Reoperative Aesthetic & Reconstructive Plastic Surgery

976
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The upper portion of LeFort fractures consists of zygomatic, nasoethmoidal, and or-
bital fractures. These fractures have been discussed previously. As a general rule, in
complicated LeFort or panfacial fractures, the mandible and frontal bone recon-
structions should be completed rst.
“Dependent” bones of the midface are shown above.The shaded structures are de-
pendent in that they depend for their support and projection on all the adjacent
bones at the midfacial periphery to be in the right position and to have suf cient
structural integrity. Because midfacial bones are weak, the principal support of the
lower midface is through IMF to an anatomically positioned and stabilized man-
dible.The frontal bone (stabilized) is the principal support of the upper midface.
The upper and lower maxilla, zygoma, and nasoethmoidal areas are dependent
structures in terms of their position being dictated by a properly positioned
mandible or frontal bone. A sequential order of treatment is therefore followed that
progresses from the facial peripheries to the midface.2,6,7,34,81

The posterior pattern of zygomatic arch fractures81,137 involves either a sagittal frac-
ture through the glenoid fossa or a lateral fracture adjacent to and perhaps through
the glenoid fossa. These fractures sometime require complicated xations such as
lag screw or plate xation on the roof of the glenoid fossa, or plate xation that ex-
tends the zygomatic reduction onto the temporal bone. All of these maneuvers in-
crease the stability of the arch reduction.These images show a high-energy fracture-
dislocation of the zygoma.The zygoma and glenoid fossae are cleaved from the skull
and should be reattached.CT scans are shown before (left) and after (right) reduction.
977
Chapter 28
Reoperative Facial Fracture Repair
The sagittal buttresses of the face are indicated
(arrows). Note that the midface has one single
sagittal buttress—the zygomatic arch. The
frontal bone and mandible thus become im-
portant in support of the central midface espe-
cially in the nose, nasoethmoid and medial or-
bit regions.
The zygomatic arch is a key landmark in a
midfacial position.* Errors in treatment often
result in its lateral displacement because of ei-
ther inaccurate reduction or failure to expose
the zygomatic arch. The zygomatic arch is re-
ally not an arch: it is at in its midportion. It
should be reconstructed as a at structure, using
plates and screws on the lateral surface of the
arch. Such xation can increase the midfacial
width in this area, which produces another de-
formity. The arch should therefore be overre-
duced to ensure its atness.
*References 6, 16, 26, 55, 65, 81, 137.

978
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Screw length in the glenoid fossa should be short to avoid penetrating the temporo-
mandibular joint. In this case the lag screws entered the joint. Drilling the screws
away from the superior aspect of the joint would have prevented this problem.
As the zygomatic arch is reduced medially, the greater wing of sphenoid and the or-
bital process of the zygoma come into alignment (see pp. 926 and 958). Proper re-
duction of the zygomatic arch is therefore con rmed by sphenoid alignment and
by assessing the length of the arch, which extends to push the anterior position of
the zygoma forward to create proper projection of the malar eminence. All of these
parameters can be used as guides to proper alignment of the zygomatic arch.
LeFort II and LeFort III fractures generally consist of combinations of lesser LeFort
fragments.* It is helpful to describe LeFort fractures in terms of the fragment car-
rying the maxillary dentition (generally a LeFort I or a LeFort II fragment with or
without a palatal split), and the fracture levels on each side, such as right III-II-I and
left II-I. Patients with reconstructed LeFort fractures generally show a tendency
toward midface shortening and malar and nasal retrusion. Patients with untreated
LeFort fractures present late with midface elongation and attening. Elongation oc-
curs secondary to midface lengthening, principally at the LeFort I level.When the
LeFort I segment drops posteriorly, it creates a premature contact with the mandible
in the molar occlusion, and an anterior open bite. Lengthening may occur through
the orbits as well. Lengthening in the maxilla, orbits, and nose can be determined
by physical examination and can be con rmed using axial and coronal CT scans.
*References 6-8, 15, 35, 87, 104, 113, 173.

Proper midface length may be established by nding at least one buttress that can
be anatomically reassembled.This sets the vertical height of the midface correctly.
In the absence of a buttress that can be anatomically reconstructed, lip-tooth posi-
tion and the vertical length of the face (dashed lines) as established from old pictures
are good guides to midface length.
The amount of shortening or lengthening required may be determined by analy-
sis of physical measurements, posteroanterior cephalometrograms, and CT scans.
Findings should be con rmed by comparing the patient’s current appearance with
the appearance in preinjury photographs.
Zygomatic and nasal retrusion are managed by osteotomy and onlay grafting as re-
quired. Seldom can a large single-segment osteotomy, such as a LeFort II or III os-
teotomy, be performed when a multiple-segment osteotomy, such as a zygomatic,
nasal, and LeFort I combination, is truly indicated. Each segment requires different
repositioning three dimensionally, which cannot be achieved with a single-segment
movement.
979
Chapter 28
Reoperative Facial Fracture Repair

980
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Planning for LeFort I segment osteotomy requires a study of the occlusion and
cephalometrograms, as well as a Panorex examination, a review of old orthodontic
or dental records, and an assessment of preinjury photographs of the patient with
the face both at rest and smiling from frontal and lateral perspectives. These pho-
tographs should show lip-tooth relations, zygomatic and malar prominence, and
nasal and midfacial length.86 Plans to lengthen the midface at the LeFort I level
and to tilt the occlusal plane must include the provision for bone grafts at the
LeFort I level to serve as buttresses to the plate xations. Bone at the LeFort I level
is thin. If shortening has occurred, it is generally because this bone is thin; it is
therefore questionable whether the bone is of suf cient thickness to heal sponta-
neously after refracture and LeFort I osteotomy. A degree of relapse can be expected
after downgraft or advancement procedures. Bone grafts may have to be added.
Edentulous maxillary fractures virtually always require bone grafts.16,174

The “buttress system analysis” for edentulous maxillary and mandible fractures re-
quires that dentures set the anterior and posterior height of the maxilla by using the
anatomically reconstructed mandible as a guide (P1
horizontal mandible). Max-
illary projection is set by alignment of the incisor portion of the denture with the
lower incisor portion of the denture of the mandible.
Patients undergoing occlusal segment osteotomy (LeFort I or II) should be pre-
pared to undergo preoperative and postoperative orthodontics to obtain the best re-
sult. In patients in whom the occlusal plane needs to be leveled, a combination
LeFort I and sagittal split procedure is needed. Hardware may need to be removed
to permit the sagittal split or LeFort I procedures to be performed. In repeat LeFort
I osteotomies three screws for xation in each segment, and bone grafts, provide
maximal stability. Postoperatively, vigilant monitoring of the occlusion is required,
and any deviation should be treated with elastic traction or intermaxillary xation.
It is not harmful (and is perhaps desirable in complicated cases) to proceed with
1 to 3 weeks of intermaxillary xation to ensure stability. In general, osteotomies are
best performed through old fracture sites.
If malocclusion is noted within 2 weeks after the initial fracture repair, the fracture
can usually be mobilized using elastic traction. After this period care must be taken
to avoid extracting teeth by elastic traction. Between 2 and 4 weeks postopera-
tively it is best to return the patient to the operating room, remove the screws from
the LeFort I segment, and mobilize the fractures using manipulation with Rowe
forceps, or by inserting an osteotome in the fracture sites to loosen them before
mobilization.The screws are then reinserted in different locations.
If malocclusion is noted after 4 weeks and does not respond to elastic traction, an
osteotomy through the fracture sites is required. It may be best at this stage to al-
low the patient to heal and acquire more mandibular motion, and then proceed
with LeFort I osteotomy after several months have elapsed. The timing of os-
981
Chapter 28
Reoperative Facial Fracture Repair
P
Z
N
P 1
P 1

982
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
teotomy must be determined on an individual basis after an analysis of general pa-
tient recovery and condition, joint motion, pain, ability to chew, and emotional
state. The range of orthodontic corrections is only several millimeters; orthodon-
tics are better suited for horizontal or lateral movements of teeth than for correc-
tion of open bites.
Patient Examples
This patient presented with an anterior open bite and a laterally displaced zygoma.
She underwent LeFort I and zygomatic osteotomies.

