Craniofacial Distraction: A Personal Odyssey

  • Joseph G. McCarthyEmail author


By the mid-1980s, approximately 20 years after Tessier reported remarkable achievements in the reconstruction of the craniofacial skeleton with radically new surgical techniques, successful massive en bloc skeletal movements were routinely employed to improve craniofacial function and appearance. Moreover, CT imaging and rigid skeletal fixation systems had been developed, allowing even more complex craniofacial surgical reconstructions. Nevertheless, there remained unsolved problems. The surgical procedures were invasive, and the operations and hospitalizations were lengthy. There was often the need for bone graft harvest, and extensive blood replacement was necessary. Soft tissue problems were often not addressed, and many of the procedures represented what I call “bone carpentry.” The relapse rate for many procedures was relatively high because of the acute intraoperative advancement of skeletal segments against restrictive and deficient soft tissue.


Distraction Osteogenesis Condylar Cartilage Craniofacial Skeleton Distraction Device Bone Graft Harvest 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Activation phase

 Often erroneously termed “distraction,” the period of active device lengthening during distraction osteogenesis.

Appendicular skeleton

 Comprised of bones of the four limbs, pectoral girdle, and pelvic girdle.

Axial skeleton

 Comprised of bones of the face, skull, chest wall, and vertebrae.

Bifocal distraction

 Distraction osteogenesis to fill a central bony defect, by distracting one flanking transport segment toward the center. One osteotomy is made.

Consolidation phase

 The period following activation, during which the bony generate undergoes remodeling.

Distraction device

 Hardware that facilitates movement of bones during distraction. May be categorized as internal or external, based upon relation to soft tissue surrounding the bone. Not to be referred to as “distractor.”

Distraction osteogenesis

 The generation of bone between vascularized bone surfaces which are separated by gradual distraction.

Endochondral bone

 Bone that forms via a cartilaginous intermediate.

Fibrous interzone (FIZ)

 Within the distraction gap, a physis-like organization of osteogenic cells.

Intramembranous bone

 Bone that forms directly from mesenchymal precursor cells, without a cartilaginous intermediate.

Latency phase

 The time following the osteotomy when initial fracture healing bridges the cut bone surfaces prior to initiating activation.

Molding of the generate

 Closed reduction maneuver of the generate, performed prior to or during the consolidation phase. Usually accomplished by manipulation of the distraction device or the application of interdental wire-rubber forces. Typically performed to improve the dental relationship following mandibular distraction.

Primary mineralization front (PMF)

 Within the distraction gap, a dense line of proliferating osteoblasts flanking the FIZ, that is actively undergoing mineralization.


 The number of millimeters per day at which bone surfaces are distracted.


 The number of device activations per day, usually in equally divided increments to total the rate.


 Refers to distraction osteogenesis performed across an osteotomy site.


 Refers to distraction osteogenesis performed across an interosseous suture, without an osteotomy.

Transchondroid bone

 A histologic finding exclusive to the distraction gap, marked by chondrocyte-appearing cells but without cartilage formation.

Transport distraction

 The generation of intercalary bone.

Transport segment

 The segment(s) of bone actively distracted during bifocal or trifocal transport distraction osteogenesis.

Trifocal distraction

 Distraction osteogenesis to fill a central bony defect, by distracting flanking transport segments toward the center. Involves two osteotomies.

Unifocal distraction

 Distraction osteogenesis to achieve simple bone lengthening, using a single osteotomy.


 The trajectory of applied distractive forces. With respect to the mandible, for example, often characterized as horizontal, vertical, or oblique.

Zone of microcolumn formation (MCF)

 Columns of ossifying bone forming within the distraction gap, surrounding the blood vessels that extend to the PMF.


