Fractures of the Midface / Orbit

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A presentation on the latest in facial fracture repair of the midface, zygoma, and partial orbit. Great history section I researched at Countway Library at Harvard Medical School.

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Fractures of the Midface / Orbit

  1. 1. Fractures of the Midface W. Thomas McClellan, M.D. www.morgantownplasticsurgery.com
  2. 2. Terms <ul><li>Zygoma – Latin and Greek Origins </li></ul><ul><ul><li>Zygoun “to join” </li></ul></ul><ul><ul><li>Zygon “yoke” </li></ul></ul><ul><li>Maxilla – Latin “jawbone” </li></ul>
  3. 3. Zygoma Anatomy <ul><li>1944 Ungley and Suggit described </li></ul><ul><ul><li>“ zygomatic tripod” </li></ul></ul><ul><li>Really a “tetrapod” with four articulations </li></ul><ul><ul><li>Greater wing sphenoid </li></ul></ul><ul><ul><li>Frontal bone </li></ul></ul><ul><ul><li>Temporal Bone </li></ul></ul><ul><ul><li>Maxilla </li></ul></ul><ul><li>Correct Terminology (Knight and North) </li></ul><ul><ul><li>Malar complex </li></ul></ul><ul><ul><li>Zygomaticomaxillary (ZMC) complex </li></ul></ul>Gray’s Anatomy
  4. 4. Maxilla Anatomy <ul><li>Second largest bone of the face (mandible) </li></ul><ul><li>Body – </li></ul><ul><ul><li>Pyramidal in shape </li></ul></ul><ul><ul><li>Contains the maxillary sinus (Antrum of Highmore) </li></ul></ul><ul><li>Four processes </li></ul><ul><ul><li>zygomatic </li></ul></ul><ul><ul><li>frontal </li></ul></ul><ul><ul><li>alveolar </li></ul></ul><ul><ul><li>palatine </li></ul></ul><ul><li>Forms </li></ul><ul><ul><li>floor of orbit </li></ul></ul><ul><ul><li>roof of the mouth </li></ul></ul><ul><ul><li>floor and lateral wall of the nose </li></ul></ul>Gray’s Anatomy
  5. 5. Midface Anatomy <ul><li>Bone </li></ul><ul><li>Vessels </li></ul><ul><li>Nerves </li></ul><ul><li>Muscles </li></ul><ul><li>Buttress Concept </li></ul>
  6. 8. Projection Impingement
  7. 9. Symmetry
  8. 10. Gray’s Anatomy Malar Branch transverse facial aa Suborbital Malar Br. Trans. Fac a Suborbital a
  9. 11. Gray’s Anatomy
  10. 12. Muscles Temporalis Orbicularis oculi Zygomaticus major Zygomaticus minor Levator labii superioris Masseter Gray’s Anatomy
  11. 13. Midface Buttresses <ul><li>First proposed in 1970 by Sicher and DeBrul </li></ul><ul><li>Expanded upon by Manson, Phillips and Forrest </li></ul><ul><li>Notion that the midface is composed of sinuses supported by vertical, horizontal, and saggital buttresses of bone. </li></ul><ul><li>Midface lacks saggital buttress in central segments = flattening after reconstruction </li></ul><ul><li>Zygomatic arch is weak saggital buttress </li></ul><ul><ul><li>Only moderate inherent stability after titanium plate fixation </li></ul></ul>Manson, P. et. Al. Subunit Principles for midface fractures: The importance of saggittal buttresses, soft tissue reductions, sequencing treatment of segmental fractures. PRS . 103(4); 1287-1307, 1999. Sicher, B., DeBrul E. Oral Anatomy 5 th Ed. St Louis: Mosby; 1970 :78
  12. 14. Midface Buttresses Frontal Bar Nasomaxillary Zygomaticomaxillary Pterygomaxillary Zygomatic arch Frontal Bone Manson, P. et. Al. Subunit Principles for midface fractures: The importance of saggittal buttresses, soft tissue reductions, sequencing treatment of segmental fractures. PRS . 103(4); 1287-1307, 1999.
