Post-traumatic Maxillofacial Defects

Definition

Aims of reconstruction

1. Save life and protect airway.
2. Preserve viable tissue and prevent infection.
3. Restore facial skeletal framework.
4. Re-establish occlusion and mandibular continuity.
5. Restore facial height, width, projection, symmetry and contour.
6. Reconstruct oral lining, palate, nasal lining and external skin cover.
7. Restore eye protection, vision, speech, mastication and swallowing.
8. Permit later dental rehabilitation with implants or prosthesis.
9. Achieve acceptable aesthetic appearance with minimum donor-site morbidity.

Classification

1. According to time of presentation

2. According to tissue involved

• Soft-tissue defect
• Bony defect
• Mucosal defect
• Composite defect: skin + mucosa + bone ± teeth ± nerve ± orbit/nose
• Functional unit defect: eyelid, lip, nose, palate, orbit, mandible, facial nerve

3. According to anatomical site

• Forehead and frontal sinus
• Naso-orbito-ethmoid region
• Orbit
• Nose
• Zygomaticomaxillary complex and cheek
• Maxilla and palate
• Mandible
• Lip, tongue and floor of mouth
• Panfacial defects

Initial Management

Flowchart 1. Acute management of severe maxillofacial trauma

PATIENT WITH FACIAL TRAUMA
           ↓
ATLS PRIMARY SURVEY
(Airway with cervical-spine protection, Breathing, Circulation,
Disability, Exposure)
           ↓
Secure airway if threatened
→ suction blood/debris
→ chin lift/jaw thrust
→ nasotracheal/orotracheal intubation when suitable
→ surgical airway if required
           ↓
Control hemorrhage
→ pressure packing / ligation / embolization if needed
           ↓
Assess associated injuries
→ head injury, cervical spine, chest, abdomen, limbs
           ↓
Secondary survey
→ vision, ocular movements, cranial nerves, occlusion,
skeletal mobility, wounds, missing teeth/foreign bodies
           ↓
CT facial bones with 3-D reconstruction
           ↓
Antibiotics, tetanus prophylaxis, analgesia,
irrigation and temporary wound dressing
           ↓
Debridement + stabilization + definitive/staged reconstruction

Assessment and planning

History

• Mechanism, time and force of injury
• Contamination: soil, glass, metal, road debris, firearm material
• Loss of consciousness and associated injuries
• Previous operations or treatment
• Medical illness, smoking, nutrition and drug allergy
• Functional complaints: malocclusion, diplopia, sensory loss, nasal blockage, inability to close eyelids

Examination

• Soft tissue: viability, contamination, avulsion, laceration, tissue loss
• Facial symmetry, contour and vertical facial height
• Eye: visual acuity, pupillary reaction, ocular movement, enophthalmos, diplopia
• Nose: septal hematoma, CSF rhinorrhea, nasal airway
• Oral cavity: occlusion, mobility of maxilla/mandible, mucosal tears, palatal defect
• Neurological: infraorbital, mental and facial nerve function
• Salivary duct injury and parotid injury
• Dental assessment: teeth, periodontal condition and alveolar bone
• Photographs, dental casts and pre-injury photographs when available

Investigations

• Contrast-enhanced CT if vascular injury is suspected
• Fine-cut CT of face with 3-D reconstruction for complex fractures and defects
• Orthopantomogram for mandibular and dentoalveolar injury
• CT angiography if vascularized flap planning is anticipated
• Ophthalmological assessment for orbital injury
• Dental models and virtual surgical planning for complex skeletal reconstruction

Principles of Reconstruction

Flowchart 2. Basic reconstructive sequence

Debridement and irrigation
           ↓
Preserve all viable tissue
           ↓
Restore skeletal framework first
→ reduction and rigid fixation
→ reconstruct facial buttresses
→ restore mandibular continuity and occlusion
           ↓
Obliterate dead space and provide vascularized tissue
           ↓
Reconstruct internal lining
→ oral, nasal, sinus or conjunctival lining
           ↓
Provide external soft-tissue cover
→ primary closure / graft / local flap / regional flap / free flap
           ↓
Functional reconstruction
→ eyelid, lip, palate, nerve, TMJ, dental occlusion
           ↓
Secondary contour correction and dental rehabilitation

