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VIJAY K. ANAND, MDNew York, NY
DAVID D. CALDARELLI, MDChicago, IL
JAMES CHOW, MDMaywood, IL
LAWRENCE DESANTO, MDScottsdale, AZ
ISAAC ELIACHAR, MDCleveland, OH
RAPHAEL FEINMESSER, MD
Petah-Tiqva, IsraelALFIO FERLITO, MDUdine, Italy
DAN M. FLISS, MDTel Aviv, Israel
JEREMY FREEMAN, MD, FRCSCToronto, Canada
PHILLIP FRIEDMAN, MDSouthfield, MI
BRUCE J. GANTZ, MDIowa City, IA
JOSEPH JACOBS, MDNew York, NY
YOSEF KRESPI, MDNew York, NY
ROEE LANDSBERG, MDTel Aviv, Israel
HOWARD L. LEVINE, MDBeachwood, OH
MAHMOOD MAFEE, MDChicago, IL
ROBERT OSSOFF, MDNashville, TN
STEPHEN S. PARK, MDCharlottesville, VA
HAROLD C. PILLSBURY, III, MDChapel Hill, NC
DALE H. RICE, MD
Los Angeles, CADAVID E. SCHULLER, MDColumbus, OH
JAMES STANKIEWICZMaywood, IL
ELLIOT STRONG, MDNew York, NY
DAVID J. TERRISAugusta, GA
DEAN M. TORIUMI, MDChicago, IL
HARVEY TUCKER, MDCleveland, OH
B. TUCKER WOODSON, MDMilwaukee, WI
Operative Techniques in
OtolaryngologyHead and Neck Surgery
EDITORIAL BOARD
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FUTURE ISSUES
HEAD AND NECK TUMORSElizabeth Blair, MDSeptember 2008, Vol 19, No 3
ENDOSCOPIC SURGERY OF THE ORBIT AND LACRIMIALSYSTEMRaj Sindwani, MD, FRCSDecember 2008, Vol 19, No 4
THYROID-PARATHYROID SURGERY David J. Terris, MD, FACSMarch 2009, Vol 20, No 1
RECENT ISSUES
MINIMALLY INVASIVE HEAD AND NECK SURGERY Conrad Timon, MB, FRCSORL, MDMarch 2008, Vol 19, No 1
IMPLANTS AND GRAFTS IN RHINOPLASTY Craig D. Friedman, MD, FACSDecember 2007, Vol 18, No 4
COSMETIC SURGERY Raghu S. Athre, MDSeptember 2007, Vol 18, No 3
ACUTE SURGICAL MANAGEMENT OF THE AIRWAY David Goldenberg, MDJune 2007, Vol 18, No 2
NEW TECHNIQUES AND APPROACHES TO SLEEP APNEA IIB. Tucker Woodson, MD, FACSMarch 2007, Vol 18, No 1
Operative Techniques in
OtolaryngologyHead and Neck Surgery
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MANAGEMENT OF FACIAL TRAUMA
CONTENTS
INTRODUCTION 79
D. Gregory Farwell, MD, FACS
FREE TISSUE RECONSTRUCTION OF TRAUMATIC FACIALBONY DEFECTS 80
Douglas A. Girod, MD, FACS
ZYGOMATICO– ORBITO–MAXILLARY COMPLEX FRACTURES 86
Stephen Maturo, MD, Manuel A. Lopez, MD
MANAGEMENT OF SOFT-TISSUE TRAUMA TO THE FACE 90
Krishna G. Patel, MD, PhD, Jonathan M. Sykes, MD
PEDIATRIC ORBITAL ROOF FRACTURES 98
T.J. O-Lee, MD, Peter J. Koltai, MD
MANAGEMENT OF SYMPHYSEAL AND PARASYMPHYSEAL
MANDIBULAR FRACTURES 108
D. Gregory Farwell, MD, FACS
MANAGEMENT OF COMMINUTED MANDIBLE FRACTURES 113
Neal D. Futran, MD, DMD
TECHNIQUES OF MAXILLARY–MANDIBULAR FIXATION 117
Johnathan D. McGinn, MD, Fred G. Fedok, MD
Operative Techniques inOtolaryngologyHead and Neck Surgery
VOLUME 19, NUMBER 2, June 2008
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INTERNAL FIXATION OF MANDIBULAR ANGLE FRACTURES
WITH THE CHAMPY TECHNIQUE 123
David M. Saito, MD, Andrew H. Murr, MD, FACS
TRACHEOSTOMY SCAR REVISION 128
Travis T. Tollefson, MD, FACS, Amir Rafii, MD,J. David Kriet, MD
SURGICAL APPROACHES TO THE ORBIT 132
Clinton D. Humphrey, MD, J. David Kriet, MD
NASO-ORBITO-ETHMOID FRACTURE MANAGEMENT 140
Terry Y. Shibuya, MD, FACS, Vincent Y. Chen, MD,Young S. Oh, MD
FREE TISSUE RECONSTRUCTION OF TRAUMATIC
SOFT-TISSUE DEFECTS 145
Shri Nadig, MD, Wesley Schooler, MD, Mark K. Wax, MD
FRONTAL SINUS FRACTURES 151
E. Bradley Strong, MD
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Operative Techniques in Otolaryngology–Head and Neck Surgeryis dedicated to detailed, thorough, finest-quality illustrationsof new surgical procedures and techniques and to discussionof issues in surgical management of problems in the areas of otology, rhinology, laryngology, reconstructive head andneck surgery, and facial plastic surgery. New techniques that
are nonoperative will also be featured.Each issue of the journal typically includes the followingsections.
Editorials
feature articles: These articles are related to a featuredtheme of the issue and will be related by anatomic area ordisease process, or both. Each feature article will includeindications and contraindications, work-up and preparationof the patient, operative technique, and complications. Thesearticles will present new material related to the technique orresults of these procedures.
difficult decisions: This section focuses on a case related to
the central theme of the issue and will be presented withpatient photographs, diagnostic images, and/or other illus-trations. The case is discussed by a panel of authorities and ismoderated by the editor of the section.
innovative techniques: This highly illustrated section com- bines two or three techniques on a topic possibly related tothe featured theme of the issue and concentrates on newconcepts, innovations, and alternatives relevant to the prob-lem being discussed. Editorial comments may compare dif-ferent approaches to the same problem.
complications: Although this section often discusses com-plications related to the central theme, it also presents otherinteresting, unusual, and previously unpublished complica-tions in otolaryngology–head and neck surgery.
The contributions in the above sections may be invited; how-ever, the Journal welcomes submissions for the followingsections:
original articles: These articles should center around atechnique which need not be a surgical technique. New tech-niques for diagnosis, treatment, or rehabilitation will all beconsidered. The guidelines for authors that are presentedsubsequently on this page all relate to original articles.Original articles need not be theme-related.
letters to the editor: This correspondence should be brief and embody a point of view. Content should relate either topreviously published material in the Journal or to other rel-
evant issues in the surgical management of otolaryngology–head and neck surgery problems. Letters may include a shortlist of references as necessary.
GUIDELINES FOR CONTRIBUTING AUTHORSPREPARATION OF MANUSCRIPT
An original plus one copy of your manuscript should besubmitted to the Editor in Chief. All parts of the manuscript,including footnotes, references, legends, quoted materials,and case studies, must be double-spaced. Leave generousmargins of at least one inch on both sides at the top and bottom of every page.
Manuscripts must be submitted on a disk, preferably inMicrosoft Word. A double-spaced hard copy version of thefinal manuscript, free of hand-written alterations, must ac-company the disk. All components of the manuscript mustappear within a single electronic file: references, figure leg-ends, and tables must appear at the end of the manuscript.Please refrain from using end notes as references or automaticlist numbering because these features are lost in conversion:simply type the reference number in parentheses in the textand type the reference list. Formatting, such as Greek letters,italics, super- and subscripts, may be used: the coding schemefor such elements must be consistent throughout.
On the Title Page please include all of the following informa-tion:
1. The names, degrees, and professional affiliations (position,department, institution, place) of all authors.
2. The name of the institution where the work reported wasdone (‘‘From . . .’’)
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4. A complete mailing address (including U.S. ZIP code orpostal code for other countries) indicating the correspond-ing author who is to receive galley proofs and reprint
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Abstracts
All feature articles and original articles must include an ab-stract. Abstracts should emphasize the topic investigated,methods, results, and conclusions.
Review of Articles
Submitted manuscripts will be reviewed by the Guest Editor,and also are subject to review by the Editor in Chief and/ormembers of the Editorial Board.
