Craniofacial Surgery

Craniofacial surgery is concerned with the management of patients presenting with congenital or acquired conditions, affecting the hard and soft tissues of the head and face. The Department of Health approves and funds designated centres for the management of craniofacial conditions including :

• Craniosynostoses
• Craniofacial dysostoses
• Orbital dysostosis
• Encephalocoeles
• Craniofacial clefts

These conditions are evident early in life and most patients are children under the age of 2. Patients referred to designated units are assessed and investigated by a multi-disciplinary team and treatment combines the principles of maxillofacial reconstruction with neurosurgery. The surgical techniques employed in congenital conditions can also be applied to good effect in the treatment of skull base tumours and craniofacial trauma.

Premature fusion of one or more skull sutures (craniosynostosis) occurs in 1 in 2,000 of the population. Syndromic craniosynostoses, such as Crouzon and Apert syndromes occur in 1 in 10,000 and 1 in 150,000 live births respectively. Facial clefts are even rarer.

Historically, patients underwent numerous procedures performed by various clinicians from different surgical specialities. Results were generally poor and associated with high morbidity and even mortality. Many patients with severe deformity were denied surgery, because of the risks involved. In the 1960's, Paul Tessier showed that facial surgery could be safely combined with neurosurgery. Craniofacial surgery was born and has continued to evolve.

The surgery is major, often protracted and associated with significant blood loss in the small child. Intensive care is needed for the more complex cases, or where the airway is compromised. Some children require more than one procedure as growth and dental development influence facial form and function. However, with an active, established team and utilising contemporary techniques, such as distraction osteogenesis, it is possible to perform fewer, more extensive procedures. The results are better and there are fewer complications.

The craniofacial principles of wide surgical exposure, primary bone grafting and internal fixation should be applied to the management of complex craniofacial trauma. Severely injured patients of all ages can be stabilised and offered early definitive treatment using these techniques. Morbidity is reduced and hospital stay shortened and there is an overall improvement in outcome. These surgical approaches can also be used to access intracranial and skull base lesions.

The management of craniofacial patients requires a collaborative and multi-disciplinary approach if optimal results are to be achieved and the core disciplines are usually maxillofacial, plastic and neurosurgery, supported by anaesthetic, ENT, ophthalmic and specialist nursing colleagues. By drawing on expertise gained in the management of trauma, tumour and congenital disease of the soft and hard tissues of the face, the maxillofacial surgeon plays a key role in craniofacial surgery.