Management of traumatic optic nerve injury remains controversial, and the debate whether observation alone is better than steroids, surgical decompression, or a combination of the two remains unresolved.²⁹^–³⁶ A regimen of megadose methylprednisolone (loading dose of up to 30 mg/kg; maintenance dose of up to 5 mg/kg per hour for 72 hours) followed by a gradual reduction has been recommended³⁷; however, the International Optic Nerve Trauma Study found no benefit from either corticosteroid therapy or optic nerve decompression.³² A Cochrane review published in 2005 noted a high rate of spontaneous recovery and concluded that traumatic optic nerve injury initially seen more than 8 hours after injury should not be treated with steroids; for those seen within 8 hours, the evidence of benefit was weak.³⁸ Several papers have reported some good results after endoscopic decompression.^33,^39,⁴⁰ A small study reported better results in those operated early³⁰; however, a further Cochrane review in 2007 was unable to find sufficient evidence from the small retrospective series available and noted the risk for complications.⁴¹

Definitive Repair

Once the necessary assessments have been completed, a treatment plan is devised by all the specialties involved. Isolated injuries rarely give rise to conflicting treatment priorities, whereas multiple injuries and complex craniofacial injuries require a clear assessment of priorities based on the degrees of urgency.

In deciding on the appropriateness of early versus delayed surgery,⁴²^–⁴⁴ the following principles need to be observed:

1 Avoid extended operations in the early phases of brain injury when the brain is highly susceptible to hypoxia and decreases in cerebral perfusion pressure. Acute brain injury is best managed by early treatment of brain compression and closure of compound wounds, followed by careful monitoring in the intensive care unit to control intracranial pressure and cerebral perfusion.

2 Avoid retraction on a recently injured brain.

3 Undertake a full radiologic assessment of the facial injury before definitive treatment.

Priorities and Staging of Procedures

1 Airway obstruction or massive bleeding requires immediate action.

2 After resuscitation, neurosurgical and ophthalmologic emergencies take priority.

3 Urgent operative intervention may be necessary for injuries to other body systems such as the thorax and abdomen. Interdisciplinary consultation will determine the order of priorities and whether simultaneous or sequential operations should be performed.

4 Soft tissue lacerations of the skin and oral mucosa should be closed as soon as possible to reduce the risk for infection and further tissue loss. Exposed dura, brain, bare cortical bone, and major vessels need to be covered urgently. At the same time, repair of vital structures such as the eyelids, nerves, and salivary ducts can be undertaken.

Timing of Repair

There may be opportunities for early repair at the time of emergency procedures without unduly extending operative time. For example, a depressed frontal bone may be elevated, dura repaired, and perhaps a ruptured eye enucleated and, at the same operation, orbital fractures fixed and an examination under anesthesia undertaken to determine the extent of any associated jaw fractures. Dental impressions can be taken in preparation for definitive correction of the jaws at a later date.

Some advocate very early definitive surgery, within 24 to 48 hours as a general rule, under the rationale that reconstruction should be undertaken before contractile scar tissue prevents correct positioning of soft tissues, particularly those within the orbit.⁴⁵ In our experience, repair of facial fractures is rarely urgent and can be carried out in one or more elective procedures 7 to 10 days after the injury or longer, depending on the state of the patient, without compromising the result. This allows time for clinical stabilization of the patient and preparation of a multidisciplinary treatment plan, which may involve ophthalmology, dentistry, and ear, nose, and throat specialists, as well as neurosurgical and craniofacial specialists.

Delayed definitive surgery can also be timed to coincide with other less urgent operative procedures.

Surgical Principles

There are three important anatomic sites of injury to the craniofacial interface.

1 The cranio-orbital interface, which is the junction between the anterior cranial fossa and frontal sinus above and the orbits and nasoethmoid region below. Posteriorly, fractures of the orbital apex and orbital roof may compromise the oculomotor nerves, the optic nerve, and ocular position and motility.

2 The zygoma, which articulates with the sphenoid, maxilla, and frontal and temporal bones. Accurate repositioning of the zygoma is essential for orbital correction. A correct and stable arch position determines the lateral midface projection and midface width.

3 The mandibular condyles, which demarcate the posterolateral limit of the middle fossa and the external auditory canal.

Craniofacial Exposures

Surgical treatment is typically based on wide exposure of the craniofacial skeleton via a bicoronal scalp flap or periorbital, intraoral, and extraoral incisions. Recently, endoscopy has been used for some orbital fractures, for fractures of the mandibular condyles, and for repair of anterior cranial base fractures with CSF rhinorrhea (see Chapter 341).

The Bicoronal Scalp Flap

This flap is placed behind the patient’s hairline when possible. The incision may be a straight line from ear to ear, as is usual in neurosurgery, or a wavy or zigzag line, which gives a better cosmetic result (Fig. 339-3). The flap is raised in a subgaleal plane to 2 to 4 cm above the supraorbital rim or the site of any fractures of the frontal bone. From this level the dissection proceeds subpericranially over the orbital rim and into the orbit. The supraorbital neurovascular bundle is carefully preserved, if necessary by fracturing the margins of the supraorbital notch with a fine osteotome.

