Complex maxillary fractures: role of buttress reconstruction and immediate bone grafts

Between 1978 and 1984, 558 patients with complex facial fractures have been treated. One hundred and seventy-one of these patients have had complex Le Fort fractures of the maxilla. In this group of patients, the importance of direct anatomic reconstruction of the anterior maxillary buttresses has been assessed. Complete exposure of the injured buttresses will facilitate assessment of the exact fracture pattern. Direct fixation of the medial and lateral maxillary buttresses on each side, in combination with immediate bone-graft reinforcement or replacement of comminuted or missing buttresses, will facilitate the reconstruction of even the most severely injured maxilla in one stage. This approach is combined with similar reconstructive techniques in other areas of the craniofacial skeleton. Associated mandibular fractures are managed with rigid internal fixation utilizing A-O techniques. The use of these techniques dramatically facilitates airway management and simplifies the treatment of the edentulous patient, the patient with bilateral condylar neck fractures, and those patients with sagittal splitting of the maxilla and palate. The use of both internal craniofacial suspension wires and external craniofacial suspension devices has become largely unnecessary, and reconstruction of even the most complex injuries in one stage with minimal complications and secondary deformities is made possible.     

Early definitive bone and soft-tissue reconstruction of major gunshot wounds of the face

The use of craniofacial surgical techniques, extended open reduction, rigid fixation with plates and screws, and the replacement of severely damaged or missing bone with immediate bone grafting in the treatment of complex facial fractures has been applied to the management of severe gunshot wounds of the face. Early definitive bone and soft-tissue reconstruction has been performed in 37 patients. One-hundred and seventy-seven primary bone grafts were utilized in 33 patients for orbital, nasal, zygomatic, and maxillary reconstruction. Twenty-six patients required mandibular repair with compression or reconstruction plates. Soft-tissue reconstruction was provided by a combination of flaps. Four patients had extensive soft-tissue loss replaced by free vascularized omental flaps. The omentum provided circumferential coverage of the mandibular reconstruction and reconstruction of the floor of the mouth and was then tunneled in a circle through both cheeks into the middle and upper face. The omentum reconstructed deficits in the hard palate and upper buccal sulcus and was then wrapped around all zygomatic, orbital, and midfacial bone grafts and used to fill in dead space in the maxillary, ethmoid, and frontal sinuses. The omentum is not used to provide contour and bulk, but to cover bone grafts and plates and fill in dead space. Carefully shaped bone grafts provide the correct craniofacial scaffold. Early restoration of a midfacial bony scaffold and the prevention of soft-tissue contraction facilitate secondary reconstruction. Four late total nasal reconstructions with tissue-expanded forehead skin wrapped around bone grafts were performed.     

Midface fractures: advantages of immediate extended open reduction and bone grafting

Experience with 240 midface (Le Fort and zygoma) fractures in multiple trauma patients has emphasized that superior aesthetic results are obtained by immediate extended open reduction with primary bone grafting. Internal fixation of 110 zygomatic and 130 Le Fort fractures was performed in the lower midface (zygomaticomaxillary and nasomaxillary buttresses). Open reduction of the condyle was employed in five concomitant Le Fort and subcondylar fractures with a loss of ramus height to prevent superior and posterior displacement of the middle and lower face. Bone grafts were utilized in 74 patients. They were most frequently employed in the orbit and less frequently in the lower midface. Bone graft survival paralleled that observed under elective conditions, and a slightly higher infection rate was observed. Extended open reduction and immediate bone grafting adds a new dimension to the aesthetic results obtained from facial fracture treatment. Structural bony integrity and pre-injury facial architecture may be restored in the absence of soft-tissue contracture. Restoration of the pre-injury facial architecture (the essence of facial fracture treatment) is more accurately accomplished when these techniques are utilized.     

