Fig. 12.15  Midface reconstruction, with initial positioning and stabilization of the zygomatico-orbital complex in the cranial and zygomatic arch region (a). Subsequent precise anatomical reconstruction of the central midface and fixation to the recon-

structed external frame and to the fronto-glabellar compartment. Bone grafts are used in cases of buttress structural deficits (b). Finally stabilization of the reduced lower maxillary fragments (medial and lateral bone struts) (c) (mod. a. Prein 1998)

12.1.5  Own Procedure: Statistics

In 75%, craniofacial reconstruction was performed using miniplate osteosynthesis only. In 10%, additional bone grafts were used, and in 12%, titanium meshes. In 3%, a combination of miniplates, bone grafts and titanium meshes was necessary (Neidhardt 2002).

(Yaremchuk et al. 1992; Manson et al. 1995; Manson 1998; Donald 1998a; Prein 1998; Greenberg and Prein 2002; Gruss et al. 1992,1999).

Craniofacial reconstruction techniques in craniofacial fractures (n = 197) (Neidhardt 2002)

12.2  NOE Fractures

Fractures of the central midfacial compartment involve the NOE complex and, optionally, the skull base (Gruss 1982, 1986; Probst and Tomaschett 1990; Prein 1998; Oeltjen and Hollier 2005).

Dependant on the complexity of the trauma, fractures of the ethmoid always bear the risk of associated

skull base fractures with intracranial injuries, also necessitating a neurosurgical approach (Ayliffe and Ward-Booth 2003).

Principle: Transfacial or transfrontal-subcranial approach, debridement of the fractures, proper treatment of the upper paranasal sinuses and exploration of the skullbase,ifnecessarywithduralrepair.Reconstruction of the nasal and interorbital structures with microplateosteosynthesis, paying attention to the intercanthal distance. Reattachment of the medial intercanthal ligaments and reconstruction of the medial orbital walls (Duvall et al. 1981; Merville et al. 1983; Gruss 1986; Markowitz et al. 1991; Leipziger and Manson 1992; Mathog et al. 1995; Ayliffe and Ward-Booth 2003).

12.2.1  NOE-Fractures Without

Skull Base Injury (Prein 1998; Donald 1998a, b)

Based on the NOE-classification from Markowitz et al. (1991) and Mathog et al. (1995), reconstruction is performed according to the following steps:

Following reduction, telescoping type 1-fractures are stabilized with 1.5/1.3-mm miniplates along the nasofrontal process (Mathog 1992; Vuillemin et al. 1988) (see Fig. 11.21a):

Fig. 12.16  NOE-fracture with canthal ligament type-2 injury (bone-ligament avulsion). (a) Intraoperative site before and after osteosynthesis of the frontal process and before fixation of the

central bone fragment with adherent canthal ligament (arrow). (b) Postoperative result

•Superiorly to the fronto-glabellar region

•Inferiorly to the maxilla

In the case of multi-fragmental NOE injuries type 2 and 3, the fragments are reduced and temporarily stabilized with wire osteosynthesis so that the entire complex can be definitely fixed to the stable surrounding midface structures — beginning at the medial orbital border — superiorly to the cranial complex and caudally to the maxillary complex (Prein 1998) (see Fig. 11.21b, c).

Fractures of the central and dorsal ethmoid can be simultaneously treated using the endonasal approach.

• Canthal ligament fixation

Transnasal wire osteosynthesis stabilizes the NOE complex, restores the normal intercanthal distance and re-establishes the anatomically correct ligament insertion (Laedrach et al. 1999; Maniglia et al. 1999; Haerle et al. 1999; Ward-Booth et al. 2003).

