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.     

The role of the zygomatic arch in the statics of the skull and its adaptive shape

The zygomatic arch of mammals is usually considered a phylogenetic relic of the fenestrations of the skull roof which may be observed in morphological sequences of primitive vertebrate skulls. If this concept is correct, the element is comparable (though not homologous) to the jugal arches of diapsid reptiles. Two major questions then remain unanswered: why different elements are maintained in reptiles and mammals during evolution, and why the arches are maintained as relics of ancestral forms. It is tempting to respond to the latter question with a very simple answer, namely that the elements function in order to sustain mechanical stresses. In this paper, we raise the questions which quality of stresses occurs in a primate skull within the zygomatic arches and what relationship these stresses hold to the morphology of these bony elements. An answer has been sought by means of finite element stress analysis. We found that the zygomatic arch in primate skulls represents a structure which carries, under all biologically relevant conditions, either compressive or tensile stresses. In a very simple model of the human skull under bite forces, a strip of stresses occurs lateral to the orbits, which seems roughly comparable to the zygomatic arch. Once such a structure exists and is used as an insertion of adductor muscles, it will be exposed to bending stress in side view and in frontal view. Morphological details of the zygomatic arch (curvature, profile, suture) are well suited to sustain the evoked stresses by a minimum of material.     

Analysis and results of treatment of established posttraumatic facial deformities.

The clinical records of 125 patients undergoing treatment for posttraumatic facial deformities (PTFD) from 1979 to 1990 were retrospectively reviewed. Patients with complex fractures had a combination of at least three of the major fracture categories [Le Fort I, II, III; naso-orbital-ethmoid (NOE); zygomatic; frontobasilar; and mandibular]. Twenty-five patients (20 percent) were found to have severe posttraumatic facial deformities resulting from a complex facial fracture pattern. Sixteen were males and nine were females, and their ages at the time of our first reconstructive procedure ranged from 22 to 64 years (mean 33 years). All patients presented to our clinic with severe posttraumatic facial deformities from 1 month to 26 years (mean 5 years) after original injury. The number of prior reconstructive attempts averaged two (range 0 to 9). Arbitrary severity scores assigned by us were mild in 4, moderate in 12, and severe in 9 patients. Once treatment was initiated in our clinic, the average number of operations was 3.76 until completion (range 1 to 15). Surgical treatment was aimed first at reestablishing proper skeletal, vertical, transverse, and sagittal proportions. Once skeletal foundations were reset, the more delicate naso-orbital-ethmoid and lateral canthal relations were addressed. Of the 25 patients, 13 (52 percent) suffered a complication at some point during their surgical management. In these 13 patients, 20 complications occurred in a total of 94 operations for an overall complication rate of 21 percent. Fifteen of the 20 complications were related to infection. Skeletal abnormalities in patients with posttraumatic facial deformities can generally be corrected with current craniomaxillofacial techniques. Ultimately, an excellent result in terms of skeletal reconstruction is compromised by the status of the surrounding soft tissue. More in-depth knowledge of the nature and magnitude of the initial and subsequent soft-tissue injury will contribute to our ability to treat these disfiguring posttraumatic sequelae.     

颞部Gillies切口在颧骨复合体骨折手术中的应用

目的:颞部Gillies切口在颧骨复合体骨折手术中的应用效果。方法:运用颞部Gillies切口治疗25例病人颧骨复合体骨折,观察手术进路,显露术区,在直视下行颧骨骨折复位内固定术。结果:25例患者应用此术式均可显露骨折区域,满足颧骨复合体骨折的手术显露需要,而且与常规颧骨复合体骨折(头皮冠状切口)手术相比,减小了出血及损伤神经的可能。结论:颞部Gillies切口在颧骨复合体骨折手术中优于其它手术路径,值得临床推广。     

The sphenozygomatic suture as a key site for osteosynthesis of the orbitozygomatic complex in panfacial fractures: a biomechanical study in human cadavers based on clinical practice

