Reconstruction of Zygoma in Total Agenesis in Treacher-Collins Syndrome Using Kerfed Rib Grafts - A Retrospective Study.

Introduction: Reconstruction of zygomatic agenesis in Treacher-Collins syndrome (TCS) poses a significant challenge. Traditional bone grafting techniques often fail to address the complex three-dimensional (3D) anatomy and biomechanical demands. This study introduces an approach using kerfed rib grafts and titanium scaffolding for such reconstructions. Materials and Methods: A retrospective review was conducted on six TCS patients (five males, one female; mean age 20.17 ± 2.91 years) with zygomatic agenesis. Pre-operative 3D computed tomography imaging guided surgical planning. Kerfed rib grafts, harvested via a subperiosteal approach, were meticulously contoured and secured to the maxilla and zygomatic root using pre-contoured titanium plates through bicoronal and intraoral incisions. Lateral canthal ligaments were repositioned and hypoplastic maxillae augmented with recombinant human bone morphogenetic protein-2 (rhBMP2). Results: All six patients underwent successful single-stage reconstruction without intraoperative or post-operative complications, including infection or donor-site morbidity. Over a 12-month follow-up, stable reconstructions with significant improvements in facial symmetry and function were observed. Radiographic assessments confirmed adequate integration of rib grafts and maintained structural stability; no revision surgeries were required. Discussion: Kerfed rib grafts, combined with titanium scaffolding, offer superior conformability, reduced donor-site morbidity and improved aesthetic outcomes compared to traditional techniques for severe zygomatic hypoplasia in TCS. This approach addresses the limitations of calvarial and non-kerfed rib grafts by providing enhanced flexibility, stress distribution and vascularisation. Long-term studies are needed to evaluate the durability of these reconstructions.