Operative Techniques in Otolaryngology - Head and Neck Surgery, Volume 19, Issue 2, Pages 79-160 (June 2008), Management of Facial Trauma

8/19/2019 Operative Techniques in Otolaryngology - Head and Neck Surgery, Volume 19, Issue 2, Pages 79-160 (June 2008),…

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VIJAY K. ANAND, MDNew York, NY

DAVID D. CALDARELLI, MDChicago, IL

JAMES CHOW, MDMaywood, IL

LAWRENCE DESANTO, MDScottsdale, AZ

ISAAC ELIACHAR, MDCleveland, OH

RAPHAEL FEINMESSER, MD

Petah-Tiqva, IsraelALFIO FERLITO, MDUdine, Italy

DAN M. FLISS, MDTel Aviv, Israel

JEREMY FREEMAN, MD, FRCSCToronto, Canada

PHILLIP FRIEDMAN, MDSouthfield, MI

BRUCE J. GANTZ, MDIowa City, IA

JOSEPH JACOBS, MDNew York, NY

YOSEF KRESPI, MDNew York, NY

ROEE LANDSBERG, MDTel Aviv, Israel

HOWARD L. LEVINE, MDBeachwood, OH

MAHMOOD MAFEE, MDChicago, IL

ROBERT OSSOFF, MDNashville, TN

STEPHEN S. PARK, MDCharlottesville, VA

HAROLD C. PILLSBURY, III, MDChapel Hill, NC

DALE H. RICE, MD

Los Angeles, CADAVID E. SCHULLER, MDColumbus, OH

JAMES STANKIEWICZMaywood, IL

ELLIOT STRONG, MDNew York, NY

DAVID J. TERRISAugusta, GA

DEAN M. TORIUMI, MDChicago, IL

HARVEY TUCKER, MDCleveland, OH

B. TUCKER WOODSON, MDMilwaukee, WI

Operative Techniques in

OtolaryngologyHead and Neck Surgery

EDITORIAL BOARD


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FUTURE ISSUES

HEAD AND NECK TUMORSElizabeth Blair, MDSeptember 2008, Vol 19, No 3

ENDOSCOPIC SURGERY OF THE ORBIT AND LACRIMIALSYSTEMRaj Sindwani, MD, FRCSDecember 2008, Vol 19, No 4

THYROID-PARATHYROID SURGERY David J. Terris, MD, FACSMarch 2009, Vol 20, No 1

RECENT ISSUES

MINIMALLY INVASIVE HEAD AND NECK SURGERY Conrad Timon, MB, FRCSORL, MDMarch 2008, Vol 19, No 1

IMPLANTS AND GRAFTS IN RHINOPLASTY Craig D. Friedman, MD, FACSDecember 2007, Vol 18, No 4

COSMETIC SURGERY Raghu S. Athre, MDSeptember 2007, Vol 18, No 3

ACUTE SURGICAL MANAGEMENT OF THE AIRWAY David Goldenberg, MDJune 2007, Vol 18, No 2

NEW TECHNIQUES AND APPROACHES TO SLEEP APNEA IIB. Tucker Woodson, MD, FACSMarch 2007, Vol 18, No 1




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MANAGEMENT OF FACIAL TRAUMA

CONTENTS

INTRODUCTION 79

D. Gregory Farwell, MD, FACS

FREE TISSUE RECONSTRUCTION OF TRAUMATIC FACIALBONY DEFECTS 80

Douglas A. Girod, MD, FACS

ZYGOMATICO– ORBITO–MAXILLARY COMPLEX FRACTURES 86

Stephen Maturo, MD, Manuel A. Lopez, MD

MANAGEMENT OF SOFT-TISSUE TRAUMA TO THE FACE 90

Krishna G. Patel, MD, PhD, Jonathan M. Sykes, MD

PEDIATRIC ORBITAL ROOF FRACTURES 98

T.J. O-Lee, MD, Peter J. Koltai, MD

MANAGEMENT OF SYMPHYSEAL AND PARASYMPHYSEAL

MANDIBULAR FRACTURES 108


MANAGEMENT OF COMMINUTED MANDIBLE FRACTURES 113

Neal D. Futran, MD, DMD

TECHNIQUES OF MAXILLARY–MANDIBULAR FIXATION 117

Johnathan D. McGinn, MD, Fred G. Fedok, MD

Operative Techniques inOtolaryngologyHead and Neck Surgery

VOLUME 19, NUMBER 2, June 2008


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INTERNAL FIXATION OF MANDIBULAR ANGLE FRACTURES

WITH THE CHAMPY TECHNIQUE 123

David M. Saito, MD, Andrew H. Murr, MD, FACS

TRACHEOSTOMY SCAR REVISION 128

Travis T. Tollefson, MD, FACS, Amir Rafii, MD,J. David Kriet, MD

SURGICAL APPROACHES TO THE ORBIT 132

Clinton D. Humphrey, MD, J. David Kriet, MD

NASO-ORBITO-ETHMOID FRACTURE MANAGEMENT 140

Terry Y. Shibuya, MD, FACS, Vincent Y. Chen, MD,Young S. Oh, MD

FREE TISSUE RECONSTRUCTION OF TRAUMATIC

SOFT-TISSUE DEFECTS 145

Shri Nadig, MD, Wesley Schooler, MD, Mark K. Wax, MD

FRONTAL SINUS FRACTURES 151

E. Bradley Strong, MD


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Operative Techniques in Otolaryngology–Head and Neck Surgeryis dedicated to detailed, thorough, finest-quality illustrationsof new surgical procedures and techniques and to discussionof issues in surgical management of problems in the areas of otology, rhinology, laryngology, reconstructive head andneck surgery, and facial plastic surgery. New techniques that

are nonoperative will also be featured.Each issue of the journal typically includes the followingsections.

Editorials

feature articles: These articles are related to a featuredtheme of the issue and will be related by anatomic area ordisease process, or both. Each feature article will includeindications and contraindications, work-up and preparationof the patient, operative technique, and complications. Thesearticles will present new material related to the technique orresults of these procedures.

difficult decisions: This section focuses on a case related to

the central theme of the issue and will be presented withpatient photographs, diagnostic images, and/or other illus-trations. The case is discussed by a panel of authorities and ismoderated by the editor of the section.

innovative techniques: This highly illustrated section com- bines two or three techniques on a topic possibly related tothe featured theme of the issue and concentrates on newconcepts, innovations, and alternatives relevant to the prob-lem being discussed. Editorial comments may compare dif-ferent approaches to the same problem.

complications: Although this section often discusses com-plications related to the central theme, it also presents otherinteresting, unusual, and previously unpublished complica-tions in otolaryngology–head and neck surgery.

The contributions in the above sections may be invited; how-ever, the Journal welcomes submissions for the followingsections:

original articles: These articles should center around atechnique which need not be a surgical technique. New tech-niques for diagnosis, treatment, or rehabilitation will all beconsidered. The guidelines for authors that are presentedsubsequently on this page all relate to original articles.Original articles need not be theme-related.

letters to the editor: This correspondence should be brief and embody a point of view. Content should relate either topreviously published material in the Journal or to other rel-

evant issues in the surgical management of otolaryngology–head and neck surgery problems. Letters may include a shortlist of references as necessary.