Fundamental principles

1. Meticulous debridement
   Remove foreign bodies, dirt, necrotic tissue and nonviable bone, while conserving all viable skin, periosteum, mucosa and bone. In crush injuries, doubtful tissues may declare their viability over 36-48 hours.
2. Early stable skeletal fixation
   Restore the facial skeleton before final soft-tissue contouring. This restores facial dimensions, reduces pain and provides a stable base for later reconstruction.
3. Restore occlusion first in mandibular and midfacial injury
   Dental occlusion is a reliable guide to skeletal reduction. Use maxillomandibular fixation when appropriate, then perform rigid internal fixation.
4. Reconstruct facial buttresses
   Vertical and horizontal maxillary buttresses must be restored to recover facial height, width, projection and resistance to masticatory forces.
5. Replace “like with like”
   • Bone with vascularized bone or bone graft
   • Oral/nasal lining with thin pliable mucosal-type tissue
   • Facial skin with colour- and texture-matched skin
   • Dynamic lip/eyelid tissue with functional tissue whenever possible
6. Provide well-vascularized soft-tissue cover
   Exposed plates, bone, grafts, sinuses and neurovascular structures require vascularized tissue. It reduces infection, promotes healing and permits later revisions.
7. Separate oral, nasal, orbital and cranial cavities
   Failure causes fistulae, chronic infection, speech and swallowing problems, CSF leak, or intracranial complications.
8. Treat the functional units individually
   The eyelid, orbit, lip, nose, palate and mandible have specific functional demands that should not be sacrificed for simple closure.
9. Plan for staged reconstruction
   Severe contaminated, crushed or ballistic defects commonly require staged treatment rather than prolonged unsafe acute reconstruction.

Timing of Reconstruction

Flowchart 3. Choosing immediate versus delayed reconstruction

Is the patient hemodynamically stable and airway secure?
          ↓
        No → damage-control treatment
              → hemorrhage control
              → wound irrigation/debridement
              → temporary stabilization/bridging plate
              → delayed reconstruction
          ↓
        Yes
          ↓
Is wound clean, tissue viable, and defect reconstructable?
          ↓
        Yes → early definitive reconstruction
              → fixation + bone/soft-tissue reconstruction
          ↓
        No / gross contamination / crush injury / infection
          ↓
Serial debridement + antibiotics + temporary stabilization
          ↓
Definitive reconstruction after healthy vascularized bed develops

Indications for early definitive reconstruction

• Clean sharp injury with clearly viable tissue
• Stable patient without major associated injuries
• Early restoration of occlusion and skeletal continuity feasible
• Defect can be covered with healthy vascularized tissue

Indications for delayed or staged reconstruction

• Gross contamination or infection
• Severe crush injury with uncertain tissue viability
• Gunshot or avulsion injury with progressive necrosis
• Hemodynamic instability or severe associated injury
• Extensive soft-tissue edema
• Need for repeated debridement
• Inadequate recipient vessels or poor wound bed

Reconstruction of Specific Defects

A. Soft-tissue defects

Reconstructive ladder

Small clean wound
      ↓
Primary tension-free closure
      ↓ if not possible
Skin graft
      ↓
Local flap
      ↓
Regional pedicled flap
      ↓
Free tissue transfer

1. Primary closure

2. Skin graft

• Split-thickness skin graft: large superficial defects with good vascular bed.
• Full-thickness skin graft: small facial defects where better colour match and less contraction are desired.
• Not suitable for exposed bone without periosteum, bare cartilage, tendon or hardware.

3. Local flaps

• Advancement flap
• Rotation flap
• Transposition/rhomboid flap
• Bilobed flap
• Nasolabial flap
• Cervicofacial flap
• Forehead flap for nasal reconstruction

4. Regional flaps

• Pectoralis major myocutaneous flap
• Deltopectoral flap
• Temporalis muscle/fascia flap
• Supraclavicular flap

5. Free flaps

• Radial forearm free flap: thin, pliable lining or intraoral cover
• Anterolateral thigh flap: large soft-tissue volume
• Latissimus dorsi flap: extensive soft-tissue loss
• Scapular/parascapular flap: broad skin and soft tissue
• Fibula osteocutaneous flap: bone plus skin paddle for mandibular/maxillary composite defects

B. Mandibular defects

Consequences

• Loss of mandibular continuity
• Facial asymmetry and lower facial collapse
• Malocclusion
• Difficulty in mastication, speech and swallowing
• Tongue fall-back and airway compromise in anterior defects
• Salivary contamination and infection
• Deviation towards the defect side if unreconstructed

Classification

• Central defect: canine to canine region
• Lateral defect: body/angle/ramus
• Hemimandibular defect: body, ramus and condyle
• Segmental defect: discontinuity defect
• Defect may involve soft tissue, mucosa, skin, tongue or floor of mouth

