CME
Two Hundred Ninety-Four Consecutive Facial
Fractures in an Urban Trauma Center:
Lessons Learned
Patrick Kelley, M.D., Marcus Crawford, M.D., Stephen Higuera, M.D., and Larry H. Hollier, M.D.
Houston, Texas
Learning Objectives: After studying this article, the participant should be able to: 1. Understand the different technical options
available for repairing facial fractures. 2. Know which technical points facilitate performance of fixation of the facial skeleton
by relatively inexperienced surgeons. 3. Have a basic understanding of the most common complications arising after facial
fracture repair. 4. Have an understanding of how to avoid surgical complications following facial fracture repair.
Among the myriad injuries seen in urban
trauma centers, facial trauma is one of the
most common. Given the broad variety of facial
bone injuries seen, management can be complicated even for the most experienced clinician. This takes on added significance when
one considers that residents in training are
frequently involved in the care of these patients. Although there are numerous ways to
handle many facial skeletal injuries, the experienced surgeon entrusted with the training of
residents must always be cognizant of emphasizing those methods that provide the desired
outcome for the relative novice. Only as trainees become more skilled with their technique
should more complex methods be introduced.
This study evaluated a large group of patients at a level I urban trauma center undergoing surgical management of facial skeletal
injuries. In all cases, the same faculty plastic
surgeon (and senior author, Dr. Hollier) was
scrubbed with a sixth-year plastic surgery resident acting in the capacity of surgeon. The
results of these operations in terms of complications were examined. Technical aspects of
the operation, which were thought to improve
the overall outcome while minimizing the complexity of the procedure itself, are examined.
Background:
The treatment of facial
trauma is associated with a myriad of potential complications. This may be compounded by the relative lack of compliance
seen in the patient population within an
urban trauma center and by the requisite
involvement of residents in this care.
Methods: This study retrospectively evaluated 189 patients with a total of 294 separate
fractures treated over a 3.5-year period.
Results: The overall rate of complications
was 7.8 percent.
Conclusions: The experience at a high-volume level I trauma center with residents as
the primary physicians has confirmed that
facial trauma surgery may be undertaken with
an acceptably low complication rate. Numerous technical factors were thought to be responsible for this, including the use of
miniplates for treatment in the majority of
mandibular fractures, overcorrection of orbital volume in fractures involving the globe,
and the use of a transconjunctival incision
with a lateral canthotomy for access to the
lower eyelid structures. (Plast. Reconstr. Surg.
116: 42e, 2005.)
From the Michael E. DeBakey Department of Surgery, Division of Plastic and Reconstructive Surgery, Baylor College of Medicine. Received
for publication August 6, 2004; revised December 14, 2004.
DOI: 10.1097/01.prs.0000177687.83247.27
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Vol. 116, No. 3 /
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FACIAL FRACTURES IN A TRAUMA CENTER
PATIENTS
AND
METHODS
We performed a retrospective analysis of 189
patients with facial fractures treated at Ben
Taub General Hospital in Houston, Texas,
from September of 1998 to February of 2002.
All of the patients were treated by residents on
the plastic surgery service under the supervision of one faculty surgeon at this level I
trauma center. Data were analyzed according
to demographics, mechanism of injury, fracture location, and surgical complications. The
follow-up ranged from 3 days to 5 years, with an
average follow-up of 74 days.
Among the study group, 158 patients (84
percent) were men and 31 (16 percent) were
women. Most of the patients were between the
ages of 21 and 30 years (Fig. 1). As in other
retrospective reviews of facial trauma in the
urban setting, interpersonal violence was the
primary mechanism of injury.1 Ninety-one patients (48.1 percent) sustained injuries in this
manner. The remaining injuries were caused
by automobile crashes, falls, automobilepedestrian accidents, and contact sports (Fig.
2). A history of drug and/or alcohol abuse was
reported by many patients. The most common
fractures treated were of the mandible (Table
I). These 140 fractures constituted 47.6 percent of the group, followed by (in decreasing
frequency) fractures of the zygoma and fractures of the orbit (Fig. 3).
FIG. 1. Facial trauma age distribution in years.
FIG. 2. Mechanisms of injury.
TABLE I
Fracture Location
Location
No. (%)
Mandible
Zygoma
Orbit
Nose
Frontal sinus
Nasoethmoidal-orbital
Palate
Le Fort I
Le Fort II
Le Fort III
Panfacial
Total
140(47.62)
51(17.35)
33(11.22)
19(6.46)
15(5.1)
14(4.76)
9(3.06)
4(1.36)
4(1.36)
4(1.36)
1(0.34)
294(100)
During the period of review, techniques of
exposure and fixation were uniform, as a single
faculty surgeon supervised all procedures.