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Editor: MICHAEL FRIEDMAN, MD30 N. Michigan Avenue, Suite 1107, Chicago, Illinois 60602Managing Editor: COLLEEN A. MARTIN


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References

Reference numbers in the text follow numerical order and areenclosed in parentheses. References are listed in the order inwhich they are cited in the text, not in alphabetical order; theymust follow the style of the samples given. All referencesmust be complete when the manuscript is submitted.

journal article: one to three authors

1. Arvvin AM: Herpes simplex infections during pregnancyand in infants. Semin Dermatol 3:89-101, 1984

2. Bromberg K, Hammerschlag MR: Rapid diagnosis of pneumonia in children. Semin Respir Infect 2:159-165, 1987

journal article: more than three authors

3. Hughes WT, Feldman S, Cox F, et al: Infectious diseases inchildren with cancer. Pediatr Clin North Am 21:583-616,1974

journal article in press

4. O’Malley JE, Eisenberg L: The hyperkinetic syndrome.Semin Psychiatry (in press)

complete book

5. Adams DO, Edelson PJ, Koren HS: Methods for StudyingMononuclear Phagocytes. San Diego, CA, Academic, 1981

chapter of book

6. Sallan SE, Weinstein HJ: Childhood acute leukemia, inNathan DG, Oski FA (eds): Hematology of Infancy andChildhood, vol 2. Philadelphia, PA, Saunders, 1987, p 1028

book that is a new edition and is in volumes

7. Altman SM, Rozells G, Jaffe J: The human brain understress, in Caster W (ed): The Causes of Stress, vol 4 (ed 4).San Diego, CA, Psychiatric Press, 1934, pp 109-199

chapter of book that is part of published meeting

8. Baron MH, Maniatis T: Stage-specific reprogramming of globin gene expression, in Stamatoyannopoulos G, Nien-huis AW (eds): Developmental Control of Globin GeneExpression, Proceedings of the Fifth Conference on Hemo-globin Switching, New York, NY, Alan R Liss, 1987

journal article in journal that is a supplement

9. Leach C, Roeder M, Cimino A: Genetic studies of lungcancer. Semin Oncol 3:27-33, 1987 (suppl)

abstract

10. Garson G, Harris B, MacDonald J: Vericeal hemorrhage. JPediatr Surg 3:17, 1987 (abstr)

editorial

11. Reasoner PH, Smith LT: An argument against laetrile.Semin Oncol 3:19-30, 1989 (editorial)

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Introduction

The management of facial trauma continues to evolve with

the development of improved techniques, surgical instrumen-

tation, and implants. From the days of wiring the jaws and

closed reduction to precise open reduction and internal fixa-

tion, the otolaryngologist-head and neck surgeon has played a

critical role in the treatment of patients with facial trauma.

This edition brings together many of the leaders in the

fields of facial trauma, reconstructive surgery, and cosmetic

surgery to summarize the state of the art approach to many

different aspects of traumatic injuries of the craniofacial

region. It is my belief that the information provided here

will provide the reader with a broad overview of the proper

workup of the patient, the surgical goals, and techniques

that will optimize patient outcomes.

I would like to extend my gratitude to the authors of

these articles for their hard work and contributions to this

volume. It is my belief that the quality of the information in

these articles will make this a very useful reference edition

for Otolaryngologists for many years to come.


Guest Editor

1043-1810/$ -see front matter © 2008 Elsevier Inc. All rights reserved.

doi:10.1016/j.otot.2008.05.001

Operative Techniques in Otolaryngology (2008) 19, 79


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Free tissue reconstruction of traumatic facial bony defects

Douglas A. Girod, MD, FACS

From the Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Kansas City,

Kansas.

Traumatic facial bony defects present one of the most challenging problems for the facial plastic

reconstructive surgeon. The most common mechanisms of trauma resulting in a bony defect of the

facial skeleton include gunshot injuries, motor vehicle accidents, and burns. These bony defects of thefacial skeleton resulting from trauma rarely occur in isolation. Rather, there is uniformly varying

degrees of soft-tissue trauma and/or loss, potential visual, neurological and spinal injuries, and other

associated life-altering implications. The application of free tissue transfer techniques to the manage-

ment of these complex defects has allowed a significant change in paradigm, permitting early inter-

vention and improved long-term outcomes.

© 2008 Published by Elsevier Inc.

KEYWORDSFacial reconstruction;

Trauma;Microvascular;

Free flap;

Bone defects

Traumatic facial bony defects are most commonly the

result of self-inflicted gunshot wounds resulting from at-

tempted suicide, followed by assault injuries (gun shot and

knife injuries) and motor vehicle accidents.1 These injuries

often include extensive soft-tissue damage, widespread con-

tamination of the wounds with orosinonasal secretions,bone fragments, and foreign body debris.1-3 Soft-tissue loss

often progresses over the course of 24-48 hours, further

complicating treatment planning. Immediate treatment of

these injuries requires a comprehensive systematic approach

to ensure all associated issues and injuries are addressed in

a timely fashion while preserving the soft-tissue envelope,

maintaining occlusive relationships and minimizing soft-

tissue contracture.

Futran and colleagues1 have proposed a protocol of

phased management of these acute traumatic bony defects.

They describe a 3-phase approach consisting of (1) initial

management, (2) definitive reconstruction, and (3) esthetic

and prosthetic refinement. This approach allows the surgeonto proceed through the many complex issues involved with

these patients in an organized fashion while accomplishing

all desired goals.

Phase I consists of the initial encounter where the ABCs

of trauma management are instituted, all life- and limb-

threatening injures are stabilized, and initial operating room

management is undertaken. Operative management should

include treatment of intracranial, ocular, and other major

injuries. Early management of the facial defect includes

establishing the occlusal relationships of the remaining

mandibular and maxillary segments and wound debride-ment of foreign material and obvious nonviable tissues. All

tissues of questionable viability should be preserved and

monitored for the need of further debridement. Major bony

segments should be repaired with the use of standard plating

techniques. Segmental mandible defects should be repaired

with bridging reconstruction plates to avoid soft-tissue

contracture. The use of locking screw reconstruction

plates of adequate size is preferable in this situation

(Figure 1A and B).4

Major maxillary, orbital, and nasal defects should be

addressed with cranial bone grafting if adequate soft tissue

exists. Because soft-tissue contracture is very difficult to

reverse, some surgeons prefer to also use temporary bonegrafting in the mid-face to maintain the soft-tissue envelope

even when adequate soft tissue is missing, with the intent of

subsequent replacement using free tissue transfer tech-

niques. Once these early goals have been completed, plan-

ning can begin for the definitive reconstruction and pros-

thetic rehabilitation. Psychiatric and social services are

often required at this time as well.

Phase II consists of the definitive reconstruction, which

should occur as soon as reasonable after the initial injury, as

dictated by the patients other major issues. Careful planning

is required to ensure the major functional and cosmetic

Address reprint requests and correspondence: Douglas A. Girod,

MD, FACS, Department of Otolaryngology-Head and Neck Surgery, Uni-

versity of Kansas School of Medicine, Mail Stop 3010, 3001 Eaton, Kansas

City, KS 66160.

E-mail address: [email protected].

1043-1810/$ -see front matter © 2008 Published by Elsevier Inc.

doi:10.1016/j.otot.2008.05.002

Operative Techniques in Otolaryngology (2008) 19, 80-85

mailto:[email protected]:[email protected]:[email protected]


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goals can be achieved. The use of free tissue transfer tech-

niques has allowed the aggressive early management of

defects where large amounts of soft tissue and bone are

missing. The long-term goals of the reconstruction willdictate the appropriate free tissue transfer flap(s) required to

provide the necessary amount of bone for mandibular and

maxillary reconstruction and soft tissue volume for bone

coverage, internal and external lining and cosmetic contour-

ing. Additional free bone grafting may also be required for

the reconstruction of the midface, nose and orbit. Local

flaps are used in a limited fashion to avoid compromise of

the soft-tissue envelope.

Phase III of patient management consists of esthetic and

prosthetic refinement, which may occur over weeks to

years. Free flap debulking and contouring is often required.

Dental rehabilitation with tissue-borne or implant-borne

prosthesis is undertaken. Additional cosmetic procedures,

facial prostheses, and tissue tattooing may also be required.

Technique

Once the initial phase of trauma management has been

completed as outlined in the previous section, the facial

plastic and reconstruction surgeon must begin the difficult

task of planning the definitive reconstruction. This often

requires a multidisciplinary team approach to define the

long term goals and objectives of the reconstruction.

Flap selection

The type of free tissue flap required will be dictated by

the defect and should be chosen to minimize the number of

Figure 1 (A) Mandible remnant after débridment of traumatic loss of the anterior mandibular arch from a self-inflicted gunshot wound.

(B) Locking screw bridging reconstruction plate applied to maintain occlusive relationships and the soft tissue envelope thus avoiding

wound contracture while waiting for definitive repair. (C) Free tissue transfer of bone contoured with 2 wedge-shaped osteotomies and

secured to the reconstruction plate with locking screws. Excellent bone contact should be achieved with the native mandible and all segments

of flap bone to facilitate bone healing.

