Craniofacial reconstruction following trauma is different for each
individual as it highly depends on the nature and location of the
patient's injuries. The first priority in any trauma patients is treating
problems with airway, breathing, circulation or any other
life-threatening emergency before treating facial injuries. Over 60% of
patients with severe facial trauma have other serious injuries in the
head, chest, or abdomen. This high rate of additional injuries reflects
the enormous forces needed to fracture human facial bones. In particular,
a doctor who is examining a patient with severe facial trauma will be
particularly concerned about damage to the brain, the spinal cord in the
neck, and the eyes. Of note, severe facial trauma often leads to
blockage of the airway thus it is important to have a protected airway
before continuing trauma resuscitation and treatment of facial injuries.
The second priority in treating traumatic facial injuries is controlling
severe bleeding.
Imaging studies of craniofacial injuries may need to be postponed for
24-72 hours in order to treat injuries to other organ systems. When the
patient is out of immediate danger, x-ray studies and computed
tomography (CT) scans are taken of the craniofacial injuries. The
accurate diagnosis of facial fractures has been greatly improved by the
addition of two- and three-dimensional CT scans which have replaced the
plain x-rays for the diagnosis of many types of fractures.
Three-dimensional reconstructions have enhanced preoperative bone
analysis and planning for reconstructive surgery by providing a
life-like simulation of the fractures.
The best way to prevent post-traumatic facial deformities is to
obtain the appropriate treatment at the time of the injury. Delayed
treatment has been replaced by early or immediate surgical treatment
and stabilization of small bone fragments augmented by bone grafts and
mini-plate fixation. These new advances have allowed surgeons to
approach and often reach the goal of restoring pre-injury facial
appearance and function in a one-stage operative repair. However,
despite many surgical advances, there are still patients that end up
with significant deformities. These are patients that for whatever
reason are treated inadequately or because of other life-threatening
injuries, cannot receive treatment of their facial injuries.
Facial reconstruction following trauma
Surgery following facial trauma may take as long as four to 14
hours, as the goal is to repair as much as possible in one operation.
The surgeon may use bone grafts, taking bone from other parts of the
body to repair the facial bones, or fill in smaller areas of missing
bone with prosthetic materials and implants. Broken facial bones are
held in place with titanium mini-plates and surgical screws. This
technique is called rigid fixation. Lacerations (tears) in the face
are usually simply closed with stitches. If large areas of skin are
missing, the surgeon may use a flap, which is a section of living
tissue carrying its own blood supply, from another area of the
patient's body and transplant it to the face. Some facial injuries
may require the assistance of a neurosurgeon, oral surgeon, or
ophthalmologist. More Facial Trauma & Facial Reconstructive Surgery Facts...
Common bony injuries to the face following facial trauma
Zygoma
The location of the zygoma makes it prone to injuries despite
its sturdiness. The zygomatic bone occupies a prominent and
important position in the facial skeleton. It plays a key role
in determining facial width as well as acting as a major support
of the midface. The mechanism of injury usually involves a blow
to the side of the face from a fist, object, or motor vehicle
accidents. Moderate force may result in minimally or nondisplaced
fractures. More severe blows result in displacement of the
zygoma.
Historically, zygomatic fractures were fixed by popping the
fragments back into alignment (closed reduction). Not only were
these results frequently unsatisfactory, but they were also
fraught with complications including visual problems, non
healing of the fracture, and significant residual deformities.
The treatment of zygomatic fractures has dramatically progressed
over the past several decades to the more aggressive open repair
using rigid mini-plates of technetium to stabilize a fracture
and align the bones in their appropriate position
(open reduction). The floor of the orbit (eye socket) is
routinely explored and reconstructed, if needed. More Facial Trauma & Facial Reconstructive Surgery Facts...
Maxilla
The maxilla is the largest part of the middle third of the facial
skeleton. Fractures of the maxilla occur less frequently than
those of the mandible or because of the strong structural support
of this bone. The midface consists of alternating thick and thin
sections of bone that are capable of resisting high amounts of
force. This structurally strong bone provides protection for the
eye socket and brain, projection of the midface, and support for
the upper bite.
