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Midface Hypoplasia and Cranial Base Morphology in Syndromic Craniosynostosis: A Comparative Analysis Study Using a Predictive Regression Model
Published on: November 4, 2025
A European Multicenter Outcome Study of Perioperative Airway Management Policies following Midface Surgery in
Iris E Cuperus1, Irene M J Mathijssen1, Marie-Lise C van Veelen2
1From the Departments of Plastic and Reconstructive Surgery and Hand Surgery.
Insights
Immediate extubation after midface advancement surgery in children with craniofacial syndromes is safe and reduces complications. This approach is recommended for most patients, including those with moderate to severe obstructive sleep apnea.
Area of Science:
- Craniofacial surgery
- Pediatric anesthesiology
- Airway management
Background:
- Perioperative airway management in children with Apert and Crouzon-Pfeiffer syndromes undergoing midface advancement is complex.
- Existing protocols for airway management and extubation timing vary significantly among institutions.
Purpose of the Study:
- To evaluate airway management strategies and postoperative respiratory complications following midface advancement procedures.
- To compare outcomes between immediate and delayed extubation in this patient population.
Main Methods:
- A multicenter, retrospective cohort study included 275 pediatric patients undergoing monobloc or Le Fort III procedures.
- Data collected included extubation timing, perioperative airway management, and respiratory complications.
- Patients were categorized into immediate extubation (n=62) and delayed extubation (n=162) groups.
Main Results:
- Immediate extubation was associated with a significantly lower rate of postoperative pneumonia (0% vs. 15%, P=0.001).
- The rate of respiratory insufficiency was comparable between groups (94% vs. 85%).
- Each additional day of intubation increased the odds of intubation-related complications by 21%.
Conclusions:
- Immediate extubation is a safe and effective strategy following midface advancement in pediatric patients.
- This approach leads to fewer postoperative complications, including pneumonia.
- Routine consideration of immediate extubation is recommended, particularly for patients with no or mild obstructive sleep apnea, and cautiously for those with moderate to severe obstructive sleep apnea.
Background:
Perioperative airway management following midface advancements in children with Apert and Crouzon-Pfeiffer syndromes can be challenging, and protocols often differ. This study examined airway management following midface advancements and postoperative respiratory complications.
Methods:
A multicenter, retrospective cohort study was performed to obtain information about the timing of extubation, perioperative airway management, and respiratory complications after monobloc or Le Fort III procedures.
Results:
A total of 275 patients (monobloc surgery, n = 129; Le Fort III surgery, n = 146) were included. Sixty-two patients received immediate extubation and 162 received delayed extubation; 42 had long-term tracheostomies, and 9 had perioperative short-term tracheostomies. In most centers, short-term tracheostomies were reserved for selected cases. Patients with delayed extubation remained intubated for 3 days (interquartile range, 2 to 5 days). The rate of no or only oxygen support after extubation was comparable between immediate and delayed extubation groups (58 of 62 patients [94%] and 137 of 162 patients [85%], respectively). However, the immediate extubation group developed fewer cases of postoperative pneumonia than did the delayed group (0 of 62 [0%] versus 24 of 161 [15%]; P = 0.001). Immediate extubation also appeared safe in moderate to severe obstructive sleep apnea, as 19 of 20 patients (95%) required either no or only oxygen support after extubation. The odds of developing intubation-related complications increased by 21% with every extra day of intubation.
Conclusions:
Immediate extubation following midface advancements was found to be a safe option, as it was not associated with respiratory insufficiency but did lead to fewer complications. Immediate extubation should be considered routine management in patients with no or mild obstructive sleep apnea, and should be the aim in moderate to severe obstructive sleep apnea cases after careful assessment.
Clinical Question/Level Of Evidence:
Therapeutic, III.
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