This patient had a retruded face after a LeFort II fracture. LeFort II osteotomy,
bone grafting, and subperiosteal rhytidectomy were performed.
983
Chapter 28
Reoperative Facial Fracture Repair

984
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
SAGITTAL FRACTURES OF THE MAXILLA
With fractures that comminute the dental arches, complex fracture reduction is
more dif cult.22,94,175-177 These fractures are diagnosed by palpation of the dental
arches to detect movement laterally and medially.177 They can be visualized on ax-
ial or coronal CT scans. Sagittal fractures (for example, an alveolar sagittal fracture
as shown, top) in adults are usually adjacent to the midline and in children are ac-
tually in the midline. Other alveolar fractures of the maxilla involve only segments
such as the molar area (bottom) or anterior (incisor) area.These fractures may exist
alone or simultaneously with other LeFort fractures. Exposure can be through the
laceration, or with a palatal degloving technique.176,177
Alveolar sagittal fracture
Alveolar fracture of the molar segment

A palatal splint175 can be used to stabilize fractures of the molar segment, but when
the fractures are sagittal and when large fragments exist, a direct open reduction in
the roof of the mouth with 2.0 mm plates and screws can correct excess maxillary
width.55,94,177 Screws are placed to avoid tooth roots.41 A plate at the piriform aper-
ture completes the reduction.
The width of the maxillary dental arch is the best guide to the width of the
mandibular dental arch. Normally the width of the mandibular dental arch should
be less than that of the maxillary arch by one cusp on each side. Direct open reduc-
tion in the roof of the palatal vault eliminates the guesswork that was previously re-
quired when dental splint reduction was used. A midface plate is also placed on the
fracture at the piriform aperture, which is accessed by a gingival buccal sulcus inci-
sion. The maxillary arch is reduced to a single segment, allowing it to be managed
in the same fashion as an intact maxillary arch. In cases in which these plates do not
provide suf cient stability, a palatal splint could be added to achieve ne adjustment
of the occlusion and to add further stability to the inclination of the dentition.
If instability of the central arch fracture xation is noted postoperatively, the patient
should be returned to the operating room for a direct open reduction or insertion
of a splint with tightening of the xation.The lateral maxillary segments often ap-
pear canted palatally (top right). The reduction of the mandible may have to be
changed if the width of the maxilla is altered.
Late postoperative maxillary alveolar fracture problems require a multiple-segment
osteotomy.The maxilla is approached through exposure at the LeFort I level.The
maxilla may be divided using a superior approach to the palate, removing a small
segment of bone, and moving the arch segments medially. Patients with these prob-
lems generally require preoperative and postoperative orthodontics and dental splint
reconstruction. A plate may be placed on the superior surface of the palate across
the palatal osteotomy from a superior exposure.
985
Chapter 28
Reoperative Facial Fracture Repair

986
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The second most common reason for poor results in the treatment of mandibular
fractures is inadequate xation of the mandibular fracture. This problem is partic-
ularly prone to occur in edentulous mandibular fractures in which the height of
bone available for “buttressing” of the fracture (necessary to supplement the strength
of plate and screw xation) is absent.179 If the height of the mandible is less than
10 mm, supplemental bone grafting and “bone gap” xation (a long, strong plate,
with at least 4 good screws on each side of the fracture is preferred).180 Elderly pa-
tients are expected to have more bone loss, poorer healing, and more xation prob-
lems.43,62,174,179-181 Alveolar fractures accompanying mandible fractures are especially
MAXILLARY (LEFORT) FRACTURES
Maxillary (LeFort) fractures must be managed according to the deformity and dis-
placement observed in their various components; the LeFort I segment must be
managed if malocclusion is present with a LeFort I osteotomy with preoperative
and postoperative orthodontia. Early elastic traction may be able to reposition the
LeFort I segment; care should be taken to observe and limit extrusion of the teeth
in response to elastic traction.In LeFort I osteotomy,both plate xation and supple-
mental bone grafting may be required, especially when the maxilla is edentulous.174
Some LeFort fractures are incomplete or impacted, demonstrate no mobility, and
must be completed by osteotomy.168
MANDIBULAR FRACTURES
Mandibular fractures can create problems that range from malocclusion and tem-
poromandibular joint disturbances to infection, nonunion, loss of motion, and pain.
The most common reasons for poor results in mandibular fracture treatment are
unstable intermaxillary xation or the establishment of inaccurate occlusion at the
time of open reduction,178 or insuf cient xation in good bone.

prone to malocclusion. In general, mandibular fractures are more extensive along
the lingual cortex than along the buccal cortex; when a plate that is too small is
used, screws are placed within (and not beyond) parts of the fracture, and stability
is not achieved. Microfractures adjacent to the more visible fractures are common
and cause unstable xation in the screws inserted.The use of small (midface) plates
and screws in mandibular fractures is appropriate only if the occlusion is moni-
tored consistently and carefully postoperatively.Their use is inappropriate in com-
minuted fractures, mandibular defect fractures, and the multiply fractured mandible.
Small xation systems with unicortical xation are inherently less stable than 2.4 or
2.7 mm systems and work by impaction of the bone edges, creating a “load shar-
ing” as a result of the impaction of the fracture fragments.
The use of smaller plates and screws in the mandible may or may not guarantee sta-
bility with early movement. Postoperative release of intermaxillary xation is un-
wise in patients with inherently less stable reductions, particularly patients with
combined LeFort and mandibular fractures. I prefer a period of postoperative rest
in IMF for 1 week for most mandibular fractures to achieve soft tissue rest.182
Personally,I prefer to place at least three bicortical screws on each side of the fracture
in solid bone beyond the fracture site as demonstrated in the illustration on p. 986.
The fracture site must be determined using preoperative CT scans because of the
differing extent of injury to the buccal and lingual cortices.43 The decision of how
much xation to use in a particular fracture depends on bone quality, bone volume,
and strength or xation.43 Establishing rigid xation requires the insertion of at
least two solid screws to either side of a fractured area. However, if one of these
screws were to become loose, and if a screw is placed in a microfracture, the frac-
ture reduction will be unstable.Thus the routine provision of a third screw on each
side allows the fracture to be stabilized with an additional measure of security. Ad-
ditional stability in mandibular reconstruction may be obtained by bicortical screw
purchase.The drill should be constantly irrigated during the drilling to avoid heat
induced bone necrosis, which could result in early screw loosening. If smoke is
seen, irrigation is insuf cient.The plate must also be properly contoured. I do not
prefer the use of resorbable plates because they generate an inflammatory re-
sponse.183
The use of compression plates in the mandible permits additional force to be ap-
plied to both the fracture gap and the occlusion. Such compressive force often cre-
ates subtle changes in the occlusal pattern from its more relaxed position in inter-
maxillary fixation before application of compression. Compression is greatly
overused in mandibular fracture treatment. My personal philosophy in complex
bone defect fractures is not to use compression but to merely use stable bicortical
xation with plates of the 2.4 or 2.7 mm systems of the reconstruction plate vari-
ety. In this way, the plate bears the weight of fracture load. Longer xation devices
may be used. Routinely avoiding compression in mandibular fractures generally
987
Chapter 28
Reoperative Facial Fracture Repair

988
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
improves occlusal results without adversely affecting stability.When plates are used
to stabilize fractures in which a mandibular bone defect exists, four or ve screws
should be placed on either side of the defect fracture to provide suf cient plate
length and stability so that screw loosening does not occur. Compression has no
place in the treatment of comminuted fractures or in mandibular defect fractures.
Reoperative treatment plans (and many fracture results) usually involve considera-
tion of preoperative and postoperative orthodontics. Mandibular fractures can be
influenced adversely by unstable or periodontally involved teeth; such teeth are
better extracted.62,184
Osteotomy of the maxilla may be easier than refracture of the mandible in some
cases of anterior open bite after malaligned subcondylar fractures, particularly if
joint function is good.
In patients presenting with postoperative malocclusion, a complete analysis of the
maxilla and mandible should be undertaken by study of current dental models,
comparison with previous models and dental records, Panorex examination, and
study of both apical lms of the teeth and CT scans.41 Based on this information,
one can decide whether early or late treatment is preferred.
Angle Fractures
Angle fractures of the mandible are the type of mandibular fracture most prone to
complications.62,159,184 The use of a tension band plate superiorly is the preferred
treatment for noncomminuted fractures in which the bone can bear the load of the
fracture xation.This technique is subject to the fewest number of complications.43
For larger fractures or comminuted fractures a 2.4 or 2.7 mm plate inferiorly (with
three screws in solid bone to each side of the fracture) provides good stability in this
area. A superior border tension band plate adds stability. In angle fractures, bone at
the superior aspect of the fracture site is usually devitalized and exposed intra-
orally.22 Open reduction further devitalizes this bone, and watertight mucosal clo-
sures are sometimes dif cult to achieve in this area, which sets the stage for local-
ized sepsis to develop.69 Allowing the soft tissue to “rest” during an initial period of
postoperative intermaxillary xation greatly reduces sepsis in these patients.
When sepsis exists in a fracture site, an antibiotic regimen should be instituted, ap-
propriate radiographs taken, and the mandible placed at a rest in intermaxillary x-
ation.3 Infections usually respond to this nonoperative treatment. Drainage should
be instituted and any devitalized bone fragments must be removed.