Operative Techniques in
OtolaryngologyHead and Neck Surgery
Editor: MICHAEL FRIEDMAN, MD30 N. Michigan Avenue, Suite 1107, Chicago, Illinois 60602Managing Editor: COLLEEN A. MARTIN
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References
Reference numbers in the text follow numerical order and areenclosed in parentheses. References are listed in the order inwhich they are cited in the text, not in alphabetical order; theymust follow the style of the samples given. All referencesmust be complete when the manuscript is submitted.
journal article: one to three authors
1. Arvvin AM: Herpes simplex infections during pregnancyand in infants. Semin Dermatol 3:89-101, 1984
2. Bromberg K, Hammerschlag MR: Rapid diagnosis of pneumonia in children. Semin Respir Infect 2:159-165, 1987
journal article: more than three authors
3. Hughes WT, Feldman S, Cox F, et al: Infectious diseases inchildren with cancer. Pediatr Clin North Am 21:583-616,1974
journal article in press
4. O’Malley JE, Eisenberg L: The hyperkinetic syndrome.Semin Psychiatry (in press)
complete book
5. Adams DO, Edelson PJ, Koren HS: Methods for StudyingMononuclear Phagocytes. San Diego, CA, Academic, 1981
chapter of book
6. Sallan SE, Weinstein HJ: Childhood acute leukemia, inNathan DG, Oski FA (eds): Hematology of Infancy andChildhood, vol 2. Philadelphia, PA, Saunders, 1987, p 1028
book that is a new edition and is in volumes
7. Altman SM, Rozells G, Jaffe J: The human brain understress, in Caster W (ed): The Causes of Stress, vol 4 (ed 4).San Diego, CA, Psychiatric Press, 1934, pp 109-199
chapter of book that is part of published meeting
8. Baron MH, Maniatis T: Stage-specific reprogramming of globin gene expression, in Stamatoyannopoulos G, Nien-huis AW (eds): Developmental Control of Globin GeneExpression, Proceedings of the Fifth Conference on Hemo-globin Switching, New York, NY, Alan R Liss, 1987
journal article in journal that is a supplement
9. Leach C, Roeder M, Cimino A: Genetic studies of lungcancer. Semin Oncol 3:27-33, 1987 (suppl)
abstract
10. Garson G, Harris B, MacDonald J: Vericeal hemorrhage. JPediatr Surg 3:17, 1987 (abstr)
editorial
11. Reasoner PH, Smith LT: An argument against laetrile.Semin Oncol 3:19-30, 1989 (editorial)
TABLES AND FIGURES
All tables and figures must be cited in the text. The appro-priate location of each table or figure should be indicated inthe margin of the manuscript in pencil.
Tables
Each table should be typed on a separate sheet and appro-priately numbered. Each table must have a title. Tables must be cited in numerical order in the text using arabic numbers(Table 1, Table 2). Table legends should be typed on the samesheets as the tables. Each table should have a legend insufficient detail to allow understanding without reference tothe text.
Figures
Figures must be cited in numerical order in the text usingarabic numbers (Figure 1, Figure 2). All line drawings should be submitted as clear, glossy, black and white photographs;clear, dark laser jet prints are acceptable. Dot matrix printsand hand-drawn or hand-lettered figures are unacceptable.Legible photocopies may be used only with the duplicatemanuscript. The name of the first author, figure number, anddesignation of the top of the figure should be identified on the back of the figure. Authors should avoid mounting figures on
boards, unless mounting is necessary to ensure proper place-ment. Legends for figures should be typewritten and DOUBLE-SPACED, on a separate sheet, and included at the end of themanuscript. A legend must be provided for each figure. Con-tributors will pay all charges involved in the processing andprinting of color photographs and illustrations.
Figures, especially charts, graphs, and line drawings, aregenerally reduced in size for publication (consult a recentissue of the journal for examples). Figures not properly pre-pared will be returned to the contributor for revision or will be relettered.
If any illustration has been previously published, a copy of the letter of permission from the copyright holder must ac-company the illustration. The source of the illustration should be included among the References to the paper. The figurelegend should conclude with ‘‘Reprinted with permissionfrom . . .’’ followed by the reference number in parentheses.Photographs of patients should be accompanied by a signedrelease form.
Because a primary goal of Operative Techniques in Otolar-yngology–Head and Neck Surgery is to present superb, de-tailed illustrations, we reserve the right to add, delete, ormodify submitted illustrations. The authors will be able toreview final art prior to publication.
ELECTRONIC ILLUSTRATION SUBMISSION
Figures may be submitted in electronic format. Images should be provided in EPS or TIF format on Zip disk, CD, floppy, Jaz,or 3.5 MO. Graphics software such as Photoshop and Illus-
trator, not presentation software such as PowerPoint, Corel-Draw, or Harvard Graphics, should be used to create the art.Color images must be CMYK, at least 300 DPI, with a digitalcolor proof, not a color laser print or color photocopy (thisproof will be used at press for color reproduction). Gray scaleimages should be at least 300 DPI and accompanied by aproof. Combinations of gray scale and line art should be atleast 1200 DPI and accompanied by a proof. Line art (blackand white or color) should be at least 1200 DPI and accom-panied by a proof. Please include hardware and softwareinformation, in addition to the file names.
PROOFREADING AND AUTHOR CHANGES
The corresponding author is sent proofs and asked to readthem for typographical errors, returning them to the pub-
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COPYRIGHT
Authors contributing a manuscript do so on the understand-ing that, once it is accepted for publication, copyright in thearticle including the right to reproduce the article in all formsof media shall be assigned exclusively to the publisher.
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Introduction
The management of facial trauma continues to evolve with
the development of improved techniques, surgical instrumen-
tation, and implants. From the days of wiring the jaws and
closed reduction to precise open reduction and internal fixa-
tion, the otolaryngologist-head and neck surgeon has played a
critical role in the treatment of patients with facial trauma.
This edition brings together many of the leaders in the
fields of facial trauma, reconstructive surgery, and cosmetic
surgery to summarize the state of the art approach to many
different aspects of traumatic injuries of the craniofacial
region. It is my belief that the information provided here
will provide the reader with a broad overview of the proper
workup of the patient, the surgical goals, and techniques
that will optimize patient outcomes.
I would like to extend my gratitude to the authors of
these articles for their hard work and contributions to this
volume. It is my belief that the quality of the information in
these articles will make this a very useful reference edition
for Otolaryngologists for many years to come.
D. Gregory Farwell, MD, FACS
Guest Editor
1043-1810/$ -see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.otot.2008.05.001
Operative Techniques in Otolaryngology (2008) 19, 79
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Free tissue reconstruction of traumatic facial bony defects
Douglas A. Girod, MD, FACS
From the Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Kansas City,
Kansas.
Traumatic facial bony defects present one of the most challenging problems for the facial plastic
reconstructive surgeon. The most common mechanisms of trauma resulting in a bony defect of the
facial skeleton include gunshot injuries, motor vehicle accidents, and burns. These bony defects of thefacial skeleton resulting from trauma rarely occur in isolation. Rather, there is uniformly varying
degrees of soft-tissue trauma and/or loss, potential visual, neurological and spinal injuries, and other
associated life-altering implications. The application of free tissue transfer techniques to the manage-
ment of these complex defects has allowed a significant change in paradigm, permitting early inter-
vention and improved long-term outcomes.
© 2008 Published by Elsevier Inc.
KEYWORDSFacial reconstruction;
Trauma;Microvascular;
Free flap;
Bone defects
Traumatic facial bony defects are most commonly the
result of self-inflicted gunshot wounds resulting from at-
tempted suicide, followed by assault injuries (gun shot and
knife injuries) and motor vehicle accidents.1 These injuries
often include extensive soft-tissue damage, widespread con-
tamination of the wounds with orosinonasal secretions,bone fragments, and foreign body debris.1-3 Soft-tissue loss
often progresses over the course of 24-48 hours, further
complicating treatment planning. Immediate treatment of
these injuries requires a comprehensive systematic approach
to ensure all associated issues and injuries are addressed in
a timely fashion while preserving the soft-tissue envelope,
maintaining occlusive relationships and minimizing soft-
tissue contracture.
Futran and colleagues1 have proposed a protocol of
phased management of these acute traumatic bony defects.
They describe a 3-phase approach consisting of (1) initial
management, (2) definitive reconstruction, and (3) esthetic
and prosthetic refinement. This approach allows the surgeonto proceed through the many complex issues involved with
these patients in an organized fashion while accomplishing
all desired goals.
