Chẩn Đoán Và Điều Trị Phẫu Thuật Tái Tạo Hiện Đại (CURRENT Reconstructive Surgery)

MANDIBULAR FRACTURES • 283
artery is typically about 3 mm below the lowest point of
the sigmoid notch. The temporal and zygomatic branches
of the facial nerve cross over the external surface of the
zygomatic arch in a region 2 cm posterior to the posterior
edge of the lateral orbital rim and 0.8 cm anterior to the
root of the auricular helix. The auriculo-temporal nerve, a
branch of the third division of trigeminal nerve, travels lat-
eral to the temporomandibular joint (TMJ) capsule, sup-
plying sensation to the joint, the external auditory meatus,
and outer surface of the tympanic membrane. It also carries
the postganglionic parasympathetic secreto-motor fi bers
to the parotid gland and plays part in the development of
gustatory sweat or Frey syndrome.
The marginal mandibular branch of the facial nerve
should be preserved during the exposure of the mandible.
The above mentioned relationship holds for the upper cer-
vical region as well: immediately deep to the subcutaneous
tissue is the platysma, a member of the mimetic muscles,
invested by the superfi cial fascia. Deep to this is the deep
fascia which envelops the major neck muscles such as the
sternocleidomastoid and the trapezius. The same deep fas-
cia that invests the parotid gland and the masseter mus-
cle (parotidomasseteric fascia) in the lower facial region
extends down in the neck, and is anchored to the inferior
mandibular border and the body of the hyoid bone. Similar
to the relationship in the midface, the marginal mandibu-
lar branch of the facial nerve is immediately deep to this
deep fascia. In nearly 100% of the cases, the marginal man-
dibular branch will cross the inferior mandibular border
within 2 cm of the border superfi cial to the facial vessels,
thus it would be safe to carry one’s dissection toward the
mandible in a plane deep to the facial vessels beginning
2 cm below the mandible.
PATIENT EVALUATION
Patients with mandibular fractures always present with a
history of trauma, usually with pain near the fracture site,
and sometimes with malocclusion. Trauma of suffi cient
force to cause fracture of the mandible usually results from
either a motor vehicle accident or an altercation. Certainly
falls can cause fractures to the symphyseal and subcondy-
lar regions as well. Physical examination can reveal local
edema or ecchymosis (which may be hidden below the
tongue), a step-off of the teeth adjacent to the fracture,
and/or malocclusion. Care must be taken to rule out cer-
vical spine trauma, as this may accompany concomitant
facial injury.
Following an accurate clinical diagnosis, radiographic
studies are important to clearly localize and characterize
the fracture pattern and identify occult fractures not previ-
ously suspected. In the absence of numerous superimposed
osseous cortices, plain fi lms are excellent for the diagnosis
of mandible fractures. Oblique views are used to separate
the two bodies from one another to better visualize the
region near the angle. An orthopantomogram places an
x-ray fi lm behind the patient and creates the image as the
beam rotates around the head. A complete study should
include both condyles and the inferior-most portion of the
chin. The modality is excellent for the more lateral regions
of the mandible, while the central portions often remain
hazy. It can accurately demonstrate the molar regions
where teeth may lie in the line of the fracture. CT scanning
is similarly an excellent modality for mandible fractures
and frequently used in conjunction with an orthopanto-
mogram, since axial slices can demonstrate differences in
fracture displacement across both cortices.
PATIENT PREPARATION
Because it is always easier to reduce and repair the acute
fracture rather than osteotomize and fi xate the healed
fracture, time to repair plays an important role. Fractures
of the mandible should generally be performed within a
week or so of injury. Immediate repair can be justifi ed, as
can waiting 3 to 5 days to allow for swelling to abate. Prior
to surgical intervention, the patient should be instructed
to frequently rinse with an antimicrobial solution such as
Listerine or Peridex several times a day.
Surgery is best performed under general anesthesia with
a reinforced angled endotracheal tube placed through the
nose and directed into the trachea with either direct vision
using Magill forceps or a thin endoscope over which the
tube is placed. It should be sutured to the caudal nasal sep-
tum and securely fi xated to the midline forehead over sev-
eral gauze pads with either suture or tape. A throat pack
should be placed to avoid aspiration of liquids or dislodged
bone or teeth. A toothbrush should be available in the
operating room to clean the visible portions of the teeth
with a dilute solution of Betadine, saline, and peroxide.
TECHNIQUE
The overall aim in mandible fracture management is to
restore the patient’s lower facial form and masticatory
function. The crucial aspects of this goal involve achiev-
ing anatomic reduction and stabilization of the fracture
fragments that will reestablish the patient’s pretraumatic
dental occlusion. If the patient’s normal skeletal and dental
relationships are reestablished, then the facial height and
projection as well as facial contour and symmetry will be
restored. This universal concept is applicable to mandible
fracture in the various anatomic locations. In general, the
options include both nonsurgical and surgical approaches.
The nonsurgical approach involve nonoperative interven-
tions while the surgical options include closed reduction
with mandibulomaxillary fi xation (MMF), open reduction,
and internal fi xation with or without maintaining MMF or
the application of external fi xation.
The nonsurgical approach may adequately manage non-
displaced stable fractures that are associated with normal
dental occlusion. These favorable fractures are usually bev-
eled and have a fracture line that resists displacement, and
the attached muscles tend to impact rather than displace

284 • CHAPTER 26
the fragment ends. The patient is typically kept on a
soft diet for about 4 weeks while maintaining good oral
hygiene. The patient is counseled to avoid further trauma
to the fracture site and encouraged to restrict excessive
or extreme mouth opening. 1 The caveat to this nonsurgi-
cal approach is that patients require close follow-up. Serial
examination should ensure that the fracture fragments
remain anatomically aligned as indicated by preservation
of the patient’s pretraumatic occlusion. Stability at a non-
tender fracture site indicates appropriate healing.
Often, there is malocclusion requiring proper reduction
by fi rst establishing the preinjured occlusion using MMF.
MMF stabilizes and maintains the position of the fracture.
When the fracture displacement is minimum, the upper
and lower jaws can be kept immobilized in normal occlu-
sion with either arch bars or Ivy loops until fracture healing
is demonstrated at around for 4 to 6 weeks. 2 Training elas-
tics allowing restricted mouth opening may be used during
the fi nal weeks of MMF. Weight loss may be minimized
on the obligatory liquid diet by appropriate dietary coun-
seling, including nutritional and vitamin supplements. The
most commonly used methods to achieve MMF include
the use of a bridle wire and placement of arch bars or Ivy
loops. Stable dentition in both the maxilla and mandible
is a necessary prerequisite. The instruments include a stout
needle driver, 24- and 26-gauge wires, a wire cutter, and
arch bars. An alternative fi xation method needs to be con-
sidered in children with primary dentition and edentulous
patients, which is outlined later in this chapter. A bridle
wire can easily be placed around the teeth adjacent to a
mandible fracture to achieve temporarily stabilize of a
fl ailing segment. If the adjacent tooth is loose, decayed, or
avulsed, one can use the nearest available stable tooth. This
technique may be preformed at the bedside under local
FIGURE 26-1. Bridle wire placement. (1) The two mandibular segments are manually
reduced by applying a compressive force across the fracture site. (2) A piece of 24- or
26-gauge wire is passed around the necks of adjacent stable teeth. (3) The fracture is
reduced and stabilized by twisting the wire using a needle driver in a clockwise direction.
FIGURE 26-2. Application of a mandibular arch bar.
anesthesia or certainly under general anesthesia when con-
comitant injuries are being treated in the operating room.
The three essential steps to correctly place a bridle wire
are outlined in Figure 26-1 .
The bridle wire technique is ideally suited to achieve
temporary stabilization of mandible fractures, especially in
patients where the defi nitive fi xation needs to be delayed
because of concomitant injuries. Additionally, it prevents
further soft tissue trauma, assists in airway protection,
and helps alleviate pain and muscle cramps from moving
unstable mandible segments.
MMF by arch bars is another very common method.
Exposure of the teeth is obtained by using a self-retain-
ing cheek retractor supplemented by a tongue retrac-
tor. Placement of a mandibular arch bar is outlined in
Figure 26-2 .

MANDIBULAR FRACTURES • 285
The fi rst step is to measure and cut a suitable length of
arch bar. It should fi t from a point distal to the molar teeth
on one side to the opposite side. The third and possibly
the second molars can be excluded if it is too challeng-
ing to pass wire around these teeth. Next, a 24-gauge wire
is pre-stressed by stretching and cut into suitable lengths
for the circumdental wires, and a 26-gauge wire which
will be used to hold the maxillary and mandibular arch
bars together. The circumdental loops of wire are placed
loosely around the teeth on both sides of one jaw exclud-
ing the central incisors, which grip wires poorly and have a
tendency to extrude. One passes the gently curved piece of
a 24-gauge wire through the interdental space, fi rst distal
and then mesial around the lingual aspect of each tooth.
The measured arch bar is then placed in these loops of
wire and loosely secured. The hooks need to be correctly
oriented to allow the box wires or elastics to hold the arch
bars together. They are tightened in a clockwise fashion
from midline to posterior to avoid excess arch bar ante-
riorly. The wire ends are cut, forming rosettes which are
turned in to the gingiva. After gross reduction of the frac-
ture segments to achieve normal occlusion, the box wires
of a 24-gauge wire are placed around four hooks and fully
tightened to maintain the teeth in a position of maximal
intercuspation. Occasionally, the arch bars have to be cut
at the site of the fracture to allow for proper reduction.
After pretraumatic occlusion is achieved, these arch bar
segments can be held together with 26-gauge wires.
Ivy loops are quicker and easier but incur some limita-
tions ( Figure 26-3 ). They do not provide an addition level
of stability offered by arch bars, although both can func-
tion as tension bands. Additionally they cannot be used to
stabilize an avulsed tooth or alveolar bone segment. Ivy
loop placement is outlined in Figure 26-4 .
The majority of the fracture will require open reduc-
tion and internal fi xation. Adequate exposure for open
reduction of most mandible fractures can be achieved via
a lower buccal sulcus incision. Typically, the patient has
FIGURE 26-3. The Ivy loop is made of 24-gauge wire by
fi rst forming a 2-mm eyelet, or loop. This is done by wrapping
the central portion of the wire around a small suction cannula.
been intubated with a nasotracheal tube that is secured to
the nasal septum with a 2-0 silk suture. A tracheotomy set
should always be available for potential airway emergen-
cies. The eyes are lubricated and taped closed for protec-
tion during the entire procedure. The oral cavity is irrigated
with an antimicrobial solution and the teeth scrubbed with
a toothbrush. After arch bars are applied, the patient’s face
and neck are prepped and draped, carefully avoiding getting
prep solution into the eyes. The patient should not remain
paralyzed for an extended period of time and the angle
of the mouth should be in full view in order to monitor
facial nerve activity. The intraoral approach provides rapid
access to fractures without signifi cant external scars. The
symphyseal, parasymphyseal and mid-body regions can be
easily exposed through intraoral approaches, but the angle
and ramus require additional buccal cheek retractors for
adequate visualization. Internal rigid fi xation and stabili-
zation of the fracture fragments is achieved by applying
plates and screws. Alternative techniques for stabilization
include lag screws that are only applicable to noncom-
minuted fractures with suffi cient overlapping of the frac-
ture surfaces. However, in the presence of other multiple
traumatic intraoral lacerations, the bony segments could
potentially be devascularized and it is diffi cult to achieve
a watertight closure of the inferior buccal sulcus incision
especially with associated tooth avulsions. This may pre-
dispose to an increased postoperative infection rate. The
intraoral approach exposes only the labial cortex of the
fracture and, as such, it is possible to have a signifi cant
undetected gap on the lingual surface. Comminuted frac-
tures may require an external approach. Nearly all regions
of the mandible can be exposed via external incisions.
FIGURE 26-4. The ends of the wire are brought around
the mesial and distal sides of these two teeth. The posterior
end of the wire is passed through the eyelet and tightened to
the anterior wire to hold the eyelet securely between these
teeth. The jaws are manipulated into the position of normal
occlusion. A small segment of 26-gauge wire is passed
through the eyelets of opposing maxillary and mandibular
teeth and tightened in a clockwise direction.

286 • CHAPTER 26
Multiple fracture fragments can be better visualized via
extraoral approach provided by either a submandibular or
a preauricular incision. Open reduction of these commi-
nuted fractures can be best achieved with optimal exposure
of the multiple fragments. Once the fracture is adequately
exposed, anatomic reduction can be confi rmed by direct
visualization of both the labial and lingual surfaces. Large
fi xation plates can be more easily applied than with more
limited access available via an intraoral approach. However,
both the condyle and subcondylar regions are technically
diffi cult to expose and provide a higher potential for bleed-
ing complications and nerve injuries. The main trunk of
the facial nerve is at risk with the preauricular approach,
while the marginal mandibular branch which innervates
the depressors of the lower lip may be injured with a sub-
mandibular incision.
Symphyseal and Parasymphyseal Fractures
True symphysis fractures are rare and may not be appreci-
ated on panorex evaluation due to the central opacifi cation
from overlapping midline structures. 3 Nondisplaced sym-
physis and parasymphysis fractures can be stabilized with
MMF alone. However, the pretraumatic occlusion must
be maintained overcoming the signifi cant torque due to
muscle pull on the anterior mandible. Intraoral exposure
via a lower buccal sulcus incision is required for displaced
symphysis and parasymphysis fractures. The lower buccal
sulcus can be delineated with the aid of retractors (two
double hook or army/navy) holding the buccal mucosa of
the lower lip in an outward and lateral direction. A cur-
vilinear incision is marked just on the mandibular side of
the deepest recess of the inferior buccal sulcus and should
leave a cuff of oral mucosa (5 mm) to allow for secure
closure. The incision line, including mucosa and muscle is
infi ltrated with local anesthetic (1% lidocaine, 1:200,000
epinephrine) to achieve vasoconstriction. A lower buccal
sulcus incision is made with a number 15 scalpel blade
perpendicular to the mucosal surface down to bone. A
needle tip electrocautery is useful for this part of dissec-
tion. It is essential to leave a cuff of mucosa and underlying
mentalis muscle attached to the superior fl ap to achieve a
secure watertight closure. The dissection is carried subpe-
riosteally, sweeping downward and laterally on the labial
surface of the mandible with a periosteal elevator to care-
fully expose the mental neurovascular bundles bilaterally.
The mental foramina are usually located below the fi rst
or second bicuspid, midway between the alveolar ridge
and the inferior mandible border on each side. The men-
tal nerves must be protected during this entire procedure.
The fracture site is identifi ed and its labial surface is fully
exposed, enabling all clot and fi brinous material to be
cleaned off. One must use the occlusion status in addition
to the exposed fracture site to achieve anatomic reduction
and avoid any gaping on the unexposed lingual surface.
The fracture site can be temporally stabilized with bone
clamps applying compression via outwardly angled drill
holes. Alternatively, unicortical interosseus wire can be
used until internal fi xation is achieved. An important step
after the fractures are rigidly fi xed is test for maintenance
of occlusion after releasing MMF. The mandible should
open and close easily while both condyles are properly
seated in their respective glenoid fossa. Once this maneu-
ver is preformed, elastic bands are reapplied to guide the
mandible during the immediate postoperative period. The
inferior buccal sulcus wound is irrigated and closed in lay-
ers. Interrupted 3-0 absorbable sutures can be used for the
muscle closure while a running 4-0 chromic catgut suture
can be used to achieve a secure mucosal layer closure. Rigid
internal fi xation using two plates is necessary to overcome
the torsional forces in the symphyseal region. Generally
one plate (2.4 mm) is placed along the inferior border and
either a monocortical tension band plate (1.5 mm) or the
arch bar is used at the superior border. Alternatively, cen-
tral fractures in this region may be amenable to lag screws
fi xation with two 35 to 45 mm screws. 4
Fractures of the Mandible Body
Fractures of the mandible body are located from the cus-
pid through the fi rst molar and thus may involve a tooth
in the line of fracture. Involved teeth require appropriate
radiological evaluation in order to decide if tooth extrac-
tion is indicated. Nonrestorable teeth need to be removed
at the time of fi xation in order to minimize postoperative
infective complications. Nondisplaced or minimally dis-
placed body fracture may be stabilized with MMF for 4 to
6 weeks. Close follow-up to ensure adequate fracture heal-
ing and maintenance of pretraumatic occlusion is required.
Training elastics allowing restricted mouth opening may
be used during the fi nal weeks of MMF. Displaced body
fractures generally require open reduction and internal
fi xation. An intraoral approach is used with placement of
a plate (2 mm) along the inferior border of the mandible.
The mandible arch bar may serve as a tension band or alter-
natively a second, upper border, plate can be placed. 5 The
use of monocortical screws at the superior border of the
mandible avoids injury to the tooth roots. A submandibu-
lar incision (Risdon) provides good exposure of bone frag-
ments in comminuted fractures of the mandible body. 6
The 6-cm skin incision should be positioned in an exist-
ing skin crease about 2 cm below but parallel to curve of the
mandibular angle to optimize the resulting external scar.
The subcutaneous tissue and the superfi cial cervical fas-
cia are dissected with cautery until the platysma muscle is
reached. Dissection then proceeds carefully to avoid injury
to the marginal mandibular branch of the facial nerve that
lies below the platysma, just deep to the superfi cial layer
of the deep cervical fascia. It has a variable course; usu-
ally no lower than 1 cm inferior to the mandibular border.
If necessary, ligation of the facial artery and vein, allows
the marginal mandibular branch of the facial nerve to be
included in the refl ected superior fl ap. Dissection is then
carried through the deep cervical fascia directly to the
inferior border of the mandible. The submandibular gland
and associated lymph nodes are located just inferior to the

MANDIBULAR FRACTURES • 287
lower border of the mandible, while the tail of the parotid
gland which is usually posterior to the ramus may wrap
around the inferior angle of the mandible. Care must be
taken to avoid disrupting the capsules of these adjacent
salivary glands because violation could result in transient
sialoceles or salivary fi stulas.
Fractures of Mandibular Angle
The angle of the mandible is prone to fracture, especially
with the weakening presence of third molars. These angle
fractures carry the highest complication rate and thus
warrant an aggressive approach to delineated involve-
ment of the third molar tooth in the line of fracture. 7
Devitalized molar teeth require extraction at the time of
reduction. Open reduction of angle fractures can usually
be accomplished via a lower buccal sulcus incision which
extends posteriorly. This intraoral approach usually pro-
vides adequate exposure. The cheek is retracted laterally
while marking the previously described lower buccal sul-
cus incision, which is carried distally along the external
oblique ridge. The superior extent of the incision is lim-
ited to the mandibular occlusal plane, avoiding entrance
into the buccal fat pad, which could potentially prolapse
in to the wound. This incision line extends to posterior
buccal mucosa and infi ltrated with local anesthetic con-
taining epinephrine to minimize bleeding and achieve
optimal visualization. The incision is made through the
mucosa and muscle, leaving an adequate superior cuff of
tissue for closure. Dissection proceeds in the subperiosteal
plane, sweeping the tissues posteriorly and laterally to
expose the body and angle of the mandible. Rigid inter-
nal fi xation usually involves placing a large angled plate
(2.4 mm) along the inferior border with a monocortical
tension band plate (1.5 mm) at the superior border. The
transcutaneous trocar system is extremely useful, if not a
necessity, in this location.
A solitary lag screw may be used to stabilize angle frac-
tures, but this method can be technically demanding. 8
Alternatively, nonrigid fi xation may be used in favorable
fractures by placing a Champy plate along the external
oblique ridge of the mandible angle. An open approach
to mandibular angle fractures using a submandibular or
modifi ed Risdon incision may be required for improved
access to achieve precise reduction and stable fi xation of
multiple fracture fragments. Fractures of the coronoid can
involve only the tip of the coronoid process or the whole
process. These simple fractures seldom produce maloc-
clusion and can usually be treated nonoperatively. Ramus
fractures are often nondisplaced because of the splinting
effect from the surrounding masseter and temporalis and
medial pterygoid muscles. They are usually vertically or
horizontally oriented. It is necessary to ensure that the
facial height and pretraumatic occlusion are maintained
in these patients. MMF may be adequate stabilization for
minimally displaced ramus fractures. However, open reduc-
tion and internal fi xation via an internal approach is neces-
sary to reduce displaced ramus fractures associated with
malocclusion and loss of facial height. Stripping off the
buccinator muscle and temporal tendon with a periosteal
elevator may be necessary to expose the anterior surface of
the ramus. The entire ramus and subcondylar region can be
fully exposed by elevating and retracting off the masseter
muscle.
Fractures of the Mandibular Condyle
Fractures of the mandible condyle are common (18%)
and can be classifi ed into those involving the head, neck,
and subcondylar regions. Fractures in these three condyle
regions require different approaches. Generally, the treat-
ment of mandible condyle fractures is conservative, aim-
ing to reestablish normal occlusion while preserving the
vertical height of the ramus and maintaining the range
of motion in the TMJ. Fractures of the condylar head
are intracapsular injuries prone to TMJ ankylosis due to
hemarthrosis and the immobilization period necessary to
achieve adequate fracture healing. These fractures can be
treated with soft diet alone if occlusion remains normal.
However, if malocclusion is present, MMF is required
for a short period of stabilization (2 weeks) after closed
reduction which manipulates the jaws in to the pretrau-
matic occlusion position. An aggressive physiotherapy
program is essential to regain normal mouth opening and
lateral excursion of the mandible after this type of injury.
Similarly fractures of the condyle neck and subcondylar
region are generally also treated by closed reduction and
stabilization with MMF (2weeks) followed by physio-
therapy. Adequate exposure of condylar neck fractures
are challenging with potential risk of facial nerve injury.
Open reduction should be reserved for specifi c circum-
stances, such as unable to obtain adequate dental occlu-
sion by closed technique. Other less common indications
include lateral extra capsular displacement of the condyle,
displacement of the condyle in to the middle cranial fossa,
and the presence of a foreign body such as a gunshot pel-
let in the TMJ. 9 Patients presenting with dental malocclu-
sion may have displacement or over riding of the proximal
condyle segment. Those patients with unilateral displaced
condyle fractures occlude prematurely on the side of the
fracture because of vertical length shortening. Patients
with bilateral displaced condyle fractures have an anterior
open bite or apertognathia, because of premature contact
of the posterior teeth. This results from a bilateral decrease
in the vertical height of the mandible rami. In panfacial
trauma bilateral subcondylar fractures may be associated
with midface fractures. Open reduction and rigid inter-
nal fi xation of the condyle neck fractures are required to
reestablish the vertical height of the lower face in these
complex injuries. A combined preauricular and modifi ed
Risdon approach generally provides the best exposure
for type of open complex reduction and internal fi xation.
The preauricular approach provides good exposure to
the condyle and subcondylar regions of the mandible as
well as the temporomandibular joint area. A preauricular
incision, 3 to 4 cm in length is made in the skin crease

