Complex facial fractures: a surgical algorithm



Complex Facial Fractures: A Surgical Algorithm

Dov C. Goldenberg, M.D., M.S.; Nivaldo Alonso, M.D., PhD.

Complex facial fractures can be defined as fractures compromising simultaneously the upper, middle and lower thirds of the face. Also, fractures that involve at least two different facial segments with a high index of comminution can be considered as complex fractures.

Surgical approach to complex facial fractures still remains controversial in relation to the best sequence of fracture stabilization and interdisciplinary priorities.

Surgical algorithm utilized by our team for repair of complex facial fractures (figure 1) is initiated by stabilization of the upper third of the face. Concomitant neurosurgical approach, when necessary, is performed at this time. Open reduction of mandibular fractures and maxillomandibular fixation with arch bars are the following steps. After establishment of occlusion, mandibular fractures are fixed, repairing lower facial height and width. With the upper and lower facial thirds stabilized, middle third fractures can be safely repaired by open reduction and internal fixation, finalizing the tridimensional reconstruction of the face. At this point, immediate bone grafting for nasal projection and other ancillary procedures can be performed.

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Figure 1. Algorithm of treatment for simultaneous upper, middle and lower facial thirds compromise.

Between February 1999 and May 2003, 195 patients with facial fractures were admitted at our Level I Trauma Center, which holds the most complex facial traumas in our town. Twenty seven patients had complex facial fractures, according to our diagnostic criteria and were treated following the proposed algorithm. Twenty four patients were male and 3 were female, with a mean age of 26.9 + 11.5 years old, ranging from 7 to 58 years old.

Etiology of facial fractures were vehicle collision in 12 cases, motorcycle accident in 10 cases, pedestrian struck in 2 cases and other causes (falls, direct impact) in the remaining 3 patients (Table 1).

|Etiology |Number of Patients |

| | |

|Vehicle collision | |

|Driver w/o seatbelt |5 |

|Driver w/ seatbelt |2 |

|Passenger front w/o seatbelt |3 |

|Passenger rear w/o seat belt |2 |

|Total |12 |

| | |

|Motorcycle accident | |

|With helmet |3 |

|Without helmet |7 |

|Total |10 |

| | |

|Pedestrian struck |2 |

| | |

|Other |3 |

| | |

|TOTAL |27 |

Table 1. Etiology of complex fractures

Upper, middle and lower thirds of the face were simultaneously compromised in 19 cases and upper and middle thirds only, with high comminution rates, were compromised in 8 cases (Table 2). The orbit and maxilla were fractured in all cases. Naso-orbito-ethmoidal fractures occurred simultaneously in 13 patients (48.1%) and mandibular fractures were present in 19 patients (70.4%) (Table 3).

|Fracture Pattern |Number of patients |

| | |

|Upper+middle+lower thirds |19 |

|Upper+middle thirds with comminution |8 |

|TOTAL |27 |

Table 2. Patterns of complex fractures

|Facial bones |Number of Patients |

| | |

|Orbit |27/27 (100%) |

|Maxila |27/27 (100%) |

|NOE |13/27 (48.1%) |

|Mandible |19/27 (70.4%) |

Table 3. Facial bones involvement in 27 complex facial fratures.

Neurological compromise (GCS below 13) was observed at admission in 11 patients (40.1%). Emergency neurosurgical procedures at admission were performed in 9 patients (33.3%), in conjunction with facial fractures approach. Complete facial fractures treatment was performed, in average, after 8.6 days of admission (standard deviation = 5.3), when no urgent surgery was necessary.

Vertical and horizontal facial proportions were restored adequately using the proposed algorithm.

The most frequent complications were enophtalmus and malloclusion. As a consequence of severity of trauma, ocular lesions with visual impairment occurred in 10 patients (37%). In two patients post-operative surgical infections occurred, needing prolonged hospitalization.

References

1.Girotto, JA., MacKenzie, E., Fowler, C., Redett, R; Robertson, B; Manson, PN: Long-term physical impairment and functional outcomes after complex facial fractures. Plast Reconstr Surg;108(2);312-27; 2001.

2.Markowitz, B., Manson, PN.: Panfacial fractures: organization of treatment. Clin Plast Surg;16(1);105-14, 1989.

3.Markowitz, BL.; Manson, PN, Sargent, L; Vander Kolk, CA; Yaremchuk, M; Glassman, D, Crawley, WA: Management of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central fragment in classification and treatment. Plast Reconstr Surg; 87(5); 843-53; 1991.

4.Manson, PN., Clark, N., Robertson, B., Slezak,S; Wheatly, M; Vander Kolk, C; Iliff, N: Subunit principles in midface fractures: the importance of sagital buttress, soft-tissue reductions ans sequencing treatment of segmental fractures. Plast Reconstr Surg 103(4);1287-306; 1999

5.Richard, L; Manson, PN;Bradley, R.: Evolution of Craniomaxillofacial Trauma. Semin Plast Surg; 16(3); 283-94; 2002.

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