The optimal timing of cranioplasty is controversial. Some experts put the time between a  craniectomy  and a cranioplasty at usually between 6 months and a year, [ 1 ]  while others say that the two operations should be more than a year apart. [ 7 ]


The timing of cranioplasty is affected by multiple factors. Sufficient time is required for the recovery of the incision from the previous operation, as well as to clear any infections (both  systemic  and cranial). [ 1 ]  Some findings showed that a greater infection rate is associated with early cranioplasty due to interruption of wound healing, [ 8 ]  as well as an increased incidence of  hydrocephalus . [ 9 ]  Contrarily, there is evidence of early cranioplasty limiting complications caused by "syndrome of the trephined", including changes in  cerebral blood flow  and abnormal  cerebrospinal fluid  hydrodynamics. [ 8 ]  Other researchers have reported no significant difference in infection rate with different operational timings. [ 8 ] [ 9 ]


Contraindications  for cranioplasty include the presence of  bacterial infection ,  brain swelling , and  hydrocephalus . [ 10 ]  Cranioplasty is withheld until all contraindications are cleared. [ citation needed ]


Before the operation,  CT scans  and  MRIs  are taken to study the cranial defect. The patient is given antibiotics to prevent bacterial infection. [ 1 ]


The patient is situated on a  foam donut  or a  horseshoe head holder  for the operation. The patient is then  anaesthetised  and an incision is made following the incision of the previous operation. The  scalp  and the  temporalis muscle  is reflected to completely reveal the cranial defect. Significant blood loss is observed as new  blood vessels  formed in  scar tissues  are damaged by incision. Any  soft tissues  at the edge of the defect are removed and the defect is cleaned. The cranioplasty material is placed on the defect and is fixed to the surrounding  skull  with standard titanium plate and screws.  CSF  may be drained from the brain to reduce  herniation . Small holes may be drilled on the bone graft or the prosthesis to prevent the  accumulation of fluid  under the repaired defect.  Soft tissues ,  temporalis , and the scalp are then fixed back in place.  Subgaleal  drain and  dressing  are applied to control facial swelling. [ 1 ]


After the operation, a  CT scan  is taken and patients may stay in intensive care for at least a night for better neurological status observation, or be placed in a regular care unit. The  subgaleal  drain and  dressing  are removed before the patient is dispatched. [ 1 ]


Special considerations to children undergoing cranioplasty are made to accommodate for their growing  cranium . Certain materials are more favoured when compared to adult cranioplasty. [ citation needed ]


Autologous bone grafts  are the most preferred materials for  paediatric  cranioplasty, as they are accepted by the host and the bone flap can be integrated into the body of the host. [ 10 ]  However, autologous bone pieces may be unavailable or unsuitable in certain occasions. The body size of children may be not enough to have bone flaps to be stored in their  subcutaneous  spaces, while  cryopreservation  facilities for bone grafts are not widely available. [ 11 ] [ 12 ]  The use of  autograft  is also associated with a high rate of  bone resorption . [ 11 ]


Synthetic materials are used for paediatric cranioplasty when the use of  autografts  is not available or not recommended.  Hydroxyapatite  is another option for children cranioplasty as it allows the expansion of cranium for children and its ability to be moulded smoothly. It is less commonly used than autografts due to its brittle nature, high infection rate, and poor ability to integrate with the human  cranium . [ 10 ]


Bilateral cranioplasties are more prone to complications compared to unilateral cranioplasties in children. This may be explained by its larger scalp wound area, a higher volume of blood loss, and the higher complexity and duration of the operation. [ 12 ]


Cranioplasty's complication risk ranges from 15% to 41%. [ 4 ]  The cause for such a high risk compared to that borne by other  neurosurgical  operations is unclear. Male patients and older patients are groups with higher rates of complication. [ 4 ]


Complications occurring after cranioplasty include  bacterial infection ,  bone flap resorption ,  wound dehiscence ,  hematoma ,  seizures ,  hygroma , and  cerebrospinal fluid (CSF) leakage . [ 4 ]


The risk of bacterial infections in performing cranioplasty ranges from 5 to 12.8%. [ 1 ]  Multiple factors are affecting the risk of infection, one being the materials used for the operation. Using  titanium , whether being custom-made or using a  mesh , is associated with a lower infection rate; [ 1 ] [ 13 ]  on the other hand, materials such as  methyl methacrylate  and autologous bone is associated with a higher infection rate. [ 1 ]  Another risk factor for bacterial infection is the location of the operation. Bifrontal cranioplasties are associated with significantly higher infection rates and higher rates for reoperation. [ 9 ] [ 14 ]  Other risk factors for infection include previous infections, contact between  sinuses  and operation site, devascularized scalp (loss of blood supply in the scalp), previous operations, and type of injury. [ 1 ]


Bone resorption  is another complication of cranioplasty with a complication rate of 0.7-17.4%. [ 1 ]  Bone resorption occurs when the  autologous graft  does not have blood supply due to  devitalisation , or when  scar tissues  or  soft tissues  remain on the edge of the cranial defect during cranioplasty. [ 1 ]   Paediatric  patients have a higher risk of resorption, [ 1 ] [ 4 ] [ 9 ]  with a resorption rate up to 50%. [ 4 ]   Bone resorption  is more likely to occur in this group of patients when their cranioplasty is carried out over 6 weeks after their previous operation. [ 9 ]  Fragmented bone flaps, as well as large bone flaps (>70 cm 2 ), are associated with a higher resorption rate. [ 4 ]


The earliest cranioplasty operation is dated to 3000 BC in the  Pre-Columbian Peruvian civilisation , where precious metals, gourds, and shells were found next to  trepanned  skulls in graveyards, suggesting that cranioplasty had been performed. [ 2 ]  In the Paracas region of present-day  Peru , a skull from 2000 BC with a thin plate of gold covering a cranial defect was found. [ 2 ]  Moreover, defective skulls were found covered with coconut shells or  palm  leaves in ancient tribes of the  Polynesian Islands . [ 15 ]  Sanan and Haines stated that the materials being used for cranioplasty were associated with the status of the patient. [ 2 ]


Research on cranioplasty was not emphasised among early surgical authors in ancient  Asia ,  Egypt ,  Greece , and  Rome , although there were research and practice on  trephination  in ancient  Greece  and  Rome . More emphasis was placed on developing skills in applying  dressing  on an open wound. [ 2 ]


The earliest modern description of cranioplasty was written by surgeon  Ibrahim bin Abdullah  of the  Ottoman Empire , in his surgical book  Alâim-i Cerrâhîn  in 1505. The book mentioned the use of  xenografts  from  Kangal dogs  or goats as materials for cranioplasty. Such materials were used due to the accessibility of these animals near battlefields, where the procedure is likely to be performed. [ 16 ]


The first true description of cranioplasty in Europe was made by  Fallopius  in the 16th century, stating that the fractured  cranium  should be removed and be reinserted with a gold plate if the  dura  was damaged. This was questioned by other practitioners at his time, concerning that surgeons may keep the gold instead of using it for surgery. The first cranioplasty was reported by the Dutch surgeon  Job Janszoon van Meekeren . The report described the use of a segment of a  canine   cranium  as a material for cranioplasty on a  nobleman  in  Moscow . The operation was successful, but its use of canine bone was not accepted by the church and the man was forced to leave Russia. [ 2 ]


Since the first operation, bones from more animal species were used as xenografts for cranioplasty. These include  dogs ,  apes ,  geese ,  rabbits ,  calves ,  eagles ,  oxen , and  buffalos . In 1917,  William Wayne Babcock  reported the use of "soup bone", a piece of cooked and  perforated  animal bone as a xenograft. [ 2 ] [ 15 ]


The prevalence of  head injuries  increased in the 20th century with the advancement of armaments, particularly the use of  hand grenades  in  trench warfare  during  World War I . [ 17 ]  Along with a decreased mortality from suffering such injuries due to the development of cell debris removal, wound closing, and the use of  antibiotics , cranioplasty techniques were therefore improved. [ 17 ]   Autografts ,  allografts  and synthetic materials are the main types of materials used for cranioplasty. [ citation needed ]


Autografts, or autologous grafts, are body tissues taken from the patient. The first successful cranioplasty using an autograft was recorded in 1821, with the bone piece being reinserted into the cranium. The operation achieved partial healing. [ 2 ] [ 10 ]  Subsequently, more studies and operations were carried out with autografts. A successful case of reimplantation of cranial bone was reported by  Sir William Macewen  in 1885, popularising autografts to be material for cranioplasty. Succeeding operations involved autografts taken from different parts of the patient's body, such as the  tibia  (leg bone),  scapula  (shoulder blade),  ilium  (hip bone),  sternum  (chest bone), along with  fat tissues  and  fascia . [ 2 ]


Allografts are tissues from another individual of the same species. The first use of allografts was reported in 1915 with  cadaver   cartilage  by Morestin. [ 3 ] [ 10 ]  Subsequently, another 32 cases of cranioplasties performed with cadaver cartilage were reported by Gosset in 1916. [ 2 ]  The use of  cadaver   cartilage  was favoured during  World War I  due to its  malleability  and resistance to infection. Its use declined because of its lack of significant  calcification  and strength. [ 2 ]   Cadaver   skull  was another type of allograft reported to be used as a cranioplasty material multiple times by Sicard and Dambrin from 1917 to 1919. [ 2 ] [ 3 ] [ 10 ]  The material was not favoured due to the high infection rate with its use. In the 1980s, the use of cadaver allograft disc for filling in small holes received a satisfactory result, and there was a resurgence of the use of  cadaver  bone. [ 2 ]  However, cadaver bones and allografts, in general, are not the preferred materials in modern operations. [ 2 ] [ 3 ] [ 10 ]


The use of  methyl methacrylate (PMMA)  for cranioplasty has been developed since  World War II , when there was a high demand for it to treat  combat injuries , and used extensively since 1954. [ 2 ] [ 17 ] [ 10 ] [ 18 ]  PMMA becomes malleable when an  exothermic reaction  occurs between its powder form and  benzoyl peroxide , allowing it to be moulded to the cranial defect. [ 1 ]  Advantages of using it are its malleability, low cost, high strength and high durability. Disadvantages include its vulnerability to  infection , as  bacteria  may adhere to its  fibrous  layer, as well as its brittle nature and absence of growth potential. [ 1 ]


Other common synthetic materials for cranioplasty include  titanium  and  hydroxyapatite . Titanium was first used for cranioplasty in 1965. [ 2 ]  It can be used as a plate or a mesh and be 3D printed as a porous form. [ 19 ]  Titanium is non- ferromagnetic  and non- corrosive , making the host free from  inflammatory reactions . [ 1 ]  It is also robust, thus preventing patients from trauma. [ 19 ]  The use of titanium is associated with a lower infection rate. [ 10 ]  Disadvantages of using titanium include its high cost, poor malleability, and disruption to  CT scan  images. [ 1 ]


