posterior tables are comminuted, ablation
of the frontal sinus can be performed. Ablation (or the
Riedel procedure) is the removal of both the anterior and
posterior tables of the frontal sinus. 5 While effective, this

222 • CHAPTER 21
procedure results in an unacceptable aesthetic result and,
therefore, should be reserved for select cases. Exenteration
is the removal of the anterior table of the frontal sinus. 6
Like the Riedel procedure, exenteration is effective, but it
results in an unacceptable aesthetic result.
In 1921, Lynch described an external frontoethmoidec-
tomy performed through a relatively small and aestheti-
cally acceptable curvilinear incision located half way
between medial canthus and nasal dorsum. 6 The Lynch
procedure provided access to the ipsilateral frontal sinus
enabling the surgeons to create a frontonasal communica-
tion by removing a portion of the nasal septum and nasal
fl oor of the frontal sinus. In the mid-1990s, the Lothrop
and modifi ed-Lothrop procedures were introduced. These
endonasal procedures enabled the removal of the inferior
portion of the interfrontal septum, the superior part of
the nasal septum, and the frontal sinus fl oor to the orbits
bilaterally. The lamina papyracea and posterior walls of the
frontal sinus remained intact. The endonasal frontoeth-
moidectomy can restore adequate drainage of the frontal
sinus, but does not provide access for reconstruction of a
comminuted, depressed anterior table.
Obliteration is the complete removal of frontal sinus
mucosa. 7 Typically, this is performed by removing the
anterior table, staining the frontal sinus mucosa with
methylene blue, and then burring the sinus to remove
the mucosa and their podocytic invaginations into the
vascular pits of Breschet (Figure 21-4). The nasofrontal
ducts are occluded with bone, fat, muscle, fascia, or peri-
cranial tissue, and anterior table is affi xed orthotopically
with resorbable or titanium miniplates.
When the posterior table is comminuted and the naso-
frontal outfl ow tracts are obstructed, cranialization is a sim-
ple procedure that allows the removal of the frontal sinus
and preservation of the forehead contour (Figure 21-5). 8
After performing an anterior table frontal sinusotomy, the
comminuted posterior table is removed, the nasofrontal
ducts are occluded with bone, fat, muscle, fascia, or peri-
cranial tissue, and the anterior table is affi xed orthotopi-
cally with resorbable or titanium miniplates. 9 The space
formerly occupied by the frontal sinus is replaced by the
anterior expansion of the frontal lobes.
Frontobasal Fractures
Frontobasal fractures result from high-energy trauma.
These skull based fractures are commonly found in asso-
ciation with NOE, non-LeFort, and LeFort fractures.
Frontobasal fractures can lead to signifi cant neurological
morbidity. Manson et al. 10 recently established a fronto-
basal classifi cation scheme: Type I fractures are isolated
linear cranial base fractures; type II fractures are vertical
linear fractures of the frontal bone (skull vault) and base;
and type III fractures are characterized by comminution
of the entire lateral and frontal skull vault and orbital roof.
The incidence of cerebrospinal fl uid (CSF) fi stula and
A
D
B
E
C
F
FIGURE 21-4. Obliteration of the frontal sinus. (A) Axial CT image demonstrating
anterior table frontal sinus fracture with comminution of the nasofrontal ducts;
(B) elevation of a pericranial fl ap. (C) The perimeter of the anterior table has been marked
in blue. (D) The anterior table of the frontal sinus has been removed and the mucosa has
been stained with methylene blue. (E) The frontal sinus mucosa has been removed with a
bur. (F) The comminuted nasal frontal ducts have been packed with bone; the pericranial
fl ap has been placed in the frontal sinus, and the anterior table has been replaced.

OVERVIEW OF FACIAL FRACTURES • 223
meningitis, the two most acute deleterious outcomes of
frontobasal fractures, relies heavily on the fracture pattern
and associated midfacial injury (eg, LeFort II/III and NOE
fractures). “Impure” fractures account for half of all fron-
tobasal fractures and for more than two thirds of compli-
cations. Half of all types II and III frontobasal fractures
have an associated NOE fracture in comparison with only
every fourth type I fracture. Naso-orbitoethmoid fractures
are more likely to produce a complication than LeFort
fractures because of its anatomical relationship to the
nasofrontal outfl ow tract.