FIGURE 339-3 A, A zigzag or wavy coronal incision gives a better cosmetic result than does a straight incision. The incision is shown in relation to the frontal branch of the facial nerve. The surface marking of the frontal branch of the facial nerve as it crosses the zygomatic arch is defined by a line between the zygomatic tubercle and the midpoint of the ear lobe. B, Exposure through a bicoronal scalp incision. The scalp flap is elevated over the superficial temporal fascia. The fascia is incised at the level of the superior orbital rim, and dissection then proceeds in the plane deep to the superficial temporal fascia down to the zygomatic body and arch. Such dissection protects the frontal branch of the facial nerve. C, The bicoronal scalp flap can be taken low enough to expose the superior orbits, nasoethmoid region, the zygoma, and the condyles of the mandible.

It is important to dissect strictly against the temporal fascia or to incise through the superficial layer of the temporal fascia and dissect at the subfascial fat plane down to the zygomatic arch to preserve the frontal branch of the facial nerve, which lies superficially within or above the superficial temporal fascia. At the level of the zygomatic arch the periosteum is stripped with great care, particularly from the middle and posterior thirds. This may be difficult when the arch is fractured, and the frontalis branch of the facial nerve can be damaged. Within the orbit the periorbita is dissected to within 1 cm of the apex. When orbital fractures are present, soft tissue may be trapped between bony fragments, which must be separated to release the soft tissue. The temporomandibular joint and the neck of the condyle can be approached by extending the bicoronal flap to the lobule of the ear. Careful dissection of the soft tissue from the lateral ligaments of the temporomandibular joint capsule enables visualization of the neck of the condyle and the sigmoid notch. Further access can be gained by dividing the most posterior fibers of the masseter muscle, and the subperiosteal dissection can be taken down to the angle of the mandible.

Subciliary lower eyelid incisions or transconjunctival incisions with or without a lateral canthotomy provide excellent exposure of the orbital floor.⁴⁶

Intraoral incisions in the upper and lower buccal sulci provide exposure of the remaining facial skeleton with the exception of the pterygoid plate. Care must be taken to avoid damage to branches of the infraorbital nerve by the upper buccal sulcus incision and the inferior dental nerve by the lower buccal sulcus incision. In an edentulous mandible the inferior dental nerve is very superficial intraorally, and in such cases an external mandibular incision is preferable.

Bone Grafting

After severe injuries bone is often missing from one or more of the vertical bony pillars of the midface.⁴³ The thin bone of the floor and medial wall of the orbit may be lost with orbital fractures.

Bone grafting is sometimes needed to reconstruct defects in the orbital rim or to correct the nasal bridge line after severe comminution of the nasal bones and bony nasal septum. Gunshot wounds may result in significant loss of bone. When this loss is greater than 3 cm in length, vascularized bone provides more certain healing.

Common donor sites for harvesting bone are the iliac crest, rib cage and skull vault (calvaria). Many factors are important for the survival of bone grafts, the most important being rigid fixation followed by good soft tissue coverage, preferably with a periosteal surface.⁴⁷ Other factors include a well-vascularized bed in the host tissues and prevention of hematoma formation.

Internal fixation is achieved with small plates and screws constructed of materials such as titanium, which is biologically inert and compatible with MRI.

Titanium mesh and other alloplastic materials can be used to reconstruct the orbits, although bone is preferable. Absorbable plates and screws have been developed and are undergoing trial for use in traumatic injuries.

Donor Sites

Hip Grafts

The wing of the ilium provides strong, yet malleable cortical and cancellous grafts that are excellent for the orbital wall and mandibular reconstruction, either as vascularized or as nonvascularized grafts. The inner table can be harvested separately and cancellous bone may be scooped out to use alone or with cortical bone. The full thickness of the ilium can be taken if needed, but it is important to spare the crest itself in both adults and children.

Rib Grafts

Rib grafts can be readily harvested through a submammary incision. The malleable ribs are useful within the orbit, for reconstruction of the calvaria, and as a costochondral graft for the nasal bridge or temporomandibular joint.

Calvarial Grafts

Calvarial bone has the disadvantage of being more rigid than either iliac bone or rib. The outer table can be safely split from the skull at sites where there is a well-formed diploic space (Fig. 339-4), as is usual in the parietal area; however, radiographs must be examined to determine whether the skull is thick enough to perform the maneuver safely. The sagittal sinus and its parasagittal venous tributaries must be avoided, and great care should be taken to avoid penetrating the dura mater. When a small square of bone is needed, as for the orbital floor, the pericranium can be left attached to prevent fragmentation of the graft. Contour defects are hard to avoid when the outer table is harvested. The inner table can be harvested when a craniotomy is being performed and the calvaria is thick enough.

FIGURE 339-4 Bone graft from the inner table of the calvaria. When a calvarial bone flap has been raised, the inner table may be harvested if the bone is thick enough. A sagittal saw is used to cut through the diploë, and the fragments are levered off with a broad osteotome.

Other Donor Sites

The anterior surface of the tibia is no longer commonly used.

Vascularized Bone Grafts

These grafts may be taken from the humerus, radius, scapula, and clavicle, as well as the ilium and calvaria.