Hydroxyapatite is a compound of  calcium phosphate  being arranged in a  hexagonal  structure. [ 2 ] [ 18 ]  It bonds well chemically with bones and inflicts little inflammatory reaction by the host, and has good  osteointegration . [ 1 ] [ 2 ] [ 10 ] [ 18 ]  It can be expanded and is used in  paediatric  cranioplasty. [ 1 ] [ 10 ]  It can be moulded smoothly and has appealing cosmetic results. [ 10 ]  However, the material is brittle and has low  tensile strength , and so is only suitable to be used for small cranial defects. [ 1 ] [ 2 ] [ 10 ] [ 18 ]  Its use is also associated with a high infection rate. [ 10 ]  Hydroxyapatite is often used with a titanium mesh to prevent fractures and for better osteointegration. [ 1 ] [ 10 ] [ 18 ]


Distraction osteogenesis  ( DO ), also called  callus distraction ,  callotasis  and  osteodistraction , is a process used in  orthopedic surgery , podiatric surgery, and  oral and maxillofacial surgery  to repair  skeletal   deformities  and in reconstructive surgery. [ 1 ] [ 2 ]   The procedure involves cutting and slowly separating bone, allowing the bone healing process to fill in the gap. [ 3 ]


Distraction osteogenesis (DO) is used in   orthopedic surgery , and  oral and maxillofacial surgery  to repair  skeletal   deformities  and in reconstructive surgery. [ 1 ] [ 2 ] [ 3 ]  It was originally used to treat problems like  unequal leg length , but since the 1980s is most commonly used to treat issues like  hemifacial microsomia ,  micrognathism  (chin so small it causes health problems),  craniofrontonasal dysplasias ,  craniosynostosis , as well as  airway obstruction  in babies caused by  glossoptosis  (tongue recessed too far back in the mouth) or micrognathism. [ 1 ]


In 2016, a systematic review of papers describing bone and soft tissue outcomes of DO procedures on the  lower jawbone  was published; the authors had planned to do a meta-analysis but found the studies were too poor in quality and too heterogeneous to pool. [ 4 ]   From what they were able to generalize, the authors found there was significant relapse in the vertical plane for bone, and a higher risk of relapse when there was an initial high  gonial angle  or Jarabak ratio (sella–gonion/nasion–menton). [ 4 ]   For soft tissue, little evidence was available regarding the vertical dimension, while a 90% correspondence between skeletal and soft tissue was found for sagittal positioning; the dental-to-soft tissue agreement was  around 20%. [ 4 ]


A 2018  Cochrane  review of DO on the  upper jawbone  to treat  cleft lip  and  cleft palate  compared with  orthognathic surgery  found only one study, involving 47 participants and performed between 2002 and 2008 at the University of Hong Kong. [ 5 ]  This was not sufficient evidence from which to generalize, but the authors noted that while both procedures produced notable hard and soft tissue improvements, the DO group had greater advancement of the maxillary and less horizontal relapse five years after surgery. [ 5 ]  There was no difference in speech or nasal emissions outcomes nor in adverse effects; the DO group had lower satisfaction at three months after surgery but higher at two years. [ 5 ]


In the first phase, called the "osteotomy/surgical phase", the bone is cut, either partially, only  through the hard exterior , or  completely , and a device is fitted which will be used in the next phases. In the second phase, the latency period, which lasts generally seven days, the appliance is not activated and early stages of bone healing are allowed.  In the third phase, the "distraction phase", the device, which is mounted to the bone on each side of the cut, is used to gradually separate the two pieces, allowing  new bone  to form in the gap. When the desired or possible length is reached, which usually takes three to seven days, a  consolidation phase  follows in which the device keeps the bone stable to allow the bone to fully heal.  After the consolidation phase, the device is removed in a second surgical procedure. [ 1 ]


The device is usually manually operated by twisting a rod that separates the bone using a  rack and pinion  or similar system ; the rate of separation is carefully determined because going too quickly can cause  nonunion , in which unstable  fibrous connective tissue  is formed instead of bone, and going too slowly can allow premature union to occur.  Generally the rate is about a millimeter per day, achieved in two steps per day.  The frequency of steps and how much the device is moved at each step, is called the "rhythm".  The devices sometimes contain a spring that provides tension to continually separate the bones, instead of being manually operated at set intervals. [ 1 ]


In addition to these manually operated systems, there are also motorized systems like the Fitbone from Wittenstein. The Fitbone is a fully implantable, motorized, lengthening and correction nail. [ 6 ]  Advantages of this device are accurate deformity correction, low scar tissue formation, and reduced risk of infection. [ 7 ] [ 8 ]  Furthermore, the patients describe the procedure as more comfortable than limb lengthening with mechanical systems. [ 9 ]


Risks include infection (5% overall, with 1% of those requiring pin removal and the bone becoming infected in 0.5%), failure of bone to grow in the desired direction (between 7 and 9%),  hardware failure (between 3 and 4.5%), failure to follow the distraction protocol (4.5% overall; too slow 2% and too fast 0.5%), 1% pain due to distraction ending the procedure; damage to the inferior alveolar nerve occurs in 3.5% of mandibular distraction, tooth bud injury in 2%, and facial nerve injury in 0.5% of cases. [ 1 ]


The procedure was first proposed by  Bernhard von Langenbeck  in 1869, but the first publication of efforts to implement it clinically was by  Alessandro Codivilla  in 1905. [ 1 ]   The paper presented the results of efforts to treat 26 people who were born with malformed legs; Codivilla cut the femur, put a pin in the  heel bone , and applied  traction  to each person. [ 1 ] [ 10 ]   His paper showed high levels of complications, including infection, tissue death, and bones that failed to join, and his methods were not adopted. [ 1 ]


The Russian orthopedic surgeon  Gavriil Ilizarov  studied DO methods in over 15,000 people starting in the 1950s; he developed external fixation devices and methods to separate severed leg bones gradually, and using them he determined optimal rates of separation.  His work led to widespread use of DO. [ 1 ] [ 2 ]


The first use in the jaw was pioneered by  Wolfgang Rosenthal  in 1930 but it was not further explored until the 1980s; the first paper of the modern era describing clinical use was published in 1992. [ 1 ] [ 11 ]


In  India , cosmetic limb-lengthening surgery is a high demand but also unregulated industry. [ 12 ] [ 13 ]  Height is highly attractive in India and cosmetic limb-lengthening has been used by some young Indians to improve marriage and career prospects. [ 14 ]  Others have used it in preparation for a new job in another country such as the United States. [ 13 ]  American and British men (with average heights of 5 feet 9.5 inches and 5 feet 9.75 inches, respectively) are around 5 inches taller than Indian men. [ 12 ]  One surgeon in India stated: "This is one of the most difficult cosmetic surgeries to perform, and people are doing it after just one or two months' fellowship, following a doctor who is probably experimenting himself. There are no colleges, no proper training, nothing." [ 14 ]


People as young as 13 or 14 have undergone the procedure in India. Some patients have received infections and had to undergo additional surgeries months later to regain the ability to walk, while others found that they gained less height than expected. [ 13 ]  Other patients have said the surgeons had misled them about the potential complications and dangers of the surgery. [ 12 ] [ 15 ]


In 2006, limb lengthening was banned by  China's Ministry of Health  after a series of operations resulting in serious side-effects. [ 16 ]


The plot of the 1997 American dystopian science fiction film  Gattaca  involves one character assuming the identity of another and leg lengthening is depicted as part of the elaborate ploy to achieve this subterfuge, along with the use of various bodily fluids to avoid detection by DNA sequencing. [ 17 ]


As of 2013, work was underway on distraction devices using  Shape-memory alloy  that could precisely separate bone without the need for intervention, as well as springs and motors; the use of biopharmaceuticals like  BMP  in combination with devices was also being explored. [ 18 ]


As of 2016, work was underway developing devices and techniques that would allow DO in more directions simultaneously. [ 19 ]


Endoscopic nasopharyngectomy  is a form of  endoscopic  surgery to treat  nasopharyngeal carcinoma . [ 1 ]  This type of  cancer  is commonly treated with  radiation therapy  and  chemotherapy , but endoscopic operation offers an alternative treatment especially when the radiation therapy fails. [ 2 ]


In the early stages oncology, endoscopic surgeries were considered to be radical treatment [ 3 ]  despite the surgery being minimally invasive. [ 4 ]  The surgery is effective the treatment of recently diagnosed localized nasopharyngeal cancer for stage I patients.


Patient selection is extremely important in order to avoid surgical complications. Patients diagnosed with rT1 or rT2 tumors, and some rT3 tumors may be candidates for the surgery. [ 5 ]


A  face transplant  is a  medical procedure to replace  all or part of a person's  face  using  tissue  from a donor. Part
of a field called "Vascularized Composite Tissue Allotransplantation" (VCA) it involves the transplantation of facial  skin , the nasal structure, the  nose , the  lips , the  muscles  of facial movement used for expression, the  nerves  that provide sensation, and, potentially, the  bones  that support the face. The recipient of a face transplant will take life-long medications to suppress the  immune system  and fight off  rejection . [ 1 ]


The world's first partial face transplant on a living human was carried out in France in 2005. [ 2 ]  The world's first full face transplant was completed in Spain in 2010. [ 3 ]  Turkey, [ 4 ]  France, the United States, and Spain (in order of total number of successful face transplants performed) are considered the leading countries in the research into the procedure. [ 2 ]


People with faces  disfigured  by  trauma ,  burns , disease, or  birth defects  might aesthetically benefit from the procedure. [ 5 ]  Professor  Peter Butler  at the  Royal Free Hospital  first suggested this approach in treating people with facial disfigurement in a  Lancet  article in 2002. [ 6 ]  This suggestion caused considerable debate at the time concerning the ethics of this procedure. [ 5 ]


An alternative to a face transplant is facial reconstruction, which typically involves moving the patient's own skin from their back, buttocks, thighs, or chest to their face in a series of as many as 50 operations to regain even limited functionality, and a face that is often likened to a mask or a living  quilt .


