The Confluence of Technique and Technology in Craniofacial Surgery

Craniofacial surgery is a relatively young field that owes a tremendous debt of gratitude to Dr. Paul Tessier. His pioneering work demonstrated that it was indeed possible to move the facial structure to improve appearance and function. His presentation at the International Congress of Plastic Surgery in Rome in 1967 electrified the surgical world. Surgeons began flocking to his operating room to learn his techniques. I vividly recall the story Joe McCarthy told me during my craniofacial fellowship about assisting Dr. Tessier in the first Le Fort III procedure performed in the United States at New York University. The procedure took all day and night and seriously depleted the blood supply of New York City. Although the technical aspects of craniofacial surgery are now well established, fundamental challenges remain. Most significantly, a tremendous amount of intraoperative judgment is required. The direction and magnitude of bone movement are largely determined by the intraoperative appearance of the patient, roughly guided by the preoperative plan. This is of course complicated by intraoperative swelling. Although experienced surgeons can deliver reliable results, the learning curve for young surgeons is steep. Given the relatively rare incidence of some of the conditions being treated, many surgeons struggle to develop the requisite expertise. Further complicating the issue is that in large osteotomies such as the Le Fort III, the different components of the bone are typically not equally malformed. That is, the zygomatic complexes are usually asymmetric and would benefit from differential positioning. In a standard operation, we are in essence moving a deformed piece of bone to a new location, but leaving it intrinsically deformed. These problems and the application of technology to address them were first well articulated by Court Cutting. He recognized the ability of computer simulation to determine the ideal position for individual components of the facial structure and pioneered intraoperative navigation to move and secure them in that position. In 1998, he reported on his clinical experience with this technology that he had begun using 4 years earlier.1 It was groundbreaking work at the time, using the same concepts that we do today, but with computer programming and equipment that he had to create. As a fellow, I had the good fortune to assist him in some of these procedures. The most vexing problem was not necessarily moving the bone to the correct location but rather maintaining it there while applying the fixation. Temporary Kirschner wires were useful in the process. It also became clear that completely stripping the bone of soft-tissue attachments and further cutting it into smaller pieces resulted in an increased risk of infection from devascularization. Minimizing exposure improved this but further complicated positioning and fixation. Further development of this field owed a great deal to facial trauma. As opposed to pediatric craniofacial deformities, patients with these injuries begin with a relatively normal facial structure, which can be treated much like a jigsaw puzzle. That is, the pieces are all there and relatively normal in shape. They only need to be moved back to their original location. In addition, there is often a contralateral normal side to act as a template during preoperative computer-assisted planning. Intraoperative scanning and navigation began to be developed in earnest, greatly facilitating treatment of these patients, particularly those with orbital fractures.2,3 The next major evolution in this field has been computer-assisted design and computer-assisted manufacturing technology. As preoperative computer-assisted planning and intraoperative navigation progressed in sophistication, it became clear that the ability to deliver on the plan was limited in part by imprecision in making the planned osteo tomies. The subsequent development of computer-assisted design and manufacturing processes to create templates for cutting and custom fixation adapted preoperatively to the correct bone position further facilitated the accuracy of the procedure. This technology is now widely used in almost all areas of craniofacial surgery, including cranial vault remodeling, midface surgery, orthognathic surgery, and mandibular reconstruction.4–8 In free fibula flaps for the mandible, templates are made for both the mandibular cuts for tumor resection and for the fibula to ensure that bone-to-bone continuity is achieved throughout the reconstructed jaw. The premorbid occlusion is ensured by the prefabricated plate. Indeed, in some published studies in orthognathic surgery, the planning and plate construction are so accurate that occlusal splints are no longer used.9 Although still a more expensive approach than previous techniques, it has been shown in many cases that there is a significant reduction in operative time and blood loss, and the result is infinitely more predictable. In essence, this technology has flattened the learning curve for the most complex craniofacial procedures. There can be no question that this field will continue to develop in terms of sophistication, ease of use, and reductions in cost. One can only imagine what Paul Tessier would say if he saw the state of our field today. We should never forget what a debt we owe to him and his first generation of trainees who pioneered a new field of surgery, paving the way for our very special profession.