Retrospective Review of the Complication Profile Associated with 71 Subcranial and Transcranial Midface Distraction Procedures at a Single Institution.

Abstract

Sir: After distraction osteogenesis was introduced by McCarthy in 1992, adding this technique to either transcranial procedures (monobloc osteotomy with or without facial bipartition) or subcranial procedures (Le Fort III osteotomy) has grown in favor among craniofacial surgeons. We have read with great interest the article entitled “Retrospective Review of the Complication Profile Associated with 71 Subcranial and Transcranial Midface Distraction Procedures at a Single Institution” by Zhang et al.1 in Plastic and Reconstructive Surgery. Through the data compared between those who underwent transcranial or subcranial midface distraction osteogenesis, the authors have concluded that complication rates in midface distraction remain high. It is necessary for surgeons and patients to pay attention when they embark on these procedures. In this communication, we would like to propose some questions to the authors. The authors have found that the majority of complications in both subcranial and transcranial procedures were infections. However, in a literature review conducted by Knackstedt et al.,2 it was reported that the highest rate of major complications in the monobloc approach with distraction, which is a transcranial procedure, was cerebrospinal fluid leak, and the highest rate of major complications that occurred following the Le Fort III approach with distraction (subcranial midface distraction osteogenesis) was for reoperation. For the latter, we consider that the reason is shifting of the external halo distractors or incomplete osteotomy when performing Le Fort III osteotomy. De Gijt et al.3 also found that the rate of infection after surgery constituted the smallest percentage. Regardless of the reasons, these conclusions differed from the findings of the article published in the Journal. Although beyond the scope of this article, what puzzles us is, in the author’s clinic, what the specific index of diagnosis of infection is, or what the criteria for inclusion in infection cases are. As we know, because of the rich blood supply of the cranium, the rate of infection is lower compared with surgery on other parts of the skeleton. Is it because of the different criteria for inclusion in infection cases that a different conclusion is reached? In addition, the authors mentioned that they have broadened antibiotic coverage to 72 hours of ampicillin/sulbactam. However, all beta-lactamase inhibitor combinations should not be used for central nervous system infections, because whether these types of antibiotics are useful for central nervous system infections has not yet been confirmed. In our experience, we use ceftriaxone as a routine perioperative antibiotic medication when we perform such surgery. We also have used ceftriaxone coverage to 72 hours postoperatively. In addition, distinguishing between “time-dependent” and “dose-dependent” antibiotics is important when we use antibiotics. It is related to the way antibiotics are used. In conclusion, the authors presented a retrospective analysis of complications following distraction surgery for midface hypoplasia at a single center. Their findings show an increased complication percentage. We expect further studies that provide more information in the future. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Chenzhi Lai, M.D.Qi Pan, M.B.Xiaolei Jin, M.D.Department of SixteenPlastic Surgery HospitalChinese Academy of Medical SciencesPeking Union Medical CollegeBeijing, People’s Republic of China