Noncomminuted parasymphyseal and body
fractures of the mandible were all treated intraorally using miniplate fixation along the
ideal lines of osteosynthesis. Mandibular angle
fractures were treated intraorally by placing a
single matrix or strut miniplate. Comminuted
fractures and fractures involving substantial
bone loss were treated with locking reconstruction plates. All subcondylar fractures were
treated using maxillomandibular fixation. Orbitozygomatic fractures were exposed using incisions in the gingivobuccal sulcus, transconjunctivally in the lower eyelid and through a
lateral extension of the supratarsal fold in the
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PLASTIC AND RECONSTRUCTIVE SURGERY,
FIG. 3. Facial fracture locations.
upper eyelid. A coronal incision was only used
if the infraorbital rim and zygomatic buttresses
were so comminuted that adequate alignment
required arch visualization. A Carol-Gerard
screw was used for disimpaction and alignment
of the fracture in all cases. All orbital floor and
medial wall fractures were treated with synthetic implants, including titanium meshes,
resorbable implants, and high-density porous
polyethylene. Exposure was exclusively by
means of a transconjunctival approach.
RESULTS
During the follow-up period, 23 complications were noted among the 294 fractures,
yielding a 7.8 percent overall complication
rate. Twenty-one of the complications required
operative repair, whereas two were managed
with nonoperative therapy. Problems after
mandibular fracture repair contributed to only
13 percent of the 23 complications. Among the
13 patients with complications related to repair
of a mandible fracture, six experienced a postoperative infection. The cause was most frequently hardware failure, treatment of which
consisted of removal of hardware and replace-
September 1, 2005
ment by more rigid fixation. The remaining
complications consisted of malocclusion, intraoral plate exposure, orofacial fistula, trismus, and a failed free fibula flap. Numbness of
the lower lip was not evaluated. There were no
complications requiring operative repair
within the subset of patients who received
treatment for subcondylar fractures, including
no cases of malocclusion.
Complications from orbital fracture repair
contributed to five of the 23 complications.
Enophthalmos (acute or delayed) was seen in
three of the 33 orbital fracture repairs, resulting in a 9 percent incidence of enophthalmos
following orbital fracture repair. The technique for correction of postoperative enophthalmos involved repeated reconstruction with
either titanium or porous polyethylene implants. No patient demonstrated diplopia at
the time of last follow-up.
After repair of frontal sinus fractures, one
patient experienced an infection of the calcium phosphate bone cement used that required removal, and another patient developed postoperative sinusitis that was effectively
treated with oral antibiotics. Of the 14 patients
who experienced nasoethmoidal-orbital
fractures, one patient experienced persistent
telecanthus. This was repaired with repeated
transnasal wiring.
Table II lists all the complications that were
encountered and their subsequent management. Table III lists the complication rates by
fracture location.
DISCUSSION
Since the initial descriptions by Michelet and
others of internal fixation with small plates and
screws for facial fractures, surgeons have developed a myriad of techniques to accompany the
ongoing development of commercially available materials.2 These methods are often variations on traditional surgical approaches that
have been adjusted to appropriately fit specific
clinical situations.
An examination of the data demonstrates
that the most common fracture treated was of
the mandible (47.62 percent, n ⫽ 140). Our
techniques vary depending on the type (simple
versus comminuted) and location of the fracture. In accordance with the principles described by Champy et al., miniplate fixation
along the ideal lines of osteosynthesis was the
preferred form of stabilization for simple
fractures.3 When used in the appropriate situ-
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FACIAL FRACTURES IN A TRAUMA CENTER
TABLE II
Fracture Repair, Complications, and Correction
Fracture Repair
Complications
Correction
Mandible
Mandible body
Mandible body
Mandible body
Mandible angle
Mandible angle
Mandible parasymphysis
Mandible angle
Mandible angle
Mandible angle
Mandible body
Mandible
Mandible angle/subcondylar
Orbital floor
Orbital floor
Orbital floor
Orbital floor
Orbital floor
Frontal sinus fracture
Frontal sinus
Orbitozygoma fracture
Zygomatic arch fracture
NOE
Intraoral plate exposure
Infected ORIF
Infected ORIF
Infected ORIF
Malocclusion
Orofacial fistula
Infected ORIF
Infected ORIF
Infected ORIF
Screws in fracture line
Failed free fibula to reconstruct lateral defect
Soft-tissue infection
Trismus
Delayed enophthalmos
Entropion
Extrusion of hardware
Lower lid retraction
Enophthalmos
Infected Mimex
Sinusitis
Enophthalmos
Malunion
Telecanthus
Pectoralis flap coverage
Removal of infected tension band
Extraction of retained tooth roots
I & D, removal of loose screw
Removal of strut plates, MMF
Closure of fistula
Removal of 2.0 plate, replaced with 2.4 LR
Third molar extraction
Third molar extraction and LR plate replacement
Repeat ORIF
Repeat free fibula
Debridement and antibiotic therapy
Oral exercises
Medpor wedge
Palatal graft for entropion
Removal of hardware
Massage
Repeat ORIF with titanium mesh
Removal
Antibiotic therapy
Medpor wedge
Osteotomy and replating
Repeat ORIF and transnasal wiring
ORIF, open reduction and internal fixation; NOE, nasoethmoidal-orbital.