  13. 15. Epidemiology <ul><li>Midface is common facial fracture (Nose) </li></ul><ul><li>60-80% male </li></ul><ul><li>Peak incidence between 15-30 yr </li></ul><ul><li>Mechanisms </li></ul><ul><ul><li>MVC, MCC, Assaults, Falls, Sports related injuries </li></ul></ul><ul><li>25% have associated extremity or chest injuries </li></ul><ul><li>32% have positive toxicology screen </li></ul>
  14. 16. Your Patient J jjj J jjj
  15. 17. Patient History <ul><li>Timing </li></ul><ul><li>Mechanism </li></ul><ul><li>Previous facial fractures </li></ul><ul><li>Smoking </li></ul><ul><li>Dentures </li></ul><ul><li>Glasses </li></ul><ul><li>Allergies to medications </li></ul>Key Questions “ Do your teeth come together normally?” “ Any changes in vision” “ Feeling of numbness”
  16. 18. Physical Exam <ul><li>Global Exam </li></ul><ul><ul><li>ABC’s – verify adequate airway </li></ul></ul><ul><ul><li>Vital Signs (HR) </li></ul></ul><ul><ul><ul><li>Occulocardiac reflex </li></ul></ul></ul><ul><ul><li>C-Spine </li></ul></ul><ul><ul><ul><li>10% Midface fx associated with cervical injury </li></ul></ul></ul><ul><ul><ul><li>15% Mandible fx have cervical injury </li></ul></ul></ul><ul><ul><li>No nasal tubes </li></ul></ul><ul><li>Evaluate associated injuries or lacerations </li></ul>
  17. 19. Physical Exam <ul><li>Orbit exam </li></ul><ul><ul><li>Globe integrity </li></ul></ul><ul><ul><li>Pupils </li></ul></ul><ul><ul><li>Ocular movement </li></ul></ul><ul><ul><ul><li>Orbital Apex Syndrome, Superior Orbital Fissure Syndrome </li></ul></ul></ul><ul><ul><li>Vision (diplopia) </li></ul></ul><ul><ul><li>Enopthalmos </li></ul></ul><ul><ul><li>Telecanthus </li></ul></ul><ul><ul><li>Orbital ecchymosis or emphysema </li></ul></ul><ul><ul><li>Ophthalmology Consult (intraocular pressure) </li></ul></ul><ul><ul><li>Lacrimal duct </li></ul></ul>
  18. 20. Physical Exam <ul><li>Facial skeletal exam </li></ul><ul><ul><li>Orbital Rim </li></ul></ul><ul><ul><li>ZF suture </li></ul></ul><ul><ul><li>Nose midline stable </li></ul></ul><ul><ul><ul><li>Septal hematoma </li></ul></ul></ul><ul><ul><ul><li>Epistaxis, unilateral or bilateral </li></ul></ul></ul><ul><ul><ul><li>CSF rhinorrhea – cribiform plate injury </li></ul></ul></ul><ul><ul><li>Symmetry, projection of midface </li></ul></ul><ul><li>Sensory and Motor exam </li></ul><ul><ul><li>CN V 2 , </li></ul></ul><ul><ul><ul><li>Ant branch verses posterior branch </li></ul></ul></ul><ul><ul><li>CN VII </li></ul></ul>
  19. 21. Physical Exam <ul><li>Oral exam </li></ul><ul><ul><li>Mucosal lacerations </li></ul></ul><ul><ul><li>Dentition (present or loose) </li></ul></ul><ul><ul><li>Occlusion – Edward Angle 1890 (I,II,III) </li></ul></ul><ul><ul><ul><li>Relationship of mesiobuccal cusp of maxillary first molar sits in the mesiobuccal groove of mandibular first molar </li></ul></ul></ul><ul><ul><li>Trismus – impingement on coronoid process </li></ul></ul><ul><ul><ul><li>Otoscopic examination (hemotympanum) </li></ul></ul></ul><ul><ul><ul><li>Battle’s sign – temporal bone fracture, especially if isolated arch fracture </li></ul></ul></ul><ul><ul><li>Midface stability </li></ul></ul>
