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24 Midface Trauma Reconstruction
325
such instrumentation can require a unique setup as well as signicant space within
the operating room, which needs to be accounted for. Further, the use of intraoperative imaging, including CT scanners, has been invaluable, especially in complex
cases. In many institutions, this modality is in high demand, and therefore, brought
into the operating room when needed during a case. The placement of the OR table
to expedite this process should be considered. Additionally, if preoperative planning
of screws and plates has been performed, these diagrams should be in the room and
available for the surgeon to evaluate during the entire procedure.
Nursing and scrub technicians should have the following available:
• Dilute betadine face prep.
• Local anesthetic.
• Items to protect the eye: lacrilube, corneal shield, erythromycin ophthalmic
ointment.
• Peridex oral solution to adequately clean the oral cavity.
• Maxillo-mandibular xation instruments of surgeon’s choice.
• Trauma midface set that includes the following:
– Oral retractor tray.
– Rowe forceps.
– McKesson bite block.
– Army/Navy retractors.
– Minnesota retractors.
– Periosteal Elevator—(#9 Elevator).
– Right angle retractor.
– Drill and Irrigation—run at 20,000 rpms.
– Carroll-Girard screw (gure of Carroll Girard).
– Midface plates with associated screws.
– Infraorbital instruments, which include Desmarres retractor, Jaeger lid plate
retractor, as well as orbital oor plates.
Surgical Approaches totheMidface
As with any facial trauma, care should be given to establishing and maintaining the
airway. Most midface injuries do not result in malocclusion or require the need for
mandibular-maxillary xation (MMF); therefore, traditional oropharyngeal intubation is adequate. In cases where MMF may be necessary, transnasal intubation may
be required. In these cases, assessment of any skull base injury is crucial. When
airway instability is a major concern, the anesthesia and surgical teams must determine the best course of action. This may include beroptic transnasal intubation,
transcutaneous submental intubation, or tracheostomy.
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326
Fig. 24.4 (a) maxillary
vestibular approach. It can
be extended (b) for greater
lateral exposure. It is
important to maintain at
least a centimeter cuff of
mucosa from the gingiva to
assist with closure
b
a
D. A. Rengifo et al.
All patients with midface fractures should receive prophylactic antibiotics since
most of these fractures are considered to be open, and mucosal disruption is either
caused by the injury or the surgical approaches. Often, intravenous steroids can aid
in perioperative edema that is commonly encountered.
Prior to discussing the operative techniques addressing bony reconstruction, the
surgeon must determine the appropriate incisions and approaches to the midface.
When available, existing lacerations often provide the most direct approach to the
bony skeleton.
The maxillary vestibular approach is the most common approach to the midface
(Fig. 24.4). Local anesthetic/vasoconstrictor is injected submucosally, just above
the mucogingival junction, to mitigate bleeding. After adequate time for vasoconstriction, the incision is made along the gingival mucosa, maintaining no more than
a centimeter cuff of the mucosa. This provides enough tissue to close the incision at
the completion of the case but does not limit exposure of inferior maxillary fractures
or the ability to place reconstructive plates. The incision is carried down to the subperiosteal plane. From there, the soft tissue of the cheek is elevated in a subperiosteal plane. As dissection is carried superiorly, identication and protection of the
infra-orbital nerve becomes important. Given that the nerve exists along the vertical
mid-pupillary line, we routinely elevate the malar tissue by creating two pockets.
One, aimed directly towards the most medial aspect of the infra-orbital rim which
exposes the medial buttress. The other is along the most lateral aspect of the rim,
which exposes the lateral buttress. Care is taken during elevation not to slip more
than 1–2mm superior to the rim edge to avoid injury of the globe. Once the elevator
is slightly over the rim, the inferior aspect of the elevator is rotated superiorly, while
the superior edge of the elevator remains xed and acts as a fulcrum on the rim.
When medial and lateral pockets are completely dissected in this fashion, most of
the soft tissue between the pockets is also elevated, and the infraorbital nerve and
foramen will come into view with minimal risk of injury. A right-angle clamp is
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24 Midface Trauma Reconstruction
Fig. 24.5 Lateral
blepharoplasty incision.
