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

2. Anatomy Upper Third Middle Third Lower Third Frontal bones
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 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

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 Middle third Lower third Coronal
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 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

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 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

18. Orbital Approach Subciliary Transconjunctival 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

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

27. 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

29. 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