Long-term physical impairment and functional outcomes after complex facial fractures

To develop an understanding of the expected functional outcomes after facial trauma, a retrospective cohort study of patients with complex facial fractures was conducted. A cohort of adults aged 18 to 55 years who were admitted to the R. Adams Cowley Shock Trauma Center between July of 1986 and July of 1994 for treatment of a Le Fort midface fracture (resulting from blunt force) was retrospectively identified.Outcomes of interest included measures of general health status and psychosocial well being in addition to self-reported somatic symptoms. General health status was ascertained using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). The Body Satisfaction Scale was used to define patient concerns about altered body image and shape. To determine whether complex maxillofacial trauma and facial fractures contributed to altered social interactions, the Social Avoidance and Distress scale was used. In addition, information about a patient, his or her injury, and its treatment were ascertained from the medical records.Using the methods described above, 265 patients with Le Fort fractures were identified. These individuals were matched to a similar group of 242 general injury patients. A total of 190 of the Le Fort patients (72 percent of those eligible for the study) and 144 (60 percent) general injury patients were successfully located, and long-term interview data were acquired.Le Fort fracture patients as a group had similar health status outcomes when compared with the group of general injury patients. However, when outcomes were examined by the complexity of the Le Fort fracture, the authors found that study subjects with severe, comminuted Le Fort injuries (group D) had significantly lower SF-36 scores (worse outcomes) for the two dimensions related to role limitations: role limitations due to physical problems and role limitations due to emotional problems (p < 0.05). SF-36 scores for all other dimensions except physical function were also lower for comminuted versus less complex Le Fort fractures, although differences were not statistically significant.Specifically, there was a direct relationship between severity of facial injury and patients reporting work disability. Of group C and D Le Fort patients (severely comminuted fractures) only 55 and 58 percent, respectively, had returned to work at the time of follow-up interview. These figures are significantly lower than the back-to-work percentage of patients with less severe facial injury (70 percent).When study participants were asked if they were experiencing specific somatic symptoms at the time of the interview that they had not experienced before the injury, a significantly larger percent of the Le Fort fracture patients (compared with the general injury patients) responded in the affirmative. Differences between the Le Fort fracture and general injury groups were statistically significant (p < 0.05) for all 11 symptoms.The percentage of patients reporting complaints increased with increasing complexity of facial fracture in the areas of visual problems, alterations in smell, difficulty with mastication, difficulty with breathing, and epiphora, and these differences reached statistical significance.Patients sustaining comminuted Le Fort facial fractures report poorer health outcomes than patients with less severe facial injury and substantially worse outcomes than population norms. It is also this severely injured population that reports the greatest percentage of injury-related disability, preventing employment at long-term follow-up. The long-term goal of centralized tertiary trauma treatment centers must be to return the patient to a productive, active lifestyle.     

Subunit principles in midface fractures: the importance of sagittal buttresses, soft-tissue reductions, and sequencing treatment of segmental fractures

The patterns of midface fractures were related to postoperative computed tomography scans and clinical results to assess the value of ordering fracture assembly in success of treatment methods. A total of 550 midface fractures were studied for their midface components and the presence of fractures in the adjacent frontal bone or mandible. Preoperative and postoperative computed tomography scans were analyzed to generate recommendations regarding exposure and postoperative stability related to fracture pattern and treatment sequence, both within the midface alone and when combined with frontal bone and mandibular fractures. Large segment (Le Fort I, II, and III) fractures were seen in 68 patients (12 percent); more comminuted midface fracture combinations were seen in 93 patients (17 percent). Midface and mandibular fractures were seen in 166 patients (30 percent). Midface, mandible, and nasoethmoid fractures were seen in 38 patients (7 percent). Frontal bone and midface fractures were seen in 131 patients (24 percent). Split-palate fractures accompanied 8 percent of midface fractures. Frontal bone, midface, and mandibular fractures were seen in 54 patients (10 percent). The midface, because of weak bone structure and comminuted fracture pattern, must therefore be considered a dependent, less stable structure. Its injuries more commonly occur with fractures of the frontal bone or mandible (two-thirds of cases) and, more often than not (>60 percent), are comminuted. Comminuted and pan-facial (multiple area) fractures deserve individualized consideration regarding the length of intermaxillary immobilization. Examples of common errors are described from this patient experience.     

