Trauma Craniofacial

dr. Umu Istikharoh, SpBP-RE

Introduction
 SURGERY REFERENCE AO FOUNDATION

General Consideration

YOU NEVER GET A SECOND CHANCE

• The time frame for primary fracture treatment is limited to 2

weeks.

• Regardless the severity and possible variety of fracture types in

the midfacial area the guideline for a successful restoration is
reconstruction of facial buttresses and prominences, recontouring
of bony cavities (eg orbit) and reestablishing occlusion.
Epidemology
Facial Bone
 FRAKTUR
MAKSILA

The Bone
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Examination of patients
 Introduction

• Airway -> IMPORTANT

• Full Examination of the head, eyes,
ears, nose, throat and neck.
 Sign and Symptoms
Midfacial Fractures
• Facial Swelling (edema, • COmpromised ocular motility
hematoma) and deformity
• Double Vision
• Subconjunctival bleeding
• Sensory deficit
• Oronasal bleeding
• Localized pain
• Palpable & crepitating dislocated
bony contour in the periorbital • Occlusal disturbance
region
• CSF leakage
• Displacement of the globe
• Displacement of the medial
canthal tendon
Instruments for Clinical Examination

• Examination Gloves
• Single-use tongue blades
• Examination light
• Visual Chart
• Nasal Speculum
 Eye Examination

• Visual Field Testing

• Ocular Motility
• Binocular Vision
• Globe Position
• Pupillary Reaction
• Remember :
• Contact lenses
• Cataract, etc
 Ear Examination

• Cauliflower Ear
• Make sure the patient can hear
with both ears
• Examine for blood and/or CSF
leakage
• Examine for laceration or collapse
of external canal
 Nose Examination

• Characteristic signs for nasal

fractures are :
• Pain
• Bleeding
• Swelling
• Compromised Nasal Airway
• Crepitation
• Palpable Bony Dislocation
 Nose Examination

• Swelling —> Medial canthal, pain

• The nose can be retruded & impacted at the nasofrontal suture area with lack of support
for the nasal septum & cartilages
 Nose Examination

• Bimanual Palpation —> linstability and crepitation —> Unstable NOE fracture
• Bow String Test —> Grab the skin in the medial canthal area and pull it
laterally
 Make Sure to Rule Out
CSF Leak
• Tilt test with positive halo sign
• CT scan with thin coronal cuts of
the cribriform plate
• Comparison of the concentration
of glucose between fluid &
patient’s serum
• Laboratory analysis for beta-
transferrin
 Oral / Throat Examination

• Intraoral Inspection
• Open Fractures
• Asymmetries
• Hematoma
• Lacerations (including salivary
ducts)
• Foreign bodies
• Avulsed & Luxated teeth
• Malocclusion
 Oral / Throat Examination

• Intraoral Palpation
• Bimanual manipulation of
mandibular segments to identify
mobile fragments
 Nerve Exam of The Face
• Sensory Nerves • Motoric Nerves
• Supraorbital • Frontal
nerve
• Zygomatic
• Infraorbital
nerve • Buccal

• Mental nerve • Marginal

Mandibular
Fracture Palpation
Fracture Palpation
Soft Tissue Injury
 “The wound of the face .… have to be
cured with extreme care because the face
is a man’s honor”

–The dawn of Plastic Surgery in Mexico : XVIth century.

PRS. -
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 Introduction

The effective treatment of fractures depends

upon good soft tissue management

Fractures with a soft-tissue injury must be

considered as surgical emergencies.

Life saving treatment must always take priority.

