Oral Maxillofacial Surg Clin N Am 17 (2005) 341 – 355 Maxillofacial Trauma Treatment Protocol David B. Powers, DMD, MDa,*, Michael J. Will, DDS, MDb, Sidney L. Bourgeois, Jr, DDSc, Holly D. Hatt, DMD, MDdaDepartment of Oral and Maxillofacial Surgery, Wilford Hall United States Air Force Medical Center, Lackland Air Force Base, 2200 Bergquist Drive, Suite 1, San Antonio, TX 78236-9908, USA b Department of Oral and Maxillofacial Surgery, Walter Reed Army Medical Center, Washington, DC 20327, USA c Department of Oral and Maxillofacial Surgery, National Naval Medical Center, Bethesda, MD 20889, USA d Department of Oral and Maxillofacial Surgery, National Naval Medical Center, San Diego, CA 92127, USA In the early days of World War I, a young sur- have forced military surgeons to reinvent how we treatgeon from New Zealand stationed in Aldershot, maxillofacial trauma patients, much like the experi-England was inundated by horrendous wounds to ences that faced Sir Harold Gillies. Unfortunately, thethe head and neck of soldiers returning from the front Israeli experience shows us that terrorists possiblylines. Because of advances in ballistics and weaponry, could use the same tactics as the Iraqi insurgents andcoupled with the fact that trench warfare necessitated expose the American populace to IEDs.the soldiers to place their maxillofacial region at great Before September 11, 2001, the protocol designedrisk to monitor the status of the enemy, this surgeon by Robertson and Manson served as an excellentwas faced with injuries never before encountered. framework for the management of high-energy bal-His name was Harold Delf Gillies, and his contribu- listic injuries to the maxillofacial region . Thetions to the medical community are universally complex nature of the wounds caused by IEDs andaccepted as the initiation of the discipline of plastic newer ballistics has rendered some portions of theirand reconstructive surgery [1,2]. Hippocrates once treatment plan ineffective and prone to secondaryfamously told his students, ‘‘War is the only proper infection. IEDs are packed with dirt, glass, rocks,school for surgeons.’’ Unfortunately, the experiences metal, bones from dead humans or animals, and otherundergone since September 11, 2001 have provided a body parts if detonated by suicide bombers. If thiswhole generation of military surgeons the opportunity technique of terrorism is used in the United States,to treat a new type of injury pattern never before seen civilian providers will be faced with the same dif-. Improved body armor, which allows soldiers to ficulties previously faced by the military. The chal-survive wounds that would have been fatal 2 to 3 years lenge was to develop a system that could be used forearlier, and the catastrophic and new injury patterns conventional ballistic injuries and injuries that resultsustained by improvised explosive devices (IEDs) from IEDs. A new protocol has been developed that serves as the current treatment regimen used by the oral and maxillofacial surgery departments at Wilford Hall USAF Medical Center, the National Naval The views presented in this article reflect those of the Medical Center – Bethesda, Walter Reed Army Medi-authors and do not represent the official policies of the cal Center, and the National Naval Medical Center –United States Air Force, the United States Army, the UnitedStates Navy, the Department of Defense, or any branches San Diego. In this article we present our treatmentof the United States government. algorithm for ballistic maxillofacial trauma based on * Corresponding author. the surgical experiences gained by performing 329 E-mail address: David.Powers@Lackland.af.mil procedures on 109 patients since September 2001(D.B. Powers). (Box 1).1042-3699/05/$ – see front matter. Published by Elsevier Inc.doi:10.1016/j.coms.2005.05.003 oralmaxsurgery.theclinics.com
342 powers et al colloids, or crystalloids as indicated. Identification Box 1. Treatment protocol for of potentially fatal situations, such as tension pneu- maxillofacial injuries mothorax, cardiac tamponade, intraperitoneal hem- orrhage, or intracranial hemorrhage, should be 1. Stabilize patient accomplished as soon as possible. 2. Identify injuries 3. Obtain radiographic studies and stereolithographic models 4. Initiate consultations (eg, psychia- Identification of injuries try, physical therapy, speech therapy) After initial stabilization of a patient, a thorough 5. Initiate cultures/sensitivities examination should be performed to document all (infectious disease consultations) injuries. If a patient is comatose or intubated or the 6. Unidertake serial debridement ´ evaluation is otherwise compromised, care should be (days 3 – 10) to remove necrotic taken to note clearly the limitations of the examina- tissues tion and the reasons for the difficulty. Detailed 7. Stabilize hard tissue base to sup- documentation of all injuries is necessary to coor- port soft tissue envelope and pre- dinate the sequence of treatment with all respective vent scar contracture before surgical services (Figs. 1 and 2). Any opportunity to primary reconstruction limit exposure to general anesthesia should be taken, 8. Conduct comprehensive review of as long as combined procedures do not affect the stereolithographic models and outcome of planned surgical interventions. Physical radiographs and determination of examination, radiographic studies, and laboratory treatment goals tests are necessary components to identify correctly 9. Replace missing soft tissue com- all potential injuries. ponent (if necessary) 10. Perform primary reconstruction and fracture management 11. Incorporate aggressive physical/ Obtaining radiographic studies and occupational therapy stereolithographic models 12. Perform secondary reconstruction (eg, implants, vestibuloplasty) Adequate radiographs are essential for diagnosis of 13. Perform tertiary reconstruction and treatment planning for complex maxillofacial (eg, cosmetic issues, scar revisions)Stabilization of the patient Although this should be intuitive, in a mass ca-sualty or acute trauma situation the basics of medi-cal care should be emphasized, because these actionsundoubtedly will save lives. Securing the airwayby whatever means necessary, including endotra-cheal intubation or surgical airway, should be per-formed immediately if there is any doubt about futurestability of the patient. A true disaster scenario eas-ily could overwhelm the ability of a medical carefacility to monitor the condition of victims with pos- Fig. 1. Drainage of left facial swelling. After fluid was sentsible or suspected future airway compromise. Bleed- to laboratory for evaluation, amylase level was noted to being should be controlled and volume expansion in excess of 3000, which is consistent with obstructedshould be accomplished to maintain perfusion of the parotid gland secondary to transection of Stenson’s ductvital organs by blood transfusion, blood substitutes, from shrapnel.
