Anthropometry of the head and face

In view of the high prevalence and the relevant impairment of patients with obstructive sleep apnoea syndrome (OSAS) lots of methods are offered which promise definitive cures for or relevant improvement of OSAS. This report summarises the efficacy of alternative treatment options in OSAS. An interdisciplinary European Respiratory Society task force evaluated the scientific literature according to the standards of evidence-based medicine. Evidence supports the use of mandibular advancement devices in mild to moderate OSAS. Maxillomandibular osteotomy seems to be as efficient as continuous positive airway pressure (CPAP) in patients who refuse conservative treatment. Distraction osteogenesis is usefully applied in congenital micrognathia or midface hypoplasia. There is a trend towards improvment after weight reduction. Positional therapy is clearly inferior to CPAP and long-term compliance is poor. Drugs, nasal dilators and apnoea triggered muscle stimulation cannot be recommended as effective treatments of OSAS at the moment. Nasal surgery, radiofrequency tonsil reduction, tongue base surgery, uvulopalatal flap, laser midline glossectomy, tongue suspension and genioglossus advancement cannot be recommended as single interventions. Uvulopalatopharyngoplasty, pillar implants and hyoid suspension should only be considered in selected patients and potential benefits should be weighed against the risk of long-term side-effects. Multilevel surgery is only a salvage procedure for OSA patients.

https://erj.ersjournals.com/content/erj/37/5/1000.full.pdf

Non-CPAP therapies in obstructive sleep apnoea

In nose surgery, carved or crushed cartilage used as a graft has some disadvantages, chiefly that it may be perceptible through the nasal skin after tissue resolution is complete. To overcome these problems and to obtain a smoother surface, the authors initiated the use of Surgicel-wrapped diced cartilage. This innovative technique has been used by the authors on 2365 patients over the past 10 years: in 165 patients with traumatic nasal deformity, in 350 patients with postrhinoplasty deformity, and in 1850 patients during primary rhinoplasty. The highlights of the surgical procedure include harvested cartilage (septal, alar, conchal, and sometimes costal) cut in pieces of 0.5 to 1 mm using a no. 11 blade. The fine-textured cartilage mass is then wrapped in one layer of Surgicel and moistened with an antibiotic (rifamycin). The graft is then molded into a cylindrical form and inserted under the dorsal nasal skin. In the lateral wall and tip of the nose, some overcorrection is performed depending on the type of deformity. When the mucosal stitching is complete, this graft can be externally molded, like plasticine, under the dorsal skin. In cases of mild-to-moderate nasal depression, septal and conchal cartilages are used in the same manner to augment the nasal dorsum with consistently effective and durable results. In cases with more severe defects of the nose, costal cartilage is necessary to correct both the length of the nose and the projection of the columella. In patients with recurrent deviation of the nasal bridge, this technique provided a simple solution to the problem. After overexcision of the dorsal part of deviated septal cartilage and insertion of Surgicel-wrapped diced cartilage, a straight nose was obtained in all patients with no recurrence (follow-up of 1 to 10 years). The technique also proved to be highly effective in primary rhinoplasties to camouflage bone irregularities after hump removal in patients with thin nasal skin and/or in cases when excessive hump removal was performed. As a complication, in six patients early postoperative swelling was more than usual. In 16 patients, overcorrection was persistent owing to fibrosis, and in 11 patients resorption was excessive beyond the expected amount. A histologic evaluation was possible in 16 patients, 3, 6, and 12 months postoperatively, by removing thin slices of excess cartilage from the dorsum of the nose during touch-up surgery. This graft showed a mosaic-type alignment of graft cartilage with fibrous tissue connection among the fragments. In conclusion, this type of graft is very easy to apply, because a plasticine-like material is obtained that can be molded with the fingers, giving a smooth surface with desirable form and long-lasting results in all cases. The favorable results obtained by this technique have led the authors to use Surgicel-wrapped diced cartilage routinely in all types of rhinoplasty.

The Turkish Delight: A Pliable Graft for Rhinoplasty

A review of the literature dealing with distraction osteogenesis (DO) of the craniofacial skeleton, provided by a PUBMED search (National Library of Medicine, NCBI; revised 3 April 2000) from 1966 to December 1999 was conducted. Key words used in the search were distraction, lengthening, mandible, mandibular, maxilla, maxillary, midface, midfacial, monobloc, cranial, craniofacial and maxillofacial. This search revealed 285 articles. One hundred and nine articles were clinically orientated and were analysed in detail in this study. The type of distraction, indications, age, type of surgery, distraction rates and rhythms, latency and contention periods, amount of lengthening, follow-up period, relapse, complications and the nature of the distraction device were analysed. This review revealed that 828 patients underwent DO of the craniofacial skeleton; 579 underwent mandibular DO, 129 maxillary DO, 24 simultaneous mandibular and maxillary DO and 96 midfacial and/or cranial DO. Craniofacial DO has proven to be a major advance for the treatment of numerous congenital and acquired craniofacial deformities. Treatment protocols and success criteria for craniofacial DO are suggested on the basis of these results. There is still, however, a lack of sufficient data, especially on follow-up and relapse, so that treatment strategies have to be validated by long-term studies in the future.

Craniofacial distraction osteogenesis: a review of the literature. Part 1: clinical

Distraction osteogenesis is becoming the treatment of choice for the surgical correction of hypoplasias of the craniofacial skeleton. Its principle is based on the studies of Ilizarov, who showed that osteogenesis can be induced if bone is expanded (distracted) along its long axis at the rate of 1 mm per day. This process induces new bone formation along the vector of pull without requiring the use of a bone graft. The technique also provides the added benefit of expanding the overlying soft tissues, which are frequently deficient in these patients. This article reviews the authors' 11-year clinical and research experience with mandibular distraction osteogenesis. It highlights the indications and contraindications of the technique and emphasizes the critical role that basic science research has played in its evolution.

