CE: A.B.; SCS-17-0918; Total nos of Pages: 5; SCS-17-0918 CLINICAL STUDY Rigid External Distractor-Aided Advancement After Simultaneously Performed LeFort-III Osteotomy and Fronto-Orbital Advancement Ali-Farid Safi, MD, DMD, Matthias Kreppel, MD, DMD, Martin Kauke, MD, Andrea Grandoch, MD, DMD, Hans-Joachim Nickenig, DMD, and Joachim Zöller, MD, DMD Abstract: Due to the complex development of the craniofacial skull, corrective surgery is a major challenge for patients with severe craniofaciostenosis. Although fronto-orbital advancement and simultaneous LeFort-III osteotomy in combination with distraction osteogenesis have been reported as a safe and successful method to obtain good esthetic and functional results, there is a lack of studies evaluating this method. Our retrospective study included 12 patients with syndromic craniofaciostenosis, who were primarily treated at our department in accordance with a standardized treatment protocol, consisting of a simultaneous fronto-orbital advancement with LeFort-III osteotomy in combination with a rigid external distractor (RED-II). Distraction distance, duration of operation, postoperative complications, perioperative hemoglobin concentration, esthetic outcome, and the subjective Whitaker Scale were used to evaluate the success of our surgical method. The esthetic outcome of all of our patients was assessed as good. Furthermore, the surgical outcome was assigned I for 11 patients and II for 1 patient, who suffered from wound healing disturbance at the left temporal site, which required revision 2 weeks postoperatively. The mean skeletal advancement of the midface was 16.4 mm, ranging from 12 to 20 mm. Our standardized treatment protocol, consisting of fronto-orbital advancement in combination with LeFort-III osteotomy and application of a rigid external distractor device (RED-III) for patients with severe syndromic craniofaciostenosis, goes along with low infection rates and more predictable and precise esthetic and functional outcomes than the conventional surgical technique without distraction osteogenesis. Key Words: Advancement, distraction, fronto-orbital, LeFort, midfacial (J Craniofac Surg 2017;00: 00–00) From the Department for Oral and Craniomaxillofacial Plastic Surgery, University of Cologne, Cologne, Germany. Received June 16, 2017. Accepted for publication August 2, 2017. Address correspondence and reprint requests to Ali-Farid Safi, MD, DMD, Department for Oral and Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Straße 62, 50931 Cologne, Germany; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2017 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000004061 The Journal of Craniofacial Surgery P atients with syndromic craniofaciostenosis frequently suffer from midfacial hypoplasia and present with esthetic impairments and severe functional problems, for example, intracranial hypertension, airway obstruction, or exophthalmos leading to corneal ulcerations.1 The surgical treatment of these patients is still a matter of debate and is mainly based on a fronto-orbito-maxillary advancement, as proclaimed by Tessier in 1971 or the monobloc frontofacial advancement, as described by Ortiz-Monasterio in 1978.2,3 However, since the introduction of these methods, the preeminent complications were high infection rates associated with contamination from the nasopharynx and the large area of frontal dead space after advancement.4 Although Whitaker reported that communication between nasal fossae and intracranial vault might be avoided by preparation of a mucoperiosteal barrier, Marchac et al indicated that within their patient cohort, especially for those with a large advancement, the mucosa ruptured perennially despite consideration of the aforementioned technique.5,6 Therefore, to overcome the severe risks of a 1-step surgical intervention, a 2-stage procedure regarding the different growth patterns of the neuro- and viscerocranium was recommended.6,7 This included an early fronto-orbital advancement and a later LeFort-III osteotomy to correct the midfacial hypoplasia.6,7 Consequently, recommendation for the 1-stage approach was generally restricted to severe craniofaciostenosis patients, being associated, for example, with strong airway obstructions or corneal ulcerations.1 However, since in 1992, McCarthy introduced distraction osteogenesis to craniomaxillofacial surgery, a large number of studies applied this technique and highlighted a larger and safer skeletal transposition in terms of fewer recurrences and lower infection rates.8 –13 The authors mainly explained their results with the limited frontal dead space, the gradual expansion of the soft tissue, and the ability of re-epithelialization of the mucosa.8,14,15 Compared with the frontofacial