Naso-ethmoid-orbital fractures: classification and role of primary bone grafting

A detailed review of 80 patients with severe naso-ethmoid-orbital injuries has facilitated the classification of these injuries into five types. The recognition and diagnosis of each specific injury pattern will define the correct treatment choice in each instance. Special attention should be focused on injuries with comminution and bone loss in the medial wall and floor of the orbit, with loss of cartilaginous nasal support, and with orbital displacement and dystopia. An open, direct approach to these fractures with meticulous reduction, internal fixation, and repair of the medial canthal ligaments provides optimal repair. The use of craniofacial surgical techniques and immediate bone graft replacement of missing or severely damaged bone will allow reconstruction of even the most difficult injuries in one stage. Two hundred and eighteen primary bone grafts have been utilized in 49 patients. No significant complications with their use have occurred. The incidence of nasolacrimal system injury in naso-ethmoid-orbital injuries is less than suspected. Eight of 46 patients (17.4 percent) required a dacryocystorhinostomy for persistent nasolacrimal system obstruction. Immediate assessment or exploration of the nasolacrimal system is not performed. Delayed assessment and dacryocystorhinostomy resulted in the relief of nasolacrimal system obstruction in all cases.     

Tissue expansion in the reconstruction of Tessier craniofacial clefts: a series of 17 patients

Tessier craniofacial clefts are among the most surgically challenging examples of craniofacial dysmorphology. These clefts are characterized by hypoplasia of soft-tissue and skeletal elements throughout the three-dimensional extent of the cleft. Whereas bone grafting and craniofacial osteotomies have been successful toward correcting the underlying skeletal abnormalities, the ultimate success of these reconstructions has been limited by the deficiency of skin and soft tissue. This deficiency demands reconstruction ideally with tissue of like texture, consistency, and, especially in the face, color. Craniofacial tissue expansion was used toward reconstructing these facial clefts with like-quality tissue, allowing for tension-free reconstruction after osteotomy and bone grafting. Seventeen patients with Tessier craniofacial clefts underwent preoperative craniofacial soft-tissue expansion in the surgical management of their clefts. Tissue expansion was used in the primary correction of facial clefts in eight patients, with nine patients undergoing expansion before secondary surgery. In this series, tissue expansion has evolved as an important element in overcoming the skin and soft-tissue deficiency associated with these clefts, allowing for tension-free closure and improved aesthetic results in these surgically challenging patients.     

Toward CT-based facial fracture treatment

Facial fractures have formerly been classified solely by anatomic location. CT scans now identify the exact fracture pattern in a specific area. Fracture patterns are classified as low, middle, or high energy, defined solely by the pattern of segmentation and displacement in the CT scan. Exposure and fixation relate directly to the fracture pattern for each anatomic area of the face, including frontal bone, frontal sinus, zygoma, nose, nasoethmoidal-orbital region, midface, and mandible. Fractures with little comminution and displacement were accompanied by subtle symptoms and required simple treatment; middle-energy injuries were treated by standard surgical approaches and rigid fixation. Highly comminuted fractures were accompanied by dramatic instability and marked alterations in facial architecture; only multiple surgical approaches to fully visualize the "buttress" system provided alignment and fixation. Classification of facial fractures by (1) anatomic location and (2) pattern of comminution and displacement define refined guidelines for exposure and fixation.     

The fate of plates and screws after facial fracture reconstruction.

Rigid plate and screw fixation is the mainstay of treatment for complex fractures of the facial skeleton. Complications of plate and screw fixation include prominence, infection, exposure, and migration. Five hundred and seven patients undergoing plate and screw fixation for facial fractures (1112 fractures) from 1983 to 1988 were followed for complications. Sixty-one patients (12 percent) required hardware removal. The location on the facial skeleton influenced symptoms and the rate of hardware removal. Infection and exposure may be decreased with antiseptic irrigations, avoiding mucosal damage, attention to proper mucosal closure, and correct placement of plates. Prominence may be decreased by the use of microplates in the supraorbital, frontal, and naso-orbital-ethmoid locations.     

