Janet
04-01-2011, 08:39 PM
Highlights of the Proceedings From the 13th International
Congress of the International Society of Craniofacial
Surgery: ISCFS 2009
James P. Bradley, MD,* Steve Warren, MD,
Þ and Michael T. Longaker, MDþ
The International Congress of the International Society of
Craniofacial Surgery (ISCFS) XIII Biennial meeting took
place in Oxford, England, from September 26 through
September 30, 2009, and was hosted by Steven Wall, MD
(president and scientific chair). This meeting represented the 26th
anniversary of the society and the first meeting since the death of
Paul Tessier (1907
Y2008). All members of the society recognized
Dr. Tessier’s important role as the father of the field of craniofacial
surgery and one of the original members of the ISCFS.
This meeting was highlighted by stimulating lectures to provocative
interactive discussions, from the opening session on controversies
and consensus in craniofacial distraction to the closing
session on aesthetic surgery. The venue in historic Oxford ranged
from a large tent outside the town to a magical dining room at
Christ’s Church (notable from Harry Potter’s Hogwarts School). As a
unique prelude to this established meeting, the Distraction Symposium
was held and organized by Eric Arnaud, MD. This Distraction
Symposium has been held in Paris 6 previous times beginning in
1997. These fruitful meetings helped transform distraction osteogenesis
in the craniofacial skeleton from a novel technique to an
established modality over the last 10 years. This Distraction Symposium
was set to be the last of the independent series of
BDistraction
Symposia in Paris.
[
2009 DISTRACTION SYMPOSIUM
Drawing from almost 20 years of distraction experience in the
craniofacial skeleton, both Joseph McCarthy and Fernando Molina
each summarized (1) their lessons learned, (2) expanding indications
for distraction, and (3) predictions on the future of the field. The
New York University (NYU) team has taken a clinical scientific
approach to investigating new techniques and the effect of distraction
surgery on growth. In addition, Dr. McCarthy emphasized
the importance of orthodontic cooperation and generate bone guidance
in the perioperative period. Dr. Molina showed his work over
the last 2 decades on some extreme syndromic cases.
One of the most active sessions in this symposium involved
neonatal mandibular distraction for micrognathia with upper airway
obstruction. Fernando Ortiz-Monasterio reported on the beneficial
effects of neonatal mandibular lengthening on feeding and the
resolution of gastrointestinal reflux. In a 5-year cost analysis study,
the University of California, Los Angeles (UCLA), group showed
that although neonatal distraction patients had higher initial costs,
tracheostomy patients had increased cost (2.5 times) in the long
term. Steven Schendel’s group has looked at sophisticated threedimensional
computed tomography (CT) imaging to show airway
improvements using a mandibular curvilinear device.
Reports on midface (Le Fort III) and monobloc distraction were
split with centers demonstrating the benefits of internal devices
(Kawamoto) and the external RED devices (Polley). Several groups
reported on the use of transfacial pin (zygomatic K-wire), external
device, and midface advancement without osteotomies in craniofacial
dysostosis in infants (Pellerin, Manard, Satoh, Arnaud).
Although these early advancement cases were successful, the indication
for this type of surgery has not been well established.
Challenging cases, such as severe micrognathia with bony ankylosis,
were reviewed by multiple groups. Transport distraction and
costocondylar joint replacement showed utility with this difficult
problem (Cheung, Lagiglia Karam). For this treatment, presenters
emphasized that postoperative physiotherapy and unloading the
joint space with elastics or with external device are critical to longterm
success.
SPECIAL EDITORIAL
944
The Journal of Craniofacial Surgery & Volume 21, Number 3, May 2010
From the *Division of Plastic and Reconstructive Surgery, University of
California, Los Angeles, CA;
†Institute of Reconstructive Plastic Surgery,
New York University Medical Center, New York, NY; and
‡Department
of Surgery, Stanford University Medical Center, Stanford, CA.
Received January 19, 2010.
Accepted for publication January 19, 2010.
Address correspondence and reprint requests to James P. Bradley, MD,
200 Medical Plaza, Suite 465, Los Angeles, CA 90095;
The authors report no conflicts of interest.