monobloc advancement with application of the gradual distraction method, the fronto-orbital advancement with LeFort-III distraction using an external distractor offers the ability to reconstruct the neurocranium and the hypoplastic midface separately.11 In 2004, Kübler et al reported from a cohort of 6 patients that this method was associated with good esthetic results and a low complication rate.11 Similarly, in 2012, Medra et al, who performed the same method, resulted from their cohort of 9 patients with syndromic craniofaciostenosis, a significant skeletal advancement, which led to good esthetic and functional results.16 Within our report, we present our experiences with 12 patients suffering from severe craniofaciostenosis, who were treated with a standardized treatment protocol, based on a fronto-orbital advancement with LeFort-III osteotomy and application of an external distraction device (RED-II; KLS Martin, Tuttlingen, Germany). MATERIALS AND METHODS Our investigation followed the guidelines of the Helsinki Declaration. The retrospective study included 12 syndromic Volume 00, Number 00, Month 2017 1 Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. CE: A.B.; SCS-17-0918; Total nos of Pages: 5; SCS-17-0918 The Journal of Craniofacial Surgery Safi et al 1 2 3 4 5 6 7 8 9 10 11 12 Syndrome Morbus Morbus Morbus Morbus Morbus Morbus Morbus Morbus Morbus Morbus Morbus Morbus Apert Crouzon Crouzon Crouzon Crouzon Apert Crouzon Crouzon Crouzon Apert Crouzon Crouzon Age at Operation, y Sex Follow-Up 3 8 5 11 8 3 9 3 2 6 5 4 Female Male Female Female Male Female Male Male Female Female Male Female 42 65 66 54 65 71 38 59 47 51 18 33 Volume 00, Number 00, Month 2017 segment was repositioned and moved anteriorly. After fixation of the position with miniplates, the frontal bone cap was adapted to the shape-altered orbital segment and attached to it with wires or microplates. The space required for the brain was gained by the fronto-orbital advancement. TABLE 1. Patient’s Clinical Characteristics Patients LeFort-III Osteotomy The osteotomy of the viscerocranium was performed by using the same coronal incision approach. Our osteotomy lines included the zygomatic arch, sphenozygomatic suture, posterior floor of the orbit, lacrimomaxillary suture, and the nasal bone. Similar to the fronto-orbito-nasal advancement by Whitaker et al, we developed a barrier between nasal fossae and intracranial vault, by leaving 3 to 5 mm of the nasal root untouched.5 Subsequently, the pterygoid plates were separated by insertion of a chisel below the zygomatic arch. If necessary, an additional mobilization or osteotomy of incomplete fractured lines was achieved by a caudal rotation of the facial skull with Rowe forceps. Afterward, 2 microplates were placed paranasal and two 0.5-mm stainless steel wires were twisted and fixed to the maxilla and passed through the skin in the region of the nasolabial folds to optimize the cosmetic outcome. After extensive blood stasis, osteosynthesis of the bone segments and suturing of the coronal incision skin line, the horseshoe-shaped RED Distractor was applied to the cranial vault. For at least 24 hours, suction drains were placed subcutaneously. All patients received perioperative antibiotics, analgetic medication, and corticosteroids in accordance to their age and weight. craniofaciostenosis patients, who were primarily treated at our department (see Table 1). All patients were assessed by a multidisciplinary team preoperatively and postoperatively on a weekly basis until removal of the distraction device. Accessory evaluation included standard preoperative hematologic diagnostics, ophthalmologic examination, and photo documentation of the patient’s dysmorphic craniofacial system. Postoperative evaluation included hematologic analysis and supervision by a pediatric specialist for 1 day on the intensive care unit as well as for the remaining days of their postoperative hospitalization. In addition, each patient was reevaluated by our head physician and surgeon. For the rest of the first postoperative year, follow-up was performed every 3 months. After this, patients were seen depending upon their clinical situation either twice or once a year. Patient’s outcomes are listed in Table 2. Distraction Osteogenesis Protocol After a period of 7 days, the distraction was started with 2 0.5 mm per day with a slight overcorrection of 3 to 5 mm at the dental occlusion level due to possible relapses, as recommended by a several authors.1,11,16 One of the main advantages of external distraction devices is the ability to change the distraction vector during the treatment period. Therefore, we adapted distraction to the profile, clinical situation, and the dental occlusion. The decision for the required amount