However, if the sepsis does not resolve promptly, another cause for persistent infec-
tion exists, such as a loose plate or loose screws in the presence of mandibular mo-
tion, infected teeth,40 or dead bone (osteitis). In some cases, infection will spread
into the deep planes of the neck,185 requiring incision; often a laceration into the
oor of the mouth opens these tissues planes initially. Thorough examination of
radiographs, including Panorex lms (bottom left), is required. Signi cant intraoral
lacerations, especially of the oor of the mouth, should be drained. In this situation
the patient must be returned to the operating room, the incision reopened, the
dead bone removed (top), and the fracture stabilized with a longer plate (2.7 mm)
with a least four screws on each side of the defect. The depths of the soft tissue
must be drained. In the case of the angle fractures, this reoperation usually requires
an external approach. Alternatively, the use of a biphasic external xation device
(bottom right) can allow the removal of internal hardware to permit soft tissue heal-
ing. Although there is some enthusiasm for immediate bone grafting in this situa-
tion, I favor bone grafting only after control of the soft tissue infection.
Nonunion is very uncommon with rigid xation. It is managed by resection of
the brotic area, bone grafting, and application of stable rigid xation, which usu-
ally means that a considerably longer plate must be applied.
989
Chapter 28
Reoperative Facial Fracture Repair
Debridement of bone
Panorex lm of defect
Biphasic appliance

990
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
External cortex
One of the most common mistakes made in treating symphysis or parasymphysis
fractures is to allow the angles to are and the teeth to tip lingually (left), which brings
the lingual cusps of the mandibular teeth out of occlusion with palatal cusps of the
maxillary teeth.This situation can be diagnosed by noting the angle of the inclination
of the lower lateral mandibular teeth at the time of reduction.The maneuver of El-
lis (right),34,172,186 pushing in on the angles until the anterior labial cortex of the
mandible gaps, is recommended. Malalignment results in excess mandibular width
and can be corrected only by refracture, watching the alignment of the labial cortex
of the mandibular symphysis while pushing inward on the angles. As one pushes in-
ward on the angles,the lingual cortex of the mandible at the symphysis will come into
approximation as the labial cortex gaps slightly. Once the labial cortex begins to gap,
proper alignment of the lingual cortex has been achieved and the plate can then be
bent to conform to the proper con guration of the anterior surface of the mandible.
A 10- or 12-hole plate helps to control displacement of the angles. A lingual splint
placed at the time of reduction helps to accurately position and rotate the lateral
mandibular segments.The plates and screws are then applied to the symphysis.
Comminuted fractures are managed by
replacing the small fragments onto the
larger bone pieces using a smaller fixa-
tion system, and then reassembling the
larger pieces.43 The larger segments are
stabilized using a “load-bearing” plate.
Immediate mandibular nonvascularized
bone grafting has a failure rate of 35% to
50%. Normally, thicker mandibular plates
should be “overbent” to allow their pro-
jection off the fracture site by 2 to 3 mm;
this maneuver improves the approxima-
tion of the lingual cortex.

Condylar Fractures
Condylar fractures in adults that do not display much malalignment between the
proximal and distal fragments, and those in which proper ramus length is preserved,
can be treated with closed reduction and intermaxillary xation14,33,187-189 or a soft
diet and close observation. When the alignment difference exceeds 30 degrees or
when the lack of bone contact in the fracture gap exceeds 3-4 mm, an open reduc-
tion should be considered.170-172,178,188 However, condylar fractures with head dislo-
cation in adults are usually best managed by open reduction and replacement of the
condyle within the fossa.184,187 Considerable resorption of the head may occur. In
patients with condylar fractures with fracture overlap treated with closed reduc-
tion, if the ramus shortens an open bite may develop when intermaxillary xation
is released.172 Generally, a short ramus length is associated with an open bite in the
contralateral lateral dentition.171,172,188 Occlusal grinding of the ipsilateral molar re-
gion can lower the height of the ipsilateral posterior teeth, permitting better occlu-
sion in minor cases of open bite.175
991
Chapter 28
Reoperative Facial Fracture Repair
Elastic traction may be used to close an anterior open bite but should not place
force directly on the anterior incisor teeth or they will extrude. An interocclusal
splint26 will prevent incisor extrusion.The lengths of the teeth should be measured
and inspected when elastic traction is employed.
Malaligned subcondylar fracture
Sagittal split osteotomy

Reduced
ramus height
992
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
When condylar motion is poor,48,189 open exploration and lysis of bony and brous
adhesions are indicated.22 If disc or meniscus tears are noted during condylar open
reduction, they should be repaired primarily. A vascularized temporoparietal fascial
flap can be used for joint disc reconstruction if an excessively shredded disc or
meniscus exists. When ramus height is reduced and malocclusion is present the
ankylosis should be resected and a costochondral graft or arti cial joint used for re-
placement.48 In the example above, the condylar head is partially resorbed and a
costochondral graft has been placed.
If a temporomandibular joint problem is noted preoperatively or postoperatively, an
MRI examination combined with a physical examination is indicated. Locking or
painful motion suggests the need for MRI examination.Tears or displacement may
occasionally require open repair if the problem does not respond to physical ther-
apy; nonoperative treatment is preferred for most problems.
Combined Mandibular Fractures
The combination of symphysis and bilateral subcondylar fractures34,171,172,190 treated
with closed reduction, especially if the condylar heads are displaced from the fossa,
almost inevitably results in an open bite. In this case, when intermaxillary xation
is released, the mandible drops into malocclusion. A small amount of malocclu-
sion, if detected early, may be managed with traction elastics or reinstitution of in-
termaxillary xation. However, once the fracture has partially healed, if elastic trac-
tion is attempted extrusion of the incisor teeth rather than movement of the
misaligned fracture fragment is a risk. Careful judgment is required when using
elastic traction. In this situation, an elective sagittal split osteotomy or maxillary os-
teotomy would be the operation of choice when good mandibular temporo-
mandibular joint motion without pain is fully established.2 Condyle open reduc-
COSTOCHONDRAL GRAFT

993
Chapter 28
Reoperative Facial Fracture Repair
The mentalis muscle is transected in intraoral approaches to the symphysis-
parasymphysis region. A cuff of muscle should be left attached to the mandibular
bone so that secure repair of the muscle can be completed with long-lasting sutures
when the incisions are closed.The muscle positions and tenses the lower lip, and lip
ectropion occurs if repair fails or is incomplete.191
Lower lip malposition (ectropion) usually results from severance and lack of repair
of the mentalis muscle attachment.The lip can be secondarily repositioned with the
procedure of Zide191 (arrow) in an attempt to achieve a higher mentalis muscular at-
tachment on the bone.This procedure requires a dissection, which leaves some soft
tissue on the bone with resuturing of the rest of the lip to this tissue. Zide prefers
suturing the mentalis to drill holes between the incisors. In this case direct attach-
ment of the mobilized lip to the bone is completed after subperiosteal mobilization.
Kirschner wires may be used through the lip but are more traumatic than soft tis-
sue anchors.
tions are plagued with the problem of poor bone:microfractures, dif culty with x-
ation, and marked tendency to condylar head resorption if the condyle is mobilized
from a dislocated position. Close postoperative evaluation of the patient’s occlusion
at twice weekly intervals and initially secure intermaxillary xation are the best
prevention for malocclusion. Patients should be closely monitored once intermax-
illary xation is released and the patient is afforded jaw function.The arch bars are
left in place for several weeks after release of the intermaxillary xation so that in-
termaxillary xation or elastic traction can be easily reinstituted if there is a prob-
lem.To permit tissue healing and joint rest, intermaxillary xation is used postop-
eratively for at least 1 week in outpatients even if a stable mandible has been
obtained by rigid xation.