ations, there can be no question that miniplate
fixation results in a lower incidence of malocclusion than does fixation with larger reconstruction plates. These smaller plates, typically
accommodating screws 2 mm in diameter, do
not have to be precisely adapted to the mandibular contour, as do larger plates. Of course,
they are not applicable to all mandibular fractures. The greater the instability present in the
mandible, the more prone one should be to
use larger plates. Comminuted fractures, fractures involving substantial bone loss, and multiple mandibular fractures should cause one to
consider using larger reconstruction plates
(Fig. 4). When such plates are chosen, however, the surgeon should typically use locking
plates.4,5 Locking reconstruction plates function in that the screw is threaded into the plate
TABLE III
Fracture Location, Complications, and Complication Rate
by Location
Fracture
Location
Complications
(% of total,
n ⫽ 23)
Complication
Rate by
Location (%)
Mandible
Orbital floor
Frontal sinus
Zygoma
NOE
13(56.52)
5(21.74)
2(8.70)
2(8.7)
1(4.35)
9.29%(n ⫽ 140)
15.15%(n ⫽ 33)
13.33%(n ⫽ 15)
3.92%(n ⫽ 51)
7.14%(n ⫽ 14)
NOE, nasoethmoidal-orbital.
FIG. 4. Locking plate.
at the end of its insertion, preventing the bone
from being pulled up to a maladapted plate. In
essence, the plate acts as a form of “internal”
external fixator. Consequently, just as with
miniplates, one need not contour the plate
exactly to the shape of the underlying mandible. These are less likely to result in a malocclusion. In addition, loose screws should theoretically never be seen, as the screw is
dependent on the plate itself for stability and
not its contact with the bone.
Another important point is the appropriate
treatment of subcondylar fractures. There are
many advocates of open reduction. Most point
out that the results of the open approach are
better with respect to range of opening, diminished deviation on opening, and restoration of
the mandibular contour at rest.6 – 8,11 Although
this may be the case, the real question is
46e
whether or not the additional morbidity of the
open approach is worth it. That is, even though
a patient treated in a closed fashion for a subcondylar fracture often deviates with maximal
opening and has some loss of definition of the
jawline at rest, we have yet to have a patient
complain of this. This must be contrasted with
a potential facial nerve injury secondary to
opening a subcondylar injury. With most open
approaches to reduce and plate the condylar
region, facial nerve injury is the primary concern. Even though this is typically temporary,
the surgeon cannot know this immediately
postoperatively. Many of these patients must be
followed for months before recovery is apparent. In addition, recovery of the nerve is not
always complete, with ongoing facial asymmetry being problematic. Although there has
been a great deal of interest in the endoscopic
approach, this has a very steep learning
curve.9,10 As such, for all but the most experienced surgeons, it is entirely appropriate to
treat the majority of these patients in maxillomandibular traction of some sort. The type of
intermaxillary fixation and its duration are entirely dependent on the patient’s occlusion. In
those cases in which, once all other mandibular fractures are fixated, the occlusion is at its
preinjury level despite the subcondylar injury,
no further treatment or intermaxillary elastics
are quite acceptable. However, when the occlusion is still quite disordered following fixation
of the other mandibular fractures, strong consideration should be given to maxillomandibular wires. Given the relative unreliability of
many patients with these injuries, elastics
should generally not be trusted. The duration
of intermaxillary fixation depends entirely on
the level of the subcondylar fracture and the
severity of the malocclusion being treated.
Rarely, however, should it exceed 3 to 4 weeks.
It is important to note that intermaxillary fixation never truly reduces the fracture. Rather, it
forces the patient to functionally adapt the bite
to the existing subcondylar displacement, restoring the preinjury occlusion.
