CME

Facial Fractures: Pearls and Perspectives

Obaid Chaudhry, M.D.
Learning Objectives: After studying this article, the participant should be able
Matthew Isakson, M.D.
to: 1. Describe the A-frame configuration of anterior facial buttresses, rec-
Adam Franklin, M.D.
ognize the importance of restoring anterior projection in frontal sinus frac-
Suhair Maqusi, M.D. tures, and describe an alternative design and donor site of pericranial flaps in
Christian El Amm, M.D. frontal sinus fractures. 2. Describe the symptoms and cause of pseudo-Brown
Oklahoma City, Okla. syndrome, describe the anatomy and placement of a buttress-spanning plate in
nasoorbitoethmoid fractures, and identify appropriate nasal support alterna-
tives for nasoorbitoethmoid fractures. 3. Describe the benefits and disadvan-
tages of different lower lid approaches to the orbital floor and inferior rim,
identify late exophthalmos as a complication of reconstructing the orbital floor
with nonporous alloplast, and select implant type and size for correction of sec-
ondary enophthalmos. 4. Describe closed reduction of low-energy zygomatic
body fractures with the Gillies approach and identify situations where inter-
nal fixation may be unnecessary, identify situations where plating the inferior
orbital rim may be avoided, and select fixation points for osteosynthesis of
uncomplicated displaced zygomatic fractures. 5. Understand indications and
complications of use for intermaxillary screw systems, understand sequencing
panfacial fractures, describe the sulcular approach to mandible fractures, and
describe principles and techniques of facial reconstruction after self-inflicted
firearm injuries.
Summary: Treating patients with facial trauma remains a core component of
plastic surgery and a significant part of the value of a plastic surgeon to a
health system.  (Plast. Reconstr. Surg. 141: 742e, 2018.)

T
he variable presentation and severity of facial
trauma, and the multiple organ systems
involved, require a gamut of technical skills
and conceptual knowledge that is concentrated in
our specialty. The plastic surgeon is often a cen-
tral part of a team of ear, nose, and throat; oral
and maxillofacial; ophthalmology; neurosurgery;
and trauma surgeons. After the initial encounter,
the plastic surgeon has to manage patient com-
pliance and expectations, and provide reliable,
cost-effective care. Emerging technologies in vir-
tual planning, prefabricated plates, and occlusal
splints promise to simplify planning and execu-
tion in severe injuries.
The incidence of motor vehicle accidents
has dropped over the past decades but may have
stabilized recently, even as the number of miles
driven increases.1 With autonomous driving tech-
nology, the incidence is expected to drop fur-
ther.2 Although motor vehicle accidents are the
From the Section of Plastic Surgery, University of Oklahoma.
Received for publication August 30, 2017; accepted
December 8, 2017.
Copyright © 2018 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000004340
most common cause of facial fractures in the
United States, altercations are the main cause in
Europe.3,4 Recreational vehicle accidents, sports-
related injuries, falls, and self-inflicted injuries are
other significant causes of facial fractures.5
The “opioid epidemic” has resulted in an asso-
ciated increase in the suicide rate. The rate of sui-
cide is 86.5 to 105 per 100,000 per year for opioid
users,6–8 up to two-thirds of these by firearm. Sur-
vivors have a low recidivism rate but face stigmati-
zation and devastating sequelae. Facial composite
allotransplantation is a newly available alternative
that has been used in cases of severe facial trauma;
however, its role needs further elucidation.9
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.
Related Video content is available for this
article. The videos can be found under the
“Related Videos” section of the full-text article,
or, for Ovid users, using the URL citations
published in the article.

742e www.PRSJournal.com
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 Volume 141, Number 5 • Facial Fractures

Treatment of facial fractures revolves around
a triad of reconstructing the anterior buttresses,
restoring occlusion, and optimizing the aes-
thetic appearance of the face. Anterior mid-
facial buttresses10 can be conceptualized as a
central A-frame structure, flanked by two inverted
A-frames (Fig. 1).
Treatment of low-energy, minimally dis-
placed, noncomminuted fractures by mechani-
cal offloading is often sufficient. In most other
cases, alignment of buttresses and interfragmen-
tary osteosynthesis is required. A severely commi-
nuted buttress is treated by spanning with a single
rigid plate between two nodes, a concept known
as “load-bearing.” Titanium is the most com-
mon material for plate-and-screw osteosynthesis.
Resorbable fixation is increasingly used for cra-
nial and maxillary fractures.11
With improved survival of major trauma,
secondary deformities of craniofacial trauma
are increasingly prevalent in the authors’
practice. Table 1 lists common sequelae and their
management.
FRONTAL SINUS FRACTURES
Management of frontal sinus fractures contin-
ues to be the subject of debate. An algorithm for
management is proposed in Figure 2.12–14
Reconstruction of the anterior wall should
emphasize restoring anterior projection. The sus-
pensory effect of a projecting glabella and nasal
dorsum acts as two tent poles to the periosteum of
the nasal sidewall, anterior limb of the medial can-
thal ligament, and superomedial orbital rim and
wall. This “tenting effect” prevents collapse and
widening of the glabella-nasion periosteal envelope
and maintains tension on the medial orbital wall
periosteum, the anterior limb of medial canthal
ligament, and “nasal valley” soft tissues (Fig. 3).
Harvesting vascularized pericranial and galeal
flaps from the frontal area may result in marked