288 • CHAPTER 26
that is easily identifi ed by pushing the ear and tragus for-
ward. Dissection is carried along the anterior aspect of the
tragus, avoiding the external auditory canal as it courses
anteromedially. The main trunk of the facial nerve is rela-
tively safe as long as the dissection is kept within 0.5 cm
anterior to the tragus. The incision is carried down to the
zygomatic process of the temporal bone. The periosteum
overlying the posterior part of zygomatic arch is sharply
incised to elevate and refl ect all soft tissues from a poste-
rior to anterior direction. The superfi cial temporal vessels,
auriculotemporal nerve, facial nerves and its branches, as
well as the parotid gland can be protected in this anterior
displaced soft tissue fl ap. The capsule of the TMJ is visual-
ized in this region. It can be opened via a transverse inci-
sion, leaving a 3-mm cuff for closure. Care must be taken
to avoid tearing the articulating disc, which is usually
attached medially. The condyle is just inferior and may be
displaced medially by the attached lateral pterygoid mus-
cle. The condyle head can be grasped and pulled laterally
into its anatomic position. It may be necessary to release
MMF in order to achieve adequate reduction of the con-
dyle neck fractures. An endoscopically assisted approach
can provide assistance with direct fracture reduction,
allowing better visualization to achieve precise anatomic
alignment of the condyle segments.
There are a number of distinctive situations that require
special consideration regarding fi xation of mandible frac-
tures. These include mandible fractures in children, the
edentulous patient, and teeth in the line of fracture.
Fractures in Children
The mandible of a child differs from an adult mandible
in a number of regards. The condyle is the major growth
center and during the fi rst three years of life it consists of
a delicate vascular sponge covered by thin cortical bone
underneath the articular cartilage. Injury to the condyle
head during this period may lead to growth disturbance.
Also, crushing injury to this highly vascular condyle head
may result in an intracapsular hemorrhage and hemarthro-
sis with a high risk of ankylosis of the TMJ. Incomplete
or greenstick fractures, especially in the condylar region,
are more common in children as the pediatric mandible is
more elastic and tends to bend rather than break. 10 In early
childhood, there are numerous primary (deciduous) and
unerupted teeth that may weaken the mandible because
of lack of cortical bone. 11
Orthopantomogram examination is a useful evaluation
of the state of mixed dentition. These unerupted teeth
must also be taken into account when using bicortical
screws with plate fi xation in order to avoid tooth bud inju-
ries. In addition, stabilization by application of arch bars,
Ivy loops, or open interosseous wiring is not recommended
before 9 years of age.12 In this period of mixed dentition,
it is diffi cult to hold wires around the bases of deciduous
teeth because of their conical shape with the widest area
of the crown located at or below the free gingival mar-
gin. Also these teeth tend to extrude when the wires are
tightened. Intermaxillary fi xation is best achieved by using
circummandibular wires connected to wires passed though
drill holes at the piriform aperture. In addition a custom-
made acrylic trough, a splint can be attached to the teeth.
Conservative nonoperative management is applicable to
most pediatric mandible fractures. Closed reduction is
always preferable if reasonable anatomic reduction of the
fracture fragments can be achieved, thus avoiding exten-
sive dissection, periosteal elevation, and interference with
growth centers in the mandible.
Condyle fractures in children deserve special mention
as indicated above. Subcondylar greenstick fractures are
more common than intracapsular fractures and tend to
be medially displaced with a resultant lateral cross bite.
Treatment of these fractures aims is to preserve the height
of the ramus and TMJ function. Closed reduction with
a short period of immobilization (1–2 weeks), followed
by active exercises is usually suffi cient. 11 More extensive
injury to the condyle region resulting in bilateral fracture
dislocations with telescoping of the fracture fragments.
This is a serious threat to growth and normal occlusion.
Closed reduction and a longer period of immobiliza-
tion (3–4 weeks) are often required. Open reduction is
reserved for signifi cantly displaced fracture fragments
resulting in malocclusion that fail closed techniques. 13
Fractures of the body of pediatric mandible are likely
to follow the line of structural weakness due to devel-
oping teeth. Their management must take into account
the child’s state of mixed dentition. Closed reduction and
fi xation by means of circummandibular wires and lingual
splints are appropriate.
Fractures in Edentulous Patients
The edentulous mandible often has loss of height with
atrophy of the alveolar ridge. The body is more prone to
fracture because of the smaller cross-sectional area and
signifi cant atrophy. This region has reduced capacity for
repair because the remaining bone is primarily cortical
bone. Fixation of edentulous mandible fractures is chal-
lenging because of lack of teeth to observe occlusion and
anchor MMF. Closed reduction of nondisplaced or mini-
mally displaced fractures may be achieved with circum-
mandibular wiring of Gunning splints or fabricated acrylic
saddles for stabilization of the fracture fragments. Fixation
using the patient’s own dentures with skeletal wires is
cumbersome and does not permit any oral hygiene to
be accomplished on the lingual aspects unless an open-
ing is made by removing the incisors of the denture. Open
reduction with rigid internal fi xation is the treatment of
choice for displaced fractures in the edentulous mandible.
This approach ensures direct visualization to provide opti-
mal stability of the fracture fragments with large plates
and screws. If the height of the atrophic mandible allows
placement of a second tension band plate, it will help avoid
any torsional instability especially on the lateral aspect of
the edentulous mandible. This method allows early return
of masticatory function. Osteogenesis is stimulated when

MANDIBULAR FRACTURES • 289
compressive plates are used. Supraperiosteal placement of
large locking reconstructive plates (2.4 mm) ensures rigid
fi xation, while avoiding compromise to the underlying
blood supply of the edentulous mandible. 13 When there is
severe atrophy, with a mandible height of less than 10 mm,
primary bone grafting should be considered because of
demonstrated impaired bone healing. Postoperative com-
plications parallel the extent of bone atrophy in this com-
promised group. If bone healing fails to occur, the plates
are at risk of breaking due to metal fatigue.
Teeth in the Line of Fracture
Mandible fractures with teeth in the line of fracture should
be considered compound. They consequently have a
higher potential for postoperative infective complications
such as osteomyelitis. Usually these patients are admitted
to hospital to administer parenteral antibiotic therapy and
to optimize oral hygiene with antimicrobial mouthwashes.
These fractures require a through radiological evaluation to
assess tooth root involvement. Panorex and special periapi-
cal dental x-rays are helpful in delineating the involvement
of the fracture line with the tooth root. 3 Teeth should be
retained whenever possible and removed only when they
are nonrestorable or severely broken. 14
Restorative dentistry should be considered if the
involved tooth is intact with a stable root. An asymptom-
atic impacted tooth in the fracture line of uncomplicated
mandible fracture should be left in place. 14 Avulsed teeth
should be replanted as quickly as possible with stabiliza-
tion of the alveolar fragment by means of an arch bar or
interdental wires.
Nonrestorable teeth that are likely to contribute to
infective complications should be removed. Patients with
fractures of the tooth root, those with severe loosening of
teeth associated with chronic periodontal disease, those
with extensive periodontal injury and broken alveolar
walls, and those with displacement of teeth from their
alveolar sockets should undergo tooth extraction at the
time of fracture reduction.
COMPLICATIONS
Complications related to mandible fractures and their
treatments are not rare, occurring in 14% of all patients. 15
They tend to occur in a predictable pattern, more com-
monly seen in patients with predisposing risk factors. For
example, angle fractures have more associated complica-
tions because of the presence of the third molar tooth.16
Complications related to mandible fracture treatment can
be divided into early and late types. Early complications
include airway compromise, hemorrhage, malocclusion,
and nerve injury. The importance of careful documentation
in the initial patient assessment cannot be over empha-
sized. Late complications include infection, such as cellu-
litis, abscess, and osteomyelitis. Altered healing may be a
late complication encompassing delayed union, malunion,
and nonunion. In addition, malocclusion, TMJ ankylosis,
and TMJ dysfunction may be long-term issues. Infection
of mandible fractures can be problematic and account for
nearly half of all postoperative complications. The spec-
trum of severity ranges from cellulites, to abscess forma-
tion, and potentially subsequent osteomyelitis. Predictably,
those patients with poor oral hygiene and nutrition com-
promised by alcohol or drug abuse, those who present
late with subsequent delay in treatment, or those who are
noncompliant with therapy are more likely to experience
infection complications. 17
Displaced fractures and those patients with teeth in the
line of fracture are at higher risk of infection. The sever-
ity of infection dictates the aggressiveness of the required
therapy. Early superfi cial cellulitis of the surrounding soft
tissue may respond to antibiotic therapy alone. The choice
of antibiotic is determined by the sensitivity of the most
likely involved organisms. Oral or intravenous Clindamycin
(600 mg q6h) is often initially used until culture results
dictate differently. Deep infection, in which the fi xa-
tion is still stable and intact, may be treated by washout.
Debridement of necrotic tissue, removal of involved teeth,
and IV antibiotic therapy are also necessary. Fixation hard-
ware if stable often can be left in place if the infection can
be adequately controlled. Alternative fi xation such as an
external fi xator may be required when the original fi xa-
tion is loose and requires removal due to infection. The
second most common complication of mandible fracture
treatment is altered healing, which includes delayed heal-
ing, malunion, and nonunion. Infections are frequently an
important cause of nonunion. Fractures of the mandible
body have the highest incidence of nonunion (3.2%).
Other conditions contributing to nonunion include inad-
equate immobilization of fractures and teeth involved in
the line of fracture. The treatment of nonunion generally
consists of washout, debridement of necrotic bone, extrac-
tion of involved teeth, and reapplication of rigid internal or
external fi xation with possible bone grafting. Bone grafting
should be delayed until all infection has been eradicated
and healthy viable soft tissue coverage can predictable be
achieved.
Malocclusion is usually related to inadequate reduc-
tion of the fracture fragments. This is often precipitated
by maladaption of the fi xation plates that do not allow
anatomic reduction of the fracture. This can be prevented
by releasing the MMF after fi xation has been applied and
reassessing the occlusion. The mandibular condyles need
to be appropriately seated in the glenoid fossae with the
dentition in a position of maximum intercuspation. Any
discrepancy in the occlusion needs to be addressed at this
stage by removing the fi xation, reestablishing MMF and
reapplying new bone fi xation plates to achieve anatomic
reduction. Arch bars may need to be cut with fi xation on
either side of the fracture. These two segments can be held
together with loops of 26-gauge wire to achieve optimal
reduction of the displaced fracture fragments. Prolonged
postoperative immobilization in MMF for more than
6 weeks may lead to stiffness and predispose to dysfunc-
tion or TMJ ankylosis.

290 • CHAPTER 26
OUTCOMES
In general, the treatments of mandibular fractures enjoy
a high rate of success with uneventful healing in more
than 85% of cases. Positive and negative results from
the treatment of mandibular fractures will ultimately be
judged by the adequacy of healing. Fractures that heal in
the prescribed time course without complication or need
for additional procedures are the goal. Specifi c measures
to examine in the postoperative period include pain,
dentition, and range of motion. Following an adequate
period of healing, patients should be free of both pain in
the mandible at rest and with mastication. The dentition
that was present before the inciting trauma should be pres-
ent and healthy after healing. And the excursion of the
mandible should be equal to that preoperatively both in
the vertical and horizontal planes. Meticulous techniques
and attention to details regarding both systemic and local
factors will increase further the success rate.
REFERENCES
1. Guerrissi JO. Fractures of mandible: Is spontaneous healing
possible? Why? When? J Craniofac Surg . 2001;12(2):157.
2. Ellis E 3rd, Moos KF, EL-Attar A. Ten yeast of man-
dibular fractures: An analysis of 2,137 cases. Oral Surg .
1985;59:120.
3. Wilson IF, Lokeh A, Benjamin CL, et al. Prospective com-
parison of panoramic tomography (zonography) and heli-
cal computed tomography in the diagnosis and operative
management of mandibular fractures. Plas Reconstr Surg .
2001;107:1369.
4. Ellis E, Ghali GE. Lag screw fi xation of anterior mandibular
fractures. J Oral Maxillofac Surg . 1991;49:13.
5. Haug RH, Fattahi TT, Goltz M. A biomechanical evaluation
of mandibular angle fracture plating techniques. J Oral Max-
illofac Surg. 2001;59:1199.
6. Fonseca RJ, Walker RV, eds. Oral and Maxillofacial Trauma .
2nd ed. Philadelphia: Saunders; 1997.
7. Ellis E 3rd. Treatment methods for fractures of the mandibu-
lar angle. Int J Oral Maxillofac Surg . 1999;28:243.
8. Shetty V, Caputo A. Biomechanical validation of the solitary
lag screw technique for reducing mandibular angle fractures.
J Oral Maxillofac Surg. 1992;50:603.
9. Zide MF, Kent JN. Indications of open reduction of mandib-
ular condyle fractures. J Oral Maxillofac Surg . 1983;41:89.
10. James DR. Maxillofacial injuries in children. In: Rowe
NL, Williams JLI, eds. Maxillofacial Injuries . New York:
Churchill Livingstone; 1985:538–542.
11. Schweinfurth JM, Koltai PJ. Pediatric mandibular fractures.
Facial Plast Surg. 1998;14(1):31.
12. Posnick JC, Wells M, Pron GE. Pediatric facial fractures:
evolving patterns of treatment. J Oral Maxillofac Surg .
1993;51:836.
13. Bradley JC. Age changes in the vascular supply to the man-
dible. Br Dent J . 1972;132:142.
14. Shetty V, Freymiller E. Teeth in the line of fracture: A review.
J Oral Maxillofac Surg . 1989;47:1303.
15. Moulton-Barrett R, Rubinstein AJ, Salzhauer MA, et al.
Complications of mandibular fractures. Ann Plast Surg .
1998;41:258.
16. Winzenburg SM, Imola MJ. Internal fi xation in pediatric
maxillofacial fractures. Facial Plast Surg . 1998;14(1):45.
17. Haug RH, Schwimmer A. Fibrous union of the mandible: a
review of 27 patients. J Oral Maxillofac Surg . 1994;52:842.

27
Panfacial Fractures
Daniel Y. Maman, MD, MBA / Mark L. Smith, MD, FACS
INTRODUCTION
The treatment of panfacial fractures requires careful patient
assessment, prioritization of injuries and consideration of
long-term function and cosmesis. The etiology of panfacial
fractures, according to a recent retrospective analysis, are
assault (36%), motor vehicle accidents (32%), falls (18%),
sports (11%), occupational injuries (3%), and gunshot
wounds (2%). 1 In young adults, sports like football, hockey,
and baseball account for a high percentage of injuries.
Panfacial injury presents a unique challenge on account
of the interrelationship between the bones and the vital
structures they house. The superfi cial facial bones include
the frontal bone, nasal bones, zygomas, maxillary bones, and
mandible. The deeper facial skeleton consists of the sphe-
noid, lacrimal, vomer, ethmoid, and temporal bones. The
temporomandibular joint (TMJ) on each side is the only
facial joint and plays important functions in oration and
mastication. The meniscus and mandibular condyle form a
hinged joint allowing for rotation. A sliding joint is formed
between the meniscus and temporal bone allowing for
additional forward translation of the mandible at the end of
opening. The direct relationship of the facial bones to vision,
breathing, smell, mastication and facial form necessitates an
understanding of the relevant anatomy in order to success-
fully treat panfacial injuries.
FACIAL ANATOMY
The vertical buttresses of the midface are regions of thick
bone designed to resist the forces of mastication and dis-
tribute them over the cranial base. They also serve as miti-
gators of energy in vertically oriented facial trauma. There
are fi ve vertical buttresses ( Figure 27-1 ):
1. Frontonasomaxillary buttress
2. Frontozygomaticomaxillary buttress
3. Pterygomaxillary buttress
4. Frontoethmoid-vomerine buttress
5. Posterior mandibular ramus/condyle
The frontonasomaxillary buttress (often referred to
as the medial buttress) begins superiorly at the maxil-
lary process of the frontal bone and superior orbital rim,
extends inferiorly to the frontal process of the maxilla,
and then caudally to lateral piriform rim and the maxil-
lary canine area. The frontozygomaticomaxillary buttress
(often referred to as the lateral buttress) begins superiorly
with the zygomatic process of the frontal bone, and then
moves downward through the lateral orbital rim, across
the zygomaticofrontal suture, through the main body
of the zygoma and the zygomatic process of the max-
illa to the zygomatico-alveolar crest junction below. The
pterygomaxillary buttress supports the posterior maxilla
via the pterygoid plates of the sphenoid bones. As opposed
to the nasomaxillary and zygomaticomaxillary buttresses,
the pterygomaxillary buttress is usually not reconstructed
in panfacial fractures due to inaccessibility. The frontoeth-
moid-vomerine buttress is an unpaired midline support
below the nasal structures on which the quadrangular car-
tilage rests. The posterior mandibular ramus and condyle
make up the most posterior vertical buttress and serve to
establish posterior facial height. 2
The horizontal buttresses are also referred to as the
anterior-posterior buttresses. There are four horizontal
buttresses (see Figure 27-2 ):
1. Frontal buttress
2. Zygomatic buttress
3. Maxillary buttress
4. Mandibular buttress
The frontal buttress is composed of the superior orbital
rims and the glabellar region. The zygomatic arch, zygo-
matic body, and infraorbital rim make up the zygomatic
c h a p t e r

292 • CHAPTER 27
buttress. The maxillary and mandibular buttress consists
of the arches of the maxillary bone and mandible, respec-
tively. These buttresses offer some protection against
horizontal forces, but are signifi cantly weaker and less pro-
tective than the vertical buttresses. Therefore, vertically
oriented trauma is better absorbed by the facial skeleton,
whereas horizontal force often overwhelms the horizontal
buttresses and causes fracturing through the vertical pil-
lars. In surgical approaches to the facial skeleton, attempts
should be made to restore both the vertical and horizontal
buttresses. Reduction at these sites will help ensure appro-
priate facial height, width, and projection. 2
The naso-orbitalethmoid (NOE) complex consists of the
confl uence of the frontal, maxillary, nasal, ethmoid, lacri-
mal, and sphenoid bones. The frontoethmoid-vomerine and
paired nasomaxillary buttresses provide the vertical support
structures of the NOE complex. The adjacent more delicate
structures are supported and protected by these buttresses.
The medial orbit is made up of the lacrimal bone which
contains the medial canthal tendon attachment and the
lamina papyracea (lateral roof of the ethmoid bone). The
ethmoid bone forms part of the fl oor of the anterior skull
base. Injury in this area can result in dural tear and resultant
cerebrospinal fl uid (CSF) leak. The anterior and posterior
ethmoid vessels exit the skull through foramina located at
the frontoethmoid suture, in the posterior-superior portion
of the orbit. Shearing of these vessels in NOE fracturing can
result in intraorbital hematoma. The optic canal is located
more posteriorly and uncommonly involved in NOE frac-
ture patterns. However, bony fragment displacement and
nerve edema within the optic canal can lead to optic neu-
ropathy. In this situation, prompt surgical decompression is
needed to prevent permanent blindness.
The ethmoid sinuses are a labyrinth of sinuses, separated
by the perpendicular plate of the ethmoid bone, forming
the inter orbital space. This interorbital space is reinforced
superiorly by the cribriform plate and posteriorly by the
skull base and the sphenoid bone. In severe NOE fractures,
collapse of the interorbital space can result in anterior
intracranial injury (frontal lobe) and injury or herniation
of the intraorbital contents.
The medial canthal tendon (MCT) inserts on the lacri-
mal bone. The MCT contains three limbs. The superfi cial
heads of the orbicularis oculi muscle create the anterior
and superior limbs of the tendon inserting on the anterior
lacrimal crest. The deep head forms the posterior limb and
inserts on the posterior lacrimal crest. The three limbs of
the MCT incase the lacrimal sac within lacrimal fossa and
FIGURE 27-1. Vertical buttresses.

PANFACIAL FRACTURES • 293
function to pump and propagate tear transmission through
the lacrimal duct system. The MCT also functions (in con-
junction with the lateral canthal tendon) to suspend the
eyelids against the globe. Other chapters in this textbook
dealing with specifi c types of fractures provide further
information on pertinent anatomy.
PATIENT EVALUATION
Advanced Trauma Life Support (ATLS) protocol takes
precedence in the initial evaluation of maxillofacial
trauma patients, especially those with panfacial injury.
Life-threatening injuries in trauma patients must be diag-
nosed immediately. Facial fractures are rarely life-threat-
ening when they occur alone, but can present signifi cant
challenges when much of the bony support to the airway is
fractured and bleeding. During the primary survey, injuries
to the face or oropharynx that compromise the airway are
assessed. Airway management indications are unchanged
in facial trauma. Orotracheal intubation is preferred over
blind nasotracheal intubation. Bleeding from severe facial
injury, either intraorally or from epistaxis may complicate
intubation. Occasionally, severe bleeding is an indication
for intubation to protect the airway. Rarely, large hema-
tomas can extend into the neck or supraclavicular region
causing external compression of the pharynx. When a dif-
fi cult intubation is suspected, a dual setup for intubation
and cricothyrotomy is prudent. Cervical spine stabilization
should be achieved via standard protocol.
Upon completion of the ATLS primary survey, the sec-
ondary survey is initiated and careful assessment of the
face is performed. In unintubated alert patients, a history
should be elicited that addresses the following areas:
1. Does the patient’s dental occlusion and sensation
feel normal?
2. Can the patient hear normally?
3. Is the patient’s vision normal and extraocular move-
ment intact?
4. Can the patient breathe through both nostrils?
5. Is the patient able to speak normally?
6. Does the patient have any history of previous facial
trauma or surgery?
Understanding the mechanism of injury, the magnitude
of force, and the vector of impact is helpful in tailoring the
FIGURE 27-2. Horizontal buttresses.