maxillofacial trauma treatment protocol 343 possible result while actually decreasing surgical time . Early initiation of consultations Returning casualties from a war zone have many needs that must be addressed in concert to treat the entire patient. Not only is the treatment of a patient’s wounds of paramount importance but also are the treatment of a patient’s psychological status, facili- tation of speech and nutrition in maxillofacial injuries, management of centrally mediated pain syndromes, Fig. 2. Shrapnel injury to right upper extremity. and identification, evaluation, and involvement of a patient’s family or peer support system. This section attempts to identify consultants who may be deemed integral in the treatment of returning casualties withtrauma. Modern radiographic techniques allow for war injuries.three-dimensional visualization of the skeleton, helpidentify foreign bodies, and evaluate displaced fracturesegments. CT scans should be the minimum informa- Infectious diseasetion obtained before surgery (Fig. 3). The current CTscanner at Wilford Hall Medical Center is the GE The importance of this consultation cannot beLightspeed 16 (GE Health Care, Chalfont St. Giles, overemphasized. Patients returning from OIF/OEFUnited Kingdom), which allows rapid assimilation of are well documented to be colonized by Acineto-data and manipulation of conventional coronal and bacter baumannii . The nature of war injuriesaxial cuts to three-dimensional images via use of the also provides an environment for the gross contami-GE Advantage Workstation AW 4.1 (GE Health Care; nation of wounds by staphylococci, enterococci,Chalfont St. Giles, United Kingdom) (Fig. 4). Klebsiella, and Clostridium perfringens and Clos- It is our opinion that complex panfacial trauma, tridium tetani. Further discussions of the infectioussuch as the injuries seen during Operations Iraqi disease consultation and the use of culture and sen-Freedom (OIF) and Enduring Freedom (OEF), sitivity testing to facilitate treatment are presentedabsolutely require the fabrication of stereolitho- in the following section.graphic (SL) models to plan treatment adequatelyand determine sequencing of fracture repair. The useof SL models allows preadaptation of surgical platesto obtain proper soft tissue projection and support thatotherwise would not be possible to the degree ofaccuracy obtained by this technique (Fig. 5). SLmodeling has the advantage of allowing customimplant fabrication to support the soft tissue envelopewhen the bony architecture is lost or irreversiblymisshapen. This has the advantage of reproducing apatient’s preoperative soft tissue profile as close aspossible to the preinjured state. Currently, WilfordHall Medical Center transfers conventional CT datavia the Materialise Mimics software program (Mate-rialise, Leuven, Belgium) for model fabrication bythe Viper SLA (3D Systems, Valencia, California).Depending on the size of the image being manufac-tured, most SL models can be completed by the ViperSLA within 6 to 24 hours. This relatively rapid Fig. 3. Conventional CT scan indicates loss of soft tissueturnaround time does not impact patient care and is and anterior mandible extending bilaterally from the angleessential in our experience for obtaining the best to angle.
344 powers et alFig. 4. (A) Stereolithography model of case presented in Fig. 3. (B) Model used as template for prebending of reconstruction bar.Psychiatry consultations and deglutition, and even if many of these structures are salvaged or reconstructed, injury to cranial nerves Injured patients who return from a war zone may may make performing these functions next to im-present with a host of psychiatric challenges, all of possible. The ability to provide nutrition to a healingwhich must be addressed for appropriate treatment of surgical patient is of primary concern in healing andthe patient. These stressors include unrecognized maintenance of a patient’s immune system. Earlycombat stress, depression related to an injury, and consultation may lead to early placement of per-guilt related to leaving fellow unit members or cutaneous endoscopic gastrostomy feeding tubes,surviving. Facial appearance has been found to be central catheters, and evaluation of the digestivean important variable in how patients are perceived and respiratory tracts.by others, and maxillofacial injury patients mustdevelop the additional coping skills throughout their Physical therapytreatment to improve their self-esteem and ability tocontinue with reconstructive surgery. The physical therapy consultation is important in the management of not only maxillofacial injuries butNutrition and speech therapy consultations also any orthopedic injuries. Maxillofacial physical therapy addresses the movement of the temporoman- Avulsive injuries to the maxillofacial region dibular joint and should address electrical stimulationremove vital structures for phonation, mastication, of facial musculature, which has been effected by Fig. 5. (A, B) Examples of three-dimensional CT scans.