of distraction was mainly based upon clinical evaluation of the profile and dental occlusion and less on numerical values obtained by radiologic examinations.11 During a retention period of 6 weeks, the distractor and the wires were left in situ without further pull activation. Subsequently, the wires and the RED distractor were usually removed again under local anesthesia. Treatment Protocol Surgery was performed mainly by a craniomaxillofacial surgery team with the assistance of a neurosurgeon. Fronto-Orbital Advancement Coronal incision served as approach to the craniofacial skeleton in order to perform a standardized bilateral fronto-orbital advancement.17 After osteotomy and removal of the bone segments, the fronto-orbital bandeau was shaped. The orbital segment was slightly bent and adapted to the cranial vault after bone incision in the central part of the forehead. Hence, the frontal bone and temporal region could be aligned. The newly formed position and shape were stabilized by microplates. Subsequently, the orbital Evaluation of the Outcome Distraction distance, duration of operation, postoperative complications, and perioperative hemoglobin concentration were used to evaluate the success of our surgical method. The surgical TABLE 2. Patient’s Outcome Patients Midface Distraction Distance, mm 1 2 3 16 16 20 4 5 6 7 8 9 10 11 12 2 Complication Preoperative Weight, kg Preoperative HB Concentration (Range), g/dL Postoperative HB Concentration (Range), g/dL Duration of Operation, min Esthetic Outcome Whitaker Score 7.4 7.7 9.7 10 14 11 8 9.5 10.7 200 185 197 Good Good Good I I II 20 6 12.3 11.8 212 Good I 17 14 16 12 16 18 7.1 8.5 6.1 7.2 8 8.7 12.1 11.5 10 12 12.7 11 10.5 10 9 10 10 10 207 157 162 178 182 210 Good Good Good Good Good Good I I I I I I 16 16 10.3 6.9 12 11.3 11 9.8 189 200 Good Good I I Wound healing disturbance temporal left # 2017 Mutaz B. Habal, MD Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. CE: A.B.; SCS-17-0918; Total nos of Pages: 5; SCS-17-0918 The Journal of Craniofacial Surgery Volume 00, Number 00, Month 2017 Fronto-Orbital Advancement AQ1 outcome was assessed with the subjective Whitaker Score Scale at the endpoint of the follow-up (ranging from 18 to 71 months) (Whitaker Category I: No further treatment desirable; Category II: Alternative bone work required, such as LeFort I or malar augmentation; Category III: Reposition necessary, such as fronto-orbital advancement or LeFort III distraction; Category IV: Major craniofacial procedure necessary, duplicating or exceeding the original operation).18 In accordance to previously performed questionnaires on the evaluation of the esthetic outcome after craniomaxillofacial surgical procedures, the surgeon, the parents of the patients, and a resident in craniomaxillofacial plastic surgery were asked to assess postoperative photographs in the sagittal, frontal, and axial view from the 1-year follow-up examination.16 If all were satisfied with the result, the esthetic result was classified as good and poor if either the parents, the surgeon, or the resident were unsatisfied.16 RESULTS Our study included 12 patients with a mean age of 5.77 years (range from 2 to 11 years). Of our patients, 58% were female and 42% male (see Table 1). The mean follow-up was 50.75 months with a standard deviation of 16 months and the median follow-up 52.5 months, ranging from 18 to 71 months. All patients suffered from airway obstructions leading to snoring and mouth breathing. Severe proptosis was present in all of our patients and a main inclusion criterion. The dental occlusion was for all of our patients assigned as class III. Furthermore, 1 of our patients suffered from open bite. Previous craniofacial operations were not performed in any of our patients. Clinical examination confirmed the typical symptoms of patients with severe craniofacial stenosis. Hence, within our cohort, brachycephaly, midfacial hypoplasia, and incompetent lips were diagnosed for all patients. Furthermore, neurologic evaluation confirmed intracranial hypertension within our cohort, due to craniofaciostenosis. Postoperatively, we could observe that airway obstructions manifesting, for example, as snoring, were diminished within all of our patients during their follow-up. Ophthalmologic examination confirmed the success of operation, as corneal erosions and papilledema were not present anymore in any of our patients. The Angle-Class III occlusion could be transformed into Angle-Class I due to the distraction treatment protocol and the ability to change and/or to rectify the distraction vector. According to the parents of the patients, the surgeon, and the resident in craniomaxillofacial surgery, the esthetic outcome of all of our patients was assessed as good (see Fig. 