Monobloc Frontofacial Advancement
S. Anthony Wolfe
Nicole C. Cabbad
DEFINITION AND ANATOMY
The Le Fort III-type osteotomy was first described by Gillies and modified by Tessier. (Tessier called it Le Fort III-type because the pterygoid plates were not fractured and it was subcranial.)
This procedure represents the highest level of maxillofacial osteotomy performed without a craniotomy. It separates the face from the skull with osteotomies across the orbital floor, lateral orbital walls, zygomatic arches, and nasofrontal area and with a pterygomaxillary disjunction (FIG 1A-C).
The orbital osteotomies go deep inside the orbit, behind the lacrimal system, and instead of going through the posterior hard palate—as originally described by Gillies— Tessier performed a disjunction between the maxillary tuberosities and the pterygoid plates (see FIG 1B).
In Tessier’s patient, interpositional bone grafts were placed into all surgical gaps, with maxillary advancement of 20 mm. Traction to a head frame was maintained for months, and intermaxillary fixation for almost a year.
Tessier then developed the simultaneous fronto-orbital advancement—referred to as the BO-Fort procedure—a combined anterior movement of the forehead with a Le Fort III-type advancement (FIG 2).
The first true monobloc frontofacial advancement was performed in Mexico City and published in 1978,1 and Tessier presented his modification of the procedure in 1995, which was designed to provide stable anterior movement of the entire facial skeleton.
It leaves the effective orbit attached to the midface, differentiating it from the Le Fort III-type and BO-Fort that Tessier had previously developed.
FIG 1 • Francine Gourdin’s drawings of Dr. Tessier’s first Le Fort III procedure. A. Osteotomy lines. B. Anterior movement of the midface. C. Bone grafts in position to stabilize the advancement. (From Wolfe SA. A Man from Héríc: The Life and Work of Paul Tessier, MD, Father of Craniofacial Surgery. Miami, FL: Lulu Press; 2011, with permission.)
The monobloc was eventually associated with a facial bipartition.
Monobloc frontofacial advancement with a facial bipartition includes removal of the interorbital naso-orbital-ethmoid maxillary bone for overcorrection of hypertelorism as seen in patients with Apert syndrome.
The new, curved frontal bandeau made it possible to correct all of the morphological alterations of Apert patients (flat face, retrusive forehead, mild to moderate orbital hypertelorism, scaphymaxillism) in one operation.
PATIENT HISTORY AND PHYSICAL FINDINGS
Patients with a retrusive forehead and midface, proptosis, and class 3 malocclusion (common in craniofacial dysostosis patients such as Crouzon or Apert) benefit from the monobloc advancement.
IMAGING
Although skull x-rays and clinical exam were sufficient for Dr. Tessier in 1958, we now rely on CT scans with 3D reconstructions.
Virtual surgical planning (VSP) is widely available.
VSP can help the less experienced surgeon determine vectors of movement.
 FIG 2 • Dr. Tessier’s drawings of the osteotomies (A) and subsequent advancement (B) for his Bo-Fort osteotomies. Notice the addition of the forehead component as compared to a traditional Le Fort III procedure. Dr. Tessier’s skull models showing his Bo-Fort osteotomies (C) and advancement (D) procedure. (From Wolfe SA. A Man from Héríc: The Life and Work of Paul Tessier, MD, Father of Craniofacial Surgery. Miami, FL: Lulu Press; 2011, with permission.) |
SURGICAL MANAGEMENT
Preoperative Planning
Evaluation by the primary care physician or pediatrician and requisite specialists (such as pulmonologists, neurosurgeons) should be completed prior to the procedure.
Anesthesia should evaluate the patient preoperatively; airway concerns should be discussed with the surgeon, given that the airway might be challenging postoperatively.
Type and cross +/− familial blood donation should all be done prior to the day of surgery.
Several units of blood should be available at the time of incision.
Positioning
Position the patient supine on the operating room table with the arms tucked in a padded, anatomically favorable position.
The head should be placed on a hydraulic donut.
A Foley catheter should be inserted.
A warming blanket should be placed either under or over the patient’s body.
All wires and monitoring devices should be padded to ensure there are no pressure points on the body during a prolonged case.
Secure the endotracheal tube with wire fixation to the dentition for easy maneuvering of the head without concern of extubation.
Approach
Coronal and intraoral upper buccal sulcus incisions are used to access the osteotomy sites.
 FIG 3 • These results show Dr. Tessier’s ability to treat a 2-year-old child with a traditional monobloc facial advancement and wire-only fixation for the osteosynthesis. A, C. Preoperatively, the patient has forehead retrusion, proptosis, and midface deficiency. B,D. Postoperatively, the degree of advancement of the alveolus and forehead is harmonious. (From Wolfe SA. A Man from Héríc: The Life and Work of Paul Tessier, MD, Father of Craniofacial Surgery. Miami, FL: Lulu Press; 2011, with permission.) |
 FIG 4 • This patient underwent a monobloc facial advancement by Dr. Tessier around age 6. Postoperative pictures demonstrate normal facial features with a normal nasofrontal relationship. (From Wolfe SA. A Man from Héríc: The Life and Work of Paul Tessier, MD, Father of Craniofacial Surgery. Miami, FL: Lulu Press; 2011, with permission.) |
TECHNIQUES
▪ Monobloc Using an Expansile Bandeau
Preparation and Exposure
A metal-reinforced endotracheal tube is placed orally and fixated using circum-mandibular wires.
If a tracheostomy is present, the tube is sutured to the chest wall to prevent dislodgement.
The nose is packed with Neo-Synephrine-soaked pledgets.
The coronal incision is marked; several mm both above and below the incision is shaved free of hair.
Hair surrounding the incisions is braided and secured with ties.
A sterile head wrap is placed and towels are stapled just below the incision to prevent occipital hair from entering the surgical field.
The scalp is infiltrated with a dilute adrenaline solution (1:250 000).
With the patient asleep, the eyelids are retracted with cotton tip applicators well beyond the equator of the globe—referred to as the “Tessier sign” (TECH FIG 1).Related posts:
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