Facial fractures the upper face

Maxillary and Periorbital Fractures Frederick Mars Untalan, MD http://entbgh.blogspot.com/

http://entbgh.blogspot.com/

Facial Injuries
Dental Terminology

Overview
Classic tripod, orbital floor, LeFort fractures better thought of as orbitozygomaticomaxillary fractures
Precise anatomic reduction is key
Goal is functional and cosmetic rehabilitation

Epidemiology
Males : Females -- 4 :1
Predominantly in 20’s or 30’s
Cause
MVA > altercation > fall
Site
Nasal > Zygoma > other
In altercations left zygoma fractured more often

History
Mechanism of Injury
Previous facial injuries / Dental AbN
Premorbid history
Loss of consciousness
Medications, Allergies, Tetanus Status
Associated Injuries

Clinical Assessment of the Face
SYMPTOMS
Diplopia
Abnormal Sensation
Malocclusion
Pain

GCS, Ocular exam, C-spine exam
Cranial nerve exam, CSF rhinorrhea
Inspect (including septum & TM)
Palpate (including midface stability)
Assess occlusion & intraoral exam

CSF rhinorrhea – Halo sign
Septal hematoma
Hemotympanum
Malocclusion
Ocular Findings
Diplopia/restricted EOM, Subconj. Hem., hyphema, anisocoria, impaired V A
Clinical Assessment of the Face http://entbgh.blogspot.com/

Reliable Physical signs
Bony facial asymmetry
True V 2 numbness
Malocclusion
Clinical Assessment of the Face http://entbgh.blogspot.com/

Physical Exam
Palpate for midface instability

Physical Exam
Often edema, swelling, or patient’s mental status make physical exam difficult
CT is modality of choice -- axial and coronal

Physical Exam
Midface asymmetry may indicate zygoma fracture

Forced Duction Testing http://entbgh.blogspot.com/

Emergency Management
C-Spine Injury
10% C-Spine Fracture
Head Injury
50% - Loss of Consciousness
5% Significant Intracranial Injury
Ocular Injury
25% - Some Degree of Injury

Emergency Management Hemorrhage
Local Pressure
Dressings / Packing
Reduction Of Facial Fractures
Endovascular Consultation
Ligation Of Vessels
IMAX

Radiographic Assessment of the Face
Water’s view
Panorex (Orthopantomogram)
Mandible views
CT scans
Standard of care for major facial trauma

Water’s view The “W” system
PA view for visualization of maxillary sinuses, maxilla, orbits, and zygomatic arches
May also see nasal bone fractures
Radiographic Assessment of the Face http://entbgh.blogspot.com/

CT areas to evaluate
Vertical buttresses
Zygomatic arch
Orbital walls
Bony palate
Mandibular condyles

Signs And Symptoms
Pain / Tenderness
Crepitus From Bony Fractures
Hypoesthesia
Paralysis
Malocclusion
Visual Disturbances
Deformity
Obstructive Respiration
Lacerations
Bleeding
Contusions
Facial Asymmetry

Soft Tissue Injuries
Tetanus Prophylaxis
Structures
Facial Nerve
Trigeminal Nerve
Parotid Duct
Lacrimal System

Principles Of Craniomaxillofacial Fracture Management
Precise anatomic diagnosis
Direct fracture exposure
Reduction / rigid internal fixation
Mandible fracture stabilization
Reconstruction of horizontal and vertical facial buttresses
Primary bone grafting
Periosteal and soft-tissue suspension and repair

Facial Fractures The Upper Face http://entbgh.blogspot.com/

Outline
Facial Fracture Basics
Nasal Fractures
Naso-orbital-ethmoidal Fractures
Frontal Sinus Fractures
Zygomatic Fractures
Maxillary Fractures
Orbital Fractures

Nasal Fractures http://entbgh.blogspot.com/

Physical Exam
Edema
Crepitus
Periorbital Ecchymosis
Epistaxis
Internal And External Lacerations
Widened Nasal Bridge
Septal Hematoma

