Facial Trauma

Facial trauma encompasses a broad range of injuries to the bony skeleton and soft tissue of the face. Each facial region has unique anatomic, aesthetic, and functional considerations to take into account during evaluation and treatment. Accordingly, this chapter is organized by region; however, in practice, trauma frequently impacts more than one area, and the interaction between multiple structures must also be considered.

Some general guidelines apply to the approach to any facial trauma. First and foremost in the trauma assessment is evaluation of airway, breathing, and circulation (the ABC's of trauma). Stabilization of life-threatening injuries is critical and should be addressed before attention is directed toward facial injury. An exception is in the case of excessive blood loss from facial soft tissue trauma, which may contribute to overall hemodynamic instability. Because facial trauma often occurs in conjunction with other injuries, repair may need to be coordinated with other services. Additionally, due to the complexity and proximity of structures in the craniofacial region, comprehensive treatment of facial injuries may require collaboration and consultation with multiple specialists, including ophthalmology, dentistry, or neurosurgery.

Documentation of pretreatment function and appearance is vital, both to monitor injury progression and for assessment of treatment outcome. Appropriate imaging must also be obtained as necessary for treatment planning; to reduce the amount of radiation exposure to the patient, acquisition of needed scans should be coordinated with the trauma team and other services.

In general, soft tissue injuries should be irrigated and repaired as soon as possible. Primary closure is preferred, if feasible. Depending on the depth of the wound, layered closure may be necessary. For example, through-and-through injuries involving the oral cavity are typically closed in three layers: mucosa, subcutaneous tissue, and skin. For optimal cosmetic outcome, nonabsorbable skin sutures on the face are typically removed within 3-5 days.

Repair of skeletal injuries is typically more involved and is usually delayed for several days after trauma to allow for decrease in reactive edema as well as stabilization of concomitant injuries.

Auricular Trauma:

Auricular soft tissue injury includes lacerations, avulsions (detachment of part or all of the auricle), and auricular hematoma. Evaluation of injury should include assessment of cartilaginous involvement and integrity of the anatomic subunits of the auricle. Repair of auricular lacerations is generally straightforward; if the laceration involves the cartilage, sutures may be placed in the perichondrium to approximate the cartilage edges and maintain the shape of the ear. In cases of earlobe tears (as can result from earring trauma), the torn edges are excised before reapproximation. A Z-plasty repair may be preferable, as scar contracture following a linear repair can produce a "W"-shaped irregularity in the lobe contour. Patients wishing to repierce the earlobe after tear repair should wait a minimum of 6 months to allow the repaired tissue to attain maximum strength.

An avulsed auricle may be replanted if a sufficient pedicle remains intact; otherwise, microvascular repair or temporary attachment of the avulsed tissue to a scalp flap (to provide a vascular supply while revascularization occurs) may be employed.

Auricular hematoma is usually the result of blunt injury, frequently sustained in sports such as wrestling. Shear force to the ear causes separation of the auricular cartilage from the overlying perichondrium and disruption of the perichondrial vessels. This results in accumulation of blood between the cartilage and perichondrium. Because the cartilage lacks its own vascular supply, separation from the perichondrium can result in cartilaginous necrosis and resorption. In untreated cases, this can lead to significant deformity ("cauliflower ear"). Prompt drainage of the hematoma is indicated to prevent this complication. After the hematoma has been evacuated, a bolster should be placed over the anterior surface of the auricle and secured with through-and-through sutures to prevent reaccumulation of blood in the subperichondrial space. A prophylactic antibiotic with pseudomonal coverage (such as a fluoroquinolone) may be administered.

Nasal Trauma:

Nasal fractures are the most common type of facial fracture. Presentation may include obvious physical deformity, contusion or laceration of the skin overlying the nose, periorbital ecchymosis, nasal obstruction, or epistaxis. If the cribriform plate has been disrupted, cerebrospinal fluid (CSF) rhinorrhea may result. Evaluation of a patient with suspected nasal injury should include palpation over the bony nasal skeleton and rhinoscopic examination to evaluate for septal injury. Septal hematoma, like auricular hematoma, requires prompt drainage to avoid avascular necrosis of cartilage. Details regarding septal hematoma can be found in Reconstructive Head and Neck Surgery. Whether the patient perceives any cosmetic deformity should be elucidated, although soft tissue edema immediately following injury may hinder accurate evaluation. Pre-injury photographs may be helpful in assessing cosmetic alteration. Isolated nasal fracture can be diagnosed clinically, such as if palpable step-off is noted over the nasal bones, without the use of radiographic imaging. However, as concurrent injuries are common, computed tomography (CT) of the maxillofacial skeleton is frequently obtained.

