lable at ScienceDirect

Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 51e54

Contents lists avai

Journal of Cranio-Maxillo-Facial Surgery

journal homepage: www.jcmfs.com

Clinical evaluation of the bicoronal flap in the treatment of facial fractures.Retrospective study of 132 patients

Marisa Aparecida Cabrini Gabrielli, Marcelo Silva Monnazzi*, Mario Francisco Real Gabrielli,Eduardo Hochuli-Vieira, Valfrido Antonio Pereira-Filho, Marcos Vinicius Mendes DantasAraraquara Dental School, UNESP e Univ Estadual Paulista, 2 andar, Departamento de Diagnóstico e Cirurgia, Rua Humaitá, no. 1680, Araraquara, CEP 14801e903, São Paulo, Brazil

a r t i c l e i n f o

Article history:Paper received 28 June 2010Accepted 3 January 2011

Keywords:Bicoronal flapFacial fracturesMiddle facial third

* Corresponding author.E-mail address: monnazzi@ig.com.br (M.S. Monna

1010-5182/$ e see front matter � 2011 European Assdoi:10.1016/j.jcms.2011.01.008

a b s t r a c t

The aim of the present study was to evaluate the postoperative complications of bicoronal flaps used totreat facial fractures. One hundred and thirty two patients that received bicoronal flaps for the treatmentof upper and middle third facial fractures were called for clinical and radiographic examination.Minimum follow-up was 1 year and all patients had charts with adequate information about theirperioperative care pertinent to the study. Results showed as complications hypoesthesia (17%), partialunilateral frontal motor deficit (11%), infection (3%), hypertrophic scars (3%), varying degrees of alopecia(18%), seroma or hematoma in the immediate postoperative period (5%). The flap provided wide surgicalaccess to the upper and middle facial thirds with very few serious complications, most frequentlyallowing good aesthetic results.

� 2011 European Association for Cranio-Maxillo-Facial Surgery.

1. Introduction

The bicoronal flap is a popular and versatile surgical approachthat provides excellent exposure to the upper and middle third ofthe face and also provides an aesthetic and low morbidity repair(Fox and Tatum, 2003; Nakamura et al., 2010). It allows ampleexposure of the frontonasal area; upper, medial and lateral orbitalwalls; zygomatic arch; temporal fossa; temporomandibular jointand even the upper portion of the mandibular ramus (Ellis et al.,1985; Ellis and Zide, 1995). Since Gruss et al. (1990) brought toattention the importance of the zygomatic arch and outer facialframe in the reconstruction of complex facial fractures this accesshas gained even more importance. That was further enhanced bythe more widespread use of cranial grafts and by the concept ofsubunits in midfacial fractures proposed by Manson et al. (1999).Concomitant intracranial neurosurgical procedures are notuncommon and the bicoronal flap fulfils both needs (Gabrielli et al.,2003).

Treatment of isolated fractures of the zygomatic complex andarch, frontal sinus and orbital walls may have to be done througha bicoronal incision in selected cases (Sullivan, 1991; Haug, 1992;Zingg et al., 1992; Zhang et al., 2006; Herlin et al., 2010).Abubaker et al. (1990) in their classical article on the subject

zzi).

ociation for Cranio-Maxillo-Facial

describe as indications for the bicoronal incisions complex cranio-facial fractures; Le Fort III, naso-orbital-ethmoidal and frontal sinusfractures; severely comminuted zygomatic complex and archfractures, simultaneous craniotomy and osteotomies for the treat-ment of sequelae (Nakamura et al., 2010). The present study eval-uated the postoperative complications of bicoronal flaps used totreat facial fractures.

The traditional coronal incision starts at the root of the helixand is carried coronally to the skull vertex and then to thecontralateral helix, the incision can be inferiorly extend to thepreauricular area if further exposure is necessary (Fox and Tatum,2003). The straight-line incision may result in a noticeable scar; tohelp diminished this problem, Munro and Fearon (1994) intro-duced a modification called the stealth incision; that modificationis done by a zigzag incision line that helps camouflage thebicoronal flap scar.

2. Patients and methods

One hundred and thirty two patients from the Oral andMaxillofacial Surgery Division of the Dental School at Araraquara,Universidade Estadual Paulista e UNESP, SP, Brazil were included inthis study. Inclusion criteria were: patients who sustained upperand/or middle third facial fractures, treated with a bicoronal flap asdescribed by Abubaker et al. (1990) and Ellis and Zide (1995)associated or not with other facial incisions; minimum follow-upof 1 year; records providing enough clinical and radiographic

Surgery.

M.A.C. Gabrielli et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 51e5452

information about their perioperative care pertinent to the inves-tigation and patients who attend to the follow-up. All patients wereoperated on by the same surgical teamwithin 72 h of their accident,between 1996 and 2009. All patients received antibiotic pre-oper-atively and post-operatively. The protocol of the project wasapproved by the Ethics Committee of this institution, and eachsubject signed an informed consent form.

