Monobloc Frontofacial Advancement: Systematic Review of Complications with Pooled Analysis
Lauren M. Yarholar, MD, Alexander Y. Lin, MD.
Saint Louis University School of Medicine, St. Louis, MO, USA.
PURPOSE: Treatment of midface hypoplasia in patients with syndromic craniosynostosis is complex and varied. Monobloc procedures were initially associated with high complication rates, but have returned to favor with the development of distraction osteogenesis (DO). The purpose of this study was to perform a systematic review of the literature to evaluate the complications associated with monobloc frontofacial advancement procedure and analyze the results based on the three different age groups of primary dentition, mixed dentition, and adult dentition. METHODS: PubMed and Scopus were searched for: Craniosynostosis AND (Monobloc OR Frontofacial Advancement OR Midface advancement) on October 8th, 2017. Duplicates and reviews were removed. Inclusion criteria were: diagnosis of syndromic craniosynostosis, underwent monobloc advancement surgery (internal distraction devices, external distraction devices, and traditional single-stage monobloc advancement), and had longitudinal followup. Exclusion criteria were: non-English articles, complications were not documented, and unclear surgical procedure performed. Major infections were defined as severe infections requiring admission to hospital and/or operative debridement, whereas minor infections were defined as infections treated with oral antibiotics and local wound care. Categorical outcomes were compared with Fisher exact tests.
RESULTS: 3010 papers were found, and 1556 duplicates removed. Abstract weed narrowed the selection to 124 papers for full-text review. Fourteen papers fulfilled criteria, with 110 patients undergoing monobloc procedures, with pooled average followup time of 57.2 months. Traditional monobloc advancement accounted for 3.6% (4/110), external distraction 55.5% (61/110), and internal distraction 40.9% (45/110). Patients were divided into three different groups according to age at the time of surgery: group 1 (younger than 5 years old), group 2 (5yo to 12yo), and group 3 (older than 12 yo). Group 1 (G1) accounted for 49% (54/110) of the patient population, group 2 (G2) 35.5% (39/110), and group 3 (G3) 15.5% (17/110). Reported outcomes were stratified by these three age categories: deaths G1 3.7% (2/54), G2 0% (0/39), G3 11.8% (2/17), P=0.116; recurrent exorbitism G1 13% (7/54), G2 0% (0/39), G3 0% (0/17), P=0.028*; major infections G1 3.7% (2/54), G2 7.7% (3/39), G3 0% (0/17). P=1.0; minor infections G1 29.6% (16/54), G2 5.1% (2/39), G3 23.5% (4/17), P=0.006**. External distractors were used at the rate of: G1 81.5% (44/54), G2 15.4% (6/39), G3 64.7% (11/17), P<0.001***.
CONCLUSION: Monobloc advancement can significantly improve function and appearance in the patient with syndromic craniosynostosis. Pooled analysis showed higher rates of recurrent exorbitism as well as minor infections in the group receiving monobloc before 5yo. The mechanism may be a higher rate of external distraction devices in the youngest age group, which may have higher rates of minor infection, and be removed earlier leading to more relapse. Additionally, earlier surgery usually has more relative relapse as the rest of the face grows except for the distracted segment. These risks and complications that should be taken into account when counseling patients on surgical options.
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