This includes open fractures with and without frontobasal and brain injuries and open subcranial injuries.

Controlled ventilation, without significant hyperventilation, must be maintained during surgery, in order to avoid cerebral swelling. It may be useful to position the patient in a 30° head-up fashion. A 6-h time-frame should be maintained due to the significant swelling potential of facial soft tissues.

8.2.2.3  Elective Primary Treatment

Closed craniofacial and subcranial fractures with mild (GCS 14–15) to moderate (GCS 13–9) head injury may be treated within12–24 h of injury.

These are:

•Craniofacial fractures without skull base involvement

•Craniofacial fractures with skull base involvement and severe head injury after stabilization of the neurological situation

•Subcranial midface fractures with/without frontobasal fractures

Craniofacial fractures and frontobasal fractures with significant fragment dislocation without significant brain injury should be treated within 12–24 h (Probst 1986).

Contraindications for elective primary treatment may be cardiorespiratory instability, coagulopathies, and other severe medical contraindications for a surgical intervention.

8.2.2.4  Delayed Primary Treatment

Patients with multiple severe injuries and patients with severe head injury (GCS < 8) and raised ICP should not be operated on before ICP remains consistently normal.

In patients with moderate head injury (GCS 13–9), neurological stabilization and normalization should be awaited before a decision for surgery is made (Dietz 1970a, b; Hausamen and Schmidseder 1975; Loew et al. 1984).

Too early surgical intervention may cause significant intraoperative brain swelling and subsequently may impair the surgical repair and adversely affect the neurological outcome.

•All craniofacial injuries with significant intracranial injury and raised ICP should only be treated after

normalization of ICP and cerebrovascular autoregulation (Metelmann et al. 1991; Zink and Samii 1991; Lee et al. 1998).

Delayed primary treatment for craniofacial and midface­ fractures with cerebral pathology should be postponed­ 5–10 days. Intracranial pressure, cerebral oxygenation,­ and cerebrovascular autoregulation must be recovered and intact. The presence of significant local brain contusion also warrants the delayed approach in order to avoid secondary brain swelling and hemorrhage (Probst and Tomaschett 1990).

Analternativetodelayingsurgeryduetoneurological­

instability may be surgery using a less invasive trans- frontal-subcranial approach (Raveh and Vuillemin 1988).

8.2.2.5  Secondary Treatment

Complex injuries of both the craniofacial complex and the brain and dura may require a delay of surgical correction beyond 10 days, because neurological stabilization may take longer than this time-frame. Late treatment is faced with a technically much more difficult situation for repairing dislocated fractures.

Complex and multiple injuries pose a significant risk, so timing and surgical technique must be decided upon an individual basis (Schweiberer et al. 1987; Waydhas et al. 1997).

8.3  Surgical Approaches

The choice of the surgical approach to the craniofacial region and frontal skull base is based upon localization and extent of the skull base and midface injuries (Dieckmann and Hackmann 1977; Draf and Samii 1983; Samii et al. 1995; Joss et al. 2001).

Access should always be chosen in such a way as to enable an optimal approach and sufficient view of the skull base, upper midface region and participating orbital region for all disciplines involved.

Simultaneous care can be taken of midface fractures and injuries of the skull base with minimal additional access (Ernst et al. 2004).

The first priority is a complete exposure of all fractured regions without consideration of fragment size