An Overview of Facial Injuries

Symposium on Plastic Surgery for the General Surgeon

An Overview of Facial Injuries Richard Carlton Schultz, M.D.,* and Roger J. Oldham, M.D. t

A high percentage of the patients presenting to the emergency room with multiple system injuries are injured in automobile accidents. Of these patients, approximately 54 per cent will have sustained significant facial trauma (Fig. 1). As the primary physician for patients who 'have sustained multiple system injuries, it is important for the general surgeon to be familiar with the early management of facial injuries, even though a plastic surgeon may ultimately become responsible for the definitive treatment. ' The general surgeon's early management of facial injuries in the emergency room plays an important role in the final outcome of these injuries. The extent of early treatment is dependent on the nature of the associated injuries. However, even in cases with intraabdominal and intrathoracic trauma, a few basic principles applied in a timely fashion will enhance the outcome of the facial injuries. There are sometimes complications even after the most competent treatment, which may eventually require complex multistaged reconstructive procedures.

TRIAGE In terms of timing, definitive treatment of most facial injuries ordinarily deserves a low priority in the total patient care. With the exception of animal bites and accidental tatoo, even soft tissue trauma can usually be safely delayed up to 24 hours (or much longer-editor) with proper preparatory wound care. Most facial fractures are best treated after several days following resorption, of edema. Whether delay is mandatory or elective, abdominal, thoracic, orthopedic, urologic, or neurologic injuries should be evaluated first. Emergency Management The priorities of early management for the patient who has sustained extensive facial trauma are the same as for any trauma patient: From the University of Illinois Abraham Lincoln College of Medicine, Chicago, Illinois ·Professor and Head, Division of Plastic Surgery tInstructor in Surgery, Chief Resident in Plastic Surgery

Surgical Clinics of North America- Vol. 57, No, 5, October 1977

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Figure 1. Prevalence of areas of associated injuries in patients sustaining facial injuries from auto accidents. Percentage markers indicate head and neck, all extremities, chest, and abdomen. (Drawing adapted from Vesalius and reproduced from Schultz, R. C.: Facial injuries from automobile accidents: A study of 400 consecutive cases. Plast. Reconstr. Surg., 40:415-425, 1967. Used with permission.)

clear airway, control hemorrhage, treat shock, evaluate associated injuries, and then treat facial injuries. The causes of airway problems following facial trauma are varied. Obstruction from dentures, bone fragments, blood, or vomitus should be treated immediately by manual removal or aspiration. Although tracheostomy is often suggested for the patient with extensive facial injury, it is seldom indicated unless there are associated injuries of the head, neck, or chest. Occasionally a patient with a bilateral mandibular fracture can suffer collapse of the mandibular arch with retrodisplacment of the tongue and subsequent airway obstruction; but this can usually be corrected by placing the patient in the sitting position, allowing the arch to fall forward to relieve the obstruction. Hemorrhage from facial trauma is usually diminished by the time the patient arrives in the emergency room. Persistent bleeding can generally be controlled by pressure alone, except for major vessels which may be clamped and ligated through the wound, being careful to avoid injury to important adjacent structures; e.g., facial nerve, parotid duct, or lacrimal sac, etc. Shock must be treated aggressively as in any trauma patient, but blood loss from facial injury alone is seldom of sufficient magnitude to cause hypotension. The cause of shock should therefore be anticipated as being more likely from associated injuries. After the patient's vital signs have stabilized, the other organ systems can be more definitively evaluated. Primary attention is directed toward the facial injuries only after the general surgeon is satisfied that no intraabdominal or intrathoracic trauma has occurred. A case history illustrates this important point.

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CASE HISTORY

A 49-year-old male professional entertainer was the driver of an automobile that crashed into and overrode the back of a tractor-trailer. He arrived at a Baltimore hospital at 12:30 A.M. A plastic surgeon was called because of extensive facial lacerations and depressed comminuted nasal fractures. The patient complained of abdominal "fullness," but attributed it to having been to a banquet. He repeatedly insisted that his face be attended to immediately. Adequate evaluation and treatment of the facial injuries required general anesthesia. Before operating, the plastic surgeon called a general surgeon fOJj consultation regarding suspected intraabdominal injuries. Abdominal x-rays were not definitive and the general surgeon, having found insufficient grounds for laparotomy, went home. The plastic surgeon began to operate at 3:00 A.M. While the patient was under anesthesia his blood pressure dropped sharply. The general surgeon was summoned again. Exploration of the abdomen revealed a torn mesentery, perforated small bowel, injured spleen, and lacerated pancreas. Despite massive transfusions and attempts to repair the lesions, the patient died several hours after completion of surgery. A postmortem test for alcohol indicated that the patient's blood alcohol concentration at the time of admission was between 0.25 and 0.33 per cent by weight, a degree of Intoxication that would have substantially interfered with his perception of pain.'