Phase I consists of the initial encounter where the ABCs
of trauma management are instituted, all life- and limb-
threatening injures are stabilized, and initial operating room
management is undertaken. Operative management should
include treatment of intracranial, ocular, and other major
injuries. Early management of the facial defect includes
establishing the occlusal relationships of the remaining
mandibular and maxillary segments and wound debride-ment of foreign material and obvious nonviable tissues. All
tissues of questionable viability should be preserved and
monitored for the need of further debridement. Major bony
segments should be repaired with the use of standard plating
techniques. Segmental mandible defects should be repaired
with bridging reconstruction plates to avoid soft-tissue
contracture. The use of locking screw reconstruction
plates of adequate size is preferable in this situation
(Figure 1A and B).4
Major maxillary, orbital, and nasal defects should be
addressed with cranial bone grafting if adequate soft tissue
exists. Because soft-tissue contracture is very difficult to
reverse, some surgeons prefer to also use temporary bonegrafting in the mid-face to maintain the soft-tissue envelope
even when adequate soft tissue is missing, with the intent of
subsequent replacement using free tissue transfer tech-
niques. Once these early goals have been completed, plan-
ning can begin for the definitive reconstruction and pros-
thetic rehabilitation. Psychiatric and social services are
often required at this time as well.
Phase II consists of the definitive reconstruction, which
should occur as soon as reasonable after the initial injury, as
dictated by the patients other major issues. Careful planning
is required to ensure the major functional and cosmetic
Address reprint requests and correspondence: Douglas A. Girod,
MD, FACS, Department of Otolaryngology-Head and Neck Surgery, Uni-
versity of Kansas School of Medicine, Mail Stop 3010, 3001 Eaton, Kansas
City, KS 66160.
E-mail address: dgirod@kumc.edu.
1043-1810/$ -see front matter © 2008 Published by Elsevier Inc.
doi:10.1016/j.otot.2008.05.002
Operative Techniques in Otolaryngology (2008) 19, 80-85
mailto:dgirod@kumc.edumailto:dgirod@kumc.edumailto:dgirod@kumc.edu
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goals can be achieved. The use of free tissue transfer tech-
niques has allowed the aggressive early management of
defects where large amounts of soft tissue and bone are
missing. The long-term goals of the reconstruction willdictate the appropriate free tissue transfer flap(s) required to
provide the necessary amount of bone for mandibular and
maxillary reconstruction and soft tissue volume for bone
coverage, internal and external lining and cosmetic contour-
ing. Additional free bone grafting may also be required for
the reconstruction of the midface, nose and orbit. Local
flaps are used in a limited fashion to avoid compromise of
the soft-tissue envelope.
Phase III of patient management consists of esthetic and
prosthetic refinement, which may occur over weeks to
years. Free flap debulking and contouring is often required.
Dental rehabilitation with tissue-borne or implant-borne
prosthesis is undertaken. Additional cosmetic procedures,
facial prostheses, and tissue tattooing may also be required.
Technique
Once the initial phase of trauma management has been
completed as outlined in the previous section, the facial
plastic and reconstruction surgeon must begin the difficult
task of planning the definitive reconstruction. This often
requires a multidisciplinary team approach to define the
long term goals and objectives of the reconstruction.
Flap selection
The type of free tissue flap required will be dictated by
the defect and should be chosen to minimize the number of
Figure 1 (A) Mandible remnant after débridment of traumatic loss of the anterior mandibular arch from a self-inflicted gunshot wound.
(B) Locking screw bridging reconstruction plate applied to maintain occlusive relationships and the soft tissue envelope thus avoiding
wound contracture while waiting for definitive repair. (C) Free tissue transfer of bone contoured with 2 wedge-shaped osteotomies and
secured to the reconstruction plate with locking screws. Excellent bone contact should be achieved with the native mandible and all segments
of flap bone to facilitate bone healing.
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subsequent procedures and donor site morbidity. The use of
vascularized tissue allows these complex contaminated
wounds to heal rapidly without infection, with minimal
contracture and a high degree of reliability (95%). In one
study of 49 patients from 2 institutions, only 4 patients
required more than one free flap.1 Bone containing flaps
were most common (33 flaps), with fibula bone most fre-
quently used, followed by radius bone, scapula, and iliaccrest, respectively. Soft tissue flaps (21 flaps) consisted of
forearm flaps followed by rectus, latissmus, and a gracilis
flap, respectively. These authors’ experience is similar to
the experience of other authors.2,3,5,6 One report describes
the use of 3 simultaneous free flaps (bilateral fibula flaps
and a radial forearm fasciocutaneous flap) for the single-
stage reconstruction of a very large facial gunshot wound
involving the mandible, maxilla, and nose.5
Although flap selection is a multifactorial process, cer-
tain generalities exist. Segmental mandible defects are usu-
ally best managed by with the fibula osteocutaneous flap,
which provides more than 20 cm of bone length o f adequate
stock to support osseointegrated dental implants
7
and ade-quate soft tissue for bone coverage. For shorter defects (9
cm or less) in patients without the means for long-term
dental implantation, the osteocutaneous forearm flap can
provide bone and soft-tissue coverage capable of supporting
a tissue-borne prosthesis.8,9
Bony maxillary defects are more complex. The anterior
maxilla and orbital complex is usually best managed with
free calvarial bone grafts and a dental prosthesis for the intra
oral defect. Alternatively, the maxillary alveolar ridge may
be reconstructed with the fibula, radius, scapula, or iliac
crest bone flaps with appropriate soft-tissue coverage. The
use of 3-dimensional models prepared preoperatively from
computed scans can be very helpful in planning the recon-
struction of the maxilla in particular.Soft-tissue flaps are most often used when either a thin
lining is required (ie, nasal lining) when a radial forearm
flap is favored or when a large volume of bulk is required
for major soft tissue defects when a rectus or latissmus
muscle flap is used. A detailed description of free flap
anatomy, surgical harvest, and donor site morbidity is well
beyond the scope of this article; however, several excellent
texts are available for reference.10-12
Recipient site preparation
The facial wound is largely prepared for the definitive
reconstruction during the initial phase of wound manage-ment as previously outlined. Maximal preservation of bony
and soft tissues, plating of fractures, free bone grafts, and
segmental mandible defect management with bridging
plates sets the stage for the free tissue transfer. Tracheos-
tomy is often required (and usually performed during initial
management) for airway protection and to allow the surgical
approach to oromandibular and maxillary defects without
interfering endotracheal tubes.
Mandibular reconstruction requires wide exposure of the
remnant mandible and the previously placed bridging plate.
This mandates an external approach, which also facilitates
exposure of the great vessels of the neck for the microvas-
cular anastomoses required for free tissue transfer. Any
nonviable tissues encountered at this time should be care-
fully débrided. Care must be taken to preserve all nervous
structures, including the lingual and hypoglossal nerves and
the inferior alveolar nerve, if possible. The mandibular
remnant ends should be exposed and cut to provide a
smooth surface for the mandible-bone flap interface. Re-
moval of the bridging plate is not required nor recom-
mended as the loss of occlusal relationships should beavoided. At this juncture the length of bone and size of the
skin paddle required for bone coverage can be readily de-
termined.
For bony maxillary defects, the wound can generally be
approached through a transoral facial degloving approach.
If temporary bone grafts were previously placed to avoid
soft tissue contracture they should be removed at this time.
The anterior maxillary arch remnant should be exposed and
prepared to allow a smooth transition to the flap bone graft.
The posterior maxilla is often a more difficult issue and only
pterygoid plates may remain for flap abutment. The flap
bone graft will ultimately be secured using mini plates
anchored on the available remaining bone and must beanticipated. The use of 3-dimensional models can be very
helpful in planning this aspect of the reconstruction. Access
to recipient vessels in the neck must also be anticipated and
an adequate tunnel created from the maxillary defect
through the cheek, over the mandible and into the neck.
Care must be taken to avoid facial nerve injury by using
blunt dissection. The tunnel must also be of adequate diam-
eter to allow for the pedicle and soft tissue swelling without
venous compression and thrombosis.
Free flap inset
Mandible reconstructionAfter harvest of the required free flap (eg, fibula flap for
mandible reconstruction), significant contouring of bone
must occur. Some surgeons prefer to perform this function
in the leg, with the flap still receiving the natural blood
supply or on the back table after flap harvest while the flap
is ischemic. The author prefers to transfer the isolated flap
into the neck and to contour the bone to the defect where the
vascular pedicle geometry can be assessed and anticipated.
Often, multiple osteotomies of the flap bone must be per-
formed, particularly when reconstructing the anterior man-
dibular arch (Figure 1C). These osteotomies should be per-
formed in a subperiosteal fashion to avoid disruption of
blood flow to the bone. Wedges of bone are removed toallow the “bending” of the bone without any resultant gaps
between bone segments. Ideally, the individual bone seg-
ments should be 3 cm in length or longer. As this process is
critical to rapid bone healing and may be time consuming.
All contouring should occur before the microvascular anas-
tomoses are performed to avoid unfavorable geometry and
undo tension or manipulation of the vascular pedicle.
