Dr. Nikil Jain discusses nasal deformities resulting from trauma and their surgical correction. Nasal fractures can cause deviations of the nasal bridge and septum. Repositioning requires an intranasal approach to mobilize the septal cartilage and reduce displaced bone through osteotomies and chondrotomies. The nasal skeleton must be precisely realigned and immobilized internally and externally until healing is complete to avoid relapse of the deformity.

1. Dr. Nikil Jain
Residual Deformity

2. Introduction
 For a variety of reasons, trauma patients
can experience unsuccessful initial
management and the associated
morbidities of a post-traumatic
craniofacial deformity (PTCD) that would
benefit from secondary correction.
 Experienced surgeons recognize the
challenge of restoring premorbid form
and function to patients with established

3. Soft tissue deformity
 Resulting from facial injuries
 For repair that problem can classified :
1)Without tissue loss
2)With tissue loss
In some cases there will some overlap and both kinds
of problem will exist side by side

4. Without tissue loss
 Scar –
 Scar excisions –
 Abrrasions

5. Scar
 Definition of scar:
 The trace of a healed wound , sore or burn. A fault or
blemish remaining as a trace of some former
condition or resulting from some particular cause.
(oxford english dictionary)
 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. Thus, scarring is a natural
part of the healing process. With the exception of very
minor lesions, every wound (e.g.
after accident,disease, or surgery) results in some
degree of scarring. An exception to this is animals
with regeneration, which do not form scars and the

6. Characteristics
 Scar usually red immediately following wound healing
considered an immature scar
 It may become hard and nonpliable
 May develop bands of fibres on or below the surface
that feel like a cord or rubber band on pressure with
finger
 May be pain full ,itchy or sensitive
 A contracture or tightness /shortening of the skin may
developes as scar heals .this is especially
characteristics of scars across joints and may limit joint

7.  The scar may become raised over the skin surface
as body produces an abundance of collagen the
substance found an abundance of collagen, the
substance found in scar tissue.
 This type of raise scar termed Hypertrophic scar
which is thick ,rough and irregular
 These scar produced in large and deeper wounds
that require skin grafting and wounds that are
delayed in healing
 Hypertrophic scar that are considerably larger than
the original wound known as Keloid

8. Scar types
1. Immature scar : A red, sometimes itchy or
painful and slightly elevated scar in the process
of remodeling. Many of these will mature
normally over time and become flat and assume
a pigmentation that is similar to surrounding
skin, although they can be paler or slightly
darker

9. 2. Mature scar : a light colored , flat scar
3. Linear hypetrophic : (surgical or traumatic scar)-
a red raised, sometimes itchy scar.
 Confined to the border of original surgical
incision.
 This usually occurs within weeks after
surgery.
 These scars may increase in size rapidly for
3 to 6 months and then after a static phase
begin to regress
 They mature to have an elevated, slightly

10. 4. Widespread hypertrophic : eg burn scar
A wide spread, red, raised, sometimes itchy scar
Confined to the border of burn injury
5. Minor keloid : a focally raised itchy scar extending
over normal tissue
 This may develop upto 1 yr after injury and does not
regress on its own
 Simple surgical excision is often followed by
recurrence
 There may be a genetic abnormality involved in keloid
scarring
 Typical site includes earlobes

11. 6. Major keloid : a large raised (>0.5 cm) scar
 Possibly painful or pruritic and extending
over normal tissue
 This often results after minor trauma and
 can continue to spread for years

15. Scar excision
 It must be made clear to the patient that it is quite
impossible to remove a scar.
 All that can be done is to replace the existing scar
with a new one which is hoped to be of better
quality
 A broad scar can be reduced in width but should
be supported with narrow adhesive tape
(Steristrips) for several weeks to minimise
stretching
 Even then the scar is likely to broaden again in an

16. Rearrangement of scar line
 A linear scar may fall naturally into an
inconspicious 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

17. Scar revision : Face
 The most common technique for scar revision is
fusiform excision
 The length of the elliptical shape is 3 to 4 times as
long as it is wide to prevent dog ears
 Short, linear and minimally wide scars of the face
generally do well with such revision

18.  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

20.  Z plasty scar revision of the face following
traumatic defects is indicated in treatment of :
1. Anti tension line scars of the eyelids, lips
and nasolabial folds
2. Scars on the forehead, temples, nose,
cheeks and chin, running at less than 35
degrees of inclination to the resting skin
tension lines
3. Severe trapdoor and depressed scars,
linear scars not amenable to simple
excision and areas of multiple scarring

21.  W plasties are often indicated for antitension line
scars of the forehead, eyebrows, temples, nose,
cheeks and chin
 The running Y-V plasty has also been described
to to help break up the direction of linear scars

22. With tissue loss
1) Minor tissue loss
2) Substantial loss of tissue

23. Minor tissue loss
 Facial skin is the most suitable, both in colour
and texture, for repairing defects which are not
too extensive
 Local flaps are given first consideration where
possible
 Skin bordering the defect is raised and rotated
into the defect, care should be taken to place
the scar of the secondary defect in a
favourable position
 Split skin grafts are not usually acceptable in
the repair of small areas of facial skin loss,
although necessary in replacing large areas of

24. Substantial tissue loss
 Gunshot wounds account for majority of
injuries of this nature
 There soft tissue loss and often associated
skeletal damage
 Flaps used for repairing outer wall of a
cavity (antrum, orbit, mouth and nose) must
have a provision of lining raw under surface
which could lead to stenosis

25.  A great degree of flexibility in case of cheek
flap may be obtained by using a double flap.
i.e.one where both the outer and inner
aspects are composed of full thickness skin
and subcutaneous tissue
 By using flaps whose component parts have
never been detached from the bloodstream,
fibrosis can be reduced
 With lip defects it is possible to lose up to one
third of tissue with only a moderate secondary
deformity following resuture

26.  Palate :
Substantial loss of tissue can be from hard
palate, soft palate or both
The hard palate defects are preferably
closed with an obturator
 In case of soft palate additional tissue
must be obtained from elsewhere

27. In larger defects a myofascial temporalis
flap may be rotated downwards following
resection of zygomatic arch and passed
through a mucosal tunnel to enter the oral
cavity (Bowerman 1983)

28. Bone grafts
 Bone graft in maxillofacial surgery are used to
correct or replace missing bone.
 Bone defect can be
 Consequence of congenital and developmental
deformities
 Originate from tumour surgery, trauma or
infection

29.  Types of graft
 Auto graft transplanted from one region to another in
same individuals.
 Allograft (Homograft) – is transplated from one individual
to a genetically non identical individual of same species.
 Xenograft (Heteorgraft) – transplant from one species to
another species.]
 Isograft – graft exchanged between genetically identical
individual such as identical things.

