Cost-Effectiveness Analysis, Psychosocial, and Utility Outcomes of Early Mandibular Distraction in Craniofacial Microsomia.

BACKGROUND: The cost-effectiveness, utility outcomes, and most optimal timing of mandibular distraction osteogenesis (MDO) in craniofacial microsomia (CFM) continue to be a topic of debate, especially in the population of patients with mild or nonsignificant functional issues. The objective of this study was to quantitatively assess the burden of mandibular asymmetry in CFM, and to accurately evaluate the impact of early MDO on patients' perceived quality of life and social acceptance, in addition to examining the cost-effectiveness of early MDO in CFM. METHODS: A validated crowdsourcing platform was utilized to recruit participants. Psychosocial acceptance and utility outcomes were assessed for patients with CFM. Participants were presented with health-state scenarios supplemented with pre- and postoperative images. Quality-adjusted life years (QALYs) were subsequently calculated and costs were estimated based on Medicare fee schedules using the Current Procedural Terminology codes. Incremental cost-effectiveness ratios for early MDO were calculated and plotted against a $100,000/QALY threshold. RESULTS:: A total of 463 participants were included in the study. The mean visual analog scale score for untreated mandibular hypoplasia in CFM was 0.48 ±â€Š0.24, which improved significantly (P < 0.0001) to 0.63 ±â€Š0.20 following early MDO. Time trade-off scores for an imaginary surgery leading to perfect health with no complications were not statistically different from undergoing early MDO (P = 0.113). Early mandibular distraction decreased social distance in all 8 social situations assessed. Incremental cost-effectiveness ratios varied by the duration of time between early MDO and a potential second intervention, ranging from $148,142.09 per QALY gained at an interval of 1 year to $9876.14 per QALY gained after 15 years. Using a willingness-to-pay threshold of $100,000/QALY, early MDO in CFM becomes cost-effective when patients enjoy an improved health-state post-MDO for more than 1.48 years before a potential second intervention, if deemed necessary. CONCLUSION: Early mandibular distraction may lead to tangible positive gains in CFM patients based on utility outcome scores, psychosocial acceptance, and social distance. Therefore, although further interventions may be needed at skeletal maturity, early MDO can improve the psychological well-being of CFM patients during their crucial developmental years in a cost-effective manner. The incremental cost per QALY gained post-early MDO correlates negatively with time until a second potential surgical intervention.

Cost Comparison of Femoral Distraction Osteogenesis With External Lengthening Over a Nail Versus Internal Magnetic Lengthening Nail.

INTRODUCTION: Femoral lengthening is performed by distraction osteogenesis via lengthening over a nail (LON) or by using a magnetic lengthening nail (MLN). MLN avoids the complications of external fixation while providing accurate and easily controlled lengthening. However, the increased cost of implants has led many to question whether MLN is cost-effective compared with LON. METHODS: A retrospective review was performed comparing consecutive femoral lengthenings using either LON (n = 19) or MLN (n = 39). The number of surgical procedures, time to union, and amount of lengthening were compared. Cost analysis was performed using both hospital and surgeon payments. Costs were adjusted for inflation using the Consumer Price Index. RESULTS: No difference was observed in the length of femoral distraction. Patients treated with MLN underwent fewer surgeries (3.1 versus 2.1; P < 0.001) and had a shorter time to union (136.7 versus 100.2 days; P = 0.001). Total costs were similar ($50,255 versus $44,449; P = 0.482), although surgeon fees were lower for MLN ($4,324 versus $2,769; P < 0.001). DISCUSSION: Although implants are more expensive for MLN than LON, this appears to be offset by fewer procedures. Overall, the two procedures had similar total costs, but MLN was associated with a decreased number of procedures and shorter time to union. LEVEL OF EVIDENCE: III.

Cost-Benefit Analysis of Three-Dimensional Craniofacial Models for Midfacial Distraction: A Pilot Study.