Once the contouring is completed, the flap bone seg-
ments are secured to the bridging reconstruction plate with
locking screws to avoid bone mobility but with the recog-
nition that these screws may interfere with future placement
of dental osseointegrated implants. The bone segments will
be only minimally load-bearing during healing as the bridg-
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ing plate will continue to bear the majority of the load with
chewing. It should also be recognized that the reconstruc-
tion of traumatic mandibular defects varies significantly
from similar reconstructions for defects, resulting from on-
cological resections, where much of the muscles of masti-
cation have been resected or detached. These muscles are
largely intact in the setting of trauma and thus forces created
during chewing are much greater.With bone contouring complete, the microvascular anas-
tomosis of the flap artery and vein to the neck vessels can be
performed safely to minimize the ischemia time of the flap
tissues. This also allows time for observation of the micro-
vascular anastomosis while the reconstruction continues. As
with tumor reconstruction of the mandible, the superior
thyroid artery and the internal jugular vein (or one of its
branches) are the most common recipient vessels. Vascular
pedicle length is rarely an issue in mandibular reconstruc-
tion so vein grafting can be avoided. Some prefer to perform
primary placement of osseointegrated dental implants. If so,
this is the appropriate time to place them while blood flow
to the bone has been reestablished and the bone is stillexposed.
Attention is now turned to the soft-tissue coverage of the
mandibular bone graft using the skin harvested with the flap.
Watertight closure over the graft is preferred to minimize
the risk of infection and salivary exposure of the flap vas-
cular pedicle which can cause thrombosis and flap failure.
Soft-tissue swelling must again be anticipated; thus, the
closure should not be overly tight. The neck incision is then
closed after placement of adequate suction drains. The do-
nor site is managed in the appropriate fashion.
The skin paddle provided by the fibula, radius and, in
particular, the scapula flap will be thicker and more redun-
dant than desired for the alveolar ridge and thus will require
thinning in a delayed fashion. Dental implants also may beplaced at the time of flap revision if indicated. This may
require the removal of some locking screws which secure
the flap bone to the plate. If this procedure is delayed at least
3 months the bone will be healed and these screws are not
necessary. Removal of the reconstruction plate itself re-
quires much more dissection and thus is typically avoided.
Maxillary reconstruction
Reconstruction of maxillary bony defects is similar to
that of the mandible with some important exceptions. Typ-
ically, there is no plate placed at the initial surgery to which
the flap bone can be contoured. A 3-dimensional model of the skull created from the computed tomography scan is
very helpful in planning the flap size, contour and approach
necessary for the reconstruction.
Once wide exposure is obtained through the facial de-
gloving approach the harvested flap is transferred into the
wound. The vascular pedicle is carefully passed through the
tunnel created in the cheek and over the mandible to reach
the neck. Vein grafts may be required to provide adequate
pedicle length to reach healthy vessels in the neck. The bone
is then contoured to fit the defect with shaped osteotomies
as with the mandible as described above. The bone is then
secured to the remaining maxilla with mini-plates. (Figure
2) Soft-tissue coverage of the bone is achieved using skin
from the flap folded on itself with a central area of de-
epithelialization. This allows skin to provide lining to the
oral palate defect and the nasal floor defect.
Premaxillary defects can be managed with the osteocu-
taneous radial forearm flap which provides an adequate
platform for a tissue-born prosthesis (partial denture) an-
chored off the remaining maxillary teeth.1,9 The fibula os-
teocutaneous flap will be more appropriate if dental im-plants are planned or the defect is more extensive.1
Perioperative management
Free tissue transfer for reconstruction of traumatic facial
bony defects is often a long operation (8 hours or longer)
that includes multiple operative sites (head and neck, flap
donor site, split-thickness skin graft site, calvarial bone graft
site). A team approach is generally preferred with one team
working in a clean-contaminated field preparing the recip-
ient wound and neck vessels and the reconstructive teamworking in a sterile field harvesting the free flap. The patient
must be positioned and prepped appropriately in anticipa-
tion of the expected surgical sites.
A tracheostomy is typically required and, depending on
the severity of the patient’s injury, a feeding tube or gas-
trostomy tube may also be indicated for preoperative nutri-
tion. Intraoperative fluid management should be reviewed
with the anesthesia team to avoid excessive use of intrave-
nous fluids that can contribute to postoperative soft tissue
edema. The use of vasoactive agents should also be avoided
during and after surgery as they may contribute to vaso-
spasm of the microvascular pedicle after anastomosis result-
ing in flap failure.
Most patients will require at least one night in the sur-gical intensive care unit for hemodynamic monitoring and
to allow close observation of flap perfusion. Vascular com-
promise of the flap is most likely to occur in the first 72
hours, with the highest risk in the 24- to 48-hour time frame.
The most common problem encountered is in the low pres-
sure venous system due to thrombosis of the venous anas-
tomosis. This can occur from technical difficulties with the
microanastomosis, wound hematoma, unfavorable geome-
try of the pedicle resulting in kinking and obstruction or
from excessive soft tissue pressure from an overly tight
closure and soft-tissue edema. Several techniques have been
evaluated for the monitoring of free flap perfusion in the
postoperative period, including temperature probes, laserDoppler probes, tissue oxygenation probes, and Doppler
monitoring of the vascular pedicle. Unfortunately, these
techniques are much more reliable for arterial inflow prob-
lems and do not detect venous problems until they progress
to include arterial thrombosis. We have found direct obser-
vation by trained personnel (resident, surgeon or experi-
enced nurse) of flap color, turgor, capillary refill and bleed-
ing to a prick created with a 30 gauge needle every 4 hours
to be most reliable.
At the first indication of vascular compromise of the flap,
a return to the operating room for wound exploration and
vascular pedicle revision will result in a satisfactory out-
come in most instances. The tracheostomy tube can be
83Girod Free Tissue Reconstruction of Traumatic Facial Bony Defects
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removed as soon as soft-tissue edema has resolved enough
(assuming it will not be needed for the treatment of other
related injuries) for the patient to have a safe airway. Oral
intake can usually be resumed within 7 to 10 days. Evalu-
ation for speech and swallow therapy is often required and
psychosocial issues should continue to be addressed.
Figure 2 (A) Normal midface skeleton. (B) Defect caused in the premaxillary segment by a self-inflicted gun shot wound involving the
anterior maxillary arch, hard palate and nasal floor. (C) Reconstruction of the maxillary bony defect with free tissue transfer of bone using
a single osteotomy and fixation using miniplates. Excellent bone contact between all segments must be achieved for rapid bone healing.
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Outcomes
Free tissue transfer for reconstruction of traumatic f acial bony
defects is a highly reliable technique. Futran et al1 reported a
take back rate of almost 10% but no flap failures in a series of
54 free tissue transfers performed for facial trauma. This rate
compares favorably with free tissue transfer for reconstruction
of the head and neck following tumor ablation.1,8,9
Woundinfection rate was only 7% in these same 54 procedures,
despite the extensive contamination and tissue damage caused
by the soft tissue trauma seen in these cases.
Long-term outcomes are mixed and largely dependent on
theseverity of the injuryat the outset. Not surprisingly, isolated
mandibular defects have the best cosmetic result and complex
mandibular, maxillary and nasal defects have the worst cos-
metic results. Most patients will recover adequate speech and
swallow function. Dental rehabilitation remains critical to the
type of oral diet a patient can handle. All patients require
multiple procedures during the reconstructive process and
those with orbital and/or nasal defects are the most complex,
requiring the largest number of procedures.
References
1. Futran ND, Farwell DG, Smith RB, et al: Definitive management of
severe facial trauma utilizing free tissue transfer. Otolayrngol Head
Neck Surg 132:75-85, 2005
2. Yuksel F, Celikoz B, Ergun O, et al: Management of maxillofacial
problems in self-inflicted rifle wounds. Ann Plast Surg 53:111-117,
2004
3. Suominen E, Tukiainen E: Close-range shotgun and rifle injuries to the
face. Clin Plast Surg 28:323-337, 2001
4. Militskah ON, Wallace DI, Kriet JD, et al: Use of the 2.0-mm
locking reconstruction plate in primary oromandibular reconstruc-
tion after composite resection. Otolaryngol Head Neck Surg 131:
660-665, 20045. Niçsanci M, Tüegün M, Er E, et al: Reconstruction of the middle and
lower face with three simultaneous free flaps: Combined use of bilat-
eral fibular flaps for maxillomandibular reconstruction. Ann Plast Surg
51:301-307, 2003
6. Duffy FJ, Gan BS, Israeli D, et al: Use of bilateral folded radial
forearm free flaps for reconstruction of a midface gunshot wound. J
Reconstr Microsurg 14:89-96, 1998
7. Frodel JL Jr., Funk GF, Capper DT, et al: Osseointegrated implants: a
comparative study of bone thickness in four vascularized bone flaps.
