Acknowledgments Inspiration for this Atlas came from the love, motivation, and understanding that I have gained from children with craniofacial deformities and their families. Special recognition and thanks go to Pulitzer-Prize-winning photographer Eddie Adams, whose cover and chapter opening photographs in Volume T capture the emotions and feelings of these families and this life-changing surgery. Credit for much of the vision and motivation for excellence goes to my mentors, teachers, and the pioneer surgeons with whom [have had the privilege to be associated, as well as to all my students, residents, and fellows. Since coauthoring the Atlas of Craniomaxiliofaciat Surgery in 1982, 1 have had numerous inquiries and requests to do an updated Aas. This Atlas contains craniofacial surgery advances and updates and now includes cleft lip and palate surgery, Both volumes of the Atlas feature detailed instructional artwork that allows better understanding and visualization of the surgical procedures. Lam deeply grateful to both artists, William Winn and Hani Elkadi Although each artist's work is very different, the division of their work into two separate companion volumes works well together to enhance understanding and learning of these techniques. My special thanks go to William Winn, whom I have admired and worked with for nearly 30 years. His ability to artistically render the important surgical and technical steps of craniofacial surgery into an understandable visual image is a special art form unto itself. The performance of this surgery becomes more realistic and possible through his beautiful illustrative art. Bill also did all the initial pencil sketches for my contributions to Volume IL Special recognition and thanks go to Dr, Janus Bardach for his precise writing and editing, which blends the two volumes as companion pieces. Over the last 25 years he has provided me with inspiration and guidan¢e in research, clinical care, and the ability to communicate those thoughts in writing. Dr, Bardach worked closely with Hani Elkadi, whose artistic technique provides the detail necessary to understand the complicated step-by-step nature of the cleft surgery in Volume TI. Many of these techniques have never been presented so clearly. ‘This Atlas represents the work of many other people. My thanks and appreciation go to each contributing author for their time and effort in bringing their surgical techniques to life and making them useful ‘The surgery that I perform, the techniques, and this Atlas would not be possible without the support of our dedicated Dallas craniofacial team, 1 am particularly indebted to Edward Genecov, D.D.S. whose orthodontic care and support has contributed so significantly to the care of these patients over 30 years. I would like to thank my associates, Dr. Eric H. Hubli, for the use of his patient photographs in Figures 4-121 through 4-124, and Dr, Robert Taylor for the use of his patient photographs in Figures 4-204 through 4-206, Both cases present good results using the techniques demonstrated. A very special thanks goes to Kimberly Hickey and Stacey Black, who organized the patient photographs and worked with the layout and design; Janice Mauck for her continued dedicated effort and support in all aspects of the project, including all transcribing; and to the media department at Medical City Dallas Hospital for their reproductions and assistance, especially Mike Lorfing and Terry Cockerham. [ am particularly grateful for the assistance of Kathleen Gleeson, whose work on both volumes aided in the copyediting and proofreading of the text. ‘The project was initiated with the insight and support of Lisa Berger at Raven Press. 1 want to acknowledge the support and encouragement given to me by the publisher, particularly Kathey Alexander, Daneite Knopp, Anne Sydor, and Diana Andrews, all of whom gave of their time and special talents to make this Adlas an expression of the work as I envisioned it. They represent the best with whom I have worked, xiiiSY BASIC SURGICAL TECHNIQUESCraniofacial surgery requires an experienced team, which includes the craniofacial surgeon, neurosur- geon, anesthesiologist, and, depending on the case, an otolaryngologist, maxillofacial surgeon, oph- thalmologist, and orthodontist. In many cases, it is important to have two teams working simultane- ously—one in the area of the head and the other, for example, at the patient’s side obtaining bone or car- tilage implants or skin grafls. The craniofacial sur- geon is the team leader, although during different stages of the operation, the leading role may be as- sumed by the neurosurgeon or another specialist. Major craniofacial surgery is performed under controlled hypotension (goal of mean arterial pros- BASIC SURGICAL TECHNIQUES 3 sure, 50-55 mm Hg), normovolemic hemodilution (Hct, 24-27%) prior to incision, and hyperventila- tion (p;GO», 22-28 mm Hg) for brain shrinkage. Controlled hypotension is achieved by the use of oral clonidine as part of the preoperative prepara- tion with the addition of IV labetalol as needed. Normovolemic hemodilution is performed after the airway has been secured and all [V and arterial lines are in place. Replacement fluids are 2-3 ml RL: 1 ml whole blood for half the collection and a 1:1 ratio of 5% plasma protein fraction for the other half of the collection. For patients heavier than 50 kg, the entire collection may be replaced with RL at 2-3 ml of whole blood collected.Figure 1-1 The basic approach to the craniofacial skeleton, whether intracranially or extracranially, is through the bicoronal skin incision. I use a zig-zag de- sign because it creates a less visible scar on the hairy portion of the skull. I do not shave the hair before surgery. The hair is washed the night before, and a stan- dard preparation is used on the face and head at the time of surgery. Depending on the condition, the inci- sion may be placed more anteriorly or more posteriorly. An anteriorly placed incision allows easy undermining and downward rotation of the scalp and forehead flap. The front of the facial skeleton can be easily reached through this incision. A posteriorly placed incision is used only when a specific area in the posterior half of the skull needs exposure. Figure 1-2 A bicoronal incision is used to turn down the scalp and pericranium, exposing the glabella, nasal bones, and supraorbital rims. Note that the temporalis muscle is turned down on the right side, a procedure I do not normally use unless I need to gain access to the area. Figure 1-3. The supraorbital nerve is released from the bony canal with an osteotome. A malleable retractor protects the globe. Frequently the nerve is contained within a notch and can be pulled downward without using an osteotome. Figure 1-4 The ostectome is used to create a notch in the supraorbital rim in order to release the supraorbital nerve.4 Figure 1-2 supraorbital nerve in the canal Figure 1-36 (CHAPTER 1 Figure 1-5 The temporalis muscle is turned down us- ing a periosteal elevator, Colorado needle, and a lighted retractor, and dissected from the lateral orbital wall. This maneuver is frequently necessary for procedures such as the Lefort IIL, in which zygomatic access to the pterygomaxillary region is required. Figure 1-6 Dissection of the soft tissue over the malar bone is performed with a periosteal elevator. The globe is retracted, providing access to the anterior surface of the facial skeleton. Figure 1-7 Dissection over the malar bone and max- illa is extended with a periosteal dissector extending from the lateral orbital wall along the zygomatic arch without damaging the frontalis branch of the facial nerve, This provides excellent access to the orbit, along the inferior orbital rim, and to the floor of the orbit.BASIC SURGICAL TECHNIQUES a maileable retractor lighted retractor subperiosteal dissection on maxilla subperiosteal dissection on zygomatic arch e1-78 CHAPTER 1 @ INTRACRANIAL EXPOSURE Figure 1-8 ‘he intracranial approach shown here is used in an infant when the fontanelle is not completely fused. By using a bicoronal incision, the skin flap is turned down. The frontal view shows the supraorbital nerves; the dotted line outlines the incisions in the peri- cranium. Figure 1-9 By using a dissector, the pediatric neuro- surgeon dissects the pericranium from the fontanelle through an incision along the bony edge. The dura re- mains attached to prevent it from being damaged. Figure 1-10 After the bifrontal craniotomy and re- moval of the bone, the left temporal lobe is retracted near the middle lobe, while the dissection is continued at the anterior bone keel. The dissection must be per- formed carefully to prevent tearing the dura.BASIC SURGICAL TECHNIQUES 9 periosteum a Figure 1-8 bone keel Figure 1-1010 CHAPTER 1 @ INTRAORAL EXPOSURE Figure 1-11 Intraoral exposure can be achieved through an incision in the gingivobuceal sulcu. ‘is incision exposes the anterior surface of the facial skele- ton, including the maxilla, zygoma, and inferior orbital rim. When combined with a bicoronal incision, access