The basic principles of treatment of post-traumatic residual deformities include an initial major osseous reconstructive surgery to restore an anatomically correct craniofacial architecture followed by selective procedures to address soft tissue deficits and functional deformities

1. GOOD MORNING

2. Department Of Oral & Maxillofacial Surgery
Presented By:
DR. Samarth Johari
Residual Deformity Correction in
Maxillofacial Trauma

3. • Introduction
• Classification Of Craniomaxillofacial Deformities
• Etiology Of Traumatic Defects
• Soft Tissue Deformities & Their Correction
• Hard Tissue Deformities & Their Correction
• Conclusion
• References
CONTENTS

4. • For a variety of reasons, trauma patients can
experience unsuccessful initial management and the
associated morbidities of a post-traumatic craniofacial
deformity that would benefit from secondary
correction.
• Experienced surgeons recognize the challenge of
restoring premorbid form and function to patients with
established deformities after craniofacial trauma
INTRODUCTION

5. The factors that lead to persistent deformities after
craniofacial trauma include:
• severe comminution (especially that which requires bone
grafting)
• lack of definitive treatment
• excessively delayed initial treatment
• inadequate initial surgical repair

6. CLASSIFICATION OF
CRANIOMAXILLOFACIAL DEFORMITIES
• No uniform or universal classification exists
• May be with soft tissue defect or without soft tissue
defect Craniomaxillofacial
Deformities
On the basis of
anatomy or
mechanism of injury
Mandibular
Midfacial
Cranial
On the basis of
etiology
Low to
moderate
energy injuries
High energy
injuries
Ultra high
energy injuries

7. TYPESOF RESIDUAL DEFORMITIES
• Post traumatic scars
• Frontal Bone Fracture (Cranial deformities)
• Nasal deformities
• Naso – orbital deformities
• Zygomatic complex
• Malocclusion (maxilla and mandible)
Mid-facial Deformities

8. ETIOLOGY OF TRAUMATIC
DEFECTS
1. Injuries Due to Road Traffic Accidents:
• Caused when a victim will be dragged
by a moving object
• Even caused if a victim falls off a
moving vehicle and slides
• This causes the damage to the
overlying soft tissues
• Infrequently, the osseous tissues will
also be avulsed.

9. 2. Gunshot Injuries:
• Within 1 to 2 milliseconds after impact,
a pressure wave from air in front of the
missile distends the soft tissues up to
four times the diameter of the projectile
• projectile itself and the pressure wave
of the temporary cavity cause damage
to the muscle, bone, blood vessels,
and nerves. The muscles become
contused, necrotic, and colonized with
bacteria. The blood vessels are
crushed, ripped, displaced, or stretched

10. 3. Explosions:
• These patients initially sustain first degree burns from
ignited explosives
• A blast wave of compressed air will then throw the
patient through the air, which will create secondary
injuries due to the fall
• Finally, the patient will be injured by the direct contact of
exploded fragments

11. 3. Injuries due to animal bite:
• Bite injuries inflicted by the teeth of animals
• In addition, the fangs of the teeth can avulse large areas of
lip, cheek, scalp, the ears, or nose
• Animals such as dogs can bite with a force of 450 lbs/in &
their mouths are contaminated with a plethora of
microorganisms
• Thus, grossly contaminated crush injuries can cause regions
of soft tissue necrosis compromised with infection

13. 4. Occupational injuries:
• These are the tearing injuries caused by the blades of
industrial machines, and ragged shearing wounds
induced by machinery blades or saws can cause both
avulsive injuries and contaminated crush injuries
• If the injury is that of a high-energy impact, large
portions of soft and hard tissue will be avulsed & if that
of a crush injury, the vascular supply of the soft and
hard tissues will be so compressed that large areas of
bone and soft tissue will be rendered necrotic

14. • The blades of machinery or saws contaminated with
airborne or earthen microorganisms can produce
contaminated crush or soft tissue avulsive injuries just as
the bites of animals can
• The underlying osseous structures may be penetrated,
fractured, fragmented, or avulsed occasionally