81Girod Free Tissue Reconstruction of Traumatic Facial Bony Defects


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subsequent procedures and donor site morbidity. The use of

vascularized tissue allows these complex contaminated

wounds to heal rapidly without infection, with minimal

contracture and a high degree of reliability (95%). In one

study of 49 patients from 2 institutions, only 4 patients

required more than one free flap.1 Bone containing flaps

were most common (33 flaps), with fibula bone most fre-

quently used, followed by radius bone, scapula, and iliaccrest, respectively. Soft tissue flaps (21 flaps) consisted of

forearm flaps followed by rectus, latissmus, and a gracilis

flap, respectively. These authors’ experience is similar to

the experience of other authors.2,3,5,6 One report describes

the use of 3 simultaneous free flaps (bilateral fibula flaps

and a radial forearm fasciocutaneous flap) for the single-

stage reconstruction of a very large facial gunshot wound

involving the mandible, maxilla, and nose.5

Although flap selection is a multifactorial process, cer-

tain generalities exist. Segmental mandible defects are usu-

ally best managed by with the fibula osteocutaneous flap,

which provides more than 20 cm of bone length o f adequate

stock to support osseointegrated dental implants

7

and ade-quate soft tissue for bone coverage. For shorter defects (9

cm or less) in patients without the means for long-term

dental implantation, the osteocutaneous forearm flap can

provide bone and soft-tissue coverage capable of supporting

a tissue-borne prosthesis.8,9

Bony maxillary defects are more complex. The anterior

maxilla and orbital complex is usually best managed with

free calvarial bone grafts and a dental prosthesis for the intra

oral defect. Alternatively, the maxillary alveolar ridge may

be reconstructed with the fibula, radius, scapula, or iliac

crest bone flaps with appropriate soft-tissue coverage. The

use of 3-dimensional models prepared preoperatively from

computed scans can be very helpful in planning the recon-

struction of the maxilla in particular.Soft-tissue flaps are most often used when either a thin

lining is required (ie, nasal lining) when a radial forearm

flap is favored or when a large volume of bulk is required

for major soft tissue defects when a rectus or latissmus

muscle flap is used. A detailed description of free flap

anatomy, surgical harvest, and donor site morbidity is well

beyond the scope of this article; however, several excellent

texts are available for reference.10-12

Recipient site preparation

The facial wound is largely prepared for the definitive

reconstruction during the initial phase of wound manage-ment as previously outlined. Maximal preservation of bony

and soft tissues, plating of fractures, free bone grafts, and

segmental mandible defect management with bridging

plates sets the stage for the free tissue transfer. Tracheos-

tomy is often required (and usually performed during initial

management) for airway protection and to allow the surgical

approach to oromandibular and maxillary defects without

interfering endotracheal tubes.

Mandibular reconstruction requires wide exposure of the

remnant mandible and the previously placed bridging plate.

This mandates an external approach, which also facilitates

exposure of the great vessels of the neck for the microvas-

cular anastomoses required for free tissue transfer. Any

nonviable tissues encountered at this time should be care-

fully débrided. Care must be taken to preserve all nervous

structures, including the lingual and hypoglossal nerves and

the inferior alveolar nerve, if possible. The mandibular

remnant ends should be exposed and cut to provide a

smooth surface for the mandible-bone flap interface. Re-

moval of the bridging plate is not required nor recom-

mended as the loss of occlusal relationships should beavoided. At this juncture the length of bone and size of the

skin paddle required for bone coverage can be readily de-

termined.

For bony maxillary defects, the wound can generally be

approached through a transoral facial degloving approach.

If temporary bone grafts were previously placed to avoid

soft tissue contracture they should be removed at this time.

The anterior maxillary arch remnant should be exposed and

prepared to allow a smooth transition to the flap bone graft.

The posterior maxilla is often a more difficult issue and only

pterygoid plates may remain for flap abutment. The flap

bone graft will ultimately be secured using mini plates

anchored on the available remaining bone and must beanticipated. The use of 3-dimensional models can be very

helpful in planning this aspect of the reconstruction. Access

to recipient vessels in the neck must also be anticipated and

an adequate tunnel created from the maxillary defect

through the cheek, over the mandible and into the neck.

Care must be taken to avoid facial nerve injury by using

blunt dissection. The tunnel must also be of adequate diam-

eter to allow for the pedicle and soft tissue swelling without

venous compression and thrombosis.

Free flap inset

Mandible reconstructionAfter harvest of the required free flap (eg, fibula flap for

mandible reconstruction), significant contouring of bone

must occur. Some surgeons prefer to perform this function

in the leg, with the flap still receiving the natural blood

supply or on the back table after flap harvest while the flap

is ischemic. The author prefers to transfer the isolated flap

into the neck and to contour the bone to the defect where the

vascular pedicle geometry can be assessed and anticipated.

Often, multiple osteotomies of the flap bone must be per-

formed, particularly when reconstructing the anterior man-

dibular arch (Figure 1C). These osteotomies should be per-

formed in a subperiosteal fashion to avoid disruption of

blood flow to the bone. Wedges of bone are removed toallow the “bending” of the bone without any resultant gaps

between bone segments. Ideally, the individual bone seg-

ments should be 3 cm in length or longer. As this process is

critical to rapid bone healing and may be time consuming.

All contouring should occur before the microvascular anas-

tomoses are performed to avoid unfavorable geometry and

undo tension or manipulation of the vascular pedicle.

Once the contouring is completed, the flap bone seg-

ments are secured to the bridging reconstruction plate with

locking screws to avoid bone mobility but with the recog-

nition that these screws may interfere with future placement

of dental osseointegrated implants. The bone segments will

be only minimally load-bearing during healing as the bridg-

82 Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008


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ing plate will continue to bear the majority of the load with

chewing. It should also be recognized that the reconstruc-

tion of traumatic mandibular defects varies significantly

from similar reconstructions for defects, resulting from on-

cological resections, where much of the muscles of masti-

cation have been resected or detached. These muscles are

largely intact in the setting of trauma and thus forces created

during chewing are much greater.With bone contouring complete, the microvascular anas-

tomosis of the flap artery and vein to the neck vessels can be

performed safely to minimize the ischemia time of the flap

tissues. This also allows time for observation of the micro-

vascular anastomosis while the reconstruction continues. As

with tumor reconstruction of the mandible, the superior

thyroid artery and the internal jugular vein (or one of its

branches) are the most common recipient vessels. Vascular

pedicle length is rarely an issue in mandibular reconstruc-

tion so vein grafting can be avoided. Some prefer to perform

primary placement of osseointegrated dental implants. If so,

this is the appropriate time to place them while blood flow

to the bone has been reestablished and the bone is stillexposed.

Attention is now turned to the soft-tissue coverage of the

mandibular bone graft using the skin harvested with the flap.

Watertight closure over the graft is preferred to minimize

the risk of infection and salivary exposure of the flap vas-

cular pedicle which can cause thrombosis and flap failure.

Soft-tissue swelling must again be anticipated; thus, the

closure should not be overly tight. The neck incision is then

closed after placement of adequate suction drains. The do-

nor site is managed in the appropriate fashion.

The skin paddle provided by the fibula, radius and, in

particular, the scapula flap will be thicker and more redun-

dant than desired for the alveolar ridge and thus will require

thinning in a delayed fashion. Dental implants also may beplaced at the time of flap revision if indicated. This may

require the removal of some locking screws which secure

the flap bone to the plate. If this procedure is delayed at least

3 months the bone will be healed and these screws are not

necessary. Removal of the reconstruction plate itself re-

quires much more dissection and thus is typically avoided.

Maxillary reconstruction

Reconstruction of maxillary bony defects is similar to

that of the mandible with some important exceptions. Typ-

ically, there is no plate placed at the initial surgery to which

the flap bone can be contoured. A 3-dimensional model of the skull created from the computed tomography scan is

very helpful in planning the flap size, contour and approach

necessary for the reconstruction.

Once wide exposure is obtained through the facial de-

gloving approach the harvested flap is transferred into the

wound. The vascular pedicle is carefully passed through the

tunnel created in the cheek and over the mandible to reach

the neck. Vein grafts may be required to provide adequate

pedicle length to reach healthy vessels in the neck. The bone

is then contoured to fit the defect with shaped osteotomies

as with the mandible as described above. The bone is then

secured to the remaining maxilla with mini-plates. (Figure

2) Soft-tissue coverage of the bone is achieved using skin

from the flap folded on itself with a central area of de-

epithelialization. This allows skin to provide lining to the

oral palate defect and the nasal floor defect.

Premaxillary defects can be managed with the osteocu-

taneous radial forearm flap which provides an adequate

platform for a tissue-born prosthesis (partial denture) an-

chored off the remaining maxillary teeth.1,9 The fibula os-

teocutaneous flap will be more appropriate if dental im-plants are planned or the defect is more extensive.1

Perioperative management

Free tissue transfer for reconstruction of traumatic facial

bony defects is often a long operation (8 hours or longer)

that includes multiple operative sites (head and neck, flap

donor site, split-thickness skin graft site, calvarial bone graft

site). A team approach is generally preferred with one team

working in a clean-contaminated field preparing the recip-

ient wound and neck vessels and the reconstructive teamworking in a sterile field harvesting the free flap. The patient

must be positioned and prepped appropriately in anticipa-

tion of the expected surgical sites.

