Reoperative Aesthetic & Reconstructive Plastic Surgery

926
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The knowledge that restoration of fa-
cial width in a particular anatomic
bone segment, such as the zygoma, is
the key to restoring facial projection
was realized in the 1980s.14,66,82,83 When
this concept is applied to maxillary
width, projection of the malar emi-
nence is reciprocally related to nar-
rowing of the midface width; medial
correction of the zygomatic arch (re-
duction of its width, horizontal arrow)
reciprocally restores malar projection
(vertical arrow) and prevents this projec-
tion from being “absorbed” when the
arch becomes a more curved structure
(displaced zygoma). Only rigid xation,
however, it suf ciently strong to permit stable reconstruction of the zygomatic arch
in a medial position (dotted zygoma). Zygomatic arch reduction is the principal de-
terminant of upper midface width, malar projection, and reduction of orbital vol-
ume by the control the zygomatic arch exerts over the lateral orbital position at the
greater wing of the sphenoid.
As shown in this CT scan, the zygomatic arch, which did not undergo open reduc-
tion, is positioned too far laterally.This malposition translates into decreased malar
projection.The arch is excessively bowed so that length is taken up in the “curve”
of the arch, preventing proper malar width projection.
Decreased malar projection
Increased width

This illustration demonstrates the technique of glenoid fossa reduction (A). A lateral
plate has been placed over the fractures (C). Lag screws may also be placed to reduce
the arch to the glenoid fossa (B).
When the zygomatic arch is cleaved through the glenoid fossa, the superior aspect
of the fossa is accessed through the coronal incision by stripping its surface. The
fossa is reassembled using rigid xation on its superior surface (A) or a lag screw
(B); then, because the fossa is stabilized, the lateral surface of the zygomatic arch is
reduced and stabilized with rigid xation (C). It is important to remember that
the normal zygomatic arch is at in its long midportion.
927
Chapter 28
Reoperative Facial Fracture Repair
A
A
C
B
C
B

928
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Craniofacial exposure techniques can set the stage for accurate reduction of facial
fragments by exposing all intact peripheral attachments and cranial base landmarks
of an anatomic area to permit using them as guides to facial bone alignment.84 For
reconstruction of the anterior facial frame (AFF), templates from undisplaced struc-
tures in the cranial base or posterior facial frame (PFF) are used as guides for accu-
rate repositioning of anterior structures.The anterior facial frame includes the front
part of the face, and low- and mid-energy fractures affect this area. Anterior inci-
sions, such as the blepharoplasty and the gingival buccal sulcus provide access to an-
terior fractures.With high-energy fractures, posterior incisions are used to access the
areas where the skull base attaches to the facial bones;the fractures extend to this area
and require exposure.These incisions provide access to the head of the condyle, the
junction of the zygomatic arch with the temporal bone, and the posterior aspects
of the orbit.With high-energy fractures, all buttress alignments with adjacent bones,
particularly if unfractured, are used. Low- and mid-energy fractures may not need
all of their buttresses exposed, and may be treated with anterior access incisions
alone. A precise knowledge of the facial fracture pattern and of craniofacial exposure
techniques, permits an accurate analysis of a particular facial skeletal malposition and
its correction.This conceptual approach provides a uniform format for establishing
facial dimensions in each facial area. Surgical repositioning should proceed from
intact facial and cranial base landmarks through the area of the malpositioned skele-
tal segment. This bone segment can then be dissected, osteotomized, and reposi-
tioned. In terms of shape and volume, the bone segment itself is almost always in-
adequate to fully recreate the original bone dimensions and contour of the malar
eminence.Therefore interposition or onlay bone grafts or both may be commonly
required in facial bone osteotomies.
PFF
AFF

Recent panel discussions on late facial fracture management have discussed whether
to perform osteotomies or onlay bone grafts. Combinations are almost always re-
quired and provide better treatment than the single approaches.The surgeon must
be willing to totally expose the bone area and use a combined approach to achieve
the best result.
DIMENSIONAL ANALYSIS OF THE FACIAL SKELETON
To assist in developing a framework for any injury treatment, the face may be di-
vided into upper and lower halves at the LeFort I level.14,16 Each facial half is then
divided into upper and lower facial subunits. In the lower face there are the occlusal
and mandibular units. The occlusal unit consists of the palate, alveolar processes,
and teeth of the maxilla and the mandible.The mandibular unit consists of horizon-
tal and vertical sections, with the vertical section containing the articulation of the
mandible with the skull at the temporomandibular joint.
In the upper face, the superior unit is the cranial unit composed of the frontal bone
anteriorly, frontal sinus centrally, and temporal bones laterally. This area contains
the superior orbital rims and the orbital roofs. The midfacial unit is composed of
the zygoma and orbits laterally and the nose and the nasoethmoidal area centrally.
Severe deformity is most difficult to resolve in this central area. The upper and
lower midface meet at the LeFort I level.
Each unit may be divided into central and lateral (frontal bone and midface) or
horizontal and vertical (mandible) sections. The bone and soft tissue structures in
each unit are assessed for position, volume, and contour. Corrections for each in-
volved area are then enumerated, and a surgical sequence for operative steps is de-
veloped—one sequence for bone and one for soft tissue. Each bone anatomic area
is assessed for low-, mid-, or high-energy injury, and the incisions necessary for ex-
posure of each anatomic area can be summed for the entire operation.
INCISIONS
Careful thought needs to be directed toward the choice of incisions for reoperative
surgery. The location and length of old incisions and lacerations, and their scar-
ring, should be carefully noted. Occasionally an incision through a preexisting lac-
eration may be used to accomplish revision surgery. Seldom, however, is a laceration
alone appropriate for exposure and even if it is, one would have to question
whether reactivating a visible scar would be worth it. Planned incisions are usually
more suitable, and alternatives should be discussed with the patient.The quality of
soft tissue must be assessed because it may not permit reconstruction (for example,
thin soft tissue over a cranial defect).This soft tissue problem might have to be ad-
dressed before the cranial reconstruction can be undertaken.85 Currently, vascular-
ized soft tissue aps may need to be added to thin soft tissue, increasing its vascu-
larity, quality, and thickness but preserving the cutaneous color match.
929
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Reoperative Facial Fracture Repair

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PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Patient Example
Scarring from an incision may at times create an appearance less desirable than the
problem the incision was meant to correct. In this African American man with
short hair, the hypertrophic scar from the coronal incision is more noticeable than
the slightly displaced frontal sinus wall that was corrected by the operation.
Cutaneous lower eyelid incisions are more visible the lower they are placed in the
lid, but the complications of scleral show and ectropion increase as the incision is
placed higher in the lid. Preservation of the pretarsal orbicularis muscle is impor-
tant in maintaining lid tone because of its ability to elevate the lid margin (arrows).
The pretarsal orbicularis muscle is the force that holds the lower lid vertically. De-
nervation and scarring in this muscle create the weakness contributing to ectropion
and scleral show. Conjunctival incisions help to avoid the orbicularis, and the lid in-
cisions of Converse (stepped muscle incision), the mid-lid, and the inferior orbital
rim help to avoid the pretarsal orbicularis muscle.

3, 4
2
1
5c
5a
5b
In general, ve incisions provide exposure to almost any area of the anterior cra-
niofacial skeleton84,86: (1) the coronal incision (access to upper face and upper and
medial orbit), (2) the lower eyelid or transconjunctival incision with or without
lateral canthotomy (access to lower orbit), (3 and 4) the maxillary and mandibular
gingival buccal sulcus degloving incisions (access to the lower maxilla and anterior
[horizontal] portion of the mandible), and (5) preauricular (5a) or retroauricular
(5b) incisions (access to the vertical portions of the mandible).The only exceptions
are the angle of the mandible (retromandibular, 5c), which is best exposed via an in-
traoral incision for a single fracture (an external incision is necessary for a complex
fracture), and the temporomandibular joint and condylar area, which are best ac-
cessed with a preauricular approach (5a). Wide subperiosteal degloving of the in-
volved bone segments through these incisions permits an analysis of the bone align-
ment using osteotomy and repositioning techniques.87 The facial soft tissue can
then be repositioned at its proper location on the bone fragment before soft tissue
closure.
931
Chapter 28
Reoperative Facial Fracture Repair

932
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
SPECIFIC PROBLEMS BY ANATOMIC REGION
FRONTAL BONE FRACTURE
Problems with the frontal bone consist of irregularity and contour problems, CSF
leak, dead space between bone and brain, bone defects, residual sinus infection, and
displacement of the superior orbital rim or roof, resulting in ocular displacement.88
Brain injuries can be easily missed.89 Asymmetry problems in the frontal bone oc-
cur because of inadequate positioning of the frontal bone segments, bone resorp-
tion from devascularized bone, or inability to reconstruct the complete arch of the
frontal vault because of the bone loss at fracture site or bone loss from osteotomies
for neurosurgery. Irregularity and “silhouettes of plates and screw xation devices”
from hardware are perhaps the most common problems.This problem is managed
by removing hardware, contouring the irregularity, interpositional bone grafting, or
onlay cranioplasty. Problems with CSF leak,90 frontal or ethmoid sinus obstruction,
and infection may jeopardize future surgery. Soft tissue loss or dehiscence creates ar-
eas of exposed bone with the risk of infection.Thin soft tissue should be replaced
before any bone reconstruction. Any nasal airway obstruction that contributes to si-
nus obstruction and an infection or opaci cation of a sinus (possible infection)28
should be eliminated in a separate operation before cranioplasty.
The systematic examination of patients with frontal bone problems demands a
complete analysis. The amount and character of the bone can be assessed by CT
scans, palpation, and measurement. The position of the superior orbital rim and
roof is initially determined by physical examination, including comparing the in-
jured side with the opposite side. Careful analysis of globe position is required, with
its location measured medially, laterally, superiorly, and inferiorly relative to the
bony landmarks such as the midline of the nose, orbital rims, and the opposite eye.
Bone position is then con rmed with three-dimensional and axial CT scans and
cephalometrograms. Preoperative evaluation of double vision and visual acuity is
absolutely necessary when surgery will enter the orbit.The integrity of the frontal
and ethmoid sinuses and their function should be assessed using CT scans. Ideally,
infection or obstruction in a sinus cavity must be treated before any reconstruction
is performed.86,91,92 Any intranasal reconstruction such as that from a blocked si-
nus, deviated septum, or turbinate hypertrophy should be accomplished beforenaso-
ethmoid or frontal bone reconstruction. Reconstruction of both areas may proceed
simultaneously with a slightly increased risk of complications. The volume of the
orbit is assessed via axial and coronal CT scans with both bone and soft tissue win-
dows to image the eye, extraocular muscle position, and soft tissue volume of the
area.65,93,94 Patients who have had previous injuries to the frontal and nasoethmoidal
areas should be assessed for integrity of sense of smell and nerve function—CN II;
visual acuity—III, IV,VI).The defects should be documented because any of these
de cits might be erroneously attributed to a surgical correction postoperatively.

