Treatment
Soft-tissue
injuries
Facial soft tissues have an excellent blood
supply and heal well. They should be sutured as soon as possible after the
injury after careful exploration, débridement and cleaning, particularly where
glass or plastic may be embedded. The tissues should be meticulously clean and
scrubbed, as retained dirt may cause tattooing and hypertophy of the scar.
Many lacerations may be closed using local anaesthesia, injecting into the edges
of the wound. If the patient is due to have a general anaesthetic and there is a
delay, the wounds should be closed in advance by local anaesthesia. Tissue
sufficiently traumatised to have lost its blood supply should be removed with a
sharp scalpel, and the edge to which it is to be apposed trimmed to fit as
appropriate.
Great
care should be taken to replace tissues very accurately, particularly in
cosmetically important landmarks such as the vermillion border of the lips, the
eyelids and nasal contours. Haemostasis is important. Muscle and underlying
layers should be brought together with absorbable sutures so that the edges of
the wound lie passively within 2 mm of their final position. Then fine
monofilament sutures (5-0 or 6-0) are
used to bring the wound edges together (Fig. 38.7). All sutures should be placed
so as to avoid compromising the blood supply of the apices of small flaps.
Vacuum drains are used where there is concern over dead space beneath the
wounds. The lacerations should be covered by antibiotic ointment and this should
be replaced two to three times per day. This prevents the sutures causing
scarring of the skin. Intravenous dexamethasone 8 mg twice daily for 2 days and
broad-spectrum antibiotics should be prescribed. Sutures may be removed from the
third day.
Facial nerve
injury
The facial nerve may be severed in the depth
of a lateral facial wound. If this is suspected, primary repair should be
attempted, particularly where clinical signs suggest that a main division is
involved. Locating the divided branches in oedematous and damaged tissue may be
extremely difficult. Proximal and distal flaps in relatively normal adjacent
tissue may have to be raised to identify the nerve on each side of the
laceration. The severed nerve may then be traced towards the laceration and the
ends approximated using an operating microscope, and the nerve and laceration
sutured. Attempt at primary repair is always worthwhile, although extremely
difficult, as secondary repair is generally unsatisfactory.
Parotid duct
Lacerations in the same vicinity as those that
transect the facial nerve may also transect the parotid duct. The suggested
management is to insert a small cannula in the parotid duct from within the
mouth and then pass it distally until it appears in the wound. The position of
the duct is identified and the proximal end may be found from the site of the
distal end as the tissues are approximated and the cannula runs into it. The
laceration of the facial tissues may be sutured in the normal way avoiding any
tendency to displacement across the ends of the duct. Some advise that the
parotid duct is sutured side to side to avoid stricture. Two days of intravenous
dexamethasone (8 mg twice a day) should follow the surgery. Antibiotics are
recommended.
The lacrimal
apparatus
The lacrimal apparatus may be involved in
damage to the eyelids and nasal bones in Le Fort II and III injuries. The
tissues are generally grossly oedematous and the manipulation required to
reduce the fractures adds to the difficulties of identifying the cannaliculae.
Most surgeons do not attempt repair primarily but refer to an appropriate
plastic or ophthalmic surgeon if epiphora become a problem later. Surprisingly,
few patients suffer epiphora after a year has elapsed from the injury.
Injuries to the
facial bones
The fractured
nose
This is the most common fracture of the face.
Best results are achieved when oedema has been allowed to settle so that
accurate reduction can be achieved. Reduction of oedema may be assisted by
intravenous or intramuscular dexamethasone 8 mg twice daily preoperatively.
However, surgery should not be left for longer than a week, as reduction may
become difficult or impossible. Accurate reduction always requires a general
anaesthetic and an endotracheal tube. A throat pack should always be inserted.