maxillofacial trauma treatment protocol 345facial nerve injury. This stimulation prevents facial Should a battlefield wound become infected,muscle atrophy and encourages facial nerve regrowth treatment should be definitive, with removal ofin the area of deficit. foreign bodies and necrotic and infected tissue. Empiric broad-spectrum antibiotics are initiated against likely pathogens for 7 to 10 days. Table 1Pain management services provides an overview of the various antibiotics and spectrum of coverage [7,8]. Gram stains, cultures, Many patients who have returned from theater and sensitivities are obtained to direct antibioticwith severe injuries manage their pain with large therapy. Because Clostridium and Bacteroides spe-amounts of opiate analgesics. Centrally mediated pain cies are difficult to culture, antibiotic therapy shouldsyndrome has been identified in a small number of be directed to cover these organisms.patients whose pain issues have been addressed It is also important for clinicians to realize thatinadequately. For both of these subgroups of patients, battlefield wounds are prone to tetanus because ofconsulting the pain management service assists in high levels of contamination with C tetani. Everyfacilitating the comfort of patients and supports in the effort should be made to investigate a patient’swithdrawal from opiate analgesics to an appropriate current tetanus immunization status and initiatelevel of pain medications. appropriate treatment or immunization. Necrotizing soft tissue infections from clostridial myonecrosis or polymicrobial infections can be the most dangerousCultures and sensitivities (infectious disease) and lethal infections that are encountered. All layers of tissue may be involved, and the treatment involves Casualties from OEF/OIF who have been treated aggressive surgical debridement combined with anti- ´in multiple health care settings, including austere biotic therapy.combat situations, bring with them complex infec- Finally, clinicians must remember that patientstious disease issues related to multiple resistant may present with a confusing picture because oforganisms. Patients with open wounds automatically infection of various other wounds or a progression toshould be started on prophylactic antibiotics for sepsis. Following the previously mentioned princi-24 hours, with the cornerstone of treatment being ples and maintaining vigilant monitoring duringsurgical serial debridement. The decision regarding ´ medical evacuation should allow a patient to arriveantibiotic use should be based on the area of injury at a large tertiary care facility for more definitiveand degree of wound contamination. treatment and reconstruction.Table 1Spectrum of selected antibiotic agents [16,17]Agent Antibacterial spectrumPenicillin G Streptococcus pyogenes, penicillin-sensitive Streptococcus pneumonia, Clostridium spAmpicillin Enterococcal sp, streptococcal sp, Proteus, some Escherichia coli, KlebsiellaAmpicillin/sulbactam Enterococcal sp, streptococcal sp, Staphylococcus (not MRSA), Escherichia coli, Proteus, Klebsiella, Clostridium sp, Bacteroides/Prevotella spNafcillin Staphylococcal sp (not MRSA), streptococcal spPiperacillin/tazobactam Enterococcal sp, streptococcal sp, Staphylococcus (not MRSA), Escherichia coli, Pseudomonas and other enterobacteriaceae, Clostridium sp, Bacteroides/Prevotella spImipenem Enterococcal sp, streptococcal sp, Staphylococcus(not MRSA), Escherichia coli, Pseudomonas and other enterobacteriaceae, Clostridium sp, Bacteroides/Prevotella spCefazolin Staphylcoccal sp(not MRSA), streptococcal sp, Escherichia coli, Klebsiella, ProteusCiprofloxacin E coli, Pseudomonas and other enterobacteriaceaeGentamycin E coli, Pseudomonas and other enterobacteriaceaeVancomycin Streptococcal, enterococcal, and staphylococcal species (incl MRSA); not VREClindamycin Streptococcus sp, Staphylococcus sp, Clostridium sp, Bacteriodes/Prevotella spMetronidazole Clostridium sp, Bacteroides/Prevotella spAbbreviations: MRSA, methicillin resistant Staphylococcus aureus; VRE, vancomycin resistant Enterococcus.Data from Schuster GS. The microbiology of oral and maxillofacial infections. In: Topazian RG, Goldberg MH, editors. Oraland maxillofacial infections. 3rd edition. Philadelphia: WB Saunders; 1994. p. 39 – 78; and Gilbert DN, Moellering Jr RC,Sande MA. The Sanford guide to antimicrobial therapy. 34th edition. Hyde Park (VT): Antimicrobial Therapy, Inc.; 2004.
346 powers et al Upon receipt of casualties in our facilities, cultureand sensitivity for A baumannii automatically areinitiated. A patient usually is placed in contact andairborne isolation pending results, a process that cantake up to 48 hours. If this resistant organism has beencultured in patients who have returned from OIF,aggressive antibiotic therapy is initiated to includecoverage with ticarcillin and an aminoglycoside. Ingeneral, comprehensive wound care managementcoupled with appropriate antibiotic coverage andconsultation with infectious disease specialists forchallenging cases can prevent life-threatening sepsis. Fig. 7. Following pulsatile irrigation. (Courtesy of D. Clifford, DMD, MD; Bethesda, MD)Serial debridement ´ The role of serial debridement cannot be over- ´ purposes. Tacking sutures may aid in securing gauzestated in dealing with patients injured in combat or packing, but they should not be placed for reap-terrorist activities. The injury patterns seen differ in proximation of wound margins. After evacuation toseveral ways from those seen in a civilian trauma a higher echelon treatment facility out of theatersetting: (1) the devastating destruction of soft and hard (eg, Europe, United States), the entire wound is re-tissues caused by high velocity, fragmentation-type explored and debridement of grossly necrotic tissue ´injury patterns leads to compromised tissue beyond is completed. Unless contraindicated because ofthe visibly damaged tissue; (2) the battlefield environ- concomitant injuries, aggressive irrigation with copi-ment in which patients are injured is grossly con- ous saline and antibiotic solution (eg, clindamycin) istaminated; (3) wound care on the battlefield and while performed with a pulsatile irrigation system (Pulsa-in transport is less than ideal; and (4) evacuation off vac, Zimmer, Warsaw, Indiana). After the firstthe battlefield is not always expeditious, which leads pulsatile irrigation, superficial wet-to-dry dressingto increased wound contamination. Initial wound changes are