3. Respiratory upper airway
Visual
Olfactory
Mastication
Cosmetic
Communication
Individual recognition
Functions of Face
4. Airway control / immobilize cervical spine
Bleeding control
Complete the primary survey
Secondary survey
Consider NG or OG tube placement
Management Sequence
5. Plain radiographs if fractures suspected
CT if suspect complex fractures
Management Sequence
6. Repair soft tissue immediately if no other
injuries
Delay soft tissue repair until patient in OR , if
surgery for other injuries necessary
Management Sequence
7. Step 1: Airway control
Oxygen for all patients
May need to keep patient sitting or prone
Stabilize C-spine early
Large bore (Yankauer) suction available
Initial Management
8. Step 1: Airway control
Orotracheal intubation preferred over
nasotracheal if possible midfacial fracture and
invasive airway needed
Combitube , retrograde wire, or
cricothyroidostomy if unable to orotracheally
intubate
Initial Management
9. Step 2 : Bleeding control
Rapid nasal packing may be necessary
Be sure blood is not just running down posterior
pharynx
10. Step 2 : Bleeding control
Rarely: emergent cutdown and ligation of
external carotid artery needed to prevent
exsanguination
Note: Although shock in facial trauma patient
is usually due to other injuries, it is possible to
bleed to death from a facial injury
11. Step 2 : Bleeding control
Rarely: emergent cutdown and ligation of
external carotid artery needed to prevent
exsanguination
Note: Although shock in facial trauma patient
is usually due to other injuries, it is possible to
bleed to death from a facial injury
12. Blood in airway
“Debris” in airway
Vomitus, avulsed tissue, teeth or dentures,
foreign bodies
Pharyngeal or retropharyngeal tissue swelling
Posterior tongue displacement from mandible
fractures
Airway Compromise
13. Scalp
Check for lacerations, hematomas, stepoffs,
tenderness
Bleeding maybe brisk until sutured
Can use stapler for rapid closure
Secondary Survey
14. Ears
Examine pinnae, canal walls, tympanic
membranes
Suction gently under direct vision if blood in
canal
Put drop of canal fluid on filter paper for “ring
sign” CSF leak
Assess hearing
15. Eyes
Pupils, anterior chamber, fundi, extraocular
movements
Conjunctivae for foreign bodies
Palpate orbital rims
No globe palpation if suspect penetration
16. Eyes
Lid injury can leave cornea exposed
Use artificial tears or cellulose gel
17. Overall facial appearance
Assess for symmetry, deformity, discoloration,
nasal alignment
Palpate forehead & malar areas
18. Nose
Check septum for hematoma & position
Check airflow in both nares
Palpate nasal bridge for crepitus
Check fluid on filter paper for “ring sign” (for
CSF leak)
19. Mouth
Check occlusion
Reflect upper & lower lips
Check Stenson's duct for blood
Palpate along mandibular and maxillary teeth
20. Major
Lefort I, II, III
Mandibular
ϕ Minor
ϕ Nasal
ϕ Sinus wall
ϕ Zygomatic
ϕ Orbital floor
ϕ Antral wall
ϕ Alveolar ridge
Fracture Classification
21. Lefort fractures can coexist with additional
facial fractures
Patient may have different Lefort type fracture
on each side of the face
Lefort Fractures
22. Pull forward on maxillary teeth
Lefort I: maxilla only moves
Lefort II: maxilla & base of nose move:
Lefort III: whole face moves:
23. Horizontal fracture extending through maxilla
between maxillary sinus floor & orbital floor
Crepitus over maxilla
Ecchymosis in buccal vestibule
Epistaxis: can be bilateral
Malocclusion
Maxilla mobility
Lefort I: Nasomaxillary
24. Closed reduction
Intermaxillary fixation: secures maxilla to
mandible
May need wiring or plating of maxillary wall
and / or zygomatic arch
Antibiotics: anti-staphylococcal
25. Subzygomatic midfacial fracture with a
pyramid-shaped fragment separated from
cranium and lateral aspects of face
Lefort II: Pyramidal
27. Hemorrhage or airway obstruction may require
emergent surgery
Treatment can often be delayed till edema
decreased
28. Usually require