to the entire facial skeleton is enhanced. Figure 1-12 The incision is made in the gingivobue- cal sulcus, leaving 1-2 mm on the labial side to allow for easy closure of the mucosa incision. Figure 1-13 When exposing the anterior surface of the maxilla, special attention must be paid to preserve the infraorbital nerve. Through the same incision, dissec- tion in the subperiosteal plane may be carried over the malar bone and zygomatic arch. This approach, along with a bicoronal incision, facilitates the separation of the soft tissue over the malar region and inferior and lateral orbital walls. Retractors must be placed on the floor of the orbit to protect the globe if Lefort or lamel- lar-split osteotomies are performed. This incision also allows the maxillary tuberosity and pterygoid region to be exposed.BASIC SURGICAL TECHNIQUES n Figure 1-11 infraorbital nerve Figure 1-13a2 CHAPTER 1 @ EXPOSURE OF THE ORBIT Figure 1-14 | use a subciliary incision to gain access to the floor of the orbit. I have not experienced compli- cations with this approach, I begin the incision through the skin and subcutaneous tissue and then angle it downward through the orbicularis oculi muscle. On the orbital rim, another incision is made through the periosteum, This stair-step approach prevents subse- quent scar contracture and other complications. Figure 1-15 The stair-step incision is used to expose the floor of the orbit. Extending the incision laterally and medially allows exposure of the lateral and medial walls of the orbit. Figure 1-16 The orbital floor may also be exposed through the transconjunctival approach. The incision is made 4~6 mm below the lid margin and extends di- rectly down to the orbital rim, where the periosteum is transected, allowing access to the globe and bony arbit.subciliary incision Figure 1-14 transconjunetival incision Figure 1-16 subciliary stair-step incision BASIC SURGICAL TECHNIQUES:4 CHAPTER 1 @ INTRAORAL EXPOSURE OF THE ASCENDING RAMUS Figure 1-17 The ascending ramus is visualized and palpated intraorally. An incision is made lateral to it in the posterior buccal sulcus by using a Colorado needle attached to an electrocautery unit. This incision is con- tinued directly over the anterior border of the ascend- ing ramus up to the level of the sigmoid notch. @ EXPOSURE OF THE CHIN Figure 1-19 The incision for exposure of the chin is carried through the labial mucosa and muscle to allow for two-layer closure after surgery. The incision is car- ried to the bone, and the tissue is undermined subpe- riosteally. Special attention is paid to exposure of both submental nerves. The tunneling technique prevents avulsion of the submental nerve at the time of surgery Figure 1-20 The chin is exposed. The mental nerve is protected by the retractor. The muscle remains at- Figure 1-18 By using a periosteal elevator, the as- cending ramus and outer angle of the mandible are completely expased. This incision may be extended an- teriorly when surgery on the mandible is planned. Lighted retractors are used when performing surgical procedures on the ascending ramus. tached to the chin. By using a reciprocating saw, I per- form the osteotomy fora sliding genioplasty. [| avoid de- gloving the chin because it may result in redundancy or lack of tone of the lower lip. Figure 1-21 A cross-section view. After the chin is slid forward, it is fixed with three wires at three sepa- rate locations. They are placed through the outer table of the proximal segment to the inner table of the distal segment. Advancement of the single-tiered sliding ge- nioplasty is limited by the thickness of the bone.BASIC SURGICAL TECHNIQUES 1s lighted medial ramus retractor Figure 1-17 dateral ramus retractor Figure 1-18 muscle cuff remains Simm below mental nerve eer interosseous wire fixation Figure 1-20 Figure 1-2116 CHAPTER 1 @ FIXATION TECHNIQUES LEFORT | ADVANCEMENT Figure 1-22 After a Lefort I osteotomy, the maxillary segments are immobilized with internal rigid fixation using the Medicon CMS System. In this case, three bar plates and a single L-shaped plate were used. Although fixation does not completely eliminate relapse, it does reduce the degree. Note the prefabricated acrylic splint, which establishes occlusion in a predetermined posi- tion. LEFORT I WITH SLIDING — GENIOPLASTY ADVANCEMENT AND ELONGATION Figure 1-24 The incision lines on the maxilla and chin. Figure 1-25 The lower maxillary segment is moved forward and downward. An interpositional grafl is in- serted between the maxillary segments to secure ap- propriate positioning, Demineralized bone from the Pa- cific Coast Tissue Bank has proven to be useful for interpositional grafts. A prefabricated acrylic wafer se- cures proper occlusion. The Medicon CMS System is used for rigid fixation of the maxillary segments. The chin is cut and moved forward. Figure 1-23 A close-up view of the placement of plates and 5- to 7-mm length screws 1.2 mm in diame- ter. The bone must be drilled under a stream of saline solution to avoid overheating the bone, Figure 1-26 Three interosseous wires are used to fix- ate the advanced chin segment. Figure 1-27 In this technique, to assure perfect stabil- ity of the newly positioned chin segment, I use two pre- fabricated plates for rigid fixation at a distance of 2, 4, 6, 8, and 10 mm of advancement.prefabricated acrylic splint Figure 1-22 Figure 1-26 Figure 1-2718 CHAPTER 1 LEFORT | ADVANCEMENT Figure 1-28 The Lefort Ill is one of the most fre- quently used procedures in craniofacial surgery. It al- lows the orbits and midfacial skeleton to be mobilized through either an extracranial approach or a combined intracranial—extracranial approach. This procedure in- corporates frontonasal disjunction allowing variations for cutting the lateral orbit. The procedure requires in- terpositional bone grafting and rigid fixation. The bone grafts, either autogenous or demineralized bone, may be placed in the frontonasal area along the orbits and in the zygomatic arches. | do not use bone grafts in the pterygomaxillary area. Intermaxillary fixation, rigid fixation, and bone grafts all complement one another in stabilizing major midface advancements. Figure 1-29 A titanium screw held by the center drive is easy to use and provides good visibility for the sur- geon. Figure 1-30 Compression titanium plates are used for rigid fixation of the fractured bone. The compression plates are designed so that the screws, when tightened at an angle, bring the bone fragments into close align- ment. | routinely use noncompression titanium plates in craniofacial fixation. Figure 1-31 The screw inside the bone must be drawn through the outer and inner cortical plates to achieve rigid fixation. Figure 1-32 Fixation of two bone segments is accam- plished by using interosseous wiring, This method is widely used in craniofacial surgery. Figure 1-33 The bony segments should be placed tightly together, fit properly, and wired securely. Figure 1-34 The wire should be secured tightly, so that the two twisted wires develop a second bend.BASIC SURGICAL TECHNIQUES: 9 Figure 1-29 Figure 1-30 Figure 1-31 Figure 1-28 Figure 1-32 Figure 1-33 Figure 1-3420 CHAPTER 1 SAGITTAL-SPLIT ADVANCEMENT OF THE MANDIBLE Figure 1-35 A single wire loop combined with inter- maxillary fixation may be used in sagittal-split forward advancement of the mandible. I keep this fixation in place for 6 weeks postoperatively. I use wire fixation even if I will subsequently use plates, screws, or other forms of fixation. Figure 1-36 Rigid fixation is achieved with a modular plate after a sagittal-split mandibular osteotomy. Two screws are used in each segment, taking care not to torque the condyle or bony segments. Figure 1-37 Three lag screws are inserted, one above and two below the inferior alveolar nerve. Although this provides good fixation, the screws must be inserted in a manner that avoids displacement of the condyle ‘An intraoral right-angle screwdriver is used. Figure 1-38 The lag screws are completely inserted after a sagittal-split osteotomy. Figure 1-39 ‘Transcutaneous drilling and insertion of the screw are performed either after a mandibular-split osteotomy or in preparation for the bone-distraction technique.interosseous wire fixation Figure 1-35 Figure 1-36 right angle screwdriver Figure 1-37 Figure 1-382 CHAPTER 1 MEDIAL CANTHAL APPROACH Figure 1-40 A skin incision is made to expose the me- dial canthal region. This technique was developed by Fuente del Campo. A back cut below the lower lid allows the straight line of the epicanthal fold to be broken up. Figure 1-41 A transverse incision allows for the ad- vancement of a small skin flap. The incision point is determined by the location of the corner of the eye and the optical level. Figure 1-42 The incision is completed. The skin is tightened when the epicanthal fold is pulled forward. with a finger. Figure 1-43 A suture is placed inte the medial can- thal ligament. The ligament can be transected and rein- serted into the periosteum or fixed transnasally to the opposite ligament with wire, as shown in the