Operative Technique in Plastic Surgery – Kevin C.Chung

FIG 3 • A. Operating room setup. B. Having the
patient’s neck extended allows an easier angle of
viewing into the patient’s orbital cone and visualization
of the orbital floor. C. If the patient’s neck is flexed or
neutral, the surgeon must lean over to visualize the
orbital floor, which is ergonomically more difficult and
tiring.
T E C H N I Q U E S

■ Subciliary Approach
■ I prefer this approach because it allows a much wider exposure of the rim
and floor, as well as provides easier placement of implants onto the floor.
Children and young adults have no lid laxity, and this incision avoids
retraction on the actual tarsal sling. (Video demonstrates subciliary approach
in a case of orbital entrapment.)
■ Placement of corneal shield (optional)
■ Retention sutures in the lower eyelid. The surgeon can place two sutures,
one on each side of the limbus. I like to place the retention suture from the
superior eyelid down to the lower eyelid and then back through the upper lid
as a horizontal mattress. This protects the cornea and globe, as well as
provides retraction during dissection.
■ Incise at the lateral corner of the eye of the palpebral crease and plan for
incision to be 2 to 3 mm below lash line (TECH FIG 1A) extending to the
medial lash line to achieve adequate exposure.
■ Dissect with tenotomy scissors under the skin in front of the septum but
underneath the orbicularis oculi. Using scissors, cut at a bevel to raise a skin
and muscle flap (TECH FIG 1B).
■ Using traction of the lower eyelid retention stitch, spread transversely along
the plane to expose the natural plane between the septum and orbicularis
oculi (TECH FIG 1C). This is continued to the orbital rim. Gentle retraction
with a Desmarres retractor while gently pressing down the orbital contents
exposes the orbital rim. Avoid making this incision too posteriorly as this will
violate the septum; an incision too anteriorly placed will incise the orbicularis
oculi muscle.
■ Incise the periosteum of the orbital rim with either needle-tip cautery or
knife.

TECH FIG 1 • A. Eyelid incisions for approach to the
orbital floor. The subciliary incision is preferred as it
provides a discreet incision yet allows full exposure of
the orbital floor. The lower eyelid incision is much
more obvious in patients with youthful skin, such as
pediatric and young adults. B. Demonstrates the
tissue plane between septum and orbicularis oculi
allowing an avascular plane of approach to the rim. C.
Sagittal depiction of the subciliary approach. Note the
septum posteriorly and muscle anteriorly. The
dissection plane traverses between these two

structures. D. Closure of the orbital septum to its
anatomic position assists in decreasing ocularis oculi
tethering to the orbital rim, thus decreasing risk of
ectropion. E. Muscle closure or lower eyelid orbicularis
oculi to lower eyelid flap orbicularis oculi. F. Skin
approximated without any gapping. If there is gapping,
readvance the lower eyelid flap in order to decrease
ectropion.
■ Subperiosteal dissection allows improved exposure and avoids the fat of the
orbital contents.
■ After reconstruction of the orbital floor, handling of the soft tissue is
important to prevent ectropion.
■ Reapproximation of the periosteum with either 4-0 or 5-0 Vicryl depending
on the amount of soft tissue dissected during exposure. An adequate
periosteal bite is required to support the soft tissue of the cheek. This is
especially important if there is also a ZMC fracture as this area is completely
degloved. If the weight of this deep layer is not supported, the risk of
ectropion is extremely high.
■ Closure of the septum with resorbable suture such as 5-0 Vicryl (TECH FIG
1D).
■ Reapproximation of the orbicularis oculi with a resorbable suture such as a
5-0 Vicryl. After this layer is closed, the skin should simply be opposing
without any gap of the eyelid in comparison to the contralateral side (TECH
FIG 1E,F). In fact, a little overlap of the lower eyelid over the incision is
ideal. If there is gapping between the skin edges after muscle
reapproximation, ectropion will most likely occur. Recheck to be certain that
the periosteum is reapproximated appropriately by providing adequate
support of the overlying soft tissue. The lower lid muscle and skin flap must
be advanced adequately superiorly.
■ Final skin closure can be completed with either 6-0 monofilament or 6-0
plain gut. I prefer to run a 5-0 fast or 6-0 fast gut. I also place a 6-0 fast
tarsorrhaphy at the lateral limbus to assist in keeping the lower eyelid
elevated during postoperative swelling. Patients can raise their upper eyelid
enough to see. This suture can be removed at day 5 to 7; however, I usually

just let it degrade, which is usually around 5 to 7 days. This prevents patient
discomfort.
■ Transconjunctival Approach
■ I prefer not to use this approach in children and younger adults as there is no
lid laxity. It can be difficult to assess the whole orbital floor, as well as place
the implant. Also, oftentimes, “bowstringing” of the lower lid can occur after
reconstructing the inferior canthus, which increases the chance of ectropion
or entropion.
■ Placement of corneal shield: optional
■ Place two lower eyelid traction sutures on each side of the limbus right
below the lash line.
■ Using a sharp pair of tenotomy scissors, make a lateral cut right at the corner
of the lateral palpebral fissure. This transects the lateral canthus separating
the inferior limb from the superior limb (TECH FIG 2A).
■ Reorient the scissors 90 degrees so that they are following the curve of the
face, and then incise only the inferior limb of the lateral canthus.
■ This should release the canthus to pull the lower eyelid out, thus exposing
the inferior fornix. The cascade of vessels behind the tarsus and the transition
to only the conjunctiva can be visualized. Make an incision with needle-tip
cautery underneath this cascade of vessels. This should be a full-thickness
conjunctival incision (TECH FIG 2B).
■ This allows placement of another traction suture as a horizontal mattress
from the upper eyelid skin down to the conjunctival flap, back through the
flap to the eyelid, and then a loose knot. This provides tension on the
conjunctival flap for easier dissection and keeps the corneal shield secure.
■ Dissection plane is the same as before, which is between the orbicularis oculi
muscle and the septum. Entering the septum allows fat to herniate out and
can make retraction more difficult but does not affect overall exploration and
floor reconstruction.
■ After floor reconstruction (see below for this procedure), closure consists of
4 steps:
■ Reapproximation of SMAS layer to the periosteum of the orbital rim
■ Reapproximation of the orbicularis oculi
■ The conjunctiva does not necessarily need to be closed. Run a 6-0 fast gut

with wide spacing between bites.
■ It is essential to reapproximate the inferior canthal tendon to Whitnall
tubercle. One can either take a bite through the periosteum or, if there is no
periosteum there, can drill a hole in the bone. The key is to make sure to
“redrape” the lid against the globe; otherwise, there will be inadequate
opposition of the lower lid against the globe.
TECH FIG 2 • A. Transconjunctival approach to the
rim. It can be difficult to get full exposure of a fracture
unless the inferior canthal tendon is released, and
even then, the exposure is limited without forceful
retraction of the lower lid. Although there is more
elasticity in a youthful/pediatric lower lid, it is also
much tighter requiring more extensive retraction,
increasing risk of entropion. B. Sagittal depiction of
the transconjunctival approach.
■ Lower Eyelid Incision
■ This is not an ideal approach for the pediatric population or the young adult,
unless there is already a laceration (see TECH FIG 1A). In the older adult
population, the scar is quite acceptable. If one does use this approach, the
patient must be aware that there may be a lid edema superior to this incision
for a prolonged time postoperatively.