While stressing the relatively low priority of definitive facial injury treatment, it must also be emphasized that early evaluation cannot be ignored. If the patient's general condition permits, he should be observed and transported in the semisitting position to minimize venous ooze and formation of edema. The patient will be made more comfortable at the same time. The patient's facial injuries should be evaluated radiographically at the initial x-ray examination for other injuries. A Ininimum number of facial x-rays is required to supplement the plastic surgeon's clinical

Figure 2. Panorex view of mandible demonstrating fracture of condyle with minimal displacement. Such an x-ray shows entire mandible on a single film by rotating both the x-ray beam and the cassette around the mandibular arch. It will often show fractures not easily demonstrable on conventional x-ray projections. (Figs. 2 and 3, E and F reproduced from Schultz, R. C.: 1000 consecutive cases of major facial injury. Rev. Surg., 27:394,1970. Used with permission.)

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Figure 3. Facial bone fractures and associated fractures of the cervical spine: A, note asymmetry of lower jaw; B, oblique fracture of mandible; C, displaced fracture of C2 on C3 ; D, demonstrates restoration of lower dental arch and excursion of mandible. Family dentist will provide dental reconstruction. (Figs. 3, A-D, reproduced from Baker, S. P., and Schultz, R. C.: Recurrent problems in emergency room management of maxillofacial injuries. CLIN. PLAST. SURG., 2:65-71,1975.)

evaluation for facial fractures. The Water's view (occipitomental) is the most valuable x-ray for evaluating the maxilla, the zygoma, and the frontal sinuses. Oblique views of the mandible give the greatest information for fractures of the lower third of the face. When available, a Panorex view of the mandible may be included for a mote sophisticated view of the entire mandible on a single film (Fig. 2). A plastic surgeon consultant should not find himself being called to the operating room for concurrent treatment of facial injuries while a laparotomy or an orthopedic procedure is being performed, only to learn that facial bone xrays were not taken at the time of the initial x-ray studies. Likewise, the condition of a patient who is settled in his hospital room in balanced traction for treatment of extremity fractures creates an unnecessary dilemma in obtaining satisfactory facial x-rays. The importance of routinely obtaining cervical spine x-rays during the initial x-ray examination for the facial injuries cannot be overem-

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Fcwce 'Alctors Accounting fOl'" Associated Fractures

F

RecLctIon of CerVICQI Spine Fracture in Presence of MandIbular Fractures

Figure 3. Con tin ued. E, Diagrammatic representation of fractures of anterior mandible, condyle, and second cervical vertebra. F, Reduction of cervical spine fracture in presence of mandibular fractures.

phasized. In a series of 400 patients with facial injuries of varied extent, an incidence of 4 per cent cervical spine fractures was found, many of which were asymptomatic. 3 In patients with extensive multiple system injuries, this incidence would likely be significantly higher (Fig. 3).

SOFT TISSUE INJURIES The most important early treatment of soft tissue injuries after securing hemostasis is cleansing of the wound. Ideally the wound is treated definitively in the first few hours after injury; but when delayed for whatever reason, soft tissue repair can safely be performed up to 24 hours if the wounds have been properly cleansed and dressed. The exceptions to this are animal bites and retained foreign bodies, both of which should be treated soon after injury to reduce the likelihood of infection and tissue entrapment of foreign material. To cleanse the wound, the surrounding skin should be washed with soap or antiseptic preparation (Betadine or Phisohex), taking care to