15. 5. Deformities due to pathology:
• These are seen in cases of aggressive surgeries for
management of a pathology which require either soft
tissue reconstruction, hard tissue reconstruction or
both.
• Facial asymmetry is a common form of residual
deformity associated with post surgical defects in
pathology

17. Post Traumatic Scars
• Scars are areas of fibrous tissue (fibrosis) that replace
normal skin after injury
• A scar results from the biological process of wound
repair in the skin and other tissues of the body.
SOFT TISSUE DEFORMITIES &
THEIR CORRECTION

18. Assessment Of Existing Scar
Types of scars
• Good scar-
 a desirable scar should be incospicuous with the face at
rest as well as in the dynamic situation
 It should be flat, the same color, as the surrounding skin,
soft, narrow, and oriented in the same direction as the
resting skin tension line
• Bad scar- is raised or depressed, hyper- or hypo pigmented,
wide and crossing the resting skin tension line

19. • Depressed scar-
 runs perpendicular to
the resting skin tension
line as a result of wound
closure under tension
 Hematoma formation,
wound infection and
inverted wound closure
are the common causes
of a depressed scar

20. • Curved scar-
 healing of a curved scar will
produce contraction along the scar,
causing a purse string effect
resulting in a trapdoor appearance
• Stitch marks-
 tensionless suturing; subcutaneous
suturing; use of skin hooks rather
than forceps; fine sutures(7/0) and

21. • Step off deformities-
 result ofinaccurate epidermal closure.
 Dermal abrasion and resurfacing with the help of lasers.
 If the step is more than 1mm, resuturing is preferred
• Painful scar-
 entrapment of anerve ending in thescarresults in a
painful scar.If analgesics are noteffective the scar
should be re-explored and the nerve should be cut and
allowed to retract tothe muscle layer and sutured

22. Treatment Options
Simple excision
• elliptical fashion
• Peripherally to facilitate undermined
closure
• reapproximated with sufficient dermal
suturing to ensure wound-edge eversion
• adequate eversion will help prevent
formation of a depressed scar following
wound contracture during healing.

23.  Rearrangement Of Scar Line-
• A linear scar may fall naturally into an inconspicuous
situation such as the hairline or along a contour line
such as junction of cheek with nose or ear
• In more exposed situations a lengthy linear scar should
be avoided as it may catch the eye as it crosses natural
lines of expression or its contraction may cause
deformity of features such as the eyelid or mouth
• For such cases Z-plasty procedures should be done

24. • The classic Z plasty involves triangular transposition flaps to
lengthen a contracted scar or to reorient a scar parallel to the
resting skin tension lines
• The limbs of Z must be of equal length
• Increasing the angles between the limbs theoretically
increases gain in length
• The usual Z plasty angle is 60 degrees

25. • W-plasty is an excisional technique, which involves
breaking up the scar margins into small triangular
components, which are simply advanced without rotation or
transposition
• Often indicated for antitension line scars of the forehead,
eyebrows, temples, nose, cheeks and chin,
Loannis G., Ali H. Y., Rei O.,
W-plasty in Scar Revision
Geometrical Considerations
and Suggestions for Site-
specific Design Modifications
Plastic and Reconstructive
Surgery – Global Open: April
2019 - Volume 7 - Issue 4 - p
e2179

26. • Another popular scar contracture release technique
includes the Y-V advancement
• The design is based on its alphabetic configuration and is
ideally indicated to release scar band contractures
• Major advantages include the lack of undermining as in Z-
plasty techniques resulting in lower risk for flap ischemia
and the greater degree of lengthening achieved compared
with Z-plasty techniques
Loannis G., Ali H. Y., Rei O., W-plasty in Scar
Revision Geometrical Considerations and
Suggestions for Site-specific Design
Modifications Plastic and Reconstructive
Surgery – Global Open: April 2019 - Volume 7 -
Issue 4 - p e2179