next se- ries of drawings.BASIC SURGICAL TECHNIQUES 23 __— specially contoured eye shields Figure 1-20 Figure 1-41 Figure 1-42 medial canthal ligament — Figure 1-4324 CHAPTER 1 MEDIAL CANTHOPEXY: TRANSNASAL WIRE FIXATION snasal wire fixation is an important anthopexies, particularly in con- genital cases. An Ethicon 3-0 wire on a swedged-on needle is inserted twice through the left medial canthal tendon and tightened down. Figure 1-45 The wire is passed through the accent nasal bones and vomer by using a modified Mustardé awl to secure an appropriate position for fixation of the medial canthus at the same level on both sides. Figure 1-46 Each wire end is threaded on a needle and inserted into the medial end of the right canthal tendon. Figure 1-47 Tightening the wire brings the medial canthal tendons into the preformed bone sockets and secures them in position. Symmetric placement of both medial tendons is imperative to achieve optimal re- sults.BASIC SURGICAL TECHNIQUES Figure 1-4526 CHAPTER 1 LATERAL CANTHOPEXY ‘One of the most frequently performed procedures in craniofacial surgery is lateral canthopexy. The jateral canthus must be adjusted 2-3 mm above the level of the medial canthus. Figure 1-48 The lateral canthus is normally attached to the periosteum at the lateral tubercle of the orbit. Frequently J use a permanent nylon suture to attach the lateral canthus to the lateral orbital wall by drilling two holes in the bone and tying the sutures over the bone. Figure 1-49 The nylon suture is passed through the lateral canthus. Two holes are drilled in the bone above the frontal zygomatic suture. Figure 1-50 To fix the lateral tendon in the appropri- ate position, the nylon sutures are passed through the holes in the bone by using a wire loop. Figure 1-51 The lateral tendon is tightly secured in the new position by tying the suture over the lateral or- bital rim. It is important to make sure the lateral can- thus is at the same level as that on the opposite eye.BASIC SURGICAL TECHNIQUES 27 Figure 1-48 Figure 1-49 Figure 1-50 Figure 1-512B CHAPTER 1 @ LACRIMAL DUCT PROBING Figure 1-52 A lacrimal dilator is inserted into the in- ferior punctum, while the lower lid is held tight with a small skin hook. Figure 1-53 A probe as large as can be easily inserted into the punctum is moved through the duct into the lacrimal sac. This procedure must be carefully per- formed to avoid perforating the duct or sac. Figure 1-54 If the probe fails, then a saline solution may be slowly and carefully injected to open the lacrimal system. See additional references for this tech- nique.BASIC SURGICAL TECHNIK _ lacrimal dilator Figure 1-52 syringe and needle for irrigation Figure 1-53 Figure 1-5430 CHAPTER 1 @ CARTILAGE AND BONE GRAFTS Autogenous cartilage and bone remain an imper- tant source of grafting material in craniofacial and cleft surgery. In my practice, | use auricular carti- lage, septal cartilage and bone, rib cartilage and bone, cancellous bone from the iliac crest, and AURICULAR CONCHAL CARTILAGE GRAFT I use cartilage from the ear to augment the nose when septal cartilage is not available. However, auricular cartilage is not as good as septal cartilage for nasal-tip support because it is curved and less rigid. Auricular cartilage requires reinforcement with a suture to create a columellar strut. Despite this drawback, auricular cartilage is my second choice for nasal-tip augmentation and even for dorsal augmentation, when required. Figure 1-55 A local anesthetic aids in dissecting the skin from the conchal cartilage. Figure 1-56 | routinely use an anterior approach, which leaves no visible deformity on the ear and is eas- ier to use than the posterior approach. The initial inci- bone grafts from the cranium. A bone substitute that I consider extremely valuable is demine ized perforated bone, produced by the Pacific Coast Tissue Bank. This material is both osteoin- ductive and osteoconductive. sion is made just inside the anterior helical rim; it ex- tends through the skin and cartilage, but not through the posterior auricular skin, Figure 1-57. The skin is dissected from the anterior surface of the conchal cartilage with small tenotomy scissors. The dissection is performed subperichondri- ally. Dissection must be completed over the entire an- terior and posterior aspects of the concha. Figure 1-58 The conchal cartilage is removed. Figure 1-59 The conchal cartilage is rolled and su- tured with 6-0 nylon, Small sections of conchal carti- lage may be used for augmentation of the nasal tip or dorsumBASIC SURGICAL TECHNIQUES: 31 Z Figure 1-55 Figure 1-56 Figure 1-57 Figure 1-59 Figure 1-5832 CHAPTER 1 SEPTAL CARTILAGE AND BONE Figure 1-60 The best source for nasal grafting is the cartilaginous and bony septum. The incision is made along the posterior margin of the columella behind the membranous septum. By using a caudal elevator, the mucoperichondrium and mucoperiostoum are elevated from the cartilaginous and bony septum on one side. The mucoperichondrium and mucoperiosteum on the other side also are undermined. Figure 1-61 Various designs of cartilaginous grafts or cartilaginous bony grafts can be obtained from the sep- tum. Figure 1-62 A segment of the cartilaginous septum is carved into the desired shape for grafting of the nasal dorsum. Figure 1-63 Various segments of the septum are pre- pared as grafts to be used for dorsal and nasal-tip aug- mentation. Note that for nasal-tip projection, the graft is carved in the shape of a button or a bilobule graft, as done by Sheen. Figure 1-64 When the vomer is deviated, it is usually necessary to remove some of the cartilaginous septum, along with the vomer, A total septoplasty may be nec- essary. Figure 1-65 The septal cartilage, when not used for grafting, can be banked subcutaneously in the retroau- ricular area.BASIC SURGICAL TECHNIQUES 33 caudal elevator Figure 1-60 Figure 1-61 Figure 1-63 Figure 1-6534 CHAPTER 1 RIB GRAFTS Figure 1-66 Rib grafts are now rarely used in cranio- facial surgery. I use a costochondral graft to create the condyle in children with ankylosis or absence of the temporomandibular joint, Growth of the costochondral graft is unpredictable however, and occasionally cor- rective surgery is required. The incision for obtaining a rib graft in the female patient should be made below the breast in the inframammary line, allowing access to the fifth or sixth intercostal areas. If necessary, a costo- chondral graft can be obtained. Figure 1-67 The incision through the periosteum and perichondrium to the bone and cartilage is made with a cutting Bovie by using a Colorado needle. Figure 1-68 The rib is exposed using a periosteal ele- vator.BASIC SURGICAL TECHNIQUES 35 Figure 1-66 forade needle riostea! elevator Figure 1-67 Figure 1-6836 CHAPTER 1 Figure 1-69 The periosteum is easily stripped from the bony and cartilaginous portion of the rib with a Doyen rib stripper. Figure 1-70 Lateral subperiosteal dissection is per- formed without extending the skin incision. The rib can be cut at any length. Figure 1-71 The wound is closed by suturing the pe- riosteum, muscles, and skin in separate layers, A saline wash checks for any air leak from the pleura before closing.BASIC SURGICAL TECHNIQUES: 37 Figure 1-69 Figure 1-70 Figure 1-7138 CHAPTER 1 ILIAC CREST BONE GRAFT In the past, large segments of bone from the iliac crest were used for reconstruction in craniofacial surgery. Now, however, only cancellous bone from the area is used. Figure 1-72 The incision is carried along the iliac crest through the skin and subcutaneous tissue to the bone. Figure 1-73 | use a wide osteotome to split the carti- laginous part of the bone and obtain cancellous bone from between the two segments. This technique, first described by Bardach, is rapid and provides easy ac- cess to the hone. After obtaining cancellous bone, | approximate both segments and suture them together. Postoperative morbidity is minimal. Figure 1-74 Cancellous bone is removed with a curette from between the inner and outer tables. Figure 1-75 With this technique, the incision is made below the cartilaginous portion of the iliac crest, By hinging this portion upward. the cancellous bone be- tween the inner and outer tables is exposed.BASIC SURGICAL TECHNIQUES 32 i a —— ‘Figure 1-72 cancellous bone40 CHAPTER 1 CRANIAL BONE GRAFTS Figure 1-76 By using a burr, the outer table is cut fol- lowing the design of the bone graft. With an osteotome, a segment of the outer table is removed. Single-Burr-Hole Craniolomy Figure 1-77 By using the single-burr-hole technique, the neurosurgeon cuts the parietal bone just off or lat eral to the midline. The dura is dissected with a small dural retractor. The block of bone is removed with craniotome. The dura is totally freed from the overlying bone by using a dural retractor or Penfield dissector be- fore the proposed cuts are made. Figure 1-78 ‘The block is split; one table is put back in place, and the other is used for grafting. Fixation is ac- complished with titanium plates and screws.42 CHAPTER 1 Two-Burr-Hole Craniotomy Figure 1-79 A periosteal elevator is used to dissect the dura from the inner surface of the temporal bone. A craniotome is inserted through the burr hole. The block of bone, designated by the dotted lines, is removed, and the bone is split. One table is returned to its place, whereas the other is used for reconstruction. Four-Burr-Hole Craniotomy Figure 1-80 The four-burr-hole technique can be used to obtain a large block of parietal, temporal, or other cranial bone. ‘The bone is split into two tables; one of which is returned to its place and fixed, while the other is used for the reconstructive procedure. Figure 1-81 ‘The dorsal nasal graft is fixed in place with titanium screws at the frontonasal junction. The two segments of split cranial bone are returned to the donor site and fixed with wires, The burr holes are filled with bone dust and covered with the pericranial flap attached to the temporalis muscle, thus sealing the entire donor site.