Copyright
* 2010 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0b013e3181d88125
Copyright © 2010 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
PRESYMPOSIUM: CONTROVERSIES AND
CONSENSUS IN CRANIOFACIAL SURGERY
The 2009 ISCFS Presymposium grouped presentations with opposing
viewpoints in an attempt to objectively look at controversial
topics in craniofacial distraction and craniofacial surgery. Although
a consensus was not reached in most topics, stimulating discussion
provided insight into the latest accepted treatments. (1) Distraction
versus traditional orthognathic surgery: traditional orthognathic surgery
with
Bon-table[ occlusal splints and rigid fixation is still the
standard of care for skeletal malocclusion in the mature patient. An
expanded role for Le Fort I maxillary distraction was noted in the
severe cleft cases and sometimes even in the skeletally mature
patients with severe hypoplasias (Cheung). (2) Mandibular relapse
versus mandibular growth: the NYU group used a long-term study
of mandibular distraction in patients with hemifacial microsomia
to show the stability of the generated bone. In their study, approximately
one third required subsequent, secondary surgery after mandibular
growth or for cant correction. (3) External versus internal
midface distraction devices: groups with external device experience
cited
Bvector control[ of the distraction segment. Groups with internal
device experience cited patient preference, longer consolidation
times, and ability to control distraction segment with orthodontic
elastics. Several groups, Wall (United Kingdom) and Morales
(Mexico), had experience with both and, at times, varied preference
based on the case. (4) Early posterior vault spring expansion versus
ventriculoperitoneal shunting: for the first time, many institutions
presented their experience of early posterior vault expansion in
craniofacial dysostosis patients using either distraction devices or
springs. Posterior vault distraction cases typically involved large
posterior craniotomies without dural dissection (Wall, Nishikawa).
Early posterior vault spring expansion often involved expansion
across the patent lambdoid sutures (Arnaud). This early posterior
expansion may also help with an evolving Chiari malformation.
Newer flow-regulated ventriculoperitoneal shunts were used for hydrocephalus
or in rare cloverleaf skull deformity cases to provide
better control of intracranial pressure changes compared with pressure
valve release shunts, which risk intermittent overdrainage of
cerebrospinal fluid (DiRocco). (5) Facial bipartition midline softtissue
excision: linear (Ortiz-Monasterio), V-Y excision (Wall), internal
B
K-stitch[ (Kawamoto). Each of these 3 different approaches
was offered as soft-tissue refinement to skeletal correction. Each
offered an acceptable method of reducing the redundant midline
soft tissue and narrowing brow width after correction of hypertelorbitism.
The K-stitch is ideal in mild or moderate cases with
normal skin because it leaves no external scar and may be redone at
a later date if necessary. The linear incision works well with hyperpigmented
or damaged midline skin or when a forehead flap for
nasal reconstruction is required. (6) Computed tomography scan
imaging: craniofacial case documentation versus irradiation risks.
The concern of cumulative radiation dosage from multiple CT scans
in children with its lifetime risk of cancer was raised. Denny carefully
looked at risks involved with three-dimensional CT scanning
of patients for preoperative planning and follow-up evaluations. He
found that the dosages his patients received were 100 to 1000 times
less than levels shown to increase the risk for carcinogenesis and
40 times less than the levels associated with developmental and
cognitive delays. Dr. Fearon advocated judicious use of CT scans
for craniosynostosis diagnosis and follow-up.
ORTHODONTICS
Many of the orthodontic studies focused on growth, stability, and
relapse. The NYU group used lateral cephalometric analysis at
skeletal maturity to show no growth difference when comparing
gingivoperiosteoplasty to no gingivoperiosteoplasty during infant
cleft lip repair after alveolar molding. Dental considerations during
midface distraction were looked at by Dunaway. Although orthodontic
alignment of the arches and protecting the permanent teeth
may help during midface advancement, optimal occlusion and
proper jaw relationship are left until skeletal maturity. Of cleft
patients with severe maxillary hypoplasia who underwent Le Fort I
distraction osteogenesis around 11 years of age, Chen (Chang Gung
Memorial, Taipei, Taiwan) showed maxillary stability, yet one third
required a revisionary Le Fort I advancement at skeletal maturity
secondary to mandibular growth.
CRANIOFACIAL MICROSOMIA
University of California, Los Angeles, reported a change in softtissue
reconstruction strategy with craniofacial microsomia patients.
