TRAUMA RECONSTRUCTION
High velocity transportation, the sharp
rise in the number of motorcycles and the lack of compliance of motorists
to regarding seat-belt laws have resulted in a sharp increase in the
number of facial injuries seen today.
The initial repair of facial injuries carried out as
soon as possible after the accident gives the patient his best chance for
an optimal result with the least amount of deformity and sequellae, before
bones have healed in unfavorable positions and soft tissue injuries have
resulted in extensive scarring.
In the era prior to the development of craniofacial
surgery, the treatment of facial injuries was, by necessity, significantly
more conservative than it is today.
The bones were approached through limited incisions and
manipulated into an approximately normal position where they were
suspended with wires from the higher, non-fractured bony structures. This
approach required long periods of immobilization and frequently resulted
in unstable results with residual deformity and functional sequellae.
As the techniques of craniofacial surgery have become
more widespread, the surgical approach to facial injuries has radically
changed. Three dimensional CT scanning and magnetic resonance imaging
allow for a much more accurate evaluation of the injuries. Surgical repair
is carried out early. The fracture sites are widely dissected and exposed.
The fractured bones are then replaced under direct vision in their normal
position, where they are firmly fixed by means of a system of specially
designed small metal plates and screws. Where bone fragments are too small
or missing, immediate bone grafting with pieces of bone taken from the
skull is used to fill the defects.
The use of intermaxillary fixation (wiring the jaws
together) is minimized, and optimal occlusion is assured by early
involvement of the orthodontist.
It should be emphasized again that repair of injuries of
the facial skeleton can (and should be) carried out concomitantly with
repair of intracranial injuries by the craniofacial team, the
craniofacial/plastic surgeon working along with neurosurgeon. There is no
need to wait for long periods of time for the patient to become «stable»
at which point it may already be too late to obtain a good result.
Matters are quite different when one is faced with an
established deformity. Evaluation is again carried out by means of 3 D-CT
as well as MRI when necessary. Repair is then carried out by means of a
combination of osteotomies. Segments of bone that have healed in bad
position are cut, replaced and fixed if possible in their original
position. Alternatively bone grafts are obtained from different parts of
the body and placed over the areas where bone is missing or where the
projection of he bony skeleton is deficient. Deformities of the soft
tissues such as excisions and revisions of scars are also carried out. The
results of a delayed repair can seldom be as good as when carried out
during the initial post-accident period.