‘BASIC SURGICAL TECHNIQUES a split thickness {fall thickness pericranial flap Figure 1-80a4 CHAPTER 1 @ TOTAL CRANIAL VAULT REMODELING Figure 1-82 Design for total cranial vault remodeling. The cranial vault is removed in four segments, which are split on another table. The shape and size of the seg- ments are redesigned for bone grafting. In cases of marked irregularity and poor shape of the frontal ban- deau, the parietal occipital bone may be designed as a frontal-bandeau replacement Figure 1-83 The occipital bandeau is removed and moved to the place of the frontal bandeau. The frontal bandeau is moved to the place of the occipital bandeau. Figure 1-84 ‘The frontal parietal bones are split, and a vise is used for fixation. The cranial bone is split into sogments, the design of which depends on the need of the particular reconstruction.BASIC SURGICAL TECHNIQUES a5 new bandeaw device used to split bone on back table Figure 1-84a6 CHAPTER 1 DEMINERALIZED BONE Demineralized bone from the Pacific Coast Tissue Bank is an alternative to cranial bone for grafting material. Demineralized bone is osteoinductive and easier to shape than cranial bone. Various types of demineralized implants are available to accommodate the various needs of reconstructive surgery. The selection of the demineralized bone implant depends on the size and location of the de- fect. I have used more than 1,400 demineralized bone implants in the last 7 years and find them an excellent bone substitute in craniofacial surgery. Figure 1-85 When cranial bone is not available, I use a cortical strip of demineralized perforated bone. The perforations in the strip allow new bone ingrowth, and the strips are pliable. I soak them in an antibiotic solu- tion for 1h before surgery. Figure 1-86 Cortical perforated strips can be easily shaped to follow the curve of the cranium. Figure 1-87 The cortical strips are sutured in place with resorbable sutures. New bone formation occurs overa period of several months and is demonstrated by the presence of osteocytes and osteoblasts. Note the zig- zag skin incision in front of the demineralized bone grafts. I avoid placing the demineralized bane grafts in the line of the skin incision to avoid complications in the healing of demineralized bone.BASIC SURGICAL TECHNIQUES a7 Figure 1-87 antibiotic solution fi48 CHAPTER 1 Types of Demineralized Bone Figure 1-88 Demineralized rib can be used for con- tour or inlay reconstruction. Figure 1-89 Perforated cortical strips used for cranial- vault reconstruction in Figures 1-85 through 1-67. Figure 1-90 Lamellar strips are available in 1-, 2-, or 3-mm thickness. The strips can be used flat or rolled and can be easily sutured and used for augmentation of the nasal dorsum or in the perinasal region. Figure 1-91 Demineralized iliac crest can be easily cut with a scissors and is my material of choice for malar augmentation. It is produced in blocks of 3- to 6- mm thickness, which allow for appropriate contour- ing. | insert the implant beneath the periosteum. Figure 1-92 For additional contouring, demineral- ized bone granules may be used as filler material in small bony defects. Figure 1-93 Demineralized bone powder also may be used as filler material.BASIC SURGICAL TECHNIQUES ao demineralized rib Figure 1-88 Figure 1-89 iliac crest (3-6 mm thick) Jamellar (1-3 mm thick) Figure 1-91@ FIBRIN TISSUE ADHESIVES Figure 1-94 [ frequently use fibrin adhesives in cran- iofacial surgery. Two components are mixed to create the fibrin tissue adhesive: (a) fibrinogen, which is ob- tained by spinning down a unit of blood from the pa- tient and separating the fibrinogen from the plasma; and (b) thrombin and CaCl, which acts as a fibrinoly- sis inhibitor. I use the fibrin adhesive for sealing leaks in the dura and mucosa, obliterating dead space, achieving hemostasis, binding bone grafts, and as a per- icranial graft adhesive. Figure 1-95 Fibrin tissue adhesive is mixed with bone dust or demineralized bone granules to form a filler for burr holes or contour defects. Figure 1-96 Bone paste is used for grafting in burr holes or bone junctions. Figure 1-97 A dural graft is sealed with a fibrin tissue adhesive. It is placed along the suture line to prevent cerebrospinal fluid leakage. See references on Fibrin Tissue Adhesive for further information. Figure 1-98 A burr hole in the cranium can be closed witha titanium plate. | use the plate designed by Medi- con CMS System. The titanium plate is fixed with smal] 0.9-mm diameter screws. The plate not only closes the burr hole but aids in fixing the bony segment.BASIC SURGICAL TECHNIQUES st fibrinogen Figure 1-94 Figure 1-06 Figure 1-97 CMS Medicon Burrhole Plate. Figure 1-9852 CHAPTER 1 Figure 1-99 Full-thickness calvarial bone is removed and split into two or more pieces with a reciprocating saw. It is held with a bone clamp and cut between the inner and outer table for split grafting or cut as a full- thickness cranial bone graft. Figure 1-100 Cuts made on the removed segment of the calvarium allow the curved bone to be flattened. The cuts are made with a reciprocating saw. Figure 1-101 1 prefer the two methods of bone bend- ing illustrated in Figures 1-101 and 1-102. In infants aged 6 months—1 year, the bone may be thin enough to be shaped by using a bone bender (modified Tessier). This technique also works for split cranial bone. Figure 1-102 Bone in older patients can be shaped by producing microfractures with a reciprocating saw.BASIC SURGICAL TECHNIQUES 33 Figure 1-99 Figure 1-100 bone bender bone bender ‘Figure 1-101 Figure 1-10254 (CHAPTER 1 Figure 1-103 The concept of recurrent parabolic shapes as a means for cutting, expanding, or shaping bone was introduced by Hendle. his concept is based on repeating ellipses, which allow expansion of the bone as the curved cranial bone becomes flat. I use this technique to change the shape of the bone in the cranial vault and in other operations requiring a change in con- tour and shape. Figure 1-104 Linear cuts are made in the bone to change its shape. Figure 1-105 Linear cuts enlarged at the ends with a drilling puncture allow an even greater change in shape. Figure 1-106 Linear cuts extended through the edge of the bone allow a greater degree of expansion. Figure 1-107 A similar technique of cuts as shown in Figure 1-106 allows more expansion without the drilled punctures Figure 1-108 A variation of cuts allows more expan- sion and change in the shape of the bone.BASIC SURGICAL TECHNIQUES ss Figure 1-107 Figure 1-10856 (CHAPTER 1 Figure 1-109 A technique reminiscent of skin-graft- ing is used to expand the surface area of a bone to 4% its original size (introduced by Argenta et al.). The orig- inal segment of bone is split into two segments. Figure 1-110 Both segments are cut along the lines on the bone fragment. Figure 1-111 The cut segments are fixed with inter- osseous wiring, Figure 1-112 The same procedure is performed with the second bone segment. Figure 1-113 When the segments are put together, they cover an area 4 that of the original bone segment. This technique provides strong and secure bone expan- sion when there is not enough bone for a reconstructive procedure.ASIC SURGICAL TECHNIQUES Figure 1-11358 CHAPTER 1 LAMELLAR-SPLIT OSTEOTOMY I developed this technique to change the shape of the outer table of a bane while keeping the inner table in place, which serves as a reference point. An interpositional bone graft can be placed be- tween the tables. This technique is superior to the onlay bone graft. I have not observed resorption of the outer table. Furthermore, this technique can be successfully used on the frontal bone, malar bone, and in the orbital, maxillary, and mandibular re- gions. Depending on the location, it can be per- formed extracranially or intracranially. Figure 1-114 Lamellar split of the malar bone is ac- complished by using the coronal approach. The same procedure can be performed by using an intraoral ap- proach. The lamellar split is carried over to the level of the inferior orbital nerve so that the entire zygomatic arch can be changed in shape, projection, and width, Figure 1-115 