OBJECTIVE: Patient-specific three-dimensional (3D) models are increasingly used to virtually plan rare surgical procedures, providing opportunity for preoperative preparation, better understanding of individual anatomy, and implant prefabrication. The purpose of this study was to assess the benefit of 3D models related to patient safety, operative time, and cost. DESIGN: Retrospective review. SETTING: Academic, tertiary care hospital. PATIENTS, PARTICIPANTS: Midfacial distraction was studied as a representative craniofacial operation. A consecutive series of 29 patients who underwent a single type of midfacial distraction was included. INTERVENTION: For a subset of patients, computed tomography-derived 3D models were used to study patient-specific anatomy and precontour hardware. MAIN OUTCOME MEASURES: Complications, operative time, blood loss, and estimated cost. RESULTS: Twenty patients underwent midfacial distraction without and nine with preoperative use of a 3D model. Seven complications occurred in six patients without model use, including premature consolidation (3), cerebrospinal fluid leak (2), and hardware malfunction (2). No complications were reported in the model group. Controlling for surgeon variation, model use resulted in a 31.3-minute (7.8%) reduction in operative time. Time-based cost savings were estimated to be $1036. CONCLUSIONS: Three-dimensional models are valuable for preoperative planning and hardware precontouring in craniofacial surgery, with potential positive effects on complications and operative time. Savings related to operative time and complications may offset much of the cost of the model.

Gastrostomy Placement Rates in Infants with Pierre Robin Sequence: A Comparison of Tongue-Lip Adhesion and Mandibular Distraction Osteogenesis.

BACKGROUND: This study was conducted to compare the gastrostomy rates in infants with Pierre Robin sequence treated with tongue-lip adhesion or mandibular distraction osteogenesis. METHODS: This was a retrospective study of symptomatic plastic and reconstructive surgery patients treated over an 8-year period. The primary predictor variable was surgical intervention (tongue-lip adhesion or distraction osteogenesis). Secondary predictor variables were categorized as demographic and clinical factors. The primary outcome was the need for gastrostomy tube placement. Secondary outcomes were complication rates, costs, and length of stay. RESULTS: Thirty-one tongue-lip adhesion and 30 distraction osteogenesis patients were included in the study. The groups were statistically comparable with regard to demographic and clinical factors (p > 0.18). Gastrostomy rates were higher in patients who underwent tongue-lip adhesion (48 percent) versus those who underwent distraction osteogenesis (16.7 percent; p = 0.008). In an adjusted model, subjects undergoing tongue-lip adhesion were more likely to require gastrostomy tube for nutritional support (OR, 6.5; 95 percent CI, 1.7 to 25.2; p = 0.007). There were two major complications in the tongue-lip adhesion group and none in the distraction osteogenesis group. There were three minor complications in the tongue-lip adhesion group and five in the distraction osteogenesis group. Total operating room costs were higher for distraction osteogenesis (p = 0.05), and total hospital costs and length of stay were higher for tongue-lip adhesion (p < 0.05). CONCLUSIONS: Among infants with symptomatic Pierre Robin sequence, treatment by distraction osteogenesis is associated with a lower risk for gastrostomy placement for nutritional support. Hospital costs are higher for tongue-lip adhesion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Knee Joint Distraction Compared to Total Knee Arthroplasty for Treatment of End Stage Osteoarthritis: Simulating Long-Term Outcomes and Cost-Effectiveness.

OBJECTIVE: In end-stage knee osteoarthritis the treatment of choice is total knee arthroplasty (TKA). An alternative treatment is knee joint distraction (KJD), suggested to postpone TKA. Several studies reported significant and prolonged clinical improvement of KJD. To make an appropriate decision regarding the position of this treatment, a cost-effectiveness and cost-utility analysis from healthcare perspective for different age and gender categories was performed. METHODS: A treatment strategy starting with TKA and a strategy starting with KJD for patients of different age and gender was simulated. To extrapolate outcomes to long-term health and economic outcomes a Markov (Health state) model was used. The number of surgeries, QALYs, and treatment costs per strategy were calculated. Costs-effectiveness is expressed using the cost-effectiveness plane and cost-effectiveness acceptability curves. RESULTS: Starting with KJD the number of knee replacing procedures could be reduced, most clearly in the younger age categories; especially revision surgery. This resulted in the KJD strategy being dominant (more effective with cost-savings) in about 80% of simulations (with only inferiority in about 1%) in these age categories when compared to TKA. At a willingness to pay of 20.000 Euro per QALY gained, the probability of starting with KJD to be cost-effective compared to starting with a TKA was already found to be over 75% for all age categories and over 90-95% for the younger age categories. CONCLUSION: A treatment strategy starting with knee joint distraction for knee osteoarthritis has a large potential for being a cost-effective intervention, especially for the relatively young patient.

A low-cost method of craniofacial distraction osteogenesis.

