Midface: Nose, Zygoma, Maxilla F# Flashcards
What is your management of a patient presenting to ER with facial fractures?
Rapid primary survey and simultaneous resiscitation
1- Assess Airway and protect C spine
2-Assess breathing
3- Assess Circulation
Defined secondary survey and definitive care
What are life threatening emergencies associated with facial f#?
- airway compromise
- hemorrhage
- identification and prevention of aspiration
- identification of occult associated injuries EBS (Eyes, Brain, Spine)
What are indications for intubation?
- decreased LOC
- massive hemorrhage/fluid rests anticipated
- Facial burns, pan facial f# w mid face and mandible
- associated chest injuries
What are indications for trach?
- prolonged ventilation
- toiling requirements
- airway obstruction
- panfacial/severe burns
How do you manage hemorrhaging form a facial fracture patient?
- direct pressure /suturing
- correct underlying coagulopathy
- Nasal packing Anterior and Posterior
- Reduce fracture and IMF
- Embolization (both common source is IMAX) +/- external carotid ligation
What are principles of facial fracture management (6)
- Timing; after life/limb threatening injuries stablilized
- Reduction: from unstable to stable, restoring buttresses
- Rigid fixation
- Bone Graft: immediate if >5mm gap
- Soft Tissue: resuspend
- Soft tissue defect management
Describe the osseocartialginous vault of the nose
Bony vault composed of nasal bones projecting from nasal process of frontal bone, supported laterally by the frontal process of maxilla, posterior by nasal spine of frontal bone
Cartilaginous vault: ULC and dorsal septum
What is the blood supply to the nose?
ICA
- Ophthalmic-> Ethmoidal, SupraOrbital , SupraTrochlear , Infratrochlear
ECA
- Facial-> Superior Labial , Angular
- IMAX-> Spenopalatine, Greater palatine, Infraorbital
How do you classify nasal bone fractures
Higuerra (PRS 2007)
- unilateral or bilateral
- Simple or communited
- open or closed
How do you make the diagnosis of nasal bone f#
- CLINICAL diagnosis
- epistaxis
- no xray needed
How do you treat nasal bone f#
- Reduce Septum- then bones as the bones will unite in the direction of the septum
How do you treat septal hematoma
Requires incision of mucoperichondrium and drainage + packing
Describe steps for nasal reduction (closed then open)
Closed
1- Timing 2-3h or 7-10days from injury
2- Local+/- sedation
3- Recreate fracture w Goldman and mould into position
4- Reduce septal dislocation w ASch forceps
5- Packing for 1-2days
6- Splint 1wk
Open (acute) - if failed closed, open fracture, NOE Open (delayed) - reduce septum and align on ANS w sutures - SMR and turbinate outf# - stuture avulsed ULC - Osteotomy of impacted f# - orif w frontal process of maxilla and nasal process of frontal bone - Grafts: onlay or cantileve
Describe an algorithm for nasal bone f#
1- Simple,uni/bi, closed 4hrs or greater than 7-10days: CR splint
2- Comminuted open/closed: rhinoplasy w septoplasty: osteotmoyies, spreder grats, splints
What are complications of a nasal bone f# (7)
Early: 1- CSF leak 2- Hemorrhage (anterior or posterior) 3- Sinusitis Late 1- Saddle nose deformity (due to septal perforation from hematoma) 2- Airway obstruction (due to thickened septum from hematoma fibrosis) 3- Malunion 4- Nasal hump 5- Synechiae 6- Nasal bone osteitis 7- Anosmia
What is the epidemiology of facial fractures?
Most common
1- nasal bones
2- zygoma
3- maxilla
What are the articulation of the zygoma?
1- ZF suture: zygomaticofrontal process
2- Arch: zygomatic process of temporal bone
3- Orbital rim: Maxilla rim and orbital floor
4- Lateral buttress: zygomaticomaxillary buttress
5- Lateral orbital wall: Greater wing of sphenoid
What are the muscle attachments to the zygoma?