30.  Anatomical Classification of Bone graft
1.Cortical bone (as block, chip)
2.Cancellous bone
3.Cortico cancellous bone
4.Periosteal and osteoperiosteal graft
5.Marrow graft
6.Segment of shaft of long bone such as clavicle, ribs,
scapula or tibia.
7. Whole bone graft
8.Osteoarticular graft
9.Pedicle bone graft
10.Free vascularized bone graft involving microvascular
ananstomosis.

31.  Clinical uses and function of bone graft
 Delayed and nonunion of fracture
 Filling of cavities in bone
 Replacement of bone and joint loss
 Augmentation of skeletal deficiency in the
forehead, nose, maxilla and mandible.
 Fusion of growth graft cartilage
Function of bone graft in mandible
 Restore normal continuity and function
 Restore an overall satisfactory appearance of
face

32.  Principles of Bone graft
 State of health and nutrition of patient
 Aseptic technique – surgical techniques
should be extra oral to prevent contamination of
oral flora.
 Graft Bed - tissue scar from previous wound
should be excises to ensure quality and quantity of
recipient site.
 Handling of the graft – graft must be handled
carefully to prevent contamination and mechanical

33. Storage media – isotonic normal saline, tissue
culture medium. Osteoprogenitor cells are
hardly capable of withstanding the trauma of
removal upto 4 hours.
 Fixation and immobilization of the graft
 Wound Closure -Wound should be closed in
layers without tension.
 Antibiotic Coverage

34. BIOLOGIC BASIS OF BONY GRAFT
 Most effective form of bone grafting is
cancellous cellular bone. Mechanism of bone
formation in a cancellous cellular bone
emanate from survival of the osteoprogenitor
cells (osteoblst & marrow cells).
 Transplanted osteoprogenitor cells
survive within the recipient tissue for first 3-4
days by a nutritional diffusion from the
surrounding vascular tissue envelop.

35.  From 3rd day – capillary buds start
proliferation from surrounding tissue. This
establish oxygen gradient and acidosis,
lactate in the graft signals macrophages to
form macrophage derived angiogenesis factor.
 Between 3rd and 14th day – complete
revascularization occur. Endosteal osteoblast
survive transplant and proliferate neoosteoid
upon the surface of the cancellous bone
trabeculae.

36.  Mineral component undergoes a gradual
physiologic resorption mediated by osteoclast.
Osteoclasts resorbs the bony trabeculae pattern,
they release bone morphogenetic protein (BMP)
from non-collagenase mineral matrix of bone.
 BMP direct stem cells transferred within the
graft, stem cell within the local tissue and
circulatory stem cells to differentiate into
functional bone forming cell.

37. Phase I Bone formation
 It arise from the survival endosteal osteoblast and
marrow stem cells transferred within the graft material
which form bone in a random haphazard fashion.
Phase II Bone formation
 The revascularization dependent resorption of
transplated bone trabeculae in the early phase I bone
followed by remodeling and replacement with new bone.
 Phase II Bone begins about the third week after
placement of graft. Via endosteum and periosteum of
bone.

38.  Importance of phase I bone arise from the
knowledge that the maximum quantity of bone
available to the graft is formed in this phase.
 The importance of phase II bone is remodeling
of phase I bone to a long lasting bone capable of self
renewal.
 Usually phase II bone replaces phase I bone in
a one to one ratio.

39. Deformities
 Nasal
 Naso – orbital
 Naso –frontal
 Naso - frontal – ethmoidal
 Zygomatic
 Maxilla
 Mandible

40. Anatomy of nose

41. Nasal Deformities (dorsum)
 In this group injury involves only nasal bridge and
lateral walls of the nasal cavity
 Pathogenesis : the fracture here involves 1) nasal
bones (2)frontal process of maxilla (3) septal
cartilage
 A force directed from lateral aspect will result in a
deviation of the nasal pyramid (bridge and lateral wall)
to the opposite side
 An impact directed in antero posterior plane will cause
a depression of nasal bridge associated with crushing

42.  It is essential to treat not only the aesthetically
unacceptable external deformity but also the
internal displacement which interferes with
function
 The repositioning of external nasal bony pyramid
or ‘porch’ must be accompanied by repositioning
of cartilaginous and bony septum ( otherwise
deviation of latter is liable to cause a relapse of
the deformity , owing to its inherent elasticity or
resilience)

43. Nasal deviation
 Requires the fragment to be freed and
repositioned
 Intra nasal approach to avoid all external
cutaneous scar
 Sepration of bony and cartilaginious
components of nasal skeleton from their
investing soft tissue
 Chondrotomy for the mobilization of septal
cartilage
 Osteotomy to reduce the displacement of the

44. Surgical approach
 It is intranasal
 Corresponds to classic incisions
employed for aesthetic rhinoplasty
 In each nasal vestibule the mucosa is
incised at a point corresponding to the
groove between the upper margin of
the alar cartilage and lower margin of
upper nasal or triangular cartilage
 Incision is carried from behind
forwards and upwards across the roof
of vestibule where it is reflected
downwards, passing from before

45. Dissection
 It consists of freeing or seperating the external
investing tissues and elevating the mucous
membrane which lines the nasal fossa
1. the liberation of underlying soft tissues is effected
through the intra nasal incisions
2. Initially perichondrium is raised from triangular
upper nasal cartilage
3. Then at the level of piriform aperture periosteum is
incised to carry out subperiosteal dissection upto
frontonasal angle

46.  The mucosa is freed at the dihedral angle (
formed at junction of medial and lateral
components )

47. Chondrotomies
 Performed at inferior and anterior margins of the
cartilage and also in the region of folds resulting
from buckling of the septum
1. Along the lower border the nasal septum is
freed from the nasal crest of maxillae
 It is more a matter of disimpaction rather than a
true chondrotomy

49. 2. At the anterior border chondrotomies are
performed bilaterally seperating on each side the
septal cartilage from the upper nasal cartilage .