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avoid soaking the wound itself with the solution. The wound should be irrigated with saline solution using a bulb syringe or a jet lavage which incorporates a pulsating water stream made for this purpose. Any solution except normal saline can be injurious to wounds, and other preparations do not provide any significant antibacterial effect. Types of Wounds Soft tissue trauma may vary in the degree of severity, but can generally be categorized as: contusion, abrasion, puncture, laceration, avulsion flap, avulsion defect, or accidental tatoo. Contusion is usually the result of blunt trauma and is managed by cleansing and possible dressings. A hematoma of significant size should be evacuated rather than be allowed to resorb. This is especially true of a hematoma overlying the ear or nasal cartilage, as spontaneous resolution will often result in resorption of cartilage, subcutaneous scarring, and deformity. An untreated nasal septal hematoma will typically resorb and destroy the septal cartilage, leaving a "saddle nose" deformity. During the early stage (the first 7 to 10 days), a hematoma can be evacuated through a small surgical incision. A more conservative approach to treatment where cartilage is not involved is needle aspiration, usually performed successfully after 10 to 14 days. Abrasions and puncture wounds are properly treated with cleansing only, provided care is taken to remove any imbedded foreign body. The treatment of accidental tatoo requires scrubbing with a stiff scrub brush. Care must be exercised to avoid overly zealous scrubbing to prevent conversion of a partial-thickness injury into a full-thickness dermal defect requiring skin grafting. Simple lacerations should be treated with skin cleansing, wound irrigation with normal saline, and primary closure. If there are beveled or "feathered" wound edges, as are frequently found associated with the old type windshield injuries,5 or if there is obviously devitalized tissue, appropriate debridement should be performed. However, most facial wounds should be managed with very conservative debridement. Questionably viable facial tissue will often survive because of the excellent blood supply of the face. Overly aggressive debridement may result in the loss of vital bits of soft tissue needed for later reconstruction. Lacerations are closed in layers, using a minimum but adequate number of sutures. Buried sutures are a potential nidus of infection, but so also is dead space filled with blood or serum. Soft Tissue Repair The cheek is the area of the face most frequently lacerated. Deep structures of concern are the facial nerve, the parotid gland, and the parotid duct (Fig. 4). Nerve Injury Facial nerve injury should be diagnosed on the basis of physical examination and anatomic landmarks. An uncooperative patient, an extensive soft tissue injury, or extensive edema may make the physical exam-

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Figure 4. Location of Stensen's duct and the buccal branch of the facial nerve.

J ination inconclusive, but under ordinary circumstances muscle paralysis on the involved side of the face indicates nerve injury. A functional as well as cosmetic deformity results from an unrepaired proximal facial nerve laceration. Division of branches of the facial nerve medial to the midpupillary line does not usually require repair, as branching cross innervation will likely reinnervate the appropriate muscle spontaneously. Lateral to this point, however, nerve repair should be attempted in order to guide the advancing axons to the motor end plate in the muscle. The most severe functional deficit from division of a single nerve branch is that of the temporal branch as this causes paralysis of the eyelid and subsequent exposure of the cornea. This nerve courses superiorly at a point halfway between the tragus and lateral canthus, becoming superficial at this point. The mandibular branch of the facial nerve is also commonly injured. This branch is always deep to the platysma muscle when posterior to the facial artery. It then courses near the lower border of the mandible, although it may be found 1 cm below the mandible. Anterior to the facial artery the nerve becomes more superficial and is nearly always found above the lower border of the mandible. When a proximal laceration of a branch of the facial nerve is suspected, exploration should be undertaken to identify the nerve ends. The epineurium is best reapproximated with fine suture material, utilizing magnification. Injury of a major nerve trunk should be repaired with fascicular sutures with the aid of an operating microscope.

Parotid Injury The parotid duct can be divided by a deep laceration posterior to the anterior border of the masseter muscle. The parotid duct courses along a line from the tragus of the ear to the midportion of the upper lip. It lies