994
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
When mandibular alveolar fractures are accompanied by other mandibular frac-
tures, they are prone to ischemia.They may be stabilized with rigid xation (above).
A lingual splint175 or an acrylated arch bar may be used to provide supplemental sta-
bilization. Premature contact of the fracture fragment (traumatic occlusion) must be
avoided or the fragment usually necroses. Treatment should include observation
for sepsis and devitalized teeth.
PEDIATRIC FRACTURES
Fractures in children should be treated as early as possible to avoid dif culty with
reduction. Because of rapid healing in children, if surgery is delayed, refracture of a
partially healed bone is often necessary to achieve reduction.40 In general, pediatric
fractures should be treated with direct open reduction if displaced. The choice of
treatment approaches requires some judgment when fractures of the maxilla and
mandible are considered because of the presence of many unerupted teeth. Appro-
priate lms demonstrating the location of the teeth must be obtained, and then
the fracture pattern must be analyzed to determine the type and location of the x-
ation necessary.
In children, arch bars and intermaxillary xation should be supplemented by skele-
tal wires because it is more dif cult to obtain stable intermaxillary xation with cir-
cumdental wires alone. The skeletal wires can be placed circumdentally, or to the
piriform aperature or the inferior orbital rim. I prefer to stabilize skeletal wires to

cortical screws that are placed away from the arch bars.The image at the bottom of
p.994 demonstrates the use of skeletal wires to support arch bars in a pediatric patient.
I believe that all cases of pediatric condylar fractures (even dislocation) in patients
less than 8 years of age can be treated using closed reduction and intermaxillary x-
ation because children have a remarkable propensity to condylar restitution by
virtue of their proliferative periosteum. If an open bite develops, the child needs to
be returned to the operating room either for reduction of occlusion and revision of
intermaxillary xation by skeletal wire placement or perhaps an open reduction.40
Adults, in contrast, require open reduction if the condylar head is dislocated from
the fossa or badly misaligned with the distal (ramus) fragment.
The possibilities for future limited growth in children are not as common as would
be expected, considering the nature of the injuries.2 I have observed midface retar-
dation after extensive midface and NOE fractures in the 2- to 4-year age group, and
in the mandible in the 6- to10-year age group.The advantages of internal (metal-
lic plate and screw) xation devices must be weighed against the possible need for
removal of the devices, and the possible injury to developing teeth and damage
caused by reduction exposures. It has been shown that routine removal of xation
devices may be more problematic than leaving them alone. Concerns about future
growth with rigid xation devices in place have not been as important as postu-
lated.The growth restriction is perhaps 5% or less and probably barely doubles the
restriction expected from interfragmentary wires or injury alone.
FACIAL FRACTURES WITH BONE
AND SOFT TISSUE LOSS
Treatment of the bone in patients with facial fractures with bone and soft tissue
loss138,147 is conceptually the same as that for reconstruction of facial fractures with-
out bone and soft tissue loss.This statement is true in that a direct immediate open
reduction, establishing anatomic position of existing bone and tolerating gaps in
bone until soft tissue cover may be provided, is the preferred primary treatment.
Closure of soft tissue should be performed for all fractures in the zone of soft tissue
injury.114 In the “zone of injury,” fractures have no signi cant bone or soft tissue loss
and may be managed with open reduction using the usual techniques.192 In the zone
of tissue loss,initial soft tissue reduction is followed by serial wound inspection in the
operating room with removal of hematomas and all devitalized tissue, always com-
pleting soft tissue closure by advancement and allograft, or if necessary by skin-to-
mucosa closure.67,193 Usually, these patients must be returned to the operating room
every 1 to 2 days for wound inspection, irrigation, and further debridement of de-
vitalized tissue.The soft tissue should be reopened and then reclosed for each of the
serial operations to prevent soft tissue contracture. Once no further hematomas or
dead tissue are seen on the serial inspections, the de cient areas of bone and soft tis-
sue are reconstructed in terms of soft tissue and bone defects.This plan for separately
managed zones of soft tissue and bony injury versus zones of soft tissue and bone loss
forms the basis for safe and effective management of these devastating injuries.
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Patient Example
Similarly, the patient has areas of bone injury and bone loss. All areas of existing
bone should be stabilized with rigid xation through the wound or through care-
fully selected incisions. These photographs depict mandibular stabilization with a
reconstruction plate.
This individual sustained a shotgun blast to the face.There are areas of soft tissue in-
jury and areas of soft tissue loss in the midface and mandible.

Replacement of the missing soft tissue and bone
(separately or together) should then occur by
free tissue transfer. In this case, a free bula for
the mandible and a bone-containing radial fore-
arm flap for the midfacial skeleton and cheek
were used. Radial forearm ap harvest is shown
below.
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Bone gaps (missing bone) are stabilized to the usual anatomic length of the bone
spanning any defects with plates. Soft tissue is closed or repaired in areas of soft tis-
sue de cit with skin-to-mucosa closure.The patient is taken back to the operating
room every 48 hours until no further devitalized tissue is seen. Reclosure of the soft
tissue keeps the soft tissue from contracting. A midface stabilization was performed
in this patient.The cutaneous defect is seen;the amount of soft tissue loss in the in-
ternal midface (“lining”) greatly exceeds the cutaneous loss.

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Later, the mismatched skin segment of the cheek free ap can be excised and re-
placed with normally matching facial skin.
Two other patients are shown with bone defects originally spanned by plates.The
provision of an intact skeletal structure in the zone of the injury allows the soft tis-
sue to heal over the repositioned bone frame, preserving soft tissue volume and
shape and preventing soft tissue contracture.67,164 Initially, bone defects may be
spanned with rigid xation, which lends support to existing soft tissue in the zone
of loss. Existing bone should be stabilized in anatomic location, and any bone de-
fects, such as those in the mandible, should be stabilized with a gap using rigid x-
ation with a large plate (2.4 or 2.7 mm system) with four to ve bicortical screws
on each side of the bone defect in solid bone.

