Major Complication and Mortality Rates in Craniofacial Surgery: An Analysis of 8053 Major Procedures
Marcin Czerwinski, MD1, Richard A. Hopper, MD2, Jeffrey A. Fearon, MD1.
1The Craniofacial Center, Medical City Hospital, Dallas, TX, USA, 2The Craniofacial Center, Seattle Children's Hospital, Seattle, WA, USA.
Almost 30 years ago, with craniofacial surgery still in its infancy, Whitaker, et al. published a multicenter report examining major complications and mortality rates following 793 craniofacial procedures.1. We sought to update this review on a larger scale, in order to: 1. Allow craniofacial surgeons to counsel families about the current risks of these major procedures, and 2. Analyze past sentinel events in hopes of applying this knowledge to reduce future incidences.
This study was comprised of two parts: 1. An 18- year retrospective review of all congenital craniofacial procedures (intracranial and subcranial mid facial advancements) performed at 2 large North American centers, including an analysis of all sentinel events (permanent neurologic loss and mortalities), and 2. An internet-based survey, sent to all remaining North American centers (identified through the American Cleft Palate-Craniofacial Association database). Respondents were asked for data on total numbers of intracranial procedures and subcranial mid facial advancements, mortalities and major complications (i.e. permanent neurologic loss), and an analysis of each sentinel event. Data were summarized using descriptive statistics.
Combining the two center data with the survey results (13/180 centers responding) resulted in a total database of 8053 major congenital craniofacial procedures. The two center comprehensive review was comprised of 1482 cases. Among the 1262 intracranial cases there were no major complications; however, there were 2 deaths (0.2%): one from a pulmonary embolus in a young adult with Crouzon, and one from a sagittal sinus tear during bipartition surgery. Among of 220 subcranial mid facial advancements, there was one major complication (0.5%) involving a partial visual loss, and one death (0.5%) from early postoperative airway obstruction. The survey identified 4 major complications (<0.1%), and 7 total mortalities (0.1%) out of 6023 intracranial procedures. There was 1 major complication (0.2%) and 1 death (0.2%) out of 548 subcranial mid facial advancements. The combined mortality rate for all intracranial cases was 0.1%, and for subcranial mid facial advancements was 0.3%. Almost half of all intracranial mortalities (43%, 3/7) were attributed to blood loss, along with one case each of: pulmonary embolism, cardiac arrhythmia, anaesthesia complication, and hyperthermia. Among the subcranial mid facial advancements, one patient succumbed from an early airway compromise, and the other death was attributed to blood loss. There were 4 cases of visual loss, from multiple presumed etiologies.
Craniofacial mortality rates for intracranial surgery are significantly lower than first reported in 1979, falling from 2.2% to 0.1%. We also found a reduction in mortality rates for subcranial mid facial advancements, falling from 1% to 0.3%. Based on our outcomes analyses, we believe further reductions in intracranial mortality rates might be achievable with a greater emphasis on blood conservation strategies. Furthermore, reductions in mortality rates following mid facial advancements may be achievable with a greater focus on postoperative airway management. Specific strategies are discussed.
1. Whitaker, L.A., Munro, I. R., Salyer, K.E., et al. Combined Report of Problems and Complications in 793 Craniofacial Operations. Plast. Reconstr. Surg. 64: 198, 1979.