Placed within a natural
skin rhytid, this incision
can be used to expose the
zygomatic-frontal
suture line
327
then used to dissect the soft tissue sitting just superior to the infraorbital nerve. This
will expose the mid portion of the infraorbital rim and, quite often, any infraorbital
rim fractures. In our hands, this has allowed for assessment and, at times, plating of
this fracture line without the need of a periorbital incision.
The transconjunctival approach is still useful when reduction and xation of the
orbital oor or infraorbital rim are required. This is our preference of surgical
approaches to the region. The details of the approach, as well as other transcutaneous approaches to the orbit, are discussed in detail in the orbital trauma chapter.
The upper blepharoplasty incision (Fig.24.5) is invaluable when assessing and
treating zygomatico-frontal (ZF) fractures. It can also be used to evaluate the
zygomatico- sphenoid (ZS) suture line within the orbit. The incision allows the surgeon to determine If the zygomatic complex has been elevated and rotated back into
place appropriately. If the ZMC complex is under-elevated or under-rotated, an
excess in overall orbital volume will remain, leading to postoperative enophthalmos
and dystopia. These are two of the most common postoperative misalignments
encountered, especially early in a surgeon’s career. The upper blepharoplasty incision heals exceptionally well, so we have utilized this approach ever-increasingly.
Prior to beginning the approach, the cornea can be protected with temporary tarsorrhaphy or corneal shields. The incision is designed in the lateral half of the upper lid
in a curvilinear fashion and can be extended into the natural lateral lid rhytids, also
known as the crow’s foot. After this marking is completed, the planned incision can
be injected with local anesthetic with vasoconstrictor. After adequate time has been
given to local anesthesia with a vasoconstrictor, a 15-blade is used to incise the skin
and subcutaneous tissue in a medial to lateral direction. Once the orbicularis oculi
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D. A. Rengifo et al.
muscle is exposed, a slit should be made in the lateral aspect to allow the introduction of scissors into the preseptal plane. The dissection continues medially underneath the muscle, and the orbicularis is then divided, which leaves the orbital septum
intact. The musculocutaneous ap is then sharply elevated in a medial-to-lateral
fashion towards the superolateral rim to expose the periosteum. The periosteum is
then sharply divided along the superolateral orbital rim. Periosteal elevators are
used to expose the lateral rim and orbit. This allows for assessment of the ZF suture
line and any fractures in the area. Dissection can then be carried into the orbit in the
subperiosteal plane. As the dissection proceeds deeper into the orbit, the ZS suture
line is exposed.
Indirect approaches to the zygomatic arch include the transoral (Keen) approach,
as well as the temporal (Gillies) approach. These are useful when treating a pure
zygomatic arch fracture without instability of the zygomatic complex. The Gillies
approach begins with a 2-cm temporal incision within the hairline, designed 2.5cm
superior to the arch and anterior to the helix. Sharp dissection continues in the subcutaneous tissue and supercial temporal fascia and terminates at the deep portion
of the deep temporal fascia. The deep temporal fascia is then incised, and a sharp
elevator is introduced deep to the temporalis fascia and moved in the windshield
wiper motion until it sits medial to the zygomatic arch. Dissection under the supercial layer of the deep temporalis fascial avoids injury to the frontal branch of the
facial nerve. An elevator of choice can then be introduced for the reduction of the
fracture. The surgeon should not use the squamous portion of the temporal bone as
a fulcrum.
The Keen approach begins by design of a 2-cm lateral maxillary vestibular incision and the mucosa is incised with electrocautery or a scalpel blade. The elevator
of choice is then introduced and advanced towards the medial aspect of the zygomatic arch fracture that needs reduction. We have found that in the majority of
cases, a Keen approach enables adequate reduction without leaving a scar on the
skin or risking injury to the temporal branch of the facial nerve. In rare cases, the
limited leverage obtained by the keen approach is not enough to reduce the fracture.
In such cases, the Gilles approach may be necessary. In both of these indirect
approaches, palpation will conrm the appropriate reduction. We have found the use
of intraoperative imaging benecial in conrming reduction.