- Temporalis
- LLS
- Masseter
- ZM, Zm
What are ligamentous attachments to the zygoma?
- Lateral Canthal tendon (to whitnall’s tubercle, 10mm below ZF suture)
- Suspensory ligament of Lockwood (suspends globe inferiorly as a sling and attaches adjacent to whitnall’s tubercle)
- Orbital septum (attached to inferior orb rim)
- Temporalis fascia (attached to arch and body)
What nerves travels through zygoma>
1- ZT (V2 br)?
2- ZF (V2 br)?
3- inferior orbital nerve (V2) - exits via formaen 1 cm below IORim inline w medial edge of pupil
How do you classify zygoma F#
- Location (body, arch or both)
What is the typical fracture pattern of a zygoma body /complex f#?
F# through ZF to ZS suture to inferior orb fissure
F# continue through orb floor and out IOforamen
F# continue down through ZM buttress and posteriorly to lat wall of maxillary sinus and 1.5cm posterior to ZT suture on arch
What are clinical symptoms and signs of a zygoma f#
Symptoms
- trismus
- diplopia
- visual acuity changes
Signs
1- EYE:- vertical and lateral canthal dystopia, subconj hemorrhage, bruising, enophthalmus, orbital apex syndrome, SOFS, proptosis
2- CHEEK: malar depression, step off, V2 paresthesia
3- MOUTH: malocclusion, trismus, UBS bruising
4- Nose: Unilateral epistaxis
What does unilateral epistaxis indicate?
maxillary sinus mucosal injury
What does trismus and malocclusion indicate in contact of OZC
impingement on coronoid and muscle spasm
What zygoma F# are treated with non-op tx and what is non-op treatment?
non-displaced zygoma # with minimal deformity
Tx: soft diet 6wks, protection from re-injury, f/u 2 and 6wks
What are indications for operative tx of a zygoma F#
1- Vertical dystopia 2- Enopthalmus 3- Entrapment 4- Truisms from impingement 5- Deformity
What are options for operative tx
ORIF
Open reduction and no fixation (Gilles or Keen)
Post- op soft diet 4wks
What zygoma F# are amenable to Gilles or Keen reduction (open reduction no fixation)?
- Arch f#
- OZC without separation at the ZF F#, non-comminuted
Describe your landmarks for the Gilles reduction
- 2.5cm superior and anterior to roo tof helix - place 2cm oblique incision
Describe anatomic layers you traverse and path to the Z arch
Cut though skin, submit, TPF, loose areolar, deep temporal fascia to get to the temporalis muscle
Path to arch is developed in the plane between the deep temporal fascia and the temporals muscle
Reduce with lateral and anterior elevation
Where does the deep temporal fascia insert
Z arch- anterior cortex
Where does the temporals muscle insert relative to the Zarch?
Onto the coronoid and anterior ramus - it passes deep to the arch
Where is the frontal branch as it crosses the Zarch?
Frontal br courses within the TPF to cross the Zarch, then travels on the undersurface of the TPF across the temporal area
Where is the frontal branch at the forehead
It enters the frontal muscle on the deep surface above the superior Orb. rim
Surface landmark: courses from 0.5cmbelow triages to 1.5cm above lateral brow
What is the relationship between the course of the frontal br and the STA
they course in the same anatomic layer
Describe the Keen open reduction no fixatio
UBS incision and access to infra temporal surface of zygoma
What is indication specifically for ORIF of zygoma (with fixation?)
OZC with separation at ZF#, comminuted
associated with other F#
Arch- comminuted, laterally displaced
How do you judge your reduction of the zygoma to the correct anatomic position?
- based on reduction at the greater wing of sphenoid (lateral orbital wall)
- IOR, ZF and lateral max buttress are anatomically aligned with direct visualization
When do you do 4point fixation over 3 point fixation?