294 • CHAPTER 27
clinical examination and ensuring that all injuries are rec-
ognized. A history of loss of consciousness or mental status
changes can be a clue to intracranial injury. Any functional
defi cits as elicited by the questions above can be a clue to
localizing fracture locations.
A general examination of the face is performed, noting
any asymmetries or motor defi cits. Subtle fi ndings, such as
mild enophthalmos or decreased globe excursion on upward
gaze, can have long-term implications if missed. Palpation
of the bony skeleton should then occur. Crepitus, severe
focal tenderness, abnormal prominences, and bony step-offs
are indications of underlying fractures. Focal areas of swell-
ing or hematoma may also be a sign of underlying fracture.
Facial nerve motor function is critical to normal facial func-
tion and each of the fi ve branches should be assessed on
clinical examination. Sensation throughout the face should
also be tested to assess for trauma to the three trigeminal
nerve branches. Photographs are helpful in preoperative
planning and postoperative outcomes assessment.
Each area of the face should then be evaluated system-
atically. In the forehead, loss of convexity, crepitus, and
focal tenderness are suggestive of frontal sinus fractures.
Evaluation of the eyes should include visual acuity and
movement of the extraocular muscles. Changes in visual
acuity may signal injury to the globe or retina, disrup-
tion of the optic canal or a neurologic injury. Assessment
of upward globe excursion is of particular importance, as
entrapment of the inferior rectus muscle in orbital fl oor
fractures is common. Periorbital swelling, ecchymosis,
hyphema, proptosis, enopthalmus, and inferior orbital
nerve parasthesia are all signs of possible orbital fractures.
Eye pain, photophobia, and tearing are signs of possible
corneal abrasions. An ophthalmologic examination in the
setting of an orbital fractures is prudent. The orbital rims
should be palpated for step-offs.
Particular to periorbital and NOE fractures, soft tissue
edema may mask fi ndings if only minimal displacement
is present. If posterior telescoping of the nasal bones and
frontal process of the maxilla are present, clinical diag-
nosis will be more obvious. Intercanthal and interpalpe-
bral distances should be measured. If the intercanthal
distance is more than 50% of the interpupillary distance,
suspicion for traumatic telecanthus should be further
explored. Telecanthus is a telltale sign of NOE fracture.
If the MCT is displaced or cut during impact, telecanthus
occurs. Usually, the MCT itself remains intact, and it is
the fragment of bone to which it is attached that becomes
displaced. Unopposed tension from the orbicularis oculi
muscle that remains attached to the lateral orbit by the
lateral canthal ligament causes unopposed pull on the
tarsal plates and eyelid skin—resulting in the telecanthus.
For MCT fracture avulsion to occur, NOE fracturing must
occur at four sites: lateral nasal bones, medial orbital wall,
nasomaxillary buttress, and frontomaxillary junction.
Integrity of the MCT can be tested manually by place-
ment of lateral traction on the upper and lower eyelids.
With instability of the MCT in NOE fracture, lateral dis-
placement will occur with traction. Compression of the
canthal-bearing medial orbital rim with the thumb and
index fi nger may reveal instability and/or crepitus. As with
all panfacial fractures, thorough examination of the eye
for visual acuity, extraocular muscle function, and pupil-
lary response is essential. Lacrimal function should also
be assessed. Lacrimal duct probing and Jones I/II dye tests
may be necessary to rule out any injury. The presence of
rhinorrhea, not uncommon in NOE fracture, is suggestive
of CSF leak. If adequate fl uid volume can be collected,
testing for beta-2 transferrin is the gold standard for con-
fi rmation of CSF rhinorrhea.
Milder NOE injuries result in minimal or no MCT dis-
placement. More severe injuries result in lateral displace-
ment of the MCT segment, resulting in telecanthus. The
severity of MCT disruption and bony comminution is the
basis for NOE fracture classifi cation ( Figure 27-3 ). All
types (I, II, III) may be unilateral or bilateral. Type III is
almost always bilateral given the impact force necessary to
generate severe comminution. 3
• Type I —Large single segment NOE fracture with no
disruption of the MCT attachment
• Type II —Comminuted fracturing of the NOE com-
plex with no disruption of the MCT attachment
• Type III —Comminuted fracturing of the NOE com-
plex with disruption of the MCT attachment
Preoperatively, distinction is only possible between
types I and II. Intraoperatively, the integrity of the MCT
and bone to which it is attached is assessed to differenti-
ate between types II and III. For appropriate preoperative
planning, the surgeon must only know if the NOE fracture
is single segment versus comminuted and unilateral versus
bilateral. This knowledge alone dictates the number of inci-
sions and types of surgical approaches described below.
Initially, evaluation of the nose should include nota-
tion of any obvious deformity or deviation of the dorsum
and nasal tip. Palpation for focal tenderness, crepitus, or
instability of the nasal bones should be assessed. Intranasal
examination with a speculum may reveal a septal hema-
toma or deviation suggestive of a fracture. A septal hema-
toma should be drained immediately, otherwise it may
lead to septal cartilage necrosis and eventual saddle nose
deformity. Rhinorrhea is a sign of CSF leak, and may indi-
cate a frontal sinus posterior table fracture or cribiform
plate fracture. Mobility of the entire nasal pyramid may be
caused by a LeFort II or III fracture. (A more detailed nasal
examination is discussed in Chapter 24 .)
Zygomaticomaxillary complex (ZMC) fractures often
result in enophthalmos or malar deformity. A depressed
zygomatic arch fracture may cause trismus, while ten-
derness and crepitus over the midcheek could signify a
maxillary sinus fracture. Anesthesia in the distribution
of the infraorbital nerve, or its dentoalveolar branches,
often accompanies fractures involving the orbital fl oor, the
orbital rim or the anterior maxillary wall.
Overall stability of the midface is assessed via inspection,
palpation, and manipulation to rule out LeFort fractures.

PANFACIAL FRACTURES • 295
This can be done by stabilizing the patient’s forehead while
grasping the anterior maxillary teeth or alveolar ridge and
pulling forward on the maxilla. Mobility of the maxilla
is a sign of fracture. Periorbital swelling may be a sign of
LeFort II or III fracturing. Retrusion of the midface from a
direct inward blow in LeFort fractures creates a “dish face”
appearance. The posteriorly displaced maxillary segment
may create premature contact between the maxillary and
mandibular molars leading to an anterior open bite.
Otoscopic examination should be performed to assess
the tympanic membrane and external canal. Hemotypanum
and/or otorrhea are a sign of serious injury. The clas-
sic “Battle’s sign,” or posterior auricular ecchymosis, is
suggestive of basilar skull fracture. This sign, however, does
not develop for 24 to 48 hours after trauma.
Intraoral examination should assess dentition, maxil-
lomandibular occlusion, stability of the alveolar ridge,
and integrity of the palate. In the awake and cooperative
patient, asking the patient to close their mouth and report
if the occlusion feels normal best assesses the dental occlu-
sion. The patient is usually more accurate than the phy-
sician given the high variability in preinjury occlusions.
The hard palate should be palpated for any step-offs or
sensitivity. The inability to fully open the jaw is suggestive
of a mandible fracture, although zygomatic arch fractures
may also limit opening. Anterior open bite, posterior open
bite, occlusal tilts, and unusual mobility of the mandible
are other clues. Impacted molars create a weak point in
the mandible and are often involved in the fracture line.
Fracture of a tooth may necessitate removal. Intraoral
palpation in the gingival buccal groove along the maxilla
may reveal contour abnormalities if maxillary fractures are
present. Caudal portions of the anterior maxillary sinus,
nasomaxillary buttress and zygomaticomaxillary buttress
should similarly be palpated.
Diagnostic Imaging
The role of plain radiographic fi lms has diminished in the
assessment of panfacial trauma, as almost all patients will
undergo a CT scan. Multiple radiographic views are needed
to fully assess the complex planes of the facial skeleton. An
occipitomental (Water’s) view and submental-vertex view
are used to visualize zygmaticomaxillary complex fractures.
A 15-degree posterior-anterior (Caldwell’s) view may reveal
injuries to the superior orbit, frontal, and ethmoid sinuses.
FIGURE 27-3. NOE fracture classifi cation.

296 • CHAPTER 27
Lateral views are helpful to assess the nose, palate, and fron-
tal and maxillary sinuses. More commonly, radiographs may
demonstrate air fl uid levels within the sinuses, suggestive of
nonvisualized wall fractures. A panorex is the single most
useful view for assessing the mandible; however, the lateral
oblique views provide good imaging of the ramus and body
while the frontomastoid (Townes’) view shows the con-
dyles. A cervical spine fi lm is helpful to exclude vertebral
column injury. Nevertheless, plain radiographs are almost
never obtained in modern facial trauma evaluation.
CT imaging provides the most accurate and thorough
evaluation of the facial skeleton and is preferable to plain
radiographs for evaluating a patient with panfacial frac-
tures. 4 It can also simultaneously evaluate for associated
intracranial and cervical spine injuries. CT imaging of the
facial skeleton should be done with 1-mm cuts and be
weighted for bony evaluation. Axial, coronal, sagittal, and
3D reformatting are helpful in delineating the full extent
of facial trauma and for visualizing fracture patterns. CT
angiography can give additional information in the set-
ting of expanding facial hematoma or concern for carotid
artery injury. Soft tissue structures such as TMJ menis-
cus, extraocular muscles, and the optic nerve may also be
visualized with CT imaging; however, soft tissues are best
imaged using MRI. The advent of specialized equipment
and software, now allows use of CT and MR imaging to
perform sophisticated preoperative planning and intraop-
erative image-guided reduction of fracture segments.
PATIENT PREPARATION
Indications for surgical intervention in panfacial trauma are
similar to those for individual facial fractures. Importantly,
defi nitive surgery should not proceed until all life-threatening
injuries have been addressed. Panfacial fractures often occur
in association with other systemic injuries. Delineating the
appropriate time for surgical intervention is of key impor-
tance. Often times, only one operation is necessary for
defi nitive treatment. However, an initial treatment may be
necessary to clinically stabilize the patient prior to undertak-
ing complete surgical repair.
Obviously, general anesthesia should not be induced
unless a secure airway is in place. As in all surgery, the risks
from general anesthesia must be weighed against any med-
ically confounding variables (eg, heart disease, pulmonary
disease). Repair of panfacial fractures is not always nec-
essary, but unaddressed fractures may lead to signifi cant
functional and cosmetic disability.
The goal of surgery for facial fractures is to promote
healing, restore function, and maximize cosmesis. Soft tis-
sue loss may necessitate delayed treatment of fractures
or required the use of distant fl aps for coverage. External
fi xation is another option. Extensive tooth loss may cause
diffi culty in reestablishing preinjury occlusion. Posterior
tooth loss and mandibular condyle fractures lead to loss
in the vertical height dimension. Primary bone grafting is
indicated to restore buttresses and to replace missing or
severely comminuted bone. In non-load bearing regions,
small bone gaps of less than 5 mm may be bridged with
a miniplate. Larger gaps or those in load-bearing regions
should be fi lled with bone grafts.
Indications for hospital admission and early repair:
• NOE fractures with CSF leak (need to monitor for
continued CSF leak and possible complications such
as meningitis)
• Frontal sinus posterior table fractures
• Zygomatic fractures with trismus
• LeFort midface fractures
• Orbital fl oor fractures with signs of ocular muscle
entrapment
Indications for immediate surgical intervention:
• Airway preservation: craniofacial fractures commonly
cause airway compromise. Immediate surgical reduc-
tion of the fractured facial bones may be necessary
to decompress the airway. Commonly, tracheostomy
is necessary both for immediate airway restora-
tion and to facilitate future surgical intervention. 5
Submandibular and endotracheal intubations are
alternatives.
• Hemorrhage: The facial skeleton is extremely well
vascularized, and any associated bony or soft tissue
facial trauma can produce massive hemorrhage. Bony
reduction or vessel ligation may be necessary in the
acute setting. Massive uncontrollable bleeding from
facial fractures is rare, but when occurs is best treated
by arterial embolization.
• Large open soft tissue wounds with exposure of vital
structures (nerves, vessels, ducts)
As long as the indications for immediate surgical inter-
vention discussed above (eg, airway compromise, hemor-
rhage, exposure of vital structures) are not present, surgery
for panfacial fracture repair can be delayed up to 2 weeks.
This allows time for adequate and accurate presurgical eval-
uation, clinical optimization of hemodynamics, decreased
facial swelling, and creation of any dental molds that may
be necessary during surgery. Surgical repair is not neces-
sary for nondisplaced fractures. Defi nitive repair in adults
is most easily performed in the fi rst 2 weeks after injury,
and sooner in children, before callus formation begins.
Dental models can be fabricated to assist in facial skele-
ton reduction and cases of malocclusion. From these mod-
els, acrylic stents for mandibulomaxillary fi xation (MMF)
and splints for palatal fractures can be made. For edentu-
lous patients, dentures are useful in creating splints and
facilitating MMF.
TECHNIQUE
Preoperatively, patients should be informed of the like-
lihood of MMF and its planned duration. The risks and
benefi ts of surgery must be discussed and informed con-
sent provided. The risks of surgery for fi xation of panfacial
fractures include but are not limited to contour deformity,

PANFACIAL FRACTURES • 297
CSF leak, temporary or permanent parasthesias, anosmia,
malocclusion, infection of implants (both alloplastic and
autogenous bone), osteomyeltis, malunion, nonunion,
meningitis, tooth root injury, plate/screw exposure, ectro-
pion, eye injury, and the need for additional or revision
surgery.
CT images should be available in the operating room for
referencing. A complete maxillofacial plating system must
also be available. Because most panfacial cases require
placement of MMF, nasotracheal intubation is preferential
(unless tracheostomy exists).
Patients with soft tissue injury may have traumatic lac-
erations or defects that allow access to the facial skeleton
for fracture repair. Otherwise, access must be gained by
strategically placed incisions:
Upper face and zygomatic arch: coronal, brow, Gillies
temporal incisions
Midface: periorbital (transconjuctival, lower eyelid,
upper eyelid, rim incision, brow), intraoral vestibular
Lower face: buccal, preauricular, retromandibular,
subman dibular
Sequencing of Surgery
Sequencing the repair is the key to treating panfacial
fractures. Traditionally, this has been described via two
main approaches: bottom-to-top or top-to-bottom. The
basic tenet of fracture fi xation from stable to unstable
while maintaining the occlusal relationship holds true
for either technique. There have been no randomized tri-
als comparing outcomes from different technique and,
therefore, surgeon preference predominates and is heavily
case dependent. Determination of which sequence to use
is predicated on the type of injury and where the larg-
est fracture segments and greatest stability are found. The
three top priorities are to establish facial width, facial pro-
jection, and occlusion.
The bottom-to-top or inside-to-out technique predates
the advent of miniplate and screw rigid internal fi xation. In
this technique, mandibular reduction and preinjury occlu-
sion are achieved via MMF. The bottom-to-top technique
establishes the mandible as the foundation for setting the
rest of the face. In the case of combined mandibular and
palatal fractures, dental impressions and occlusal splints
are helpful in trying to properly align maxillary and man-
dibular fragments in the correct occlusion. Arch bars are
applied to the upper and lower jaws. If the mandible is
comminuted and the maxillary arch can be easily reduced,
it is helpful to fi x the palatal fracture fi rst so a stable maxil-
lary arch can aid in the alignment of the mandibular seg-
ments. There are fewer muscle forces acting to displace
palatal fractures than mandibular fractures.
Mandibular condyle fractures must be repaired prior to
placement of MMF in order to ensure proper facial height.
If any other mandibular fracture (eg, body, ramus, angle,
symphysis) requires rigid fi xation, it is done immediately
after placement of MMF and before progressing outward
to other facial regions. If there is signifi cant comminution
or loss of the mandible bone then the top-to-bottom tech-
nique may provide better accuracy in fracture reduction.
Once the mandible is reduced and plated, fi xation of the
maxillary arch, ZMC, and zygomaticomaxillary buttress is
performed. Frontal sinus fractures are reduced, followed
by NOE repair. Care must be taken to ensure that the con-
dyles are properly situated in the glenoid fossa. In addi-
tion, it is important that the mandible is not over- rotated
upward, otherwise the midface height will be shortened
and an anterior open-bite deformity may result upon
release of MMF. Overall, the bottom-to-top technique is a
mandibulo-centric technique that relies on primary reduc-
tion of the mandible and maxilla to align and reduce the
remainder of the upper face. 6 , 7
The opposite approach, or top-to-bottom or outside-
in technique, begins with fi xation of the frontal sinus and
then the bilateral zygomatic regions. Attention to the
lateral orbital wall and zygomatic arch helps to properly
align the ZMC. This sets the proper width and projection
of the facial frame. Once the outer upper facial frame is
reduced and fi xated, reduction and fi xation of NOE frac-
tures should be performed. The maxilla is addressed next
and any LeFort fracture patterns would be addressed now.
The zygomaticomaxillary and nasomaxillary buttresses
should then be repaired. This provides stable support for
fi xation of maxillary sinus fractures. Palatal fractures are
repaired and the reestablished maxillary arch is secured
to the zygomaticomaxillary and nasomaxillary buttresses.
The mandible is then placed in MMF with the intact max-
illary arch and mandibular fractures are plated. In the
top-to-bottom approach, mandibular condyle fractures
often do not need to be addressed with open technique.
The interval of MMF may vary depending on the type of
condylar neck facture and the degree of rotation or medi-
ally displacement. Edentulous patient creates less concern
about restoring precise occlusion since adjustments can be
made in their dentures after healing. However, the lack of
dentition necessitates the use of splints if MMF is needed
for condylar neck fracture treatment. Otherwise, open
reduction internal fi xation (ORIF) or external fi xation is
required to repair the condylar neck to maintain posterior
facial height. 8
Manson et al. 6 described a sequencing technique to pan-
facial fractures that takes a slightly different approach by
conceptualizing the face upper and lower facial groups. The
upper facial group is divided into the cranial unit and the
midfacial unit. The lower facial group is divided into the
occlusal unit and mandibular unit. Each unit is fi xed accord-
ing to facial landmarks taking into account facial width,
projection and height. After fi xating units, the upper and
lower facial groups are anatomically linked at the LeFort I
level using the medial and lateral vertical buttresses. 9
In practice, the route of starting with known and work-
ing to unknown is usually taken. For example, if a patient
has panfacial fractures with severe comminution of the
mandible, it would be advisable to start with the upper
face and work down to the mandible. This would allow

298 • CHAPTER 27
the grossly disrupted and unstable mandible to be fi xated
to the more rigid and less destabilized midface. Reducing
larger fragments that are easy to align, as well as those
that can be stabilized to the skull base, helps facilitate the
reduction of smaller fracture segments. Key steps in all
approaches are wide exposure to identify fractures, resto-
ration of occlusion, reestablishment of facial height, width
and projection, and bone grafting for stability.
After internal rigid fi xation, soft tissue suspension
should be performed, particularly in panfacial fractures
where signifi cant soft tissue degloving of the midface is
necessary for fracture exposure. Special attention should
be paid to the zygomatic arch and infraorbital rim, as fail-
ure to resuspend the soft tissues in these areas leads to
malar descent with exposure of the bony prominences and
associated hardware. Suture through the malar soft tissues
may be suspended to the temporal fascia, drill holes in the
bone, or the plates themselves.
Zygomaticomaxillary Complex Fractures
The zygomaticomaxillary complex is important in defi ning
facial width and malar prominence. ZMC fractures are the
second most common facial fracture in adults, only after
nasal fractures. ZMC fractures involve the inferior and lat-
eral orbital rim, the zygoma, and the maxilla. A complete
ZMC fracture involves the following four stability points
( Figure 27-4 ):
1. Zygomaticofrontal suture
2. Zygomaticomaxillary buttress
3. Zygomaticotemporal suture
4. Zygomaticosphenoidal suture
FIGURE 27-4. ZMC complex. (Reprinted with permission
from Stone CK, Humpries RL. Current Diagnosis & Treatment:
Emergency Medicine . 6th ed. New York: McGraw-Hill; 2008. )
The zygomaticomaxillary buttress and zygomaticospeh-
noid suture where the zygoma attaches to the greater
wing of the sphenoid is often considered a single unit,
thereby, yielding the name “tripod” fractures. Although,
“tetrapod” or “quadripod” may in fact be more accurate
nomenclature. 10
Clinically, these fractures may result in fl attening of
the zygomatic prominence, infraorbital nerve parasthe-
sias, ocular dystopia, palpable orbital rim step-offs, lateral
canthal ptosis, and enopthalmus. Separation at the zygo-
maticofrontal suture predisposes to downward displace-
ment of the ZMC from unopposed tension exerted by
the masseter muscle. If left untreated, unacceptable facial
asymmetry may result with permanent enopthalmos and
malar fl attening.
Displaced ZMC fractures require repair via open reduc-
tion and internal fi xation. Precise reduction of the zygo-
maticofrontal suture, zygomaticomaxillary buttress, and
zygomatic arch must be performed. Ideally 3 points of
fi xation, at the zygomaticofrontal suture, the infra-orbital
rim and the maxillary buttress, are required to minimize
risk of the ZMC rotating during mastication. The inferior
orbital rim often requires plating when reconstruction of
the orbital fl oor is necessary.
Numerous surgical approaches to the ZMC exist—
coronal, upper or lower eyelid, transconjunctival, brow, and
maxillary vestibular incisions are used as needed depend-
ing on what other fractures are present. A transverse buccal
sulcus incision permits access to the zygomaticomaxillary
buttress for plating. L-shaped plates are specifi cally made
for this purpose and should be placed high to prevent
injury to the maxillary canine tooth roots. A lower eyelid
incision is used for the inferior orbital rim. An upper eye-
lid or brow incision allows access to the frontozygomatic
suture, but is unnecessary if a coronal incision is present.
In the setting of panfacial trauma, segmental fractures
through the zygomatic arch are typically exposed through
a coronal incision to allow reduction and fi xation while
avoiding injury to the facial nerve. Isolated arch fractures are
uncommon in panfacial trauma; therefore, the Gillies
approach using a small temporal incision and a Dingman
elevator to reduce the segment is rarely used. A common
pitfall in reducing zygomatic arch fractures is aligning the
fragments as an arch rather as an anatomically correct fl at
surface. In the setting of panfacial fractures, this leads to
decreased facial projection and increased facial width.
Maxillary (LeFort) Fractures
In 1901, Rene LeFort reported his work on cadaver skulls
subjected to blunt forces. He described three predomi-
nant predictable midface fracture patterns: transmaxillary
(type 1), pyramidal (type 2), and craniofacial (type 3).
Importantly, all fracture patterns end posteriorly with sep-
aration of the pterygoid plates.
A LeFort I is a transverse fracture pattern beginning
medially at the rim of the piriform aperture and then
extending laterally through the maxillary sinus, traversing

PANFACIAL FRACTURES • 299
above the maxillary tooth roots. It crosses below the ZMC
into the pterygomaxillary junction, with interruption of
the pterygoid plates. Intranasally, the base of the nasal sep-
tum is fractured. Clinically, mobility of the maxilla upon
grasping and rocking of the upper teeth is noted (the fore-
head must be held stationary). This fracture pattern may
result from a traumatic force to the maxillary alveolar rim
( Figure 27-5A ).
MMF is used to align the fracture segment with the man-
dible. Almost all LeFort I fractures will require open reduc-
tion and fi xation. Miniplate fi xation is the treatment of
choice in acute noncontaminated LeFort I cases. Exposure
is achieved through a gingival buccal incision made with
a needle-tip electrocautery. This incision is made approxi-
mately 0.5 to 1.0 cm labial to the sulcus apex, preserving a
mucosal cusp to allow for an easy and well-sealed closure
Anterior views
Le Fort
I
Le Fort
II
Le Fort
III
Lateral views
FIGURE 27-5. (A) LeFort I fracture. (B) LeFort II fracture. (C) LeFort III fracture.
(Reprinted with permission from Stone CK, Humpries RL. Current Diagnosis & Treatment: Emergency
Medicine . 6th ed. New York: McGraw-Hill; 2008. )
A
B
C

