Pre-Operative Considerations for a Patient with Pan-Facial Fractures  
Ann Marie Visosky, M.D.
March 11, 2004

Regarding maxillofacial trauma, motor vehicle accidents and assault remain the main mechanisms for maxillofacial fractures. Alcohol intoxication is often an important contributing factor. ENT colleagues out of Mount Sinai in Chicago performed a retrospective review of severely injured patients at this Level I trauma center from 1996 to 2000. They looked at 151 patients and used an injury severity score to determine which patients were considered to have severe injuries, and they found that 41% sustained their injuries secondary to aggravated assault and 27% were due to motor vehicle accidents. What they found as the most common facial bone fracture appeared to be the orbital fractures, at 24%—and this included both complex and isolated orbital fractures—22% suffered maxillary fractures, and 19% nasal fractures. The most common isolated facial fracture was the nasal fracture at 23%. The most common serious concomitant injury was cerebral hematoma at 44%, with subdural being the most frequent. They accounted for 41% of all cerebral hematomas. Pulmonary injuries equaled 31%, with contusions and pneumothoraces being the most common; and abdominal and pelvis injuries equaled 18%, with pelvic being the most common of the two. Seven percent were also found to have cervical spinal injuries. Forty-two percent of these patients required intubation at some point during their hospital stay, and 15% required the placement of the trach at some point as well. This study reported very similar results to a previous study that had been done and published in 2000 in The Journal of Trauma. Now in studies that have not included just severely injured patients, mandible fractures are often what are seen to be the most common fracture.

Now when analyzing patients for repair, you must remember that the mid one-third of the face has a system of vertical and horizontal buttresses. The vertical buttresses include the medial nasomaxillary, the lateral zygomaticomaxillary, and the posterior pterygomaxillary. The nasomaxillary buttress extends from the cuspid and anterior portion of the maxillary alveolus along the piriform aperture, the medial side of the orbit, through the anterior lacrimal crest, and the nasal process of the maxilla to the superior orbital rim and nasoethmoidal region, as seen by this medial arrow. The zygomaticomaxillary buttress extends from the maxillary alveolus across the anterior molar to the zygomatic process of the frontal bone and laterally to the zygomatic arch. The pterygomaxillary buttress attaches the maxilla posteriorly to the pterygoid plates of the sphenoid bone. It is these vertical struts of the midface that are the most important with respect to managing midface fractures. They are mechanical adaptations of mastication forces and are quite strong against vertically directed forces but cannot withstand similar forces in the transverse plain. The greatest load is on the zygomaticomaxillary buttress. Now the horizontal reinforcements include the frontal bar, which includes the superior orbital rims and the thick glabellar region and inferiorly the reinforcement or the inferior orbital rims, the zygomatic arch, and the maxillary alveolar and palate.

Now an important concept to understand is that the horizontal buttresses are really of two types, both coronal and sagittal. Now the midface lacks good sagittal buttresses, especially in the central segments, resulting in weakened potential strength of projection. Therefore, with severe injury you can see flattening even though there has been attempted reconstruction.

What these pictures demonstrate is that the lower midfacial segment in comminuted fractures depends mostly on the mandible and not on the midface for load bearing, where the frontal bone buttresses the upper midface. Now the picture on the right illustrates that it is in this dotted region that our midface has poor sagittal buttresses and is inherently prone to deficient projection after injury. Now, although the zygomatic arch is considered a landmark in repairing midface fractures by some—and I will discuss this a bit later—others comment that it is really still quite thin and that only moderate inherent stability can result even after titanium plating.

Regarding fracture classification, in 1901 the French surgeon, Dr. Rene LeFort published his results from experiments aimed to describe fracture patterns. He performed a number of experiments on cadaver heads. These experiments included blows to the cadaver head at different angles with a wooden club. He also hurtled the head against stationary objects and kicked it in various places in the face. The LeFort classification system developed through interpreting the skulls after these types of procedures and, as he said, he described as the great lines of weakness. His descriptions are based on the highest level of fracture and often occur in combination. This picture on the right is a drawing of one of the fractures after one of his experiments.

For review, the LeFort I fracture is a low horizontal fracture with disruption of tooth-bearing section of the maxilla. It extends horizontally through the inferior portion of the maxilla separating the maxillary alveolus from the rest of the midface. The LeFort II fracture is a pyramidal fracture which involves the nasal bones, frontal process of the maxilla, the inferior orbital and lateral maxillary sinus walls; where the LeFort III is a high horizontal fracture alongside the junction between the cranial and facial skeleton. It results in craniofacial disjunction and separation of the midface from the cranium at the level of the nasofrontal sutures lateral through the orbits to the zygomatic arch and posteriorly to the pterygoid plates.