Instead of using an IMECS (inframammillary extended circumflex
scapular, ie, parascapular) flap at skeletal maturity after bony
reconstruction, they showed improved volumetric outcomes with
serial autologous fat grafting. Dr. Diner (Paris) echoed his similar
experience with fat grafting in craniofacial microsomia and Treacher
Collins patients. Guerrero reviewed details of his intraoral mandibular
distraction techniques with emphasis of (1) unloading the
temporomandibular joint with class II elastics and (2) designing the
osteotomy location based on the deformity and consideration of
nerve protection. For microtia repair, the use of cultured human
auricular chondrocytes with long-term stability was studied by
Furukawa (Osaka, Japan). The final results were still considered, by
those that commented on the study, inferior to current accepted
techniques with the use of rib graft for framework fabrication.
HYPERTELORBITISM
Three large, long-term series of hypertelorbitism correction
(Mexico, UCLA, Shanghai), agreed that (1) the technique should be
tailored to the specific deformity and (2) early correction resulted in
growth discrepancy. In addition, a new technique of gradual orbital
contraction for wide 0 to no. 14 craniofacial clefts (performed with
a distraction device placed between bipartition segments) was successfully
demonstrated by UCLA.
SYNDROMIC CRANIOSYNOSTOSIS
Reports of late-presentation, normocephalic pansynostosis at
Children’s Hospital of Philadelphia and Children’s Hospital of
Boston showed a mean diagnostic delay of 3.2 years and a cranial
vault remodeling surgical delay of 3.8 years. Careful monitoring of
cranial circumference was stressed to identify these unusual cases.
Craniofacial center genetic screening of syndromic craniosynostosis
patients has become more widespread. However, it has not been
shown that identification of a specific genetic mutation, deletion, or
translocation can direct surgical approach or predict surgical outcome.
A call for simplification of syndromic classifications with
the use of both genotype and phenotype was made.
NONSYNDROMIC CRANIOSYNOSTOSIS
For outcome assessment of scaphocephaly correction, 2 centers
offered new three-dimensional morphometric analysis that may be
more accurate than the accepted cephalic index linear measurement
(Toronto, Melbourne). Limited incision sagittal strip craniectomy
with postoperative helmet therapy with or without the use of the
endoscope was found by several centers to be a safe and effective
way to treat scaphocephaly (Dallas, Utah, Boston). Claus Lauritzen
and Lisa David further reported refinements on spring cranioplasty.
For scaphocephaly correction, Dr. Lauritzen reported on the
beneficial effects of gradual biparietal expansion and the impact
The Journal of Craniofacial Surgery
& Volume 21, Number 3, May 2010 Special Editorial
*
2010 Mutaz B. Habal, MD 945
Copyright © 2010 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
on normal adjacent sutures. The use of distraction for cranial
expansion and correction of plagiocephaly was reported as having
less morbidity to traditional total cranial vault remodeling for
craniosynostosis (Japan, China [Shanghai]). New neuropsychological
outcome studies showed cognitive, language, fine motor skill
deficiencies, and developmental delays with isolated craniosynostosis,
particularly with delay in age at operation (Yale, Great Ormond
Street).
MONOBLOC AND MIDFACE ADVANCEMENT
A radiographic study of ocular movement after monobloc distraction
showed anterior displacement of the globe by as much as 40%
of the distraction length but with no implication to optic nerve damage
(Great Ormond Street). Reports on the use of internal, intraoral,
and external devices showed success with each monobloc advancement
method. The need for (1) preoperative planning, (2) distraction
phase manipulation of the segments, and (3) orbital correction as the
end point to distraction was emphasized by each group. In addition,
improvement in posterior nasopharyngeal airway anatomy translated
into objective obstructive sleep apnea parameter improvement.
TRAUMA
Hopital Enfants Malades in Paris advocated surgical repair for
severe orbital fractures even if treatment is delayed due to neurologic
injury. They also commented that secondary correction in these
cases might often be necessary. Although prosthetic cranial vault
implants are controversial in the pediatric patient population, 2
centers reported their positive experience with PMMA (polymethyl
methacrylate) and PEEK (polyEther Ethyl[Ketone]) implants
(Toronto, Toulouse, [France]). Presenters also described their use
of distraction for the reconstruction of mandibular defects and for
mandibular condylar fractures (Egypt, Japan).