performed three times per day. Aftermanagement involves hemostasis, dressing, awaiting 48 to 72 hours, the procedure is repeated. At thatevacuation to an aid station, and ultimately, a higher point, the surgeon is faced with the decision of whenlevel facility in the combat theater. to perform the primary closure [9,10]. It has been our Upon presentation at a higher echelon facility, experience that definitive closure should not beaggressive irrigation and foreign body removal and performed if any sign of nonviable tissue is presentlimited soft tissue debridement are completed; the ´ upon exploration of the wound (Figs. 6 and 7).wounds should be left open or packed for hemostatic Delayed primary closure of the wound is generally performed after the second washout, although the threshold for continuing the debridement is low ´Fig. 6. Initial presentation with irrigation and debridement; ´tacking sutures placed. (Courtesy of D. Clifford, DMD, MD; Fig. 8. Healthy appearance of tissue at time of primaryBethesda, MD) closure. (Courtesy of D. Clifford, DMD, MD; Bethesda, MD)
maxillofacial trauma treatment protocol 347(Fig. 8). Generally the hard tissue base is stabilized atthe time of primary closure.Stabilization of hard tissue base to support softtissue envelope and prevent scar contracturebefore primary reconstruction Because of the high risk of infection and extensivesoft tissue injury in these patients, definitive recon-struction is often deferred to a secondary phase. Ourexperience has demonstrated that with a lack of bony Fig. 10. Stereolithographic model demonstrates avulsivesupport, fibrous tissue and scar contracture compro- defect of midface region seen in Fig. 9. (Courtesy of D.mise the eventual functional and aesthetic result of Clifford, DMD, MD; Bethesda, MD)any reconstruction. In the routine trauma setting,bone grafting or alloplastic implants may be placed atthe initial surgery with immediate soft tissue cover-age. We have opted to use standard rigid fixation tion can be undertaken. Such support also maintains asystems to span bony gaps and give support to tissue plane, which provides easier dissection uponoverlying soft tissue with only limited bone grafting secondary reconstruction with either autogenous oror other alloplast use (eg, Medpor Porex, Newnan, alloplastic materials.Georgia) as necessary to reduce scar contracture.Complete reconstruction is often deferred to a sec-ondary phase. The placement of rigid fixation fol- Comprehensive review of stereolithographylows standard trauma protocol to provide support models and radiographs and determination ofof the facial pillars. One of the risks of using titanium treatment goalsplates in this manner is that of plate exposure.Although it occurred in some patients, the associated The ultimate treatment goal for our combatmorbidity was low, the area was excised, and primary casualties with facial injuries is the restoration ofclosure was performed with minimal cosmetic defect. function and cosmesis. Most injured patients haveAnother option for supporting the soft tissue is the significant avulsive defects of facial structures. CTapplication of an external fixator, which has proved scans are the gold standard for imaging of facialsuccessful in projecting the mandible and zygomat- fractures (Fig. 9). Three-dimensional reconstructedicomaxillary complexes until the primary reconstruc- CT scans and stereolithographic models are essential adjunctive elements in preparing a treatment plan for avulsive-type defects (Fig. 10). The most important aspect of treating avulsive defects is using appro- priate imaging to develop a staged reconstruction plan with the final endpoint in mind before any re- construction begins. Items for consideration in view- ing the studies and models are (1) which structures are missing, (2) which structures remain, (3) the effect of each on the reconstruction goals, (4) which structures require replacement, (5) how those struc- tures will be replaced (nonvascularized versus vas- cularized tissue), (6) identifying stabilization points for replacement structures, (7) soft tissue consider- ations, (8) choice of grafting material, and (9) the effect of grafting plan on future implant reconstruc- tion or dental rehabilitation. The choice of grafting or replacement material includes (1) bone (eg, cra-Fig. 9. CT scan demonstrates avulsive defect of midface nial, iliac crest [block versus particulate], osteomyo-region. (Courtesy of D. Clifford, DMD, MD; Bethesda, MD) cutnaeous vascularized flaps), (2) myocutaneous
348 powers et al Fig. 13. Custom Medpor implant for avulsive midface defectFig. 11. Replacement of avulsed tissue with wax for seen in Figs. 9 and 10. (Courtesy of D. Clifford, DMD, MD;template formation. (Courtesy of J. Solomon, DMD and Bethesda, MD)G. Waskewicz, DDS; Bethesda, MD) bacteria from the oral cavity or external environmentvascularized flaps, and (3) alloplast. Stereolitho- (Fig. 14). Once scar contractures develop, it isgraphic models allow for wax replacement of avulsed essentially impossible to recover from this and createstructures (Fig. 11) or generation of mirror-image a normal soft tissue appearance. In our experience,structures, prebending of plates (Fig. 12), fabrication vascularized tissue is more resistant to secondaryof templates for contouring of bone grafts, fabrica- infection and scar contracture and gives the mosttion of custom implants (Fig. 13) (Medpor Porex, ideal result. Patients who present with injuriesNewnan, Georgia, titanium, or polymethylmethacry- sustained by IED blasts usually are already contami-late), or use of stock alloplasts (eg, Medpor) . nated with multiple bacterial species and are highly susceptible to recurrent infections and secondary scarring. The use of vascularized tissue has helpedReplacement of missing soft tissue component minimize complications in these cases. When faced with the dilemma of using a local rotational flap If soft tissue has been avulsed or is lost over the versus free flap, the reconstructive surgeon shouldcourse of serial debridement, it is absolutely critical ´ determine whether a satisfactory result can beto replace this tissue with some form of vascularized obtained in one surgical procedure or if severalflap—either rotational flap or free flap—before the revision surgeries are necessary (Fig. 15). If a singledevelopment of scar contractures or colonization with surgery is planned, rotation of a local flap may be indicated because of the similarities in tissue colo- ration, consistency, and appearance. If the need for future surgical intervention is necessary, considera- tion should be given to using the free tissue transfer initially to inhibit scar contracture and finalize treat- ment at the secondary and tertiary surgeries with the local flap (Fig. 16). We recommend waiting a mini- mum of 8 to 12 weeks after placement of a graft to allow for maturation before the next surgical proce- dure at that site (Fig. 17). Primary reconstruction and fracture management The goal of primary reconstruction should beFig. 12. Plates prebent to wax template replacing avulsed to obtain the best functional and cosmetic resultstissue. (Courtesy of J. Solomon, DMD and G. Waskewicz, possible, because the tissues injured by explosiveDDS; Bethesda, MD) projectiles may have significant scar contracture at
