Sequencing In Panfacial Trauma

Shivani gabaJR-II,OMFS

The panfacial injury Conceptually, panfacial fractures are defined as those involving the upper,middle and lower third of face(peterson). In practice, when two out of these three areas are involved, the term “panfacial fracture” has been applied.These complex facial injuries are generally result of high velocity trauma and often produce complex fractures that are extensive and not in the patterns as cleanly outlined by Le Fort.

What is it if someone says that you have a Pan face??

The face which is flattened due to an extreme blow by a pan

Panfacial fractures

Racist used to describe it as one of a Chinese decent

Treatment of facial trauma, damage to the dentition and anatomic structures subsequent to maxillofacial injury is an issue of paramount importance in traumatology. Because in this field, unlike other parts of the body, not only does the surgeon have to deal with the management of the facial fractures, but must also restore the facial functions and features such as visual function (i.e. diplopia), olfaction, breathing (i.e. airway management), mastication (i.e. restoration of teeth and occlusion), deglutition and articulation (in addition to the facial appearance of the patient and symmetry).

In no other part of the body is the management of trauma so complex.

Why the management of this type of trauma is so complex?

Pan facial fractures concurrently involve the following bones :•Frontal bones, •Zygomatico-maxillary complex,• Naso-orbitoethmoid region, •Maxilla and mandible.

Contents

Incidence And EtiologyAnatomical ConsiderationImagingTimingSurgical ApproachingGoals & Sequence Of TreatmentBone Grafting And Soft Tissues ResuspensionConclusion

Motor vehicle collisionsAssault Sports related accidentsIndustrial accidentsGunshot wounds

INCIDENCE

Kapoor P, Kalra N. A retrospective analysis of maxillofacial injuries in patients reporting to a tertiary care hospital in East Delhi. Int J Crit Illn Inj Sci 2012;2:6-10

Raval CB, M. Airway management in patients with maxillofacial trauma - A retrospective study of 177 cases. Saudi J Anaesth 2011;5:9-14

ETIOLOGY

INCIDENCE & ETIOLOGY

Fossilized cranium and finite element model of Australopithecus africanus. Bright colors indicate high strain.

Buttress:A means or device that keeps something erect, stable, or secure

Anatomical considerations’

Facial buttress

The buttress system of face is formed by strong frontal, maxillary, zygomatic ,sphenoid and mandible bones and their attachments to one another. The central midface contains many fragile bones that could easily crumble when subjected to strong forces. These fragile bones are surrounded by thicker bones of the facial buttress system lending them some strength and stability. These buttress represent the best available understanding of the mechanical support of face as they determine how an impact is distributed over the face

For better understanding the components of the facial buttress system have been divided into:

1. Vertical buttresses2. Horizontal buttresses

Vertical buttress: These buttresses are very well developed. Described by manson et al.vertical buttress are responsible for three dimentional projection of midface .They include:1. Nasomaxillary2. Zygomaticomaxillay3. Pterygomaxillay4. Vertical mandible

Majority of the forces absorbed by midface are masticatory in nature (vertically oriented). Hence the vertical buttresses are well developed in humans .

Horizontal buttresses:These buttresses interconnect and provide support for the vertical buttresses. They include:

a. Frontal barb. Infraorbital rim & nasal bonesc. Hard palate & maxillary alveolus

The buttresses represent areas of relative increased bone thickness that support the functional units of the face (muscles, eyes, dental occlusion, airway) in an optimal relation and define the form of the face by projecting the overlying soft-tissue envelope.

Facial buttress pearls are as follows:

(a) The buttress concept was intended for improved appreciation of facial structure; it does not replace traditional anatomic terms.

(b) Buttresses have sufficient bone thickness to accommodate metal screw fixation.

(c) Buttresses are all linked either directly or through another buttress to the cranium or cranial base as a stable reference point.

(d) Transverse buttress reduction restores facial profile and width; vertical buttress reduction restores facial height.

(e) Buttress reduction establishes a functional support for the teeth and globes.