Classification Stranc and Robertson
Lateral Impact Injuries
Unilateral vs. Bilateral
Frontal Impact Injuries
Plane I
Plane II
Plane III

Treatment Lateral Impact Injuries
Early Versus Delayed Treatment
Closed Reduction (Local vs. General)
Drainage of Septal Hematoma
Simple Repositioning of Deviated Nasal Bones and Septum
Completion Of The Fracture
Internal Packing and External Splint

Treatment Frontal Impact Injuries
Plane I
edema / ecchymosis distal nasal bridge and tip
possible septal distortion
closed reduction with internal support
possibly may require secondary septorhinoplasty

Plane II
Increased Comminution of the Nasal Pyramid
Bilateral
Possible “Saddling”
Initial Closed reduction
May Require Delayed Septal Reconstruction With Grafts

Plane III
Extend Into Pyriform Aperture And Medial Orbital Rim
ie. Naso-Orbital-Ethmoidal Fractures
Open Reduction an Internal Fixation of Frontal Process of Maxilla
Transnasal Reduction of Medial Canthal Ligaments

Complications
Occur In Up To 70%
Deviated Nasal Pyramid
Nasal “Hump”
Septal Deformity With Respiratory Obstruction

Naso-Orbital-Ethmoidal Fractures http://entbgh.blogspot.com/

Naso-Orbital-Ethmoidal Fractures
Interorbital “Space”
two ethmoidal labyrinths
superior and middle turbinates
perpendicular plate of ethmoid
Medial Orbital Wall
anteriorly - lacrimal bone and lamina papyracea
posteriorly - body of sphenoid

Interorbital space displaced backwards
Medial Canthal Tendon and Lacrimal Apparatus frequently injured
May extend into:
cribriform plate and anterior cranial fossa
optic foramen
Associated Orbit and Midface Fractures Common

Flat nose
Swollen medial canthal area
Telecanthus (12-20%)
Lack of skeletal support on palpation of nose
CSF leak
Positive eyelid traction test

Naso-Orbital-Ethmoidal Fractures Telecanthus
Normal intercanthal distance (Stranc)
White males: 33-34mm
Females: 32-33mm
Consider >35mm abnormal (Manson)

Naso-Orbital-Ethmoidal Fractures Classification Markowitz
Type I - Single central segment
Type II - Comminuted central segment
Type III - Avulsed medial canthal tendon

Naso-Orbital-Ethmoidal Fractures http://entbgh.blogspot.com/

Naso-Orbital-Ethmoidal Fractures Classification - Gruss
Isolated injury to bony naso-orbital region
Associated fractures of the central maxilla
Associated LeFort II and III
Naso-orbital fractures with orbital dystopia
Naso-orbital fractures with bone loss

Naso-Orbital-Ethmoidal Fractures Management
Early open reduction
Four Objectives:
correct epicanthal folds
restore bony contour
reestablish lacrimal system continuity
medial canthoplasty / canthopexy

Wide Exposure
coronal incision
“ open sky” - transverse across root of nose
vertical midline nasal
subciliary
buccal sulcus
extend existing lacerations

Correct nasofrontal separation
Elevate nasal bones
Reduce comminuted nasal bones
Bone graft where needed
Explore septum
Stabilize nasomaxillary buttresses

Frontal Sinus Fractures http://entbgh.blogspot.com/

Frontal Sinus Embryology
Begin to Develop At 2 Years of Age
Extension of the Ethmoid Air Cells
Radiographically Evident At ~ 8 Years
Do Not Reach Adult Size Until 12 or Older
10% - Unilateral Development
4% - Absent All Together
Drain Into Middle Meatus

Frontal Sinus Anatomy
Supraorbital / Temporal vs Frontal Sinus
Anterior Wall and/or Posterior Wall
Nasofrontal Duct

Frontal Sinus Diagnosis
Signs And Symptoms
Forehead Laceration
CSF Rhinorrhea
Supraorbital Nerve Anesthesia
Depressed Frontal Region
Subconjunctival Ecchymosis