maxillofacial trauma treatment protocol 349Fig. 14. (A) Presurgical appearance. Soft tissue closure accomplished at field hospital. (B) Avulsive injury with significant loss ofsoft tissue.any future procedure and the opportunity to obtain a Replacement of missing bone should be included insatisfactory result will be decreased. Preoperative this treatment planning, because support of the softplanning is of paramount importance, with support of tissue envelope is important. A strong recommenda-the soft tissue envelope being a priority for main- tion is to consider exhausting native bone grafttaining as normal a facial contour as possible. options before resorting to other choices. If theFig. 15. (A) Location of latissimus dorsi free flap donor site. (B) Mobilization of the flap and preservation of vascular access.(C) Latissimus dorsi free tissue transfer to the mandibular region. The vascular supply is from the superior thyroid artery.Note presence of reconstruction bar to provide support to the free flap and assist with prevention of scar contracture.Osseous reconstruction is attempted at secondary surgery with corticocancellous bone graft. (D) Reconstruction of the floor ofmouth with the muscular component of the latissimus dorsi flap.
350 powers et al dures also allows for dental impressions and splint fabrication to occur to a known reference point, the newly reconstructed mandible. One of the more common errors associated with panfacial trauma reconstruction is inadequate re- duction of the mandibular archform, which results in excessive facial width secondary to splaying of the mandibular angles . Excessive width of the mandibular angles results in the appearance of retrognathia because of posterior positioning of the mandibular symphysis. If the mandible is plated in the wrong position, ultimately the maxilla and zygo- Fig. 16. Appearance of flap immediately postoperatively. maticomaxillary complex also are improperly posi- tioned, which results in excessive width to the face and the appearance of midfacial deficiency. This com-recipient site is contaminated or infected, which is not plication can be prevented by using prebent surgicalunlikely in cases of IED blasts, our experiences have plates made from stereolithographic or cadaveric/shown that allogeneic bone has a high propensity for anatomic models to ensure accurate gonial width andresorption and chronic foreign body reaction. Native anterior projection of the mandibular symphysisbone, particularly bone transferred with periosteal (Fig. 18).coverage, has been less likely to show evidence of After proper fixation of the mandible, attention islate infection and better maintains the soft tissue directed to zygomaticomaxillary complex and archprojection obtained. In cases of significant panfacial projection. Our experience has been that accuratetrauma that involves the maxilla and mandible, we positioning of the malar prominence and zygomaticrecommend sequencing of treatment as previously arch is best accomplished by direct visualization ofpublished by Wong and Johnson (Box 2) . the zygomaticomaxillary and zygomaticotemporal Our clinical experience has been to secure theairway and reconstruct the mandible as a first stage insurgery. In most cases of panfacial fractures, accom-plishing these procedures takes several hours at a Box 2. Sequencing of treatment forminimum, and proceeding immediately to a lengthy panfacial traumareconstruction of the midface and orbital fracturesmay not be advised because of potential fatigue of the Secure definitive airwaysurgical team. Breaking after the mandibular proce- Obain reduction and fixation of man- dibular fractures Obtain mandibular arch impressions for fabrication of occlusal/palatal splints as necessary using the fixed mandible as template Position LeFort fractures into occlusion with mandibular dentition using maxillomandibular fixation Obtain reproducible seating of man- dibular condyles into fossa Repair frontal sinus fractures if present Reduce zygomatic complexes and re- construct nasofrontal junction Reduce naso-orbital-ethmoid complex fractures and medial canthopexies Reduce infraorbital rims Reduce LeFort I level fractures Reduce orbital floor fractures Undertake nasal grafting Fig. 17. Appearance of patient 4 months after free flap.
maxillofacial trauma treatment protocol 351Fig. 18. (A) Three-dimensional CT scan shows excessive widening of the mandibular angles before definitive treatment ofmandibular fractures. Anterior symphysis plate currently serves to stabilize fracture segments. Note open lingual cortical plate.(B) Stereolithography model of radiograph shown in (A). (C) Stereolithography model is sectioned and repositioned inaccordance with accepted anatomic norms for gonial distance and ramus distance. Reconstruction bar is prebent to newdimensions to correctly position the segments intraoperatively. Condylar fracture reduction occurs during the same operation tocorrect vertical and anteroposterior position of the mandible before treatment of maxillary fractures. (D) Intraoperative view ofmandibular fracture reduction and positioning of reconstruction bar. Proper positioning of mandibular angles is obtained by thesurgical assistant, who places pressure in the region of the mandibular angles until fractured segments passively fit thereconstruction bar. The gonial distance was reduced 2.5 cm in this case from the presurgical dimensions. (E) Postoperative three-dimensional CT scan shows improved dimensions of gonial distance and mandibular contour and shape. Proper reduction ofmidfacial fractures can occur at this time to optimize aesthetic and functional result.