Contour problems of the frontal bone are most frequently caused by bone irregu-
larity or palpable plates. Palpable plates can be removed and the bone smoothed, but
such a correction (if a separate procedure) should not be performed until nal bone
volume has stabilized (usually 6 months postoperatively). Frequently, reopening the
coronal incision is necessary because access through a laceration is seldom ade-
quate. The surgeon may nd the palpable plate to be positioned up on a ridge of
bone or brous tissue, especially if the plate is mobile; sometimes a bony “ridge”
persists because of resorption and atrophy of adjacent bone areas. Removal of plates
and smoothing the bone often results in dramatic improvement. The surgeon has
to be careful not to damage the supraorbital or frontal branches of the facial nerve
in repeat soft tissue dissections. Repeat dissections should be performed on the deep
temporal fascia, or perhaps below it. Repositioning the soft tissue to correct a ptotic
brow deformity may also improve the region. One of the most dif cult problems
associated with frontal bone fractures is to correct a superiorly positioned brow on
the side of the injury. This defect is usually the result of tissue loss or contracture
within forehead soft tissue.The patient who wishes to have normal brow position
reestablished after forehead skin contracture has occurred would require tissue ex-
pansion of the contracted area, which results in excess tissue that can lower the
brow position.The deformity will usually not respond to bone surgery alone with-
out the addition of extra tissue.
Complications from harvesting cranial bone grafts are both functional and aes-
thetic. Aesthetic complications require cranioplasty.39,95 Functional problems in-
clude absent or weak bone,20,36,45,91 and brain or dural injury. A fascial patch should
be used to reinforce weak dura, and may be taken from the temporal fascia or fas-
cia of the lateral thigh.
Frontal bone contour problems are frequently the result of small bone defects or
burr holes. Cranioplasty using small amounts of alloplastic material may be safely
accomplished if there is no sinus obstruction, the area is not adjacent to a sinus
cavity, and there has been no previous infection. If an adjacent sinus cavity or mu-
cosa is present, they must rst be eliminated with mucosal removal and bone graft-
ing before proceeding with alloplastic cranioplasty. If these conditions are ful lled,
the long-term risk of infection is approximately 3% using alloplastic materials.71
When soft tissue thickness and quality are compromised or thin, tissue may be aug-
mented or replaced by free tissue transfer. Although many surgeons who perform
craniofacial procedures object to the use of alloplastic material, the use of bone
grafts in the frontal area is seldom predictable enough (up to 60% resorption) to
achieve the perfectly smooth contour that can be obtained with alloplastic material.
933
Chapter 28
Reoperative Facial Fracture Repair

934
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
If cranioplasty with methylmethacrylate is not appropriate, split-skull or split-rib
cranioplasty can be performed. Split ribs should be placed into the defect and bent
under slight compression to achieve slightly projecting contour; they should be
slightly overlapped and rigidly xed to the internal rim of the bone defect (left).
Split calvarium is nely contoured to just t the bone defect and is usually secured
with microsystem plates (right). Cranial prostheses that are custom-made from CT
data are also available but expensive.98
Micromesh
Only a cranioplasty with a screw anchorage or inlay cranioplasty may be performed
without risk of migration.39,96 With inlay cranioplasty the bone edges are dissected
and a step (groove) is created in the adjacent bone edge. This groove allows for
methylmethacrylate to be poured over an inlaid metallic grid that is stabilized by
rigid xation to the internal rim of the bone. Curing the methylmethacrylate in
situ produces an absolutely stable construct. Irrigation must be profuse to prevent
excess heating of the tissue by curing methylmethacrylate. A large shaping burr
can then be used to smooth the “joint” between the methylmethacrylate and the
normal bone, permitting an accurate and pleasing restoration of the original con-
tour. The use of a coronal incision allows a panoramic comparison of both sides,
which assists the surgeon in obtaining maximal symmetry. Cranioplasties are fre-
quently “overdone” in terms of thickness, producing too much contour elevation.
Only the exact natural contour should be reestablished.44,97

Patient Example
935
Chapter 28
Reoperative Facial Fracture Repair
This patient had a frontal cranial defect and underwent split-skull cranioplasty with
good postoperative results.

936
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
If the functional integrity of the frontal sinus cannot be con rmed, or if recon-
struction must extend into the frontal sinus, this cavity should be eliminated by
definitive sinus mucosal removal and bone obliteration.61,93,99-102 This procedure
consists of mucosal removal;103 dissection of the mucosa down into the frontal ducts
(top left) and burring of the sinus walls (top center); plugging the ducts with a form-
t graft of calvarial bone (top right); lling the sinus cavity with particulate bone
from either the calvarium or iliac crest (bottom left); and reconstruction of the an-
terior sinus wall with split calvarial or split-rib bone (bottom right). On the average,
at least 50% resorption of native split rib and 25% resorption of calvarial bone can
be expected.29,36,91 One-hundred percent take and 100% loss are also possible.
In reoperative surgery in the frontal area, the surgeon must be aware of the location
of the brain and the position of the dura.The possibility of dural stula from areas
of inadequate or fragile dural repair11,61,86 must be contemplated, and if encoun-
tered these areas must be reinforced with suitable fascial grafts as required (for ex-
ample, fascia lata).The brain, for instance, might be prolapsed inferiorly under the
back of the nose as the result of a previous cranial base frontonasal-ethmoidal in-
jury.87,104 This condition is easily determined from coronal and axial CT scans. Bone
that is normally present for protection may not be present especially in the orbital
Form-fit
calvarial
bone graft
Particulate
calvarial
bone graft

roof, and dissection may inadvertently penetrate and injure the brain. These con-
ditions can be partially con rmed using preoperative coronal CT scans. Such pro-
lapse is corrected by bone grafting. Detecting this prolapse and protecting the brain
with a frontal bone ap, using careful exposure of the area as would be obtained in
craniofacial surgery, allows safe access to the upper orbits and frontal bone.
The position of the orbital roofs and superior orbital rim may explain inferior or
superior globe dystopia. The surgeon must analyze preinjury patient photographs
to be certain that dystopia was not present before the injury. The superior orbital
rim has a complex “double curvature” of the bone of the roof that can seldom be
reconstructed precisely with either methylmethacrylate or bone grafts.
937
Chapter 28
Reoperative Facial Fracture Repair
Frequently (after panfacial fractures) the superior orbital rim is replaced in a slightly
inferior and slightly posterior position. The rounded arch of the roof is lost be-
cause gravity, bone loss, and the at bone of the calvarial donor site tend to atten
the reconstruction. The position leads to asymmetry of the frontal bone and re-
duced volume in the superior portion of the orbit. The globe is displaced slightly
downward and, if orbital volume is suf ciently reduced, slightly forward (left). One
might mistakenly diagnose this deformity as being caused by displacement of the
inferior orbital rim. In inferior orbital rim dystopia, the globe is usually posteriorly
displaced (right). If the problem is severe, an osteotomy of the superior orbital rim
alone or perhaps of the superior orbit and roof or the entire superior and inferior
orbital rim as a monoblock (“orbital dystopia procedure”) should be performed.
Occasionally, a minor problem can be resolved by contouring the rim or the roof.
The orbital roof is thin, and may be especially so after trauma.When the superior
orbital roof is dissected, bone defects are frequently encountered; a dissector may
easily penetrate the subdural space and enter the brain. When the superior orbital
rim is being reconstructed, an intracranial approach is best, with removal of the
frontal bone and superior orbital rim. Dissection of the roof of the orbit can then
be undertaken under direct vision with protection of the brain on one side and the

938
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Rigid fixation to superior orbital rim
Orbital roof bone
graft in anterior
cranial fossa
Repositioned
superior orbital rim
Brain
After the superior orbital rim is positioned, a bone graft can be placed above (ex-
ternal to) the lip of the defect in the roof. Rarely, these grafts need to be placed
within the orbit rather than external to it to improve projection.The reconstructed
rim and the exposed, nondisplaced posterior orbital roof are beneath the new graft.
Rigid xation of the graft is accomplished with either a lag screw or preferably a
small plate.The proper contour of the orbital roof should be recalled;it arches up-
ward from two directions—from medial to lateral and from anterior to posterior—
creating a superior space for the globe within the orbit. Bone grafts placed in the
superior orbit beneath the original position of the roof narrow and reduce orbital
volume, causing the globe to be positioned downward and forward.Therefore x-
ation of the bone grafts external to the intact edges of the roof establishes the proper
contour of the orbital roof and usually achieves the proper result. Reconstruction of
the orbital roof also prevents the possibility of pulsating exophthalmos from trans-
mission of intracranial brain pulsations to the globe.
orbital contents on the other. The dislocated portions of the roof can then be re-
moved back to intact, normally positioned bone. The superior orbital rim should
then be repositioned and stabilized with rigid xation. Generally a 1.2 mm system
or microplate system (1.0 mm) is appropriate for xation.3,105,106

Infection
Some acute problems from frontal bone and superior orbital injuries begin with in-
fection.11,63,64,71,107 Sometimes the infection is minor and can be treated with an-
tibiotics alone. Sometimes the infection can be managed simply by drainage with
or without plate or localized bone removal. An area of exposed bone may require
local debridement. If the infection is signi cant, removal of all devitalized bone in
the area allows collapse of the skin against the dura, which eliminates dead space.
Most frontal bone infections have their genesis in a frontal or ethmoid sinus injury.*
The majority of infectious problems in the frontal area are the result of sinus ob-
struction and intracranial dead space.11,63,71,72,110 The intracranial dead space will
sometimes become lined by granulation-like tissue (essentially a pyogenic granu-
loma) that on biopsy does not disclose any frontal sinus mucosa.107 If an infection
is encountered in the frontal area, the surgeon must evaluate the ethmoid and
frontal sinuses. If these areas are obstructed, they should be debrided, drained, and
eliminated. After obliteration of the sinus, I line the skull base area with calvarial or
iliac crest bone graft to create a “bone partition” between the sinus, nose, and in-
tracranial cavity.101,111-113 This construction allows a safe return for cranioplasty. Si-
nus drainage, cranial base reconstruction, and frontal bone reconstruction can be ac-
complished as one or two steps, depending on the surgeon’s judgment. A persistent
CSF leak should be managed by exploration and repair, and weak dural areas should
be reinforced with a dural patch of fascia taken from the lateral thigh or pericra-
nium. The anterior inferior dura is thin, adherent to the bone, and easily torn in
secondary procedures.67 A low threshold for reinforcing leaking and weak areas
with grafts should exist. Sometimes devitalized, infected bone presents as a stula
through the skin, and frequently through a previous incision or laceration (such as
the coronal).
Rarely, bone infection will progress to nonfractured adjacent frontal bone, which has
blood supply. Most infection in devitalized frontal bone can be described as “os-
teitis,” indicating a limited infection in devascularized bone.When infection spreads
to adjacent bone with blood supply, true “osteomyelitis” may develop, which re-
quires prolonged antibiotic treatment and perhaps debridement.
Hematoma
It is not unusual for a hematoma to develop beneath a coronal incision. The fail-
ure of postoperative swelling in the orbit or the coronal region to improve or dis-
appear with time indicates either infection or hematoma. Reexploration is neces-
sary to confirm either condition; early edema and trauma in the area prevent
distinguishing a small hematoma from swelling. Postoperatively, if the area is heal-
ing properly, there should be a general regression of swelling with time.The failure
of swelling to undergo regression is an indication of a problem and a diagnostic
evaluation should be forthcoming.
939
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Reoperative Facial Fracture Repair
*References 15, 55, 65, 83, 96, 108, 109.

