Bradley Robertson

blindness after Reduction of Facial Fractures

&NA; Blindness in patients suffering maxillofacial trauma is usually caused by optic nerve or optic canal injuries. It is, however, an uncommon complication of facial trauma, with a reported incidence of only 2 to 5 percent.1–6 Blindness may also follow surgical repair of facial fractures. Many mechanisms, such as intraoperative direct nerve injury,7 retinal arteriolar occlusion associated with orbital edema,8–11 or delayed presentation of indirect optic nerve injury sustained at the time of the initial trauma,12 have been implicated in causing this blindness. In this article, four cases of visual loss after surgical repair of facial trauma are reported. In a review of the University of Maryland Shock Trauma experience with facial trauma over 11 years, we discovered that 2987 of the 29,474 admitted patients (10.1 percent) sustained facial fractures, and that 1338 of these fractures (44.8 percent) involved one or both of the orbits. One thousand two hundred forty of these patients underwent operative repair of their facial fractures. Three patients experienced postoperative complications that resulted in blindness, a total incidence of only 0.242 percent. Postoperative ophthalmic complications seem to be primarily mediated by indirect injury to the optic nerve and its surrounding structures. The most frequent cause of postoperative visual loss is an increase in intraorbital pressure in the optic canal. When our data were added to the summarized cases, blindness was attributable to intraorbital hemorrhage in 13 of 27 cases (48 percent). In addition, 5 cases in our review attribute the visual loss to unspecified mechanisms of increased intraorbital pressure, bringing the total cases of visual loss caused by intraorbital pressure or hemorrhage to 18 of 27 cases, or 67 percent. Within the restricted confines of the optic canal, even small changes in pressure potentially may cause ischemic optic nerve injury. (Plast. Reconstr. Surg. 102: 1821, 1998.)

Subunit principles in midface fractures: the importance of sagittal buttresses, soft-tissue reductions, and sequencing treatment of segmental fractures.

The patterns of midface fractures were related to postoperative computed tomography scans and clinical results to assess the value of ordering fracture assembly in success of treatment methods. A total of 550 midface fractures were studied for their midface components and the presence of fractures in the adjacent frontal bone or mandible. Preoperative and postoperative computed tomography scans were analyzed to generate recommendations regarding exposure and postoperative stability related to fracture pattern and treatment sequence, both within the midface alone and when combined with frontal bone and mandibular fractures. Large segment (Le Fort I, II, and III) fractures were seen in 68 patients (12 percent); more comminuted midface fracture combinations were seen in 93 patients (17 percent). Midface and mandibular fractures were seen in 166 patients (30 percent). Midface, mandible, and nasoethmoid fractures were seen in 38 patients (7 percent). Frontal bone and midface fractures were seen in 131 patients (24 percent). Split-palate fractures accompanied 8 percent of midface fractures. Frontal bone, midface, and mandibular fractures were seen in 54 patients (10 percent). The midface, because of weak bone structure and comminuted fracture pattern, must therefore be considered a dependent, less stable structure. Its injuries more commonly occur with fractures of the frontal bone or mandible (two-thirds of cases) and, more often than not (>60 percent), are comminuted. Comminuted and pan-facial (multiple area) fractures deserve individualized consideration regarding the length of intermaxillary immobilization. Examples of common errors are described from this patient experience.