- inferior displacement of arch
- assocaite dF# where occlusion needs to be re-established (left 3 or mandible f#)
What are the key steps for ORIF of zygoma
1- Reduction - according to ZS with anatomic visualization of ZF, IOR, ZM
2- Fixation - plates 3points (ZF, IO, ZM) or 4 points (ZF, IO, ZM, ZA)
3- Orbital floor - possible recon required
4- Periosteal resuspension of Malar soft tissue
5- Lateral canthoplasty
What are the plate sizes for the ORIF of zygoma
ZF- 1.2mm 4 hole
IOR- 1.2 or 1.7mm 4hole
ZM- 2.0mm curved 4hole
ZA- 2.0mm 4hole
What are the approaches for zygoma orin to the ZF
1- Lateral limb of upper bleph incision **
2- Subciliary with cantonal detachment
3- Lateral brow
What ar the approaches for zygoma orif to the IOR
1- MIdlid
2- Subciliary
3- Transconjunctival
4- Transconjunctival with lateral canthotomy
What are the approaches for zygoma oRIF to ZM?
UBS
When is a bicoronal incision sued for zygoma orif?
4pt fixation is needed (4th at arch):
- arch is laterally/inferior displaced
- associated fractures where occlusion needs to be re-establshed (associated lefort 3/mandible)
Describe incision and elevation of bicoronal
1- Incision straight, curved anterior, multiple curves
2- Elevate SUB-Galeal (deep to TPF) raising whole flap right off deep temporal fascia (leaving frontal br in the undersurface of TPF and loose areaolar tissue ** want to clearly see deep temporal fascia***
3- 2cm above arch (near midlevel of lateral orbital wall) incision through superficial leaflet of deep temporal fascia
4- transverse the superficial temporal fat pad to expose arch
OR
- dissect deep to the deep temporal fascia from the beginning * less risk to CN7 but greater risk of injury/devasc to temporal fat pad/temporal hollowing
Describe the relevant anatomy of the DTF, TPF, PMF
TPF continues as the SMAS below the arch and contains the frontal br at the level of the arch
DTF - divides into deep and superficial leaflets at line of fusion. Sup.leaf is thick and attaches to superior superficial edge of arch. Deep leaf is thin and attaches to superior deep edge of arch.
The slDTF and dlDTF surround superficial temporal fat pad above the arch
Sl of DTF continues as the PMF below the arch.
Dl of DTF continue as the posterior mastered fascia below the arch
The slDTF and dlDTF surround master muscle below the arch
What is the blood supply to the superficial temporal fat pad?
middle temporal artery
Why is the lateral canthoplasty NECESSARY after zygoma orif?
stripping of lat orb wall for reduction at ZS suture means the lateral cantonal tendon is stripped off whitnalls
- use stainless steel wire and overcorrect (approx 10mm below zf)
What are complications of a zygoma F# orif
Early (2)
- Globe injury
- Sinusitis
Late (9)
- Malunion (increased width, decreased projection, exophthalmus, dystopia
- Incision ectropion, alopecia
- diplopia
- V2 paresthesia
- CN7 frontal injury/weakness
- lateral canthal dystopia
- ptosis malaria soft tissue
- coronoid ankylosis
What are the 4 processes of the maxilla?
- frontal
- zygomatic
- alveolar
- palatine
What are the 3 vertical buttresses of the maxilla?
- Nasomaxillary (medial)
- Zygomaticomaxillary (lateral)
- pterygomaxillary (posterior)
What is the horizontal buttress of maxilla?
palate
what is the blood supply of the maxilla?
