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Mark Wells, MD, FRCS(C), FACS

Assistant Clinical Professor of Plastic Surgery Grant Medical Center Columbus, OH

Panfacial Fractures
Management of facial fractures has historically been broken down into thirds

Upper Third
Frontal bone Supraorbital rim

Middle Third
Zygoma Nasal bone Maxilla

Lower Third

Definition of Panfacial Fracture

Definition is not clearly delineated in the literature For the purpose of this discussion it is defined as fractures involving all three regions of the face Represent about 10% of the facial fracture population
Journal of Trauma-Injury Infection & Critical Care. 63(4):831-835, October 2007

Panfacial Fractures
Often involve high velocity injury Associated with other polytrauma Facial fracture treatment is not generally the priority

Panfacial Fracture
Definitive care of the maxillofacial injury should only be rendered after a thorough multisystem evaluation
Airway Blood Loss Central Nervous System Injury
Brain C-spine

Panfacial Fractures
Concentrate on the ABC's during the resuscitation Do not allow the facial injury to distract your from the priorities

Epidemiology of Facial Fractures

Lee et al Semin Plast Surg 2002, 109:409
Maryland Shock Trauma Center Review of 73,000 patients admitted over a 10 year period Average Age 33 years 2:1 male to female ratio

Epidemiology of Facial Fractures

Automobile Assaults Altercations Motorcycle Home Industrial Athletic

Epidemiology of Facial Fractures

National Trend
Decrease in the incidence of facial injury related to MVAs
Etiology Seat Belts Air Bags Stricter drunk driving laws

Epidemiology of Facial Fractures

Mid facial structures are the most commonly injured bones
Nose Maxilla Zygoma Orbital walls

Epidemiology of Facial Fractures

Associated injuries are present in 11% of the population of facial fracture patients
8% 5% 4% 1% Extremities Neurosurgical Ocular Spinal

Cervical Spine Injuries

10% of facial fracture patients have cervical spine injuries 18% of cervical spine fracture patients have facial fractures

Cervical Spine Injuries

Most commonly missed cervical injuries are at the upper and lower end of the cervical spine(C12, C6-7) CT scans are more accurate and require less neck movement than plain radiographs

Brain Injury
CT scan of the brain, face, skull and neck should be completed on all facial trauma patients The presence of coma should not preclude the treatment of associated facial injuries once the patient is stable

Panfacial Injuries
Indications for immediate operative intervention
Airway Bleeding Compound Injuries

Early concerns
Securing and adequate airway in the face of unstable fractures, bleeding and soft tissue injury

Late concerns
Surgical access for repair during general anesthesia

Clear oral cavity of debris, blood, teeth and clot Loss of support of the base of the tongue can cause airway obstruction Traction on the mandible and tongue can avert asphyxiation

Endotracheal intubation with C-spine control is the most expeditious method to secure and airway in an acutely compromised airway
Oral Nasal

In extremely urgent situations where oral or nasal intubation is not possible emergency cricothyroidotomy is indicated

Cricothyroidotomy is converted in the operating room to formal tracheotomy
Facilitates placement of the patient into intermaxillary fixation Makes pulmonary management easier Minimizes inadvertent extubation in a swollen patient

Profuse Blood Loss

Life threatening blood loss occurs in 1 to 5% of all patients with mid facial injuries Bleeding is due to bleeding from the internal maxillary artery in 70% of the cases
Internal Maxillary Artery

Profuse Bleeding
Superficial bleeding can often be controlled by packing or temporarily closing open wounds over fractures

Profuse Bleeding
Treatment of closed hemorrhage is often more difficult
Anterior and posterior nasal packing Reduction of displaced fracture fragments

Profuse Bleeding
Selective arterial embolization of branches of the external carotid artery Profuse bleeding from the carotid artery and dural venous sinuses at the base of the skull is difficult and often fatal Selective arterial ligation of both external carotids and superficial temporal arteries is a last resort

Contaminated Compound Wounds

Indication for Immediate intervention
Large open wounds (compound fractures)
Debridement Dressings Vac

Diagnosis of Facial Fractures

Physical examination Radiographic Evaluation

Physical Examination
Careful history and thorough clinical examinations form the basis of the diagnosis Orderly examination from superior to inferior aspect of the craniofacial skeleton