•Type 1 canthal ligament injuries (avulsion of the medial canthal ligament)

The canthal ligament is fixed by a transnasal titanium wire. The wire is secured contralaterally using 1.3-mm microplates or miniscrews (Jackson 1989; Prein 1998; OeltjenandHollier2005;Hammer2001).Alternatively, a barbed titanium wire can be used to fix the canthal ligament (Hammer 2001). After localizing the ligament, the titanium wire is inserted through it and the hooks grip the ligament. The ligament is then correctly placed; the titanium wire is passed transnasally and fixed to the contralateral medial orbital wall. The point of insertion of the ligament lies posterior and superior to the lacrimal fossa (Hammer 1995; Hammer and Prein 1998; Ward-Booth et al. 2003).

•Type 2 and 3 canthal ligament injuries (bone-ligament avulsion)

The displaced central fragment is reduced, together with the attached medial canthal ligament, using a transnasal wire or, if technically possible, stabilized with microplates (Mathog 1992; Mathog et al. 1995). The transnasal wire is fixed contralaterally using a miniscrew or 1.3-mm miniplate (Hammer 2001) (Fig. 12.16).

In the case of missing central bone fragments, the ligament is fixed by guiding the titanium wire through a hole of a 1.3/1.5-mm miniplate bridging the defect on the affected side. The wire is then directed transnasally towards the contralateral side and anchored to another plate (“toggle-plate”) or screw.

Alternatively, the medial orbital wall can be reconstructed with a bone graft. The ligament insertion is then positioned at the stabilized bone graft using a transnasal wire, which is guided through a hole in the graft. (Markowitz et al. 1991; Ellis 1993; Hammer 1995; Hammer and Prein 1998; Oeltjen and Hollier 2005; Stewart 2005) (Figs. 12.17 and 12.18).

12.2.2  NOE Fractures with Skull Base Injury

(Prein 1998; Donald 1998a, b)

As a rule, injuries concerning the NOE complex and involving the skull base are complex fractures, necessitating a structured revision. Depending on the extent of injury and accompanying midface fractures, there is a surgical indication for a transfacial subbasal or transfrontal extradural procedure to treat the injuries of the NOE complex.

Fig. 12.17  Reconstruction of the medial canthal ligament in type-2 injury with missing bone (a). In case of missing bone (central fragment) at the fracture side the medial canthal ligament is secured by transnasal canthopexy through a positioning

Fig. 12.18  Reconstruction of the medial canthal ligament in case of missing bone at the fracture side (NOE fracture type 2).

(a) Reconstitution of the medial orbital wall with a bone graft. Securing the medial canthal ligament with a transnasal wire. The wire passes through the bone graft at the fracture site and secures the right medial canthus. (b) Naso-orbital reconstitution with bilateral canthal dystopia in case of unilateral missing bone at one fracture side (NOE fracture type 3). Unilateral repair of the medial orbital wall with a bone graft and bilateral canthopexy. The wires (b) pass through a hole in the bone graft and secure the right medial canthus. The wires (a) fix the left canthal ligament to the central fragment (mod. a. Merville 1985; McMahon et al. 2003)

plate. The direct transnasal wire passes the hole of the positioning plate and is contralaterally twisted over a microplate (“tog- gle-plate”) (b, c) (mod. a. Merville 1985; McMahon et al. 2003)

Reconstructive Sequence (Markowitz et al. 1991; Gruss 1990; Gruss et al. 1985, 1992)

•Reconstruction of the frontonasal strut and the external medial orbital ring either via transfacial naso-orbital or the coronal approach

•Treatment of frontal sinus, skull base, and dura

•Reconstruction of the nasal frame by interfragmentary osteosynthesis

•Reconstruction of the medial orbital wall

•Re-attachment of the medial canthal ligaments

•Reconstruction of the nasal bridge, correcting nasal projection (plate, graft) (bear in mind the frontonasal angle)

•Splinting the nasolacrimal duct

The initial “en bloc” reduction of the naso-ethmoidal complex, often simultaneously reduces the dislocated fractures in the area of the cribriform plate, which resul­ ted from compression of the bony complex.

