Facial InjuriesBy Iman Labib Salem Professor of Plastic & Reconstructive Surgery

FACIAL INJURIES (incidence)

Is high because the face is exposed andbecause there is little protective covering.

2/3 of trauma patients commonly haveinjuries of the head and face.

FACIAL INJURIES

A facial injury victim often sustains multiple injuries to other organs.Early definitive treatment of maxillofacial injuries must be accomplished safely at the same time that other, even life threatening conditions are evaluated and treated.

FACIAL INJURIES

Nowadays it is mandatory that an aggressive expedient and well-planned program be outlined and maintained in order to return the patient to an active productive life as soon as possible with minimal scars and functional disability.

60% of patients with severe facial trauma have multisystem trauma and the potential for airway compromise. 20-50% concurrent brain injury. 5-10% cervical spine injuries. Blindness occurs in 0.5-3%

FACIAL INJURIES (causes)

Motor car accidents. Assaults. Animal bites. Burns (thermal, chemical, electrical) Home and industrial. Athletic injuries. By far car accidents cause 75% of all serious facial injuries.

FACIAL INJURIES (preventive measures)

Helmets.Padded dashboards.

Multilaminated windshield.Speed limits and checkpoints on highways.

Facial trauma continues to be treated by a variety of specialists, including plastic surgeons, otolaryngologists, and oral surgeons. Plastic surgeons, however, are uniquely trained to handle the full range of issues present in the trauma patient.

INITIAL MANAGEMENT

Facial injuries themselves are rarely lifethreatening, but are indicators of the energy of injury. Should focus on the algorithmic protocol of ATLS (Advanced Trauma Life Support). Should alert the examiner to the possibility of airway compromise, cervical spine injuries, or central nervous system injuries.

History

Obtain a history from the patient, witnesses and or emergency team. AMPLE (allergies, medications, past history, last meal, events surrounding the accident) Mechanism of Injury Previous facial injuries / Dental AbN Loss of consciousness Tetanus Status Associated Injuries

History

Specific Questions: Was there LOC? If so, how long? How is your vision?

Hearing problems?

History

Specific Questions: Is there pain with eye movement? Are there areas of numbness or tingling on your

face? Is the patient able to bite down without any pain? Is there pain with moving the jaw?

FACIAL TRAUMA EVALUATIONHead and Neck Examination

Inspect open wounds for foreign bodies. assesses the face for asymmetry or neurologic deficits, including the trigeminal and facial nerves. A complete ocular examination includes the evaluation of ocular history, acuity, light and red light perception, ocular motility, pupillary exam, and examination of the conjunctiva and eyelids. Examination of the oral cavity is essential, especially in the obtunded patient who may have loose teeth, bone fragments, or foreign bodies. Inspect the nose for asymmetry, telecanthus, widening of the nasal bridge. Inspect nasal septum for septal hematoma, CSF or blood. Examine and palpate the exterior ears. Examine the ear canals.

FACIAL TRAUMA EVALUATION

Palpate the entire face. Supraorbital and Infraorbital rim Zygomatic-frontal suture

Zygomatic arches Palpate nose for crepitus, deformity and

subcutaneous air.

Photographic consents should routinely be obtained as part of the treatment consent upon entrance to the emergency department.

Imaging

Plain radiographs (anteroposterior [AP], lateral, Caldwell, and Water views). Helical CT scanners. Panoramic radiograph is helpful in the evaluation of mandibular fractures.

CT ScanGold Standard for assessment of facial skeleton and Sinuses. The one area where this exam may not be entirely sufficient is the mandible.

Panorex

CT Scan Coronal AxialCT Scan

3D

FACIAL INJURIES (Timing of treatment)

Timing is highly important in the optimal management of facial injuries.It should start as soon as the general condition of the patient is stabilized. Early, skillful management decreases the possibility of permanent facial disfigurement and limits serious functional disturbances.

EVALUATION OF THE MULTIPLY INJURED PATIENT

Evaluation of this group of patients shouldinclude exclusions of any other serious

injuries, i.e., control of the airway,control ofexternal bleeding, insertion of I.V. lines, insertion of a Foley catheter.

Cervical spine injuries: all patients with severe panfacial injuries should be considered to have cervical spine injury till proved otherwise. Studies associated cx. spine inj. at C1-C2 and C6C7 to mandible fractures.CT scans are more sensitive than plain x-rays in showing these fractures.

EVALUATION OF THE MULTIPLY INJURED PATIENT

TREATMENT OF MAXILLOFACIAL INJURIES

Should be organized in several phases.EMERGENCY MEASURES.

EARLY TREATMENT.DELAYED TREATMENT.