The use of Champy miniplates for osteosynthesis in craniofacial deformities and trauma

Champy miniplates have been used in the treatment of craniofacial fractures and in osteotomies for correction of posttraumatic deformities, congenital craniofacial deformities, and secondary bony deformities due to pathologies such as hemangioma and neurofibroma. An additional use has been to stabilize free and vascularized bone grafts. The total number of cases reviewed were 50 (25 acute trauma, 4 vascularized mandible reconstruction, and 21 osteotomies of varied types). There were three infections, two in mandibular fractures that were comminuted and compound into the mouth and one in a compound comminuted fracture of the frontal and maxillary area that was judged to be infected when the plate was placed in position. Two plates have been obvious under the skin. No patient has requested plate removal. The advantages of plating in selected cases are decreased operating time, rigid fixation at surgery, good fixation of bone grafts, and the ability to remove intermaxillary fixation in children at the end of the procedure or within the first few postoperative days.     

Maxillofacial fractures in the elderly: a comparative study

Previous maxillofacial trauma research has dealt primarily with facial bone fractures in the general population. Very few studies have specifically addressed maxillofacial fractures in the elderly. We compared 45 elderly (65 years of age or older) and 201 younger adult (16 to 64 years of age) patients admitted to our hospital with maxillofacial fractures. The percentage of patients admitted with nasal bone fractures was much greater in the elderly population, while mandibular fractures were more common in the adult group. Motor vehicle accidents accounted for over half the injuries in both groups, while falls were more prevalent in the elderly. Management of the elderly patient may be complicated by their associated injuries or underlying medical problems, perhaps partially accounting for their longer median length of hospital stay. The elderly are a unique subpopulation of maxillofacial fracture patients and deserve further study regarding their injuries and optimal methods for treatment.     

Rigid internal fixation in the hand: 104 cases

One-hundred and four patients with fractures of the metacarpals and phalanges have been treated with rigid internal fixation over a 6-year period. Patients with both open and closed injuries had their fractures fixed by tension band wires, interosseous compression screws (lag screws), or plates and screws. The concepts of primary bone healing and its variations, methods of fixation, and the importance of interfragmentary compression are defined and stressed. Illustrative cases of each technique are described and the applicable principles are enunciated.     

Review of 1,000 major facial fractures and associated injuries.

The records of 1,020 major facial fractures were reviewed, and it was found that the occurrence of life-threatening associated injuries was highly predictable on the basis of the pattern of facial fractures and the circumstances of the injury. Certain groups of patients have a high probability of associated serious injuries of the central nervous system, the trunk, or the extremities. Probably these patients should be primarily under the care of a surgeon who is capable of the diagnosis and emergency therapy of these associated injuries, as well as the facial injuries, so that appropriate priorities can be established and put in effect.     

Primary closure of human bite losses of the lip.

Human bite injuries of the lip have, because of the potentially contaminated nature of the wounds, been managed by delayed repair after an interval of about 3 months or more when the infection was controlled and the wound healed. On the contrary, from 1985 to 1990, at a plastic surgery unit in Nigeria, a developing country, 37 patients with human bite losses of the lip were managed by an aggressive approach utilizing (1) a 5-day course of antibiotics locally known to be effective against bacterial flora and (2) immediate surgical operation employing the diamond wedge excision method under local anesthesia with direct wound closure. The results have been so favorable that this method of management of human bite injuries is considered a treatment advance.     

Correction of severe facial deformity.

A craniofacial team has been developed to corrdinate the treatment of patients with severe facial deformity and to minimize the surgical risks. Two hundred patients have been evaluated in the last 4 years and more than 100 treated by this team to correct orbital hypertelorism, oxycephaly and plagiocephaly with exophthalmos, features of Crouzon''s disease and Apert''s and Treacher Collins syndromes, hemifacial microsomia, and severe lower facial deformity and malocclusion. Surgical principles include extensive subperiosteal stripping of bone, osteotomy as necessary, and repositioning maintained by bone grafts. Postoperative evaluation is being maintained for 5 years or to maturity in younger children. Although many of the results are less than perfect, there has been sufficient improvement, especially psychologic and functional, to warrant continuation of the surgical program under closely controlled conditions.     

