Craniofacial Surgery

The term craniosynostosis refers to premature fusion of one or more of the 6 cranial sutures, the midline metopic and sagittal sutures, and each bilateral coronal and lambdoid suture. It usually manifests as an observable deformity within the first few months of life. Craniosynostosis can be present at birth but can be missed if mild. The premature fusion of sutures can produce intracranial hypertension, which may lead to abnormal neurocognitive development in affected children. The image below depicts unilateral coronal craniosynostosis.

Plastic surgery is a medical procedure with the purpose of alteration or restoring the form of the body. Though cosmetic or aesthetic surgery is the most well-known kind of plastic surgery, plastic surgery itself is not necessarily considered cosmetic; and includes many types of reconstructive surgery, craniofacial surgery, hand surgery, microsurgery, and the treatment of burns. Reconstructive plastic surgery is performed to correct functional impairments caused by burns; traumatic injuries, such as facial bone fractures and breaks; congenital abnormalities, such as cleft palates or cleft lips; developmental abnormalities; infection and disease; and cancer or tumours. Reconstructive plastic surgery is usually performed to improve function, but it may be done to approximate a normal appearance. Cosmetic surgery is an optional procedure that is performed on normal parts of the body with the only purpose of improving a person’s appearance and/or removing signs of aging. Craniofacial surgery is divided into paediatric and adult craniofacial surgery. Paediatric craniofacial surgery mostly revolves around the treatment of congenital anomalies of the craniofacial skeleton and soft tissues, such as cleft lip and palate, craniosynostosis, and paediatric fractures.

Facial reanimation is the process of surgically correcting facial paralysis; congenital or acquired through trauma or disease. Facial paralysis can be a consequence of traumatic facial nerve injury, iatrogenic causes, malignancy, congenital syndromes, and viral infections. Prolonged paralysis can result in ocular complications, articulation difficulties, impaired feeding, and difficulty in conveying emotion through expressive movement. Dynamic procedures aim to restore some voluntary movement and, thus, are more desirable. Numerous reanimation techniques are available to restore function and are based on the cause of the facial paralysis, type of injury, its location, and the anticipated duration.

These methods are broadly classified into 4 types as follows: (1) neural methods, (2) musculofascial transpositions, (3) microneurovascular transfer (4) facial plastic procedures, and (5) prosthetics.

The static facial surgeries include:

• Fascia lata sling &Static sling
• A dynamic lower lip tightening& Eyelid procedures

The dynamic facial reanimation surgeries include:

• Digastric transfer
• Temporalis Muscle techniques
• Nerve repairs, transfers and grafting
• Free muscle flaps

Traditionally, reconstruction of the nasal supporting structure has been achieved with septal or auricular cartilage grafts or a combination of the two. Bone graft nasal reconstruction is advantageous, however, when significant structural support is needed or when cartilage donor sites are inadequate. The technique of bone graft nasal reconstruction has evolved over time. Cartilage: Autogenous cartilage grafts are the most frequently used material for nasal augmentation. Collagen gel matrix: Britt and Park stated that tissue-engineered cartilage can be produced reliably and that predetermination of graft shape is possible.

Despite increasing specialization of craniofacial surgery, certain craniofacial techniques are widely applicable. In the top five widely applicable craniofacial procedures perialar rim bone graft is the one.

The shape of the eye is determined by the relation of the upper and lower eyelids. The space between the upper and lower lids that frames the eye itself is called the palpebral fissure. In young adults with normal facial skeletons, this opening is long and narrow. Heredity, aging, paralysis, trauma and previous surgery can all impact this youthful shape. Aging eyes have a rounder shape, due to the gravitational descent, or droop, of the lower lid, and the medial migration of the lateral canthus when the outer corner of the eye, where the eyelids meet, moves inward.