Fig. 1. Midfacial buttress biomechanics. Note the inverted A-frame made by the two
paired frontonasomaxillary and lateral zygomaticomaxillary buttresses. When an A-frame
is loaded, the horizontal truss is in tension. Finite element modeling shows diffusion of
compressive (blue) and tensile forces (red). Buttresses in tension, such as the inferior orbital
rim, do not require osteosynthesis if their periosteal envelope is intact. When viewed from
below, the buttresses are remarkably straight within the complex facial framework.

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 Plastic and Reconstructive Surgery • May 2018

Table 1.  Secondary Deformities and Prevention

Secondary Deformity
Forehead contour deformity
Frontal osteoplasty resorption
Cicatricial ectropion
Secondary enophthalmos
Secondary exophthalmos
Medial canthal malposition
Lateral canthal malposition
Condylar resorption
Temporomandibular disorder
Cause/Prevention/Management
Avoid vascularized galeal flaps/use grafts; use midline pedicled galea flap and plan on fat
grafting
Use high frontal laterally based pericranial flap
Meticulous hemostasis; cheek soft-tissue suspension; orbicularis flap; canthopexy
Incorrect posterior position of floor plate; inadequate reconstruction of medial wall;
incorrect zygoma position; fat volume loss because of dissection
Avoid use of nonporous “smooth” plates
Incorrect posterosuperior vector of suspension; avoid use of flexible sutures/semirigid
wires preferred
Overcorrection needed for proptotic globes
Class 2 vector intermaxillary elastics; may be unavoidable in comminuted intraarticular
fractures; consider early prosthetic arthroplasty
Class 2 elastics/orthodontic treatment; bite block; myorelaxants; botulinum toxin

Fig. 2. Decision tree for management of frontal sinus fractures (after Echo A, Troy JS, Hollier LH Jr. Frontal sinus fractures. Semin
Plast Surg. 2010;24:375–382). fx, fracture; CSF, cerebrospinal fluid; NFOT, nasofrontal outflow tract; ORIF, open reduction and inter-
nal fixation.

postoperative osseous and soft-tissue contour
irregularity. In the setting of severe frontal lobe
damage and use of dural replacement patches,
the frontal lobe and dura may not readily expand
to contact the frontal osteoplasty, leaving the peri-
cranium as the only osteogenic surface for the
devascularized bone. In such cases, harvesting a
large pericranial flap from the low frontal area
may lead to significant resorption of the bone
flaps. The size and design of the pericranial flap
may be modified by harvesting a high pericranial
bucket handle flap based laterally (Fig. 4).
NASOORBITOETHMOID FRACTURES
So you see, it is simply a rhinoplasty.
—P. Tessier, concluding about
hypertelorism surgery
Nasoorbitoethmoid fractures involve disrup-
tion of the medial canthal support system, with its
attendant lacrimal system and underlying naso-
frontal duct (Fig. 5).15 Severe nasoorbitoethmoid
fractures are disfiguring injuries. Proper tech-
nique, timing, planning, and sequencing combine
to restore optimum form and function. Techni-
cally, the surgeon has to possess a diverse toolkit to
implement hard-tissue and soft-tissue repair, and
must be familiar with concepts, approaches, and
instruments used in multiple specialties. Repair
within 2 weeks is essential, as late and secondary
repairs often result in sometimes irreversible sub-
optimal results.
A coronal incision provides adequate access
in most cases, and Sargent recommends an addi-
tional small midline incision at the nasion for eas-
ier access.16 We prefer to use bilateral upper eyelid
medial incisions.17 The medial wall and inferior
orbital rim can be accessed using a transcarun-
cular/retrocaruncular approach extended into a
transconjunctival approach at the lower fornix.

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 Volume 141, Number 5 • Facial Fractures

Fig. 3. Illustration of the tenting effect of the forehead and dorsal nasal periosteal envelope. Markedly depressed
frontal sinus fracture with nasoethmoid splayed fracture. The patient is shown after restoration of forehead convexity
and nasal projection but before any medial canthal work. Restoring the nasal and glabellar “tent poles” resulted in a
secondary decrease of the intercanthal distance, improvement of the medial canthal soft-tissue valley contour, and
superior orbital rim angulation.