■ Orbital Floor Dissection
■ Subperiosteal dissection posteriorly provides a cleaner dissection plane to
expose the fracture and herniated orbital contents (TECH FIG 3).4
■ In larger fractures, it is common to encounter the inferior orbital nerve and
this must be separated inferiorly. Removal of comminuted bone fragments
will help delineate path of the nerve.
■ Sweep laterally and medially to help find the posterior shelf. Using either a
malleable or orbital content retractor, retract the orbital contents superiorly
allowing the edge of the retractor to rest on the posterior shelf. During this
maneuver, let the anesthesiologist know there may be vagal stimulation
causing bradycardia. This should provide a clear view of the orbital floor
defect to help shape the implant.
■ CN II and the superior fissure are located superomedially. Be cautious when
dissecting toward the fissure. Having an exact idea of the length of your
dissection tool is mandatory; the distance from the rim to the apex of the
orbital cone ranges will vary according to the patient’s age and can be
premeasured in the sagittal window preoperative CT scan.
■ Shape the orbital plate, and while gently retracting superiorly, place the plate
into position.
■ When looking down at the surgical site, the surgeon must be able to see the
plate. If the plate cannot be visualized, then the placement is not appropriate
and the plate is in the maxillary sinus.
TECH FIG 3 • Amount of exposure capable with a
subciliary incision. Orbital floor is easily visualized,
including the entrapped orbital contents in this
particular case.

■ Secure the plate to prevent any form of movement because movement can
cause migration and extrusion. One can simply secure the plate with a 4-mm
screw in the orbital floor.
■ If there is a trap door injury, simply reducing the trapped orbital contents is
enough to reduce the orbital floor anatomically. The very elastic nature of the
pediatric orbital floor bone causing the trapdoor mechanism is also what
allows the bone to reduce, thus obviating the need for an implant. Using a
small nerve hook can help reduce the orbital floor into its anatomic location,
but one must be careful not to completely fracture the floor. This will turn a
greenstick fracture into a complete orbital floor defect requiring
reconstruction.
PEARLS AND PITFALLS
Preoperative
preparation
■ Judicious infiltration of vasoconstrictive local anesthetic.
Adequate
exposure
■ Optimal positioning can improve the ease and efficiency of the
procedure. Extension of the head allows better visualization of the
orbital floor.
■ Although technically either transconjunctival or subciliary
incisions can give adequate exposure, subciliary incision can be
more easily extended medially for full exposure of floor and
medial wall.
Implant
placement
■ Need to have adequate exposure and visualize or palpate the
posterior shelf
■ Visualize the implant when looking straight down into the orbit
(see FIG 3C)
Soft tissue
■ Resuspension and “no tension” closure will help prevent ectropion
and entropion.
Postoperative
care
■ Obtain postoperative imaging (either CT scan or skull films).
■ Steroid ophthalmic drops to assist in keeping lower eyelid elevated
during postoperative period where swelling can cause
“bowstringing” of the lower eyelid
POSTOPERATIVE CARE

■ Repeat x-ray; lateral films are adequate to demonstrate appropriate placement.
If there are other facial fractures, repeat CT scan. In pediatric patients, avoid
unnecessary radiation.
■ Temporary tarsorrhaphy
■ Steroid ophthalmic ointment or drops
■ Head of bed elevated
■ Visual checks
■ Sinus precautions
COMPLICATIONS
■ Diplopia
■ Enophthalmos
■ Ectropion
■ Entropion
■ Reconstruction malposition
■ Palpebral fissure discrepancy
REFERENCES
1. Losee JE, Afifi A, Jiang S, et al. Pediatric orbital fractures: classification,
management, and early follow-up. Plast Reconstr Surg. 2008;122:886-897.
2. Broyles J, Jones D, Bellamy J, et al. Pediatric orbital floor fractures: outcome
analysis of 72 children with orbital floor fractures. Plast Reconstr Surg.
2015;136:822-828.
3. Kothari N, Avashia Y, Lemelman BT, et al. Incisions for orbital floor
exploration. J Craniofac Surg. 2012;23(7 Suppl 1):1985-1989.
4. Gart M, Gosain AK. Evidence-based medicine: orbital floor fractures. Plast
Reconstr Surg. 2014;134(6):1345-1355.

75
CHAPTER
Surgical Correction of
Pediatric Midface Fractures
Eric Lowry Cole and Shelby R. Lies
DEFINITION
■ Le Fort fracture
■ Le Fort I dentoalveolar separation including pterygoid plates
■ Le Fort II bilateral pyramidal fracture including pterygoid plates
■ Le Fort III craniofacial separation involving the frontonasal articulation,
traversing the orbital walls with disjunction of pterygoid plates and
zygomatic arch (FIG 1)
■ Nasal bone fracture
■ Naso-orbitoethmoid fracture
■ Zygomaticomaxillary complex fracture
■ Frontal bone fracture
ANATOMY
■ The zygoma articulates with the frontal bone, maxilla, temporal bone, and
sphenoid. All fractures of the zygoma affect the orbital floor or lateral orbital
wall.
■ The zygomaticosphenoid junction is the key anatomical articulation in the
reduction of these fractures (FIG 2).
■ Naso-orbitoethmoid (NOE) fractures are defined as a comminuted fracture of
the nose and orbit involving the medial orbital walls, ethmoid sinus, and bony
and cartilaginous structures of the nose.

FIG 1 • Le Fort fracture classifications.
PATHOGENESIS
■ Motor vehicle collisions and assault are the most common causes of facial
fractures in children.1
■ Consider possible nonaccidental injury if the history does not match the injury
or if there are multiple emergency room visits.
■ The prominent cranium and mandible in children make isolated midface
fractures uncommon, and their presence should prompt a search for associated
intracranial and cervical spine injuries.2
■ Pure Le Fort fractures are rare and oblique hemi–Le Fort patterns are more
common in children.
■ Relative underdevelopment of the maxillary sinus allows the
zygomaticomaxillary buttress to resist classic Le Fort I level fractures, and
instead, force is transferred to dentoalveolar segments causing alveolar and

dental injuries.
■ Le Fort II and Le Fort III level injuries often present with NOE fractures
combined with zygomaticomaxillary complex and orbital wall fractures.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Blunt trauma causes fractures at articulations.
■ Direct impact to the lateral face may cause an isolated depressed zygomatic
arch fracture.
FIG 2 • Zygomaticomaxillary complex articulations.
■ Significant medial displacement may result in the loss of lateral facial width
or trismus through impingement on the coronoid.
■ Higher-velocity injuries often cause comminution and deformity in facial
width, orbital rim step-offs, flattening of malar prominence, and globe
malposition.