50. Osteotomies
 These are performed laterally at the base of each
side the nasal pyramid and medially on each side
of nasal crest or bridge
 Lateral osteotomies: a small incision made at the
edge of piriform fossa, close to the floor of the
nasal cavity, allows the soft tissues covering the
frontal process of maxilla to be elevated from the
bone
 the osteotomy commences at the rim of the
base of piriform aperture and terminates above

52.  Median osteotomies: these separate the nasal
bones from the osseous part of the nasal septum

53. Immobilisation
 Before suturing it is essential to the perfect alignment
of nasal crest both in median sagittal plane and also
with regard to the profile
 Immobilisation is ensured both externally and
internally by means of a double procedure
 External device, of plaster of paris, holds the nasal
crest as well as the lateral walls of the nose in a
straight line in the median vertical plane to achieve
perfect symmetry
 Internal device is an intranasal pack or stent which
maintains the septum in a strictly midline position and
ensures that the dimesnsions of nasal passages are
identical

54. Depression of the nose
1. Total depression
2. Depression of lower half of nasal
crest

55. Total depression
 When the deformity is due to depression of
the dorsum of the nose along its entire
length, it is simple, more rapid and more
certain to insert a bone graft
 Best type of material is autogenous bone
graft
 Procedure is divided into :
A) Surgical approach
B) Preparation of bony bed
C) Removal of graft from donor site

57. Surgical approaches:
 Intranasal route, the classic technique employed
for rhinoplasty
 A vertical columella incision
 A combined incision shaped like ‘yoke of an ox’

59. Preparation of bony bed:
 The bone is freshened the upper half of
depressed nasal crest in the region of bridge is
levelled
 It is done by use of a raspatory

60. Removing the bone graft:
 Opttimum donor site is iliac crest
 Triangular in cross section
 Forming the future roof of the crest
 Cortical on the anterior surface and cancellous on
the undersurface or base

61. Fixation :
 It must be firm to maintain
perfectly in the median
plane, vertical and
sagittal planes the
position achieved
following reconstruction
 It is achieved by 3 factors
1. Mortise and tenon
joint above
2. The osteosynthesis
3. The support below

62.  Mortise and tenon joint is assured by mortise slot or
atleast by a transverse retentive groove in anteroposterior
plane
 The osteosynthesis is carried out by means of a nasal
transfixion
 The support at the lower end is derived from the septum
upon which the graft rests

63. Depression of lower half of nasal
crest
 2 different concepts for correction of this particular
deformity:
1. Resection of the upper half of nasal crest
in this way the width of the upper half of the crest
increases and to correct this lateral osteotomy of
lateral walls to bring the sectioned edges of nasal
crest together
2. In selected cases a cartilage graft, taken at the
expense of the septum, provides a simple solution
to the problem

65. Naso – Orbital deformity
 Extreme severity of impact received by the
nasal complex
 To involve the frontal process of maxillae
and the two orbital plates of ethmoid bone
 Comparatively small area,complexity of its
osseous structure,variety of displacements
make impossible to classify

66.  3 essential anatomical factor specific to
and characterstic of frontal process:
1)They determine the morphology of base of
nasal pyramid and orbito nasal angle
2)They form the anterior part of the lacrimal
fossa
3)They provide a point of insertion for medial
palpebral ligament in the region of anterior

67.  Ethmoid bone participates in the
formation of lacrimal canal on its lateral
aspect
 It is continued posteriorly as the orbital
plate which forms the medial wall of the
orbit
 It contributes to the formation of
posterior part of the nasal septum

68.  If untreated or inadequately treated NOE
injury not only leads to residual deformity
to nasal crest but equally to:
 Orbito nasal angle
 Dystophy to medial canthus
 Alteration to continuity of lacrimal passage
 Reduction in the patency of nasal airway

69. Clinical features
 Nasal crest may be deviated or depressed
 There will be either lateral displacement or an
anteroposterior crusshing of nasal bone
 Orbital – nasal angle reduced or obliterated
 Widening of bridge of the nose either due to
displacement of frontal process of maxilla
outward and backwards or due to exuberant
callus produced by malunion
 Medial canthus deviation
 Lacrimal passage may be torn
 Patency of nasal airway altered

70.  Basic Principles for treatment:
 The nasal porch or pyramid can not be
effectively reconstituted if not supported on a
solid bone
 Reconstruction can not be aestheticaly
acceptable if the revision of the base or
foundation is not itself smooth,regular and
well proportioned
 Shape of nose can not be satisfactory if two

71.  Medial canthal ligament prevents surgical access to the
lacrimal passage ,if an approach to these structures is
necessary the insertion of ligament must be divided and
subsequently reattached
 An infection in region of lacrimal passage will have an
adverse effect on healing and compromise the quality of
repair,so appropriate prophylactic measures essential
 Relatively small amount of tissue in the region of naso-
orbital angle makes it very difficult to carry out a
repeated number of operations without incurring the risk
of beneficial effect of preceding interventions
 How ever deviated a septum may be ,it may still
provide a sound support for a nasal reconstruction

72. Reconstruction of nasal base and orbito
nasal angle
Resection –
 Comminuted fracture produces excess amount of
callus which thickens and widens the nasal bridge
and nasal base
 Reduced by rotating bone file mounted in the
handpiece of dental drill
 Thin down the area to an acceptable contour
 Maintain sufficient degree of solidity to support the
nose and retain the ligatures used for canthoprexy

73.  Osteotomy –
 Frontal process of maxillae displaced,but fracture is a
single isolated fragment of adequate width,logical to
consider repositional osteotomy
 Taking care to avoid injury to nasal mucosa on internal
aspect
 After osteotomy necessary to to carry out
osteosynthesis for fixation of fragments and to insert a
bone graft into gap created by the reduction of
displacement

74.  Holes drilled for passage of wire should not weakens
the strength of bone at opening for transnasal
canthprexy
 Take care that bone graft does not became a factor
producing thikness of lateral nasal wall or medial
part of inferior orbital margin

76. Bone graft
 callus associated with
malunion at naso orbital
angle is too thin to permit
abrasion
 And existence of many
multiple fragments makes it
impossible to divide these
by osteotomy
 So a complete resection of
affected area should be
carried out and then to
reconstitute this
immediately by means of
bone graft

77. Canthopexy
 Whether it has been cut across, avulsed or
displaced with the frontal process, the medial
palpebral ligament must be reinserted or
repositioned
 Technique by Tessier et al 1962

