Distraccion Osteogenica Esqueletal

CME
Distraction Osteogenesis of the Craniofacial
Skeleton
Jack C. Yu, M.D., D.M.D., Jeffrey Fearon, M.D., Robert J. Havlik, M.D., Steve R. Buchman, M.D., and
John W. Polley, M.D.
Augusta, Ga.; Dallas, Texas; Indianapolis, Ind.; Ann Arbor, Mich.; and Chicago, Ill.

Learning Objectives: After studying this article, the participant should be able to: 1. Review the biomechanical principlesand pertinent cellular and molecular biology of distraction osteogenesis of the craniofacial skeleton. 2. Describe the
clinical indications and applications of distraction osteogenesis of the craniofacial skeleton. 3. Describe maxillary,
mandibular, midface, and calvarial procedures in distraction osteogenesis. 4. Discuss the clinical outcomes and complications of distraction osteogenesis of thecraniofacial skeleton.

developed and refined by Ilizarov.4,5 Ilizarov’s
meticulous work definitively established the
fact that bone will form in response to tension.
This apparently contradicted Wolff’s law regarding bone remodeling, which associates
bone formation with compression and bone
resorption with tension.6 In 1992, McCarthy et
al.7 reported in the English literature the firstapplication of distraction osteogenesis to
lengthen the human mandible. This method is
now used extensively at every level of the
craniofacial skeleton.8 –13 There are three main
phases to distraction osteogenesis: latency, activation, and consolidation. Latency is that period immediately following the osteotomy and
application of distractor; it ranges from 1 to 7
days. After the latency phaseis the activation
phase. During this phase, the distraction device
is activated by turning some type of axial screw,
usually at 1 mm/day in four equal increments
of 0.25 mm each. Once activation is complete,
the third and final phase is the consolidation
phase. Typically, the consolidation phase is
twice as long as the time required for activation. The above three phases constitute theIlizarov protocol designed for lengthening the
long, endochondral bones of the lower extremity. Whether this is the optimal protocol for the

The year 2002 marked the end of the first decade in
clinical distraction osteogenesis of the craniofacial skeleton. In this short period, its application has increased
exponentially. More than 3000 cases have been performed
according to a recent survey,and more than 700 articles
have been written on this subject in the MEDLINE database since 1996. It is a powerful surgical tool and enables
surgeons to achieve results not previously attainable. Despite all this, distraction osteogenesis is practiced by only
a small number of plastic surgeons. This article reviews the
biomechanical principles; the pertinent cellular and molecular biology; andthe clinical indications, applications,
controversies, and complications of distraction osteogenesis of the craniofacial skeleton. (Plast. Reconstr. Surg.
114: 1e, 2004.)

Plastic surgeons alter the product of morphogenesis. The natural attainment of body
form is a multifactorial, polygenic process. A
key ingredient of this complex process is mechanical force. Force is completely ubiquitous;it can originate from local growth, the earth’s
gravitation, muscular contraction, and surface
tension, to name just a few sources. Cellular
response to force is therefore a very ancient
and critical part of the biotic process.1,2 Distraction osteogenesis, like soft-tissue expansion,
taps into this ancient, universal property: grow
if stretched. Initially used in orthopedic surgery byCodivilla in 1905,3 it was systematically

From the Section of Plastic Surgery and Craniofacial Center, Medical College of Georgia; the Craniofacial Center, Medical City Dallas Hospital;
Riley Hospital for Children, Indiana University School of Medicine, Section of Plastic Surgery; Craniofacial Anomalies Program, C. S. Mott
Children’s Hospital, Section of Plastic Surgery, University of Michigan;...