A new transplant bone for maxillary alveolar cleft

An innovative technique with distraction osteogenesis has been developed in our research group to explore autogenous bone transplantation into craniofacial bone defects. This technique was designed to investigate bone-marrow transplantion using a chondroid or fibula bone graft into simulated alveolar bone defects in mice in terms of the osteogenic process and activity. As an experimental model of maxillary alveolar bone cleft available for testing bone-inductive materials, a critical-size defect was formed in the pre-maxillary bone of male mice using a surgical trephine bur with a low-speed dental engine. Distraction osteogenesis was performed using an external fixation device. The osteotomy site was occupied by an external callus consisting of hyaline cartilage with a large quantity of chondroid bone. Moreover, bone remodelling with new bone formation was demonstrated 30 days after the transplantation. Bone adhesion was better in chondroid bone grafting than in fibula bone grafting. The present findings are the first to demonstrate the potential of chondroid bone transplantation as a new therapeutic system of bone grafting, suitable for bone substitutes in craniofacial bone defects.     

Accurate,firm stabilization using external pins: a proposal for closed reduction of unfavorable nasal bone fractures and their simple classification

Nasal bone fractures are the most common among facial fractures and are the third most common fractures in the human frame. Although many forms of treatment have been introduced, controversy regarding the optimal treatment still remains. Nasal bone fractures are complex, with significantly varying types that are often undermanaged in closed reduction procedures. The authors' experiences with nasal bone fractures have shown that the baseline for surgical intervention depends on the type of fracture and the method of maintenance after reduction, both of which have considerable impact on the final result. Therefore, it is very important and challenging to determine the proper method of reduction and maintenance. The periosteal covering plays an important role in the splinting action after closed reduction, but sagging, depression, and instability remain major complications in some cases. The authors devised a new method of accurate, firm stabilization of the fractured nasal bone by using external pins in those unfavorable fractures determined radiologically to gain optimal reduction and fixation. In the present study, fractures were grouped into favorable and unfavorable fractures, the latter being those that remained unstable or impacted even after reduction and thus needed open reduction. Unfavorable fractures were divided into four subclasses according to radiologic findings: (1) type I (frontal), including chip or tip fractures, which often depress the upper lateral cartilage and tend to sag after reduction; (2) type II (lateral), or laterally depressed segmental fractures with a lateral shift of the arch in fragments or as a unit; (3) type III (mixed), or type II with septal involvement; and (4) type IV (complex), including open or multiple comminuted fractures. After an initial evaluation to determine the fracture type, closed reduction and external fixation were performed for types I, II, and III fractures and open reduction was performed for type IV fractures 5 to 7 days after the fracture. Closed reduction with the use of external pins was done in eight cases: type I (two), type II (four), and type III (two). The mean age of the patients was 27.8 years, and the average follow-up period was 11.7 months. Functional and aesthetic results were satisfactory. This new method for support and fixation is an alternative to the conventional closed reduction and a promising way to prevent secondary deformity.     

Facial fractures from dog bite injuries

Dog bites are commonly associated with soft-tissue injury to the face but rarely result in facial fractures. This article reports six new cases of facial fractures associated with dog bites and reviews additional cases reported in the literature. The demographics of the patients attacked, the location of facial fractures, and the characteristics of associated soft-tissue injuries or complications developing from the dog bite are described. With six new cases and 10 from the literature, this article reviewed a total of 16 cases involving 27 facial fractures. Eighty-seven percent of the cases involved children less than 16 years of age. The periorbital or nasal bones were involved in 69 percent of the cases. Lacerations were the most frequently associated soft-tissue injury. Additional injuries included facial nerve damage, lacrimal duct damage requiring stenting and reconstruction, ptosis from levator transection, and blood loss requiring transfusion. Although facial fractures are not commonly considered to be associated with dog bite injuries, the index of suspicion for a fracture should be raised when the injury occurs in a child, particularly when injury occurs near the orbit, nose, and cheek.     

