目的 探讨采用矢状劈开患侧下颌骨外板并植入健侧切取的下颌骨外板修复重建半侧颜面短小的新方法。 方法 回顾性分析2006年3月至2023年3月，中国医学科学院整形外科医院颅颌面外科收治的半侧颜面短小患者临床资料。术前根据临床表现和影像学检查结果进行诊断和手术设计。所有病例均在全身麻醉下完成手术。经口内入路将患侧下颌骨外板劈开，然后根据术前设计采取健侧适当形态和大小的下颌骨外板植入劈开的骨间隙并采用钛合金小夹板予以坚强内固定。术后随访患者的并发症发生、面部形态改善情况及患者对手术效果满意度，满意度评分为1～5分，分数越高表示越满意。在术前、术后即刻和术后远期(末次)随访时拍摄照片并分析畸形严重程度。将患者术前、术后即刻、术后远期随访CT数据以Dicom格式导入Surgicase Proplan医学三维图像工作站后，利用Segmentation功能重建下颌骨，测量术前、术后即刻和术后远期随访的下颌骨厚度，对其测量值比较采用重复测量方差分析，多重比较采用LSD检验；用多样本Kruskal－Wallis秩和检验对畸形矫正外观满意度评分进行统计分析，以P<0.05为差异具有统计学意义。 结果 共纳入39例患者，女13例，男26例，年龄(22.2±4.56)岁(15～27岁)。所有患者术后随访(45.56±39.41)个月(6～153个月)，植入的下颌骨外板与邻近骨组织结合良好，并获得下颌角区以及下颌骨体部明显的增宽效果。39例中，1例术后1年感染，钛板外露，经过清创并取出固定的小夹板以后愈合；其余患者面部形态均得到明显改善。35例患者对手术效果满意，3例非常满意，1例对术后1年感染不满意，但是对手术效果满意。术前与术后即刻、术后远期随访的患侧下颌骨厚度测量值分别进行两两比较，差异均有统计学意义(P均<0.05)；患者畸形矫正外观满意度术前评分[2.0(1.5，2.0)分]、术后即刻评分[4.0(4.0，4.0)分]及术后末次随访评分[4.0(4.0，4.0)分]比较，差异有统计学意义(P<0.01)。其中，术前评分与术后即刻、术后末次随访的评分分别比较，差异均有统计学意义(P均<0.01)；术后末次随访与术后即刻评分比较，差异无统计学意义(P>0.05)。 结论 下颌骨外板矢状劈开符合下颌骨解剖学特点并为自体骨的植入和愈合提供了良好条件。健侧下颌骨外板的切取，在充填患侧增加厚度的同时，缩小健侧下颌角区厚度，从而有效矫正下颌骨不对称畸形。该方法操作简单，并发症少，效果良好，是矫正半侧颜面短小的理想治疗手段之一。 Objective To investigate a new method for the reconstruction of hemifacial microsomia by sagittal osteotomy of the affected mandibular outer cortex combined with bone graft of mandibular outer cortex from healthy side. Methods From March 2006 to March 2023, the clinical data of patients with hemifacial microsomia admitted to the Department of Craniomaxillofacial Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences were analyzed retrospectively. Preoperative diagnosis and surgical design were performed based on clinical manifestations and imaging findings. All cases were operated under general anesthesia. The affected mandibular outer cortex was previously split by an intraoral approach, and then the mandibular outer cortex of appropriate shape and size on the healthy side was harvested and grafted into the split bone space according to the preoperative design, following by internal rigid fixation. Complications, facial appearance improvement, and patient satisfaction were followed up. Photographs were taken preoperative, immediately postoperative and at the long-term(last) postoperative follow-up, and the severity of the deformity was analyzed. CT data from preoperative, immediate postoperative, and long-term follow-up visits were imported into Surgicase Proplan medical three-dimensional image workstation in Dicom format. The mandible was reconstructed using Segmentation, and the thickness of the mandible was measured during pre-operative, immediate post-operative and long-term follow-up visits. Anova with repeated measurement design was used to compare measurements and LSD test was used for multiple comparisons. The Kruskal-Wallis rank sum test were used to statistically analyze malformation severity. P< 0.05 is considered statistically significant. Results A total of 39 patients were included in this study, including 13 females and 26 males, with an average age of (22.21±4.57) years (15-27 years). All patients were followed up for an average of (45.56±39.41) months (6-153 months) after surgery. The grafted mandibular outer cortex grows well with the adjacent bone tissue, and the mandibular angle and mandibular body are significantly wider. Of the 39 cases, 1 developed an infection 1 year after surgery, the titanium plate was exposed, and the patient healed after debridement and removal of the immobilizing splint. The facial appearance of the other patients improved significantly. Preoperative, immediate postoperative and long term follow up of mandibular thickness measurements were compared in pairs, and the differences were statistically significant (all P<0.05). The patient’s appearance satisfaction score: the preoperative score was [2.0(1.5, 2.0)] points, the immediate postoperative score was [4.0(4.0, 4.0)] points, the score of the last postoperative follow up was [4.0(4.0, 4.0)] points. There was statistical difference in satisfaction among the three groups (P<0.01). The preoperative scores were compared with the scores of the immediate postoperative and the last postoperative follow-up respectively, and the differences were statistically significant(P<0.01). There was no statistical significance in satisfaction between the immediate postoperative score and the score of the last postoperative follow up (P>0.05). Conclusion The sagittal splitting osteotomy of the mandibular outer cortex is consistent with the features of mandibular anatomy, and provides a good condition for the grafting and healing of autogenous bone. Removing the outer cortex of the mandible on the healthy side not only increases the thickness of the affected side, but also decreases the width of the angle of the mandible on the healthy side, so as to effectively correct the asymmetric deformity of the mandible. The method is simple, with few complications and good results, and is one of the ideal treatments to correct hemofacial microsomia.