352 powers et aljunctions by the use of the coronal flap (Fig. 19). possible formation of traumatic alopecia that canSome surgeons may argue that the scar from the occur during prolonged reconstruction cases.coronal flap is unsightly and an ‘‘acceptable’’position of the zygomaticomaxillary complex canbe obtained by other approaches. In cases of minimalor isolated fractures of the zygomaticomaxillary Aggressive physical and occupational therapycomplex we would agree. Our bias in cases ofsignificant midfacial destruction or gross comminu- Oral and maxillofacial disability can result fromtion of the maxilla is that proper projection of the scar contracture, soft or hard tissue fibrosis, andmidface cannot occur without direct visualization, muscle atrophy caused by prolonged maxilloman-and ultimately secondary scar contracture continues dibular fixation. Injured soldiers returning from OIF/to displace the segments and results in the previously OEF often present with some degree of maxillofacial‘‘acceptable’’ appearance ultimately becoming un- disability. The injuries sustained typically involveacceptable. Our technique is to use the stereolitho- soft tissue and hard tissue loss and comminution ofgraphic model as a template for plate adaptation. If the facial bony structure.the contralateral side is unaffected, we bend surgical Soft tissue fibrosis and scar contracture areplates to that side of the model and place them on the typically seen weeks to months after injury repairaffected side whenever possible to reproduce accu- [13,14]. Initial management after adequate healingrately a patient’s preinjury skeletal contours and involves mandibular opening exercises with lateralmaximize the potential for an accurate zygomatic excursive movements. The patients also performwidth and good soft tissue projection after healing. manual massage of the injured area in an effort to When properly designed and positioned, the soften fibrosis and contracture bands. The goal ofcoronal flap can be aesthetically pleasing. Our this modality is to reduce the soft tissue tensiontechnique involves placing approximately 10 cc of and allow a full range of mandibular movement2% lidocaine with 1:100,000 epinephrine along the . If this conservative therapy is not successful, aproposed incision site. We place the local anesthesia more aggressive regimen is followed to include abefore performing the surgical scrub and address any commercially available mandibular functional de-obvious sources of vascular bleeding with cautious vice. Our institutions use the Therabite device (Atosapplication of electrocautery. After reflection of the Medical AB, Horby, Sweden) for cases that require ¨flap, a moist surgical sponge is placed over the cut further therapy. The protocol for this device is sevenedges to prevent desiccation at the incision edge and mandibular stretches held at maximum openingassist with control of bleeding. Blood loss in all cases for 7 seconds. This routine is repeated seven timeshas been minimal. This technique has been used in daily until a patient achieves a maximum incisalmore than 20 cases by one of the authors and opening larger than 35 mm or improvement is noeliminates the need for scalp clips, which prevents longer achieved. Another modality of therapy for soft tissue fibrosis involves injection of steroids into the fibrotic area. This approach promotes the re- configuration of collagen fibrils and softening of the scar, which releases the tension of the soft tis- sue. Mandibular function is reassessed after 4 to 6 months of healing and therapy. For areas with high tension that have not responded to prior inter- ventions, scar revision is considered with excision of fibrotic tissue and soft tissue release using rotational flaps or undermining procedures. Emphasis is placed on tension-free closure to allow optimal healing with minimal scarring. Hard tissue fibrosis is seen in patients who sustain maxillofacial injuries caused by the degree of boneFig. 19. Accurate reproduction of zygomaticomaxillary destruction and secondary blast effects. Patients withcomplex and zygomatic arch accomplished by prebending severe comminution of the mandible or maxilla typi-surgical plates on contralateral side of stereolithography cally undergo maxillomandibular fixation for 6 weeks.model to reproduce preinjury facial projection and use of After the release of fixation, patients typically dem-coronal flap for access. onstrate a maximum incisal opening smaller than
maxillofacial trauma treatment protocol 35315 mm [13,14]. Patients are instructed on active indications, such as vestibuloplasty, ridge augmenta-mandibular range-of-motion exercises and manual tion, alveolar distraction, or orthognathic surgery totechniques to aid in opening. These exercises are correct maxillary-mandibular arch discrepancies.performed with minimal pressure so as not to affect In dealing with soft tissue injuries as seen inthe healing fracture. For patients who do not respond terrorist attacks or warfare, a surgeon must show someto mandibular opening or manual manipulation, the creativity while maintaining basic surgical principles.Therabite device is introduced to their routine and the Replacement of soft tissue can be as simple as skinstandard protocol is used. For patients with man- grafting or local flap advancement, or it can be asdibular disability secondary to temporalis fibrosis advanced as tissue expansion or free flaps. Micro-who do not respond to conservative therapy, coro- stomia secondary to tissue loss or scarring may benoidectomies may be considered. The goal of this addressed initially to give better access for intraoralintervention is to release the temporalis muscle procedures, which may be a necessity for dentalattachment to the mandible and allow normal man- impressions to be taken. Intraoral fibrous scar bandsdibular function. can be excised and grafts placed. In areas that have Because of the destructive nature of the injuries suffered from avulsive injuries, local recruitment ofsustained by soldiers in support of OIF/OEF, many tissues should be the first option, with regional or freecasualties with oral and maxillofacial injuries pre- flaps used when the local tissues are inadequate. Freesent with mandibular disability secondary to either gingival grafts or connective tissue grafts are per-soft tissue or hard tissue fibrosis. The management formed to restore