Intermaxillary fixation
Interosseous wiring or plating of infraorbital
rims, nasal-frontal area, & lateral maxillary
walls
May need additional suspension wires
Antibiotics
29. Craniofacial dissociation
Bilateral suprazygomatic fracture resulting in a
floating fragment of mid-facial bones, which
are totally separated from the cranial base
Lefort III
30. Signs and Symptoms
Face lengthening: “caved-in” or “donkey face”
Malocclusion: “open bite”
Lateral orbital rim defect
Ecchymoses: periorbital, subconjunctival
31. Signs and Symptoms
Bilateral epistaxis
Infraorbital paresthesia
Often medial canthal deformity
Often unequal pupil height
32. Usually associated with major soft tissue injury
requiring emergent surgery for bleeding
control
Surgery can be delayed till edema resolves
Intermaxillary fixation
33. Transosseous wiring or plating
Frontozygomatic suture
Nasofrontal suture
May need extracranial fixation if concurrent
mandibular fracture
Antibiotics
34. Airway obstruction from loss of attachment at
base of tongue
>50 % are multiple
Condylar fractures associated with ear canal
lacerations & high cervical fractures
High infection potential if any violation of oral
mucosa
Mandible Fractures
35. Signs and symptoms
Malocclusion
Decreased jaw range of motion
Trismus
Chin numbness
Ecchymosis in floor of mouth
Palpable step deformity
36. Tongue blade test: have patient bite down
while you twist. If no fracture, you will be able
to break the blade.
37. Treatment
Prompt fixation: intermaxillary fixation (arch
bars), +/- body wiring or plating
38. Can occur from direct blow to mandible
Can occur “spontaneously” from yawning or
laughing
Mandible dislocates forward & superiorly
Concurrent masseter & pterygoid spasm
TMJ Dislocation
39. Symptoms
Patient presents with mouth open, cannot close
mouth or talk well
Can be misdiagnosed as psychiatric or dystonic
reaction
40. Treatment
Manual reduction: place wrapped thumbs on
molars & push downward, then backward
Be careful not to get bitten
Usually does not require procedural sedation
or muscle relaxants
41. Often diagnosed clinically: x-ray not needed
Emergent reduction not necessary except to
control epistaxis
Usually do not need antibiotics
Early reduction under local anesthesia useful if
nares obstructed
Nasal Bone Fractures
42. Nasal septal hematoma: incise & drain, anterior
pack, antibiotics, follow-up at 24 hours
Follow-up timing for recheck or reduction:
Children: 3 to 5 days
Adults: 7 days
43. Tripod (tri-malar) fracture
Depression of malar eminence
Fractures at temporal, frontal, and maxillary
suture lines
Isolated arch fracture
Less common
Shows best on submental-vertex x-ray view
Painful mandible movement
Usually treat with fixation wire if arch
depressed
Zygomatic Fractures
44. Tripod S & S
Unilateral epistaxis
Depressed malar
prominence
Subcutaneous
emphysema
Orbital rim step-off
Altered relative
pupil position
Periorbital
ecchymosis
Subconjunctival
hemorrhage
Infraorbital
hypoesthesia
45. Frontal sinus fracture
Often associated with intracranial injury
Often show depressed glabellar area
If posterior wall fracture, then dura is torn
Ethmoid fracture
Blow to bridge of nose
Often associated with cribiform plate fracture,
CSF leak
Medial canthus ligament injury needs
transnasal wiring repair to prevent telecanthus
Supraorbital Fractures
46. “Blow out” fracture of floor
Rule out globe injury
Visual acuity
Visual fields
Extraocular movement
Anterior chamber
Fundus
Fluorescein & slit lamp
Orbital Fractures
48. Diplopia with upward gaze: 90%
Suggests inferior blowout
Entrapment of inferior rectus & inferior oblique
Diplopia with lateral gaze: 10%
Suggests medial fracture
Restriction of medial rectus muscle
49. Sometimes extraocular muscle dysfunction can
be due to edema and will correct without
surgery
Persistent or high grade muscle entrapment
requires surgical repair of orbital floor (bone
grafts, Teflon, plating, etc.)