Naso-Orbitoethmoid Fractures
Clinically, NOE fractures differ from simple nasal frac-
tures by an apparent telecanthus (increased distance
between the internal canthi), globe malposition, and
a loss of nasal projection in profi le (Figure 21-6). The
medial canthal region, the ethmoids and the medial
orbital walls are fractured. This corresponds to a disrup-
tion of the medial and upper transverse maxillary but-
tresses. The medial canthal ligament can be avulsed from
its osseous insertion, in the region of the lacrymal fossa,
causing lateral drifting of the internal canthus and loss
of the normal shadow defi nition of the brow-nose line.
The Manson classifi cation of NOE fractures is based on
the degree of injury to the medial canthal attachment
(Figure 21-7). A type I fracture involves a large bone frag-
ment, displaced only inferiorly at the infraorbital rim and
A
C
B
D
FIGURE 21-5. Cranialization of the frontal sinus.
(A) Perimeter of the frontal sinus outlined in blue. (B) After
removal of the anterior table, the comminuted fragments of
the posterior table were removed and the dural injury was
repaired. (C) Bone was used to occlude the comminuted
nasofrontal ducts and pericranial fl aps were placed into the
space formerly occupied by the frontal sinus. (D) The anterior
table was been replaced and the displaced nasal bones have
been temporarily wired to the glabella.
A
B
C
E
D
F
FIGURE 21-6. Patient with naso-orbital-ethmoidal
injury. (A) The patient demonstrates telecanthus. (B) The
patient demonstrates a collapse nasal dorsum, forehead
irregularity, and an obtuse nasolabial angle. (C) Axial CT
scan demonstrating anterior and posterior table frontal sinus
fractures. Note the nasal bones can be seen in the frontal
sinus. (D) Axial CT scan demonstrating medial orbital wall
and ethmoid fractures. (E) Axial CT scan demonstrating nasal
fractures and lateral displacement of the canthal bearing
segments. (F) Three dimensional CT demonstrating NOE
fracture.
piriform margin. Type I fractures can commonly be ana-
tomically reduced and plated. A type II fracture involves
a comminuted fracture with the medial canthal tendon
still attached to a bony fragment. Type II fracture frag-
ments are usually too small to anatomically reduce and
plate. These fractures typically require transnasal wiring.

224 • CHAPTER 21
In type III NOE fractures, the medial canthal ligament
are either avulsed from there osseous attachments or the
bone fragments are severely comminuted. Either way, a
type III NOE fracture requires transnasal reduction.
In addition to restoring medial canthal position, a
patient with an NOE fracture requires reconstruction of
his/her nose. Often, the nasal bones can be retrieved from
the ethmoid or frontal sinuses, anatomically reduced, and
FIGURE 21-7. The classifi cation of NOE fractures is based on the degree of injury
to the medial canthal attachment. (A) Type I fracture involves a large bone fragment
(open reduction and internal fi xation). (B) Type II fracture involves a comminuted fracture
with the medial canthal tendon still attached to a bony fragment (transnasal wiring).
(C) Type III NOE fractures, the medial canthal ligament is either avulsed from its osseous
attachments or the bone fragments are severely comminuted (transnasal wiring). (Adapted
from Markowitz BL, Manson PN, Sargent L, et al. Management of the medial canthal tendon in
nasoethmoid orbital fractures: the importance of the central fragment in classifi cation and treatment.
Plast Reconstr Surg. 1991;87(5):843–53.)

OVERVIEW OF FACIAL FRACTURES • 225
FIGURE 21-8. Cantilever bone graft treatment of a patient with a NOE fracture.
(A) After anatomic reduction of the type I NOE fracture fragments, the patient’s
comminuted nasal bones could not be reconstructed. Note the collapse of the nasal
dorsum. (B) A unicortical cranial bone graft was harvested and fashioned to reconstruct
the nasal dorsum. (C) After placement of the cantilever bone graft the nasal dorsum has
been restored.
A
C
B
plated. When the nasal bones are comminuted, a cantile-
ver bone graft is necessary to rebuild the nasal dorsum.
The cantilever bone graft can be harvested from the cra-
nium or rib (Figure 21-8). The bone graft is cantilevered
from the inferior aspect of the glabella and tucked under
the lower lateral cartilages.
The medial orbital walls must also be reconstructed.
The surgeon may choose alloplastic materials or autoge-
nous bone to rebuild the medial orbital walls (see below).