AIM: Distraction osteogenesis is an effective treatment modality for the correction of craniofacial deformities. The cost of these devices is significant and may preclude routine use of these distractors in developing countries. Hence, distraction osteogenesis was performed using medical equipment that was readily available in any hospital at minimal cost. PATIENTS AND METHODS: From 2008 to 2013, a retrospective study was performed on infants and neonates who underwent primary distraction for craniofacial abnormalities. Midface or mandibular distraction was performed because of respiratory impairment and/or globe exposure. The apparatus used included Steinmann pins, stainless steel wires, attachment bolts, orthopaedic pulleys, string and intravenous bags for weights. For midface distraction, a transzygomatic pin was inserted, and a transmandibular pin or a cerclage wire was inserted into the mandible through the symphysis or body of the mandible and connected to the pulley system. RESULTS: Distraction osteogenesis was performed on five patients - three mandibular distractions (Pierre Robin sequence) and two transfacial distractions (Apert syndrome/Pfeiffer syndrome type III). The mean age, duration of distraction and duration of consolidation at the time of distraction was 60.5 days, 18.6 days and 16.4 days, respectively. The mean length of distraction achieved was 12 mm. Common complications observed were pin loosening, pressure necrosis of the skin and uneven pull. A major disadvantage was the longer hospital stay required. CONCLUSION: The African method of distraction is effective, easy and cost effective and could be used in third-world hospitals where surgical expertise or expensive distraction sets are not freely available.

Cost analysis of mandibular distraction versus tracheostomy in neonates with Pierre Robin sequence.

OBJECTIVE: To evaluate costs associated with surgical treatment for neonates with Pierre Robin sequence (PRS). STUDY DESIGN: Retrospective cohort study. SETTING: Cincinnati Children's Hospital Medical Center. SUBJECTS AND METHODS: With Institutional Review Board approval, we retrospectively studied neonates with PRS treated from 2001 to 2009 with either tracheostomy (Trach), mandibular distraction (MD), or Trach with subsequent MD (Trach+MD). Actual charges over a 3-year period associated with operative costs, hospital stay, imaging and sleep studies, clinic visits, and related emergency room visits were collected. Home tracheostomy care charges were estimated individually for each patient. Charges were compared using regression and appropriate statistical analyses. RESULTS: Forty-seven neonates were included in the study (MD, n = 26; Trach, n = 12; Trach+MD, n = 9). Trach group patients had 2.6-fold higher charges than the MD group despite no difference in length of hospital stay. This difference increased to 7.3-fold when including home trach care-related costs. Trach+MD group patients had longer hospital lengths of stay and higher operation room (OR) fees, but no increased total charges compared with the Trach only group. CONCLUSIONS: For patients with severe PRS, mandibular distraction provides significant cost savings over tracheostomy ($300,000 per patient over 3 years). Increased costs with tracheostomy come from greater hospital-related charges, more frequent airway procedures, a higher incidence of gastrostomy tube feeds, and home trach care costs. A careful examination of long-term outcomes will be critical as mandibular distraction continues to gain acceptance for treatment of PRS.

Tracheostomy versus mandibular distraction osteogenesis in infants with Robin sequence: a comparative cost analysis.

Many treatments have been described for infants with Robin sequence and severe respiratory distress, but there have not been many comparative studies of outcome and cost-effectiveness. The aim of this study was to compare the cost and complications of two common interventions - mandibular distraction osteogenesis and tracheostomy. Nine patients with isolated Robin sequence (mandibular distraction osteogenesis, n=5, and tracheostomy, n=4) were included in the analyses. Predetermined costs and complications were obtained retrospectively from medical records and by questionnaires to the parents over a 12-month period. Overall direct costs (admission to hospital, diagnostics, surgery, and homecare) were 3 times higher for tracheostomy (€105.523 compared with €33.482, p=0.02). Overall indirect costs (absence from work) were almost 5 times higher (€2.543 compared with €543, p=0.02). There was a threefold increase in overall total cost/patient (both direct and indirect) for tracheostomy (€108.057 compared with 34.016, p=0.02) and 4 times more complications were encountered. This study shows that mandibular distraction osteogenesis in infants diagnosed with Robin sequence costs significantly less and results in fewer complications than tracheostomy, and this contributes to our current knowledge about the ideal approach for infants with Robin sequence and might provide a basis for institutional protocols in the future.

Mandibular distraction osteogenesis in the micrognathic neonate: a review for neonatologists and pediatricians.

In the past, severe neonatal upper airway obstruction secondary to micrognathia was managed with a tracheostomy. Although effective, tracheostomy can cause many short-term and long-term complications. More recently, mandibular distraction osteogenesis (MDO) has become a well-accepted surgical option in treating micrognathic newborns. Overall, MDO has been reported to be an effective intervention in alleviating the micrognathia-associated airway compromise. Furthermore, it seems to be well tolerated and has supplanted the need for tracheostomy in many patients. Neonatologists and pediatricians commonly care for these children, and therefore an up-to-date clinical narrative review regarding MDO is presented to increase the awareness of this relatively new surgical option.

