What to Expect:
Midfacial Advancement
Traditional Advancement versus Distraction Osteogenesis:
Your surgeon will discuss with you at your pre-operative visits the surgical method that will be used. The midface can be moved forward in one stage and fixed in place with plates and screws, with the use of bone grafts (traditional method). Alternatively, if the midface must be moved forward a long distance, then distraction osteogenesis will be used. In this method, the bones of the midface are cut just as in the traditional method, but then a device is attached (either externally attached to the head and face or internally placed under the skin depending on what will be best for each particular child) that will gradually move the midface forward, allowing new bone to gradually fill in the gaps that result from the advancement of the midface. Your surgeon will have determined the appropriate method for your child and explain it to you in detail.
Before Surgery:
You will meet with your surgeon to discuss the details of the surgery and to have all of your questions answered in detail. A preoperative history and physical exam will be done, and you will be given an informed consent form to sign that gives us permission to do the surgery. You will also get detailed instructions for the preoperative and postoperative period, including wound care, and how to detect problems. Your child will have to have an empty stomach before going to surgery, and you will be given specific instructions on when to stop feeding him/her. If your child gets sick before surgery, you should notify us so that we can decide whether or not to proceed with the scheduled procedure
You will also have an appointment this same day with the anesthesiologist in Pre-operative clinic. At this appointment you will be instructed when to arrive the day of surgery and when your child needs to stop eating and drinking before surgery. We encourage you to have the child drink a lot the day before surgery. It is more difficult to place IVs in children who are dehydrated (from not drinking enough fluids). During this visit with the Pre-op clinic you will also be instructed where to check-in on the day of surgery.
If you are traveling from a long distance and would like to stay at the Ronald McDonald house the night before, these arrangements can be made.
The Day of Surgery:
You will be instructed to arrive at the Surgery Center an hour or two before the surgery. You will check in at registration on the first floor of the hospital. Once you are checked in, you will be taken to the pediatric holding area (you may be with your child in this area). When it is time for the child to come down to the operating room, you will be asked to bring the baby to the holding area of the operating room (again you will be allowed to be with your child). The baby will be examined by the plastic surgeon and the anesthesiologist again, and this is a good opportunity to ask any last minute questions you may have. The child will be given some oral medication to help make him/her sleepy. When it is time to go back to the operating room, the anesthesiologist will take the child and you will be shown how to obtain a pager so that we may be able to contact you during the case.
The child will be put under anesthesia using a mask. Once he/she is asleep, the IV will be started and the child will be intubated (the breathing tube will be inserted to breathe for the baby during surgery). A catheter will usually be placed in the bladder before surgery since it will be a long procedure. Other monitors and catheters may be placed. The child will be positioned on the table and prepared for surgery. Once the case starts, the nurse in the operating room will call out periodically to update you on the progress of the surgery. When surgery is almost complete, the nurse will call you to come to the waiting area to meet with your surgeon, who will discuss the surgery with you.
The child will remain intubated (have the breathing tube in place) and will be transferred to the Pediatric Intensive Care Unit. Once the child is settled in, you will be able to visit with him/her. The breathing tube will be in place, and he/she will be sedated. Do not let this alarm you. If the midfacial advancement is being done by distraction, there will either be an external distraction device attached to the head and face or just the activation arms for internal distraction devices coming out through the skin in the scalp. Your surgeon will have shown you these devices during your pre-operative visits. The incision is kept open to air but will have bacitracin ointment on it; the nurses will apply the bacitracin ointment to the incision regularly. The child will remain intubated for about 48-72 hours usually.
The child will remain in the PICU for several days. When medically stable, he/she will be transferred to the pediatric ward.
In the Hospital:
One parent is allowed to stay with the child during the hospitalization. There is a waiting room at the end of the hall of the pediatric ward which has chairs that convert into beds. The other parent is welcome to stay there, and the parents may switch off during the course of the child's stay.
Your child will be visited each day by the plastic surgery team. You will be given an update on your child's condition each day. Please feel free to ask any questions during this time. You will also be visited daily by the pediatric plastic surgery nurse who will ensure that you understand how to care for your child after discharge from the hospital. All of your questions will be answered, and you will receive detailed discharge instructions before you leave the hospital.
If distraction is being done, a distraction table will be constructed for your child. The distraction table will detail how often the distractor will be turned and the millimeters of distraction. The surgeon or the nurse will turn the distractor using a special screwdriver. Once we have reached the maximum distraction desired, the distractors remain in place for approximately 6 weeks until we can obtain a CT scan to make sure the bone has re-ossified (grown in between the gap created).
After Discharge until the First Postoperative Clinic Visit:
You will be instructed to keep bacitracin ointment on the incisions and to give your child only a soft/puree diet.
Your child will be seen in the clinic for the first postoperative visit approximately one week after surgery. During this first week, he/she may not be quite normal; children can be more fussy than usual or have disturbed sleep schedules.
When your child comes to the clinic, the incisions will be examined and we will address any concerns you may have.
Subsequent Postoperative Visits:
If distraction is being used, you will see your surgeon weekly in the clinic for the first several weeks. If distraction is not being used, the next postoperative visit occurs at three weeks after surgery. In most cases, after the three-week visit, we will see your child again at six weeks postoperatively. If distraction was used, at approximately four-to-six weeks after distraction has stopped, a repeat CT scan will be ordered to ensure that the bone in the midface has re-ossified (consolidated). If the bone has consolidated, then the distractors can be removed (exactly how they are removed depends on the type of distractor used; your surgeon will discuss this with you).
If distraction was not used, then a CT scan is obtained about six weeks after surgery.
Your child will then be seen at about three months after surgery, and then every three months or so for the rest of the first post-operative year.