■ Assess facial symmetry and occlusion; palpate to determine integrity of frontal
bones, orbital rims, and malar eminence of zygomatic arch.
■ Check stability of the maxilla including dentoalveolar segments by stabilizing
the head and attempting to mobilize the dentition. Ecchymosis may be present
in the gingivobuccal sulcus.
■ Visual acuity and globe integrity must be documented. Examine extraocular
movement and pupillary response.
■ Enophthalmos. Lateral and/or inferior displacement of the zygoma may
increase orbital volume and lead to enophthalmos. Greater than 3 mm change
in globe position compared to contralateral eye appears clinically significant.
Relation of the corneal surface to the lateral orbital wall can be measured with
a Hertel exophthalmometer device.
■ Diplopia. Symptoms occur mostly in upward gauze due to hypotropia where
the focus is on the eye with a visual axis lower than the contralateral fixating
eye, most commonly with injury to the inferior rectus muscle.
■ Traumatic optic neuropathy can present with subtle findings of diminished
color perception. Consult an ophthalmologist.
■ Oculocardiac reflex involves classic triad of bradycardia, nausea, and syncope.
If symptoms occur in any phase of treatment, suspect periorbital entrapment,
which necessitates release. Pediatric patients are more prone to sustain a
trapdoor deformity of the orbital floor, leading to entrapment and persistent
nausea (FIG 3A,B).
■ Cheek numbness as a result of infraorbital nerve injury.
■ NOE fracture deformity includes loss of nasal bridge projection, upturned
nose, and telescoping nasal length (FIG 3C,D).
■ The varying degree of loss of canthal attachment creates an increase in
intercanthal distance with blunting of the palpebral fissures. A bowstring test
can assess for tendon avulsion.
■ Intranasal speculum examination for epistaxis and septal hematoma
■ Rule out CSF leak with a tilt test for halo sign and/or beta-transferrin analysis.
IMAGING
■ Plain occipitomental views demonstrate distraction of articulations and
zygomatic arch anatomy.
■ Computed tomography (CT) max-face is the diagnostic study of choice to
evaluate the characteristics of fracture patterns. Considerable information can

be obtained from CT imaging.
■ Manson’s classification according to degree of displacement/comminution is
useful based on CT3:
■ Minimal displacement, no comminution
■ Moderate displacement, mild comminution
■ Severe displacement, major buttresses comminuted in multiple locations
■ Three dimensional (3D) reconstruction offers interpretation of complex
fractures (FIG 4).
FIG 3 • Restriction of the left eye (A) correlating with

radiographic evidence of snapback entrapment (B).
C,D. Preoperative photographs of a patient with hemi–
Le Fort II and NOE fracture demonstrate loss of nasal
bridge projection, upturned nose, and telescoping nasal
length.
FIG 4 • A. Coronal CT hemi–Le Fort II NOE fractures.
B. CT 3D Reconstruction hemi–Le Fort III.
DIFFERENTIAL DIAGNOSIS
■ Skull fractures from frontal impact are more common in young children, and
older teens have a higher probability of facial fractures.2
■ Intracranial abnormalities
■ Cervical spine injury
■ Nasal bone

■ Mandible, particularly the subcondylar region
■ Frontonasoethmoid region
■ Orbit, most frequently involving the orbital roof in children under 7, as
compared to the floor in adults
NONOPERATIVE MANAGEMENT
■ In the pediatric patient, rigid skeletal fixation can do more harm than good.
Children have significant capability of bony remodeling and dental
compensation.
■ Fractures should be managed conservatively whenever possible.
■ Nondisplaced and minimally displaced fractures, in the absence of orbital
dysmorphology or malocclusion, may be treated with nonoperative care.
■ Close follow-up and a soft diet for 4 weeks are recommended.
■ Bone fragment displacement can be caused by muscles of mastication;
therefore, parents should be advised to provide appropriately “mushy” meals
that can be squeezed between the fingers and instruct children to avoid force
while eating.
SURGICAL MANAGEMENT
■ Many of the same principles in the treatment of adult midface fractures apply
to children.
■ Notable exceptions include the avoidance of implants in tooth-bearing areas
to prevent damage to tooth buds and the use of resorbable plates.
■ Resorbable plating systems composed of polylactic and polyglycolic acids are
readily available and preferred when possible.
■ The plates are usually resorbed within a year and are of adequate strength for
fixation of thin bones.4
■ The goals of reconstruction include obtaining pretraumatic occlusion along
with re-establishing the buttresses (medial nasomaxillary and lateral
zygomaticomaxillary) to restore the width and projection of the midface.
■ The indications for surgical treatment of fractures include malocclusion,
trismus, and significant displacement causing enophthalmos or a noticeable
contour deformity.
■ Treatment involves open reduction and fixation with miniplates, preferably
resorbable.
■ Le Fort I displaced fractures require MMF and ORIF of the medial
nasomaxillary and lateral zygomaticomaxillary buttresses.

■ Le Fort II fractures are often unilateral (hemi) and can present with NOE
fractures. Treatment of displaced fractures requires fixation of the medial and
lateral buttresses and the orbital rim. A coronal incision may be necessary to
address the nasofrontal region.
• NOE fractures are particularly difficult to manage in children.
• Complete avulsion of the medial canthal tendon is the strongest indication
for surgery.
• Avulsion of the canthal tendon is best managed with open transnasal
canthoplasty.
• Cantilever bone graft should also be considered during primary
reconstruction.
■ Le Fort III fractures are often unilateral with multiple fragments and present
with NOE combined with zygomaticomaxillary complex fractures.
• Synchronous ORIF of each subunit fracture through existing lacerations, a
coronal approach, or a glabellar incision.
• Lower lid incisions are needed to assess and treat orbital rim and floor
defects if present.
Preoperative Planning
■ CT scans and 3D reconstructions should be carefully reviewed and available
for display intraoperatively.
■ Pediatric dental and orthodontic evaluation should be considered especially if
impressions and models were taken before injury.
■ A palatal splint can be fabricated to treat palatal fractures without open
reduction internal fixation.
■ Occlusion and fracture site mobility should be examined.
■ The bowstring test and inserting a clamp intranasally with the index finger
externally palpating medial canthus can assess for instability.
■ Evaluation of occlusal relationship requires nasotracheal intubation in most
cases.
■ Depending on patient’s condition, a submental intubation or tracheostomy
might also be considered.
Positioning
■ The child is placed in the upper corner of the operating table with a shoulder
roll, donut cushion under the head, and arms tucked.

■ Minimize blood loss with slight head-up position, controlled blood pressure,
and local infiltration with epinephrine.
■ A Mayfield head ring attachment to bed may facilitate exposure with coronal
approach.
Approach
■ Incision selection is based on the desired exposure of displaced articulations.
■ Surgical approaches include using existing lacerations; the maxillary vestibule;
the lower and upper eyelid to expose the infraorbital rim and zygomaticofrontal
sutures, respectively; the glabellar approach; the coronal approach; and the
temporal Gillies approach for zygomatic arch reduction.
■ The ethmoidal approach is not recommended due to potential scar contracture.
■ Le Fort I: Maxillary vestibule
■ Le Fort II: Maxillary vestibule, lower eyelid, with or without coronal
■ Le Fort III: Eyelid, coronal, or glabella
■ Comminuted NOE fractures: Coronal approach
T E C H N I Q U E S
■ Le Fort I Open Reduction Internal Fixation
■ Nasotracheal intubation is necessary. An oropharyngeal pack protects the
upper aerodigestive tract from blood and debris. First, arch bars are secured
to dentition. Developing dentition requires adjustment in securing
maxillomandibular fixation.5
■ If the patient is less than 2 years old, higher-energy injuries can be
managed with closed reduction and acrylic splints secured with circum-
mandibular or piriform drop wires.
■ If the patient is 2 to 5 years old, arch bars can be secured to the deciduous
teeth.
■ If the patient is 6 to 12 years old with mixed dentition, stable teeth vary by
age. From 6 to 7 years, the deciduous molars are relatively stable.
■ At 8 to 10 years, the permanent first molars and central incisors appear.
■ By age 10, adequate permanent teeth allow arch bar placement.
■ Local anesthetic with epinephrine is injected in the gingivobuccal sulcus for