Maxillary fractures today are often the result of motor vehicle
accidents. These high-velocity injuries are diagnosed by
computerized tomographic (CT) scans. Once again, the more recent
development of 3-D reconstructions have aided greatly in the
diagnosis, classification, and preoperative planning of these
complex maxillary fractures.
Maxillary fractures are treated by realignment and immobilization
of the bones that make up the maxilla. Establishment of
pre-injury bite and midface alignment provides the foundation for
this treatment. Early placement of the patient in Internal
Maxillary Fixation (IMF) will decrease the chance of Internal
Soft tissue deformities. IMF is established by securing wire arch
bars to the upper and lower set of teeth. The appropriate
occlusion of the teeth (or bite) is then determined and the
maxillary and mandibular (jaw bone) arch bars are secured
together. This is one of the simplest and most effective forms
of treatment.
Recent advances in the treatment of maxillary fractures include
the use of open-repair and realignment (open reduction)
techniques using rigid plate and screw fixation of the facial
bones. Bone grafts have been used to replace missing or severely
fractured bones. This more aggressive surgical approach has
dramatically improved the aesthetic results now obtainable with
fewer secondary deformities. More Facial Trauma & Facial Reconstructive Surgery Facts...
Nasoethmoid Orbital Skeleton
Trauma to the central midface frequently results in fractures of
the nasoethmoid orbital (NOE) skeleton. This complex area
consists of a union of bones from the nose, orbits, maxilla, and
cranium. These fractures may be the most difficult and
challenging of all facial fractures to diagnose and treat. To
the inexperienced examiner, NOE fractures may be misdiagnosed
as simple nasal fractures, and a high degree of suspicion is
necessary to make the diagnosis. These fractures may occur as
isolated injuries or as part of more complex (LeFort) facial
fractures. Failure to diagnose these injuries or inadequate
treatment will result in both functional and cosmetic deformities
that are very difficult to correct secondarily.
The best results of the NOE fracture are obtained with early
diagnosis and aggressive surgical treatment. Complications result
when this injury has been misdiagnosed or inadequately treated.
Successful surgical treatment of these complex injuries consist
of early open reduction and stabilization of bone fragments.
Bone grafts are used to restore contour and support to areas of
severely fractured or missing bone. Unstable or displaced
fractures that are left untreated result in permanent
deformities once healed. Late reconstruction is a difficult task
that requires repositioning of both bone and soft tissue.
Although late reconstruction of these deformities is possible,
in general, the best aesthetic results are obtained with
definitive repair at the time of injury, avoiding the common
pitfalls.
To repair severe fractures around the nasal bone (A), an
incision is made into the patient's skin at the top of the head
(B). The skin is pulled off the face to expose the fracture (C),
which then can be repaired with plates and screws (D).
(Illustration by GGS Inc.) More Facial Trauma & Facial Reconstructive Surgery Facts...
Orbit
An orbital blow-out fracture consists of a fracture of the bones
of the eye "socket". This may involve the orbital floor, walls,
or roof. Most cases, however, involve the orbital floor. An
orbital blow-out fracture is almost always secondary to a blunt
blow from a relatively large object, such as a fist, elbow,
baseball bat, or sever motor vehicle accident. Most patients
will present with pain, tenderness around the eye, swelling,
and double vision. Despite this potential for wide variation of
internal orbital fractures, there are basic principles that can
be applied to aid in diagnosis and treatment. The bony orbits
play a vital role in maintaining normal function and aesthetics
of the eyes therefore, realignment and reconstruction of the
bony orbit of the eye is essential to maintain normal function
and appearance of the eyes.
A number of advances have been made in the past 10 to 15 years
in the diagnosis and treatment of internal orbital fractures.
These advanced techniques have allowed for better exposure of
the fractures and better exposure allows fore more precise
reduction and stabilization of the fractures. The use of mini-
or microplates and metal meshes in combination with bone grafts
has also improved stabilization and enhanced the healing of
orbital fractures.