27. Subcision
• management of depressed scars that may have resulted
from insufficient wound-edge eversion or excessive scar
contraction during healing.
• circumferential insertion of a hypodermic needle into a
depressed scar, followed by a gentle lifting maneuver to
elevate the overlying epidermal tissue from the underlying
dermis.
• pain, swelling, bruising, hyperpigmentation, and hematoma
formation can occur if the procedure is carried out too vigorously
or if needle penetration traverses too deeply

28. Preoperative anterior and bird’s-eye views. (C,D)Thesameviews showing
improvement in the early postoperativestage

29. Dermabrasion
• involves sanding of the scar using a high-speed rotary device.
• It is performed down to the level of the papillary dermis, which is
recognized by looking for pinpoint bleeders.
• When dermabrading a raised scar, pinpoint bleeding occurs
almost instantaneously; therefore, care must be taken
when performing this procedure.
• treating raised scars as well as atrophic or pitted scars acne pits
• Dermabrasion in dark-skinned individuals can cause
significant dyspigmentation that may be permanent.

30. AIKhawam L.; Alam M.; Dermabrasion and Microdermabrasion; FACIAL
PLASTIC SURGERY/VOLUME 25, NUMBER 5 2009

31. AIKhawam L.; Alam M.; Dermabrasion and Microdermabrasion; FACIAL
PLASTIC SURGERY/VOLUME 25, NUMBER 5 2009

33. Laser resurfacing
• Carbon dioxide ultrapulse laser remains the gold standard.
• Laser resurfacing effectively removes the entire epidermis
and upper dermis and can stimulate significant neocollagen
formation.
• Laser resurfacing is indicated in flat scars

34. Ectropion
• an eversion or outward turning of the eyelid margin
• may be classified as congenital, involutional, paralytic,
cicatricial, or mechanical
Involutional Ectropion- caused by horizontal eyelid laxity of
the medial and/or lateral canthal tendons
Cicatricial Ectropion- caused by shortening of the anterior
and/or middle lamella
Paralytic Ectropion- caused by CN VII paralysis or palsy
resulting in loss of orbicularis muscle tone
Mechanical Ectropion- caused by gravity, mass effect of a
tumor, fluid accumulation, herniated orbital fat, or poorly fitted
spectacles
Bergstrom R, Czyz CN. Ectropion Lower Eyelid Reconstruction. StatPearls. Treasure Island (FL): StatPearls Publishing;
2019 Jan

35. • Ectropion of lower eyelid may
result from scarring in which
there has been minimal tissue
loss but correction of deformity
is rarely possible without
tissue.
• Post- auricular Wolfe Graft
gives excellent functional &
cosmetic result

36. volume-restorative techniques include
• adjacent transfer of tissue
• free transfer of tissue
• prosthetic or alloplastic volumereplacement
Post-traumatic facial soft-tissue volume deficiency

37. Local Rotational And Advancement Flaps
• Local flaps may be vascularized by specific vessels
• In general, the thickness and quality of the tissue adjacent to an
avulsed defect is similar to that of the missing tissue
• The lips and oral aperture are another location amenable to this
type of treatment when tissue is avulsed or necessarily
surgically debrided early on.
• In some cases, for example with cheek defects, a facial
artery musculomucosal flap may be indicated.

38. Free Tissue Transfer
• When viable tissue is needed and local tissue is insufficient, not
indicated, or undesirable, free tissue may often restore volume
and structure in alastingway.
• such asin radial forearm flaps for lipreconstruction
• these techniques restores form andfunction

39. Full-Thickness Skin Grafting
• Grafting of free tissue may also take the form of full-thickness
skin grafts and fat grafting.
• Fullthickness skin grafting provides a good match for soft-tissue
tone, quality, and thickness.
• For skin replacement, if rotational flaps are not available
or provide incomplete coverage, a skin graft may be
obtained.
• Excellent graft may be obtained from the preauricular and
postauricular areas in many individuals.