The world's first full-face replant operation was on 9-year-old Sandeep Kaur, whose face was ripped off when her hair was caught in a  thresher . Sandeep's mother witnessed the accident. Sandeep arrived at the hospital unconscious with her face in two pieces in a plastic bag. An article in  The Guardian  recounts: "In 1994, a nine-year-old child in northern India lost her face and scalp in a  threshing machine  accident. Her parents raced to the hospital with her face in a plastic bag and a surgeon managed to reconnect the arteries and replant the skin." [ 12 ]  The operation was successful, although the child was left with some muscle damage as well as scarring around the perimeter where the facial skin was sutured back on. Sandeep's doctor was  Abraham Thomas , one of India's top  microsurgeons . In 2004, Sandeep was training to be a nurse. [ 13 ]


In 1996, a similar operation was performed in the Australian state of  Victoria , when a woman's face and scalp, torn off in a similar accident, was packed in ice and successfully reattached. [ 14 ]


The world's first partial face transplant on a living human was carried out on 27 November 2005 [ 15 ] [ 16 ]  by  Bernard Devauchelle , an  oral and maxillofacial surgeon , Benoit Lengelé, a Belgian plastic surgeon, and  Jean-Michel Dubernard  in  Amiens , France. [ 17 ]   Isabelle Dinoire [ 15 ]  underwent surgery to replace her original face, which had been mauled by her dog. A triangle of face tissue from a brain-dead woman's nose and mouth was grafted onto the patient. On 13 December 2007, the first detailed report of the progress of this transplant after 18 months was released in the  New England Journal of Medicine  and documents that the patient was happy with the results but also that the journey has been very difficult, especially with respect to her immune system's response. [ 18 ] [ 19 ]  Dinoire died on 22 April 2016
at the age of 49 following cancer from medications. [ 20 ]


A 29-year-old French man underwent surgery in 2007. He had a facial tumor called a  neurofibroma  caused by a genetic disorder. The tumor was so massive that the man could not eat or speak properly. [ citation needed ]


In March 2008, the treatment of 30-year-old Pascal Coler of France, who has neurofibromatosis, ended after he received what his doctors call the world's first successful almost full face transplant. [ 21 ] [ 22 ]  The operation, which lasted approximately 20 hours, was designed and performed by Laurent Lantieri and his team (Jean-Paul Meningaud, Antonios Paraskevas and Fabio Ingallina).


In April 2006, Guo Shuzhong at the Xijing military hospital in  Xi'an , transplanted the cheek, upper lip, and nose of Li Guoxing, who was mauled by an  Asiatic black bear  while protecting his sheep. [ 23 ] [ 24 ]  On 21 December 2008, it was reported that Li had died in July in his home village in  Yunnan . Prior to his death, a documentary on the  Discovery Channel  showed he had stopped taking immuno-suppressant drugs in favour of herbal medication; a decision that was likely a contributing factor to his death, according to his surgeon. [ 25 ]


Selahattin Özmen  performed a partial face transplant on 17 March 2012 on Hatice Nergis, a twenty-year-old woman at  Gazi University 's hospital in  Ankara . It was Turkey's third, the first woman-to-woman and the first three-dimensional with bone tissue. The patient from  Kahramanmaraş  had lost her upper jaw six years prior in a firearm accident, including her mouth, lips, palate, teeth and nasal cavity, and was since then unable to eat. She had undergone around 35 reconstructive plastic surgery operations. The donor was a 28-year-old Turkish woman of Moldavian origin in  Istanbul , who had died by suicide. [ 26 ] [ 27 ] [ 28 ]  Nergis died in  Ankara  on 15 November 2016 after she was hospitalized two days prior complaining about acute pain. [ 29 ]


In December 2011, a 54-year-old man underwent a partial face transplant to the lower two-thirds of the face (including bone) after a ballistic accident. The operation was performed by a multidisciplinary team led by plastic surgeon Phillip Blondeel; Hubert Vermeersch, Nathalie Roche and Filip Stillaert were other members of the surgical team. For the first time 3D CT planning was used to plan the operation that lasted 20 hours. As of 2014 the patient is alive, with "good recovery of motor and sensory function and social reintegration". [ 30 ]


In September 2018, a 49-year-old woman affected by Neurofibromatosis type I received a partial face transplant from a 21-year-old girl at Sant'Andrea Hospital of Sapienza University in Rome. The procedure took 27 hours and was carried out by two teams led by Fabio Santanelli di Pompeo and Benedetto Longo. [ 31 ]  The patient had a complication and after two days the surgeons had to replace the facial graft with autologous tissue. The patient is still alive and waiting for a second face transplantation. [ 32 ]


In May 2018, the first Canadian complete face transplant was performed under the leadership of  plastic surgeon   Daniel Borsuk  at the Hopital Maisonneuve Rosemont, in  Montreal ,  Quebec . [ 33 ] [ 34 ]  The transplant took over 30 hours and replaced the upper and lower jaws, nose, lips and teeth on  Maurice Desjardins , a 64-year-old man that shot himself in a hunting accident. At that time, Mr. Desjardins was the oldest person to benefit from a face transplant. [ 35 ] [ 36 ]


On 20 March 2010, a team of 30 Spanish doctors led by plastic surgeon Joan Pere Barret at the  Vall d'Hebron University Hospital  in  Barcelona  carried out the world's first full face transplant, on a man injured in a shooting accident. [ 37 ]


On 8 July 2010, the French media reported that a full face transplant, including tear ducts and eyelids, was carried out at the  Henri-Mondor hospital  in  Créteil . [ 38 ]


In March 2011, a surgical team, led by  Bohdan Pomahač  at  Brigham and Women's Hospital  in  Boston, Massachusetts , performed a full face transplant on  Dallas Wiens , who was badly disfigured in a power line accident that left him blind and without lips, nose or eyebrows. The patient's sight couldn't be recovered but he has been able to talk on the phone and smell. [ 39 ]


In April 2011, less than one month after the hospital performed the first full face transplant in the country, the  Brigham and Women's Hospital  face transplant team, led by Bohdan Pomahač, performed the nation's second full face transplant on patient Mitch Hunter of Speedway, Indiana. It was the third face transplant procedure to be performed at BWH and the fourth face transplant in the country. The team of more than 30 physicians, nurses, anesthesiologists and residents worked for more than 14 hours to replace the full facial area of the patient, including the nose, muscles of facial animation and the nerves that power them and provide sensation. Hunter had a severe shock from a high voltage electrical wire following a car accident in 2001. [ 40 ]


On 15 May 2013, at the  Maria Skłodowska-Curie Institute of Oncology  branch in  Gliwice , Poland, an entire face was transplanted onto a male patient, Grzegorz (aged 33) after he lost the front of his head in a machine accident at work. The surgery took 27 hours and was directed by Professor Adam Maciejewski. There had not been much planning or prep time before the surgery, which was performed about one month after the accident, because the transplantation was done as an urgent life-saving surgery due to the patient's difficulty in eating and breathing. Shortly after the donor's death, the decision to perform the surgery was made and his body was transported hundreds of kilometers to Gliwice once his relatives gave their consent. The doctors believe that their patient has an excellent chance to live a normal, active life after surgery, and that his face should operate more or less normally (his eyes survived the accident untouched). [ 41 ]


Seven months later, on 4 December, the same Polish medical team in Gliwice transplanted a face onto a 26-year-old female patient with  neurofibromatosis . Two months after the operation, she left the hospital. [ 42 ] [ 43 ]


On 21 January 2012, Turkish surgeon  Ömer Özkan  and his team successfully performed a full face transplant at  Akdeniz University 's hospital in  Antalya . The 19-year-old patient, Uğur Acar, was badly burnt in a house fire when he was a baby. The donor was 39-year-old Ahmet Kaya, who died on 20 January. [ 44 ]  The Turkish doctors declared that his body had accepted the new tissue. [ 45 ]


Almost one month later on 24 February 2012, a surgical team led by  Serdar Nasır  conducted the country's second successful full face transplant at  Hacettepe University 's hospital in  Ankara  on 25-year-old Cengiz Gül. The patient's face was badly burned in a  television tube implosion  accident when he was two years old. The donor was a undisclosed 40-year-old (the donor's family did not permit the identity of the donor to be revealed), who experienced  brain death  two days before the surgery following a motorcycle accident that occurred on 17 February. [ 46 ]


On 16 May 2012, surgeon Ömer Özkan and his team at the Akdeniz University Hospital performed the country's fourth and their second full face transplant. The face and ears of 27-year-old patient Turan Çolak from  İzmir  were burnt when he fell into an oven when he was three and half years old. The donor was Tevfik Yılmaz, a 19-year-old man from  Uşak  who had attempted suicide on 8 May. He was declared brain dead in the evening hours of 15 May after having been in intensive care for seven days. His parents donated all his organs. [ 47 ]


On 18 July 2013, the face of a Polish man was successfully given to a Turkish man in a transplant performed by Özkan, at Akdeniz University hospital following a 6.5-hour operation, making it the fifth such operation to take place in the country. It was the 25th face transplant operation in the world. The donor was Andrzej Kucza, a 42-year-old Polish tourist who was declared brain dead following a heart attack on 14 July while swimming in Turkey's sea resort  Muğla . The receiver was 27-year-old patient Recep Sert from  Bursa . [ 48 ]


On 23 August 2013, surgeon Ömer Özkan and his team at Akdeniz University performed the sixth face transplant surgery in Turkey. Salih Üstün (54) received the scalp, eyelids, jaw and maxilla, nose and the half tongue of 31-year-old Muhittin Turan, who was declared brain dead after a motorcycle accident that took place two days before. [ 49 ]


On 30 December 2013, Özkan and his team conducted their fifth and Turkey's seventh face transplant surgery at the hospital of Akdeniz University. The nose, upper lip, upper jaw and maxilla of brain dead Ali Emre Küçük, aged 34, were successfully transplanted to 22-year-old Recep Kaya, whose face was badly deformed in a shotgun accident. While Kaya was flown from  Kırklareli  to Antalya via Istanbul in four hours, the donor's organs were transported from  Edirne  by an ambulance airplane. The surgery took 4 hours and 10 minutes. [ 50 ]


In October 2006, surgeon  Peter Butler  at London's  Royal Free Hospital  in the UK was given permission by the  NHS  ethics board to carry out face transplants. His team will select four adult patients (children cannot be selected due to concerns over consent), with operations being carried out at six-month intervals. [ 51 ]  As of 2022, neither Butler nor any other UK surgeon has performed a face transplant. [ 52 ]


In 2004, the  Cleveland Clinic  became the first institution to approve this surgery and test it on cadavers.


In 2005, the Cleveland Clinic became the first US hospital to approve the procedure. In December 2008, a team at the Cleveland Clinic, led by  Maria Siemionow  and including a group of supporting doctors and six plastic surgeons (Steven Bernard, Dr Mark Hendrickson, Robert Lohman, Dan Alam and Francis Papay) performed the first face transplant in the US on a woman named  Connie Culp . [ 53 ] [ 54 ] [ 55 ]  It was the world's first near-total facial transplant and the fourth known facial transplant to have been successfully performed to date. This operation was the first facial transplant known to have included bones, along with muscle, skin, blood vessels, and nerves. The woman received a nose, most of the sinuses around the nose, the upper jaw, and even some teeth from a brain-dead donor. As doctors recovered the donor's facial tissue, they paid special attention to maintaining arteries, veins, and nerves, as well as soft tissue and bony structures. The surgeons then connected facial graft vessels to the patient's blood vessels in order to restore blood circulation in the reconstructed face before connecting arteries, veins and nerves in the 22-hour procedure. She had been disfigured to the point where she could not eat or breathe on her own as a result of a traumatic injury several years ago, which had left her without a nose, right eye and upper jaw. Doctors hoped the operation would allow her to regain her sense of smell and ability to smile, and said she had a "clear understanding" of the risks involved. Connie died 29 July 2020.
The second partial face transplant in the US took place at  Brigham and Women's Hospital  in Boston on 9 April 2009. During a 17-hour operation, a surgical team led by  Bohdan Pomahač , replaced the nose, upper lip, cheeks, and roof of the mouth – along with corresponding muscles, bones and nerves – of James Maki, age 59. Maki's face was severely injured after falling onto the electrified third rail at a Boston subway station in 2005. In May 2009, he made a public media appearance and declared he was happy with the result. [ 56 ]  This procedure was also shown in the eighth episode of the ABC documentary series  Boston Med .


