This study compares internal and external distraction devices in the treatment of midface retrusion. 20 patients were treated with midface distraction (12 Crouzon, 4 Apert, 4 others); 12 with internal distraction (MID device), 8 with external distraction (Red or Blue device). The two groups were compared regarding operation time, peroperative blood loss and complications. The groups were comparable regarding patient age, sex, weight and diagnosis. In the MID-group, 7 of 12 patients (58%) underwent Le Fort III, 5 underwent 12 monobloc (32%). In the Blue device group, three of eight patients underwent Le Fort II (38%), three of eight underwent Le Fort III (38%), and two of eight underwent monobloc (25%). Operation time was shorter in the Blue device (mean 298 min) than in the MID group (mean 354 min). Peroperative blood loss and complication rates were similar. The internal distraction device is the ‘gold standard’ for treating midface retrusion. The use of an external distraction device in midface distraction osteogenesis is associated with a shorter operation time; peroperative blood loss and complications were similar. An external device affords better 3-dimensional control during the distraction process, so external distraction is preferable in patients who will tolerate this treatment.
Treatment of the hypoplastic midface in syndromic craniosynostosis remains a challenge, from a functional and an aesthetic point of view. Several surgical techniques have been developed to advance the midface, including the Le Fort II, the Le Fort III and monobloc osteotomies. Skeletal advancements using traditional surgical techniques were often inadequate , necessitating numerous reoperations . With the advent of craniomaxillofacial distraction osteogenesis , significantly larger and safer skeletal advancements were allowed, leading to several studies on midface distraction at the Le Fort III level and at the monobloc level .
The distraction apparatus can consist of an internalized push-screw device, as developed by C ohen et al. in 1995 ( Fig. 1 A and B ), an external halo-frame-based pulling device, as developed by P olley & F igueroa in 1997 ( Fig. 1 C and D), or an internal distraction spring or coil, as developed by L auritzen et al. in 1998 . Each system has its pros and cons.
The potential benefits of internal devices include: elimination of skin scarring caused by translation of transcutaneous fixation pins; improved patient compliance during the consolidation phase; and improved stability of the attachment of the device to the bone . The major drawbacks are: the need for precise positioning of the device, regarding alignment between the two sides and the angulation, which can be challenging in patients with numerous previous operations and subsequent cranial thinnings or deficiencies; the inability to alter the distraction vector during the distraction process; and the need for a second major operation to remove the device, although this can be overcome by using biodegradable devices .
The potential benefits of external devices include: unsurpassed three dimensional (3D) control during distraction; the ability to alter the distraction vector during the process; and the avoidance of major resurgery for device removal after the consolidation phase. The major drawbacks are: skin scarring caused by translation of transcutaneous fixation pins and/or skin infections around the pins ; pin loosening ; the need for patient compliance during the consolidation phase; and intracranial pin migration, either accidental or gradual .
The authors compared the clinical outcomes of patients who underwent midface distraction osteogenesis using either an internal or an external device in the treatment of syndromal midface retrusion.
Patients and methods
20 subjects with syndromal midface retrusion underwent distraction osteogenesis between October 1999 and September 2007, some of whom have been reported previously . There were 9 male and 11 female patients with a median age of 11.3 years (range 1.4–25.0 years) ( Table 1 ). Five patients had Apert’s syndrome, 12 had Crouzon’s syndrome and four had other craniofacial syndromes.
|Internal device||External device|
|Age (mean, range)||10.2 years, 1.4–16.8||14.3 years, 6.2–25.0|
|Weight (mean, range)||33.7 kg, 9.0–67.5||40.3 kg, 14.3–60.0|
|Previous CF-operations (mean, range)||3.9, 1–8||2.0, 0–8|
|Apert (number, percent)||2, 17%||2, 25%|
|Crouzon (number, percent)||9, 75%||3, 38%|
|Other (number, percent)||1, 8%||3, 38%|
Most patients were complex cases and had undergone several previous craniofacial surgeries (mean 3.2, range 0–8), including previous monobloc osteotomy in one patient, Le Fort III surgery in 4 patients and fronto-orbital advancements in 15, as well as miscellaneous craniectomies ( Table 1 ). 12 patients had undergone shunt surgery for hydrocephalus (60%).
Nine patients had mental development within the normal range, nine had mild mental retardation, and two had severe retardation. In the severely mentally retarded patients, the indications for surgery were severe exophthalmos and severe airway obstruction. The remaining patients had combinations of moderate-to-severe midface deficiency presenting as retrusion associated with Angle’s class III malocclusion.
Seven patients underwent monobloc distraction, seven had Le Fort III distraction only, three had Le Fort III distraction in combination with an acute fronto-orbital advancement, and three had Le Fort II distraction ( Table 2 ).
|Internal device||External device|
|LeFort III + acute frontoorbital||2||1|
|Length of operation (mean, range)||354 min, 240–535||298 min, 210–420|
|Peroperative blood loss (mean, range)||1383 ml, 280–2700||1388 ml, 0–4000|
|Peroperative blood loss (mean, range)||53 ml/kg, 8–121||40 ml/kg, 0–90|
|Time on ventilator postop. (mean, range)||48 h, 0–144||23 h, 0–36|
|Time on PICU (mean, range)||3 days, 1–7||2 days, 1–4|
|Length of antibiotics-use postop. (mean, range)||13 days, 2–35||16 days, 5–53|
|Length of hospital stay (mean, range)||27 days, 16–38||27 days, 12–41|
|Distraction distance (mean, range)||24 mm, 15–30||19 mm, 14–28|
|Consolidation (mean, range)||143 days, 88–188||118 days, 21–218|
|Reoperation||6 pts||2 pts|
|Local wound infection||4 pts||3 pts|
|Subcutaneous infection||1 pts||1 pts|
|Ostemyelitis||0 pts||0 pts|
|CSF leak||0 pts||0 pts|
|Pin readjustments under GA||0 pts||4 pts|
The patients were operated on by the Norwegian craniofacial team. A Le Fort II ( Fig. 2 A) , Le Fort III ( Fig. 2 B) or monobloc osteotomy ( Fig. 2 C) was performed in the standard fashion and craniofacial disjunction was undertaken.