This view from above shows the pro- posed lamellar split (dotted line), which is carried to the inferior orbital nerve. Figure 1-116 The outer table of the malar bone is ad- vanced after a lamellar-split osteotomy, An. interpasi- tional bone graft is inserted between the outer and in- ner tables to project the malar eminence. Figure 1-117 The left side is corrected by using the lamellar-split technique with the insertion of a bone graft. On the right side, an interpositional bone graft is ready for insertion,BASIC SURGICAL TECHNIQUES 59 Figure 1-115 Figure 1-114 Figure 1-117 Figure 1-11660 (HAPTER 1 Figure 1-118 Lamellar split of the supraorbital ban- deau through a bicoronal approach with a bifrontal craniotomy. The frontal lobes are retracted, and a lamellar split is performed on the bandeau under direct visualization. Figure 1-119 The outer table is advanced forward and changed in shape. An interpositional bone graft is in- serted to create a new arc of the frontal orbital temporal region. Figure 1-120 The outer table of the bandeau is se- cured in a new position with screw fixation.BASIC SURGICAL TECHNIQUES 61 Figure 1-118SURGERY FOR Snes etter ee eesteeeees CRANIOSYNOSTOSIS Kenneth E. Salyer Daniel MarchacCraniofacial surgery has significantly improved the treatment outcomes of craniosynostosis. New techniques of remodeling and reshaping the cra- nial vault allow for rapid expansion and growth of the brain. | prefer to operate on infants with cran- iosynostosis at the age of 6 months. Craniofacial remodeling techniques were devel- oped in the early 1970s. Marchac popularized the floating-forehead procedure, whereas other sur- geons used the tongue-in-groove method, These methods offered a major advancement over strip craniotomy or morselization. I developed the tech- nique of total cranial-vault remodeling and have found it to be the best approach for severe syndro- mal craniosynostosis and other extensive cranial- vault deformities, such as severe plagiocephaly or craniofacial scoliosis. My technique includes os- teotomies in the anterior, middle, and posterior cranial fossa, as well as in a portion or all of the cranial vault. SURGERY FOR CRANIOSYNOSTOSIS IN INFANTS 65 A craniotomy is performed by a pediatric neuro- surgeon to remove the deformed section of the cra- nium, Frequently a bifrontal craniotomy is per- formed, which may be expanded to remove the entire cranial vault and allow osteotomies to be performed in the cranial base. The skeletal seg- ments are reshaped and replaced into new posi- tions by using interosseous wire fixation, resorb- able sutures, or miniplates. Simple craniosynostosis resulting in plagio- cephaly, brachycephaly, or trigonecephaly and other related deformities can be successfully treated with frontocranial remodeling. Lambdoid synostosis, which rarely requires surgical correc- tion, may be treated with occipital bandeau re- modeling. I treat syndromal synostosis in complex deformities such as Crouzon’s, Apert's, Saethre— Chotzen, Pfeiffer, and Kleeblatschadel syndromes with total cranial remodeling,CHAPTER 2 MARCHAC’S ORIGINAL TECHNIQUES s Daniel Marchac Figure 2-1. ‘The floating-forchead advancement tech- nique was described by Marchac. Advancement of the bandeau is accomplished with bone-plate fixation at the fronto-orbital suture. A bone plate is fixed with interosseous wiring. In an infant, the bandeau may be advanced 1—2 cm. Figure 2-2 The advanced bandeau is fixed with a block of bone, reinforcement plate, and a strut wired to the roof of the nose. Figure 2-3. Tho floating-forehead technique with di- rect wiring is used in older patients.SURGERY FOR CRANIOSYNOSTOSIS IN INFANTS o7 bandeau reinforcement plate bone plate sutured over frontozygomatic suture in infant Figure 2-1 direct wiring in older patient Figure 2-368 CHAPTER 2 Figure 2-4 The floating-forehead technique is de- signed for advancement and remodeling of the fore- head. The replaced bone may consist of the same bone that has been removed, reshaped, or segmented to achieve the optimal configuration. Figure 2-5 The remodeled forehead is secured with interosseous wiring and bone plates. Figure 2-6 Marchac introduced the floating-forehead technique for changing the frontonasal angle. This ap- proach can be used in infants and older patients. Cut- ting the bandeau at the frontonasal junction and fronto- orbital junction and extending into the temporal bone allows the angle of the bandeau to be changed. In this procedure, the parietal bone (C) will be moved forward, replacing the bone segment (B). Figure 2-7 Segments A, B, and C are mobilized and prepared for new positioning and fixation. The change in the frontonasal angle is determined by the surgeon.SURGERY FOR CRANIOSYNOSTOSIS IN INFANTS 62 Figure 2-570 CHAPTER 2 Figure 2-8 Segment C becomes the new forehead, whereas segment B replaces the defect left by segment © Figure 2-9 Marchac’s version of forehead advance- ment uses the tongue-in-groove technique. A frontal bandeau is cut at the frontonasal junction and at the lat- eral fronto-orbital junction with an extension into the temporal bone, Figure 2-10 The bandeau has been advanced forward and fixed with interosseous wiring. The bandeau tongue-in-groove secures the new position. The cranial segment (B) has been rotated 90° and reshaped to form the new forehead, whereas bony segment C is used to close the defect created after rotating bone segment B.SURGERY FOR CRANIOSYNOSTOSIS IN INFANTS nmCHAPTER FLOATING FOREHEAD WITH BONE GRAFT THE NOSE Kenneth E. Salyer Figure 2-11 The floating-forehead technique is used in combination with a bone graft to the dorsum of the nose. The forehead is remodeled using original bone af- ter various cuts have been made and reshaping done. Figure 2-12 The forehead and frontal bones are re- moved, cut, and reshaped, to allow for expansion and recontouring, Figure 2-13 Fixation of two bony segments with in- terosseous wiring maintains the new shape of the fore- head, Figure 2-14 Forehead advancement occurs at the level of the coronal suture with recontouring of the forehead and changing the frontonasal angle. A dorsal nasal bone graft improves the frontonasal angle.SURGERY FOR CRANIOSYNOSTOSIS IN INFANTS 7 Figure 2-13 nasal bone graft74 CHAPTER 2 @ PLAGIOCEPHALY Plagiocephaly is a descriptive term derived from the Greek plagio, meaning oblique or slanted, and cephalo, meaning head. Synostotic plagiocephaly results from premature closure of a unilateral coronal suture and may also involve a unilateral lambdoidal suture. In rare cases, the premature closure involves only an isolated lambdoidal su- ture. Simple plagiocephaly can be corrected by using either a unilateral or bilateral procedure. I prefer to use a bilateral procedure even in minor deformi- ties because better symmetry can be obtained. I modified the unilateral procedure, originally de- scribed by Hoffman, in the following ways. Figure 2-15 ‘The unilateral frontal craniotomy, as de- scribed by Hoffman. It is designed at the level of the coronal suture and extends into the midline. Forehead and bandeau advancement correct the asymmetry. Three burr holes are generally used for the craniotomy. ‘The hemibandeau is also reshaped and advanced for- ward, Figure 2-16 Advancement of the bony segment leaves a defect along the coronal suture. In infants, this defect fills with new bone. Figure 2-17 A view from above of the deformity and design of the operation. Figure 2-18 Viewed from above, the forehead and hemibandeau have been advanced by using a tongue- in-groove technique. The bony defect is evident along the coronal suture.SURGERY FOR CRANIOSYNOSTOSIS IN INFANTS 7s Figure 2-16 Figure 2-15 bandeau advanced and reshaped76 CHAPTER 2 Figure 2-19 Bilateral correction of plagiocephaly with frontal-bone remodeling. Burr holes are prepared for a bifrontal craniotomy at the level of the supraor- bital region, allowing a 1-cm bandeau, which extends into the temporal fossa. Figure 2-20 ‘The asymmetric forehead and orbit are best viewed fram above. Note the marked retrusion of the supraorbital area on the left side and overextension of the forehead and cranial vault on the right. Figure 2-21 The removed bandeau has been scored and prepared for reshaping. Figure 2-22 ‘The bandeau is reshaped and ready to be put in place,SURGERY FOR CRANIOSYNOSTOSIS IN INFANTS nW Figure 2-19 Figure 2-20 Figure 2-21 Figure 2-227 CHAPTER 2 Figure 2-23 The bandeau and forehead bone are cut, reshaped, and ready to be put in place. Figure 2-24 The forehead and bandeau are in place after remodeling and recontouring of the forehead, or- bit, and frontonasal junction, Wire sutures are used for fixation Figure 2-25 An intraoperative view. The bifrontal craniotomy has been performed, and the frontal bone has been removed. The bandeau has been cut. The pro- posed advancement is shown on the right side. Figure 2-26 A right lateral view. The bandeau has been advanced; its fixation was facilitated by a lamel- lar-split-type cut. Figure 2-27 The orbit and bandeau have been ad- vanced on the right side, and the temporalis