So restoration of 3-D shape of face after panfacial fracture requires precise reduction of these buttress against stable cranial base or mandible

Source : Diagnosis of Midface Fractures with CT: What the Surgeon Needs to Know.Richard A. Hopper. RadioGraphics 2006; 26:783–793

When there is panfacial fractures ,reconstruction should be approached as a puzzle. Known landmarks can be used to reconstruct more precisely those areas that have been damaged. These landmarks may help in establishing the proper positioning of facial skeleton:

1. Dental arches2. The Mandible3. Sphenozygomatic suture4. Intercanthal region

Anatomical considerations’

Key Landmarks

Dental arches

• When one or both dental arches are intact they can be used to a guide to establish proper dental width.

• Clinical scenario of Midpalatal split + fracture of the tooth bearing region of the mandible + condylar fracture. 3 options:

1. Establish maxillary width by exposing the palatal fracture and doing reduction and rigid fixation.

2. Take impressions for fabrication of dental models . Perform simulated surgery on upper and lower arches and fabricate a surgical splint.

If the patient has dental models from preinjury orthodontic or prosthodontic rehabilitation, these can provide good clues to establishing proper arch form.

3. Reconstruct the mandible first as it is a very robust bone that can be anatomically reduced if attention is paid to detail.

The mandible• Aim to achieve anatomical reduction of both lingual and buccal cortical surfaces

prior to fixation.• Bilateral subcondylar fractures must be treated to establish posterior facial height

and facial width.• Bilateral subcondylar fracture + fracture of the symphysis and or body- the

mandible may undergo splaying (widening).The condyle can be reconstituted to ramus to help establish facial height and width.

Sphenozygomatic suture

• Situated along the internal surface of the lateral orbital wall.• Is a key landmark for reduction and fixation of the zygomaticomaxillary complex

provided the orbital roof and lateral orbit are intact .• Likewise the zygomatic buttress is important in establishing the proper position of

the zygoma and or maxilla.• If there is gross bone loss in this are, primary bone grafting may be indicated to

reestablish the buttress.The surgeon should pay particular attention to the alignment of the zygomaand sphenoid at the lateral orbital wall, since angulation here after fixation of the remaining buttresses reflects a residual rotational deformity and an associated increased orbital volume.

Intercanthal region

• Intercanthal distance if fairly constant in adult facial skeleton.• May be used to reestablish midfacial width if the naso-orbitoethmoid complex is

not severely comminuted.• Direct measurement in cases of severe comminution can help in establishing the

proper facial width

Before the advent of CT scanning, plain film radiography and linear tomography were the gold standard for imaging of facial trauma.Initially, 5mm cuts through facial skeleton could be made; now 0.75mmaxial cuts with coronal reconstructions is possible (allows 3-D reconstructions if needed and decreases the number of repeat scans)

Imaging

High resolution CT scanning allows the surgeon to i. evaluate details of the fracture patternii. View hard and soft tissue details-intracranial injuries; injuries to the globe; foreign bodies; extra-ocular muscle entrapment; soft tissue avulsion; displaced teeth and the airway.iii. Simultaneous imaging of cervical spine if injury is suspected.Iv. Allows better treatment planning/sequencing

If the rectus remains flattened in cross-section and in the correct position, the fascial sling is likely intact and the surgeon will encounter minimal entrappedperiorbital tissue (Fig 10a). However, ifthe inferior rectus is round and inferiorly displaced, the fascial sling is disrupted and the periorbita and muscle have prolapsed into the orbital floor defect

ORBITS

Orbital apex. (a) normal anatomy of the orbital apices (b) impingement of the orbital apex secondary to a sphenoid–skull base fracture.

An isolated blow-in fracture of the left orbital roof .The associated exophthalmos and dural tears were treated with an intracranial approach.

