By JOHN MARQUIS CONVERSE, M.D., and DAUBERT TELSEY, D.D.S.

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1 THE TRIPARTITE OSTEOTOMY OF THE MID-FACE FOR ORBITAL EXPANSION AND CORRECTION OF THE DEFORMITY IN CRANIOSTENOSIS By JOHN MARQUIS CONVERSE, M.D., and DAUBERT TELSEY, D.D.S. Center for Craniofacial Anomalies of the Institute of Reconstructive Plastic Surgery, New York University Medical Center CRANIOSTENOSIS is a term employed to designate the premature (prenatal) closure of the cranial bones which are normally separate from one another at the time of birth. Full growth of the brain is possible only when the bones of the skull remain ununited and capable of expansion. Restriction of brain growth occurs if premature closure of cranial sutures is present at birth. The cranial deformities vary according to the sutures involved (scaphocephaly, acrocephaly, plagiocephaly, trigonencephaly, oxycephaly). The type of craniostenosis for which the plastic surgeon can be of greatest service is oxycephaly, in which the base of the skull is pushed downward and the mid-facial skeleton, the maxillary and ethmoid sinuses and the orbits remain undeveloped. The patient has exophthalmos and associated ocular anomalies, the facial deformity is characterised by a mid-facial retrusion and the dental occlusion is characteristic of a Class III type (Angle). These basic characteristics appear to be common to both Crouzon's disease and Apert's syndrome (acrocephalosyndactyly). Since Gillies reported in I95o-51 a modified Le Fort III osteotomy and advancement of the mid-facial skeleton for the relief of the characteristic mid-face hypoplasia deformity of Crouzon's disease as well as of the exophthalmos, a number of variations of the Le Fort III osteotomy have been developed for the treatment of the facial deformity of craniostenosis and similar deformities (Tessier, I967; Murray, I968; Obwegeser, I969 ; Jabaley and Edgerton, I969). The Le Fort III advancement-osteotomy increases the forward projection of the entire mid-facial skeleton framework comprising the nose, the maxilla and the zygomas including the maxillary and zygomatic portions of the orbital cavity. The orbital cavity is thus deepened and the exophthalmos improved. Adequate occlusal relationships of the maxillary and mandibular teeth can be established and the mid-face retrusion deformity corrected. Three objections have been noted to this "en masse" type of advancement: In certain cases there may be excessive protrusion of the nasal pyramid producing an Assyrian-like profile. Difficulty may be encountered in completing the osteotomy through the orbital floor because of the small size of the maxillary sinus and resulting thickness of the floor. In certain cases there is a tendency to backward recession during the post-operative period. This paper proposes some alternative and more selective operative procedures. The Tripartite Osteotomy.--As its name implies, the tripartite osteotomy divides the mid-facial skeleton into three segments, a central nasomaxillary or maxillary segment and two lateral orbitozygomatic segments. The position of the central segment may be controlled independently from the lateral segment ; a second advantage is the possibility of expanding the lateral segment as well as advancing it, thus further 365

366 BRITISH JOURNAL OF PLASTIC SURGERY enlarging the orbkal cavity. The three segments can be placed into a position which is most favourable from an msthetic standpoint.

2 366 BRITISH JOURNAL OF PLASTIC SURGERY enlarging the orbkal cavity. The three segments can be placed into a position which is most favourable from an msthetic standpoint. Depending on the deformity, the tripartite osteotomy may be done in a number of different ways, each of which includes the expansion and advancement of the lateral segment. Type L--The central segment includes the nasal pyramid which is moved forward by a n~omaxillary advancement (Fig. I), the maxillary osteotomy extending through the premolar area. A missing first molar tooth prompted us to perform the osteotomy at this level on one side. FIG. I The tripartite osteotomy (Type I). The central naso-orbito maxillary segment can be placed in the desired position to achieve adequate contour. The lateral segments are displaced forward and laterally to achieve orbital expansion. Type//.--The nose is undisturbed and a low maxillary advancement is done by a premolar segmental maxillary osteotomy (Fig. 2) or a Le Fort I complete transverse osteotomy. Type III.--In the above-mentioned procedures the orbital expansion operation is done extracranially. An intracrardal-extracranial procedure was done in one patient. This patient had consulted Dr Reed O. Dingman. Her orbits were so small that the orbital contents were resting on the orbital rims. The " exorbitism" resulted in inability to close the eyelid, corneal exposure and repeated ulceration. Decompression procedures had been attempted unsuccessfully, by means of a Naffziger operation (resection of the orbital roof) and a Kroulein operation (resection of the lateral wall) ;