1A-D). Furthermore, the surgical outcome was assigned I for 11 patients and II for 1 patient, who suffered from wound-healing disturbance at the left temporal site, which required revision 2 weeks postoperatively. Our distraction osteogenesis treatment protocol led to a mean skeletal advancement of the midface of 16.4 mm, ranging from 12 to 20 mm. DISCUSSION Since the introduction of craniofacial surgery in the 1960s by Tessier, major problems for patients, affected with craniofacial deformities, were on the one hand the high operative risk based upon the technical circumstances at that time and on the other hand the high infection risk, due to the developing communication between the nasopharynx and the intracranial vault after frontoorbital advancement.19 Therefore, reported complication rates associated with the 1 stage fronto-orbito-maxillary advancement by Tessier and the monobloc frontofacial advancement by Ortiz-Monasterio led to the recommendation to restrict these 1-step procedures only to severe patients with craniofaciostenosis, for example, for patients suffering from strong airway obstructions or proptosis # 2017 Mutaz B. Habal, MD FIGURE 1. Photographs of female patient at 6 months (top left), 14 months (top right), and 5 years of age (bottom left and right). leading to corneal ulcerations.6 However, with the rise of distraction osteogenesis, as first applied by Codivilla and popularized by Ilizarov, substantial efforts could be made for reconstructive surgery handling with bone deformities, describing it as a relatively safe lengthening method.10,20 For craniomaxillofacial surgery, the most favorable advantage of distraction osteogenesis is the possibility to minimize the frontal epidural dead space, which fills with blood and therefore is more susceptible to infection in terms of communication between the nasopharynx and the intracranial cavity.21 In 1997, Sugawara et al described their experience on gradual cranial vault expansion for the treatment of craniofacial synostosis and reported good results without observing any complications in 3 patients.4 Furthermore, Hirabayashi et al indicated that fronto-orbital advancement and gradual distraction are associated with a clinically irrelevant deterioration of the dura and a minimal resorption of the advanced bone, thus minimizing relapse.22 They highlighted that distraction obviates the need for bone or skin grafts and therefore is a recommendable corrective surgical technique.22 However, in accordance with the recommendation of Tessier, both Sugawara et al and Hirabayashi et al suggested to limit the distraction distance to 10–12 mm in order to avoid a large dead space.2 Moreover, Hirabayashi et al indicated that usage of an external distraction device goes along with scars, a second operation to remove the device, a relatively long treatment and a possible infection at the site of the device.22 In 2007, Pelo et al compared within a literature survey, internal and external craniofacial distractor devices and concluded that although both methods are effective, significant differences exist concerning the surgical aspects, and the practical differences experienced by the patients.23 They indicated that for severe patients external devices go along with a better control of the vectors and assure more predictable and 3 Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. CE: A.B.; SCS-17-0918; Total nos of Pages: 5; SCS-17-0918 Safi et al The Journal of Craniofacial Surgery effective final results.23 Hence, for our patients, we used a rigid external distraction device (RED-II), first described by Polley et al in 1998, in order to modify the vector in all 3 dimensions.24 By placing the wires near to the piriform aperture, the distraction forces can be applied in the central part of the facial skeleton, thus enabling better cosmetic results than anchoring the wire on the teeth or the lateral part of the zygoma.11 Compared with the monobloc frontofacial advancement, proclaimed by Ortiz-Monasterio in 1978, the main advantage of the fronto-orbital advancement and LeFort-III osteotomy is the ability to correct both areas separately and thus have more options to correct the midfacial hypoplasia and occlusion.3,6,17,25 However, advocates of the combination of frontofacial monobloc advancement with gradual distraction argue that due to the larger monobloc segment, the distraction force is much greater than it is for the LeFort-III segment.21 Kamoshima et al, for example, stated that within their cohort of 3 patients, who underwent a frontofacial monobloc advancement using the gradual distraction method the mean lengths ranged from 19 to 25 mm.21 Witherow et al indicated for their study group of 21 patients that the midface could be distracted at a mean of 16.4 