Physical Examination
Bilateral orbital ecchymosis Lengthening of the face Mobility Intraoral step off Malocclusion Panda face

Physical Examination
Loss of nasal projection Telecanthus Enophthalmos Entrapment

Radiographic Evaluations
CT scan With 3-D Reconstruction
Brain, Face and Neck

Plain Films Panorex

Radiographic Evaluation
Plain films
Difficult to evaluate Require multiple views Require a larger radiation dose Generally not cost effective

Radiographic Evaluation
Not readily available in most hospitals Critically ill patients cannot sit in the panorex machine to have the film completed Has been largely supplemented by CT scanning

Radiographic Evaluation
3 D CT scan of facial bone
Can be quickly and economically generated Superior to multiplanar 2D images in demonstrating the spatial relationships between the bone fragments in complex facial trauma

Goals of Treatment
Restore function Maintain facial aesthetics Earlier treatment generally results in superior results
Soft tissue contracture is minimized Infection rates are decreased

Historical Treatment of Panfacial Fractures

Suspension Wires External Fixation Interosseous Wires Plate and screws

Historical Treatment of Panfacial Fractures

Suspension Wires
Suspend the maxilla to a stable portion of the frontal bone or maxilla No direct exposure of the fracture fragments Problem with compression and shortening of the face

Historical Treatment of Panfacial Fractures

External Fixation
Essentially and external suspension device Difficult to apply Required constant adjustment Pin track infections and external scars

Historical Treatment of Panfacial Fractures

Interosseous Wires
Required subperiosteal exposure of all fracture fragments Anatomic reduction under direct vision Difficult to maintain reduction because wires do not provide rotational control

Historical Treatment of Panfacial Fractures

Miniplate Fixation
Has replaced all previous methods Prevents rotation of the fixed fragments in three dimensions Allows operator to bridge small defects in the skeleton (<0.5 cm)

Miniplate Stability
Decreased the incidence of infection Decreased the need for tracheotomy Earlier release of IMF

Intermaxillary Fixation
Important to establish IMF prior to plating fractures Only a small error in plate fixation can result in significant malocclusion With rigid fixation, IMF can often be released at the end of the case

Anatomy of the Facial Skeleton

Skeleton is supported by areas of bony thickening surrounded by pneumatized sinuses Areas of thickening are called buttresses

Anatomy of the Facial Skeleton

Buttresses of the face provide structural support to the face Accurate reconstruction of the buttress anatomy provides for normal facial, projection, length and width

Buttresses of the Face

Analogy has been made to the structural pillars in a building Provides support in all three axis
Vertical Transverse Horizontal

Basic Tenants of Management

Early one stage repair Wide exposure of all fracture fragments Precise anatomic reduction

Basic Tenants of Management

Rigid fixation Reconstruction of the three buttresses of the face Restoring preinjury occlusion

Basic Tenants of Management

Immediate bone grafting of missing segment Working from stable to non stable/ less comminuted to more comminuted fracture fragments

Basic Tenants of Management

Simultaneous replacement of missing soft tissue to prevent secondary contracture

Early Replacement of Missing Components

Skin Grafts Regional Flaps Nonvascularized Bone Vascularized Bone Composite Free Tissue Transfer

Early Replacement of Missing Components

Access Incisions
Depend on the underlying fracture pattern In panfacial injuries, rarely can wide exposure be performed through overlying lacerations

Upper Third Access

Bicoronal Incision
Parallel to hair follicles Zigzag to hide the scar Care must be taken to avoid the supraorbital and supratrochlear nerves Fontal branch must be preserved

Middle Third Access

Upper blepharoplasty incision Transconjunctival incision with lateral canthotomy Upper buccal sulcus incision

Minimize Morbid Exposures

Transconjunctival Incision vs. Lid Cheek Incision

Lower Third Access

Lower buccal sulcus incision Risdon Preauricular

Advances in Facial Fracture Management

Endoscopic condyle and orbital floor repair Percutaneous fixation through limited incision Intraoperative CT guidance

Facial injury remains one of the most common injuries presenting to regional trauma units Recognition of associated life threatening conditions is key to preventing loss of life or further morbidity Early treatment with modern craniofacial techniques speeds recovery and prevents secondary deformity