  20. 22. Radiology <ul><li>CT Scan facial bones </li></ul><ul><ul><li>Axial, Coronal, Saggittal required. </li></ul></ul><ul><li>Three Dimensional reconstructions helpful for symmetry only </li></ul><ul><li>Plain films – no current preoperative role </li></ul><ul><ul><li>Waters </li></ul></ul><ul><ul><ul><li>30 degrees occipitomental projection </li></ul></ul></ul><ul><ul><ul><li>Buttresses </li></ul></ul></ul><ul><ul><li>AP, Lateral, Submentovertex (“Jughandle”) </li></ul></ul>
  21. 26. ER Management <ul><li>Elevate head of bed 30 degrees </li></ul><ul><li>Ice </li></ul><ul><li>NPO (or soft diet) </li></ul><ul><li>Antibiotics </li></ul><ul><ul><li>Cefazolin shown to reduce perioperative incidence of infections in facial fractures by 34% </li></ul></ul><ul><ul><li>Chole, R. et al. Antibiotic prophylaxis for facial fractures. A prospective, randomized trial. Arch Otolaryngol Head Neck Surg, 113(10): 1055-7. 1987 </li></ul></ul><ul><li>Tetanus </li></ul><ul><li>Repair Lacerations </li></ul><ul><li>Visual acuity checks </li></ul>
  22. 27. Case J jjj J jjj
  23. 31. J jjj
  24. 32. J jjj
  25. 34. <ul><li>Fracture Patterns </li></ul>
  26. 35. Rene LeFort, M.D. <ul><li>French Surgeon </li></ul><ul><li>Cadaver heads </li></ul><ul><ul><li>Dropped from top floor </li></ul></ul><ul><ul><li>Striking them with piano leg </li></ul></ul><ul><li>Determined three basic fault lines for facial fractures </li></ul>
  27. 36. Fracture Patterns <ul><li>LeFort I – </li></ul><ul><ul><li>transmaxillary fracture at the level of the piriform rim back to pterygoids </li></ul></ul>
  28. 37. Fracture Patterns <ul><li>LeFort II – </li></ul><ul><ul><li>“ pyramidal” fracture through the nasofrontal junction to the anterior maxilla and back to the pterygoids </li></ul></ul>
  29. 38. Fracture Patterns <ul><li>LeFort III – </li></ul><ul><ul><li>“ craniofacial disjunction” </li></ul></ul><ul><ul><li>ZF suture through the orbital floors, medial walls, nasofrontal junction and zygomatic arch </li></ul></ul>
  30. 40. Knight and North Classification of Malar Fractures <ul><li>Nondisplaced 6% </li></ul><ul><li>Displaced 10% </li></ul><ul><ul><li>Arch </li></ul></ul><ul><ul><li>Body </li></ul></ul><ul><ul><ul><li>Simple </li></ul></ul></ul><ul><ul><ul><ul><li>Depression without rotation 33% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Depression with Medial Rotation 11% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Depression with Lateral Rotation 22% </li></ul></ul></ul></ul><ul><li>Complex 18% </li></ul>Knight, JS. Et al. The Classification of malar fractures: An analysis of displacement as a guide to treatment. Br. J Plast Surg. 13:325-339
  31. 41. Manson, P., Markowitz, B., Mirvis, S., Dunham, M., Yaremchuk, M. CT Based Facial Fracture Treatment. Plas Recon Surg 85(2): 202 –12 1990. <ul><li>3 years, </li></ul><ul><li>4648 blunt facial trauma admissions </li></ul><ul><li>Define fractures by CT scan correlated with mechanism energy and relate those to exposure and fixation required </li></ul><ul><ul><li>Low, Middle, High energy fractures </li></ul></ul><ul><ul><ul><li>Location </li></ul></ul></ul><ul><ul><ul><li>Comminution: low, moderate, highly </li></ul></ul></ul><ul><ul><ul><li>Displacement </li></ul></ul></ul>