40. Structural Fat Transfer
• Intermediate level soft tissue volume may be regained via
fat transfer
• Effective means of adding bulk to atrophied areas as
well as smoothing out irregularities.
• It may be used in conjunction with subcision of depressed
scars or in recontouring larger defects, such as temporal
hollowing

42. Complications of structural fat grafting
• Overcorrection
• Undercorrection
• surface irregularity
• graft migration
• infection.

43. Soft-Tissue Fillers
• Examles -nonanimal stabilized hyaluronic acids, such as
Restylane and Juvederm.
• improve the appearance of scars
• sterile, and can be injected at various levels in the dermis and
subdermal level for the desired effect.
• Surgeons should consider these materials as adjuncts available
for use when contemplating minor revisional procedures

44. A) Frontal scarthat became depressed after healing. Treatment
was injection of hyaluronic acid(B).
44

45. Botulinum Toxin
• Main aim is to to create temporary symmetry while awaiting the
possible return of nerve function
• Botulinum neurotoxin causes a muscle paralysis lasting for
approximately 3 months which causes the muscles of the
unaffected side appear similar to that of affected site by
paralyzing them
Clark P. R., Berris E. C.; Botulinum toxin: a treatment of facial asymmetry caused by
facial nerve paralysis; Journal of American society of plastic surgeons; 1989;84;2

46. Hair Transplant
• In order to camouflage scar, hair transplant is done
• Transplantation is done even in the scar line

47. Alloplastic And Prosthetic Reconstruction Of Soft-
tissue Defects
Auricular prosthesis used for reconstruction following traumatically avulsedear.
Theprosthesis is retained by 2 craniofacial implants

48. • titanium mesh
• porous polyethylene (ie, Medpor)
• PEEK (poly ether ether ketone)
• implants such as Medpor, silicone, and PEEK may be
custom- modeled from computed tomography scans to
match the patient’s individual bony contours and
provide a facial profile mirroring the contralateral side.

50. • Frontal bone deformities &
their correction
• Naso-orbito-ethmoid
fractures
• Orbitozygomatic fractures
• Orbital fractures
• Post traumatic malocclusion
• Maxillary deformities
• Mandibular deformities
HARD TISSUE DEFORMITIES &
THEIR CORRECTION

51. Frontal Bone Deformities & Complications
• constitute approximately 8% of all facial fractures
• Many of these fractures are open injuries with breach of skin
externally and often communicate with sinuses
• predisposed to both contamination and sinus infection and
obstruction

52. • Involvement of frontal recess
Causes sinus obstruction & mucocoele formation
Management:
remove frontal sinus mucosa meticulously from
walls of sinus & bone before replacing them
frontonasal duct area should be cleaned of
mucosa & obliterated bilaterally with autogenous tissue
This is done to prevent infection from nasal cavities

54. • Involvement posterior wall
Causes CSF Leak
Management:
cranialisation of sinus after removal of all sinus
mucosa & obliteration of nasofrontal duct area
To prevent infection from nasal cavity,
pericranial/frontogaleal flap is used in area of anterior
skull base defect
In case of infection
local drainage & antibiotics should be started
CSF fistula requires dural closure with facia lata
reinforcement

55. Figure 1: Upper row: Appearance 6 months after depressed fractures frontal bone
and bone loss along with saddle nose deformity. Patient had cerebrospinal fluid leak
for 2 weeks and globe injury also. The eye has been enucleated. Lower row:
Reconstruction of frontal bone defect with cranial bone graft along with saddle nose
correction with a cantilever bone graft. The contracted eye socket was released and
an ocular prosthesis was inserted

56. • Cosmetic
deformity with
depressed
frontal bone
fractures
Management:
camouflage
surgery using a
combination of
autogenous, bone
hydroxyapetite
Figure 2: Contour deformity following
depressed fracture frontal bone (upper row).
Camouflage done with a combination of
hydroxyapatite cement and split cranial
bone grafts (lower row)