Orbital fracture pearls are as follows: (a) Orbital fractures can occur in isolation or with other fracture patterns. (b) The position and shape of the medial and inferior rectus muscles can indicate whether entrapment and clinical diplopia are likely. (c) Pediatric trapdoor orbital fractures are a surgical emergency. (d) The size of the orbital floor defect can be underestimated in severely Impacted ZMC fractures. (e) Medial orbital wall blow-out fractures cause enophthalmos if the posterior- medial orbital bulge is lost. (f) Orbital apex compression with clinical decreasing vision is a surgical emergency.

NOE fractures

Radiologic description of NOE fractures should comment on the degree of comminution of the medial vertical maxillary buttress, specifically in the region of the lacrimal fossa, where the medial canthus attaches.

Nasofrontal ducts.

NOE fracture pearls are as follows: (a) NOE fractures are distinguished from simple nasal fractures by posterior disruption of the medial canthalregion, the ethmoids, and the medial orbital walls. (b) Clinically, the most obvious deformity is loss of nasal projection in profile and apparent increased distance between the inner corners of the eyes. (c) NOE fractures can be classified by the degree of injury to the region where the medial canthus attaches around the lacrimal fossa.(d) Although the frontal sinus may not be directly injured, if the nasofrontal ducts are disrupted, then frontal sinus surgery is needed to prevent a mucocele in the future.

ZMC fracturesa displaced fracture of the left zygoma.The rotational deformity of the zygoma is demonstrated by angulation of the lateral orbital wall at the zygomaticosphenoid suture. The lateral displacement (black arrow) of the lateral vertical buttress (*) has resulted in increased orbital volume and enophthalmos

As long as the rotational deformity is corrected and the other maxillary buttresses are fixated by means of limited incisions, the zygomatic arch does not need to be exposed

ZMC fracture pearls are as follows: (a) The ZMC relates to the temporal bone, maxilla, frontal bone, and skull base and is therefore a quadripodstructure. (b) Displaced ZMC fractures often increase orbital volume by angulation of the lateral orbital wall at the zygomaticosphenoid suture or blow-out of the orbital floor. (c) The zygomatic arch establishes both facial width and profile. Surgical exposure is indicated if it is severelycomminuted or angulated.

Bilateral Le Fort I, II, and III fractures. The lateral and medial maxillary buttresses (white lines) are fractured inferiorly and superiorly (junctions of white lines andblack lines). To confirm the diagnosis, pterygomaxillarydisjunction and fractures of the zygomatic arches would need to be observed on axial images.

A right-sided unilateral pterygomaxillary disjunction, which has resulted in separation of the posterior vertical maxillarybuttress (*) from the rest of the maxilla; this appearance is indicative of a Le Fort fracture. The contralateral pterygomaxillary junction is intact because the fracture exited in the form of a parasagittal palate fracture

Le Fort fracture pearls are as follows: (a) All Le Fort fractures require disruption of the pterygoids from the posterior maxilla, as seen at

axial imaging. (b) Any combination of Le Fort I, II, and III patterns can occur. (c) A sagittal or parasagittal hard palate fracture with a Le Fort pattern will result in a widened

maxillary arch. (d) Displaced unilateral Le Fort fractures are possible only with a sagittal or parasagittal palate fracture.

Fracture repair should be initiated as soon as the patient's other injuries permit. Particularly in midfacial fracture repair Paul Manson’s quote: “you never get a second chance” has to be kept in mind .Early management of fractures facilitates reduction and avoids the insult of a second injury to soft tissues in a vulnerable period of early wound healing. Reduction and fixation of complex injuries within 48 hours is ideal; management within 10 days is critical because soft-tissue stiffening and interfragmentary healing make later corrections very difficult.

It is not so much the fracture morphology in the midfacial area that limits the intended treatment but mainly the preexisting general health status and the severity of associated accompanying injuries or in the vicinity of the midface (optic nerve trauma, CSF leakage, bleeding, etc) or in independent locations.

TIMING

Surgical Approaches

Designed to achieve wide exposure of the fracture lines which is essential for accurate anatomic reduction.The location and extent of exposure are dependent upon fracture severity and combination.

