Craniofacial surgery is a surgical

subspecialty A subspecialty (US English) or subspeciality (international English) is a narrow field of professional knowledge/ skills within a specialty of trade, and is most commonly used to describe the increasingly more diverse medical specialties. A sub ...

that deals with

congenital A birth defect, also known as a congenital disorder, is an abnormal condition that is present at birth regardless of its cause. Birth defects may result in disabilities that may be physical, intellectual, or developmental. The disabilities can ...

and acquired deformities of the

head A head is the part of an organism which usually includes the ears, brain, forehead, cheeks, chin, eyes, nose, and mouth, each of which aid in various sensory functions such as sight, hearing, smell, and taste. Some very simple animals ...

skull The skull is a bone protective cavity for the brain. The skull is composed of four types of bone i.e., cranial bones, facial bones, ear ossicles and hyoid bone. However two parts are more prominent: the cranium and the mandible. In humans, th ...

face The face is the front of an animal's head that features the eyes, nose and mouth, and through which animals express many of their emotions. The face is crucial for human identity, and damage such as scarring or developmental deformities may aff ...

neck The neck is the part of the body on many vertebrates that connects the head with the torso. The neck supports the weight of the head and protects the nerves that carry sensory and motor information from the brain down to the rest of the body. In ...

, jaws and associated structures. Although craniofacial treatment often involves manipulation of bone, craniofacial surgery is not tissue-specific; craniofacial

surgeons In modern medicine, a surgeon is a medical professional who performs surgery. Although there are different traditions in different times and places, a modern surgeon usually is also a licensed physician or received the same medical training as ...

deal with bone, skin, nerve, muscle, teeth, and other related anatomy. Defects typically treated by craniofacial surgeons include

craniosynostosis Craniosynostosis is a condition in which one or more of the fibrous sutures in a young infant's skull prematurely fuses by turning into bone (ossification), thereby changing the growth pattern of the skull. Because the skull cannot expand perpe ...

(isolated and syndromic), rare craniofacial clefts, acute and chronic sequelae of facial fractures,

cleft lip and palate A cleft lip contains an opening in the upper lip that may extend into the nose. The opening may be on one side, both sides, or in the middle. A cleft palate occurs when the palate (the roof of the mouth) contains an opening into the nose. The ...

, micrognathia, Treacher Collins Syndrome, Apert's Syndrome, Crouzon's Syndrome, Craniofacial microsomia, microtia and other congenital ear anomalies, and many others.Training in craniofacial surgery requires completion of a Craniofacial surgery fellowship. Such fellowships are available to individuals who have completed residency in oral and maxillofacial surgery,

plastic Plastics are a wide range of synthetic or semi-synthetic materials that use polymers as a main ingredient. Their plasticity makes it possible for plastics to be moulded, extruded or pressed into solid objects of various shapes. This adapta ...

and

reconstructive surgery Reconstructive surgery is surgery performed to restore normal appearance and function to body parts malformed by a disease or medical condition. Description Reconstructive surgery is a term with training, clinical, and reimbursement implicat ...

, or

ENT surgery Otorhinolaryngology ( , abbreviated ORL and also known as otolaryngology, otolaryngology–head and neck surgery (ORL–H&N or OHNS), or ear, nose, and throat (ENT)) is a surgical subspeciality within medicine that deals with the surgical a ...

. Those who have completed residency in oral and maxillofacial surgery may be either single degree or dual-degree surgeons with no differences. There is no specific board for craniofacial surgery. In the US, cleft and craniofacial centers are found in many major academic centers.

Craniosynostosis

The bones of the human skull are joined by cranial sutures (see figure 1). The anterior fontanelle is where the metopic, sagittal and coronal sutures meet. Normally the sutures gradually fuse within the first few years after birth. In infants where one or more of the sutures fuses too early the growth of the skull is restricted, resulting in compensation mechanisms which cause irregular growth patterns. Growth in the skull is perpendicular to the sutures. When a suture fuses too early, the growth perpendicular to that suture will be restricted, and the bone growth near the other sutures will be stimulated, causing an abnormal head shape. The expanding brain is the main stimulus for the rapid growth of the skull in the first years of life. Inhibited growth potential of the skull can restrict the volume, needed by the brain. In cases in which the compensation does not effectively provide enough space for the growing brain,

results in increased intracranial pressure.JJ van der Vlugt, JJ van der Meulen and HE Creemers, et al., The risk of psychopathology in children with craniosynostosis, Plastic and Reconstructive Surgery, December 2009, pp 2054-2060 Craniosynostosis is called simple when one suture is involved, and complex when two or more sutures are involved. It can occur as part of a syndrome or as an isolated defect (nonsyndromic).

