Intraoperative Skull Fracture During Halo Application in Subcranial Le Fort III: Strategies for Managing a Rare Complication.

External rigid distraction is an established method for achieving subcranial Le Fort III advancement in severe syndromic craniosynostosis. Craniofacial surgeons commonly use halo-type devices for these corrections, as they allow for multiple vectors of pull and facilitate larger midfacial advancements. Although most complications related to their use involve pin displacement or infection, rare complications such as skull fractures have been reported. At 3 months of age, a patient with Apert Syndrome underwent endoscopic-assisted craniectomies for bilateral coronal craniosynostosis. After a year of helmet therapy, he developed pansynostosis and required fronto-orbital advancement. Later at the age of 6, a Le Fort III distraction using a RED II rigid external distractor was performed to address his midfacial hypoplasia, exorbitism, and severe obstructive sleep apnea. While placing the RED II distractor, a shift in the device was noted upon pin fixation, raising suspicion for a unilateral depressed skull fracture. Although computed tomography imaging revealed pin displacement, there was no clinical indication for immediate repair. Given the surgical and psychological burden this could have on the patient, the decision was made to leave the RED II device in place and proceed with the distraction. After distraction and an 8-week latency period for complete consolidation of the facial bony architecture, the RED II device was removed, and the skull fracture was repaired. In patients with multi-operated skulls and residual cranial defects, halo-type devices may present an increased risk of skull fractures. This report discusses alternatives in the literature and presents an example of a rare complication successfully managed with delayed repair.