940
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Medial
orbital wall
Central
fragment
Lacrimal
system
Anterior and posterior limbs
of medial canthal ligament
Anterior and posterior limbs
of lateral canthal ligament
Globe
Malposition of the canthus from either partial stripping, detachment in the injury,
or unsuccessful or inaccurately positioned reattachment is common. Lacrimal ob-
struction usually accompanies malpositioned bone of the nasolacrimal duct and
sets the stage for infection.118,119
The most important aspect of the treatment is early de nitive reduction with spe-
ci c management of the canthus and canthal-bearing bone fragment.120 After the
Small areas of exposed bone can be managed expectantly. The bone can be re-
moved or burred to the point of bleeding. If the surgeon does not want to remo-
bilize the scalp to close the area, a thin skin graft can be applied directly to the
bleeding bone or dura as a temporary covering and excised during a future revision.
Remobilizing an entire scalp would devascularize adjacent bone that is in the
process of revascularization and might spread infection or be hazardous to the sur-
vival of larger areas of bone. If the patient is otherwise doing well, extensive acute
salvage procedures for small areas of bone exposure are probably ill-advised.
NASOETHMOIDAL AND MEDIAL CANTHAL INJURIES
Injuries of the central portion of the midface—the nasoethmoidal region—are per-
haps the most complex of all facial injuries to manage, both diagnostically and ther-
apeutically.35,114-116 Delayed or inadequate therapy can result in telecanthus, enoph-
thalmos, a shortened or retruded nose, a shortened palpebral ssure, thickening of
the skin of the region of the nasoorbital valley, and ocular dystopia that may not be
completely correctable.4,35,40 Errors relate to missed diagnosis, inadequate reduction
or loss of bone, detachment of the canthus, and unsatisfactory position of the can-
thus.117 Perhaps the most common mistake is inadequate reduction of the lower
two thirds of the medial orbital rim and the attached canthus, which yields a wide
bony intraorbital distance.115

941
Chapter 28
Reoperative Facial Fracture Repair
The bone to which the canthus is attached, the frontal process of the maxilla, is
most accurately controlled by one or two sets of transnasal wires placed posterior
and superior to the upper portion of the lacrimal fossa. Placing transnasal reduction
wires anterior to the canthus results in lateral rotation of the central fragment,
which produces telecanthus (left). Proper posterior positioning of the central frag-
ment (right) guarantees the proper architecture of the medial orbital region. After
the bone reduction, the skin and the canthus must be closely adapted to the bone
(if detached) using both a separate set of transnasal wires for the canthus and a soft
tissue “bolster” snugly holding the skin to the bone while healing occurs.
The errors involved in NOE treatment begin with missing the diagno-
sis. An NOE fracture is frequently mistaken for a nasal fracture.117 On
examination signi cant injuries of the central midface should always be
suspected of having a nasoethmoidal-orbital component; suspicious
physical ndings can always be con rmed by a bimanual examination.123
Placing one palpating nger external to the canthus and a clamp intranasally under-
neath the frontal process of the maxilla, a loose “central fragment” can be moved be-
tween the index nger and the clamp. This maneuver is the most accurate way
original injury, the canthus usually remains attached to a signi cantly sized seg-
ment of the lower two thirds of the medial orbital rim—the bony “central frag-
ment.” Use of this fragment and its attached ligament in the original reduction is
the means to control canthal position.17,26 By virtue of the attached medial canthal
ligament, in acute fractures the central fragment may be used to manipulate both
the bone and soft tissue in the nasoethmoidal region. Reattaching this fragment in
a transnasal fashion to the canthal-bearing fragment of the other side creates a
transnasal reduction of the medial orbital rims and therefore of the canthal ligament,
which is the essential step in nasoethmoidal fracture repair.121,122
Repair of Unilateral Nasoethmoidal Fractures:
Oblique Transnasal Reduction of the Central Fragment

942
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
to identify a mobile nasoethmoidal fracture that requires reduction. It should be
emphasized that barely mobile fractures can be seen on CT images and can be
stabilized with inferior approaches alone. Most nasoethmoidal fractures require
approaches to both the upper and lower ends of the central fragment.11,17 The CT
appearance of the NOE fracture does not clearly de ne the mobility of the mini-
mally displaced fracture, but only the displacement of the “central fragment.” The
central fragment is the bone bearing the medial canthal ligament.
In general three incisions—a coronal incision, a lower eyelid incision, and a gingi-
val buccal sulcus incision (for the piriform aperture component of the fracture)—
are required for complete nasoethmoidal fracture reduction and stabilization. Fail-
ure to expose, reduce, and stabilize all three areas of the “central fragment” results
inevitably in fracture displacement. The height of the nose, for instance, is con-
trolled by reduction along the piriform aperture. Although some additional nasal
height is usually obtained from bone grafts, there is no substitute for accurate reduc-
tion of the underlying nasal skeleton. Considerable time must be spent piecing seg-
ments of the nasal skeleton together with ne wires.The addition of a small bone
graft on top of this assembled network results in subtle improvements that restore
the nasal pro le.Without the reduction of the nasal bone fragments, the individual
fragments of the nasal fracture cannot be controlled and some disorganization in-
evitably occurs, resulting in an unsatisfactory appearance of the nose—wide, at,
misshapen, and irregular with disjunction between the bone and the cartilage.
It becomes progressively more dif cult to perform a nasoethmoidal fracture reduc-
tion with each passing day after the original injury. Ideally, the best results are ob-
tained when nasoethmoidal fracture reduction is performed within 48 hours of the
injury. In fractures treated 1 week after the injury, a certain amount of softening of
the canthus has occurred. In late injury treatment, the canthus usually must be de-
tached to allow the bone reduction to be performed; the bone and the canthus
must therefore be managed separately. If a softened canthal ligament must be de-
tached, attempts to reattach it frequently result in dehiscence and produce telecan-
thus despite an initially adequate bone and soft tissue reduction. Because of soften-
ing and friability of the canthus, repeat early canthal repositioning seldom results in
any improvement. Any attempt to reposition a canthus 1 or 2 weeks later results in
it “pulling out,” frustrating both the surgeon and the patient. Occasionally, a canthus
is so damaged that it requires replacement with a palmaris tendon graft as a sepa-
rate procedure.

When canthal repositioning is required, it should be accomplished by a suture
placed in the canthal tendon exactly adjacent to the medial commissure of the
palpebral ssure. The lacrimal system may be avoided by passing ne probes for
guidance.Two passes of the suture in the tendon are suggested.The nasoethmoidal
area must have normal (or even medially overcorrected) medial orbital rim stabiliza-
tion, preferably by both transnasal reduction wires and junctional rigid xation.
Osteotomy is required to reposition the bone fragments;nasal bone fragments may
be removed to facilitate placement of transnasal reduction wires for the canthi.
Lacrimal probes may be placed so that the location of the lacrimal system is evident
and is avoided by the canthal suture. A 2-0 braided nonabsorbable suture is passed
through the medial canthal ligament at least twice, and then passed superior to the
canthus to the inner aspect of the coronal incision and connected to the loop of a
separate set of transnasal wires.
943
Chapter 28
Reoperative Facial Fracture Repair
Transnasal reduction wires
(Two sets: one for bone and
one for ligament reduction)
Medial orbital rim
Medial
canthus
Braided
suture

944
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R EOPERATIVE SURGERY OF THE HEAD AND NECK
Reduction of the Medial Canthal Ligament Using Transnasal
Wire Placement
A pair of separate No. 28 wires are linked to a suture placed directly in the canthus
through an external access incision. The wires are threaded through both sides of
the bone of the medial orbits at a point posterior and superior to the lacrimal fossa.
One set of wires should be used for each canthus (bottom). When tightened, the
wires are twisted over a microscrew in the frontal bone.This maneuver directs the
canthus toward its ideal position.
Correction of the Slumped
Short Nose
Significant nasoethmoidoorbital fractures
are always accompanied by loss of septal
support:the columella rotates superiorly and
the nasal dorsum sinks posteriorly (left). The
nose is therefore short and slumped. Dorsal
nasal bone grafting can correct the loss of
the dorsal height. Furthermore, reposition-
ing of the septum to align it with the ante-
rior nasal spine and with the dorsal bone
graft centralizes the septum. The surgeon
may place a “Fernando Ortiz Monasterio”
triangular graft of cartilage into the col-
umella to increase nasal length (right).124 The
nose may be lengthened by extensions of
Columellar cartilage graft

spreader grafts (technique of Bahman Guyuron).125 These maneuvers improve the
length of the nose in patients with retrusion. Separate tip grafts may be required.
These grafts may be placed in a separate procedure, or through an open rhinoplasty
incision. The internal nasal septum should be repositioned, and “quilting sutures”
of 4-0 plain gut on a short straight needle and Doyle nasal splints should be used
for septal mucosal positioning.
Nasal Lengthening
945
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Reoperative Facial Fracture Repair
Nasal lengthening involves recruiting skin and mucosa by wide dissection of their
respective envelopes within the nose and across the face, stretching them maxi-
mally, and lling them with bone grafts linked in the shape of the nose and xed
to the frontal bone and anterior nasal spine.
Tessier-Wolfe Procedure for Total Nasal Lengthening
In the Tessier-Wolfe procedure, the entire nasal mucosa may be dissected, and a
gap created at the nasal frontal area for total nasal lengthening.126 The dorsal bone
graft is connected to a columellar graft in the nasal tip and the columellar graft an-
chored to the anterior nasal spine. This technique is the most effective, but is de-
pendent on wide and separate dissections of the skin and mucosa to gain the nec-
essary length for each. A forehead ap may also be used to improve the quality or
amount of soft tissue available.
MEDIAL CANTHAL AND CENTRAL SEGMENT R EPOSITIONING
In patients who require late nasoethmoidal correction, the surgeon must be pre-
pared to reposition the canthus and to reposition or perhaps restructure the entire
frontal process of the maxilla with a bone graft. It is dif cult to overcorrect the in-
tercanthal distance.127 Soft tissue in the nasoethmoidal area has often thickened and
requires extensive thinning;the lacrimal system must be protected in dissection. In
patients with malpositioned nasoethmoidal fractures, the “nasoorbital valley” area