The aims of this study were to determine the forces required for fracturing the intact orbitozygomatic complex and to evaluate the strength of the orbitozygomatic complex-fixation, especially with regard to the sphenozygomatic suture as a fixation point. In severe midfacial and panfacial fractures, the sphenozygomatic suture is routinely used in the authors' practice as a key site for fixation of the orbitozygomatic complex, thus establishing a stable outer frame as a basis for subsequent reconstruction. However, this has never been formally described, nor has it been biomechanically tested. Eight human cadaver heads were subjected to forces applied in a standard fashion to the orbitozygomatic complex on both sides (n = 16) using a servohydraulic testing machine. The force required to break the intact orbitozygomatic complex was measured on both sides. Subsequently, fracture patterns were noted and each orbitozygomatic complex (n = 16) was assigned to one of four groups: four-point fixation (zygomatic arch, frontozygomatic suture, infraorbital rim, zygomaticomaxillary buttress) using a 1.3/2.0-mm titanium system (group 1) and a 2.0-mm bioresorbable system (group 3); or three-point fixation (zygomatic arch, frontozygomatic suture, sphenozygomatic suture) using 1.3/2.0-mm titanium system (group 2) and a 2.0-mm bioresorbable system (group 4). Forces for failure of the constructs were measured. The force for failure of the intact orbitozygomatic complex was 1826 +/- 852 N. The mean force required for failure of the reconstructed orbitozygomatic complex was 504 +/- 178 N for group 1, 620 +/- 304 N for group 2, 93 +/- 22 N for group 3, and 133 +/- 31 N for group 4. The titanium constructs provided 27.7 percent (four-point fixation) and 31.7 percent (three-point fixation) of the intact breaking strength of the orbitozygomatic complex, which was significantly higher (p < 0.05) compared with 5.4 percent (four-point fixation) and 7.7 percent (four-point fixation) for the bioresorbable system. Plate bending (91 percent) was the primary cause for failure in the titanium plating system, whereas plate and screw breakage (57 percent) was responsible for failure of the resorbable system. The fixation of the sphenozygomatic suture was a key site in the fixation of the orbitozygomatic complex, which could be demonstrated with superior results in the three-point fixation group compared with the four-point fixation group. The bioresorbable system showed the lowest values in this cadaver study. Further experimental and clinical studies might determine whether the bioresorbable materials are sufficient for the treatment of complex fractures of the orbitozygomatic complex.     

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.     

Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad

The anatomy of the temporal region, with reference to the frontal branch of the facial nerve, was examined in 12 fresh cadaver dissections. In all dissections, the frontal branch traveled in a constant plane along the undersurface of the temporoparietal fascia and was quite superficial as it crossed the zygomatic arch. The deep temporal fascia and superficial temporal fat pad are anatomically important structures which adjoin the periosteum of the zygomatic arch and lie deep to the frontal nerve. Based on these relationships, a safe method of dissection within the temporal region is formulated.     

Intraoral approach for reduction malarplasty: a simple method

Young Korean women with prominent zygoma may experience stress in daily life because the Oriental physiognomy often associates prominent zygoma with bad luck. Moreover, prominent zygoma in a wide Oriental face has the effect of making a person appear older and stubborn. Zygomatic reduction is often necessary to relieve stress from self-consciousness about facial appearance and to obtain younger and softer features. As such, most zygomatic procedures are cosmetic; therefore, an entirely intraoral approach with no skin incision is desirable. The current operative method of zygomatic reduction consists of two steps. The zygomatic body and arch are exposed through a mucoperiosteal incision from the maxillary canine to the first molar area. The first step is to grind and file the zygomatic body. The second step is made on the zygomatic arch. Using an oscillating saw, a partial-thickness osteotomy is made just posterior to the orbital rim, and a full-thickness osteotomy is made just anterior to the articular tubercle of the zygomatic arch. Light pressure on the posterior part of the arch produces a greenstick fracture of the anterior osteotomy site and a complete fracture of the posterior osteotomy site, resulting in inward repositioning of the zygomatic arch. This method of zygomatic reduction is simple, easy, effective, and leaves no conspicuous scars on the face.     

颧骨复合体骨折手术治疗的临床研究

目的：观察和对比头皮冠状切口及小切口联合入路在各种颧骨复合体骨折治疗中的效果。方法：分析2002年～2005年于我院口腔颌面外科救治的62例颧骨复合体骨折病人手术入路及临床效果。结果：根据不同类型的骨折,选择不同术式和切口,术中患者使用微型钛板行坚固内固定,术后均达到面形及功能的恢复。结论：对于大部分颧骨复合体骨折可以采用小切口的单独或联合入路进行治疗,对于颧骨体颧弓粉碎性骨折及陈旧性骨折应采用头皮冠状切口加必要的辅助切口。     

