BACKGROUND AND OBJECTIVES:The use of bone grafts is a vital component of a surgeon's armamentarium in the reconstruction of congenital and acquired deformities of the craniofacial region. A thorough understanding of bone graft physiology and the factors thought to affect graft behavior is essential in order to develop a more intelligent use of the grafts in clinical applications.METHODS AND MATERIALS:This article presents a brief review of the basic physiology of bone grafts along with a survey of pertinent concepts and research currently available. Mechanical stress, rigid fixation, graft orientation, and the recipient sites are reviewed.RESULTS AND/OR CONCLUSION:In an attempt to bring together various issues that exist in current bone graft science, the authors propose new concepts. They suggest that the mechanical environment in which a bone graft is placed, revascularization of the graft, and the interaction between those two factors are the major predictors of clinical results.
BACKGROUND AND OBJECTIVES:The use of bioabsorbable materials in craniomaxillofacial surgery began a new era in fracture fixation. The purpose of this paper is to review the historical perspectives and the current concept of bioresorbable materials in fracture fixation.METHODS AND MATERIALS:The authors review the biochemistry and clinical characteristics of bioabsorbable polymers--polylactic acid (PLA), polyglycolic acid (PGA), polydioxanone (PDS), and their copolymers. Their use and clinical perspectives by the Helsinki (authors') group and other study groups are presented.RESULTS AND CONCLUSIONS:These materials have proven to be safe in clinical applications. When manufactured with current technology, they are easy to handle. Economically, they are nearly equal to similar metal devices. The materials have met clinical success throughout the world, first in orthognathic surgery, followed by treatment of fractures of the upper facial skeleton and the mandible. Today, most maxillofacial fractures and osteotomies may be adequately fixed with bioabsorbable materials.
BACKGROUND AND OBJECTIVES:The optimal method of treating frontal sinus fractures has remained undetermined. The purpose of this retrospective review is to compare the mechanism of injury, diagnostic techniques, methods of fracture management, complications, and long-term results in different types of frontal sinus fractures.METHODS AND MATERIALS:Over 4,000 records of patients with frontal bone or skull fractures, treated during a 30-year period in an academic nonprofit tertiary Level I trauma center, were considered. From these, the authors selected 150 patients with frontal sinus fractures--with complete records and adequate follow-up time--and conducted a retrospective review.RESULTS AND/OR CONCLUSIONS:For anterior fractures, observation alone had a high rate of complications (18.2%). Reconstruction with obstruction of the nasofrontal ostia by vascularized tissue was found to be the best treatment, followed by osteogenesis (9.1%) or obliteration (7.7%). Cranialization was the safest form of management for posterior table fractures that were either comminuted or involved the nasofrontal ostia. The preferred obliteration materials were vascularized flaps, cancellous bone, temporalis muscle, and fat; hydroxyapatite cement was a good alloplastic alternative.
BACKGROUND AND OBJECTIVES:Correction of the deviated nasal pyramid is frequently incomplete and may result in a sub-optimal surgical outcome. Precise anatomic analysis of the deformity and a thorough understanding of available techniques improve the surgical osteotomy.METHODS AND MATERIALS:The advantages and disadvantages of the various osteotomy techniques are analyzed, based on the cadaver studies and clinical experience of the authors. The cadaver studies demonstrate the anatomic results when various osteotomes are used in specified ways. Clinical outcomes in the treatment of posttraumatic nose deviations correlate well with these results.RESULTS AND/OR CONCLUSIONS:A thorough understanding of the advantages and disadvantages of various osteotomy techniques enables the surgeon to apply them to specific anatomical deformities in posttraumatic nose deviations more precisely. In general, perforating osteotomies preserve more soft tissue support than the linear osteotomies. Sequential osteotomies, occasionally combined with intermediate osteotomies, are useful in straightening the extremely deviated nasal pyramid.
