Craniofacial surgery in its purest form is plastic surgery of the skeleton of the face and skull. It was developed into a subspecialty of plastic surgery based on several principles and discoveries put forward by Paul Tessier of Paris in the 1960’s. Tessier proved in the laboratory and the operating room that it was possible to move large fragments of the facial skeleton and skull into a new position and stabilize them there with internal fixation (wires at that time, more often plates and screws today, sometimes of the absorbable variety) and autologous bone grafting.
Professor Tessier described himself as “refaisseur des orbites” – the remaker of orbits – to underline the central position of correction of the position of the eyesockets in craniofacial deformities. He also introduced the concept of “usable orbit” for the anterior skeletal components of the eyesocket, which can be detached from the facial skeleton as whole or in part and moved into a new three dimensional position provided that the orbit is approached from a transcranial route (by opening the skull) and not a transfacial one (by incisions on the face). This latter true stroke of a genius made it eventually possible for him to successfully tackle reconstructions around the orbits, which had eluded Gillies and many others of his famous predecessors.
It can also be said that Paul Tessier trained directly or indirectly all of today’s craniofacial surgeons, as the current heads of accredited training programs are all first or second generation students of Professor Tessier, who died in 2008.
Thus Dr. Schleich’s “lineage”, who graduated from the renowned vonDeilen-Curtis Fellowship in Craniofacial Surgery at Indiana University School of Medicine can be traced directly to the originator of craniofacial surgery.
Today craniofacial surgeons are able to predictably correct and improve such diverse entities as craniosynostosis, Crouzon’s and Apert’s syndromes, Treacher-Collin’s syndrome, hemifacial microsomia, Pierre-Robin sequence and other mandibular growth disturbances, primary cleft lip and palate and its secondary sequelae as well as primary trauma or secondary posttraumatic deformities and provide skeletal and soft tissue reconstructions after neurosurgical or head and neck tumor resections.
Crouzon’s syndrome and Apert’s syndromes make up roughly eighty or more percent of the “big four” syndromes in craniofacial surgery (the other two being Pfeiffer’s and Carpenter’s syndromes), are ineritable deformities and prototypical for craniofacial surgical thinking and technique.
The skeletal pathology is dominated by a bilateral coronal or even more extensive synostosis (fusion of skull bones), midface retrusion with class III malocclusion putting the lower jaw far in fron of the upper, shallow, incorrectly situated orbits with proptosis (bulging of the eyes). These anomalies alone or in combination may on occasion be severe enough to necessitate emergency interventions for increased intracranial pressure, impending permanent ocular damage or airway obstruction.
Mental retardation is generally not recognized as part of Crouzon’s syndrome but is a prominent part of Apert’s syndrome, which is also characterized by the presence of complex bilateral syndactilies of the hands and feet.
In a sense, Crouzon’s syndrome is one of the starting points of craniofacial surgery. It was considered intractable until Paul Tessier revolutionized both the principles and techniques of management in the 1960’s with his modification of the LeFort III osteotomy.
Contemporary management is still evolving but tries to address the entire spectrum of the deformity, often in stages. Cranial vault and fronto-orbital reshaping and advancement are carried out in infancy, often with a planned revision later in childhood. An extracranial LeFort III osteotomy follows, which increasingly is performed as a midface distraction. Total one stage correction by monobloc osteotomy was thought to be associated with increased morbidity and decreased flexibility compared with a multi-stage approach, but may find a new role with the increased sophistication of distraction techniques. An orthognathic procedure to optimize the occlusion may become necessary.
If we ask ourselves what the function of the human face my firm answer is to “have human form”. Thus reconstruction of the face is aesthetic and functional surgery at the same time as appearance is the function.
Craniofacial procedures are the most powerful aesthetic and cosmetic procedures available. The changes in appearance achieved are long lasting, often dramatic, highly predictable and are able to achieve rebalancing of the face and profile enhancement long after implants, fat grafts, fillers, lifts or any other soft tissue procedure have reached limits of their performance or failed.
Facial beauty, attractiveness, ideal proportions or even plain normalcy are first and foremost determined by the configuration of the underlying skeleton. In a sense, the skin and soft tissue envelope just drapes over it, conforming by and large to whatever three dimensional structure the skeleton imparts. The importance of this concept is apparent after severe facial trauma, which literally flattens the face with loss of projection in the sagittal and widening in the frontal plane if not expertly repaired in the acute stage. The paradigm of attractiveness and beauty however is “fullness”, convexity in the sagittal plane, a projecting skeleton filling the soft tissue envelope. Flatness, concavity, lack of projection and a skeleton not filling the soft tissue envelope well are amenable to craniofacial reconstruction, not only after severe facial trauma, but also to correct facial appearances electively.
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