Le Fort fractures without mobility

The Le Fort fracture without maxillary mobility constitutes 9 percent of maxillary fractures observed over a 3-year period. A high Le Fort (level II or III) injury exists as a one- or two-piece incomplete fracture. The degree of fracture is insufficient to permit mobility of the maxillary alveolus. Frequently, an obvious unilateral zygomatic fracture is present. Physical findings consist of bilateral eyelid ecchymosis and malocclusion. The occlusal disturbance may consist of either crossbite, open bite, maxillary rotation, or lack of proper dental intercuspation. On CT scan, fractures are best demonstrated in the posterior and medial maxillary walls at the Le Fort I level; they are most obvious unilaterally with contralateral fractures that may be subtle. Bilateral maxillary sinus fluid is consistently present on CT. Treatment usually consists of observation and traction elastics but may require mobilization of the fragments followed by open reduction and rigid fixation.     

The Le Fort III osteotomy: to distract or not to distract?

Treatment of the craniofacial dysostoses (e.g., Crouzon, Apert, Pfeiffer, Saethre-Chotzen syndromes) is critically dependent on the successful advancement of the midface with a Le Fort III procedure. The purpose of this retrospective clinical outcome study was to evaluate a new technique for distracting the Le Fort III procedure and to compare its results in growing children with those of the standard Le Fort III osteotomy. The records of 22 children were reviewed; 10 patients (mean age, 6.5 years) underwent a standard Le Fort III procedure, and 12 patients (mean age, 7.5 years) underwent a Le Fort III distraction procedure. The distraction group included two separate techniques, bilateral buried distraction (n = 2) and halo distraction (n = 10). Preoperative and 2- to 3-month postoperative cephalograms were analyzed. The average horizontal advancement achieved in the standard Le Fort III group was 6 mm, compared with 19 mm of advancement in the distraction group (p 相似文献   

Dual midfacial distraction osteogenesis: Le Fort III minus I and Le Fort I for syndromic craniosynostosis

Midfacial hypoplasia has been corrected by Le Fort III or monobloc forward advancement in one stage in syndromic craniosynostosis, but recently developed distraction osteogenesis has been in use. Whereas the amount of forward mobilization in Le Fort III conventional osteotomy is determined by the preplanned fabricated interdental splint, that in Le Fort III distraction is determined by the positions of the inferior orbital rim, malar complex, and nose. Therefore, the forward mobilization of the upper part of the midface may sometimes be insufficient when one focuses on the final occlusion, and the occlusion might not be satisfied when the forward mobilization is sufficient. Correction of the midfacial hypoplasia should be considered differently in the upper and lower portions of the midface. The upper portion contains the inferior orbit and nose, and the lower portion contains the occlusal structure of the maxillary dentoalveolar portion with the mandible. Separating the midface into two portions and conducting the distraction osteogenesis in both portions separately in different amounts and vectors of distraction is described in this article. Although distraction of the upper portion of the midface can be conducted in one direction with an internal device, distraction of the lower portion of the midface is preferred for conduction by a controllable device because of the need to obtain the preferred occlusion. To obtain better functional and aesthetic results in midfacial distraction in adults and adolescents with syndromic craniosynostosis, dual Le Fort III minus I and Le Fort I midfacial distraction osteogenesis was performed in four cases (in two patients with Crouzon syndrome and in two patients with Apert syndrome). Two females and two males are described (age range, 13 to 26 years). An internal device was used for the upper portion of the midface and an external device was used for the lower portion. The amount of distraction ranged from 14 to 21 mm in the upper portion of the midface and from 11 to 18 mm in the lower portion. No particular complications were noticed over a follow-up period of 10 to 38 months (average follow-up, 19.8 months).     