Cartilage Grafts

Costal cartilage can be harvested from ribs and used for small orbital floor defects. Cartilage can also be harvested from the nasal septum or the concha of the ear.

Specific Fracture Patterns

Fractures Involving the Frontal Sinus

A compound depressed fracture of the frontal sinus involving the anterior and posterior walls is best approached through a bicoronal scalp flap (Figs. 339-5 and 339-6). A small frontal craniotomy is made above the sinus area to expose the posterior wall of the sinus, and the depressed fracture is approached extradurally. If the dura is torn, the posterior wall of the frontal sinus is drilled away and the sinus mucosa stripped. The dura is repaired in a watertight manner by primary suture or by patching with a graft of temporal fascia or pericranium placed intradurally if possible. The sinus ostia can be plugged with muscle. A pericranial graft attached inferiorly is turned forward and sutured to the dura to seal the frontal sinus. If soft tissue injuries prevent such grafting, a free graft of temporal fascia can be laid over the exposed frontal sinus and sutured to the dura and to the pericranium. The technique is designed to obliterate the sinus. The anterior wall of the frontal sinus is preserved. If it is comminuted, the fragments are wired or plated in good position.⁴⁸

FIGURE 339-5 A and B, Computed tomographic scans showing fractures of the anterior and posterior walls of the frontal sinus and the cribriform region on the left.

FIGURE 339-6 A, When there is a wound in the forehead and depression and comminution of the frontal bone, the dura and cerebral cortex may be lacerated. B, A standard bicoronal scalp flap is reflected and the depressed bone fragments are carefully removed. The dural tear is enlarged, the lacerated cortex is cleaned by irrigation, and the clot is removed by gentle suction. C, The posterior wall of the sinus is resected. The sinus ostia may be closed with muscle or a pericranial graft (or both). The dura is closed, and the bone fragments are replaced with miniplate or wire fixation. The scalp flap is sutured in two layers. D, Bifrontal exposure of a frontal sinus fracture. The comminuted outer table has been removed piecemeal and will be reconstructed; the posterior wall is removed, the dura repaired, and the sinus obliterated.

(A-C, From David and Simpson 1995, with permission.)

Central depressed fractures of the frontal region may be associated with orbitoethmoid fractures and fractures of the floor of the anterior cranial fossa, often complicated by CSF rhinorrhea. This constellation of injuries is best managed by a combined operation in which the fractures are elevated and fixed with miniplates and the anterior fossa is explored intradurally and repaired if the disruption is severe and the degree of brain swelling is not prohibitive.

A closed depressed fracture of the anterior wall of an extensive frontal sinus without damage to the posterior wall may be reconstructed with small wires or microplates.

Closed anterior and posterior wall fractures with CSF leakage are observed, and if the leak persists beyond 1 week, dural repair is performed.

A simple posterior wall fracture without a dural fistula need not be treated.

Naso-orbito-ethmoid Fractures

These injuries result from a direct impact to the midface, with the primary point of contact being at the nasal complex. High-energy impacts cause fractures that extend posteriorly into the delicate ethmoid bone, superiorly into the frontal sinus, inferiorly into the nasal septum, and laterally into the orbital floor. The anterior fossa floor may be fractured. The central unstable bone fragments include the attachment of the medial canthal ligaments. These in turn are part of the eyelid suspensory ligaments and surround the lacrimal sac.

These fractures may be unilateral or bilateral, simple or comminuted, closed or compound. They may occur in isolation or in association with more extensive fracturing of the forehead, orbit, or maxilla.⁴⁹

The characteristic deformity is best seen in lateral profile. Collapse of the nasal pyramid results in posterior displacement of the nasal dorsum and upward tilting of the nasal tip. When viewed from the front, flattening and spreading of the intercanthal region are observed.

Ophthalmologic examination is essential to exclude associated injuries to the globe and adnexa. Neurosurgical evaluation is necessary because of the potential for an anterior fossa dural tear and cranionasal fistula.

Operative Management

Nasoethmoid fractures are treated by open reduction and interfragmentary fixation with screws. If necessary, primary bone grafts are applied to the medial orbital walls and nasal dorsum, and the medial canthal ligaments are reattached.^50,⁵¹

A bicoronal scalp incision and subperiosteal dissection are performed to expose the orbital roof, medial orbital walls, nasal bones, and frontal processes of the maxillae. Care must be taken to preserve any attachment of the medial canthal ligaments. Conjunctival or subciliary incisions are made to expose the orbital floor. Upper buccal sulcus incisions give access to the nasomaxillary buttresses. Limited access may be obtained through nasofrontal lacerations.

If the naso-orbito-ethmoid complex is fractured as a single segment, the block can be reduced and fixed with microplate and screw fixation at two points. The canthal attachments remain intact and the canthal relationships are not disturbed. When the injury is more severe and fragmentation extends into the medial orbital wall, reconstruction proceeds from posterior to anterior. Bone grafts are applied to the medial orbital wall and the fragments fixed with miniplates or microplates. A transnasal canthopexy is performed in which transnasal 28-gauge wires are passed through the canthal ligaments and then posterior and superior to the lacrimal fossa. In severe cases, a primary bone or costochondral graft placed as a cantilever restores the nasal bridge and maintains the soft tissue by preventing scar contracture, which makes secondary surgery very difficult. The graft is fixed superiorly by plates and screws or by screw fixation alone. The distal portion is inserted under the lower lateral nasal cartilage to maintain nasal tip position. The nasal septum is invariably buckled and is best managed at this stage by gentle closed manipulation, with definitive correction left for a later time.