While the lacrymal drainage system may be injured in an
NOE fracture, the duct is typically not explored. If the
canaliculus is lacerated, it may be repaired over a silastic
tube.
Orbital Fractures
Orbital fractures alone or in conjunction with other facial
skeletal fractures are the second most commonly encoun-
tered midfacial fractures (nasal fractures are most com-
mon). Orbital fl oor fractures can cause diplopia, dystopia,
and enophthalmos. While orbital apex fractures are rare,
patients can suffer superior orbital fi ssure syndrome or
orbital apex syndrome. In such cases, a combined endovas-
cular and intracranial approach may be necessary to treat
an injured carotid artery, decompress the optic nerve, and
repair the dural injury.
Orbital fl oor fractures can be approached through a
lower lid incision or endoscopically. At least four access
routes to the orbital fl oor pass through the lower lid:
(1) the subciliary (composite skin-muscle fl ap) incision
was described by Converse in 1944; (2) the subtarsal
(muscle-splitting incision) described by Converse in the
1960s; (3) the transconjunctival incision fi rst described
by Bourquet in 1924, but popularized by Converse and
Tessier in the 1970s; and fi nally, (4) the lower eyelid–cheek
junction incision.
As a general rule, in acute trauma, subciliary incisions
should be avoided because of a higher risk of ectropion. 1
Nevertheless, if one chooses a subciliary incision, the
nonstepped variant (skin-muscle fl ap) is preferred over
the stepped (skin fl ap with preservation of a orbicularis
muscle sling) because of the risk of skin loss in contused
eyelids. (In secondary cases, when circulation to the skin
may be expected to be near normal, the stepped inci-
sion provides less risk of ectropion than the nonstepped
incision). The subtarsal approach should be avoided in
young patients, where the transcutaneous incision can-
not be camoufl aged in a natural skin crease.
Many surgeons favor the transconjunctival incision. A
lateral canthotomy may be added to increase lid mobi-
lization and exposure. The transconjunctival incision is
made 3 to 4 mm above the fornix, to avoid entropion.
The transconjunctival approach can either be presep-
tal or retroseptal. In the later, the orbital fat is exposed
and must constantly be reclined. Our preference goes to
the preseptal approach, where the periosteum is incised
2 mm below the orbital fl oor and elevated to expose
the orbital fl oor. Two concomitant procedures are added
before skin closure: (1) a lateral canthopexy (if lateral
canthotomy was performed) and (2) a cheek resuspen-
sion. 11 Regarding the choice of material for the repair,
as usual in plastic surgery, repair should be performed
following the Gillies principle of replacing like with like.
When the skull is readily available (eg, in a complex pan-
facial fracture, where a coronal incision was necessary), a
cortical graft can be harvested from the outer table of the
calvaria. Nevertheless, substitutes have been developed,
such as polyethylene with incorporated titanium mesh,
PSD plaque, Medpor, etc. The surgeon should explain
the risk of and benefi ts of autologous versus alloplastic
reconstructions.
The lower eyelid/cheek junction incision is positioned
directly over the bony orbital rim. While this approach
is faster than other eyelid incisions and is associated
with minimal risk of postoperative eyelid malposition, it
results in a visible cutaneous scar and can be associated

226 • CHAPTER 21
with lower eyelid edema. Consequently, most surgeons
avoid this incision except in patients with signifi cant
rhytides and minimal concerns of an external scar.
The endoscopic approach can also be used to repair the
orbital fl oor and medial wall fractures. The most accepted
approach to the orbital fl oor goes through the maxillary
sinus and visualizes the orbital fl oor from beneath. 4 An
upper sulcus incision followed by a maxillary antrostomy
gives adequate exposure to trapdoor fractures and blowout
fractures located between the infraorbital nerve and the
medial wall of the orbit. The fl oor is then replaced by a
0.85 mm thick porous polyethylene sheet or by bioresorb-
able sheets (polydiaxone) or by a titanium mesh. 4
Orbital fractures rarely entrap the inferior rectus mus-
cle; however, the authors of this chapter would consider
the treatment of a trapped inferior rectus muscle analo-
gous to treatment of any other ischemic muscle. That is to
say, inferior rectus muscle entrapment in the orbital fl oor
is a surgical emergency.