Donat and colleagues out of Wayne State University published an article in the Archives in 1988 discussing the inadequacies of the LeFort classification system. They mention that it provides no definition of the facial skeletal supports. It does not describe severely comminuted, incomplete, or combination maxillary fractures, and the LeFort system fails to describe the part bearing the occlusal segment. In essence, the LeFort system can underestimate the complexity of a patient's fractures and limits the complete description of the fracture pattern. They developed an alternative fracture classification system. They performed a retrospective review of patients with midfacial fractures and evaluated both their axial and coronal CTs and tested a group of people on the ease of communication of their system and looked at the LeFort patterns as well. They looked at 170 patients and found that only 29% met criteria for a classic LeFort pattern, and only 11 of the 170 patients were identified as having bilateral LeForts of the same level, although often with much variation and complexity between the sides. They proposed a classification that partitioned the face into three pairs of horizontal beams and three pairs of horizontal buttresses. Further classification put these beams into central and lateral segments and the vertical beams into superior and inferior. So this picture is explaining the vertical and the horizontal and the more central and lateral and superior and inferior. Then they gave each segment an abbreviation to describe the different fracture patterns. Now they state in their study that the system was well received and study participants thought it was easy to use, but they do admit that the shortcoming of this alternative system is that it is not all inclusive, does not consider soft tissues, and does not describe the status of the nasal bones, the orbital lamina, or necessarily the displacement of the comminution of fractures.

Once you have determined the magnitude and pattern of the fracture that a patient has, you can turn your attention to repair options, specifically how to approach the fractures for repair. Incisions for adequate exposure are based on the fracture location; pattern of displacement; comminution of individual fracture areas; and a thorough analysis of the width, projection, and height of each anatomic subunit. Now some of the commonly used incision types include the coronal incision, which is advantageous because it provides wide and direct visualization of the upper one-third and superior regions of the face. It allows for repair of multiple fracture types, including the frontal bone and sinuses, supraorbital areas, zygomatic arches, nasoethmoidal area, the frontal process of the zygoma, and lateral orbit; and it is also ideal if a neurosurgical procedure is also being required at that time. The main disadvantage is that there is the potential for thick scars and hair loss along the incision spot, which can be especially unsightly in any patient with alopecia. Much rarer complications include skin necrosis, hematomas, infections, loss of forehead animation, and sensory deficits.

For the commonly encountered orbital floor fractures, two possible incision types include the transconjunctival and subciliary incisions, both with or without lateral campotomy. As the picture illustrates, the transconjunctival incision provides a superior cosmetic result given its placement under the lid. Disadvantages include ectropion, entropion, lower lid shortening, hematoma, or seroma. Now the subciliary incision can also heal with minimum scarring and has similar disadvantages as the transconjunctival, but it also has the potential for skin lumps overlying the orbicularis oculi muscle.

Midface degloving allows wide exposure for repair of the entire midface with hidden scars. Disadvantages of using midface degloving is that occasionally severe postop swelling may occur, hematoma formation, or the potential for a widened alar base with nasal tip deformity if the nasal cartilaginous structures are not reapproximated, and paresthesia. Intraoral incisions are also commonly used for many mandible fractures, including angle body and parasymphyseal exposures.

Airway management is an important consideration, especially if the patient's fractures warrant MMF. It is wise to discuss this management with your anesthesiologist ahead of time to plan for the appropriate course of action. Choices include blind or fiberoptic nasotracheal intubation, oral intubation. If MMF is being performed, this will need to be secured through a gap in the teeth, or a procedure called a lateral submental tracheal intubation. Now this is much less popular within the United States, but it involves having an ET tube come through the floor of the mouth through an incision along the submental region, or a tracheostomy can be performed.

In a survey conducted out of the University of Tennessee, published in Craniofacial Surgery in 1997, there was an aim to investigate the trends of airway management in midface which often includes pan-facial fractures around the country. They surveyed plastic and reconstructive surgeons, otolaryngologists, oral surgeons, and anesthesiologists and gave them a number of different fracture patterns, including those saying that you know the status of the cribriform plate and those patterns in which you did not know the status of the cribriform plate. They found that 64% of the surgeons favored nasotracheal intubation and 56% of the anesthesiologists did as well, and that is in all countings of all patterns, whether they knew the status of the cribriform plate or not. Though not statistically different, they also found that there was a breakdown in the surgeons' preferences with plastic and reconstructive surgeons often preferring fiberoptic intubation, oral surgeons blind intubations, and the ENTs liked to perform the trachs.

Now following World War II cranium and facial injuries were directed more toward the CNS management, and facial fracture repair was considered more of a deferred operation. When it was done, it was more in a limited fashion because there was fear of interrupting blood supply. Nowadays we have improved overall trauma care and radiographic techniques, along with 3D understanding of the importance of facial height, width, and projection—all of which have allowed us to achieve a better cosmetic result, as well as functional fracture repairs.

There have been multiple proposed orders for the repair of pan-facial fractures, including what is called inside-out or top-to-bottom, bottom-to-top, outside-to-inside which emphasizes the zygomatic arch; but the exact order is not as important as developing a plan that permits accuracy of your anatomic positioning of the various facial fragments. The three important things to keep in mind are your exposure, your identification of the fractures, and the fixation of the facial buttresses.

