Adjunct Procedures Related to Mandibular Reconstruction and Soft Tissue Facial Improvement

Microtia is commonly associated with various syndromes including craniofacial microsomia and Treacher Collins syndrome. Additional facial anomalies involving the mandible, zygoma, orbit, and soft tissue are often present with these syndromes. Reconstruction of the mandible is guided by the Pruzansky-Kaban mandibular classification. Less severe mandibles with identifiable anatomy but are insufficient in size typically benefit from distraction osteogenesis. Conversely, more severe mandible deformities with atypical anatomy and a malfunctioning temporomandibular joint often require additional bony constructs in the form of costochondral grafts. While rib grafting provides a stable construct, due to its variable rates of growth, distraction is often required, the location of which is important in optimizing results and reducing complications. Finally, orthognathic surgery is typically considered the final bony surgical intervention required to correct and level dental occlusion. This not only improves skeletal dental alignment but also assists in achieving maximum soft tissue facial balance. If soft tissue volume remains inadequate, fat grafting is a useful low-risk tool. Since Treacher Collins patients often require coronal incisions for zygomatico-orbital correction, it is important to preserve the temporoparietal fascia (TPF) and associated vascular supply. This is particularly important since a TPF flap is often used in ear reconstruction. Understanding the proper timing and management of anomalies of neighboring structures surrounding the ear is important. Patients with microtia often experience varying degrees of mandibular, orbital, zygomatic, and soft tissue insufficiencies that must be treated in a succinct order that optimizes skeletal and soft tissue alignment, without compromising tissues and vascular supplies ultimately required for microtia correction.