Major craniofacial clefts: case series and treatment philosophy.

Background: The treatment of major facial clefts has evolved greatly over the past 40 years. Early in the authors' experience, soft tissues were treated by Z-plasty and local flap rotation, resulting in a patchwork effect and noticeable scars. Bony deficits were treated with bone grafts that often failed to restore normal facial contour. In 1985, the authors developed a treatment philosophy to resolve these issues, and its tenets have formed the foundation of treatment since then.

Methods: From January of 1965 to January of 2006, a series of 495 patients with major craniofacial clefts were treated in the authors' unit. Sixty-five percent had multiple clefts and 35 percent had a single cleft. In 33 percent of patients, the clefts were unilateral and in 67 percent the clefts were bilateral. The objectives of the authors' current treatment philosophy are restoration of the craniofacial skeleton, reconstruction with skin and soft tissue of like color and texture, generous use of tissue expanders, aesthetic unit reconstruction, scar location at limits of aesthetic subunits, and symmetric repositioning of key facial landmarks.

Results: Patients underwent a total of 1338 operations. Follow-up ranged from 8 months to 35 years. All patients who underwent primary reconstruction after 1985 underwent successful reconstruction using the aesthetic subunit principle. Fifty-three percent of patients required formal craniofacial osteotomy and 24 percent required bone grafting to restore the craniofacial skeleton.

Conclusions: The authors' results have improved considerably both in primary and in secondary reconstruction by incorporating their revised treatment philosophy. The authors have reduced scar visibility and facial asymmetry, allowing these patients to live more normal lives.