Tracheostomy versus mandibular distraction osteogenesis in Canadian children with Pierre Robin sequence: a comparative cost analysis.

INTRODUCTION: Upper airway obstruction in newborns with Pierre Robin sequence (PRS) may be severe enough to require a surgical intervention. Tracheostomy has been the traditional gold standard, but mandibular distraction osteogenesis (MDO) has been proven to be an effective alternative procedure. OBJECTIVE: The objective of the present study was to conduct the first comparative cost analysis between tracheostomy and MDO in Canada. METHODS: All patients with PRS who underwent tracheostomy or MDO between January 2005 and December 2010 were included. Tracheostomy and MDO procedures were broken down into individual components, and the associated costs for these components were totaled. The average per-patient cost for each modality was then compared. RESULTS: During the study period, 52 children underwent either a tracheostomy (n  =  31) or MDO (n  =  21). The average age at surgery, gender, and presence of associated syndromes were similar in both groups. Taking into account the cost of the surgeries, health care professional fees, and hospital stay, the total per-patient treatment cost was determined to be $57,648.55 for MDO and $92,164.45 for tracheostomy. The majority of the cost for the tracheostomy group was associated with prolonged hospital stay after the operation ($72,827.85). Overall, the average per-patient cost was 1.6 times greater in the tracheostomy group compared to the MDO group (p  =  .039). CONCLUSION: The initial cost of MDO was less than the tracheostomy cost for newborns with PRS and severe upper airway obstruction at our health care centre. Further prospective analysis considering the long-term costs is required to possibly reduce long-term health care costs.

Role of lumbar interspinous distraction on the neural elements.

The interspinous distraction devices are used to treat variable pathologies ranging from facet syndrome, diskogenic low back pain, degenerative spinal stenosis, diskopathy, spondylolisthesis, and instability. The insertion of a posterior element with an interspinous device (ISD) is commonly judged responsive to a relative kyphosis of a lumbar segment with a moderate but persistent increase of the spinal canal and of the foraminal width and area, and without influence on low-grade spondylolisthesis. The consequence is the need of shared specific biomechanical concepts to give for each degenerative problem the right indication through a critical analysis of all available experimental and clinical biomechanical data. We reviewed systematically the available clinical and experimental data about kyphosis, enlargement of the spinal canal, distraction of the interspinous distance, increase of the neural foramina, ligamentous structures, load of the posterior annulus, intradiskal pressure, strength of the spinous processes, degeneration of the adjacent segment, complications, and cost-effectiveness of the ISD. The existing literature does not provide actual scientific evidence over the superiority of the ISD strategy, but most of the experimental and clinical data show a challenging potential. These considerations are applicable with different types of ISD with only few differences between the different categories. Despite--or because of--the low invasiveness of the surgical implantation of the ISD, this technique promises to play a major role in the future degenerative lumbar microsurgery. The main indications for ISD remain lumbar spinal stenoses and painful facet arthroses. A clear documented contraindication is the presence of an anterolisthesis. Nevertheless, the existing literature does not provide evidence of superiority of outcome and cost-effectiveness of the ISD strategy over laminectomy or other surgical procedures. At this time, the devices should be used in clinical randomized independent trials in order to obtain more information concerning the most advantageous optimal indication or, in selected cases, to treat tailored indications.

Clinical reliability of closed techniques and comparison with open strategies to achieve union at the docking site.

PURPOSE: This retrospective review follows 31 tibial nonunions to compare union at the docking site using closed versus open strategies. In this cohort of patients, all but five were infected nonunions. METHODS: Thirteen patients initially treated with single compression were compared with 18 patients treated by open revision of the docking site. In the single compression group, an average of 6.5 cm of bone was resected and index lengthening was 2.04. In the open revision group, a mean of 9.4 cm was resected and the index lengthening was 1.73. RESULTS: Consolidation at the docking site occurred in all subjects in both groups. There was no statistical difference between the two groups. Conclusive evidence of superiority of one modality of treatment over the other cannot be drawn from our data. CONCLUSIONS: The simple compression procedure requires less invasive surgery and is probably less demanding and more cost-effective in short transports.

Distraction osteogenesis versus fibula free flap for mandibular reconstruction after gunshot injury: socioeconomic and technical comparisons.

