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from Section 20 - Plastic and Reconstructive Surgery
Published online by Cambridge University Press: 05 September 2013
Facial fractures are common problems encountered by the plastic surgeon. The increased incidence of patients with facial fractures is related to the frequency of motor vehicle accidents. Management of these fractures requires a team approach, because patients usually present with multiple injuries. Plastic surgeons must be familiar with the best methods of preoperative assessment and imaging to optimally manage the patient with a facial fracture.
Initial management of severe facial fractures and injuries to the face begins with the ABCs of trauma management. The airway is established via either intubation or tracheotomy. High-velocity injuries as well as mandibular injuries have a high rate of airway compromise requiring urgent intervention. Bleeding is controlled with direct pressure, and a secondary survey is performed to evaluate concomitant injuries.
As soon as the patient is stabilized, the initial treatment starts with a clinical examination that focuses on assessment of soft tissue loss if present, occlusion of the mandible, and evaluation of the sensory and motor nerves. In general, patients with facial fractures have limited evaluation of their bony architecture because of the soft tissue swelling, ecchymoses, gross blood, and hematoma. The face and cranium should be palpated to detect bony irregularities, step-offs, and crepitus. Mobility of the midface may be tested preoperatively by grasping the anterior alveolar arch and pulling forward while stabilizing the patient with the other hand. The size and location of the mobile segment may identify which type of Le Fort fracture is present. A thorough nasal and intraoral examination should be completed. The nasal bones are typically quite mobile in Le Fort II fractures, along with the rest of the pyramidal free-floating segment. Intranasal examination may reveal fresh or old blood, septal hematoma, or cerebrospinal fluid rhinorrhea. The intraoral examination should assess occlusion, overall dentition, stability of the alveolar ridge and palate, and soft tissue.
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