This is not to say, however, that no subcondylar fracture should be treated in an open
fashion.11 In any patient in whom intermaxillary fixation is contraindicated, such as those
with a severe poorly controlled seizure disorder, open reduction should be strongly considered. In addition, in patients with massive panfacial injuries with bilateral subcondylar
fractures, open reduction of one side should
PLASTIC AND RECONSTRUCTIVE SURGERY,
September 1, 2005
be considered to establish the posterior facial
height. We must emphasize that no subcondylar injuries in this series were treated in an
open fashion.
Mandibular angle fractures must be given
special attention. These are some of the most
difficult fractures to treat successfully. There
are several issues to consider, including difficulty with intraoral visualization and the problem of third molar management. Although the
majority of uncomplicated angle fractures may
be managed using intraoral incisions and
transbuccal drill and screw placement, consent
should be given by all patients for an external
incision should the intraoral approach prove
too problematic. When placing fixation using
the intraoral approach, we have found the matrix or strut plate to be very useful (Fig. 5).
Generally the plate is placed in the midportion
of the angle and secured using 6-mm-long
screws that are 2 mm in diameter. The plate
itself needs no contouring and provides excellent stabilization.
With respect to the management of third
molars, the literature is replete with different
viewpoints.12–15 The only real benefit to retention of this tooth is in its contribution to the
stability of the angle. When large plates (2.4
mm) are used for fracture fixation, there is
relatively little benefit to retaining the molar.
However, when the intraoral approach is used
and small plates are applied, serious consideration should be given to maintaining the tooth
if possible because it adds stability. In general,
the novice surgeon should err on the side of
removing the molar when there is any question
regarding the condition of the periodontal tissues or possible damage to the molar itself.
FIG. 5. Mandibular strut/matrix plate rigidly fixating a
mandibular angle fracture (note that the mandibular third
molar has been removed).
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FACIAL FRACTURES IN A TRAUMA CENTER
Two infections in this series occurred in angle
fractures with third molars left in position.
With respect to malar injuries, the most common severe complication seen was
enophthalmos.16,17 Even in the best of hands,
this is not an uncommon complication. When
teaching residents the technique for correcting
the fracture, there are several important points
to emphasize. First, the vast majority of these
injuries can be corrected without a coronal
incision. The only instance in which the coronal incision is needed is when there is so much
comminution at the level of the infraorbital
rim and the zygomaticomaxillary buttress that
these two cannot be used for accurate positioning of the fragment. In these situations, visualization and alignment of the zygomatic arch
are helpful. Perhaps the most important point
to emphasize in teaching reduction and fixation of malar fractures is the need to overcorrect the position of the globe (Fig. 6). At the
end of procedure, the globe on the affected
side should project more anteriorly than the
unaffected globe. Given the swelling induced
by the injury and the operation, the eye on the
operative side must project more. If at the end
of the procedure the globes are symmetric, one
should expect postoperative enophthalmos. If
the overcorrection is not seen at the end of the
procedure, the surgeon has several options.
One option is to remove the fixation and reposition the malar fragment. However, if the
surgeon is confident in the positioning of the
zygoma, the second option is to overcorrect the
orbital floor and intraorbital volume. As the
vast majority of these injuries do require repair
of the orbital floor, this may be the source of
the error. One should not hesitate to add extra
volume to the orbital cone should the globe
not be in an appropriate position at the end of
the procedure. In this series, only one of 51
47e
malar fractures developed clinically significant
enophthalmos using this philosophy.
Another important technical aspect facilitating correction of the malar position is the use
of a Carol-Gerard screw (Fig. 7). This instrument is available as a self-drilling screw that
may be placed through the lower eyelid incision into the zygoma, allowing it to be used
essentially as a handle. One may use this to
both disimpact the zygoma and to position it
much like a joystick for fixation. This greatly
facilitates ease of handling of the zygoma during these procedures.
In isolated orbital injuries, the same issues
apply with respect to enophthalmos.17,18 At the
end of the procedure to reconstruct the fractured walls, the orbital volume should be overcorrected. The globe should project more anteriorly. If it does not, adding additional
volume to the orbital cone is mandatory to
ensure appropriate position postoperatively.
Only one of the 33 patients with orbital floor
injuries developed clinically significant enophthalmos in this series. On repeated scanning,
the enophthalmos in this case was thought to
be related solely to inaccurate reconstruction
resulting in an increase in orbital volume.
Another major issue in teaching techniques
of orbital surgery is to studiously avoid the
transcutaneous approaches to the orbital floor.
