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Cummings Ch 23/24 Maxillofacial Trauma Reconstruction of Facial Defects

Cummings Ch 23/24 Maxillofacial Trauma Reconstruction of Facial Defects. Julianna Pesce October 29, 2014. Anatomy. Upper Third Frontal bones Middle Third Zygomas, orbits, maxillae, nasal bones Lower Third Mandible. Evaluation and Diagnosis. ABCs Airway

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Cummings Ch 23/24 Maxillofacial Trauma Reconstruction of Facial Defects

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  1. Cummings Ch 23/24Maxillofacial TraumaReconstruction of Facial Defects Julianna Pesce October 29, 2014

  2. Anatomy • Upper Third • Frontal bones • Middle Third • Zygomas, orbits, maxillae, nasal bones • Lower Third • Mandible

  3. Evaluation and Diagnosis • ABCs • Airway • High rate of c-spine fractures if facial trauma • PE • scalp, forehead • Orbits/vision, zygomas, nasal bones, septum, maxillae • Teeth, mandible, occlusion • Sensation, facial nerve function • CT is workhorse

  4. Frontal Sinus • Anterior/posterior table, comminution, thickness • Sakas and colleagues: the more central and the more severe the fracture, more likely csf leakage

  5. Frontal Sinus Repair • Is exploration necessary? Is obliteration necessary? • Anterior wall for cosmesis • Posterior wall to protect anterior cranial fossa • If nasofrontal ducts involved may lead to infection • Obliteration via cranialization if posterior wall severely comminuted

  6. Le Fort • Le Fort I • Horizontal maxillary fx • Le Fort II • Pyramidal fx • Le Fort III • Complete craniofacial separation

  7. Midface Repair • Reestablish buttress system • Horizontal butresses serve as connectors across vertical buttresses • Lateral vertical buttress of midface extends from frontal bone along frontozygomatic area down across zygomaticomaxillary area • Medial vertical buttress extends from frontal bone across frontonasal region and down across nasomaxillary junction

  8. NOE A: type 1- solid central segment to which medial canthus is attached B: type II- more comminuted but still central segment to which medial canthus is intact C: type III- completely comminuted

  9. NOE repair • Difficult, esp if comminuted • Ensure positioning and fixation of canthal ligament to prevent telecanthus • If medial canthal ligaments attached to central bone– stablize bone to surrouding skeleton • If comminuted expose ligament and fix to frontal bone

  10. Mandible • Symphyseal, parasymphyseal, body, angle, ramus, condyle, coronoid • Favorable vs unfavorable: • Upward forces of temporalis and masseter • Downward forces of suprahyoid musculature • Almost all angle fxs are unfavorable

  11. Occlusion • Angles Classification • Class I: mesiobuccal cusp of maxillary 1st molar rests withing mesiobuccal groove of mandibular 1st molar • Class II: maxillary molar is more anterior • Class III: maxillary molar is more posterior

  12. Mandible Repair • Occlusion! • Plating if displaced, comminuted, unfavorable • Subcondylar fxs are controversial • MMF • Open reduction if condylar displacement into middle fossa, inability to obtain reduction, lateral extacapsular displacement of condyle, invasion by foreign body • Teeth in fracture line: pull if infected

  13. Surgical Approach • Upper third • Coronal • Middle third • Gillies, gingivobuccal, • Upper lid blepharoplasty • Transconj, subciliary • Lower third • Transoral • Transcervical

  14. COCLIA • Review the LeFort Fracture levels • When would you obliterate a frontal sinus fracture and what would you use? • What are indications for opening a condyle fracture? • Discuss subciliary vs transconjunctival approach to orbital fractures.

  15. Le Fort • Le Fort I • Horizontal maxillary fx • Le Fort II • Pyramidal fx • Le Fort III • Complete craniofacial separation

  16. Frontal sinus fractures and obliteration are controversial • Posterior table displaced more than one table width • Very comminuted fractures • Persistant csf leak • Obliteration with fat, bone, pericranial fat

  17. Condyle • Absolute indications for ORIF • Displacement into middle cranial fossa • Inability to obtain occlusion • Lateral extracapsular dislocation • Foreign body or contaminated open wound • Relative ORIF • Bilateral condylar fracture in edentulous mandible • Bilateral condylar fracture with midface fracture

  18. Orbital Approach • Subciliary • Higher risk of lower lid retraction • Transconjunctival

  19. Facial Defects • Local flaps: • Pivotal • Advancement • hinged

  20. Pivotal flaps • Move towards defect by rotating base of flap around pivot point • Rotational • Transposition • Interpolated • The greater the degree of pivot, the shorter the length

  21. Advancement flaps • Move towards defect by stretching or recoiling the tissue of the flap • Unipedicle • Bipedicle • V-Y and V-V

  22. Nasal repair • Small defects with adjacent nasal skin • Full thickness skin graft for shallow defects • Interpolated paramedian forehead flap or melolabial flap for deeper defect • Full thickness requires replacement of internal lining, structural support with cartilage or bone, external coverage with interpolated cheek or forehead flap

  23. Lip reconstruction • Less than one half with primary wound closure or local flap • ½ to 2/3 require full thickness flap from opposite lip or cheek • Full thickness >2/3 need regional flap or vascularized microsurgical flap

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