Fig. 4. Contour deformities secondary to harvest of a vascularized pericranial flap. A 32-year-old man
with major cranial, frontal sinus, and facial fractures. The patient underwent cranialization of his frontal
sinus and a large pericranial flap transposition to cover comminuted ethmoid fractures. The patient had
extensive resorption of his frontal bone. (Right) Modification of the pericranial flap design and donor site
to preserve pericranial coverage to the frontal bone segments.

This may require division of the inferior oblique
muscle at its origin just medial to the lacrimal
crest, which may lead to a secondary dysfunc-
tion of the superior oblique muscle. The patient
may present to the clinic with a chin-up posture
to avoid the uncomfortable diplopia on upward
gaze. This pseudo-Brown syndrome often resolves
spontaneously in a few months.18
In selected cases, an upper buccal sulcus
approach supplemented with upper eyelid inci-
sions is adequate, avoiding a coronal incision
and lower eyelid incisions. Individual miniplate
or microplate osteosynthesis of bone fragments
may be adequate for type 1 and certain type 2
fractures. Load-bearing plates spanning the
frontomaxillary buttress (Fig. 6) may be used

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 Plastic and Reconstructive Surgery • May 2018

Fig. 5. The Markowitz-Sargent-Manson classification of nasoorbitoethmoid fractures. Type 1 is characterized

by a large bony segment supporting an intact medial canthal attachment. Type 2 describes fractures with
comminuted osseous framework, and type 3 describes fractures with avulsed or disrupted medial canthal
insertion. The medial canthal ligament separates into three limbs (i.e., anterior, posterior, and superior) that
surround the lacrimal sac. Deep divisions of the orbicularis oculi muscle tent the lateral wall of the sac and
create the negative-pressure phase of the lacrimal pump mechanism. Reduction of the posterior limb of the
medial canthal ligament is sufficient to correct intercanthal distance, and is safer than percutaneous or trans-
caruncular methods of fixation.

to isolate the reconstruction from the compres-
sive forces of mastication. The nasofrontomaxil-
lary buttress is almost straight from the canine
fossa to the superomedial orbital rim, and such
a plate requires minimal contouring. (See Video
1, Supplemental Digital Content 1, which dis-
plays minimal incision approach to nasoorbito-
ethmoid fracture. This video is available in the
“Related Videos” section of the full-text article
on PRSJournal.com or at http://links.lww.com/
PRS/C724.) The nasal process of the maxillary
bone is often comminuted and not amenable
to individual fragment osteosynthesis. Tradi-
tionally, surgeons have relied on closed reduc-
tion with packing/splinting for fixation. We
have found this to be insufficient to counteract
the forces of mastication and pull of the facial
musculature, often resulting in asymmetric wid-
ening of the base of the nasal pyramid. Single
buttress-spanning plates may prevent such sec-
ondary deformities.
Medial canthal fixation is a technically
challenging step of the repair. Several options
are available, including mini-plate anchoring,
Mitek anchoring, and osteosynthesis screw
anchoring fixation. (See Video 2, Supplemen-
tal Digital Content 2, which displays methods
of medial canthopexy. This video is available
in the “Related Videos” section of the full-text
article on PRSJournal.com or at http://links.
lww.com/PRS/C725.) Transnasal wiring is the
most versatile and applicable in most scenarios.
(See Video 3, Supplemental Digital Content 3,
which displays medial canthopexy by transna-
sal stainless steel wiring. This video is available
in the “Related Videos” section of the full-text
article on PRSJournal.com or at http://links.
lww.com/PRS/C726.) A posterosuperior vector

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 Volume 141, Number 5 • Facial Fractures

Fig. 6. Spanning plate of frontomaxillary buttress. Note the straight configuration. Because of x-ray scatter, the 0.8-mm titanium
mini-plate appears thicker on computed tomography than it actually is. Note narrow and symmetrical nasal basal width on post-
operative photographs.

Video 1. Supplemental Digital Content 1, which displays minimal

incision approach to nasoorbitoethmoid fracture, is available in the
“Related Videos” section of the full-text article on PRSJournal.com or
at http://links.lww.com/PRS/C724.

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 Plastic and Reconstructive Surgery • May 2018

Video 2. Supplemental Digital Content 2, which displays methods

of medial canthopexy, is available in the “Related Videos” section of
the full-text article on PRSJournal.com or at http://links.lww.com/
PRS/C725.