BACKGROUND: Since the birth of maxillofacial surgery, ballistic injuries are a real challenge for surgeons. For more than 20 years, fibula free flap (FFF) became the criterion standard for mandibular reconstructions. But FFF is not always the perfect answer for mandibular reconstruction, and a technique named distraction osteogenesis (DO) was raised. The purposes of this study are to estimate the financial cost and reattempt for the patient each techniques in our experience to determine the best-choice criteria for mandibular reconstruction after gunshot injury. METHODS: We performed a retrospective study over the last 15 years, including 15 patients with a mandibular ballistic injury. Ten patients were treated with FFF, and 5 with DO. We evaluated the complications and morbidity encountered with each technique. We also decided to estimate the cost of different rehabilitations, including the cost of the device and hospitalization. RESULTS: In our study, the global cost of the DO protocol appears as not more expensive than the FFF one. Postoperative complications encountered during the FFF protocols were related to donor-site morbidity. The DO patient had pseudoarthrosis, mucosa irritation, or local infection. DISCUSSION: Our study demonstrated both the economic and technical interest of DO compared with the FFF for mandibular reconstruction. Thus, nowadays, DO appears as an alternative to the FFF for mandibular reconstruction, the main decisional criterion being the evaluation of the tissues dilapidated during the initial traumatism, but social environment of the patient shall also be considered.

Economic advantages to a distraction decision tree model for management of neonatal upper airway obstruction.

BACKGROUND: Neonatal upper airway obstruction demands urgent attention. Tracheostomy can prove to be lifesaving but has morbidities. Recently, the authors found reduced morbidity/mortality when using a distraction decision tree model compared with conventional "case-by-case" management. In this current study, the authors assess the long-term costs of (1) a decision tree model versus conventional treatment and (2) tracheostomy versus distraction osteogenesis. METHODS: An inpatient cost-matrix analysis study on neonates with upper airway obstruction and micrognathia was performed (n=149). In Part I, conventionally treated neonates managed on a case-by-case basis received home monitoring or a tracheostomy. Decision tree model-managed newborns had specialist consultations and diagnostic testing to determine whether home monitoring, tracheostomy, or distraction osteogenesis would be implemented. In Part II, tracheostomy treatment was compared directly to distraction osteogenesis. RESULTS: In Part I (conventional versus decision tree model), taking into account the costs of the distraction, tracheostomy, hospital stay, diagnostic studies, physician fees, and emergency department visits, the total per patient treatment cost was 1.5 greater in the conventional treatment group ($332,673) compared with the decision tree model ($225,998) (p<0.05). In Part II (tracheostomy versus distraction osteogenesis), the total per-patient treatment cost in the tracheostomy group was two times greater than in the distraction group ($382,246 versus $193,128) (p<0.05). CONCLUSIONS: In treating newborns with micrognathia and upper airway obstruction, a decision tree model with mandibular distraction decreases long-term health care costs compared with conventional treatment. Furthermore, when comparing distraction to tracheostomy, similar decreases in long-term health care costs occurred.

[Distraction osteogenesis in orthopaedics]. / Distractieosteogenese in de orthopedie.

For several decades, distraction osteogenesis has been applied in orthopaedics for lengthening limbs. Other indications for distraction osteogenesis in orthopaedics are nonunions, open fractures, oncologic defects, and ankle osteoarthritis. The main principle of distraction osteogenesis is that, with a certain degree of distraction of 2 bone segments, linear bone generation will take place between the 2 segments. The most frequent complications are infection, loosening and breaking of the introduced pins, osteomyelitis, and fracture of the newly generated bone. Disadvantages of distraction appliances are expensiveness, degree of technical difficulty, and a long training period. Distraction osteogenesis in orthopaedics is a very intensive treatment. Therefore, only patients who are motivated and well instructed and who are physically and mentally capable of coping with the fixtures are suitable.

Outcome of treatment of Class II malocclusion by intraoral mandibular distraction.

Our aim was to find out long-term results of treatment in patients treated orthodontically and by mandibular distraction osteogenesis. Data on duration of treatment, costs, and results of 26 patients (13 girls and 13 boys) with a mean age of 15 years were analysed. The preoperative cephalograms were compared with those taken at the last follow-up visit. There was a significant reduction in duration of treatment when patients were treated without a first phase that included functional appliances. The differences in costs of orthodontic treatment were not significant. The costs of the operation for distraction were significantly higher compared to BSSO, mainly because of the costs of the distraction devices. Comparison of the cephalograms showed a significant increase in SNB angle, Wits value, ANB angle, overjet, and overbite. The Y-axis, MP/S, and SpP/MP angle increased. Orthodontic treatment and distraction of the mandible was a successful, but more expensive, treatment.