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deep near the anterior border of the masseter muscle, emptying into the oral cavity adjacent to the first maxillary molar tooth (see Fig. 4). Laceration of the parotid duct will also frequently damage the buccal branch of the facial nerve. When there is complete laceration of the parotid duct, an end-to-end anastomosis over a small Silastic catheter can be performed. The proximal cut end of the duct can be sutured to the oral mucosa as an alternate procedure to maintain parotid function. When clear fluid is seen leaking from a wound in the parotid region, injury to the gland should be suspected, but the gland itself need not be sutured. Salivary fistula is a common complication following skin repair of an underlying glandular laceration. This usually closes without treatment in about 3 weeks. Eyelid Injury Injuries to thIn eyelid skin may result in small avulsion flaps which appear questionably viable. Such flaps usually survive if replaced anatomically. Divided muscle and tarsal plate should be identified and sutured separately with fine absorbable suture. The tarsal plate is adherent to the conjunctiva and can be repaired with the conjunctiva. Lacerations of the thin orbital septum usually do not require separate closure providing the orbicularis oculi muscle is repaired. Lacerations of the lacrimal apparatus must be recognized and repaired to prevent epiphora and dacryocystitis postoperatively. The divided lacrimal duct may be cannulated with a heavy nylon suture and then reapproximated with fine absorbable sutures. After a week the nylon stent is removed. Fine, soft polyethylene catheters can also be used for cannulization. When injury to the lacrimal system is severe, primary dacryorhinocystostomy should be considered. Ear Injury Lacerations through the full thickness of the ear are best repaired by cutaneous-perichondrial sutures. The cartilage margins may require conservative trimming to facilitate skin closure, but cartilage itself need not be sutured. Hematoma of the ear from blunt trauma may be potentially disfiguring if left untreated. Aspiration or incision and drainage will evacuate the hematoma in the early stages. If untreated, the hematoma undergoes organization and fibrosis leading to the classical "cauliflower ear." Nasal Injury Lacerations through the nostrils are repaired by closure of the mucous membrane with absorbable sutures and monofilament nylon in the skin. Special pains are taken to accurately align the nostril border but suturing of the alar or upper lateral cartilages is not ordinarily necessary. Nasal fracture, of course, should always be suspected. These can often be diagnosed clinically and treated at the time of soft tissue repair. Techniques of closed reduction of displaced nasal fractures are discussed below.

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FACIAL BONE FRACTURES DIAGNOSIS

The patient suffering extensive facial fractures can present an awesome appearance. Forces sufficient to fracture the bony facial structure may also cause disfiguring soft tissue injury, as previously discussed. Displacement of the bony fragments further distorts the facial contour. As emphasized earlier, the severity of a facial wound must not draw the examiner's attention away from potentially more severe visceral injuries. Similarly the severity of soft tissue destruction should not distract the examiner from a complete examination of the facial skeleton. The diagnosis of bony injuries must sometimes result from the clinical evaluation alone, as the initial x-ray examination may not always demonstrate facial fractures. Poor dental occlusion may be the first clue of mandibular or maxillary fracture. Diplopia may be the only positive finding of a fractured orbital floor. Careful observation can disclose depressed frontal sinuses, a deviated nasal complex, a depressed zygoma, enophthalmus, an asymmetric mandible, or a malaligned dental arch. Systematic bimanual palpation will help to avoid missin'g less obvious fractures (Fig. 5). palpation

.---- Visualization of gross dental occlUSIon

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Figure 5. A-C. Techniques for bilateral palpation about the orbits. D, Palpation for irregularities of zygomatic arch. E, Visualization of interdental occlusion. F, Maneuver to ascertain maxillary motion. (Reproduced from Schultz, R. C., and Wood, J. R.: Facial fractures. PRIMARY CARE, 3 :641-663, 1976.)

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Upper

Middle

Figure 6. Identification of facial bones by region. (Figs. 6, 8, 10-13, 14B, 15-17 reproduced from Schultz, R. C.: The management of common facial fractures. SURG. CLIN. N. AM., 53:3-32, 1973.)

Lower

of the bony parts can usually elicit tenderness and sometimes motion and crepitus at the fracture sites.

FRACTURES OF THE UPPER THIRD OF THE FACE

Fractures of the upper third of the face are less common than those of the lower two-thirds of the face because of the protection afforded by an energy absorbing projecting part, the nose (Fig. 6). Fractures of the

Figure 7. Fractures of upper third of face as well as frontal and parietal skull from auto accident. This victim was able to survive 8 hours in part because of the decompressing nature of the injury. (Figs. 7, 9, 19, and 20 reproduced from Schultz, R. C.: Frontal sinus and supraorbital fractures from vehicle accidents. CLIN. PLAST. SURG., 2:93-106,1975.)

