What Is Midface?

What Is Midface?


Many children with a cleft lip and palate have a sunken in face around their nose. This condition is called midface, or maxillary hypoplasia.

Midface hypoplasia usually causes the face to have a hollow appearance. It also causes dental and chewing problems because teeth do not line up correctly.

If your child has midface hypoplasia, they will eventually need surgery. Surgery will move the bones in the middle of your child’s face and upper jaw forward.

What is Midface Surgery?

Surgery to correct your child's midface has two parts. The first part of the surgery is called LeFort 1 osteotomy. During this procedure, surgeons cut the bone in the midface.

The second part of the surgery your child will need is called maxillary advancement. This allows surgeons to pull your child's midface forward.

normal lateral xray
X-ray of a normal jaw
midface hypoplasia lateral
X-ray of a midface jaw

Surgeons can perform advancement surgery slowly or at the same time. If your child has a severely sunken in face, they may need these surgeries during grade school. Some children will need surgery as early as between the ages of 6 and 9.

Deciding to have LeFort advancement when your child is in grade school shouldn't be taken lightly.


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Types of Midface Surgery (Maxillary Advancement)

Surgeons can use two techniques to slowly pull your child’s midface forward. Pulling the midface forward is also called maxillary advancement. Types of surgery includes:

  1. Distraction Osteogenesis, and
  2. Maxillary advancement with rigid fixation.

Distraction Osteogenesis

Younger children need midface surgery for a severely sunken face the shape of their face is causing:

  • problems with their teeth that can't be fixed later on,
  • or psychosocial/emotional problems.

Some children need to have their midface moved forward more slowly. In these cases, children have a type of surgery called distraction osteogenesis. During this procedure, surgeons cut into the upper jawbone and slowly move the jaw forward.

Slowly moving your child's upper jawbone causes new bone to grow. This treatment is called midface distraction. After a bone scar forms, surgeons then slowly move the upper jaw into its final correct position.

Some older children need their midface moved a long way. These children will need midface distraction during the teen years as their face grows closer to its adult size and shape. These children may also need surgery in early adulthood.

Midface Distraction During Early Childhood

Because younger children's teeth are still forming, children who have distraction osteogenesis usually need a device to protect their teeth as their facial bones slowly move forward. Surgeons give children a headgear device that attaches to their skull like a large hat band. This headgear is called a HALO. It safely pulls your child’s face forward.

Midface distraction surgery can be difficult for a child. We try to reserve this treatment for only those children with the most severe problems.

Midface Distraction in Adolescence

Older children can have advancement surgery with help from a different device that surgeons place on a child’s cheekbone..This device slowly advances—or moves—the upper jaw forward. This device sits almost entirely on the inside of a child's face. Wearing it is also much easier for children to handle.

This device has a flexible arm (or activator) that sits in a child’s upper gum line. The arm helps surgeons slowly advance the device so your child’s jaw can grow.

Slowly moving your child's upper jaw forward stimulates bone growth where your child’s bone scar is located. Once your child’s upper jaw is in the correct position, the bone continues to harden over several weeks.

Maxillary Advancement With Rigid Fixation

Distraction osteogenesis slowly move a child's jawbone forward over weeks or months. But if your child has maxillary advancement with rigid fixation, surgeons will move and set her jawbone in place during one surgery. Surgeons pull your child’s jaw to its new location during surgery (called advancement) and lock it in place (called rigid fixation). This type of surgery works best for children whose faces are fully developed.

During the surgery, surgeons secure the upper jaw in place with small metal plates and screws. Surgeons will hold your child’s facial bones in place by using a similar method to fixing facial bones that are broken during trauma. The entire procedure is done is the operating room.

When the surgery is over, devices will sit and stay on the inside of your child's face. These devices do not need to be removed.

Sometimes, surgeons must remove these devices because of an infection, but this isn't common.

When Should My Child Have Midface Surgery?

Performing surgery when your child is young has some disadvantages. The upper jaw may have trouble growing as your child continues to grow. Because of this, your child may need another surgery.