50. Before repair, rule out injury to:
Facial nerve
Trigeminal nerve
Parotid duct
Lacrimal duct
Medial canthal ligament
Remove embedded foreign material to prevent
tattooing
Facial Soft Tissue
Injuries
51. For lip lacerations, place first suture at
vermillion border
Never shave an eyebrow: may not grow back
If debridement of eyebrow laceration needed,
debride parallel to angle of hairs rather than
vertically
52. Antibiotics for 3 to 5 days for any intraoral
laceration (penicillin VK or erythromycin) and
if any exposed ear cartilage (anti-staphylococcal
antibiotic) – no evidence
Remove sutures in 3 to 5 days to prevent cross-marks
53. Most face bite wounds can be sutured
primarily
Clean facial wounds can be repaired up to 24
hours after injury
Place incisions or debridement lines parallel to
the lines of least skin tension (Lines of Langer)
56. Cleft lip
Cleft palate
misaligned jaws.
Accident victims suffering facial injuries,
Dental implant surgery,
patients with tumors and cysts of the jaws and
functional and esthetic conditions of the
maxillofacial areas.
Condition requiring
surgery
57. Surgery performed at outside institution
without reconstruction after parotid surgery.
58.
59. If cleft lip is present, its repair can precede
palatoplasty. Although early repair seems to
have an advantage in decreasing the chances of
speech delays, the risk for facial growth
abnormalities and other midface-related
problems may be increased.
60. General Principles of Facial Reconstruction
Development of Facial Surgical Reconstruction
Replacing Tisssue Loss
Returning to Normal
Facial Reconstruction by Unit
Facial Function over Form
Invisible Scars
Facial Reconstruction
following Trauma or Surgery
61. Our faces play a pivotal role in our daily social
interactions, through expression of emotions,
appearance and most importantly identity.
The face is our carte visite, the place where our
individuality and our personality is manifested.
It is understandable then that permanent scarring of
the face caused by severe trauma or surgery can be
profoundly damaging for the person affected.
For this reason facial reconstruction is extremely
important and there are a number of fundamental
general principles that underpin the surgical
techniques employed.
General principles
62. The first attempts at facial reconstruction took place
several hundred years ago and are attributed to one
of the forefathers of modern reconstructive surgery,
the genius Gaspare Tagliacozzi. Tagliacozzi was
Professor of Anatomy at the Medical School of
Bologna in Italy in the late 16th century. He is
credited with being the first surgeon to attempt
reconstruction of the nose by using a flap of skin
taken from the forearm. The flap, called a pedicle,
was attached to the nose and the patient's arm was
bandaged in a raised position until the skin of the
arm had attached itself to the nose. The pedicle was
then cut from the arm and the attached skin could
then be shaped so that it resembled the nose.
The development
63. This in effect corresponds to a method that
was later called "Robin
Hood's tissue apportionment", where tissue from an
area of abundance is used to make up for tissue
deficiencies in another part of the body. This was
achieved by using "advancement" or "rotational"
flaps. The full development of this notion gave birth
to modern ideas of "transfer" of flaps from other
areas of the body and ultimately "transplantation" of
flaps. The former requires the employment of
"micro-vascular" techniques that involve the
"transfer" of tissue together with their supporting
arteries and veins, which then have to be connected
to the recipient vessels in the neck.
64. Close collaboration with immunological
manipulation techniques is also necessary as
part of anti-rejection treatment of the
"transplant". The reported success stories of
total face transplants ultimately signify how
advanced reconstructive surgery has become.
However, surgical success would not be
possible without close interaction between
various medical disciplines including
immunology, intensive care and post-surgery
neurological and psychological rehabilitation.
65. Dr Ralph Millard, one of the founders of
modern reconstructive surgery, summarised
the main "executional principles" on which
reconstruction of the face should be based by
stating that "tissue losses should be replaced in
kind.”