A tracheostomy is typically required and, depending on

the severity of the patient’s injury, a feeding tube or gas-

trostomy tube may also be indicated for preoperative nutri-

tion. Intraoperative fluid management should be reviewed

with the anesthesia team to avoid excessive use of intrave-

nous fluids that can contribute to postoperative soft tissue

edema. The use of vasoactive agents should also be avoided

during and after surgery as they may contribute to vaso-

spasm of the microvascular pedicle after anastomosis result-

ing in flap failure.

Most patients will require at least one night in the sur-gical intensive care unit for hemodynamic monitoring and

to allow close observation of flap perfusion. Vascular com-

promise of the flap is most likely to occur in the first 72

hours, with the highest risk in the 24- to 48-hour time frame.

The most common problem encountered is in the low pres-

sure venous system due to thrombosis of the venous anas-

tomosis. This can occur from technical difficulties with the

microanastomosis, wound hematoma, unfavorable geome-

try of the pedicle resulting in kinking and obstruction or

from excessive soft tissue pressure from an overly tight

closure and soft-tissue edema. Several techniques have been

evaluated for the monitoring of free flap perfusion in the

postoperative period, including temperature probes, laserDoppler probes, tissue oxygenation probes, and Doppler

monitoring of the vascular pedicle. Unfortunately, these

techniques are much more reliable for arterial inflow prob-

lems and do not detect venous problems until they progress

to include arterial thrombosis. We have found direct obser-

vation by trained personnel (resident, surgeon or experi-

enced nurse) of flap color, turgor, capillary refill and bleed-

ing to a prick created with a 30 gauge needle every 4 hours

to be most reliable.

At the first indication of vascular compromise of the flap,

a return to the operating room for wound exploration and

vascular pedicle revision will result in a satisfactory out-

come in most instances. The tracheostomy tube can be



13/89

removed as soon as soft-tissue edema has resolved enough

(assuming it will not be needed for the treatment of other

related injuries) for the patient to have a safe airway. Oral

intake can usually be resumed within 7 to 10 days. Evalu-

ation for speech and swallow therapy is often required and

psychosocial issues should continue to be addressed.

Figure 2 (A) Normal midface skeleton. (B) Defect caused in the premaxillary segment by a self-inflicted gun shot wound involving the

anterior maxillary arch, hard palate and nasal floor. (C) Reconstruction of the maxillary bony defect with free tissue transfer of bone using

a single osteotomy and fixation using miniplates. Excellent bone contact between all segments must be achieved for rapid bone healing.



14/89

Outcomes

Free tissue transfer for reconstruction of traumatic f acial bony

defects is a highly reliable technique. Futran et al1 reported a

take back rate of almost 10% but no flap failures in a series of

54 free tissue transfers performed for facial trauma. This rate

compares favorably with free tissue transfer for reconstruction

of the head and neck following tumor ablation.1,8,9

Woundinfection rate was only 7% in these same 54 procedures,

despite the extensive contamination and tissue damage caused

by the soft tissue trauma seen in these cases.

Long-term outcomes are mixed and largely dependent on

theseverity of the injuryat the outset. Not surprisingly, isolated

mandibular defects have the best cosmetic result and complex

mandibular, maxillary and nasal defects have the worst cos-

metic results. Most patients will recover adequate speech and

swallow function. Dental rehabilitation remains critical to the

type of oral diet a patient can handle. All patients require

multiple procedures during the reconstructive process and

those with orbital and/or nasal defects are the most complex,

requiring the largest number of procedures.

References

1. Futran ND, Farwell DG, Smith RB, et al: Definitive management of

severe facial trauma utilizing free tissue transfer. Otolayrngol Head

Neck Surg 132:75-85, 2005

2. Yuksel F, Celikoz B, Ergun O, et al: Management of maxillofacial

problems in self-inflicted rifle wounds. Ann Plast Surg 53:111-117,

2004

3. Suominen E, Tukiainen E: Close-range shotgun and rifle injuries to the

face. Clin Plast Surg 28:323-337, 2001

4. Militskah ON, Wallace DI, Kriet JD, et al: Use of the 2.0-mm

locking reconstruction plate in primary oromandibular reconstruc-

tion after composite resection. Otolaryngol Head Neck Surg 131:

660-665, 20045. Niçsanci M, Tüegün M, Er E, et al: Reconstruction of the middle and

lower face with three simultaneous free flaps: Combined use of bilat-

eral fibular flaps for maxillomandibular reconstruction. Ann Plast Surg

51:301-307, 2003

6. Duffy FJ, Gan BS, Israeli D, et al: Use of bilateral folded radial

forearm free flaps for reconstruction of a midface gunshot wound. J

Reconstr Microsurg 14:89-96, 1998

7. Frodel JL Jr., Funk GF, Capper DT, et al: Osseointegrated implants: a

comparative study of bone thickness in four vascularized bone flaps.

Plast Reconstr Surg 92:449-455, 1993

8. Militsakh ON, Werle A, Mohyuddin N, et al: Comparison of radial

forearm to fibula and scapula osteocutaneous free flaps for oroman-

dibular reconstruction. Arch Otolaryngol Head Neck Surg 131:571-

575, 2005

9. Kim JH, Rosenthal EL, Ellis T, et al: Radial forearm osteocutaneous

free flap in maxillofacial and oromandibular reconstructions. Laryn-goscope 115:1697-701, 2005

10. Strauch B, Yu HL: Atlas of Microvascular Surgery. New York, NY,

Thieme Medical Publishers, 1993

11. Urken ML, Cheney ML, Sullivan MJ, et al: Atlas of regional and free

flaps for head and neck reconstruction. New York, NY, Raven Press,

1995

12. Day TA, Girod DA: Oral Cavity Reconstruction. New York, NY,

Taylor & Francis, Incorporated, 2006



15/89

Zygomatico–orbito–maxillary complex fractures

Stephen Maturo, MD, Manuel A. Lopez, MD

From the Facial Plastic and Reconstructive Surgery Service, Department of Otolaryngology,

Wilford Hall Medical Center, Lackland AFB, Texas.

Zygomatico–orbito–maxillary complex fractures are the second most common facial fracture. As with

all facial fractures, wide exposure and accurate fixation will lead to optimal functional and cosmetic

results. Surgical techniques to expose the orbital floor, zygoma, and maxilla are discussed.Published by Elsevier Inc.

KEYWORDSFacial fracture;

Midface fracture;Zygoma fracture;

Orbit fracture

Zygoma and orbital fractures make up an estimated 15%

and 10%, respectively, of all facial fractures.1 Most zygo-

matico–orbito–maxillary complex (ZOMC) fractures are

caused by violent assaults, followed by motor vehicle acci-

dents The majority of patients are young males in their third

decade of life. Thirty to fifty percent of patients have asso-

ciated concomitant facial fractures.2 Associated ocular in-

juries occur in 10% to 50% of midface fractures, with

greater rates in isolated orbital fractures.2

The zygoma attaches to the frontal, maxillary, temporal,and sphenoid bones. The zygomatic–temporal relationship

provides anterior facial projection whereas the zygomatic-

frontal provides mid-face height. ZOMC fractures left un-

treated can result in cosmetic deformity, enophthalmos,

entrapment of ocular muscles, and persistent diplopia. Oph-

thalmology referral is usually recommended and clearance

from other injuries and medical issues is necessary. Al-

though cervical spine injuries occur in less than 10% of

midface fractures it is optimal to have the spine cleared

before surgery.1 High-resolution computed tomography

scans of the face in both axial and coronal planes provide

the most detailed information for planning surgical ap-

proaches.

The goal of ZOMC reduction and fixation is 3-pointalignment (zygomatic-frontal, zygomatic-maxillary, and in-

fraorbital rim) with at least a 2-point fixation.3,4 Specifically

with orbital floor involvement, the goals of repair are to

release entrapped ocular tissue and establish normal orbital

volume and globe position.5 The most important feature to

ensure proper reduction and alignment of ZOMC fractures

is excellent exposure. Improper alignment results in enoph-

thalmos, orbital dystopia, and midface flattening. These

complications are difficult to revise making precise align-

ment imperative during the initial operation. The following

descriptions provide for optimal exposure needed in ZOMC

fractures.