Frontal Sinus Diagnosis
X-Ray
Air Fluid Levels
CT Scan
Axial and Coronal Images

Frontal Sinus Treatment
Operative Indications
Anterior Table Displacement With Contour Change
Nasofrontal Duct Involvement
Displaced Posterior Table

Nasofrontal Duct Injury
Remove Mucosa
Burr Inner Cortex
Occlusion Of Duct
Sinus Obliteration

Posterior Table
Cranialization
Bicoronal Approach
Preserve Pericranial Flap
Dural Repair
Remove Sinus Mucosa
Obliterate Nasofrontal Duct
Remove Intersinus Septum And Posterior Wall
Pericranial Flap To Floor Of Sinus

Frontal Sinus Complications
Early (within 6 months)
Frontal Sinusitis
Meningitis
Late
Mucocele
Mucopyocele
Brain Abcess
Osteomyelitis

Frontal Sinus Complications
Incidence Of Late Complications
Freihofer
71 Fractures
2 Patients - Meningitis
1 Patient - Mucopyocele With Osteomyelitis Of Frontal Bone

Orbital Fractures http://entbgh.blogspot.com/

Orbital Blowout Injury http://entbgh.blogspot.com/

Orbital Fractures Blowout Fractures
Pure Blowout - only orbital floor or medial wall injured
Impure Blowout - associated orbital rim fractures

Orbital Blowout Injury http://entbgh.blogspot.com/

Orbital Blowout Injury
Usually inferior and/or medial wall
Cone will become more spherical
Leads to enophthalmos, inferior displacement
Muscle entrapment causes diplopia

Orbital Fractures Physical Exam
Diplopia
Enophthalmos
Inferior Displacement Palpebral Fissure
Anesthesia of Infraorbital Nerve
Orbital Emphysema

Diplopia
Commonly on Upward Gaze
Primary (Central Gaze) or Secondary (Perpheral)
Mechanical (incarceration of infraorbital tissue) or Nonmechanical (paresis)
Forced Duction Test

Orbital Fractures Forced Duction Test http://entbgh.blogspot.com/

Enophthalmos
Inferior and Posterior Displacement of Globe and Intraorbital Soft Tissue
Etiology
Enlargement of the Bony Orbital Cavity
Escape of Orbital Fat or Fat Necrosis
Muscle Entrapment in Fracture Line
Soft Tissue Scarring and Contracture

Orbital Fractures Enophthalmos http://entbgh.blogspot.com/

No Diplopia + No Enophthalmos
?Significant Fracture
Diplopia + No Enophthalmos
Incarceration Only
No Diplopia + Enophthalmos
Volume Discrepancy Only
Diplopia + Enophthalmos
Incarceration + Volume Discrepancy

Orbital Fractures Indications For Exploration
Symptomatic Diplopia With Positive Forced Duction Test
Xray evidence of Extraocular Muscle Entrapment
Early Enophthalmos (>3mm)
Large Orbital Floor Defect
Abnormally Low Vertical Globe Level
Associated Orbital Rim or Other Craniofacial Fractures

Orbital Rim Access
A -- subciliary
B -- lower eyelid
C -- infraorbital

Orbital Fractures Incisions http://entbgh.blogspot.com/

Orbital Fractures Management
Grafts
Autologous Bone
Cartilage
Fascia lata
Alloplastic Implants
Teflon
Silastic
Titanium

Orbital Floor
Dotted line shows anatomic goal of restoration

Orbital Fractures Complications
Infection
Implant problems
Persistent Diplopia (2-50%)
Persistent Enophthalmos (15-22%)
Ectropion (1%)
Blindness

Superior Orbital Fissure Syndrome
extension of fracture into SOF
ophthalmoplegia with injury to III, IV or VI
anesthesia in V1 plus loss of corneal reflex
ptosis and proptosis
parasympathetic block
fixed, dilated pupil

