Unfavourable outcomes in maxillofacial injuries: How to avoid and manage

Abstract

Faciomaxillary injuries remain one of the common injuries managed by plastic surgeons. The goal of treatment in these injuries is the three-dimensional restoration of the disturbed anatomy so as to achieve pre-injury form and function. In this article, the authors review the anatomic, diagnostic and management considerations to optimise results and minimise the late post-traumatic deformities. Most of the adverse outcomes are usually a result of poorly addressed underlying structural injury during the primary management. An accurate physical examination combined with detailed computed tomographic scanning of the craniofacial skeleton is required to generate an appropriate treatment plan. This organised approach has proven effective in restoring the injured structures to pre-injury status. Multiple clinical cases are used to illustrate the different fracture patterns along with various surgical techniques to achieve an acceptable outcome. Early diagnosis and timely management of complications in these complex injuries is also discussed.

Keywords: Craniofacial skeleton; faciomaxillary injuries; fracture; post-traumatic deformity.

Conflict of interest statement

Conflict of Interest: None declared.

Figures

Figure 1

Upper row: Appearance 6 months after depressed fractures frontal bone and bone loss along with saddle nose deformity. Patient had cerebrospinal fluid leak for 2 weeks and globe injury also. The eye has been enucleated. Lower row: Reconstruction of frontal bone defect with cranial bone graft along with saddle nose correction with a cantilever bone graft. The contracted eye socket was released and an ocular prosthesis was inserted

Figure 2

Contour deformity following depressed fracture frontal bone (upper row). Camouflage done with a combination of hydroxyapatite cement and split cranial bone grafts (lower row)

Figure 3

Method of canthopexy using a two hole plate (upper row). The steps of canthopexy (middle and lower row). Mustardee's dancing man flap has also been done for correcting the epicanthal fold

Figure 4

A case of nasoethmoid fracture in acute stage (upper row). The fracture has been dis-impacted and reduced successfully (lower row). It is possible in type 1 and 2 NOE fractures

Figure 5

Late neglected case of type 3 nasoethmoid fracture with gross contour deformity and saddle nose (upper 2 rows). He underwent onlay bone grafting for contour correction and a cantilever bone grafting for the saddle nose deformity correction (lower two rows)

Figure 6

Malunited fracture zygoma with malar flattening 6 months after the injury. The lateral wall and floor show a bony gap (upper row) the segments were re-fractured and fixed in the correct position. The bony gaps in the floor and lateral wall required bone grafts (lower row)

Figure 7

Extensive injury to the orbit resulting in total disorganization of orbit and loss of eye (upper row). All the orbital walls need reconstruction. Contoured cranial bone grafts are planned to be harvested (middle row). The contracted eye socket was released and an ocular prosthesis was placed (lower row)

Figure 8

Midface fractures can be associated with fractures of the frontobasilar region when the trauma is severe. The frontobasilar region can also get injured because of direct trauma also

Figure 9

First and second row: Extensive communition in fracture maxilla and zygoma. There are fractures of all the orbital walls also. Third row showing extensive bone loss which is planned to be reconstructed with split cranial bone grafts. Fourth row: Reconstructed bony frame work. Fifth row: Post-operative result

Figure 10

Submental intubation for maxillofacial injury (above). Well healed and cosmetically acceptable scar of the submental intubation (below)

Figure 11

A panfacial fracture involving frontobasilar region, maxilla, zygoma, orbit and mandible (upper two rows). He also had cerebrospinal fluid leak. The facial palsy can also be seen. Third row shows planning of the reconstruction. The defect in the orbital roof was also repaired using bone grafts. The medial orbital wall floor, infraorbital margin and the malar region also required bone grafting. The mandible and maxilla were fixed with plates and screws. Fourth row shows post-operative appearance