78. Identification of ligament
 Introduce a small curved hemostat into the medial
angle of conjunctival fornix
 After having been located the ligament is
transfixed with 2 stainless steel wires
 Localisation of medial ligament has correctly
achieved if traction exerted on wires draws the
canthus in desired direction
 This mobilisation requires liberation of periorbital
tissues

81. Liberation of periorbital tissues
 Requires subperiosteal dissection of lower and
internal surface of orbit
 Inferior oblique muscle will also be released from its
bony margin during operation
 This stage is complete when medial canthus can be
mobilised easily
 Further impediment to this mobilisation may occur as
result of dense scar tissue in region of lacrimal
passages

82. Liberation of lacrimal pathways
 Ligament first should be seperated from lacrimal sac
 Assistance may be derived from introduction of a fine
lacrimal sound passed through the lacrimal canals
 Free any adhesions of lacrimal pathways which are
causing retraction of the tissues
 Dissection must be pursued as far as nasolacrimal
canal

83. Nasal transfixion
 This may be achieved by a special awl using hand
pressure or with a bur driven by an electric motor
 The position and direction of holes are of cardinal
importance for precise alignment of canthopexy
 On the opposite lateral nasal wall the drill hole is
made at level of anterior lacrimal crest and in front of
ligamentous insertion when not involved in injury
 When the medial canthopexy is bilateral, after their
transnasal passage, twist each of the canthopexy
wires wih those of the other side over the nasal crest

84. Reconstitution of lacrimal passages
 This procedure should be carried out at the same
time as canthopexy because reinsertion of
ligaments block further access posteriorly
 If the sac although obstructed remains intact, the
method of ensuring the drainage of lacrimal fluid
is by means of a dacryocystorhinostomy
 If this is not the case, it will be necessary to
perform a conjunctivorhinostomy

87. Surgical approaches
 To carry out these surgical procedures it
is necessary to achieve a wide exposure
of the lesion
 Different routes:
Original facial scars
Lateral nasal incisions
A frontal scalp flap

88. Original facial scar
 Their extent and location may provide adequate
exposure
 Used when scars are hypertrophic and unsightly
 Also used when scar excision is to be performed
where fibrous tissue contracture restricts
mobilisation of either the medial or lateral canthus

89. Lateral nasal incision
 Placed vertically in the naso orbito angle and may
be extended as required by an incision beneath
the lower rim of the orbit
 An incision which is limited to the naso orbital
angle is adequate for an approach to contralateral
aspect when this is required for unilateral
canthopexy
 Should be supplemented by a columella incision
for introduction and fixtion of a nasal bone graft

90. Bicoronal incision
 The frontal scalp is raised by making a
transverse or coronal incision behind the
hairline and extending this laterally just
in fron of tragus on both sides
 The dissection is carried downwards
and forwards in the plane immediately
superficial to pericranium

91. Operative sequence
1. Reconstruction of the bony base of the nose is the
initial procedure upon which all steps will be based
2. Canthopexy may then be undertaken, but it will not
be complete till the time wires are twisted together
3. Repair of lacrimal passages is undertaken before
the canthopexy is complete by twisting of wires
4. Restoration of nasal crest may then be effected
5. Final tightening of the wires used in bilateral
canthopexy
6. Suturing followed by application of cotton wool rolls
or pledgets in the region of each orbito nasal angle
held in position by a transnasal loop or suture and
followed by application of an external plaster of
paris

92. Naso-frontal deformity
 Deformity not confined to the pyramid region but
also involves its base,or area of implantation into
frontal bone, thus altering the shape, both from a
frontal and lateral aspect, of naso frontal angle
Pathogenesis :
 When the frontal reegion, in the median and
paranasal portion inferiorly is involved in injury, the
secondary malunited callus formed in this
locationdeforms the profile at naso frontal angle

93. Lesions of anterior wall
 It gives rise to a hollow in the midline
 Taken in isolation without any involvement of other
walls of sinus, this injury is of cosmetic importance
only
Lesions of inferior wall or floor
 Occuring in midline such injuries involve nasal spine
 A depression in this area will alter frontonasal angle
and may affect patency of fronto nasal duct
 It can also involve the medial portion of roof of orbit
and may give rise to alteration of naso orbital angle

94. Lesions of posterior wall
 An injury into this area endangers brain and
meninges
 Persistent unhealed fissure following such
fracture may allow infection to reach
meninges from the sinus
 It may also cause herniation of brain and
meninges
 Sharp bone fragment may penetrate the

95. Treatment
 A simple onlay graft may be sufficient to fill up the
defect arising from depression of nasal crest or
anterior wall of frontal sinus
 Grossly dis organised sinus must be treated in its
entirety and concurrently with nasal
reconstruction
 The following procedures are considered:
1. Fronto nasal graft
2. Repair of frontal sinus

96. Fronto Nasal graft
 Only indicated in the lesion confined to the nasal
crest or bridge and the anterior wall of frontal sinus,
without any obstruction to patency of naso frontal
canal
 The material of choice is iliac crest
 The best contour will be obtained by placing the
cortical aspect of graft towards the anterior or
subcutaneous surface
 Secure the graft in position by means of pressure
exerted by the overlying tissues and support obtained

97. Repair of frontal sinus
Depression of anterior wall and floor
 Obliteration is effected by filling up the cavity
 The procedure consists of:
1. A bitemporal coronal incision and turning
downward of scalp flap
2. Resection of malunited callus on anterior wall
3. Careful removal of all mucous membrane
4. Examination of posterior wall for its integrity

98. 5. The inversion, like a pouch, of the nasal mucosa
into the naso frontal canal
6. Total blockage of naso frontal canal by forcibly
impacting a wedge or plug of cancellous bone above
the invaginated nasal mucosa
7. Filling in every portion of the extensive frontal sinus
8. Covering the area with a corticocancellous bone
graft secured firmly to the margins of defect by
transosseous wires

101. Depression of posterior wall
 The obliteration of sinus in this case is effected by
cranialisation.
Technique
1. A transfrontal approach by means of an
osteoplastic flap
2. Resection of entire posterior wall
3. Removal of all traces of mucous membranes
4. Careful invagination of nasal mucosa into the
drainage canals