There can be no question when the literature
and personal experience are reviewed that
lower eyelid retraction is much more common
when transcutaneous lower eyelid approaches
are used for facial trauma (Fig. 8).19 The one
exception may be a subtarsal approach to the
lower eyelid in which the skin incision is placed
low on the eyelid in a preexisting crease.20
Although this may be applicable to older patients, it should generally be avoided for the
more common younger patient with facial
FIG. 6. Overcorrection of the right globe consistent with anatomical reconstruction of an orbital floor fracture.
48e
FIG. 7. Carol-Gerard screw.
FIG. 8. Lower eyelid retraction following a subciliary incision for repair of orbital floor fracture.
trauma, because of the visibility of the scar. We
prefer the transconjunctival approach. It substantially lowers the risk of retraction and completely avoids a visible scar. Unless corneal exposure or significant globe irritation is present,
it is best to manage these cases conservatively
with massage. The vast majority of cases will
resolve. If after 4 to 6 months there is still a
substantial problem, operative intervention
should be considered. All patients in this series
were treated exclusively using the transconjunctival approach. Only one case of lower eyelid retraction (an entropion) required operative correction.
In the majority of patients, a lateral canthotomy is preferable to improve visualization of
the orbital floor. Although fracture repair is
possible without this, the inexperienced clinician is at a disadvantage performing the procedure. At the end of the procedure, a canthoplasty is typically required. Although simple
reattachment of the lower lid to the upper lid
can occasionally suffice to produce an acceptable appearance to the canthal angle, it is safer
to perform a canthoplasty. This does require
some degree of skill. The point of fixation of
PLASTIC AND RECONSTRUCTIVE SURGERY,
September 1, 2005
the lateral canthus should be to the periosteum
on the inner aspect of the orbital rim. It is
helpful to use a very small curved needle, such
as a P-2, to facilitate this.
Another important aspect of training residents is in the choice of implant for reconstruction of the orbit. Although a great deal has
been written about the use of a bone graft in
floor reconstruction, this requires a donor site
and in some cases a degree of shaping of the
graft. Although this technique works quite
well, it is more difficult and offers little in the
way of advantages over synthetic implants. There
are a vast array of implants for floor and medial
wall reconstruction that function very well, with a
negligible rate of infection. Among these are
titanium meshes, resorbable implants, and highdensity porous polyethylene.21–23 For smaller defects, the resorbable materials are quite nice, as
they slide over the defect easily without catching
any of the periorbita, as titanium has a tendency
to do. However, for larger defects of the orbital
floor, titanium offers excellent support and is
easy to contour. It may be easier for the novice
surgeon to contour these implants preoperatively
using a standard skull model and then subsequently sterilize the implant and cut it to the
appropriate size intraoperatively. The orbital
floors of most adults are similar in shape, and this
may prevent the surgeon from grossly maladapting the implant. In this series, none of the orbital
floor prostheses used had to be removed.
It is also important to emphasize the need to
dissect the floor defect cephalically, not
straight posteriorly. As the orbital floor inclines
superiorly, frequently the posterior ledge of
the defect is higher than anticipated. Dissecting directly posterior may result in the implant
essentially being placed in the maxillary sinus
(Fig. 9). When the surgeon encounters difficulty in locating the posterior aspect of the
defect, it may be helpful to place an elevator
into the defect and back to the posterior wall of
the maxillary sinus. The elevator can then be
lifted up against the undersurface of the posterior aspect of the remaining floor, to help
the surgeon define the defect.
CONCLUSIONS
This experience at a high-volume level I
trauma center with residents as the primary
physicians has confirmed that facial trauma
surgery may be undertaken with an acceptably
low complication rate. The above technical
points facilitate performance of fixation of the
Vol. 116, No. 3 /
FACIAL FRACTURES IN A TRAUMA CENTER
FIG. 9. Orbital floor implant in the maxillary sinus.
facial skeleton by relatively inexperienced surgeons. Although there are many ways for the
experienced physician to approach facial fractures, some of the techniques do require a
greater degree of skill. As with any reconstructive procedure, the specifics of the patient’s
fracture pattern are the ultimate guide to the
appropriate technique.
Larry H. Hollier, M.D.
Clinical Care Center, Suite 620
6621 Fannin Street, MC CC 620.10
Houston, Texas 77030-2399
[email protected]
ACKNOWLEDGMENTS
Financial support for this study was provided by Walter
Lorenz Surgical, Inc. Dr. Larry H. Hollier, Jr., also receives
additional financial support from Walter Lorenz Surgical,
Inc., for his research team.
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