Standard blepharoplasty or eyelid surgery techniques, which remove lower eyelid skin, and often muscle, tend to drop the lower lid margin, further rounding the palpebral fissure. Newer blepharoplasty techniques, including arcus marginalis release with fat transposition, have been designed to avoid this rounding effect. Two related procedures, canthopexy and canthoplasty, are used to elevate the lower lid when it has already fallen or to prevent it from falling during a lower eyelid procedure.

The chin is vital to the human facial morphology as it contributes to the facial aesthetics and harmony both on frontal and lateral views. Osseous genioplasty, the alteration of the chin through skeletal modification, can lead to significant enhancement of the overall facial profile. A Sliding Genioplasty is a less-invasive surgical procedure designed to correct a retrusive chin and achieve a more aesthetically pleasing facial structure. Different from other forms of Chin Augmentation, the Sliding Genioplasty procedure involves making a cut through the bone of the chin, which is called an osteotomy. By freeing up the malposition bone, is able to reposition the area to an ideal orientation. A small plate, made from titanium, is used to secure the chin in its new position on the jawbone. 

Autogenous bone grafts are the gold standard for reconstruction of maxillofacial defects. Autogenous bone becomes osseointegrated and vascularized at its site of implantation, which decreases the chances of infection, displacement, and foreign body reaction compared with alloplastic implants. The drawbacks are the harvest time, donor site morbidity, graft resorption, modeling changes, and harvest volume limitations. Autogenous bone can be harvested from multiple sites, including the calvarium, tibia, anterior ileum, posterior ileum, rib, sternoclavicle, zygoma, mandible, and so forth. The use of calvarial bone grafts (CBGs) was first reported in 1670, when Van Meekren reconstructed a Russian soldier's calvarial defect utilizing a CBG from a dog.

Fronto-orbital dysmorphology in nonsyndromic bilateral coronal synostosis includes frontal flattening, supraorbital recession, and ocular globe protrusion. Surgical advancement of the supraorbital region ("bandeau") is performed to correct these deformities. bilateral coronal synostosis was performed to assess the effect of two types of bandeau fixation at the nasion. The surgical goals of FOA are threefold:

Ø  To release the synostosed suture and decompress the cranial vault,

Ø  To reshape the cranial vault and advance the frontal bone, and

Ø  To advance the retruded supraorbital bar, providing improved globe protection and an improved aesthetic appearance.

Paediatric cleft lip and cleft palate is congenital disorders of craniofacial complex which occur in the early part of pregnancy and are present at birth. Paediatric cleft palate occurs when the shelves of the palate fail to meet or fuse together, resulting in an opening in the roof of the mouth. Paediatric cleft lip occurs when the presence of one or two vertical fissures in the upper lip can be on one side only or on both sides resulting from failure of the normal process of lip fusion during embryonic life.

A pediatric plastic surgeon and oral maxillofacial surgeon are critical members of child's pediatric reconstructive surgery team. Their role and goal is to create a functional lip and palate that will appear as normal as possible, providing support for the lip and base of the nose area.

Facial trauma, also called maxillofacial trauma, is any physical trauma to the face. Facial trauma can involve soft tissue injuries such as burns, lacerations and bruises, or fractures of the facial bones such as nasal fractures and fractures of the jaw, as well as trauma such as eye injuries. Symptoms are specific to the type of injury; for example, fractures may involve pain, swelling, loss of function, or changes in the shape of facial structures.

Facial injuries have the potential to cause disfigurement and loss of function; for example, blindness or difficulty moving the jaw can result. Although it is seldom life-threatening, facial trauma can also be deadly, because it can cause severe bleeding or interference with the airway; thus a primary concern in treatment is ensuring that the airway is open and not threatened so that the patient can breathe. Depending on the type of facial injury, treatment may include bandaging and suturing of open wounds, administration of ice, antibiotics and pain killers, moving bones back into place, and surgery. When fractures are suspected, radiography is used for diagnosis. Treatment may also be necessary for other injuries such as traumatic brain injury, which commonly accompany severe facial trauma.