Replacing tissue
66. What this means in practice is that bone should
be replaced with bone, muscle with muscle and
skin with skin. Nevertheless, the 3-dimensional
complexity of the anatomy of facial structures,
including a multitude of small muscles
attached to thin, sometimes hollow bones of
irregular, complex shape makes such a
principle difficult to apply successfully.
67. In particular, "transitional" areas between dry
skin and moist mucosa, such as at the junction
of the outer lip to vermillion border and inner
lip and the junction of thin eyelid skin to the
tarsal plate and the conjunctiva of the eye make
reconstructive planning a daunting surgical
task.
68. For the reason set out above, the further
principle of "return what is normal to the
normal position and retain it there" is of
paramount importance. Displacement, or loss
of structures, can occur as a direct result of
trauma or planned surgical excision or even
scar contraction. The surgical correction needs
to take into account the normal appearance or
in cases of long established deficit the aesthetic
projection of what normal would have been for
the missing facial structure.
Returning to normal
69. Nowadays, this can be facilitated with the use of
technology, namely with the use of 3-dimensional
images obtained by computer tomography. By using
these radiological images and by utilising 3-
dimensional "printers" it is possible to create
custom-made plastic models, where the missing part
has been recreated as a "mirror" image of the
opposite healthy side. Obviously there are more
complex defects or defects of a single structure, such
as the nose, where the recreated missing part
represents an estimate of the size and shape of the
deficient organ. This assessment is based on data on
size and shape depending on the gender, age and
ethnic variation of the patient and ultimately on the
anticipated symmetry of the new "organ" in relation
to the surrounding structures.
71. This diagram* demonstrates how the face can
be divided into "unit borders" that are
demarcated by natural folds, creases and
generally "transitional" anatomical areas.
Respecting the boundaries of these "aesthetic
units" during surgical procedures gives a more
"natural" expression to the reconstructed area,
concealing the differences in texture, thickness,
composition, colour and light reflection
between the native and the reconstructed
tissues.
72. In addition, this breaking down of the face into
aesthetic units provides the surgeon with an
operative "road map" of the exact
reconstructive needs caused by the defect. In
this way, a complex 3-dimensional defect
involving various anatomical borders can be
divided into smaller anatomical units, which
can then be considered almost independently
during the planning of the surgical procedure.
73. There are a number of other principles that
could be included but amongst them I would
just like to underline the importance of
"function over form”, especially applicable
with patients being treated for major trauma or
defects following major ablative surgery.
The functions of the face can be grouped into
physiological, expressive and aesthetic. The
face also plays a very important role in the
patient's identity.
Importance of function
over form
74. The physiological functions of the face include
the crucial anatomical barrier that the skin of
the face provides between the internal and
external environments and the abundance of
sensory cutaneous nerves that can be seen as
the primary sensory organ of the body. The
mouth forms part of the alimentary tract; and
the nose (and secondarily mouth),
the respiratory tract, whilst also hosting the
olfactory nerve endings that provide the all-important
sense of smell.
75. Finally the external parts of the eyelids protect
the orbital globes from mechanical injury while
the internal side together with
the conjunctiva provides a pliable, thin layer
protecting the cornea of the globe.
The expressive function of the face is
underscored by its importance as the main
instrument of non-verbal communication,
allowing us to express and communicate our
thoughts and feelings. Finally, the aesthetic
function of the face allows social acceptance
and integration.
76. The quest of modern facial reconstructive
surgery techniques then is to provide, as far as
possible, "invisible scars" in the face, which
means concealing outside the most visible
anatomical areas. Fortunately the face does
offer such an opportunity. There is a vast array
of operations that can be performed through
the oral cavity including surgical procedures
for the bones of the mid- and lower third of the
face and their overlying soft tissues.
Invisible scars
77. Equally, surgery around the orbital globes can be
performed through the conjunctiva, allowing access
to the eye socket and the supportive bone with no
need for skin incisions. Finally, the combination of
facial incisions in conjunction with concealing
incisions behind the ears or within the hairline can
provide almost seamless, invisible access to the
entire surface of the face and the facial skeleton. This
allows not only cosmetic improvement of facial
features, but primarily serves the ongoing need for
social integration by minimising defects and scars
and subsequently by minimising the indelible traces
of previous illnesses