EMERGENCY TREATMENT

There are three life-threatening facialemergencies:

1. Respiratory obstruction.2. Hemorrhage.

3. Aspiration.

Airway

Direct laryngeal injury, foreign bodies (including aspirated teeth and bone fragments), excessive bleeding from an upper airway source. When the floor of mouth and tongue lose support from a comminuted mandible fracture Treatment of the compromised airway is complicated by the likelihood that 10% of facial trauma patients have cervical spine injuries.

Emergency Management Airway Control

Control airway: Chin lift. Jaw thrust.

Oropharyngeal suctioning. Manually move the tongue forward. Maintain cervical immobilization

Emergency Management Intubation Considerations

Avoid blind nasotracheal intubation: Nasocranial intubation Nasal hemorrhage

Avoid Rapid Sequence Intubation. Consider an awake intubation. Sedate with benzodiazepines.

Emergency Management Intubation Considerations

Consider fiberoptic intubation if available. Alternatives include percutaneous transtracheal ventilation and retrograde intubation. Be prepared for tracheostomy.

Hemorrhage

The dense vascularity of the head and neck can cause significant blood loss from soft-tissue injuries. Fortunately, most of these injuries allow sufficient access for direct pressure to control hemorrhage. The control of bleeding vessels should be accurate and directed. Bleeding that cannot be controlled with direct pressure requires packing. Massive hemorrhage should be approached with emergent intubation followed by packing and direct pressure.

Emergency Management Hemorrhage Control

Maxillofacial bleeding: Direct pressure. Avoid blind clamping in wounds.

Nasal bleeding: Direct pressure. Anterior and posterior packing. transnasal balloon catheter in the nasopharynx

Pharyngeal bleeding: Packing of the pharynx around ET tube.

Massive Hemorrhage

The source of bleeding is most commonly a branch of the external carotid system, which is most appropriately controlled with angiographic embolization. Surgical ligation of the external carotid artery will not control bleeding from its injured branches because of the robust collateralization present and should not be attempted

Central Nervous System

Patients with facial trauma rarely die from facial injuries, but can die from associated injuries of the central nervous system. As part of a complete trauma evaluation most patients with facial trauma undergo computed tomography (CT) scanning to rule out head injury The most widely accepted method for expressing the degree of neurological injury is the Glasgow Coma Score (GCS).

As a general rule, concomitant head injury is not a contraindication to facial fracture repair assuming the neurologic injury is stable and not in the process of evolution. In the event of acute brain injury, surgical repair of facial fractures generally is delayed to avoid the fluid overload associated with surgery and, most importantly, to avoid undetected decline of neurologic function during the period of general anesthesia when clinical neurologic examination cannot be performed.

CLINICAL EXAMINATION

There are 3 categories of facial injuries:1. soft tissue injuries. 2. soft tissues associated with fractures. 3. facial fractures without soft tissue wounds.

TREATMENT OF SOFT TISSUES

I. Tetanus prophylaxis.II..Primary wound closure.

III. Cleaning of the wound.IV. Anaesthesia.

V. Debridement and care.

Types OF SOFT TISSUE Injuries

Abrasions. Contused wounds. Lacerated contused wounds. Deep lacerations. Facial nerve. Parotid duct lacerations. Lacrimal system lacerations.

TREATMENT OF SOFT TISSUES

Small facial defects can be excised and reconstructed with small flaps using a technique that will place the scars as close to the RSTLs as possible

Forehead defects

Forehead defects up to 3.5 cm in size, especially when near the midline, can be closed by mobilizing the surrounding tissue with various advancement, rotation, and transposition flaps

Wedge-shaped midline defects that are based on the glabella or frontal hairline can be closed primarily by making an incision above the eyebrow or along the hairline and mobilizing the forehead skin.

The H-flap is suitable for defects approximately 4 cm wide. Incisions are made along the eyebrow and hairline, extending through all layers in their lateral portions.

A double rotation flap can be used to close larger midline and paramedian defects in the forehead. Again, the scars are located principally along the eyebrow and hairline

A wedge-shaped lateral forehead defect can be closed with a rotation flap

Scalp Injuries

Profuse bleeding Suspicion of Intracranial Injury Irrigate copiously and close Avoid shaving hair Limit debridement (excellent vascularity of scalp)

Eyelids

The most important aspect of evaluating trauma to the eyelids is ensuring that injury to the globe has not occurred. Perhaps the most critical step in suturing the eyelid is to place an everting stitch along the lid margin. This not only facilitates proper anatomic alignment, but also prevents notching of the lid margin. In general, all layers of the eyelid (inner, middle, and outer lamellas) should be repaired. Although the conjunctiva will heal well without sutures, injuries associated with significant deformity should be sutured with plain gut suture

Eyelids Injuries

Ears

Ear lacerations can usually be sutured in one layer, It is typically unnecessary to place a separate layer of sutures within the cartilage. The two most prominent concerns in ear injuries are :hematoma and chondritis. Collections of blood in proximity to the cartilage can result in cartilage resorption or a reactive chondrogenesis, which ultimately leads to the cauliflower ear deformity.