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R EOPERATIVE SURGERY OF THE HEAD AND NECK
(the junction of the eyelids and nose) is normally a few millimeters thick;this area
is often more than 1 cm thick in established NOE deformities. The surgeon can-
not hope to achieve correction of the telecanthus without greatly reducing this
bulky soft tissue.Therefore both bone and soft tissue thickness must be considered
when analyzing the telecanthus.The operative plan must begin with repositioning
the skeletal structures and eliminating any ethmoidal or frontal sinus obstruction.
Next, the internal portions of the orbit are bone grafted and the canthus is skele-
tonized and repositioned. Generally a canthus cannot be adequately repositioned
without mobilizing the soft tissue from at least two thirds of the orbital rim circum-
ference, the internal orbit, and generally across the upper and lower orbital rims
and down the medial maxilla. All medial, superior, and inferior attachments of the
orbital soft tissue to the orbital rim are freed to permit maximum soft tissue exi-
bility for tension-free repositioning of the canthus. The periosteal layer and addi-
tional soft tissue may need to be resected to thin the tissue or to permit increased
exibility. The lacrimal system must be mobilized by subperiosteal dissection well
into the nasolacrimal duct and be carefully protected during mobilization. On some
occasions, the lacrimal system must be severed to permit mobility of the canthus,
and a secondary dacryocystorhinostomy must be performed to promote tear
drainage. Some established canthal deformities are short of soft tissue.The ap re-
construction designed for congenital deformities is sometimes very useful (a “pen-
nant” ap transposed from the area medial to the medial canthus to the lower lid).
Patient Example
This patient is shown before and after nasoethmoidal osteotomy and orbital and
nasal reconstruction. On the left, a foreshortened nose, exophthalmos, and telecan-
thus are present following initial unsatisfactory revision of LeFort III and orbital
fractures. Both soft tissue and bone needed to be modi ed to yield the result seen
on the right.

NASAL FRACTURES
Nasal fractures have two categories of sequelae: those related to appearance and
those related to function. Functional nasal airway obstruction is managed using
septal resection, spreader grafts, sidewall grafts, dorsal grafts, rim struts, and/or ante-
rior turbinectomy as required. I prefer to wait 6 or more months after a nasal frac-
ture before considering corrective septorhinoplasty. Septoplasty is best performed
through an open rhinoplasty technique, especially when deviation of the caudal
septum requires de nitive open correction.The mucoperiochondrium is vasocon-
stricted with topical Afrin and the mucosa over the septum and turbinates is “bal-
looned” by injecting 1:200,000 epinephrine solution. These injections facilitate
dissection of the delicate mucosa from the cartilage. Separation of the mucoperi-
chondrium from the cartilage is achieved with gentle dissection using a semiblunt
elevator such as a Cottle. Dissection begins in smooth areas and progresses into the
dif cult areas and the undercuts, with the nasal lining teased from cartilage under-
cuts and areas of septal overlap. Dissection may also begin on the nasal oor and ad-
vance into the more dif cult areas of the vomer. Septal mucosal tears may be su-
tured with 5-0 chromic suture on a Castroviejo needle holder. Tears that are not
bilateral at the same location will usually heal without septal perforation. The de-
viated portion of the septum should be resected, leaving at least a 1.5 cm dorsal and
caudal strut. Some of the removed cartilage may be crushed and replaced between
the mucosal layers as structural reinforcement.
To straighten a crooked nose, the residual dorsal strut can be bent or scored at its
junction with the perpendicular plate of the ethmoid, sectioned at the piriform
aperture, and rejoined to the anterior nasal spine with a wire or a suture. Areas of
septal overlap are resected.The remaining deviated septal strut may be scored lightly
in three directions on the side opposite the side on which bending is desired. In
some septal injuries, the remaining cartilage is weak and therefore permits devia-
tion.These areas require support with dorsal and caudal cartilage support grafts su-
tured to the weakened septal cartilage.
In acute nasal fracture treatment, failure to manually replace the septum in the mid-
line after mobilization is one mechanism of septal deviation. If the nose and septum
are mobilized properly, it should be possible to deviate them easily both medially
and laterally.The septum is then splinted to support the reduction.We prefer Doyle
(Medtronic-Xomed Co, Jacksonville, FL) or similar nasal splints to support the
septal reduction and mucosa. If the nasal septum is dislocated from the anterior nasal
spine, it should be openly reduced to the spine with suture or ne wire.
Quilting sutures of 4-0 plain gut on a short straight needle are placed through and
through the septal mucoperichondrium and septum before placement of the Doyle
947
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Reoperative Facial Fracture Repair

948
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R EOPERATIVE SURGERY OF THE HEAD AND NECK
splints to minimize space for hematoma.If the nasal septum is dislocated from the an-
terior nasal spine, it should be openly reduced to the spine with suture or ne wire.
After fracture, the nasal pyramid demonstrates two types of displacement: lateral
and posterior. Lateral deviations after a closed reduction are caused by incomplete
mobilization of the nose to complete the fracture at the time of closed reduction,
or by the warping forces of damaged cartilage that occur with healing. Repeat
closed reductions are seldom able to prevent the deviated nose from twisting again.
The patient is usually best served by waiting until an open procedure such as sep-
torhinoplasty can be accomplished.
Patient Example
In this patient, a Doyle splint supports the septal repair and is visible just inside the
nostril. One splint is placed in each nasal cavity to support the septal repair. Nasal
packing is often not necessary. A Mirocel pack may be used in addition if bleeding
is a problem.
Errors in Nasal Fracture Reduction
Three errors are commonly made in nasal fracture reductions.They are described be-
low.These errors can be avoided by accurate detection of the fracture pattern on CT
scans, and the performance of reduction maneuvers speci c for each fracture pattern.
Splint

949
Chapter 28
Reoperative Facial Fracture Repair
In a frontal impact nasal fracture that causes widening of the nasal bridge and loss
of dorsal nasal height, lateral osteotomies permit infracture of the nasal bones (top).
Late correction of loss of dorsal height calls for onlay bone cartilage grafting (bottom),
or AlloDerm, with or without osteotomy if narrowing of the nose and projection
are required.
Insuf cient Mobilization
Unilateral or bilateral fractures with lateral deviation without significant loss of
height should be managed with complete bilateral mobilization of the nasal bones,
which “completes” the fracture; a unilateral osteotomy is sometimes needed to
complete a greenstick fracture. The nasal pyramid may then be freely deviated to
each lateral direction and then replaced into the midline. Failure to completely
mobilize the nose bilaterally is a common reason for residual deformity.
Failure to Perceive Loss of Dorsal Height
Loss of nasal height is caused by loss of bone or cartilage support. A unilateral or bi-
lateral fracture of only the distal portion of the nasal bones may escape detection,
resulting in a saddle-nose deformity. These fractures are usually accompanied by a
fracture of the nasal septum that is telescoped and overlapped so that septal height
is lost, creating a dorsal nasal support loss.

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In acute Stranc Plane II frontal impact nasal fractures, percutaneous nasal splints
with padded bolsters constructed of Xeroform-wrapped orthopedic felt can be
used to control the width of the nose;they may also recruit some nasal height.The
position of these nasal bolsters is controlled by two transnasal wires passed through
the most posterior nasal fracture on each side. They are positioned by passing a
large curved needle through the skin and the most posterior fracture site, and then
across the nose and out the contralateral fracture site and the skin of the other side
Failure to Perceive the Comminuted Nasal Fracture
Fractures of the nose with signi cant loss of height are most commonly nasoeth-
moidoorbital fractures in which the medial orbital rims are fractured. Less com-
monly, a variety of nasal fracture occurs in which there is dramatic loss of both
dorsal nasal bone and septal support, without fracture of the medial orbital rims
(Stranc Plane II).110,122 In this type of fracture, there may be fractures of the piriform
aperture, but not of the medial orbital rims. In these fractures, the nasal bones are
comminuted, the septum has multiple fractures that allow collapse, the nose sinks
posteriorly, and the nasal tip is upturned. Palpation of the nasal dorsum and col-
umella con rm the lack of bony and cartilage support. The entire nose, without
septal or nasal bone support, becomes wider, atter, and sinks into the midface.

Dorsal graft
Tip grafts
Columellar graft
The addition of a dorsal nasal bone graft,a cartilage graft,or placement of AlloDerm
or dermis can acutely or secondarily add height to the nose.Three types of grafts can
be used to add projection to the nose:(1) dorsal grafts, which may require stacking,
(2) columellar graft that may be linked to the distal end of the dorsal graft to enhance
tip projection and lengthen the nose, and (3) tip grafts, which may require stacking
or crushed cartilage dorsal augmentation. Dorsal grafts may be added primarily or
secondarily if there is not too much foreshortening of the nose with contracture of
the internal lining and skin envelope. Alloderm and dermal grafts add 1 to 2 mm.
Cartilage grafts add 2 to 6 mm, and the bone grafts are used if more height is re-
quired. In cases in which foreshortening is severe, the nasal soft tissue envelope (skin
and lining) must be dissected suf cient to be expanded to the original nasal volume
with dorsal nasal and caudal strut grafts.“Guyuron-type” spreader lengthening grafts
may also be used to prevent shortening, or to repair nasal length and resist soft tis-
sue contracture (“spreader” graft of Bahman Guyuron).125 Late correction of lining
shortage requires dissection of the lining and skin separately, with sectioning of the
lining high in the nose. The defect is thus superior, not inferior. These secondary
“nasal lengthening” procedures have been described by Wolfe (after Tessier).126
951
Chapter 28
Reoperative Facial Fracture Repair
of the nose. The needle is “walked” along the nasal bone until the fracture is pal-
pated by the needle tip, and then the needle is pushed through the fracture. Some
nasal height is invariably lost, however. If dislocated, the septum can be reattached
to the nasal spine by open wire xation.