Plast Reconstr Surg 92:449-455, 1993
8. Militsakh ON, Werle A, Mohyuddin N, et al: Comparison of radial
forearm to fibula and scapula osteocutaneous free flaps for oroman-
dibular reconstruction. Arch Otolaryngol Head Neck Surg 131:571-
575, 2005
9. Kim JH, Rosenthal EL, Ellis T, et al: Radial forearm osteocutaneous
free flap in maxillofacial and oromandibular reconstructions. Laryn-goscope 115:1697-701, 2005
10. Strauch B, Yu HL: Atlas of Microvascular Surgery. New York, NY,
Thieme Medical Publishers, 1993
11. Urken ML, Cheney ML, Sullivan MJ, et al: Atlas of regional and free
flaps for head and neck reconstruction. New York, NY, Raven Press,
1995
12. Day TA, Girod DA: Oral Cavity Reconstruction. New York, NY,
Taylor & Francis, Incorporated, 2006
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Zygomatico–orbito–maxillary complex fractures
Stephen Maturo, MD, Manuel A. Lopez, MD
From the Facial Plastic and Reconstructive Surgery Service, Department of Otolaryngology,
Wilford Hall Medical Center, Lackland AFB, Texas.
Zygomatico–orbito–maxillary complex fractures are the second most common facial fracture. As with
all facial fractures, wide exposure and accurate fixation will lead to optimal functional and cosmetic
results. Surgical techniques to expose the orbital floor, zygoma, and maxilla are discussed.Published by Elsevier Inc.
KEYWORDSFacial fracture;
Midface fracture;Zygoma fracture;
Orbit fracture
Zygoma and orbital fractures make up an estimated 15%
and 10%, respectively, of all facial fractures.1 Most zygo-
matico–orbito–maxillary complex (ZOMC) fractures are
caused by violent assaults, followed by motor vehicle acci-
dents The majority of patients are young males in their third
decade of life. Thirty to fifty percent of patients have asso-
ciated concomitant facial fractures.2 Associated ocular in-
juries occur in 10% to 50% of midface fractures, with
greater rates in isolated orbital fractures.2
The zygoma attaches to the frontal, maxillary, temporal,and sphenoid bones. The zygomatic–temporal relationship
provides anterior facial projection whereas the zygomatic-
frontal provides mid-face height. ZOMC fractures left un-
treated can result in cosmetic deformity, enophthalmos,
entrapment of ocular muscles, and persistent diplopia. Oph-
thalmology referral is usually recommended and clearance
from other injuries and medical issues is necessary. Al-
though cervical spine injuries occur in less than 10% of
midface fractures it is optimal to have the spine cleared
before surgery.1 High-resolution computed tomography
scans of the face in both axial and coronal planes provide
the most detailed information for planning surgical ap-
proaches.
The goal of ZOMC reduction and fixation is 3-pointalignment (zygomatic-frontal, zygomatic-maxillary, and in-
fraorbital rim) with at least a 2-point fixation.3,4 Specifically
with orbital floor involvement, the goals of repair are to
release entrapped ocular tissue and establish normal orbital
volume and globe position.5 The most important feature to
ensure proper reduction and alignment of ZOMC fractures
is excellent exposure. Improper alignment results in enoph-
thalmos, orbital dystopia, and midface flattening. These
complications are difficult to revise making precise align-
ment imperative during the initial operation. The following
descriptions provide for optimal exposure needed in ZOMC
fractures.
Transconjunctival approach with canthotomyand cantholysis
The transconjunctival approach with canthotomy and can-
tholysis provides superb exposure to the inferior orbital rim,
the orbital floor, and the lateral orbital wall. Combining this
approach with a transcaruncular approach will allow expo-
sure of the medial orbital wall.6 Canthotomy and cantholy-
sis is not a requirement, but we have found that exposure is
significantly enhanced when lower eyelid tension is mini-
mized. Advantages of the transconjuctival approach as op-
posed to the subciliary approach include lack of external
scar and decreased risk of ectropion.
The transconjunctival approach begins with placement of a corneal shield protector impregnated with ophthalmic bac-
itracin. The contralateral face is included in the surgical
field so that facial projection, orbital projection, and lid
positioning can be compared. One cc of 1% lidocaine with
1/100,000 epinephrine is injected into the lateral canthus
and conjunctival region. Two 5-0 nylon sutures are placed
through the tarsus and used as stay sutures to help aid with
retraction. A 1 cm horizontal incision is made from the
lateral canthus and carried down to the lateral orbital rim
(Figure 1). Curved iris scissors are then used to carry out the
cantholysis where the result is complete lower lid laxity.
Address reprint requests and correspondence: Stephen Maturo,
MD, Facial Plastic and Reconstructive Surgery Service, Department of
Otolaryngology, Wilford Hall Medical Center, Lackland AFB, TX 78236.
E-mail address: stephen.maturo@lackland.af.mil.
1043-1810/$ -see front matter Published by Elsevier Inc.
doi:10.1016/j.otot.2008.04.004
Operative Techniques in Otolaryngology (2008) 19, 86-89
mailto:stephen.maturo@lackland.af.milmailto:stephen.maturo@lackland.af.mil
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(Figure 2). Bishop Harmann forceps then retract the lowereyelid inferior-medially and Wescott scissor is used to de-
velop the plane lateral to medial between the orbital septum
and the anterior lamellae. The Wescott scissor is then used
to release the lower eyelid retractors from the inferior tarsal
border (Figure 3). We avoid using Bovie cautery on the
transconjunctival incision to decrease the risk of retraction
from septal scarring. Stay sutures (5-0 nylon) are then
placed through the conjunctival/septal flap to help provide
counter-traction as blunt dissection with a cotton tip appli-
cator is performed preseptally. Preseptal dissection is car-
ried down to the orbital rim. The orbital periosteum is
identified and then incised 3 to 5 mm inferior to the orbital
rim (Figure 4).
The periosteum of the orbital rim and orbital floor is then
raised as the orbital contents are gently retracted. The orbital
floor fracture is exposed in its entirety being aware that the
optic nerve is approximately 40 mm from the anterior lacrimal
crest. Options for treatment of an orbital floor fracture are
numerous and include split-calvarial bone, titanium mesh, and
Medpor (Porex Surgical Products Group, Newnan, GA). The
implant used to reconstruct the floor should be fixed with
4-mm 1.0 titanium screws. The orbital rim is fixated with a
1.0 plate using 4- to 5-mm screws. Forced duction is then
performed to ensure that there is no entrapment.
The periosteum is then closed with interrupted 4-0 Vicryl
sutures. The conjunctival incision is generally not closed.The canthus is resuspended to the medial portion of the
lateral orbital rim. Mild overcorrection is preferred as the
suture will loosen over the perioperative period. The impor-
tance of this suspension suture cannot be overemphasized as
lower lid laxity and ectropion can result in disastrous com-
plications. The canthal incision is then closed with simple
interrupted skin sutures.
Sublabial approach
The sublabial approach provides access to the zygomatic-
maxillary buttress and the naso-maxillary buttress. Thisapproach also provides access for inspection of the inferior
orbital rim, although reducing a rim fracture via the subla-
bial approach is extremely difficult.7 The sublabial approach
begins with injection of 1% lidocaine with 1/100,000 epi-
nephrine into the gingival mucosa lying above the maxillary
teeth. The incision is made in the gingivobuccal sulcus
being cognizant to leave a cuff of 5- to 10-mm tissue above
the gum line to help aid with closure. Cautery is then used
to incise the submucosal, muscular and periosteum layers
down to bone. A periosteal elevator is used to elevate the
periosteum superiorly toward the inferior orbital rim. Care
is taken to preserve the infraorbital nerve, usually located 10
mm inferior to the orbital rim in a vertical plane in line with
Figure 1 Canthotomy is demonstrated. A 1-cm incision is made
in the lateral canthus and carried down to the lateral orbital rim.
Wescott scissors or a knife may be used.
Figure 2 Cantholysis is demonstrated. Scissors are verticallyoriented and the lateral orbital rim is palpated with the scissor tip.
Result is total lower lid laxity.
Figure 3 Conjunctival incision is made at inferior tarsal border.
Stay suture through the tarsus aids with counter traction. Medial
extent of incision is lacrimal puncta. Notice complete laxity of
lower lid provided with canthotomy/cantholysis.
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the pupil. Conservative back elevation along the inferior
gingiva will help with final closure. Wide exposure of the
maxilla and zygoma is achievable with retraction of the soft
tissue (Figure 5). Access from superiorly and inferiorly is
achieved with combining the transconjunctival and subla-
bial approach. Accurate reduction of ZOMC fractures re-
quires analysis of the three-dimensional plane to achieve
three point alignment. The Carroll-Girard or T-screw canhelp with manipulation of the zygoma to achieve accurate
three dimensional reduction.
The zygoma and maxilla are usually plated with an
appropriately bent “L-type” plate using 5-mm screws. If a
nasomaxillary buttress fracture is evident this is easily
plated with a straight, appropriately bent 1.5 plate. The
overlying mucosa is closed with a running 4-0 Chromic
suture.