The first full face transplant performed in the US was done on a construction worker named  Dallas Wiens  in March 2011. He was burned in an electrical accident in 2008. This operation, performed by Bohdan Pomahač and BWH plastic surgery team, [ 57 ]  was paid for with the help of the US defense department. They hope to learn from this procedure and use what they learn to help soldiers with facial injuries. [ 58 ]  One of the top benefits of the surgery was that Dallas has regained his sense of smell. [ 59 ]


The  Brigham and Women's Hospital  transplant team led by Bohdan Pomahač, performed the nation's second full face transplant on patient Mitch Hunter of Speedway, Indiana. Hunter, who is a US war veteran, was left disfigured in a car accident, burning about 94% of his face. It was the third face transplant procedure to be performed at BWH and the fourth face transplant in the country. The team of more than 30 physicians, nurses, anesthesiologists and residents worked for more than 14 hours to replace the full facial area of patient Mitch Hunter including the nose, eyelids, muscles of facial animation and the nerves that power them and provide sensation. Mitch Hunter was a passenger in a single cab pick-up truck, upon exiting the vehicle and pulling another passenger off a downed line, Hunter was then struck by a 10,000-volt 7-amp power line for a little under five minutes. The electricity entered his lower left leg, with the majority exiting his face, leaving him severely disfigured. He also lost part of his lower left leg, below the knee, and lost two digits on his right hand (pinkie and ring finger). Hunter has regained almost 100% of his normal sensation back in his face and his only complaint is that he looks too much like his older brother. [ 40 ]


57-year-old  Charla Nash , who was mauled by a chimpanzee named Travis in 2009, after the owner gave the chimp  Xanax  and wine. She underwent a 20-hour full face transplant in May 2011 at  Brigham and Women's Hospital  in  Boston . Nash's full face transplant was the third surgery of its kind performed in the United States, all at the same hospital. [ 3 ]


In March 2012, a face transplant was completed at the University of Maryland Medical Center and R Adams Cowley Shock Trauma Center under the leadership of plastic surgeon  Eduardo Rodriguez  and his team (Amir Dorafshar, Michael Christy, Branko Bojovic and  Daniel Borsuk [ 60 ] ). [ 61 ]  The recipient was 37-year-old Richard Norris, who had sustained a facial gunshot injury in 1997. This transplant included all facial and anterior neck skin, both jaws, and the tongue. [ 62 ]


In September 2014, another face transplant was performed by the Cleveland Clinic group. The patient had had complex trauma that masked the development of a rare type of autoimmune disease (granulomatosis with polyangiitis and pyoderma gengrenosum) affecting the face. It was the first face transplant in a patient with an autoimmune disease involving the craniofacial region. Prior to surgery, an analysis of renal transplant outcomes in granulomatosis with polyangiitis was conducted to evaluate allograft outcomes in these cohorts. That literature established feasibility and encouraged the Cleveland Clinic team to proceed with the surgery. The intervention was reported successful up to three years post-transplantation. [ 63 ] [ 64 ] [ 65 ] [ 66 ]


In August 2015, a face transplant was completed at the NYU Langone Medical Center under the leadership of the chair of plastic surgery  Eduardo D. Rodriguez  and his team. A 41-year-old retired fireman named Patrick Hardison received the face of cyclist David Rodebaugh. [ 67 ]


In June 2016, a multidisciplinary team of surgeons, physicians and other health professionals completed a near-total face transplant at  Mayo Clinic 's Rochester campus. Patient Andrew Sandness, a 32-year-old from eastern Wyoming, had devastating facial injuries from a self-inflicted gunshot wound in 2006. The surgery, which spanned more than 50 hours, restored Sandness' nose, upper and lower jaw, palate, teeth, cheeks, facial muscles, oral mucosa, some of the salivary glands and the skin of his face (from below the eyelids to the neck and from ear to ear). The care team led by Samir Mardini, and Hatem Amer, the surgical director and medical director, respectively, for the Mayo Clinic Essam and Dalal Obaid Center for Reconstructive Transplant Surgery, devoted more than 50 Saturdays over  3 + 1 ⁄ 2  years to rehearsing the surgery, using sets of cadaver heads to transplant the face of one to the other. They used 3-D imaging and virtual surgery to plot out the bony cuts so the donor's face would fit perfectly on the transplant recipient. Today, in addition to his physical transformation, Sandness can smell again, breathe normally and eat foods that were off-limits for a decade. [ 68 ]


In a 31-hour operation starting on 4 May 2017, surgeons at the Cleveland Clinic transplanted a face donated from Adrea Schneider, who had died of a drug overdose, to Katie Stubblefield, whose face had been disfigured in a suicide attempt by rifle on 25 March 2014. As of 2018 [update] , Katie is the youngest person in the United States to have had a face transplant, age 21 at the time. Surgeons originally planned to leave her cheeks, eyebrows, eyelids, most of her forehead, and the sides of her face alone. However, because the donor face was larger and darker than Katie's, they made the decision to transplant the donor's full face. This holds the risk that in case of acute  rejection  in which the face must be removed, she would not have enough tissue for reconstructive surgery. Katie was featured on the cover of  National Geographic  in September 2018 for an article entitled "The Story of a Face." [ 69 ] [ 70 ]


In July 2019, 68-year-old Robert Chelsea became the oldest person, as well as the first black person in the world, to receive a full face transplant. On 6 August 2013, Robert was involved in an horrific car accident, leaving burns over 75% of his body. The severe damage meant that Robert was missing significant facial elements such as a part of his nose, which limited his ability to eat and drink. Functionality was important to Robert and was a key reason behind his pursuit of the surgery. In 2016, a face transplant was first discussed. Yet, health care disparities have led to a lack of black organ donations. This meant that Robert waited two years to find a face that matched something close to his own complexion. [ 71 ]  The surgery was performed on 27 July 2019 at Brigham and Women's Hospital. [ 72 ]


In February 2024, 30-year-old Derek Pfaff received a full-face transplant from an anonymous donor. Pfaff had previously shot himself in the face during a suicide attempt in March 2014, 10 years prior to the surgery. The results of the surgery were later revealed in November 2024. [ 73 ] [ 74 ]


A number of combined VCA procedures, such as bilateral  hand transplants , have been described in the literature and media sources. These combined procedures also include attempts at triple-limb [ 75 ] [ 76 ]  and quadruple-limb [ 77 ]  transplants, however, only three face transplants have been attempted in combination with other allografts.


In 2009, Laurent Lantieri and his team attempted a face and bilateral hand transplant on a 37-year-old man who sustained extensive injuries during a self-immolation attempt one year prior. The patient ultimately died of anoxic brain injury two months after his initial transplant during surgical management of infectious and vascular complications. Autopsy revealed no signs of rejection in any of the allografts. [ 78 ]


On 12 August 2020, at NYU Langone Health in New York, New York,  Eduardo D. Rodriguez  led a team of over 140 personnel in successfully transplanting the face and bilateral hands of a brain dead donor onto 22-year-old Joe DiMeo, who sustained disfiguring burns after a car accident in 2018. [ 79 ] [ 80 ]  The procedure lasted approximately 23 hours, and involved the entire facial soft tissue (extending from the anterior hairline to the neck, including the eyelids, nose, lips, and ears, along with strategic skeletal components), as well as both hands at the distal forearm level. [ 81 ]


Charla Nash's face transplant, described above, also initially included bilateral hands from the same donor. Circulation to Nash's transplanted hands was compromised after she was started on  vasopressors  as part of treatment for sepsis. [ 78 ]  The hands were ultimately amputated, however the patient survived, as did her facial allograft.


In May 2023, a team of 140 doctors at  NYU Langone Health  successfully conducted the first combination eye transplant and partial face transplant. The patient, a 46-year-old linesman, was electrocuted by high voltage wires in 2021 causing the loss of the lower portion of his face and his left eye. The eye, while not restoring vision to the patient, has successfully received blood flow to the retina. [ 82 ]


The procedure consists of a series of operations requiring rotating teams of specialists. With issues of tissue type, age, sex, and skin color taken into consideration, the patient's face is removed and replaced (sometimes including the underlying fat, nerves, blood vessels, bones, and/or musculature). The surgery may last anywhere from 8 to 36 hours, followed by a 10- to 14-day hospital stay.


There has been a substantial amount of ethical debate surrounding the operation and its performance. [ 83 ]  The main issue is that, as noted below, the procedure entails submitting otherwise physically healthy people to potentially fatal, lifelong immunosuppressant therapy. So far, four people have died of complications related to the procedure. Citing the comments of various plastic surgeons and medical professionals from France and Mexico, anthropologist Samuel Taylor-Alexander suggests that the operation has been infused with nationalist import, which is ultimately influencing the decision-making and ethical judgements of the involved parties. [ 84 ]  His most recent research suggests the face transplant community needs to do more in order to ensure that the experiential knowledge of face transplant recipients is included in the ongoing evaluation of the field. [ 85 ]  As of October 2019, the  AboutFace Project   Archived  1 February 2021 at the  Wayback Machine , funded by a  UKRI Future Leaders Fellowship  awarded to  Dr Fay Bound Alberti , is exploring these debates as part of its wider research into the emotional and cultural history of face transplants. [ 86 ]  The AboutFace project has entered its second phase as  Interface , a research project which explores the relationship between identity, emotion, and communication, as revealed through the human face.


After the procedure, a lifelong regimen of  immunosuppressive  drugs is necessary to suppress the patient's own  immune systems  and prevent rejection. [ 87 ]  Long-term immunosuppression increases the risk of developing life-threatening infections, kidney damage, and cancer. The surgery may result in complications such as infections that could damage the transplanted face and require a second transplant or reconstruction with skin grafts.


A  facial cleft  is an opening or gap in the  face , or a malformation of a part of the face. Facial clefts is a collective term for all sorts of clefts. All structures like bone, soft tissue, skin etc. can be affected. Facial clefts are extremely rare  congenital anomalies . There are many variations of a type of clefting and classifications are needed to describe and classify all types of clefting. Facial clefts hardly ever occur isolated; most of the time there is an overlap of adjacent facial clefts. [ 1 ]


There are different classifications about facial clefts. Two of the most used classifications are the  Tessier classification [ 2 ]  and the  Van der Meulen classification . [ 3 ]  Tessier is based on the anatomical position of the cleft and Van der Meulen classification is based on the embryogenesis.


