Le Fort III Midfacial Distraction Using an Internal Distraction Device for Syndromic Craniosynostosis

Abstract

Le Fort III midfacial distraction using internal and external devices is a well-accepted procedure for the midfacial retrusion of craniosynostosis syndrome patients. The authors described 20 consecutive series of Le Fort III midfacial distraction using internal distraction devices. Two types of devices were utilized. One type was a zygoma-skull device (the anterior part of the device is attached to the zygoma, and the posterior part is attached to the skull), which was used in six cases. The other was a zygoma-zygoma device (the anterior and posterior parts of the device are attached to the osteotomized zygoma, respectively), which was used in 14 cases. Subject ages ranged 3-32 years. A 14-20-mm distraction length was obtained by 1 mm/day. Satisfactory distraction of the midface was obtained in 17/20 cases. In 3/6 cases in which a zygoma-skull device was used, an unsatisfactory result was obtained. In these three cases, a fracture of the zygomatico-maxillary suture was encountered, resulting in the Le Fort III portion being left behind. In all 14 cases in which a zygoma-zygoma device was used, a satisfactory result was obtained. During the distraction period, the connection of the distraction device was dislodged, resulting in re-connection in three cases. Slight asymmetry was noticed in two cases without any need for management. In order to obtain parallel setting of the bilateral distraction devices, a newly developed parallel bar was used and demonstrated to be effective.

Guideline for Care of Patients With the Diagnoses of Craniosynostosis

“…It is not easy to summarize the results of the distractions with internal distractors. Individual publications report reasonable results, but at the same time in Satoh, 174 the internal distractors are eventually replaced with an external frame in 3/20 patients, whereas in Meling, 175 problems are reported in 2/7 patients. In Holmes, 176 we find a policy change on account of poor results with internal distractors in 7 patients in favor of the push–pull technique, in Cedars 178 the internal distractors were removed prematurely in 2/14 patients, and lastly in Gosain 177 the internal distractors were replaced with an external frame in 2/7 patients.…”

“…The mean midface advancement reached was 20 mm. Satoh et al 174 described 20 syndromic craniosynostosis patients with mean age at surgery 9.6 years. A 14 to 20 mm distraction length was obtained.…”

Frontofacial advancement by internal distraction devices. A technical modification for the management of craniofacial dysostosis in early childhood

“…7 Midfacial advancement should be achieved by gradual distraction using internal distraction devices. 13,14 For that purpose one pair of KLS-Martin temporal distraction devices for adults according to Marchac (Art. 51-620-35, maximum feed of 35 mm, Gebrüder Martin GmbH, 78532 Tuttlingen, Germany) with Molina pivots (Art.…”

Unanticipated Fractures of the Zygomatic-Maxillary Suture in LeFort III Internal Distraction: Salvage of Midfacial Advancement via Rigid External Distraction of an Orphaned LeFort II Segment

“…6 Internal distraction can be accomplished with skull-zygoma or zygoma-zygoma devices. 9 One complication that can arise from internal distraction of the midface is fracture of the zygomatic-maxillary junction, which bears the load of the distracting forces in skullzygoma devices 6 (Figure 1). The zygomatic-maxillary suture is frequently a weak point in the facial structure and may not be fully mature until patients are older than 15 years old.…”

“…[10][11][12] In the case of convex temporal bones, as seen in Pfeiffer and Apert syndromes, the force on the zygomatic-maxillary junction is further increased. 9,13 Fractures of the zygomatic-maxillary junction occur most commonly intraoperatively, while fractures during the distraction process are relatively less common. 14,15 A number of salvage options have been described in the case of intraoperative fracture, including rigid fixation across the midface, pinning, or switching to an external distraction system.…”