Bicoronal flap

•Frontal sinus•Superior part of naso-orbito ethmoid•Medial canthal tendon•Supraorbital rim•Orbital roof•Superior aspect of lateral orbital wall•Zygomatic arch•Mandibular condyle (with preauricular extension)

Subciliary and transconjuctival incision with lateral canthotomy

•Infraorbital rim•lateral orbital wall•Orbital floor & frontozygomatic suture: transconjuctival incision with lateral canthotomy .It requires detachment of lateral canthal ligament and incision through orbicularis oculi muscle and periosteum deep to lateral periorbital skin.•The subciliary approach :lateral nasal region.

Upper eyelid crease incision•Superior and lateral orbital region•Frontozygomatic suture•Not required when the bicoronal flap is used

Perinasal incisions•Naso-orbitoethmoid region•Medial canthal tendon•Nasolacrimal sac•Disadvantage: significant scarring occurs•Not required if Bicoronal flap is used

Maxillary vestibular incisions

•Maxilla•Zygomaticomaxillary buttress

Mandibular vestibular incision

•Mandible from ramus to symphysis

•Not recommended for comminuted fractures

Cervical incisions•Mandible except for high condylar neck fractures.•Indicated when anatomic reduction is • Crucial•Comminuted mandibular fractures and fracture of edentulous and atrophic mandible•Allows the surgeon to visualize the reduction of the lingual cortex.

The 3 goals of therapy in treating panfacial fractures are To restore functional occlusion To stabilize the major facial skeletal supports, thereby restoring the premorbid 3-dimensional

contour (height, width, and projection) to the face; and Proper restoration of the bony facial scaffold to provides a stable support upon which the

overlying soft tissue matrix may heal.

Facial Fracture Classification According to Skeletal Support MechanismsTerry L. Donat, Carmen Endress, Robert H. Mathog, .Arch Otolaryngol Head Neck Surg. 1998;124(12):1306-1314

Goals

Unsatisfactory results in pan facial # treatment:MisdiagnosisInadequate planningLack of exposureInadequate reduction or fixation of soft tissue or bone andInsufficient primary bone grafting

Crucial decision

Dictated by fracture pattern, extent of other injuries

Extensive head injuries and prolonged intubation anticipated-tracheostomy(it also facilitates management of multiple facial #.

Extensive injuries in NOE Region make nasal intubation difficultIf IMF is not possible or not indicated- oral intubation /submental /retromolar (in c/o symphysis/body #submental intubation hinders access

Airway management

Sequence Of RepairManson says that when multiple areas of face are fractured ,an order of treatment needs to be developed.

The exact order of treatment is not as important as the development of the plan that permits both flexibily and reproducibly accurate positioning of the various fracture segments.Different orders of treatment have been proposed ,any of which are satisfactory if one understands the anatomy ,goals, and procedures. This issue however relate more to the experience and habits of surgeon and prevention of common treatment errors.

Much has been written about proper sequencing of treatment for Panfacial fractures. “Bottom up & inside out” or “Top down & outside in” have been used to describe 2 of classic approaches for management of Panfacial fractures

Traditionally, complex reconstruction began with the reestablishment of occlusion and repair of mandibular fractures. From this foundation, the upper face was reconstructed.

Another strategy supported by craniofacial surgeons began reconstruction with the external frame of the face, including the frontal bar, zygomatic arches, and orbital rims .This approach emphasized the importance of the zygomatic arch in the control of facial width and its reciprocal, facial projection.

One strategy focuses on repair of the central upper midface after occlusion has been reestablished . This technique, although emphasizing the importance of controlling facial width, recognizes that , the NOE , is the most difficult region to narrow acutely. Minor deformities in this aesthetic core, which is one of the primary focuses of visual attention in human interaction, are easily noticeable and extremely difficult to repair secondarily.

Addressing lateral midface first risks compounding small unavoidable imperfections in reduction, thus compromising the central core. With this in mind, the lateral zones including the zygomatic arches and orbital rims are repaired after frontal and naso-orbital-ethmoid repair hasbeen optimized.

How these approaches came in use with time?