Lateral frontal fracture
A superior zygomatic-frontal fracture may not be easilyaccessible through the transconjunctival approach with a
canthotomy and cantholysis. Access is then obtained
through an extended upper lid blepharoplasty incision. The
most lateral aspect of the blepharoplasty incision is ex-
Figure 4 Preseptal dissection is completed and periosteum has
been incised on the anterior face of the orbital rim approximately
3 to 5 mm from its superior edge. The entire orbital rim is exposed.
Conjunctival-septal flap is retracted superiorly.
Figure 6 Extended upper lid blepharoplasty incision is demon-
strated. Plating of the zygomatic-frontal, orbital rim, and lateral
buttress fractures are complete.
Figure 5 Exposure of the anterior face of the maxilla is dem-onstrated. Infraorbital nerve is identified and kept intact. Fractures
of the medial and lateral buttresses can now be reduced and plated.
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tended to just past the lateral orbital rim in a curvilinear
fashion. Needle tip cautery is then used to expose the bone.
Periosteal dissection is then used to expose the fracture in its
entirety. A 1.0 plate with 4-mm screws is used to plate the
fracture. Classical teaching dictates that the zygomatic fron-
tal buttress should be plated first as it establishes midface
height, yet one should continue to be vigilant of the three
dimensional aspect of the zygoma to ensure acceptable postoperative cosmesis (Figure 6).4
Conclusion
ZOMC fractures are the second most encountered facial
fracture. Preoperative evaluation should include a compre-
hensive ophthalmologic evaluation as well as high resolu-
tion coronal and axial computed tomography scans. Atten-
tion to the accurate three dimensional reduction of the
zygoma and careful attention to the dissection planes in the
transconjunctival approach can help avoid poor postopera-
tive cosmesis and ectropion complaints. The sublabial ap-proach combined with an extended upper blepharoplasty/
lateral brow incision is usually adequate for two point
fixations while the transconjunctival approach is used when
the orbital rim and/or floor needs repair.
References
1. Kelley P, Crawford M, Higuera S, et al: Two hundred ninety four
consecutive facial fractures in an urban trauma center: Lessons learned.
Plast Reconstr Surg 116:42e-49e, 2005
2. Shere JL, Boole JR, Holter MR, et al: An analysis of 3599 midfacial and
1141 orbital blowout fractures among 4426 United States Army sol-
diers, 1980-2000. Otolaryngol Head Neck Surg 130:164-170, 2004
3. Shaw GY, Khan J: Precise repair of orbital maxillary zygomatic frac-
tures. Arch Otolaryngol Head Neck Surg 120:613-619, 1994
4. Holmes KD, Matthews BL: Three-point alignment of zygoma fractures
with miniplate fixation. Arch Otolaryngol Head Neck Surg 115:961-
963, 1989
5. Patel BC, Hoffman J: Management of complex orbital fractures. Facial
Plast Surg 14:83-104, 1998
6. Garcia GH, Goldberg RA, Shorr N: The transcaruncular approach in
repair of orbital fractures: a retrospective study. J Craniomaxillofac
Trauma 4:7-12, 1998
7. Shumrick KA, Campbell AC: Management of the orbital rim and floor
in zygoma and midface fractures: Criteria for selective exploration.
Facial Plast Surg 14:77-81, 1998
89Maturo and Lopez ZOMC Fractures
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Management of soft-tissue trauma to the face
Krishna G. Patel, MD, PhD, Jonathan M. Sykes, MD
From the Department of Otolaryngology–Head and Neck Surgery, University of California, Davis Medical Center,
Sacramento, California.
The management of acute soft-tissue trauma can be very challenging for the facial plastic surgeon. The
goals of management of facial trauma are the preservation of form and function. These goals are
particularly important in facial soft-tissue trauma, where injuries can cause not only esthetic deformitiesbut also can affect neural function, normal mastication, visual fields, and salivary outflow. This article
outlines the evaluation and treatment of acute soft-tissue facial trauma. The key components include
allowing for the stabilization of the patient, complete examination of the injury and face, thorough
wound irrigation and debridement of necrotic tissue, preservation of all viable tissue, tension-free
closure, and realignment of important facial esthetic structures. Special consideration must be given to
injuries of functional structures such as the facial nerve, ductal systems or organs, and ensuring
appropriated management of these structures.
© 2008 Elsevier Inc. All rights reserved.
KEYWORDSSoft tissue trauma;
Facial trauma;Facial injury
In the United States, more than 146,000 patients per year
are treated for soft-tissue trauma in emergency centers.1 The
most common cause for soft-tissue trauma is motor vehicle
accidents. Other common etiologies of trauma include falls,assault/altercations, sports, industrial accidents, self-in-
flicted trauma, and bites (both human and animal).1,2 The
appropriate initial management of soft-tissue trauma during
the acute phase can be invaluable for the long-term esthetic
and functional outcomes.
Given that many patients with soft-tissue trauma present
with multiple injuries, the patient must first undergo a thor-
ough evaluation under the standard guidelines of the Ad-
vance Trauma Life Support (ATLS) system.3,4 This evalu-
ation allows the trauma patient to be stabilized if there are
life-threatening injuries. However, soft-tissue trauma of the
face can contribute to airway compromise if there is signif-
icant edema or oral bleeding.4 Mandible fractures that
avulse the tongue’s attachment to the lingual mandible or
mobilize the central mandible, such as bilateral parasym-
physeal fractures, can reposition the tongue base posteriorly
causing airway compromise. In addition to the airway, fa-
cial trauma can also play a role in circulatory compromise if
significant hemorrhage occurs. In the setting of hemorrhage,
initially packing and applying pressure allows for the tem-
porary tamponade of the vascular injury until the lacerated
vessel can be identified and ligated, repaired, or embolized.If epistaxis is present, temporary nasal packing often suffi-
ciently manages the bleeding.
Evaluation
Once the initial assessment has been performed and the
patient stabilized, the soft-tissue facial trauma can be care-
fully evaluated. Obtaining the patient’s history, such as the
time and mechanism of the injury, aides in the management
Address reprint requests and correspondence: Krishna G. Patel,
Department of Otolaryngology–Head and Neck Surgery, University of
California, Davis Medical Center, 2521 Stockton Blvd, Suite 7200, Sac-
ramento, CA 95817.
E-mail address: krishnapatel72@gmail.com.
Table 1 Tetanus prophylaxis in wound management
History of tetanus
immunization (doses)
Clean, minor
wounds, Td TIG
All other
wounds, Td TIG
Unknown or 3 doses Yes, No Yes, Yes3 or more doses No,* No No,† No
Recommendations are based upon the CDC, Department of Health
and Human Services Center for Disease Control and Prevention ( www.
cdc.gov/vaccines/ ).
Td, diphtheria-tetanus toxoid; TIG, tetanus immune globulin.
*Yes, if 10 years since last dose.†Yes, if 5 years since last dose.
1043-1810/$ -see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.otot.2008.05.004
Operative Techniques in Otolaryngology (2008) 19, 90-97
mailto:krishnapatel72@gmail.commailto:krishnapatel72@gmail.comhttp://www.cdc.gov/vaccines/http://www.cdc.gov/vaccines/http://www.cdc.gov/vaccines/mailto:krishnapatel72@gmail.comhttp://www.cdc.gov/vaccines/http://www.cdc.gov/vaccines/
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of care. If the mechanism of injury involved armory often
there is deep tissue destruction and burn injury.5 Injuries
involving motor vehicles or gunshots often require explo-
ration and removal of foreign body material. Human and
animal bites and contaminated wounds require extensive
irrigation to prevent wound infection. Obtaining past med-
ical history and social history can help identify factors that
may affect wound healing. Comorbidities such as diabetes, alcohol or tobacco abuse, or past radiation therapy may
negatively affect wound healing.1 Under circumstances of
deep penetrating injuries, patients should be questioned
regarding their tetanus immunization status and updated if
Figure 1 A photograph displaying a lateral view of an intubated
patient involved in a motor vehicle accident. Note the extensive
asphalt tattooing over the cheek and multiple contaminated lacer-ations and abrasions. (Color version of figure is available online.)
Figure 2 An intraoperative photograph of the patient from Fig-
ure 1 demonstrating the use of high-pressure pulsatile irrigation to
clean and debride the contaminated facial wounds. (Color version
of figure is available online.)
Figure 3 A postoperative photograph displaying a lateral view
of the patient from Figure 1 after high-pressure pulsatile irrigation,
debridement of necrotic tissue, and reapproximation of the wounds.
The tattooing of the cheek has significantly improved and will de-
crease the degree of permanent tattooing as well as the risk of post-
trauma infection. (Color version of figure is available online.)
Figure 4 A Standard instrument set used for soft-tissue plastic
surgery including fine-tipped forceps, skin hooks, and fine-tipped
scissors. (Color version of figure is available online.)
