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Hemifacial microsomia is the second most common facial clefting condition after cleft lip and palate. The deformity affects the skeleton and soft tissues in the temporal region of the affected side, although the degree of involvement is markedly variable.
We describe a modification of surgical technique in a skeletally mature case who had previously undergone mandibular reconstruction with a costochondral graft.
Reconstruction of the mandibular ramus and temporomandibular joint in hemifacial microsomia in early childhood using a costochondral graft is well established
and we wish to report a modification in technique that was required when an adult patient subsequently underwent bi-maxillary surgery.
The patient originally had a Pruzansky grade 3 mandible on the left side, reconstructed with a costochondral graft when aged eight years which had overgrown, it being well recognised that graft growth can be difficult to predict.
At the age of 16 years this resulted in a significant deviation of the mandible to the nonaffected side and to the development of a cross bite. Corrective surgery consisted of maxillary centralisation and advancement, with a vertical subsigmoid osteotomy on the normal side of the mandible and a modified inverted ‘L’ on the reconstructed side.
At the time of surgery the maxillary osteotomy and the right mandibular osteotomy proceeded in the classical manner. However, the osteotomy on the left (reconstructed) side was modified due to the significant graft overgrowth, thus not disturbing the satisfactory functioning of the modified temporomandibular joint or compromising the blood supply to the rib graft. The position of the transverse cut of the modified osteotomy could be positioned more inferiorly because of the absence of the inferior alveolar foramen, and this is shown on the nylon model (Fig. 1) . This was achieved via an external approach utilising the old scar from the rib graft insertion. The pre-determined occlusal position was easily obtained and the mandible was fixed using illiac crest bone graft and lag screws. The post-operative recovery was uneventful and the position has been maintained.
Fig. 1The customised nylon model of the patient, with the position of the modified osteotomy marked on the reconstructed mandible. The outline of the fixation plate used at the time of graft placement can be seen along the lower border.
We would recommend that surgeons undertaking the management of hemifacial microsomia may wish to consider this surgical modification if faced with a similar clinical situation.
References
Kaban L.B
Moses M.H
Mulliken J.B
Surgical correction of hemifacial micosomia in the growing child.
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