IMAGING
This section stimulated important discussion on the prudent
use of CT scan imaging for diagnostic, postoperative, and follow-up
assessment. Denny presented a well-conducted study on screening
CT scans and the radiation exposure risk with the implication to the
cause of cancer or developmental delay. He concluded that effects
of low linear energy transfer are different than data obtained using
the linear no-threshold hypothesis, and the risk of tumorigenesis
from pediatric CT scans is actually 100 times lower than previously
reported. Dr. McCarthy’s group reported on their development of a
three-dimensional surgical atlas for modeling craniosynostosis as a
tool for teaching and simulation. Multiple centers reported the use
of three-dimensional photography for surgical outcome assessment
based on shape and volumetric analysis.
SCIENTIFIC RESEARCH
In several translational investigations, BMP-2 was studied as a
way to promote bone tissue repair. To reduce donor-site morbidity,
the clinical use of BMP-2 in pediatric cranial vault defects was
documented (Genecov, Dallas). Experimentally, BMP-2 was investigated
with smart scaffolding to direct the location of bone healing
(Losse, Pittsburgh). In addition, BMP-2 was found to promote
healing in critical-size murine defects (Reid, Chicago) and with
dura-repaired beagle cranial defects (Opperman, Dallas). Dr. Wilkie
described how an ALX3 mutation was found to cause
frontorhiny,
a distinguishing phenotype with hypertelorbitism and bifid nose.
Dr. Longaker’s Stanford research group has continued to further
characterize and manipulate adipose-derived stem cells (hASCs) for
potential use in hard and soft-tissue engineering. Their laboratory
showed for the first time that these hASCs could be induced via
lentivirus Oct4, Sox2, Klf4, and c-MYC to pluripotent stem cells.
AESTHETIC SURGERY
Simultaneous correction of exophthalmoses with orbital expansion
and facial aging with complementary blepharoplasty and
face-lift procedures were advocated by the Buenos Aires group.
Craig Hobar suggested his method of subperiosteal rejuvenation
to the midface and periorbital regions for correction of more difficult
B
negative vector[ orbital cases. Yu-Ray Chen outlined his successful
technique in more than 1200 asymmetric, double-jaw cases
of single-splint,
Bon-table[ referencing, and orthognathic correction.
UNTIL THE XIVTH INTERNATIONAL CONGRESS
IN SOUTH AFRICA
During the meeting, our acting president, Steve Wall, MD,
announced the ISCFS’s decision to award the 2009 Paul Tessier
Medal to Linton Whitaker of the Children’s Hospital of Philadelphia,
University of Pennsylvania. This recognized Dr. Whitaker’s longterm
contributions to craniofacial care and his service as the ISCFS
chief financial officer. Also announced was the selection of Scott
Bartlett, MD (Children’s Hospital of Philadelphia, University of
Pennsylvania), as the 2013 president of the ISCFS and host of the
XVth International Congress to be located in Jackson Hole,
Wyoming.
Dedicated to the memory of Paul Tessier, the 13th Congress of
the International Society of Craniofacial Surgery was successful in
meeting its goals. Advances in craniofacial surgical technique and
technology were shared. Clinicians and researchers reflected on the
evolution of approaches and compared our contemporary results
with Paul Tessier’s criterion standard.
From expanding applications of BMPs to the more widespread
adoption of springs and the refined use of distraction osteogenesis,
palpable optimism was evident, fostering great excitement for the
next congress in South Africa.
Special Editorial
The Journal of Craniofacial Surgery & Volume 21, Number 3, May 2010
946
* 2010 Mutaz B. Habal, MD
Copyright © 2010 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
EDITORIAL NOTE
In the past, since the beginning of the international society, we have
published the highlights in the journal that will give the reader a
taste of the great and progressive material that is coming in the
future issues of the journal. We also had an agreement with the
publisher that because the published abstracts are not indexed in
Index Medicus, we will take the expanded version when submitted
as an original submission and review it with the editorial board as
a newly submitted paper with original work or work in progress
and will have the possibility of acceptance, rejection, or revisions.
The highlights as noted by Dr. Bradley and colleagues are primarily
to whet the appetite as the details of the new original material
will be forthcoming, as it is up to the original work done by each
author what and how to proceed. It will be also recommended that
each original work should have a footnote that it was in part published
or it was in part noted in whatever publication, for future
reference.