57. Naso-Orbito-Ethmoid Fractures
• Majority of the complications occur as a result of:
 Failure to make accurate diagnosis
 Inadequate exposure
 Incomplete reduction and stabilization
 Unsatisfactory positioning of medial canthus
 Loss of fixation of canthi
 Loss of nasal lining

58. • In most nasoethmoidal fractures, the canthus
remains attached to a relatively large bony fragment
of medial orbital rim
• Adequate repositioning of this ‘central fragment’ is
key to accurate positioning of medial canthus & if
the segment is large enough with stable
surrounding bony structures; plate and screw
fixation is usually sufficient

59. • If canthal ligament is partially or completely
stripped or the canthus bearing segment is
communited
canthus should be re-attached to a site
and superior to lacrimal fossa after bone reduction
and fixation is complete
to avoid splaying of posterior aspect of frontal process
of maxilla which can create telecanthus
Reduction & fixation of medial canthus is done by
transnasal wiring

60. Figure 3: Method of canthopexy using a two hole plate (upper row). The steps
of canthopexy (middle and lower row). Mustardee’s dancing man flap has also
been done for correcting the epicanthal fold

61. • In nasoethmoidal fractures with extensive
communition
improvement of nasal height and contour requires
placement of bone graft over re-assembled nasal
framework
Splintage of soft- tissue over reconstructed
area during healing phase further improves the contour
• In fractures treated late
extensive stripping is required to free the bony
fragments from scar tissue to accomplish reduction
followed by dorsal nasal bone grafts for adequate
nasal height and projection

62. Figure 5: Late neglected case of nasoethmoid fracture with gross contour
deformity and saddle nose (upper 2 rows). He underwent onlay bone grafting
for contour correction and a cantilever bone grafting for the saddle nose
deformity correction (lower two rows)

63. Orbitozygomatic Fracture
• Zygomatic mal-position after treatment is related to
failure to achieve reduction at all the buttresses usually
secondary to incomplete exposure
• Common deformities encountered following zygomatic
bone reduction:
 Lack of projection of malar eminence
 Residual rotational deformity
 Lower positioning of orbital rim leading to increase
in orbital volume and enophthalmos

64.  lack of projection of malar eminence
Occurs if zygoma is not tipped up at the time of
fracture reduction and maintained in that position
while plate fixation is being applied
Fig.: Carrol Girard Screw Fig.: Bone Hook

65. Management of facial symmetry
restore 3-D position of malar prominence
 Residual rotational deformity
Occurs if displacement is at zygomaticosphenoid
surface
 Lower positioning of orbital rim leading to
increase in orbital volume and enophthalmos
restored by
alignment of the zygoma with the sphenoid

66. NOTE
The displaced naso-orbito-ethmoid should
always be addressed before the final
reduction of the zygoma
 palpability of plates
Due to thin overlying skin at inferior orbital rim and
frontozygomatic suture
can be minimised by using low profile 1.5 mm
plates
at these sites

67. Orbital Fracture
• most common indication for surgery is a large floor
defect usually >1 cm2
• Surgical exposure can be achieved by:
 subciliary or transconjunctival incision with
lateral canthotomy
Associated with higher incidence of lid retraction
 trans-caruncular incision – for medial wall
component of orbital fracture
 subtarsal incision - has the advantage of avoiding
lid retraction but the scar is more obvious

70. Management of the defect:
• Place elevator into defect
• Elevate prolapsed periorbita in an upward
sweeping motion (to prevent damage to
extraocular muscles)
• place the periosteal elevator straight back and
contact the posterior wall of the maxillary sinus,
then slide the elevator superiorly until the under
surface of the intact orbital floor is reached
• slide the elevator anteriorly, to identify the
location of the posterior edge of the defect
• After defining the defect, implant or grafts can
used