Fractures of the Zygoma

The zygomatic bone forms part of the lateral wall and floor of the orbit and makes an essential contribution to orbital contour and facial width and projection.⁵²

Zygomatic fractures may be indicated by swelling, bruising, subconjunctival hemorrhage (particularly laterally), double vision, or blurred vision. Numbness or altered sensation commonly occurs in the distribution of the infraorbital nerve. Trismus and complaints of malocclusion indicate that the arch fractures are impinging on the underlying temporalis muscle.

Palpation will readily identify displacement. The inferior orbital rim may exhibit a palpable “step-down” on palpating in a medial-to-lateral direction. When the zygomatic fracture is associated with extensive midfacial fracturing, the zygomatic arch is bowed outward and the anteroposterior projection of the zygomatic prominence is diminished. Intraoral examination will show bruising in the upper vestibule.

Detailed ophthalmologic examination is essential.

Coronal CT scans show the orbital walls and the floor. Axial views show the deformation of the zygomatic body, arch, and lateral and medial orbital walls.

Treatment

An undisplaced zygomatic fracture requires no operative intervention.

An isolated, displaced zygomatic arch fracture is usually treated by closed reduction.⁵³

Orbitozygomatic fractures require careful open reduction and internal miniplate fixation. Wide operative exposure of the orbitozygomatic skeleton allows anatomic restoration of the zygomatic prominence with fewer positional disturbances of the globe, such as enophthalmos and vertical dystopia. Because the masseter muscle is the major displacing force acting on the zygoma, miniplate fixation of the zygomaticomaxillary buttress and the zygomaticofrontal articulation should orientate the vertices of fixation in the optimal axis.

If there is significant comminution at the zygomaticomaxillary buttress, it may be necessary to bone-graft the resultant gap after reduction has been achieved.

Comminuted and grossly displaced orbitozygomatic fractures are almost always caused by high-velocity impacts and are associated with major midface or panfacial fractures. Gruss and colleagues advised first restoring the anterior projection of the zygomatic arch because this is key to restoring facial projection.⁵² The zygomatic arch is the significant reference point with respect to midfacial width and anteroposterior projection in panfacial fractures. CT will indicate the possibility of loss of bone in the orbital floor. In severe fractures, the medial orbital wall can be damaged as well, and bone grafting may be necessary in both these sites to restore orbital volume. The orbital wall components of zygomatic fractures do not require exploration if CT shows no displacement.

Orbital Injury

High-resolution axial CT scans with bone and soft tissue windows will show the medial and lateral walls and extension of fractures into the cranial base, zygoma, and midface. Coronal views will show the orbital roof, medial and lateral walls, and orbital floor.

When a pure blow-out fracture is suspected, direct coronal scans of the orbit will accurately identify the extent of involvement of the floor and medial wall and the nature of the soft tissue abnormality.

Hematomas may also be identified. Comparison with the contralateral orbit on an axial CT scan provides qualitative assessment of the degree of enophthalmos; quantification of posttraumatic enophthalmos and the changes produced by surgical correction are revealed by comparison of precorrection and postcorrection CT scans.

Management of orbital injury aims to accurately restore first the orbital rim and then the walls to return the globe to its preinjury position with full ocular motility. This should be done early to prevent the development of soft tissue fibrotic changes. The orbital rim is reduced and fixed internally with microplates or miniplates, and the orbital walls are reconstructed with primary bone grafts if comminuted or bone loss is extensive.

The floor is approached through a transconjunctival incision or subciliary lower eyelid incision (Figs. 339-7 and 339-8).

FIGURE 339-7 A, Coronal computed tomographic scan showing a blow-out fracture of the orbital floor. B, The orbital floor has been reconstructed with a thin bone graft harvested from the medial part of the ilium.

FIGURE 339-8 A, Massive orbital floor blow-out fracture and global dystopia. B and C, A lower eyelid incision plus removal of a segment of orbital rim exposes the defect in the orbital floor. The infraorbital nerve can be seen bridging the defect. D, The orbital floor has been reconstructed with a bone graft, and the orbital rim has been replaced and fixed with microplates.

The lateral wall may be approached through an eyebrow incision, and the medial wall, roof, and lateral walls can be approached via a bicoronal scalp flap. Fractures of the medial orbital wall have been approached endoscopically through incisions in the medial canthal region. The dissection is in the subperiosteal plane. Herniated soft tissues are replaced in the orbit when possible and the defects repaired.