In 1976  Paul Tessier  published a classification on facial clefts based on the anatomical position of the clefts. The different types of Tessier clefts are numbered 0 to 14. These 15 different types of clefts can be put into 4 groups, based on their position: [ 4 ]  midline clefts, paramedian clefts, orbital clefts and lateral clefts. The Tessier classification describes the clefts at soft tissue level as well as at bone level, because it appears that the soft tissue clefts can have a slightly different location on the face than the bony clefts. [ citation needed ]


The midline clefts are Tessier number 0 ("median craniofacial dysplasia"), number 14 ( frontonasal dysplasia ), and number 30 ("lower midline facial cleft", also known as "median mandibular cleft"). These clefts bisect the face vertically through the midline. Tessier number 0 bisects the  maxilla  and the nose, Tessier number 14 comes between the nose and the  frontal bone . The Tessier number 30 facial cleft is through the tongue, lower lip and  mandible . The tongue may be absent, hypoplastic, bifid, or even duplicated. [ 5 ]  People with this condition may be  tongue-tied . [ 5 ]


Tessier number 1, 2, 12 and 13 are the paramedian clefts. These clefts are quite similar to the midline clefts, but they are further away from the midline of the face. Tessier number 1 and 2 both come through the maxilla and the nose, in which Tessier number 2 is further from the midline ( lateral ) than number 1. Tessier number 12 is in extent of number 2, positioned between nose and frontal bone, while Tessier number 13 is in extent of number 1, also running between nose and forehead. Both 12 and 13 run between the midline and the orbit. [ citation needed ]


Tessier number 3, 4, 5, 9, 10 and 11 are orbital clefts. These clefts all have the involvement of the  orbit . Tessier number 3, 4, and 5 are positioned through the maxilla and the orbital floor. Tessier number 9, 10 and 11 are positioned between the upper side of the orbit and the forehead or between the upper side of the orbit and the  temple  of the head.
Like the other clefts, Tessier number 11 is in extent to number 3, number 10 is in extent to number 4 and number 9 is in extent to number 5.


The lateral clefts are the clefts which are positioned horizontally on the face. These are Tessier number 6, 7 and 8. Tessier number 6 runs from the orbit to the cheek bone. Tessier number 7 is positioned on the line between the corner of the mouth and the ear. A possible lateral cleft comes from the corner of the mouth towards the ear, which gives the impression that the mouth is bigger. It's also possible that the cleft begins at the ear and runs towards the mouth. Tessier number 8 runs from the outer corner of the eye towards the ear.
The combination of a Tessier number 6-7-8 is seen in the  Treacher Collins syndrome . Tessier number 7 is more related to  hemifacial microsomia  and number 8 is more related to  Goldenhar syndrome .


Van der Meulen classification divides different types of clefts based on where the development arrest occurs in the  embryogenesis . A primary cleft can occur in an early stage of the development of the face (17 mm length of the embryo). The developments arrests can be divided in four different location groups: internasal,  nasal , nasalmaxillar and maxillar. The maxillar location can be subdivided in  median  and lateral clefts.


Internasal  dysplasia  is caused by a development arrest before the union of the two nasal halves. These clefts are characterized by a median cleft lip, a median notch of the  cupid's bow  or a duplication of the labial  frenulum . Besides the median cleft lip,  hypertelorism  can be seen in these clefts. Also sometimes there can be an underdevelopment of the  premaxilla .


Nasal dysplasia or nasoschisis is caused by a development arrest of the lateral side of the nose, resulting in a cleft in one of the nasal halves. The nasal septum and cavity can be involved, though this is rare. Nasoschisis is also characterized by hypertelorism.


Nasomaxillary dysplasia is caused by a development arrest at the junction of the lateral side of the nose and the maxilla, which results in a complete or non-complete cleft between the nose and the orbital floor (nasoocular cleft) or between the mouth, nose and the orbital floor (oronasal-ocular cleft). The development of the lip is normal.


Maxillary dysplasia can manifest itself on two different locations in the maxilla: in the medial or the lateral part of the maxilla.


It is possible that facial clefts are caused by a disorder in the migration of  neural crest cells . [ 6 ]


Another theory is that facial clefts are caused by failure of the fusion process and failure of inwards growth of the  mesoderm .


Other theories are that genetics play a part in the development of facial clefts [ 7 ]  or that they are caused by amniotic bands. [ 8 ]


Around one in 700 individuals are born with craniofacial clefts. [ 9 ]  There are multiple genetic and environmental factors which contribute to craniofacial development. Within craniofacial disorders and  abnormalities , orofacial clefts, and specifically  cleft lip  (CL) and  cleft palate  (CP) are the most common in humans. [ 9 ]  Occurrences of CL/P are most often (around seventy percent of cases) isolated and nonsyndromic, meaning they are not associated with a syndrome or inherited genetic conditions. [ 9 ] [ 10 ]  Around thirty percent occur with other structural variances, and over 500 syndromes have been identified in which clefting is a principal feature. [ 9 ] [ 10 ]  Clefting can result from  teratogens , an agent that disrupts embryo development such as, radiation, maternal infection, chemicals, or drugs. [ 9 ] [ 10 ]   Chromosomal abnormalities  or  mutations  at single gene loci have also contributed to clefting development. [ 9 ] [ 10 ]  Genetic causes are linked with most craniofacial syndromes, and CL/P and other orofacial clefts are recognized as  heterogeneous disorders , meaning there are multiple recognized causes. [ 9 ] [ 11 ]  Orofacial clefts have great phenotypic diversity, and their associated genetic environments have called for vast research and investigation.


Craniofacial disorders have high variance in phenotypic expression, and researchers have suggested this variance could be due to interactions between the mutated/deviated genes and other genes, along with interactions with environmental factors. [ 12 ] [ 13 ]  Environmental causes have been found to contribute to craniofacial clefting, however, these are still influenced by and supported by genetic factors. Many studies, for example, have linked maternal smoking to increased CLP risk; however, the increased risk suggests that genes in metabolic pathways could still contribute to susceptibility or formation of CL/P. [ 14 ]


The craniofacial complex begins its progress in the fourth week of development, and results from  neural crest  cells migrating to form and fuse the facial primordia. [ 9 ] [ 10 ]  Failures or deviations in this process result in craniofacial clefts, either CL or CP. [ 6 ]  The range of variation in phenotype aligns with ancestry. [ 9 ] [ 14 ]  Studies have found increased amounts of clefting in the relatives of patients with clefts, suggesting genetic factors are the underlying cause for CL/P. [ 9 ]  Inheritance has a known and significant role in human craniofacial morphology. This is supported through cephalometric and anthropometric comparisons of family members including between triplets, twins, siblings, and parents and children. [ 15 ]


Genetic factors of craniofacial clefting can be investigated and tracked through several methods including  sequencing  in humans,  Genome-wide association studies  (GWAs),  fate mapping , expression analysis, and animal studies (knockout experiments or models with clefting from chemical mutagenesis). [ 16 ]   Twin studies  and familial clustering have also revealed that facial structure and formation are genetically linked. Several genes have been associated with craniofacial disorders through experimentation, including sequencing Mendelian clefting syndromes. [ 9 ]  Over 25 loci have been identified as potential influencers of craniofacial clefts across populations. [ 12 ]


The  transforming growth factor  ( TGF ) family has provided multiple candidate genes linked with craniofacial development and malformation. [ 17 ] [ 18 ] [ 14 ] [ 10 ]   TGF  is involved in cell migration, differentiation, and proliferation, as well as regulating the extracellular matrix. [ 17 ]  Another gene that has been flagged as causal for craniofacial disorders, including CL/P, is  interferon regulatory factor 6  or,  IRF6 . [ 9 ] [ 14 ] [ 19 ]  Mutations in  IRF6  cause  Van der Woude syndrome , the most common clefting syndrome. [ 9 ]   Ventral anterior homeobox 1 ,  VAX1,  and  noggin ,  NOG , were identified with genome-wide significance for contributing to CL/P. [ 14 ]  Additionally, mutations in  SPECC1L  have recently been identified as influential to facial structure formation, and as causal for syndromic facial clefting. [ 19 ] [ 20 ]  Nonsyndromic CL/P has been associated with the transcription factor  forkhead box protein E1  ( FOXE1 ), as mutations have resulted in cases of CL/P in mice. [ 10 ]  Other genes which have been found to interact with or contribute to craniofacial clefting include  FGFR s,  TWIST ,  MSX s,  GREM1 ,  TCOF1 ,  PAX s,  MAFB ,  ABCA4,  and  WNT  allowing great cause for more research into the genetic basis for craniofacial disorders. [ 11 ] [ 18 ] [ 12 ] [ 13 ] [ 14 ]


Because the cause of facial clefts still is unclear, it is difficult to say what may prevent children being born with facial clefts. It seems that  folic acid  contributes to lowering the risk of a child being born with a facial cleft. [ 21 ]


There is no single strategy for treatment of facial clefts, because of the large amount of variation in these clefts. Which kind of surgery is used depends on the type of clefting and which structures are involved. There is much discussion about the timing of reconstruction of bone and soft tissue. The problem with early reconstruction is the recurrence of the deformity due to the intrinsic restricted growth. This requires additional operations at a later age to make sure all parts of the face are in proportion. [ 22 ]  A disadvantage of early bone reconstruction is the chance to damage the tooth germs, which are located in the maxilla, just under the orbit. The soft tissue reconstruction can be done at an early age, but only if the used skin flap can be used again during a second operation. The timing of the operation depends on the urgency of the underlying condition. If the operation is necessary to function properly, it should be done at early age. The best aesthetic result is achieved when the incisions are positioned in areas which attract the least attention (they cover up the scars). If, however, the function of a part of the face isn't damaged, the operation depends on psychological factors and the facial area of reconstruction.


The treatment plan of a facial cleft is planned right after diagnosis. This plan includes every operation needed in the first 18 years of the patients life to reconstruct the face fully.
In this plan, a difference is made between problems that need to be solved to improve the health of the patient (coloboma) and problems that need to be solved for a better cosmetic result (hypertelorism).


The treatment of the facial clefts can be divided in different areas of the face: the cranial anomalies, the orbital and eye anomalies, the nose anomalies, the midface anomalies and the mouth anomalies.


The most common cranial anomaly seen in combination with facial clefts is  encephalocele .


The treatment of encephalocele is based on surgery to repair the bony gap and provide adequate protection of the underlying brain. The question remains if the external brain tissue should be put back into the skull or if it is possible to cut off that piece of brain tissue, because its claimed that the external piece of brain tissue often isn't functional, [ 23 ]  with the exception of a basal encephalocele, in which the pituitary gland can be found in the mouth.


The most common orbital /eye anomalies seen in children with facial clefts are colobomas and vertical dystopia.


