|2009 Annual Meeting Abstracts
Critical Analysis of 81 Monobloc Frontofacial Advancements Over a 27 Year Period: Should They All be Distracted, or Not
S. Anthony Wolfe, M.D..
Miami Children's Hospital, So. Miami, FL, USA.
PURPOSE: To document a large experience of over 27 years with a monobloc frontofacial advancement.
METHODS: Retrospective chart analysis of all patients undergoing either monobloc frontofacial advancement or monobloc frontofacial advancement with facial bi-partition. At present, this series stands at 81 monobloc frontofacial advancements (MBFFA), or MBFFA with facial bipartitions. The greater number were performed in Miami, with others being done in Gainesville, Galveston, Caracas, Campinas, Managua, and Guatamala City. There were 49 MFFA and 32 MBFFA+FB.
RESULTS: Complications of both of the standard operation without distraction and those performed with distraction were looked at specifically. There were significant complications in the distracted group and fewer in the non-distracted group. Complications included 2 deaths, (1-Caracas, from sudden cardiac arrythmia at end of the case; 1, Campinas, one week post-op from complications arising from hypovolemia). I case aborted due to large volume blood loss from tear in sigmoid sinus (eventual loss of eye due to exposure); 3 frontal sequestrations requiring subsequent subtital frontal reconstruction; 1 CSK leak, closed successfully on POD 3; no meningitis. 5 MBFFA and 1 MBFFA+FB were performed by distraction, with 1 zygomatico-maxillary disjunction and frontal infection, and 1 intraorbital osteoneogenesis preventing proptosis correction, resulting in corneal scarring. One "classic" MBBFA was converted to distraction at 2 weeks post-op, after development of an epidural fluid correction (successful outcome). In the only RED device used, there was a cranial perforation (5 years of age). Blood replacement was required for removal of all internal devices. 11 patients had subsequent maxillary advancement: 2 MBFFA, 4 Le Fort 3, and 5 Le Fort 1 (only one case was non-distraction).
CONCLUSION: For the majority of patients with craniofacial dysostoses, a transcranial procedure provides a superior morphological result to a Le Fort 3 advancement, since the forehead is advanced with the face, and the nose is not overlengthed.; all patients operated upon in the preferred age group of 5-7 will require subsequent maxillary advancements at either Le Fort 1 or Le Fort 3 level. Earlier operation may even call for a second monobloc; blood loss and operating time are equivalent for "classic" and distraction procedures; CSF leaks and meningitis can be avoided with meticulous neurosurgical inspection of the anterior cranial base, suture of ALL dural tears, and systematic use of a pericranial patch; greater advancement at the alveolar level (and airway enlargement) can be obtained by distraction, although the morphological results are not as good as with the "classic" procedure; for the majority of patients, a "classic" operation is preferred, realizing it may be converted to distraction, if required; each team based on their own experience and the needs of the particular patient will decide between classic operation and distraction.