300 • CHAPTER 27
at case completion. The incision is then carried down per-
pendicular to the alveolar bone. Once the periosteum is
opened, a Freer elevator can be used to expose the fracture
lines. The length of the incision is surgeon dependent, but
may stretch from the fi rst molar all the way to the con-
tralateral side. As the periosteum is elevated, care must be
taken not to injure the infraorbital nerve as it exits the
infraorbital foramen in the maxilla. The periostial eleva-
tor should be used to completely expose the nasomaxillary
and zygomaticomaxillary buttresses. The piriform aper-
ture, nasal spine, and premaxilla should also be cleaned so
that the entire fracture line can be easily visualized.
Miniplate fi xation with low-profi le titanium plates
secured with monocortical self-tapping screws is the pre-
ferred method for ORIF. For adequate stabilization of
LeFort I fractures, the medial and lateral buttresses should
be plated across the fracture. An L-shaped plate is usually
used, with the long limb oriented along the length of the
buttress, and the short limb horizontally across the top of
the alveolar ridge. When plating, at least two screws should
be placed on each side of the fracture. Malleable plating
templates can be used to assist in more accurately contour-
ing the titanium plates to lie fl ush on the bone.
Interosseous wiring is an alternative to miniplates. In
this technique, opposing drill holes should be made on
each side of the fracture and wire passed through each hole
and the twisted tight to bring the fracture edges together.
Interosseous wiring is less secure than miniplating and
requires longer midface stabilization with MMF.
A LeFort II is a pyramidal shaped fracture pattern that
begins superiorly on the nasal bridge, at or below the naso-
frontal suture. It then extends laterally through the frontal
process of the maxilla and the lacrimal bones. It progresses
inferiorly to the inferior orbital rim and/or fl oor and
then across the anterior maxillary sinus. It then extends
under the zygoma, across the pterygomaxillary fi ssure
and through the pterygoid plates. With the forehead held
steady, the fractured maxilla and nasal complex will move
as a unit when grasped and rocked. This fracture pattern
may result from a traumatic force to the lower or midmax-
illa ( Figure 27-5B ).
As for all LeFort fractures, fracture disimpaction and
MMF is required. Access for ORIF is achieved through
ginigival buccal incisions similarly to LeFort I repair as
described above. This allows visualization of the LeFort II
fracture as it courses across the maxillary sinus, through
the zygomaticomaxillary buttress into the pterygomax-
illary fi ssure. Additional incisions are necessary to gain
access to the superior portions of the LeFort II. This can be
achieved through transconjunctival or subcilliary incisions,
allowing access to the orbital rim and fl oor. If additional
access is needed centrally, a transfi xation incision to sepa-
rate the columella from the septum allows further deglov-
ing of this region.
Fracture reduction should be performed fi rst prior to
any plate fi xation. Once adequate reduction has been
achieved, the pyramidal shaped LeFort II maxillary seg-
ment can be secured laterally to the stable zygomatic
portion of the zygomaticomaxillary buttress. Fixation of
the inferior orbital rim and/or fl oor, as well as the fron-
tonasal buttress should then be performed. Monocortical
self- tapping screws should be used.
A LeFort III fracture pattern entails a craniofacial dys-
junction, with the entire midface separated from the cra-
nial base. The fracture begins medially at the nasofrontal
and frontomaxillary suture and extends posteriorlaterally
along the medial orbital wall. It traverses the nasolacri-
mal groove and ethmoid bones until it reaches the lesser
wing of the sphenoid in the posterior orbit. The sphenoid
bone in the posterior orbit contains thicker bone providing
greater protection of the optic nerve as it enters the optic
canal. This bony thickness protects the nerve and defl ects
the fracturing force inferiorly through the inferior orbital
fi ssure and across the orbital fl oor. It then extends laterally
through the lateral orbital wall, through the zygomaticof-
rontal suture and across the zygomatic arch. Like LeFort II,
it then extends under the zygoma, across the pterygomax-
illary fi ssure, and through the pterygoid plates. Intranasally,
the fracture extends from the perpendicular plate of the
ethmoids, through the vomer and across the base of the
sphenoid. A CSF leak can occur. This fracture pattern may
result from a traumatic force to the upper maxilla or nasal
bridge ( Figure 27-5C ).
Often times, maxillary fractures occur in more com-
plex patterns than initially described by LeFort. The basis
for fracture patterns depends primarily on two factors.
First, the anatomy of the midface with its vertical and
horizontal buttresses is designed to bolster the midface and
orient traumatic forces away from vital intracranial struc-
tures. Second, depending on the mechanism of injury and
the force generated, maxillary fractures may be unilateral or
bilateral. Often, a combination of various LeFort patterns is
seen and an associated ZMC fracture is not uncommon.
LeFort III fractures involve a total dissociation of the
midface from the cranial skeleton. Stabilization and fi xa-
tion is necessary to the frontal bone cephalically and man-
dible caudally. MMF should be achieved after disimpaction
of the maxilla. Once satisfactory occlusion is achieved, a
bicoronal incision is used to access the upper nasal bones,
lateral orbital rim, and zygomatic arch; and lower eyelid
or transconjunctival incisions are used to access the orbital
fl oor. Bicoronal fl aps are raised via either a linear or zig-zag
incision extending from the posterior-superior portion of the
auricular helix, over the top of the scalp, to the contralateral
side. The fl ap can be raised centrally either in the subpe-
riosteal or subgaleal plane. The supratrochlear and supraor-
bital nerves exit the skull just above the superior orbital rim.
If dissecting in the subgaleal plane, the pericranium should
be incised just above the exit points of these nerves to pre-
serve the blood supply to the fl ap. However, this eliminates
the potential use of the pericranium as a fl ap in the future.
A small osteotomy can be made in the supraorbital foramen
to allow the nerve to fall into the orbit, allowing for greater
inferior folding of the soft tissue fl ap.
Laterally, care must be taken not to injure the frontal
branch of the facial nerve as it courses superior to the

PANFACIAL FRACTURES • 301
zygomatic arch and lateral brow. The nerve runs on the
underside of the superfi cial temporal fascia (also known as
tempoparietal fascia). In order to avoid injury, at approxi-
mately 1 to 2 cm above the zygomatic arch, the superfi cial
layer of the deep temporal fascia should be incised, expos-
ing the temporal fat pad. Dissection is then carried down
within the fat pad until the superior aspect of the zygo-
matic arch is reached. Once adequate reduction has been
attained, miniplate fi xation is performed. In LeFort III frac-
tures, plate fi xation is necessary at the bilateral frontozy-
gomatic buttress, nasofrontal buttress, and zygomatic arch.
Repair of the orbital fl oor should then be performed.
Maintenance of fracture immobilization is the most
important aspect of postoperative LeFort fracture manage-
ment. This is primarily achieved in the postoperative period
via compliant MMF. The duration of MMF is surgeon and
case dependent, but traditionally ranges from 3 to 8 weeks.
In general, miniplate fi xation allows for earlier MMF removal
as compared with interosseous wiring or suspension wiring.
During this time, keen oral hygiene with prescribed antiseptic
rinses is essential. Chlorohexidiene mouthwash is commonly
used. Midface fracture union and callus formation may be
tested both clinically and radiographically. Maxillary stabil-
ity may be tested by grasping the maxillary arch and asking
the patient to repeatedly clench and relax their muscles of
mastication. Maxillary motion indicates that fracture healing
has not yet occurred and arch bar removal at this stage would
be detrimental. In the late postoperative period, maxilliary
motion is a sign of nonunion or malunion. A CT scan is help-
ful in confi rming the diagnosis.
NOE Fractures
Naso-orbitoethmoid fractures involve concurrent fractures
of the nasal, ethmoid, and medial orbital bones. The NOE
region is prominent on the facial profi le and, therefore, is
susceptible to injury. NOE fractures usually occur from a
forceful impact at the upper midface, just over the nasal
bones and radix. Severe injury to the NOE complex pres-
ents one of the greatest challenges in facial fracture man-
agement because of the displacing force of the orbicularis
oculi muscles and diffi culties in restoring proper alignment
of the medial canthus. The force required to create NOE
fracturing is less than that necessary for frontal or zygo-
matic fractures. However, as in all panfacial fractures, a
thorough history and mental and physical examination is
necessary to rule out concomitant injuries. Motor vehicles
accidents are the most common mechanism, followed by
assault.
NOE fractures can result in signifi cant physical, func-
tional, and cosmetic deformity. Only fractures with no
signs of instability on physical examination and no dis-
placement on CT imaging, can avoid repair. Surgical repair
in a timely fashion is recommended. Although delay is not
life-threatening, scar formation and soft tissue retraction
can make later repair more diffi cult. The primary goal in
surgical ORIF is to restore native position of the MCT and
the bony segment to which it is attached. Secondary goals
include restoration of preinjury intercanthal distance, sym-
metric canthal positioning, maintenance of nasal projec-
tion, and normal soft tissue contour. Failure to treat can
result in long-term severe aesthetic distortion, lower eyelid
laxity, and lacrimal gland dysfunction.
ORIF of the NOE complex requires access through
multiple incisions. A Lynch incision (direct vertical inci-
sion just medial to the MCT) provides direct access to the
fracture site; however, the resultant scar is unsightly and
easily visible. A bicoronal incision is most often necessary
for adequate exposure in conjunction with a periorbital
incision (either lower eyelid transconjunctival or lower
subciliary incision). The frontonasal suture and superior
and medial orbital rims are exposed through the bicoronal
incision. In bald or elderly patients, a vertical midline inci-
sion in the glabellar region allows direct access via small
incision and requires less dissection. The lower eyelid inci-
sion allows visualization of the fracture segments along
the inferior-medial orbital wall/fl oor and nasomaxillary
junction. Additional exposure may be achieved through
medial conjunctival incisions (paracaruncular and tran-
scaruncular approaches). A maxillary gingivobuccal sulcus
incision allows access to fractures along the nasomaxillary
buttress and piriform aperture. Obviously, any overlying
skin lacerations may be used (and extended) for exposure.
Once adequate NOE fracture exposure has been achieved,
the medial canthal tendon and its attachment should be
delineated. This delineation defi nes the type of NOE fracture
pattern based on the classifi cation discussed above. Usually,
the MCT remains fi xated to a lacrimal crest bone fragment
without being entirely avulsed. However, if avulsed, the ten-
don leafs should be identifi ed and suture tagged for later can-
thopexy after bone segment reduction. Overall surgical repair
is NOE “type” specifi c and described below.
A type I fracture is a large single segment NOE frac-
ture. Bone reduction with either digital manipulation or
instrumentation should be performed. A penetrating towel
clamp or bone reduction clamp can be used to hold the
fracture segment in place while fi xation is performed.
Fracture segments that involve the frontal process of the
maxilla or inferior orbital rim, should be miniplated with
monocortical screws. Wire fi xation with 28-gauge steel
wire is an alternative method of fi xation.
In rare cases where MCT avulsion from the bony frag-
ment has occurred, refi xation to the lacrimal crest is nec-
essary. Two small holes (4 mm apart) should be drilled
in the superior-posterior lacrimal crest. A strong perma-
nent suture or 30-gauge steel wire should then be passed
through the avulsed canthal tendon and secured to the
bone. Of utmost importance is adherence to repair of the
MCT to the superior and posterior portion of the lacrimal
crest to prevent poor eyelid apposition to the globe and a
potential “clothes line” effect.
In type II fractures, there is comminuted fracturing of
the NOE complex, but the bony segment to which the
MCT is attached remains intact. Surgical exposure is the
same as for type I repairs. Meticulous subperiosteal dis-
section is necessary to delineate the MCT and associated

302 • CHAPTER 27
comminuted bony fragments. If entrapment of the medial
rectus or superior oblique muscles is encountered, they
should be released back into the orbit.
In minimally displaced and minimally comminuted
type II fractures, miniplate fi xation with monocortical
screws can be performed, as done for type I fractures.
Fracture segments must be large and rigid enough to sup-
port screw placement. In fractures with severe bony dis-
placement or severe comminution with very small bone
fragments, transnasal wiring is additionally necessary for
fi xation. In these cases, an additional exposure of the con-
tralateral medial orbital wall is necessary.
Transnasal wiring is performed using 28- or 30-gauge
steel wire. For unilateral fractures, two small holes should
be drilled on the ipsilateral canthal-bearing bone segment.
Drill holes should be made superior and posterior to the
native canthal tendon insertion. Using a large curved nee-
dle, the wire is passed through the drill holes, then through
the nasal septum, and out through similar drill holes in
the contralateral lacrimal crest. The wire or suture may be
secured around a monocortical screw inserted on the supe-
rior medial orbital rim or to itself. If the NOE fractures
are bilateral, central bone fragments are best stabilized to
each other with transnasal wiring. The nasal bones may be
removed and subsequently replaced, for better visualiza-
tion during transnasal wiring. During transnasal wiring of
bilateral segments, the wire should be placed so that the
twist is located intranasally. Once the intercanthal distance
of the NOE complex has been reestablished, the NOE
complex should be secured to the superior orbital rim and
frontonasal suture with either miniplate or wire fi xation.
In type III fractures, comminuted fracturing of the NOE
complex with disruption of the MCT attachment occurs.
The MCT may not be avulsed, but regardless, the bony
fragment to which it is attached is too small for fi xation.
These are the most severe type of NOE fractures and,
therefore, have a higher incidence of intraorbital, dural and
skull base injury.
Transnasal wiring to reposition the lacrimal crest should
be performed as described for type II fractures above. The
canthus should be reattached to the bone segment using
additional transnasal wires or to the existing wire using
suture. As with type II fractures, any additional bone seg-
ment fractures can be secured with monocortical screw
miniplate fi xation. After restoration of the intercanthal dis-
tance, the NOE complex should be secured to the superior
orbital rim and frontonasal suture with miniplate or wire
fi xation. In severe comminution with loss of lacrimal bone,
monocortical calvarial bone grafts may be used to restore
bony contour and provide a site for attachment of the
medial canthal tendon. Bone grafting to the nasal dorsum
and medial orbital wall and fl oor may also be needed.
Immobilization of the NOE complex with a nasal
splint is recommended. Wired cross-nasal compression
splints help the soft tissues to adhere to the underlying
bone. Postoperative antibiotics are recommended given
the continuity with the sinus cavities. In the immediate
postoperative period, the head of the bed should stay
elevated greater than 30 degrees. Serial eye examinations
should be performed every hour for the fi rst 24 hours, and
observation for any increase in intraorbital pressures (ie,
from hematoma) is essential.
Postoperative Management
Intraoperative antibiotics, ideally 1 hour prior to skin inci-
sion, are almost always used in the operative treatment of
panfacial fractures. The question as to whether postopera-
tive antibiotics are necessary is still debated. In general,
if the fracture sites were initially exposed to the external
environment through open soft tissue wounds or are in
continuity with any of the sinuses, nasal cavity, tooth roots,
or mouth, broad-spectrum antibiotics are recommended
for 7 to 10 days. Postoperatively, patients should be moni-
tored for changes in vision, bleeding, airway problems,
CSF leak, fever, and vomiting. If MMF with wires is used,
wire cutters should be with the patient at all times, in both
the inpatient and outpatient settings. Patients should be
instructed on how and when to remove wires if vomiting
or airway compromise occurs.
COMPLICATIONS
Skin and Soft Tissue
Facial incision healing is no different in the treatment
of panfacial trauma than in any other type of facial sur-
gery. Skin edges should be handled with great delicacy. A
double-layered closure is always preferable to take tension
off the skin closure. Soft tissue complications may result
from damage during the initial trauma, improper suturing
technique, and/or intraoperative trauma from stretching or
devascularization.
Dehiscence of intraoral incisions may occur as a result
of poor oral hygiene, excessive motion, or poor technical
closure. As previously mentioned, correct design of the
buccal incision is the key to a good closure. It is impor-
tant to keep a cuff of mucosa for purposes of suturing on
the gingival side of the gingivobuccal incision. Good oral
hygiene facilitates wound healing.
Infection
The facial skeleton and soft tissue is relatively well vascu-
larized compared with other areas of the body. However,
infections after panfacial fractures still occur. Patients with
extensive soft tissue trauma, open fractures, and contami-
nated wounds are at higher risk. Fractures and fi xation
hardware continuous with the nasal passage, the sinuses,
or the oral cavity can become infected if not empirically
treated with antibiotics. If empiric antibiotics are inad-
equate for preventing or treating infection, incision and
drainage may be necessary.
Long-standing or untreated infections may result in
osteomyelitis of the facial skeleton. Plates and screws

PANFACIAL FRACTURES • 303
used for bony fi xation may be a cause of the infection.
Treatment usually involves 4 to 6 weeks of IV antibiot-
ics. If antibiotic treatment is inadequate, bony debride-
ment may be necessary. Internal fi xation of involved bone
often becomes loose, requiring removal of the infected
hardware. Premature removal and/or infection may result
in malunion or nonunion. Sinusitis can occur if fracture
patterns or surgical hardware block drainage through sinus
ostia. In cases unresponsive to decongestants and antibiot-
ics, surgical drainage may be necessary.
Facial Asymmetry and Bony Malposition
Postoperative facial asymmetry may occur in up to 40%
of panfacial trauma patients. Any early error in operative
reduction may result in a series of compounding errors,
often resulting in increased facial width, decreased poste-
rior facial height, or decreased anterior-posterior projec-
tion. Telecanthus is common after NOE fracture. For this
reason, the surgeon must work carefully, using stable seg-
ments and known landmarks to get excellent reduction.
Correction of major asymmetry may require surgical inter-
vention with osteotomies and bone grafting.
Neurologic Defi cits (Motor and Sensory)
A well-documented preoperative facial neuromotor and
neurosensory examination is important, as nerve defi cits
may be a result of the inciting trauma or operative pro-
cedure. In patients with extensive midface and maxillary
trauma, neuropraxia or permanent infraorbital nerve dam-
age is common. The infraorbital nerve courses through the
inferior orbital fi ssure and exits the facial skeleton through
the infraorbital foramen, just below the orbital rim. As this
foramen creates a structural weakness in the maxilla, frac-
tures often occur through this site. The result is ipsilateral
anesthesia of the medial cheek, maxillary teeth, and upper
lip. Damage to the nerve may occur from the initial trauma
or intraoperatively during exposure and fi xation of the
maxillary sinus or orbital rim. Often, extensive retraction
through a gingival buccal incision or periorbital incision can
result in a prolonged postoperative neuropraxia.
The supraorbital nerve may be injured in trauma to
the forehead region, supraorbital rim, frontal sinus, and in
NOE fractures. Intraoperatively, the supraorbital nerve may
be injured during bicoronal approaches to the superior or
medial orbital rim. This can occur from accidental nerve lac-
eration or from excessive retraction of the forehead fl ap.
The frontal branch of the facial nerve may be injured
during the dissection of bicoronal fl aps or from retraction
through a lateral brow incision. Injury to the facial nerve
may also occur from traction during exposure of the man-
dibular condyle from a Risdon (submandibular) approach.
Bleeding
The internal maxillary artery provides most of the vascu-
lar supply of the midface. Extensive anastomosis of the
branches of the external carotid systems occur in the facial
skeleton. Facial fracturing may result in profuse bleeding
requiring embolization or ligation of the internal maxillary
artery. This is also a common site of bleeding during LeFort
fracture treatment, as the vessel is in proximity to the pos-
terior fracture line at the pterygomaxillary junction.
Ophthalmologic
Panfacial fracturing and fracture repair involving the orbit
may result in injury to the lacrimal duct, optic nerve,
globe, cornea, and extraocular muscles. Extraocular muscle
entrapment may occur between bone segments or between
internal plating systems and bone.
Lower eyelid ectropion is a common complication of
periorbital incisions for maxillary fracture exposure. It is
believed that a transconjunctival incision decreases the risk
of ectropion as compared with subcilliary or lower eyelid
incisions. Care should be taken not to aggressively stretch
the lower eyelid during retraction. The risk of lower eyelid
ectropion may be decreased by not elevating the pretar-
sal portion of the orbicularis oculi muscle and meticulous
dissection and hemostasis of the orbital septum to mini-
mize scar formation. Panfacial fracture patients with lower
eyelid laxity or negative vector morphology may benefi t
from canthopexy after fracture fi xation. Adequate malar
suspension after facial degloving will minimize downward
pull on the eyelid. A Frost suture is left until major swell-
ing subsides to mechanically elevate the lower eyelid and
help keep the lamellae of the eyelid properly aligned and
to prevent them from adhering to the orbital rim.
Traumatic or iatrogenic blindness is one of the most seri-
ous complications associated with facial trauma. Swelling,
malpositioned bone grafts and bleeding are potential causes
of postoperative vision loss. Scheduled postoperative visual
acuity checks by nursing and physician staff are essential.
Approximately 30% of postoperative patients may expe-
rience transient mild visual acuity changes. Any signifi -
cant postoperative loss of visual acuity is an indication for
immediate orbital re-exploration and decompression.
Malunion/Nonunion
Malunion or nonunion may occur secondary to infection,
unstable fi xation, or patient noncompliance with MMF.
Persistent telecanthus is the most common postopera-
tive complication after NOE fracture repair. It can be the
result of either delayed or inadequate repair. Separation or
detachment of the transnasal wiring can also occur, revers-
ing the results from initial repair. In all cases, surgical re-
exploration and revision is recommended. Lower eyelid
laxity, ectropion, and scleral show may occur from incor-
rect positioning of the transnasal wire.
Lacrimal System Injury
Routine exploration of the lacrimal system in NOE frac-
tures is not indicated because the incidence of injury is low