When soft tissue health is stable, a free (vascularized) bone graft should be trans-
ferred for the zones of midface or mandibular bone loss. Mandibular bone defects
exceeding 4 cm are best managed by vascularized bone transfers.The bula and il-
iac crest are the most common donor sites and permit osteotomy of bone graft
segments to reestablish normal mandibular contour and occlusion. Smaller bone
defects are managed by nonvascularized cortical and cancellous bone grafts or tita-
nium trays with cancellous bone.Bone grafts with lining (a “composite” tissue trans-
fer with a cutaneous paddle) can also be unicortical with the bone graft–composite
soft tissue ap designed to simultaneously ll lining and skin cover defects, and a
bone defect.
It is emphasized that patients with signi cant soft tissue and skeletal injuries should
frequently be returned to the operating room for “second-look” procedures193 to ob-
serve for infection, hematoma, or additional death of tissue; the surgeon should not
wait for these problems to surface by obvious symptoms of infection or skin necro-
sis.114,192 The early serial return to the operating room allows the surgeon to assess
the stability of xation, to evacuate hematomas, and to excise any devitalized tissue,
which prevents infection. Although the soft tissue wound must be reopened and re-
closed frequently in these cases, this process is less harmful than allowing an infec-
tion to occur.These “second-look”193 procedures permit debridement at the time
of the initial injury to be more conservative and therefore more bone and soft tis-
sue can ultimately be preserved. In mandibular fractures in which multiple frag-
ments of the mandible are replaced as nonvascularized bone grafts, there is a 25%
rate of infection and bone loss.This statistic could be viewed however as a 75% suc-
cess rate in these complex cases. Patients must be counseled appropriately and re-
turned to the operating room for removal of the bone fragments if they become in-
fected. The bone defect produced can then be managed secondarily with a free
tissue transfer, preserving the correct anatomic shape and position of the existing
bone with rigid xation to stabilize the length of the bone defect.
CONCLUSION
Reoperative treatment of facial injuries requires a complete understanding of the
basic techniques of initial fracture repair and soft tissue healing. Facility with rhino-
plasty and with orthognathic surgery principles is required. Analysis of the portion
of the facial skeleton involved should be completely accessed before the secondary
correction is undertaken.The success of correction relates to the accuracy of pre-
operative analysis and to the ability to expose the injured area to permit satisfactory
realignment of the malpositioned bone segments.The covering tissue must often be
reshaped, repositioned, and less commonly, replaced. Preparation for secondary pro-
cedures in the mandible or the maxilla requires orthodontic treatment and occlusal
analysis. Soft tissue cannot be neglected in secondary reconstruction. Proper soft tis-
sue position and shape indeed dramatically in uence the nal result. Both bone
and soft tissue therapy must be incorporated into any reoperative facial injury treat-
ment plan.
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127. Freihofer HPM. Inner inter-canthal and interorbital distance. J Maxillofac Surg 8:324-326,
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128. Antonyshyn O, Gruss JS. Complex orbital trauma:the role of rigid xation and primary bone
grafting. Adv Ophthalmol Plast Reconstr Surg 7:61-92, 1988.
129. Antonyshyn O, Gruss JS, Cassle EE. Blow-in fractures of the orbit. Plast Reconstr Surg 84:10-
20, 1989.
130. Antonyshyn O, Gruss JS, Galbraith DJ, et al. Complex orbital fractures: A critical analysis of
immediate bone graft reconstruction. Ann Plast Surg 22:220-235, 1989.
131. Marsh J, Gado M.The longitudinal orbital CT projection. A versatile image for orbital assess-
ment. Plast Reconstr Surg 71:308-317, 1983.
132. Manson PN, Clifford CM, Su CT, et al. Mechanisms of global support in post traumatic
enophthalmos. I.The anatomy of the ligament sling and its relation to intramuscular cone or-
bital fat. Plast Reconstr Surg 77:93-101, 1986.
133. Chen CT, Chen YR,Tung TC, et al. Endoscopically assisted reconstruction of medial orbital
wall fractures. Plast Reconstr Surg 103:714-723, 1999.
The authors present their experiences in repairing orbital oor fractures using transantral endoscopy
without open lid incision. Using this technique, the authors successfully reconstructed the orbital oor
defects, minimized ocular globe manipulation, and eliminated a lower eyelid incision.
134. Zachariades N.The superior orbital ssure syndrome:Report of a case and review of the lit-
erature. Oral Surg Oral Med Oral Path 53:237-240, 1982.
135. Manson PN, Ruas EJ, Iliff NT. Deep orbital reconstruction for the correction of post-trau-
matic enophthalmos. Clin Plast Surg 14:113-121, 1987.
136. Aronowitz JA, Freeman BS, Spira M. Long-term stability of Te on orbital implants. Plast Re-
constr Surg 78:166-173, 1986.
137. Gruss JS, Mackinnon SE. Complex maxillary fractures: Role of buttress reconstruction and
immediate bone grafts. Plast Reconstr Surg 78:9-22, 1986.
138. Gruss JS, Antonyshyn O, Phillips JH. Early de nitive bone and soft-tissue reconstruction of
major gunshot wounds of the face. Plast Reconstr Surg 87:436-450, 1991.
The use of craniofacial surgical techniques, extended open reduction, rigid xation with plates and
screws, and the replacement of severely damaged or missing bone with immediate bone grafting in the
treatment of complex facial fractures has been applied to the management of severe gunshot wounds
of the face. Soft-tissue reconstruction was provided by a combination of aps. Early restoration of a mid-
facial bony scaffold and the prevention of soft-tissue contraction facilitate secondary reconstruction.
139. Kawamoto HK Jr. Late posttraumatic enophthalmos: A correctable deformity? Plast Recon-
str Surg 69:423-430, 1982.
140. Glassman RD,Vander Kolk CA,Yaremchuk MJ, et al. Rigid xation of orbital fractures. Plast
Reconstr Surg 86:1103-1109, 1990.
141. Converse JM, Smith B. Enophthalmos and diplopia in fractures of the orbital oor. Br J Plast
Surg 9:265-274, 1957.
142. Converse JM, Smith B, Obear MF, et al. Orbital blow-out fractures. A ten-year survey. Plast
Reconstr Surg 39:20-36, 1967.
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Reoperative Facial Fracture Repair

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R EOPERATIVE SURGERY OF THE HEAD AND NECK
143. Hawes MJ, Dortzback RK. Surgery of orbital oor fractures. Ophthalmology 90:1066-1070,
1983.
144. Kline LB, Morawitz RB, Swaid SN. Indirect injury of optic nerve. Neurosurgery 14:756-
764, 1984.
145. Putterman AM, Stevens T,Urist MJ. Nonsurgical management of blowout fractures of the or-
bital oor.Trans Am Acad Ophthalmol Otolaryngol 77:232-239, 1974.
146. Putterman AM. Late management of blow-out fractures of the orbital oor.Trans Am Acad
Ophthalmol Otolaryngol 87:650-659, 1973.
147. Fackler ML.Wound ballistics:A review of common misconceptions. JAMA 259:2730-2736,
1988.
148. Esser J, Mohr C. Development of postoperative motility in orbital oor, zygomatic and mid-
face fractures. Fortschr Ophthalmol 88:286-290, 1991.
149. Fujino T, Makino K. Entrapment mechanisms and ocular injury in orbital blow-out frac-
tures. Plast Reconstr Surg 65:571-576, 1980.
150. Riley WB, Maxo ML. Recognition and avoidance of ocular motility pitfalls in plastic sur-
gery. Plast Reconstr Surg 66:153-157, 1980.
151. Gellrich N, Schramm A, Hammer B, et al. Computer-assisted secondary reconstruction of
unilateral posttraumatic orbital deformity. Plast Reconstr Surg 110:1417-1429, 2002.
152. Kurza A, Patel M. Superior orbital ssure syndrome associated with fractures of the zygoma
and orbit. Plast Reconstr Surg 64:715-719, 1979.
153. Chen Y-R, Fischer DM. Discussion:Blindness as a complication of Le Fort osteotomies:The
role of atypical fracture patterns and distortion of the optic canal. By Girotto JA, Davidson J,
Wheatly M, et al. Plast Reconstr Surg 102:1422-1423, 1998.
154. Manson P, Iliff N, Robertson B.The hope offered by early surgical treatment to those patients
whose blowout fractures demonstrate tight muscle restriction or true muscle incarceration.
Plast Reconstr Surg 109:490-495, 2002.
155. Iliff N, Manson P, Katz J, et al. Mechanisms of extraocular muscle injury in orbital fractures.
Plast Reconstr Surg 103:787-799, 1999.
156. Forrest CR, Khairallah E, Kuzon W. Intraocular and intraorbital compartment pressures fol-
lowing orbital bone grafting:A clinical and laboratory study. Plast Reconstr Surg 104:48-54,
1999.
157. Dufresne CR, Manson PN, Iliff NT. Early and late complications of orbital fractures. Clin
Plast Surg 15:239-253, 1988.
158. Glat PM, Jelks GW, Jelks EB, et al. Evolution of the lateral canthoplasty:Techniques and in-
dications. Plast Reconstr Surg 100:1396-1405; discussion 1406-1408, 1997.
159. Ellis E III, Walker LR. Treatment of mandibular angle fractures with one noncompression
miniplate. J Oral Maxillofac Surg 54:864-871, 1996.
160. Pearl RM,Vistnes L. Orbital blow out fractures. Ann Plast Surg 1:267-270, 1978.
161. Yaremchuk M. Changing concepts in the management of secondary orbital deformities. Clin
Plast Surg 19:113-124, 1992.
162. Edgerton MT Jr. Causes and prevention of lower lid ectropion following blepharoplasty. Plast
Reconstr Surg 49:367-373, 1972.
163. Glassman RD, Manson PN, Iliff N. Techniques for improved visibility and lid protection in
orbital exploration. J Craniofac Surg 1:169-171, 1990.
164. Hollier L, Thorton J, Pazmino P, et al. The management of orbitozygomatic fractures. Plast
Reconstr Surg 111:2386-2392, 2003.
165. Jackson IT. Classi cation and treatment of orbito-zygomatic and orbito-ethmoid fractures:
The place of bone grafting and plate xation. Clin Plast Surg 16:77-91, 1989.
166. Balle V, Christensen PH, Greisen O, et al. Treatment of zygomatic fractures: A follow-up
study of 105 patients. Clin Otolaryngol Allied Sci 7:411-416, 1982.
167. LeFort R. Etude experimental sur les fractures de la machoire superiore. Parts I, II, III. Rev
Chir 23:208, 1901.
168. Romano JJ, Manson PN, Mirvis WE, et al. LeFort fractures without mobility. Plast Reconstr
Surg 85:355-362, 1990.