While rare, orbital fl oor fractures in children will more
commonly entrap the inferior rectus than an orbital fl oor
fracture in an adult. In children, it is hypothesized that the
fl exible orbital fl oor fractures and is displaced inferiorly,
allowing infraorbital tissue to enter the fracture site. The
orbital fl oor trapdoor then recoils, trapping the inferior
rectus. Children with an entrapped inferior rectus muscle
will have upward gaze restriction and diplopia. The CT
may demonstrate an entrapped inferior rectus muscle,
but this is maybe equivocal (Figure 21-9). The surgeon
may look for additional signs and symptoms to make the
diagnosis. When the inferior rectus muscle is trapped, the
ophthalmic division of the trigeminal nerve is stimulated
FIGURE 21-9. CT suspicious of entrapped inferior
rectus muscle. This child presented with nausea and vomiting.
Altogether, this highly favored entrapment, indicating urgent
operation (compartment syndrome).
and, through the reticular formation, it transmits a sig-
nal to the vagus nerve, which then carries the efferent
impulse to the stomach, producing nausea. 12 Cohen and
Garrett studied 29 children with orbital fl oor fractures
and found that one fourth of the children had nausea/
vomiting, and half had trapdoor fractures. Seventeen per-
cent of patients had entrapment of the inferior rectus.
The positive predictive value of nausea/vomiting with a
trapdoor fracture for entrapment was 83.3% ( P 50.002;
Fisher exact test). 12
Isolated orbital roof fractures are rare in adults, but
more common in children. Patients with orbital roof frac-
tures are at risk of retrobulbar hematoma, optic nerve
impingement by a bone fragment, and dural tear. The sur-
geon should rule out superior orbital fi ssure syndrome and
orbital apex syndrome.
Orbitozygomatic Fractures
Clinically, the zygomaticomaxillary complex fracture
defor mity presents as a loss of cheek projection and
enlargement of facial width. The zygoma is commonly
referred to as a “tripod,” but it actually articulates with
four bones (ie, maxilla, frontal bone, temporal bone, and
sphenoid) and, therefore, is more correctly referred to
as a “tetrapod.” Because the zygoma has four sutures
and two orthogonal buttresses (ie, the lateral maxil-
lary and the superior transversal maxillary buttresses),
a fracture along the zygomaticomaxillary suture may
include the inferior orbital foramen. If the zygomaticos-
phenoid suture and the two buttresses are not anatomi-
cally reduced, there will be a rotational deformity that
increases the orbital volume.
Most fractures can be treated through eyelid incisions
and gingivobuccal sulcus incisions (Figure 21-10). A cor-
onal incision is required only if the infraorbital rim and
zygomaticomaxillary (superior transverse) buttresses are
so comminuted that adequate alignment requires arch
visualization. 1 The gingivobuccal sulcus incision is per-
formed fi rst. Subperiosteal dissection of the medial and
lateral maxillary buttresses is carried all the way to the
inferior orbital rim, taking care to identify and preserve
the inferior orbital nerve (V2). The dissection of the
inferior orbital rim extends laterally, revealing the dis-
placed fracture. A fi rst attempt of reduction should be
made at this point with a blunt elevator inserted beneath
the zygomatic arch. In case of successful reduction, a
miniplate (L shape) will usually be suffi cient to ensure
fi xation. If reduction is not optimal, a lower lid inci-
sion should be performed to allow visualization of the
fracture. If the zygomaticotemporal suture is displaced,
a lateral extension of the upper blepharoplasty incision
will allow exposure, reduction, and fi xation of the frac-
ture (steel wire or 1.0-mm miniplate). This should be
done before fi xing the inferior orbital rim, to serve as
a reference point while still allowing rotational control.
Using a Caroll-Girard screw placed in the lateral por-
tion of the zygoma through the lower lid incision or by

OVERVIEW OF FACIAL FRACTURES • 227
planting a Ginestet hook in the inferior portion of the
zygoma, the inferior orbital rim is then realigned. The
lateral orbital wall should be monitored before fi xation,
to prevent a rotational deformity. Miniplates (1.5 mm)
and screws should be placed on the superior aspect of
the infraorbital rim rather than on the anterior aspect to
avoid palpability. An L miniplate is placed on the lateral
maxillary buttress. The orbital fl oor fracture should then
be addressed with a cortical bone graft or an implant
(polyethylene with incorporated titanium mesh, PSD
plaque, or Medpor).