muscle has been reattached. The forehead has been reshaped and fixed with osseous wiring. Figure 2-28 Preaperative frontal view of a 2-year-old patient with plagiocephaly with retrusion of the right side of the forehead, supraorbital rim, inferior orbit, and malar area. Figure 2-29 Postoperative frontal view 4 1/2 years af- ter bilateral correction using the technique presented in Figures 2-19 through 2-24. Figure 2-30 Preoperative right lateral view demon- strating the same deformity. Figure 2-31 Postoperative right lateral view 4 1/2 years after correction.SURGERY FOR GRANIOSYNOSTOSIS IN INFANTS 73 Figure 2-23 Figure 2-24 Figure 2-25 Figure 2-26 Figure 2-27 Figure 2-30 Figure 2-3180 CHAPTER 2 @ BRACHYCEPHALY BILATERAL CORONAL SYNOSTOSIS Brachycephaly is frequent in syndromal cases in association with other suture involvement and is seldom encountered as simple coronal synostosis. Closure of the coronal sutures results in an abnor- mal vertical height of the forehead with supraor- bital retrusion. Frequently more than just the front of the head is affected, in which case, total cranial- vault remodeling may be indicated. In minor de- formities, remodeling with a bandeau and fronto- orbital remodeling may suffice. Figure 2-32 Design of total cranial-vault remodeling in a case of brachycephaly. A bifrontal craniotomy is performed by removing the frontal bone in one piece and removing the parietal occipital bones in halves. The bandeau is removed just above the frontonasal junction and above the orbits; the orbital roof is cut from the inside out, protecting the frontal lobes. The proposed orbital osteotomies may extend into the infe- rior orbital fissure and around the front of the orbit, to allow for greenstick advancement. Figure 2-33. Total cranial-vault remodeling: All seg- ments have been removed, cut, and reshaped to allow for rotation and optimal recontouring. The supraorbital bandeau has been cut and advanced. The osteotomies in the orbits, extending intracranially to the inferior or- bital fissure, are completed. The osteotomy extends through the malar bone, where the lateral inferior orbit can be greensticked anteriorly. When performed bilat- erally, the bandeau and orbits can be advanced. Figure 2-34 The entire cranial vault is reshaped and remodeled. The orbits are advanced and extended lat- erally, Two occipitopariotal segments are reshaped and changed in position. Interasseous wiring is used for fix- ation. Figure 2-35 Preoperative 3-D computed tomography (CT) reconstruction in a case of plagiocephaly. Figure 2-36 Postoperative 3-D CT 2 years after the surgical procedure. showing total cranial-vault remod- eling Figure 2-37 Preoperative frontal view of a 6-month- old patient with brachycephaly with bicoronal synos- tosis Figure 2-38 Postoperative frontal view of the same patient 1 year after total cranial-vault remodeling.Figure 2-32 Figure 2-35 inferior orbital fissure 4 ee greenstick site Figure 2-33 Figure 2-3682 CHAPTER 2 @ TRIGONOCEPHALY Trigonocephaly is a keel-shaped skull deformity resulting from premature closure of the metopic suture. 2-39 Incisions in the frontal bone and supraor- bital bandeau are designed. Figure 2-40 The design of the operation as seen from above. Note the burr holes prepared for the craniotomy. Figure 2-41 The removed frontal bone is cut and ex- panded. Figure 2-42 The expanded forehead. Figure 2-43 With retraction and protection of the frontal and temporal lobes, the bandeau is removed with an oscillating saw. Figure 2-44 The supraorbital bandeau is reshaped with cuts made on the inner table to allow for expan- sion and the creation of a better curve. Figure 2-45 ‘The bandeau is reinforced at the midline with an additional bone plate,Figure 2-39 Figure 2-43, % bone plate Figure 2-4584 CHAPTER 2 Figure 2-46 The new position of the bandeau is checked, and the amount of temporal expansion deter- mined. The frontal bone is remodeled to fit the new shape of the bandeau. Figure 2-47 Intraosseous fixation of the advanced and reshaped supraorbital bandeau and frontal bone. Figure 2-48 Preoperative axial CT of a patient with trigonocephaly. Figure 2-49 Intraoperative birds-eye view of the ban- deau expansion. Figure 2-50 Preoperative birds-cye view of the top of the head showing the keel-shaped deformity. Figure 2-51 Postoperative birds-eye view of the top of the head after surgical correction, 1 year after surgerySURGERY FOR CRANIOSYNOSTOSIS IN INFANTS Figure 2-46 Figure 2-47 Figure 2-48 Figure 2-49 Figure 2-50 Figure 2-5186 CHAPTER 2 1 SCAPHOCEPHALY Scaphocephaly is premature closure of the sagittal sutures, which may or may not include the metopic suture. This condition results in a long, narrow skull. The surgical correction of scapho- cephaly may be performed at any age, but it is eas- ier when performed at 6 weeks of age. When per- formed at an older age, the skull is thicker, and a more complex procedure is required. Figure 2-52 A segment of bone is removed trans- versely from the front and back of the head to shorten the length, whereas the two temporoparietal bones are widened. This technique allows the bitemporal width to be expanded. Alternatively, the bone marked for re- moval can be used in the midline to increase the width of the skull. Figure 2-53 The design of the operation as seen from above. The amount of bone to be removed behind the coronal sutures and in front of the occipital suture is shown. Figure 2-54 Ananterior segment of the occipital bone is removed. The remaining occipital bone is advanced anteriorly to shorten the anteroposterior dimension of the skull. Figure 2-55 The temporoparictal bone is removed and rotated 90° to widen the skull. Excess bone is used to fill any defects left after achieving the optimal skull shape. Figure 2-56 Preoperative view from above ofa patient with scaphocephaly. Figure 2-57 Preoperative lateral view of the same pa- tient demonstrates the occipital deformity. Figure 2-58 Postoperative lateral view 1 year after surgery. Note the marked shortening of the anteropos- terior dimension. Figure 2-59 Postoperative lateral view 2 years after surgery.segments removed to shorten pm Figure 2-52 Figure 2-53 increased width of skull creating parietal eminences Figure 2-54 Figure 2-56 Figure 2-5988 CHAPTER 2 SPIRAL TECHNIQUE FOR CORRECTION OF SCAPHOCEPHALY Figure 2-60 The technique is shown with the use ofa posterior occipital bandeau, which allows for new po- sitioning of the posterior cranial vault. A lateral view of the spiral technique after the skull has been cut, ex- panded laterally, and shortened in the anteroposterior dimension. The bony segments are fixed with inter- osseous wires. Figure 2-61 View from above shows remodeling of the posterior two thirds of the cranial vault. The spiral technique creates two parietal eminences and increases the posterior cranial vault with lowering of the vertical height for correction of sagittal synostosis. Figure 2-62 Intraoperative lateral view shaws the sur- gical technique during the operation. Figure 2-63 Intraoperative view from above shows the technique for expansion of the posterior width of the cranial vault before inserting the bone graft. Figure 2-64 Preoperative frontal view of a 2%-year-old patient with scaphocephaly. Figure 2-65 Postoperative frontal view 6 months after correction using a modification of this technique. Figure 2-66 Preoperative left lateral view shows a long, narrow skull associated with scaphocephaly. Figure 2-67 Postoperative left lateral view after total cranial-vault remodeling using the spiral osteotomy technique. Figure 2-68 Preoperative view from above shows marked elongation of the skull. Figure 2-69 Postoperative view from above 6 months after correction. Figure-2-70 Anteroposterior radiograph shows spiral technique postoperatively. Figure 2-71 Lateral radiograph reveals the osteo- tomies performed in the total cranial-vault correction of scaphocephaly using the spiral technique.Figure 2-60 bilateral parietal eminences Figure 2-61 Figure 2-66 Figure 2-68 Figure 2-70 Figure 2-65 Figure 2-67 Figure 2-69 Figure 2-7130 CHAPTER 2 = LAMEDOID SYNOSTOSIS True isolated unilateral lambdoid synostosis is rare and must be differentiated from positional plagiocephaly, which does not require surgical in- tervention. The surgical treatment of this condi- tion is similar to that used in plagiocephaly or brachycephaly, but the bandeau is used in the pos- terior occipital region. The parietal bones are re- shaped and replaced. In lambdoid synostosis, the bandeau and occipital bone are removed from the occipital region and reshaped to create a normal- looking skull. If the forehead is involved, it is cor- rected in a second procedure. Figure 2-72 Lateral view of the cuts on the occipital bone and bandean. Figure 2-73 Design of the bioccipital craniotomy and occipital bandeau. Figure 2-74 The bandeau is removed. Figure 2-75 In the view from above, note the marked deformity of the skull in the occipital region. Figure 2-76 The bioccipitoparietal bone segments are removed.SURGERY FOR CRANIOSYNOSTOSIS IN INFANTS posterior