The coronal approach is rarely used in the setting of midface reconstruction
unless there are severe fractures of the zygomatic arch or trauma is in conjunction
with panfacial fractures. In these cases, this approach is used to treat the zygomatic
arch or the ZF suture line via a direct approach. The incision should be designed to
sit several centimeters posterior to the hairline . Care should be given to the regression of the natural hairline with time, which may lead to exposure of a once-hidden
scar. The incision is extended inferiorly, either pre- or postauricular, to expose the
zygomatic arch. Hair preparation and design of incision (zigzag, bow, wave pattern)
should be performed per the surgeon’s preference. Local anesthetic with vasoconstrictor is then injected into the subgaleal plane, and after the appropriate time for
effect is allowed, the initial incision is made with a scalpel or electrocautery. We
routinely utilize bipolar cautery for hemostasis of the skin edge of the coronal ap.
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24 Midface Trauma Reconstruction
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Studies have shown possible alopecia with the use of hemostatic clips. After hemostasis, the incision is carried down to the supraperiosteal plane. We routinely elevate
a pericranial ap as part of our dissection. If not utilized during the case, the pericranial ap can be sutured back in place for future use. We often raise the coronal
ap and pericranial ap as a single unit after making the lateral and inferior cuts of
the pericranial ap. The combo ap is then raised from posterior to anterior in the
subperiosteal plane as dissection is carried anteriorly until the superior orbital rims
are encountered. Care should be taken to protect the supraorbital and supratrochlear
neurovascular units. Dissection can be carried anteriorly along the midline down
over the root of the nose. The superior aspects of the orbits can also be entered with
this approach if the supraorbital complex enters the area through a foramen; a chisel
and blunt dissection may be required to free them from the foramen and elevate the
soft tissue unit of the coronal ap.
After carrying the incision down to the supraperiosteal plane, the surgeon should
begin the lateral component of the coronal ap just supercial to the temporalis
fascia and continue towards the level of the zygomatic arch. Soft tissue elevation
proceeds anteriorly and inferiorly along this plane until the supercial temporal fat
pad is seen through the supercial layer of the deep temporal fascia. The fascia is
transected at a 45-degree angle (in the same direction that the temporal branch of the
facial nerve runs) to enter the fat pad. The dissection is carried antero-inferiorly to
the arch by staying immediately deep to the supercial layer of the temporalis fascia. Staying in this plane will protect the temporal branch of the facial nerve. Care
is given to limit trauma to the fat pad itself, thereby limiting post-operative temporal
hallowing, which is caused by devascularization of the fat pad. If the reconstruction
necessitates the maximum midface exposure, the lateral subperiosteal dissection
can be continued from the lateral orbital rim downward over the body of the zygoma.
This exposure allows for direct reduction of the lateral half of the orbital oor. The
exposure necessary to reach the upper midface, medial orbital wall, infratemporal
fossa, temporomandibular joint, and mandibular condyle/ramus is covered in other
chapters of this text.
Site-Specific Surgical Techniques
1. Isolated ZMC
2. Le Fort 1
3. Le Fort II
Zygomaticomaxillary Complex Fractures
While there are always multiple fractures with any zygomatic complex fractures, a
signicant portion does not require multiple approaches. Often, depending on the
mechanism of injury, the force applied to the complex causes it to rotate medially,
posteriorly, and inferiorly without vertical separation of the ZF suture line or
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D. A. Rengifo et al.
signicant disruption of the orbital oor. Often, this can be determined preoperatively through imaging and physical exam. In simple, straightforward injuries, the
appropriate reduction can often be achieved by simply disimpacting the complex
and reducing it by rotating the zygomatic complex anteriorly and laterally through
a transoral approach. In many cases, once the complex is reduced, it will not fall
back to its injury position. We routinely utilize an elevator for reduction. After elevation of the soft tissue envelope through a vestibular incision, the elevator is passed
through the comminuted bone of the anterior maxillary sinus into the sinus itself.
The elevator edge is then placed against the most anterior lateral edge of the maxillary sinus. Then, either lifting the elevator or cantilevering it off the nonfractured
portion of the maxilla, the ZMC complex can be rotated back into place. In these
cases, often, a single reconstructive plate placed along the ZM suture line is enough
to xate the fracture.