In the absence of CSF leak, septal hematoma, or severe septal deviation resulting in nasal obstruction, treatment of nasal fractures is primarily a cosmetic procedure. If the patient presents for treatment within 2 weeks of injury, a closed reduction can be performed. A splint is placed over the nasal bones for 1 week following the procedure to maintain alignment while the bones heal. If more than 2 weeks have elapsed since the time of fracture, closed reduction is no longer feasible, and open reduction (with osteotomies to refracture the healed bone) must be performed. Open reduction is typically deferred until 2-3 months after injury to allow edema to subside.

Orbital Trauma:

The orbit is a pyramidal cavity that houses the globe (eyeball). It is formed by the contribution of seven cranial bones: frontal, lacrimal, ethmoid, sphenoid, zygoma, maxilla, and palatine. Orbital fractures frequently occur in conjunction with other bony injury (such as in naso-orbital ethmoid fractures, discussed below). Isolated orbital injuries are most commonly orbital blow-out fractures involving the floor of the orbit (composed of the maxilla, zygoma, and palatine bones, ). When injury occurs to the orbit, preservation of visual function is the primary concern. Visual acuity and ocular movement should be evaluated and documented immediately. Ophthalmologic consultation is recommended in most cases and must be ordered if visual disturbance is noted. The entrapment of extraocular muscles due to fracture causes impaired extraocular movements. If the patient is unconscious or otherwise unable to actively move the eyes, forced duction testing should be performed (wherein the sclera is grasped with forceps and the globe is passively moved in all directions). The physical examination should also include palpation of the orbital rim to detect obvious step-offs and assessment of facial sensation. The maxillary division of the trigeminal nerve (V2) passes through the orbital floor and may be disrupted or compressed as a result of an orbital blow-out fracture. In such cases, patients develop decreased sensation (hypesthesia) or paresthesia of the upper lip. This should also be documented prior to undertaking surgical repair to establish it as a preexisting condition (as opposed to a complication of repair). A CT scan of the maxillofacial skeleton should be obtained.

Indications for repair of orbital fractures include extraocular muscle entrapment, enophthalmos causing cosmetic deformity or diplopia, or significantly increased orbital volume relative to the uninjured eye on CT (a risk factor for development of enophthalmos). The surgical approach to the orbit may be via a subciliary or transconjunctival incision. Details regarding open reduction and internal fixation (ORIF) of orbital floor fracture can be found in Chapter 29.

Frontal Sinus Trauma:

Trauma to the upper third of the face is primarily concerning for injury to the frontal sinus. The forehead serves as a protective barrier to brain injury and is therefore very resilient. However, severe trauma, such as in high velocity motor vehicle collisions, can cause fractures of the frontal sinus. The paired frontal sinuses are bounded anteriorly by the anterior table, which forms the forehead. Posteriorly, the frontal sinuses are bounded by the posterior table, which overlies the anterior cranial fossa. The posterior table is significantly thinner and less resistant to injury than the anterior table.

Evaluation of blunt head trauma involves a complete neurologic examination and typically radiographic imaging of the head. Frontal sinus fractures may occasionally be identified on clinical examination as step-offs in the forehead, but are much more likely to be discovered on CT. Because of the significant force required to fracture the frontal sinus, concomitant injuries are extremely common. Presentation of frontal sinus fracture may include pain, hypesthesia or paresthesia of the forehead, visual disturbance, or CSF rhinorrhea. Forehead lacerations are present in 80% of patients with frontal sinus fractures. In a small percentage of patients, frontal sinus fracture may be asymptomatic.

The approach to treatment of frontal sinus fractures depends on the extent of injury. Evaluation of posterior table integrity and involvement of the frontonasal recess on thin-cut axial and coronal facial CT is essential, but may be challenging. Violation of the posterior table can result in a number of complications, such as mucocele or mucopyocele formation, meningitis, brain abscess, or persistent CSF leak. Some of these complications may be delayed, manifesting months or years after injury. Disruption of the frontonasal recess impairs drainage of the frontal sinus and can result in chronic sinusitis or frontal pain.