The subjects were called for clinical and radiographic exami-nation. Posteroanterior and profile cranial radiographs were taken,as well as other views as needed relative to the follow-up of thefacial fracture treatment, looking for any signs of bone infection,resorption or lesions that could be related to the flap. All clinicalexaminations were performed by three examiners of the samesurgical team. Patients were asked about the presence of abnormalsensations and sensitivity was tested by pinprick. Integrity of thefacial nerve was evaluated by visual inspection of facial move-ments, looking for deficits and asymmetries. Scars were classifiedas discreet (thin incision line without fibrosis), with fibrosis (visibleand presenting discreet fibrosis on the incision line), hypertrophic(with wider fibrosis line). Ptosis of the upper lid, epiphora andalopecia were also recorded. Demographic data, treated fractures,hematoma, seroma, drainages, infections or other complicationswere noted. Data were tabulated and presented as percentages.

3. Results

One hundred and eighteen patients (89%) included in the studywere male and 14 (11%) were female. The mean age was 33,04years, ranging from 4 to 75 years (Fig. 1) and the mean follow-upwas 43.91 months. Causes of fractures were motor vehicle acci-dents (63%), assaults (20%), explosions (1%), animal trauma (3%),sports accidents (3%), working accidents (5%), gunshot wounds(1%), bicycle accidents (1%), and falls (1%). Table 1 shows the treatedfacial fractures.

Hypoesthesia was found in 22 patients (17%), 10 in the scalp and12 in the frontal region. Only 9 of the patients described theconditionwhen questioned, while in 13 patients the sensory deficitwas observed with the pinprick test. Unilateral partial deficit of thefrontal branch of the seventh cranial nerve was found in 14 cases(11%). However, in only 3 cases it was noticeable, while in the other11 cases this complication showed very discretely. One patient (1%)had necrosis of borders of the flap with some purulent exudate, one

1

15

50

35

20

63 2

0

10

20

30

40

50

60

0 -- 10 11 -- 20 21 -- 30 31 -- 40 41 -- 50 51 -- 60 61 -- 70 71 -- 80

st

nei

ta

Pf

or

eb

mu

N

Age Distribuition

Fig. 1. Age distribution of patients.

Table 1Treated facial fractures.

Number ofpatients

LeFort I

LeFort II

Mandible LeFort III

Orbitalwalls

132 9 15 5 18 57

(1%) presented with a soft tissue abscess, and one (1%) had cranialvault osteomyelitis. Three patients (2%) extruded isolated poly-vicryl deep sutures. Six patients (5%) developed small hematomasor seromas under the flap. One patient had a small suture dehis-cence (1%). Using the 3-point classification we found 117 cases ofdiscreet scar (89%), 11 patients with fibrosis (8%), and 4 patientswith hypertrophic scars (3%). Fig. 2 shows the characteristics of thescars.

Twenty-four patients (18%) had areas of partial alopecia relatedto the incision, excluding 4 bald patients. In 21 of these, thecondition was localized and less than 1 cm, whereas in 3 itextended along thewhole line of incision. Palpebral ptosis was seenin 1 patient (1%) who had had a traumatic palpebral laceration.Epiphora was observed in 2 patients (2%) who sustained naso-orbital-ethmoidal fractures. Table 2 shows the morbidity related tothe flap.

4. Discussion

Patients with middle third facial fractures had the same patternof gender, age and cause of injury as other facial trauma patients(Gruss, 1982), although differences may occur due to characteristicsof the studied population (Ellis and Zide, 1995). The prevalence ofsubstance abuse, mainly alcohol, was high. High-speed driving andpoor compliance to the speed limits were not uncommon.

The age range of the patients showed a peak in the 21e30-yearold group. This population is socially and economically very activeand needs treatment that results in as few sequelae as possible,evenwhen faced with very severe trauma. They should also be ableto return to normal function and activities as soon as possible.

The bicoronal flap is frequently used for surgical accesses fortreatment of midface fractures above the level of Le Fort I(Niederdellmann and Shetty, 1987). It provides the best access tothe upper and middle facial thirds while resulting in an acceptableand concealed scar (Markowitz and Manson, 1989; Manson et al.,1999).

One possible complication of the flap is the occurrence ofhypertrophic scars (Zhang et al., 2006). Some individuals may bepredisposed to fibrosis even if the surgical procedure was asatraumatic as possible. Most patients (97%) had satisfactory scars,while 4 (3%) young patients, ages 16, 19, 22, and 29, developedhypertrophic scars. Iizuka and Lindqvist (1993) made similarobservations in patients between the ages of 10e25 years-of age.Twenty-four patients (18%) presented with some degree ofalopecia, usually limited to small lateral areas of the incision. In the4 patients with hypertrophic scars, alopecia occurred along thewhole extension of the incision. In general the scar was concealed,but was disfiguring when the hair was wet (Fox and Tatum, 2003).Alopecia in those patients may be related to the prolonged use ofRaney or Cologne clips in extensive facial reconstruction or even tothe use of cauterization in order to prevent or to managehaemorrhage.

