Assessment and treatment of facial deformity resulting from radiation to the orbital area in childhood.

Children who receive radiation for malignant tumors in the orbital area frequently develop widespread craniofacial deformities. These affect the skull, orbit, maxilla, and mandible. When these patients seek treatment at a later age, they require careful assessment using cephalometrics and three-dimensional imaging. It is recommended that the four levels of skeletal deformity be corrected in a single procedure, that is frontotemporal expansion with repositioning of the skull base area, orbital expansion and repositioning together with maxillary and mandibular surgery. Bone grafts should be inlay rather than onlay and soft tissue should be supplied by free-tissue transfer. This counteracts any residual ischemia related to the previous radiation therapy. The second surgical stage is designed to reconstruct the socket and the eyelids to allow more satisfactory rehabilitation with an ocular prosthesis. In patients who have a globe present, the usual enophthalmos can be corrected by repositioning of the eye as part of the first procedure by reducing the anteroposterior dimensions of the socket. In bilateral cases, the deformity is hourglass in nature and requires correction in the frontal and temporal area with lateral displacement of the orbits. A bimaxillary procedure is also indicated. It is emphasized that to formulate a satisfactory operative plan an in-depth three-dimensional analysis of the deformity is mandatory.

Traumatic cranial injury sustained from a fall on the rigid external distraction device.

Distraction osteogenesis has become a popular treatment of congenital maxillocraniofacial anomalies. Many ingenious internal and external devices have been developed and used. The rigid external distraction system based on systems previously used in correction of maxillary retrusion offers postoperative adjustment in two dimensions. Figueroa and Polley reported the use of this device with minimal morbidity in children as young as 5 years of age. They reported no problems with infection, bleeding, pain, loosening of the intraoral splint, dental injury, or wear problems in a series of 14 consecutive cleft patients. Recent modification of the system, rigid external distraction II, has allowed it to be applied to more complex craniofacial deformities that require a LeFort III osteotomy. A review of the neurosurgery and orthopedic literature revealed that halo complications relate primarily to the skull pins. In most cases, these complications can be prevented if the device is carefully applied and monitored. Early recognition and prompt treatment of complications are important. After experience with this system for advancement at the LeFort III level, six patients with various syndromes involving the craniofacial skeleton have undergone LeFort III level distraction osteogenesis with the rigid external distraction device in combination with a planned and stabilized frontosupraorbital advancement. In one of these cases, a 7-year-old child fell on the device after discharge from the hospital and sustained a compound depressed skull fracture that required debridement and repair.