an adequate amount of attachedapproach to these patients—after all injuries are gingiva. After the primary bone grafting is complete, ahealed—follows a conservative algorithm with esca- prosthodontic consultation should be obtained forlation as needed to achieve normal mandibular definitive treatment planning. A maxillofacial pros-function. For this approach to be successful, patient thodontist should be involved early in the treatment ofcompliance is necessary with diligence in following large avulsive injuries, notably when an obturator forinstructions as prescribed. maxillary defects is proposed.Secondary reconstruction Posttraumatic scarring and cosmetic management The primary purposes of secondary reconstructive Complex maxillofacial penetrating trauma relatedprocedures should be to increase functional activity to blast and ballistic injuries frequently results inof the maxillofacial complex, correct obvious errors aggressive, disfiguring scars. The combination of aor bony relapses from the primary surgical interven- high degree of wound contamination, wound avul-tion, and improve the cosmetic appearance of a sion, and loss of tissue vitality contributes to sig-patient. As with any trauma patient, a surgeon should nificant cicatrix formation and facial disfigurement.begin to formulate the long-term reconstruction plans Our experiences managing these complex woundsbefore any surgical treatment to avoid performing sustained by servicemen and servicewomen in sup-procedures that may limit definitive reconstruction. port of OIF and OEF have served as a basis for theAs many authors have expressed and we have following discussion according to the lessons learnedemphasized repeatedly in this article, the success of by our surgeons.long-term reconstruction depends greatly on initial The key to a successful cosmetic outcome afterwound management and the prevention of scar these devastating injuries is based on interveningcontracture. The ideal end result of the reconstructive procedures designed to prevent cicatrix formationprocess is to restore a patient to a functional dentition rather than strictly addressing wound scarring as awith optimal cosmesis. With avulsion of tissue secondary procedure. Initial management of theseassociated with high-energy injury patterns, we have injuries must include early, extensive wound debride- ´found that definitive reconstruction of the jaws is ment of contamination through serial ‘‘wash outs’’limited by the hard and soft tissue defect and the with copious antibiotic-containing irrigation solutionsassociated scarring, which often requires numerous and obtaining wound cultures along the way tosecondary procedures. Common procedures per- identify infective organisms and their appropriateformed during this phase from the maxillofacial sensitivities. Assessment of the degree of missingsurgery perspective include placement of ocular, tissue present after these blast injuries is imperative.auricular, or dental implants for prosthetic replace- Patients who present with tissue loss or avulsion thatment or preprosthetic surgery wholly for dental is left to heal secondarily will develop severe
354 powers et aldisfiguring scar formation. Early identification of tattooing: the Nd Yag (1064 nm) infrared laser andtissue loss followed by procedures to bring vascular- the red Alexandrite laser (755 nm). We are convincedized tissue through local rotation flaps or distant free that persistence of these foreign particles within theflaps is essential to minimize scarring and maximize soft tissues provides the impetus and etiology forform and function. Early reduction and fixation of significant hypertophic scar formation. Prompt scarunderlying bony fractures and replacement of missing excision and revision coupled with laser-assistedosseous structures with bone grafts or alloplastic phagocytosis and elimination of metallic particlesaugmentation also are essential for a favorable return provide the greatest likelihood of a favorableof form and function and minimization of cicatrix cosmetic soft tissue wound result .formation. Early intervention regarding reconstruc- Facial scarring secondary to ballistic and blast-tion of the underling bony defects and overlying related injuries is a significant cosmetic concern. Thecutaneous defects should b accomplished within 10 to outcome can be made more predictable and cosmeti-14 days of injury to avoid extensive wound contrac- cally pleasing if certain treatment protocols andture and aggressive scarring. This is certainly a modalities are used. Essential considerations mustreasonable time period to initiate these surgical include early fixation and reconstitution of the facialprocedures once appropriate consultations have been skeleton, followed by passive soft tissue woundaccomplished and wound infection has been ruled out closure through use of local rotational flaps or distantor appropriately treated. If this protocol is followed, free flaps. In our experience, early scar excision andthe resultant scar formation should be minimized and revision along with early program dermabrasion andamenable to the following treatment options to use of laser technology to remove tattooing of softaccomplish a cosmetically acceptable outcome. tissue seem to provide the most favorable cosmetic Scarring associated with ballistic and blast injuries outcome for these devastating facial injuries. Mea-usually presents with tattooing of the penetrated sures used to prevent or eliminate wound contami-tissues secondary to impregnation of the skin by nation and contraction provide the foundation for themetallic fragments. In addition to the tattoo effect, most favorable cosmetic outcome. Preventive mea-there is usually hypertophic cicatrix formation. Early sures always outweigh the benefits of secondaryprogram dermabrasion of these scars 4 to 6 weeks management of posttraumatic scarring.after soft tissue closure or scar excision/revision hasproved to be beneficial to leveling the skin andimproving cosmesis. Injecting subcutaneous kenalogto reduce hypertrophic scarring is also beneficial as Summarylong as long as low doses are used so as not to causesignificant dermal atrophy or liponecrosis. Topical The management of complex maxillofacial inju-application of silastic gel or sheets through a relatively ries sustained in modern warfare or terrorist attackunknown mechanism also improves wound levels