Due to good vascularisation, proper sutures, drainage andcompressive dressings, the incidence of postoperative infectionsseen in bicoronal flaps used to treat facial fractures is very low(Rontal, 2008). Localized hematomas and seromas were treated byincision and drainage without complications. Three patients (3%)developed infections. One presented a localized 2 cm abscess 15

Frontal boneand sinus

NOE Zygomaticarch

Zygomaticcomplex

Total offractures

63 45 33 48 293

Fig. 2. Characteristics of scar.

Table 2Morbidity of the bicoronal flap used to treat facial fractures.

Complication Number of patients Percentage

Hypoesthesia 22 17%Partial déficit of frontal ramus 14 11%Infection 3 3%Areas of alopecia 24 18%

M.A.C. Gabrielli et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 51e54 53

days after surgery, probably due toan infectedhematoma, treatedbyincision, drainageandantibioticswithout complications. Theother2cases were atypical. One 24- year-oldman had attempted suicide byshooting himself in the face with a 12-gauge shotgun causingextensive injuries. He received emergency treatment for soft tissueand bone lesions as well as multiple blood component transfusions.His systemic status was further complicated by pneumonia andnutritional deficits. He had a secondary reconstructive procedure 14days later and developed border necrosis of the flap with somepurulent exudate. This was treated by improving systemic condi-tions, with frequent cleaning of the area, debridement andadvancement of the scalp flaps without further complications. One23-year-old-woman had craniofacial trauma in a motor vehicleaccident with a frontal laceration that was grossly contaminated bysoil, grass and animal faeces. Thirty days post-operatively, shedeveloped osteomyelitis of the craniotomy flap used to treat a cere-brospinal fluid leak. This only resolved by removal of the involvedcranial bone and further secondary reconstruction.Whether raisingthe flap in the first 72 h after trauma under those poor local condi-tions contributed to thedevelopmentof infection is not clear. In suchcases, it may be advisable, if possible, to allow longer time for betterhealing before surgery, especially if there is gross comminution ofthe cranial vault.

It was not possible to access the presence of preoperative dys-aesthesias due to the lack of information in the charts. Also, severecraniofacial trauma patients frequently have altered consciousnesslevels that impair sensitivity testing. Furthermore, sensitivity maybe altered secondary to trauma, pain, oedema, fractures, andcomminution of the frontal area. All these features make it difficultto determine if dysaesthesias are related to the trauma or thesurgical procedure to raise the flap (Rontal, 2008). The test used(pinprick) gives a gross estimate of sensitivity alterations as relatedto pressure and pain, but it is practical and commonly employed inthis kind of evaluation (Iizuka and Lindqvist, 1991; Munro andFearon, 1994; Gabrielli et al., 2003). All 12 patients (9%) that pre-sented with hypoaesthesia in the territory of the supraorbital andsupratrochlear nerves had extensive and comminuted frontalfractures. However, in 10 patients (8%), limited areas of

hypoaesthesia were noted in the scalp along the incision line,probably due to damage to the auriculotemporal nerve by theincision itself or prolonged use of haemostasis clips.

The facial nerve is well protected when bicoronal flaps are used.There is a potential risk when the zygomatic arch is to be exposed.This was the case of 2 patients presenting with a partial unilateralfrontal deficit. Another had the same problem although access tothe arch was not necessary. In the remaining 11 cases we founda minimal partial frontal deficit, 7 patients had had zygomatic archaccess and 4 patients did not. Two cases of epiphora treated withdacriocystorhinostomy were seen, both related to naso-orbital-ethmoidal fractures and not to the flap. The only case of partialpalpebral ptosis was due to traumatic laceration of the levatormuscle and not to the surgical procedure.

The bicoronal flaps had a low rate of significant complicationsand allowed good aesthetic results while providing ample access tothe upper and middle facial thirds (Posnick et al., 1992; Mitchellet al., 1993; Montovani et al., 2006; Matic and Kim, 2008).

5. Conclusions

Coronal incisions offer advantages and disadvantages, just likeany other incision. We agree that the indications for this incisionshould be strictly applied and that it should not be overused,however, according to our results the authors concluded thefollowing.

The bicoronal flap provided wide surgical access to the upperand middle facial thirds with very few serious and long-termcomplications, with good aesthetic results and low morbidity.

Conflict of interestAll authors disclose any financial and personal relationships

with other people or organizations that could inappropriatelyinfluence this work. This work was not financed by any organiza-tion as well.