Video 3. Supplemental Digital Content 3, which displays medial

canthopexy by transnasal stainless steel wiring, is available in the
“Related Videos” section of the full-text article on PRSJournal.com or
at http://links.lww.com/PRS/C726.

and overcorrection are critical. Securing the
medial canthus should be the last step before
closure to minimize secondary disruption.16
Nasal reconstruction centers on restoring
structural support. Loss of support is evaluated by
digital pressure on the nasal bony pyramid (upper
third), septum (middle third and supratip area),
and nasal tip, as each requires separate recon-
struction steps (Table 2).19 During that surgical
time, severe edema has typically set in, hiding the
residual deformities and distorting the minutiae
of reconstruction. A cantilevered or L-strut graft
should not obliterate the depth of the nasofron-
tal angle at the nasion. Its function is to restore

Table 2.  Decision-Making for Nasal Reconstruction in Nasoorbitoethmoid Fracture

Loss of/and Osseous Upper Third Septal Middle Third Tip
Osseous upper third Cantilevered graft Cantilevered graft L-shaped graft
Septal middle third Cantilevered graft Septal strut graft Septal extension graft
Tip L-shaped graft L-shaped graft Columellar strut

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 Volume 141, Number 5 • Facial Fractures
Fig. 7. External splinting. Rigid external splint with underlying
padding. Note location of holes through rigid external splint,
just anterior to medial canthal insertion and just caudal to the
nasal bone at the pyriform aperture. Stainless steel wires are
passed transnasally, joined to each other and over the dorsum.
(Above) Lateral view; (below) cross-section.
dorsal support for the middle and inferior thirds
of the nose.
Soft-tissue redraping is critical for the medial
canthal and nasal sidewall areas. Use of internal
and external suspension, and postoperative care
are critical for optimal results16,20,21 (Figs. 7 and 8).
ORBIT
Orbital fractures result in volumetric dis-
placement of orbital content. Contusion of the
extraocular muscles results in diplopia in certain
quadrants, with resultant avoidance posturing.
Diplopia in primary gaze indicates a more severe
acute globe displacement or asymmetric ophthal-
moplegias. Videos 4 and 5 illustrate salient points
of orbital floor and roof fractures. (See Video 4,
Supplemental Digital Content 4, which displays
orbital fractures. This video is available in the
“Related Videos” section of the full-text article on
PRSJournal.com or at http://links.lww.com/PRS/
C727. See Video 5, Supplemental Digital Content
5, which displays orbital roof fractures. This video
is available in the “Related Videos” section of the
full-text article on PRSJournal.com or at http://
links.lww.com/PRS/C728.)
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Fig. 8. Soft-tissue suspension at the nasion using the “K-stitch.”
(Above) Cross-section; (below) bird’s-eye view from the coronal
approach.
Orbital floor fractures may be managed
expectantly if the resultant defect is smaller than
a critical size, generally accepted to be approxi-
mately 1 cm2. Larger defects generally require
intervention, although historically these have
been managed expectantly, allowing for edema
to resolve, and operated on if enophthalmos
were to develop. In such cases, delayed repair of
enophthalmos is an exponentially more difficult
problem to treat, and no more than 2 to 3 weeks
should be allowed to elapse before surgery. Hypo-
thetically, a relatively intact periorbita can provide
sufficient support until secondary ossification,
but it is difficult to estimate the integrity of the
periorbital envelope from physical examination
and computed tomographic findings alone.22–25
“Rounding” of the inferior oblique on coronal
cuts suggests severe disruption of the orbital liga-
mentous system and is associated with postinjury
enophthalmos.26
The orbital floor can be approached through
a transconjunctival approach extended through
a lateral cantholysis, or through percutaneous
external incisions. A lower orbital rim incision
often results in contour disruption of the eyelid-
cheek junction, but provides broad and easy
access to the orbital floor, and results in fewer
cicatricial ectropions. That approach may be
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Video 4. Supplemental Digital Content 4, which displays orbital

fractures, is available in the “Related Videos” section of the full-text
article on PRSJournal.com or at http://links.lww.com/PRS/C727.