bandeau for expansion Figure 2-74 Figure 2-7692 CHAPTER? Figure 2-77 The posterior third of the skull and ban- deau are removed. Figure 2-78 The bandeau is reshaped to form a new contour. Figure 2-79 The parieto-occipital bone segment is di- vided in half, The design of the cuts on the bony sep- ments is evident. Figure 2-80 Radial cuts of the bony segment allows for occipito-parietal expansion. Figure 2-81 The bandeau and paricto-occipital bony segments are placed in position and secured with in- terosseous wires. Figure 2-82 The reconstructed posterior half of the skull allows for expansion in the posterior cranial-vault region. Figure 2-83 Preoperative CT scan shows a flat poste- rior skull. Figure 2-84 Intraoperative view. Note the occipital bandeau and expansion with bilateral parieto-occipital bone segments, which have been cut and remodeled. Figure 2-85 Preoperative left lateral view of a flat oc- cipital bone caused by lambdoid synostosis in a 6- month-old patient. Figure 2-86 Postoperative left lateral view 1's years af- ter surgical correction.SURGERY FOR CRANIOSYNOSTOSIS IN INFANTS 93 Figure 2-77 Figure 2-78 _- expansion of constricted cranial bone Figure 2-80 Figure 2-79 Figure 2-81 Figure 2-84 Figure 2-85 Figure 2-86458 CHAPTER 11 LIP RECONSTRUCTION Figure 11-58 Construction of the nasal floor is com- pleted. Before lip closure, it is important to make sure that the orbicularis oris muscle is dissected from its bony attachments. Note the excessive vermilion that re- mains on the cleft side. Figure 11-59 A key suture is inserted on the skin—ver- milion border joining both sides at the high point of the Cupid’s bow. This suture helps to maintain proper alignment of the lip segments when suturing the mus- cles and skin. Figure 11-60 Sutures are inserted into the orbicularis oris muscle. Figure 11-61 The suture on the skin—vermilion bor- der is tied, Dotted lines, proper adjustment for good symmetry and balance. Two more key sutures are in- serted to fit the triangular flaps into the appropriate de- facts,PRIMARY UNILATERAL CLEFT=LIP/NOSE REPAIR 459 Figure 11-58 Figure 11-59 Figure 11-60460 CHAPTER 11 Figure 11-62 Excessive vermilion is removed. More sutures are inserted into the skin to achieve perfect ad- justment of the skin margins. Figure 11-63 Final appearance after primary lip/nose repair. Figure 11-64 A, B: Unilateral cleft lip and alveolus with severe nasal distortion. C, D: Four years after pri- mary cleft-lip/nose repair, Nate normal facial growth, nasal symmetry, and slight asymmetry of the vermil- ion,PRIMARY UNILATERAL CLEPT-LIP/NOSE REPAIR 461 Figure 11-62 Figure 11-63 Figure 11-64524 CHAPTER 12 @ SEMIOPEN TECHNIQUE FOR CORRECTION OF THE SECONDARY UNILATERAL CLEFT-LIP AND NASAL DEFORMITY My modification is a variation of Bardach’s tech- nique in which he uses an open approach. I repo- sition and reshape the cartilages and create sym- metry without raising the columella. Bardach’s technique is presented later in the chapter. Figure 12-61. ‘The alar cartilage on the cleft side is dis- placed laterally, inferiorly, and posteriorly. Figure 12-62 A rim incision is made with a no. 11 blade. The incision is extended along the lateral edge of the columella and is carried on both sides. Figure 12-63 ‘The skin is widely undermined from the underlying lower lateral cartilages with a small teno- tomy scissors, a small Metzenbaum scissors. or a com- bination of both, Figure 12-64 Delivering the lower lateral crus after careful dissection of the skin and nasal mucosa,SECONDARY UNILATERAL CLEFT-LIP AND NASAL DEFORMITIES 525 Figure 12-61 Figure 12-62 Figure 12-63 Figure 12-64526 CHAPTER 12 Figure 12-65 Both lower lateral cartilages are deliv- ered and inspected for symmetry. Figure 12-66 Partial removal of the lateral crus of the lower lateral cartilage on the noncleft side is performed to match the cartilage on the cleft side. Figure 12-67 ‘ho alar cartilage on the cleft side is re- shaped and repositioned to match the cartilage on the noncleft side. Both cartilages are sutured at the dome. Figure 12-68 ‘The medial crura and domes of both car- tilages are sutured together, lengthening the columella and projecting the nasal tip,SECONDARY UNILATERAL CLEFT-LIP AND NASAL DEFORMITIES S27 Figure 12-65 Figure 12-66 Figure 12-67 Figure 12-68Salyer & Bardach's Atlas of Craniofacial & Cleft Surgery Volume I: Craniofacial SurgerySalyer & Bardach's Atlas of Craniofacial & Cleft Surgery Volume I: Craniofacial Surgery Kenneth E, Salyer, M.b. Director and Founding Chairman International Craniofacial Institute Cleft Lip and Palate Treatment Center Dallas, Texas Hlustrations by William M. Winn, ™.s., cut Photographs by Eddie Adams NN Lippincott - Raven Bee Bik dee Ay Bet ARS. Philadelphia + New YorkAcquisitions Editor: Danette Knopp ‘Developmental Editor; Anne M. Sydor Manufacturing Manager: Dennis Teston ‘Production Manager: Jodi Borgenicht Production Editor: Deindre Marino-Vasquez ‘Cover Designer: Diana Andrews Indexer: Susan Thomas Compositor: Maryland Composition ‘Printer: Toppan Printing (01999, by Lippincott-Raven Publishers. All rights reserved. This book is protected by copyright. No: part of it may be reproduced, stored im a retrieval system, or transmitted, in any form or by any means—electronie, mechanical, photocopy, recording, or ctherw ise—without the prior written consent of the publisher, except for brief quotations embodied in eritical articles und reviews. For information write Lippincott-Raven Publishers, 227 East Washington Square, Philadelphia, PA 19106-3780. Materials appearing in this book prepared by individuals as part of their official duties as US. Government employees are not covered by the above-mentioned copyright Printed in Japan, 987654321 Library of Congress Cataloging-in-Publication Dats Salyer and Bandach's stlas of craniofacial & cleft surgery pom. Includes index. Contents: v. 1. Craniofacial surgery / Kenneth E. Salyer, — 2. Cleft lip and patate surgery / Januse Bardach. ISBN 0-397-51807-2 (hard cover) 1. Skull—Abnormalitics—Surgery—Atlases. 2, Face—Abnormnalities—Surgery Ailases. 3. Cleft palate—Surgery—Aulases. 4. Cleft lip—Surgery—Allases. Salyer, Kenneth E. I. Bardach, Janusz (DNLM: 1. Facial Bones—surgery atlases. 2. Skull—surgery atlases. 3. Cleft Lip—surgery atlases. 4. Cleft Palate—surgery atlases. 5. Craniofacial Abnormalitier—surgery atlases. 6. Reconstnuetive Surgical Procedures—methoels atlases. WE 17 $1845 1998] RDIOI.S25 1998 617 5°2—de21 DNLMDLC or Libary of Congress 9813316 cP Care has been taken to confirm the accuracy of the information presented und uo describe generally accepted practices. However, the authors, editors. and publisher are not responsible for errars or omissions or for any consequences from application of the information in this book and make no warranty, express or implied, with respect tothe comtents of the publication. ‘The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in acenrdance with current recommendations and practice atthe time of publication. However, in view of ongoing research, changes in government regulations, abd the constant flow of information relating to drug therapy andl drug reactions. the reader is urged to eheck the package inser for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is @ NeW OF infrequently employed drug. Somme drugs and medical devices preseated in this publication have Food and Drug Administration (FDA) clearance for limited use in resricied research settings. [es the responsibility of the health care provider fo ascertain the FDA status of each drag or device planned for use in their clinical practiceContributing Authors Bernard S, Alpert, nubs FACS. Associate Clinical Professor of Surgery, Division of Plastic and Reconstractive Surgery, University of California; Chief, Division of Plastic Surgery, Vice-Chief, Microsurgery Department, Davies Medical Center, Suite 150, San Francisco, California 94114 Stephen P. Beals, M.., F.A.C.8. Assistant Professor, Department of Plastic Surgery, Mayo Medical School, Rochester, Minnesota 55902; Co-Director, Southwest Craniofacial Center, 1331 North 7th Street, Suite 250, Phoenix, Arizona 85006 Antonio Fuente del Campo, M.D. Clinica Cirugia Craniofacial, Hospital Dr. Manuel Gea Gonzalez and Hospital Infantil de Mexico, Camino a Sta. Teresa #1055-239, Colonia Heroes de Padierna Mexico, D.F, 10700, Mexico David Hidalgo, M.p. Associate Professor of Surgery, Cornel? University Medical College: Chief, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10021 Jargen Halle, sup. Professor, Department of Plastic Monilearstrasse 37, AL1O0 Vienna, Austria nel Reconstrative Surgery, Wilheminenspital, Edward Joganic, M.p. Craniofacial Consultant, Barrow Neurological Institue; Assistant Professor of Plastic Surgery, Mayo Medical School; Co-Director, Southwest Craniofacial Center, 1331 North 7th Street, Suite 250, Phoenix, Arizona 85006 Daniel Marchac, M.D, Professeur Assovie, College Médecine des Hospitaux de Paris; Director Craniofacial Unit (Plastic Surgery), Pediatric Neurosurgery Department, Hopital Necker-Enfant Maladies, 130 