Orbital Apex Syndrome
same as superior orbital fissure syndrome
plus blindness

Transconjunctival Approach
Conjunctiva is being used to protect globe

Materials for reconstruction
Autogenous tissues
Avoid risk of infected implant
Additional operative time, donor site morbidity , graft absorption
Calvarial bone, iliac crest, rib, septal or auricular cartilage

Orbital Floor Bone Grafting
Need to support floor full 4 cm

Alloplastic implants
Decreased operative time, easily available, no donor site morbidity, can provide stable support
Risk of infection 0.4-7%
Gelfilm, polygalactin film, silastic, marlex mesh, teflon, prolene, polyethylene, titanium

Orbital Floor Materials
Marlex mesh
needs 360 degree support
better for concave anterior floor only
Medpor
needs medial/ lateral support
can use for anterior/posterior defect
Calvarial bone graft
Titanium mesh

Synthetic Mesh http://entbgh.blogspot.com/

Orbital Metallic Mesh http://entbgh.blogspot.com/

Orbital Roof
Uncommon due to high levels of force needed to fracture orbital roof
Commonly with intracranial problems

Orbital Roof Repair
Repair roof higher on frontal bar

From: Strong EB, Sykes JM. Zygoma Complex Fractures. Facial Plastic Surgery 1990;14(1):109. http://entbgh.blogspot.com/

Periorbital & Zygomatic bone Fractures http://entbgh.blogspot.com/

Zygoma Fractures
Results from lateral forces

Zygoma Anatomy
Tetrapod Structure
Frontal Bone
Temporal Bone
Maxilla
Greater Wing Of Sphenoid

Zygoma Anatomy http://entbgh.blogspot.com/

Zygoma Anatomy
Muscular Attachments
Masseter
Temporalis
Zygomaticus
Zygomatic Head of Quadratus Labii Superioris

Zygoma Physical Exam
Circumorbital Swelling / Ecchymosis
Subconjunctival Hemorrage
Abnormal Sensation V2 Distribution
Diplopia or Globe Displacement
Increased Facial Width
Depressed Malar Prominence
Palpable Step Deformities
Unilateral Epistaxis
Hematoma Upper Buccal Sulcus
Trismus Due To Coronoid Process Impingement

Zygoma Physical Exam http://entbgh.blogspot.com/

Zygoma Fracture Classification
Knight
Undisplaced
Arch Fractures
Unrotated Body Fractures
Medially Rotated Body Fractures
Laterally Rotated Body Fractures
Complex Fractures - Additional Fractures Across Zygoma

Zygoma Fracture Classification
Manson
Low Energy
minimal displacement
do not require operative reduction
Middle Energy
High Energy
often part of panfacial fractures

Zygoma Radiology
X-Ray
Water’s View Most Useful
CT Scan
Coronal Cuts For Orbital Anatomy

Zygoma Fractures
Impacted zygoma may mask orbital floor defect

Treatment of Zygomaticomaxillary Complex fractures
Restore pre-injury facial configuration
Prevent cosmetic deformity
Prevent delayed visual disturbances
Repair within 5-7 days allows edema to decrease and avoids shortening of masseter with lateral and inferior rotation

Zygoma
Ideally done between 5-7 days for resolution of edema
Pre- or intra-operative steroids can help with edema
After 10 days masseter begins to shorten

Zygoma
reduction only - Minimally displaced, non comminuted
plating of lateral antrum, orbital rim, ZF suture, and even the zygomatic arch - for Increasing amounts of displacement & comminution
One can wire the ZF suture first to assist with reduction, then plate it after other areas stabilized

Zygoma Algorithm http://entbgh.blogspot.com/

Zygoma Management
Undisplaced
Nonoperative
Displaced
Isolated Zygomatic Arch - Gilles Elevation
Orbitozygomatic Fractures - Open reduction and Stabilization