169. Merville L. Multiple dislocations of facial skeleton. J Maxillofac Surg 2:187-200, 1974.
170. Assael L. Open versus closed reduction of adult mandibular condyle fractures:An alternative
interpretation of the evidence. J Oral Maxillofac Surg 61:1333-1339, 2003.
171. De Riu G, Gamba U, Anghinoni M, et al. A comparison of open and closed treatment of
condylar fractures: A change in philosophy. Int J Oral Maxillofac Surg 30:384-389, 2000.
172. Ellis E. Complications of mandibular condylar fractures. Int J Oral Maxillofacial Surg 27:255-
257, 1998.
173. Manson PN, Hoopes JE, Su CT. Structural pillars of the facial skeleton: An approach to the
management of Le Fort fractures. Plast Reconstr Surg 66:54-62, 1980.
174. Crawley W, Azman P, Clark C, et al.The edentulous LeFort fracture. J Craniofac Surg 8:298-
308, 1997.
Conservative (nonsurgical treatment methods) and classic open reductions produce aesthetic and func-
tional results that lead to posterior and oblique positioning of the maxillary occlusal segment in com-
minuted fractures. Attention to positioning the maxilla by relating it to the mandible through max-
illomandibular xation minimized these deformities. Establishing maxillary-mandibular relationships
in edentulous fractures, therefore, seems to have the same importance as establishing occlusion in pa-
tients who are dentulous as an important initial step in the treatment of comminuted LeFort fractures.
175. Cohen S, Leonard D, Markowitz B, Manson PN. Acrylic splints for dental alignment in com-
plex facial injuries. Ann Plast Surg 31:406-412, 1993.
176. Denny A, Celik N. A management strategy for palatal fractures: A 12-year review. J Cranio-
fac Surg 10:49-57, 1999.
177. Hendrickson M, Clark N, Manson P. Sagittal fractures of the maxilla:Classi cation and treat-
ment. Plast Reconstr Surg 101:319-332, 1998.
178. Armaratunga NA. The relation of age to the immobilization period required for healing of
mandibular fractures. J Oral Maxillofac Surg 45:111-113, 1987.
179. Buchbinder D.Treatment of fractures of the edentulous mandible, 1943 to 1993:A review of
the literature. J Oral Maxillofac Surg 51:1174-1180, 1993.
180. Eyrich GKH, Gratz KW, Sailer HF. Surgical treatment of fractures of the edentulous
mandible. J Oral Maxillofac Surg 55:1081-1087, 1997.
181. Falcone PA, Haedicke GJ, Brooks G, et al. Maxillofacial fractures in the elderly: A compara-
tive study. Plast Reconstr Surg 83:443-448, 1990.
182. Fisher SE. Respiratory/cardiac arrest complicating intermaxillary fixation. Br J Oral Surg
20:192-195, 1982.
183. Lambott CG, Landes CA, Kreener S. Resorbable plate osteosynthesis of sagittal split with os-
teotomies with major bone movement. Plast Reconstr Surg 111:828-840, 2003.
184. James RB, Frederickson C, Kent JN. Prospective study of mandibular fractures. J Oral Surg
39:257-281, 1981.
185. Bahna M, Canalis RF. Necrotizing fasciitis (streptococcal gangrene) of the face. Report of a
case and review of the literature. Arch Otolaryngol 10:648-651, 1980.
186. Ellis E III: Personal communication, 1999.
187. Chuong R, Donoff RB. Intraoral open reduction of mandibular fractures. Int J Oral Surg
14:22-28, 1985.
188. Ellis E III,Throckmorton GS, Palmieri C. Open treatment of condylar process fracture: As-
sessment of adequacy of repositioning and maintenance of stability. J Oral Maxillofac Surg
58:27-34, 2000.
189. Haug RH, Assael LA. Outcomes of open versus closed treatment of mandibular subcondylar
process fractures. J Oral Maxillofac Surg 59:370-375, 2001.
The purpose of this study was to compare the long-term treatment results of open reduction and rigid
internal xation (ORIF) with closed reduction and maxillomandibular xation (CRMMF) for sub-
condylar fractures when guided by speci c indications and contraindications. A protocol for the treat-
ment of condylar process fractures was developed that included absolute and relative indications and
contraindications as well as a technique regimen. Using a treatment protocol, there were few differences
in outcomes between patients treated with CRMMF and ORIF for subcondylar fractures.
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1008
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
190. Evans G, Clark N, Manson PN, et al. The role of mini- and micro-plate xation in signi -
cant fractures of the midface and mandible. Ann Plast Surg 34:453-456, 1995.
191. Zide BM.The mentalis muscle:An essential component of chin and lower lip position. Plast
Reconst Surg 105:1213-1215, 2000; Plast Reconst Surg 83:413, 1989.
192. Robertson B, Manson P.The importance of serial debridement and second look procedures
in high-energy ballistic and avulsive facial injuries. Oper Tech Plast Reconstr Surg 5:236-
246, 1998.
193. Hollier L, Grantcharova EP, Kattash M. Facial gunshot wounds: A 4-year experience. J Oral
Maxillofac Surg 59:277-282, 2001.

1009
Chapter 28
Reoperative Facial Fracture Repair
1. What tissue most opposes secondary reconstructive procedures?
a. Bone
b. Soft tissue
c. Plates
d. Wires
2. What percentage of bone graft persistence is commonly expected?
a. 100%
b. 90%
c. 40% to 75%
d. 10%
3. What is the most common reason for failure of alloplastic cranioplasty?
a. Poor skin cover
b. Intraoperative contamination
c. Bloodborn contamination
d. Performance next to sinuses
4.What is the best material to use for frontal sinus obliteration?
a. Methylmethacrylate
b. Bone
c. Plaster of paris
d. Porous polyethylene
5. Is osteomyelitis common after frontal sinus repair?
a. Yes
b. No
6. In what direction do supraorbital fractures usually displace the globe?
a. Downward
b. Backward
c. Laterally
d. Medially
7. An acute nasoethmoid fracture can usually be repaired by leaving the medial
canthal ligament attached to what structure?
a. Frontal bone
b. Ethmoid bone
c. Lamina papyracea
d. Tarsal plates
e. Frontal process of the maxilla
R EVIEW QUESTIONS

1010
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
8. A Stranc Plane II nasal fracture would be expected to require which of the
following?
a. Reduction rhinoplasty
b. Dorsal augmentation
c. Prolonged nasal packing
d. Excision of excess skin
9. The majority of zygomatic fractures need which of the following?
a. Closed reduction
b. A coronal incision
c. A secondary rhytidectomy
d. Endoscopic sinus surgery
e. Limited open reduction
10. Complete this statement: A patient with 6 mm of enophthalmos and 20-20
vision, who has diplopia looking upward ______.
a. Should not have correction of enophthalmos until the double vision is
corrected.
b. Can expect the exophthalmos correction to improve the double vision.
c. Should only have bone used in the orbit.
d. Should be prepared for separate procedures—one to correct enophthal-
mos and one to correct double vision.
11. A Lefort fracture doesn’t exist if the maxilla is not mobile.
a. True
b. False
12. Rigid xation of a LeFort fracture allows one to return the patient to a regu-
lar diet and avoid observation of the occlusion.
a. True
b. False
13. Which of the following is true regarding split palate fractures?
a. They should always be treated with a splint
b. They are generally managed by an orthodontist
c. They should be xed last in the sequence of panfacial injury repair
d. They may usually be stabilized by rigid xation in the palatal vault and
at the piriform aperture

1011
Chapter 28
Reoperative Facial Fracture Repair
14. A mandibular subcondylar fracture that has healed with a shortened ramus
height but has good condylar motion would usually be managed with which
of the following?
a. A dental splint
b. Extraction or occlusal grinding of the posterior maxillary teeth
c. A costochondral graft
d. A sagittal split osteotomy
15. Which of the following statements is true regarding a comminuted, open an-
terior mandibular fracture?
a. The exposure should only be extra oral
b. Loose bone fragments should be removed and discarded and a load-
bearing plate used to span the defect
c. Multiple miniplate xation application connecting all the fragments is
suf cient
d. A long, load-bearing plate connects the major fragments. The smaller
fragments are connected to the larger fragments with miniplate xation
16. Which of the following is true regarding a close-range shotgun wound of the
central midface and mandible?
a. Debridement and allografting should be the rst step
b. No acute open reduction should be performed in this contaminated
wound.
c. IMF should be omitted to permit wound access
d. Immediate stabilization of existing bone in anatomic position is the rst
step
e. The soft tissue should be left open until dressings have satisfactorily
cleaned the wound

(Trang không có chữ)

1013
Secondary Corrections for Cleft Lip
and Cleft Lip Nasal Deformity
Ian T. Jackson
C ha pter 2 9
Reoperative Problems
Scarring
Nasal tip asymmetry
Asymmetry
Airway blockage
Transverse de ciency
Alar base asymmetry
Vertical de ciency
Columellar asymmetry
Poor muscle reconstruction
Displaced lower lateral cartilage
Bony de ciency
The important thing is that we surgeons have
a life that combines science and humanism.They are
inextricably woven together. If you’re alert enough
to appreciate it, you won’t get discouraged.
Joseph E. Murray, MD
Craniomaxillofacial Surgery