  32. 42. Manson, P., Markowitz, B., Mirvis, S., Dunham, M., Yaremchuk, M. CT Based Facial Fracture Treatment. Plas Recon Surg 85(2): 202 –12 1990. <ul><li>Low Energy (18%) </li></ul><ul><li>ZF suture usually unaffected </li></ul><ul><li>Incomplete fractures through articulations </li></ul><ul><li>No reduction </li></ul><ul><li>Middle Energy (77%) </li></ul><ul><li>Complete fractures all buttresses </li></ul><ul><li>Moderate displacement </li></ul><ul><li>Variable comminution </li></ul><ul><li>ORIF of anterior buttresses via 2 incisions </li></ul><ul><li>Adequate reduction based on alignment of greater wing of sphenoid in the lateral orbit. </li></ul><ul><li>High Energy (5%) </li></ul><ul><li>Infrequently observed as isolated fracture </li></ul><ul><li>Associated with Pan or LeFort Fractures </li></ul><ul><li>Extensive posterior and lateral displacement of malar eminence </li></ul><ul><li>Recommend coronal exposure to correct facial width </li></ul><ul><li>Alignment of sphenoid wing </li></ul>Zygoma
  33. 43. Manson, P., Markowitz, B., Mirvis, S., Dunham, M., Yaremchuk, M. CT Based Facial Fracture Treatment. Plas Recon Surg 85(2): 202 –12 1990. <ul><li>Low Energy (9%) </li></ul><ul><li>Simple “buckle” in posterior or medial aspect of maxillary sinus </li></ul><ul><li>Pterygoid plates and Anterior Walls uninvolved </li></ul><ul><li>Malocclution </li></ul><ul><li>No Maxillary movement </li></ul><ul><li>MMF + Elastics </li></ul><ul><li>Middle Energy (85%) </li></ul><ul><li>Ant + Post Wall + Pterygoid Fracture </li></ul><ul><li>Often LeFort I and II fracture patterns </li></ul><ul><li>Direction of impact influences associated fractures </li></ul><ul><li>ORIF and Rigid Fixation </li></ul><ul><li>High Energy (6%) </li></ul><ul><li>Comminution and extreme displacement </li></ul><ul><li>Associated components severely fractured </li></ul><ul><li>Most unstable and challenging to repair </li></ul>Maxilla
  34. 44. October 16, 1846 John Mason Warren William T.G. Morton Edward Gilbert Abbott John Collins Warren
  35. 45. History of Management <ul><li>1751 duVerney reports 2 cases </li></ul><ul><li>1794 Wiseman “Chirurgical Treatise” – Curved instrument / Hook </li></ul><ul><li>1896 Matas - suture around arch for traction </li></ul><ul><li>1906 Lothrop - Transantral approach </li></ul><ul><li>1909 Keen – Intraoral reduction –criticized for contamination </li></ul><ul><li>1913 Manwaring - towel clip </li></ul><ul><li>1927 Kazanjian – screw into malar bone with transcutaneous wire and headcap traction </li></ul>
  36. 46. <ul><li>1927 Gillies – Temporal incision </li></ul><ul><li>1928 Gill – Cow horn dental forceps </li></ul><ul><li>1931 Shea - Transnasal approach </li></ul><ul><li>1942 Adams – Suspension wires </li></ul><ul><li>1950 Fryer – Transcutaneous Kirschner wires </li></ul><ul><li>1952 Anthony – Inflatable antral balloon </li></ul><ul><li>1973 Michelet describes first rigid fixation </li></ul>History of Management
  37. 47. History of Management
  38. 48. History of Management <ul><li>1906 </li></ul><ul><li>Lothrop </li></ul><ul><li>Transantral approach </li></ul>Kazanjian, V, Converse, J. Surgical Treatment of Facial Injuries. William and Wilkins. Baltimore. 1949
  39. 49. History of Management <ul><li>1909 </li></ul><ul><li>Keen </li></ul><ul><li>Oral reduction </li></ul>Kazanjian, V, Converse, J. Surgical Treatment of Facial Injuries. William and Wilkins. Baltimore. 1949
  40. 50. History of Management 1927 Kazanjian, V, Converse, J. Surgical Treatment of Facial Injuries. William and Wilkins. Baltimore.