3 TRIPARTITE OSTEOTOMY OF THE MID-FACE 367 Fig. 2.--The tripartite osteotomy (Type II). The nasal portion of the central segment is undisturbed. A segmental maxillary advancement osteotomy is done. Expansion of the orbit and advancement of the lateral segment is done as in Type I. Fig. 3.--The tripartite osteotomy (Type III). An intractranial approach is necessary when the orbital cavities are miniscule in order to obtain sufficient orbital expansion to allow the ocular globes to occupy the orbits. Maxillary advancement can then be accomplished concomitantly or in a second stage. A and B, The lines of osteotomy are traced. Note that they rejoin the inferior orbital fissure. C, Illustrating an osteotome cutting through the medial portion of the orbital ring and floor. D, Expansion is obtained in two directions : forward and laterally. Bone grafts fill the bony gaps. FIG. 2 / i FIG. 3

Fig. 4.--Because of the small size of the maxillary sinus and the dense bone in the area in patients with craniostenosis, a useful manoeuvre is the one illustrated.

4 Fig. 4.--Because of the small size of the maxillary sinus and the dense bone in the area in patients with craniostenosis, a useful manoeuvre is the one illustrated. A sharp osteotome cuts through the base of the zygoma and rejoins the transverse line of osteotomy through the orbital floor. Fig. 5.--The premolar maxillary advancement osteotomy. A, The transverse osteotomy through the hard palate. The gap has been filled with bone grafts. B, The raised mucoperiosteal flap covers the bone graft; the exposed anterior portion of the palate epithelises spontaneously. C, A flap of gingival mucoperiosteum is raised and provides coverage for the bone grafts after advancement of the anterior portion of the maxilla. D, Mucoperiosteal flap sutured in position. Fixation of the mobilised anterior maxilla is maintained by an edgewise orthodontic appliance (not represented in the drawing) anchored to the molar teeth (see Figs. 6 and 7). FIG. 4

5 TRIPARTITE OSTEOTOMY OF THE MID-FACE 369 near-complete tarsorrhaphy had been done to protect the corneas. It was proposed by one of us (J. M. C.) that an intracranial approach be employed to permit adequate expansion of the orbit. This procedure (Fig. 3) was done successfully in December 1969 at the University of Michigan Hospital conjointly with Dr Dingman. The morning following the operation the orbital contents filled the expanded orbit, the exophthalmos had been corrected and the patient could occlude her eyelids. Since the operation the patient has been comfortable. A pyramidal maxillary osteotomy and advancement are planned for the next and final stage and will be reported later. Technique.--Through a scalp incision extending behind the hairline curving bilaterally downward toward the pre-auricular area, the frontal bone, the root of the nose and the major portion of the lateral orbital wall are exposed. The inferior orbital rim and floor of the orbit are also exposed through a lower eyelid incision which extends laterally downward over the zygoma. When a nasomaxillary osteotomy is required (Type I ; Fig. I), it extends across the root of the nose, backward through the medial orbital wall, downward behind the lacrimal groove, through the maxilla terminating in the premolar area between the first molar and second premolar teeth, or between the two premolars. An interdental osteotomy is done without endangering the teeth. A palatal mucoperiosteal flap is raised and the palate and vomer are cut, through a transverse osteotomy. The central nasomaxillary segment may now be advanced after eliminating any resistance from the septum by cutting the septal cartilage with scissors, if necessary, in its posterior portion through the fronto-nasal osteotomy line. The lateral orbital segments are released from the cranium by osteotomy, transecting the upper portion of the lateral orbital wall, then descending through the lateral wall of the orbit to the inferior orbital fissure. The maxillary sinus is usually poorly developed in cases of Crouzon's disease, and the small size mid-facial skeleton consists of dense bone. An osteotome directed obliquely through the lower portion of the zygoma, sections the zygoma and exits through the orbital floor, thus establishing an osteotomy line which joins the inferior orbital fissure (Fig. 4) to the nasomaxillary osteotomy line when a nasomaxillary osteotomy is done (Type I). When a nasomaxillary advancement is not required (Type II) but only a maxillary advancement, the transverse osteotomy across the orbital floor is angulated forward transsecting the orbital rim and maxilla to rejoin the transverse cut through the lower portion of the zygoma (Fig. 2). Bone grafts fill the gaps between fragments and provide additional contour restoration (Fig. 5). An edge-wise arch and band fixation appliance is employed to maintain the maxillary segment in an adequate position for contour restoration and satisfactory occlusal relationships with the mandibular teeth (Figs. 7 and IO). Advantages and Disadvantages.--The advantages of the technique are twofold : the advancement is stable because of the presence of a solid molar alveolar area which provides anchorage for the fixation appliance and a more solid posterior buttress than that of the pterygoid area when Le Fort I or III osteotomies are done (even when a bone graft is wedged into the pterygoid area) ; secondly, as mentioned above, there is greater selectivity in the mobilisation of various portions of the mid-facial skeleton and a more efficient expansion of the orbital cavity when indicated. In very small orbits when the orbital contents are not contained within the orbit (" exorbitism ") the intracranial approach is the only solution. The disadvantage of the segmental premolar osteotomy of the maxilla is that of inadequate soft tissue coverage of the bone grafts in the line of osteotomy. Careful technique (Fig. 5) is necessary to ensure such coverage.