Zygoma Management http://entbgh.blogspot.com/

ORIF of Lateral Antral Wall http://entbgh.blogspot.com/

Gillies Reduction http://entbgh.blogspot.com/

Post-Gillies Reduction http://entbgh.blogspot.com/

Surgical Approaches
Coronal
Sublabial
Transconjunctival
Lateral Brow

Coronal Approach http://entbgh.blogspot.com/

Coronal Approach
Supraorbital nerve may be released for more exposure

Hemicoronal Approach http://entbgh.blogspot.com/

Lateral Brow Incision
Avoid shaving brow hairs
Goal is the ZF suture

Sublabial Approach
Leave mucosa to sew to later
Identify and preserve V2

Zygoma Gilles Elevation http://entbgh.blogspot.com/

Zygoma Operative Exposure http://entbgh.blogspot.com/

Zygoma Complications - Early
Bleeding
Infection
Exacerbation of Sinus Disease
Malfunction of Extraocular Muscles
Blindness

Zygoma Complications - Late
Nonunion / Malunion
Diplopia (10% initial, 5% permanent)
Persistent V2 Anesthesia (24%)
Orbital Dystopia
Chronic Maxillary Sinusitis (4-7%)
Scarring
Ectropion
Problems With Mandible Motion
Enophthalmos (3%)
Soft Tissue Descent With Loss of Malar Prominence

Treatment of Zygomaticomaxillary Complex fractures
Restore pre-injury facial configuration
Prevent cosmetic deformity
Prevent delayed visual disturbances
Repair within 5-7 days allows edema to decrease and avoids shortening of masseter with lateral and inferior rotation

Soft diet and malar protection
Closed reduction
ORIF with plating of one to four buttresses
Provide fixation as necessary for stable reduction

Maxillary Fractures http://entbgh.blogspot.com/

Types
LeFort or Maxillary fractures
Zygomaticomaxillary complex fractures
Orbitozygomaticomaxillary complex fractures

Anatomy of the Maxilla
Paired embryologically
Functionally acts with palatine bone

Anatomy of the Maxilla http://entbgh.blogspot.com/

LeFort fractures
Rene LeFort 1901 in cadaver skulls
Based on the most superior level
Frequently different levels on either side
LeFort I
LeFort II
LeFort III

Facial Buttress system From: Celin SE. Fractures of the Upper Facial and Midfacial Skeleton. In: Myers EN ed., Operative Otolaryngology Head and Neck Surgery , Philadelphia, WB Saunders Company 1997:1143-1192. http://entbgh.blogspot.com/

From: Dolan KD, Jacoby CG, Smoker WR. Radiology of Facial Injury . New York, MacMillian Publishing Company 1988, pg76. http://entbgh.blogspot.com/

Facial buttress system http://entbgh.blogspot.com/

Vertical Buttresses
Resist occlusal load

Horizontal Buttresses http://entbgh.blogspot.com/

LeFort fractures
Rene LeFort 1901 in cadaver skulls
Based on the most superior level
Frequently different levels on either side
LeFort I
LeFort II
LeFort III

LeFort Fractures
Experimentally determined weak points
Can be in combinations bilaterally
Useful descriptor
Results from anterior forces

Forces of mastication From: Banks P, Brown A. Fractures of the Facial Skeleton , Oxford, Wright 2001 pg.6 http://entbgh.blogspot.com/

Facial Buttress system From :Stanley RB. Maxillary and Periorbital Fractures. In :Bailey BJ ed., Head and Neck Surgery-Otolaryngology , third edition, Philadelphia, Lippincott Williams & Wilkins 2001, pg 777. http://entbgh.blogspot.com/

From: Marciani RD. Management of Midface Fractures: fifty years later. J Oral Maxillofac Surg 1993;51:962. http://entbgh.blogspot.com/

From: Dolan KD, Jacoby CG, Smoker WR. Radiology of Facial Injury . New York, MacMillian Publishing Company 1988, pg76. http://entbgh.blogspot.com/

