Mobilization of the entire midfacial skeleton: "wing"-shaped midfacial osteotomy

Hypoplasia and retrusion of the midfacial skeleton may only involve the dentoalveolar area or central facial region (nasal and paranasal [Binder's syndrome]) or the whole midface (paranasal, maxillary, malar, and zygomatic areas). The principal clinical findings are flattened paranasal, cheek, and malar areas. Class III malocclusion or normal dental occlusion can also be present. Treatment of midface retrusion is difficult because the final result depends on a high degree of harmonic aesthetic appreciation, the use of adequate surgical technique (adequate facial osteotomy), and the final relation obtained between soft tissue and facial bones. Many surgical treatments have been proposed for correction of midfacial retrusion. A new osteotomy is proposed involving advancement of maxillary and malar bones and the lower half of both zygomatic arches, when the whole midfacial skeleton is retrused and hypoplastic (both maxillary and malar bones are involved). The orbital osseous structures are not included in the osteotomy; the infraorbitary nerve remains intact. Using this technique, all clinical features are corrected. The advancement and mobilization of the whole body of the maxillary and malar bones along the lower part of the zygomatic arch contribute to three-dimensional facial reconstruction because they produce an increase in anteroposterior projection of the middle third facial region. Rigid internal fixation by means of miniplates and screw of 1.5 or 2 mm on four principal maxillary buttresses is used. No onlay bone grafts are used for obturing the gaps of osteotomy.