 Pathophysiology &
Biomechanics
Type of insult & area of contact (blunt, penetrating,
crushed, etc)

Force applied

Direction of force

Area(s) of body affected

Wound contamination

General physical condition of the patient

Types of Injuries
Abrasions (with or without tattoo)

Lacerations

Avulsions

Skin and soft tissue loss

Injury to spesi c facial parts

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Abrasions - Management
Local or Under general anesthesia

Clean with mild surgical soap

Remove dust using a light brush to avoid tattooing

Cover with a thin layer of topical antibiotic ointment

Reepithelialization within - days

Avoid UV exposure for weeks

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Management Facial Abrasion
Traumatic Tattoo
 Lacerations
Under local or general anesthesia

Irrigate when wound is contaminated

Always attempt primary closure

Refresh wound, trim jagged edge

Approximate the ‘puzzle’ pieces of stellated laceration before

suturing

Repair layers:

Absorbable thread for inner layers

Non-absorbable for skin

Simple Lacerations
 Avulsions
Due to shearing force tearing part
of skin or soft tissue

Irrigation and debridement

Evaluate vitality by marginal excision

Excise minimally, stop at rst sight of blood

If in doubt, return the avulsed skin onto the bed,

suture or tape, then observe

Split thickness skin avulsion should be returned,

and treated as skin graft
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Avulsion of the Temporal Skin

Debridement,
Marginal excision,
Avulsion returned,
Remaining surface approximation
Local Flaps
Skin and Soft Tissue Loss
Complex laceration and avulsion with
part of skin or soft tissue missing
Irrigation and debridement

Evaluate vitality by marginal excision

Trim remaining jagged edges

Attempt to close defect primarily when possible, preferably

by local aps obtained from the healthy surrounding tissue

Suture without tension

Skin graft is an alternative option

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Skin & Soft Tissue Loss
Skin & Soft Tissue Loss
 Eyebrows

Protects the eyes

Facilitate expressions
De nes the eyes & forehead
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 DO NOT SHAVE
Eyebrows are never shaved in
prepara on for wound closure

The neighboring hair are important

as landmark for wound
reapproxima on
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Misaligned Lacerations
 Super cial Lacerations

Super cial linear lacera ons

Me culously close with nonabsorbable sutures
Carefully align the margins
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Super cial Lacerations
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Eyelids & Lacrimal Ducts
Goals of Eyelid Repair
There must be a smooth mucous
membrane lining inner eyelid surface
to avoid ocular damage and provide
lubrication for the eye

Lid margin must have structural stability

and fixation to maintain eyelid contour

Muscle function must be adequate to

provide appropriate eyelid closure

Eyelid should have enough capacity to

open for proper visibility
 Eyelid Structures
Orbital fat
Eyelid is the most
Orbital delicate structure
septum of the face
It consists of
Fusion point several layers of
Levator ne musculature
aponeurosis Lid crease Improper repair
may result in
Orbicularis ptosis or a
Tarsus muscle retracted eyelid
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Horizontal Lacerations
Horizontal Lacerations

Deeper horizontal lacerations may require

inner layer (muscle) absorbable sutures
 Vertical Lacerations

Close super cial vertical lacerations in layers

Key suture is placed at the ciliary margin
Close skin with - nonabsorbables sutures
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Tarsal Loss

Superior tarsal
loss realigned,
skin loss full-
thickness skin
grafted
Complex Eye Injury
Complex Eye Injury
Lacrimal Duct Injury
Injuries to the medial
canthal region must be
inspected for lacrimal duct
injury.

With complete transection,

if the ends of the duct can
be identified, align the
ends, cannulate and repair
with fine sutures.
Dacrocystorhinostomy
Medial Canthal Laceration
Complex Eye Laceration
NOSE
 Nasal Lacerations
Use simple nonabsorbable skin sutures.
Superficial Deeper bites used if laceration extends to
cartilages with no significant deviation.

Close in layers. Mucous with 4-0 to 6-0

Full-thickness absorbable sutures. Skin and cartilage
with nonabsorbable interrupted.

First place key sutures on nasal rim, nostril

Landmarks border, or alar rim to ensure smooth,
continuous contours without notching.

In general, nasal packing is unnecessary.

Petrolatum-impregnated gauze may be
Packings used to pack nose if underlying cartilage
or bone is unstable.
Avulsed Nasal Skin
Nasal Tip Loss
Ears
 Otohematomas
Is the accumulation of blood between
perichondrium and cartilage of the auricle
resulting from blunt trauma or traction

Treatment goal: Evacuate blood and prevent

reaccumula on, done within 7 days of traum

Untreated,
otohematomas can
form asymmetric
neocartilage,
resulting in
cauli ower ear
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Partial Amputation of Ear

Near-total amputa on of the ear

Lower branch of auricular artery intact
Debridement and apposi on of avulsed ear
5 days later, ear was vital, raw surface gra ed
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Super cial Lacerations
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Repair of Deeper Lip Laceration
Muslce: buried absorbable sutures
Mucous: absorbable sutures
Skin: - or - nonabsorbables
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Deeper Lacerations
Total Avulsion/Rupture

White roll, philtrum, dry and wet vermilion borders,

columella, and nasal p are iden ed.