A histologic evaluation of fracture repair in the midface

Although much has been written regarding the treatment of facial bone fractures, at the present time there are no available investigations of human microscopic sections to verify the exact nature of the healing process. The consensus in the literature is that following fractures of the midface, the bone segments are united by fibrous union. Biopsies of the healed fracture sites were obtained in 10 consecutive patients who underwent secondary reconstructive procedures to correct residual deformities. Clinical assessment confirmed that the fractures were completely healed and stable. Histologic sections were obtained across the healed fracture sites, sent for H&E staining, and then examined by light microscopy. All specimens showed that the defects between the segments were obliterated by the formation of a mature compact bone. This bridging bone was characterized by concentric lamellae surrounded by a typical bony architecture. From this study it can be concluded that fractures of the midface heal by direct bony union.     

The role of primary bone grafting in complex craniomaxillofacial trauma

The role of craniofacial surgical techniques and immediate bone grafting in the management of complex craniofacial trauma has been reviewed. Four hundred and one patients with complex facial injuries have been treated. Two hundred and forty-one primary bone and cartilage grafts have been performed in 66 patients. Complex facial injuries should be managed by direct exposure, reduction, and fixation of all fractures utilizing interfragmentary wiring. Very comminuted or absent bone is replaced by immediate bone grafting, producing a stable skeleton without the need for external fixation devices. Associated mandibular fractures are managed with rigid internal fixation utilizing A-O technique. Results of immediate bone grafting have been excellent, and complications are rare. All deformities should be corrected, whenever possible, during the initial operation. This one-stage reconstruction of even the most complex facial injuries will prevent severe postoperative traumatic deformity and disability that may be extremely difficult or impossible to correct secondarily.     

Immediate versus delayed midface distraction in a primate model using a new intraoral internal device

The theoretic advantage of distraction osteogenesis of the craniofacial skeleton, especially in cases of severe midface retrusion and in the presence of maxillary scarring, is prevention of relapse following significant advancements. The purpose of this study is to demonstrate the utility of a new low-profile, intraoral, internal device for midface distraction at the conventional or high Le Fort I level. In addition, the present study compares the efficacy of immediate versus delayed distraction on subsequent maxillary relapse. Four adult rhesus Macaca mulatta monkeys were divided into two groups. Group 1 underwent immediate midface distraction; group 2 underwent delayed distraction. All four monkeys underwent a modified Le Fort I osteotomy through an upper buccal sulcus incision and bilateral application of the intraoral midface distraction devices. No other osteotomies or incisions were necessary. Immediate distraction, performed in group 1, entailed intraoperative activation of the devices and distraction of 10 mm followed by a 5-day lag period before postoperative activation and distraction of an additional 10 mm at the rate of 1 mm/day. Delayed distraction, performed in group 2, entailed a 5-day postoperative lag period before device activation and distraction of 20 mm at the rate of 1 mm/day. Both groups thus underwent 20 mm of midface distraction. All devices were removed 6 weeks after completion of distraction. All monkeys tolerated the devices and daily distraction uneventfully. On the basis of serial cephalograms and dental models obtained throughout the experimental period, there was no evidence of relapse in either the immediate or delayed groups 6 months after distraction. In addition, on the basis of histologic, ultrastructural, and dry skull analysis, no significant differences were observed in the quality of regenerate bone obtained when comparing the immediate and delayed distraction groups. Significant midface advancement is thus feasible using this new internal, intraoral distraction device, which presents several advantages over other internal devices that require coronal incisions and additional osteotomies to achieve midface advancement. In addition, immediate distraction may abbreviate the distraction period without adverse sequelae.     

Care of maxillofacial injuries: survey of plastic surgeons.

The purpose of this survey was to evaluate the current trends in the care of facial trauma. Data were obtained through the responses of a survey mailed to all those members and candidates listed in the 1989 American Society of Plastic and Reconstructive Surgeons Directory. A total of 2777 questionnaires were sent, with 1113 (40 percent) returned by means of a self-addressed envelope. Demographic results show that over 70 percent of the treating plastic surgeons fall within the age range 30 to 50 years. Although significant advances have occurred, treatment goals have remained unchanged. These center around the principles of accurate reduction and precise stabilization of fracture segments. The results of this survey reveal that a number of acceptable techniques were employed in the surgical repair of mandibular and zygomatic complex fractures. In the care of Le Fort III fractures, 59 percent of the respondents preferred the use of miniplates and screws for stabilization. Only 26.8 percent believed that facial fracture repair should be performed within the initial 24 hours. With frontal sinus fractures, the vast majority of plastic surgeons (82.1 percent) obtained a neurosurgical consultation. When the posterior wall was involved, 45.6 percent favored removal of the sinus mucosa, 29.7 percent obliterated the frontal sinus with a variety of autogenous materials, while 20.5 percent preferred cranialization. In summary, this survey shows a wide variation in the practice of facial fracture management within the plastic surgical community.     