After reduction and xation, it is important to conrm that the ZF suture line is
still in correct alignment/reduction. This can be assessed by digital palpation along
the lateral orbital rim. If uncertain, then intraoperative imaging or direct assessment
of the suture line through a lateral blepharoplasty incision is warranted. The other
area that must be assessed is the orbital oor. It is possible that during the reduction
of the ZMC complex, the orbital oor fracture has shifted and is now of a signicant
size that requires treatment or shift, causing the inferior rectus muscle of the orbit to
become entrapped. We have found that it is possible to assess the quality of the
orbital oor after reduction by placing an elevator within the maxillary sinus along
the orbital oor and then gently pushing on the globe. The surgeon can feel if there
is signicant displacement of orbital contents. Similarly, an angled endoscope can
be passed into the sinus for direct observation of the oor. Once again, if there is any
doubt, imaging or direct surgical assessment and treatment may be performed.
Finally, a forced duction test should be performed at the conclusion of any ZMC
case to rule out entrapment of the inferior rectus muscle.
In cases that are more complex with signicant disruption of the ZMC complex,
a single transoral approach will not sufce. These cases typically require multiple
approaches, including lateral upper blepharoplasty to assess the ZF and ZS suture
lines and a transconjunctival approach to examine and treat the orbital oor and rim.
We have found in complex cases, it is best to utilize multiple approaches early in the
surgery to identify fractures, assess their reduction, and, when needed, xate. When
reducing the ZMC in multiple vectors at the same time, it is not uncommon to correctly reduce and xate one fracture line while misaligning the other.
Once the soft tissue is elevated and the fractures are exposed, the surgeon needs
to determine the best manner in which to reduce the fracture. As with simple ZMC
fractures, reduction with periosteal elevator or bone hook, may be enough to reduce
the complex and hold it place. In other cases, the amount of malar deformity is too
substantial, or adequate torque to reduce the fracture cannot be generated by the use
of an elevator or hook. In such cases, a Carroll-Girard screw can be used. The instrument can either be placed transcutaneous through a small stab incision through the
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24 Midface Trauma Reconstruction
331
overlying skin or the soft tissue can be elevated and the instrument placed through
the trans vestibular incision. When utilizing a Carroll-Girard screw, it is important
to place it in an area of adequate bone stock so that it does not become dislodged
when manipulating the malar complex. Once placed, this instrument cannot be
removed and replaced multiple times. A disadvantage of the Carroll-Girard screw is
that its overall size and placement can often make it difcult to observe the skeleton
directly behind the instrument. This can also make the placement of screws and
plates markedly more difcult. To circumvent these drawbacks, we often utilize the
placement of a longer midface or mandible recon screw in the same location as we
would normally place the Carroll-Girard. The midface screw is not completely
tightened, with a signicant portion of the screw left exposed above the bone edge.
A clamp or hemostat can then be used to grab onto the screw, and the new construct
can be manipulated like the Carroll-Girard. The hemostat can also be removed or
replaced depending on necessity.
It is not unusual in complex cases to nd that the fractures remain mobile after
reduction, making it difcult to maintain ZMC reduction in all directions while plating. As each fracture line is xated, the amount of mobility in the other directions
decreases, thereby making each subsequent reduction easier to hold in place.
Unfortunately, it is quite easy to plate one fracture in appropriate reduction, only to
nd that the other fracture lines have shifted out of correct reduction, and that the
plate that was placed, will not allow the rest of the complex to be reduced accurately. Therefore, the order of xation that that the surgeon chooses has its own
benets and limitations. While each surgeon has an order that they prefer to xate
fractures, we nd that with a mobile ZMC, we routinely xate the ZF fracture rst.
By doing this, we have corrected the vertical height of the midface. Fixation of the
ZF suture line rst still allows manipulation of the ZMC in some directions. The
medial portion of the complex can be rotated in the superior-inferior direction as
well as in the anterior-posterior direction. This limited mobility lets us rotate the
ZMC complex and reset the zygomatico-sphenoid (ZS) suture line correctly, thereby
correcting the orbital volume. We do not nd that the ZS suture line routinely needs
xation, though some surgeons prefer to place a small plate there. With the persistent mobility allowed by ZF xation, we can also correctly reduce the infraorbital
(IO) rim, which is the fracture line we xate second. Finally, after conrming that
the ZF, ZS, and IO lines are reduced correctly, we xate the zygomatic maxillary
(ZM) suture line. Of all the fracture lines, it is the easiest to access and plate. Also,
slight malposition of the ZM has a limited impact on malar projection and overall
appearance. We rarely nd that the zygomatic arch (ZA) requires plating unless
there is a signicant palpable step-off noted on palpation. After xation of the ZF,
IO and ZM fractures, we then treat the orbital oor fracture if necessary. Occasionally,
when there is signicant comminution of the infraorbital rim along with an orbital
oor fracture, we will next place an orbital oor plate that extends over the rim to
treat both the oor and IO areas simultaneously.