Management

Mandibular defect
      ↓
Assess: occlusion, bone loss, soft-tissue loss, contamination,
dentition, condyle involvement
      ↓
Small defect with healthy soft tissue
(< about 5 cm)
      ↓
Rigid fixation ± nonvascularized autogenous bone graft
      ↓
Large defect / composite defect / infected bed /
poor soft tissue / defect > about 5-6 cm
      ↓
Vascularized osseous free flap
      ↓
Restore contour + occlusion + soft-tissue cover
      ↓
Dental implants / prosthetic rehabilitation

Options

• Reconstruction plate alone: temporary bridge in unstable patient or contaminated wound. It is not ideal as a permanent solution due to risk of plate exposure, fracture and facial asymmetry.
• Nonvascularized bone graft: useful in small, well-vascularized, noninfected defects with adequate soft-tissue coverage. Sources include iliac crest, calvarium and rib.
• Vascularized bone flap: preferred for large, composite, infected or poorly vascularized defects.

Common vascularized bone flaps

C. Maxillary and palatal defects

Functional problems

• Oroantral or oronasal communication
• Hypernasal speech
• Nasal regurgitation of food and fluids
• Loss of midface support and facial projection
• Loss of orbital support causing enophthalmos or diplopia
• Defective dentition and mastication

Principles

1. Restore horizontal and vertical maxillary buttresses.
2. Re-establish orbital floor and rim support when involved.
3. Separate oral cavity from nasal and maxillary sinus cavities.
4. Restore palatal surface for speech and swallowing.
5. Restore dental arch and support for future prosthesis or implants.
6. Obliterate dead space with vascularized tissue.

Treatment options

• Small palatal defect: obturator prosthesis or local palatal flap
• Moderate defect: temporalis muscle flap, buccal fat pad flap, nasolabial flap or radial forearm flap
• Large composite maxillary defect: osteocutaneous free flap, such as fibula, scapula or iliac crest flap
• Orbital floor: titanium mesh, autogenous bone graft or patient-specific implant where indicated

D. Orbital and eyelid defects

Priorities

1. Preserve vision.
2. Relieve orbital compartment syndrome immediately if present.
3. Restore orbital volume and bony boundaries.
4. Restore eyelid closure and corneal protection.
5. Correct diplopia and enophthalmos.

Management

• Ophthalmology consultation is mandatory in significant orbital trauma.
• Orbital floor/rim reconstruction uses titanium mesh, bone graft or patient-specific implant.
• Eyelid defects require precise layered repair and canthal support.
• Avoid vertical tension in lower eyelid reconstruction because it can produce ectropion.
• Large defects may need local flaps, forehead flap, temporoparietal fascia flap or free flap.

E. Nasal defects

Components to reconstruct

Nasal defect
   ↓
Internal lining
   + 
Structural framework (cartilage/bone)
   +
External skin cover

Reconstructive options

• Small cutaneous defect: local flap or full-thickness skin graft
• Moderate defect: bilobed flap, nasolabial flap
• Large nasal defect: paramedian forehead flap
• Structural support: septal, auricular or costal cartilage graft
• Lining: septal mucosal flap, turnover flap, nasolabial flap or free flap in major defects

F. Lip and oral commissure defects

Goals

• Oral competence
• Adequate mouth opening
• Speech and articulation
• Sensation and facial expression
• Symmetry of vermilion and commissure

Options

• Small defect: primary layered closure
• Up to one-third lip: local advancement flap
• Larger lower-lip defects: Karapandzic flap, Abbe flap, Estlander flap, Bernard-Burow technique
• Near-total defects: free flap, often with static suspension and later functional revision

Management of Associated Complications

Rehabilitation

Flowchart 4. Long-term rehabilitation

Stable healed facial framework
          ↓
Assess occlusion, mouth opening, speech, swallowing,
vision, airway, appearance and psychosocial status
          ↓
Physiotherapy
→ jaw exercises, scar massage, facial muscle training
          ↓
Speech and swallowing therapy
          ↓
Dental rehabilitation
→ obturator / removable prosthesis / implant-supported prosthesis
          ↓
Secondary refinement
→ scar revision, fat grafting, contour correction, nasal/lid revision
          ↓
Psychological and social rehabilitation

Dental rehabilitation

• Interim obturator for palatal defects
• Removable partial or complete prosthesis
• Implant-supported prosthesis after bone healing
• Orthodontic correction where needed
• Occlusal rehabilitation and TMJ physiotherapy

Conclusion

Life-saving care
→ debridement and infection control
→ skeletal reconstruction and occlusal restoration
→ soft-tissue lining and cover
→ restoration of facial function
→ dental, aesthetic and psychosocial rehabilitation