Marchac Alexandre, Arnaud Eric
Craniofacial Unit, Hôpital Necker Enfants Malades, Paris, France.
J Craniofac Surg. 2012 Jan;23(1):235-8. doi: 10.1097/SCS.0b013e318241b96d.
The adaptation of distraction osteogenesis (DO) to the midface and cranium in the 1990s and the advancements that followed at the turn of the century resulted in a shift of paradigm in craniofacial surgery. Because skeletal advancement was not sudden anymore, but incremental, the monobloc advancement became safer to perform. Because bone was generated in the distraction gap, bone grafts were no longer needed, and younger patients could benefit from craniofacial advancement. Today, DO is the most powerful tool to simultaneously correct both exorbitism and the respiratory impairment of the faciocraniosynostosis, but practices vary greatly between teams.
Current practices, controversies, and near-term future applications will be outlined and discussed.
Our current treatment strategy for faciocraniosynostosis is based on early intervention (<18 months of age) to prevent irreversible brain damage. In the first 6 months of life, infants with faciocraniosynostosis receive posterior vault decompression. We currently use posterior vault distraction, using 2 internal distractors. Around 18 months of age, a frontofacial monobloc advancement with DO is performed. It further decompresses the brain, improves respiratory function, and corrects exorbitism. Because we operate at such an early age, we favor internal over external distractors. In severe faciocraniosynostosis, when midface hypoplasia causes major exorbitism endangering the eye or causes respiratory distress requiring a tracheotomy, we do not hesitate to perform a frontofacial monobloc advancement with DO before the age of 18 months, reinforcing the frontozygomatic junction with a plate and placing a transzygomatic pin. The pin is then connected to a traction rope. We frequently use the external distractors, which allow precise control over the rotation of the maxilla and are well tolerated after 5 years of age. When midface hypoplasia is very severe, we combine external and internal distractors.
The ongoing debate between proponents of internal versus external distractors or 1-stage versus 2-stage approach is based mostly on anecdotal data. Multicenter prospective studies are necessary to bring objective data to answer these questions.
20世纪90年代牵引成骨术（DO）应用于中面部和颅骨，随后在世纪之交取得的进展导致颅面外科手术模式发生转变。由于骨骼前移不再是突然的，而是渐进的，整块前移手术实施起来更安全。由于在牵引间隙中会生成骨组织，不再需要骨移植，年轻患者也能从颅面前移手术中受益。如今，DO是同时矫正面颅缝早闭症的眼球突出和呼吸功能障碍的最有效工具，但各团队的做法差异很大。
将概述并讨论当前的做法、争议及近期的未来应用。
我们目前对面颅缝早闭症的治疗策略基于早期干预（<18个月龄）以防止不可逆的脑损伤。在出生后的前6个月，面颅缝早闭症婴儿接受后颅顶减压。我们目前使用后颅顶牵引，采用2个内置牵引器。在18个月龄左右，进行带DO的额面部整块前移手术。这进一步为大脑减压，改善呼吸功能，并矫正眼球突出。由于我们在如此小的年龄进行手术，我们更倾向于使用内置牵引器而非外置牵引器。在严重的面颅缝早闭症中，当中面部发育不全导致严重眼球突出危及眼睛或导致呼吸窘迫需要气管切开时，我们毫不犹豫地在18个月龄之前进行带DO的额面部整块前移手术，用钢板加固额颧交界处并放置颧弓针。然后将针连接到牵引绳上。我们经常使用外置牵引器，其可精确控制上颌骨的旋转，且5岁后耐受性良好。当中面部发育不全非常严重时，我们会联合使用外置和内置牵引器。
关于内置与外置牵引器支持者之间或一期与二期手术方法之间的持续争论大多基于轶事数据。需要多中心前瞻性研究来提供客观数据以回答这些问题。
