Last updated: 11/24/2009

General background

Craniofacial reconstruction dates back to the late nineteenth century, when doctors in Germany and France first used it to produce more accurate images of the faces of certain famous people who had died before the...

invention of photography. Early craniofacial reconstructions included those of Bach, Dante, Kant, and Raphael. The technique was then applied to reconstructing the appearance of prehistoric humans for museums and research institutions. An important contribution to the field was the publication in 1901 of three major papers on the classification of facial fractures by René Le Fort, a French surgeon. Le Fort identified the lines of weakness in the facial bones where fractures are most likely to occur. Traumatic injuries of the facial bones are still classified as Le Fort I, II, and III fractures. A Le Fort I fracture runs across the maxilla, or upper jaw; a Le Fort II fracture is pyramidal in shape, breaking the cheekbone below the orbit (eye socket) and running across the bridge of the nose; a Le Fort III fracture separates the frontal bone behind the forehead from the zygoma (cheekbone) as well as breaking the nasal bridge. A Le Fort III fracture is sometimes called a craniofacial separation.

In the 1920s, British physicians pioneered the application of facial reconstruction to unsolved criminal cases and to treating World War I veterans who had been disfigured in combat. Prior to the invention of the computer, craniofacial reconstruction was done either by applying soft clay to the skull (or a cast of the skull) to recreate the person's features, or by making a two-dimensional drawing over a photograph or x-ray picture of the skull. It was difficult for surgeons operating on mutilated patients to predict the outcome of the operation from these two-dimensional sketches.

The first attempts at craniofacial reconstruction in children with congenital abnormalities were made in the late 1940s by Sir Harold Gillies, a British plastic surgeon who had treated disfigured World War II veterans. More recent advances in craniofacial reconstruction include improved understanding of the soft tissues of the face and better surgical techniques for repairing injuries to these tissues; the invention of surgical plastics that can be used instead of bone grafts to fill in missing pieces of bone; new techniques for fixing the facial bones in place during the healing process; and computerized imaging programs that help the surgeon analyze the patient's facial abnormality or injury. Some of these programs allow doctors to download data directly from x rays, computed tomography (CT) scans, or other diagnostic imaging programs in order to plan the operation and have a clearer picture of the results. In the case of children, computer imaging can be used to estimate the future growth lines of a child's skull and facial bones as well as his or her present condition. Orthodontists and other dental specialists have developed additional imaging programs that provide more details about the mouth and jaw area than can be obtained from CT scans and x-ray studies.

Craniofacial reconstruction of birth defects and genetic abnormalities

Craniofacial reconstruction in children with congenital abnormalities of the head and face is preceded by a consultation between the surgeon, other specialists, and the child's parents. It is important to determine the exact cause of the child's deformities, since some abnormalities may be found in as many as 150 different genetic disorders. Following the diagnosis, a comprehensive treatment plan is made that includes long-term psychosocial as well as surgical follow-up. Craniofacial reconstruction in children is complex because the surgeon must allow for changes in the proportions of the child's face and skull as he or she matures as well as attempt to make the facial features look as normal as possible. It is difficult to provide a general description of craniofacial surgery in children because there are many variables among children diagnosed with the same disorder as well as a large number of different disorders requiring craniofacial reconstruction. Reconstructions in children, however, are always done under general anesthesia and usually take between three and six hours to complete.

Craniofacial reconstruction following trauma or surgery

Craniofacial reconstruction following trauma is a highly individualized process, depending on the nature and location of the patient's injuries. Emergency workers are trained to evaluate and clear the patient's airway before treating facial injuries as such; severe injuries to the midface and lower face frequently result in airway blockage caused by blood, loose teeth or bone fragments, or the tongue falling backward toward the windpipe. The trauma team may have to intubate the patient or perform an emergency cricothyroidotomy in order to help the patient breathe. The second priority in treating traumatic facial injuries is controlling severe bleeding.

Imaging studies of craniofacial injuries may need to be postponed for 24–72 hours in order to treat injuries to other organ systems. Over 60% of patients with severe facial trauma have other serious injuries in the head, chest, or abdomen; this high rate reflects the tremendous forces needed to fracture the human frontal bone, zygoma, and maxilla. In particular, a doctor who is examining a patient with severe facial trauma will be particularly concerned about damage to the brain, the spinal column in the neck region, and the eyes. All Le Fort II and III fractures have the potential for permanent damage to the eyes. There are specific maneuvers that the doctor can perform to assess the location and severity of bone fractures, possible dislocation of the jaw, and injury to the eyes and nose before taking an x ray or CT scan.

When the patient is out of immediate danger, x-ray studies and computed tomography (CT) scans are taken of the craniofacial injuries. Three-dimensional scans assist the surgeon in analyzing the fractures and the condition of the other structures in the face and head. Imaging studies can be used to generate computer images for plastic or metal implants to be matched to the patient's injuries for filling in sections of missing bone.

Surgery following facial trauma may take as long as four to 14 hours, as the goal is to repair as much as possible in one operation. The surgeon may use bone grafts, taking bone from other parts of the body to repair the facial bones, or fill in smaller areas of missing bone with hydroxyapatite cement or polymer implants. Broken facial bones are held in place with titanium miniplates and surgical screws. This technique is called rigid fixation; it often does away with the need to wire the jaws in place, and it speeds the patient's recovery. Lacerations (tears) in the skin are usually simply closed with stitches, although the surgeon will be careful to minimize scarring. If large areas of skin are missing, the surgeon will cut a flap, which is a section of living tissue carrying its own blood supply, from another area of the patient's body and transplant it to the face. Some facial injuries may require the assistance of a neurosurgeon, oral surgeon, or ophthalmologist.

Cancers on the skin of the face are usually removed and closed with a few stitches, although skin flaps may be required if the area of the face that is affected is large. Cancers of the head or neck may require bone grafts as well as skin flaps after the tumor has been removed. Reconstructive surgery after cancer treatment may involve the use of a microscope and special instruments to rejoin the facial blood vessels and nerve fibers. This technique, which is known as microsurgery, is done to preserve the function of the muscles in the face as well as restoring the patient's appearance as much as possible.