One should expect an overcorrection of the globe on
the operated side at the end of the surgery because of
the swelling caused by the trauma and the surgery. If the
globes are in identical position at the end of the surgery,
enophthalmos will likely occur. The extensive subpe-
riosteal undermining, necessary for the exposure of zygo-
maticomaxillary fractures, may be a cause of postoperative
ptosis of the cheek with traction on the lower lid, therefore
causing ectropion.
Cheek resuspension should be performed at the end
of the procedure; either by suturing the cheek periosteum
to the orbital periosteum on the inferior orbital rim, or by
transosseous stitches. The endoscopic approach has not yet
gained acceptance in zygomatic arch fractures, because of
the diffi culty to fi x the arch in place with miniplates and
the risk of transient frontal nerve palsy. 4
Nasal Fractures
Nasal fractures are the most common facial fractures.
Care should be taken when reducing nasal fractures,
because torrential epistaxis and airway obstruction are
avoidable complications. Local anesthesia (1:200.000
adrenaline 1 0.5% lidocaine) and oxymetazoline gauze are
used to control bleeding. A septal hematoma must be
diagnosed and drained to avoid septal necrosis and its
sequelae, septal perforation, and saddle nose deformity.
A deviated septum must be placed back into its original
position. A septal Doyle splint and trans septal (“quilting”)
stitches maintain the septum in place and prevent recur-
rence of hematoma. The fractures are reduced with a blunt
instrument (reversed scalpel handle). In case of greenstick
fractures, it is important to complete the fracture. The
fragment must be mobilized freely to avoid relapse. In any
case, patients must be warned that 50% will require sec-
ondary procedure to correct airway obstruction or residual
deformity.
Maxillary (LeFort) Fractures
In 1901, René LeFort described patterns of fractures
that separated the maxilla from the skull base. LeFort
fractures occur when the pterygoid plates are disrupted
from the posterior maxilla (pterygomaxillary dysjunc-
tion), disrupting the posterior vertical buttress. If the
A
B
C
D
FIGURE 21-10. Treatment of zygomatic fracture. (A) Axial CT image of a fracture
right zygoma. Note zygomatic arch fracture. (B) Maxillomandibular fi xation was performed
to establish centric occlusion. (C) Titanium miniplate fi xation of the zygomatic arch and
lateral orbital rim. (D) Inferior orbital rim and orbital fl oor plates were used.

228 • CHAPTER 21
inferior aspects of the medial and lateral maxillary but-
tresses are fractured at or below the level of the piriform,
the maxillary arch (lower transversal maxillary buttress)
is set free from the skull base ( LeFort I fracture ). If the
inferior lateral maxillary buttress (zygomaticomaxillary
suture) and the superior medial maxillary buttress (fron-
tomaxillary suture) are fractured, then the entire maxilla
is set free from the skull base ( LeFort II fracture ). If the
upper transverse maxillary buttress (zygomatic arch),
superior lateral maxillary buttress (frontozygomatic),
and superior medial maxillary buttress (maxillofrontal)
are fractured, then craniofacial separation has occurred
( LeFort III fracture ). Patients often combine LeFort I,
II, and III asymmetric fractures. The hard palate can be
fractured sagittally or parasagittally, resulting in a widen-
ing of the maxillary arch, causing malocclusion. Sagittal
palatal fracture can also explain a unilaterally displaced
LeFort fracture.
Treatment of midface fractures should focus on res-
toration of the patient’s baseline dental occlusion and
reestablishing the key buttresses of the midface. In
severely comminuted fractures, temporary MMF is useful
before plating the two bone fragments. Intraoral cortical
bone screws are a valid alternative to Erich arch bar and
are placed much faster. Nevertheless, the surgeon should
be careful not to injure the dental roots while placing the
screws. In LeFort I fractures, an intraoral superior sulcus
incision provides good visualization of the fracture line.
In severely comminuted fractures with bone impaction,
corticocancellous bone grafting should be performed
immediately to restore maxilla height. Unlike mandib-
ular fractures, muscular tractions are minimal on the
maxilla. Therefore, miniplates are suffi cient to assure
fi xation. Resorbable devices are widely used in pediatric
craniofacial surgery, but Dorri et al. showed that there
is so far no evidence supporting superiority of resorb-
able material over titanium plates and screws in facial
fractures. 13
In LeFort II fractures, a combination of intraoral supe-
rior sulcus incision and lower lid incision is necessary to
ensure proper reduction and fi xation of the inferior lat-
eral maxillary buttress (zygomaticomaxillary suture) and
the superior medial maxillary buttress (frontomaxillary
suture). Associated fractures (orbital fl oor especially) are
treated simultaneously by the same incisions. Care must
be taken to avoid injury to the lacrymal duct.