In small isolated blow-out fractures of the orbital floor, the displaced bony fragment may be elevated and allowed to override. In the majority of cases, however, this is inadequate and correction requires orbital wall reconstruction. The materials used can be either autogenous bone or cartilage grafts or alloplastic implants, absorbable or nonabsorbable. Titanium mesh has very suitable biocompatibility and can be used to restore the orbital cavity contours in complex facial fractures because it can be shaped accurately. It is best used in combination with autogenous bone grafts. Autogenous bone on its own is the best material for orbital repair, provided that the grafts are adequately shaped, placed anatomically, and fixed when possible. They are less prone to infection or extrusion. Bone grafts may be calvarial, rib, or hip. For the medial orbital wall, a thinned portion of the inner table of the ilium shaped to replace the eggshell-like lateral wall of the ethmoid is introduced via the bicoronal scalp flap and subperiorbital dissection.

The most common complication is enophthalmos, which is often due to inadequate exposure of the full extent of the bony defect, particularly a medial orbital wall fracture. Ocular and canthal dystopia results from inaccurate reduction of the zygoma and failure to maintain the bony attachments of the medial canthus and restore the lateral canthal region.⁵⁴ There may be damage to the globe or impaired motility from scarring or tethering.

Fractures of the Mandible

Fractures of the mandible are relevant to craniofacial surgery as an important component of panfacial fractures. Correct realignment of the mandible is mandatory for rebuilding the maxilla and the orbits to restore correct facial proportions (Fig. 339-9).

FIGURE 339-9 A, Condylar fractures pass through the sigmoid notch and separate the condylar head from the body of the mandible but exclude the coronoid process. B, Three-dimensional computed tomographic scan of a condylar neck fracture after fixation.

Stable fractures without displacement are best treated conservatively.

A displaced fracture of the body or angle of the mandible in an adult usually requires reduction and stabilization for 6 weeks. Any displaced fracture through a tooth root is inevitably compound. Fractures of the ramus and condylar region are not compound unless caused by a penetrating agent.

An orthopantogram gives an excellent view of the angles and coronoid and condylar processes. A CT scan may give useful information regarding the integrity of the buccal and lingual plates.

In patients with a displaced fracture, dental impressions are taken to provide plaster casts of occlusion in the position resulting from injury. These casts are then cut at the fracture site and mounted on an articulator in the predicted pretraumatic position so that they can be used as models in planning management.

Maxillary Fracture Patterns

Maxillary fractures are still most often classified according to the original description by Le Fort (Fig. 339-10), although fractures rarely conform to this pattern and more detailed and accurate descriptions are now based on CT scanning.⁵⁵

• Le Fort I—a horizontal fracture through the piriform aperture, the zygomatic buttresses, and the pterygoid plates.

• Le Fort II—a horizontal fracture that detaches the upper jaw and passes across the nasal bones through the inferior orbital rims, the zygomatic buttresses, and the pterygoid plates but leaves the zygomas intact

• Le Fort III—craniofacial dislocation with the fracture line including the zygomas

FIGURE 339-10 A, Le Fort I fracture—a transverse fracture of the middle third of the face. B, Le Fort II fracture—the zygomas are intact but the pyramid of the maxilla and the nasoethmoid complex are displaced. C, Le Fort III fracture—total craniofacial disjunction, in this case in fragments.

Clinical Assessment

With high midface fractures in which the force was transmitted to the cribriform plate and beyond, CSF rhinorrhea must be considered possible.

The clinical signs depend on the degree of displacement and on whether the fracture extends to the orbits and nasal bone. There may be bruising, swelling, and elongation of the midface, mobility of the midface, and malocclusion. An intraoral examination may elicit pain and show crepitus and abnormal movement.

CT scanning with axial, coronal, and three-dimensional reformatting is essential to delineate the fracture pattern and establish a treatment plan.

Management

Conservative management is undertaken in the following two situations:

1 When clinical and radiologic examination confirms a nondisplaced fracture

2 In an edentulous patient with only minor radiologic evidence of displacement and in whom the fracture appears to be stable with mastication.⁵⁶

Displaced upper jaw fractures require open reduction and internal fixation.⁴³

Preoperative dental impressions of the dental arch are used to cast a plaster model. The pretrauma occlusion is determined and an acrylic bite wafer constructed on the dental cast. This is used perioperatively and often postoperatively to maintain the correct occlusion.

Because upper jaw fractures may compromise both the oral and nasal cavities, preoperative airway management needs careful planning.

After careful disimpaction and mobilization of the fractures, an acrylic occlusal wafer is wired to the upper jaw. The jaw is placed in occlusion and stabilized with intermaxillary wires. The relationship of the upper jaw to the midface buttresses is established with the mandibular condyles properly seated in the glenoid fossae. Fixation is achieved through the four anterior vertical midface buttresses. If any of these buttresses is comminuted, vertical height can be maintained with bone grafting. After all four buttresses are stabilized with miniplates or bone grafting, the intermaxillary fixation may be released and the success of the reduction confirmed by seeing the lower teeth engage cleanly into the wafer. The fracture is then supported with one or two very light elastic bands between the upper and lower jaws.

Different sequences must be considered when the bones of the upper midface are also fractured and when there is a simultaneous mandibular fracture.⁵⁷

When the upper jaw fracture is associated with displaced orbital fractures, particularly the zygomatic or naso-orbital component, these are first stabilized. The occlusal complex, which consists of the upper and lower jaws united, is then brought up to the stabilized upper midface, and the final fixation, with or without bone grafting, is carried out along the lines of the buttresses (Fig. 339-11).