71. Figure 7: Extensive injury to the orbit resulting in total disorganization of orbit
and loss of eye (upper row). All the orbital walls need reconstruction. Contoured
cranial bone grafts are planned to be harvested (middle row). The contracted
eye socket was released and an ocular prosthesis was placed (lower row)

72. Post Traumatic Malocclusion
• It is present following malunion of any fracture that
directly or indirectly involves the alveolar segments of
the maxilla or mandible.
• The introduction of ORIF makes direct anatomical
segment reduction the primary aim.
• If this is achieved, a normal occlusion should
automatically follow.
• Infection of mandibular fractures, particularly those
involving the tooth-bearing segment of the mandible or
angle, may result in non-union, malunion and segment
displacement with malocclusion.

73. Maxillary Deformities
Indications
• In order to correct occlusal abnormalities due to maxillary
malunion, Le Fort I osteotomy is indicated.
• Osteotomy at Le Fort II or III level, or variations of these
procedures tailored to the individual needs of the patient,
may be required in some instances where simultaneous
correction of midface deformity is necessary.
• Le Fort I osteotomy is therefore indicated for most cases of
maxillary occlusal abnormality, when segmental or one-piece
maxillary repositioning is necessary
.

74. • Once the correct maxillary position is established, any
significant bony gaps or deficiencies are bone grafted.
• These insure union, stability and support for the overlying
soft tissues of the cheek.
• the use of bone grafts in Le Fort I osteotomies to correct
posttraumatic occlusion is uncommon due to the relatively
small movements involved

75. Mandibular Deformities
• Malunion of fractures behind the tooth-bearing segment
of the mandible result in displacement of the whole
dentoalveolar arch.
• Severe condylar malposition with dislocation allows
vertical shortening of the ascending ramus and this may
be associated with restricted mouth opening or
deviation on opening due to mechanical disruption of
the temporomandibular joint.

77. Unilateral condylar malunion
• The aim of treatment in unilateral cases is to restore
the pretraumatic ramus height and correct posterior
mandibular displacement if present.
• This corrects the occlusal plane cant and restores a normal
occlusion
• an osteotomy at the site of the original fracture, repositioning
and if necessary interpositional bone grafting to maintain
lengthening of the ramus
• a ramus osteotomy distant from the fracture site

78. Bilateral condylar malunion
• results in anterior open bite and class II jaw relationship.
• The correction is achieved by adjusting the maxilla to
accommodate this reduced posterior face height by
carrying out a posterior maxillary impaction.
• This results in an increase of the occlusal plane
angle, but this is of little significance and will result in
a stable correction of the anterior open bite
component of the deformity, as a consequence of
mandibular autorotation.

79. • Careful preoperative assessment, establishment of
reasonable reconstructive goals and detailed surgical
planning at the time of primary procedures can prevent the
occurrence of the secondary/residual deformities
• The basic principles of treatment of post-traumatic residual
deformities include an initial major osseous reconstructive
surgery to restore an anatomically correct craniofacial
architecture followed by selective procedures to address
soft tissue deficits and functional deformities.
CONCLUSION

80. • Rowe and Williams’ Maxillofacial Injuries 2nd edition
• Richard H. et al; etiology, distribution & classification of
craniomaxillofacial deformities: traumatic defects
• Parashar A., Sharma R. K; unfavourable outcomes in maxillofacial
injuries: how to avoid and manage
• Mario J. et al; the secondary correction of post traumatic craniofacial
deformities
• K. Ranganath, H. R. Hemanth Kumar; The Correction of Post-
Traumatic Pan Facial Residual Deformity- K.
• Bergstrom R, Czyz CN; Ectropion Lower Eyelid reconstruction.
StatPearls. Treasure Island (FL): StatPearls Publishing; 2019 Jan
• Loannis G., Ali H. Y., Rei O., W-plasty in Scar Revision Geometrical
Considerations and Suggestions for Site-specific Design
Modifications Plastic and Reconstructive Surgery – Global Open:
April 2019 - Volume 7 - Issue 4 - p e2179
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