Scaphocephaly

In scaphocephaly the sagittal suture is prematurely fused. The sagittal suture runs from the front to the back of the head. The shape of this deformity is a long narrow head, formed like a boat (Greek ''skaphe'', "light boat or skiff"). The compensatory head-growth forward at the coronal suture gives a prominent forehead, frontal bossing and a prominent back of the head, called coning. The incidence of scaphocephaly is 2.8 per 10 000 births in the Netherlands and is therefore the most common form of craniosynostosis.CF Kweldam, JJ van der Vlugt and JJNM van der Meulen, The incidence of craniosynostosis in the Netherlands 1997 – 2007, Journal of Plastic, Reconstructive & Aesthetic SurgeryBL Hutchison, Alistair W Stewart and Edwin A Mitchell, Characteristics, head shape measurements and developmental delay in 287 consecutive infants attending a plagiocephaly clinic, Acta Paediatrica98, September 2009, pp 1494–1499

Trigonocephaly

In trigonocephaly the metopic suture is prematurely fused. The metopic suture is situated in the medial line of the forehead. Premature fusion of this suture causes the forehead to become pointed, giving the head a triangular shape when viewed from above (Greek ''trigono'', "triangle"). The incidence of trigonocephaly is 1 - 1.9 per 10 000 births in the Netherlands.

Plagiocephaly

In plagiocephaly one of the coronal sutures is prematurely fused. The coronal sutures run over the top of the head, just in front of the ears. The shape of this deformity is an asymmetrical distortion (flattening of one side of the head) as you can see in figure 2. The incidence is 1 in 10 000 births.

Brachycephaly

In brachycephaly both of the coronal sutures are prematurely fused. The shape of this deformity is a wide and high head. The incidence at birth is 1/20 000.

Team

Craniofacial surgery and follow-up care are usually conducted by a multidisclinary team of doctors, surgeons, nurses, and various therapists. As of 2016, there is a new multidisciplinary care team of Neuroplastic Surgeons working with Neurosurgeons to prevent and/or correct neurosurgical-related deformities and to maximize outcomes in adult patients.

Surgical procedures

In cases where the forehead is involved (trigonocephaly and plagiocephaly), a technique called fronto-supraorbital advancement is used to correct the shape of the head. The procedure is performed at a young age in order to provide the brain with enough space to grow and prevent further abnormal growth of the skull. Fronto-orbital advancement literally means moving the front of the skull including the eye sockets forward. A section of the skull, ranging from the coronal sutures to the eye sockets is cut loose in order to correct the shape of the skull. The incision is cut in a zigzag shape from ear to ear so that the hair will cover the scar and make it less visible. The incision is made to the bone only, leaving the underlying meninges intact. The top half of the eye sockets is cut loose. Once the eye socket section has been cut loose, a vertical incision is made in the midline, and the whole section of the eye socket is bent outwards in order to correct the pointed shape of the forehead. Because the section is now too wide, a wedge needs to be cut on either side to allow the section to fit into the skull. Figure 4 shows the sections that are loosened and adjusted, and figure 3 shows the location of the vertical incision (arrow A) and the two wedges (arrow B). In scaphocephaly the sagittal suture is prematurely fused, preventing the skull from growing perpendicular to the suture. Thus the head becomes very narrow and long. If a scaphocephaly is diagnosed within 4 to 5 months after birth, it can be corrected with a relatively simple procedure whereby the sagittal suture is surgically reopened. Once the suture has been opened the bone segments will be able to grow again and the head can regain its normal shape. This operation is only performed on patients younger than five months old with a scaphocephaly. This is due to the fact that the bone segments only have the ability to adapt so severely when the operation is performed at this young age. A scaphocephaly that is diagnosed and treated later in life requires a more extensive secondary operation than one which is treated before five months. A major focus in craniosynostosis reconstruction is maintaining normalized aesthetics of temporal region, and avoiding temporal hollowing. Despite attempts to avoid temporal hollowing by employing overcorrection techniques, autologous fat transfer, and bone grafts, up to 50% of patients still present with depression in the temporal fossa post-operatively. Cranioplasty, or skull reconstruction, is the main concentration of a new field for adult neurosurgical patients known as Neuroplastic Surgery. There are now several centers around the world, including the United States and Israel. The first center of Neuroplastic Surgery was started at Johns Hopkins by Dr. Chad Gordon and the Department of Neurosurgery, which is where this new craniofacial subspecialty was born ().

Complications in craniofacial surgery

Some of the surgical complications in craniofacial surgery may include Death, Shock, Haemorrhage, visual loss, Intracranial collection of air/fluid, Epileptic seizures, Unexpected respiratory complications, etc.

References

External links

Journal of Craniofacial Surgery

American Society of Craniofacial Surgery
Surgical specialties Oral and maxillofacial surgery Otorhinolaryngology