FIGURE 339-11 When fixing a maxillary fracture, the plates should be placed along the lines of the anterior load-bearing buttresses on each side.

Postoperatively, the intermaxillary fixation is released early. The acrylic occlusal wafer may be left on the upper jaw and the mandible permitted to engage in the dental facets on the inferior aspect of the wafer for a number of days. Light rubber band traction may be placed between the upper and lower jaws in the premolar region after the first 24 hours to inhibit contraction of the medial pterygoid muscles during the earlier stages of mobilization. Patients are nursed while sitting up as soon as possible to reduce facial swelling, and jaw mobilization is commenced almost immediately.

Multiple and Panfacial Fractures

Severe impact to the central part of the face may damage all regions to varying degrees (Fig. 339-12). Because the fracture patterns are extremely variable, there is no standard approach to management. Repair requires repositioning existing bone, replacing severely comminuted or lost bone with primary autogenous bone grafts, and replacing or expanding craniofacial soft tissues to the pretraumatic state.

FIGURE 339-12 A, Three-dimensional computed tomographic reconstruction of a panfacial fracture involving the body of the left mandible, a Le Fort I fracture, and fracture of the left zygoma and the nasoethmoid complex. B, After reconstruction of the panfacial fracture in A, by mandibular plating, zygomatic plating, bone grafting of the comminuted area of the left zygoma and maxilla, plating along the buttresses of the maxilla, and a bone graft to the nasal dorsum.

The first step in management is to restore midface projection and width in relation to the cranial base and mandible.

Gruss and associates grouped these complex injuries into three broad anatomic divisions ⁴³:

1 Central—a central impact to the frontonasal region that splits the central facial buttress from the anterior skull base. Fractures may extend into the frontal bone, orbital roof, midface, and central mandible.

2 Lateral—a lateral impact damaging the lateral facial buttress (frontozygomaticomaxillary) and extending into the greater wing of the sphenoid, temporal, and parietal bones.

3 Combined central and lateral—a major impact causing extensive comminution of the central and lateral elements, often with sagittal fracturing of the midface and mandible and with condylar fractures.

In most cases there are three key anatomic sites of injury:

1 Cranio-orbital. The cranio-orbital interface is the junction between the anterior cranial fossa and frontal sinus above and the orbits and nasoethmoid region below. A secure interface between the contents of the anterior cranial fossa and the nasal cavity is essential for avoiding intracranial infection. Extension of cranial base fractures through the sphenoid bone may injure the neurovascular structures of the orbital apex, superior orbital fissure, and cavernous sinus. Damage to the orbital roof and lateral walls may affect the projection or motility of the eye (or both) or cause orbital pulsation. These injuries may be complicated by frontal lobe injury.

2 Zygomaticomaxillary junction. The zygomatic arch and the lateral orbital wall most accurately relate the orbit and midface to the cranial base above. Correct stable arch position determines the lateral midface projection and midfacial width. Reconstruction of the maxilla in its correct place between the zygomas will complete the midfacial arch and central midfacial projection with a proper relationship to the mandible.

3 Mandibular condyles. The mandibular condyles demarcate the posterolateral limit of the craniofacial interface. The condyles and rami establish the posterior facial height. The condyles are frequently injured with panfacial fractures and must be carefully restored to reestablish the vertical dimension of the face. The midface must be related to the intact mandibular arch at the occlusal level because the mandibular arch determines facial height and, to a lesser extent, central facial projection.

Clinical Assessment

After immediate resuscitation as set out earlier, neurological and ophthalmologic assessments must be undertaken. There may be marked bruising and swelling, deformity, and abnormal movement of the facial skeleton. Injuries to the globe may be obscured by orbital swelling.

Radiologic Assessment

The definitive fracture pattern can be determined only by high-resolution CT scans. In very complex cases, nylon models generated from the scan are valuable in planning the reconstructive surgery.

Treatment

Complex craniofacial fractures ideally require definitive correction of the bony injuries within the first 5 to 7 days. As noted earlier, some aim for primary fixation within 12 to 48 hours of injury, but this early time frame may not allow adequate preoperative radiologic, ophthalmologic, and dental assessment, especially when the patient is comatose or poorly cooperative. During this early phase, soft tissue swelling makes operative exposure and assessment of facial projection and symmetry difficult. CSF rhinorrhea or an intracranial aerocele may provide additional reasons for delay to determine whether dural repair is necessary.

When early acute neurosurgical intervention is necessary for intracranial clots or compound calvarial fractures, the scalp incisions should be designed to allow later exposure and stabilization of the craniofacial fractures. Because fixation of a mobile face requires an intact fronto-orbital bar, a frontal bone flap elevated to expose the anterior cranial fossa must be positioned to maintain the stable superior points for fixation. When treating a depressed fracture of the temporal region, it may be possible to stabilize fractures extending into the lateral orbital wall and greater wing of the sphenoid. Indeed, delayed repair of an orbital fracture may risk displacing a previously corrected cranial component and causing intracranial bleeding or dural injury.