Maxillary reconstruction: functional and aesthetic considerations

Maxillary reconstruction is a challenging endeavor in functional and aesthetic restoration. Given its central location in the midface and its contributions to the key midfacial elements--the orbits, the zygomaticomaxillary complex, the nasal unit, and the stomatognathic complex--the maxilla functions as the keystone of the midface and unifies these elements into a functional and aesthetic unit. Maxillary defects are inherently complex because they generally involve more than one midfacial component. In addition, most maxillary defects are composite in nature, and they often require skin coverage, bony support, and mucosal lining for reconstruction. In the reconstruction of maxillary defects secondary to trauma, ablative tumor surgery, or congenital deformities, the following goals must be met: (1) obliteration of the defect; (2) restoration of essential functions of the midface, such as mastication and speech; (3) provision for adequate structural support to each of the midfacial units; and (4) aesthetic reconstruction of the external features. This review will discuss the pertinent anatomic considerations, the historical approaches to maxillary reconstruction, and the merits of the techniques in use today, with an emphasis on state-of-the-art reconstruction and dental rehabilitation of extensive maxillary defects.     

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.     

Accuracy and reproducibility of voxel based superimposition of cone beam computed tomography models on the anterior cranial base and the zygomatic arches

Superimposition of serial Cone Beam Computed Tomography (CBCT) scans has become a valuable tool for three dimensional (3D) assessment of treatment effects and stability. Voxel based image registration is a newly developed semi-automated technique for superimposition and comparison of two CBCT scans. The accuracy and reproducibility of CBCT superimposition on the anterior cranial base or the zygomatic arches using voxel based image registration was tested in this study. 16 pairs of 3D CBCT models were constructed from pre and post treatment CBCT scans of 16 adult dysgnathic patients. Each pair was registered on the anterior cranial base three times and on the left zygomatic arch twice. Following each superimposition, the mean absolute distances between the 2 models were calculated at 4 regions: anterior cranial base, forehead, left and right zygomatic arches. The mean distances between the models ranged from 0.2 to 0.37 mm (SD 0.08-0.16) for the anterior cranial base registration and from 0.2 to 0.45 mm (SD 0.09-0.27) for the zygomatic arch registration. The mean differences between the two registration zones ranged between 0.12 to 0.19 mm at the 4 regions. Voxel based image registration on both zones could be considered as an accurate and a reproducible method for CBCT superimposition. The left zygomatic arch could be used as a stable structure for the superimposition of smaller field of view CBCT scans where the anterior cranial base is not visible.     

Sagittal fractures of the maxilla and palate

Sagittal fractures of the maxilla and palate are infrequent and can demonstrate significant instability with conventional methods of treatment. They require that rigid, horizontal stability of the dentition be obtained, as well as restoration of midface projection and height. The most effective and precise management has utilized a combination of open reduction and internal fixation at the piriform aperture and zygomatic buttress and posterior palate, use of a maxillary arch bar as a tension band, and utilization of a palatal splint.     

Endoscopically assisted malarplasty: one incision and two dissection planes

Asian society is uniquely concerned about the distinctive facial features associated with malar prominence. Various methods of reduction malarplasty have been developed and are currently being applied. In this study, a new approach to malarplasty was experimentally assessed between December of 1999 and August of 2001. After having received careful observations of their facial features and full counseling sessions, 32 patients were selected. These patients had three distinctive characteristics: (1) severe zygomatic arch prominence and normal zygomatic body prominence, (2) desire for only a reduction of the lateral prominence, and (3) desire for a less invasive surgery. Through a short incision in the temporal area, the authors performed the dissection as two different planes. Endoscopic dissection between the superficial layer of deep temporal fascia and the temporoparietal fascia to the zygomatic body and blunt dissection under the deep layer of the deep temporal fascia to the zygomatic arch were performed. Complete osteotomy of the zygomatic arch and an incomplete osteotomy of the zygomatic body were then performed with a reciprocating saw. Finally, the zygomatic arch for the zygoma infraction was pressed manually. The major advantages of this procedure are its simplicity and the short operation and recovery time, with little bleeding and edema.     

Maxillary hypoplasia secondary to midfacial trauma in childhood

Three normal children who suffered midfacial trauma and developed midfacial retrusion that would require Le Fort III advancements for correction of the deformity are described. The common denominator in these three cases seems to be an injury to the medial facial structure including the nasal septum. It is concluded that midfacial fractures in childhood may be a cause of subsequent midfacial hypoplasia.     

Periosteal suspension of the lower eyelid and cheek following subciliary exposure of facial fractures

Following craniofacial procedures that involve stripping of the periosteum and soft tissue over the zygomatic maxillary complex, descent of soft tissue with a decrease in anterior projection over the malar area and increase in fullness in the nasolabial fold have been seen to be a problem by these authors. Simple repositioning of the soft tissues to their normal anatomic position may be used to alleviate this problem.     