hemostatic effect.
■ Incise perpendicular to the mucosa with needle-tip electrocautery or scalpel
in gingivobuccal sulcus with care to leave a myomucosal cuff for closure.
■ Proceed with dissection through the periosteum of the maxillary bone.
Perform subperiosteal dissection with malt elevator to expose the fracture
site. Identify stable bone above and below the medial and lateral buttresses.
■ Reduction of the maxilla may be difficult due to telescoping and impaction
and may be complicated if healing has commenced because of significant
time between injury and treatment. Rowe disimpaction forceps may be
needed to obtain adequate repositioning of the maxilla. A Stromeyer hook
can also be placed in the piriform aperture and used for manipulation.
■ After the fracture has been mobilized, remove the throat pack and secure
MMF with wires.
■ Ensure the condyles are properly seated, and reduce the maxilla for optimal
bone contact. Five-millimeter or smaller gaps may be tolerated6; however, for
comminuted fractures with a larger bony defect, a bone graft may be required
for complete osteosynthesis.
■ Resorbable plates may be used to decrease the risk of growth disturbances
and injury to tooth buds.7 The plate is contoured and secured across the
zygomaticomaxillary buttress. An additional plate is fixed to the
nasomaxillary buttress (TECH FIG 1).
■ After internal fixation, MMF is released and occlusion is determined. If an
open bite or class III occlusion is present, the condyles may not have been
seated appropriately in the glenoid fossa. This requires plate removal and
repositioning for proper positioning of the condyles.
■ The wound is irrigated. The gingivobuccal incision is closed with a 4-0
Vicryl running suture.

TECH FIG 1 • Vestibular approach plating medial and
lateral buttresses.
■ Le Fort II Open Reduction Internal Fixation
■ Preoperative markings include an existing subtarsal lower eyelid skin crease
for orbital rim exposure.
■ After nasotracheal intubation and throat pack placement, arch bars are
secured to the dentition.
■ The fracture segments are exposed through a maxillary vestibular approach.
■ The fracture fragments are mobilized and disimpacted by forceps or bone
hooks.
■ After adequate reduction, MMF is secured. Reduction and fixation of Le
Fort fractures should occur before addressing the orbital wall.
■ A resorbable L-shaped plate is applied to the zygomaticomaxillary buttress.
The foot of the plate should be placed in a manner to avoid damage to the
tooth roots with screw placement.
■ The orbital rim should then be explored. Subtarsal incision is made with a
no. 15 blade scalpel and extended through orbicularis oculi preseptally to the
orbital rim with a needle-tip electrocautery.
■ Using a Desmarres for retraction, subperiosteal dissection is performed

using an elevator and a curved malleable retractor to widely expose the
orbital floor and the orbital wall.
■ A contoured plate is applied to the infraorbital rim and secured (TECH
FIG 2A).
■ If the Le Fort II segment is stable, the MMF wires are removed and
occlusion is checked.
■ Depending on the fracture pattern, an inverted Y-plate or multiple miniplates
are used for securing the nasofrontal fracture (TECH FIG 2B).
■ If there is a defect of the maxillary sinus wall, it may be bridged by
resorbable mesh.
■ The periosteum is resuspended near the arcus marginalis.
■ The eyelid incisions are closed with 6-0 fast-absorbing gut suture and
surgical glue.
■ The gingivobuccal incision is closed with 4-0 Vicryl running suture.
TECH FIG 2 • A. Subtarsal approach infraorbital rim
plate. B. Plating of a comminuted NOE fracture.
■ Le Fort III Open Reduction Internal Fixation
■ Preoperative markings include an existing subtarsal lower eyelid skin crease
for orbital rim exposure.
■ Nasotracheal intubation is required to assess occlusal relationship. If not
possible, submental intubation should be considered.
■ The hairline can be clipped if a coronal or bitemporal approach is planned.
■ Arch bars are secured to dentition.
■ The coronal incision is made with a graduated subperiosteal plane, leaving

the pericranium intact superiorly and incising deep through the periosteum
several centimeters above the orbital rims (TECH FIG 3A).
■ If a pericranial flap is planned for frontal sinus injury, however, begin the
incision in a subperiosteal plane to raise the skin and pericranial flaps
together.
■ When approaching the zygomatic arch, to avoid injury to the temporal
branch of the facial nerve, transition to incising the deep temporal fascia
several centimeters above the arch and dissect within the intermediate fat pad
to complete exposure.
■ A reduction hook can be used for manipulating the Le Fort complex and
zygoma.
■ The tip of the Stromeyer hook can be inserted percutaneously 4 cm below
the lateral canthus below the arch for repositioning.
■ A threaded reduction tool such as Carroll-Girard might also prove helpful
to align the midface in three dimensions.
■ Generally, plate fixation is applied to fractures at the zygomaticofrontal
suture, the zygomatic arch, and the nasofrontal junction.
■ The zygomaticofrontal fracture site can often be palpated. If not exposed
through a coronal incision, a 1-cm incision is made directly over the suture
site parallel to the lateral orbital rim for exposure.
■ A low-profile resorbable plate may be used for fixation.
■ Nasofrontal plates are secured if needed in the appropriate configuration.
■ Plates are then applied to the zygomatic arch to reestablish the sagittal
buttress (TECH FIG 3B).
■ After internal fixation, MMF is released and occlusion checked.
■ The incisions are closed in layers.
■ TECH FIG 3C demonstrates a postoperative CT 3D reconstruction with
plates in situ.

TECH FIG 3 • A. Coronal exposure graduated plane.
B. Coronal approach plating zygomaticofrontal
articulation and zygomatic arch. C. Hemi–Le Fort III
postoperative CT 3D reconstruction with
zygomaticofrontal, infraorbital rim, nasomaxillary,
zygomaticomaxillary buttress, and zygomatic arch
plate fixation as well as posts for MMF.
■ Zygomaticomaxillary Complex Fracture Open
Reduction Internal Fixation

