Surgical Repair of Craniofacial Fractures

In the surgical management of complex maxillofacial fractures with frontobasal involvement, several important issues must be considered:

•Indication for surgery

•Surgical timing

•Surgical approach

•Surgical strategy

•Surgical technique

8.1  Indications for Surgery

8.1.1  Emergency Surgery (Probst 1971;

Schwab 1995; Zink and Samii 1991;

Schneider and Richter 1993)

From the sole neurosurgical perspective, surgery may be required as a life-saving procedure without delay (Schneider and Richter 1993).

Emergency surgical management will be indicated when there is:

•Evidence of raised intracranial pressure (ICP) due to epidural hematoma, subdural hematoma, intracerebral hematoma, cerebral contusion, and in rare cases due to intracranial air entrapment (Boenninghaus 1971; Loew et al. 1984)

•Life-threatening hemorrhage due to rupture of skull base vessels

•Open brain injury with exposed brain tissue

urgent injuries or letting excessive swelling subside. Repair of a manifest frontobasal rhinorrhea falls under this category (Probst and Tomaschett 1990).

Indications are:

•Evidence of cerebrospinal fluid (CSF) leakage

•Significant pneumocranium with evidence for bone fragment dislocation

•Orbital complications with acute visual failure and/ or double vision

Individual decision-making will to a certain degree inevitably depend on pragmatic evaluation of individual circumstances. Frontal skull defects, the degree of bone fragment dislocation, as well as the extent and timely reabsorption of intracranial air, may be considered to be surgical indications.

8.1.3  No Surgical Indication

Frontobasal fractures without dislocation and without evidence of CSF leakage.

8.2  Surgical Timing

Three aspects are critical for correct surgical timing (Samii et al.1987):

•Evidence of raised ICP

•Frontobasal injury with CSF leak

•Presence of major craniofacial deformation

8.1.2  Semi-Elective Surgery for Frontobasal and Midface Fractures

Under certain circumstances surgery will be indicated on a semi-elective basis, allowing for time to treat more

Frontobasal injuries frequently (68%) coincide with intracranial injuries (Probst and Tomaschett 1990):

•Intracranial hemorrhage and cerebral edema (41%)

•Injury to basal cerebral arteries (21.2%)

•Open brain injury (30.3%)