304 • CHAPTER 27
and often asymptomatic. Symptomatic obstruction to the
lacrimal system is usually treated secondarily with dacro-
cystorhinostomy. Occasionally, lacrimal system injury may
occur during transnasal wire fi xation. Wires positioned too
low on the lacrimal crest may cause impingement of the lac-
rimal sac, resulting in obstruction or epiphora. Prophylactic
intraoperative lacrimal duct stenting can be performed to
diminish the risk of iatrogenic injury. Obstruction of the
nasofrontal duct can also occur. Patients will complain of
progressive frontal pressure. Treatment involves duct recan-
nulation or obliteration of the frontal sinus in severe cases.
Dental Injury
Iatrogenic injury to tooth roots may occur from improper
placement of arch bars or screws. When fi xating maxillary
or mandible fractures, use monocortical screws if in prox-
imity to tooth roots and avoid plating directly over them.
Malocclusion is not uncommon and may require dental
manipulation and occasionally reoperation.
OUTCOMES
Given the inherent nature of traumatic facial injuries, pro-
spective studies assessing outcome measures are lacking.
Repair of simple panfacial fractures usually results in satis-
factory restoration of facial appearance, bony contour, and
function. Severe panfacial fractures, despite appropriate
operative repair, often have persistent sequelae.
Since the 1980s, miniplate fi xation has gained popularity
over interosseous wiring. Despite its intended permanence,
indications for hardware removal do exist. Palpability of
the plates and screws remains the most common indica-
tion for removal (35%), followed by loosening of the fi xa-
tion devices (25%), infection and pain. Cold sensitivity is a
rare indication for hardware removal. 11
REFERENCES
1. Erdmann D, Follmar KE, Debruijn M, et al. A retrospec-
tive analysis of facial fracture etiologies. Ann Plast Surg .
2008;60(4):398–403.
2. Thaller SR, McDonald WS. Facial Trauma . New York:
Marcel Dekker; 2004.
3. Sargent LA. Nasoethmoid orbital fractures: diagnosis and treat-
ment. Plast Reconstr Surg . 2007;120(7 Suppl 2): 16S–31S.
4. DeMarino DP, Steiner E, Poster RB, et al. Three-dimensional
computed tomography in maxillofacial trauma. Arch Otolar-
yngol Head Neck Surg . 1986;112(2):146–150.
5. Babu I, Sagtani A, Jain N, Bawa SN. Submental tracheal intu-
bation in a case of panfacial trauma. Kathmandu Univ Med J
(KUMJ) . 2008;6(1):102–104.
6. Kelly KJ, Manson PN, Vander Kolk CA, et al. Sequencing
LeFort fracture treatment (organization of treatment for a
panfacial fracture). J Craniofac Surg . 1990;1(4):168–178.
7. Markowitz B. Rigid fi xation of panfacial injuries. In:
Yaremchuk M, Gruss J, Manson P, eds. Rigid Fixation of
the Craniomaxillofacial Skeleton . Stoneham, MA: Butter-
worth-Heinemann; 1992.
8. Gruss J, Phillips J. Rigid fi xation of lefort maxillary fractures.
In: Yaremchuk M, Gruss J, Manson P, eds. Rigid Fixation of the
Craniomaxillofacial Skeleton . Stoneham, MA: Butterworth-
Heinemann; 1992.
9. Moe K. Facial trauma, management of panfacial frac-
tures. September 2009.
article/1283471-overview .
10. Evans BG, Evans GR. MOC-PSSM CME article: Zygomatic
fractures. Plast Reconstr Surg . 2008;121(1 Suppl):1–11.
11. Orringer JS, Barcelona V, Buchman SR. Reasons for removal
of rigid internal fi xation devices in craniofacial surgery.
J Craniofac Surg . 1998;9(1):40–44.

c h a p t e r
Pediatric Facial Fractures
Sanjay Naran, MD / Ahmed M. Afi fi , MD / Joseph E. Losee, MD, FACS, FAAP
INTRODUCTION
Pediatric facial fractures are recognized as separate enti-
ties from those occurring in the adult. They differ sig-
nifi cantly in their epidemiology, diagnosis, and treatment.
The aim of this chapter is to highlight differences and
review the principles of management of pediatric facial
fractures. The pediatric population is defi ned by the
American Academy of Pediatrics as those younger than
21 years of age; however, most of the discussion in this
chapter will focus on those before puberty, as it is in this
age group that the major differences are most apparent.
At or after puberty, the frequency, distribution, and treat-
ment strategy approaches those of the adult population.
Anatomic Differences and
Special Fracture Patterns
The higher cranial to facial proportion in children reduces
the risk that a frontal impact will cause a facial fracture,
but increases the risk of skull fractures and intracranial
injuries. At birth, the cranial to facial proportion is 8:1,
gradually becoming 4:1 at the age of 5 years and 2:1 at
adulthood. This unfolding of the face from underneath
the skull increases the risk of facial fractures with age.
Consequently, younger children whose trauma is of a
magnitude to cause a facial fracture will usually have sig-
nifi cant concomitant neurological injuries 1 ( Table 28-1 ).
With age, the fracture frequency shifts from the upper
face (with frontal and orbital fractures more common in
the fi rst 5 years of life), to the lower face (with mandible
fractures having a higher incidence after 6 years and into
adulthood). Facial bones in children have a higher can-
cellous to cortical bone ratio and higher cartilage con-
tent. This imparts more elasticity to the pediatric facial
skeleton, decreasing the probability of fractures. When
fractures do occur they are rarely comminuted and more
commonly greenstick and minimally displaced. In addi-
tion, patent suture lines commonly separate, leading to
unusual fractures not seen in adults.
Developing teeth and sinuses affect the way fractures
form and are treated. At birth, sinuses have not yet devel-
oped and exist only as a bud of mucosa surrounded by can-
cellous bone. Therefore, the facial skeleton in the child is
composed of solid blocks of bone, in contrast to that of the
adult skeleton whose sinuses are surrounded by buttresses
that dissipate injury leading to more common fracture
patterns. This solid architecture makes the pediatric facial
skeleton more resistant to trauma and more liable to
unusual fracture patterns. In general, bone-bearing mixed
dentition is more resistant to fracture. The shape and posi-
tion of deciduous and mixed dentition has a major impact
on several aspects of fracture reduction and fi xation in the
mandible and the midface. Most importantly, mixed denti-
tion in the mandible can occupy almost the entire vertical
length of the mandible, placing the teeth and the inferior
alveolar nerve at risk during screw placement.
Physiological
The speed of bone healing and the remodeling capacity of
pediatric facial bones can be incredibly fast. The surgeon
should appreciate this healing potential and reduce these
fractures as early as possible, utilizing shorter immobiliza-
tion periods after reduction. After 3 to 5 days, fractures
begin to heal, making fracture identifi cation, disimpaction,
and reduction harder. On the other hand, the surgeon can
accept minor misalignment of the often greenstick frac-
tured segments, knowing that the remarkable remodeling
capacity of the pediatric skeleton will compensate for such
discrepancy.
28

306 • CHAPTER 28
Psychological
The child and the parents’ fear and anxiety are unique,
leading to an uncooperative apprehensive child and par-
ents with clouded judgment. Handling both the child
and his family in the emergency room necessitates wise
assessment of the situation, and should be considerate.
These children are at risk to develop post-traumatic stress
disorder, and every effort should be made to help them
overcome the possible functional, aesthetic, and psycho-
logical consequences of the fracture.
The Fourth Dimension
Perhaps the most important difference that the surgeon
should consider when managing these fractures is that
a primary aim of surgery is to not only achieve a three-
dimensional fracture reduction, but to allow for normal
unimpeded growth of the skeleton, the so-called “fourth
dimension.” Knowledge of the growth periods of regions
within the pediatric facial skeleton is therefore essen-
tial ( Table 28-2 ). Our understanding of the effect of
TABLE 28-1. Pediatric Facial Trauma at Children’s Hospital of Pittsburgh of the University
of Pittsburgh Medical Center: Demographic of Age, Fracture Type, Cause of Injury and
Associated Injuries
Age Group (n)
Fracture Type (%)
Causes of
Injury (%)
Associated Injuries (%)
Required
Surgery n (%)
Admitted to
ICU n (%)
0–5 y (156)
Orbit (57.3)
Skull (41.0)
Mandible (22.9)
Nasal (20.3)
Maxillary (14.0)
Dentoalveolar (7.6)
Zygomatic (1.9)
NOE (0.6)
ADL (38.5)
Play (23.7)
MVC (21.8)
Sports (0.63)
Soft Tissue (96.6)
Neurologic (61.4)
Musculoskeletal (10.1)
Ophthalmological (8.2)
43 (27.6)
44 (28.2)
6–11 y (272)
Orbit (51.0)
Nasal (29.6)
Skull (27.90)
Mandible (27.5)
Maxillary (16.8)
Dentoalveolar (8.2)
Zygomatic (3.7)
NOE (1.65)
MVC (31.6)
Play (20.5)
Sports (13.9)
ADL (7.4)
Assault (1.2)
Soft Tissue (95.2)
Neurologic (54.8)
Ophthalmological (17.5)
Musculoskeletal (15.3)
91 (36.1)
52 (20.6)
12–18 y (373)
Orbit (45.6)
Nasal (39.9)
Maxillary (22.8)
Mandible (21.2)
Skull (15.20)
Zygomatic (7.6)
Dentoalveolar (6.7)
NOE (1.9)
Assault (26)
MVC (24.7)
Sports (22.2)
Play (10.3)
ADL (4.9)
Soft Tissue (94.4)
Neurologic (43.9)
Ophthalmological (22.2)
Musculoskeletal (10.3)
143 (38.3)
47 (12.6)
ADL, activities of daily life; MVC, motor vehicle collision; NOE, naso-orbitoethmoid.
From Grunwaldt L, Madia JV, DeCesare GE, et al. Pediatric craniofacial fracture demographics: a fi ve year institutional review of 1508 consecutive
patients. Plastic Surgery Research Council, 54th Annual Meeting. Pittsburgh, PA: 2009.
TABLE 28-2. Table of Facial Growth
Onset (y)
Maximum
Growth (y)
Growth
Complete (y)
Cranium
0
1–2
10
Nose
5
10–14
16
Orbit
0
1–2
7
Frontal Sinus
5
8–16
20
Maxillary Sinus
5
10–12
14
Maxilla
5
8–12
16
Mandible
1–4
8–12
20
From Mathes SJ, Hentz VR. Plastic Surgery . Philadelphia: Saunders;
2006.
fractures and their management on craniofacial growth is
limited because of the paucity of data, following through
to adulthood, regarding the growth and development of
facial fractures treated in childhood. Data that do exist

PEDIATRIC FACIAL FRACTURES • 307
focus on pediatric mandible fractures and suggest that
these do not result in a higher incidence of orthodon-
tic intervention, and that there do not appear to be any
growth disturbances associated with indicated conserva-
tive or surgical treatment. 2
Theoretic growth disruption can occur due to the
fracture itself, its operative exposure, or the rigid fi xa-
tion. Furthermore, scarring within the soft tissues may
impede bone growth. When a fracture does require open
exposure, soft tissue undermining should be kept to a
minimum. Fixation of bone can have deleterious effects
secondary to mechanical restriction of growth across the
plate and by relieving the bone from the usual stresses
stimulating its growth.
PATIENT SELECTION
In general, children are less prone to facial fractures
(1%–15% of all facial fractures affect children 3 ), due to
their protected environment, the decreased facial to cra-
nial proportion, the fl exibility of their facial bones and
the considerable fat pads around their mandible. Motor
vehicle accidents, including all-terrain vehicles, account
for the vast majority of these fractures, followed by falls
form a height and sporting accidents 1 , 4 ( Table 28-1 ).
Child abuse is a less common cause but one that should
be bore in mind.
The resiliency of the pediatric facial skeleton implies
that those who do sustain fractures will have been sub-
jected to trauma of such a high force that they are likely
to have signifi cant associated injuries ( Table 28-1 ). The
injured child with multiple or severe trauma poses a sig-
nifi cant challenge to the resuscitating physician. In the
presence of extensive craniofacial injury, provision of a
safe airway should be the fi rst priority. Children have
a relatively larger tongue and tonsils, and a smaller tra-
chea and pharynx that are easily obstructed. In addition,
infants younger than 6 months are obligate nasal breath-
ers. Pulling the tongue or mandible forward, removing
foreign bodies, and suctioning the upper airway should
be done promptly. It is rare to have a grossly mobile max-
illa, and this should not be initially considered the cause
of any airway compromise. A tracheostomy or endotra-
cheal intubation can provide a defi nitive airway.
Resuscitation is usually started with a warmed crystal-
loid at a rate of 20 mL/kg, assessing response by hemo-
dynamic parameters, level of consciousness, and urine
output. Once the airway and hemodynamic stability
are secured, the secondary survey begins to identify and
treat different injuries. In the child with facial trauma,
three injuries are particularly common and should be
vigilantly looked for: intracranial, ophthalmologic, and
cervical-spine injuries.
The examination of the craniofacial skeleton should
proceed in an orderly fashion assessing pain, tenderness,
swelling, asymmetry, step-offs, crepitus, paresthesia, and
facial nerve function. Ophthalmologic and neurosurgi-
cal consultations should be obtained if necessary. An
intraoral examination is part of the facial examination,
and should include a search for mucosal wounds and
missing or loose dentition. Assessment of the occlusion
is of paramount importance in fractures involving tooth-
bearing bones. Orthodontic records, dental models, and
photographs are useful in determining pretraumatic
occlusion.
PATIENT PREPARATION
Conventional x-ray imaging is largely nondiagnostic in
the pediatric population, as fracture lines are diffi cult
to localize in an immature skeleton with high cancel-
lous bone content. CT scans are considered the fi rst-line
radiographic modality in diagnosing pediatric facial frac-
tures. Coronal and axial thin-cut sections will accurately
defi ne the presence and features of most fractures and
will aid in treatment planning. A 3D reconstruction is a
helpful modality that is handy to have as a quick refer-
ence during surgery. The only conventional x-ray image
still recommended is an orthopantomogram (panorex),
which provides a panoramic view of the mandible that
can diagnose mandible fractures with a reasonable accu-
racy. It is also commonly used postoperatively to assess
reduction, the dentition, and for long-term follow-up of
mandible growth.
As stated above, assessment of the occlusion is of para-
mount importance in fractures involving tooth-bearing
bones. In the presence of a traumatic malocclusion, dental
models are useful in determining pre-traumatic occlusion.
These are fabrication from an alginate impression of the
patient’s maxillary and mandibular dental surfaces. From
these negative models, plaster casts of each dental surface
can be created. The two individual models can then be
manipulated or cut at suspected fracture lines and re-glued
together to obtain a preinjury ideal occlusion. From these
altered models, acrylic splints can be made to be used
either alone or in conjunction with surgical intervention.
Patients with orbital fractures need proper ophthal-
mologic evaluations, as these fractures are frequently
associated with ocular injuries. Injury to the globe must
be identifi ed to prevent vision loss.
TECHNIQUE
Principles of Management and Repair
An infant with a minimal fracture does not require oper-
ative intervention, while an older child with a grossly
displaced comminuted fracture is best served with open
reduction internal fi xation (ORIF). Unfortunately, most
patients fall in the large watershed area in between,
where the experience and preference of the surgeon will
oftentimes determine the course of management. Until
further evidence is available to provide accurate guide-
lines as to the degree of reduction accepted, it rests upon
the surgeon to decide for each case individually whether
closed or open reduction is warranted, and in doing so

308 • CHAPTER 28
consider the degree of displacement, the feasibility of
open reduction, and the age of the patient. 5
Conservative (Nonsurgical) Management
Closed reduction or simple observation is often employed
in children due to the high frequency of minimally dis-
placed and greenstick fractures. Factors favoring this
approach are the younger age of the patient, absence of
malocclusion or other functional defi cits, and good align-
ment of the fracture segments. In all cases, the patient
must be followed on a yearly basis to monitor skeletal
and soft tissue growth.
Surgical Management
The trend in adults to treat most facial fractures with
ORIF does not translate to children. ORIF provides per-
fect reduction of the fracture and often avoids the need
for mandibulomaxillary fi xation (MMF), which can be
a diffi cult procedure in children with developing teeth;
however, this is at the risk of potential growth retardation.
Clear indications for surgery are failure of closed reduc-
tion and a signifi cantly displaced or comminuted fracture.
All cases of internal fi xation should be performed with
minimal but adequate exposure of the fracture, avoiding
unnecessary soft tissue undermining and dissection.
Fixation Hardware
A better understanding of the biological and mechanical
properties of hardware has facilitated many innovations
and refi nements in their material and design. The sur-
geon should be able to choose the proper shape, size, and
type of hardware, which may be easily applied with the
least soft tissue dissection, while providing suffi cient load
sharing. Debate regarding the use of permanent hard-
ware versus absorbable plates continues. 6 Absorbable
plates subjugate the need for a second surgery; however,
they likely do not provide the same degree of rigid fi xa-
tion that can be provided by metallic plates. Some argue
that metallic hardware should be removed after 3 to 6
months in order to avoid growth disturbances or trans-
location of the plates (cranial plates have been found
to translocate from the external surface of bone to its
endocranial or internal surface).
Mandibulomaxillary Fixation
MMF provides accurate reduction and stabilization while
avoiding the growth insult of open reduction. However, this
technique remains challenging in the pediatric population,
particularly those in primary and mixed dentition. The
surgeon must be facile in the various different methods of
MMF. Arch bars, the most common method in adults, may
not suit children due to the conical shape of their decidu-
ous dentition, partially erupted secondary dentition, and
carious teeth, all of which do not provide a strong founda-
tion for MMF. In addition, injury to permanent teeth or
their periodontal ligament may result from the circumden-
tal wiring. If used, wires should be placed below the gum
line, and should encircle stable or multiple teeth. Similarly,
interdental wires provide a minimally invasive method of
fracture stabilization; however, one must choose the cor-
rect teeth for fi xation of the wires.
Challenges associated with circumdental wiring have
lead surgeons to use wires that either wrap around the
mandible (circum-mandibular) and/or wires that drop
down from more stable bones such as the piriform aper-
ture ( Figure 28-1 ). These wires are then connected to each
other by another wire to achieve and maintain proper arch
relationship. Alternatively, these wire fi xation techniques
can be used to help maintain the position of arch bars.
As described above, acrylic splints provide another
modality to assist in obtaining and maintaining arch rela-
tionship, but requires time, special equipment, and exper-
tise to utilize. These splints are fabricated after accurate
reduction of the fracture (closed reduction or interdental
wiring), should include both lingual and buccal surfaces
of the dentition, and should taper posteriorly so as not
to create an open bite. They are fi xed to the mandible by
circum-mandiblar wires. Acrylic splints have signifi cant
advantages, namely that they are applicable to all ages
(including infants where other forms of MMF are fraught
with diffi culties or complications), and do not stress the
teeth but rather fi x them in place. They may also be used
in the setting of the edentulous neonate or infant.
Bone Substitutes
While the use of bone grafts in the immature craniofa-
cial skeleton is controversial, due to their unpredictable
long-term results and their unknown effect on growth,
they remain preferable to alloplastic materials. Common
donor sites for bone grafts are the iliac crest, ribs, and
FIGURE 28-1. Alternative forms of MMF: skeletal wires
through the piriform aperture and mandible.

PEDIATRIC FACIAL FRACTURES • 309
the skull. When harvesting an iliac crest bone graft, the
surgeon should avoid injury to the superior cartilaginous
lip of the iliac crest, which is the growth center. The skull
is an excellent source for bone grafts in older ages, and
CT scans can be used to detect the presence of a diploic
space, which denotes the feasibility of harvesting calva-
rial bone grafts.
Mandible Fractures
Mandible fractures are one of the more common pediat-
ric facial fractures, representing 20% to 50% of all pediat-
ric facial fractures, 1 , 3 and are more likely to require some
form of surgical reduction or fi xation. The goal is to gain
adequate reduction with proper occlusal relationship
while maintaining the growth potential of the mandible,
and avoiding interference with the eruption and devel-
opment of dentition. The distribution of fractures within
the mandible differs from that of the adult ( Table 28-3 ),
with the incidence of condylar fractures being higher. 2
TABLE 28-3. Mandibular Fractures at
Children’s Hospital of Pittsburgh of the
University of Pittsburgh Medical Center:
Demographic of Age and Fracture
Location
Age Group (%)
Fracture Location (%)
0–5 y (25.14)
Condylar head (27.27)
Parasymphysis (20.45)
Condylar neck (18.18)
Angle (11.36)
Body (11.36)
Ramus (6.82)
Symphysis (4.55)
Coronoid (0)
6–11 y (40.57)
Condylar neck (28.17)
Condylar head (26.76)
Parasymphysis (16.90)
Symphysis (8.45)
Angle (8.45)
Ramus (5.63)
Body (5.63)
Coronoid (0)
12–18 y (34.29)
Condylar neck (31.67)
Parasymphysis (28.33)
Angle (16.67)
Condylar head (6.67)
Ramus (6.67)
Body (5.00)
Symphysis (5.00)
Coronoid (0)
From Smith DM, Bykowski MR, DeCesare GE, et al. 179 mandible
fractures in 96 children: demographics, early outcomes, and a
prospective analysis of growth and development. International
Society of Craniofacial Surgeons XII Biennial International
Congress. Oxford, UK; 2009.
FIGURE 28-2. Pediatric dentition and hardware
placement: panorex of a pediatric mandible showing metallic
hardware and asymmetry of the mandible.
Many pediatric fractures are either minimally displaced
or greenstick fractures, and may be adequately treated
conservatively (cervical-spine collar, soft diet, pain control,
avoidance of intense physical activity, and observation).
The risk of growth retardation imposed by open reduction
is justifi ed when occlusion cannot be achieved or main-
tained by closed reduction or MMF, when the fracture is
grossly comminuted or displaced, and in cases of multiple
fractures and certain condylar fractures.
As with all pediatric fractures, open reduction with
internal fi xation of the mandible follows the same prin-
ciples, including minimal exposure and limited soft tissue
dissection and undermining. Awareness of the position of
teeth in relation to the age of the patient, especially dur-
ing drilling and plating the mandible, will further help
the surgeon avoid many of the most commonly dreaded
complications. To avoid disruption of unerupted denti-
tion, it is recommended to place the plates on the inferior
border of the mandible and fi x them using monocortical
screws 6 ( Figure 28-2 ).
Condylar Fractures
Condylar fractures remain one of the most controversial
and diffi cult to treat types of mandible fractures. There
are three main reasons why condylar fractures pose such
a challenge; the fi rst is the effect of these fractures on
long-term mandibular growth. The condyle is purported
to be the primary growth center of the mandible in the
postnatal life. 6 Injury to the condyle may lead to growth
retardation, and unfortunately no treatment modal-
ity has been shown to prevent this. The second reason
is the concern for TMJ ankylosis following these frac-
tures. The third reason is the diffi cult approach used for
exposure of the condyle, which puts the facial nerve at
risk of injury. MMF has been the most commonly used
method for treating these fractures, on the assumption
that achieving correct occlusion will reduce the fracture
and allow for healing in an acceptable position. However,
this remains debatable as MMF only repositions the dis-
tal segment and has no effect on the proximal segment.