  1. 1.
    Karp NS, Thorne CHM, McCarthy JG, Sissons HA. Bone lengthening in the craniofacial skeleton. Ann Plast Surg. 1990;24:231.CrossRefPubMedGoogle Scholar
  2. 2.
    Karp NS, McCarthy JG, Schreiber JS, Sissons HA, Thorne CHM. Membranous bone lengthening: a serial histologic study. Ann Plast Surg. 1992;29:2.CrossRefPubMedGoogle Scholar
  3. 3.
    McCarthy JG, Schreiber J, Karp N, Thorne CH, Grayson BH. Lengthening the human mandible by gradual distraction. Plast Reconstr Surg. 1992;89(l):1–8; discussion 9–10.Google Scholar
  4. 4.
    Stelnicki EJ, Hollier L, Lee C, Lin WY, Grayson B, McCarthy JG. Distraction osteogenesis of costochondral bone grafts in the mandible. Plast Reconstr Surg Mar 2002;109(3):925–33; discussion 934–5.Google Scholar
  5. 5.
    Regev E, Jensen JN, McCarthy JG, Grayson BH, Eski M. Removal of mandibular tooth follicles before distraction osteogenesis. Plast Reconstr Surg. 2004;113(7):1910–5.CrossRefPubMedGoogle Scholar
  6. 6.
    McCarthy JG, Staffenberg DA, Wood RJ, Cutting CB, Grayson BG, Thorne CH. The introduction of an intraoral bone lengthening device. Plast Reconstr Surg. 1995;96:978.CrossRefPubMedGoogle Scholar
  7. 7.
    McCormick SV, McCarthy JG, Grayson BH, Staffenberg DA, McCormick SA. The effect of gradual distraction of the mandible on the temporomandibular joint: part I, experimental canine study. J Craniofac Surg. 1995;6:358.CrossRefPubMedGoogle Scholar
  8. 8.
    McCormick SV, Grayson BH, McCarthy JG, Staffenberg DA. The effect of gradual distraction of the mandible on the temporomandibular joint: part II, clinical study. J Craniofac Surg. 1995;6:364.CrossRefPubMedGoogle Scholar
  9. 9.
    Stucki-McCormick SU, Fox RM, Mizrahi RD. Reconstruction of a neocondyle using transport distraction osteogenesis. Semin Orthod. 1999;5(1):59–63.CrossRefPubMedGoogle Scholar
  10. 10.
    Mackool RJ, Hopper RA, Grayson BH, Holliday R, McCarthy JG. Volumetric change of the medial pterygoid following distraction osteogenesis of the mandible: an example of the associated soft-tissue changes. Plast Reconstr Surg. 2003;111(6):1804–7.CrossRefPubMedGoogle Scholar
  11. 11.
    McCarthy JG. Distraction of the craniofacial skeleton. New York: Springer; 1999.CrossRefGoogle Scholar
  12. 12.
    Staffenberg DA, Wood RJ, McCarthy JG, Grayson BH, Glasberg SB. Midface distraction advancement in the canine without osteotomies. Ann Plast Surg. 1995;34(5):512–7.CrossRefPubMedGoogle Scholar
  13. 13.
    Glat PM, Staffenberg DA, Karp NS, Holliday RA, McCarthy JG. Multidimensional distraction osteogenesis: the canine zygoma. Plast Reconstr Surg. 1994;94:753.CrossRefPubMedGoogle Scholar
  14. 14.
    Bouletreau PJ, Warren SM, Paccione MF, Spector JA, McCarthy JG, Longaker MT. Transport distraction osteotomies: a new method to heal calvarial defects. Plast Reconstr Surg. 2002;109:1074.CrossRefPubMedGoogle Scholar
  15. 15.
    Levine JP, Rowe NM, Bradley JP, Williams JK, Mackool RJ, Longaker MT, McCarthy JG. The combination of endoscopy and distraction osteogenesis in the development of a canine midface advancement model. J Craniofac Surg. 1998;9:423.CrossRefPubMedGoogle Scholar
  16. 16.
    Jensen JN, McCarthy JG, Grayson BH, Nussbaum AO, Eski M. Bone deposition/generation with Le Fort III (midface) distraction. Plast Reconstr Surg. 2007;119(1):298–307.CrossRefPubMedGoogle Scholar
  17. 17.
    McCarthy JG, Williams JK, Grayson BH, Crombie JS. Controlled multiplanar distraction of the mandible: part I device development and clinical application. J Craniofac Surg. 1998;9:323.Google Scholar
  18. 18.
    Williams JK, Rowe NM, Mackool RJ, Levine JP, Hollier LH, Longaker MT, Cutting CB, Grayson BH, McCarthy JG. Controlled multiplanar distraction of the mandible part II: laboratory studies of sagittal (anteroposterior) and vertical (superoinferior) movements. J Craniofac Surg. 1998;9:504.CrossRefPubMedGoogle Scholar
  19. 19.
    Hollier LH, Rowe NM, Mackool RJ, Williams JK, Kim JH, Longaker MT, Grayson BH, McCarthy JG. Controlled multiplanar distraction of the mandible part III: laboratory studies of sagittal and horizontal movements. J Craniofac Surg. 2000;11:83.CrossRefPubMedGoogle Scholar
  20. 20.
    McCarthy JG, Hopper RA, Hollier Jr LH, Peltomaki T, Katzen T, Grayson BH. Molding of the regenerate in mandibular distraction: clinical experience. Plast Reconstr Surg. 2003;112(5):1239–46.CrossRefPubMedGoogle Scholar
  21. 21.
    Hollier LH, Kim JK, Grayson BH, McCarthy JG. Mandibular growth after distraction in patients under 48 months of age. Plast Reconstr Surg. 1999;103:1361.CrossRefPubMedGoogle Scholar