mm with a range from 12 to 22 mm.1 However, we also achieved advancements of the midface of up to 20 mm with a mean distraction distance of 16.40 mm. Therefore, the esthetic and surgical outcomes were good and did not necessitate larger skeletal transpositions, as for example described by Kamoshima et al.21 Our distraction distances were similar to those reported by Kübler et al with a mean rate of 15.8 mm and a maximum distance of 18 mm.11 In 2012, Medra et al indicated that the clinical distraction distance within their patient cohort ranged from 15 to 20 mm with a mean transposition of 18 mm. Both Kübler et al and Medra et al reported low complication rates and good esthetic outcomes using a standardized treatment protocol similar to ours. In 1 of our patients, we could observe wound-healing disturbances, which necessitated reoperation 2 weeks postoperatively. For the rest of our patients, no complications particularly infections were diagnosed. This finding is in accordance with the majority of published literature, who reported low complication rates using external distraction devices in combination with advancement of the fronto-orbital region and the midface.1,23 Furthermore, as Whitaker et al reported that by means of a sufficiently deep or basal osteotomy in the area of the nose/frontobase the risk for ascending infections might be reduced, we assume that application of this technique played also an important role for the low complication rate within our study.5 A further important factor to prevent infection is that distraction should start from the 7th postoperative day so that the soft tissue in the area of the frontal skull is given enough time to consolidate and thereby adhere to the adjacent bone.11,26 Thus, although several disadvantages of external distraction devices are reported within literature, we could not observe infections at the exposed site of the device and obtained good results with the method of fronto-orbital advancement with LeFort-III osteotomy in combination with a rigid external distractor (RED-II). Another potential factor for infection is the usage of titanium plates. Fixation of the newly shaped neuro- and viscerocranium must be enabled by a rigid system, which is reliable in terms of stability, ductility, and biocompatibility.27,28 Since, in the late 1980s, titanium plates were introduced into craniomaxillofacial surgery, they were frequently used for fixation and led to excellent results.27,28 However, some authors noticed a risk of growth restriction, transcranial migration and highlighted a higher surgical risk, as removal of the titanium plates in a second surgical procedure is necessary.27,28 Therefore, with the rise of biodegradable polymeric materials in the mid-1990s, a second intervention could be avoided and therefore are nowadays favored.28,29 However, some reports on resorbable plates indicated a potential risk of inflammatory reaction, incomplete resorption, granuloma formation, 4 Volume 00, Number 00, Month 2017 osteolysis at the location of the plates, sterile fistula formation, or sterile abscesses.29–31 At our department, we routinely use titanium plates in all of our patients and remove these in a second operation regularly after approximately 5 to 6 months. In our study, we could not observe any complications related to the titanium plates, for example, growth-induced intracranial migration or infection at the plate sites, as our protocol is specifically intended to reduce the risk of such sequelae. CONCLUSION Our standardized treatment protocol, consisting of fronto-orbital advancement in combination with LeFort-III osteotomy and application of a rigid external distractor device (RED-III) for patients with severe syndromic craniofaciostenosis, goes along with low infection rates and more predictable and precise esthetic and functional outcomes than the conventional surgical technique without distraction osteogenesis. However, further studies conducted on larger study groups and long-term follow-up results are needed to evaluate our findings. REFERENCES 1. Witherow H, Thiessen F, Evans R, et al. Relapse following frontofacial advancement using the rigid external distractor. J Craniofac Surg 2008;19:113–120 2. Tessier P. Relationship of craniostenoses to craniofacial dysostoses, and to faciostenoses: a study with therapeutic implications. Plast Reconstr Surg 1971;48:224–237 3. Ortiz-Monasterio F, del Campo AF, Carrillo A. Advancement of the orbits and the midface in one piece, combined with frontal repositioning, for the correction of Crouzon’s deformities. Plast Reconstr Surg 1978;61:507–516 4. Sugawara Y, Uda H, Sarukawa S, et al. Multidirectional cranial distraction osteogenesis for the treatment of craniosynostosis. Plast Reconstr Surg 2010;126:1691–1698 