Sequence of Repair

The sequence of repair depends on the status of the boundaries of the injured face—the calvarial vault above and the mandible below.⁵⁸

When the frontal cranium is intact, there is fracturing but no loss of bone in the anterior cranial fossa or fronto-orbital bar, or these structures have already been rigidly fixed at a previous operation, the orbitozygomatic and midfacial regions can be built from above downward. The key steps in this sequence are proper positioning and fixation of the zygomatic arches.

There are other situations in which repair proceeds from below upward. If the mandibular arch is disrupted, especially if it is foreshortened as a result of fracture or fracture-dislocation of the condylar processes, it should be repaired initially to establish a solid basis and posterior facial height. Once the mandible is rigidly restored, the midface can be disimpacted and placed in the predicted occlusion. Intermaxillary fixation is then instituted. Repair subsequently proceeds from above down to meet the already fixed maxillary-mandibular segment. Miniplate fixation or bone grafting is used to reconstitute the four anterior buttresses (Fig. 339-13).

FIGURE 339-13 A, Patient with a panfacial fracture and the typical long face. B, Three-dimensional reconstruction showing the fractures involving the mandibular symphysis and condyle, the maxilla, and the zygomas. C, Fixation of the mandibular symphyseal fracture with two miniplates. D, Open reduction and internal fixation of the condylar fracture. E, Fixation of the maxillary fracture with four miniplates placed on the anterior buttresses. The sequence of events is fixation of the mandible to establish a platform, disimpaction and attachment of the maxilla to the mandible with intermaxillary fixation, attachment of the jaw components to the zygomatic buttresses, and fixation with four miniplates.

Repair also proceeds from below upward if there has been cranial bone loss and disruption of the floor of the anterior cranial fossa such that the superior reference points have been lost or distorted. The mandible and midface are repaired first, and this reconstituted complex is reattached to the cranium above after any necessary anterior fossa dural repair has been performed.

Sagittal Fractures of the Midface

Vertical fractures through the alveolar process and palate occur in 24% of Le Fort fractures, and 78% are associated with mandibular fractures.⁵⁹ They require careful presurgical dental modeling, sequential repair as outlined, and on occasion, open fixation of the hard palate fracture.

Infancy and Childhood

The skeleton and dentition in children are evolving entities. Development of the skeleton and soft tissues is interrelated and dependent on the functional status of the matrix on which the tissues are growing. Both trauma and surgical intervention can interfere with the growth processes in ways that may not be apparent until years later.^60,⁶¹

The incidence of facial fractures is lower in childhood and particularly in infancy. Reasons given for this lower incidence are

• A more protected environment

• A small face-to-vault mass ratio

• Thicker adipose tissue, which protects the craniofacial skeleton

The most common causes of injury are falls in play or sports.^4,⁶¹

Pediatric injuries in motor vehicle accidents often result from severe impact, and associated injuries have been reported in more than 60% of children.^60,⁶³

The patterns of injury are different from those seen in adults. The calvaria is more prominent in early life and therefore more exposed to injury. The frontal bone in infancy is a thin plate of woven bone and can become indented (a “ping-pong” fracture). There is a greater risk for contrecoup contusions with frontal impact because of the thinner skull.

As the calvarial bone thickens and becomes more resistant to injury, linear and depressed fractures can occur, frequently with fracture lines extending into the orbit.

The facial skeleton at birth contains relatively more cancellous bone and cartilage than the adult facial skeleton. It contains all the unerupted teeth and has not yet been weakened by development of the paranasal sinuses. This accounts for the resilience of the infant’s mandible and midfacial complex to impact. Greenstick fractures are more common. Before completion of eruption of the permanent dentition (5 to 12 years), the presence of unerupted teeth predisposes the bones of the midface and mandible to more oblique and sagittal fractures through the developing tooth crypts.⁶⁴

The most common facial fractures in childhood are nasal and mandibular.^65,⁶⁶ Isolated fractures of the midface are rare. Orbital roof fractures may be overlooked and should be considered if there is evidence of injury about the eye.^67,⁶⁸

By 7 years, orbitocranial growth is very nearly completed. After the age of 12 years, sinus aeration is near completion, adult dentition is established, and mineralization of the skeleton becomes complete. The facial skeleton has changed from a solid resilient mass to a complex system of robust but rigid pillars and thin plates. The fracture patterns therefore become those of the adult.¹²

General Principles

For fractures with minimal displacement, treatment should be conservative.

Greenstick fractures should be reduced without fixation.

Severely displaced fractures need to be reduced and fixed with minimal exposure.

Minimal rigid fixation should be accomplished with plates and screws, which are removed later if they are placed in areas that may interfere with growth.

Teeth should be preserved whenever possible.

Long-term follow-up is essential to detect any growth abnormality and determine the need for later operations such as bone grafting.⁶⁹

Senescence

As with other forms of trauma, craniofacial injuries have a worse outcome in older age.

Factors that affect outcome include

• Osteoporosis present after the age of 45 years and particularly in postmenopausal women

• Loss of teeth

• Vulnerability of the aging brain to injury

• General health and concurrent medications

Gunshot Wounds

Management

For low-velocity injuries, the missile tract should be excised and the fractures fixed early.

For high-velocity injuries, the aim should be to achieve early soft tissue closure, followed by secondary débridement as necessary and later definitive bone repair.