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ORBITAL FRACTURES
Fractures involving the orbit are common injuries because the orbital rim occupies
a prominent place on the facial skeleton. An understanding of orbital injury de-
mands knowledge of the anatomic structures of the orbital cavity, the lids, the oc-
ular globe, and periorbital contents.128-130
The magnitude of orbital fractures varies considerably. An orbital fracture may be a
simple blowout fracture of the orbital oor, or portions of the orbit may be involved
in a complex multiple wall injury in which several portions of the orbital rim and
orbital walls are fractured simultaneously. With the latter type of injury there is a
dramatic potential for globe and soft tissue displacement and marked deformity.
Knowledge of the dimensions, contours, and anatomy of the orbit are the most im-
portant information required for successful surgical management of fractures in this
region. High-resolution CT in axial and coronal planes with bone (top left) and soft
Bone window
Soft tissue window
(retrobulbar hemorrhage)
Three-dimensional image

The bony orbit should be conceptualized in anterior, middle, and posterior sec-
tions.The anterior third of the orbit, shown above, consists of the bony orbital rim.
The rim is divided into three section: zygomatic, supraorbital, and nasoethmoidal.
The supraorbital section begins at the frontomaxillary suture, the junction of the in-
ternal angular process of the frontal bone with the frontal process of the maxilla, and
extends laterally to the zygomaticofrontal suture. The lateral and inferior walls of
the orbit are formed by the zygoma, which provides major support for the orbital
soft tissue.The zygoma, by virtue of its orbital process, articulates with the anterior
lip of the great wing of the sphenoid intraorbitally and with the orbital process of
the maxilla medially.The lower two thirds of medial orbital rim form the nasoeth-
moid area; anatomically, they are the frontal processes of the maxilla. The medial
canthal ligament attaches to the frontal process of the maxilla with the medial horn
of the levator palpebrae superioris and the medial attachment of Lockwood’s liga-
ment.58,59 The lateral canthal ligament, lateral attachment of Lockwood’s ligament,
and lateral horn of the levator palpebrae superioris attach to Whitnall’s tubercle, a
rounded eminence on the interior surface of the frontal process of the zygoma, lo-
cated 10 mm below the zygomaticofrontal suture and 2 to 4 cm posterior to the
lateral orbital rim.85,94,108,109,132
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Chapter 28
Reoperative Facial Fracture Repair
Zygomatic
Nasoethmoidal
Supraorbital
tissue (top right, retrobulbar hemorrhage) windows, and three-dimensional reconstruc-
tions (bottom) permits a complete analysis of orbital bone and soft tissue injuries.131
Two-dimensional and three-dimensional CT scans provide valuable anatomic in-
formation about fracture patterns and displacements of the bone fragments.Three-
dimensional CT scans are invaluable to compare symmetry and displacement with
the uninjured side. Soft tissue windows precisely depict the relationship of the soft
tissue (extraocular muscles, fat, and orbital soft tissue ligament systems) to the bone.
Three-dimensional images add a geographic perspective, but often in reality do not
supply any new information. The perspective they provide in asymmetrical cases,
however, is dif cult to visualize without this three-dimensional information.
Anterior third of orbit

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Lateral wall
Floor
Roof
Medial wall
The middle third of the orbit, shown above, is composed of thinner bone and in-
cludes four sections: roof, medial wall, lateral wall, and oor. The roof is a portion
of the frontal bone and separates the anterior cranial fossa from the orbital cavity.
It begins as a thin extension of the superior orbital rim and is curved in two dimen-
sions superiorly, both from anterior to posterior and medial to lateral.The surgeon
must note the contour of the roof as it extends backward from the superior orbital
rim. It travels distinctly upward, then posteriorly, and nally inferiorly near the or-
bital apex.106 A common mistake in orbital roof reconstruction is to make this area
too at and too inferior, which causes inferior globe displacement.The medial wall
of the orbit is formed by the thin orbital plate of the ethmoid bone and separates
the orbital cavity from the cavities of the ethmoid sinus.The medial wall is bowed
inward (laterally) behind the globe. The anterior and posterior ethmoid vessels in
the medial wall of the orbit are at the same level as the optic canal.They are located
24 and 30 mm, respectively, from the anterior lacrimal crest; the optic nerve is 40
mm from this bony landmark,132 and is directly in the path of medial orbital dissec-
tion.35,133 Therefore these vessels provide a landmark for optic nerve protection in
medial orbital dissections. Anatomically, the medial wall of the orbit bows laterally
into the orbital cavity so that it causes a postbulbar constriction of the medial por-
tion of the orbit. Some authors prefer endoscopically assisted visualization.133 The
orbital oor separates the orbital cavity from the maxillary sinus. The oor bends
superiorly behind the globe, creating a postbulbar constriction of the orbit.132 The
oor and the medial walls of the orbit are the most commonly injured areas of the
middle third of the orbit;next is the lateral wall, which is involved in any zygomatic
fracture.The remaining unfractured bone of the posterior orbital oor is generally
35 to 40 mm from the medial orbital rim, and may be located by placing a freer el-
evator against the back wall of the maxillary sinus and moving it superiorly. One
can feel the ledge as a “lip” in the superior portion of the sinus wall. The optic
nerve in oor dissection is above the plane of the oor dissection; it is therefore
protected and not directly vulnerable as it is in dissection of the medial orbital wall.
Posterior third of orbit

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Reoperative Facial Fracture Repair
The posterior third of the orbit, shown above, is constructed of thicker bone and
incorporates the superior and inferior orbital ssures and optic foramen. Although
fractures occur in this region, displacement of bone is less common but is signi -
cant because of the possibility of blindness and the superior orbital fissure syn-
drome.53,54,134
The anterior and middle sections of the orbit absorb fracture forces and are princi-
pally involved in fracture displacement.83,132 The accuracy with which the rim and
walls of the orbit are reconstructed controls the appearance and position of the globe
and periorbital contents. Differences of a few millimeters in the orbital rim and wall
position may produce signi cant change in orbital volume and appearance.
There is a relationship between the bony volume of the orbit and the soft tissue of
the orbit:the bony volume of the orbit controls the vertical and anterior-posterior
position of the ocular globe.32 Approximately 10% of orbital fractures85 demon-
strate signi cant fat atrophy.Therefore in 90% of orbital fractures, globe protrusion
and eye position are best regulated by accurately reassembling the bony volume of
the orbit. Because the volume of the orbit is about 30 cc, even small changes in the
orbital volume (as little as 10%) can begin to cause a globe positional change. Con-
ceptualizing the orbit as a cone, the relative volume of bone contained in the struc-
ture is approximated using the following equation: R2
1⁄2h (R, radius;h, height).
R

h
R

h

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Therefore the most important consideration in volume increase is the radius of the
cone (orbital rim), which is determined by the rim position. If the inferior orbital
rim is out of position by only a few millimeters, the volume of the orbit is in-
creased proportional to the square of the increase in radius of the orbital rim, which
can mean a signi cant increase in orbital volume.73,85,108,132,135 Displacement of one
of the internal walls of the orbit increases the volume of the orbit in a linear fash-
ion, as does displacing the rim posteriorly (decreasing the height of the cone).The
most common mistakes in orbital reconstruction involve failure to place the orbital
rim in the proper position and failure to reconstruct the oor and lateral and me-
dial walls of the orbit in their proper position. These walls are usually displaced
outward, contributing to an increase in orbital volume.
Reoperative Strategies
The superior orbital rim and roof of the orbit are often placed too inferiorly, nar-
rowing the volume of the orbit.106 In these cases, the displaced orbital roof and rim
cause downward displacement of the globe; attempting to correct the downward
globe displacement by pushing up on the inferior rim or oor accentuates exoph-
thalmos rather than corrects orbital dystopia because the globe has nowhere to go
superiorly and is forced anteriorly (see below). In these situations, the superior orbital
rim requires repositioning by osteotomy. Normally there is a space superior to the
globe in the curving arch of the roof that allows the globe to rest comfortably within
the bony orbit and at a proper vertical location.
In terms of the medial wall, a postbulbar constriction of the orbit gently pushes
the globe forward, upward, and laterally. Commonly, the injured ethmoid bone is
compressed medially by fracture (center), increasing the volume of the orbit. The
globe moves medially, signaled by a reduced distance of the ipsilateral pupil from the
midline of the nose. By comparing the width of the injured ethmoid with the con-
tralateral intact ethmoid at the same level in the CT scan, the surgeon can assess the
amount of correction required. This correction should be made by insertion of
layers of stacked alloplast136 or bone grafts inserted medial to the medial wall of the
orbit (right). They must be supported in these cases by the medial portion of the or-
bital oor reconstruction.

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Reoperative Facial Fracture Repair
30°
45°
Beyond the initial concavity behind the inferior orbital rim, the orbital oor in-
clines upward at a 30-degree angle from anterior to posterior. From lateral to me-
dial across the orbital oor approaching the medial portion of the orbit, the orbital
oor inclines superiorly at a 45-degree angle to meet the medial wall in the post-
bulbar constriction behind the globe.77-80 This inferior medial “bulge” is often not
reconstructed properly and it is a key determinant of globe position. It is supported
by a “buttress” continuous with the middle turbinate in the nose. It is dif cult in the
reconstruction of combined medial and inferior orbital wall fractures to recreate
this bulge without using some kind of “strut,” whether it is bone or a metallic im-
plant. This bulge must be reconstructed to achieve a stable, corrected internal or-
bital volume.57 Alloplast containing a smooth surface (Barrier Medpor;Porex, Fair-
burn, GA) is available with and without an internal titanium grid.
At the time of surgical correction, intraoperatively, the vertical position of the globe
is a good predictor of the desired postoperative vertical position of the globe.116
Anteroposterior globe position at operation however is not a good guide to nal
globe position because swelling and the release of periorbital soft tissues from dis-
placed bone fragments temporarily improves globe position. Too often surgeons
base the endpoint of the orbital reconstruction on the AP position of the globe at
the end of the operation, rather than on an anatomically reconstructed orbital wall
by known landmarks.The former approach consistently leads to undercorrection of
anteroposterior globe position and residual enophthalmos. It is better to rely on
restoration of normal orbital bone anatomy than on globe position at surgery, but
both should be used as a check and balance.The orbit should be corrected anatom-
ically by identifying posterior unfractured intact bone. The position of this intact
bone is identi ed preoperatively using CT scans. Reconstruction of the internal
portion of the orbit, in cases in which there was a previous failure to achieve proper
globe position, is best approached by dissecting back to intact posterior bone land-
marks and proceeding forward with reconstruction to an anatomically recon-
structed rim. In orbital oor reconstruction a bone strut is placed between these
normal posterior landmarks (the “ledge”) and the reconstructed rim. The medial
wall and inferomedial orbit require some additional bone augmentation.The prin-
cipal bone struts can be anchored to the rim using a lag screw technique or can be
connected with a small Microplate to the rim to ensure stability.