[Class II malocclusion. Time and cost of a combined orthodontic and surgical treatment]. / Klasse II-malocclusie. Duur en kosten van een gecombineerde orthodontische en chirurgische behandeling.

During orthodontic treatment of 29 patients with a Class II malocclusion, the remaining overjet was corrected surgically by intraoral mandibular distraction osteogenesis. The patients were divided in two groups. Group A was treated orthodontically in a two-phase approach, using functional and fixed appliances. Group B was treated in a one-phase approach with only fixed appliances. Before treatment the differences in age, gender and severity of the malocclusion between the groups, were not statistically significant. After distraction-osteogenesis, all orthodontic treatments could be finished successfully. The mean treatment time was for group A 44.2 and for group B 28.6 months. The difference was statistically significant (p < 0.001). The mean orthodontic treatment time after distraction osteogenesis was 9.1 months. The mean cost for the orthodontic treatment was not statistically significant different between the groups.

Cost, operation and hospitalization times in distraction osteogenesis versus sagittal split osteotomy.

INTRODUCTION: Distraction osteogenesis in 'common' surgical orthodontics is mentioned as an alternative for conventional sagittal split osteotomy. After a 'learning curve' in the surgical skills of distraction, the two techniques can be compared concerning time and cost aspects. PATIENTS: Forty-seven patients (male n=28, female n=19, age 11.7-17.9 yr (mean 14.2) with an Angle's class II division 1malocclusion of skeletal mandibular origin were operated on using distraction osteogenesis and were compared with a second group of 21 patients (male n=4, female n=17, age 16-36yr (mean 22.8) who underwent bilateral sagittal split osteotomies in the same period in order to correct the same type of dysgnathia. METHOD: The first group of 47 patients was treated with intraorally placed bone-born distraction devices to correct mandibular deficiency following a standard protocol, with removal of the third molar tooth germs if present. The second group of 21 patients underwent standard sagittal split osteotomies to correct the mandibular deficiency. The costs of hospitalization, distraction devices and operation time were compared. RESULTS: In this study, distraction osteogenesis took on average more operative time (mean 37%), but 1 day less hospitalization than the bilateral sagittal split osteotomies. The surgical cost of distraction osteogenesis was 36% higher than the conventional sagittal split osteotomy. CONCLUSION: In this study, correcting Angle's class II deficiencies by means of distraction osteogenesis was shown not to be a time-saving procedure when compared with sagittal split osteotomy. Surgical costs were significantly higher using distraction, mainly due to the price of the distractors. Changes in hospital policies concerning hospital admission of adults and children and European legislation concerning re-usability of surgical instruments may balance the cost of both procedures.

Distracción maxilar en pacientes fisurados con distractor externo / Maxilary distraction in cleft patients with external distractor

El presente artículo revisa el tratamiento de pacientes fisurados con hipoplasia maxilar severa mediante un distractor externo. Estos pacientes presentan múltiples problemas a resolver por el equipo médico, que incluyen déficit óseo, fisura residual y cicatrices; tradicionalmente debían esperar hasta alcanzar la maduración ósea para que se les pudiera practicar una cirugía ortognática clásica. Empleamos esta nueva alternativa de tratamiento a base de distracción maxilar mediante un distractor externo con un sistema parecido al sistema RED descrito por Polley y Figueroa en 1997. Hicimos algunas pequeñas modificaciones sobre el sistema y sobre los alambres de tracción. Su coste es mucho menor del regular. Presentamos una descripción de la técnica que incluye: fabricación del dispositivo intraoral, cirugía mediante osteotomía tipo Lefort I y emplazamiento del sistema de distracción rápida, a un ritmo de 1 mm. diario durante 3 semanas hasta que conseguimos las proporciones adecuadas. En ese momento se retira el halo cefálico y se continúa la distracción mediante una máscara externa durante 6 - 8 semanas. Las complicaciones fueron menores y correspondieron a insuficiencia velofaríngea o desplazamiento del halo. En todos nuestros pacientes conseguimos un avance horizontal del maxilar de 8 mm. de media con una relación normal entre el maxilar y la mandíbula. Este procedimiento puede ser aplicado a partir de los 5 años, es bien tolerado y requiere de una gran coordinación entre el cirujano y el ortodoncista (AU)