Table 2 Local anesthetic maximal dosing concentrations
AnestheticDose(mg/kg)
Onset(min)
Duration(hr)
Lidocaine 1% 3 to 4 2 1.5 to 2Lidocaine 1% with epinephrine
1:100,000
5 to 7 2 2 to 6
Bupivacaine 0.25% 2.5 5 2 to 4
91Patel and Sykes Management of Soft-Tissue Trauma to the Face
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necessary. Current tetanus prophylaxis is based on the rec-
ommendations by the Center for Disease Control and Pre-
vention in Table 1.6
Physical examination
After obtaining the patient’s information, a thorough phys-
ical evaluation is imperative. This evaluation includes close
examination of the head and face for any signs of skeletal
instability, bony step-offs, or dental malocclusion. In the
event that there is suspicion of more than soft-tissue injury,
appropriate radiographic imaging should be obtained, such
as a computed tomography scan of the head or face or
radiographs of the facial skeleton. Injuries that involve theeye should include ophthalmology consultation.4 A thor-
ough examination of the skin, eyes, ears, nose, oral cavity,
oral pharynx, and cranial nerves should be performed. Early
recognition of any injury to the facial nerve, lacrimal ducts,
or Stensen’s ducts is important.
Initial wound management
Before any repair, the wound must be thoroughly cleansed.Obtaining important facts regarding the mechanism of in-
jury can help determine if there are significant foreign
bodies within the wound (Figure 1). If computed tomogra-
phy scans had been obtained previously, these can reveal
radiopaque foreign bodies such as glass and can be helpful
in localizing deep foreign bodies. The best means for
cleansing the wound and removing foreign body material is
high-pressure irrigation (Figure 2). Multiple methods can be
used, such as high-pressure pulsatile irrigation or bulb sy-
ringe irrigation. This author prefers the use of high-pressure
pulsatile irrigation (Figure 3).7,8 Both methods should use
copious amounts of irrigant to remove contaminants and
bacteria. Irrigants commonly used include saline or antibi-otic-infused saline (such as, 50,000 units of bacitracin to 1
liter of saline). Once the wound has been irrigated, the areas
of tissue revealing frank necrosis should be débrided. If left,
the necrotic tissue can serve as a nidus for infection. How-
ever, any tissue that appears partially viable should be
Figure 5 An illustration depicting the use of deep sutures to reapproximate the wound edges (A) to allow for an even and everted skin
edge (B). Use of a layered closure relieves the tension on the epidermal sutures and minimizes scar widening during wound healing.
(Reprinted with permission.9)
Figure 6 Illustration depicting the management of wounds when there is an uneven thickness of the dermal edges being reapproximated
(A). The use of a layered closure first involves placement of deep sutures to even realign the deep tissues (B). After closure of the deep
tissues, if the dermal edges are uneven (C), placing the dermal suture such that the suture is placed more deeply through the thinner dermal
edge and more superficially through the thicker dermal edge (D) will bring the epidermal edges together in an even manner (E). (Reprinted
with permission.9)
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preserved to allow for the opportunity to revascularize and
to lessen the degree of tissue loss sustained. If the patient is
awake, the wound may need to be anesthetized before irri-
gation to thoroughly cleanse the wound without inflicting
too much pain.
Surgical repair
The setting for surgical repair of the injury may occur in
either the operating suite or in the emergency room. This
decision should depend on the severity of the injury and the
patient’s medical condition. The operating suite provides a
more controlled environment in terms of the patient’s air-
way and pain management. Additionally, operating rooms
have superior lighting and usually have access to better
instruments (Figure 4). If there is concern for nerve or
ductal injury, the operating suite should be used to allow for
the use of microscopic techniques. However, waiting for an
operating room may delay the closure of open wounds,
Figure 7 A photograph displaying a complex laceration involv-
ing the full-thickness of the skin and cartilage of the right ear.
Closure of this wound required a layered closure of the cartilage
and skin, as well as attempts to regain the original shape and
contour of the ear. Lacerations of the ear also require close eval-
uation of the external auditory canal and tympanic membrane. If
significant soft tissue edema is present within the external auditory
canal, a wick should be placed temporarily to prevent canal ste-
nosis. Note the ischemic discoloration of the ear lobule, which was
later sutured to its original position. (Color version of figure is
available online.)
Figure 8 A photograph of the patient from Figure 7 at 1-month
follow-up revealing complete viability of the tissues repaired and
good contouring of the concha, antihelix and ear lobule. Mild
notching is noticed along the helical rim. (Color version of figure
is available online.)
Table 3 Suture caliber guidelines for facial subunits
Region Cutaneous suture Subcutaneous/fascia suture Comments
Eyelid and periorbital #6-0, #7-0 #4-0, #5-0 Minimal tensile strength requirements; aesthetic
concerns at a premiumNose and pinna #5-0, #6-0 #4-0, #5-0 Small tensile strength requirements; aesthetic
concerns at a premium
Lip and vermilion #6-0 #3-0, #4-0 Moderate tensile strength requirements becauseof highly active region; aesthetic concerns at
a premiumGeneral facial and anterior neck #4-0, #5-0 #6-0 #3-0, #4-0 Moderate-to-high tensile strength requirements
because of regional mobility; significantaesthetic concerns
Nasal and oral mucosa #3-0, #4-0 #3-0, #4-0 Moderate tensile strength needed due to tissue
mobility; may select suture based on ease orno need for removal; no aesthetic concern
Scalp and posterior neck #3-0, #4-0 #2-0, #3-0 Tensile strength needed for moderately heavytissue and very mobile region; minimal
aesthetic concern
Reprinted with permission from Baker S, Swanson N, Skyes J, et al: Suture needles and techniques for wound closure, in Local Flaps in Facial
Reconstruction. New York, Mosby, 1995.
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which can allow for increased edema of the soft tissues.
Additionally, the severity of injury often does not warrant
use of the operating room facilities. Typically, 1% lidocaine
with 1:100,000 epinephrine provides anesthesia that is ef-
fective in the awake or intubated patient. The longevity of
the anesthetic can be increased by using a 1:1 mixture of 1%
lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine
(Table 2). The injection of the anesthesia can be painful for
the awake patient; this pain can be alleviated by buffering
the anesthetic with a ratio of 9:1 lidocaine to bicarbonate.
Additionally, waiting 10 to 15 minutes to allow for the
vasoconstrictive effects of the epinephrine in the patientgreatly aides one in visualization within the wound.
Techniques for wound closure depend on the location,
depth, and characteristics of the injury. Abrasions should be
kept clean and moist with application of a thin layer of
antibiotic ointment, such as bacitracin. If the wound is
significantly contaminated or inflicted by a human or animal
bite, loose closure helps prevent deep tissue abscess forma-
tion. Hematomas involving the ear and nasal septum shouldbe evacuated to prevent cartilage loss and subsequent future
deformities, such as a cauliflower ear or nasal dorsal col-
lapse, respectively. After relieving the hematoma, the ear
should be bolstered or the septum bilaterally splinted to
prevent re-accumulation of blood with subsequent cartilage
loss.
The method of wound closure should be designed to
minimize wound tension and maximize eversion of the skin
edges (Figure 5).9 Any tension on the skin layer increases
risk of a widened scar or wound dehiscence. Employment of
a multi-layered closure most ably creates a tension-free
wound.10 In addition to eversion, placement of the sutures to
ensure the wound edges are even provides the best outcomefor wound healing (Figure 6).9 Table 3 provides a guideline
for the recommended suture selection for wound closure
(Table 3).9 Additional key elements include covering any
exposed cartilage or bone with soft tissue. If the cartilage
has been disrupted, such as the upper or lower lateral car-
tilages of the nose, or the helical cartilage of the ear, reap-
proximation of the cartilage edges with absorbable suture
helps regain structural support (Figures 7 and 8). If there is
interruption of muscle, such as the orbicularis oculi or
orbicularis oris muscles, these muscle edges should be re-
aligned to maximize posttraumatic recovery of muscle func-
tion (Figures 9 and 10). Placement of horizontal mattress
sutures with absorbable suture helps to efface the muscle
Figure 9 A photograph of a patient who sustained a full-thick-
ness laceration through the left upper lip. To restore muscle func-
tion and improve esthetic outcome, a layered closure reapproxi-
mating the orbicularis oris muscle as well as a meticulous
realignment of the vermilion–cutaneous border was performed.
(Color version of figure is available online.)
Figure 10 A photograph of the patient from Figure 9 several
months postoperatively revealing excellent realignment of the ver-
milion–cutaneous border. (Color version of figure is available
online.)
Figure 11 An illustration demonstrating the facial esthetic
subunits.
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edges in a tension-free manner. Failure to realign muscle
layers can lead to both esthetic and functional deficit that isoften later nonrepairable.