Reduction should be directed first to repositioning the nasal bones,
disimpacting with Walshams’s forceps with the external blade covered with
rubber tubing so as to avoid damage to the skin. The nasal bones are first taken
laterally to disimpact them, and then medially to reposition them. It is wise to
start on the side opposite to the blow which broke the nose. The septum is then
grasped with Asch’s forceps, manipulated until it is straight, and then
positioned in the groove of the nasal crest and vomer. Asch’s forceps may be
used to pull the disimpacted nasal bones forward to their previous un fractured
position. If there is a suggestion that the insertion of inner canthi has been
involved, or the nasal bones have been thrust into the ethmoid sinuses, then
open reduction may be required (see treatment of Le Fort III). The nasal bones
may need supporting by a pack within the nasal bridge. This is best done using
ribbon gauze inserted into the finger(s) of a rubber surgical glove previously
placed beneath the reduced nasal bones (to reduce the discomfort of pack removal
at 3 days). A protective nasal plaster may be placed and removed at 1 week.
Fractures of
the maxilla
Treatment of fractures of the maxilla should
be undertaken in a maxillofacial unit. They always require a general anaesthetic
given through a cuffed nasotracheal tube. Careful intubation is required
ensuring that the tube is directed posteriorly, not superiorly, on insertion.
Correctly placed tubes are of no risk to the cranial base however extensive the
fracture. Occasionally it may be necessary to begin the operation with an oral
tube, and then transfer to a nasal tube once the maxillas reduced and held.
Final positioning of a concomitant fractured nose may be left until the end of
the operation, just after the nasal tube has been removed. Conversely, if it is
necessary to leave in a nasopharangeal airway, a second airway should be
inserted in the other nostril, so as to keep the nares equally distended. A
tracheostomy may be required occasionally.
The
principle of reducing and stabilising fractures of the frontal and facial bones
is that the surgeon starts at the top and works down. Where there are extensive
lacerations,
When
the stabilisation of the upper part of the face is complete, attention may be
given to the midface. Incisions in the lower eyelid (blephoroplasty incisions)
or lower conjunctival sac are used to explore fractures of the infraorbital
margin. These also give access to the orbital floor and are used to treat
blow-out fractures. The rim may be fixed using miniplates or microplates or
wires as above, and the floor of the orbit reconstituted with bone, titanium or
alloplastic material according to choice, held by wires or screws.
The
lower part of the maxilla is approach through a gingival sulcus incision above
the maxillary teeth as far back as the second molar. Fractures may be identified
with ease through this route and fixed with plates or wires. The dental arch is
restored to its original shape as far as possible so that it matches the
previous occlusion with the lower teeth. To achieve accurate location, dental
arch wires or eyelet wires (see below) may need to be inserted. Where this is
anticipated, the necessary wiring is done before the main part of the
operation is commenced.
The
principle of treatment is to restore the fragments to their original position.
To achieve this, usually it is necessary to reduce the maxilla first with
Rowe’s disimpaction forceps which grasp the palate between the nasal and
palatal mucosa. Considerable force is sometimes required in a series of
downward, forward and sideways movement to free it, particularly where the
operation has been delayed. After 3 weeks, full disimpaction is often
impossible.
With
the advent of miniplates and microplates, indirect fixation with pins and halo
frame is seldom used. If the fragments are multiple and the whole restored
maxilla remains unstable, external fixation may be the only answer. Then the
principle is that the mandible is fixed to the cranium, with the maxilla as a
sandwich between the two. Cranial fixation is by
Fractures of
the mandible
Fractures of the mandible frequently are
reduced and then fixed with intermaxillary fixation (IMF). IMF is a means of
splinting the upper and lower arches of teeth together. First, eyelet wires or
arch bars are fixed to the upper and lower teeth. Eyelet wires consist of a
small loop about 4 mm in diameter twisted in the centre of a length of 0.35-mm
stainless steel wire. Each loop is threaded between and around pairs of teeth,
and twisted together on the buccal side, with one of the ends going through its
own loop. This makes very secure fixation. Four or five eyelets are required for
each dental arch. These are most suitable where there is a full, or near full,
arch of teeth in each jaw. Where there has been tooth loss with irregular gaps
around the mouth, then arch bars may have to be used. These are prefabricated
lengths of stainless steel tape or wire, with hooks coming off at 8—10-mm
intervals. These are wired to individual teeth so that there are two arch bars
opposing one another in each jaw. IMF is applied between the loops of the eyelet
wires or the hooks of the arch bars. In the past, custom-made silver cap splints
were used, cemented to the opposing jaws. These are rarely used now.