Video 5. Supplemental Digital Content 5, which displays orbital roof

fractures, is available in the “Related Videos” section of the full-text
article on PRSJournal.com or at http://links.lww.com/PRS/C728.

suitable for older patients. The subtarsal and sub-
ciliary incisions are more cosmetically acceptable,
but result in a relatively high incidence of ectro-
pion.27,28 Cicatricial ectropion is compounded by
insufficient resuspension of cheek soft tissues,
inadequate hemostasis, and denervation of the
orbicularis oculi caused by disruption of the distal
zygomatic nerve branches penetrating the under-
surface of the muscle at the orbitomalar retaining
ligament.29 In secondary revisions, it is prudent
to access the orbit through the same approach to
minimize disruption of lower eyelid structures.
Several implant materials are available for
orbital wall reconstruction. Newer implants
such as combined porous polyethylene-titanium
implants do not yet have long-term safety infor-
mation (Fig. 9).30,31 Autogenous bone graft is
preferred in cases where a dural tear is present,
cases where revision is likely, and in multiple wall
involvement. Biomaterials have proven noninferi-
ority in selected cases.32
Secondary enophthalmos is significantly
more difficult to treat; once the periorbita have
scarred in a particular configuration, the geom-
etry becomes more difficult to restore (Fig. 10).
Three-dimensional volumetric planning is par-
ticularly useful in such cases, and orbital volume
and geometry are carefully examined, compared
with contralateral anatomy or with controls. In
planning these repairs, the shape of the floor

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 Volume 141, Number 5 • Facial Fractures

Fig. 9. Late progressive exophthalmos caused by a seroma cavity surround-

ing a nonporous orbital floor plate. The material consisted of titanium mesh
with a porous polyethylene envelope, with a “smooth surface” at the globe
interface. This complication is historically reported with use of silicone orbital
floor implants.

Fig. 10. Late enophthalmos and canthal dystopia. (Left) After a rollover motor vehicle accident with ejection. (Center)
After initial reconstruction with severe soft-tissue and skeletal sequelae. Note deep right superior tarsal sulcus and
effaced right medial canthal contour and foreshortened nose and left alar cicatricial defect. (Right) After second-
ary reconstruction, medial wall and floor reconstruction, nasal cantilever graft, and soft triangle reconstruction with
composite graft. Note persistent foreshortened nose caused by mucosal contraction, and right lower lid ectropion.

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 Plastic and Reconstructive Surgery • May 2018

may be particularly straight, in which case simple
orbital floor augmentation results in concomitant
elevation of the globe. Custom-designed “enoph-
thalmos wedges” should instead be inserted poste-
riorly behind the globe, to restore and accentuate
the “S-shape” of the orbital floor. Several studies
estimate the desired volume of the implant rela-
tive to the existing enophthalmos, and a ratio of
1 cm3 for 1 mm of correction is a useful conserva-
tive rule of thumb. Autogenous bone grafts usu-
ally fail to hold up to the cicatricial process, and
are molded by the periorbital scar envelope rather
than vice versa; therefore, secondary enophthal-
mos is best corrected with alloplast.33
ZYGOMATICOMALAR COMPLEX
Malar complex fractures are common facial
fractures but differ significantly in cause, level of
energy, periosteal disruption, and biomechanics.
Direct trauma to the zygomatic arch results in a
common buckling fracture pattern that is amena-
ble to closed reduction with a Gillies elevator. The
resultant deformity is visible, even in the setting of
acute facial edema. Two-fragment comminution is
almost always stable after closed reduction without
internal fixation. Under fluoroscopic control, a
transmalar Kirschner pin tunneled under the arch
fragments can support unstable arch fractures in
select cases.34 Unstable arch fractures with com-
minution otherwise require a coronal approach
for reduction and fixation.35 Direct percutaneous
suspension is reported as an alternative, although
manipulation is often through the path of the
frontal branch of the facial nerve.
In altercations, blunt energy is imparted
directly to the malar prominence, which fractures
and displaces inferomedially, with minimal disrup-
tion of the periosteal envelope. Usually, the but-
tress aligned with the offending energy vector is
comminuted with an intervening fragment, typi-
cally the inferior zygomaticomaxillary buttress.
The malar complex can be reduced using a variety
of “closed” approaches, with our preference being
a Gillies temporal approach, because of superior
reduction of rotational deformities compared
with the intraoral Keen approach.36 (See Video
6, Supplemental Digital Content 6, which displays
the Gillies approach to treatment of a minimal
energy zygomaticomalar fracture. Reduction and
­retention in preparation for osteosynthesis of a
moderate energy fracture is also discussed. This
video is available in the “Related Videos” section of
the full-text article on PRSJournal.com or at http://
links.lww.com/PRS/C729.) A Carroll-Girard screw
provides direct control of the fracture fragment,
but is less useful when the body of the zygoma is
comminuted or nearly comminuted. If the malar
complex is properly reduced and stable, with mini-
mal stepoff at the inferior rim and zygomaticofron-
tal suture, no internal fixation may be required.
The patient is placed on a soft diet for 3 to 6
weeks to minimize the effect of masseter activity,
which tends to displace the malar complex in an

Video 6. Supplemental Digital Content 6 displays the Gillies

approach to treatment of a minimal energy zygomaticomalar frac-
ture. Reduction and retention in preparation for osteosynthesis of
a moderate energy fracture is also discussed. This video is available
in the “Related Videos” section of the full-text article on PRSJournal.
com or at http://links.lww.com/PRS/C729.