The maxillofacial region has an excellent blood supply, and the risk for secondary infection and secondary hemorrhage is slight; hence treatment consists of minimal débridement and early closure with reconstruction in the early phase. Gruss and coworkers recommended the following ⁷⁰:

1 Immediate conservative débridement with coverage of exposed bone

2 A delay of 7 to 10 days for primary definitive repair, during which the bones of the midface and mandible are reconstructed with modern fixation techniques

3 Late repair as necessary for secondary revisions and further reconstruction of the mandible, in particular, with vascularized bone grafts.

Timing of Repair

With moderate injuries, all necessary surgery may be achieved in one early operation without extra stress on the patient. In those requiring complex surgery, reconstruction of the bony and soft tissues of the face and skull should be undertaken in the first 7 to 21 days after injury.⁷⁰

Soft Tissue Injury

Soft tissue injuries should be closed as soon as possible; however, in multiply injured patients requiring urgent stabilization or surgery, closure can be delayed for up to 48 hours. If delay is necessary, the wounds should be cleaned, irrigated with normal saline to remove as much foreign material as possible, and covered with a sterile dressing. Antibiotics are given only for gross contamination.

Definitive closure can usually be performed under local anesthesia. Copious irrigation, careful inspection for foreign material, minimal débridement, and precise anatomic suturing are required.

Tattooed Foreign Matter

Foreign material may be embedded to varying depths in the skin, particularly with abrasions. The tattooed material should be removed as soon as possible by scrubbing with a soft nylon brush. Deeply embedded matter may need to be removed with fine-tipped scissors or a scalpel.⁷¹

Puncture Wounds

Puncture wounds can be deceptive, with the depth and direction of penetration not being clear from superficial examination.⁷² Deeply situated vital structures may be injured. The penetrating object is not usually sterile, and the distal part may break off. The wound should be carefully explored with a blunt instrument. Radiography or CT may show embedded matter. MRI may be necessary to identify wood or glass fragments. Penetration near a major vessel may require angiography.

Wounds near the upper eyelid, especially in children, should be treated with caution because an object such as pencil or chopstick can quite easily penetrate the thin orbital roof,⁷³ yet there may be little or no external signs of penetration. Careful neurological and neuro-ophthalmologic assessment should be undertaken, and if deep penetration is suspected, scanning should be performed to identify the bony defect and the track. Retained wood fragments should be removed because they present a risk of infection. Penetration by metal objects may be treated with antibiotics alone.

Complications

Dural Fistula

Fractures of the midface (Le Fort I and II) and nasoethmoid fractures may lead to cranionasal fistulas through the cribriform plates and frontal, ethmoid, or sphenoid sinuses.⁷⁴ CSF rhinorrhea should be searched for in all patients who may have an anterior fossa fracture and confirmed by β₂-transferrin testing. It has been estimated that 35% of patients with severe facial fractures have a CSF fistula and that 60% will cease within 10 days. This may be assisted by accurate reduction of the facial fractures. If the leak persists beyond 10 days, surgical treatment may be necessary (see Chapter 341).

Infection

Craniofacial wounds are naturally contaminated by the flora of the skin, upper respiratory tract, and mouth, as well as by organisms introduced by the injury. Nonetheless, the incidence of infection of scalp and facial wounds is low as a result of the rich blood supply and because the number of endogenous potential pathogens is low.⁷⁵

Steps to prevent infection include

1 Primary wound care consisting of débridement, removal of foreign bodies, and irrigation with saline

2 Elimination of local causes of infection, such as with oral hygiene

3 Prophylactic preoperative and postoperative antibiotics for other than soft tissue injuries alone

4 Nutritional support

Vascular Injury

Severe frontal impact may result in vascular injury that is often not apparent or overlooked in the early assessments.^76,⁷⁷ Such injuries include carotid cavernous fistulas and carotid or vertebral artery dissection, thrombosis, or aneurysm.

Carotid-Cavernous Fistulas

The most common cause of carotid cavernous fistulas is head trauma, usually blunt and less often penetrating.⁷⁸ They occur in approximately 1% of patients with facial fractures.⁷⁹ The internal carotid artery is vulnerable to shearing forces acting between the fixed points of attachment at its dural entry and exit to the cavernous sinus. The fistula may result from a tear in the artery itself or from a tear in meningeal branches of the internal carotid or external carotid arteries within the cavernous sinus. Traumatic fistulas are most often due to a single tear in the internal carotid artery and are high flow. The visual symptoms and signs are chiefly due to the elevated venous pressure. Flow in the superior and inferior ophthalmic veins is frequently reversed, with engorgement and dilation of these vessels. High venous pressure causes chemosis, proptosis, and elevated intraocular pressure and glaucoma; venous distention may also cause paralysis of the third, fourth, and sixth cranial nerves. There is often a latent interval between injury and the signs of a fistula. In such cases, it is considered likely that a minor tear in the internal carotid artery gave rise to a traumatic aneurysm and that delayed rupture of the aneurysm led to the fistula. A few patients suffer cerebral ischemia from diversion of arterial blood into the fistula (steal effect),⁸⁰ especially if the circle of Willis is markedly asymmetric.⁸¹ Nontraumatic fistulas are more often due to tears in meningeal branches and are low flow.