Correction of Congenital deformities of skull, face, and jaw (craniofacial deformities)

Facial skeletal deformities include: deformed and underdeveloped lower jawbones (microgenia, progenia), upper jaw deformity (progenia, estrogenic, etc), nasal deformities (nasal hump, saddle nose, deviation, cleft nasal tip, etc).).

Pic. 1 shows possible mandible deformation schemes and types of osseous genioplasty, in the course of osteotomy with certain mandibular areas separation to be properly repositioned and secured to the bone by sutures or special tiny medical titan screws.

To treat and resolve the excessive horizontal maxillary misbalance (underbite) or protrusion (overbite), in the course of (LeFort types I, II, or III) osteotomies, we use either (partial) skeletal segment resection and titanium plates placement or external/internal distraction (skeletal traction).

Pic. 2. Use of external/internal distraction devices for midfacial skeletal area extension.

In cases when existing skeletal deformities require considerable volume augmentation, facial implants and lipo-filling is practiced. Facial implants – thick formations made of silicone elastomer or porous hydroxipatyte.

Pic. 3. Displays facial implants major localization sites and shapes.

Implants are placed subperiosteally and secured to the bone using sutures or titanium screws. The insertion is performed through natural skin folds (like the subcillary incision in the lower lid blepahroplasty or through submental fold). When needed, implants can be placed through intra-oral incision made in the mucous lining (Pic. 4)

Another option to correct facial volume deficiency is autologous free fat grafting (fat, adipose tissue injections). Adipose, fat tissue is harvested from the thigh and belly area by means of liposuction. The required amount of fat implant is then acquired by centrifugation and decanting of the refined tissue. Fat grafts are injected subcutaneously through small puncture sites. Due to the resorbable qualities of the transferred fat tissue, this procedure can be repeated 3-4 times a year. Pic. 5 shows malar area fat grafting example.

Pic. 5. Before and after fat grafting to malar region

Some cases of congenital nasal deformations like nasal hump, broad nasal tip, deviated nose etc. are subjects for rhinoplasty (see rhinoplasty section) 
Physically, the most appropriate age for nasal plastic surgery as well as other craniofacial operations, is 18 years and older when bone (osseous) and cartilaginous facial structures have already completed their growth. The most well known and frequent oral-facial deformities are cleft lip and cleft palate birth defects that present not only aesthetic but also functional problems. A cleft in the roof of the mouth often causes gagging, choking or milk coming out through the nose while feeding. In such cases the first surgery to close the palate of the newly born is done.
Depending on the cleft degree the closure can be accomplished by either elevation and advancement (reapproximation) of muscoperiosteal flaps with (by either advancement and suturing muscoperiosteal flaps in the midline) or rotation and mucous lining grafting along with titan plates or autobone placement.

There are many various kinds of lip clefts (see Pic. 6).

Surgeries to correct this type of deformity resorbable begin right after the birth and continue later at 3 - 4 years of age, at school age and during facial skeletal formation. This is related to the fact that while the baby’s face continues to grow the existing deformation also alters. Plastic surgeons usually correct nasal and facial deformities as a secondary problem.

Any secondary deformities of the face either after the lip or nose correction, besides possible complicated asymmetry, is associated with scarring defects after the initial surgery. For instance, lip surgery combines different surgical approaches (F-Y fashion rotation advancement technique) and lipo-filling (autologous free fat tissue) or injections of biodegrading injectables like derivates of hyaluronic acid, etc. Pic. 8,9:

Pic. 7. After upper lip fat grafting.

Pic. 8. Combination of plastic surgery and upper lip fat grafting.

Typical signs of cleft lip deformation are marked asymmetry of nostrils associated with maxillar spine deviation towards healthy side, flattened alar (excessively flared nostril) on the problem side, marked deviation of both nasal spine and nasal tip towards the problem side, crooked nasal base and tip, nasal drooping. Successful rhynoplasty outcome depends on considering and correcting all these signs and symptoms. According to our observation, practically all patients with cleft lip diagnosis show intranasal structures asymmetry (septal deviation) and compensatory mechanism development on the healthy side (hypertrophy of nasal conchaes). Such cases require not just aesthetic but also functional correction (septoplasty). That is why this type of plastic surgery is usually performed by both plastic surgeons and ENT doctors.

Pic. 9. After secondary rhinoseptoplasty with upper lip fat grafting.

Pic. 10. After secondary rhinoseptoplasty.

Pic. 11. After secondary rhinoseptoplasty.

Severe facial and skull deformities like (Crouzon syndrome, Craniosynostosis etc ) are treated by craniofacial surgeons. Skull reshaping surgery is considered to be a very complicated and unsafe procedure, which is performed in stages and requires the expertise of a professional craniofacial team comprised of: a pediatrician, a pediatric plastic surgeon (with expertise in Craniofacial Deformities), a neurosurgeon, a pediatric dentist, a orthodontist, a speech therapist, a E.N.T. specialist etc.
Some ear deformities are also related to congenital syndromes. For instance microtia represents a hypoplastic condition with varying degrees of ear absence while anotia is a complete ear absence. Children with protruding or abnormally folded ears can benefit from otoplasty, surgery that sets prominent ears back closer to the head or reduces the size of large ears. It can be performed at any age after the ears have reached full size, usually at five or six years of age. Having the surgery at a young age has two benefits: the cartilage is more pliable, making it easier to reshape and the child will experience the psychological benefits of the cosmetic improvement.

Pic. 11. After bilateral otoplasty.

Reconstructive surgery for microtia and anotia are considered to be very complicated procedures due to the three-dimensional framework of the ear which consists of a thin layer of skin that covers the cartilaginous structure. This type of otoplasty can safely be performed on children as young as 6 years old. The treatment is recommended to be performed before the child enters school to avoid low self-esteem and inadequacy. Surgical correction is done in a series of stages and can be completed within two years. In the first stage, rib cartilage is taken from the chest and used to create a three-dimensional ear framework. Pieces of cartilage are then carved into the shape of an ear and held together using very fine stainless steel wire sutures. The second stage involves the ear lobe formation while the third provides framework elevation to help project the ear outward from the head. Most recent and modern techniques (Nagata) combine 2 surgery stages via additional covering of ear framework by temporal fascial flap.

Pic. 15.Second stage of Nagata technique. Ear framework elevation and postauricular sulcus creation using temporal fascia and skin graft.

Vascular malformations or gemangioms can also be included into congenital deformations and are treated by vascular or craniofacial surgeons. In some cases of flat or superficial gemangioms (so called Port wine stain (PWS) can be removed by special vascular lasers that do not ablate skin (burn the skin surface) and thus avoid scarring.