BACKGROUND AND OBJECTIVES:The primary repair of facial fractures requires sufficient subperiosteal dissection and mobilization of soft tissues to permit accurate fracture reduction. Improper repositioning of soft tissues predisposes the site to deformities with subsequent adverse effects on the aesthetics of the final result. The purpose of this paper is to describe these deformities, the modification of surgical approaches to avoid them, and the various techniques for secondary soft tissue reconstruction.METHODS AND MATERIALS:The paper reviews the assessment of soft tissue deformity and the principles of soft tissue reconstruction in addressing temporal contour deformity, cheek ptosis, eyelid deformities, and medial and lateral canthal dystopia.RESULTS AND/OR CONCLUSIONS:The morbidity of remote incisions and soft tissue degloving used in primary facial fracture repair can be minimized by using a meticulous technique and precise soft tissue repositioning at closing.
BACKGROUND AND OBJECTIVES:Since the introduction of antibiotics in the late 1940s, open reduction and internal fixation (ORIF) gradually replaced various dental splints and devices as a means of providing additional reduction and fixation of mandibular fractures. Stainless steel wire has been recently replaced by plate-and-screw fixation. When properly utilized, this method provides convalescent function without maxillomandibular fixation (MMF). The purpose of this article is to review the evolution of small versus large plate fixation of mandibular fractures.METHODS AND MATERIALS:In the context of reports in the literature and 26 years of clinical experience, the authors review the types of mandibular rigid fixation, healing of fractures, morbidity of fracture repair, indications for rigid fixation, and evolution of techniques of treatment.RESULTS AND/OR CONCLUSIONS:Although numerous devices and techniques--bone clamps, intra- and extramedullary K-wires, metallic mesh, and other means--have been used and abandoned, modern plate and screw systems, if not the standard of care, have become widely accepted and used.
BACKGROUND AND OBJECTIVESThe orbital floor may fracture alone, and the fracture is then defined as "pure"; when there is a rim involvement, the fracture may be defined as "impure". Controversy exists as to the pathophysiology of orbital floor fractures and the incidence of orbital rim involvement. The purpose of this retrospective review was to determine the incidence of purity in orbital floor blowout fractures and the rate of ocular injuries in pure and impure floor fractures.METHODS AND MATERIALSThe charts of 250 patients with orbital fractures, treated at a primary trauma center between 1992 and 1996, were reviewed. All fractures had been examined by the Ophthalmology Service and confirmed by high-resolution computerized tomography scans. The average age of the patients was 45 years; more than 90% were male. Motor vehicle accidents were the most commonly documented mechanism of injury, followed by interpersonal violence and falls. Almost 50% could not be categorized for mechanism of injury.RESULTS AND/OR CONCLUSIONSThe incidence of ocular injuries in pure fractures (n = 54; 5.6%) was higher than in impure fractures (n = 26; 2.0%) (p = 0.05). Serious visual injuries following orbital fractures occurred in 17.1% of the patients; they were more common in patients with pure fractures.
BACKGROUND AND OBJECTIVESProviding thin, well-vascularized lining flaps is still the most elusive achievement in corrective nasal surgery. The purpose of this article is to reexamine some of the principles of correction.METHODS AND MATERIALSTo demonstrate the importance of releasing or sectioning nasal lining, the authors review the principles of lengthening the nose, illustrated with seven clinical cases from their surgical experience and a detailed 12-drawing presentation of the surgical approach by Tessier--the senior surgeon.RESULTS AND/OR CONCLUSIONSThe nose is the center of the face and a major determinant of facial appearance. The short nose has been one of the more difficult conditions to treat in rhinoplastic surgery. To optimize the result, procedures developed from experience in craniofacial surgery should be combined with the existing methods, developed primarily by rhinoplastic surgery and confined to the nasal tip.