Repair in order of:

White-roll, muscle, inner mucous, outer mucous, skin
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Injury to The Parotid/Stenson Duct
Suspect parotid injury in any wound along
the line from tragus to the mid portion of
the upper lip

Consider injury if there is clear discharge

from the cheek wound

A sagging upper lip also indicates possible

injury (buccal branches of N.VII run along
with the duct)
If transverse facial artery is injured,
bleeding into the tissues, may obscure
structures identification
 Incomplete Duct Transection

The middle-third of a line

between the tragus and
the middle of the upper lip
de nes the course of the
parotid duct
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Facial Nerves
 Facial Nerve Injury
Because of its super cial distribu on,
facial nerve is suscep ble to injuries

Infraorbital n • Creates wrinkles in the cheek

• Inability to raise eyebrows

Temporal n.
• Unable to close eyelids
• Inability to raise eyebrows
Zygomatic n.
• Unable to close eyelids
• Inability to smile or move lips
Buccal n.
• Loss of nasolabial crease

Mandibular n. • Inability to frown

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 Facial Nerve Repair
Explore all nerve injury opera vely
Golden period of repair: 72 hours
Anastomose nerve under microscope
Use 8-0, 9-0, 10-0 nylon epineural sutures
If nerve ends are jagged, trim rst
In case of nerve loss:
tag nerve ends for future gra ing
Buccal nerve branch medial to the lateral canthus
do not require repair (spontaneous heal in 3-6 mo)
Time of regenera on: 1 mm per day
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Bite Wounds
 Bite Wounds
Dog, cat, and human bites account for
99% bite wounds
Only 1% of the wound presents on the
face
So ssue injuries commonly:
Lacera ons and tears of scalp, cheek,
lips, or neck
Main concern:
wound insec on
Human bites are more infec ous than
that of animal
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Radiological Findings
 Conventional Imaging
(Plain X-rays)
• Water’s View
• Poor Visualization of fractures
• No information about fracture displacement
• Orthopantomogram or Panoramic —> Mandible
• Lateral VIew
• Submentovertex view
 CT-Scanning

• Recommended Scanning Protocol

for CT includes :
• 2-3 mm sliced thickness (orbital
fractures : 1 mm)
• Hard and soft tissue window
rendering
CT-Scanning
 MRI

• MRI might be indicated to better detect soft tissue problems such as :

• Optic nerve edema or hematoma
• Ocular muscle disorders (incarceration, hematoma, disruption)
• Intraocular disorders (hematoma)
• Foreign bodies in the orbit
Treatment
Target Operasi

Mengembalikan Oklusi

Memperbaiki Diplopia
Oklusi

segarisnya
kuspid
mesiobuccal
dari M1
maksila
dengan
buccal
groove M1
mandibula
 CLASSIFICATION

• Buttress System

• Vertical Buttressess
• 1. Naso-Maxillary (NM)

• 2. Zygomatico-Maxillary (ZM)

• 3. Pterygo-Maxillary (PM)

• 4. Nasal Septum

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 Target Operasi
• Horizontal Beams

• 1. Frontal Bar

• 2. Inferior Orbital Rims

• 3. Maxillary Alveolus and Palate

• 4. Zygomatic Process

• 5. Greater Wing of the Sphenoid

• 6. Medial and Lateral Pterygoid Plates

• 7. Mandible

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 Surgical Complication

Postoperative Blindness
CSF Leak
Persistent Enophthalmos and Diplopia
Ectropion
Entropion
Cheek Hypesthesia
Extrusion of Grafts
Malunion, nonunion,PlateExposureOsteomyelitis
Palpable or Observable Plates

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