102. 5. Obstructing and blocking of these canals by
wedges of cancellous bone
6. Reinforcing the strength of anterior wall by
joining together a double layer of bone graft
7. Finally complete isolation of cranium from facial
skeleton is increased by placing layers or
lamellae of cancellous bone along the floor of the
sinus and filling up all crevices with bone powder
derived from the discs of bone left over from the
original trephining of the skull

104. Naso-fronto-ethmoidal injury
 When an even greater degree of force strikes the central
bony mass,the shock wave will be transmitted as far as
the cribriform plate of ethmoid bone which forms its upper
wall or roof in posterior part
 Pathogenesis
 Fracure lines pass in front to behind across the nasal
spine,floor of the sinus and extend into the cribriform
plate
 Associated displacement of fragments involves the
section through which the filaments of olfactory nerve
pass and gives rise to a laceration of dura mater which
produces an escape of cerebrospinal fluid or CSF

105. Clinical features
 The extension of injury into the region of the
cribriform plate does not further increase the degree
of deformity
 There is an associated anosmia and CSF
rhinorrhoea if the tear in the meninges does not
become spontaneously sealed off
 Even though the leak dries up, the patient remains
under the threat of a long term risk because of poor
quality of scar tissue and the permeability of the
malunited callus

106. Treatment
 There is tear in dura and nasal deformity
 Combining neurosurgery and omfs team in same
operation for repair of dura mater and complete
isolation of nasal and cranial cavities from one
another.
 Transfrontal approach
 Also knowns as open sky technique
 Safer and providing great access

107. Neurosurgical operation
 Transfrontal approach and osteoplastic
flap to provide access to adhesions of
dura mater to the floor of anterior fossa
 Carefully and meticulously dissection
 Pattern and distribution of fracture
examined
 Suture of the tears in dura
 Reinforcement of sutured dura with an
extensive lining,
 The graft being taken from epicranial
aponeurosis or if area too great ,from

108.  Resection of crista galli with associated
displaced fragments
 Take care not to dammage nasal mucosa
 Any torn fragments of nasal mucosa turned
downwards or inverted or coagulated
 Lamellae or layers of cortical bone from
illiac to fill up gaps in anterior fossa and act
as a re-inforcement
 Hemetic seal is further enhanced by fillin
up spaces between graft used

113. Fracture of the zygomatic complex
 Both facial deformity and malfunction of
eye can result from malunited zygomatic
complex fracture
 After 10 weeks of injury a fractured
zygomatic complex is called as a old
fracture
 Slightly different technique to repair

115. Symptoms and clinical findings
 In case of trauma to zygomatic complex bone
may be:
Broken or dislocated
Soft tissue torn ,squeezed,strangulated
,incarcerated
Clinical sign and symptoms
Facial assymetry
Dislocation of eyeball
Diplopia
Paresthesia of infraorbital nerve

117. Radiographs
 Occipito mental waters view for fronto-
zygomatic-suture inferior orbital rim
maxillary sinus
 PA view to study orbital rim and floor
 Submentovertex or jug handle view
 Tomograms to examine orbital floor space
btween the coronoid process and
zygomatic arch

118. Indications for surgical treatment
 Aestheticaly unacceptable bony steps or
obvious asymmetries of orbital rims and
pathological diffrences between the two malar
prominences of more than 5 mm
 Diplopia not caused by pure or muscular
damage with or without downward
displacement of eyeball by more than 3 mm
due to displacement of orbital floor .
 Treat enopthalamos when it is found in
combination either with a downward

119.  Paresthesia of infraorbital nerve which
has persisted for more than 12 months
after surgical reposition of bony
fragments
 A depressed zygomatic arch which has
radiologically been proven to be bony
obstacle to free mandibular excursions

120. Therapeutic Measures
 The surgeon has to choose from among
the following procedures:
1) Minor operative corrections like removing
obvious bony steps or freeing the
infraorbital nerve from small stangulating
bone fragments
2) osteotomy and reposition of malunited
fragnments

121.  From among the following approaches
one is selected depending on the
prevailing situation and advantage
offered
1)Bicoronal
2)Peri-orbital
3)Oral
4)Through old facial scars

122. Removal Or Reposition of malunited fragments
 If intercuspation and occlusion appear to
be unaltered by the trauma , if no abnormal
ophthalmological findings can be detected
and the overall symmetry and harmony of
face is undisturbed , no major osteotomy is
indicated
 If a visible bony step at the orbital rim is
present it should be removed surgically
through an lower eyelid incision
 Orbital floor is explored subsequently so as

123.  If persistent paraesthesia is present , infra
orbital foramen is widened to free the nerve
 It can be done through intra oral approach
 If a depressed zygomatic arch hindering the
coronoid’s free excursion is the finding it can
be approached by a bicoronal or a curvilinear
pre-auricular and/or lateral eyebrow incision

124.  Refracture , reposition and fixation are
therapy of choice
 It is advised to glue a cellulose gauze
roll , 3 cm in diameter and 10 cm long ,
on to the skin of cheek above as well as
below the arch.
 This dressing discourages the patient
from lying on the operated side of face

125.  A completely dislocated zygoma with a depressed malar
prominence , a caudally displaced eyeball and diplopia
should be treated by osteotomy
 The zygomatic complex is detached at F-Z suture , at
inferior orbital margin , inferior and lateral orbital walls
and at zygomatic arch
 The orbital floor is covered with a sheet of lypophilised
dura or PDS foil
 Special miniplates have been developed to stabilize the
zygomatic bone
 If antral pack is used , a gauze bandage soaked in

126. Inlays and onlays
 If the only pathological finding in a patient
is either a downward displacement of the
globe or asymmetry of the malar
prominences, contour restoration with
implants is preferred
 Today a great variety of materials is being
used as implant material by surgeons all
over the world: autologous, homologous
and heterologous bone, cartilage and

127.  Depending on the size of the graft, this is
placed on zygoma using infraorbital or an
intra oral approach
 No specific fixation is necessary if the soft
tissue pocket into which the transplant is
placed not too large

128.  If the downward displacement of the orbital
floor is to be corrected the following schedule
is recommended:
1. Minor differences in the level of globes can
be compensated by two or three layers of
lyophilised dura
2. Downward displacement by up to 5 mm can
be corrected, in the first instance, by either
a lyophilised or an autologous cartilage chip
of equivalent thickness
3. However major displacement by more than