Meticulous realignment of skin edges is important, es-
pecially along the borders of esthetic subunits (Figure 11).
In closing the skin edges, a size 6.0 or smaller caliber suture
should be used. Special attention should be paid to realign
the vermilion-cutaneous border, eyelid margin, nasal rim,
brow or any hair-bearing borders (Figures 12-15). Using
vertical mattress suture technique is excellent for the re-
alignment of esthetic borders such as the eyelid margin and
vermilion-cutaneous border of the lip. If the edges are not
well everted, notching will occur as the wound contracts,
which is particularly noticeable at esthetic subunit borders.
The traditional teachings for eyelid margin lacerations de-
scribe a three-layer closure realigning the lash line, gray
line, and meibomian glands with 7.0 silk vertical mattress
sutures that leave the tags long enough to secure more
peripherally to prevent corneal abrasions (Figure 16).8,11
However, more recent literature advocates the use of ab-
sorbable suture for the eyelid margin closure.12 In either
situation, the tarsal plate should be reapproximated with
absorbable suture to relieve tension from the skin closure.
With injuries near the medial canthus, secondary healing is
often preferred to prevent webbed scarring.
10
In general,concave surfaces heal well by secondary intention (Figures
Figure 12 A photograph of the left forehead and eyebrow of a
patient involved in a motor vehicle accident. The complex lacer-
ation crossed the hair-bearing eyebrow subunit and exposed skull
on the forehead. (Color version of figure is available online.)
Figure 13 An immediate postoperative photograph of the left
forehead and eyebrow from the patient in Figure 12. A layered
closure was performed, a drain was placed in the forehead to
prevent hematoma formation, and meticulous attention was paid in
realigning the eyebrow. (Color version of figure is available on-
line.)
Figure 14 A postoperative photograph of the left forehead and
eyebrow from the patient in Figure 12 during a 6-month follow-up
visit. The patient’s subunits are well aligned but the soft tissuetrauma resulted in hair loss within the eyebrow subunit. (Color
version of figure is available online.)
Figure 15 A postoperative photograph of the left forehead and
eyebrow from the patient in Figure 14 after undergoing a revision
w-plasty of the scarred tissue. Restoration of the natural contour of
the eyebrow camouflages the scar significantly. (Color version of
figure is available online.)
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17 and 18). These concave surfaces include the lateral
forehead subunits, glabella, medial canthal subunit, de-
pressed areas of the ear, supra-alar crease, soft tissue trian-
gles, philtral subunit, and the perinasal melolabial crease
(Figure 19).13
Wound edges that are uneven in depth are both difficult
to realign and often create a pin-cushioning effect during the
healing period. Superiorly based wound flaps are particu-
larly susceptible to pin-cushion defects.8 Sharply creating a
ninety-degree angle with the skin edge can help prevent this
complication; however, one must be careful not to remove
too much skin that would prevent closure of the wound(Figure 20). If tissue loss is significant and inhibits wound
closure, as much of the wound as possible should be reap-
proximated. For the remaining open wound, wet-to-dry
dressings help débride the wound and allow it to heal with
plans for later reconstruction.14 Immediate reconstruction
using soft tissue flaps is possible but discouraged given the
wound is not sterile. Thus, delayed reconstruction of gaping
wounds allows the edema and risk of infection to resolve.15
If there is suspicion that the facial nerve has been injured
and the penetrating injury lies lateral to a vertical line drawn
from the lateral canthus, the wound should be immediately
explored for transection of facial nerve branches. Identified
transected nerves should be repaired under microscopic
Figure 16 An illustration depicting the repair of a full-thickness
eyelid laceration. First, deep sutures are placed to reapproximate
the tarsal plate. At the eyelid margin, three vertical mattress su-
tures are placed at the lash line, gray line and meibomian glands
with 7.0 silk (A). The mattress suture tags are left long enough to
secure more peripherally to prevent corneal abrasions (B). (Re-
printed with permission.18
)
Figure 17 A photograph of a patient who has a full-thickness
tissue defect exposing bone near the left medial canthus. (Color
version of figure is available online.)
Figure 18 A photograph of the patient from Figure 17, who
healed the full-thickness defect via secondary intention. Note the
significant wound contraction after 1 month of healing. (Color
version of figure is available online.)
Figure 19 An illustration of the face. The shaded areas represent
concave regions of the face that heal well through secondary
intention. These concave surfaces include the lateral forehead
subunits, glabella, medial canthal subunit, depressed areas of the
ear, supra-alar crease, soft tissue triangles, philtral subunit, and the
perinasal melolabial crease. (Reprinted with permission.13) (Color
version of figure is available online.)
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technique, usually with a 7.0 or smaller permanent mono-
filament suture to realign the epineurium. Using a nerve
stimulator can also be helpful in identifying the severed
nerve branches. Nerve injuries medial to a vertical line
drawn from the lateral canthus are thought to have enough
cross-innervation from surrounding branches to regain func-
tion. For this reason, nerve repair is usually not attempted
for medial injuries to the facial nerve. Injuries over the
buccal region should be carefully explored to rule out injury
to Stenson’s duct. Using lacrimal probes or silastic tubing
cannulated through the buccal orifice aides in identifying
the injured duct. Again, microscopic repair is warranted and
stenting the duct for 3 to 4 weeks with silastic tubing canhelp prevent postoperative ductal stenosis.8,14
Key adjunctive treatments include providing antibiotic
prophylaxis to prevent wound infection. Often cefazolin or
cephalxin is appropriate, however, if the injury was from an
animal or human bite, broader spectrum antibiotic coverage
is advisable such as amoxicillin-clavulanate.14 If stents,
bolsters or nasal packing is used, the patient should be kept
on antibiotic prophylaxis as long as the packing is in place.
Tetanus immunization is important for all deep penetrating
wounds. For bites, infectious disease status of the offender
such as rabies, HIV, or hepatitis should be investigated and
the patient treated when question of exposure exists.14
Postoperative care
Diligent postoperative wound care is essential for good
healing of soft tissue wounds. Keeping the reapproximated
skin edges free of dried blood improves wound healing.
Open wounds or abrasions should be kept moist with a thin
layer of antibiotic ointment, such as bacitracin, to prevent
wound desiccation. Moist wounds have been shown to re-
epithelialize 50% faster compared with desiccated wound
beds.16,17 If the patient develops sensitivity to topical anti-
biotic ointments, petroleum jelly is equally effective. Ap-
proximately 3 to 4 weeks after wound closure, massaging of
the wound can help soften scars and decrease hypertrophy
of the scar edges. If scarring becomes raised or uneven,
dermabrasion may be initiated as early as 4 weeks after
wound closure.
Summary
In summary, soft tissue trauma is often complex and re-
quires thorough evaluation. The key for good wound heal-
ing includes repair of any injured functional structures,
copious irrigation, debridement of necrotic tissue, with me-
ticulous tension-free closure. During the wound closure,
utmost attention should be paid to realigning all esthetic
subunit borders.
References1. Hochberg J, Ardenghy M, Toledo S, et al: Soft tissue injuries to face
and neck: Early assessment and repair. World J Surg 25:1023-1027,
2001
2. MacBean CE, Taylor DM, Ashby K: Animal and human bite injuries
in Victoria, 1998-2004. Med J Aust 186:38-40, 2007
3. American College of Surgeons. Advanced Trauma Life Support. 2003.
Available at: http://www.facs.org/trauma/atls/index.html. Accessed
May 20, 2008
4. Perry M, Dancey A, Mireskandari K, et al: Emergency care in facial
trauma—a maxillofacial and ophthalmic perspective. Injury 36:875-
896, 2005
5. Motamedi MH: Primary treatment of penetrating injuries to the face.
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6. Halaas GW: Management of foreign bodies in the skin. Am Family
Physician 76:683-688, 20077. Svoboda SJ, Bice TG, Gooden HA, et al: Comparison of bulb syringe
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Facial Plastic Surgery, The Essential Guide. New York, Thieme, 2005,
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Philadelphia, Lippincott-Raven, 1995
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15. Ueeck BA: Penetrating injuries to the face: Delayed versus primary
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1987, p 108
Figure 20 An illustration of an oblique skin laceration that
results in uneven dermal edges (A). These wounds are difficult to
reapproximate and often cause a pin-cushioning skin defect. Skin
edge eversion can be improved by sharply creating new edges with
90-degree angles (B); however, one must be careful not to remove
too much skin that would prevent closure of the wound. After
creating the new skin edges (C), reapproximation of the wound in
a layered closure helps to relieve tension off the skin edges (D).
97Patel and Sykes Management of Soft-Tissue Trauma to the Face
http://www.facs.org/trauma/atls/index.htmlhttp://www.facs.org/trauma/atls/index.html
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Pediatric orbital roof fractures
T.J. O-Lee, MD,a,b Peter J. Koltai,
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