Julianna Pesce October 29, 2014 Cummings Ch 23/24 Maxillofacial Trauma Reconstruction of Facial Defects Julianna Pesce October 29, 2014

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

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

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

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

Le Fort Le Fort I Le Fort II Le Fort III Horizontal maxillary fx Pyramidal fx Le Fort III Complete craniofacial separation Le fort 1- horiztonal maxillary fracture Le fort 2- pyramidal fracture Le fort 3- complete craniofacial separation

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

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

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

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

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

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

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

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.

Le Fort Le Fort I Le Fort II Le Fort III Horizontal maxillary fx Pyramidal fx Le Fort III Complete craniofacial separation Le fort 1- horiztonal maxillary fracture Le fort 2- pyramidal fracture Le fort 3- complete craniofacial separation

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

Condyle Absolute indications for ORIF Relative 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

Orbital Approach Subciliary Transconjunctival Higher risk of lower lid retraction Transconjunctival

Facial Defects Local flaps: Pivotal Advancement hinged

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

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

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

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