8.2.1  Evaluation

The timing and indication for surgical repair of craniofacial injuries depends upon the extent of the primary brain injury, as well as the anticipated development of secondary injury (cerebral edema, impairment of blood supply, inflammation, hyperexcitation, and seizures). Depending upon circumstances, the effects of secondary injury may be both mitigated and worsened as a result of early or late craniofacial repair.

•The assessment of individual circumstances and surgical timing always require the close interdisciplinarycooperationoftheneurosurgeonandmaxillofacial surgeon (Samii et al. 1995; Joss et al. 2001)

8.2.1.1  Neurosurgical Aspects

The primary factors to consider in surgical timing are the extent of direct cerebral injury, the degree of impaired consciousness (GCS), and the ICP (Piek and Jantzen 2000).

1.Intracranial injuries (cerebral contusion, cerebral edema, elevated ICP) determine the surgical timing in combined craniofacial fractures (Derdyn et al. 1990; Lausberg 1987; Metelmann et al. 1991; Hardt et al. 1992). Delaying surgery until after cerebral swelling has subsided was found to be preferable in terms of intraand postoperative complications (Schroth et al. 1998).

2.Circumscribed intracranial lesions have to be addressed before the repair of frontobasal and maxillofacial injuries. Frontobasal and craniofacial reconstruction may be time-consuming and should thus be delayed until direct primary or secondary cerebral injury has begun to subside (Lausberg 1987; Piek and Jantzen 2000).

3.The cranial injuries themselves must be addressed according to the priorities listed in the previous chapter (Metelmann et al. 1991).

8.2.1.2  Maxillofacial Surgical Aspects

Surgical timing is primarily determined by the extent and severity of the traumatic damage. Soft tissue and osseous injuries, fracture dislocation and mainly the associated neurosurgical and ophthalmologic injuries indicate the necessity of an immediate intervention (Krafft et al. 1991; Metelmann et al. 1991; Zink and Samii 1991; Ewers et al. 1995).

1.The timing and sequence of surgical procedures, as well as the interdisciplinary coordination, must be individualized in each case depending on the severity of the injuries (Derdyn et al. 1990).

2.Maxillofacial reposition and stabilization procedures for complex craniofacial injuries should be performed simultaneously to the neurosurgical repair of frontal dural lacerations, to avoid disruption of dural grafts by maxillofacial interventions performed at a later stage (Joss et al. 2001). An unstable maxillofacial fracture may threaten any dural repair (Machtens 1987).

3.Early repair of maxillofacial fractures should be attempted to avoid bone healing in an incorrect position. Secondary surgery to correct midface fractures ismoredifficultandlesssatisfactory(Machtens1987). For this reason, the maxillofacial surgeon tends to favor an early surgical approach.

4.The earlier surgical correction of craniofacial injuries is performed the smaller the surgical infection risk will be (Machtens 1987; Joss et al. 2001). According to international statistics (Buchanan et al. 2004; Joseph et al. 2004) “primary” surgical repair carries a statistical infection risk of between 4.6 and 7.1%, while late secondary surgery carries a risk of up to 17%. It appears that the concern about an increased infection risk due to combined intracranial, transoral, and transnasal approaches is unfounded (Götzfried et al. 1984).

5.Facial fractures with soft tissue injuries without skull base and/or dural injuries should be repaired in a single early surgical intervention whenever possible.