Craniofacial skeletal abnormalities may be associated with other syndromic abnormalities

They may have sleep apnoea related to a small volume postnasal space. The airway may be improved postoperatively as the postnasal airspace is enlarged by midface advancement

These are major and prolonged procedures

A submental tracheal tube is often necessary—the nasal route is unavailable, and the oral route precludes an assessment of dental occlusion

A throat pack is needed

Significant intraoperative blood loss may occur

Meticulous eye protection is needed

Prophylactic antibiotics and dexamethasone are routine

Distraction frames restrict access to the airway. The application of a facemask is difficult and rigid laryngoscopy is impossible with the frame in place. They can be disarticulated but a special screwdriver is required and the joints tend to become stiff with time²⁶. A dedicated screwdriver and wirecutters should be available at the bedside in the postoperative period

Patients may present for alteration of the frame to change the distraction vectors. This may be possible under sedation. Alternatively, the frame can be disarticulated prior to induction or a laryngeal mask can be used to manage the airway²⁷. An awake, oral fibreoptic intubation is a reasonable alternative. A facemask technique with manual occlusion of the nostrils has also been described²⁸

Extubate awake: airway exchange catheter is a good option. It is well tolerated, allows administration of oxygen, and can be used as a conduit if reintubation is required

Nurse sitting up to reduce swelling and bleeding

If oxygen is needed postoperatively, humidification prevents drying and crusting of blood in the nose

Regular analgesics are required during the postoperative period and the distraction phase as soft tissue stretching is painful