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frontal area usually involve the thinner bones of the frontal sinuses or the supraorbital ridges. Because of the close proximity to the brain, injuries in this area are more likely to have a higher morbidity and to be more life-threatening than any other facial fractures 6 (Fig. 7). Positive physical findings usually appear in the ocular region due to extravasation of blood into the orbital area. Periorbital ecchymosis is observed in nearly all cases; diplopia is inconstant. Diplopia is seen with depressed supraorbital fractures, but is not commonly found with glabellar fractures. 6 Nasal fractures and overlyipg lacerations of the forehead are commonly found in association with fractures of the upper third of the face. 6 Treatment of these fractures involves reduction of the bony fragments by either the direct or indirect approach6 and interosseus fixation when required for stabilization (Fig. 8). Appropriate debridement of avascular or pulped sinus mucosa, accurate replacement of soft tissue, and systemic antibiotic therapy should accompany the bony reduction (Fig. 9). Some surgical disciplines have advocated removal of the comminuted bone fragments and extirpation of the sinus, but this bone loss results in gross deformity. Such deformity requires extensive secondary reconstructive procedures to correct, whereas primary bony reconstruction as outlined above has given excellent functional and aesthetic results without complications 6 (see Figs. 19 and 20).

Figure 8. Operative technique for elevation of comminuted depressed glabellar fracture fragments.

A Depres sed, asymmetrical deformity of forehead and nose

B Fractures of frontal sinuses and nasal bones

Depressed segments elevated after removing center fragment

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Figure 9. Typical comminuted depressed fractures of the frontal sinuses seen through retracted overlying forehead laceration.

FRACTURES OF THE MIDDLE THIRD OF THE FACE

Because of the prominence of the nasal complex and the thin bones supporting it, nasal fractures are the most common of all facial fractures. In a series of 1083 consecutive facial fractures, the nasal bones were the most commonly involved. 4 Other fractures commonly seen in the middle third of the face involve the maxilla, zygoma, and zygomatic arch, and the bones making up the orbit. Nasal Fractures Clinical findings are the most reliable means of making the diagnosis of a nasal fracture, as positive x-ray visualization is sometimes absent even in a nose with gross traumatic deformity.7 A history of a nose bleed following injury, deviation of the nasal pyramid, and crepitus on palpation are the most helpful clinical findings. History of a previous fracture or nasal deviation is important, since a healed displaced nasal fracture often cannot be reduced by the usual closed reduction techniques. Unless one can treat the patient prior to the onset of edema, closed reduction should be delayed 5 to 7 days to allow for its resolution. Reduction can be delayed up to 2 or 3 weeks if necessary. The need for reduction can best be determined after the edema has resorbed, since nondisplaced nasal fractures require no reduction. Anesthesia of the nose is accomplished by intranasal packs soaked in a 5 per cent cocaine solution accompanied by an external block using 1 per cent lidocaine with epinephrine.7 After the nose has been anesthetized, disimpaction and reduction of the nasal bone fragments is done

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with three nasal reduction instruments (Fig. 10). This is followed by immobilization of the fragments with a plaster splint for 1 week. Although a severely displaced nasal fracture may be reducible by closed techniques for several months, a minimally displaced fracture will often become fixed by fibrous union within 3 to 4 weeks. Efforts to correct the deformity after such healing often require open reduction with osteotomies. Maxillary Fractures The mechanism of injury for maxillary fractures is usually direct impact to the midface as in an automobile or motorcycle accident. In 1901 the French surgeon, Le Fort, described three common fracture lines of the maxilla based on weak points of the midfac& (Fig. 11). Clinically, however, maxillary fractures are often a modification or combination of these classic fracture lines. Combinations of such fractures have given rise to the term "panfacial fractures." TRANSVERSE MAXILLARY FRACTURE (LE FORT I). This fracture is often associated with a blow to the upper lip. It often results in a single segment made up of the alveolar process, the palate, and the pterygoid process. Inspection of the dental arches usually demonstrates an open

Welshem forceps used 10 disimpacl and reconslrucl nasal pyramid

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Figure 10. Instruments for reduction of nasal fractures and techniques of their use.

Asch forceps used to disimpact and replace nasal seplum in midline

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RICHARD CARLTON SCHULTZ AND ROGER

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Figure 11. Le Fort Classification of Maxillary Fractures. I. Transverse fracture of maxilla. II. Pyramidal fracture of maxilla. III. Craniofacial dysjunction.