In LeFort III fractures, a coronal approach is neces-
sary to expose the root of the nasal pyramid, the zygoma
at the zygomaticofrontal suture, the zygomatic arch and
the lateral and medial walls of the orbit. The infraorbital
rim is explored through a lower eyelid incision, which
provides exposure for the medial maxillary buttress fi xa-
tion. After careful assessment of the dental occlusion,
open reduction and internal fi xation with microplates
and screws is performed. In severely impacted fractures,
immediate bone grafting is necessary to restore the
height and the width of the face, and especially the nasal
dorsum.
Mandible Fractures
Mandible fracture patterns are infl uenced by the force and
direction of impact. For example, Fridrich and associates
reported the frequency of mandible fractures in adults
according to anatomic location: body (29%), condyle
(26%), and angle (25%). Symphyseal fractures accounted
for 17% of all mandibular fractures, whereas fractures of
the ramus (4%) and coronoid process (1%) occurred less
frequently. 14 In automobile accidents, the condylar region
was the most common fractured site. In motorcycle acci-
dents, the symphysis was fractured most often. When
assault was the cause of injury, the angle was most com-
monly fractured. 14
Children have distinctly different fracture patterns
than adults. The younger child has more soft tissue cush-
ioning and the mandible tends to be smaller and relatively
more protected. Moreover, the force generated in most
childhood falls is low. When a child falls, the force of
impact tends to be directed at the chin and transmitted
to the condylar heads, which sustain a crush-type injury.
In Thoren’s 1992 study, the condylar region was the most
common location of fracture in all pediatric age groups,
accounting for 60% of all fractures. 15 In 1993, Posnick
et al. reported that most pediatric mandibular fractures
occurred at the condyle (55%), followed by the para-
symphysial region (27%), then the body (9%), and angle
(8%). 16 As the patient ages, the relative incidence of con-
dylar fractures decreases and fractures of the body and
angle increase. Patients aged 10 years and older are similar
to adults in cause and fracture pattern.
In addition to physical examination, diagnosis of
mandible fractures is made radiographically; a pan-
orex and low Townes view (which show the condylar
processes) may be suffi cient for diagnosis and surgical
treatment planning. If a patient has multiple facial frac-
tures, is restrained in a cervical collar, is uncooperative
or combative, a maxillofacial CT scan can be obtained.
In both adults and children, the surgeon should consider
the mandible as a closed “ring”; therefore, if the surgeon
identifi es a fracture, he or she should look for a second
fracture. Multiple mandible fractures has been reported
to be as high as 67%. 17
Successful management of all mandible fractures begins
with the restoration of centric occlusion. Under general
anesthesia, the mandible is manually manipulated with
care taken to look for wear facets and mammelons on the
dentition. These occlusal cues will guide the surgeon to
reestablishing the patient’s preinjury occlusion. Centric
occlusion can be maintained by performing MMF (apply-
ing arch bars or screws with wires or elastics).
Fractures of the condyle may be successfully managed
with MMF and physical therapy alone (Figure 21-11).
Functional treatment of condylar fractures includes
early mobilization (starting at day 14, when pain has
decreased) to restore normal mouth opening (45 mm).
Guiding elastic therapy may be used for 6 to 8 weeks. The
purpose of functional treatment is to maintain posterior

OVERVIEW OF FACIAL FRACTURES • 229
A
B
FIGURE 21-11. Condylar fractures. (A) Axial CT image of bilateral condylar fractures.
(B) Coronal CT image of bilateral condylar fractures. Note: these fractures were treated
with maxilomandibular fi xation and early movement.
mandibular height and to intentionally create a pseudo-
arthrosis. Indications for open treatment of the condyle
include displacement into the middle cranial fossa, pre-
existing medical condition precluding MMF (epilepsy,
severe mental disorder), inability to obtain occlusion by
closed reduction, lateral extracapsular displacement of
the condyle, presence of a foreign body, or open fracture
with potential for fi brosis.