1014
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The cleft lip and palate deformity continues to be a signi cant challenge. One of
the main reasons that this is true is that we and our patients are continually “rais-
ing the bar” in terms of expectations, probably because primary repairs have im-
proved so much.These repairs can be demonstrated by looking at older textbooks,
which concentrated mainly on soft tissue repair. In these books, the fact that the
maxilla on the cleft side is frequently hypoplastic or displaced is ignored.
The lack of bony support can easily be demonstrated by placing the
index ngers just lateral to each alar base.This simple test graphically
illustrates the bony asymmetry.
If this oversight were related to house building, it would be disastrous! Another
basic misconception in older textbooks has been the tenet of “no subperiosteal
dissection.”
Those of us who are performing corrective surgery of the bony facial
skeleton know that subperiosteal dissection in the growing face forms
bone, and dissection above the periosteum produces scar tissue.
For years, this basic concept has delayed adequate nasal repair in the primary sur-
gery, and should be totally discredited and dropped from the literature. (Readers
are advised to study the work of Harold McComb.1)
TREATMENT FOR THE PATIENT W ITHOUT
CLEFT DEFORMITIES
The effect of soft tissue scarring on the inhibition of three-dimensional facial
growth is becoming more accepted, and the techniques that cause this result are
now avoided as much as possible during the primary repair. Another interesting
fact that is not discussed in the older textbooks when considering the patient with
cleft deformities is that midface retrusion occurs in a proportion of the general
population who do not have clefts. If this fact is considered when conducting post-
operative surveys, our results may be better than those reported.

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Chapter 29
Secondary Corrections for Cleft Lip and Cleft Lip Nasal Deformity
Patient Example
This patient has minimal soft tissue cleft deformities; however, he demonstrates
midface retrusion and nasal deformity.
He is shown postoperatively after one-stage correction using LeFort I osteotomy
and rhinoplasty.
The standard of cleft surgery has improved dramatically in recent years, particu-
larly in many European countries where centers focusing on the treatment of pa-
tients with cleft problems have been established. All patients with cleft deformities
are referred to these hospitals. Universal standards have been established and are
strictly adhered to and monitored by external reviewers from time to time (for ex-
ample, Eurocleft cleft centers in the United Kingdom).2-4

1016
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
In Europe, surgeons and centers that do not meet the standards must undergo ad-
ditional training. Although there is no similar situation in the United States at the
moment, there has been a movement to establish treatment centers for patients
with cleft deformities. However, there is currently no system to monitor quality
or to perform regular independent audits.The sooner this method of quality assur-
ance can be established, the sooner we will see an improvement in the standard of
care for patients, and good results in all facial areas.
TWO-STAGE R EPAIR
Patient Examples
This patient underwent a two-stage repair of a complete unilateral cleft of the pri-
mary and secondary palate.The procedure consisted of unilateral cleft lip, nose, and
alveolar correction at 3 months;a cancellous bone graft was placed into the alveo-
lar gap at this time.The palate was repaired at 6 months.
The patient is shown 7 years postoperatively.

1017
Chapter 29
Secondary Corrections for Cleft Lip and Cleft Lip Nasal Deformity
This patient underwent a two-stage repair of a wide unilateral cleft lip, nose, and
alveolus. A primary bone graft was performed, followed by palate repair. The up-
per arch and dental occlusion are satisfactory.
The patient is shown 8 years postoperatively.

1018
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The ideal result continues to elude the vast majority of surgeons involved in the
treatment of cleft deformities. A patient with a very good result at age 5 may show
a completely different result at age 15. Another problem is that there are many
good surgeons performing satisfactory primary repair who seem uncomfortable
when dealing with secondary corrections, especially bone grafting and osteotomies.
Unfortunately, these procedures are required in many patients who present for sec-
ondary corrective surgery.This area needs improvement. Surgeons trained in max-
illofacial surgery are much more comfortable dealing with these problems. This
treatment must be a team effort. A plastic surgeon who is not trained or is unsure
about how to correct these deformities should cooperate with oral and maxillofa-
cial surgeons.
The most important concept in the management of secondary cleft deformities is
assessment in three dimensions. In addition to obtaining acceptable scars, there are
the problems of correct lip volume, proper muscle function, nasal airway function,
position and shape of the maxillary segments, the extent of intraoral scarring, the
presence of stulas, dental occlusion, and dental hygiene. Without analyzing these
elements of the cleft area it is unlikely that a good aesthetic and functional result
will be obtained.5 A signi cant and related problem is that many plastic surgeons
have some degree of discomfort in their ability to routinely close and bone graft a
stula, and to deal with maxillary hypoplasia on the cleft side.Very few plastic sur-
geons will attempt osteotomies of the maxilla and mandible, or even have a satis-
factory relationship with another surgeon who can do this, especially one in the
maxillofacial eld.6 Some surgeons may be uncomfortable performing nasal air-
way rehabilitation in patients with cleft deformities; however, these are basic re-
quirements for appropriate treatment and should be performed by anyone claim-
ing to be a cleft lip and palate surgeon. Alternatively, the facilities to deal exclusively
with these problems should be set up.
DIAGNOSTIC TESTS
Assessment techniques that may be used in addition to the clinical examination are
plain radiographs, Panorex lms, and cephalograms, including anterior and lateral
three-dimensional CT scans, dental impressions, dental models, speech assessment,
nasendoscopy, and cineradiography.
UNILATERAL DEFORMITY
Secondary problems after primary repair relate most often to the nose, the lip, and
the underlying maxilla. In the nose and lip, there are both functional and aesthetic
elements to consider.The maxilla is the foundation and it must be symmetrical. Ap-
propriate training as well as experience using certain devices has resulted in greater
success in achieving maxillary symmetry in the primary surgery.We use the Latham
appliance soon after birth.7,8 This practice allows the maxillary segment to be placed
in a more anatomically correct position before reconstructing the cleft. It should,
however, be appreciated that the lesser segment and the cleft edge of the greater

1019
Chapter 29
Secondary Corrections for Cleft Lip and Cleft Lip Nasal Deformity
segment always remain hypoplastic to a variable degree; these should be assessed
during the primary repair. If this condition is signi cant, I have no hesitation in
placing a small onlay cancellous bone graft to achieve absolute symmetry of the
alar base position.This graft lls the subperiosteal dead space after facial soft tissue
mobilization and periosteal repositioning, and may eliminate the need for bone
grafting later; this possibility is currently being investigated. Similarly, if there is
nasal tip asymmetry, the lower lateral cartilage should be dissected out and its po-
sition corrected in three dimensions. On long-term follow-up there has been no
deterioration of nasal tip shape. It cannot be claimed, however, that there is always
absolute symmetry in all dimensions.
Another area of dispute is the septum; there has been a reluctance to reposition it.
There is absolutely no reason that any deviation should not be corrected using
whatever xation is deemed necessary to maintain the septum’s position.The child
should be given the best airway possible to ensure optimal speech development
and facial growth. Others have achieved good results using early nonsurgical treat-
ment.9
It is inconceivable that areas of deformity should be left for secondary correction.
Working in the proper planes—subperiosteal and subperichondrial—does not pro-
duce scarring, and our preliminary studies show that over the long term, growth is
not impeded.10 A much larger cohort is presently under investigation and will be
published in the near future.The maxilla demonstrates this situation very well—if
it is hypoplastic before repair, it will always remain so!
LIP
In spite of improved techniques, patients continue to present with lip shortening,
poor scars, unorthodox repairs, and lack of muscle reconstruction. These patients
frequently have signi cant nasal deformity, poor nasal function, and lack of bony
support on the cleft side as a result of the hypoplasia of the lesser segment of the
maxilla. Scar tissue often provides an additional growth insult.
When the lip functions, there may well be bunching of the muscle in the lesser
segment; this is only the beginning of the assessment. It is important that all as-
pects of the deformity are considered. For example, when there is maxillary hy-
poplasia on the cleft side, the nasal deformity will not be corrected without supply-
ing bony support to the alar base. Repair of the lip in isolation will deal only with
one aspect of what usually is a complex three-dimensional problem.
The lip should be examined at rest and while it is functioning. Frequently there has
been no true anatomic muscle repair and this causes the bunching of the lesser seg-
ment when the lip functions, as mentioned above.This is exactly what is seen in an
infant’s lip before the repair is done! This response results from the lack of orbicu-
laris continuity, the area of insertion, and the muscle shape adjacent to the cleft.