Ear Injuries

Suspicion of adjacent skull injury Irrigate copiously Limit debridement Repair to realign helical margin

Nose

When lacerations involve the underlying cartilaginous support system of the nose, all layers should be repaired after appropriate anatomic reduction.

Nasal Injuries

Suspicion of assc. nasal, skull base, orbital & maxillary injuries Irrigate copiously & Limit debridement Repair in 3 layers. Repair to realign distinct structures, such as nasal rim Nasal packing as necessary

advancement flap

Trapezoidal V-Y advancement flap

Nasal reconstruction using a large median forehead flap. a The forehead flap is outlined. The nasal lining can be reconstructed with split-thickness skin, a nasolabial flap, or a sliding flap b Inset of the flap into the defect. c, d The donor defect can be closed with an H-flap (c) or bilateral rotation flaps (d)

Lips

Accurate re-approximation of the injured structures, especially the vermilion IS the most important consideration in repairing soft-tissue injuries involving the lips. Great care must be taken to separately reapproximate the underlying orbicularis oris muscle. Mucosal lacerations are repaired using a resorbable suture such as chromic or Vicryl Any loose or damaged teeth are documented.

Lip Injuries

Suspicion of adjacent dental, intraoral, maxillary & mandibular injuries Irrigate copiously & Limit debridement Mark key structures prior to local an. Repair in 3 layers . Repair to realign vermilion-cutaneous junction and distinct structures

Large superficial mucosal defect in the lower lip (involving less than one-third of the lip).

Facial Nerve

One should specifically test elevation of brow, forced closure of the eyes, voluntary smile, and eversion of the lower lip. These injuries should be repaired using microscopic magnification and 9-0 or 100 nylon epineural sutures within 48 to 72 hours.

Parotid Gland/Duct Injuries

The most significant concern in parotid injuries is the possibility of facial nerve injury A parotid gland injury does not require intervention unless the underlying parotid duct is involved. Involvement of the Stensen duct will result in a parotid fistula unless corrected. Duct injuries should be repaired over a stent to allow healing.

FACIAL FRACTURES

Fractures of the mandible

May occur at the symphysis, body, angle, ramus, coronoid process, condylar process, or alveolar process. They are classified according to direction (horizontal or vertical), according to severity (simple, Comminuted, Multiple, Impacted or open)

Mandible Fractures Pathophysiology

Mandibular fractures are the third most common facial fracture. Assaults and falls on the chin account for most of the injuries. Multiple fractures are seen in greater then 50%. Associated C-spine injuries 0.2-6%.

Mandible Fractures Clinical findings

Mandibular pain. Malocclusion of the teeth Separation of teeth with intraoral bleeding Inability to fully open mouth. Preauricular pain with biting.

Mandible Fractures

Radiographs: Panoramic view Plain view: PA, Lateral

Mandibular Fractures Treatment

All fractures should be treated with antibiotics and tetanus prophylaxis Nondisplaced fractures: Analgesics Soft diet

Displaced fractures, open fractures and fractures with associated dental trauma

Treatment Closed reduction Open reduction with rigid internal

fixation Open reduction with semi rigid fixation with plate and screw

Indications for closed reduction

Nondisplaced favorable fractures Grossly comminuted fractures Severely atrophic edentulous mandibles: These have little cancellous bone remaining and minimal osteogenic potential for fracture healing. Closed reduction with the use of circummandibular wires offers a more conservative approach Fractures in children involving the developing dentition

Indications for open reduction

Displaced unfavorable fractures through the angle of the mandible Condylar fractures Absolute indications

Displacement of the condyle into the middle cranial fossa Inability to obtain adequate occlusion by closed techniques Lateral extracapsular dislocation of the condyle Bilateral condylar fractures in an edentulous patient Unilateral or bilateral condylar fractures when splinting is not recommended Bilateral fractures associated with comminuted midfacial fractures

Relative indications

Medically compromised patients Complex facial fractures

Mandible FracturesAll open fractures should be treated in 48 hrs operative Goal is to restore normal occlusion

Orbital Blowout Fractures Clinical Findings

Periorbital tenderness, swelling, ecchymosis. Enopthalmus or sunken eyes. Impaired ocular motility. Infraorbital anesthesia. Step off deformity

Orbital Blowout Fractures Imaging studies

CT of orbits Details the orbital

fracture Excludes retrobulbar hemorrhage.

CT Head intracranial injuries

Orbital Blowout Fractures Treatment

Blow out fractures without eye injury do not require admission

Maxillofacial and ophthalmology consultation Tetanus Decongestants for 3 days Prophylactic antibiotics Avoid valsalva or nose blowing

Patients with serious eye injuries should be admitted to ophthalmology service for further care.