129.  In the first operation an alloplastic implant
is brought in and its size, shape and
location are tested postoperatively
 If the result is acceptable, it is replaced by
an autologous or a lyophilised cartilage
graft 3 months later
 During this second operation minor
improvements can also be carried out

130. Residual Maxillary deformities
 Untreated dislocated fractures of maxilla
and mid face complex can be regarded as
old 2-3 weeks after trauma
 After this period rapid inter fragmentary
cicatrisation and the formation of callus
normally make it impossible to repostion

131. Planning of corrective
therapy
 Detailed assessment of complete dentition
,vitality,apical and periodontal conditions
 Lateral cephalogram and analysis. It is important
soft tissue clearly visible in ceph .It permits
assessment of vertical relationship
 Photographs
 Models and model operations

132. Therapeutic possibilities of treatment
1.Gradual repositioning of maxilla and mid-face
complex-
 Fixation had already done
 Mobilisation method to produce slow non –
surgical reposiotioning via
1. Intermaxillary elastics traction
2. Elastic traction using the wassmund method
(1938)
3. Roll extension with traction
4. Orthopaedic apparatus
5. Elastic traction or buccally placed wires attached

133. 2. Immidiate repostioning of maxilla and
mid-face complex:
Closed active mobilisation
Open operative mobilisation

134.  Closed active mobilisation
 Indicated only for malpostioned maxilla with
cicatrical fixation
 Using first 2-5 weeks after the accident
 Ruttelung procedure consist of totally mobilising the
maxilla with special instrument under GA
 3-4 weeks of IMF
 In Principle the same treatment as for fresh
maxillary fractures with impacting and telescoping
of mid face fractures

135.  Open immediate mobilisation :
 Applied in case where total mobilisation
impossible
 Mostly used in cases in which the mid facial
fractures were only treated 6 weeks or more after
trauma or perhaps year later and in which
consolidation has taken place
 In order to prevent damage to the roots of
teeth,osteotomy carried out not exactly along the
path of previous fracture

136. 3. Old fractures of alveolar process segments:
 Cases with residual deformities after fractures of
segments of the upper alveolar process occur rarely
 In the region of anterior maxilla the operating procedure
used are those described by Wassmund (1935) and
Wunderer (1962) in cases of protrusion of anterior
maxilla
 The Wunderer method is dependent on labial blood
supply to the alveolus, so there should be no scar
present in the maxillary vestibule
 Dislocation of lateral maxillary alveolar process are
corrected as recommended by Schuchardt 1955

137. Old le fort I and II fractures
 In residual deformity resulting from untreated
le Fort I fractures osteotomy should be
carried out so that wire sutures or mini plates
are located on both sides of osteotomy in
stable regions of bone
 Osteotomy line does not follow the fracture
line
 The approach in most cases being
horizontally through the lateral and the

138.  For old le fort II fractures same type of osteotomy
is carried out provided dislocation in the nasal
bones is minor
 If bridge of nose is sunk and midface shortened ,
le fort II osteotomy is carried out
 The vertical dimension of midface is restored by
forward and downward displacement of
osteotomised midface
 Bone grafts are introduced in region of bridge of

139. Old Le fort III Fractures
 Where the entire midface region including the
inferior orbital margins and the zygoma are
dislocated a Le Fort III osteotomy is indicated
 If only half of the face is affected unilateral le
Fort III osteotomy and refracture in the region
of alveolar process carried out
 In cases of midface comminuted fractures it is
neccesary to carry out a Le Fort I osteotomy
in addition to Le Fort III osteotomy for
treatment of craniofacial malformation

142. Post Traumatic Hypertelorism
 Fractures involving dislocation of one or
both orbits can be treated in the same way
as congenital hypertelorism
 Transcranial access is necessary

143. Residual deformity of Mandible
 Deformity in the ascending ramus
 Deformity of angle and body
 Deformity of larger defects of ascending
ramus and body of mandible

144. Deformity in the ascending ramus
 Providing that occlusion is satisfactory, defects in
this region produce minimal deformities and may not
need any treatment
 An exception to this is destruction of developing
mandibular condyle
 Destruction of articular cartilaginous disc allows the
bony fragments of ascending ramus and glenoid
fossa to come into direct contact

145.  Ankylosis
 Apart from this pseudoankylosis should be
identified as a separate pathological state.
It affects joint mobility indirectly by
mechanical interference
 Early surgical intervention should be done
along with aggressive physiotheraupy
Produces marked cosmetic
deformity
Can cause obstruction to airway

146. Deformity of Angle and Body
 Fracture in angle region are frequently
associated with a fracture on contralateral
side (usually in canine region)
 In such injuries if more anteriorly placed
fracture is incorrectly positioned and a
malunion develops, this will be reflected in
an angulation in the region of angle of
mandible
 Non union at this site develops if medial

147.  Defects present in this region can be
restored by blocks of bone from ilium,
angle of rib or by cancellous bone chips
 According to Mowlem 1945, cancellous
bone chips are rapidly vascularised and
stabilised in this site

148. Malunion and Non union
 Deviation from normal course of healing
may lead to delayed union, malunion or non
union which requires surgical correction
 Failure to reduce displaced fracture leads to
disturbed occlusion with corresponding
impairment of masticatory efficiency and at
times pain on occluding the teeth (either in
tooth bearing area or TMJ region)
 Excessive seperation between bone ends

149.  As a guiding rule seperation of more than
1.5 cm will not readily unite without
introduction of a bone graft
 In gunshot wounds of mandible, the remaining
fragments must be placed in their correct
relationship with upper jaw and a bone graft
used to bridge the gap
 When the gap is present in tooth bearing
segment then slight forward movement of
edentulous posterior fragment is permissible
 If malunion in edentulous is such that fitting of
dentures becomes impossible then surgical
intervention is imperative

150.  In the elderly edentulous mandible, particularly when
bilateral fractures have occurred at parasymphysis
region, suprahyoid musculature causes the anterior
segment to rotate (as if it were the handle of bucket)
 The proximal fragment under the inflence of
pterygomassetric sling rotates in opposite direction
 In such cases even gunning splint is not effective
 Malunion resulting from this may make the fitting of
denture insatisfactory because of lack of space b/w
maxillary tuberosity and malpositioned fragment