SEQUENCING AND ORGANIZATION OF THE REPAIR OF PANFACIAL FRACTURES.MICHAEL A. FRITZ, MD, PETER J. KOLTAI,

MD .OPERATIVETECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 13, NO 4 (DEC), 2002: PP 261-264

It is important to recognize the contributions of each facial component to critical dimensions of facial width, projection and height. Key contributors to central facial width are the naso-orbital-ethmoid complex, the palate, and the mandibular arch. Lateral facial width :The frontal bar, zygomatic arches, malar eminences, and mandibular angles Projection, the reciprocal of width, :frontal bar, frontonasomaxillary buttresses, zygomatic arches, and mandible from angle to symphysis.Facial height: The frontal bone, midface buttresses, and mandibular angles and condyles.

SEQUENCING AND ORGANIZATION OF THE REPAIR OF PANFACIAL FRACTURES.MICHAEL A. FRITZ, MD, PETER J. KOLTAI,

MD .OPERATIVETECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 13, NO 4 (DEC), 2002: PP 261-264

An exploded view of a child's facial skeleton highlighting component units. For severe injuries, comminutedcomponent units are first reconstructed individually

Units are then connected to each other and to the cranium via their associatedbuttresses.

Review of facial subunitsThe face is divided into upper and lower half at lefort –I level.Each facial half is divided into two facial units:1.Lower face-occlusal unit-teeth,palate,dentition ,alveoler process of maxilla and mandiblemandibular units-1.horizontal(basal mandible)-distal angle,body,symphysis,parasymphysis2.vertical section-condyle2.Upper faceCranial unit-frontal ,ant. Temporal bones , supraorbital rims, orbital roofs, frontal sinus.Upper midface-zygoma laterally, nasoethmoid area centrally ans medially, lat. & inferior portion of the orbits bilaterally.

occlusion : (1,2,3)•First attention•Arch bars.

•#of the hard palate are repaired first(rigid) to set the width of the lower central face.

•If palatal # and comminuted mandibular # coexist, occlusal relationships are very difficult to ascertain, Reducing and rigidly fixing hard palate # on both inside and A-S in the nasal spine and pyriform region can provide stable guide for mandibular reconst.

•Severely comminuted # of palate and horizontal mandible necessitates the manufacture of a splint .(key)

•After occlusion has been restored, attention can be directed to either the central upper or lower face depending on concomitant neurosurgical Intervention.

Lower face: (4,5/11,12)•Central fractures are exposed, reduced, and rigidly fixed.

•Check occlusion always

•Attention is then directed to the lateral mandible.

•Comminuted mandibular fractures are repaired through reassemblyof small fragments into larger segments and subsequent linkage and bone grafting when necessary under a sturdy reconstruction plate scaffold.

•Loss of vertical mandibular height, significant fracture displacement, and co- existing mobile LeFort fractures require open reduction and fixation of ramus fractures, subcondylar fractures, and cond¥lar dislocations (particularly when they are bilateral).This importantly reestablishes the appropriate length & relationshipWith cranial base

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Cranial unit (6)• Frontal bone fractures are reduced•Frontal sinuses are obliterated or cranialized when mandated by presense or absense of the posterior frontal sinus wall, respectively. •Isolate nose from cranial cavity by by cranial base grafting•The frontal bar is then reconstructed by stabilizing lower ant. Sinus with S-O rim.-stable landmark.(temporal bone alingment must be correct to assure proper projection of frontal bar.•Orbital roof reconst. With grafts.(avoid over grafting)

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Upper mid face unit:Central (7)•After the frontal bar has been stabilized, a rigid horizontal buttress for fixation of nasoethmoid fractures has been created and its appropriate relationship to the anterior cranial base has been restored.

•Adequate reduction and fixation of the nasoethmoid complex, the aesthetic core of the face, is the most important determinant of upper midfacial width and the most critical step in complex fracture reconst.