■ Preoperative markings include an existing subtarsal lower eyelid skin crease
for orbital rim exposure.
■ The course of the superficial temporal artery can be palpated and marked to
confine the area of the planned Gillies incision within the temporal hairline.
■ Surgical approaches typically include the marked lower eyelid, directly over
the zygomaticofrontal suture, the Gillies, and the gingivobuccal sulcus to
expose displaced articulations. General endotracheal anesthesia is
administered.
■ The planned areas of dissection are infiltrated for hemostatic effect.
■ The zygomaticofrontal fracture site can often be palpated. A 1-cm incision is
made directly over the suture site parallel to the lateral orbital rim for
exposure.
■ The orbital floor should be explored before and after reduction to ensure the
fixation did not alter orbital volume or floor stability.
■ Subtarsal incision is made with a no. 15 blade scalpel and extended
through orbicularis oculi preseptally to the orbital rim with Colorado tip
Bovie electrocautery.
■ Using a Desmarres for retraction, subperiosteal dissection is performed
using a Molt no. 9 elevator and a curved malleable retractor to widely
expose the orbital floor and the lateral orbital wall to precisely assess
anatomic alignment after reduction.
■ Anatomic reduction is largely based on the lateral orbital wall, specifically
the relationship of the zygomatic bone and the greater wing of the
sphenoid.
■ The zygomaticosphenoid junction is the most accurate assessment of
proper reduction.
■ The Gillies incision is made and an elevator inserted deep to the temporal
fascia superficial to the temporalis muscle to lever the zygomatic arch and
obtain restoration of the malar eminence.
■ A Carroll-Girard screw may also prove beneficial to allow manipulation of
fragments as a joystick.
■ The gingivobuccal sulcus incision is made and subperiosteal dissection
performed to expose the zygomaticomaxillary buttress.
■ Each fracture line is inspected to assess the correct position at the exposed
articulations.
■ While holding reduction with a hook on the zygomatic body and the elevator

under the arch, an L-shaped miniplate is used to fixate the ZMB.
■ A small resorbable miniplate is used to fixate the ZF suture.
■ The orbital floor is again inspected, and if a defect remains, a resorbable
mesh implant is placed. A forced duction test is performed.
■ The periosteum is resuspended near the arcus marginalis.
■ The eyelid incisions are closed with 6-0 fast-absorbing gut suture and
surgical glue.
■ The Gillies is reapproximated with 4-0 Monocryl deep dermal and gut
suture.
■ The gingivobuccal incision is closed with 4-0 Vicryl running suture.
PEARLS AND PITFALLS
Proper
reduction
■ Rowe disimpaction forceps and/or a Stromeyer hook are useful
instruments to obtain adequate repositioning of the maxilla. Le Fort
I osteotomy may be required if conventional methods are
unsuccessful. Zygomaticosphenoid articulation is key to prevent
future deformity with regard to orbit volume and facial symmetry.
Conservative
management
■ Avoid internal fixation for stable or nondisplaced fractures. Use the
least invasive approach for manipulation of displaced fragments to
obtain acceptable reduction. Good bone remodeling allows
satisfactory long-term results.
Implant
choice
■ Avoid implants in tooth-bearing areas due to the risk of damaging
tooth buds. Resorbable fixation decreases the risk of growth
disturbances and injury to developing teeth.
Malocclusion
■ Check occlusion for open bite or class III tendency. The condylar
heads need to be positioned correctly in their respective glenoid
fossae when securing MMF.
POSTOPERATIVE CARE
■ Visual acuity and extraocular motions are examined in the postanesthesia care
unit upon awakening.
■ Wire cutters should always be available postoperatively for emergent MMF
release.
■ Elevate the head of bed, keep incisions clean and dry for 36 hours, and then
resume bathing. Allow surgical glue applied to skin incisions to fall off on its

own.
■ Chlorhexidine swish and spit TID for 1 week
■ Liquid diet for 48 hours
■ Soft diet at least until adequate healing of maxillary vestibular incision
■ Patients in MMF will remain on high-protein liquid diet until MMF release.
■ The duration of MMF is dependent on fracture complexity and stability of
fixation.
■ For NOE fractures, soft tissue support stressed with compressive dressings and
splinting for careful postoperative molding of epicanthal folds during the
healing process.
■ Oral antibiotics for 3 to 5 days. Analgesics as needed
■ Follow up serial physical examination to assess globe position and symmetry
as edema subsides
OUTCOMES
■ Fortunately, pediatric facial fractures are rare; however, when faced with the
challenge of reconstruction, it is important to consider potential future growth
deformities while planning restoration of pretraumatic anatomy.
■ Cephalometric follow-up shows clinically significant impairment in growth in
horizontal and vertical planes.
■ Mean deficiency in growth for all landmarks was 3.7 mm in the x axis and
2.9 mm in the y axis.8
■ Employ conservative management when possible because children have great
capacity for bony remodeling.
■ Contour deformities are usually mild. Aesthetic outcome is also dependent on
soft tissue involvement (FIG 5).
■ Orbital function is generally restored fully with proper repair of floor defects.
■ Nonunion and malunion are rare.
■ Interference with nasal growth and distortion of the medial canthal areas are
observed in pediatric NOE fractures if not managed appropriately.

FIG 5 • Postoperative photographs of the patient in FIG
3C,D after repair of hemi–Le Fort II and NOE fractures.
COMPLICATIONS
■ Complications associated with specific pediatric facial fracture can be
classified as intrinsic, secondary to intervention, or resulting from growth and
development.9
■ Malocclusion, TMJ decreased motion, pain
■ Facial asymmetry can be caused by inadequate reduction, or ptosis of the
malar fat pad, which can be prevented by periosteal suspension of the soft
tissue.
■ Diplopia can occur initially in 10% of patients with a ZMC fracture; up to 5%
may have permanent diplopia.
■ Diplopia occurs most commonly with injury to the inferior rectus muscle.
■ Follow up with scans, and if no improvement is seen in 4 to 6 months, the
patient may need rebalancing of extraocular muscles.
■ Enophthalmos is defined as posterior displacement of the globe within the
orbit due to changes in the volume of the orbital vault relative to its contents.
■ There is approximately 1 mm of enophthalmos for every cubic centimeter
increase in orbital volume. Greater than 3 mm change in globe position
compared to contralateral eye appears clinically significant.
■ Approximately 20% of patients with orbital fractures have globe malposition.

It is most commonly associated with incomplete zygomatic reduction.
■ Etiology of enophthalmos includes fractured medial wall composed of thin
lamina papyracea, fat atrophy, extraocular muscle atrophy, and scar
contracture.
■ Mild to moderate deformity can be corrected with orbital floor implants.
■ Available options to fill appropriate volume include bioresorbable mesh,
biocompatible porous polyethylene, and/or titanium implants; bone graft is
preferable for the pediatric patient. Convert every 1.5 cc of graft material to
get 1 mm of globe position advancement. The corrected eye should look
proptotic compared to the contralateral eye on the table.
■ Severe enophthalmos requires osteotomies and repositioning of the zygoma.
■ Traumatic optic neuropathy can occur in 1% to 2% with ZMC fractures. This
condition can present with subtle findings of diminished color perception.
■ Consult an ophthalmologist, treat with steroids, and assess for improvement
or stabilization of visual deficit prior to surgical intervention.
■ Bradycardia: The oculocardiac reflex involves classic triad of bradycardia,
nausea, and syncope. The reflex is mediated by the ophthalmic division of the
trigeminal nerve, which passes through the reticular formation to the vagus
visceral motor nuclei. The efferent limb message is carried by the vagus nerve
to the heart.
■ If symptoms occur in any phase of treatment, suspect periorbital entrapment,
which necessitates release.
■ Inadequate reduction of the zygomaticomaxillary complex causes loss of
midface projection, increased facial width, and enophthalmos, which should be
avoided by proper planning and assessment of alignment throughout the
operation.
■ NOE: Complications of untreated NOE fractures include nasolacrimal duct
obstruction, telecanthus, and saddle nose deformity. Repair includes ORIF and
cantilever bone graft.
■ Nasal and septal deformities may require secondary rhinoplasty after
completion of midfacial growth.
REFERENCES
1. Hoppe IC, Kordahi AM, Paik AM, et al. Examination of life-threatening
injuries in 431 pediatric facial fractures at a level 1 trauma center. J Craniofac
Surg. 2014;25(5):1825-1828.
2. Imahara S, Hopper R, Wang J, et al. Patterns and outcomes of pediatric facial