151.  Bloomquist 1982 advocates the use of a
body sagittal osteotomy in management of
such cases
 Advantages are:
1. Osteotomy is performed at original site of
fracture
2. A relatively good area of bone contact
exists allowing freedom in movement of
fragments
3. The plane of sagittal cut allows rotation
of both fragments in a manner that will
restore a normal functional position

152.  In dentate cases, the same degree of rotation of
anterior segment is unlikely
 Exposure of mandible at lower border and
approximation of bone ends accurately may
produce occlusal discrepancy and vice versa
 Equal attention should be given to occlusal
surface of teeth and inferior border of mandible
 A preoperative evaluation is necessary and based
on this evaluation decision is made as to whether
use of cap splints will facilitate correct alignment
of occlusion

153. Rconstruction of larger defects of the
ascending Ramus and Body of the
mandible
 Gunshot wounds account for the majority of
injuries where both soft tissue and bone
has to be restored
 If the periosteum in children, it retains
remarkable osteogenic properties and in
absence of any graft, large areas of
mandible may regenerate spontaneously
 Where bone is transplanted it acts as a

154.  In large grafts the objective is to find an adequate
source of bone which is going to induce
osteogenesis without itself being resorbed or lost
before this process is complete
 For osteogenic purposes, cancellous bone, with
its large endosteal surface area and rapid ability
with which it can be invaded by blood vessels, is
vastly superior to cortical bone
 The ilium is ideal source of such large quantities
of cancellous bone
 In cases where a particularly strong piece of bone
is required or where the ilium is unduly thin, the

155.  In the event of larger defects in the mandible
requiring reconstruction, various other
alternatives have been advocated:
1. Metallic implants
2. Temporary metallic implants
3. An immediate extensive bone graft
4. Bone grafts associated with a vascular pedicle
5. Free transfer of osteomyocutaneous grafts and
microvascular anastomosis

156. Metallic Implants
 A permanent metallic implant may provide a
satisfactory replacement because of
simplicity with which they may be inserted
 Disadvantages
They are purpose made for specific
patients, involving a two stage operative
procedure
Incompatible with body tissues

157.  In 1969, Bowerman and Conroy introduced
a jaw replacement kit in titanium- which is
both malleable and readily acceptable to
body tissues
 The selected unit is bolted to the lingual
aspect of the mandible on either side of the
defect, producing a rigid mandible
 It also provides positive immobilisation of
fragments without the need of Intermaxillary
fixation

158. Temporary Metallic implants
These may be used in one of 2 ways :
 If inserted initially they may be replaced
subsequently by a bone graft
 In this way many of previously mentioned
benefits of prosthesis may be exploited and
their disadvantages avoided
 Spiessl 1980 advocates a second approach
in which mandibular bone ends are secured
by means of a 3 dimensionally bendable

159.  A minimum of 4 screws are inserted in
each segment to ensure rigid fixation
 Utilising a cancellous bone press, the body
of mandible can be moulded, with the aid of
suitable tools, in 3 separate segments
 Resultant pressed body will fit accurately
into the defect

160. Immediate extensive Bone Grafting
 When extensive bone grafting is required in
excess of the size previously described the
operative procedure is prolonged as is the period
of immobilisation of the jaw
 Restoration in the mental region is essential but
difficult
 Various techniques have been described using rib
which may be notched on its inner aspect to
enable it to be bent round to a more acute curve
 Periosteum is retained on the outer aspect to
increase the strength of this rather weak

161.  If rib happens to fracture, advantages of a
one piece graft are lost
 Split rib grafts may be used since they can be
more readily curved to conform to a desired
shape and subsequently wired together to
restore their strength
 In either case, a careful apposition of the graft
to the lingual aspect of mandible and fixation
by transosseous wiring is important for
establishment of bony union
 Ilium is an optimum site for a graft and a

162.  The only disadvantage of this graft is that
its limbs are relatively short and it may be
necessary to join 3 pieces of bone together
in order to obtain a graft of adequate size
 Fixation can be achieved by external pins
secured where necessary to supraorbital
pins, a Levant frame or a halo.
 Now a days direct bone plating is used for
fixation

163. Bone grafts associated with a
vascular pedicle
 Depending on how extensive the defect of the
overlying tissues are, grafts may include bone,
muscle and overlying skin
 These are achieved by vascularised regional flaps
 Where bone is predominantly involved, possible
donor sites are rib or the clavicle
 Where more soft tissue is required, greater use may
be made of pectoralis major myocutaneous flap,
including a segment of underlying attached rib

164.  Conley 1972 discussed the use of compound
myoosseous flaps for mandibular reconstruction
 Siemssen et al 1978 first described the use of
sternocleidomastoid clavicular myoosseous flap in
the reconstruction of mandibular defects resulting
from trauma
 The vascular supply is derived from thyrocervical
trunk which serves the inferior third of the muscle, the
middle third by branches superior thyroid artery and
superior third by branches from posterior auricular
artery
 The medial portion of the clavicle can be taken as a

165.  In extensive injuries requiring grafts
involving skin, it is possible to gain bone
from underlying 5th or 6th ribs in
association with a pectoralis major
musculocutaneous flap, utilising only the
pectoral portion of the muscle, based on
its supply from thoracoacromial artery
 Such flap provides soft tissue which can
be used to line a defect of oral cavity as

166. Free osteomyocutaneous grafts and
microvascular anastomosis
 With the development of microvascular
surgical techniques it has become feasible
to transfer larger portions of bone and soft
tissue in a single procedure in order to
reconstruct extensive defects
 The advantage of free bone grafts
supported by microvascular anastomoses
are that the immediate re establishment of
an intact blood supply to the graft results in

167. ILIAC GRAFT
Ilium is major source of graft for maxilllofacial
reconstruction.
Anatomy of Iliac
Medially - iliac muscle, ceacum, ascending colon
Laterally - Abductor muscle of hip (gluteas
muscle)
Nerves - Lateral Femoral nerve  innervate
lateral thigh.
Subcostal nerve  over anterior iliac spine
Iliohypogastric nerve  over iliac tubercle

170. Approach to Iliac crust
 Lateral approach stripping tensor fascia lata and gluteas
medius
 Medial approach stripping iliac muscle
 Crystal approach splitting or removing proportion of iliac
crest
Disadvantages of Lateral Approach
 Dissection of tensor fascia lata muscle laterally create gait
disturbance.
 Difficult to the strip muscle from the lateral aspect of ilium
 Failure to appose the muscle to the ilium can results in gait
disturbance. In extreme situation dragging limp or gluteal gait
occur

171. Disadvantages of Crestal Approach
 In long term will usually result in irregularity of crest -
below the age of 20.
Disadvantages of Medial Approach
 It is associated with greater risk of damage to lateral
fermoral cutaneous nerve of thigh. Meralgia paraesthesia in the
upper lateral thigh.
 Increased incidence of post operative ileus.
 Increase post operative pain from disruption of abdominal
wall musculature

172. Surgical Approach
 Guideline to length of incision is depend on the maximum width of
bone to be harvested.
Types of Incision
 Lateral incision
 Medial incision
Lateral Incision Approach
 Incision is less likely visible than medial incision
 Incision are made lateral to crest to avoid lateral fermoral nerve,
1cm posterior to anterior ilia spine to avoid subcostal nerve, extend upto
2cm posterior iliac tubercle.