Sagittal splitting osteotomy of the mandibular outer cortex and autologous bone grafting for the treatment of hemifacial microsomia
Objective To investigate a new method for the reconstruction of hemifacial microsomia by sagittal osteotomy of the affected mandibular outer cortex combined with bone graft of mandibular outer cortex from healthy side. Methods From March 2006 to March 2023, the clinical data of patients with hemifacial microsomia admitted to the Department of Craniomaxillofacial Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences were analyzed retrospectively. Preoperative diagnosis and surgical design were performed based on clinical manifestations and imaging findings. All cases were operated under general anesthesia. The affected mandibular outer cortex was previously split by an intraoral approach, and then the mandibular outer cortex of appropriate shape and size on the healthy side was harvested and grafted into the split bone space according to the preoperative design, following by internal rigid fixation. Complications, facial appearance improvement, and patient satisfaction were followed up. Photographs were taken preoperative, immediately postoperative and at the long-term(last) postoperative follow-up, and the severity of the deformity was analyzed. CT data from preoperative, immediate postoperative, and long-term follow-up visits were imported into Surgicase Proplan medical three-dimensional image workstation in Dicom format. The mandible was reconstructed using Segmentation, and the thickness of the mandible was measured during pre-operative, immediate post-operative and long-term follow-up visits. Anova with repeated measurement design was used to compare measurements and LSD test was used for multiple comparisons. The Kruskal-Wallis rank sum test were used to statistically analyze malformation severity. P< 0.05 is considered statistically significant. Results A total of 39 patients were included in this study, including 13 females and 26 males, with an average age of (22.21±4.57) years (15-27 years). All patients were followed up for an average of (45.56±39.41) months (6-153 months) after surgery. The grafted mandibular outer cortex grows well with the adjacent bone tissue, and the mandibular angle and mandibular body are significantly wider. Of the 39 cases, 1 developed an infection 1 year after surgery, the titanium plate was exposed, and the patient healed after debridement and removal of the immobilizing splint. The facial appearance of the other patients improved significantly. Preoperative, immediate postoperative and long term follow up of mandibular thickness measurements were compared in pairs, and the differences were statistically significant (all P<0.05). The patient’s appearance satisfaction score: the preoperative score was [2.0(1.5, 2.0)] points, the immediate postoperative score was [4.0(4.0, 4.0)] points, the score of the last postoperative follow up was [4.0(4.0, 4.0)] points. There was statistical difference in satisfaction among the three groups (P<0.01). The preoperative scores were compared with the scores of the immediate postoperative and the last postoperative follow-up respectively, and the differences were statistically significant(P<0.01). There was no statistical significance in satisfaction between the immediate postoperative score and the score of the last postoperative follow up (P>0.05). Conclusion The sagittal splitting osteotomy of the mandibular outer cortex is consistent with the features of mandibular anatomy, and provides a good condition for the grafting and healing of autogenous bone. Removing the outer cortex of the mandible on the healthy side not only increases the thickness of the affected side, but also decreases the width of the angle of the mandible on the healthy side, so as to effectively correct the asymmetric deformity of the mandible. The method is simple, with few complications and good results, and is one of the ideal treatments to correct hemofacial microsomia.
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