One approach often discussed in the literature by Dr. Manson or Dr. Markowitz is a zone-type approach to repair. They describe dividing the face into upper and lower halves at the LeFort I level and then dividing these halves into two facial units. The lower facial unit includes the occlusal and mandibular units and the upper face the frontal unit. To simplify the reconstruction, then they also divided into central and lateral zones. In this picture you would be at the LeFort I level and than having your central and your lateral and separating each upper into a half and each lower into a half as well. The reconstruction is initiated centrally to first address the central facial width, and then they say the lateral zones are then related and stabilized to this central core. With this method, the superior midface width is determined by the nasoethmoidal region, the lower midface determined by the maxillary arch and palate, and the inferior facial width by the mandibular arch. Lateral zones are determined by the frontal bar, the zygomatic arch, the malar eminence, and the mandibular angles. Facial height then gets determined by the midface and frontal bone buttresses, the mandibular ramus and condyles, and facial projection is determined by the frontal bar, the frontal nasomaxillary buttresses, zygomatic arches, and mandible from angle to symphysis.

Now before we go on to the next slide, I just want to give you one example of Dr. Manson's repair. Their sequence of treatment would involve starting with the inferior division of the central zone, repairing occlusions and placing MMF, and fixing any palatal fractures. Next, either the upper or the lower central zones could be addressed. Now, in most of their literature they describe usually completing the mandibular reconstruction, both the central and the lateral, before moving to the upper face. And the lateral zone to the upper face then follows with repair of the zygomatic fractures. Lastly, reconstruction of the LeFort I level would reestablish the vertical height.

Another common method in the literature is referred to as the outside-to-inside approach, as advocated by Dr. Gross, out of Harvard University Medical in Washington. His approach stresses the importance of the zygomatic arch. Reduction and repair of the zygomatic arches first produces an outer frame to correct the facial width, and then the upper and inner frame is then repaired within this outer frame. He stresses that the lateral and medial buttress reconstruction should be next to correct the midface and projection. And these first two pictures just show through the sequence of his repair where you want to start with the zygomatic arches and then move centrally and then correct the maxillary width and arch in relation to anterior maxillary buttresses and, lastly, reestablish your mandibular width.

In a paper that was published in The Journal of Craniofacial Surgery, in 1998, from a group out of Germany, they describe progression of repair in a top-to-bottom approach. They approached the repair from forehead, to midface, to mandible. They start with nasofrontal structures to align the orbital rims and achieve proper transverse dimension, then reduction of your zygomatic arches for suitable sagittal dimension, and next is the realignment of the maxilla central to the lateral to reestablish height and projection. Then they link the maxilla back to the midface and, lastly, comes the alignment of the mandible.

So, in recapping our patient in terms of his airway management, he had a nasotracheal intubation. The type of incisions that were performed included a bicoronal, a transconjunctival, and midface degloving. His sequence of repair, he first had his palatal splint placed and MMF, but after that we went pretty much in a top-to-bottom approach, fixing his frontal fractures, his NOE fractures, moving to orbital and infraorbital rim, and then fixing his frontal zygomatic fracture and, lastly, his buttress fractures.

In conclusion, patients with maxillofacial fractures often have some prominent injuries that should be assessed accordingly. A good history and physical exam are as important as the CT findings in getting the overall picture of the patient. Airway management is a crucial step in planning your repair, and before you go to the OR, you must understand the relationship of your fracture patterns and have an organized plan for repair. This includes the type of incisions you plan to make and your steps for repair.

Case Presentation

The patient is a 43-year-old Caucasian man who presented to the Ben Taub Emergency Center after experiencing an aggravated assault. He had been kicked and hit with a metal bar in the face. He was intoxicated and uncooperative on arrival to the EC.

On physical exam, he was in no acute distress and had a stable airway. His eyes were severely edematous. He had limited vision due to the swelling. He had palpable nasal fractures with nasal ecchymosis and edema. On initial exam, he had no septal hematoma or CSF leak. He had an edentulous maxilla which exhibited movement with palpation. He also had a right EAC laceration, but no hemotympanum. The remainder of his physical exam and labs were normal.

A maxillofacial CT scan indicated multiple facial trauma. His films indicated a comminuted nasal fracture, right frontal sinus fracture and a cribriform plate fracture resulting in intracranial air. He also had bilateral LeFort II fractures, pterygoid plate fractures, a right zygomatic arch fracture and a right orbital floor fracture.

He received both neurosurgical and ophthalmology consults while in the EC. He was found to have no emergent neurosurgical issue and his vision was normal. He was admitted to the ENT service for anticipated repair of his facial fractures.

On hospital day one, he developed a CSF leak. The neurosurgical service placed a lumbar drain, which was removed on hospital day five. He was also followed by OMFS, who constructed a palatal splint for the patient.

He was taken to the OR for repair of his facial fractures. His surgical procedure included placement of a palatal splint, MMF, a frontal sinus obliteration, ORIF of left NOE fracture, left orbital floor fracture, right trimalar fracture, right and left vertical buttress fractures and nasal bone fractures.

His post-operative course was uneventful. He was discharged home with MMF. He followed-up in post-op clinic and was found to have well-healed scars, good occlusion and good facial dimensions.

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