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 Volume 141, Number 5 • Facial Fractures
inferior and posterior vector. Even a small change
in malar position can have a profound effect on
orbital volume.22,23,37 Otherwise, in higher energy
injuries with unstable reduction, a poorly com-
pliant patient, or in patients with a penetrating
energy, internal fixation is required. The number
of buttresses that require fixation depends on the
comminution, displacement, and instability of the
fragments.38 Plating the zygomaticofrontal buttress
prevents secondary distraction of the fracture cal-
lus, leading to elongation of the lateral rim. This
is a common deformity observed in secondary
repositioning of a malar bone malunion.37 Plating
the inferior zygomaticomaxillary buttress provides
two-buttress fixation, which is sufficient fixation for
most cases. The inferior orbital rim functions as a
truss under traction during mastication, and does
not require protection from compressive forces. If
the rim fragments are reasonably aligned, with an
intact periosteal envelope and no palpable stepoff,
the biomechanical benefit of osteosynthesis of the
inferior rim may not outweigh the morbidity of
violating the inferior eyelid. The zygomatic arch
and the lateral orbital wall provide two additional
buttresses (zygomaticotemporal and sphenozygo-
matic) that can be used for fixation in severe com-
minution, or in secondary cases.37
In most low-energy cases, the orbital floor may
not require reconstruction because the periorbita
are relatively intact. If more than 2 cc of orbital
content is herniated into the sinus on preopera-
tive computed tomographic scan, if enophthal-
mos develops intraoperatively after reduction, or
if other midfacial bones are fractured (e.g., naso-
orbitoethmoid), the senior author (C.E.A.) pro-
ceeds to reconstruct the orbital floor.
In motor vehicle accidents, the energy vec-
tor is anteroposterior and transmitted through
the maxilla and dental structures. The zygomas
are splayed laterally, multiple midfacial bones
are fractured, and the orbital walls are severely
disrupted. These higher energy injuries require
precise reduction of translational and rotational
displacement of the body of the zygoma. All five
perizygomatic buttresses should be incrementally
considered for reconstruction to restore premor-
bid anatomy. This is essential to provide a stable
foundation for fixation of the central osseous
structures, such as the nasoorbitoethmoid frag-
ments. Knowledge of the original impact zone,
energy transmission, and fracture biomechanics
provides useful insight for sequencing reduction
and judicious selection of osteosynthesis sites. As
stated above, it is generally more efficient to prog-
ress from more stable to less stable.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
High-energy frontal impact in adults produces
a deformational wave that propagates through
the base of the skull into facial structures, caus-
ing otherwise inexplicable bilateral isolated zygo-
matic arch fractures,39 progressing to Le Fort III
craniofacial disjunction (with intact facial struc-
tures) in higher energy cases. The prognosis is
reserved because of the extent of neurologic dam-
age, and the management should therefore be
conservative.
MAXILLARY FRACTURES
The classic Le Fort fracture lines (Fig. 11)
indicate progressive crumple zones that collapse
sequentially when energy is imparted to the occlu-
sal arches. A force imparted cephalad through
the dentition will drive the maxillary body into
the sinuses, producing the Le Fort I fracture line.
Further force displaces the maxilla posteriorly
and slightly cephalad to produce the nasoorbito-
ethmoid fracture patterns, following the Le Fort
II patterns. Somewhat concomitantly, the midface
is wedged between the malar bones fracturing the
zygomas outward, completing the Le Fort III frac-
ture lines. Often, the crumple is asymmetrical and
may skip levels partially. As stated above, pure Le
Fort III craniofacial disjunction often results from
propagation of a deformation wave from a cranial
vertex impact with a small contrecoup from the
mandible.
After disimpaction of the maxilla, intermaxil-
lary fixation provides the cornerstone of accurate
reduction and should be the initial step in fractures
involving the dentition.40 Other midfacial struc-
tures are reduced beforehand, and osteosynthesis
Fig. 11. Le Fort classic description of midfacial fracture lines. Bio-
mechanically, these function as crumple zones and protect the
neurocranium from frontal trauma.
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of the four paired nasomaxillary and inferior zygo-
maticomaxillary buttresses is performed. The
pyriform rim and maxillary sinus walls offer thin
bones unsuited for buttress reconstruction. The
nasofrontal buttress is found between these two
structures, and good purchase for the osteosyn-
thesis screws can be obtained in the canine fossa
extending superiorly. Halfway through the but-