310 • CHAPTER 28
The three main factors infl uencing the decision to
treat conservatively versus surgically are the location of
the fracture, the degree of displacement or angulation,
and the relation of the condylar head to the glenoid fossa.
Condylar fractures are divided according to location into
three subsets, fractures of the intra-articular head, frac-
tures of the neck (above the level of the sigmoid notch
but outside the capsule), and subcondylar fractures. In
general, fractures with normal occlusion, no open bites,
and good range of motion are treated with a soft diet
and physiotherapy. If the above conditions are not met,
high condylar fractures are treated with MMF and low
fractures are treated with ORIF. Other indications for
ORIF are foreign bodies in the joint, bilateral condylar
fractures (in which case at least one should be fi xed),
and associated midface fractures. In the patient with pri-
mary or mixed dentition, almost always, a conservative
approach is taken when treating condylar fractures.
Nasal Fractures
Nasal fractures are extremely common, and as a result
of its role in growth of the midface, can have dire long-
term consequences. Nasal fractures in children present
differently than in adults due to their different anatomy. 7
The nasal bones are not united, explaining the possibil-
ity of a unilateral nasal bone fracture (a rare occurrence
in adults) and the frequency of the open book fracture,
a peculiar fracture in children where the nasal bones
are splayed open and override the frontal process of the
maxilla. The pediatric nasal skeleton also has a higher
proportion of cartilage that is highly vascular and grows
rapidly. A careful clinical examination, including intrana-
sal examination and palpation for tenderness and mobil-
ity, is therefore required. Many surgeons will rely solely
on the clinical picture for diagnosis of nasal fractures,
with some being more obvious than others ( Figure 28-3 ).
Plain x-rays are of limited value in the cartilaginous skel-
eton of a child. If a naso- orbitoethmoid (NOE) fracture
FIGURE 28-3. Nasal Fracture: collapse of the nasal
septum.
is suspected, a CT scan should be obtained. Septal hema-
tomas should be suspected and appropriately managed
in all nasal injuries, as they may have dire consequences,
namely abscess formation, septal perforation, pressure-
induced avascular necrosis of the nasal cartilage, saddle
nose deformity, infection, fi brous thickening, and nasal
obstruction. Septal hematomas usually appear as a blu-
ish red bulge in the anterior part of the septum, can be
of variable size and location, and may obstruct nasal
breathing. Although usually associated with a fracture
of the septum, this is not necessarily true in all cases.
Septal hematomas should be drained promptly through
an appropriately placed incision in the nasal septum. The
incision should provide access to the whole hematoma
and should ensure dependent drainage.
While the closed reduction of nasal fractures in adults
result in a high percentage of persistent nasal deformi-
ties, nasal fractures causing a visible deformity in the
pediatric population should be reduced once diagnosed.
Although local anesthesia supplemented with IV seda-
tion may be used, children are usually better served by
a general anesthetic if feasible. Reduction of the fracture
is achieved with the aid of a long straight fl at instrument
inside the nose (Ash forceps or the back of a scalpel) and
digital pressure on the outside. An external and occasion-
ally an internal nasal splint is used for 5 to 7 days.
Naso-Orbitoethmoid Fractures
These involve the nasal bones, the medial orbital wall
and the ethmoid bones. They may be associated with
fractures of the frontal bone, skull base, infraorbital rim,
or blowout orbital fractures. If a NOE fracture is sus-
pected, a CT scan should be obtained ( Figure 28-4 ).
Classically, the nasal bones are posteriorly and laterally
displaced, and the medial orbital rim bearing the medial
canthal ligament is laterally displaced. This results in the
classical clinical picture of a depressed nasal dorsum and
telecanthus. To judge the presence of telecanthus, one
should compare the intercanthal distance with the width
of the palpebral fi ssure (they are normally similar), or
use age-specifi c values of interorbital distance.
The most important determinant for the need to
intervene (and for adequacy of treatment) is the posi-
tion and mobility of the central (canthal bearing) bone
fragment. 8 A simple way to test this is by external trac-
tion on the medial canthal ligament laterally. This is
especially important as telecanthus may not be apparent
initially but may develop in the weeks to follow.
NOE fracture reduction can be technically demand-
ing and the degree of displacement and mobility will
determine the operative approach, with the most impor-
tant goal being the restoration of intercanthal distance.
In minimally displaced fractures, conservative manage-
ment is advocated. If operative reduction is planned
because of signifi cant displacement, the anatomy of the
fracture and the proposed points of fi xation will dictate
the choice of incisions and follow the same principles as

PEDIATRIC FACIAL FRACTURES • 311
FIGURE 28-4. Naso-orbitoethmoid fracture: bilateral
NOE fractures on CT scan.
TABLE 28-4. Pediatric Orbital Fracture
Classifi cation
Type 1
Pure orbital fractures
1a
Floor fractures
1b
Medial wall fractures
1c
Roof fractures
1d
Lateral wall fractures
1e
Combined fl oor and medial wall fractures
Type 2
Craniofacial fractures
2a
Growing skull fractures
Type 3
Orbital fractures associated with common
fracture patterns
3a
Fractures of the fl oor and inferior orbital rim
3b
Zygomaticomaxillary fractures
3c
Naso-orbitoethmoid fractures
3d
Other fracture patterns
From Losee JE, Afi fi A, Jiang S, et al. Pediatric orbital fractures:
classifi cation, management, and early follow-up. Plast Reconstr
Surg. 2008;122(3):886–897.
in the adult. Usually coronal, lower eyelid and gingival
buccal sulcus incisions are needed. If the medial canthal
ligament is still attached to a bone fragment, that frag-
ment is reduced and fi xed. If the ligament has been sepa-
rated from the bone, transnasal wiring is required. NOE
fractures may require bone grafts to fi ll the gaps in the
inferior and the medial orbital walls, as well as to recre-
ate the nasal dorsum and provide stabilization.
Zygomaticomaxillary Complex Fractures
Zygomaticomaxillary complex (ZMC) fractures are not
common in children, and when they do occur they are
often minimally displaced. They may not follow the stan-
dard fracture patterns, and may be associated with other
injuries, most notably neurological and ophthalmologic
injuries. ZMC fractures lead to a constellation of signs
and symptoms, including epistaxis, upper buccal sulcus
hematomas, loss of malar eminence, enophthalmos, and
an inferiorly displaced lateral canthus.
Minimally displaced ZMC fractures not causing
functional (eg, malocclusion or muscle entrapment)
or aesthetic (eg, vertical orbital dystopia or cheek
retrusion) problems do not require surgical correction.
As in the adult, most displaced ZMC fractures will
require exposure through a lower eyelid and upper buc-
cal incisions. Despite the age of the patient, standard
three-point fi xation is commonly used, 7 , 9 with fi xation
at the zygomaticofrontal suture, inferior orbital rim,
and the zygomaticomaxillary buttress, once the frac-
ture is reduced at the lateral orbital wall (zygomatic-
sphenoid bone). The orbital fl oor is explored as part of
the surgery and any fractures or defects are dealt with
appropriately.
Orbital Fractures
Patients with orbital fractures need proper ophthalmo-
logic evaluations, as these fractures are frequently associ-
ated with ocular injuries. Trapdoor fractures, an entity
more commonly seen in children, are fractures that
entrap the extraocular muscles as the bone rebounds
faster than the soft tissues. Muscle entrapment is diag-
nosed by limitation of extraocular motion or by a forced
duction test. This is a true emergency necessitating imme-
diate surgery to release the trapped muscle and hopefully
prevent irreversible muscle necrosis and fi brosis.
Unlike adults, where the size of the orbital wall defect
dictates treatment, in children other factors dictate
treatment recommendations. 10 Pediatric orbital fractures
may be classifi ed into one of three groups ( Table 28-4 ).
Pure orbital fractures are the most common pediatric
orbital fracture and should be followed conservatively
regardless of defect size, unless there is acute evidence
of entrapment, enophthalmos, or vertical orbital dysto-
pia ( Figure 28-5 ). Craniofacial fractures involving the
orbital roof are common, occurring as oblique fractures
in children, and should be treated conservatively with
vigilant follow-up, including serial CT scans and detailed
physical examinations, with particular attention paid to
the potential development of a growing skull fracture.
Orbital fractures associated with common fracture pat-
terns (eg, NOE, ZMC) should be treated surgically as
part of the concomitant fracture, employing resorbable
plating systems when feasible. Operative approach is

312 • CHAPTER 28
FIGURE 28-5. Orbital fractures: (A) herniation of orbital globe contents on CT
through a fracture of the orbital fl oor. (B) Enophthalmos may be assessed by observing
the patient from a worm’s eye view. (C) Vertical orbital dystopia may be subtle; a tongue
blade may be employed to determine orbital height.
A
B
C
dictated by fracture location and follows the same tech-
nique as in the adult.
Frontal Bone Fractures
The frontal sinus begins to pneumatize around the age
of 5 years, and is not fully developed until after puberty.
Therefore, frontal bone fractures in infants and children
are skull base fractures. The large cranium-to-face ratio in
young children results in a relatively higher incidence of
frontal bone fractures in these patients. In children, frac-
tures are usually linear and extend from the temporal or
frontal skull in an atypical oblique fashion to the orbits.
Indications for surgery in frontal bone fractures are sig-
nifi cant displacement, intra- or extracranial hematomas,
pneumocephalus, brain injury, or persistent CSF leak.
The goal of surgery is to “separate the brain from the nose
and external environment,” manage the brain and dural
injury, avoid CSF leak, and correct facial contour. This goal
usually necessitates a procedure with neurosurgical col-
leagues for a combined extra- and intracranial approach.
Several factors will affect the decision on how to deal with
the fracture, including the exact location and extent of the
fracture, integrity of the nasofrontal duct, and associated
intracranial and facial bone injuries. 5 A “safe sinus” can be
achieved by repairing the fracture if the duct is intact. If
the surgeon doubts the integrity of the duct or the pos-
sibility of achieving a “safe sinus,” one should opt for cra-
nialization or obliteration of the sinus. In all cases, these
patients should be carefully followed as they may develop
a mucocele years later with drastic sequelae.
COMPLICATIONS
Complications may occur early in the postinjury period
or later whether or not surgical intervention has been pre-
formed. Most complications in the immediate postopera-
tive period relate to imperfect reduction or fi xation of the
fracture. These may manifest as malocclusion, decreased
mouth opening, orbital dystopia, or facial asymmetry.
While infection is a rare complication in the highly
vascular craniofacial skeleton, it is one that can have seri-
ous consequences and will usually result in removal of
implanted hardware and grafts. Antibiotics are there-
fore usually administered empirically. Further studies are
needed in order to better assess the need and benefi t of
empiric antibiotic treatment.
Careful surgical technique will reduce the occurrence
of damage to the mental nerve and permanent dentition
while repairing mandibular fractures. Temporomandibular
dysfunction, TMJ ankylosis, and growth disruption are the
most common long-term complications of condylar frac-
tures. In the case of unilateral injuries, stress imposed on
the injured side by the intact TMJ is thought to be the
cause of temporomandibular dysfunction. TMJ ankylosis
is often the result of articular disc damage and is seen in
the setting of severe comminuted fractures of the condyle.
Prolonged MMF may also be a contributing factor, again
advocating for a short immobilization period.
With orbital fractures, common complications include
ocular injury, enophthalmos, diplopia, and residual tele-
canthus. Injury to the nasolacrimal apparatus and anosmia
may also occur. Complications related to nasal fractures
again apply here. Growth disruption and midface retru-
sion may also develop and will require secondary surgery
once growth is complete. Blindness, while rare, is a dreaded
complication. Persistent enophthalmos or vertical orbital
dystopia may also result from inadequate reduction and
treatment, or unpredictable postoperative growth and
development. Routine postoperative and follow-up oph-
thalmologic evaluation of visual acuity and ocular function
is essential.
Facial asymmetry secondary to resultant midface hyp-
oplasia may develop from midfacial fractures due to dis-
ruption of growth centers. Parents should be counseled in
regard to growth disruption and deformity, with manage-
ment tailored at a time when growth is complete.
Of special importance in frontal, skull, and orbital roof
fractures in children is the possibility of developing grow-
ing skull fractures. 10 This occurs when an associated dural

PEDIATRIC FACIAL FRACTURES • 313
injury allows brain pulsations to slowly and persistently
separate the fracture, resulting in nonunion and growth of
the fracture ( Figure 28-6 ). For this concern, it is suggested
that pediatric craniofacial fractures be followed clinically
and radiographically. If a growing skull fracture is found, it
will often necessitate surgical repair of the dura and recon-
struction of the bone.
OUTCOME
It is the late consequences of pediatric facial fractures that
make them unique compared to those of the adult, with
disruption of facial growth being the primary concern.
Routine follow-up, on a yearly basis, is suggested for pedi-
atric patients, and may include the cooperation of multi-
ple specialties, including a neurosurgeon, ophthalmologist,
orthodontist, and a psychiatrist in addition to the plastic
surgeon. Serial radiographic studies are useful and cepha-
lometric analysis may be employed to objectively evaluate
facial growth.
Follow-up for mandible fractures should be in conjunc-
tion with the orthodontist. Occlusion should be checked
routinely to ensure that the reduction is stable. Nutrition
and oral hygiene should not be overlooked. The maximal
incisor opening should also be measured routinely. Growth
and development may be followed using panorex radio-
graphs and cephalometric analysis.
Nasal fractures require long-term follow-up in order to
assess for late complications such as airway obstruction,
saddle nose deformity, maxillary hypoplasia, and other
growth disruption. These late complications should pref-
erably be approached in the late teens, when nasal growth
is complete and the patient is mature enough to compre-
hend and elect to undergo surgery.
REFERENCES
FIGURE 28-6. Growing skull fracture. (A) Three-dimensional CT scan of a growing
skull fracture. (B) Intraoperative exposure of the fracture.
A
B
1. Grunwaldt L, Madia JV, DeCesare GE, et al. Pediatric cran-
iofacial fracture demographics: a fi ve year institutional
review of 1508 consecutive patients. Plastic Surgery Re-
search Council, 54th Annual Meeting. Pittsburgh, PA;
2009.
2. Smith DM, Bykowski MR, DeCesare GE, et al. 179 Mandible
fractures in 96 children: demographics, early outcomes, and a
prospective analysis of growth and development. International
Society of Craniofacial Surgeons XII Biennial International
Congress. Oxford, UK; 2009.
3. Vyas RM, Dickinson BP, Wasson KL, Roostaeian J, Bradley JP.
Pediatric facial fractures: current national incidence, distri-
bution, and health care resource use. J Craniofac Surg. 2008;
19(2):339–349.
4. Ferreira PC, Amarante JM, Silva PN, et al. Retrospective
study of 1251 maxillofacial fractures in children and adoles-
cents. Plast Reconstr Surg. 2005;115(6):1500–1508.
5. Hatef DA, Cole PD, Hollier LH Jr. Contemporary manage-
ment of pediatric facial trauma. Curr Opin Otolaryngol Head
Neck Surg. 2009;17(4):308–314.
6. Smartt JM Jr, Low DW, Bartlett SP. The pediatric mandible:
II. Management of traumatic injury or fracture. Plast Recon-
str Surg. 2005;116(2):28e–41e.
7. Dufresne CR, Manson PM. Pediatric Facial Injuries. Vol 3.
2nd ed. Philadelphia: Saunders Elsevier; 2006.
8. Sargent LA. Nasoethmoid orbital fractures: diagnosis and treat-
ment. Plast Reconstr Surg. 2007;120(7 suppl 2):16S–31S.
9. Kelley P, Hopper R, Gruss J. Evaluation and treatment of zy-
gomatic fractures. Plast Reconstr Surg. 2007;120(7 suppl 2):
5S–15S.
10. Losee JE, Afi fi A, Jiang S, et al. Pediatric orbital fractures: clas-
sifi cation, management, and early follow-up. Plast Reconstr
Surg. 2008;122(3):886–897.

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29
Reconstruction of the Ear
Christopher J. M. Brooks, MD
PATIENT EVALUATION
The goal of ear reconstruction is to provide a realistic
appearing and functional (eyeglass-supporting) auricle in
patients who are missing all or part of an ear due either
to a congenital malformation or to a secondary insult.
The majority of patients who seek total ear reconstruc-
tion are those with microtia. Microtia affects 0.76 to 2.35
in 10,000 live births and can be unilateral or bilateral.
Hispanics and Asians have a signifi cantly higher incidence
of microtia than do Caucasians and blacks. Males and the
right ear are also disproportionately affected. There is a
wide spectrum of severity ranging from complete anotia to
minor deformities. Microtia is typically classifi ed into three
types: lobule, concha, and small concha. Microtia may also
be a part of a larger syndrome with associated anoma-
lies affecting other organ systems, most commonly facial
clefts and cardiac defects. Microtia is frequently associated
with craniofacial microsomia and many feel that isolated
microtia is actually the most mildly affected variant of this
malformation. In children with microtia, one of the bigger
determinants in patient selection is the age of the patient.
The appropriate age will be determined by which recon-
structive technique is selected.
The second subset of patients is those who have suf-
fered trauma, burns, cancer, or infection affecting the auri-
cle. Clearly, reconstruction of an ear should be addressed
only when the cancer or infection has been cleared and
the major threats to life and limb have been addressed. In
traumatic, sharp, complete amputation of the ear, replan-
tation should be attempted when possible. In subtotal
amputations and avulsions, this is rarely possible due to
lack of suitable vessels. Except in the very young, com-
posite grafting is most often unsuccessful. Reconstruction
of partial ear defects is also possible using the techniques
outlined below.
When examining the auricular deformity, it is impor-
tant to note what structures are present, what structures
are absent, and what structures are present but deformed.
The microtic ear is also usually abnormally positioned
over the temporal scalp. It is often more inferior and
anterior to the normal side. Microtia is classifi ed into
different grades depending upon severity ( Figure 29-1 ).
Anotia represent the most severe form in which no
external ear tissue is present. In grade 1 microtia, the ear
is smaller than normal but retains most of the features of
a normal ear, including a well-defi ned lobule, helix, and
antihelix. An external auditory canal may or may not be
present. In grade 2 microtia, the normal features of the
ear are missing. A lobule and remnants of the helix and
antihelix remain. In grade 3 microtia, the ear consists of
disorganized cartilage beneath a skin envelope attached
to a displaced lobule. Usually there is no external audi-
tory canal.
PATIENT PREPARATION
Given the spectrum of anomalies and the multiple needs
of a patient with microtia, referral to a craniofacial team
is recommended. This will allow for a thorough physical
examination, a genetic evaluation, audiologic evaluation as
well as the host of important ancillary services provided
by this team approach. A temporal bone CT scan is crucial
to determine the status of the middle ear as the severity
of the external deformity does not necessarily correlate
well with the development of these structures. This may
be deferred until the time of reconstruction to minimize
early radiation exposure.
This information, together with audiologic evalua-
tion, can determine the need for any otologic surgery to
improve hearing. Given that most children with microtia
c h a p t e r

316 • CHAPTER 29
will have some degree of decreased hearing, augmenta-
tion of hearing on the affected side coupled with preser-
vation and protection of hearing on the unaffected side
is critical. Hyper vigilance against infection is important.
The affected side hearing can be augmented by head-
band-based bone conduction hearing aids, bone anchored
hearing aids, atresia surgery, or middle ear surgery.
Once a technique has been selected, and the appro-
priate age has been reached, surgery can be scheduled.
One consideration in the pediatric population can be the
school schedule. Scheduling the stages of ear reconstruc-
tions to coincide with summer and winter breaks can
help minimize absence from school. Typically, after the
rib harvest stage of any of the reconstructions, children
will require 2 to 3 weeks for recovery before returning
to school. Smaller revisions and stages may require less
time.
TECHNIQUE
In general, there are three broad categories of total auric-
ular reconstruction: (1) autologous reconstruction, (2)
alloplastic reconstruction, and (3) prosthetic reconstruc-
tion. Autologous reconstruction is typically a multistaged
procedure based around a costal cartilage construct,
which is harvested, carved to the desired shape, and bur-
ied beneath the skin. The subsequent stage elevates the
reconstructed ear and to provide projection. Between
two and four stages of surgery are required to complete
the reconstruction, with the remaining stages devoted to
positioning of the lobule, creating the tragus, and deep-
ening the conchal bowl. There are several approaches to
this type of reconstruction, some of which will be dis-
cussed below.
Alloplastic reconstruction provides a realistic appear-
ing ear in as little as one operation, without the asso-
ciated morbidity and possible donor defect involved
with harvesting rib. The material used is high-density
porous polyethylene, which has multiple applications
in cosmetic surgery and craniofacial reconstruction. The
reported advantage of this material is that the porous
nature of the product allows tissue ingrowth into the
synthetic material, which may render it more resistant to
infection or exposure. Its critics argue that the infection
and exposure rates resulting in explantation are higher
than that seen in autologous reconstruction. Many of the
early alloplast ear reconstruction failures occurred prior
to the standard use of temporoparietal fascial coverage.
Despite its critics, reconstruction with porous polyethyl-
ene has evolved since its inception and is widely a viable
option in auricular reconstruction.
For prosthetic reconstruction, a silicone framework is
created and is affi xed in the proper location by adhesives
or systems using osseointegrated magnets or clips. This
can be performed in one to two steps. Aside from patient
preference, there are often valid reasons to select this type
of reconstruction. Patients with poor skin secondary to
burns, trauma, radiation, or prior attempts at reconstruc-
tion may require prosthetic based reconstruction due to
the poor quality of the surrounding skin. Also, patients
Anotia
Grade 1
Grade 3
Grade 2
FIGURE 29-1. Classifi cation of microtia severity.