Mutaz B. Habal, MD, FRCS, FACS
Tampa, Florida
The Journal of Craniofacial Surgery
& Volume 21, Number 3, May 2010 Special Editorial
*
2010 Mutaz B. Habal, MD 947
Copyright © 2010 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Congress of the International Society of Craniofacial
Surgery: ISCFS 2009
James P. Bradley, MD,* Steve Warren, MD,
Þ and Michael T. Longaker, MDþ
The International Congress of the International Society of
Craniofacial Surgery (ISCFS) XIII Biennial meeting took
place in Oxford, England, from September 26 through
September 30, 2009, and was hosted by Steven Wall, MD
(president and scientific chair). This meeting represented the 26th
anniversary of the society and the first meeting since the death of
Paul Tessier (1907
Y2008). All members of the society recognized
Dr. Tessier’s important role as the father of the field of craniofacial
surgery and one of the original members of the ISCFS.
This meeting was highlighted by stimulating lectures to provocative
interactive discussions, from the opening session on controversies
and consensus in craniofacial distraction to the closing
session on aesthetic surgery. The venue in historic Oxford ranged
from a large tent outside the town to a magical dining room at
Christ’s Church (notable from Harry Potter’s Hogwarts School). As a
unique prelude to this established meeting, the Distraction Symposium
was held and organized by Eric Arnaud, MD. This Distraction
Symposium has been held in Paris 6 previous times beginning in
1997. These fruitful meetings helped transform distraction osteogenesis
in the craniofacial skeleton from a novel technique to an
established modality over the last 10 years. This Distraction Symposium
was set to be the last of the independent series of
BDistraction
Symposia in Paris.
[
2009 DISTRACTION SYMPOSIUM
Drawing from almost 20 years of distraction experience in the
craniofacial skeleton, both Joseph McCarthy and Fernando Molina
each summarized (1) their lessons learned, (2) expanding indications
for distraction, and (3) predictions on the future of the field. The
New York University (NYU) team has taken a clinical scientific
approach to investigating new techniques and the effect of distraction
surgery on growth. In addition, Dr. McCarthy emphasized
the importance of orthodontic cooperation and generate bone guidance
in the perioperative period. Dr. Molina showed his work over
the last 2 decades on some extreme syndromic cases.
One of the most active sessions in this symposium involved
neonatal mandibular distraction for micrognathia with upper airway
obstruction. Fernando Ortiz-Monasterio reported on the beneficial
effects of neonatal mandibular lengthening on feeding and the
resolution of gastrointestinal reflux. In a 5-year cost analysis study,
the University of California, Los Angeles (UCLA), group showed
that although neonatal distraction patients had higher initial costs,
tracheostomy patients had increased cost (2.5 times) in the long
term. Steven Schendel’s group has looked at sophisticated threedimensional
computed tomography (CT) imaging to show airway
improvements using a mandibular curvilinear device.
Reports on midface (Le Fort III) and monobloc distraction were
split with centers demonstrating the benefits of internal devices
(Kawamoto) and the external RED devices (Polley). Several groups
reported on the use of transfacial pin (zygomatic K-wire), external
device, and midface advancement without osteotomies in craniofacial
dysostosis in infants (Pellerin, Manard, Satoh, Arnaud).
Although these early advancement cases were successful, the indication
for this type of surgery has not been well established.
Challenging cases, such as severe micrognathia with bony ankylosis,
were reviewed by multiple groups. Transport distraction and
costocondylar joint replacement showed utility with this difficult
problem (Cheung, Lagiglia Karam). For this treatment, presenters
emphasized that postoperative physiotherapy and unloading the
joint space with elastics or with external device are critical to longterm
success.
SPECIAL EDITORIAL
944
The Journal of Craniofacial Surgery & Volume 21, Number 3, May 2010
From the *Division of Plastic and Reconstructive Surgery, University of
California, Los Angeles, CA;
†Institute of Reconstructive Plastic Surgery,
New York University Medical Center, New York, NY; and
‡Department
of Surgery, Stanford University Medical Center, Stanford, CA.
Received January 19, 2010.
Accepted for publication January 19, 2010.
Address correspondence and reprint requests to James P. Bradley, MD,
200 Medical Plaza, Suite 465, Los Angeles, CA 90095;
The authors report no conflicts of interest.