tress, in the nasal sidewall area, the external sur-
face of the maxilla thins out again as the buttress
is typically found underneath within the lateral
nasal wall. Thicker bone may be found superiorly
starting at the medial canthal area, extending into
the superomedial orbital rim. When adequate
purchase cannot be obtained in the lateral nasal
area, spanning plates should be considered. The
inferior (lateral) zygomaticomaxillary buttress
has thicker bone posterolaterally within the zygo-
matic process of the maxilla, and better purchase
can be obtained by placing a short L- or T-plate
on the lateral surface rather than anteriorly. In
cases with a comminuted buttress, osteosynthesis
may be obtained using a spanning L-plate placed
along the anterior surface of the buttress, secur-
ing purchase on the thicker body of the zygoma
superiorly and the body of the maxilla inferiorly.
If comminution involves only the anterior por-
tion of the buttress, with preserved alignment and
bone-to-bone contact along the posterolateral
maxillary sinus wall, a spanning plate is sufficient,
ignoring the anterior comminuted fragments. If
the lateral buttress is comminuted, reconstructing
the buttress span may require a bone graft.10
Isolated palatal fractures in the absence of
malocclusion do not require internal fixation.
In the setting of a displaced Le Fort fracture, a
comminuted palatal fracture may require fixation
through a transpalatal approach,41 as an alterna-
tive to interocclusal splints.
Alveolar fractures and comminution of the
anterior and lateral surface of the maxilla may be
treated with resin or wire loop bonding to adja-
cent stable teeth42 or through direct osteosyn-
thesis with microplates and small monocortical
screws. Salvage of mobile teeth and comminuted
alveolar segments is often possible.
MANDIBLE FRACTURES
Reconstruction of the mandibular arch is pro-
portional to the energy involved in its fracture,
the level of comminution, and fracture location.
A linear nondisplaced favorable fracture with
no malocclusion may be treated with a no-chew
diet and observation, especially in the pediatric
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Plastic and Reconstructive Surgery • May 2018
population. A severely comminuted mandible
is treated with a supraperiosteal “locking recon-
struction” plate, attempting to minimize disrup-
tion of the periosteum. In dentate regions of the
mandible, an alternative approach would be to
establish the occlusion with intermaxillary fixa-
tion and secondarily reconstruct the mandible.
For intermediate energy fractures, choice of fixa-
tion method is proportional to the disruption,
whereas load-sharing monocortical plates along
the “line of ideal osteosynthesis” should be the
starting consideration.43,44
Intermaxillary fixation is needed in various sit-
uations, and has traditionally relied on arch bars.
Rapid maxillomandibular fixation screws have been
available for several years and have seen increased
acceptance and use as a replacement to arch bars.
Early reports use maxillomandibular fixation screws
for fractures not involving the dentate segments45–47
and, more recently, in single fracture lines.48 Rapid
maxillomandibular fixation screws have better
patient acceptance, improve periodontal health,
facilitate hygiene, and decrease accidental sticks to
the operator. Potential side effects include loss of
anchorage after 5 to 6 weeks and a risk of dental root
injury, although most of these recover spontane-
ously. Maxillomandibular fixation screws are easily
removed in the clinic with topical anesthesia. (See
Video 7, Supplemental Digital Content 7, which dis-
plays alternatives to arch bars for intermaxillary fix-
ation. This video is available in the “Related Videos”
section of the full-text article on PRSJournal.com or
at http://links.lww.com/PRS/C730.)
Plate exposure, wound dehiscence, and infec-
tion collectively occur in 12 to 18 percent of
patients. These complications are more common
with intraorally placed plates and parasymphyseal
and body plates.49,50 The attached gingiva at the site
of fracture is often contused and partially avulsed.
The additional devascularizing effect of a gingivo-
buccal sulcus incision should be a consideration
for the choice of approach. Salivary pooling in the
sulcus over the suture line may also be a contrib-
uting factor. The sulcular approach elevates the
attached gingiva, preserving its lateral blood sup-
ply. When intermaxillary fixation screws or hybrid
intermaxillary fixation systems are used, they are
placed after elevation of the gingival flap. The
retaining screws are temporarily removed to allow
for suturing of the gingival incision and replaced
afterward using the original holes in the mandible.
A sulcular incision may be closed with a mandibu-
lar arch bar in place by using circumdental sutures.
This approach avoids devascularizing the attached
gingiva, and avoids salivary pooling over the suture
 Volume 141, Number 5 • Facial Fractures