In case of multifragmentation of the naso-ethmoidal complex with frontal skull base fractures and simultaneous midface fractures, it is advisable to begin with the reconstruction of the naso-fronto-maxillary struts, including the naso-orbital complex, and then continue with the reduction and stabilization of the central midface fractures, before treating the skull base fractures.

12.3  Panfacial Fractures (Markowitz and Manson 1989; Manson 1998; Kelly et al. 1990; Manson et al. 1995, 1999; Marchena and Johnson 2005; McGraw-Wall 2005)

There is no general consensus as to which is the best sequence in treating PFs (Haerle et al. 1999; Hausamen and Schierle 2000), although there is consent that fracture dislocation and extent of comminution are decisive in choosing the surgical procedures (Mathog 1992; Markowitz and Manson 1998; Haerle et al. 1999; McMahon et al. 2003).

Rohrich and Shewmake (1992) advise primary reconstruction of the lower facial level, so enabling correct reconstruction of the dorsal vertical height and lower facial width.

12.3.1  Concept of Reconstruction

The preferred sequence in complex panfacial fractures starts with mandibular reconstruction, including fractures of the temporo-mandibular joints, particulary in case of bilateral condylar neck fractures. As the next step, the fronto-facial and zygomatico-orbital compartments are reconstructed, which are the key for subsequent midfacial reconstruction (Markowitz and Manson 1989; Kelly et al. 1990; Manson et al. 1995, 1999; Haerle et al. 1999; Fonseca 2000; McMahon et al. 2003; Stewart 2005; McGraw-Wall 2005).

Reconstructive sequence (Ward-Booth et al. 2003; McMahon et al. 2003)

•Mandibular reduction and osteosynthesis as well as maxillary reduction and maxillo-mandibular fixation

•Reconstruction and osteosynthesis of the frontofacial region and the zygomatico-orbital and NOE complex

•Completion of midface reconstruction through osteosynthesis of the external and internal facial frames

•Treatment of the frontal sinus, skull base and dura

•Reconstruction of the nasal frame and orbital cavity (bone grafts if necessary)

1.Treatment of the mandible (lower facial level) Correct reconstruction of the mandible, including

condylar fractures, is considered to be a crucial factor for three-dimensional midface reconstruction (Zide and Kent 1983; Hayward and Scott 1993).

This is the key to avoid loss of anterior-posterior dimensions and posterior vertical lower facial height. The maxilla is than positioned and fixed in centric occlusion in relation to the mandible (Kelly et al. 1990; Manson et al. 1995; Haerle et al. 1999).

2.Treatment of the central and upper midface Following the precise transverse and sagittal recon-

struction of the upper midfacial level (fronto-facial bandeau), the central midface is reconstructed starting with reduction and osteosynthesis of the zygomatic complex and zygomatic arch. Optionally, osteosynthesis of the zygomatico-maxillary buttress (external frame) in the adjusted lower midface can follow, thus

facilitating the positioning of the central midfacial structures (internal frame).

In the next step, reconstruction of the NOE complex is carried out and, consecutively, the periorbital ring is completed (Haerle et al. 1999; Fonseca 2000; Marchena and Johnson 2005).

3.Treatment of the lower midface

Midface reconstruction is completed with stabiliza-

tion of the vertical naso-maxillary and zygomaticomaxillary struts. If necessary, a medial canthopexy is finally done and bone grafts are inserted for orbital or nasal reconstruction (Figs. 12.19-12.23).

Fig. 12.20  (a–c) Panfacial fracture (frontobasal - NOE-fracture, Le Fort-III, left Le Fort-II, and zygomatico-orbital fracture, mandibular fracture). (d–f) Post-reconstructive result after

Fig. 12.21  Panfacial fracture. Internal osteosynthesis with multiple 2.0-mm miniplates after craniotomy, skull base exploration and reconstruction of the frontofacial bandeau

reduction and fixation of the midfacial frame with multiple 2.0- mm miniplates. (g–h) Frontal craniotomy and cranialization of the frontal sinus