  41. 51. History of Management
  42. 52. History of Management
  43. 53. History of Management <ul><li>1928 </li></ul><ul><li>Gill </li></ul><ul><li>Cow Horn Forceps </li></ul>Kazanjian, V, Converse, J. Surgical Treatment of Facial Injuries. William and Wilkins. Baltimore. 1949
  44. 54. History of Management 1927
  45. 55. Current Management <ul><li>Nondisplaced fractures </li></ul><ul><ul><li>Soft Diet </li></ul></ul><ul><ul><li>Protection of Malar eminence </li></ul></ul><ul><ul><li>+/- antibiotics </li></ul></ul><ul><ul><li>Reexamine one week </li></ul></ul><ul><li>Isolated Arch </li></ul><ul><ul><li>Operative </li></ul></ul><ul><ul><ul><li>Contour deformity </li></ul></ul></ul><ul><ul><ul><li>Trismus </li></ul></ul></ul><ul><ul><li>Gillies, Keen, Coronal ( severe ) </li></ul></ul>
  46. 56. Indications for Surgery <ul><li>Presence of fracture not indication for surgery </li></ul><ul><li>Moderate to severe displacement </li></ul><ul><li>Zygomaticofrontal suture displacement </li></ul><ul><li>Change in orbital volume (floor or zygoma) </li></ul><ul><ul><li>Enopthalmos or proptosis </li></ul></ul><ul><ul><li>Entrapment </li></ul></ul><ul><ul><li>The malar complex forms the majority of the lateral orbital wall </li></ul></ul>
  47. 57. Indications for Surgery <ul><li>Midface instability </li></ul><ul><li>Impingement on mandible excursion / malocclusion </li></ul><ul><li>Asymmetry </li></ul><ul><li>Diplopia > 2 weeks </li></ul><ul><li>Timing to repair </li></ul><ul><ul><li>Associated injuries stable </li></ul></ul><ul><ul><li>Facial edema subsided 7-10 days </li></ul></ul>
  48. 58. Operative Goals <ul><li>Proper exposure </li></ul><ul><li>Mobilization of fracture fragments </li></ul><ul><li>Correction of width, projection, height with adequate reduction </li></ul><ul><li>Utilize the facial buttresses </li></ul><ul><ul><li>The midface should be considered a dependent structure </li></ul></ul><ul><ul><li>Therefore build from known stability </li></ul></ul><ul><li>Always consider MMF - Manson </li></ul><ul><li>Soft tissue resuspension </li></ul>
  49. 59. Operative - Access Punctum
  50. 61. Operative – Access +/- <ul><li>Coronal – Access to superior orbital rim, zygomatic arch </li></ul><ul><ul><li>Alopecia improved with Stealth incision </li></ul></ul><ul><ul><li>Frontal branch of facial nerve </li></ul></ul><ul><li>Subciliary – 2-3 mm below lash line </li></ul><ul><ul><li>12% rate ectropion with skin muscle flap verses 3% with transconjunctival preseptal </li></ul></ul><ul><ul><ul><li>Appling, W. et. Al. Transconjunctival approach verses subcilliary skin muscle flap approach for orbital fracture repair. Arch Otolaryngol Head Neck Surg, 119(9): 1000-7, 1993. </li></ul></ul></ul><ul><li>Transconjunctival </li></ul><ul><ul><li>Preseptal dissection essential for visualization </li></ul></ul><ul><ul><li>Requires lateral canthotomy for optimal access </li></ul></ul><ul><ul><li>Canthopexy </li></ul></ul><ul><ul><li>May result in asymmetry in inexperienced hands </li></ul></ul>
  51. 62. Operative – Access +/- <ul><li>Subtarsal – 5-7mm below lash line </li></ul><ul><ul><li>More obvious scar </li></ul></ul><ul><ul><ul><li>Compared to subciliary </li></ul></ul></ul><ul><ul><ul><li>Rohrich, R. et. Al. Subciliary verses subtarsal approaches to orbitozygomatic fractures. PRS. 111(5); 1708-1714, 2003 </li></ul></ul></ul><ul><li>Buccal Sulcus </li></ul><ul><ul><li>Remember to leave cuff </li></ul></ul><ul><li>Traumatic lacerations </li></ul>Ectropion reduced 6.3% to 1.4% Scleral show reduced 18.8% to 4.4%
  52. 63. Operative - Reduction <ul><li>Correct reduction of fractures imperative to optimal outcome and stability </li></ul><ul><li>Aids in reduction </li></ul><ul><ul><li>Aggressive mobilization of the fracture fragment </li></ul></ul><ul><ul><li>Intraoral elevator or hook for reduction </li></ul></ul><ul><ul><li>Rowe Forceps may be used to disimpact maxilla </li></ul></ul><ul><ul><li>Carroll-Girard Screw placed in malar prominence. </li></ul></ul><ul><ul><ul><li>Used as a handle for reduction </li></ul></ul></ul>Hollier, L., et.al. The management of orbitozygomatic fractures. PRS. 117(7); 2386-2393, 2003.