For
future comfort of the patient, it is very important to restore the dental
occlusion to its original position. With simple minimally displaced fractures,
eyelet wiring is all that is required (Fig. 38.8). This may be achieved without
general anaesthetic. Undisplaced fractures and fractures of the mandibular
condyle may require no active treatment.
Displaced
fractures, or fractures which have markedly disturbed the occlusion, will
require a general anaesthetic. A cuffed nasotracheal tube is required without a
throat pack (a throat pack may make it difficult to achieve the correct
occlusion). Fractures of the body of the mandible may be explored through intra
oral or extra oral incisions according to the access required, and the
fractures reduced and fixed with miniplates and/or wires. Any fractured teeth
should be removed and also those previously compromised by extensive caries or
infection. It is unnecessary to remove healthy teeth in the fracture line. To be
sure of achieving a correct occlusion it is wise to use temporary intraoperative
IMF. There are occasions when the best results can be achieved with IMF alone.
In this event, it is necessary to remove the IMF during recovery, so as not to
risk complications involving the airway. IMF may be inserted after 12 hours
Fractures
of the edentulous mandible generally are plated using miniplates. In the
atrophic mandible, the raising of periosteum should be kept to a minimum as the
blood supply to the jaw may be compromised. Where there is fear that the blood
supply may be seriously disadvantaged by the insertion of plates, Gunning’s
splints may be constructed. These require dental impressions and are then
constructed in the laboratory. In effect, these are like upper and lower
dentures, but with the teeth replaced with plastic in which hooks are placed
(the patient’s dentures may be used). Each splint is wired to the respective
jaw the mandible, with wires going around the mandible (circumferential
wires) and the maxilla, with wires going around the zygomatic arches. The
circumferential wires around the mandible are sited to stabilise the fracture
line. The hooks placed on the buccal surfaces of the plastic arch are used to
apply IMF when the patient has recovered from the anaesthetic. The IMF is
released after 4—6 weeks.
Fractures
of the mandibular condyle may cause disturbance to the occlusion with
deviation of the mandible to the side of the fracture. In unilateral fractures,
this disturbance may correct spontaneously in a few days. If it is still present
at 10 days, or where both condyles are fractured, open surgery may be required
to one of the condyles to prevent an anterior open bite developing. The open
bite occurs due to the vertical pull of the muscles of mastication shortening
the ramus. The posterior teeth contact first and the anterior teeth remain
apart. Functionally and cosmetically, this is very undesirable and is almost
impossible to counteract by secondary procedures. Simply to fix the mandible
in IMF, with or without posterior block to overcome the tendency to open bite,
is insufficient. Direct surgical approaches to the condylar neck are difficult
owing to the parotid gland and facial nerve lying in close proximity.
Preauricular incisions combined with incisions at the lower border of
the mandible do give access but reduction of the bones is difficult through
these approaches. A simple and effective approach is via a tangential incision
at the angle of the mandible that gives access to the bone beneath, between the
facial and cervical branches of the facial nerve. The angle of the mandible is
identified and the periosteum raised up both sides of the ramus as far as the
fracture line. Access to the displaced condyle is achieved by removing the
posterior border of the mandible with a vertical subsigmoid cut, running from
the sigmoid notch of the mandible down to the angle of the jaw. The condyle may
then be removed and offered up to the excised segment of mandible. The two bone
fragments are located and fixed together with miniplates outside the body. The
restored bone is then returned to the patient and secured to the distal mandible
with a miniplate.
