Craniofacial reconstruction at Chester, The Grosvenor Hospital

What is craniofacial reconstruction?

Craniofacial reconstruction is surgery to correct problems with the bones and tissues of the skull, face and jaws. It treats both conditions you're born with and problems caused later by injury, tumours, or the treatment of a tumour.

What conditions does it treat?

Craniofacial reconstruction treats birth conditions such as craniosynostosis, where the skull bones fuse together too early, along with conditions including Crouzon's syndrome, Apert's syndrome, hemifacial microsomia and facial clefts. Some of these conditions, if left untreated, can cause serious problems, including pressure inside the skull that affects a child's sight.

It's also used after facial injuries, including fractures of the cheekbone, jaw, or the bones around the eyes and nose, and to rebuild the face after a tumour or treatment.

What are the benefits of craniofacial reconstruction?

Surgery can relieve serious functional problems, such as making more space inside the skull for the brain to grow properly, protecting eyes that are dangerously prominent, and making breathing or feeding easier.

It can also restore a more typical facial structure and appearance after injury, a tumour, or its treatment.

Are there different types of surgical approaches?

There are several surgical techniques used in craniofacial reconstruction, and your surgeon will choose based on the condition being treated:

• bone grafting: bone is taken from elsewhere in your body, most often the hip or skull, and used to fill gaps or provide support. Your own bone is generally the best material to use, since it carries a low risk of infection and good potential to grow with you
• genioplasty: surgery to reposition the chin bone forwards, backwards, upwards or downwards, through a cut inside the mouth, with the bone fixed in its new position using wires or titanium screws that stay in place permanently
• distraction osteogenesis: rather than repositioning bone in one step, a small device gradually moves bone into a new position over time, allowing new bone to form and fill the gap as it goes
• direct repositioning and fixation: broken or misshapen facial bones are cut, moved into a better position, and held there with mini-plates, screws or wires while they heal.

In children, treatment is usually planned by a multi-disciplinary team, which may include plastic surgeons, oral and maxillofacial surgeons, paediatric neurosurgeons, orthodontists, paediatricians, speech and language therapists, psychologists, geneticists and ear, nose and throat specialists.

What happens before the operation?

If your child needs craniofacial surgery, they'll usually be seen by a multi-disciplinary team who plan treatment together. Because these operations are often carried out on young children, parental consent and discussion is a crucial part of the process, and parents are asked to think particularly carefully about surgery requested for cosmetic reasons alone, as opposed to correcting a serious functional problem.

In the run-up to surgery:

• X-rays and CT scans, including 3D scans, are taken to assess the condition or injury in detail and help plan surgery
• if a facial injury happened alongside other injuries, assessment of the face may be delayed by 24 to 72 hours while more urgent problems are treated first
• you'll have blood tests and a general health assessment, and any medications may need adjusting
• you'll be given specific instructions to follow the day before and after your operation.

What happens during the procedure?

1. You're given a general anaesthetic, so you're fully asleep and pain-free throughout.
2. Your surgeon cuts and repositions the affected facial bones into a more typical structure.
3. If bone is missing or needs extra support, a graft is used, taken from your pelvis, ribs or skull, to fill the gaps.
4. Small titanium screws and plates are often used to hold the bones in their new position, and sometimes the jaw is wired together to help keep everything in place while it heals.
5. If significant swelling is expected in your face, mouth or neck, your medical team may place a breathing tube directly into your windpipe through a small cut in your neck (a tracheotomy) instead of the usual tube, to keep your airway safe.

The operation can take anywhere from 4 to 14 hours, depending on how complex your case is.

What does recovery look like?

Depending on how extensive your surgery was and how you're breathing, you may spend the first 2 days in intensive care. Without complications, most people are able to leave hospital within a week.

Operations on the face and skull are usually accompanied by surprisingly little pain. Swelling is normal and should settle between 2 to 4 weeks, with full recovery between 6 to 12 months. It is important to note that recovery varies from patient to patient. Your healthcare team will let you know what to expect during recovery.

If you had a bone graft from your hip, this area is usually sore afterwards, with walking uncomfortable for a few weeks depending on the size of the graft, though there's no permanent effect on how your hip or leg looks or works. After a genioplasty, some numbness below the lower lip for a few days is normal, and using an antiseptic mouthwash while avoiding brushing your lower teeth for about a week, until the gum heals, are both important parts of recovery.

What are the risks and complications?

As with any operation under general anaesthetic, there's a risk of bleeding, breathing problems, bruising, infection, or a reaction to the anaesthetic.

Risks more specific to craniofacial surgery include:

• changes in nerve function, causing numbness or, rarely, weakness in part of the face
• changes to facial height, width or projection that don't fully match what was planned
• problems with your bite (malocclusion)
• nasal blockage or changes to the shape of the nose
• in rare cases, leakage of the fluid that surrounds the brain, loss of sense of smell, or loss of vision.

Complications following craniofacial surgery are uncommon, and even for the most complex procedures, severe complications are rare. Generally, the more complex the surgery, the higher the chance of a complication, so your surgeon will explain how this applies to your specific operation.

Certain things can affect how well you heal, including poor nutrition, a weakened immune system, connective tissue diseases such as lupus, smoking, skin damage from previous radiotherapy, poor circulation in the affected area, and a long delay between an injury and its surgical treatment.