Transconjunctival approach with canthotomyand cantholysis

The transconjunctival approach with canthotomy and can-

tholysis provides superb exposure to the inferior orbital rim,

the orbital floor, and the lateral orbital wall. Combining this

approach with a transcaruncular approach will allow expo-

sure of the medial orbital wall.6 Canthotomy and cantholy-

sis is not a requirement, but we have found that exposure is

significantly enhanced when lower eyelid tension is mini-

mized. Advantages of the transconjuctival approach as op-

posed to the subciliary approach include lack of external

scar and decreased risk of ectropion.

The transconjunctival approach begins with placement of a corneal shield protector impregnated with ophthalmic bac-

itracin. The contralateral face is included in the surgical

field so that facial projection, orbital projection, and lid

positioning can be compared. One cc of 1% lidocaine with

1/100,000 epinephrine is injected into the lateral canthus

and conjunctival region. Two 5-0 nylon sutures are placed

through the tarsus and used as stay sutures to help aid with

retraction. A 1 cm horizontal incision is made from the

lateral canthus and carried down to the lateral orbital rim

(Figure 1). Curved iris scissors are then used to carry out the

cantholysis where the result is complete lower lid laxity.

Address reprint requests and correspondence: Stephen Maturo,

MD, Facial Plastic and Reconstructive Surgery Service, Department of

Otolaryngology, Wilford Hall Medical Center, Lackland AFB, TX 78236.


1043-1810/$ -see front matter Published by Elsevier Inc.

doi:10.1016/j.otot.2008.04.004


mailto:[email protected]:[email protected]


16/89

(Figure 2). Bishop Harmann forceps then retract the lowereyelid inferior-medially and Wescott scissor is used to de-

velop the plane lateral to medial between the orbital septum

and the anterior lamellae. The Wescott scissor is then used

to release the lower eyelid retractors from the inferior tarsal

border (Figure 3). We avoid using Bovie cautery on the

transconjunctival incision to decrease the risk of retraction

from septal scarring. Stay sutures (5-0 nylon) are then

placed through the conjunctival/septal flap to help provide

counter-traction as blunt dissection with a cotton tip appli-

cator is performed preseptally. Preseptal dissection is car-

ried down to the orbital rim. The orbital periosteum is

identified and then incised 3 to 5 mm inferior to the orbital

rim (Figure 4).

The periosteum of the orbital rim and orbital floor is then

raised as the orbital contents are gently retracted. The orbital

floor fracture is exposed in its entirety being aware that the

optic nerve is approximately 40 mm from the anterior lacrimal

crest. Options for treatment of an orbital floor fracture are

numerous and include split-calvarial bone, titanium mesh, and

Medpor (Porex Surgical Products Group, Newnan, GA). The

implant used to reconstruct the floor should be fixed with

4-mm 1.0 titanium screws. The orbital rim is fixated with a

1.0 plate using 4- to 5-mm screws. Forced duction is then

performed to ensure that there is no entrapment.

The periosteum is then closed with interrupted 4-0 Vicryl

sutures. The conjunctival incision is generally not closed.The canthus is resuspended to the medial portion of the

lateral orbital rim. Mild overcorrection is preferred as the

suture will loosen over the perioperative period. The impor-

tance of this suspension suture cannot be overemphasized as

lower lid laxity and ectropion can result in disastrous com-

plications. The canthal incision is then closed with simple

interrupted skin sutures.

Sublabial approach

The sublabial approach provides access to the zygomatic-

maxillary buttress and the naso-maxillary buttress. Thisapproach also provides access for inspection of the inferior

orbital rim, although reducing a rim fracture via the subla-

bial approach is extremely difficult.7 The sublabial approach

begins with injection of 1% lidocaine with 1/100,000 epi-

nephrine into the gingival mucosa lying above the maxillary

teeth. The incision is made in the gingivobuccal sulcus

being cognizant to leave a cuff of 5- to 10-mm tissue above

the gum line to help aid with closure. Cautery is then used

to incise the submucosal, muscular and periosteum layers

down to bone. A periosteal elevator is used to elevate the

periosteum superiorly toward the inferior orbital rim. Care

is taken to preserve the infraorbital nerve, usually located 10

mm inferior to the orbital rim in a vertical plane in line with

Figure 1 Canthotomy is demonstrated. A 1-cm incision is made

in the lateral canthus and carried down to the lateral orbital rim.

Wescott scissors or a knife may be used.

Figure 2 Cantholysis is demonstrated. Scissors are verticallyoriented and the lateral orbital rim is palpated with the scissor tip.

Result is total lower lid laxity.

Figure 3 Conjunctival incision is made at inferior tarsal border.

Stay suture through the tarsus aids with counter traction. Medial

extent of incision is lacrimal puncta. Notice complete laxity of

lower lid provided with canthotomy/cantholysis.

87Maturo and Lopez ZOMC Fractures


17/89

the pupil. Conservative back elevation along the inferior

gingiva will help with final closure. Wide exposure of the

maxilla and zygoma is achievable with retraction of the soft

tissue (Figure 5). Access from superiorly and inferiorly is

achieved with combining the transconjunctival and subla-

bial approach. Accurate reduction of ZOMC fractures re-

quires analysis of the three-dimensional plane to achieve

three point alignment. The Carroll-Girard or T-screw canhelp with manipulation of the zygoma to achieve accurate

three dimensional reduction.

The zygoma and maxilla are usually plated with an

appropriately bent “L-type” plate using 5-mm screws. If a

nasomaxillary buttress fracture is evident this is easily

plated with a straight, appropriately bent 1.5 plate. The

overlying mucosa is closed with a running 4-0 Chromic

suture.

Lateral frontal fracture

A superior zygomatic-frontal fracture may not be easilyaccessible through the transconjunctival approach with a

canthotomy and cantholysis. Access is then obtained

through an extended upper lid blepharoplasty incision. The

most lateral aspect of the blepharoplasty incision is ex-

Figure 4 Preseptal dissection is completed and periosteum has

been incised on the anterior face of the orbital rim approximately

3 to 5 mm from its superior edge. The entire orbital rim is exposed.

Conjunctival-septal flap is retracted superiorly.

Figure 6 Extended upper lid blepharoplasty incision is demon-

strated. Plating of the zygomatic-frontal, orbital rim, and lateral

buttress fractures are complete.

Figure 5 Exposure of the anterior face of the maxilla is dem-onstrated. Infraorbital nerve is identified and kept intact. Fractures

of the medial and lateral buttresses can now be reduced and plated.



18/89

tended to just past the lateral orbital rim in a curvilinear

fashion. Needle tip cautery is then used to expose the bone.

Periosteal dissection is then used to expose the fracture in its

entirety. A 1.0 plate with 4-mm screws is used to plate the

fracture. Classical teaching dictates that the zygomatic fron-

tal buttress should be plated first as it establishes midface

height, yet one should continue to be vigilant of the three

dimensional aspect of the zygoma to ensure acceptable postoperative cosmesis (Figure 6).4

Conclusion

ZOMC fractures are the second most encountered facial

fracture. Preoperative evaluation should include a compre-

hensive ophthalmologic evaluation as well as high resolu-

tion coronal and axial computed tomography scans. Atten-

tion to the accurate three dimensional reduction of the

zygoma and careful attention to the dissection planes in the

transconjunctival approach can help avoid poor postopera-

tive cosmesis and ectropion complaints. The sublabial ap-proach combined with an extended upper blepharoplasty/

lateral brow incision is usually adequate for two point

fixations while the transconjunctival approach is used when

the orbital rim and/or floor needs repair.

References

1. Kelley P, Crawford M, Higuera S, et al: Two hundred ninety four

consecutive facial fractures in an urban trauma center: Lessons learned.

Plast Reconstr Surg 116:42e-49e, 2005

2. Shere JL, Boole JR, Holter MR, et al: An analysis of 3599 midfacial and

1141 orbital blowout fractures among 4426 United States Army sol-

diers, 1980-2000. Otolaryngol Head Neck Surg 130:164-170, 2004

3. Shaw GY, Khan J: Precise repair of orbital maxillary zygomatic frac-

tures. Arch Otolaryngol Head Neck Surg 120:613-619, 1994

4. Holmes KD, Matthews BL: Three-point alignment of zygoma fractures

with miniplate fixation. Arch Otolaryngol Head Neck Surg 115:961-

963, 1989

5. Patel BC, Hoffman J: Management of complex orbital fractures. Facial

Plast Surg 14:83-104, 1998

6. Garcia GH, Goldberg RA, Shorr N: The transcaruncular approach in

repair of orbital fractures: a retrospective study. J Craniomaxillofac

Trauma 4:7-12, 1998

7. Shumrick KA, Campbell AC: Management of the orbital rim and floor

in zygoma and midface fractures: Criteria for selective exploration.

