Facial Trauma Surgery

The leading cause of facial trauma is road traffic accidents and interpersonal insolence. The face consists of over 14 bones and these could be fractured either individually or in a combination. In addition there may also be a soft tissue, eye or nerve damage

Facial trauma surgery can be complex as care has to be taken to prevent any unsightly scars caused due to the surgery. In addition the bones are very thin as compared to bones elsewhere in the body and micro and miniplates have to be used. Previously these injuries used to be treated by closed reduction alone with poor results. Lately the trend is to treat these injuries with open reduction and internal fixation. The advantages of internal fixation are:

• Improves anatomical reduction
• Reduces malunion and non-union
• Facilitates early soft diet rather than a liquid diet
• Prevents weight loss
• Improves lung function ( IMF {wiring jaws together} has been shown to decrease lung function in numerous studies)
• Permits speech
• Is more comfortable to the patient

A 20 year old presented to us following a severe road traffic accident in which he sustained multiple facial bony injuries. Clinical examination and CT scans revealed a fracture of his maxilla ( upper jaw) on both sides at a Le Fort III level along with a split palate and a mandible ( lower jaw) fracture. It was decided to go for open reduction and internal fixation under general anesthesia. The approach used was bicoronal flap ( scalp) and intraoral and the fractures were all reduced anatomically and plated in the correct position. The patient recovered well postoperatively going on to a normal diet within a month with no residual facial deformity.

Maxillary Led Fort III fracture with split palate and mandible fracture plated via bicoronal and intraoral approach. As you can see results are spectacular.

A 40 year old was involved in a RTA ( road traffic accident) in which he sustained a severe comminuted fracture of his left zygoma. Clinical examination and CT facial bones were done and the patient was taken up for surgery. A bicoronal flap approach was done and the fractures exposed, reduced and plated. Postoperatively he recovered very well with no complications. Once the hair has grew back the scars were all completely hidden in the scalp.

Severe comminuted zygoma treated via bicoronal flap approach and plating. The scars are all hidden in the hairline and not visible in spite of an extensive surgical approach.

This young man presented to us following an assault in which he sustained a fracture of his nasal bones with decreased air entry. Under general anesthesia the nasal bones were reduced.

Mandibular fractures are one of the most commonly seen maxillofacial injuries. The entire surgery is done intra-orally from inside the mouth in 99.9% of the cases. This prevents scar and potential injury to the facial nerve. Plates made of stainless steel or titanium are used. Both these materials are biocompatible with titanium being a better choice albeit it being more expensive. Lately resorbable plates are available though they are still unproven in a large series of patients. Mandibular plates are mono-cortical in nature and there is no place for bi-cortical heavy plates as used elsewhere in the body. These plates are very thin and do not need to be removed in the vast majority of patients.

At our centre we routinely recommend and do internal fixation as the first line of treatment and a large series of patients have greatly benefited from this modality of treatment from us.

This young man had a history of a severe fungal infection of his maxilla and orbit for which he had undergone a medial maxillectomy to get rid of this severe infection. He was now clear from the fungal infection but had a severe orbito-maxillary defect with inability to close his eye completely and also severe enopthalmos and hypoglobus(eye has sunken inwards and backwards). A CT scan taken showed a completely missing orbital floor and medial maxilla. Conventional techniques of a recon plate would have got less than ideal results and plating would have been difficult due to the bony deficiency. It was decided to go for a custom made 3D printed prosthesis to correct this deformity

The entire virtual surgery was done online– the CT scans were sent to the manufacturer in bangalore, the planning was done via secure internet protocols meeting US healthcare security and confidentiality standards as this manufacturer regularly does these cases for US hospitals. A virtual orbito-maxillary plate was designed and it was then 3D printed/ milled using medical grade titanium.

The surgery by itself was straightforward barring the fact that there was severe scarring all around making dissection extremely cumbersome. The approach was through the old maxillectomy/ infraorbital scar and the plate was held in place using microscrews. Meticulous closure was done in layers. The post-operative results are shown. There was a nearly 70-80% improvement in enopthalmos and hypoglobus and the patient was able to close his eye completely. Vision was as it was preoperative– 9/6. The patient was very happy with the results. In severe facial and cranial deformities a new option available to us is 3D printed / milled custom made prosthesis– cost is however very high as it is a technologically intensive procedure currently—as volumes increase we expect the cost to come down to reasonable levels. These cutting edge technologies and surgical procedures are now available to our patients in Madurai itself

Orbital deformity corrected using custom made 3D printed titanium plate. These cutting edge procedures are now done routinely at our centre.

Soft tissue injuries can occur due to road traffic accidents, assaults using knifes and so on. On the face these injuries are of special concern to minimize scarring associated with these injuries. In this case a young man sustained a severe facial laceration following a fall from his bike. He had managed to literally tear half of his face off and his cheeks and nose were hanging on by a thin tissue flap. Meticulous multilayer closure was done using resorbable and non–resobable sutures under general anesthesia. Care was taken to reconstruct the bones, nerves and blood vessels of the face in a systematic manner.