fractures in the United States: a survey of the National Trauma Data Bank. J
Am Coll Surg. 2008;207(5):710-716.
3. Manson P, Markowitz B, Mirvis S, et al. CT based facial fracture treatment.
Plast Reconstr Surg. 1990;85(2):202-212.
4. Bali RK, Sharma P, Jindal S, Gaba S. To evaluate the efficacy of
biodegradable plating system for fixation of maxillofacial fractures: a
prospective study. Natl J Maxillofac Surg. 2013;4(2):167-172.
5. Thaller SR, Huang V. Midfacial fractures in the pediatric population. Ann
Plast Surg. 1992;29(4):348-352.
6. Gruss JS, Phillips JH. Complex facial trauma: the evolving role of rigid
fixation and immediate bone graft reconstruction. Clin Plast Surg. 1989;16:1.
7. Eppley BL. Use of resorbable plates and screws in pediatric facial fractures. J
Oral Maxillofac Surg. 2005;63(3):385-391.
8. Davidson EH, Schuster L, Rottgers SA, et al. Severe pediatric midface
trauma: a prospective study of growth and development. J Craniofac Surg.
2015;26(5):1523-1528.
9. Chao MT, Losee JE. Complications in pediatric facial fractures.
Craniomaxillofac Trauma Reconstr. 2009;2(2):103-112.

76
CHAPTER
Management of Pediatric
Mandible Fractures
Nataliya I. Biskup and Brian S. Pan
DEFINITION
■ The pediatric facial skeleton is largely protected from fractures due to larger
facial fat pads, more malleable bone, and a larger head-to-face ratio compared
to that of adults.1
■ Mandible fractures are one of the most common pediatric facial fractures.2
■ Proper management of the pediatric mandible fracture is critical to limit
disruptions in growth and dental development that can ultimately impact
occlusion and function.
ANATOMY
■ The mandible is a unique bone composed of vertical and horizontal elements
that form a U-shaped construct.
■ The growth pattern of the mandible occurs in a superior and posterior
direction, resulting in a concomitant downward and forward displacement of
the mandibular body and symphysis.3
■ From early childhood through adolescence, the inferior alveolar nerve changes
in position as the canal migrates cephalically from the lingual inferior border of
the mandible to a more superior position.
■ The preadolescent mandible has high osteogenic potential due to its rich blood
supply from the inferior alveolar artery.
■ Following permanent tooth eruption, the medullary center of the mandible
becomes more thickened and calcified.
PATHOGENESIS
■ The most common cause for facial injuries in children is motor vehicle

collisions.
■ Sports-related injuries are the second most common cause of facial fractures.
■ These injuries occur more commonly in older children and in adolescence.
■ Childhood falls and assault/nonaccidental trauma are the least common causes.
■ Assaults occur most commonly in adolescence.
■ Males are twice as likely to sustain facial fractures compared with females.4
■ Condyle fractures are considered the most common type of mandible fractures
followed by the symphysis, the body of the mandible, the angle, and lastly the
ramus.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Depending upon the age of the child, an accurate history may not be available.
■ If patient compliance for an adequate exam is not possible, proceed with
imaging and consider an exam under sedation.
■ Physical exam findings may include pain on palpation over the fracture site,
malocclusion, decreased maximal incisive opening, jaw deviation with
opening, loose teeth, and intraoral lacerations or ecchymosis.
■ Assess for paresthesia or anesthesia caused by injury of the inferior alveolar
and mental nerves.
■ Chin abrasions and lacerations, coupled with blood in the external auditory
canal, should raise suspicion for a condylar fracture.5
IMAGING
■ Although a panorex and plain films of the mandible can be obtained, a
computed tomographic (CT) scan is the standard for imaging in the setting of
facial trauma.
■ Cone beam CT (CBCT) scans are another means for accurately diagnosing
facial fractures and have the advantage of exposing the child to less radiation.
NONOPERATIVE MANAGEMENT
■ Most pediatric mandible fractures are treated conservatively. Minor
malocclusions will self-correct by the ability of the pediatric mandible to
remodel and with minor orthodontic manipulations at skeletal maturity.
■ Children with deciduous and mixed dentition have a capacity for spontaneous
occlusal readjustment after injury and treatment, as deciduous teeth are shed
and permanent teeth erupt.6
■ Observation is indicated for:

■ Patients with condylar and subcondylar fractures
• Mild malocclusions may be treated with soft diet and/or maxillomandibular
fixation (MMF).
• Moderate to severe malocclusion may be treated with closed reduction and
MMF. Open reduction is rarely indicated, especially in intracapsular
fractures. Open reduction risks vascular compromise to the condyle, which
is a growth center for the mandible with high remodeling capacity.7,8
■ Minimally displaced fractures in the tooth-bearing mandible, namely,
parasymphysis, body, angle. These areas are filled with developing tooth
follicles, and thus operative intervention should be avoided if possible.
■ Start the patient on a mechanical soft diet, rigorous physiotherapy, avoidance
of rigorous physical contact, and symptomatic pain control for 4 to 6 weeks.
Arrange long-term follow-up to closely monitor mandibular growth.
SURGICAL MANAGEMENT
Position
■ Place the patient supine under anesthesia with nasotracheal intubation.
■ May consider sedation-only anesthesia, if only closed reduction is to be
performed without MMF or with minimal MMF (such as an Ivy loop or lingual
splint).
T E C H N I Q U E S
■ Closed Reduction and Maxillomandibular Fixation
Options
Reduction
■ Reduce fractures manually as appropriate depending on fracture pattern and
direction of displacement.
■ Verify adequate reduction by assessing occlusion while the patient is in
centric relation. The pediatric mandible can tolerate a greater degree of
variability in fracture reduction than the adult patient.
IMF Bone Screws
■ Obtain preoperative imaging (either CT scan or panorex) to identify

positions of permanent and deciduous dentition.
■ Place screws in appropriate locations to avoid injury to dental structures:
■ Verify CT scan (ideally one with 2-mm cuts) to accurately identify location
of tooth roots to avoid during screw placement.
■ Use self-drilling, self-tapping bone screws, placing at minimum two within
the mandible and two within the maxilla (TECH FIG 1):
■ Consider placement of a single midline screw in the mandible and one in
the maxilla as this can often be adequate for fixation and ideal to avoid
tooth roots.
■ Secure centric occlusion with 25-gauge wire loops.9
Arch Bar Application
■ Measure and apply the Erich arch bars of appropriate lengths to the maxilla
and mandible to allow for all teeth to be wired.
■ Secure the arch bars with prestretched stainless steel 26-gauge wire, passing
one end of the wire through the buccal gingiva above the arch bar:
■ The wire is then captured on the lingual side and passed through the lingual
gingiva, capturing the wire on the buccal side of the tooth (TECH FIG
2A).
■ The ends of the wire are then twisted clockwise until the bar is tightly
coapted to the tooth (TECH FIG 2B).