Video 7. Supplemental Digital Content 7, which displays alter-

natives to arch bars for intermaxillary fixation, is available in the
“Related Videos” section of the full-text article on PRSJournal.com or
at http://links.lww.com/PRS/C730.

line. Disadvantages include a risk of gingival reces-
sion, which is mitigated by cleaning existing plaque
and advancing the flaps apically during closure.
(See Video 8, Supplemental Digital Content 8,
which displays the sulcular approach to mandible
fractures. This video is available in the “Related
Videos” section of the full-text article on PRSJour-
nal.com or at http://links.lww.com/PRS/C731.)
PANFACIAL FRACTURES
Panfacial fractures combine maxillary and
mandibular fractures and should be treated
at a tertiary referral center because of the high
incidence of associated injuries and the level of
expertise required.10,51 Intracranial, vertebral, and
visceral injuries take precedence, but fracture
treatment should not be delayed, to avoid loss of
domain or difficult-to-reverse cicatricial changes.
In the acute setting, a tracheostomy should be
considered. Profuse bleeding is often observed,
and initial attempts at control are made by pack-
ing and preliminary reduction/stabilization of
the maxilla. After securing the airway, packing
the oral cavity with large vaginal packs supports
the body of the maxilla inferiorly, followed by

Video 8. Supplemental Digital Content 8, which displays the sulcu-

lar approach to mandible fractures, is available in the “Related Vid-
eos” section of the full-text article on PRSJournal.com or at http://
links.lww.com/PRS/C731.

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Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • May 2018

Video 9. Supplemental Digital Content 9, which displays Le Fort I

fracture with edentulous mandible and fractured dentures, is avail-
able in the “Related Videos” section of the full-text article on PRS-
Journal.com or at http://links.lww.com/PRS/C732.

packing of the nasal cavity with custom-designed
nasal balloons, Foley catheter balloons, or nasal
packing material.52,53 Packing the nasal cavity with-
out stabilizing the maxilla may further worsen
the displacement and result in failure to control
bleeding. Endovascular embolization of the inter-
nal maxillary arteries is indicated as a second-line
option in the unstable patient, and provides useful
additional information about carotid or vertebral
artery intimal injuries.54,55 It should be noted that
even profuse bleeding usually stops after accurate
reduction and fixation of midfacial structures.
(See Video 9, Supplemental Digital Content 9,
which displays Le Fort I fracture with edentulous
mandible and fractured dentures. This video is
available in the “Related Videos” section of the
full-text article on PRSJournal.com or at http://
links.lww.com/PRS/C732.)
After obtaining intermaxillary fixation,
sequencing the repair is variable. We prefer an
“outside-in” approach starting with most stable,
using the less-affected side as a guide, and ending
with osteosynthesis of the tooth-bearing segments.
This may minimize revisions and manipulation of
the hardware holding the tooth-bearing segments,
which are typically comminuted and fragile. If the

Video 10. Supplemental Digital Content 10, which displays recon-

struction of self-inflicted shotgun wounds, is available in the
“Related Videos” section of the full-text article on PRSJournal.com or
at http://links.lww.com/PRS/C733.

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Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 141, Number 5 • Facial Fractures
frontal sinus is involved and/or craniotomies are
required, the coronal incision provides great access
for judging fragment reduction and obtaining
bone grafts (often for the orbital roof and walls),
and great access to the zygomatic arch. In a typical
scenario, we start by reduction and osteosynthesis
of the zygomas, using lateral orbital wall alignment
to verify rotational correction. This provides a suf-
ficient frame of reference for adequate orbital wall
and floor reconstruction. We address the nasoor-
bitoethmoid complex next, with cantilever bone
graft if needed. Transnasal canthopexy wires are
passed but not tightened. In cases where the facial
height reference is lost, such as bilateral subcon-
dylar fractures or comminuted ramus fractures,
bilateral preauricular incisions are used for open
reduction and internal fixation. For unilateral
condylar/subcondylar fractures, where one side
can be used as reference, the indication for open
reduction is less absolute, although we have a low
threshold for open repair. The mandible fractures
are treated first, followed by the perimaxillary but-
tresses. If spanning plates over the nasomaxillary
buttress have been used, the maxillary screws are
placed at this stage. The reduction and occlusion
are verified, adjustments made, and the medial can-
thopexy wires tightened before soft-tissue closure.
Video 10 shows principles and techniques
of treating self-inflicted shotgun injuries.56 (See
Video 10, Supplemental Digital Content 10, which
displays reconstruction of self-inflicted shotgun
wounds. This video is available in the “Related
Videos” section of the full-text article on PRSJour-
nal.com or at http://links.lww.com/PRS/C733.)
Christian El Amm, M.D.
825 NE 10th Street, Suite 1G
Oklahoma City, Okla. 73104-0464
Christian-elamm@ouhsc.edu
PATIENT CONSENT
Patients and parents or guardians provided written
consent for use of patients’ images.
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