Rue de te Pompe, 75116 Paris, France Satoru Nagata, M.D. Department Director, Department of Reconstructive Plastic Surgery, Chiba Tokushaukai Hospital, Tokyo Senbai Hospital, Plastic Surgery, 1-4-3 Mita, Minato-Ku, Tokyo 108, Japan Kenneth E, Salyer, 4.0. FA.C-S. Director and Founding Chairman, International Craniofacial Institute, Cleft Lip and Palate Treatment Center, 7777 Forest Lane, Suite C-717, Daltas, Texas 75230SALYER AND BARDACH'S tlas of Craniofacial & Cleft Surgery MAME Pi CRANIOFACIAL SURGERY era ie oC) K EN NETH Ee. . SALYERContents Volume [ CORGUINE AUTROR. crsceceee coamiavaweeessnes ees vevererseeaess baw dares ix Pitted nc. Procumiagiastiinsiese tas sanwereay ia hainaew eis ee xi Acknowledgments ......0.0. SOND SUS Gane emenmiemareensenes . xii Special Acknowledgments ....... Much oem, : ee ee 1. Basic Surgical Techniques ..0........0..... bocce —— wan Kenneth E. Salver 2, Surgery for Craniosynostosis in Infants ...0..0.00 0000005 ‘ a 63 Kenneth E. Salyer and Daniel Marchac 3. Primary and Secondary Surgery for Cranial and Forehead Deformities 109 Kenneth E. Saiver 4. Orbital Surgery, Hypertelorism, and Nasal Reconstruction .....0.6.000605 2 135 Kenneth E, Salyer , 5. Maxillary Osteotomies oo... 00... ayaa wos. 207 Kenneth E. Salyer 6. Mandibular Osteotomies and Genioplasty 243 Kenneth E. Salyer 7. Syndionial Suigery saga vis asi vetanneccerineeevaveaaeees seas deus 279 Kenneth E. Salyer and Antonio Fuente del Campo 8. Secondary Correction of Posttraumatic Deformities ... 0c... essceeeeeeeeeeees 323 Kenneth E. Salyer 9. Craniofacial Tumors . a Kenneth E. Salyer, Stephen P. Beals, Edward Jogani and David Hidalgo 10. Microsurgery, Microtia, and Soft Tissue Reconstruction ....... cove cence ee 389 Kenneth E. Salyer, Jiirgen Holle, Bernard 8. Alpert, and Satoru Nagata Bibliography ....... . sree EONAR OER meee aR REN ReaRIERTTOv 417 SUB MIE oe crea scone nemceusrs cerinennnneny sansa raimeaaRR TE LI viiTo the love of my life and best friend, my wife Luci, for her love, understanding, and unconditional support; ‘My father and mother, Everett and Laurene, who have given me the ability and direction to be the best I can be and who have served as the guiding light for our whole family; My two children, Ken Jr. and Leigh, who are two wonderful, loving, accomplished parents and of whom I am so proud for their happiness and full lives of contribution: My six grandchildren, Ken III, Hartman, Ashley Nicole, Everett, Thomas, and Erin Adelle, for their creativity, innocence, and for all they have given me They are the joy of my life This volume is also dedicated to my mentors and the many students and fellows who requested a book on technique. Finally. this volume is dedicated to all the children and other patients who may benefit from the techniques described in this Atlas, Look Up My Child Look! My child, who is coming unto you; Lock up, my lietle one. now your trowble Goes away, away; Look! Above you flies one who guards you, Whose presence brings you joy. Now your sorrow has departed. Ah, you look! See the eagles flving over you From up above they come, From the clear blue sky where Father dwells; They t@ you this peace-bringing solace give. A happy little child now is smiling here, Light-hearted. From Incidental Rituais, The Hako, translated by Alice FletcherPreface Craniofacial and cleft surgery is a noble craft and a healing art, To understand the seience of craniofacial surgery is the beginning—the goal is to achieve aesthetic excellence. which is more art than science. L believe that careful technique. experience, and a sense of aesthetic balance and harmony is important in performing this three-dimensional surgery. This two volume atlas contains proven techniques, new and old, that allow previsualization of the surgical steps in preparation for the performance of craniofacial and cleft surgery. This Atlas was written at the request of the many students, feLlows, and surgeons from the United States and abroad who have requested a better way lo visualize and understand the surgical techniques used by the authors and contributors, This Atlas is meant to augment knowledge and to demonstrate proven techniques for surgeons in order to improve their methods and results. There are brief, pointed comments to help surgeons understand the procedure; left out is the philosophy. thinking, selection, sequencing, and planning of the procedures. It is meant to be helpful to all surgeons involved in or entering into craniofacial andor cleft lip and palate surgery, and to serve as s resource for those interested in improving or expanding their perspectives on surgery of the cranial vault, head, and face. The text includes procedures of interest to plastic and reconstructive, maxillofueial, and ophthalmic plastic surgeons, as well as otolaryngologists and pediatric neurosurgeons. This Atlas will ultimately be judged on its own merits and usefulness by those surgeons interested in its contents. Itis intended to be a step-by-step manual used to learn new procedures or to prepare for tomorrow's surgery by reviewing the surgical steps necessary for that procedure. Take if to the operating room, soil it with coffee or your favorite prep solution, but use it, Use it not as another attractive atlas with beautiful color illustrations and pictures to be placed in your library as a passive adornment, but as a user-friendly atlas, This Adas evolved from my close collaboration with Janusz Bardach through over 25 years of writing, lecturing, giving courses together, operating together, and demonstrating surgery. as well as our cochairing a symposium on surgical techniques in cleft lip and palate for 18 continuous years. He is truly an international authority and true scholar and professor of cleft lip and palate surgery. It was through these courses and other symposiums that T had an opportunity to meet the contributors to this Atlas, Hearing their presemtations, viewing their results, and holding many panels and discussions with them about their techniques and results led to their involvement, They all have performed the procedures described, and have critically looked at and shared their results, trying to improve their performance. The end results are the techniques and procedures that have been very carefully outlined in their contributions. ‘The contributors are truly international, representing nine countries. Their common bond is their ability to achieve excellence with their surgical skills, They have done more than this in sharing their experience with their peers through the written or spoken word. My international involvement in traveling and teaching craniofacial surgery has made me aware of the desperate need in many parts of the world for the detailed surgical procedures presented in this Atlas. There are many parts of the world where this surgery does not exist, | believe we have a humanitarian obligation tohelp all patients with these deformities and to share the developments, refinements, and improvements that have occurred as a result of the advances made in this field én the last few years, This Atlas presents these techniques developed by proven authorities. Craniofacial and cleft surgery requires a multidisciplinary approach of a dedicated team to deliver the optimal care demonstrated in this Atlas, No longer can a surgeon work in isolation and achieve the excellent results demonstrated in these two volumes, The support of 2 pediatric hospital with pediatric anesthesiol- ogists and intensivists who are trained in the care of children who have had major intracranial procedures, or of infants with major airway problems or other specialized pediatric problems is required. xixii / PREFacr ‘My patieats and I have been fortunate to have the availability of an excellent team that was assembled ten years ago as a dedicated center in Dallas for the treatment of these deformities. All the techniques | have presented are based on my personal experience gained over three decades of performing over 8000 craniofacial and cleft lip and palate procedures. This Atlas represents the culmination of some of the best techniques that T use today in performing this work. T have spent many years traveling to foreign countries and instructing local doctors in the surgical treatment of craniofacial and cleft deformities. My hope is that this Atlas will be an extension of this work, that surgeons throughout the world will be able to use the described techniques to help their patients live normal, fulfilling lives. Kenneth E. SalyerSpecial Acknowledgments ‘The following companies provided grants for Volumes 1 and 2. Th contributions are greatly appreciated: John Newkirk, mp., President, Colorado BioMedicals, Inc., 6851 Highway 73, Evergreen, Colorado, 80439 Dennis A. Youde, President, DAY Surgical Products, Inc., P.O. Box 69, Black Diamond, Washington 98010 Hubert Scholz, Managing Director, Medicon Instrumente, MEDICON eG, P.O. Box 4455, D-78509 Tuttlingen, Germany El Gendler, M.b., PH.D., President and CEO, Pacific Coast Tissue Bank, 2500-19 South Flower, Los Angeles, California 90007. xv