bite with superior displacement of the maxillary incisors. Motion of the entire upper dental arch and palate sometimes can be detected by grasping the upper teeth; but this must be differentiated from an isolated alveolar ridge fracture. Treatment consists of reduction and immobilization. This is usually best accomplished by intermaxillary fixation with arch bars and suspension from the lateral orbital rims (Fig. 12). However, in some cases interosseus wire fixation along the fracture site along with intermaxillary fixation may be sufficient for good stabilization. PYRAMIDAL FRACTURE (LE FORT II). An impact higher on the midface may result in a fracture which passes from the alveolus posteriorly along the nasal processes of the maxillary bone, across the root of the nose, posteriorly through the lacrimal bones, the floor of the orbit, and . the pterygoid process. The isolated maxillary fragment is pyramid shaped. Unless the blow has impacted the maxilla posteriorly or superiorly, motion can be detected at the medial portion of the orbital floors by grasping the upper teeth and exerting a rocking movement. Reduction and immobilization of this fracture can be similarly accomplished with wire suspension from the frontal bone or zygoma. However, this fracture is more unstable because of the tendency to displace posteriorly. Direct wiring at the infraorbital rim may add some stability but comminution is sometimes found at these points making interosseus wiring difficult.

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Pyramidal maxillary fractures and proposed orbital incisions

Figure 12. Technique for wire suspension of fractured maxilla from temporal bones bilaterally.

Trochar method of passing suspension wires behind zygoma

CRANIOFACIAL DYSJUNCTION (LE FORT III). Powerful forces delivered to the maxilla may result in complete separation of the facial bone structures from the base of the skull, remaining attached only by soft tissue. It is more severe than the pyramidal fracture even though the maxilla may remain intact, because the fractures extend transversely across the nasal bridge, both posterior orbital walls, the lateral orbital rims, and the zygomatic arch, separating the face from the cranium. This facial fracture may result in death from an associated intracranial injury. Treatment consists of reduction and immobilization of the fracture similar to the Le Fort II with the addition of interosseus wiring at the zygomaticofrontal suture to provide greater immobilization. The deformity that results from inadequate treatment of a severe maxillary fracture is a flattened, elongated, or depressed midface. Zygomatic Fractures The zygoma has two components: the malar eminence and the zygomatic arch. Fractures may occur in each segment separately or in combination, but an isolated arch fracture is uncommon. The most common fracture of the zygoma involves depression of the malar eminence. This consists of three fracture lines - thus the terms "tripod fracture" or "trimalar fracture." The fracture sites are usually found at the zygomaticotemporal and zygomaticofrontal suture lines, and through the

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E Elevation of Zygoma by upward-forward force

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Figure 13. A-D, Operative technique for open reduction and internal wire fixation of fractures of zygoma and orbital floor. E and F, Reduction of zygoma and drilling holes for wire fixation. G and H, Implant used to reinforce the orbital floor.

infraorbital foramen. The fractured zygoma may undergo varying degrees of rotation and depression, depending on the mechanism of injury. Treatment usually requires open reduction and internal interosseous fixation at two of the three fracture sites, usually at the inferior and lateral orbital rims (Fig. 13). Failure to effect an anatomic stable reduction will frequently result in an obviously flattened and depressed malar eminence after the swelling has resorbed. Some authors have advocated semiclosed reduction with the force applied under the arch through an intraoral approach or scalp incision. Without interosseous wiring, however, this method of reduciton often results in recurrence of the displacement with late postoperative deformity.

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Another technique of reduction of zygomatic fractures is through a Caldwell-Luc incision into the maxillary sinus. The reduction is performed through a sinus. The sinus is then packed to maintain reduction. This is a somewhat hazardous technique because blindness has been reported secondary to bony fragments injuring the optic nerve at the time of manipulation. If packing of the maxillary sinus is necessary to maintain reduction, it should be done with direct visualization of the orbital floor.

Orbital Fractures The bones making up the orbital walls include the zygoma, maxilla, and the frontal, sphenoid, lacrimal, and ethmoid bones. Any of them may be fractured in extensive midface fractures. Commonly, however, an orbital floor fracture, involving the thin maxillary portion, accompanies a depressed zygoma fracture. Rarely, an isolated fracture of the orbital floor occurs leaving the orbital rims intact. The mechanism of the injury consists of a blow to the globe which transmits the force posteriorly and inferiorly through the weakest point in the orbital walls, the paper-thin orbital floor. This has been called a "blow-out" fracture from the mechanism of injury. Clinical findings may include diplopia, enophthalmos, and extraocular muscular entrapment necessitating reduction of the periorbital fat and occasionally eye muscles from the fracture site. The floor is commonly reinforced with a thin Silastic sheet. Some authors advocate "conservative" management, awaiting resolution of swelling and hematoma to evaluate the permanency of the enophthalmos, diplopia, or muscle entrapment. Our experience has shown the presence of post-traumatic induration and fibrosis often precludes an acceptable functional and asthetic result when treatment is delayed.