and has presented military surgeons with a new form ofcosmesis. Topical application of imiquimod 5% cream injury pattern previously not discussed in the medicalalso has been reported to reduce hypertrophic scar literature. The unique wounding characteristics of theformation by activating cellular cytokines and alpha IED, the portability of the weapon platform, and theinterferon. This agent is helpful if initiated by the relative low cost of development make it an idealsecond week after the wound repair . weapon for potential terrorist attacks. If potential Tattooing of the skin with gray-blue pigmentation future terrorist attacks in the United States follow theafter penetrating metallic injury can be reduced same pattern as the incidents currently unfolding insignificantly or eliminated with treatments using the the Middle East, civilian practitioners will be requiredpulsed-dye laser. The pulsed dye laser (595 nm, to manage these wounds early for primary surgicalyellow light laser) provides collagen rebuilding and intervention and late for secondary and tertiaryreorganization while normalizing neovascularization. reconstructive efforts.These treatments can be repeated on a monthly basis The use of stereolithographic models in presur-for eight to ten applications. The tattooing is gical planning of complex maxillofacial injuries issecondary to implanted metallic fragments that critical and should be considered the standard of care.consist of copper, zinc, graphite, and other metals. These models can be manufactured during the initialThe metallic fragments can be disrupted through 48- to 72-hour period of serial debridement and ´‘‘photo acoustic shattering’’ of the pigmented par- surgical washouts. They are invaluable in visualizingticles using a ‘‘Q-switched’’ laser. Two other lasers the bony architecture of the skeletal framework. Ourhave been effective in our experience in reducing experiences with patients injured by IED blasts
maxillofacial trauma treatment protocol 355indicate that they are highly likely to become infected  Powers DB, Edgin WA, Tabatchnick L. Stereolitho-by some type of organism, the only variable being graphy: a historical review and indications for use inwhen the infection will develop over the course of the management of trauma. J Craniomaxillofac Trauma 1998;4(3):16 – 23.treatment. Scar contracture that occurs either sec-  Scott PT, Peterson K, Fishbain J, et al. Acinetobacterondary to infection or as a consequence of improper baumannii infections among patients at military medi-positioning of the bony substructure of the face is cal facilities treating injured US service members,almost impossible to recover from if inadequate 2002 – 2004. MMWR Morb Mortal Wkly Rep 2004;projection of the soft tissue envelope is not main- 53(45):1063 – 6.tained. The treating surgeon should not fall victim to  Schuster GS. The microbiology of oral and maxillo-the mistake of rushing these patients to the operating facial infections. In: Topazian RG, Goldberg MH,room for definitive treatment before gathering the editors. Oral and maxillofacial infections. 3rd edition.appropriate preoperative data. Projection and support Philadelphia7 WB Saunders; 1994. p. 39 – 78.of the soft tissue envelope is critical to the success of  Gilbert DN, Moellering Jr RC, Sande MA. The Sanford guide to antimicrobial therapy. 34th edition.any surgical treatment initially performed. We also Hyde Park (VT)7 Antimicrobial Therapy, Inc.; 2004.have used this treatment protocol on civilian pan-  Eppley BL, Bhuller A. Principles of facial soft tissuefacial trauma casualties, such as victims of automo- repair. In: Booth PW, Eppley B, Schmelzheisen R,bile accidents or isolated gunshot wounds, and have editors. Maxillofacial trauma and esthetic facial recon-found it to be successful. Whereas our wish is that the struction. Edinburgh7 Churchill-Livingstone; 2003.information presented in this article never will be p. 107 – 20.used in the United States for the treatment of patients  Clark N, Birely B, Manson PN, et al. High-energyinjured in another terrorist attack, the lessons learned ballistic and avulsive facial injuries: classification,in the management of modern ballistic injuries and patterns, and an algorithm for primary reconstruction.wounds sustained in warfare should be shared with Plast Reconstr Surg 1996;98(4):583 – 601.  Wong MEK, Johnson JV. Management of midfacethe civilian community so that if that day ever comes, injuries. In: Fonseca RJ, editor. Oral and maxillofacialwe shall all be prepared. surgery. 1st edition. Philadelphia7 WB Saunders; 2000. p. 245 – 99.  Ellis E, Tharanon W. Facial width problems associatedAcknowledgments with rigid fixation of mandibular fractures: case reports. J Oral Maxillofac Surg 1992;50(1):87 – 94. The authors would like to acknowledge the chief  Dolwick MF, Armstrong JW. Complications in tem-residents of the National Capitol Consortium Oral poromandibular joint surgery. In: Kaban LB, Pogreland Maxillofacial Surgery Training Program, Michael MA, Perrott DH, editors. Complications in oral andJ. Doherty, DDS, and Charles G. Stone, Jr, DDS, for maxillofacial surgery. Philadelphia7 WB Saunders; 1997. p. 98 – 9.their assistance with the research and preparation of  Keith DA. The long-term unfavorable result inthis article. temporomandibular joint surgery. In: Kaban LB, Pogrel MA, Perrott DH, editors. Complications in oral and maxillofacial surgery. Philadelphia7 WB Saunders;References 1997. p. 301 – 2.  Van Sickles JE, Parks Jr WJ. Temporomandibular joint  Sakula A. Sir Harold Gillies, FRCS (1882 – 1960). region injuries. In: Fonseca RJ, editor. Oral and J Med Biogr 2004;12(2):65. maxillofacial surgery. 1st edition. Philadelphia7 WB  Triana Jr RJ. Sir Harold Gillies. Arch Facial Plast Saunders; 2000. p. 146 – 7. Surg 1999;1(2):142 – 3.  Berman B. Pilot study of the effect of postoperative  Shaolin Wahnam Institute. Quotes from famous imiquimod 5% cream on the recurrence rate of excised warriors. Available at: http://wongkiewkit.com/forum/ keloids. J Am Acad Dermatol 2002;47:S209 – 11. showthread.php?t=642. Accessed April 18, 2005.  Maggio K. Clinical experience, laser and cutaneous  Robertson BC, Manson PN. High-energy ballistic surgery center. Washington, DC7 Walter Reed Army and avulsive injuries: a management protocol for the Medical Center; 2004. next millennium. Surg Clin North Am 1999;79(6): 1489 – 502.