Facial Plast Surg 14:77-81, 1998

89Maturo and Lopez ZOMC Fractures


19/89

Management of soft-tissue trauma to the face

Krishna G. Patel, MD, PhD, Jonathan M. Sykes, MD

From the Department of Otolaryngology–Head and Neck Surgery, University of California, Davis Medical Center,

Sacramento, California.

The management of acute soft-tissue trauma can be very challenging for the facial plastic surgeon. The

goals of management of facial trauma are the preservation of form and function. These goals are

particularly important in facial soft-tissue trauma, where injuries can cause not only esthetic deformitiesbut also can affect neural function, normal mastication, visual fields, and salivary outflow. This article

outlines the evaluation and treatment of acute soft-tissue facial trauma. The key components include

allowing for the stabilization of the patient, complete examination of the injury and face, thorough

wound irrigation and debridement of necrotic tissue, preservation of all viable tissue, tension-free

closure, and realignment of important facial esthetic structures. Special consideration must be given to

injuries of functional structures such as the facial nerve, ductal systems or organs, and ensuring

appropriated management of these structures.

© 2008 Elsevier Inc. All rights reserved.

KEYWORDSSoft tissue trauma;

Facial trauma;Facial injury

In the United States, more than 146,000 patients per year

are treated for soft-tissue trauma in emergency centers.1 The

most common cause for soft-tissue trauma is motor vehicle

accidents. Other common etiologies of trauma include falls,assault/altercations, sports, industrial accidents, self-in-

flicted trauma, and bites (both human and animal).1,2 The

appropriate initial management of soft-tissue trauma during

the acute phase can be invaluable for the long-term esthetic

and functional outcomes.

Given that many patients with soft-tissue trauma present

with multiple injuries, the patient must first undergo a thor-

ough evaluation under the standard guidelines of the Ad-

vance Trauma Life Support (ATLS) system.3,4 This evalu-

ation allows the trauma patient to be stabilized if there are

life-threatening injuries. However, soft-tissue trauma of the

face can contribute to airway compromise if there is signif-

icant edema or oral bleeding.4 Mandible fractures that

avulse the tongue’s attachment to the lingual mandible or

mobilize the central mandible, such as bilateral parasym-

physeal fractures, can reposition the tongue base posteriorly

causing airway compromise. In addition to the airway, fa-

cial trauma can also play a role in circulatory compromise if

significant hemorrhage occurs. In the setting of hemorrhage,

initially packing and applying pressure allows for the tem-

porary tamponade of the vascular injury until the lacerated

vessel can be identified and ligated, repaired, or embolized.If epistaxis is present, temporary nasal packing often suffi-

ciently manages the bleeding.

Evaluation

Once the initial assessment has been performed and the

patient stabilized, the soft-tissue facial trauma can be care-

fully evaluated. Obtaining the patient’s history, such as the

time and mechanism of the injury, aides in the management

Address reprint requests and correspondence: Krishna G. Patel,

Department of Otolaryngology–Head and Neck Surgery, University of

California, Davis Medical Center, 2521 Stockton Blvd, Suite 7200, Sac-

ramento, CA 95817.


Table 1 Tetanus prophylaxis in wound management

History of tetanus

immunization (doses)

Clean, minor

wounds, Td TIG

All other

wounds, Td TIG

Unknown or 3 doses Yes, No Yes, Yes3 or more doses No,* No No,† No

Recommendations are based upon the CDC, Department of Health

and Human Services Center for Disease Control and Prevention ( www.

cdc.gov/vaccines/ ).

Td, diphtheria-tetanus toxoid; TIG, tetanus immune globulin.

*Yes, if 10 years since last dose.†Yes, if 5 years since last dose.

1043-1810/$ -see front matter © 2008 Elsevier Inc. All rights reserved.

doi:10.1016/j.otot.2008.05.004


mailto:[email protected]:[email protected]://www.cdc.gov/vaccines/http://www.cdc.gov/vaccines/http://www.cdc.gov/vaccines/mailto:[email protected]://www.cdc.gov/vaccines/http://www.cdc.gov/vaccines/


20/89

of care. If the mechanism of injury involved armory often

there is deep tissue destruction and burn injury.5 Injuries

involving motor vehicles or gunshots often require explo-

ration and removal of foreign body material. Human and

animal bites and contaminated wounds require extensive

irrigation to prevent wound infection. Obtaining past med-

ical history and social history can help identify factors that

may affect wound healing. Comorbidities such as diabetes, alcohol or tobacco abuse, or past radiation therapy may

negatively affect wound healing.1 Under circumstances of

deep penetrating injuries, patients should be questioned

regarding their tetanus immunization status and updated if

Figure 1 A photograph displaying a lateral view of an intubated

patient involved in a motor vehicle accident. Note the extensive

asphalt tattooing over the cheek and multiple contaminated lacer-ations and abrasions. (Color version of figure is available online.)

Figure 2 An intraoperative photograph of the patient from Fig-

ure 1 demonstrating the use of high-pressure pulsatile irrigation to

clean and debride the contaminated facial wounds. (Color version

of figure is available online.)

Figure 3 A postoperative photograph displaying a lateral view

of the patient from Figure 1 after high-pressure pulsatile irrigation,

debridement of necrotic tissue, and reapproximation of the wounds.

The tattooing of the cheek has significantly improved and will de-

crease the degree of permanent tattooing as well as the risk of post-

trauma infection. (Color version of figure is available online.)

Figure 4 A Standard instrument set used for soft-tissue plastic

surgery including fine-tipped forceps, skin hooks, and fine-tipped

scissors. (Color version of figure is available online.)

Table 2 Local anesthetic maximal dosing concentrations

AnestheticDose(mg/kg)

Onset(min)

Duration(hr)

Lidocaine 1% 3 to 4 2 1.5 to 2Lidocaine 1% with epinephrine

1:100,000

5 to 7 2 2 to 6

Bupivacaine 0.25% 2.5 5 2 to 4

91Patel and Sykes Management of Soft-Tissue Trauma to the Face


21/89

necessary. Current tetanus prophylaxis is based on the rec-

ommendations by the Center for Disease Control and Pre-

vention in Table 1.6

Physical examination

After obtaining the patient’s information, a thorough phys-

ical evaluation is imperative. This evaluation includes close

examination of the head and face for any signs of skeletal

instability, bony step-offs, or dental malocclusion. In the

event that there is suspicion of more than soft-tissue injury,

appropriate radiographic imaging should be obtained, such

as a computed tomography scan of the head or face or

radiographs of the facial skeleton. Injuries that involve theeye should include ophthalmology consultation.4 A thor-

ough examination of the skin, eyes, ears, nose, oral cavity,

oral pharynx, and cranial nerves should be performed. Early

recognition of any injury to the facial nerve, lacrimal ducts,

or Stensen’s ducts is important.

Initial wound management

Before any repair, the wound must be thoroughly cleansed.Obtaining important facts regarding the mechanism of in-

jury can help determine if there are significant foreign

bodies within the wound (Figure 1). If computed tomogra-

phy scans had been obtained previously, these can reveal

radiopaque foreign bodies such as glass and can be helpful

in localizing deep foreign bodies. The best means for

cleansing the wound and removing foreign body material is

high-pressure irrigation (Figure 2). Multiple methods can be

used, such as high-pressure pulsatile irrigation or bulb sy-

ringe irrigation. This author prefers the use of high-pressure

pulsatile irrigation (Figure 3).7,8 Both methods should use

copious amounts of irrigant to remove contaminants and

bacteria. Irrigants commonly used include saline or antibi-otic-infused saline (such as, 50,000 units of bacitracin to 1

liter of saline). Once the wound has been irrigated, the areas

of tissue revealing frank necrosis should be débrided. If left,

the necrotic tissue can serve as a nidus for infection. How-

ever, any tissue that appears partially viable should be

Figure 5 An illustration depicting the use of deep sutures to reapproximate the wound edges (A) to allow for an even and everted skin

edge (B). Use of a layered closure relieves the tension on the epidermal sutures and minimizes scar widening during wound healing.

