Midfacial augmentation in teenage cleft patients using malar and paranasal Medpor implants

Abstract

Malar and paranasal implants offer a way to augment and reconstruct midfacial deformities, and can be used across a broad spectrum of craniofacial deformities. Three patients aged between 13 and 15 years underwent such a procedure. Access was achieved via a labial mucosal approach; ‘super petite’ and ‘petite’ malar and paranasal Medpor implants were inserted in a subperiosteal plane and secured with titanium screws. All patients underwent an uneventful postoperative recovery and have remained pleased with their reconstruction at follow-up. In carefully selected patients, Medpor implants may have a role in teenage cleft patients with subtle midfacial hypoplasia, where formal osteotomies are not felt to be required, or where the lengthy preparation period might not be tolerated. In the cases described, they were used as a bridging or temporizing measure as there was not yet the skeletal maturity for definitive osteotomies. These patients may otherwise face a lengthy wait during their teenage years, in which they may struggle to manage what they may perceive as a significant facial deformity.

Malar and paranasal implants offer a way to permanently augment and reconstruct malar hypoplasia and midfacial defects. These implants can also be used as temporizing procedures in young teenagers who are felt to have sufficient social and psychological reasons to warrant their use.

Clinical history and operative procedure

Three cases are described. All three presented with psychological distress that was directly related to facial appearance, in particular midfacial hypoplasia. Orthognathic intervention or distraction osteogenesis was not a valid alternative at that moment in time. All three were assessed by clinical psychologists before their procedures.

Case 1

A 15-year-old female with a previously treated bilateral cleft lip and palate presented with a negative overjet class III malocclusion. She underwent augmentation with Medpor (Porex Surgical, Inc., College Park, GA, USA) ‘super petite’ malar and ‘petite’ paranasal implants. Access was achieved via a labial mucosal approach and implants were inserted in a subperiosteal plane and secured with titanium screws. The wounds were closed with 4/0 Vicryl sutures (Ethicon, Somerville, MA, USA). The implants were soaked in an antibiotic (gentamicin) solution prior to insertion. Intravenous co-amoxiclav was given at induction and for two postoperative doses, followed by a week of oral treatment. Long-term planning is for orthodontic decompensation and a bimaxillary osteotomy ( Fig. 1 ).

Fig. 1
Preoperative (upper images) and postoperative (lower images) views of case 1, a 15-year-old female with a bilateral cleft lip and palate who underwent augmentation with Medpor malar and paranasal implants.

Case 2

A 14-year-old male was seen with a previously repaired isolated cleft palate and hypoplasia of the midface, with a complete class III malocclusion and a negative overjet of −2 mm. He underwent augmentation with Medpor ‘super petite’ malar and ‘petite’ paranasal implants. The technique used was the same as described for case 1. We are planning orthognathic surgery at around 17 or 18 years of age.

Case 3

A 13-year-old female with Klippel–Feil syndrome and a repaired isolated cleft palate and a class III malocclusion, underwent insertion of bilateral ‘super petite’ malar implants. The procedure was complemented with a simultaneous genioplasty. Subsequent orthognathic surgery remains a long-term option.

Outcome

All patients underwent an uneventful postoperative recovery, with no episodes of infection or implant exposure. At the 3-, 10-, and 24-month follow-ups, all remained pleased with their reconstructions. Evaluation for subsequent orthognathic surgery in these patients is ongoing.

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Jan 19, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Midfacial augmentation in teenage cleft patients using malar and paranasal Medpor implants
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