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Alternatively, the use of an orbital
floor or medial orbital wall plate
may be used in select cases in which
there is no other mechanism to en-
sure bone stability.137,138 An orbital
oor plate may be trimmed to the
required size for an inferomedial
strut and then used alone (preferred
method) or to support bone grafts.
Because bone disappears partially,
the logic of using it here disap-
pears. The plate is anchored to the
inferior orbital rim with screw x-
ation. Such plates dramatically sim-
plify reconstruction and are not subject to absorption. Rarely, they fail to mucosalize
in the orbital oor, develop recurrent cellulitis, and require replacement.
A common cause of undercorrection of enophthalmos is the failure to ll the space
between displaced bony walls and soft tissue after initial soft tissue release by dissec-
tion. These areas, if not lled by bone graft or arti cial material, will again retract
the orbital soft tissues to the bone postoperatively, contracting on the globe inferi-
orly as scar contracture appears. The original globe displacement, which appeared
corrected at the time of surgery, will recur as the scar tissue contracts again, pulling
the globe into the recess.
The lateral wall of the orbit is consistently undercorrected in comminuted zygo-
matic fractures.16 In simple zygomatic fractures the lateral wall of the orbit breaks
at the junction of the orbital process of the zygoma with the greater wing of the
sphenoid. When comminution increases, the anterior 1 to 1.5 cm of the greater
wing of the sphenoid fractures, and is a separate fragment located behind the zygo-
maticosphenoid suture. Zygomaticosphenoid alignment provides a key landmark to
Zygoma
First fracture
(junction of orbital
process of zygoma
and greater wing
of sphenoid)
Second fracture
(within greater wing
of sphenoid)
Greater wing
of sphenoid

zygomatic position. In comminuted zygomatic fractures, it is common to position
the orbital process of the zygoma in line with the anterior (displaced) sphenoid
fragment, which is incorrectly perceived as the stable “normally positioned” bone
of the sphenoid. The lateral wall alignment is therefore “off” by 4 to 5 mm. This
places the zygoma too far laterally, making reconstruction of the proper anterior
position of the malar eminence projection impossible.The orbit is greatly enlarged
laterally, producing enophthalmos. Referring to the formula that approximates the
relative volume of bone in the orbital cone (see p. 955), it becomes clear that the
misalignment greatly increases the size of the orbit.The proper approach is to dis-
sect back to what is known to be intact bone, using the CT scan as an index to the
depth of orbital dissection required and using intact bone as a guide to lateral or-
bital wall position.The reassembly of the lateral wall of the orbit must include cre-
ating a straight line. If a lateral wall fragment is missing, a bone graft must be placed
between the intact portion of the greater wing of the sphenoid and the reposi-
tioned orbital process of the zygoma anteriorly. The zygoma will be undercor-
rected if the entire greater sphenoid wing area is not aligned visually by dissection.
The CT scan can be used as a guide to locate the approximate position of intact
posterior fragments (see the gure on p. 958).
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Proper restoration of globe position begins with the measurement of the distance
from the pupil to the middle of the nose on each side as a guide to the desired globe
position.56 Globe displacement is most commonly inferior, posterior, and medial160;
comparison with the other eye provides an index of what needs to be done in terms
of moving the globe at the time of an osteotomy. Palpation of the orbital rim fol-
lows, with careful measurement of displacement and position and comparison with
those dimensions on the contralateral side, if unfractured. External measurements,
plain lms, or a three-dimensional CT scan may be used for this purpose.139 These
measurements are crucial and can be used to predict the degree to which the rim
needs to be corrected to achieve improved globe position. A three-dimensional
CT scan is an excellent tool to use to evaluate differences in orbital rim position.
In general, complete osteotomy of an orbital segment (versus marginal osteotomy
of the rim) yields the best aesthetic results unless displacement is required in a sin-

960
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
gle direction (that is, vertical displacement of the inferior orbital rim). Onlay and in-
lay grafting often have to be performed in conjunction with an osteotomy to
achieve the proper volume and contour of the osteotomized bone segment, and
thus restore preinjury bone dimensions. One must remember to reposition the soft
tissue on the bone before closing the incisions. Two months usually elapse before
globe position is stable, and early readjustment of globe position is not recom-
mended. Generally, arti cial material should be used for orbital wall reconstruc-
tion only in limited defects or in late reconstruction in which the orbital defect is
not widely open to the sinuses. Plate xation is extremely useful in large defects.140
The risk of postoperative infection is reduced if the arti cial materials are not ex-
posed to the nose or sinuses.136
Patient Example
This patient presented for correction of enophthalmos. Zygomatic osteotomy and
internal orbital bone grafting were performed. Good results were achieved postop-
eratively.

Visual Disturbances
Orbital fractures are associated with visual disturbances and globe positional
changes.* Globe positional changes dramatically alter the patient’s appearance and
ability to make focused eye contact.The most signi cant functional and visual se-
quelae involve double vision and alterations in visual acuity.60,147-149 Postoperative vi-
sual acuity and diplopia can only be accurately evaluated in perspective when com-
pared with preoperative visual acuity and diplopia.110,150 Reoperative surgery must
always be performed with the knowledge of what the preinjury eye function and
appearance were, and what happened after each operation. In patients who are not
cooperative, the speed of pupillary reaction to light compared with contralateral
pupillary reaction can be used as a rough guide to evaluate light perception and
pupil reactivity. In patients who present with postoperative acuity changes, a full in-
traocular examination including visualization of the retina and anterior and poste-
rior chambers should be performed.
Any visual acuity change rst must be assumed to be an optic nerve functional
de cit, and contusion or compression23,107 must be searched for.Thorough CT scans
of the posterior portion of the orbit and optic canal may or may not demonstrate
fracture107,151;these exams are also used to detect edema, hematoma, and other con-
ditions that may respond to orbital or nerve decompression. For all patients with vi-
sual acuity change and presumed optic nerve damage, megadose steroid administra-
tion (medical optic nerve decompression) has been traditionally recommended.
Recently however, some surgeons have, based on experimental evidence, argued
against steroid treatment. Early optic nerve decompression has been advocated re-
cently in acute complete visual defects,152 which contrasts with previous recom-
mendations of nonoperative observation.53,54 It was formerly believed that visual
loss from nerve injury was mostly caused by axonal shearing and injury; therefore
surgical decompression was not considered effective in reversing visual loss.53 How-
ever, there is growing evidence that decompression can improve or partially sal-
vage some injuries previously considered to be beyond therapeutic improvement.153
The mechanism of injury is probably a mixture of causes, including nerve loss (that
is, edema and axonal injury). It is argued that decompression of the optic nerve
should be performed if visual acuity loss is complete because there is “little to lose”
with this procedure.58 If there is any light perception present or only decreased vi-
sual acuity, treatment with high-dose steroids or observation alone is recommended.
The common approach to decompression is through the medial aspect of the orbit
within the ethmoid sinuses, approaching the optic canal from the medial aspect.
The tight bony ring of the canal is located anteriorly but a full decompression of the
entire canal length and a release of the dural sheath by incision should be accom-
plished under direct vision. The use of an operating microscope is usually recom-
mended to assist differentiation of adjacent structures.The internal carotid artery is
immediately adjacent to the path of dissection.The bone behind the anterior ring
961
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*References 11, 22, 47, 88, 141-146.

962
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R EOPERATIVE SURGERY OF THE HEAD AND NECK
of the optic canal is thinner and more easily removed than the initial constricting
ring.The microanatomy of the optic canal should be thoroughly reviewed.53,54 The
superior orbital ssure compression syndrome134,152 also may present with restricted
eye motion. Most surgeons favor nonoperative treatment, but again there are pro-
ponents of surgical decompression of the superior orbital ssure. Partial recovery is
the rule. Carotid cavernous sinus stula presents with lid swelling and conjunctival
congestion, proptosis, ophthalmoplegia, and frequently visual acuity de cit.23 These
stulas are managed with angiographic embolization.
Many patients with orbital fractures, particularly inferior blowout fractures, present
with double vision.146
The musculo brous ligament system of the orbit is a system of ne ligaments in-
terconnecting all orbital structures. Incarcerated perimuscular fat, by virtue of these
connections, can restrict the action of an extraocular muscle. In this transverse sec-
tion of the orbit, the ne fascial connections can be appreciated between the lob-
ules of intraconal fat.
Small fascial connections link all intraorbital soft tissue structures so that tethering
of one area of the soft tissue (the posteroinferior orbital fat) may restrict the action
of an extraocular muscle without the presence of a true speci c muscular incarcer-
ation.8,56,60,108 The result is incomplete excursion of that muscle, producing
diplopia.148 Entrapment of the brous connective tissue near a muscle can be de-
tected by the presence of diplopia, a positive forced duction (ocular motility) exam-
ination, and analysis of axial and coronal CT scans that have both bone and soft tis-
sue windows.148 These scans accurately identify both contusion and entrapment of
orbital soft tissue. If the forced duction examination demonstrates limited motility
and the CT scans con rm an area of soft tissue incarceration, enough evidence is
present to justify operative release.154 If these criteria are present and impingement
of tissue can be demonstrated, there is no reason to wait for spontaneous improve-
ment because the ultimate function will be improved by early release. As a rule,
some spontaneous improvement in eye motion can be expected even with contin-
ued soft tissue incarceration. Early release, however, permits brous scarring and
contracture to occur in a more anatomic position; therefore the therapeutic bene-