  53. 64. Operative - Reduction
  54. 65. Operative - Reduction <ul><li>Determining proper reduction </li></ul><ul><ul><li>Visualized rim, ZF, ZM, Nasomaxillary buttress </li></ul></ul><ul><ul><li>Alignment of the zygoma with the greater wing of the sphenoid in the lateral orbit </li></ul></ul><ul><li>Three point fixation optimal </li></ul><ul><ul><li>If ZF suture stabile then 2 point adequate </li></ul></ul><ul><ul><li>Rigid fixation maintains bone graft position and volume in areas of high shear and torsion </li></ul></ul><ul><ul><li>Lin. K., et al. The effect of ridged fixation on the survival of onlay bone grafts: an experimental study. PRS. 86(3); 449-456,1990. </li></ul></ul>
  55. 66. Operative - Plates <ul><li>Infraorbital rim – </li></ul><ul><ul><li>High incidence palpable plate </li></ul></ul><ul><ul><li>Place on superior aspect of rim </li></ul></ul><ul><ul><li>1.0 to 1.5 plate </li></ul></ul><ul><li>Zygomaticofrontal – 1.0 mm plate </li></ul><ul><li>Nasomaxillary buttress – 1.0 to 1.5 mm plate </li></ul><ul><li>Zygomaticomaxillary buttress – </li></ul><ul><ul><li>Typically last plate applied </li></ul></ul><ul><ul><li>Should accommodate 1.5 or 2.0 mm. </li></ul></ul>Hollier, L., et.al. The management of orbitozygomatic fractures. PRS. 117(7); 2386-2393, 2003 .
  56. 67. Operative – Soft tissue <ul><li>Re-suspension of the cheek soft tissue critical to prevent asymmetry </li></ul><ul><ul><li>Two mechanisms of soft tissue malposition </li></ul></ul><ul><ul><li>Descent </li></ul></ul><ul><ul><ul><li>reattach soft tissue at malar eminence, orbital rim, and canthus </li></ul></ul></ul><ul><ul><li>Diastasis </li></ul></ul><ul><ul><ul><li>close muscle and periosteal layers prevents internal displacement of tissue layers </li></ul></ul></ul><ul><li>P-2 needle for lateral canthus reinsertion </li></ul>Philips, J. et. Al. A periosteal suspension of the lower eyelid and cheek following subcilliary exposure to facial fractures. PRS 88:145. 1991. Manson, P. et. Al. Subunit Principles for midface fractures: The importance of saggittal buttresses, soft tissue reductions, sequencing treatment of segmental fractures. PRS . 103(4); 1287-1307, 1999.
  57. 68. Post Operative - Caveats <ul><li>Remove scleral shield – “Details….details” </li></ul><ul><li>BSS to wash eyes </li></ul><ul><li>Forced Duction test </li></ul><ul><li>Erythromycin ophthalmic ointment </li></ul><ul><li>Visual acuity examination within 60 minutes post operative </li></ul><ul><li>Lacrilube twice daily </li></ul><ul><li>Wire cutters at bedside </li></ul><ul><li>Peridex swish and spit </li></ul><ul><li>+/- zygoma protection device </li></ul>
  58. 69. Complications Spinelli, H. Atlas of Eyelid and Periocular Surgery. Saunders. Philadelphia. 2004 <ul><li>Enopthalmos </li></ul><ul><ul><li>- Any increase in orbital volume will result in posterior displacement of the globe </li></ul></ul><ul><ul><li>5mm globe displacement noticeable </li></ul></ul><ul><ul><li>3-4% </li></ul></ul>
  59. 70. Complications <ul><li>Infraorbital Nerve Dysfunction </li></ul><ul><ul><li>Foramen a natural weak spot for fracture </li></ul></ul><ul><ul><li>Neuropraxic injuries common </li></ul></ul><ul><ul><li>Sensory usually returns </li></ul></ul><ul><ul><li>2.4 to 32% of midface fractures have alteration in cheek sensation, however length of follow up is limited </li></ul></ul><ul><ul><ul><li>McCoyF. Et al. An analysis of facial fractures and their complications. PRS. 29:381. 1962 </li></ul></ul></ul><ul><ul><li>Girotto, et al. Long term physical impairment and functional outcomes after complex facial fractures PRS 108(2)312-327 2000. </li></ul></ul><ul><ul><li>Afzellius reported a decrease is alterations from 37.5% to 4.3% from 9 months to 90 months post trauma. </li></ul></ul><ul><ul><li>Afzellius, L et.al. Facial fractures: A review of 368 cases. Int J Oral Surg. 9:25, 1980. </li></ul></ul>