(Reprinted with permission.9)

Figure 6 Illustration depicting the management of wounds when there is an uneven thickness of the dermal edges being reapproximated

(A). The use of a layered closure first involves placement of deep sutures to even realign the deep tissues (B). After closure of the deep

tissues, if the dermal edges are uneven (C), placing the dermal suture such that the suture is placed more deeply through the thinner dermal

edge and more superficially through the thicker dermal edge (D) will bring the epidermal edges together in an even manner (E). (Reprinted

with permission.9)



22/89

preserved to allow for the opportunity to revascularize and

to lessen the degree of tissue loss sustained. If the patient is

awake, the wound may need to be anesthetized before irri-

gation to thoroughly cleanse the wound without inflicting

too much pain.

Surgical repair

The setting for surgical repair of the injury may occur in

either the operating suite or in the emergency room. This

decision should depend on the severity of the injury and the

patient’s medical condition. The operating suite provides a

more controlled environment in terms of the patient’s air-

way and pain management. Additionally, operating rooms

have superior lighting and usually have access to better

instruments (Figure 4). If there is concern for nerve or

ductal injury, the operating suite should be used to allow for

the use of microscopic techniques. However, waiting for an

operating room may delay the closure of open wounds,

Figure 7 A photograph displaying a complex laceration involv-

ing the full-thickness of the skin and cartilage of the right ear.

Closure of this wound required a layered closure of the cartilage

and skin, as well as attempts to regain the original shape and

contour of the ear. Lacerations of the ear also require close eval-

uation of the external auditory canal and tympanic membrane. If

significant soft tissue edema is present within the external auditory

canal, a wick should be placed temporarily to prevent canal ste-

nosis. Note the ischemic discoloration of the ear lobule, which was

later sutured to its original position. (Color version of figure is

available online.)

Figure 8 A photograph of the patient from Figure 7 at 1-month

follow-up revealing complete viability of the tissues repaired and

good contouring of the concha, antihelix and ear lobule. Mild

notching is noticed along the helical rim. (Color version of figure

is available online.)

Table 3 Suture caliber guidelines for facial subunits

Region Cutaneous suture Subcutaneous/fascia suture Comments

Eyelid and periorbital #6-0, #7-0 #4-0, #5-0 Minimal tensile strength requirements; aesthetic

concerns at a premiumNose and pinna #5-0, #6-0 #4-0, #5-0 Small tensile strength requirements; aesthetic

concerns at a premium

Lip and vermilion #6-0 #3-0, #4-0 Moderate tensile strength requirements becauseof highly active region; aesthetic concerns at

a premiumGeneral facial and anterior neck #4-0, #5-0 #6-0 #3-0, #4-0 Moderate-to-high tensile strength requirements

because of regional mobility; significantaesthetic concerns

Nasal and oral mucosa #3-0, #4-0 #3-0, #4-0 Moderate tensile strength needed due to tissue

mobility; may select suture based on ease orno need for removal; no aesthetic concern

Scalp and posterior neck #3-0, #4-0 #2-0, #3-0 Tensile strength needed for moderately heavytissue and very mobile region; minimal

aesthetic concern

Reprinted with permission from Baker S, Swanson N, Skyes J, et al: Suture needles and techniques for wound closure, in Local Flaps in Facial

Reconstruction. New York, Mosby, 1995.



23/89

which can allow for increased edema of the soft tissues.

Additionally, the severity of injury often does not warrant

use of the operating room facilities. Typically, 1% lidocaine

with 1:100,000 epinephrine provides anesthesia that is ef-

fective in the awake or intubated patient. The longevity of

the anesthetic can be increased by using a 1:1 mixture of 1%

lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine

(Table 2). The injection of the anesthesia can be painful for

the awake patient; this pain can be alleviated by buffering

the anesthetic with a ratio of 9:1 lidocaine to bicarbonate.

Additionally, waiting 10 to 15 minutes to allow for the

vasoconstrictive effects of the epinephrine in the patientgreatly aides one in visualization within the wound.

Techniques for wound closure depend on the location,

depth, and characteristics of the injury. Abrasions should be

kept clean and moist with application of a thin layer of

antibiotic ointment, such as bacitracin. If the wound is

significantly contaminated or inflicted by a human or animal

bite, loose closure helps prevent deep tissue abscess forma-

tion. Hematomas involving the ear and nasal septum shouldbe evacuated to prevent cartilage loss and subsequent future

deformities, such as a cauliflower ear or nasal dorsal col-

lapse, respectively. After relieving the hematoma, the ear

should be bolstered or the septum bilaterally splinted to

prevent re-accumulation of blood with subsequent cartilage

loss.

The method of wound closure should be designed to

minimize wound tension and maximize eversion of the skin

edges (Figure 5).9 Any tension on the skin layer increases

risk of a widened scar or wound dehiscence. Employment of

a multi-layered closure most ably creates a tension-free

wound.10 In addition to eversion, placement of the sutures to

ensure the wound edges are even provides the best outcomefor wound healing (Figure 6).9 Table 3 provides a guideline

for the recommended suture selection for wound closure

(Table 3).9 Additional key elements include covering any

exposed cartilage or bone with soft tissue. If the cartilage

has been disrupted, such as the upper or lower lateral car-

tilages of the nose, or the helical cartilage of the ear, reap-

proximation of the cartilage edges with absorbable suture

helps regain structural support (Figures 7 and 8). If there is

interruption of muscle, such as the orbicularis oculi or

orbicularis oris muscles, these muscle edges should be re-

aligned to maximize posttraumatic recovery of muscle func-

tion (Figures 9 and 10). Placement of horizontal mattress

sutures with absorbable suture helps to efface the muscle

Figure 9 A photograph of a patient who sustained a full-thick-

ness laceration through the left upper lip. To restore muscle func-

tion and improve esthetic outcome, a layered closure reapproxi-

mating the orbicularis oris muscle as well as a meticulous

realignment of the vermilion–cutaneous border was performed.

(Color version of figure is available online.)

Figure 10 A photograph of the patient from Figure 9 several

months postoperatively revealing excellent realignment of the ver-

milion–cutaneous border. (Color version of figure is available

online.)

Figure 11 An illustration demonstrating the facial esthetic

subunits.



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edges in a tension-free manner. Failure to realign muscle

layers can lead to both esthetic and functional deficit that isoften later nonrepairable.

Meticulous realignment of skin edges is important, es-

pecially along the borders of esthetic subunits (Figure 11).

In closing the skin edges, a size 6.0 or smaller caliber suture

should be used. Special attention should be paid to realign

the vermilion-cutaneous border, eyelid margin, nasal rim,

brow or any hair-bearing borders (Figures 12-15). Using

vertical mattress suture technique is excellent for the re-

alignment of esthetic borders such as the eyelid margin and

vermilion-cutaneous border of the lip. If the edges are not

well everted, notching will occur as the wound contracts,

which is particularly noticeable at esthetic subunit borders.

The traditional teachings for eyelid margin lacerations de-

scribe a three-layer closure realigning the lash line, gray

line, and meibomian glands with 7.0 silk vertical mattress

sutures that leave the tags long enough to secure more

peripherally to prevent corneal abrasions (Figure 16).8,11

However, more recent literature advocates the use of ab-

sorbable suture for the eyelid margin closure.12 In either

situation, the tarsal plate should be reapproximated with

absorbable suture to relieve tension from the skin closure.

With injuries near the medial canthus, secondary healing is

often preferred to prevent webbed scarring.

10

In general,concave surfaces heal well by secondary intention (Figures

Figure 12 A photograph of the left forehead and eyebrow of a

patient involved in a motor vehicle accident. The complex lacer-

ation crossed the hair-bearing eyebrow subunit and exposed skull

on the forehead. (Color version of figure is available online.)

Figure 13 An immediate postoperative photograph of the left

forehead and eyebrow from the patient in Figure 12. A layered

closure was performed, a drain was placed in the forehead to

prevent hematoma formation, and meticulous attention was paid in

realigning the eyebrow. (Color version of figure is available on-

line.)

Figure 14 A postoperative photograph of the left forehead and

eyebrow from the patient in Figure 12 during a 6-month follow-up

visit. The patient’s subunits are well aligned but the soft tissuetrauma resulted in hair loss within the eyebrow subunit. (Color

version of figure is available online.)

Figure 15 A postoperative photograph of the left forehead and

eyebrow from the patient in Figure 14 after undergoing a revision

w-plasty of the scarred tissue. Restoration of the natural contour of

the eyebrow camouflages the scar significantly. (Color version of

figure is available online.)



