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Cummings Ch 23/24

Maxillofacial Trauma
Reconstruction of Facial Defects
Julianna Pesce
October 29, 2014
• Upper Third
– Frontal bones
• Middle Third
– 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,
• Sakas and colleagues: the more central and
the more severe the fracture, more likely csf
Frontal Sinus Repair
• Is exploration necessary? Is obliteration
• Anterior wall for cosmesis
• Posterior wall to protect anterior cranial fossa
• If nasofrontal ducts involved may lead to
• Obliteration via cranialization if posterior wall
severely comminuted
Le Fort
• Le Fort I
– Horizontal maxillary fx
• Le Fort II
– Pyramidal fx
• Le Fort III
– 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
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
• If medial canthal ligaments attached to central bone– stablize
bone to surrouding skeleton
• If comminuted expose ligament and fix to frontal bone
• Symphyseal, parasymphyseal, body, angle, ramus, condyle,

• Favorable vs unfavorable:
– Upward forces of temporalis and masseter
– Downward forces of suprahyoid musculature
– Almost all angle fxs are unfavorable
• 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
– 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
– Coronal
• Middle third
– Gillies, gingivobuccal,
– Upper lid blepharoplasty
– Transconj, subciliary
• Lower third
– Transoral
– Transcervical
• 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
• Discuss subciliary vs transconjunctival
approach to orbital fractures.
Le Fort
• Le Fort I
– Horizontal maxillary fx
• Le Fort II
– Pyramidal fx
• Le Fort III
– Complete craniofacial separation
• Frontal sinus fractures and obliteration are
• Posterior table displaced more than one table
• Very comminuted fractures
• Persistant csf leak
• Obliteration with fat, bone, pericranial fat
• 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
Orbital Approach
• Subciliary
– 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