RECONSTRUCTION OF THE EAR • 317
who cannot tolerate a more involved reconstruction due
to comorbidities may benefi t from a prosthesis. There is
some controversy regarding the use of osseointegrated
prostheses as a fi rst line therapy in the pediatric microtia
patient. While a prosthesis can appear quite realistic, it
does require replacement every 2 to 5 years, and more
frequently with higher sun exposure and smokers. Many
surgeons have been concerned that a prosthetic ear does
not become incorporated into the body image. Multiple
studies, however, have shown a generally satisfi ed patient
population.
General anesthesia is required for most types of ear
reconstruction. Smaller revisions may be done under local
anesthesia with or without sedation. Patients are generally
positioned supine with both ears prepped into the fi eld
to allow reference to the unaffected ear as necessary to
maximize symmetry. Access to the chest is necessary for
harvesting rib grafts if needed. Sterile technique is manda-
tory especially when using rib grafts or prosthetic materi-
als such as porous polyethylene. If required, some of the
hair may be clipped after induction. Preoperative antibi-
otics are given, with Pseudomonas and possibly methicil-
lin-resistant Staphylococcus aureus coverage re quired for
those with a patent ear canal.
For the most part, no special equipment is required.
When performing autologous reconstruction with rib,
some surgeons like to use special carving tools, but this
is not mandatory. If split-thickness skin grafting is being
used, a dermatome may be used.
Brent Technique for
Autologous Reconstruction
This involves three to four stages typically beginning any-
time after 5 years of age.
Stage One . A template for the ear to be reconstructed
is created by tracing the contralateral ear on a piece of
x-ray fi lm ( Figure 29-2 ). (In those patients with bilateral
FIGURE 29-2. Planning the position of the ear
reconstruction using x-ray fi lm.
microtia, a sibling’s or parent’s ear may be traced.) This
template is then reduced in size by a few millimeters on
all borders to account for the thickness of the skin. The
template is then reversed and positioned on the affected
side using measurements taken from the contralateral
side and anatomic landmarks for reference. Again, x-ray
fi lm can be used to mark the desired location of the ear
using various anatomic landmarks (eyebrow, eyelid com-
missure, oral commissure) on the normal side and trans-
posing them to the contralateral side. Generally, the angle
of the nasal dorsum, the distance to the lateral canthus
and the lobular position are utilized. In patients with
hemifacial microsomia, this is more diffi cult due to the
diminished size of the face. In these patients, better sym-
metry can be obtained by referencing the height of the
contralateral helical apex.
A chest incision is then created to harvest the contral-
ateral ribs 6 through 8 ( Figure 29-3A ). This allows the
use of the synchondrosis of ribs 6 and 7 to be utilized
to construct the wide helical base. This base is carved
that exaggerates the peaks and troughs so as to maximize
surface when placed beneath the thick skin of the scalp.
The rib 8 is then used to create the helix. It is attached to
the base using clear nylon sutures ( Figures 29-3B, 29-3C,
and 29-3D ). An incision is then created at the poste-
rior aspect of the auricular remnant and a subcutane-
ous pocket is created. The abnormal vestigial cartilage is
carefully excised so as not to damage the overlying skin.
The cartilage ear framework is then placed in the pocket
which needs to be large enough to accommodate the
high-profi le construct without undue tension. Suction
drains are then placed and the skin is closed.
Stage Two . This stage is performed several months after
the fi rst. In this stage, the lobule is simply transposed on an
inferior-based pedicle, rotating posteriorly and inferiorly
into position. Sometimes it is necessary to create a pocket
in the lobule to accept the inferiormost aspect of the car-
tilage construct.
Stage Three . In this stage, the construct is elevated to
achieve projection of the ear. To do this, an incision is
created along the posterior margin of the helical con-
struct and dissection continues anteriorly beneath the
construct. It is crucial to leave the capsule (think neo-
perichondrium) along the deep margin of the construct.
Once an adequate amount of dissection has been com-
pleted, a piece of banked cartilage left over from the fi rst
stage in a subcutaneous pocket is trimmed to the appro-
priate size using the contralateral ear as a reference. It
is then placed beneath the main construct, against the
capsule, and held in place with nylon suture. Some sur-
geons opt to place extra cartilage beneath the graft at the
initial inset. The postauricular scalp is then elevated and
advanced anteriorly as much as possible. The remain-
ing open area is covered with a split-thickness skin graft
( Figure 29-4 ).

318 • CHAPTER 29
Stage Four. The fourth stage involves creation of the
tragus, excavation of the concha and procedures to both
the reconstructed ear and the contralateral normal ear to
maximize symmetry. The tragus is created by harvesting
a composite graft from the contralateral ear. A J-shaped
incision is then created on the posterior margin of the
tragus. Via this incision, the region of the conchal bowl
is deepened by removing the subcutaneous tissue. The
composite graft is then placed so as to provide projection
to the tragus and a shadow in the area of the bowl. More
recently, Brent began adding a segment of tragal cartilage
to the original auricular construct. Finally, at this stage,
fi ne-tuning of the contour, projection and position of
both the reconstructed ear and the native ear can occur.
FIGURE 29-4. Skin graft used to cover the posterior
aspect of the elevated ear.
A
C
D
B
FIGURE 29-3. Fabrication of the autogenous ear framework.
Nagata Technique
This technique requires only two stages. Creation of the
framework, transposition of the lobule, and creation of the
tragus are all accomplished in the fi rst stage. The second
stage, done several months later, elevates the construct for
projection.
Stage One . Creation of the template and markings
for the positioning of the construct are similar to those
described for Brent technique. Next, a W-shaped inci-
sion is created along the proposed border of the helix and
the inferior margin of the posterior lobular remnant. It is
critical that a subcutaneous pedicle be left intact imme-
diately posterior to the lobular remnant to provide blood
supply to the posterior skin fl ap. In addition, a small cir-
cular incision is made at the anteriormost aspect of the
W. This will be closed in a cone to create a depression at
the incisura intertragica. Via this incision, the abnormal
auricular remnants are excised carefully, and the subcuta-
neous pocket developed.
The construct in the Nagata technique is a layered con-
struct. It requires more rib cartilage which is why recon-
struction must be delayed until around nine years old.
Nagata utilizes the ipsilateral ribs 6 to 9. The posterior
perichondrium is left intact and the harvested segments
are turned upside-down. Ribs 6 and 7 become the base.
Using the template, depressions are carved into this base
to represent the cymba and cavum conchae. The helix is
formed from rib 8. The rib 9 is used for the antihelix. Once
created, these pieces are stacked on the base to provide an
extremely high level of relief. The segments are attached to
the base using wire sutures.

RECONSTRUCTION OF THE EAR • 319
Once the construct is created, it is placed in the pocket
without disrupting the subcutaneous skin pedicle. The
lobule is then transposed similar to a z-plasty and the skin
is closed. Bolsters are then placed with mattress sutures
for 2 weeks to accentuate the relief.
Stage Two. The elevation of the reconstructed ear takes
place 6 months after stage one. An incision is created
about 5 mm posterior to the helix. Dissection then con-
tinues anteriorly and the construct is elevated with a piece
of banked cartilage placed in the subcutaneous tissues in
stage one. This cartilage wedge is carved into a semilunar
shape, fastened behind the contours of the antihelix to
recreate the posterior wall of the concha. This is then
covered with a temporoparietal fascia (TPF) fl ap which
is then covered with a delicate, hand-harvested, split-
thickness skin graft from the scalp. A tie-over bolster is
used to hold this in place.
Firmin Modifi cations
While Firmin technique, which is the author’s preferred
method, shares many similarities with Nagata, there are
signifi cant modifi cations. Firmin has classifi ed three types
of skin incisions and three types of constructs. A similar
z-plasty (type I) incision is used for the lobular micro-
tias and a “transfi xion” (type II) incision is used for the
conchal types. A type III skin incision is used in cases of
anotia or when the ear has a normal size but deformed
cartilage. A similar multilayer construct is used though
the body of the antihelix together with the superior and
inferior crus tend to be a single piece. A type I construct is
a complete framework, type II lacks a tragus, and type III
lacks a tragus and an antitragus. Lately, an additional
piece has been added to the construct behind the root of
the helix and the tragus to increase their projection and
improve their contour. A subcutaneous pedicle to the
skin is not used and fewer wires (and much less time)
is required in creation of the construct. Closed suction
drains instead of tie-over bolsters are used to help the
skin adhere to the framework. The rib used in the sec-
ond stage for elevation is wired to the bare cartilage of
the posterior aspect of the base and the TPF fl ap is fre-
quently, but not always, used to cover this graft. Firmin
feels that direct cartilage-to-cartilage contact provides
for better adherence and stability.
Alloplast Reconstruction
Reconstruction with porous polyethylene has been pre-
sented as the ideal solution to auricular reconstruction.
It offers the advantage of a one-stage operation without
the donor site defect found with autologous reconstruc-
tion. Early results, however, were frequently unsuccess-
ful and many abandoned the approach. There are still
many proponents of this technique. Using this approach,
the procedure can be performed on as young as 3 years
of age, though at this time the implant needs to be made
FIGURE 29-5. Elevation of a temporoparietal fl ap for
coverage of an alloplastic ear framework.
15% larger than the contralateral side and patient com-
pliance may be an issue. Markings for the position of
the reconstruction are similar to those described in the
autologous reconstruction. An anteriorly based conchal
fl ap is elevated by incising the skin immediately posterior
to the proposed location of the construct. This incision
is then connected to a modifi ed Y-shaped incision in the
scalp for harvest of a TPF fl ap ( Figure 29-5 ). (This fl ap is
now frequently harvested endoscopically.) The abnormal
auricular remnants are removed and the anteriorly based
conchal fl ap elevated leaving a subcutaneous pedicle to
augment blood supply. The porous polyethylene implant
is constructed from its component parts and placed in the
appropriate location ( Figure 29-6 ). The entire implant is
then draped with the TPF fl ap. This is crucial and is most
likely responsible for the improved success of this tech-
nique. The lobule is transposed and the TPF fl ap is then
covered with the conchal fl ap. The lateral portion of the
ear reconstruction is covered with a contralateral, post-
auricular, full-thickness skin graft for color match. The
posterior aspect of the reconstruction is covered with a
full-thickness skin graft from the groin. It is felt that the
combination of the TPF and the full-thickness skin grafts
make the reconstruction more resistant to contracture
and the resultant obliteration of the sulcus.
Prosthetic Reconstruction
A variety of methods can be utilized to fi x a prosthesis
in the appropriate place. Traditionally, adhesives were
used, but these have been replaced by methods offering
better stability and retention. While subcutaneous mag-
nets offer an attractive option, the majority of prosthe-
ses are now secured with osseointegrated posts. For an
osseointegrated auricular prosthesis, the mastoid must
be of adequate thickness to accept the implants. This
is felt to occur by the age of 5 years. Most often, this
is a two-staged procedure with the fi rst stage consisting
of the placement of the osseointegrated implants. Once

320 • CHAPTER 29
FIGURE 29-7. Effacement of the antihelical fold in
prominent ear deformity.
healing occurs, generally 3 to 6 months later, the implants
are uncovered and the prosthetic affi xed. Patients with
extensive trauma or temporal bone resection undergo
preopertaive CT scans and Simplant planning studies.
Those who have a history of radiotherapy are sometimes
treated with a course of hyperbaric oxygen therapy
before the fi rst stage.
PROMINENT EAR DEFORMITY
Prominent ear deformity is the result of one or more char-
acteristic fi ndings. Most often there is effacement of the
superior crus of the antihelix ( Figure 29-7 ). The severity
of the prominence varies according the degree to which
the antihelix is fl attened. Next, there may be excess height
or widening of the conchal bowl. Finally, there may be
a combination of the two, which serves to worsen the
prominence.
Correction of the prominent ear is directed at the spe-
cifi c deformity of the auricle. If the antihelix is effaced
producing prominence at the middle and upper thirds,
then the antihelical fold must be created, often exagger-
ated. The anterior surface of the antihelix is weakened
via a small anterior incision high along the antihelix with
an “otobrader,” mattress sutures are placed from medial
to lateral across the posterior aspect of the antihelix to
cause it to fold, and additional sutures may be placed
from the conchal bowl to the mastoid fascia to hold the
reconstructed ear closed to the head. If there is conchal
excess, then either conchal excision or conchal setback
with suture techniques must be used. Likewise, if there
is prominence of the lobule, posterior lobule skin needs
to be resected. Often, it is a combination of these tech-
niques which are used to tailor the operation to the indi-
vidual patient. It should be noted that if prominent ears
or other relatively mild deformities are recognized early
enough (in the fi rst few weeks of life), custom splints
can be used to correct many minor auricular deformities.
This is thought to be secondary to the high levels of cir-
culating maternal estrogens during this time period.
FIGURE 29-6. Components of the alloplastic ear
framework. Each may be modifi ed to suit the deformity.

RECONSTRUCTION OF THE EAR • 321
PARTIAL AURICULAR
RECONSTRUCTION
Much more common than microtia, partial auricular
defects are common after trauma or cancer resection. Each
defect is unique and therefore reconstruction is individu-
alized to the specifi c need. Conceptually, there are two
requirements which must be met: ears need structural sup-
port and skin coverage. If possible, these needs should be
met with local tissues. However, cartilage and skin grafts
from distant sites are sometimes required.
Small skin defects with good cartilage support and
intact perichondrium can be treated with simple skin
grafts. Full-thickness skin from the retroauricular area is
often used as it resists contraction and provides a good
color match from the same operative fi eld. Two layer
defects which have one layer of skin and a small cartilage
defect can also be treated with skin grafting, provided
that there is adequate support from the surrounding car-
tilage. Larger defects lacking adequate support or cov-
erage require local fl aps, local grafts, distant grafts, or a
combination thereof.
Cartilage grafts can be obtained from either ipsilateral
or contralateral ear or from the rib. Use of auricular car-
tilage is preferable, as it provides support but is thinner
and more pliable than costal cartilage. Conchal grafts can
be obtained from either ear using either a posterior or
an anterior approach. The anterior approach allows for
direct visualization and the scar is usually quite accept-
able. For small (,1.5 cm), full-thickness defects, com-
posite grafts can be used from the contralateral ear. These
can be wedge shaped from the scapha and helix, or an
ellipse from the conchal bowl. The resultant defect can
be closed primarily, closed with a local fl ap, or covered
with a skin graft.
Helical rim defects are most often treated by a proce-
dure known as the Antia-Buch fl ap. This is a technique
which allows advancement of the remaining helical rim
both superiorly and inferiorly into the defect. Incisions
are created in the remaining helical sulcus through the
anterior skin and cartilage but leaving the posterior skin
intact. After completely freeing the remaining helical rim
from the scapha, the posterior auricular skin is under-
mined to allow the advancement of the helical rim seg-
ments into the defect. This is then closed, usually with
the excision of a posterior dogear.
Partial auricular defects are often classifi ed based on
their location in the upper third, middle third, lower third,
and lobular defects. While countless techniques have been
described for reconstruction of these defects, the principles
of cartilaginous support and skin coverage remain true.
This is most often achieved using a retroauricular fl ap and
a cartilage graft (auricular or costal) in a two-stage proce-
dure. The resultant retroauricular defect can be closed pri-
marily or grafted. Both the Dieffenbach technique and the
Converse tunnel technique are variations on this theme.
Earlobe deformities can be the result of trauma or
frequently the resection of large keloids which formed
secondary to ear piercing. Two-staged operations with
formation of a tubed pedicle from the adjacent skin is
quite common. In addition, there are some ingenious
single-stage, two-fl ap techniques described by Alanis, by
Converse, and by Brent.
COMPLICATIONS
Complications of this complex, often multistaged opera-
tion range from mild annoyances to major disasters. While
the carving of the rib cartilage construct can seem daunting
to the inexperienced, it is more often complications of the
skin envelope which can lead to problems. Areas of skin
necrosis can occur and must be dealt with expeditiously to
prevent deformation or resorption of the cartilage frame-
work. The necrotic areas must be debrided and covered
with healthy vascularized tissue such as fascial or skin fl aps
The TPF fl ap is a good bailout, but will obviously make it
unavailable for the second stage in the Nagata technique.
Cartilage which has become exposed will quickly be
resorbed. Restoration of these contour defects can be dif-
fi cult. Alloplast that becomes exposed will persist since
the underlying framework is avascular ( Figures 29-8
and 29-9 ). The temptation to treat exposure conserva-
tively with dressing changes and antibiotic creams should
be resisted. Other problems which can severely compro-
mise the reconstruction are seromas, hematomas, and
infection. These issues are uncommon but are mentioned
to emphasize the importance of aseptic technique, anti-
biotic coverage, hemostasis, and drain placement. The
closure of the incisions need to be airtight and the drains
brought through separate distant incisions. Pressure dress-
ings are typically avoided as they can cause ischemia of the
tight overlying skin fl aps. As mentioned, Nagata prefers
sutured bolsters for the initial 2 weeks—most surgeons
FIGURE 29-8. Deformation of a costocartilaginous
framework.
A
B

322 • CHAPTER 29
changes. Hair on the reconstruction can be addressed
with laser hair removal as needed. (It should be noted
that some tend to use laser hair removal prior to recon-
struction to address this potential problem, as they feel
the presence of hair overlying the cartilage reconstruc-
tion can lead to increased incidence of infection.)
In addition to the complications at the site of recon-
struction, donor site morbidity can be a problem. Incidents
of pneumothorax, atelectasis, and chest wall deformity
are noted. Usually, a pneumothorax is quickly identifi ed
and easily treated with a small catheter. It is unusual to
require a chest tube and pleurevac. Atelectasis secondary
to pain was quite common. The use of local anesthetic
(bupivacaine) pumps for the fi rst few days after sur-
gery has dramatically decreased this problem leading to
decreased postoperative pain and narcotic use. Anterior
chest wall deformities are nearly universal, especially
with the larger rib resections required of the Nagata and
Firmin techniques. This donor site morbidity is felt to
be outweighed by the improvement in the more readily
apparent facial morphology. Some groups have reported
a decrease in chest wall contour abnormalities when
more perichondrium is left behind. In fact, some are now
advocating leaving all of the perichondrium behind or
creating a Vicryl tube and fi lling it with diced remnants
of cartilage left over from the creation of the construct.
Early results of these techniques to diminish donor site
contour problems are promising and long-term studies of
rib regeneration are ongoing.
OUTCOMES ASSESSMENT
Clearly the measure of outcome in any type ear recon-
struction should be symmetry with a pleasing contour
and adequate projection. A reconstruction which is incor-
porated into the overall body image is certainly the goal.
Overcoming the psychosocial barriers resulting from the
congenital malformation, deformation, or acquired auric-
ular defect can often require a multidisciplinary team
approach, a skilled and experienced surgeon, and a patient
patient. At the completion of the reconstruction, there is
no better indicator of success than when a patient enters
the offi ce with hair short or pinned back and a smile on
her face.
now substitute closed suction drains, as they are felt to
be an ischemic risk. And even with perfect technique, the
cartilage framework can warp, deform, or migrate.
Finally, there are smaller complications which are eas-
ier to handle. These include wire extrusion, small open
wounds, or skin graft loss without cartilage exposure and
hair on the reconstruction. Once the cartilage has incor-
porated, wires can be easily removed. Open wounds with-
out cartilage exposure typically respond well to dressing
FIGURE 29-9. Skin necrosis over a reconstructed ear.
SUGGESTED READING
Braun T, Gratza S, Becker S, et al. Auricular reconstruction with
porous polyethylene frameworks: outcome and patient
benefi t in 65 children and adults. Plast Reconstr Surg . 2010;
126(4):1201–1212.
Brent B. Microtia repair with rib cartilage grafts: a review of
personal experience with 1000 cases. Clin Plast Surg . 2002;
29(2):257–271.
Brent B. Technical advances in ear reconstruction with autogenous
rib cartilage grafts: personal experience with 1200 cases. Plast
Reconstr Surg . 1999;104:319–334, discussion 335–338.
Byrd HS, Langevin CJ, Ghidoni LA. Ear Molding in newborn in-
fants with auricular deformities. Plast Reconstr Surg . 2010;
126(4):1191–1200.
Chen ZC, Goh RC, Chen PK, Lo LJ, Wang SY, Nagata S. A
new method for the second-stage auricular projection of
the Nagata method: ultra-delicate split-thickness skin graft
in continuity with full-thickness skin. Plast Reconstr Surg .
2009;124(5):1477–1485.
Federspil PA. Auricular prostheses. Adv Otorhinolaryngol . 2010;
68:65–80.

RECONSTRUCTION OF THE EAR • 323
Firmin F. State-of-the-art autogenous ear reconstruction in cases
of microtia. Adv Otorhinolaryngol . 2010;68:25–52.
Horlock N, Vogelin E, Bradbury ET, Grobbelaar AO, Gault DT.
Psychosocial outcome of patients after ear reconstruc-
tion: a retrospective study of 62 patients. Ann Plast Surg .
2005;54(5):517–524.
Jinguang Z, Leren H, Hongxing Z. Experience of correction
of prominent ears. J Craniofac Surg . 2010;21(5):1578–1580.
Korus LJ, Wong JN, Wilkes GH. Long-term follow-up of os-
seointegrated auricular reconstruction. Plast Reconstr Surg .
2011;127(2):630–636.
Nagata S. Modifi cation of the stages in total reconstruction of the
auricle. Part I. Grafting the three-dimensional costal carti-
lage framework for lobule-type microtia. Plast Reconstr Surg .
1994;93:221–230, discussion 267–268.
Nagata S. Modifi cation of the stages in total reconstruction of the
auricle. Part III. Grafting the three-dimensional costal carti-
lage framework for small concha-type microtia. Plast Recon-
str Surg . 1994;93:243–253, discussion 267–268.
Nagata S. Modifi cation of the stages in total reconstruction of
the auricle. Part IV. Ear elevation for the constructed auricle.
Plast Reconstr Surg . 1994;93:254–266, discussion 267–268.
Pearl RA, Sabbage W. Reconstruction following traumatic
partial amputation of the ear. Plast Reconstr Surg . 2011;
127(2):621–629.
Reinisch JF, Lewin S. Ear reconstruction using a porous polyeth-
ylene framework and temporoparietal fascia fl ap. Facial Plast
Surg . 2009;25:181–189.
Shonka DC Jr, Park SS. Ear defects. Facial Plast Surg Clin North
Am . 2009;17(3):429–443.
Siegert R, Weerda H, Magritz R. Basic techniques in autog-
enous microtia repair. Facial Plastic Surg . 2009;25(3):
149–157.
Steffen A, Wollenberg B, Konig IR, Frenzel H. A prospective eval-
uation of psychosocial outcomes following ear reconstruc-
tion with rib cartilage in microtia. J Plast Reconstr Aesthet
Surg. 2010;63(9):1466–1473.
Walton RL, Beahm EK. Auricular reconstruction for microtia. In:
Siemionow MZ, Eisenmann-Klein M, eds. Plastic and Recon-
structive Surgery. Springer Specialist Surgery Series. Part IV.
London: Springer; 2010:357–378.