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17 and 18). These concave surfaces include the lateral

forehead subunits, glabella, medial canthal subunit, de-

pressed areas of the ear, supra-alar crease, soft tissue trian-

gles, philtral subunit, and the perinasal melolabial crease

(Figure 19).13

Wound edges that are uneven in depth are both difficult

to realign and often create a pin-cushioning effect during the

healing period. Superiorly based wound flaps are particu-

larly susceptible to pin-cushion defects.8 Sharply creating a

ninety-degree angle with the skin edge can help prevent this

complication; however, one must be careful not to remove

too much skin that would prevent closure of the wound(Figure 20). If tissue loss is significant and inhibits wound

closure, as much of the wound as possible should be reap-

proximated. For the remaining open wound, wet-to-dry

dressings help débride the wound and allow it to heal with

plans for later reconstruction.14 Immediate reconstruction

using soft tissue flaps is possible but discouraged given the

wound is not sterile. Thus, delayed reconstruction of gaping

wounds allows the edema and risk of infection to resolve.15

If there is suspicion that the facial nerve has been injured

and the penetrating injury lies lateral to a vertical line drawn

from the lateral canthus, the wound should be immediately

explored for transection of facial nerve branches. Identified

transected nerves should be repaired under microscopic

Figure 16 An illustration depicting the repair of a full-thickness

eyelid laceration. First, deep sutures are placed to reapproximate

the tarsal plate. At the eyelid margin, three vertical mattress su-

tures are placed at the lash line, gray line and meibomian glands

with 7.0 silk (A). The mattress suture tags are left long enough to

secure more peripherally to prevent corneal abrasions (B). (Re-

printed with permission.18

)

Figure 17 A photograph of a patient who has a full-thickness

tissue defect exposing bone near the left medial canthus. (Color


Figure 18 A photograph of the patient from Figure 17, who

healed the full-thickness defect via secondary intention. Note the

significant wound contraction after 1 month of healing. (Color


Figure 19 An illustration of the face. The shaded areas represent

concave regions of the face that heal well through secondary

intention. These concave surfaces include the lateral forehead

subunits, glabella, medial canthal subunit, depressed areas of the

ear, supra-alar crease, soft tissue triangles, philtral subunit, and the

perinasal melolabial crease. (Reprinted with permission.13) (Color




26/89

technique, usually with a 7.0 or smaller permanent mono-

filament suture to realign the epineurium. Using a nerve

stimulator can also be helpful in identifying the severed

nerve branches. Nerve injuries medial to a vertical line

drawn from the lateral canthus are thought to have enough

cross-innervation from surrounding branches to regain func-

tion. For this reason, nerve repair is usually not attempted

for medial injuries to the facial nerve. Injuries over the

buccal region should be carefully explored to rule out injury

to Stenson’s duct. Using lacrimal probes or silastic tubing

cannulated through the buccal orifice aides in identifying

the injured duct. Again, microscopic repair is warranted and

stenting the duct for 3 to 4 weeks with silastic tubing canhelp prevent postoperative ductal stenosis.8,14

Key adjunctive treatments include providing antibiotic

prophylaxis to prevent wound infection. Often cefazolin or

cephalxin is appropriate, however, if the injury was from an

animal or human bite, broader spectrum antibiotic coverage

is advisable such as amoxicillin-clavulanate.14 If stents,

bolsters or nasal packing is used, the patient should be kept

on antibiotic prophylaxis as long as the packing is in place.

Tetanus immunization is important for all deep penetrating

wounds. For bites, infectious disease status of the offender

such as rabies, HIV, or hepatitis should be investigated and

the patient treated when question of exposure exists.14

Postoperative care

Diligent postoperative wound care is essential for good

healing of soft tissue wounds. Keeping the reapproximated

skin edges free of dried blood improves wound healing.

Open wounds or abrasions should be kept moist with a thin

layer of antibiotic ointment, such as bacitracin, to prevent

wound desiccation. Moist wounds have been shown to re-

epithelialize 50% faster compared with desiccated wound

beds.16,17 If the patient develops sensitivity to topical anti-

biotic ointments, petroleum jelly is equally effective. Ap-

proximately 3 to 4 weeks after wound closure, massaging of

the wound can help soften scars and decrease hypertrophy

of the scar edges. If scarring becomes raised or uneven,

dermabrasion may be initiated as early as 4 weeks after

wound closure.

Summary

In summary, soft tissue trauma is often complex and re-

quires thorough evaluation. The key for good wound heal-

ing includes repair of any injured functional structures,

copious irrigation, debridement of necrotic tissue, with me-

ticulous tension-free closure. During the wound closure,

utmost attention should be paid to realigning all esthetic

subunit borders.

References1. Hochberg J, Ardenghy M, Toledo S, et al: Soft tissue injuries to face

and neck: Early assessment and repair. World J Surg 25:1023-1027,

2001

2. MacBean CE, Taylor DM, Ashby K: Animal and human bite injuries

in Victoria, 1998-2004. Med J Aust 186:38-40, 2007

3. American College of Surgeons. Advanced Trauma Life Support. 2003.

Available at: http://www.facs.org/trauma/atls/index.html. Accessed

May 20, 2008

4. Perry M, Dancey A, Mireskandari K, et al: Emergency care in facial

trauma—a maxillofacial and ophthalmic perspective. Injury 36:875-

896, 2005

5. Motamedi MH: Primary treatment of penetrating injuries to the face.

J Oral Maxillofac Surg 65:1215-1218, 2007

6. Halaas GW: Management of foreign bodies in the skin. Am Family

Physician 76:683-688, 20077. Svoboda SJ, Bice TG, Gooden HA, et al: Comparison of bulb syringe

and pulsed lavage irrigation with use of a bioluminescent musculo-

skeletal wound model. J Bone Joint Surg Am 88:2167-2174, 2006

8. Park S, Frodel J: Maxillofacial and soft tissue trauma, in Park SS (ed):

Facial Plastic Surgery, The Essential Guide. New York, Thieme, 2005,

pp 161-222

9. Sykes J, Byorth P: Suture needles and techniques for wound closure,

in: Baker SR, Swanson NA (eds): Local Flaps in Facial Reconstruc-

tion. New York, Mosby, 1995, pp 39-62

10. Key SJ, Thomas DW, Shepherd JP: The management of soft tissue

facial wounds. Br J Oral Maxillofac Surg 33:76-85, 1995

11. Mustarde J: Primary and secondary repair, in: Repair and Reconstruc-

tion in the Orbital Region. Baltimore, Williams & Wilkins, 1966

12. Perry JD, Aguilar CL, Kuchtey R: Modified vertical mattress tech-

nique for eyelid margin repair. Dermatol Surg 30:1580-1582, 2004

13. Larabee WF, Sherris DA: Principles of Facial Reconstruction (ed 1):

Philadelphia, Lippincott-Raven, 1995

14. Hogg NJ, Horswell BB: Soft tissue pediatric facial trauma: A review.

J Can Dent Assoc 72:549-552, 2006

15. Ueeck BA: Penetrating injuries to the face: Delayed versus primary

treatment—considerations for delayed treatment. J Oral Maxillofac

Surg 65:1209-1214, 2007

16. Goslen JB: Wound healing for the dermatologic surgeon. J Dermatol

Surg Oncol 14:959-972, 1988

17. Hinman CD, Maibach H: Effect of air exposure and occlusion on

experimental human skin wounds. Nature 200:377-8, 1963

18. Lisman R, Spinelli H: Orbital adenexal injuries, in Sherman JE (ed):

Surgery with Facial Bone Fractures. New York, Churchill Livingstone,

1987, p 108

Figure 20 An illustration of an oblique skin laceration that

results in uneven dermal edges (A). These wounds are difficult to

reapproximate and often cause a pin-cushioning skin defect. Skin

edge eversion can be improved by sharply creating new edges with

90-degree angles (B); however, one must be careful not to remove

too much skin that would prevent closure of the wound. After

creating the new skin edges (C), reapproximation of the wound in

a layered closure helps to relieve tension off the skin edges (D).


http://www.facs.org/trauma/atls/index.htmlhttp://www.facs.org/trauma/atls/index.html


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Pediatric orbital roof fractures

T.J. O-Lee, MD,a,b Peter J. Koltai,

Documents

Operative Techniques in Otolaryngology - Head and Neck Surgery, Volume 19, Issue 2, Pages 79-160 (June 2008), Management of Facial Trauma