t of releasing the musculo brous ligament system is maximal in the immediate
postinjury period. Recently, there has been evidence that sagging or prolapse of a
muscle into an orbital fracture alters the path of the muscle so that diplopia may de-
velop. There has also been evidence that some of the brous septae described by
Koorneef function as “pulleys” for the muscle, and that this displacement alters
muscle function suf ciently to produce diplopia on the basis of distortion of the
special anatomy of the musculo brous system of the orbit.74,155
After extensive material for intraorbital reconstruction has been placed, it is com-
mon to notice a restriction in extraocular motility. Forrest et al156 showed that there
is a temporary increase in intraorbital pressure that resolves in 30 minutes. Either
condition, however, prompts a full examination of the area where the bone graft has
been placed to determine whether the bone graft is somehow impinging on the
extraocular brous ligament network, thus tethering the action of the extraocular
muscles. Before orbital surgery is begun, preoperative forced duction maneuvers
are performed to assess the amount of restriction caused by edema or previous scar-
ring in the muscle network. Once the intraorbital dissection has been completed,
another assessment of extraocular motility should be obtained to determine
whether the dissection has improved or worsened the motility. Only with this in-
formation can an ocular motility examination after bone grafting have meaning by
comparison with the two previous measurements.
If a signi cant loss of visual acuity is con rmed postoperatively, all bone graft ma-
terial is removed to decrease intraorbital pressure, and a release of the lateral canthal
ligament is performed. The lateral canthus should be divided and all incisions
opened. Optic nerve decompression can be considered but the results are equivo-
cal. Such decompressions should be accomplished urgently after an emergency CT
scan is performed with an optic nerve protocol.
Commonly, dissection produces edema, which adversely affects ocular motility.157
Similarly, the occurrence of diplopia postoperatively after early or late orbital frac-
ture surgery is common. It is expected temporarily in late enophthalmos correc-
tions.88,141,142 Diplopia is usually the result of muscular contusion and edema. In that
regard, it must be understood that the extraocular muscles run adjacent to the or-
bital walls in the posterior portion of the orbit.The periosteum is often torn in ar-
eas of fracture, thus in enophthalmos corrections the surgeon is operating immedi-
ately adjacent to the muscles.The use of careful dissection with loupe magni cation
will allow identi cation and preservation of muscle tissue and its surrounding mus-
culo brous ligament system. Entering an adjacent tissue structure such as the max-
illary sinus or the temporal region to avoid muscle injury in an area of dif cult
muscle scarring and abnormal anatomy allows the surgeon to limit extraocular
muscle injury in some cases. Retractors, when placed within an orbit, should be
gently positioned;nostrong retraction should be placed on an intraorbital retractor
because this exerts excessive pressure on the extraocular muscles and the globe. If
dissection has been adequate, the intraorbital retractor may be loosely positioned
and an area can be visualized without strong retraction. Retraction and dissection
963
Chapter 28
Reoperative Facial Fracture Repair

964
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
injury are the most common causes of postoperative diplopia induced by opera-
tion.140,158 Intraoperative or postoperative hemorrhage into a contused area of mus-
cle may suddenly result in postoperative diplopia. Such hemorrhage is minimized
by gentle retraction and dissection to avoid bruising the muscles.
The management of postoperative diplopia is usually expectant. A CT scan can be
obtained to demonstrate whether adequate release has been accomplished around
speci c muscles identi ed as causing diplopia. Eye muscle function and formal ex-
traocular muscle testing identify the muscle involved in the production of diplopia,
and its progress in healing may be measured by serial examinations including clin-
ical ductions. Most visual acuity changes after enophthalmos correction are caused
by edema and swelling. For instance, edema of the conjunctiva manifests as slight
opacity of vision.With time, the edema will clear and visual acuity will improve. It
is common for refraction changes to accompany enophthalmos corrections on the
basis of edema and distortion of the shape of the globe.
Orbital fractures produce volume changes that can contribute to either exophthal-
mos, as shown above,116,129,159 or more frequently enophthalmos.97,160 Superior orbital
rim fractures are usually displaced posteriorly and inferiorly, producing exophthal-
mos. Most often the fractures compress the orbit, pushing the globe downward and
forward. Zygomatic fractures may be displaced outward (laterally) or inward (medi-
ally).16,60 Commonly, they are displaced medially,producing a “blow-in” fracture that
reduces the volume of the orbit and causes exophthalmos.116,129 In these injuries,
contusion of the lateral rectus muscle is common.The zygoma is frequently laterally
displaced, increasing the volume of the orbit, which results in enophthalmos with
backward, downward, and lateral displacement of the globe into the expanded orbit.
Computer programs are now available to calculate volume changes and to assist with
surgical correction.151 Generally, enophthalmos is produced by postfracture enlarge-
ment of the orbit medially, inferiorly, and posteriorly. The combination of a dislo-
cated zygoma, a fractured greater wing of the sphenoid, and fractures of the orbital
oor and medial orbital wall create a “three-wall” orbital fracture, which may greatly
expand the volume of the orbital cavity.116,125 Such volume changes set the stage for
inadequate restoration of orbital volume and dramatic enophthalmos.42,86
Orbital fracture causing constriction of the lateral wall and exophthalmos

This CT scan shows a reconstructed right orbit that is enlarged laterally, inferiorly,
and medially.
965
Chapter 28
Reoperative Facial Fracture Repair
Signi cant orbital enlargement is usually the result of lateral displacement of the zy-
goma. Moving the zygoma vertically and medially (single arrows) usually accom-
plishes the proper reduction. As the zygoma is brought into proper position, the
alignment in the lateral wall of the orbit between the greater wing of the sphenoid
and the orbital process of the zygoma will be a straight line (double-headed arrow).
Lid and Canthal Malposition
Some of the most distressing postoperative complications relate to lid and canthal
position abnormalities.* Both facial fractures and operations to correct them may
produce these problems by moving the bone to which the ligaments are attached,or
by detaching the ligaments during surgical dissection. Canthal position should be
assessed bilaterally. Normally the medial canthus, if reapproximated, should be di-
rected to a point posterior and superior to the lacrimal fossa. This orientation pro-
vides the proper traction on the canthus to give it the best vertical and anteropos-
terior positional relationships. The lower lid, by virtue of this posteriorly directed
*References 42, 46, 66, 158, 160, 161.

966
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
traction of the canthus, is maintained tangent to the globe. Similarly, the lateral can-
thus should be directed to a point above its normal attachment at Whitnall’s tuber-
cle. In most cases it should be directed toward the zygomaticofrontal suture verti-
cally, and toward the immediate internal aspect of the orbital rim anteroposteriorly.
Drill holes can be placed in the rim and a suture in the canthus can be pulled toward
a wire inside the lateral orbital rim. Canthi should be reattached only after all other
work has been completed and just before the coronal or eyelid incisions are closed.158
This canthal reapproximation using an adjustable wire provides the proper direction
of the canthus and the proper contour of the lid relative to the globe.Canthi may be
secondarily repositioned only with wide subperiosteal dissection and re xation.
After lower lid incisions are made, lid shortening, ectropion, and entropion can oc-
cur in some cases.157,162,163 At least 10% of patients having an incision in the upper
portion of the lower eyelid will experience some permanent vertical lid shorten-
ing.The possibility of lid shortening must be kept in mind when operating on pa-
tients who are elderly or who have lax lower eyelids;a lower orbital rim incision or
conjunctional incisions might be preferred in these individuals. A lax lower lid may
be documented using the lid distraction test. The use of a conjunctival fornix in-
cision with an inferolateral canthotomy places the incision in the fornix of the con-
junctiva rather than immediately beneath the tarsal plate. A fornix incision avoids
lower lid structures, and of all the lower eyelid incisions, this incision seems to cause
the fewest problems with scleral show108; although no objective data exist to prove
its superiority. Standard lower lid incisions dissect the external lamella from the in-
ternal lamella of the lid, which increases potential for in ammation, surgical dam-
age, and lid shortening, which contribute to ectropion and scleral show. Damage to
the orbicularis oculi muscle and orbital septum, resuturing the septum to the peri-
osteum at an abnormal location, in ammation around plates and screws, and infe-
rior positioning of the orbital rim all produce lid shortening. The surgeon should
realize that the lower lid will be able to project only a certain number of millime-
ters above the lower orbital rim. Therefore moving the orbital rim upward is one
mechanism to achieve a better lower lid position. The lower lid should just over-
lap the iris in straightforward gaze and should be able to be pulled superiorly to
above the pupil if normal lid exibility is present. Loss of lid exibility accompa-
nies scleral show and may be assessed by nger pressure, pushing up on the lid to
see how far upward it can be lifted over the surface of the globe.
The initial management of scleral show or ectropion includes massage,“squinch-
ing” orbicularis oculi muscle exercises, and applying warm compresses which will
soften the lid, making it more exible and allowing it to move upward. In the ab-
sence of corneal exposure, 6 months should be permitted for the lid to achieve
maximum spontaneous improvement before secondary corrections are undertaken.
In the absence of spontaneous improvement, there are several lid repositioning
techniques that may be used to correct lower eyelid scleral show and ectropion.The
lid can be redissected, lysing broses or contractures (p. 967, left) in the anterior or
posterior lid lamella (p. 967, center). Graft material may be needed in conjunctival in-
ternal layers (conjunctival, oral, or palatal mucosa with or without cartilage to splint

the internal lid structures) or skin (below right). The lid is then held superiorly for
days with a Frost traction suture.The lower lid may also be splinted to the upper lid
temporarily using an intermarginal suture placed over a soft bolster.
967
Chapter 28
Reoperative Facial Fracture Repair
Nasal septal
cartilage graft
Soft tissue slip
permits inferior
displacement of
normal attachment
of lid at infraorbital
margin
Normal attachment
of lid at infraorbital
margin
Superior traction can also be placed on the lid by correcting the lateral canthal po-
sition and by undermining the periosteum over the lateral and anterior face of the
zygoma (left). The soft tissue of the cheek is mobilized and held upward by virtue
of canthal reattachment and suture reattachment of cheek soft tissue to bone (right).
This maneuver repositions the inferiorly displaced soft tissue at a higher location
and reduces traction on the lower lid. Repositioning the orbital rim upward by os-
teotomy helps to vertically reposition the soft tissue as well.
In cases in which internal support of the posterior lid lamella is desired, a thin wafer
of cartilage from the nasal septum can be used as an interposition material between
the divided orbital septum and the inferior orbital rim.The cartilage acts as an in-
ternal splint to hold the orbital septum superiorly. Recently, there has been enthu-
siasm for using a 0.4 mm Medpor wafer for this purpose.
Contracture
Lysis of scar and septum
Cartilage placed

968
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R EOPERATIVE SURGERY OF THE HEAD AND NECK
Skin graft
Nasal septal
cartilage graft
The worst cases of scleral show and ectropion involve contracture and brosis in
both the anterior and posterior lid lamellae. Note the skin contracture and inter-
nal lid contracture depicted in the illustration (above left). This problem may be ad-
dressed using a combination of the techniques described earlier, with the addition
of a skin graft superiorly at the lower lid tarsal margin. Skin grafts look best when
taken from the contralateral upper eyelid (or as a second choice the postauricular
area from the thinnest postauricular skin), and when placed in the subciliary region
over the orbicularis oculi muscle and over the lower lid tarsal plate. In these cases,
the dissection and incisions should be designed to leave orbicularis oculi muscle
over the tarsal plate so that it can accept a skin graft (Converse approach). Existing
lower eyelid skin is thus approximated to the skin graft at the lower margin of the
tarsal plate. A cartilage graft can be added to support the posterior lamella.
Entropion is usually caused by brosis within the internal lamella, pulling the lid
into an inverted posture. Dissection with lysis of the stricture and the appropriate
use of orbicularis oculi tension-traction sutures on the orbicularis oculi muscle and
lateral canthal repositioning usually correct the problem.
ECTROPION
ENTROPION