Non- or minimally displaced anterior table fractures alone can be managed conservatively, without surgery. Anterior table fractures that are displaced by more than 1-2 mm should generally be repaired via open reduction and internal fixation due to cosmetic deformity and increased risk for mucocele formation. Injury to the frontonasal recess is an indication for frontal sinus obliteration, although many practitioners advocate a more conservative approach, deferring intervention until sinus dysfunction has been documented. The approach to posterior table fractures is more complicated; some have recommended that all posterior table fractures should be explored and repaired to minimize the risk of complications. Others suggest that nondisplaced posterior table fractures can be observed in the absence of other indications for surgery. Most would agree that displaced posterior table fractures should be explored, as herniation of brain tissue into the sinus may be present that was not detected on CT. In the case of severe posterior table comminution where repair of the bone is not feasible, the posterior table fragments are removed, leaving the frontal sinus in communication with the anterior cranial fossa. This procedure is referred to as cranialization of the frontal sinus.

Midface Trauma:

The middle third of the face includes the orbits and nose (previously discussed) and the zygomatic and maxillary bones. The midface is supported by a buttress system that provides structural integrity and protection to its contents. There are three main vertical midface buttresses: nasomaxillary, zygomaticomaxillary, and pterygomaxillary. They are connected and strengthened by the horizontal buttresses, which include the orbital rims, hard palate and maxillary alveolus, pyriform aperture, and skull base. Restoration of these buttresses should be attempted when addressing midface fractures, which include naso-orbital ethmoid (NOE) fractures, fractures of the zygomaticomaxillary complex (ZMC), and LeFort (maxillary) fractures.

Nasal fractures that occur in conjunction with fractures of the orbit and ethmoid bone are classified as naso-orbital ethmoid fractures. These cases are significantly more complex and challenging to treat than simple nasal bone fractures. Complications of NOE fractures can include telecanthus (increased distance between the medial canthi), visual disturbance, enophthalmos (sunken eyeball), sinusitis, CSF leak, and midface retrusion. Evaluation should include a maxillofacial CT and ophthalmologic assessment. NOE fractures can be classified into three types, depending on the extent of fracture comminution and the impact on the medial canthus tendon. Surgical repair of NOE fractures is among the most technically difficult of maxillofacial procedures and requires meticulous planning and precise fracture reduction to achieve satisfactory cosmetic and functional outcome.

Zygomaticomaxillary complex fractures are the second most common type of facial fracture. ZMC fractures are characterized by disruption at four sites: the lateral orbital rim, inferior orbital rim, zygomaticomaxillary buttress, and zygomatic arch. Because the ZMC includes the malar eminence, or cheekbone, fractures in this area can cause significant cosmetic deformity (typically posterior depression of the injured cheek). Additional presenting symptoms may include facial pain, infraorbital ecchymosis, trismus, or paresthesia in the distribution of V2. Because the orbital walls are involved in the fracture, ophthalmologic consultation is advised. Dental examination should also be performed, as the maxillary alveolus may be involved, with injury to the maxillary tooth roots. Conservative treatment may be pursued in cases of ZMC fracture that are non- or minimally displaced and asymptomatic. More severe cases can be treated with open reduction and internal fixation (i.e., placement of titanium plates across fracture lines). The choice of surgical approach depends on the extent of injury and desired access; multiple incisions may be necessary to address different fracture lines.

Maxillary fractures are classified according to the Le Fort system, which separates maxillary injury patterns into three types. Type I Le Fort fractures occur when the traumatic force is applied at the level of the teeth (or just superior). This results in separation of the palate from the rest of the midface. The action of the muscles of mastication pulls the mobile palate posteriorly, resulting in malocclusion. Le Fort II fractures are pyramidal in shape and occur as a result of traumatic force at the level of the nasal bones. They involve the nasomaxillary buttress and cause mobility of the upper midface in addition to the palate. The skull base may also be disrupted, resulting in CSF leak. Le Fort III fractures result from traumatic force at the level of the naso-orbital region of higher intensity than in Le Fort II fractures. This causes complete craniofacial dysjunction (separation of the face from the cranial vault).

The first priority in cases of Le Fort fractures is to secure the airway. Retrusion of the mobile palate can obstruct the oropharynx, which may be further exacerbated by significant facial and oral edema due to the extent of trauma. Intubation is indicated in cases of severe intraoral bleeding or if placement of an oral airway is insufficient to correct the obstruction. A nasotracheal intubation should not be attempted if a skull base fracture is likely (such as in a Le Fort type II or III fracture), as the tube may be inserted through the fracture into the intracranial cavity. In cases where a cervical spinal injury is present or suspected, the neck cannot be extended to allow oral insertion of an endotracheal tube and tracheotomy or cricothyroidotomy should be performed instead.