•Reconstruction begins with repair of the nasomaxillary and nasofrontal buttresses.(a)

•The medial orbital walls are then reduced and repaired

•Transnasal reduction of the medial orbital rims is the next step and the most important maneuver in controlling midfacial width).(b),(c )

(a)Sequencing of comminuted nasoethmoid fractures begins with reconst. of the nasomaxillary and nasofrontalButtresses

(b) Transnasal reduct. of the medial orbital rims performed next, wires are placed a/b the tendons and each is properly oriented in the a-p plane

(c ) If the medial canthal tendon has been avulsed , it is suspended from the transnasal wire with (4.0 polypropylene) suture after rigid fixation of the facial skeleton has been completed,Incorporating the tendon with the transnasal wire runs the risk of shredding the tendon.

(d) After medial canthal reconstruction, a cantilever cranial bone graft is used to rebuild the nasal dorsum(LAST STEP)

(a)

(b)

©

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A, Clinical photograph of patientwho has a naso-orbitoethmoid fracture with anintercanthal distance of 43 mm.

B,Intraoperativephotograph showing exposure of the nasoorbitoethmoidfracture.

•Upper mid face unit:•Lateral(8,9,10,11)

•Accurate repositioning of the zygomatic complex ensures•the restoration of lateral facial width and projection.

•The zygomatic arches are reconstructed and reunited to the temporal bone posteriorly.

•Key to proper reduction is alignment of orbital portion of the zygoma and the greater wing of the sphenoid at the lateral orbital wall.“

• The inferior orbital rim is then stabilized.

•The last area of the lateral midface to be addressed is the Z-F suture because this relationship contains the strongest bone and is the poorest guide to proper reduction.

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Linking upper and lower face:•The upper and lower midface are linked at theLeFort I level through fixation of the four anterior maxillarybuttresses. (13)•Midfacial height is determined using an intact or reconstructed maxillary buttress as a guide.• Liptooth position may provide information about facialheight if extensive comminution or bone loss is present.“•Buttress gaps exceeding 5 mm should be bone-grafted.•After this has been accomplished, the orbital floors areaddressed with reduction, fixation, and bone grafting asindicated. (12)•The nasal dorsum is then reconstructed with acantilever cranial bone or rib graft with columellar strutgrafting and reattachment of the septum to the nasal spineas necessary.(14)

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Facial width is the most important component of facial dimentions .In treated #,facial height ↓,projection ↓,but width ↑ ,as a result face looses its elongated, sophisticated look and becomes more spherical.

Control o f Width allows projection to be reciprocally established.

Malar eminence projection is assessed by inspecting Sphenozygomatic suture.

Pterygoid buttress are not addressed in any current facial repair scheme. Its stab. Is achieved indirectly by relating u/l alveoli by IMF

In severe hypertelorism ,it may not be possible to reduce palate until upper face is reduced. Muscular origins must be reduced before their insertions can be narrowed.

In edentulous max. #, proper projection is only confirmed by relating U/L ridges by splints/dentures as buttress are guide for max . height not projection.

The fracture pattern occurring in symphysis/parasymphysis region associated with fracture of condyle(s) result in retrodisplacement of mandible with widening at angles. Under such conditions all fractures should be exposed prior to reduction and fixation of anyone of them. Pressure should be applied at gonial angles to close any lingual gap to establish lower facial width and achieve correct anterior projection.

Some important points

BOTTOM UP ,INSIDE OUT

•Repair of palatal fracture•Maxillomandibular fixation•Repair of mandibular #•Repair of condyle #•Repair of frontal sinus #•Repair of NOE complex•Repair of ZMC # including arches•Repair of maxilla

TOP-DOWN,OUTSIDE IN

•Repair of frontal sinus fracture•Repair of ZMC(bileteral) # including arches•Repair of NOE complex•Repair of le fort including mid palatal split•Maxillomandibular fixation•Repair of bicondyle #•Repair of mandibular #

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Re-establish the maxillo-mandibular unit as the first major step of the sequencing

Starting with the reduction and fixation at the level of the calvarium and working in a caudal direction

Top- down ,outside inAdvantage: Open treatment of condyle may not be necessary. The patient is treated with varying period of IMF ,which may be valid approach in c/o comminuted intracapsular #

Potential complication:1.unrecognized rotation of body or ramus of mandible ,resulting in widening.2.TMJ ankylosis caused by inability to begin early physical therapy-compromised result.