颧骨颧弓骨折的分类及诊治

颧骨颧弓骨折是最常见的面中部骨折之一,迄今为止,在其分类及诊治的选择上仍然存在一定争议,本文对目前颧骨颧弓骨折的分类及诊治的现状和进展作一综述,以期对临床工作提供参考。     

Hyoid and pharyngeal arch function during ventilation and feeding in elasmobranchs: Conservation and modification in function

The hypothesis that the mandibular and hyoid arches evolved from anterior pharyngeal arches to increase ventilation performance and subsequently became adapted for feeding is widely accepted. As jaws evolved, the morphology of the hyoid arch changed notably from that of a pharyngeal arch. Furthermore, hyoid arch morphology varies considerably among elasmobranch taxa and has been shown to be related to feeding style. The goal of this study is to determine whether the function (direction of movement or change in cavity cross‐section) of the hyoid arch is altered from that of the pharyngeal arch, and whether function is altered between ventilation, the basal behavior, and feeding, the derived behavior. Similar effects and associations of the pharyngeal arches by orientation to feeding or ventilation are also investigated. The kinematics of the hyoid and second pharyngeal arch during ventilation and feeding are quantified using sonomicrometry and hyomandibular angle measured in five shark and one skate species representing widely divergent hyomandibular morphologies. Hyoid and pharyngeal cavity width follows the same pattern of movement during ventilation; therefore the hyoid arch retains the ancestral function of the pharyngeal arches. The orientation of the hyomandibular cartilage appears to influence the pattern of arch movement during ventilation: anterior directed elements decrease in cavity width; laterally directed elements increase in cavity width; while posterior directed elements increase in cavity width or do not change; while cavity depth increases in all species. Hyoid and pharyngeal cavity width movement differs among the species during feeding and also appears to be related to hyoid arch orientation as well as feeding style. There appears to be a division between those species with hyomandibular angles less than 110° from those that are greater between feeding mode and hyoid cavity width movement. Primarily suction feeding species decrease hyoid cavity width whereas primarily bite feeding species increase hyoid cavity width during feeding while all species increase hyoid cavity depth.     

Anatomicohistologic study of the retaining ligaments of the face and use in face lift: retaining ligament correction and SMAS plication

Plastic surgeons have sought to improve nasolabial folds, jowls, jaw lines, and cervical contour with face-lifting procedures that are abundant in the literature. The retaining ligaments of the face support facial soft tissue in normal anatomic position, resisting gravitational change. As this ligamentous system attenuates, facial fat descends into the plane between the superficial and deep facial fascia, and the stigmata of facial age develop. In this study, surgical correction of the retaining ligaments and plication of the superficial musculoaponeurotic system (SMAS) to reposition the structures that have descended with gravitation are discussed. The anatomy of the facial retaining ligaments was studied in 22 half-faces of 11 fresh cadavers, and the localization, extension, and width of the ligaments were examined macroscopically and histologically. Surgical correction of the retaining ligaments and plication of the SMAS have been accomplished in 27 face-lift patients with this anatomicohistologic study taken into consideration. There was hematoma in one patient at the cheek region and a permanent dimple caused by postoperative edema in two patients, with a localization of one zygomatic and two parotidomasseteric ligaments. In one patient, hypesthesia in the mandibular nerve region was seen, which remitted at 14 weeks. There were no other complications, and with a follow-up of 24 months, excellent aesthetic results and a high level of patient satisfaction were encountered.     

Reduction malarplasty through an intraoral incision: a new method

Until recently, osteotomies and surgeries to reposition prominent zygoma have been performed by means of a coronal incision or intraoral and preauricular incisions. Such incisions have penalties such as scars, the possibility of facial nerve injury, and long operative times. After reflecting on their past experiences with facial bone surgery, the authors developed an alternative approach. In this method, the cheekbone protrusion is corrected by performing an osteotomy and repositioning through an intraoral incision only. During the past 3 years, the authors have operated on 23 patients with malar prominences. The amount of bone to be removed is determined by preoperative interviews, physical examinations, and x-rays. Intraoral incisions provide access to the zygomatic body and lateral orbital rim. After L-shaped osteotomies (two parallel vertical and one transverse osteotomy at the medial part of the zygomatic body), the midsegment is removed. The posterior portion of the zygomatic arch was approached through the medial aspect and was outfractured using a curved osteotome. After completing the triple osteotomy, the movable zygomatic complex was reduced medially and fixed with miniplates and screws on the zygomaticomaxillary buttress. The patients were followed for 9.5 months, with acceptable results and few complications. The authors conclude that this technique is an effective and safe method of reduction malarplasty.