Copyright
* 2010 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0b013e3181d88125
Copyright © 2010 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
PRESYMPOSIUM: CONTROVERSIES AND
CONSENSUS IN CRANIOFACIAL SURGERY
The 2009 ISCFS Presymposium grouped presentations with opposing
viewpoints in an attempt to objectively look at controversial
topics in craniofacial distraction and craniofacial surgery. Although
a consensus was not reached in most topics, stimulating discussion
provided insight into the latest accepted treatments. (1) Distraction
versus traditional orthognathic surgery: traditional orthognathic surgery
with
Bon-table[ occlusal splints and rigid fixation is still the
standard of care for skeletal malocclusion in the mature patient. An
expanded role for Le Fort I maxillary distraction was noted in the
severe cleft cases and sometimes even in the skeletally mature
patients with severe hypoplasias (Cheung). (2) Mandibular relapse
versus mandibular growth: the NYU group used a long-term study
of mandibular distraction in patients with hemifacial microsomia
to show the stability of the generated bone. In their study, approximately
one third required subsequent, secondary surgery after mandibular
growth or for cant correction. (3) External versus internal
midface distraction devices: groups with external device experience
cited
Bvector control[ of the distraction segment. Groups with internal
device experience cited patient preference, longer consolidation
times, and ability to control distraction segment with orthodontic
elastics. Several groups, Wall (United Kingdom) and Morales
(Mexico), had experience with both and, at times, varied preference
based on the case. (4) Early posterior vault spring expansion versus
ventriculoperitoneal shunting: for the first time, many institutions
presented their experience of early posterior vault expansion in
craniofacial dysostosis patients using either distraction devices or
springs. Posterior vault distraction cases typically involved large
posterior craniotomies without dural dissection (Wall, Nishikawa).
Early posterior vault spring expansion often involved expansion
across the patent lambdoid sutures (Arnaud). This early posterior
expansion may also help with an evolving Chiari malformation.
Newer flow-regulated ventriculoperitoneal shunts were used for hydrocephalus
or in rare cloverleaf skull deformity cases to provide
better control of intracranial pressure changes compared with pressure
valve release shunts, which risk intermittent overdrainage of
cerebrospinal fluid (DiRocco). (5) Facial bipartition midline softtissue
excision: linear (Ortiz-Monasterio), V-Y excision (Wall), internal
B
K-stitch[ (Kawamoto). Each of these 3 different approaches
was offered as soft-tissue refinement to skeletal correction. Each
offered an acceptable method of reducing the redundant midline
soft tissue and narrowing brow width after correction of hypertelorbitism.
The K-stitch is ideal in mild or moderate cases with
normal skin because it leaves no external scar and may be redone at
a later date if necessary. The linear incision works well with hyperpigmented
or damaged midline skin or when a forehead flap for
nasal reconstruction is required. (6) Computed tomography scan
imaging: craniofacial case documentation versus irradiation risks.
The concern of cumulative radiation dosage from multiple CT scans
in children with its lifetime risk of cancer was raised. Denny carefully
looked at risks involved with three-dimensional CT scanning
of patients for preoperative planning and follow-up evaluations. He
found that the dosages his patients received were 100 to 1000 times
less than levels shown to increase the risk for carcinogenesis and
40 times less than the levels associated with developmental and
cognitive delays. Dr. Fearon advocated judicious use of CT scans
for craniosynostosis diagnosis and follow-up.
ORTHODONTICS
Many of the orthodontic studies focused on growth, stability, and
relapse. The NYU group used lateral cephalometric analysis at
skeletal maturity to show no growth difference when comparing
gingivoperiosteoplasty to no gingivoperiosteoplasty during infant
cleft lip repair after alveolar molding. Dental considerations during
midface distraction were looked at by Dunaway. Although orthodontic
alignment of the arches and protecting the permanent teeth
may help during midface advancement, optimal occlusion and
proper jaw relationship are left until skeletal maturity. Of cleft
patients with severe maxillary hypoplasia who underwent Le Fort I
distraction osteogenesis around 11 years of age, Chen (Chang Gung
Memorial, Taipei, Taiwan) showed maxillary stability, yet one third
required a revisionary Le Fort I advancement at skeletal maturity
secondary to mandibular growth.
CRANIOFACIAL MICROSOMIA
University of California, Los Angeles, reported a change in softtissue
reconstruction strategy with craniofacial microsomia patients.