  60. 71. Complications <ul><li>Diplopia </li></ul><ul><ul><li>Following surgical repair </li></ul></ul><ul><ul><ul><li>Inadequate release of initial incarceration </li></ul></ul></ul><ul><ul><ul><li>Reincarceration – possibly from floor implant </li></ul></ul></ul><ul><ul><ul><li>Adhesions </li></ul></ul></ul><ul><ul><ul><li>Neuropraxia </li></ul></ul></ul><ul><ul><li>Conflicting data concerning resolution over time </li></ul></ul><ul><ul><li>Initial 19-32% after one year 1.4-8% </li></ul></ul><ul><ul><ul><li>Al Qurainy, I. et al. Diplopia following midface fractures. Br. J Oral Maxillofac. Surg. 29:302. 1991 </li></ul></ul></ul><ul><ul><ul><li>Steidler, N. et al. Residual complications in patients with major middle third facial fractures. Int. J Oral Surg. 9: 259, 1980. </li></ul></ul></ul><ul><ul><li>Initial 23.16% yet no significant decline over time </li></ul></ul><ul><ul><li>Girotto, et al. Long term physical impairment and functional outcomes after complex facial fractures PRS 108(2)312-327 2000. </li></ul></ul><ul><ul><li>Persistence longer than 6 months </li></ul></ul><ul><ul><ul><li>Rebalancing of extraocular muscles </li></ul></ul></ul>
  61. 72. Complications <ul><li>Ectropion </li></ul><ul><ul><li>5.4% to 12% with subciliary </li></ul></ul><ul><ul><li>Zhong, L., Subciliary incision and lateral cantholysis in rigid internal fixation of zygomatic complex fractures. Chin J Traumatol. 7(3); 170-4, 2004. </li></ul></ul><ul><ul><li>If going transcutaneous </li></ul></ul><ul><ul><ul><li>Frost suture for 24-48 hours </li></ul></ul></ul><ul><ul><ul><li>Scar massage beginning 5 days post op </li></ul></ul></ul><ul><ul><ul><li>Subtarsal incision </li></ul></ul></ul><ul><ul><ul><li>Skin muscle flap </li></ul></ul></ul><ul><ul><li>Decreased incidence via transconjunctival approach </li></ul></ul>
  62. 73. Complications <ul><li>Plate complication </li></ul><ul><ul><li>Most common (35%) palpable plate at IO rim or ZF </li></ul></ul><ul><ul><li>Orringer, J. et al. Reasons for removal of ridgid internal fixation devices in craniofacial surgery. J Craniofac </li></ul></ul><ul><ul><li> Surg 9(1); 40-4, 1998 . </li></ul></ul><ul><ul><li>Pain, infection, loosening </li></ul></ul><ul><li>Blindness </li></ul><ul><ul><li>0.242% (1240 pts. 11 years) </li></ul></ul><ul><ul><li>Post op documentation of pupil reaction and visual acuity essential </li></ul></ul><ul><ul><li>~ 60 min before irreversible damage </li></ul></ul><ul><ul><li>Grotto, J.A. Manson,P. et al. Blindness after reduction or facial fractures. PRS: 102(6) 1998 pp 1821-1834 </li></ul></ul><ul><li>Others </li></ul><ul><ul><li>Asymmetry – inadequate 3D malar reduction </li></ul></ul><ul><ul><li>Infection <1% </li></ul></ul><ul><ul><li>Malunion/ Nonunion </li></ul></ul><ul><ul><li>Trismus/ Malocclution </li></ul></ul>
  63. 74. The Future <ul><li>Smaller access incisions </li></ul><ul><li>Endoscopic treatment fractures </li></ul><ul><li>Screwless fixation systems </li></ul><ul><li>Adult use of absorbable plating systems </li></ul><ul><li>Improved orbital floor implants </li></ul><ul><li>Improved diagnostic CT scanning </li></ul><ul><li>Improved outcomes </li></ul>

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