FRACTURES OF THE LOWER THIRD OF THE FACE (MANDIBULAR FRACTURES)

In the large series of facial fractures referred to previously,4 the mandible ranked third in frequency behind nasal and zygomatic fractures. Patients with mandibular fracture, in contrast to other facial bone fractures, sometimes experience pain because of muscular distraction of the fragments. The fracture sites are frequently predictable based upon the mechanism of injury. An assailant's blow to the side of the mandible often results in a subcondylar fracture on the side of contact with an associated contralateral angle or corpus fracture. An automobile accident victim receiving a direct blow to the symphysis may sustain bilateral angle or subcondylar fractures. Treatment of a fractured mandible is dependent on the location of the fracture, the angle of the fracture line, and the amount of displacement. Figure 14 demonstrates the directions of muscular pull about the mandible. A fracture line angulated posteriorly-superiorly toward anteriorly-inferiorly would tend to be impacted into a favorable position because of the action of the masseter

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Fracture of Mandible

Fracture of Condyle

Fractures of Mandible

A Figure 14.

B

Controctuire of Mylohyoid m.

Muscles which tend to distract mandibular fracture segments.

and internal pterygoid muscles inserting on the lower border of the mandible at the angle. Conversely, the muscle pull on a fracture line angulated in the opposite direction would distract the fragments farther apart. A nondisplaced unilateral mandibular fracture can usually be treated by intermaxillary fixation with the teeth held in occlusion using arch bars or Blair-Ivy loops (Figs. 15 and 16). A fracture which is unstable, because of marked displacement, an unfavorable angle, or bilaterality will more commonly require open reduction and interosseous fixation. This can be approached by either an intra- or extraoral incision (Fig. 17). Stabilization by means of intraoral splinting, percutaneous Kirschner wires, or external traction devices has been used in various circumstances but their indications are limited. Facial Fractures in Children In general, the mechanism of injury, the diagnosis, and the management of facial bone fractures in children does not differ greatly from that in the adult, though a few differences do exist. Lack of cooperation on the part of the patient may make the diagnosis rely more heavily on x-ray findings than on clinical examination. Because of greater resiliency in the facial bones of children, green stick fractures rather than completely displaced fractures are more common. As bony union may occur early in children, fractures should be reduced in the first week after injury whenever possible.

Cutting and shaping metal arch bar

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Figure 15. Technique for immobilization of mandible with arch bars and elastics.

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Figure 16. Technique for immobilization of mandible with Blair-Ivy loops and elastics.

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Bloir·lvy loop completed Formation of Blair-Ivy

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E Intermaxillary elastics

applied about eyelets and twisted ends of wire

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Fracture of angle of Mandible showing displacement by action of Masseter muscle

Holes drilled with power equipment through Dingman bone holding forceps

Figure of 8 wiring for secure

interosseous fixation

Figure 17. Operative technique for open reduction and figure- of-8 internal wire fixation at mandibular angle.

Condylar fractures in children may cause a potential growth problem because of involvement of the epiphyseal growth center. Although retardation of growth on the involved side can occur, it is only seen rarely. As with adults, closed treatment is the preferred method of management even in instances of a medially displaced condyle. Intermaxillary fixation is made more difficult in children because of the instability of deciduous teeth; this occasionally precludes using the teeth to maintain occlusion.

AUTOGENOUS BONE GRAFTS Despite timely and skillful reduction, occasionally postoperative deformities cannot be avoided either because of severe comminution or displacement which could not be corrected. Reconstruction of such defects with many different materials has been described, but the most physiologic, and in many ways the most satisfactory, is autogenous bone grafting. Bone grafts for facial reconstruction are most commonly taken from rib, iliac crest, or tibia, depending on the specific requirements at the re-