Maxillary Fractures LeFort Fractures
LeFort I
Transverse Fracture That Separates Maxillary Alveolus From Midface Skeleton
Runs Above Roots of Maxillary Teeth, Across Lower Pyriform Aperature, and Severs Pterygoid Process

Le Fort I http://entbgh.blogspot.com/

Lefort II
“ Pyramidal” Fracture of Maxilla
Separates Nasomaxillary Segment from Zygomatic and Upper Lateral Midface
Fracture Line May Go Above or Beneath Medial Canthal Ligament Insertion
Lacrimal System May Be Involved

Le Fort II http://entbgh.blogspot.com/

LeFort III
Craniofacial Dysjunction
Zygomaticofrontal Junction, Traverses Lateral, Inferior, and Medial Orbit, Separates Frontal Process of Maxilla From Frontal Bones

Le Fort III http://entbgh.blogspot.com/

Maxillary Fractures LeFort Fractures http://entbgh.blogspot.com/

Modified LeFort Classification From: Marciani RD. Management of Midface Fractures: fifty years later. J Oral Maxillofac Surg 1993;51:962. http://entbgh.blogspot.com/

Donat, Endress, Mathog classification From: Donat TL et al. Facial Fracture Classification According to Skeletal Support Mechanisms. Arch Otolaryngol Head Neck Surg 1998;124:1306-1314. http://entbgh.blogspot.com/

Maxillary Fractures Examination and Diagnosis
Epistaxis
Ecchymosis (periorbital, conjunctival, and scleral)
Malocclusion With Anterior Open Bite
Buccal Mucosa Hematoma
Tear in Intraoral Soft Tissues
Elongated, Retruded Appearance
“ Donkey-Like” Facies
CSF Leak in 25-50% of LeFort II and III

Maxillary Fractures Radiology
X-Rays
Bilateral Maxillary Sinus Opacification
Pterygoid Plate Fracture On Lateral Projection
Fracture Through ZF and Nasofrontal Suture

From: Som PM, Curtin HD. Head and Neck Imaging ;. Fourth Edition; St. Louis, Mosby 2003, pg 386. http://entbgh.blogspot.com/

Maxillary Fractures Complications
Early
Extensive Hemorrhage
Airway Obstruction
Infection
CSF Leak
Blindness

Late
Palpable Hadware
Non-Union / Malunion
Plate Exposure
Lacrimal System Obstruction
V2 Anesthesia
Devitalized Teeth
Extra-Occular Muscle Imbalance

Late
Diplopia
Enophthalmos
Orbital Dystopia
Change In Facial Appearance
Facial height and width
Nasal Obstruction
Malocclusion

Maxillary Fractures Management
Goals
re-establish midfacial height and projection
establish occlusal relationship
maintain integrity of nose and orbits

Intermaxillary Fixation
Open Reduction
LeFort I
Bilateral Buccal Sulcus Incisions
LeFort II and III
Coronal and Lower Eyelid Incisions

Treatment http://entbgh.blogspot.com/

Treatment
Goal is functional and cosmetic restoration
Treatment must be individualized
Various factors can affect management strategies
Multi-trauma
Concomitant mandible injury
Only-seeing eye

Rigid Internal Fixation
Frontal Bone as a Guide
Mandibuar Ramus Dictates Facial Height
Stabilize Vertical Buttresses
Bone Grafts If Necessary

Maxillary Fractures Palatal Fractures
8% of LeFort fractures
Younger vs. Older
<30 years
midline fracture
>30 years
sagittal fractures adjacent to midline or alveolus

Maxillary Fractures Palatal Fractures
Stabilize before IMF
Open reduction of palatal roof
Pyriform aperture plate to unite maxillary segements
Dental splints to prevent occlusion

Maxillary Fractures Palatal Fractures http://entbgh.blogspot.com/

Associated Injuries
Brandt et al 1991
59% caused by MVA had intracranial injury
10% caused by fall/beating had intracranial injury