TECH FIG 1 • Place at minimum two screws within the
mandible and two screws in the maxilla.
■ Repeat this process until the majority of the dentition is secured and the
arch bars are stable.
■ Check the stability of the anchoring teeth with bimanual palpation.
■ Cautiously apply wires around deciduous teeth because they are more prone
to extraction by wire tightening:
■ Note that primary teeth have short conical roots, wide cervical margins
without a well-defined cingulum that makes securing the wire more
technically challenging. Ideally, apply arch bars in patients older than 9 to
11 years of age.10
■ Cautiously, apply wires around erupting secondary teeth; periodontal
ligaments are not well attached to the bone, and, therefore, the teeth can be
extruded by the wire.
■ Use rigid wires or elastics to secure occlusion. Elastics may be better
tolerated in children with equivalent outcomes as far as fracture healing and
mandibular function (TECH FIG 2C).11
Interdental Wiring (Bridle Wire, Ivy Loops)
■ Consider Ivy loops in younger patients who are not good candidates for arch
bars as interdental wiring is less prone to tooth avulsion.
■ Apply Ivy loops or bridle wire using prestretched 26-gauge wire (TECH
FIG 3A).
■ Make an eyelet with the wire and insert between the teeth (step 1).
■ Bring the wires around the contralateral side of the teeth (step 2).
■ Insert dorsal wire through loop (step 3), and twist the wire until secure (step
4) (TECH FIG 3B).
■ Apply loops to the mandibular and maxillary dentition.
■ Use a 25-gauge wire to secure the eyelets from maxillary dentition to the
mandibular dentition.
Circum-mandibular and Drop Piriform Wires
■ This form of MMF avoids the risk of damaging tooth buds by penetrating
the mandible, avulsing existing teeth with interdental wiring, and

inaccuracies of splint fabrication. Efficacy of this technique may be limited in
fractures of the non–tooth-bearing mandible, and these wires can often
loosen.
■ For a single fracture, place three total wires: two wires mesial (or anterior)
and one wire distal (or posterior) to the fracture:
■ For double fractures, place four total wires: two wires mesial (anterior) to
the fractures and one wire distal (posterior) to each fracture.
■ Avoid injuring the mental nerve, which is located at the level of the primary
first molar in the deciduous dentition, and the permanent first premolar in
permanent dentition:
■ Do not engage the fracture line with the wires.
■ To place circum-mandibular wires, pass a 16-gauge intravenous catheter
stylet (IVCS) percutaneously from the submandibular region, hugging the
lingual cortex, and exit on the lingual side close to the alveolus.
■ Pass a 26-gauge wire through the lumen of the IVCS. Clamp wire intraorally
to avoid pulling through (TECH FIG 4A).

TECH FIG 2 • A. Pass one end of the wire through the
buccal gingiva above the arch bar. The wire is then
captured on the lingual side and passed through the
lingual gingiva, capturing the wire on the buccal side
of the tooth. B. The ends of the wire are then twisted
clockwise until the bar is tightly coapted to the tooth.
C. Place elastics around the arch to securely coapt
the dentition.
TECH FIG 3 • A. Step 1: Make a loop with the wire
and insert between the teeth. Step 2: Bring the wires
around the contralateral aspects of the teeth. B. Step
3: Insert dorsal wire through loop. Step 4: Twist the
wires until secure around the dentition.

(Trang không có chữ)

TECH FIG 4 • A. Pass a 16-gauge intravenous
catheter stylet percutaneously from the submandibular
region exiting on the lingual side close to the alveolus.
Then pass a 26-gauge wire through the lumen of the
IVCS. B. Guide the IVCS around the inferior border of
the mandible onto the buccal surface, passing the
needle and wire through the gingivobuccal sulcus, and
recapture the wire. C. Use a 1-mm drill to make a hole
on each side of the piriform rim, and pass a 26-gauge
wire through each side. Twist each wire down.
■ Guide the IVCS around the inferior border onto the buccal surface of the
mandible, hug the buccal cortex, rotate the IVCS such that the bevel is on the
leading side and the wire on the nonleading side. Then, pass the needle and
wire through the gingivobuccal sulcus, and recapture the wire, twisting it
down between an interdental space (TECH FIG 4B)12:
■ Twist wires down with enough tension to reduce fractures but not so much
tension as to damage the growing bone.
■ These wires may be twisted down over an arch bar.
■ Alternatively, an awl may be used to place wires.8
■ To place drop piriform wires, make a high circumvestibular incision around
the piriform aperture, and use a Freer elevator to develop a subperiosteal
plane around the rim of the piriform:
■ Release attachments of the anterior nasal spine.
■ Elevate floor of the nose and lateral piriform rim in a subperiosteal plane.
■ Use a 1-mm drill to make a hole on each side of the piriform rim, and pass a
separate 26-gauge wire through each side (TECH FIG 4C):
■ Create a loop of wire by twisting the wire down on an instrument outside
the mucosal surface to facilitate future lateral wire removal.
■ Use an intermediate wire to engage the two circum-mandibular wires and the
piriform drop wire in a triangular arrangement (see TECH FIG 4C).13
Splint Application
■ This form of MMF is especially useful in patients less than 3 years of age

who have few stable dental structures.
■ Obtain maxillary and mandibular impressions using alginate impression
material.
■ Prepare the casts.
■ Cut mandibular cast into two pieces at the fracture line and reassemble to
articulate with the maxillary dentition in the best occlusion. Affix the two
pieces with hot glue:
■ Construction of a well-fitting splint via model surgery is technically
challenging and may result in occlusal inaccuracy.
■ Construct a lingual splint with an acrylic material. Drill holes in the splint at
each interdental space to facilitate the insertion of circumdental wires or
apply circum-mandibular wires.
TECH FIG 5 • Mold splint to the reduced mandible and
dentition, allow to set, and secure to the mandible with

interdental or circum-mandibular wires.
■ Reduce fracture, and insert the splint on the lingual aspect of the mandible:
■ Pass 25-gauge wires from the splint holes to the corresponding interdental
spaces and then around each erupted tooth.
■ Alternatively, manufacture the splint in one stage in the operating room:
■ Reduce fracture manually and secure reduction with interdental wiring or
monocortical bone wires.
■ Apply catalyst-activated acrylic material to mold splint, allow to set, and
then secure to the mandible with interdental or circum-mandibular wires10
(TECH FIG 5).
■ Remove the splint at 2 to 3 weeks if the occlusion is stable.14
■ Open Reduction and Internal Fixation
■ Apply Erich arch bars.
■ For patients without dentition, use circum-mandibular wiring, or drop
piriform aperture suspension wires.
■ For patients with deciduous dentition (3–6 years old), tooth roots are strong
enough to withstand interdental wiring.
■ For patients with mixed dentition (6–12 years old), apply MMF carefully
(refer to adult mandibular MMF) as deciduous roots may be undergoing
resorption by permanent dentition:
■ Consider obtaining a panorex to verify root status of each tooth. If many
unstable and resorbing roots are present, use circum-mandibular wiring,
acrylic splints, or drop piriform wires.
■ For patients with adult dentition, apply MMF as one would for an adult.
■ Employ the least invasive surgical approach to access the fracture and allow
stable reduction.15
■ Inject fracture sites and proposed incision sites with 0.25% lidocaine with
epinephrine 1:400 000.
■ Use needle-point cautery to incise:
■ In gingivobuccal sulcus for parasymphysis or body fractures (TECH FIG
6A)
■ Along external oblique ridge for angle and ramus fractures

■ Use a Freer elevator to expose fractures.
■ Limit exposure to only what is needed to reduce and fixate the fracture.
■ Expose inferior border clearly as this is the safest place to plate and apply
screws, especially in patients less than 9 years of age (TECH FIG 6B).
TECH FIG 6 • A. Incise along the gingivobuccal sulcus
over the fracture site (parasymphysis fracture). B.
Expose the fracture and the inferior border of the
mandible. C. Place plate along the inferior border of
the mandible, and adapt the plate to site passively
along the bony surface.
■ Curette the fracture site to debride the callus. Do so conservatively to avoid
tooth root and tooth bud injury.
■ Reduce fracture. Avoid bone reduction clamps as these require deep
purchase and can migrate through the bone.