173.  Incision carried down through – skin, subcutaneous fact,
scarpa’s fascia to the muscular aponeurosis.
 Iliac bone is approach 1cm below the crest in young.
(Where the crest is cartilaginous and growth is expected) and
5mm below in adult.
VARIOUS APPROACH TO PARTICULATE CANCELLOUS BONE
MARROW
 Clamshell approach – expand medial and lateral cortex to
gain access to cancellous bone.
 Trap door approach – pedicle the medial or lateral cortex
on muscle to gain access.

175.  Tschopp approach – pedicle the iliac crest on the external
oblique muscle to gain access.
 Tessier approach – pedicle the medial and lateral portion of
the crest by mean of oblique osteotomy.
TREPHINE TECHNIQUE
 Incision is 2cm in length
 No medial lateral stripping and incision carried down to iliac
crest.
 Trephine is used to perforate iliac crest and cancellous
bone is harvested upto depth of 3cm using a rotatary action.
 Trephine is angulated 30° to vertical proceed between
medial and lateral cortex.

176. Approach to posterior Iliac Bone
 Posterior approach is used when a greater quantity of
particulate bone is required.
Advantage
 More cancellous bone is available – approx. 2 to 2.5times
the quantity taken from anterior iliac.
 Less bleeding, less gait pain and disturbance
Disadvantage
 Overall operative time increased
 Nerve damage (cluneal nerve)

178. Approach
• Incision is made at well defined bone prominence laterally,
where gluteaus maximumus inserts.
 Curvilinear incision course medially about 3cm lateral to
midline ending at length of about 10cm.
 Direct approach avoid damage to superior cluneal and
middle cluneal ner

179. ILIAC GRAFT FOR MANDIBULAR RECONSTRUCTION
 Iliac crest to form the lower border of the mandible
 Anterior superior iliac spine – angle of the mandible
 Anterior inferior iliac spine - condyle
 Ipsilateral iliac crest is harvested pedicle emerges
from the newly constructed angle to recipient vessels in
the same side of the neck.
 Contralateral crest – pedicle is positioned anteriorly
and is positioned for vessel in apposide of the neck.

183. Complication
 Hernia formation is 12% in osteocutaneous flap and 4% pure
osseous flap.
Advantages
 Iliac provides 6-16cm graft in length which allows three
dimensional carving the shape of hemimandible.
Disadvantage
 Iliac crest is not ideal for angle to angle defect
 Intra oral defect is not handle well by the bulk is skin paddle
 Color match of iliac skin to fascia skin is poor

184. FIBULA GRAFT
 First reported by Ueba and Fujikawa in Japan and O’Brien
& Morrison in Melbourne in 1977.
 Hidalgo was the first to describe fibula transplantation for
reconstruction of the mandible.
Surgical Anatomy
 Fibula head articulated with tibia 2cm below the knee joint.
 A fibula is 40cm long bone this provide upto 26cm for
transplantation.
 Peroneal nerve run around the fibula head. Damage to the
peroneal nerve are avoided by leaving 8cm of cranial fibula and
angle joint by leaving 8cm of distal end.

186.  Anterior to fibula – extensor hallucis longus muscle and extensor
digitorium longus muscle.
 Laterally - Peroneus longus and peroneus brevis
muscle.
 Dorsally - Soleus muscle and centrally flexor
hallucis
 Distally - Peroneus brevis muscle
Vascular supply
 Fibula is supply by peroneal artery
 It is a branch of posterior tibial artery and it run dorsal to
intraosseous membrane and medial to fibula between tibialis posterior
muscle and flexor hallucis longus muscles.

187.  Anterior crural septum –
between peroneus and extensor lodge
 Posterior crural septum –
peroneus and flexor lodge
Incision
 Fibula is situated at the point of
attachment of triceps fermoralis tendon.
 Straight line connecting the
fibula head and lateral malleolar mark
the posterior crural septum.
 Fibula is accessed by dissection on the front or rear surface of the
posterior crural septum.

188.  Detachment of anterior
crural septum is followed by
detachment of extensor
digitorium longus and extensor
hallucis longus as far as
intraosseous band.
 Peroneal artery is ligated
and is dissected with the bone in
lateral dorsal direction.
Advantage
 Constant topography
 Long bone

189. Disadvantage
 Short vascular pedicle
 Low height of bone
 Low height of recipient site for endosteal
implant
Complication
 Damaged peroneal nerve will result in foot
drop, loss of arches of the foot. Flaccid foot

190. Radial forearm flap - Chinese flap
 Flap originate in China, it was used to cover burn surface.
 It was introduces to Western country by Muhlbauer
Indication
 Mandible
 Anterior wall of maxillary (orbital rim and floor are maintain)
 Palatal defect
Anatomy
 Flap depends on ascending vascular radicals from radial artery to
the over line fascia and skin and descending branch to the underlying
periosteum of the radius.
 Venous – superficial cutaneous vein and comitants accompanying
the radial artery.

192. Advantages
It is ideal for elderly patient with an edentulous mandible
with vertical height of 13 cm.
Disadvantages
 Inadequate bone for mandibular reconstruction
 Two weak to withstand normal masticatory force.
 Limbs is immobilized for 8 weeks
 Incision on forearm hypertrophy and unsighty.

193. References
 Rowe and Williams’ Maxillofacial Injuries 2nd
edition
 Textbook of Oral and Maxillofacial surgery by
Peterwardbooth
 Facial Plastic, Reconstructive and Trauma
surgery by
Dolan