LACRIMAL O BSTRUCTION
Lacrimal obstruction should be anticipated in old nasoethmoidoorbital fractures
and can be diagnosed using lacrimal irrigation, probing, or dacyocystogra-
phy.19,116,119,161 Lacrimal obstruction is best treated with dacryocystorhinostomy and
generally is accomplished as a separate procedure. If persistent in ammation and ab-
scess formation exist, the area should be drained;if the duct is simply obstructed, the
sac is then excised at primary correction and dacryocystorhinostomy is performed
as a secondary procedure. It is my impression that primary dacryocystorhinostomy
at the time of canthoplasty is less satisfactory in terms of functional results.
ZYGOMATIC FRACTURES
Zygomatic fracture malposition is commonly noted in postoperative evalua-
tions.42,164,165 The genesis of the malposition is directly related to the failure to ex-
pose the zygoma and its ve buttress articulations at the zygomaticofrontal suture,
inferior orbital rim, zygomaticomaxillary buttress (attaching to the maxillary alve-
olus), internal orbit, and zygomatic arch.16,166 To expose all of these areas, three sep-
arate incisions (coronal, lower lid, and gingival buccal sulcus) are required. In com-
plex cases the use of more limited approaches may permit a false perception of the
true alignment because of incomplete visualization. However, many simple zygo-
matic fractures that are only slightly displaced can be adequately managed by reduc-
ing the zygoma through limited (anterior) exposures via lower eyelid87 and gingival
buccal sulcus incisions,detaching the lateral canthus to expose the zygomaticofrontal
suture.Whenever the zygomatic arch is displaced laterally, a coronal incision is re-
quired to accurately reduce the fracture. Medially displaced arch fractures accom-
panying zygomatic fractures may be reduced through Gillies’closed reduction ap-
proaches.165,166
At least 25% of zygoma fractures are so minimally displaced that they do not need
an open reduction. Many zygoma fractures are minimally medially displaced, with
minimal comminution of the orbital oor, and these may be stabilized after reduc-
tion through a gingival buccal sulcus incision alone.The orbital oor may be visu-
alized using an endoscope through the maxillary sinus.The integrity of the orbital
oor is then determined by palpating the globe and noting displacement of the
oor. Zygomatic fractures displaced at the zygomaticofrontal suture must have a
lateral upper blepharoplasty incision (unless a coronal incision is present). Zygo-
matic fractures with a comminuted orbital oor require a lower eyelid or conjunc-
tival incision. Only 5% of isolated zygoma fractures need a coronal incision, and
these are characterized by lateral displacement of the zygomatic arch or extreme
posterior displacement of the malar eminence. Using these graded principles of
exposure, the most minimal amount of soft tissue exposure (exposures damage tis-
sue and have their own problems) is necessary for a given fracture.
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Reoperative Facial Fracture Repair

970
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
One of the best ways to align the complicated zygoma59 fracture is to simultaneously
assess multiple points of alignment with adjacent bones, including the greater wing
of the sphenoid (see p.958).This structural relationship is a particularly helpful guide
in secondary zygomatic osteotomies, although it takes some practice to use zygo-
maticosphenoid alignment as an indicator of zygomatic position.The anterior pro-
jection of the malar eminence can be assessed by palpation and comparison with
the other side.The position of the orbital rim vertically in the face can also be as-
sessed by nger palpation and comparison with the contralateral orbital rim.
When performing osteotomies, all fracture sites are visualized and the zygoma is
mobilized. One or two alignment points are provisionally positioned and linked
with wires or screw plate xation.Then, once the reminder of the articulations are
adjusted and alignment is veri ed, rigid xation is completed. Bone gaps can be
maintained with rigid xation, and bone grafts can be added. Displaced zygomatic
fractures require refracture and then repositioning of the soft tissue at its proper lo-
cation on the zygoma. In general, early repositioning is not indicated because of the
poor reaction of the lower eyelid to early secondary incisions. If possible, I prefer to
wait 3 to 6 months postoperatively before surgically approaching the area again.

LEFORT FRACTURES
The diagnosis of LeFort fractures is usually con rmed by assessing maxillary mo-
bility.167 In some cases maxillary fractures will be incomplete, with a nonmobile
maxilla. In these cases, a minor malocclusion is present that sometimes initially es-
capes detection.The patient is the most sensitive evaluator of the occlusion, and the
presence of bilateral maxillary sinus uid and fractures of the posterior walls of the
maxillary sinuses should prompt a thorough evaluation to exclude an incomplete,
nonmobile LeFort: fracture diagnosed by a subtle malocclusion.
Patient Examples
971
Chapter 28
Reoperative Facial Fracture Repair
In this photograph, there is rotation of the mandible around a point in the right
parasymphysis area, bringing the incisors and lingual cusps of the left mandibular
dentition out of occlusion. In addition, the maxilla is not level, and is probably ro-
tated to the patient’s left. Postoperatively, when the IMF was released, the patient
was found to have a bilateral open bite in the lateral dentition.The cause was found
to be loose xation in small plates at the angle and ramus (subcondylar) areas.
This patient had an incomplete LeFort fracture and demonstrated no maxillary mo-
bility but did have a minor malocclusion.168 The CT scan shows the presence of bi-
lateral maxillary sinus uid and fractures of the posterior walls of the maxillary sinuses.

972
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R EOPERATIVE SURGERY OF THE HEAD AND NECK
In LeFort fracture open reduction,55,104,169 the failure to completely mobilize the
palatoalveolar or occlusal segment allows the nonmobile maxilla, by intermaxillary
xation, to move the mandible forward in its mandibular muscle sling.The condyle
is moved anterior to its proper position. In such cases the jaws are placed in occlu-
sion, but the condyle has been tracted out of its normal position to meet a slightly
displaced and nonmobile maxilla (arrow). On release of intermaxillary xation, the
mandible returns to its proper position and the patient is left with malocclusion
(usually rotation, tilting, or an anterior open bite). If healing has occurred, the pa-
tient requires maxillary osteotomy. If the condition is diagnosed early, the patient
can be returned to the operating room, the hardware loosened, and the maxilla
mobilized or a LeFort I osteotomy completed.
A patient with a subtle malocclusion and an incomplete LeFort fracture bene ts
from the application of arch bars and elastic traction for several weeks, which is
generally the only treatment these fractures require. Such fractures are often “sin-
gle-segment” LeFort II or LeFort III fractures in which the maxilla is displaced a
fraction of a cusp at the occlusal level and are accompanied by periorbital ecchy-
mosis and bilateral maxillary sinus uid.
In the case of simultaneous mandibular sub-
condylar and maxillary fractures, only man-
dibular subcondylar fracture reduction can
achieve proper positioning of the jaws.The
condylar fracture permits the mandible to be
dislocated out of normal position to meet a
displaced, impacted maxilla.

The failure to bone graft the LeFort I level in cases of bone loss results in poor sta-
bility, especially in the edentulous patient. Bone grafting the LeFort I level also pre-
vents soft tissue buccal fat from prolapsing into the maxillary sinus. Edentulous pa-
tients generally have thin bone, and often the lower end of the plates must be xed
directly onto the alveolar ridge to achieve stability. These plates must be removed
to permit wearing of a denture. Even if no denture is worn, the plates will eventu-
ally wear through the gingiva.
One of the most frequent problems with maxillary or mandibular fractures is the
improper application or use of arch bars.When applied in a loose or mobile fash-
ion, arch bars permit intraoperative displacement at the time of open reduction or
postoperative movement, resulting in malocclusion. After such displacement, the
reconstruction can rarely be salvaged using postoperative elastic traction because
elastics merely aggravate the loose arch bar condition. The proper application of
arch bars begins with careful wiring of the bars to the teeth, usually with No. 24
wire. When the initial wire tightening has been completed, all wires are then
retightened and the bar is checked to see that it is not mobile in any direction. Af-
ter several days, the wire stretches;it is my practice to return the patient to the op-
erating room at this time to reestablish the integrity of tight, secure intermaxillary
xation.
Patient Example
973
Chapter 28
Reoperative Facial Fracture Repair
Proper occlusion is determined by an analysis of cusp position using wear facets and
dental models. It must be emphasized that the routine use of dental models will pre-
vent many errors in alignment.These dental models allow a relaxed study of the oc-
clusion; the ideal occlusal relationship can then be marked with a pencil on the
models at the rst molar, cuspid, and central incisor points. The models are taken
into the operating room or the ward to use as a guide for proper position. In most
cases, arch bars serve to bring the jaws into occlusion at intervals determined by the
surgeon with the application of guiding elastics. Application of nighttime elastics is
a common practice. A soft diet is preferred until healing has occurred.

974
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R EOPERATIVE SURGERY OF THE HEAD AND NECK
In some cases splints on the lingual aspect of the mandible or palatal splints in the
maxilla can accurately position segments in the jaws that are involved in alveolar
fractures for better open reduction. Occlusal surface splints do not work as well in
fracture treatment.
Far more serious problems have been created by the early release of intermaxillary
xation than has been caused by stiffness experienced after prolonged intermaxil-
lary xation. Maxillary fracture reductions are seldom rigid because of the thinness
of the bone, and many maxillary fractures bene t from several weeks of intermax-
illary xation. If (after the release of intermaxillary xation) malocclusion is ob-
served, intermaxillary xation should be reinstituted immediately. The bene ts of
the early release of intermaxillary xation have been overemphasized in the liter-
ature; more complex fractures bene t from occlusal guidance by light elastic trac-
tion in the period of early mobilization.
Normally the mandible is used as a guide for proper position of the lower portion
of a LeFort fracture.The maxillary teeth and the supporting alveolar bone are po-
sitioned by intermaxillary xation to a properly positioned mandible. Therefore
open reduction of the ramus and subcondylar areas48,170-172 in selected cases, as well
as open reduction of the horizontal portion of the mandible, are necessary to de-
termine the position of the lower maxilla; a stabilized mandible dictates accurate
position of the lower maxilla. Treating the displaced mandibular ramus fracture
closed—when the mandible is used as a basis for LeFort fracture reduction—will
often guarantee displacement and an occlusal cant in the maxilla.