■ Place the patient into MMF.
■ Apply preferred plating system. May consider resorbable plates, as they have
been shown safe and effective in pediatric fractures16,17
■ Consider application of MMF concurrently with resorbable fixation.
■ Resorbable systems require a large plate and larger screws to provide
similar stability as a titanium plate, thus increasing the risk of root injury
during tapping and plate application.
■ May use titanium plates; however, these should be removed in 3 to 6 months
after fracture healing has occurred, especially in patients less than 10.
■ When applying titanium plates and screws, place 1.0- to 1.3-mm plates in
those under 3 years, 1.3 to 1.5 mm in 4 to 9 years, and 2.0 mm in
preadolescents and adolescents.
■ Place the plates along the inferior-most portion of the mandibular border.
■ Adapt the plate to sit passively along the bony surface (TECH FIG 6C).10
■ Use monocortical screws almost exclusively.
■ Reserve bicortical screws for patients older than 11 years of age.
■ Apply plates along the inferior-most position of the mandibular border, and
direct screws posteromedially, not superiorly.
■ If fixation of the superior mandibular border is required, do so with
interdental wiring and splinting to avoid tooth root injury.
■ Test occlusion by releasing the patient from MMF, and gently lift the
mandible by grasping the lower lip:
■ If the patient’s occlusion is appropriate, replace MMF with wires or
elastics.
■ Close incision with resorbable suture.
PEARLS AND PITFALLS
Preoperative
■ Rule out cervical spine injury given that the force to produce a
fracture of the pediatric mandible is significant.
■ Conservative management should be strongly considered in
nondisplaced and minimally displaced fractures.
Physical
findings
■ Malocclusion is the most sensitive finding for diagnosis of a
mandible fracture.

■ If compliance during examination is an issue, repeat exam under
sedation or anesthesia.
Technique
■ Avoid injuring teeth, tooth roots, and tooth buds. The patient’s
dentition will determine the technique for MMF.
■ Pediatric fractures have a higher tolerance for variability in
reduction due to restitutional remodeling, but gross malocclusion
is unacceptable.
Postoperative
■ Follow these patients long term as the child’s growth needs to be
monitored until after the pubertal growth spurt.
■ Consider involving an orthodontist for long-term care.
Occasionally, functional appliances or corrective jaw surgery may
be necessary in the setting of asymmetric growth secondary to
condyle fractures.
■ Shorten the period of immobilization and MMF to 2 to 3 wks.
POSTOPERATIVE CARE
■ If MMF is utilized, the patient is discharged home with wire cutters and/or
scissors to release the elastics holding the dentition in occlusion.
■ In the setting of open reduction with internal fixation, consider releasing MMF
if the child is cooperative and close supervision is possible.
■ If MMF is applied, do not leave on for longer than 2 to 3 weeks as pediatric
fractures heal quickly:
■ Temporomandibular joint (TMJ) ankylosis may result from prolonged
immobilization.
■ Guiding elastics may be used especially in the setting of a condyle fracture.
■ Liquid/pureed diet is indicated postoperatively.
■ A soft diet is initiated at 3 weeks, and a regular diet is resumed at 6 weeks
following surgery.
■ Chlorhexidine mouthwash is recommended after meals accompanied by gentle
tooth brushing.
OUTCOMES/COMPLICATIONS
■ Available data suggest that appropriately managed fractures have good long-
term functional outcomes.
■ Fractures managed with ORIF with or without MMF were more likely to
have adverse outcomes related to dental trauma and TMJ clicking.2
■ The impact of mandible fractures on growth is another highly debated topic:

■ Multiple studies have suggested that condyle fractures, and those limiting
TMJ movement, are prone to causing growth abnormalities.18
■ Other potential complications mirror those encountered in adult patients
including dental injuries, hardware infections, and need for subsequent surgery.
■ Long term follow-up is indicated especially for patients who have suffered
fractures prior to adolescence.
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PART 3
Head and Neck Reconstruction

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1
CHAPTER
Section I: Anesthesia
Local Anesthesia of the
Face
Cerrene N. Giordano and Anthony M. Rossi
DEFINITION
■ Local or regional anesthesia involves the injection or application of a
medication to a specific area of the body to minimize procedural-related pain.
■ Various types of local anesthesia exist including topical, infiltrative, nerve
block, and tumescent.
■ The number of office-based procedures utilizing local anesthesia continues to
rise, particularly in the dermatologic setting.
■ In-office procedures performed under local anesthesia have reduced recovery
time, decreased cost, and improved safety relative to those performed under
general anesthesia or intravenous sedation.
ANATOMY
■ Effective local anesthesia for the face, particularly with peripheral nerve
blocks, requires a complete understanding of the underlying nervous anatomy.
■ The 11 branches of the trigeminal nerve (cranial nerve V) and 2 branches of
the cervical plexus (C2, C3) are primarily responsible for the cutaneous
sensory innervation of the face and neck (FIG 1).
■ The trigeminal nerve is divided into three main components—V1 (ophthalmic
nerve), V2 (maxillary nerve), and V3 (mandibular nerve) with further smaller
divisions.
■ V1 is composed of the supraorbital, supratrochlear, infratrochlear, external
nasal, and lacrimal nerve branches and is primarily responsible for the sensory
innervation of the upper eyelids, glabella, forehead, dorsal nose, and anterior

portion of the scalp.
■ V2 is composed of the zygomaticotemporal, zygomaticofacial, and
infraorbital branches and supplies innervation to the central face including the
lower eyelids, medial cheeks, temples, lateral nasal sidewall and alar rim of
the nose, and the upper cutaneous and mucosal lip.
■ V3 is composed of the auriculotemporal, buccal, and mental nerves and
innervates the lateral and lower halves of the face including the preauricular
region, portions of the anterior ear, jawline, chin, and lower lip.
■ The supraorbital, infraorbital, and mental nerves exit their respective foramen
all located in the midpupillary line.
■ Cervical nerves C2 and C3 form the great auricular and lesser occipital nerves
that complete the innervation of the lateral and anterior neck, the ear, and the
postauricular scalp.
FIG 1 • Trigeminal and cervical plexus nerve
distribution.
■ The great auricular and lesser occipital nerves emerge from Erb point in the
posterior cervical triangle, located approximately at the midpoint of the
posterior border of the sternocleidomastoid muscle.
■ The greater occipital (C2) and third occipital (C3) nerves supply the posterior
scalp and neck.
MECHANISMS OF ACTION