Younger children also need to wear a HALO device. This can make recovery from surgery much more challenging.

If you choose to wait until your child is an adult, your child’s facial bones will be fully grown. When your child is grown, surgeons can move the upper jaw to its final position and stabilize the jaw with firm plates. Most adult children don't need surgery more than once.

If your child is an adult, surgeons usually perform LeFort surgery before definitive rhinoplasty (also called a nose job). This will set the base of your child's nose in the correct position.

Will My Child's Speech Change After Surgery?

When your child's midface is moved forward, air may escape through your child's nose when they talk. As the midface is pulled forward, the palate is pulled with it too, and this causes air to escape.

Sometimes air escapes through the nose when the palate is pulled forward. This is called velopharyngeal insufficiency (VPI). Doctors can treat VPI if the problem doesn't go away.

Planning For Jaw Surgery

We must carefully plan jaw surgery to make sure your child's upper jaw moves in the right direction. Our surgeons use three-dimensional modeling to determine where your child's upper jaw should sit after their distraction or advancement surgeries.

Will My Child's Lower Jaw Need Surgery Too?

Planning for upper jaw surgery can help surgeons find problems with the position of your child's lower jaw. Sometimes the lower jaw is too long or shaped abnormally. Sometimes children have sleep apnea which needs to be treated in addition to any problems with the upper jaw.

Children and young adults with these problems sometimes need surgery on both their upper and lower jaw. Surgeons perform both surgeries to give your child's face a normal appearance.

Recovering from both upper and lower jaw surgery isn't too different than recovering from upper jaw surgery by itself. Your surgeon can discuss if your child will need lower jaw surgery in addition to upper jaw surgery.

Why Do Surgeons Operate on the Bones in My Child’s Face?

Pediatric facial plastic & ENT surgeons operate on the bones in children's faces for many reasons. Surgeons use these types of surgeries to:

  • remove tumors from deep inside the nose;
  • repair broken facial bones;
  • treat teeth, nose, or facial infections;
  • change the position of facial bones to improve the airway in children with sleep apnea,
  • and more.

Our surgeons have expertise operating on bones inside the face and we can help your child achieve the best results.

What To Expect

  • Younger children usually stay in the hospital overnight. This allows our staff to make sure they are not in too much pain. 
  • The sutures (or stitches) above your child’s gum line will dissolve on their own. You do not need to remove them.
  • Your child will use an antiseptic mouth wash for a week. This will help your child prevent infection.
  • Your child will take an oral antibiotic. This antibiotic will prevent an infection from developing inside the bone scar your child will form. Children usually only need an antibiotic during active distraction osteogenesis. Infections that develop after distraction osteogenesis can weaken your child's new bone, but fortunately infections aren't common in the midface. 
  • We will give your child pain medication. Our staff will closely monitor and adjust the amount of pain medication to make sure your child is not in too much pain.
  • We will closely monitor your child to make sure they can breathe easily. We will also watch how much your child is eating and drinking. 

Our nursing staff cares for many children who have facial surgeries. Our staff will provide you with tips as well as compassionate care after your child’s surgery. 

Common Questions

Are there restrictions on how my child can eat and drink?

We don’t put restrictions on how your child eats or drinks after her surgery. Most children heal well. After jaw surgery, your child will need to avoid hard foods. Hard foods may cause your child's jaw to shift while it's healing. It also usually hurts to eat hard foods.

Will my child be able to eat and drink after their surgery?

Most children eating and drink easily after jaw surgery. Your child’s jaw will be sore, so we will monitor your child to make sure they are drinking enough to stay hydrated.

Will my child have breathing problems after jaw surgery?

We will monitor your child closely for breathing problems, but your child most likely won't have a problem. 

Will my child's teeth be numb after surgery?

Some children will have temporary numbness in their upper teeth after surgery. But any numbness shouldn't last long. It's rare for children to have permanent numbness in their lip or midface after surgery.

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