Fracture management of civilian gunshot wounds to the hand

Civilian gunshot wounds to the hand are typically caused by low-velocity weapons, which create a localized pattern of soft-tissue and bone injury that usually allows for early definitive treatment. A retrospective chart review of 72 patients treated for 98 gunshot wound fractures at an urban level I trauma center was conducted to evaluate the results of limited debridement and early definitive fracture fixation of urban gunshot wound fractures of the hand. The incidence of hand fractures, means of fracture fixation, number of operations, occurrence of infection, and level of patient compliance were determined. Twenty-nine fractures were managed definitively with reduction and splinting in the emergency department or intensive care unit. Sixty-eight fractures were treated surgically, at a mean of 2 days after injury. Eleven patients required more than one operation. The overall infection rate was 8 percent and was not influenced by the fracture fixation method. All infections were superficial and resolved with antibiotics alone. Thirty-nine percent of patients were lost to follow-up after hospital discharge and 85 percent of patients were lost to follow-up before documented fracture healing. Twenty-six percent of patients were lost to follow-up with a removable fixation device in place. Limited debridement and early definitive fracture fixation are associated with low rates of complications for typical civilian handgun wound fractures. Cases with extensive injury or contamination do require a staged approach to treatment. Poor patient compliance in the urban trauma setting should be expected and may affect the management plan.     

Management of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central fragment in classification and treatment

The medial canthal tendon and the fragment of bone on which it inserts ("central" fragment) are the critical factors in the diagnosis and treatment of nasoethmoid orbital fractures. The status of the tendon, the tendon-bearing bone segment, and the fracture pattern define a clinically useful classification system. Three patterns of fracture are appreciated: type I--single-segment central fragment; type II--comminuted central fragment with fractures remaining external to the medial canthal tendon insertion; and type III--comminuted central fragment with fractures extending into bone bearing the canthal insertion. Injuries are further classified as unilateral and bilateral and by their extension into other anatomic areas. The fracture pattern determines exposure and fixation. Inferior approaches alone are advised for unilateral single-segment injuries that are nondisplaced superiorly. Superior and inferior approaches are required for displaced unilateral single-segment injuries, for bilateral single-segment injuries, and for all comminuted fractures. Complete interfragment wiring of all segments is stabilized by junctional rigid fixation. All comminuted fractures require transnasal wiring of the bones of the medial orbital rim (medial canthal tendon-bearing or "central" bone fragment). If the fracture does not extend through the canthal insertion, the canthus should not be detached to accomplish the reduction.     

Lamellar split osteotomy: a new craniofacial technique

Craniofacial osteotomies have by convention been bilamellar translocations of the entire substance of the dysmorphic bone. This approach limits the surgeon by reducing the stable bone mass available for fixation, creating dependence on concave surfaces. Most important, it changes the bony topography that determines the preoperative plan. This paper presents a new craniofacial concept and technique used in 26 patients with various dysmorphic syndromes who were reconstructed by performing a lamellar split osteotomy. This technique maintains the internal lamella in its native position, thereby allowing it to act as a reference for the bony topography and providing a stable facial framework for rigid fixation. This interlamellar osteotomy has led to improved aesthetic results in the orthomorphic reconstructions of congenital and other deformities. It can be used in any aesthetic patient in whom contour changes or augmentation of form is desired. It is recommended as a preferred method for achieving quantitative contour improvement in patients over 3 years of age.     

Risk factors contributing to symptomatic plate removal in maxillofacial trauma patients

This study analyzed the fate of plates used to correct maxillofacial injuries and defined risk factors that eventually resulted in plate removal. The outpatient clinic files of 108 patients treated with rigid internal fixation after maxillofacial trauma were reviewed. Study variables included age, sex, trauma circumstances, diagnosis, type of fracture, approach to the facial skeleton, presence of teeth in the line of fracture, plate material, site of plates, and reasons for plate removal. Of 204 plates used for fixation, 44 plates (22 percent) were removed. When all factors were considered together, only fracture diagnosis (mandibular body and angle) and plate location (mandibular body and angle) were statistically significant. Only when each factor was considered separately, the approach to the facial skeleton (intraoral) and the type of fracture (comminuted and compound fractures) were statistically associated with plate removal. Selection of favorable plate location, the extraoral approach, and vigilant infection control may reduce plate removal in patients with maxillofacial injuries. Special attention should be given to compound and comminuted fractures of the mandibular body and angle.