Instead of using an IMECS (inframammillary extended circumflex
scapular, ie, parascapular) flap at skeletal maturity after bony
reconstruction, they showed improved volumetric outcomes with
serial autologous fat grafting. Dr. Diner (Paris) echoed his similar
experience with fat grafting in craniofacial microsomia and Treacher
Collins patients. Guerrero reviewed details of his intraoral mandibular
distraction techniques with emphasis of (1) unloading the
temporomandibular joint with class II elastics and (2) designing the
osteotomy location based on the deformity and consideration of
nerve protection. For microtia repair, the use of cultured human
auricular chondrocytes with long-term stability was studied by
Furukawa (Osaka, Japan). The final results were still considered, by
those that commented on the study, inferior to current accepted
techniques with the use of rib graft for framework fabrication.
HYPERTELORBITISM
Three large, long-term series of hypertelorbitism correction
(Mexico, UCLA, Shanghai), agreed that (1) the technique should be
tailored to the specific deformity and (2) early correction resulted in
growth discrepancy. In addition, a new technique of gradual orbital
contraction for wide 0 to no. 14 craniofacial clefts (performed with
a distraction device placed between bipartition segments) was successfully
demonstrated by UCLA.
SYNDROMIC CRANIOSYNOSTOSIS
Reports of late-presentation, normocephalic pansynostosis at
Children’s Hospital of Philadelphia and Children’s Hospital of
Boston showed a mean diagnostic delay of 3.2 years and a cranial
vault remodeling surgical delay of 3.8 years. Careful monitoring of
cranial circumference was stressed to identify these unusual cases.
Craniofacial center genetic screening of syndromic craniosynostosis
patients has become more widespread. However, it has not been
shown that identification of a specific genetic mutation, deletion, or
translocation can direct surgical approach or predict surgical outcome.
A call for simplification of syndromic classifications with
the use of both genotype and phenotype was made.
NONSYNDROMIC CRANIOSYNOSTOSIS
For outcome assessment of scaphocephaly correction, 2 centers
offered new three-dimensional morphometric analysis that may be
more accurate than the accepted cephalic index linear measurement
(Toronto, Melbourne). Limited incision sagittal strip craniectomy
with postoperative helmet therapy with or without the use of the
endoscope was found by several centers to be a safe and effective
way to treat scaphocephaly (Dallas, Utah, Boston). Claus Lauritzen
and Lisa David further reported refinements on spring cranioplasty.
For scaphocephaly correction, Dr. Lauritzen reported on the
beneficial effects of gradual biparietal expansion and the impact
The Journal of Craniofacial Surgery
& Volume 21, Number 3, May 2010 Special Editorial
*
2010 Mutaz B. Habal, MD 945
Copyright © 2010 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
on normal adjacent sutures. The use of distraction for cranial
expansion and correction of plagiocephaly was reported as having
less morbidity to traditional total cranial vault remodeling for
craniosynostosis (Japan, China [Shanghai]). New neuropsychological
outcome studies showed cognitive, language, fine motor skill
deficiencies, and developmental delays with isolated craniosynostosis,
particularly with delay in age at operation (Yale, Great Ormond
Street).
MONOBLOC AND MIDFACE ADVANCEMENT
A radiographic study of ocular movement after monobloc distraction
showed anterior displacement of the globe by as much as 40%
of the distraction length but with no implication to optic nerve damage
(Great Ormond Street). Reports on the use of internal, intraoral,
and external devices showed success with each monobloc advancement
method. The need for (1) preoperative planning, (2) distraction
phase manipulation of the segments, and (3) orbital correction as the
end point to distraction was emphasized by each group. In addition,
improvement in posterior nasopharyngeal airway anatomy translated
into objective obstructive sleep apnea parameter improvement.
TRAUMA
Hopital Enfants Malades in Paris advocated surgical repair for
severe orbital fractures even if treatment is delayed due to neurologic
injury. They also commented that secondary correction in these
cases might often be necessary. Although prosthetic cranial vault
implants are controversial in the pediatric patient population, 2
centers reported their positive experience with PMMA (polymethyl
methacrylate) and PEEK (polyEther Ethyl[Ketone]) implants
(Toronto, Toulouse, [France]). Presenters also described their use
of distraction for the reconstruction of mandibular defects and for
mandibular condylar fractures (Egypt, Japan).