Because most of the bone of the internal orbit is thin and weak,
it is frequently difficult to reduce and adequately stabilize
without the use of autogenous or alloplastic materials.
Autogenous bone grafts have been the material most often
used by craniomaxillofacial surgeons for reconstruction of
the internal orbit. Split skll bone has gained popularity
because of its low rate of infection and decreased
resorption. Other autogenous materials that have been used
include bone from the hip (iliac crest) and ribs or from
cartilage.
A variety of alloplastic material such as silicone,
teflon, tantalum mesh, polyethylene, and methyl methacrylate
have been used for orbital reconstruction. The primary
concern with the use of these materials is the risk of
infection. More Facial Trauma & Facial Reconstructive Surgery Facts...
Mandible
The mandible is a unique bone having a complex role in both
aesthetics of the face and functional occlusion (bite). Because
of the prominent position of the lower jaw, mandible fractures
are the most common fracture of the facial skeleton.
Fractures of the mandible will typically reveal a malocclusion
(inability to bite down), pain at fracture site, significant
internal bruising, or laceration with bleeding between teeth at
the fracture site.
Reduction and stabilization of the mandible fracture is the key
to successful treatment. The method of management may vary based
on the severity, location of the fracture and presence or
absence of teeth. Mandible fractures are usually treated by
closed reduction with wiring of the teeth or open reduction with
internal rigid fixation using plates. Non-operative management
of a mandible fracture with a soft diet is rarely indicated. The
technique of closed reduction involves wiring the teeth for 4 to
6 weeks. Internal rigid fixation when performing open reduction
requires exposure of the fracture sites and stabilization with
plates and/or screws. Accurate reduction with good stabilization
can frequently avoid complications and help to restore the
patients primary occlusion and facial appearance. More Facial Trauma & Facial Reconstructive Surgery Facts...
Mandible stabilized with plate-and-screw fixation
(www.emedicine.com/plastic/topic480.htm)
Soft Tissue Deformities
Soft tissue deformities may involve the skin, subcutaneous
tissue, underlying muscle or a combination of any of these
elements. Traumatic facial injuries may be blunt, penetrating
and/or avulsive in nature. An avulsion, or loss of soft tissue,
may create a significant deformity which requires reconstruction.
Generally the facial bony deformities are reconstructed first
followed by correction of soft tissue problems.
One example of a severely deforming and psychologically crippling
injury is the scalp avulsion. This presents a very challenging
problem particularly if the avulsed portion is very large and
cannot be replanted by microvascular technique. A new and
innovative approach to this type of problem has been the use
of the tissue expander. These expanders are much like deflated
balloons placed beneath adjacent normal tissue. Over a period of
weeks these expanders are gradually inflated, stretching the
normal skin for use in reconstruction. An example of this
technique is shown for reconstruction of the scalp. More Facial Trauma & Facial Reconstructive Surgery Facts...
Complications and Risks of Surgery
Some of the risks of craniofacial reconstruction are common to
all surgical procedures done under general anesthesia. These
include bleeding, breathing problems, bruises underneath the
skin, reactions to the anesthesia, and infection.
Risks that are specific to craniofacial reconstruction include:
Neurologic deficits, including motor and sensory (anesthesia, paresthesia) deficits
Decrease in facial height
Increase in facial width
Decrease in facial projection
Traumatic telecanthus
Malocclusion
Nasal obstruction and deformities
Cerebrospinal fluid leak
Anosmia
Blindness
Risk factors that can affect the results of
craniofacial reconstruction include:
poor nutrition
HIV infection
a weakened immune system
damage to the skin from radiation therapy
a connective tissue disease, such as lupus or scleroderma
smoking
time elapsed between a traumatic injury and surgical treatment
Disclaimer:
This information is intended only as an introduction to this procedure.
This information should not be used to determine whether you will
have the procedure performed nor does it guarantee results of your
elective surgery. Further details regarding surgical standards and
procedures should be discussed with your physician.
Cosmetic/Plastic Surgery