BACKGROUND AND OBJECTIVES:Surgical repair of the acutely fractured orbit strives to restore appearance, preserve ocular and orbital function, and avoid enophthalmos or hypoglobus. Repair is achieved with autologous bone graft, synthetic substitutes, or both. The purpose of this article is to present an alternative procedure--use of implants, cut from a titanium mesh screen, without bone graft.METHOD AND MATERIALS:A total of 51 orbital floor fractures in 43 patients were repaired with titanium mesh screen implants. In three patients with bilateral orbital floor fractures repaired with titanium mesh, intraoperative symmetry was improved with bone graft added to the mesh on one side.RESULTS AND/OR CONCLUSIONS:Follow-up was available for 42 orbits in 35 patients and averaged 9 months. The transconjunctival approach with lateral canthotomy yielded better results than the subciliary approach, which often caused transient scleral show or ectropion. One patient underwent surgery for ectropion following a subciliary approach, and one patient developed a 4-mm enophthalmos. Routine bone grafting is unnecessary, even in large floor defects. Titanium mesh implants are a simple and reliable option for orbital floor repair.
BACKGROUND AND PURPOSE:Electromyography is used in conjunction with clinical diagnosis to determine the presence and extent of craniofacial injuries; it is also an aid in prognosis of recovery. This article reviews the neural pathophysiology following trauma and the basic principles of electrodiagnostic testing; such understanding helps to determine indications for electrodiagnostic testing.METHODS AND MATERIALS:Electrodiagnostic techniques can detect and differentiate the degree of injury. There are three major categories of nerve injury--neurapraxia, axonotmesis, and neurotmesis. In neuropraxic injuries, stimulation distal to the lesion will continue to elicit a response indefinitely; in more severe injuries, axonal degeneration begins within 3 to 5 days postinjury.RESULTS AND/OR CONCLUSIONS:Electromyography may be used as a valuable adjunct to traditional forms of diagnosis and prognosis. The accuracy of electrodiagnostic data reported in the literature ranges from 50% to 67% in some studies and 77% to 90% in others. Studies with larger patient populations and longer follow-up periods are required.
BACKGROUND AND OBJECTIVES:Ocular injuries occur commonly in patients with facial trauma. Patients with significant eye injuries may present with grossly normal eyes and good visual acuity; however, subsequent ocular disorders may become apparent. The estimates of incidence vary considerably. Trauma is the second leading cause of blindness, and a review is, therefore, warranted.METHODS AND MATERIALS:Several extensive studies are reviewed. Blunt and penetrating trauma are examined by their respective subdivisions. The initial assessment and ophthalmologic examination of patients with facial trauma are discussed, and the type of injury that may occur secondary to trauma is delineated. Management is reviewed and discussed, including a recently developed diagnostic scoring system. Three clinical cases illustrate the procedure.RESULTS AND/OR CONCLUSIONS:The diagnosis of ocular injuries resulting from trauma is difficult. The recently introduced scoring system was found to improve the procedure. Based on this system, the authors have devised an algorithm to assist the clinician, with emphasis on visual acuity and the importance of visual examination.
BACKGROUND AND OBJECTIVES:Objective measuring of globe position is not a universal practice in the management of orbital trauma. Few studies in the literature advocate its routine use.METHODS AND MATERIALS:The Hertel exophthalmometer is the most widely used instrument; however, in trauma involving the lateral orbital rim (e.g., in zygoma fractures), the results are inaccurate because the displacement of the zygomatic bone interferes with its reference point on the lateral orbital rim. A more recent measuring device, the Naugle orbitometer, was introduced in 1992. It uses the superior orbital rim (frontal bar) and inferior orbital rim (malar eminence) as reference points.RESULTS AND/OR CONCLUSIONS:This article reports experience with this instrument in objective measuring the position of the globe in orbital trauma. These measurements are used 1) to monitor fractures that may not require repair but should be followed and observed for dystopia or enophthalmos, 2) to determine the adequacy of fracture repair, and 3) to determine the volume adjustment required for correcting enophthalmos. Future studies will be directed to compare the accuracy of Naugle and Hertel exophthalmometers.