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30
Reconstruction of the Nose
Peter J. Taub, MD, FACS, FAAP
PATIENT EVALUATION AND SELECTION
The nose is arguably one of the most obvious features of
the human body. Its structure is complex and its function
is one of the most intricate. As such, reconstruction of
the nose following trauma, cancer ablation, infection, or
congenital malformation may present diffi cult challenges
for the plastic surgeon. There are essentially three com-
ponents of the nose: a thin, vascularized lining of mucosa
lined with squamous epithelium, a supporting framework
of bone and cartilage, and an outer skin envelope with
variable colors and textures. When analyzing a defect and
planning a reconstruction, tissue loss to each of these lay-
ers must be identifi ed, including any losses to surround-
ing cheek or upper lip. Simple closure of the wound often
accomplishes only the functional goal while sacrifi cing the
aesthetic result.
The skin of the nose may be thought of as several adja-
cent convex and concave subunits. 1 Each subunit has its
own characteristic geometry and neighboring subunits
are separated by natural lines that refl ect light and cast
shadows onto the surrounding skin. The various subunits
include the midline nasal dorsum, tip, and columella and
the paired sidewalls, alar rims, and soft triangles. For exam-
ple, the dorsum is half of a cylinder and the tip half of a
sphere. Each convex subunit has a central highlight and
each concave subunit has a central shadow. The combina-
tion of highlights and shadows gives the nose its character-
istic aesthetic appearance.
Flaps of skin and subcutaneous tissue form a sheet of
scar on the recipient bed and undergo centripetal contrac-
tion by myofi broblasts during wound healing, resulting in
a bulging or “trapdoor” effect. This phenomenon is used
to the surgeon’s advantage in recreating the contour of a
convex subunit, but detracts from the fi nal result if a fl ap is
placed on a concave area. Skin grafts form a similar layer of
scar tissue that undergoes contraction, but does not bulge
c h a p t e r
due to the lack of subcutaneous tissue. This makes full-
thickness grafts a better choice for reconstructing concave
subunits.
The subunit principle can also be applied secondarily
in the case of a large defect spanning several nasal sub-
units, or a composite defect involving surrounding tissue
of the cheek or upper lip. In these circumstances, it is often
necessary to perform a staged reconstruction and initially
transfer a bulky fl ap with enough skin area to resurface the
missing nasal subunits, surrounding skin, and restore deep
tissue loss.
Once the fl ap is inset, a secondary refi ning procedure
may be performed at a later date. Incisions are made in
the desired location along the borders of the subunit based
on the contralateral intact side. Through these incisions,
the underlying soft tissue may be sculpted, and the sur-
face lines of contour created using quilting sutures. These
additional scars may be hidden in the deep contour lines
establishing the aesthetic appearance of light and shadow
regions.
Similarly, skin quality across the nose is not identical.
Several distinct areas exist. The skin over the glabella,
upper dorsum, and paired nasal sidewalls is usually thin,
smooth, nonsebaceous, and pliable. It moves easily over
the underlying bony and cartilage support. The skin cov-
ering the majority of the tip and alar regions is thicker,
more adherent, and pitted with sebaceous glands. A layer
of dense subcutaneous fat is present that provides defi ni-
tion and contour. This area also overlies the lateral crura
of the lower lateral cartilages. A third skin type covers the
alar margins, the soft triangles, and columella. It is similar
in quality and color to the skin of the dorsum, but is fi rmly
fi xed to the underlying cartilage.
Local skin damage from radiation injury should be
questioned and sought. Often, skin and soft tissues around
a defect are unsuitable for reconstruction. It is better to

326 • CHAPTER 30
avoid the problem of fl ap necrosis beforehand than manage
it afterwards. In certain instances, pre- and postoperative
hyperbaric oxygen therapy may ameliorate the deleterious
effects of radiation damage. 2
Visual inspection and manual palpation of the nose
externally, as well as speculum examination with an ade-
quate lightsource intranasally, should evaluate the existing
bony and cartilaginous support to the nose. Superiorly, the
nasal pyramid is composed of two small bones anchored
to the frontal bone superiorly, to the maxilla laterally, and
to each other medially. The cartilaginous septum provides
most of the support caudally with contributions from the
upper and lower lateral cartilages to prevent collapse of the
internal nasal valves and nostrils with inspiration. The sym-
metry of the nose is best appreciated on frontal view, while
the height and straightness of the dorsum is best appreci-
ated from the side. The respective contributions of bone
loss as well as cartilaginous septal loss should be noted.
Prior to speculum examination, a topical vasoconstric-
tive spray may be used to better visualize the intranasal
anatomy. The caudal edge of the bony pyramid may be
noted as well as the support provided by the upper and
lower lateral cartilages. The internal nasal valve angle
should be noted. The septum should be visualized and pal-
pated and any deformations or communications should be
appreciated. Gentle pressure on the septum with a cotton-
tipped applicator will identify areas defi cient in cartilage
and whether suffi cient stock remains as a source of graft
material.
Much of the lining of the nose is not easily visible on
cursory examination. The mucosa extends over the tur-
binates, which should be inspected for hypertrophy and
airway compromise. Preoperatively, the intranasal exami-
nation will highlight areas of defi cient mucosa that may
need to be addressed. In addition, areas of scarring that
may contribute to postoperative airway compromise
should be noted.
Respiratory function needs to be addressed preopera-
tively. A thorough history should identify any evidence of
diffi culty breathing through the nose. Specifi c questions to
ask the patient include when the problem began, whether
or not there is a seasonal component to the symptoms, and
whether or not the patient uses medications such as anti-
histamines to address the problem.
Casual observation of the external nasal valves on inspi-
ration may identify weakness of the lower lateral cartilages.
Intranasal inspection should be performed on all patients
with and without a topical vasoconstrictive agent to shrink
the nasal mucosa. This should identify lesions or bands
of scar tissue that may need to be addressed in order to
improve postoperative nasal function.
The Cottle test attempts to identify collapse at the
internal nasal valve. The patient is asked to breathe in and
the ease or diffi culty of simple air exchange is noted. The
maneuver is then repeated while gently pulling on the
cheek just lateral to the nostril. Improvement in breath-
ing may be interpreted as a sign of internal valve com-
promise. It should be noted, however, that some surgeons
FIGURE 30-1. Total rhinectomy defect following
resection of a squamous cell carcinoma.
question the validity of the test because most symptomatic
and nonsymptomatic patients will report benefi t with the
maneuver.
PATIENT PREPARATION
There is a well-intended adage that the best procedures
should be reserved for the best patients. Often, the ideal
reconstructive procedure for any given patient requires
multiple stages with close follow-up between each stage
and good communication between the patient and the sur-
geon. In a retrospective analysis of more than 1000 cases,
over 70% required at least two procedures and a large
percentage even more. 3 Patients in whom follow-up is
anticipated to be diffi cult or comprehension regarding the
chronicity of the reconstruction to be lacking may be bet-
ter served with a lesser procedure.
A variety of conditions may produce defects of the
nose. In the case of a malignant neoplasm, confi rmation
that the malignant process has been completely excised is
imperative prior to beginning a lengthy and complicated
reconstruction. This is best achieved with lateral and deep
biopsies of the wound margin for local involvement and
any number of radiographic studies for distant spread.
The initial surgical intervention should achieve nega-
tive margins in the case of malignant disease ( Figure 30-1 ).
Scars and contractures may be released so that the full size
of the defect may be appreciated and the tissues returned
to their normal anatomic position. This may be done at a
separate procedure following temporary coverage of any
raw surfaces with split-thickness skin grafts and/or direct
approximation of the wound margins or it may be done
as the initial part of the actual reconstruction. Many sur-
geons prefer the use of Mohs micrographic surgery for the
excision of skin malignancies versus wide local excision.
The Mohs technique attempts to maximize the amount of
normal tissue left in place after surgical resection.
A guiding principle of reconstruction is that destruc-
tion of at least half of a subunit warrants reconstruction
of the entire subunit. Incisions should ideally be designed

RECONSTRUCTION OF THE NOSE • 327
along the lines separating any two subunits. Recent arti-
cles have challenged the need to reconstruct entire sub-
units with larger defects citing the benefi ts of retaining
as much native, healthy tissue as possible. Newer tech-
niques of laser and dermabrasion make softening the
edges between the fl ap and the surrounding native skin
much more effective. 3
TECHNIQUES
The reconstruction of nasal deformities is both an artistic
and scientifi c endeavor. The nose is the visual centerpiece
of the face and is essential to an aesthetically pleasing
appearance. In addition, the nose offers protection to sur-
rounding structures and is vital to maintaining a patent
airway. Therefore, reconstruction of the nose must address
both functional and aesthetic concerns.
The principles of the reconstructive ladder should be
applied to the reconstruction of the nose. Small defects cer-
tainly may be left to heal by secondary intention and often
this is the ideal course of treatment. Outside of the social
stigmata of a nasal dressing, local wound care is usually not
diffi cult. For larger defects, each component of the nose
must be considered when the reconstruction is planned.
Mucosal Lining
The replacement of adequate nasal lining is perhaps the
most challenging component of complex nasal defects.
The ideal donor site for nasal lining replaces the defect
with like tissue of equal vascularity and pliability. Any fl ap
used must be thin enough to avoid airway obstruction, pli-
able enough to conform to an underlying cartilage or bone
graft, and vascular enough to provide nourishment to the
grafts. 1 Poor perfusion may result in overlying fl ap isch-
emia, necrosis, infection, and/or extrusion of the underly-
ing cartilage or bone grafts. Failure of the lining is the most
common cause of functional and aesthetic compromise.
Several options exist for nasal lining, including skin
grafts, local mucoperichondrial fl aps, and foldover fl aps.
Many techniques date back to the work of Harold Gillies
during World War I who popularized the use of the turn-
over hinge fl ap, which involves using small, adjacent fl aps
folded over on themselves with the epithelium facing
intranasally. Based on scar tissue, they create a lining of
limited length due to the inherently poor blood supply. As
a result, all cartilage grafts should be placed secondarily to
maximize their viability. Delaying transfer of the fl aps may
also gain additional length. Skin grafts, on the other hand,
require a well-vascularized bed, which is often defi cient in
the presence of exposed bone or cartilage.
First described by Millard, the ipsilateral septal mucosal
fl ap based on the septal branch of the superior labial artery
is a commonly used option. 4 A pedicle slightly larger than
1 cm allows for the elevation and transfer of septal mucosa.
The fl ap can be modifi ed to allow for the simultaneous
reconstruction of lining and cartilage support. A compos-
ite fl ap of septal cartilage and mucosa can be rotated out
of the piriform aperture at the posterior septal angle to
cover defects of the lower half of the nasal vestibule. In
the case of bilateral lining defects, right and left mucosal
fl aps are elevated and rotated downward and laterally, and
the septal cartilage is sculpted to replace the medial crura
and columella.
For defects of the nasal margin, remaining intact nasal
lining skin above the defect can be brought down as a
bipedicle fl ap to provide vascular squamous epithelium
to the desired alar rim level in a bucket-handle fashion.
The secondary defect may be closed with a full-thickness
skin graft, or by ipsi- or contralateral septal mucosal fl aps.
The contralateral septal mucoperichondrial fl ap involves
the removal of the central septal cartilage, raising a long
dorsally based contralateral mucosal fl ap, and delivering
it through an incision high in the ipsilateral mucosa. The
septal cartilage can then be used to fabricate any variety of
onlay, cantilever, or strut grafts for support. Other options
exist for situations where mucosal lining fl aps are unavail-
able. These include the inferior turbinate fl ap, 5 and a three-
layer sandwich graft of cartilage and skin taken from the
root of the ear helix for alar rim defects less than 1 cm.
Skin grafts applied to the surface of a forehead fl ap,
braced by cartilage grafts within the fl ap is another
accepted technique. This composite version of the fore-
head fl ap can be prefabricated and banked prior to transfer
for several weeks to ensure viability of the fl ap elements.
The nasolabial fl ap can also be folded on itself to supply
both cover and lining and close defects along the alar rim.
These techniques are limited by bulk and often require
aggressive secondary thinning procedures to prevent air-
way obstruction. Defects involving the entire nasal unit
require large lining fl aps such as microvascular free fl aps or
a depilated scalp fl ap.
It is not generally necessary to replace the lining of
the narrow middle and upper portions of the nasal vault.
These areas are often not present in Asians, and are not
touched by normal horizontal airfl ow patterns in the nose.
Reconstruction of the nasal septum should be avoided due
to the likely possibility of airway obstruction. There is no
functional defi cit in creating a nose with a single, large
vestibule. 6
Nasal Support
Solid tissue support is essential for maintaining long-term
aesthetic results. Bone and cartilage grafts prevent the skin
and lining from collapsing under the forces of scar con-
tracture. In addition, they help to ensure airway patency
during inspiration by preventing sidewall collapse, and pre-
vent cephalic retraction of the alar rim. 1 Early attempts
at reconstruction without using support grafts resulted in
disfi guring scar contracture or soft tissue collapse.
Reconstruction of the bony nasal pyramid or dorsum
often requires autogenous bone grafts. Sources include the
skull, iliac crest ( Figure 30-2 ), and rib cage ( Figure 30-3 ).
Bone provides a rigid framework to address collapse of
the osseocartilaginous vault as a result of tumor resection

328 • CHAPTER 30
or trauma ( Figure 30-4 ). Due to the limited quantities
required, most bone graft may be harvested with minimal
donor site morbidity. 7 The grafts may be anchored to the
maxilla and/or frontal bone using titanium microplates.
Alloplastic alternatives include thin sheets of porous
hydroxyapatite. 8
FIGURE 30-2. Bone harvested from the iliac crest.
Cartilage grafts rely on the vascularity of the wound
bed and/or the overlying fl ap. Whenever possible, these
grafts should be placed primarily at the time of fl ap trans-
fer to prevent the need for re-expansion after scarring has
occurred which will compromise the fi nal aesthetic result.
The nonanatomic placement of bone and cartilage grafts
from the existing nasal bone to the alar margin and colu-
mella will help maintain the desired dimensions, projec-
tion, and contour of the reconstruction.
Common donor sites for cartilage grafts include septal,
conchal, and costal cartilage. Each donor site has distinct
advantages and disadvantages. Septal cartilage is strong and
easily carved ( Figure 30-5 ). It is easily harvested during the
fabrication of intranasal lining fl aps; however, its supply
is limited and may be affected by the initial defect itself.
Conchal cartilage has a natural curve that lends itself well
to reconstruction of the alar rim, and has minimal donor
site morbidity. It is signifi cantly weaker than other donor
options and may collapse if the skin envelope is excessively
FIGURE 30-3. Bone harvested from the rib cage.
FIGURE 30-4. Saddle-nose deformity secondary to
trauma reconstructed with a costal rib graft.
A
B
FIGURE 30-5. Cartilage harvested from the septum.

RECONSTRUCTION OF THE NOSE • 329
thick or scarred. Costal cartilage is abundant, strong, and
easy to carve, but has the tendency to warp during healing
and is moderately prone to reabsorption over time.
Cartilage grafts are perhaps most important when
reconstruction of the alar rim is required. Nonanatomic
placement of cartilage grafts is a key concept for recreating
the support and projection of the alar rim and nasal tip.
Arches of donor cartilage are fabricated with a thickness of
1 to 2 mm and bend at one end to recreate the genu of the
medial crura. These arches can be anchored to remnants of
the existing medial and lateral crura, or fastened to a central
columellar strut of stiff cartilage. If necessary, the points of
greatest projection are weakened by repeated puncturing
with a fi ne-gauge needle. Batten grafts placed in a subcuta-
neous pocket along the alar rim are fastened in place with
sutures spanning the graft and nasal lining that eliminate
any dead space between tissue layers. Other techniques
such as tip grafts, spreader grafts, and contouring sutures
can be utilized to fi ne-tune the ultimate aesthetic result.
Current research has focused on the use of technology,
specifi cally in the areas of structural grafting. The use of allo-
plastic implants with or without acellular human cadaveric
dermal grafts (Alloderm) has been reported with success-
ful outcomes. 9 In addition, the applications of tissue-engi-
neered cartilage from the patient’s own chondrocytes are
being investigated. 10 – 12 Tissue engineering has the potential
to create “autogenous” cartilage grafts in an exact three-
dimensional shape with minimal donor site morbidity.
Skin Coverage
The fi nal component of nasal reconstruction, and perhaps the
most important to the aesthetic outcome, is the skin coverage.
The type of fl ap or graft used for reconstruction is dependent
on the size, anatomic location, and skin zone of the defect, as
well as the quality of surrounding skin. The literature reports
a wealth of different fl ap types and potential graft donor sites
for use in all possible defect locations. These techniques can
be used alone for superfi cial defects, or in combination with
any of the previously mentioned techniques of nasal lining
and structural support in full-thickness defects.
For areas where the skin is thin, smooth, and mobile,
such as the nasal dorsum, primary closure is often possible.
For larger defects, a skin graft is another option. The choice
of donor site depends on the location and size of the defect.
Superfi cial defects of the upper twothirds of the nose with
a vascularized recipient bed can be resurfaced with a full-
thickness skin graft. The preauricular skin is an ideal donor
site on account of its color, texture, and quality. Grafts up
to 2 cm or more can be harvested with primary closure and
minimal donor site morbidity. Secondary donor sites include
the postauricular and supraclavicular skin. The former may
easily conceal an incision but tends to have a less satisfactory
color match. The latter has the advantage of being plentiful
and blends well in older patients with actinic damage. It is
important to remember that skin grafts will appear thin and
shiny after transfer due to relative ischemia, and frequently
become hyperpigmented or hypopigmented. 6
Composite grafts of skin and cartilage may be used as a
one-stage reconstructive option for defects of the alar rim.
The most common donor site for a full-thickness defect
is a sandwich graft of cartilage between two layers of skin
from the root of the auricular helix ( Figure 30-6 ). Perfusion
limits the size of the graft to between 1 and 2 cm. Other
composite donor sites include the helical rim, helical crus,
antihelix, or tragus. All grafts have the potential for central
FIGURE 30-6. Composite skin and cartilage graft from the helical root for
nasal alar reconstruction.
A
B

330 • CHAPTER 30
necrosis. This should be allowed to separate naturally over
time and heal by secondary intention. If possible, skin grafts
should be secured on the recipient bed with a bolster to
limit shear and prevent hematoma or seroma formation.
Split-thickness grafts tend to contract over time with a
poor aesthetic result. As such, they have little role in nasal
reconstruction other than for temporary closure.
Smaller defects of the lower twothirds of the nose may
also be reconstructed using full-thickness skin grafts. The
forehead is considered to be the gold standard in terms of
skin match. Grafts can be harvested from near the hair-
line with considerably less donor site morbidity than a
large fl ap. Some advocate grafts from the nasolabial fold to
match the color, texture, and contour of the alae or nasal
tip. 13 These grafts revascularize well with only peripheral
perfusion due to the thick dermis of the donor site, and the
donor scar is easily camoufl aged in the nasolabial fold.
Single-stage local fl aps should be the method of choice
if the aesthetic and functional goals can be achieved. These
fl aps range in complexity from a simple rotational fl ap,
V-Y advancement fl ap, and cheek advancement fl ap, to the
bilobed fl ap. They should be designed using the contralateral,
unaffected side as a model and not the actual defect. A model
of the fl ap may be sterilized for use in the operative fi eld. 14
The bilobed fl ap is most useful for small to medium
defects of the lower third of the nose. It has the advantage
of allowing easier transposition of thick, sebaceous skin
under less tension with no dog-ear formation versus rota-
tional fl aps. It relies on a random cutaneous vascular pat-
tern. The fl ap consists of two lobes: one to fi ll the primary
defect, and a second to fi ll the secondary defect created by
the primary lobe ( Figure 30-7 ). This ultimately creates a
remote, tertiary defect that may be closed primarily.
FIGURE 30-7. Design of a bilobed fl ap.
There are several important keys to success when
designing and transferring a bilobed fl ap. In general, the
diameter of the primary lobe should be smaller than the
defect, while the secondary lobe should be smaller than
the fi rst. Since each fl ap suffers from loss of effective
length during rotation, each lobe must be slightly longer
to overcome the difference. Undermining in a suprap-
eriosteal plane promotes adequate perfusion of the fl ap.
Closure should begin with primary closure of the tertiary
defect at the glabella.
Skin over the tip and alar margins is thick, sebaceous,
and more diffi cult to manipulate. Smaller defects less than
1.5 cm may be amenable to adjacent tissue transfer with
a random cheek advancement fl ap, lateral nasal fl ap, or
dorsal nasal fl ap. The dorsal nasal fl ap is particularly use-
ful in defects of the dorsum and/or tip. The fl ap is incised
along the lateral ridge superiorly, and a backcut is made
across the glabellar region. The skin of the upper twothirds
of the nose and glabella is then be rotated inferiorly onto
the nasal tip ( Figure 30-8 ).
A nasolabial fl ap from the cheek may be used for super-
fi cial coverage of certain nasal defects. The fl ap is based
on the angular branch of the facial artery and is desirable
since the donor scar falls within the natural nasolabial
crease ( Figure 30-9 ). It may be left longer than required
for skin coverage but folded onto itself to provide addi-
tional lining. A secondary procedure may then be required
to remove the bulkiness of the fl ap, which may compro-
mise the airfl ow through the nares.
Paramedian Forehead Flap
The paramedian forehead fl ap has arguably been consid-
ered the workhorse fl ap for coverage of large nasal defects.
It is the preferred method for resurfacing larger defects
of the nasal tip, lobule, dorsum, or columella greater than
2 cm in diameter. The fl ap is versatile and can be designed
to cover defects crossing multiple subunits.
Its blood supply is derived from one or both supra-
trochlear systems and may be considered an axial fl ap
proximally and a random fl ap distally. The fl ap may be
prefabricated with thin grafts of cartilage and/or split-
thickness skin to provide support and/or lining to areas
of reconstruction that require more than simple skin
coverage. At the time of prefabrication, a gauze dressing
spread with petrolatum jelly may be left beneath each
“heminostril” to provide a desired curvature to the new
alar rim.
Burget described the forehead fl ap as a three-staged
procedure with each stage having individual goals toward
the shaping of the fi nal product. 6 Stage one involved eleva-
tion and transposition of a viable fl ap with adequate length.
Stage two focused on refi ning, sculpting, and detailing the
fl ap. Accessory cartilage grafts were added in this stage if
necessary. Stage three involved division of the pedicle and
fi nal inset of the fl ap.
The paramedian forehead fl ap is based proximally with
the pedicle centered most commonly over the ipsilateral

RECONSTRUCTION OF THE NOSE • 331
supratrochlear artery ( Figure 30-10 ). The vessel consis-
tently lies between 1.7 and 2.2 cm lateral of midline at
the medial border of the eyebrow. At this level, the vessel
pierces the orbicularis oculi and frontalis muscles and runs
vertically in a subcutaneous plane. The course of the ves-
sel can be assessed using Doppler ultrasound. The pedicle
should be designed between 1 and 1.5 cm in diameter at
the proximal attachment. This allows for more length and
prevents tension and strangulation when the fl ap is rotated
inferiorly into position.
Prior to incision, a template of the defect is fabricated
from suture foil or glove paper. The fl ap should be designed
with a vertical axis, which may be extended distally into
the hairline and proximally over the supraorbital rim if
more length is needed. The design should be centered on
the previously identifi ed vascular pedicle. Some authors
advocate angling the skin fl ap obliquely near the hairline
to prevent the inclusion of hair-bearing skin. Due to the
extensive arborization of the musculocutaneous arterial
supply of the forehead skin, a randomly based oblique fl ap
FIGURE 30-8. Design and inset of a dorsal nasal fl ap.
A
B
FIGURE 30-9. Design and inset of a nasolabial fl ap.
B
A