Orbital Floor Fracture

Indications for Surgery: evidence of mechanical entrapment of an extraocular

muscle causing diplopia. evidence of enophthalmos. any defect greater than 1 cm2 benefits from surgical repair because of the likelihood of subsequent enophthalmos.

the operated eye is overcorrected so that it projects a little farther than the uninjured eye immediately following surgery.

Incisions/Technique

Subciliary approach, clearly has the highest risk of associated lower lid retraction. Transconjunctival approach has consequently gained popularity. The subtarsal incision can also be employed, especially in older patients with prominent lower lid rhytides within which the incision can be concealed.

Orbital Floor Fracture

Floor Implants

In the past, there was a general consensus among maxillofacial surgeons that bone was the best implant for reconstruction of the floor. Alloplastics enjoy several advantages over bone grafts, including immediate availability and no risk of resorption. Shorter operative time, no potential donor site

morbidity

Among the implants available are titanium mesh, high-density porous polyethylene, and resorbable materials.

Complications

lower-eyelid retraction and enophthalmos. Persistent diplopia may also be seen following repair of orbital fractures.

Orbitozygomatic Fractures Periorbital edema and

ecchymosis Anesthesia in the distribution of the infraorbital nerve Palpation may reveal step off Concomitant globe injuries are common

Orbitozygomatic Fractures

The decision to operatively reduce an orbitozygomatic fracture is largely dependent on the CT scan data, as swelling often precludes accurate determination of the degree of deformity. Nondisplaced fractures may be safely managed with a nonchew diet and close clinical followup. Displacement of the fracture is a definitive indication for operative reduction and fixation,

Complications

The most common complication following repair of orbitozygomatic fractures is enophthalmos. Maxillary sinusitis and persistent numbness in the infraorbital nerve distribution may complicate orbitozygomatic fractures less frequently.

Nasal Fractures

Most common of all facial fractures. Injuries may occur to other surrounding bony structures. 3 types: Depressed Laterally displaced Nondisplaced

Nasal Fractures

Ask the patient: Have you ever broken your nose before? How does your nose look to you?

Are you having trouble breathing?

Nasal Fractures

Clinical findings: Nasal deformity Edema and tenderness

Epistaxis Crepitus and mobility

Nasal Fractures

Diagnosis: History and physical

exam. Lateral or Waters view to confirm your diagnosis.

Nasal Fractures

Treatment: Control epistaxis. Drain septal

hematomas.

Maxillary Fractures

High energy injuries. Patients often have significant multisystem trauma. Classified as LeFort fractures.

Maxillary Fractures LeFort I

Definition: Horizontal fracture of

the maxilla at the level of the nasal fossa. Allows motion of the maxilla while the nasal bridge remains stable.

Maxillary Fractures LeFort I

Clinical findings: Facial edema Malocclusion of the

teeth Motion of the maxilla while the nasal bridge remains stable

Maxillary Fractures LeFort I

Radiographic findings: Fracture line which

involves

Nasal aperture Inferior maxilla Lateral wall of maxilla

CT of the face and head coronal cuts 3-D reconstruction

Maxillary Fractures LeFort I treatment

Le Fort I injuries can be adequately exposed through an upper gingivobuccal sulcus incision and maxillary degloving.

Maxillary Fractures LeFort II

Definition: Pyramidal fracture

Maxilla Medial aspect of the orbits Nasal bones

Maxillary Fractures LeFort II

Clinical findings: Marked facial edema Nasal flattening

Traumatic telecanthus Epistaxis or CSF

rhinorrhea Movement of the upper jaw and the nose.

Maxillary Fractures LeFort II

Radiographic imaging: Fracture involves:

Nasal bones Medial orbit Maxillary sinus Frontal process of the maxilla

CT of the face and head

Treatment

Le Fort II injuries often require a lower lid incision. As in orbital fractures, a transconjunctival incision is preferred over a subciliary incision.

Maxillary Fractures LeFort III

Definition: Fractures through:

Maxilla Zygoma Nasal bones Ethmoid bones Base of the skull

Maxillary Fractures LeFort III

Clinical findings: Dish faced deformity Epistaxis and CSF

rhinorrhea Motion of the maxilla, nasal bones and zygoma Severe airway obstruction

Maxillary Fractures LeFort III

Radiographic imaging: Fractures through:

Zygomaticfrontal suture Zygoma Medial orbital wall Nasal bone

CT Face and the Head

Le Fort IIITreatment

Le Fort III injuries may be approached through a combination of buccal sulcus and lower-lid incisions in low to moderate impact injuries. More severe injuries require a coronal approach for exposure of the nasofrontal and medial orbital regions and the zygomatic arch.

SPECIAL TYPES OF FACIAL INJURIES

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