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Facial nerve
damage
Dissection of nerve proximal and distal to injury, followed by
microscopic primary repair using 8-0 nonresorbable sutures or
interpositional nerve graft (great auricular nerve)
Parotid duct injury Nonresorbable suture repair over silicone catheter if proximally intact
Complete removal of duct with extensive proximal damage, using
protective pressure dressings and adjunct therapy (e.g.,
neuromodulator injection) to decrease salivation
Nose Septal hematoma Incision and drainage with adjunct antibiotic therapy, placement of
drains and light packing
Full-thickness
injury
Primary layered closure with mucosal, lower lateral cartilages
(LLCs), and cutaneous sutures; marginal wounds closed with
eversion of wound edges
Purse-string (elliptical) sutures used to close avulsion injuries or
cover cutaneous gaps
Alar margin injury Eversion of wound edges prior to layered closure with vertical
mattress sutures
Extensive injury Injuries extended to subunit margins, covered with melolabial flap
(alar injury) or paramedian forehead flap (multiple subunits)
>50% nasal
subunit
Intranasal injury Intranasal flaps transected from septal hinge or inferior turbinate for
reconstruction of nasal lining
Septal or auricular cartilage for reconstruction of supportive tissues
Columellar strut grafts for additional aesthetic improvement
Fig. 17 A male patient with a large nasal cutaneous defect, which can be covered sufficiently by a
local rotational flap [162]
Lacerations of the lower face frequently involve the lips and perioral
regions of the lower face and jaw, which makes aesthetic reconstruction of
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these defects somewhat difficult. Wounds extending into or at the vermilion
border of the lips should be repaired aesthetically to match the uninjured
side as closely as possible. Preoperative markings are made hours before
the surgery and local anesthesia injections to improve accuracy. Deep
subcutaneous lacerations are sutured using primary four-layered closure
(mucosal, muscular, subcutaneous, then cutaneous) and are repaired
aesthetically based upon the pre-made markings. Horizontal mattress
sutures are used to fasten the vermilion border. This precise repair is
performed when tissue loss is less than 33% of the total lip width, and these
relatively smaller lacerations generally require deep extension prior to
closure for an optimally aesthetic reconstruction [127, 129].
Additional repair techniques vary depending on the extent of the injury.
Wounds resulting in severe tissue loss or damage of more than one-third of
the total lip width can be repaired with primary layered closure in some
elderly patients and/or patients with increased skin laxity. Reconstruction of
these lacerations in the younger demographics generally require more tissue
replacement, and they are repaired using an Abbe or lip switch flap,
Karapandzic musculocutaneous flap containing labial artery, or Estlander
flap. The lip switch flap utilizes the existing tissue of the lips for coverage
of the perioral, and generally only works when injury is not impacting more
than half of the total perioral tissue. In cases where there is damage to the
oral comissures, which are the lateral junction of upper and lower lip tissue,
an Abbe-Estlander flap is created to transfer and rotate a flap of preserved
local perioral tissue [127, 129] (Fig. 18).
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Fig. 18 An intraoperative view of a large lip defect reconstruction using a modified Abbe-Estlander
flap preserved on the same side vascular pedicle [163]
5.3 Reconstruction and Stabilization of Facial Fractures
As previously mentioned, orbital fractures usually require additional
imaging to assess the level of damage and determine a reconstructive
strategy. The orbital walls are thinner at the floor and medial wall, and as
such they are frequently damaged with trauma. In cases of trapdoor
fractures with muscle impingement and/or diplopia resultant from injury,
immediate treatment is necessary [127, 133].
CT scans should be obtained to measure the orbital volume and predict
outcomes. Fluid buildup lending to volume changes greater than 8% is
often indicative of poor outcomes. Enophthalmos (global protrusion) is
present in severe cases, and immediate repair is indicated when measured
protrusion is greater than 2 mm. In less severe cases, reconstruction is
performed within the first two weeks of injury [134].
The fracture is approached through the skin, conjunctiva, or
endoscopically through the maxillary sinus. Implants are better utilized than
standalone reduction, due to the fragile nature of the orbital wall bones.
Various materials used include autogenous cartilage or bone (split calvarial,
iliac, rib) and titanium mesh, among others [134–136]. We encourage
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interested readers to learn more about the detailed reconstruction of various
intraorbital fracture repair techniques for different injury presentations in
the cited article [164] (Fig. 19).
Fig. 19 CT scans demonstrating (a) a medial orbital wall and floor blowout fracture and (b) a blow-
in orbital roof fracture , both of which are emphasized by the yellow arrows [164]
Fractures of the frontal bone may not be observed with initial
presentation, depending on the severity of the swelling. The injury may be
localized to the posterior sinus table, anterior sinus table, or involve both
layers. Surgeons should be suspicious of frontal bone fractures when
patients present with periorbital bruising, forehead lacerations, and loss of
sensation to the upper third of the face [137, 138]. Fractures with less than
4–5 mm are not indicated for repair unless the patient has nasofrontal duct
injury and/or leakage of spinal fluid [139].