6 370 BRITISH JOURNAL OF PLASTIC SURGERY A B D FIG. 6 Case r.--pre-operative (A) and post-operative (B) appearance following tripartite osteotomy (Type I). In the profile views note the change of facial contour. The exophthalmos is more evident in the profile view (C) ; it has been corrected (D) and the maxillary contour improved.

The orthodontic appliance has been maintained after consolidation of the osteotomy line for

7 TRIPARTITE OSTEOTOMY OF THE MID-FACE 371 B FIG. 7 Case I.--Pre-operative (A) and post-operative (B) relationships of the teeth. The orthodontic appliance has been maintained after consolidation of the osteotomy line for the purpose of aligning the teeth and to serve as a retaining appliance. I A B FIG. 8 Case r.--pre-operative (A) and post-operative (B) cephalometric tracings.

372 BRITISH JOURNAL OF PLASTIC SURGERY FIG. 9 Case 2.--Tripartite osteotomy (Type II). A, Pre-operative appearance of the patient. B, Post-operative appearance.

8 372 BRITISH JOURNAL OF PLASTIC SURGERY FIG. 9 Case 2.--Tripartite osteotomy (Type II). A, Pre-operative appearance of the patient. B, Post-operative appearance. C, Profile view, pre-operative ; note the exophthalmos. D, Post-operative appearance ; the ocular protrusion has been corrected and the lower maxillary contour improved.

TRIPARTITE OSTEOTOMY OF THE MID-FACE 373 Results. The patients shown in Figures 6 (Type I) and 9 (Type II) have been followed for 23 months and 21 months respectively.

--Pre-operative (A)and post-operative (B)relationships ofthe teeth. tj A FIG. II Case 2.--Pre-operative (A) and post-operative (B) cephalometric tracings. avoidable complication.

9 TRIPARTITE OSTEOTOMY OF THE MID-FACE 373 Results. The patients shown in Figures 6 (Type I) and 9 (Type II) have been followed for 23 months and 21 months respectively. In the patient shown in Figure 9 the left central and lateral teeth were injured and may require restorative dentistry, an A B FIG. IO Case 2.--Pre-operative (A)and post-operative (B)relationships ofthe teeth. tj A FIG. II Case 2.--Pre-operative (A) and post-operative (B) cephalometric tracings. avoidable complication. The follow-up studies of these patients will be of interest as the patients were operated upon at the age of 14 and 15 years respectively. Cephalograms (Figs. 8 and I I) taken before and after surgery will provide the basic information in this regard. Further growth of the mandible may change facial relationships and require additional later surgery. 40 B

10 374 BRITISH JOURNAL OF PLASTIC SURGERY Summary.--A new concept of dividing the mid-facial skeleton into three parts (the tripartite osteotomy) permits a more selective correction of the varied deformities characteristic of craniostenosis. Three variations of this type ofoperation which remedies some of the deficiencies of the Le Fort III advancement osteotomy are discussed. REFERNCES CONVERSE, J. M. and DINGMAN, R. O. (1969). Unpublished case report. GILLIES, H. and HARRISON, S.H. (I95O~5I)- Operative correction by osteotomy of recessed malar maxillary compound in a case of oxycephaly. British Journal of Plastic Surgery, 3, JABALEY, M. E, and EDGERTON, M. E. (1969). Surgical correction of congenital midface retrusion in the presence of mandibular prognathism. Plastic and Reconstructive Surgery, 44, 1-8. MURRAY, J. E. and SWANSON, L. T. (1968). Mid-face osteotomy and advancement for craniostenosis. Plastic and Reconstructive Surgery, 41, 299-3o6. OBWEGESER, H. L. (1969). Surgical correction of small or retroplaced maxillae " the dishface deformity ". Plastic and Reconstructive Surgery, 43~ TESSIER~ P. (1967). Osteotomies totales de la face. Syndrome de Crouzon. Syndrome d'apert. Oxycephalies. Scaphocephalies. Turricephalies. Annales de Chirurgie Plastique, I2,

OPERATIVE CORRECTION BY OSTEOTOMY OF RECESSED MALAR MAXILLARY COMPOUND IN A CASE OF OXYCEPHALY

OPERATIVE CORRECTION BY OSTEOTOMY OF RECESSED MALAR MAXILLARY COMPOUND IN A CASE OF OXYCEPHALY By Sir HAROLD GILLIES, C.B.E., F.R.C.S., and STEWART H. HARRISON, F.R.C.S., L.D.S., R.C.S. From the Plastic