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D. A. Rengifo et al.
Le Fort IFractures
Le Fort I fracture treatment aims to restore normal occlusion and vertical height to
the midface. Treatment begins by conrming occlusion. If there is no malocclusion,
then the patient is placed in maxilla-mandibular xation (MMF) prior to performing
a vestibular incision. This is done so that the reduction of the midface fractures does
not alter the patient’s occlusion. When the patient does not easily go back into
occlusion, reduction of the maxilla may be required. Often, this can be done with a
simple periosteal elevator after exposure of the fracture lines. In cases where greater
traumatic forces were applied to the maxilla, Rowe disimpaction forceps may be
required to mobilize the maxilla prior to MMF utilization. After occlusion is reestablished with MMF and the fractures are exposed, stabilization is required. While
all four vertical buttresses can be xated, a minimum of two are required so that the
maxilla does not shift or rotate when the patient chews. When placing midface
plates, at least two screws must be placed on either side of the fracture line. L- or
T-shaped plates are very useful in this area because they allow the placement of
enough screws along the inferior aspect of the fracture while simultaneously avoiding the tooth roots. If there is bone loss within the vertical buttress, bone grafts
should be used. Bridging gaps with plate xation alone may lead to an alteration of
the achieved occlusion or plate exposure. Generally, if bone grafting is not required
and when reduction is rigid, the surgeon may elect to discontinue MMF at the end
of the case.
Le Fort II Fractures
Le Fort II fracture reconstruction begins with the sequence as a Le Fort I fracture;
however, the surgeon may need to expose the orbital rim and oor. The rim may be
repaired with low-prole miniplates, and bone loss can be addressed via bone grafting to avoid cosmetic deformities. The reconstruction of the orbital oor is further
explained in the orbital trauma chapter of this text. In cases where there are bilateral
midface fractures, we once again address occlusion rst. From there, treatment
begins on the side of the face that is less comminuted and, therefore, easier to correctly reduce and xate fracture. As variables become reestablished, they can be
used to help conrm the correct reduction on the more comminuted side. Minimizing
the number of variables gives the best chance of a successful outcome.
Pan Facial Fractures
Determining the order of reduction and xation varies greatly from case to case in
pan facial fractures. There is no denitive order of reconstruction. At best, general
guidelines can be given. Function is the main concern, and therefore, reestablishing
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24 Midface Trauma Reconstruction
333
occlusion when possible is paramount. From there, the literature describes various
directional reconstructions, such as a bottom-to-top or inside-to-out reconstruction,
for example. As with bilateral midface fractures, after establishing occlusion, we
start with the areas of least comminution and move on to progressively more complex areas. Experience also teaches us to monitor for common mistakes such as
over-widening of the lateral face. This can be caused by something as seemingly
innocuous as overly curving the zygomatic arches, which, despite their name, are
mostly a straight structure in the anterior-posterior direction. Beyond just falling
back on previous experience, the use of modern technology has made these exceptionally tough cases easier. Liberal utilization of intraoperative navigation and
imaging allows the surgical team to assess their work in real time and adjust quickly.
Ever increasing ease of use and application of surgical planning software with
patient specic hardware is quickly taking the guesswork out of these cases and
optimizing outcomes.
Pediatric Midface Fracture Management
Midface fractures in the pediatric population, while uncommon, are often the result
of blunt trauma from sports injuries, falls, transportation incidents, and assault and
tend to occur in the older pediatric population. The pediatric facial bones have more
elasticity and cartilage framework when compared to the adult facial skeleton. Also,
late aeration of the maxillary sinus, along with unerupted teeth in younger children,
act as buttresses and limit displaced fracture occurrence. The majority of ZMC fractures occur with limited displacement and are best treated with observation and a
soft diet. Fractures of the zygomatic complex with signicant displacement, comminution or diplopia should be treated with open reduction and internal xation.