Surgeons begin by exposing the fracture with a coronal approach,
bilateral supraciliary approach (open sky technique), or endoscopically
through the maxillary sinus. Anterior table fractures can be repaired with
titanium plates and screws, although it may be necessary to camouflage a
deformity with delayed intervention. Titanium mesh is well utilized to
contain smaller fractured bone [140, 141].
In cases of posterior sinus table fractures, the sinus mucosa should be
thoroughly debrided with a curette and the entire posterior table removed. If
necessary, any dural tears are sutured after the fracture has been reduced
and stabilized. Nasofrontal duct injury frequently occurs with posterior
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table fractures, and these ducts are obliterated with cancellous bone chips,
hydroxyapatite, pericranium, or fat autografting [140, 141].
Anatomically, the zygomaticomaxillary complex (ZMC) is a bony
prominence which contains articulations of maxillary, frontal, sphenoidal,
and temporal bones. Reconstructive surgeons will repair any defects related
to fractures either with fat allografts, Medpore titanium implants, or bone
grafts in conjunction with ORIF. It should be noted that nondisplaced
standalone ZMC fractures occur in about one in four cases, contradicting
the use of ORIF. Greenstick fractures can be repaired through the
gingivobuccal sulcus, and complete separations of the bony articulations are
repaired through a lower blepharoplasty incision [142].
Nasal fractures have variable presentations in terms of severity,
depending on the etiology of trauma and existing patient factors. Minor
injury can result in isolated nasal bone fracture, while more severe trauma is
capable of disrupting the medial orbital wall, nasal, and lacrimal bones
[143]. Medial canthal ligament avulsion, NOE complex deformity, and
telecanthus are indivative of a Type III comminuted fracture, which requires
ORIF.
For most isolated nasal fractures, closed reduction is the optimal
technique as it can be performed under general or local anesthesia. NOE
fractures require open surgery to allow for repositioning and fastening of
the maxillary-frontal buttress and medial orbital wall. Ligamental avulsion
is repaired after bone repositioning via reinsertion and suture/wire
attachment [144, 145].
The bones of the lower face include the mandible, which is considered a
strong bone despite the fracture-prone thinner mandibular angles between
the thicker body and ramus. Class I fractures occur between teeth, and
despite their simplicity, it is best to utilize ORIF. Comminutal fractures
induce damage to most aspects of the bone, which may indicate the use of
four or more internal fixation plates. Generally, the horizontal or vertical
intraoral approach is well utilized in mandibular reconstruction in these
cases [146, 147].
When bone damage occurs in two to three facial regions, the injury is
classified as a panfacial fracture. Ideally, these should be repaired within
hours of injury. If reconstructive surgery is delayed, the soft tissues are
closed and an intermaxillary fixation device is applied. The timeline and
order of the facial bone reconstruction should work outward from the most
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stable point, although some find it easier to fixate the mandible after the
maxilla has been aligned [53].
6 Psychological Implications
Many patients who have undergone severe trauma experience resultant
PTSD and major depressive disorder (MDD) as a result of their
experiences. Severe burn injuries incur psychosocial consequences in the
impacted individuals. The resulting morbidity and mortality explain why
burns are considered one of the most traumatic events. As with other
physical trauma, patients experience negative aesthetic outcomes, loss of
function, and difficulty socializing [148–150].
It is recommended to implement coping mechanisms when caring for
traumatically injured patients and patients diagnosed with a life-threatening
illness. Coping techniques may focus on active discussion of past trauma
(approach-oriented) or help patients disengage or suppress their feelings
(avoidance-oriented). Approach-oriented coping techniques are beneficial
for patients diagnosed with PTSD, while avoidance therapy can be
counterintuitive. Psychiatric interventions can be tailored to each patient for
optimal recovery, with the goal of reducing psychosocial consequences
and/or achieving posttraumatic growth [151–156].
Despite the difficult experience and recovery from traumatic injury or
cancer, some of the surviving individuals describe a positive outcome of
their previous trauma. Originally described by Calhoun and Tedeschi, their
influential model attributes posttraumatic growth (PTG) to the patient’s
trauma-related struggles. These individuals describe a changed philosophy
of life, self-perceived change, and improved social relationships. Survivors
of various trauma such as life-threatening illness, natural disasters, burns,
and rape often experience PTG [157–161]. We hope to enhance the
awareness of the care team of the emotional impact on patients after
traumatic injuries or experiences. Teaching patients about healthy coping
techniques and providing postoperative psychological support may improve
the overall medical outcome for these individuals as well as their mental
health both throughout and after the healing process.
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