1020
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
All clefts have hypoplastic edges.
The lip and facial aspects are probably the most important to consider for the pa-
tient with total cleft deformity. The intraoral aspect should be examined for scar-
ring to assess the alveolus for stulas, bony defects, missing teeth, and dental occlu-
sion. The alveolus is the support system of the lip and nose and it may require
simultaneous reconstruction.
The nose should also be examined to assess symmetry and alar base position in
three dimensions, the appearance of the nostril sill, the position and size of the
turbinates, and the relative positions of the lower lateral cartilages. This complex
anatomic and functional deformity requires simultaneous correction.The support
or lack of support supplied by the maxilla should be noted, with an overall assess-
ment of the bony anatomy on the cleft side. Septal deviation is investigated clini-
cally and radiologically; if necessary, the nasendoscope is used.
If possible, nasal and/or alveolar and maxillary problems and poor lip repair should
be corrected at the same time because they are interrelated. Some surgeons may not
appreciate that opening the lip for revision provides wonderful exposure to repair
and bone graft the alveolar defect and/or to augment a hypoplastic maxilla.
LIP R EPAIR
For our own patients, we do not use the traditional Millard design of the rotation
advancement repair. An incision is no longer made around the alar base;this is con-
sidered to be an affront to the facial anatomy. If possible, normal anatomy should
not be violated during cleft repair and should be preserved if at all possible. Every
effort should be made to prevent secondary deformities.
Patient Examples
This child was born with a wide left unilateral cleft lip and palate.The lip, nose, and
palate were repaired with primary bone graft followed by palatal reconstruction at
6 months.

1021
Chapter 29
Secondary Corrections for Cleft Lip and Cleft Lip Nasal Deformity
The upper arch and dental occlusion are satisfactory at 6 years of age.
At rest, there may be asymmetry of lip size and shape, thus the anatomy and func-
tion of each area must be analyzed carefully. If there is too much lip transversely,
careful measurements are made, the excess is removed, and the resulting defect is
closed with or without a lengthening procedure, as indicated.The best situation for
lengthening occurs when only an elliptical excision of the previous repair is
needed.
Skin, muscle, and mucosa must all be considered with the lip repair. Fre-
quently the main problem lies in the muscle, even in a well-repaired lip.11
This problem may only manifest as bunching of the lesser muscle segment when the
lip functions, and is very obvious.The position of the alar base may be an additional
problem;it is frequently positioned too far laterally.The worst situation is to have it
displaced medially. This condition requires a Z-plasty with the alar base being one
part of the Z.The perialar base scar resulting from the traditional Millard repair may
be improved but it can never be eradicated.
Problems with the lip may be complicated by previous repairs. It is advised, if pos-
sible, to excise the scars as an ellipse and close. If this simple solution is not possi-
ble, a modified rotation advancement repair is advocated. When the underlying
muscle has not been considered in the original repair or if the reconstruction is
inadequate, a proper muscle repair must be carried out with careful interdigitation
of the free ends of the muscles to provide satisfactory lip function and vertical lip
elongation.

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PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
To review, areas that may have to be repaired are the nose, lip, skin, muscle, and
mucosa.The alveolus is frequently neglected, but it is the foundation and must also
be evaluated.Without the bony support of the normal-sized alveolus and maxilla,
it is not possible to acquire symmetry, especially of the nose.The alveolus should be
compared with the foundation of a building. If the foundation is not constructed
correctly and does not provide adequate support, the building will not sustain its
symmetry.12 This asymmetry is exactly what happens in the unilateral cleft situation.
In the patient with a bilateral cleft there may be symmetrical sinking of the alar
bases as a result of a bilateral lack of support.
This patient presented with a unilateral cleft without a stula. Maxillary hypopla-
sia and nasal asymmetry were present. He underwent reconstruction of the maxilla
with cancellous bone. The displaced lower lateral cartilage was repositioned and
the lip was repaired with orbicularis oris muscle reconstruction.
Immediate and long-term results are shown.

1023
Chapter 29
Secondary Corrections for Cleft Lip and Cleft Lip Nasal Deformity
VERMILION CORRECTION
The junction of the wet and dry vermilion is the landmark area in treatment of the
vermilion.This juncture must be aligned properly because the texture and color of
the wet vermilion is very obvious if it is exposed. If the vermilion is in excess it can
be excised directly by a transverse excision. If there is concern that this excision
would result in a deformity of the lip and its margin, a staged excision can be per-
formed. In most situations the vermilion excision is vertical and may extend into
the mucocutaneous junction.
Any narrow vertical shortness of lip mucosa can be corrected using a Z-plasty pro-
cedure if the defect is small.When the deformity is signi cant, a V-to-Y advance-
ment on the inner aspect of the lip will move mucosa down into the defect. Oc-
casionally a straight excision and closure will suf ce. Wet mucosa should not be
brought onto the external aspect of the lip.This mucosa is red, appears to be wet,
and will crust as a result of exposure.
Mucosal grafts have also been used to correct defects of the vermilion.These grafts
can be harvested from the oral or lip vermilion or from the undersurface of the
tongue.They can only be used for surface replacement and do not add signi cant
bulk; their main function is to cover defects after excision of scarred areas. Mu-
cosal grafts are not recommended and should only be used when there is no “like”
material available, which, in my experience, is an extremely rare situation.
PHILTRAL COLUMN DEFICIENCY
Philtral column de ciency is a very dif cult problem to deal with, especially in the
patient whose column on the noncleft side is well-demarcated.The old scar can be
deepithelialized, leaving dermis that can then be sewn edge-to-edge to produce a
roll;the skin is closed over it. Unfortunately it has been noted on long-term follow-
up that this technique does not produce a very prominent ridge in most patients.
In spite of this result, many patients are satis ed with even moderate ridge forma-
tion. Cartilage and foreign implants are not recommended for the treatment of
philtral column de ciencies. The most logical material to use is fat, but results are
not yet predictable. Undoubtedly, studies will reveal long-term results using fat.
Materials such as Restylane may be used, but these resorb. Other injectable mate-
rials are available that are permanent (for example, polyacrylamide, manufactured by
Contura, Soeborg, Denmark).13 However, these materials are not yet available in
the United States.

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PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
SECONDARY CORRECTION OF UNILATERAL
CLEFT NOSE DEFORMITY
With more aggressive and well-planned approaches to surgery for the primary nasal
deformity, there are fewer indications for secondary correction and fewer patients
seek treatment. The more comprehensive approach to the lip and nose at the ini-
tial cleft repair has resulted in far fewer major nasal reconstructions as secondary
procedures. Unfortunately, there are still many older patients with signi cant sec-
ondary nasal deformities. In addition to concerns about appearance, patients seek
treatment for airway blockage, which requires an accurate diagnosis to determine
its exact cause. Although various techniques have been described to correct nasal
deformities, there is wide variation in the overall deformity.Therefore the aesthetic
nature and function of each nose must be analyzed carefully. Another variable that
affects the outcome is the surgeon, who must be very experienced in all aspects of
nasal correction. An inexperienced surgeon should consult the appropriate specialist.
When the patient presents, a careful history is taken, particularly regarding function
and allergies. The nose is carefully examined externally and internally, including
its relationship to the rest of the face. Internally, the position of the septum and the
position, size, and shape of the turbinates are noted.The lateral nasal wall position
is noted, and its change of position on aspiration is assessed. The lateral wall posi-
tion can be moved outward and stabilized with an instrument to determine
whether this maneuver improves breathing. These ndings may suggest that nasal
valving is present. In this case, a cartilage graft from the ear or sometimes from the
nasal septum should be inserted to support the valves and improve nasal function.
A submucosal pocket is created in the weakened area, and septal or ear cartilage is
placed in a way that provides a linking support system between the upper and lower
segments of the nose to prevent valving.This technique does not always provide a
clear airway; further surgery may be necessary.This situation can be most frustrat-
ing and is frequently seen, especially after previous attempts at correction. Some
patients have significant airway problems that make diagnosis difficult. In these
cases, examination with a exible endoscope is performed to assess the posterior
airway, which is often where the functional problem lies; the cause may be devia-
tion of the bony septum. All surgeons who treat cleft deformities should be able to
perform endoscopy. Anteroposterior facial radiographs show turbinate size and sep-
tal shape and position.They will also provide information on maxillary and frontal
sinus involvement. If there is any question of sinus disease, a CT scan is performed
and an ENT specialist should be consulted. In addition to nasendoscopy, cineradi-
ography can be performed to compile further useful information related to soft
palate function.14