Subcondylar fractures are often incorrectly treated like
condyle fractures. The purpose of condylar fracture treat-
ment is to intentionally create a pseudoarthrosis. The
purpose of subcondylar fracture treatment is to heal the
fracture in anatomic alignment. While some surgeons use
an open approach to subcondylar fractures, we prefer an
endoscopic approach because it reduces the risk of facial
nerve injury and eliminates preauricular or retroman-
dibular scars (Figure 21-12). After establishing MMF, an
intraoral incision is used to expose the fracture. An endo-
scope is inserted to assist in anatomic reduction of the frac-
ture fragments. A plate is positioned and screws are placed
trough cheek stab incisions. MMF is removed at the con-
clusion of the operation.
Fractures of the body, parasymphysis, and symphysis
usually require rigid fi xation because the forces exerted
on the mandible by the muscles of mastication (eg, tem-
poralis, masseter, medial and lateral pterygoids, and strap
muscles) tend to distract the fracture fragments. While
favorable fracture patterns do exist in this region and
they can be managed with MMF or a soft diet, most sur-
geons perform open reduction and internal fi xation. An
intraoral approach is commonly used to treat fractures
in these areas. The incision should be made at least 1
cm below the level of the attached gingival (to allow
for an adequate cuff of tissue for closure). Care must be
taken to avoid the inferior alveolar nerve in the canal
and the mental nerve exiting the mental foramen. The
inferior alveolar nerve travels in the mandibular canal at
the junction of the middle and lower thirds of the man-
dibular body. 18 , 19 The mandibular canal terminates by
wrapping 4.5 mm beneath the mental foramen and then
looping 5.0 mm anteriorly before delivering the mental
nerve. 18 , 19 Fractures in the body, parasymphysis, and sym-
physis are typically treated with a monocortical “tension
band” and a bicortical plate at the lower border.
Fractures of the mandibular angle may be favorable or
unfavorable. Favorable fractures may be managed with
MMF or a soft diet, but most surgeons perform open
reduction and internal fi xation. Angle fractures were
treated with a tension band and compression plate (simi-
lar to body, symphyseal, and parasymphyseal fractures).
Alternatively, angle fractures may be treated with a sin-
gle plate along the external oblique line as described by
Khouri and Champy. 20 Exposure and visualization of the
fracture line may be diffi cult for fractures at the angle;
in addition to an intraoral approach, a system of cheek
retractors and transbuccal trocars may be used to facili-
tate fi xation. Alternatively an extraoral approach may be
used, but this exposure increases the risk of facial nerve
injury.
The presence of teeth in the fracture line is a point of
controversy most relevant in mandibular angle fractures
because angle fracture tends to involve the second molar
or impacted third molar (when present). Indications for
removing a tooth include(1) longitudinal fracture involv-
ing the root; (2) dislocation or subluxation of the tooth
from its socket; (3) presence of periapical infection;
(4) infected fracture line; (5) acute pericoronitis; and
(6) inability to achieve anatomy reduction of the mandib-
ular fracture fragments.
COMPLICATIONS
Cerebrospinal Fluid Fistula
Cerebrospinal fl uid otorrhea and rhinorrhea are impor-
tant to detect: clear fl uid leakage in facial fractures (upper
and midfacial fractures) may indicate a traumatic dural
tear, accompanied in 10% to 50% by pneumocephalus. 10

230 • CHAPTER 21
A
C
E
B
D
F
FIGURE 21-12. High subcondylar fracture. (A) Axial CT image of high subcondylar
fracture. (B) Coronal CT image of high subcondylar fracture. (C) Endoscopic view of
screw placement. (D) Endoscopic view of miniplate fi xation. (E) Postoperative panorex
demonstrating anatomic reduction of the left subcondylar and right symphyseal fractures.
(F) Postoperative posterior-anterior cephalogram demonstrating anatomic reduction of
the left subcondylar, right symphyseal fractures, and restoration of posterior mandibular
height. Note: maxilomandibular fi xation was removed at the conclusion of the operation.
The Erich arch bars were left in situ for postoperative guiding elastic therapy.
In case of doubt, especially when it is mixed with blood,
the presence of glucose (urinary strip) is an indication
of CSF fi stula, but has 20% false-positives. Detection of
beta-trace protein indicates CSF contamination in oto-
and rhinorrhoe with a sensitivity of .90% at a specifi city
of 100%. It is faster and cheaper than beta-2 transfer-
rine. 21 Non–contrast-enhanced, high-resolution CT scans
have a specifi city of 70% in CSF fi stula detections. 10
Pneumocephalus is often associated with dural fi stula.