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.     

Transblepharoplasty lower eyelid and midface rejuvenation: part II. Functional applications of midface elevation

Lower eyelid malposition is the cause of many ophthalmologic complaints, including ocular foreign-body sensation, irritation, excessive tearing, and sensitivity to light. The lower eyelid and midface are intimately associated structures. Midface descent frequently occurs in conjunction with lower eyelid laxity and descent. Elevating the lower eyelid and midface back to their normal anatomic positions frequently improves symptoms in these patients. The author has utilized the same techniques frequently used by aesthetic surgeons to elevate the lower eyelid and midface for patients, with improvement or resolution of their ocular complaints. The technique and results are presented.     

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.     

Exposure through a coronal incision for initial treatment of facial fractures.

The coronal incision approach to Le Fort III fractures gives excellent exposure for anatomical reduction and internal fixation of the fracture sites. Either an extracranial, or a combined intracranial procedure, is feasible. The exposure obtained not only facilitates the reduction and the fixation but, with the addition of transconjunctival incisions, the patient benefits by not having multiple surgical scars in the face.     

A new classification of palatal fracture and an algorithm to establish a treatment plan

Palatal fractures have previously been classified according to the anatomic location of the fracture line, which is helpful for understanding the types of palatal fracture, but which is insufficient for helping the surgeon to decide which fracture to open and how to do so. The purpose of this study was to aid in the establishment of a precise treatment plan by determining the surgical approach and the types of stabilization that should be used for different types of palatal fracture.In a retrospective review of 136 consecutive Le Fort maxillary fractures over 6 years, 18 patients (13.2 percent) with palatal fractures were analyzed. The principle of open reduction and internal fixation was applied to all the patients. In six patients (33 percent), exploration and fixation was done in the palatal surface. Eight patients (44 percent) needed an extended period of immobilization (4 to 6 weeks). No major complications were observed during the follow-up period.An algorithm was devised to help establish a proper treatment plan, and palatal fractures were classified into four types: closed reduction, anterior treatment, anterior and palatal treatment, and combined. The key elements considered in deciding the treatment principle and the classification of a palatal fracture were the possibility of closed reduction, surgical exposure, site of rigid fixation, and stability of fractured segments after rigid fixation. The outcome of reconstruction and the postoperative course differed depending on the type of palatal fracture. This classification scheme provided an easy and simple way to establish a treatment plan and was helpful in learning the treatment principles of palatal fracture.     

Blindness as a complication of Le Fort I osteotomy for maxillary distraction

High Le Fort I osteotomy and maxillary distraction has become an accepted method for the treatment of maxillary retrusion in children and teenagers with cleft lip and palate or craniofacial anomalies. This procedure effectively corrects the dentofacial deformity in these patients. No major surgical morbidity has been reported. During the past 4 years, 94 cleft patients with maxillary hypoplasia received Le Fort I osteotomy and distraction osteogenesis at the authors' center. Two of them developed blindness after this operation. The first case was a girl with bilateral cleft lip and palate with median facial dysplasia. She received high Le Fort I osteotomy at age 12 years 4 months to correct maxillary retrusion. Right eye swelling and ecchymosis was found after surgery. The patient complained of vision loss in that eye 2 days later. Computed tomography showed subarachnoid hemorrhage and skull base hematoma. There were no atypical fractures in the orbit, pterygoid plates, sphenoid bone, and skull base. Angiogram revealed left ophthalmic and basilar artery aneurysm. The second case was a 12-year-old boy with left cleft lip and palate. He received Le Fort I osteotomy to correct maxillary retrusion. During surgery, abnormal pupil dilatation was found after the osteotomy and down-fracture of maxilla. Emergent computed tomography found no hemorrhage or atypical fractures. Examination revealed complete left optic neuropathy and partial right abducens nerve palsy with mydriasis. Magnetic resonance imaging, magnetic resonance angiography, and repeated computed tomography revealed no sign of orbital injury, vascular problem, or abnormal fractures. The cause of blindness was unknown. In both cases, a steroid was used. Maxillary distraction was continued. Recovery of meaningful visual sense did not occur after 3 and 2 years' follow-up, respectively. A review of the literature revealed five other patients who suffered from visual loss after Le Fort I osteotomy. Inadvertent skull base fractures were identified in two cases, but a cause for the blindness was not known in the others. Induced hypotension and indirect trauma may be responsible for the optic nerve injury. In none of the cases was meaningful visual sense recovered, although high-dose steroids were given. In conclusion, a total of seven cases developed blindness after Le Fort I osteotomy. Once blindness develops, the prognosis is poor. High Le Fort I osteotomy should be performed with extreme care, and perhaps the informed consent should include visual loss as a complication of the procedure.     