5. Whitaker LA, Broennle AM, Kerr LP, et al. Improvements in craniofacial reconstruction: methods evolved in 235 consecutive patients. Plast Reconstr Surg 1980;65:561–570 6. Marchac D, Renier D, Broumand S. Timing of treatment for craniosynostosis and facio-craniosynostosis: a 20-year experience. Br J Plast Surg 1994;47:211–222 7. Dunaway DJ, Britto JA, Abela C, et al. Complications of frontofacial advancement. Childs Nerv Syst 2012;28:1571–1576 8. Nonaka Y, Oi S, Miyawaki T, et al. Indication for and surgical outcomes of the distraction method in various types of craniosynostosis. Advantages, disadvantages, and current concepts for surgical strategy in the treatment of craniosynostosis. Childs Nerv Syst 2004;20:702–709 9. Muhling J. Osteotomies for treating developmental disorders of the neurocranium and visceral cranium. Fortschr Kieferorthop 1991;52:15–20 10. McCarthy JG, Schreiber J, Karp N, et al. Lengthening the human mandible by gradual distraction. Plast Reconstr Surg 1992;89:1–8 11. Kübler AC, Speder B, Zoller JE. Fronto-orbital advancement with simultaneous LeFort III-distraction. J Craniomaxillofac Surg 2004;32:291–295 12. Chin M, Toth BA. Le Fort III advancement with gradual distraction using internal devices. Plast Reconstr Surg 1997;100:819–830 13. Gosain AK, Santoro TD, Havlik RJ, et al. Midface distraction following Le Fort III and monobloc osteotomies: problems and solutions. Plast Reconstr Surg 2002;109:1797–1808 14. Cohen SR, Boydston W, Hudgins R, et al. Monobloc and facial bipartition distraction with internal devices. J Craniofac Surg 1999;10:244–251 15. Holmes AD, Wright GW, Meara JG, et al. LeFort III internal distraction in syndromic craniosynostosis. J Craniofac Surg 2002;13:262–272 16. Medra AM, Marei AG, Shehata EA, et al. Simultaneous and differential fronto-orbital and midface distraction osteogenesis for syndromic craniosynostosis using rigid external distractor II. J Craniofac Surg 2012;23:1306–1313 17. Mühling J, Reuther J, Collmann H, et al. Principle of osteotomy for craniosynostoses: craniofacial abnormities and clefts of lips, alveolus and palate. Thieme Verlag 1985;52:88–90 # 2017 Mutaz B. Habal, MD Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. CE: A.B.; SCS-17-0918; Total nos of Pages: 5; SCS-17-0918 The Journal of Craniofacial Surgery Volume 00, Number 00, Month 2017 18. Whitaker LA, Bartlett SP, Schut L, et al. Craniosynostosis: an analysis of the timing, treatment, and complications in 164 consecutive patients. Plast Reconstr Surg 1987;80:195–212 19. Tessier P. Total facial osteotomy. Crouzon’s syndrome, Apert’s syndrome: oxycephaly, scaphocephaly, turricephaly. Ann Chir Plast 1967;12:273–286 20. Codivilla A. On the means of lengthening, in the lower limbs, the muscles and tissues which are shortened through deformity. 1904. Clin Orthop Relat Res 1994:4–9 21. Kamoshima Y, Sawamura Y, Yoshino M, et al. Frontofacial monobloc advancement using gradual bone distraction method. J Pediatr Surg 2008;43:1944–1948 22. Hirabayashi S, Sugawara Y, Sakurai A, et al. Frontoorbital advancement by gradual distraction. Technical note. J Neurosurg 1998;89:1058–1061 23. Pelo S, Gasparini G, Di Petrillo A, et al. Distraction osteogenesis in the surgical treatment of craniostenosis: a comparison of internal and external craniofacial distractor devices. Childs Nerv Syst 2007;23:1447–1453 24. Polley JW, Figueroa AA. Rigid external distraction: its application in cleft maxillary deformities. Plast Reconstr Surg 1998;102:1360–1372 # 2017 Mutaz B. Habal, MD Fronto-Orbital Advancement 25. Tessier P. The monobloc frontofacial advancement—do the pluses outweigh the minuses discussion. Plast Reconstr Surg 1993;91: 988–989 26. Kübler A, Zoller J. Trans-facial distraction of the facial skull at the LeFort III level. Mund Kiefer Gesichtschir 2002;6:153–157 27. Prein J. Manual of Internal Fixation in the Cranio-Facial Skeleton. Techniques as recommended by the AO/ASIF-Maxillofacial Group. Berlin: Springer Science & Business Media; 1998 28. Branch LG, Crantford C, Cunningham T, et al. Long-term outcomes of pediatric cranial reconstruction using resorbable plating systems for the treatment of craniosynostosis. J Craniofac Surg 2017;28:26–29 29. Konofaos P, Goubran S, Wallace RD. The role of resorbable mesh as a fixation device in craniosynostosis. J Craniofac Surg 2016;27:105–108 30. Arnaud E, Renier D. Pediatric craniofacial osteosynthesis and distraction using an ultrasonic-assisted pinned resorbable system: a prospective report with a minimum 30 months’ follow-up. J Craniofac Surg 2009;20:2081–2086 31. Kumar CR, Sood S, Ham S. Complications of bioresorbable fixation systems in pediatric neurosurgery. Childs Nerv Syst 2005;21:205–210 5 Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.