The coloboma which occurs often in facial clefts is a cleft in the lower or upper eyelid. This should be closed as soon as possible, to prevent drought of the eye and a consecutive loss of vision. [ 24 ]


Vertical orbital dystopia can occur in facial clefts when the orbital floor and/or the maxilla is involved in the cleft. Vertical orbital dystopia means that the eyes do not lay on the same horizontal line in the face (one eye is positioned lower than the other). The treatment is based on the reconstruction of this orbital floor, by either closing the boney cleft or reconstructing the orbital floor using a  bone graft . [ 25 ]


There are many types of operations which can be performed to treat a hypertelorism. 2 options are: box osteotomy and facial bipartition [ 26 ]  (also referred to as a median fasciotomy).
The goal of the box osteotomy is to bring the orbits closer together by removing a part of the bone between the orbits, to detach both orbits from the surrounding bone structures and move both orbits more to the centre of the face.
The goal of the facial bipartition is not only to bring the orbits closer together, but also to create more space in the maxilla. This can be done by splitting the maxilla and the frontal bone, remove a triangular shaped piece of bone from the forehead and nasal bones and pulling the two pieces of forehead together. Not only will the hypertelorism be solved by pulling the frontal bone closer together, but because of this pulling, the space between the both parts of the maxilla will become wider.


The nose anomalies found in facial clefts vary. The main goal of the treatment is to reconstruct the nose to get a functional and esthetic acceptable result. A few possible treatment options are to reconstruct the nose with a forehead flap or reconstruct the nasal dorsum with a bone graft, for example a rib graft. The  nasal reconstruction  with a forehead flap is based on the repositioning of a skin flap from the forehead to the nose. A possible downside of this reconstruction is that once you performed it at a younger age, you can't lengthen the flap at a later stage. A second operation is often needed if the operation is done on early age, because the nose has a restricted growth in the cleft area. Repair of the  ala  (wing of the nose) often requires the inset of cartilage graft, commonly taken from the ear. [ 27 ]


The treatment of soft tissue parts of midface anomalies is often a reconstruction from a skin flap of the cheek. This skinflap can be used for other operations in the further, as it can be raised again and transposed again. In the treatment of midface anomalies there are generally more operations needed. Bone tissue reconstruction of the midface often occurs later than the soft tissue reconstruction. The most common method to reconstruct the midface is by using the fracture/ incision lines described by  René Le Fort . When the cleft involves the maxilla, it is likely that the impaired growth will result in a smaller maxillary bone in all 3 dimensions (height, projection, width).


There are several options for treatment of mouth anomalies like Tessier cleft number 2-3-7 . These clefts are also seen in various syndromes like Treacher Collins syndrome and hemifacial microsomia, which makes the treatment much more complicated. In this case, treatment of mouth anomalies is a part of the treatment of the syndrome.


Related articles


Syndromes


Joel Ferri  is a  French   Stomatologist , Oral and Maxillofacial Surgeon,  academic  and  author . He is the chairman and head of the Department of Oral and Maxillofacial Surgery at the Lille Medical School. [ 1 ]


Ferri is most known for his contributions to  stomatology  and maxillofacial surgery outcomes, with a special involvement in bone surgery ( orthognathic surgery , bone reconstruction, TMJ prosthesis). Among his notable works are his publications in academic journals, including the  American Journal of Orthodontics and Dentofacial Orthopedics  and  Journal of Oral and Maxillofacial Surgery  as well as an edited book titled  Preprosthetic and Maxillofacial Surgery: Biomaterials, Bone Grafting and Tissue Engineering . [ 2 ]


Ferri earned his  medical degree  from  Nantes University  in 1990. Additionally, he acquired a Specialized  Diploma  in  Stomatology  and Maxillofacial Surgery, along with a diploma in Facial and Neck Surgery. Subsequently, in 1996, he successfully completed his  Ph.D . [ 1 ]


Ferri was appointed as a  professor  in the Department of Oral and Maxillofacial Surgery at the  University of Lille  in 1997. From 2004 to 2008, he served as the president of the International Bone Research Association and as the president of the French Society of Stomatology and Maxillofacial Surgery in 2011. In 2022 as a result of his involvement of the head and neck malformations he was admitted as a member of the Undiagnosed Disease Network International (UDNI). He was admitted as a member of the European Society of TMJ Surgeons (ESTMJS) and was appointed president of this society in 2017. Moreover, he has been serving as the chairman and head of the Department of Oral and Maxillofacial Surgery at the Lille medical school since 1997. [ 1 ]


Ferri's early research was focused on the bone of the maxillo-facial area. He conducted a retrospective study comparing the advantages and disadvantages of mandibular reconstruction using a fibula free flap versus other techniques. The study found that while the fibula flap offers benefits like bone length and low donor site morbidity, it may not be suitable for large soft tissue defects, with the conclusion that it is satisfactory for defects over 20 cm in size. [ 3 ]  While investigating the relationship between the fiber-type composition of the masseter muscle and different bite patterns in individuals undergoing surgical correction of malocclusion, his 2005 research revealed significant associations between muscle composition and vertical bite characteristics, particularly in Class III subjects. [ 4 ]  In the same year, through his research, he presented a surgical protocol utilizing bimaxillary advancement and adjunctive procedures for the treatment of obstructive sleep apnea syndrome (OSAS) in patients affected by facial or mandible retrusion, demonstrating a high success rate in reducing the apnea/hypopnea index and improving patient outcomes. [ 5 ]


Ferri's 2010 work examined the impact of orthognathic surgery on temporomandibular joint (TMJ) disorders, finding that while the surgery significantly reduces TMJ symptoms in patients with pre-operative symptoms, there is a risk of new onset of TMJ symptoms post-surgery, albeit with a low occurrence rate. [ 6 ]  In 2011, he co-edited the book titled  Reprosthetic and Maxillofacial Surgery: Biomaterials, Bone Grafting and Tissue Engineering , wherein he provided a comprehensive overview of preprosthetic and maxillofacial surgery, focusing on bone grafting, reconstructive surgery, and tissue engineering to enhance dental implant success and patient rehabilitation. [ 2 ]  His 2014 work with Andreas Neff and others evaluated treatment strategies for mandibular condylar fractures, finding a growing consensus among experts favouring open reduction with internal fixation (ORIF) as the gold standard, especially for displaced fractures, with considerations for endoscopic approaches and pediatric cases. [ 7 ]  In 2016, he reported a case of osteochimionecrosis on a fibula flap transferred for mandibular reconstruction, demonstrating that the transferred bone behaved similarly to the original one, thereby proving that environmental factors dictate bone behavior and pathophysiology regardless of its original nature. [ 8 ]  His 2017 work was a retrospective study comparing recurrence rates of ameloblastoma following conservative and radical treatments, revealing a significantly higher recurrence rate in the conservative treatment group, suggesting treatment should be tailored based on tumor characteristics and patient factors. [ 9 ]  More recently in 2022, he explored the regeneration potential of bone substitutes using a rabbit model with two different types of critical-sized defects, validating the model for calvaria defects but not for mandibular defects, and suggesting further research to improve mandibular defect design. [ 10 ]


Genioglossus advancement  ( GA ) is a  surgical procedure  or  sleep surgery  in which the base of the  tongue  is pulled forward. [ 1 ]  It is usually to increase airway size due to deformity or a  sleep breathing disorder . This procedure is frequently performed with either  uvulopalatopharyngoplasty  or  maxillomandibular advancement  surgeries.


Tongue muscles (genioglossus, geniohyoid and others) are attached to the lower jaw below the teeth. During a genioglossus advancement procedure, a small window or bone cut is made in the front part of the lower jaw (mandible) at the level of the geniotubercle which is where the genioglossus muscle is attached. This piece of bone along with the attachment for the tongue (genial tubercle) is pulled forward and is subsequently secured to the lower jaw, usually with a single screw or with a plate(s) and screws.


This procedure is often combined with other surgeries such as uvulopalatopharyngoplasties or maxillomandibular advancement surgeries. It is rare to have this procedure performed as the only surgical treatment for sleep apnea, as obstruction in sleep apnea is most often at multiple levels (nose, palate, tongue, etc.).


Hyoid suspension , also known as hyoid myotomy and suspension or hyoid advancement, is a  surgical procedure  or  sleep surgery  in which the  hyoid bone  and its muscle attachments to the tongue and airway are pulled forward with the aim of increasing airway size and improving airway stability in the retrolingual and hypopharyngeal airway (airway behind and below the base of tongue). The horseshoe shaped hyoid bone sits directly below the base of tongue with the arms of the bone flanking the airway. Hyoid suspension is typically performed as a treatment for  obstructive sleep apnea  (OSA). This procedure is frequently performed with a  uvulopalatopharyngoplasty  (UPPP) which targets sites of obstruction higher in the airway. Typically, a hyoid suspension is considered successful when the patient's  apnea-hypopnea index  is significantly reduced after surgery.


The American Academy of Otolaryngology–Head and Neck Surgery position statement considers hyoid suspension "effective and non-investigational with proven clinical results when considered as part of the comprehensive surgical management of symptomatic adult patients with mild obstructive sleep apnea (OSA) and adult patients with moderate and severe OSA assessed as having tongue base or hypopharyngeal obstruction." [ 1 ]


The  American Sleep Apnea Association  (ASAA) website  describes  hyoid suspension as a minimally invasive procedure where: "Success from this procedure has been outstanding and is becoming a valuable tool in the surgeon's armamentarium."


Hyo-mandibular advancement along with genioglossus advancement was originally described by in 1984. [ 2 ]   Published clinical experience with hyoid suspension can be summarized into three different approaches to the hyoid suspension procedure: hyo-mandibular suspension, hyo-thyroid suspension, and genioglossus advancement and hyoid myotomy.


In hyo-mandibular suspension, sutures are looped around the anterior section of the hyoid bone, the hyoid is advanced typically 2–3 centimeters (until the muscle attachments to the hyoid are tensioned) using the sutures, and the hyoid advancement is locked into place and secured via bone anchors on the front lower inside portion of the jaw. This procedure is typically performed with two incisions, one incision under the chin for placement of bone anchors into the jaw and one incision directly over the hyoid bone for the most direct access to the bone.  Some surgeons perform the procedure from only the single incision below the chin. Potential complications and side effects from the procedure include neck seromas, edema, and surgical site infection.


In hyo-thyroid suspension, sutures are looped around the hyoid, and the hyoid bone is advanced using the sutures to the upper edge of the thyroid cartilage where it is sutured and tied to the top of the thyroid cartilage. This procedure is typically performed from a single incision directly over the hyoid bone. Potential complications and side effects from the procedure include neck seromas, edema, transient dysphagia, and surgical site infection.


In genioglossus advancement and hyoid myotomy (GAHM), a genioglossus advancement is performed at the same time as either a hyo-mandibular or hyo-thyroid suspension. Potential complications and side effects from the procedure include lip and chin hypoanesthesia, seromas, edema, transient dysphagia and aspiration, and surgical site infection.


