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PRINCIPLES OF CRANIOFACIAL SURGERY

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Anthony Wolfe, MD

1.1  Introduction

The field of craniofacial surgery owes its beginnings to Dr. Paul Tessier more than any other individual. After performing the first successful Le Fort III-type osteotomy in 1958, he went on to develop procedures for correcting virtually every major orbitocranial malformation: Crouzon’s disease, Apert’s syndrome, orbital hypertelorism and other orbital dystopias, Treacher Collins-Franceschetti syndrome, hemifacial microsomia, arrhinias, and orbitofacial clefts, with “spinoffs” having a profound effect on the primary treatment of trauma, excision of facial tumors and primary reconstruction, and aesthetic surgery. He could provide methods to correct these conditions because of his understanding of the underlying skeletal abnormality and his surgical ability to work with autogenous bone. His powers of observation and cataloguing of his patients led to his empiric classification of facial clefts, published in 1976, which is used throughout the world.¹

Dr. Tessier, considered to be the father of craniofacial surgery, wrote relatively little in his career, perhaps because of his demanding surgical schedule. He worked in Paris, 6 days a week, often until midnight, and traveled extensively in the United States as an invited surgeon. What follows are some notes that he made in 2001.

1.2  Notes by Tessier

After 40 years, let us cast a glance back on our craniofacial adventure. From 1940 to 1960, reconstruction of the facial structures was done mostly for the lower jaw, nose, and zygoma. However, (1) skin flaps were often used to mask skeletal defects, (2) the orbital cavity was almost completely ignored except for fractures, (3) the cranial cavity was the exclusive game preserve of the neurosurgeons, and (4) the orbitofrontal bar (which I consider one of my significant contributions) was a barrier not crossed by ophthalmologists or plastic surgeons, and only rarely by neurosurgeons.

Such limitations made radical treatments impossible for all major disorders: Crouzon’s disease, Apert’s syndrome, the orbitofacial clefts, plagiocephaly, frontonasal dysplasia, all kinds of hypertelorism, basicranial tumors, and countless orbitocranial trauma cases.

1.2.1  The clinical impulse to craniofacial surgery (1958–1963)

Craniofacial surgery did not develop from an unarticulated desire for a new specialty, not at all. In fact, over a 5-year period, the impetus came from observing eight patients. By chance, all were mentally normal, although each one represented an extreme and monstrous form of a given type of malformation.

In none of these patients could form and function have been corrected by procedures in use at that time. Consequently, new procedures were developed after a careful evaluation of the skeletal disorder. But, in 1960, there was no CT scanner, no 3-D imaging for the skeletal structures, and no MRI for the brain and eyes. Animal experiments could not help, since the primate head has little in common with the human head.

1.2.2  Five basic principles and two technical procedures

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