IMAX (greater palatine, alveolar, sphenopalatine, infraorbital) - Gp.A.Sp.I
Describe the nerve supply of the V2 maxillary branch
1- Infraorbital & Zygomatic br ->supply cheek and up flip
2- Greater & Lesser palatine br -> supply palate mucosa
3- Nasopalatine -> supply prefixal mucosa
4- SUperior alveolar br -> supply teeth
Define Lefort 1 f#
trasnmaxillary F# through - Zm buttress, NM buttress, nasal septum and pterygomaxillary jx or palatine bone
Define lefort 2f#
Pyramidal f# through - NF suture, frontal process of maxilla, medial orbital wall, orbital floor, orbital rim, ZM buttress, pterygomax jx
Define lefort 3 f#
Craniofacial dysjx with f# through NF suture, frontal process maxilla, medial orbital wall, orbital floor, ZF suture, ZArch and pterygomax jx
what are symptoms of a lefort f#
malocclusion, visual changes, epistaxis
What are signs of lefort f#
EYE - enopthal, diplopia, vertical dystopia, subconj hem, periorb bruise
NOSE - epistaxis, wide bridge, septal hematoma, CSF rhinorrhea
MOUTH - mucosal bruising, malocclusion (anterior open bite, crossbite) maxilla mobility
What are indications for non-operative tx of lefortt f#?
Edentulous pt with lefort 1
What are indications of operative tx of lefort f#?
displacement or malocclusion
What establishes the verticla height of the face when reducing lefort F#?
the vertical rami
What do you do if you have a lefort f# and both vertical rami disrupted?
you need to establish height by either
1- fix condylar/ramus fracture to establish facial height (done if >2 maxilla buttress have bone deficits
2- use maxilla buttress to establish height if there are no bone defect in >2 maxilla buttress
How do you disimpact a maxilla?
Rowe forceps, wire through ANS or osteotomy
Describe the order of operative repair of a lefort 3 f#
- Arch bar application
- Approaches - bicoronal (or lateral limb of upper bleph), midlid, UBS
- exposure all fractures
- reduce and fix from top down
- frontal, zygoma, NOE and orbital # reduced anatomically relative to cranial base
- MMF
- seed condyles to reduce maxilla relative to stable upper base
- plate ZM and NM buttresses as they lie
What is the indication for 1’ BG with rigid fixation?
> 5mm gap in buttress (use split calvarial, ICB, rib)
What is the post-operative course?
6wk soft diet
MMF elastics for 4 weeks
arch bars for 6wks total
How do you treat a non-union of lefort f#?
- excision of fibrous tissue
- BG
- ORIF
What are signs of malunion in lefort f# (3)
- malocclusion (anterior open bite, cross bite)
- midface retrusion
- vertical facial lengthening
Describe the SEQUENCE of midface fracture repair (antonyshyn and forrest paper)
Recon Upper face
1- WIDTH: ORIF zygoma = restore superior lateral buttress
2- PROJECTION: ORIF NOE = restore superior medial buttress
Recon Lower face
1- MMF: restore occlusion
Recon Midface HEIGHT
1- If no vertical rami disruption, use mandible to index height and ORIF lefort 1 to upper face
2- if vertical rami disruption, look at # of maxilla buttresses with bone deficit
- if >2 no no bone deficit, use maxilla to determine height
- if >2 have bone deficit, cannot use maxilla and need to ORIF the condyle
What is the blood supply to the palate?
Greater Palatine
Ascending Palatine br (of facial)
Anterio br of Ascending pharyngeal
What is the wekest bone of the palate?
parasagittal (at vomer suture/fusion)
How do you classify palate fractures? (Hendrickson)
By location 1- Alveolar ( Anterior or Posterior) 2- Sagittal 3- Parasagittal 4- Paraalveolar 5- COmplex 6- Transverse
How do your repair type 1 palate fracture?
Anterior f#: orthodontic brackets x6wks
Posterior #: ORIF or splint
How do you repair type 2,3,4 palate #
Arch bar, MMF, ORIF 4 buttresses - to reconstitute maxilla and dental arch - if no mmf and just plates, palatal archs will splay apart
How do you repair type 5,6 palate fracture
Arch bar, MMF, ORIF 4 buttresses + Palate splint
What are specification considerations of pediatric midface fractures?
- Early/immediate treatment as healing occurs fast
- MMF difficult b/c unerupted teeth, shallow roots - use skeletal wires
- minimal subperiosteal dissection to limit growth restriction
- considering bioresorbable plates or removal of hardware
- shorter periods of IMF
What are the aims of rigid fixation in facial fracturs?