Maxillary fractures with malocclusion are often best managed with a short course
of MMF with elastics for no longer than 1–2weeks. If the ZMC is signicantly
displaced, xation with miniplates should be performed. Great care should be taken
to avoid placing screws into the undescended tooth buds. There continues to be a
lack of consensus regarding internal xation plate management because of the controversial risk of halting facial growth. Some surgeons will elect to remove plates
around 3–6months after xation, while others do not believe permanent plates signicantly impact facial growth. Unfortunately, there is no signicant evidence to
sway the decision towards a standard of care. Literature does suggest for consideration of plate removal in the setting of highly complex and involved facial fractures,
younger patients, and the presence of facial deformity. Absorbable plates are another
option; however, there is no signicant evidence to prove their superiority over nonabsorbable plating. There is also a learning curve to their correct placement; therefore, they have not become the standard of care. Overall, a thorough discussion with
the parents or guardians should include the potential risks and benets of surgical
management, absorbable and nonabsorbable plates, as well as temporary and permanent plating.
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D. A. Rengifo et al.
Complications
Complications of midface trauma may result from sequelae of injury, delayed therapy, infection, and improper surgical technique. It is important to keep in mind that
the severity of injury and incidence of complications have a direct relationship.
Severely comminuted fractures may often exhibit associated bone loss, which further complicates appropriate xation. The vast vascular supply of the midface aids
in decreased risk of nonunion and infection, and the feared complication of osteomyelitis is thankfully rarely encountered due to this vascularity.
While nasal bone fractures are covered in more detail in other chapters of this
text, it should be noted that they are the most common fractures of the midface.
Minimal displacement of the nasal bones and septum may result in epistaxis, septal
hematoma, cosmetic deformity, and nasal obstruction. Proper initial management
and subsequent septo-rhinoplasty are important to address these risks.
Postoperatively, residual deformities and continual nasal obstruction are the most
common complications. Sufcient time to heal after initial repair is important to
keep in mind, even with suboptimal results. This time allows edema and inammation, making for a proper facial analysis to consider revision.
A full review of orbital fractures and associated complications is beyond the
scope of this chapter; however, it is important to briey cover the basics of these
complications. When orbital fractures are included in ZMC injury, symptoms may
include periorbital bruising, swelling, diplopia, enophthalmos, and hypoesthesia of
the inferior orbital (V2) nerve. Entrapment of the inferior rectus can also limit extraocular movement, while traumatic palsy of CN III can present in a similar or more
severe fashion. Oculocardiac reex is the one true emergency complication of
orbital fractures and should be addressed in a timely fashion. Postoperative complications include inferior orbital nerve paresthesia, as well as diplopia and enophthalmos due to malposition of the reconstructed zygoma. Persistent diplopia may,
unfortunately, be a relatively common complication, with literature noting up to 7%
incidence postoperatively. Long-term enophthalmos may be due to perioperative
edema and orbital fat atrophy.
Complications of ZMC fractures can include loss of facial lateral projection,
trismus due to impingement of depressed zygomatic arch on the coronoid process
or direct compression of the temporalis by the zygomatic arch. As discussed previously, several orbital complications may present as sequelae of ZMC injury.
Common complication from improperly repaired ZMC fractures include facial
asymmetry, poor aesthetics, and cheek ptosis. The subciliary approach can lead to
persistent lower lid edema. Likewise, ectropion may also present as a complication
of the transconjunctival approach. Daily massage of the area postoperatively may
result in the spontaneous resolution of these complications.
Le Fort I fractures result in mobile palatomaxillary segment, mucosal lacerations
and palatal ecchymosis. Le Fort II fractures often result in infraorbital nerve paresthesia, with these patients exhibiting reduced sensitivity in the frontal teeth, upper
lip, cheeks, and skin of the lateral nose. Le Fort III fractures may exhibit epistaxis,
massive swelling of oral mucosa and orbit, cerebrospinal uid rhinorrhea. All Le
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