Distraction osteogenesis of the craniofacial skeleton.

A modified technique for mandibular distraction is reported: an oblique corticotomy is made in the external cortex of the mandible at the level of the gonial angle. Two intraosseous stainless steel pins are inserted and are joined by a softer distraction screw. We make two corticotomies, one horizontal and one vertical, and insert three pins to achieve bidirectional distraction when the mandibular body and the ascending ramus are hypoplasic. This procedure has been used in 87 patients with unilateral hemifacial microsomia and 19 patients with bilateral mandibular hypoplasia. A mean elongation of 19 mm was obtained in the unilateral group. In the bilateral cases a mean vertical elongation of 7.5 mm and a mean horizontal elongation of 14 mm were obtained. A great improvement of the facial asymmetry was achieved in all the patients. The follow-up in this series varies from 3 months to 3 1/2 years (mean, 19 months in unilateral cases and 12 months in bilateral cases). No relapses have been observed.

Mandibular elongation and remodeling by distraction: a farewell to major osteotomies.

INTRODUCTION Sleep apnea is one of the most frequent manifestations of respiratory obstruction. Historically this clinical entity has stimulated the production of numerous valuable contributions with one purpose in mind: the improvement of airway permeability. A multi-disciplinary approach is required to define the problem in anatomic and functional terms to avoid a tracheostomy and prevent long-term sequels. We decided on an approach that focuses on improving the projection of the tongue in the posterior pharynx; by lengthening the mandible and bringing the muscular insertions of the floor of the mouth forward, the antero-posterior dimensions of the airway are increased. OBJECTIVE To evaluate mandibular distraction osteogenesis as a simple mandibular lengthening procedure useful as a definite treatment in patients with obstructive sleep apnea. MATERIAL AND METHODS The series consisted of 15 consecutive patients, divided in four groups. Patients with acute upper airway obstruction who required endotracheal intubation, patients with no acute upper airway obstruction but with severe respiratory distress, patients with milder degrees of airway obstruction, and patients with long-term tracheostomies. Therapeutic interventions were performed according to the findings of each group. RESULTS The patients were evaluated according to cephalometric analysis, polysomnograms, nasopharyngoscopy, and clinical data. Significant changes were seen in the cephalometric studies. There were no postoperative episodes of apnea; clinical improvement occurred in all patients and decannulation was possible in all patients. CONCLUSION Mandibular distraction is a safe and reliable procedure for treating patients with obstructive sleep apnea.

Distraction osteogenesis in Pierre Robin sequence and related respiratory problems in children.

Pierre Robin sequence is characterized by micro-gnathia, glossoptosis, feeding difficulties, and upper respiratory obstruction, which are frequently complicated by bronchial aspiration and pulmonary infection. Gastroesophageal reflux is also common in these patients. To assess the results of mandibular distraction, a study was performed in 18 patients to detect swallowing disorders associated with apnea episodes and gastroesophageal reflux. Polysomnography, barium pharyngoscopy, determination of blood gases, and esophageal pH measurements were undertaken before and 4 months after distraction osteogenesis. Bilateral corticotomies, followed by distraction with external devices, were performed, achieving 7 to 19 mm of elongation (mean = 12 mm). Gastroesophageal reflux was found in 83% of cases associated with apnea episodes, but it disappeared after distraction osteogenesis. Mean preoperative oxygen saturation was 72%, and it was 93% afterward. The preoperative apnea index was 18.3, and the preoperative 8.5 hypopnea index was 8.5; both disappeared. Pharyngeal transit time became less than 1 second after treatment. Abnormal tongue movements and barium stasis in the pharyngeal recess and in the trachea were eliminated in all the patients.

Swallowing disorders in Pierre Robin sequence: its correction by distraction.

Background: The treatment of major facial clefts has evolved greatly over the past 40 years. Early in the authors' experience, soft tissues were treated by Z-plasty and local flap rotation, resulting in a patchwork effect and noticeable scars. Bony deficits were treated with bone grafts that often failed to restore normal facial contour. In 1985, the authors developed a treatment philosophy to resolve these issues, and its tenets have formed the foundation of treatment since then. Methods: From January of 1965 to January of 2006, a series of 495 patients with major craniofacial clefts were treated in the authors' unit. Sixty-five percent had multiple clefts and 35 percent had a single cleft. In 33 percent of patients, the clefts were unilateral and in 67 percent the clefts were bilateral. The objectives of the authors' current treatment philosophy are restoration of the craniofacial skeleton, reconstruction with skin and soft tissue of like color and texture, generous use of tissue expanders, aesthetic unit reconstruction, scar location at limits of aesthetic subunits, and symmetric repositioning of key facial landmarks. Results: Patients underwent a total of 1338 operations. Follow-up ranged from 8 months to 35 years. All patients who underwent primary reconstruction after 1985 underwent successful reconstruction using the aesthetic subunit principle. Fifty-three percent of patients required formal craniofacial osteotomy and 24 percent required bone grafting to restore the craniofacial skeleton. Conclusions: The authors' results have improved considerably both in primary and in secondary reconstruction by incorporating their revised treatment philosophy. The authors have reduced scar visibility and facial asymmetry, allowing these patients to live more normal lives.

Fernando Ortiz Monasterio

Papers

Mandibular elongation and remodeling by distraction: a farewell to major osteotomies.

Distraction osteogenesis in Pierre Robin sequence and related respiratory problems in children.

Swallowing disorders in Pierre Robin sequence: its correction by distraction.

Major craniofacial clefts: case series and treatment philosophy.

Cleft lip rhinoplasty: the role of bone and cartilage grafts.