There is no source of support or conflict of interest in this work.

References

Abubaker OA, Sotereanos G, Patterson QT: Use of the coronal surgical incision forreconstruction of severe craniomaxillofacial injuries. J Oral Maxillofac Surg 48:579e586, 1990

Ellis III E, Moos KF, el-Attar A: Ten years of mandibular fractures: an analysis of 2.137cases. Oral Surg Oral Med Oral Pathol 59: 120e129, 1985

Ellis III E, Zide MF: Coronal approach. In: Ellis III E, Zide MF (eds), Surgicalapproaches to the facial skeleton, Philadelphia: Williams & Wilkins, 81e107,1995

Fox AJ, Tatum AS: The coronal incision. Arch Facial Plast Surg 5: 259e262, 2003Gabrielli MAC, Gabrielli MFR, Marcantonio E, Houchuli-Vieira E: Fixation of

mandibular fractures with 2.0 miniplates: review of 191 cases. J Oral MaxillofacSurg 61: 430e436, 2003

Gruss JS: Fronto-naso-orbital trauma. Clin Plast Surg 9: 577e589, 1982Gruss JS, Van Sick LV, Phillips JH, Antonyshyn O: The importance of the zygomatic

arch in complex midfacial fracture repair and correction of post traumaticorbitozygomatic deformities. Plast Reconstr Surg 85: 878e890, 1990

Haug RH: Management of fractures of the frontal bone sinuses. In: Peterson LJ,Indresano AT, Marciani RD, Roser SM (eds), Principles of oral and maxillofacialsurgery, Philadelphia: JB Lippincott Co, 575e591, 1992

Herlin C, Koppe M, Béziat JL, Gleizal A: Rapid prototyping in craniofacial surgery:using a positioning guide after zygomatic osteotomy e a case report. J Cranio-maxillofac Surg 31 Aug 2010, 31 Aug 2010 [Epub ahead of print]

Iizuka T, Lindqvist C: Sensory disturbances associated with rigid internal fixation ofmandibular fractures. J Oral Maxillofac Surg 49: 1264e1268, 1991

Iizuka T, Lindqvist C: Rigid internal fixation of fractures in the angular region of themandible: an analysis of factor contributing to different complications. PlastReconstr Surg 91: 265e271, 1993

Manson PN, Clark N, Robertson B, Slezak S, Wheatly M, Kolk CV, et al: Subunitprinciples in midface fractures: the importance of sagittal buttresses, soft-tissue, reductions, and sequencing treatment of segmental fractures. PlastReconstr Surg 103: 1287e1306, 1999

Markowitz BL, Manson PN: Panfacial fractures: organization of treatment. Clin PlastSurg 16: 105e114, 1989

M.A.C. Gabrielli et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 51e5454

Matic DB, Kim S: Temporal hollowing following coronal incision: a pro-spective, randomized, controlled trial. Plast Reconstr Surg 121: 379e385,2008

Mitchell DA, Barnard NA, Bainton R: An audit of 50 bitemporal flaps in primaryfacial trauma. J Cran Maxillofac Surg 21: 279e283, 1993

Montovani JC, Nogueira EA, Ferreira FD, Lima-Neto AC, Nakajima V: Surgery offrontal sinus fractures: epidemiologic study and evaluation of techniques. Braz JOtorhinolaryngol 72: 204e209, 2006

Munro IR, Fearon JA: The coronal incision revisited. Plast Reconstr Surg 93:185e187, 1994

Nakamura N, Sasaguri M, Okawachi T, Nishihara K, Nozoe E: Secondary correction ofbilateral cleft lip nose deformity e clinical and three-dimensional observationson pre and postoperative outcome. J Craniomaxillofac Surg 16 Aug 2010, 16 Aug2010 [Epub ahead of print]

Niederdellmann H, Shetty V: Solitary lag-screw osteosynthesis in the treatment offractures of the angle of the mandible: a retrospective study. Plast Reconstr Surg80: 68e74, 1987

Posnick JC, Goldstein JA, Clokie C: Advantages of the postauricular coronal incision.Ann Plast Surg 29: 14e16, 1992

Rontal ML: State of the art in craniomaxillofacial trauma: frontal sinus. Curr OpinOtolaryngol Head Neck Surg 16: 381e386, 2008

Sullivan WG: Displaced orbital roof fractures: presentation and treatment. PlastReconstr Surg 87: 657e661, 1991

Zhang QB, Dong YJ, Li ZB, Zhao JH: Coronal incision for treating zygomatic complexfractures. J Craniomaxillofac Surg 34: 182e185, 2006

Zingg M, Laedrach K, Chen J, Chowdhury K, Vuillemin T, Sutter F, et al: Classificationand treatment of zygomatic fractures: a review of 1025 cases. J Oral MaxillofacSurg 50: 778e790, 1992