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.     

Avianca flight No. 052 accident: a plastic surgical perspective

The crash of Avianca Airlines flight no. 052 en route to JFK Airport on January 25, 1990, in Cove Neck, New York, resulted in the death of 72 passengers. Eighty-nine victims were admitted to 13 regional hospitals. Despite difficult access to the wooded crash site, early warning and prompt response by 37 volunteer fire and rescue units resulted in organized EMS triage and rapid hospital transport. This report reviews the specific injuries incurred, highlights the team management approach to a major aviation accident in a suburban area, and studies the likelihood of accidents of this magnitude. Thirty-eight patients triaged to two level I trauma centers, North Shore University Hospital-Cornell University Medical Center and Nassau County Medical Center, form the basis of this report. Seventeen patients were male; 21 were female. The average patient age was 33 years. Eight patients were children. The average length of stay was 30.9 days (range 2 to greater than 90 days). Twenty-six patients (including nonsurvivors) (68 percent) sustained significant multiple orthopedic injuries. The majority of fractures were open grade II to III tibia-fibula fractures. Bilaterality was commonly seen. Soft-tissue coverage of open long bone fractures was required in 10 patients (11 extremities) and included 3 microvascular muscle transfers, 7 muscle transposition flaps, and 3 skin grafts. Seven patients required open reduction and fixation of complex facial fractures (two of Le Fort II to III type, four of complex naso-orbital-ethmoid type). Plastic surgical repair of complex lacerations was common. Peripheral nerve exploration was required in three patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Treatment of Mandibular Condyle Fractures Using a Modified Transparotid Approach via the Parotid Mini-Incision: Experience with 31 Cases

Surgery for mandibular condyle fractures must allow direct vision of the fracture, reduce surgical trauma and achieve reduction and fixation while avoiding facial nerve injury. This prospective study was conducted to introduce a new surgical approach for open reduction and internal fixation of mandibular condyle fractures using a modified transparotid approach via the parotid mini-incision, and surgical outcomes were evaluated. The modified transparotid approach via the parotid mini-incision was applied and rigid internal fixation using a small titanium plate was carried out for 36 mandibular condyle fractures in 31 cases. Postoperative follow-up of patients ranged from 3 to 26 months; in the first 3 months after surgery, outcomes for all patients were analyzed by evaluating the degree of mouth opening, occlusal relationship, facial nerve function and results of imaging studies. The occlusal relationships were excellent in all patients and none had symptoms of intraoperative ipsilateral facial nerve injury. The mean degree of mouth opening was 4.0 (maximum 4.8 cm, minimum 3.0 cm). No mandibular deviations were noted in any patient during mouth opening. CT showed complete anatomical reduction of the mandibular condyle fracture in all patients. The modified transparotid approach via the smaller, easily concealed parotid mini-incision is minimally invasive and achieves anatomical reduction and rigid internal fixation with a simplified procedure that directly exposes the fracture site. Study results showed that this procedure is safe and feasible for treating mandibular condyle fracture, and offers a short operative path, protection of the facial nerve and satisfactory aesthetic outcomes.     

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.     

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.