Associated injuries
Haug et al 1990
402 patients
Zygoma fractures:
Lacerations 43%
Orthopedic injuries 32%
Additional facial fractures 22%
Neurologic injury 27%
Pulmonary, abdominal, cardiac 7%, 4.1%, 1%

Maxillary fractures:
Lacerations and abrasions 75%
Orthopedic injury 51%
Other facial fractures 42%
Neurologic injury 51%
Pulmonary 13%, abdominal 5.7%, cardiac 3.8%

Midface
“ Rigid” fixation misnomer with small plates and thin bones
Semirigid fixation (wire) sometimes preferable
Early function can be achieved with soft diet only

Vertical Buttress Algorithm http://entbgh.blogspot.com/

Midface Disimpaction
May be necessary to restore facial dimensions before fixation

Palate Fracture
Wire can be placed posteriorly for stabilization before triangular reduction

ORIF of Midface http://entbgh.blogspot.com/

Order of Repairs
Work from stable to unstable
Use occlusion as guide
Generally stabilize mandible, zygoma and palate before midface before orbit and NOE

Order of Repairs http://entbgh.blogspot.com/

Treatment of maxillary fractures
Early repair
Single-stage
Extended access approaches
Rigid fixation
Immediate bone grafting
Re-suspension of soft tissues

Maxillary fractures
Steps of reconstruction-Rohrich and Shewmake
Reestablish facial height and width
IMF with ORIF of mandible
Zygomatic arch reconstruction restores facial width and projection
Reconstruction continues from stable bone to unstable and from lateral to medial

Internal fixation vs. traditional methods
Klotch et al 1987
43 patients
22 treated with ORIF using AO miniplates
21 treated with combination of intermaxillary fixation, and/or interosseous wiring, and/or primary bone grafting

Most severe injuries in rigid internal fixation group
Shorter IMF, early return to diet, lower percentage of tracheotomy
No plate infections

Haug et al 1995
134 patients treated by maxillomandibular fixation or rigid internal fixation
Postoperative problems in 60% vs 64%

Treatment of maxillary fractures
Early repair
Single-stage
Extended access approaches
Rigid fixation
Immediate bone grafting
Re-suspension of soft tissues

Approaches
Circumvestibular
Facial degloving
Bicoronal
Transconjuctival

From: Haug RH, Buchbinder D. Incisions For Access to Craniomaxillofacial Fractures. Atlas of the Oral and Maxillofacial Surgery Clinics of North America 1993;1(2):23. http://entbgh.blogspot.com/

From: Haug RH, Buchbinder D. Incisions For Access to Craniomaxillofacial Fractures. Atlas of the Oral and Maxillofacial Surgery Clinics of North America 1993;1(2):25. http://entbgh.blogspot.com/

Bicoronal approach From: Celin SE. Fractures of the Upper Facial and Midfacial Skeleton. In: Myers EN ed., Operative Otolaryngology Head and Neck Surgery , Philadelphia, WB Saunders Company 1997:1143-1192. http://entbgh.blogspot.com/

From: Celin SE. Fractures of the Upper Facial and Midfacial Skeleton. In: Myers EN ed., Operative Otolaryngology Head and Neck Surgery , Philadelphia, WB Saunders Company 1997:1143-1192. http://entbgh.blogspot.com/

Cutting Edge Topics
Bioresorbable plates
Intraoperative CT
3-D CT reconstruction
Endoscopic assistance

Conclusion
Goal is functional and cosmetic rehabilitation
Precise anatomic restoration key
Treatment tailored to each individual
Knowledge of anatomy and techniques will lead to superior results

Conclusions
High index of suspicion for associated injuries- especially ocular
Assessment of buttress system
Wide exposure via cosmetically acceptable incisions
Rigid fixation
Soft tissue resuspension

Case Presentation http://entbgh.blogspot.com/

30 yo WF
MVA
PMH unknown

Maxillary and Periorbital Fractures Frederick Mars Untalan, MD http://entbgh.blogspot.com/

Facial fractures the upper face

by Frederick Mars Untalan

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