Fractures of
the zygoma
Second to the fractured nasal bone, this is
the most common fracture of the maxilla. Displacement is usually posteriorly,
but it is important to assess the actual displacement by studying the
occipitomental radiographs. Most fractures may be reduced by the Gillies
approach. This entails an incision in the hairline superficial to the temporal
fossa about 15 mm long, at 45degree
to the
vertical. It is deepened down to and through the temporal fascia. A channel is
prepared behind the fascia and down to the body of the zygoma and arch. A
Bristow’s or Rowe’s elevator is then inserted beneath the body of the zygoma
or arch, according to the site of fracture. Considerable force is applied in the
opposite direction to that calculated to have been delivered by the blow which
caused the fracture. After reduction, the position of the zygoma can be checked
by palpating the bony prominences of the arch, and the lateral and inferior
orbital rims. As all fractures of the zygoma involve the orbital floor, it is
essential to apply a forced duction test to the globe to ensure that the
inferior oblique or inferior rectus muscle is not trapped. For this to be done
properly, the lower eyelid should be retracted and the inferior rectus muscle
grasped in the lower fornix. The globe can then be rotated upwards and should
move freely. Any restriction in movement suggests entrapment of intra orbital
tissues and the floor of orbit should be explored as for a blow-out fracture
(see below). It is essential to warn the anaesthetist that this manoeuvre is
being done, as it can lead to a severe bradycardia.
Should
the fracture seem unstable, direct wiring or plating may be necessary. The
frontozygomatic suture should be exposed by a small incision just behind the
lateral part of the eyebrow and visualised. Displacements may be reduced and
generally the fracture becomes stable once this fracture is fixed. Occasionally
it is necessary to explore and fix fractures of the infraorbital rim (see
above).
If
the fragments are very unstable owing to comminution, packing the antrum via a
Caldwell—Luc incision in the mouth may be necessary. The antrum should be
first examined using a fibre-optic light source, with particular attention given
to the orbital floor. Then, with the orbital floor reduced and protected, and
the body of the zygoma supported by an assistant, the antrum may be packed from
above down with a 2-inch ribbon gauze soaked in Whitehead’s varnish. Great
care must be exercised not to overpack the antrum and displace the orbital
contents. The incision is closed with a tail of ribbon gauze sutured into the
wound to allow drainage. The pack is removed at 3 weeks.
All
patients who have had operations around the orbit should be observed formally at
15-minute intervals for 9—12 hours. The condition of the eye, the pupil size
and the appreciation of light should be recorded. Occasional complications
arise, the most serious of which is a developing haematoma in the peri orbital
tissues or the cone between the ocular muscles. Increasing exophthalmous and
loss of vision constitute a postoperative emergency requiring immediate action
to reduce the pressure of the haematoma.
Blow-out
fractures
The mechanism has been explained above. The
floor of the orbit is approached either through a blephoroplasty incision in the
lower eyelid or through the inferior fornix. Keeping superficial to the tarsal
plate of the lower lid, the infraorbital margin is identified and the periosteum
raised, being careful not to displace the delicate fragments of bone
constituting the fracture. The peri orbital tissues are gently separated from the
bones of the fracture and freed so that no trapping remains. The apex of the
orbit should not be explored for fear of damage to the optic nerve or spasm of
the retinal artery. Defects of the orbital floor may be made up with bone from
the cranium (see above) or the opposite antral wall, titanium mesh, or other
suitably rigid materials. Reinforced silastic sheet is no longer thought
adequate. The materials are fixed with wires, screws or plates and the wound is
closed.
General
Fractures of the facial skeleton are almost
always compound and prophylactic antibiotics are important. Penicillin and
metronidazole singly or in combination are ideal for those patients who are not
allergic. The cephalosporins are an alternative. Where there is the possibility
of a CSF leak from a dural tear above a fractured cribriform plate of the ethmoid
bone (Le Fort II and III), suitable
antibiotics which cross the blood—brain barrier (chloramphenicol, for example)
should be given to avoid the risk of meningitis or later intracranial abcess.
All patients with fractures of the facial skeleton benefit from intraoperative
and postoperative dexamethasone, to reduce swelling.
Intermaxillary
fixation makes it impossible to chew It is important that the patient receives
the advice of a dietician so that high calorific value food may be taken through
the IMF. It is surprising how patients find a way to take fluid and semi-solids
through clenched teeth. In the badly injured, parenteral feeding may be
required. It is wise to leave a nasogastric tube in place, inserted at the time
of operation, for as long as food cannot be taken normally.
Dislocation of
the mandibular condyles
Dislocation of the mandibular condyles is a
relatively uncommon condition and occurs usually after a wide opening of the
mouth. Occasionally it may accompany a blow to the face, particularly a blow to
the jaw with the mouth already open. The patient is unable to close the mouth as
the