On physical examination, the facial skeleton should be palpated, noting any crepitus, step-offs, or mobile segments. The maxillary alveolus can be grasped and pulled anteriorly to evaluate for palatal separation and mobility. A dental examination should be performed to assess for damaged or missing teeth and changes in occlusion. If possible, the status of the patient's pre-injury occlusion should be determined. An ophthalmologic examination should be performed in cases of orbital involvement. In Le Fort III fractures, patients may exhibit telecanthus or epiphora due to obstruction of the nasolacrimal duct. The presence of CSF rhinorrhea should be noted.

As patients with Le Fort fractures have typically sustained multiple serious injuries, a period of time may be required for the overall condition to stabilize sufficiently before fracture repair can be considered. In the interim, prophylactic antibiotics are given to prevent infection (particularly in cases of skull base disruption, where risk of meningitis is increased). To prevent worsening of CSF leakage, the patient is advised to remain in a semi-recumbent position and to avoid nose-blowing, sneezing with the mouth closed, and unnecessary straining. Because Le Fort fractures invariably alter occlusion, patients are placed in maxillomandibular fixation (MMF, also known as intermaxillary fixation, or IMF), wherein the maxillary teeth are wired to the mandibular teeth in a position that approximates pre-injury occlusion as closely as possible. Patients usually remain in MMF for 4-6 weeks, allowing sufficient time for recovery from other injuries and subsidence of facial edema before surgical repair is attempted. Surgical treatment of Le Fort fractures is via open reduction and internal fixation; the approach depends on the extent of injury. A Le Fort I fracture may be disimpacted and plated via a gingival buccal incision, whereas an extensive Le Fort III fracture may require multiple external incisions or even degloving of the entire midface.

Mandibular Trauma:

The mandible forms the majority of the lower face and, like much of the maxillofacial skeleton, is structured to absorb impact and protect the skull base. Trauma to the lower third of the face frequently results in multiple or bilateral mandibular fractures. The mandible consists of a horizontal body (which contains the alvelolus) with two vertical rami that terminate in a coronoid process anteriorly and a condylar head posteriorly. The condylar head articulates with the skull at the temporomandibular joint (TMJ), allowing for opening and closing of the mouth. Fractures of the mandible can be classified based on the anatomic area of the mandible involved. Symphyseal fractures refer to injury occurring in the midline of the mandibular body (symphysis). The term parasymphyseal fracture is used to describe a fracture just lateral to the midline, but occurring between the two canine teeth. Mandibular body fractures describe injury occurring in the region bounded by the canine tooth medially and the angle of the mandible (where the mandibular body meets the ramus) laterally. Angle fractures involve the posterior body of the mandible near the third molar and can extend posteriorly into the ramus; this is a common location for mandibular fractures as the angle is a natural break point. Another common location for mandibular fractures is the condylar process. The segment of bone connecting the condylar head to the ramus is particularly weak, and subcondylar fractures frequently occur with application of force to the contralateral side (midline impacts may cause bilateral subcondylar fractures).

Evaluation of a mandibular fracture should include a thorough dental examination, noting disruption or loss of teeth and any changes in occlusion. If tooth injury is present or suspected, a referral to a dental specialist is indicated. Gingival or oral mucosal tears are common. Trismus (inability to open the mouth) is often present and can be quantified by measuring the maximal interincisor distance (IID, the distance between the maxillary and mandibular incisors when the patient has opened the mouth as wide as possible). The patient may also exhibit deviation of the mandible to one side when opening the mouth. The entire mandible should be palpated, including the temporomandibular joints, which should be palpated as the patient opens and closes the mouth. The inferior alveolar nerve is a branch of the mandibular division of the trigeminal nerve (V3). It travels within the mandibular bone and provides sensation to the teeth. The mental nerve is a branch of the inferior alveolar nerve that provides sensory innervation to the lower lip and chin. Accordingly, disruption of these nerves due to mandibular fracture can result in hypesthesia or paresthesia of these regions. The preferred imaging modality for mandibular fractures is the orthopantomographic radiograph (panoramic tomograph or Panorex film), which provides excellent visualization of the entire mandible, including the condylar heads.

The approach to treatment of mandibular fractures depends on the extent and location of injury and effect on occlusion. Unilateral, nondisplaced fractures of the condyle or ramus that do not alter occlusion may be managed conservatively. Other fractures typically require intervention to prevent permanent functional impairment. MMF is typically the first step in management; to reapproximate pre-injury occlusion may entail a closed reduction of the fracture. In some cases, leaving the patient in MMF for several weeks is sufficient; however, more complicated cases necessitate open reduction and internal fixation. Typically, this procedure is delayed for 5-7 days after injury to allow edema to subside. In the interim, the patient is kept in MMF and given prophylactic antibiotic therapy to reduce the risk of infection.