IMAGING
This section stimulated important discussion on the prudent
use of CT scan imaging for diagnostic, postoperative, and follow-up
assessment. Denny presented a well-conducted study on screening
CT scans and the radiation exposure risk with the implication to the
cause of cancer or developmental delay. He concluded that effects
of low linear energy transfer are different than data obtained using
the linear no-threshold hypothesis, and the risk of tumorigenesis
from pediatric CT scans is actually 100 times lower than previously
reported. Dr. McCarthy’s group reported on their development of a
three-dimensional surgical atlas for modeling craniosynostosis as a
tool for teaching and simulation. Multiple centers reported the use
of three-dimensional photography for surgical outcome assessment
based on shape and volumetric analysis.
SCIENTIFIC RESEARCH
In several translational investigations, BMP-2 was studied as a
way to promote bone tissue repair. To reduce donor-site morbidity,
the clinical use of BMP-2 in pediatric cranial vault defects was
documented (Genecov, Dallas). Experimentally, BMP-2 was investigated
with smart scaffolding to direct the location of bone healing
(Losse, Pittsburgh). In addition, BMP-2 was found to promote
healing in critical-size murine defects (Reid, Chicago) and with
dura-repaired beagle cranial defects (Opperman, Dallas). Dr. Wilkie
described how an ALX3 mutation was found to cause
frontorhiny,
a distinguishing phenotype with hypertelorbitism and bifid nose.
Dr. Longaker’s Stanford research group has continued to further
characterize and manipulate adipose-derived stem cells (hASCs) for
potential use in hard and soft-tissue engineering. Their laboratory
showed for the first time that these hASCs could be induced via
lentivirus Oct4, Sox2, Klf4, and c-MYC to pluripotent stem cells.
AESTHETIC SURGERY
Simultaneous correction of exophthalmoses with orbital expansion
and facial aging with complementary blepharoplasty and
face-lift procedures were advocated by the Buenos Aires group.
Craig Hobar suggested his method of subperiosteal rejuvenation
to the midface and periorbital regions for correction of more difficult
B
negative vector[ orbital cases. Yu-Ray Chen outlined his successful
technique in more than 1200 asymmetric, double-jaw cases
of single-splint,
Bon-table[ referencing, and orthognathic correction.
UNTIL THE XIVTH INTERNATIONAL CONGRESS
IN SOUTH AFRICA
During the meeting, our acting president, Steve Wall, MD,
announced the ISCFS’s decision to award the 2009 Paul Tessier
Medal to Linton Whitaker of the Children’s Hospital of Philadelphia,
University of Pennsylvania. This recognized Dr. Whitaker’s longterm
contributions to craniofacial care and his service as the ISCFS
chief financial officer. Also announced was the selection of Scott
Bartlett, MD (Children’s Hospital of Philadelphia, University of
Pennsylvania), as the 2013 president of the ISCFS and host of the
XVth International Congress to be located in Jackson Hole,
Wyoming.
Dedicated to the memory of Paul Tessier, the 13th Congress of
the International Society of Craniofacial Surgery was successful in
meeting its goals. Advances in craniofacial surgical technique and
technology were shared. Clinicians and researchers reflected on the
evolution of approaches and compared our contemporary results
with Paul Tessier’s criterion standard.
From expanding applications of BMPs to the more widespread
adoption of springs and the refined use of distraction osteogenesis,
palpable optimism was evident, fostering great excitement for the
next congress in South Africa.
Special Editorial
The Journal of Craniofacial Surgery & Volume 21, Number 3, May 2010
946
* 2010 Mutaz B. Habal, MD
Copyright © 2010 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
EDITORIAL NOTE
In the past, since the beginning of the international society, we have
published the highlights in the journal that will give the reader a
taste of the great and progressive material that is coming in the
future issues of the journal. We also had an agreement with the
publisher that because the published abstracts are not indexed in
Index Medicus, we will take the expanded version when submitted
as an original submission and review it with the editorial board as
a newly submitted paper with original work or work in progress
and will have the possibility of acceptance, rejection, or revisions.
The highlights as noted by Dr. Bradley and colleagues are primarily
to whet the appetite as the details of the new original material
will be forthcoming, as it is up to the original work done by each
author what and how to proceed. It will be also recommended that
each original work should have a footnote that it was in part published
or it was in part noted in whatever publication, for future
reference.
Mutaz B. Habal, MD, FRCS, FACS
Tampa, Florida
The Journal of Craniofacial Surgery
& Volume 21, Number 3, May 2010 Special Editorial
*
2010 Mutaz B. Habal, MD 947
Copyright © 2010 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.