With high-velocity trauma, comminution and loss of bony segments can occur in the buttress and “nonbuttress” areas of the face. When these defects are significant, the surgeon may consider the use of bone grafting to prevent soft tissue collapse and to allow for structural support of the facial skeleton.Common areas that may require primary bone grafting include the frontal bone, nasal dorsum, orbital floor, medial orbital wall, and zygomaticomaxillary buttress.There are many potential sources of bone for a graft, but calvarial bone may be the best.Access is often achieved through a Bicoronal flap that has already been created during the management of the fractures.Rigid fixation of these grafts has been shown to decrease resorption.

Bone Grafting andSoft Tissue Resuspension

Two procedures have improved outcomes in the management of panfacial trauma:Primary bone grafting Resuspension of the soft tissue after extensive exposure of the facial skeleton

Bone Grafting

Primary bone graft rigidlyfixed into position to reconstruct the anterior maxillary sinus wall including the nasomaxillaryand zygomaticomaxillary buttress

Soft tissue resuspension after surgical access to facial fractures is important for long-term facial esthetics. For repair of PANFACIAL face fractures, usually large exposure of # sites is required.The soft tissue attachment over the midface is almost completely stripped.This frequently results in sagging of the soft tissue, with reattachment at a more inferior position.

Manson stated two steps to placing the soft tissue back into proper position after exposure : Refixation of the periosteum or fascia to the skeleton, Closure of the periosteum, muscle fascia, and skin where incisions have been made. The periosteum is inflexible and limits soft tissue lengthening and migration. Its reattachment is usually accomplished by drilling holes in key locations to fix the periosteum to the bone.

Areas where periosteal reattachment should be obtained include - malar eminence and infraorbital rim, temporal fascia over the zygomatic arch, medial and lateral canthi, and mentalis muscAreas where periosteal closure should be obtained include - f-z suture, infraorbital rim, deep temporal fascia, and muscular layers of maxillary and mandibular incisions.

Soft tissue resuspension

Reconstruction of pan facial injuries is simplified by a highly organized treatment sequence that conceptualizes the face in two groups of two subunits.

Each unit is divided into sections and each section is assembled in three dimentions.

Sections are integrated into units and units into a single reconstruction.

Conceptually ,in each unit.facial width must first be controlled by orientation from cranial base landmarks .Projection is then established.

Finally ,facial length is set both in individual units and in the upper and lower face.

Soft tissue is considered as the “fourth dimention” of facial reconstruction.Bone reconstruction shd be completed as early as possible to minimize soft tissues in non anatomic positions . S/T that heals from a single insult over anatomically constructed bone support provides the most natural facial appearance.

Conclusion

Neither one of these techniques will achieve optimal results in every situation. Instead, an approach that goes from known to unknown is certainly more accurate.For e.g. if there is significant calvarial injury , it may be difficult to start from cranium and proceed caudally. In this case ,a sequence that starts caudally and proceeds cranially may achieve more optimal results, allowing the surgeon to reconstruct the damaged cranial portion last.Conversely, if there communication of mandible ,it maybe more appropriate to start cranially and proceed caudally.Thus a maxillofacial trauma surgeon must be comfortable with both approaches and use known landmarks to achieve optimal results.

Incisions frequently used for orbital surgery. Deep approaches: A, Stallard-Wright lateral orbitotomy incision; B, lid crease with lateral extension; C, modified Berke lateral canthotomy incision; D, transcaruncular incision; E, frontoethmoidal “Lynch” incision. Anterior approaches: F, upper lid crease incision, G, vertical lid split incision; H, transconjunctival medial orbitotomy; I, lateral canthotomy incision; J, lower lid percutaneous incision; K, transconjunctival lower lid incision.