Surgical Management through Skeletal Maturity in Craniofacial Microsomia

Purpose: Due to the complex and diverse nature of craniofacial microsomia (CFM) and the variety of treatment options available, there is little consensus around an optimal management algorithm. This study examines treatment patterns for CFM over a 24-year period at a tertiary care center, with an emphasis on the controversial role of early mandibular distraction osteogenesis (MDO) as it relates to need for orthognathic surgery at skeletal maturity.

 

Methods: A retrospective review of all CFM patients evaluated between January 1993 and March 2017 was conducted. A subset analysis was performed on subjects who had reached skeletal maturity to evaluate need for orthognathic surgery for correction of maxilla-mandibular asymmetries, specifically examining whether MDO had been previously performed. Demographic characteristics were assessed with descriptive statistics.  Univariate analysis was conducted using chi-square and Fisher exact tests for categorical variables, and Mann-Whitney U test for continuous variables.

 

Results: 179 patients were identified (55.9% male, mean follow-up age 11.3 ± 5.6 years), with 148 having adequate data for analysis. 29.9% were Kaban-Pruzansky Grade I, 16.3% Grade IIa, 14.3% Grade IIb, and 17.0% Grade III. 122 subjects underwent a total of 543 procedures (mean 4±3 procedures per subject). The mean age at first intervention was 6.0±4.6 years, with ear reconstruction (30.1%) and mandibular distraction (20%) being the most frequent procedures. Higher Kaban-Pruzansky Grade was significantly associated with earlier age at first intervention (p=0.001). Other major interventions included costochondral rib grafting, fat grafting, cleft repair, and orthognathic surgery. 38 subjects (17 MDO, 21 non-MDO) who had reached skeletal maturity were included in the subset analysis. Cohorts were matched in Kaban-Pruzansky Grade (p=0.788). Need for orthognathic surgery did not differ significantly between the two cohorts (MDO=8; non-MDO =10; p=0.203).

 

Conclusion: Life-long management of CFM requires a multi-faceted treatment plan tailored to each patient’s evolving needs; careful sequencing and timing of operations is essential for optimal restoration of craniofacial form and function. CFM patients with more severe mandibular deformity are significantly younger at time of initial intervention. There appears to be similar orthognathic surgery rates at skeletal maturity between CFM subjects who underwent early-MDO and those who did not undergo early-MDO. Future studies and continuing experience can inform the best timing and technique of early-MDO for long-term retention of facial symmetry.