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cipient site. All three areas contain cortical bone. Large amounts of cancellous bone can also be obtained from the iliac crest and tibia. Recipient areas requiring structural support must be grafted with cortical bone. When large defects must be spanned split rib grafts are usually the most suitable. A smaller defect can more easily be filled with a shaped iliac bone graft. The disadvantage of cancellous bone is the unpredictable resorption which may take place. The healing which occurs following bone grafting is one of continuing resorption and new bone formation. Successful incorporation of a bone graft is dependent upon a net increase in viable osteocytes in the graft following bony union to the recipient bone. Adding chips of porous cancellous bone can increase the volume of viable bone graft. Areas of the facial structure most amenable to bone grafting include the nose, mandible, forehead, and orbital rims. A severely comminuted nasal fracture may heal with insufficient available bone to reshape the pyramid adequately. After approximately 1 year of wound maturation, an iliac bone graft can be taken and shaped to effectively correct a resultant saddle nose deformity (Fig. 18). Other materials including cartilage and silicone have been used for augmenting the nasal dorsum, but bone grafts have been found to have a much lower incidence of resorption or extrusion. Iliac bone gives the necessary support and has cancellous bone in sufficient quantity. It is readily incorporated into the nasal

Figure 18. Pre- and postoperative pictures of patient with saddle-nose deformity secondary to numerous nasal bone and septal cartilage fractures. Patient was treated with cantilever bone graft from ilium.

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Figure 19. Reconstruction of glabellar prominence with split rib grafts. Deformity followed neurosurgical resection of frontal sinuses for glabellar fractures. A, Deformity. B, Bony defect exposed through coronal reflection of forehead flap; split rib grafts in place. C, Contour of forehead restored. D. Lateral facial bone x-rays demonstrating viable split rib grafts in place 2 years following graftin g.

complex provided that an appropriate pocket and bony platform have been created to allow for sufficient bony contact of the graft with the recipient nasal bones. Bone grafts to the superior or inferior orbital rim may be indicated following unreduced fractures with bone resorption of these structures. These bony prominences are vulnerable to violent external forces and following comminution or marked displacement, grafting may be the only means of resioring adequate contour (Fig. 19). Rib or iliac bone may also be shaped to provide suitable reconstruction in these areas.

ALLOPLASTIC MATERIAL Alloplastic materials are being used for implantation with increasing frequency as new compounds are developed. Silicone rubber and

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Figure 20. A, Patient with healed depressed glabellar fracture, B, reconstructed with shaped implant made of silicone rubber. C, Postoperative view taken 2 years following alloplastic implantation.

methyl methacrylate are currently the most commonly used, each with its individual advantages. Silicone must be custom prefabricated to fit the existing defect (Fig. 20). It is inert, having essentially no antigenic potential. Like any foreign body, however, it has a higher incidence of extrusion than does autogenous bone or cartilage grafts. Methyl methacrylate, a cold curing acrylic, has the advantage of being moldable in situ. It is available as a powder which rapidly hardens into solid form after being mixed with a liquid catalyst. While still puttylike the mixture can be placed directly into the exposed defect and molded into the desired shape. Upon hardening, it often attaches firmly to the bony crevasses so that final shaping can be accomplished with a power tool. These alloplastic materials are most applicable for reconstruction of the glabellar, supraorbital, and infraorbital areas.

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CONCLUSION General surgeons are frequently called to the emergency room to care for patients who have sustained "multiple trauma"-injury to several organ systems including severe soft tissue and bony trauma of the face. The preceding discussion has outlined the important early management of these injuries. Various specific types of injuries and the principles of definitive treatment are discussed. Occasionally extensive facial trauma requires secondary reconstructive procedures to obtain the best possible result. The principles of bone grafting and alloplastic implantation are given to familiarize the general surgeon with the basic techniques involved.

REFERENCES 1. Baker, S. P., and Schultz, R. C.: Recurrent problems in emergency room management of maxillofacial injuries. CLIN. PLAST. SURG., 2:65,1975. 2. Le Fort, P.: Experimental study of fractures of the jaw. Rev. Chir. de Paris, 479, 1901. (Trans. by P. Tessier, Plast. Reconstr. Surg., 50:600, 1972.) 3. Schultz, R. C.: Facial injuries from automobile accidents: a study of 400 consecutive cases. Plast. Reconstr. Surg., 40:415, 1967. 4. Schultz, R. C.: One thousand consecutive cases of major facial injury. Rev. Surg., 27:394, 1970. 5. Schultz, R. C.: The changing character and management of soft tissue windshield injuries. J. Trauma, 12:1,1972. 6. Schultz, R. C.: Frontal sinus and supraorbital fractures from vehicular accidents. CLIN. PLAST. SURG., 2:93,1975. 7. Schultz, R. C., and De Villers, Y. T.: Nasal fractures. J. Trauma, 15:319, 1975. 1600 Dempster Street Park Ridge, Illinois 60068