Published clinical results for hyoid suspension performed with a UPPP are presented in the table below. [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 7 ] [ 8 ] [ 9 ] [ 10 ] [ 11 ] [ 12 ] [ 13 ] [ 14 ] [ 15 ] [ 16 ] [ 17 ] [ 18 ] [ 19 ]  Surgical success typically means that the AHI is reduced at least 50% and that the post-operative AHI is less than 20.


Published clinical information for the three hyoid suspension variations without a UPPP is very limited. [ 20 ] [ 21 ] [ 22 ]


For many years, a genioglossus advancement was consistently performed with a hyoid suspension where the more invasive and morbid genioglossus advancement was considered a necessary component for the overall success of the tongue base intervention. Hyo-thyroid suspension published evidence comes entirely from Europe where the low cost, reduced morbidity, and nearly equivalent results to GAHM have made it the preferred technique.
Recent publications have suggested that hyo-mandibular suspension may be the most effective hyoid suspension technique in treating tongue base and hypopharyngeal obstructions. [ 23 ]   The technique is similarly invasive to hyo-thyroid suspension and available clinical data shows 25% greater efficacy for the reduction of AHI when compared to hyo-thyroid suspension. Data available for hyo-mandibular suspension also shows similar superior efficacy to the GAHM procedure. Hyo-mandibular suspension requires a surgical kit and implants ( Siesta Medical Encore  or  Medtronic Airvance ) which make the procedure marginally more expensive than hyo-thyroid suspension.


A  labial frenectomy  is a form of  frenectomy  performed on the lip.


The  labial   frenulum , also known as lip-tie, often attaches to the center of the upper lip and between the upper two front teeth. This can cause a large gap and gum recession by pulling the gums off the bone. A labial frenectomy removes the labial frenulum. Orthodontic patients often have this procedure done to assist with closing a front  tooth gap . When a  denture  patient's lips move, the frenulum pulls and loosens the denture, which can be uncomfortable. This surgery is often done to help dentures fit better. [ 1 ]  A labial frenectomy can result in significant improvement in  breastfeeding  outcomes. [ 2 ]


Laboratory Unit for Computer Assisted Surgery   is a system used for virtual  surgical planning . Starting with 1998, LUCAS was developed at the  University of Regensburg, Germany , with the support of the  Carl Zeiss Company . The resulting surgical planning is then  reproduced  onto the patient by using a  navigation system . In fact, LUCAS is integrated into the same  platform  together with the  Surgical Segment Navigator (SSN) , the Surgical Tool Navigator (STN), the Surgical Microscope Navigator (SMN) and the 6 DOF  Manipulator (or, in German, "Mehrkoordinatenmanipulator" - MKM), also from the  Carl Zeiss Company .


Data from separate  bidimensional  slices generated by a  CT  or  MRI  scan are uploaded into the LUCAS system. The resulting  dataset  is then processed, in order to eliminate  image noise , and to enhance the anatomical contours and also the general contrast of the images. The next step is to create a virtual  3D  model from the gathered collection of  2D  images. The bone segment that is to be repositioned is marked, on the 3D grid reconstructed model; then, the actual repositioning of that bone segment is done on the virtual model, until the optimal anatomical position is obtained. The criteria for the optimal position of the bone segment are: symmetry with the opposite side, the continuity of the normal bone contours, or the normal volume of an anatomical region (such as the  Orbit . Afterwards, a  textured  final image is rendered. The calculated vectors for the bone segment repositioning, together with the whole virtual model are finally transferred to the  Surgical Segment Navigator .


The  Le Fort  (or  LeFort )  fractures  are a pattern of midface fractures originally described by the French surgeon,  René Le Fort , in the early 1900s. [ 1 ]  He described three distinct fracture patterns. Although not always applicable to modern-day facial fractures, the Le Fort type fracture classification is still utilized today by medical providers to aid in describing  facial trauma  for communication, documentation, and  surgical planning . [ 2 ]  Several surgical techniques have been established for facial reconstruction following Le Fort fractures, including  maxillomandibular fixation (MMF)  and  open reduction and internal fixation (ORIF) . The main goal of any surgical intervention is to re-establish  occlusion , or the alignment of upper and lower teeth, to ensure the patient is able to eat. [ 2 ]  Complications following Le Fort fractures rely on the anatomical structures affected by the inciding injury.


When discussing the anatomy of the face, it is often divided into thirds. The lower third extends from the chin to approximately the level of the upper teeth. The middle third continues from the teeth to just below the brow line. Finally, the upper third stretches from the brow to the hairline. [ 3 ]


The middle third of the face, or the midface, is the anatomical location in which Le Fort fractures occur. It comprises the  maxillary bone ,  palatine bones ,  zygomas ,  zygomatic processes (of the temporal bone) ,  ethmoid bone ,  vomer ,  nasal concha ,  nasal bones , and  pterygoid processes (of the sphenoid bone) . [ 2 ] [ 3 ] [ 4 ]


The maxillary bone contains important anatomical structures which are prone to injury during trauma. The  maxillary sinuses  are housed within the maxillary bone, and traumatic injury to these sinuses may cause  sinus infections , and changes in eye placement and movement. [ 4 ]  The  infraorbital nerve  (a terminal branch of  CNV2 ) courses through the maxillary bone and provides sensation to the central face. Additionally, the maxillary bone contains the upper row of teeth (maxillary dentition).  Occlusion , or the alignment of upper and lower teeth, is vital following midface trauma to ensure a patient is able to eat and speak. [ 2 ]


Facial  biomechanics , or the study of forces on the facial bones, plays an important role in midface reconstruction following trauma. Although the biomechanics of the face are not fully understood due to their complex nature, several vertical and horizontal buttresses, or pillars, have been established. These buttresses dissipate the powerful forces the skull endures during biting and chewing. [ 2 ] [ 5 ] [ 6 ]


The Le Fort fractures are a pattern of midface fractures originally described by the French surgeon,  René Le Fort , in the early 1900s. [ 1 ]  Le Fort studied the effect of  facial trauma  by dropping cadavers from various heights and recording the different fracture patterns observed. [ 2 ]  Today, with the evolution of high-speed  motor vehicle accidents  and advancements in  medical imaging  and surgical techniques, the low-speed fracture patterns originally described by Le Fort are not always applicable. [ 7 ]  Modern midface fractures typically do not neatly fit into one of the Le Fort classifications and often occur in combination with other  craniofacial trauma . [ 1 ]  Nevertheless, the Le Fort type fracture classification is still used today as a starting point for describing midface fractures for communication, documentation, and treatment planning. [ 2 ]


Traditionally, Le Fort described three types of fractures. All three fractures involve the  nasal septum  and the  pterygoid plates . [ 2 ]


Every trauma patient presenting to the hospital should first be evaluated according to the  Advanced Trauma Life Support (ATLS) protocol , which follows the ABC's ( airway ,  breathing ,  circulation ) of trauma. This includes ensuring the patient is able to breathe, confirming that the patient is actively  breathing , and identifying and minimizing major bleeding. [ 1 ] [ 2 ] [ 6 ]  Le Fort fractures have the potential to obstruct a patient's  airway  for a variety of reasons, preventing him or her from being able to breathe. [ 1 ] [ 6 ]  Medical providers should be prepared for  emergency airway management  should the patient develop an obstructed airway due to bleeding or swelling. [ 6 ]  Other life-threatening injuries, including those to the  brain ,  spine , or  abdomen , should receive prompt evaluation by the appropriate  medical specialist . [ 6 ]


After the initial evaluation is complete and the patient is  stable , the patient should be evaluated by a surgeon that specializes in facial trauma, such as a  plastic surgeon , an  otolaryngologist  (ear, nose, and throat surgeon), or an  oral and maxillofacial surgeon  (OMFS). The surgeon will perform a thorough facial exam, paying special attention to any new-onset facial asymmetry or distortion. [ 1 ]  Facial swelling and bruising is very common in Le Fort fractures and can make evaluation of facial changes challenging. [ 6 ]  It can be helpful to have a picture of the patient prior to his or her facial trauma as a comparison.


If the surgeon suspects a Le Fort fracture, they may test for abnormal movement of the  maxillary bone  by planting one hand on the patient's forehead and using the other hand to press on the roof of the patient's mouth. [ 1 ]  Movement in the  maxillary bone  either in isolation or with the nose is suggestive of a Le Fort I or II fracture, respectively. [ 1 ]


The  cranial nerves (CNs)  should be  examined  if the patient is awake and able to participate in the exam process. [ 2 ]  The  CN exam  evaluates facial movement and sensation. Special attention should be made to the  fifth CN (CNV)  as one of its branches (the  infraorbital nerve ) courses through the  maxillary bone . [ 2 ]  If this nerve is injured during trauma, it can result in numbness or tingling around the nose or within the mouth. [ 2 ]


The surgeon will also examine the patient's mouth for bleeding, swelling, cuts, foreign objects, changes in bite, and newly lost teeth. Additionally, an eye exam assessing vision and  pupillary response  may be warranted, especially in Le Fort II and III fractures due to the involvement of the  orbit . [ 2 ]  If there is suspicion that the  skull base has been injured , such as during a Le Fort III fracture, the patient should be examined for clear drainage from the ear or nose which may be caused by a  cerebrospinal fluid (CSF) leak . [ 2 ] [ 6 ]  Abnormal findings during these mouth, eye, ear, or nose exams may require further evaluation.


If it was determined that the patient lost a tooth during the inciting trauma, the tooth's location should be identified as it could have become lodged in the airway,  aspirated into the lungs , or swallowed. [ 1 ]  If there is concern for an  aspirated  tooth, an  x-ray  can confirm the tooth's location. [ 1 ] [ 6 ]  If the eye exam reveals abnormalities in either vision or the  pupillary response , prompt evaluation by a  neurosurgeon  and an  ophthalmologist  should occur. [ 2 ]   Skull base injuries  can result in a  cerebrospinal fluid (CSF) leak , which can present as a clear, metallic-tasting liquid draining from the  nose  or the ear. [ 2 ]  If a CSF leak is suspected, the patient should be evaluated by a  neurosurgeon . [ 6 ]


Although diagnosis can be suspected by history and physical exam, imaging is required for an accurate diagnosis. A  computed tomography (CT)  of the face and skull is the imaging of choice for diagnosing Le Fort fractures. [ 5 ] [ 7 ]  CT imaging has greatly replaced the use of  plain x-ray  as CTs are significantly more likely to show when a fracture is present compared to an x-ray. [ 7 ]  Additionally, CT imaging is far more useful in visualizing the skeletal injuries in Le Fort fractures than  magnetic resonance imaging (MRI) . [ 7 ]  However, MRIs may be useful if there is extensive  soft tissue injuries . [ 6 ]


Surgical  treatment of Le Fort fractures is almost always necessary, especially if the fractures are displaced or impact facial functions like eating and speaking. [ 6 ]  Fractures can be repaired through  maxillomandibular fixation (MMF)  and/or  open reduction and internal fixation (ORIF)  after life-threatening injuries have been addressed.