Most CSF fi stulae can be observed and 80% will spon-
taneously resolve in 1week. 10 In case of isolated CSF
leak, the risk of meningitis following 1-week CSF leak
is only 3%. Nevertheless, after 2-weeks duration, the risk
exceeds 50%. 10 Prophylactic antibiotic therapy should
not exceed 24 hours. Prolonged antibiotic therapy does
not reduce the rate of meningitis but increases bacterial

OVERVIEW OF FACIAL FRACTURES • 231
resistance to antibiotics. Proper surgical wound treat-
ment, dural repair, removal of the mucosa and oblitera-
tion of any communication with the contaminated nasal
fossa are crucial steps to avoid meningitis. 10 Although
its incidence is very low (around 2%), late meningitis
(,1 year after trauma) can occur several months after
the trauma and patients treated conservatively should be
warned and monitored. 10
Ectropion
Ectropion can be observed postoperatively in 14% of
transcutaneous subciliary incision. 1 It results of a com-
bination of factors such as orbicularis oculi muscle trau-
matic dissection, lateral canthal laxity, and cheek descent
following extensive undermining of the soft tissues. The
transconjunctival approach should be preferred over the
transcutaneous approach when exposing the orbital fl oor
in order to limit injury to the orbicularis oculi. Correction
of tarsoligamentous laxity (lateral canthal support with
lateral canthopexy) 22 and cheek suspension should be
performed at the end of the bony repair. If massive swell-
ing is expected, a temporary tarsorraphy will prevent
exposure of the conjunctiva and stretching of the inferior
canthal sling. If minimal swelling is expected, a tempo-
rary (4–5 d) lower lid suspension preserving sight will
provide similar protection. 23
Entropion of the lower lid is seen as the lashes are turned
upward toward the cornea, causing trichiasis. 23 Entropion
is consecutive to transconjunctival incision (1.5%), when
the scarring or reduction of conjunctiva, subconjunc-
tiva, or internal tarsus results in an inward bowing of the
eyelid. 22 , 23
Facial Hypoesthesia
Hypoesthesia is a common complication in facial frac-
tures treatment. The three branches of the trigeminal
nerve exit the facial skeleton in a reproducible pattern.
Traumatic section is less frequent than nerve compres-
sion by bone fragments, especially at the maxillary level.
Hyposesthesia can also result from excessive traction on
a retractor during surgery. Neurapraxia is reversible in a
few weeks, but in case of neurotmesis, either traumatic or
surgical, sensory recovery will not occur unless a micro-
surgical end-to-end suture is performed.
Secondary Displacement
(Titanium vs Resorbable Osteosynthesis)
Secondary displacement of the fractures is rare at the
upper and midface but can be seen in the mandible,
where the powerful mastication muscles apply divergent
forces on the fracture lines. Adequate placement of the
plates and rigid osteosynthesis material prevents second-
ary displacement. In the past decade, several resorbable
plates and screws have been introduced. Dorri et al., 13
from the Cochrane Collaboration, a UK public health
institute, reviewed the literature looking for randomized
controlled trials comparing resorbable versus titanium
fi xation systems used for facial fractures. After analyz-
ing 53 studies, none were found to be statistically sound
and therefore no data were available for analysis. As of
today, there is no strong evidence in favor of either fi xa-
tion system.
OUTCOMES
In general, the outcome from managing facial fractures
should be excellent. Specifi c measures involve form and
function. Patients should have a symmetrical appearance
with minimal scarring and no functional concerns. Either
observation of minimally displaced fractures or reduction
and internal fi xation of displaced fractures should yield
minimal complications. Understanding the etiology of the
notable short-term complications described above and
taking appropriate measures to avoid them can minimize
their occurrence. Problems arise from internal fi xation of
poorly reduced fractures. In the periorbital region, this
will lead to vertical dystopia and diplopia. In the mandi-
ble, it will lead to malocclusion that often puts abnormal
wear on the occlusal surface and disproportionate force
on the temporomandibular joints. Long-term complica-
tions are rare. Occasionally, recurrent infl ammation at the
site of previously placed hardware warrants removal once
the fractures have healed.
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