  22. 22.
    Shetye PR, Grayson BH, Mackool RJ, McCarthy JG. Long-term stability and growth following unilateral mandibular distraction in growing children with craniofacial microsomia. Plast Reconstr Surg. 2006;118(4):985–95.CrossRefPubMedGoogle Scholar
  23. 23.
    Weichman K, Jacobs JMS, Patel PA, Shetye PR, Grayson BH, McCarthy JG. Early distraction for mild to moderate unilateral craniofacial microsomia (UCFM): long-term follow-up outcomes and recommendations. Plast Reconstr Surg. 2017.Google Scholar
  24. 24.
    Grayson BH, McCormick S, Santiago PE, McCarthy JG. Vector of device placement and trajectory of mandibular distraction. J Craniofac Surg. 1997;8(6):473–80; discussion 461–2.Google Scholar
  25. 25.
    Vendittelli BL, Dec W, Warren SM, Garfinkle JS, Grayson BH, McCarthy JG. The importance of vector selection in preoperative planning of bilateral mandibular distraction. Plast Reconstr Surg. 2008;122(4):1144–53.CrossRefPubMedGoogle Scholar
  26. 26.
    Dec W, Peltomaki T, Warren SM, Garfinkle JS, Grayson BH, McCarthy JG. The importance of vector selection in preoperative planning of unilateral mandibular distraction. Plast Reconstr Surg. 2008;121(6):2084–92; discussion 2093–4.Google Scholar
  27. 27.
    Shetye PR, Davidson EH, Sorkin M, Grayson BH, McCarthy JG. Evaluation of three surgical techniques for advancement of the midface in growing children with syndromic craniosynostosis. Plast Reconstr Surg. 2010;126(3):982–94.CrossRefPubMedGoogle Scholar
  28. 28.
    Shetye PR, Caterson EJ, Grayson BH, McCarthy JG. Soft-tissue profile changes following early Le Fort III distraction in growing children with syndromic craniosynostosis. Plast Reconstr Surg. 2013;132(4):945–54.CrossRefPubMedGoogle Scholar
  29. 29.
    Shetye PR, Boutros S, Grayson BH, McCarthy JG. Midterm follow-up of midface distraction for syndromic craniosynostosis: a clinical and cephalometric study. Plast Reconstr Surg. 2007;120(6):1621–32.CrossRefPubMedGoogle Scholar
  30. 30.
    Patel PA, Shetye PR, Warren SM, Grayson BH, McCarthy JG. Five year follow-up of midface distraction in growing children with syndromic craniosynostosis. Plast Reconstr Surg. 2016.Google Scholar
  31. 31.
    Flores RL, Shetye PR, Zeitler D, Bernstein J, Wang E, Grayson BH, McCarthy JG. Airway changes following Le Fort III distraction osteogenesis for syndromic craniosynostosis: a clinical and cephalometric study. Plast Reconstr Surg. 2009;124(2):590–601.CrossRefPubMedGoogle Scholar
  32. 32.
    Shetye PR, Grayson BH, McCarthy JG. Le Fort III distraction: controlling position and path of the osteotomized midface segment on a rigid platform. J Craniofac Surg. 2010;21(4):1118–21.CrossRefPubMedGoogle Scholar
  33. 33.
    Shetye PR, Giannoutsos E, Grayson BH, McCarthy JGL. Fort III distraction: part I. Controlling position and vectors of the midface segment. Plast Reconstr Surg. 2009;124(3):871–8.CrossRefPubMedGoogle Scholar
  34. 34.
    Rowe NM, Mehrara BJ, Dudziak ME, Steinbreck DS, Mackool RJ, Gittes G, McCarthy JG, Longaker MT. Rat mandibular distraction osteogenesis, Part I. Histologic and radiographic analysis. Plast Reconstr Surg. 1998;102:2022.CrossRefPubMedGoogle Scholar
  35. 35.
    Mehrara BJ, Rowe NM, Steinbrech DS, Dudziak ME, Saadeh PB, McCarthy JG, Gittes GK, Longaker MK. Rat mandibular distraction osteogenesis: part II. Molecular analysis of transforming growth factor beta-1 and osteocalcin gene expression. Plast Reconstr Surg. 1999;103:536.CrossRefPubMedGoogle Scholar
  36. 36.
    Grayson BH, Rowe NM, Hollier Jr LH, Williams JK, McCormick S, Longaker MT, McCarthy JG. The development of a device for the delivery of agents to bone during distraction osteogenesis. J Craniofac Surg. 2001;12:19.CrossRefPubMedGoogle Scholar
  37. 37.
    Ashinoff RL, Cetrulo Jr CL, Galiano RD, Dobryansky M, Bhatt KA, Ceradini DJ, Michaels VJ, McCarthy JG, Gurtner GC. Bone morphogenic protein-2 gene therapy for mandibular distraction osteogenesis. Ann Plast Surg. 2004;52:585.CrossRefPubMedGoogle Scholar
  38. 38.
    Cetrulo Jr CL, Knox KR, Brown DL, Ashinoff RL, Dobryansky M, Chang EI, Bhatt KA, McCarthy JG, Gurtner GC. Stem cells and distraction osteogenesis: endothelial progenitor cells selectively home to the regenerate during activation and consolidation. Plast Reconstr Surg. 2005;116:1053.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Wyss Department of Plastic SurgeryNYU Langone Medical CenterNew YorkUSA

Personalised recommendations