The primary goal of any intervention is to ensure that a patient is able to eat and speak. This is done by re-establishing  occlusion  (alignment of upper and lower teeth) and stabilizing  facial biomechanics  (via the vertical and horizontal facial buttresses discussed previously) to support chewing. [ 1 ]  Other goals of intervention include restoring cosmetic deformities from the trauma, but this should never be prioritized over re-establishing occlusion. [ 1 ]


Maxillomandibular fixation (MMF) , also known as intermaxiallary fixation (IMF), is a surgical procedure to re-establish  occlusion  by fixating the upper and lower teeth in their correct position. It can be used in isolation or in combination with  open reduction and internal fixation (ORIF)  in treating Le Fort fractures. [ 6 ]  Several surgical techniques exist for establishing MMF, with selection relying on the individual patient injury and surgeon preference. [ 1 ] [ 2 ]  MMF involves fixation of the upper and lower teeth for 6-8 weeks, which limits a patient's ability to speak, eat, breathe through their mouth, and maintain adequate  oral hygiene . [ 1 ]  MMF patients should be provided with wire cutters or scissors for emergency situations. [ 1 ]  A patient in MMF will be placed on a liquid-only diet during the entirety of their treatment, which may result in weight changes. [ 1 ] [ 8 ]  MMF has some effect on a patient's ability to breathe through their mouth while in place, so patients with a history of  pulmonary disease  who rely on mouth breathing may not qualify for MMF. [ 8 ]   Additionally, patients with psychological or seizure disorders may not be good MMF candidates. [ 1 ]


Open reduction and internal fixation (ORIF)  is a surgical term that refers to open surgical repair of broken bones. It is required for correction of complex Le Fort fractures affecting facial function or involving neurological complications (visual changes,  CSF leak ). [ 6 ]  ORIF is especially important for repairing unstable facial buttresses in order to allow the patient to tolerate chewing. Plates and screws are often permanently fixated to facial bones to stabilize the lateral and medial vertical buttresses bilaterally. [ 2 ]  Bone grafts may also be required to stabilize the buttresses. [ 2 ]  ORIF can be used in isolation or in combination with  maxillomandibular fixation (MMF)  in treating Le Fort fractures. [ 6 ]  Following surgery, patients may require up to six weeks of rest before they are able to return to the demands of their daily life. [ 6 ]  As all patients heal slightly differently, ORIF may result in a less-than-ideal correction of facial bones, resulting in poor  occlusion  or facial asymmetries. Furthermore, as with any surgery, ORIF comes with risk of scarring, nerve injury, and infection. [ 2 ]


The role of  antibiotics  in midface trauma is a complex and highly patient-dependent topic. Facial trauma patients with  lacerations  (or wounds) to the inner lining ( mucosa ) of the  mouth  or the  nose  traditionally have been started on antibiotics as soon as they enter the hospital and have remained on antibiotics for a minimum of 24 hours after surgery. [ 2 ]  However, some preliminary studies on  preoperative  antibiotic use suggest that they may not be necessary to prevent  bacterial infections , though these are based on small patient populations and are not strong enough studies to set specific recommendations regarding preoperative antibiotic use. [ 9 ]  Therefore, patients are still often placed on antibiotics before surgery, especially if they are at an increased risk of developing infection (including, but not limited to, patients that are elderly,  tobacco users ,  diabetic , and/or  immunocompromised ). [ 9 ] [ 10 ]  If a patient is begun on antibiotics, it is difficult to determine how long they should remain on antibiotics  postoperatively . [ 10 ]  Although multiple studies have been performed examining postoperative antibiotic use, they have come to contradicting conclusions. [ 11 ]  The more recent studies have suggested that antibiotics may not have any advantage in preventing postoperative bacterial infections. [ 10 ] [ 11 ]  However, these studies acknowledge that their results are based predominantly on the young, healthy, male patients with non-specific  facial trauma  that make up the majority of the studies' participants and may not be applicable to the everyone experiencing midface trauma. [ 10 ]  With limited studies specifically on midface trauma, no standards for postoperative antibiotic use has been determined. The use of postoperative antibiotics relies on the surgeon's clinical recommendations and individual patient risk factors. [ 10 ]


Longterm outcomes of Le Fort fractures depend on the severity and location of the fracture. The most common complication of Le Fort fractures include imperfect fracture reduction resulting in poor  dental occlusion . [ 2 ]  Other longterm effects of Le Fort fractures include various nerve injuries, either from the inciting injury or from surgical correction, resulting in facial movement and sensory deficits. [ 2 ]  If one or both of the  maxillary sinuses  are injured during the trauma, it can result in  chronic sinus infections  or injuries to the eye which may require further surgical correction. [ 2 ]  Le Fort III fractures that injure the  optic nerve  or the  extraocular muscles  that move the eye may result in visual defects. [ 2 ]


The  Le Fort III Osteotomy  for  oral and maxillofacial surgery , is used to correct generalised growth failure of the midface involving the upper jaw nose and cheek bones ( zygomas ). [ 1 ]  The surgical approach and post operative management is similar as for the Le Fort II procedure. [ 2 ]


Brow lift procedures may be carried out at the same time as  Le Fort II  and Le Fort III osteotomies. [ citation needed ]


A  Le Fort osteotomy  is the name for three types of  osteotomies  of the jaw and face. They are based on [ 1 ]  the  analogous bone fractures  described by the French surgeon and physician  René Le Fort . [ 2 ]


A Le Fort I osteotomy surgically advances the upper jaw to correct misalignment and deformities. It is used in the treatment for several conditions, including skeletal  class II malocclusion ,  cleft lip and cleft palate ,  vertical maxillary excess  (VME) or deficiency, and some specific types of  facial trauma , particularly those affecting the mid-face. The procedure involves separating the upper jaw, repositioning it forward, and then securing it with plates and screws. [ 1 ] [ 3 ]


The Le Fort II osteotomy treats maxillary fractures. [ 4 ]


The Le Fort III osteotomy treats midfacial abnormalities and deficiencies. [ 5 ]


"Le Fort IV" has been used to describe a monobloc frontofacial osteotomy in 2000s French literature, but the use is heavily disputed. [ 6 ]  In 2014, the same term was used by a Japanese group to describe a "monobloc minus Le Fort I" osteotomy. [ 7 ]


Lifestyle Lift  (stylized in uppercase in its logo) was a national facial  cosmetic surgery  practice with headquarters in  Troy, Michigan , United States. The company's name in all caps is a  trademarked  brand name [ 1 ]  used to market a particular type of facial surgery called the lifestyle lift. In 2012,  Debby Boone  became the spokesperson for the company in its television commercials and its half-hour  infomercial . [ 2 ]  The company discontinued using Boone in late 2013 shifting to a new advertising campaign. [ 3 ]   The company abruptly closed all its offices in early March 2015 and announced its intention to declare bankruptcy. [ 4 ]


The procedure is advertised as a minimally invasive, short-flap  face lift  performed under  local anesthesia .  The procedure involves the excess skin and  superficial muscular aponeurotic system  (SMAS) layer. [ 5 ]


Lifestyle Lift was founded by Dr. David Kent, whose previous medical practice focused on  otolaryngology  head and neck surgery, facial plastic surgery and hair replacement.  Kent completed an  osteopathic residency  in otolaryngology-head and neck surgery and facial plastic surgery.  He is a member of the  American Academy of Facial Plastic and Reconstructive Surgery [ 6 ]  and board certified by the  American Osteopathic College of Otolaryngology - Head and Neck Surgery . [ 7 ]  Kent was recently named Ernst & Young's 2012 Entrepreneur of the Year. He started Lifestyle Lift in 2001 with one office and has grown it to over 50 surgical, consultation and affiliated offices with more than 100 physicians. [ 8 ]  R. James Koch joined Lifestyle Lift in 2006 as medical director and oversaw medical training for the company.  Prior to joining Lifestyle Lift, Koch was a full-time faculty member at the  Stanford University School of Medicine  where he served as associate professor, co-director of the Division of Facial Plastic Surgery, and co-director of the Fellowship for Advanced Facial Plastic & Reconstructive Surgery. [ 9 ] [ unreliable source? ]  Koch resigned from the organization in 2010 and was replaced by three regional medical directors that same year and who were subsequently named medical directors in 2012: David Santos, Pacific and Mountain Regions; Jason Swerdloff, Southeast and Northeast Regions; Carlos Farias, Midwest and Northeast Regions. [ 10 ]  The company closed its operations and filed for bankruptcy on March 2, 2015. [ 11 ]


The company website lists 172,255 completed surgeries as of 5 February 2014. [ 12 ]   There are almost 200 reviews of the company out of over 150,000 customers—some of them negative—on  RealSelf .com, which Lifestyle Lift sued for trademark infringement (the case was settled). [ 13 ]  Lifestyle Lift has attempted to sue other companies based on trademark infringement, including informercialscams.com (now defunct). In 2008, Lifestyle Lift was the subject of an eight-part mini-series by the  CBS  affiliate in  Atlanta  featuring three dissatisfied Lifestyle Lift patients, and former employees and their complaints against the company. [ 14 ] [ 15 ]  In 2009, a Florida woman died just hours after undergoing a cosmetic facial surgery at a Lifestyle Lift center in Maitland, Florida. [ 16 ]


Lifestyle Lift® and/or its doctors have been the subject of multiple alleged malpractice claims in the state of Florida. [ 17 ]


In 2009 Lifestyle Lift reached a settlement with  New York  state over claims it had posted false customer endorsements on third-party websites, including RealSelf.com, [ 18 ]  and on some websites the company had created for the purpose. [ 19 ]  Lifestyle Lift was ordered to pay $300,000 to the state, and it agreed to cease the practice. [ 18 ]
In 2013, after a three-year review of all aspects of Lifestyle Lift marketing, the Florida Attorney General found that Lifestyle Lift was compliant with all state regulations. As a result, no fines were levied, but Lifestyle Lift reimbursed the State of Florida for costs of the investigation and made a donation to a Florida Attorney General sponsored charity. During the course of the investigation, Lifestyle Lift voluntarily made several minor changes to its marketing materials to ensure clarity for consumers. [ 20 ]


In 2008, an  Orlando, Florida , plastic surgeon filed a complaint with the Florida Board of Medicine, seeking payment for emergency room services he provided to a Lifestyle Lift patient; the company denied that it was negligent. [ 19 ]  Lifestyle Lift was also the subject of a March 2010 lawsuit filed by the family of a Massachusetts patient who died as a result of complications with local anesthesia in July 2009. The suit alleged that doctors failed to monitor the woman's vital signs during the procedure; in a statement, Lifestyle Lift responded that the woman had failed to disclose pertinent medical information. [ 21 ]  In an August 2011 lawsuit filed in  Broward County, Florida , a patient claimed she developed  keloid  scars within days following a Lifestyle Lift facelift, and that the doctor had lied about the risks of scarring. [ 22 ]  In a statement to the press, Lifestyle Lift indicated disagreement with the "accounting of events" described in the suit, and said it remained supportive of its surgeon. [ 23 ]