- 1’ bone healing
- early functional rehab
- prevent soft tissue contracture
- support revascularization of BG
What is stainless steel made of?
molybdenum, iron, chromium, nickel
What are bioresorbable plates made of?
PGA polyglycolic acid and PLLA poly-L-lactic acid
How long do biorsorbable plates last?
strength maintianed 4 months, resorbed by 1yr
When do you use self tapping screws in facial f# orif?
when bone
What does compression plating accomplish?
- increase contact surface and frictional force
When are recon plates used (2.4mm or 2.7 mm)
load bearing plates
- segmental F#
- bone gap
- comminution
- edentulous (poor bone stock and blood supply)
When do you use lag screws in facial f# ORIF
- to compression across fracture site in mandible
- need >2 lags or lag and plate to resist rotation
- for oblique, spiral F# or onlay bone graft
what are complications of ORIF
- delayed union, nonunion malunion
- infection
- exposure
- loosening
- palpability
- cold intolerance
- imaging interference
List the principles of management of craniofacial fractures
- Timing: early definitive, single stage repair
- Restoration of form and functional units
- Wide subperiosteal exposure and precise anatomic reduction
- rigid fixation
- immediate autogenous bone graft for defect > 5mm
- Definitive management of soft tissue defects
- Resuspsension of soft tissues & anatomic landmarks
List the principles of craniofacial SOFT TISSUE trauma:
- Thorough cleanse
- Minimal debridement
- Look for underlying injuries
- Align anatomic structures
- Careful suture technique & remove sutures early
What are the KEYS to fracture pattern and management in frontal sinus, NOE, OZC, lower midface fractures
- Frontal sinus - Key is nasofrontal outflow tract
- NOE - key is status and reduction of MCT
- OZC - key is checking reduction at lateral orbital wall / ZS suture
- lefort 1 - occlusion
Why do we surgically correct facial fractures?
- to improve function
- to address deformity
Describe sequence of repair for isolated lefort 1 fracture
1) Apply arch bars
2) Exposure: UGBS
3) Expose fracture in subperiosteal plane, dissect mucopericondrium from piriform and ANS, expose and protect infraorbital nerve
4) Reduce fracture with maxillary disimpaction using row forceps or wire through ANS or manual
5) note if unable to establish reduction, consider other fracture, condyle fracture
6) Wire in MMF in centric occlusion/relation
7) Rigid internal fixation: 1.5mm L plate medial buttress; 2.0mm L plate lateral buttress
8) prepare for autogenous bone graft if defect > 5mm
9) close incision
10) release MMF, check occlusion
Describe sequence of repair for isolated lefort II fracture
1) Arch bars
2) Subperiosteal Exposure: bicoronal, UGBS, mid-lid
3) Reduce fracture
4) Apply MMF
5) Rigid internal fixation: 1.2-1.5mm plate NF, 1.2-1.5mm plate rim +/- implant to floor, 2.0mm plate to lower lateral buttress (ZM)
6) Close, release fixation, check occlusion
Describe sequence of repair for isolated lefort III fracture
1) Arch bars
2) Subperiosteal exposure through bicoronal +/- lateral rim/upper bleph
3) Reduce fracture, apply MMF
4) Plate - 1.2-1.5 @ NF and ZF +/- implant to floor
5) Close, release MMF
List specific considerations / differences in management of pediatric craniofacial fracture compared to adult
1) no arch bars
2) establish MMF using circumdental wires, drop wires from piriform & use shorter peiror od IMF
3) absorbable plates and screws b/c permanent can become incorporated and affect growth
4) monocortical screws given mixed dentition
5) more conservative tx - minor occlusal differences can be accommodated by 2’ dentition and/or orthodontics
6) early repair - bc bone heals more quickly
7) dynamic growing framework capable of remodelling
8) sinuses are small
9) wide subperiosteal undermining can lead to restricted facial growth