Traumatic optic neuropathy: a review of 61 patients

The outcome of traumatic optic neuropathy was evaluated following penetrating and blunt injuries to assess the effect of treatment options, including high‐dose steroids, surgical intervention, and observation alone. Factors that affected improvement in visual acuity were identified and quantified. Sixty‐one consecutive, nonrandomized patients presenting with visual loss after facial trauma between 1984 and 1996 were assessed for outcome. Pretreatment and posttreatment visual acuities were compared using a standard ophthalmologic conversion from the values of no light perception, light perception, hand motion, finger counting, and 20/800 down to 20/15 to a logarithm of the minimum angle of resolution (log MAR). The percentage of patients showing visual improvement and the degree of improvement were calculated for each patient group and treatment method. Measurements of visual acuity are in log MAR units ± standard error of the mean. Patients who sustained penetrating facial trauma (n = 21) had worse outcomes than patients with blunt trauma (n = 40). Improvement in visual acuity after treatment was seen in 19 percent of patients with penetrating trauma compared with 45 percent of patients with blunt trauma (p < 0.05). Furthermore, patients with penetrating trauma improved less than those with blunt trauma, with a mean improvement of 0.4 ± 0.23 log MAR compared with 1.1 ± 0.24 in blunt‐trauma patients (p = 0.03). The patients with blunt trauma underwent further study. There was no significant difference in improvement of visual acuity in patients treated with surgical versus nonsurgical methods; however, 83 percent of patients without orbital fractures had improvement compared with 38 percent of patients with orbital fractures (p < 0.05). The mean improvement in patients without orbital fractures was 1.8 ± 0.65 log MAR compared with 0.95 ± 0.26 in patients with orbital fractures (p = 0.1). Twenty‐seven percent of patients who had no light perception on presentation experienced improvement in visual acuity after treatment compared with 100 percent of patients who had light perception on admission (p < 0.05). The mean improvement in patients who were initially without light perception was 0.85 ± 0.29 log MAR compared with 1.77 ± 0.35 in patients who had light perception (p < 0.05). There were no significant differences in improvement of visual acuity when analyzing the effect of patient age and timing of surgery. Patients who sustain penetrating trauma have a worse prognosis than those with blunt trauma. The presence of no light perception and an orbital fracture are poor prognostic factors in visual loss following blunt facial trauma. It seems that clinical judgment on indication and timing of surgery, and not absolute criteria, should be used in the management of traumatic optic neuropathy. (Plast. Reconstr. Surg. 107: 1655, 2001.)

Limb salvage of lower-extremity wounds using free gracilis muscle reconstruction.

&NA; An extensive series reviewing the benefits and drawbacks of use of the gracilis muscle in lower‐extremity trauma has not previously been collected. In this series of 50 patients, the use of microvascular free transfer of the gracilis muscle for lower‐extremity salvage in acute traumatic wounds and posttraumatic chronic wounds is reviewed. In addition, the wound size, injury patterns, problems, and results unique to the use of the gracilis as a donor muscle for lower‐extremity reconstruction are identified. In a 7‐year period from 1991 to 1998, 50 patients underwent lower‐extremity reconstruction using microvascular free gracilis transfer at the University of Maryland Shock Trauma Center, Johns Hopkins Hospital, and Johns Hopkins Bayview Medical Center. There were 22 patients who underwent reconstruction for coverage of acute lower‐extremity traumatic soft‐tissue defects associated with open fractures. The majority of patients were victims of high‐energy injuries with 91 percent involving motor vehicle or motorcycle accidents, gunshot wounds, or pedestrians struck by vehicles. Ninety‐one percent of the injuries were Gustilo type IIIb tibial fractures and 9 percent were Gustilo type IIIc. The mean soft‐tissue defect size was 92.2 cm2. Successful limb salvage was achieved in 95 percent of patients. Twenty‐eight patients with previous Gustilo type IIIb tibia‐fibula fractures presented with posttraumatic chronic wounds characterized by osteomyelitis or deep soft‐tissue infection. Successful free‐tissue transfer was accomplished in 26 of 28 patients (93 percent). All but one of the patients in this group who underwent successful limb salvage (26 of 27, or 96 percent) are now free of infection. Use of the gracilis muscle as a free‐tissue transfer has been shown to be a reliable and predictable tool in lower‐extremity reconstruction, with a flap success and limb salvage rate comparable to those in other large studies. (Plast. Reconstr. Surg. 106: 1507, 2000.)

Footprints of the globe: a practical look at the mechanism of orbital blowout fractures, with a revisit to the work of Raymond Pfeiffer.

Multiple mechanisms of orbital blowout fractures have been proposed since the fracture was described at the beginning of this century. The original theory of direct globe-to-wall contact was abandoned long ago for the more contemporary hydraulic and bone conduction theories. Although the more widely accepted theories play an obvious role in fracture generation and its associated complications, it is our contention that direct globe-to-wall contact is an important and largely unrecognized mechanism in orbital blowout fracture production. By means of a critical review of the historical literature and an analysis of patient computed tomography scans, support is presented for the original theory first proposed by Raymond Pfeiffer in 1943.

HIGH-ENERGY BALLISTIC AND AVULSIVE INJURIES A Management Protocol for the Next Millennium

This article discusses high-energy ballistic and avulsive injuries, which are a formidable challenge to the reconstructive surgeon. Management protocols are provided for the next millennium.

The MCFONTZL classification system for soft-tissue injuries to the face.

A review of the literature and case records reflected a need for the development of a clinically applicable assessment scheme and classification system for soft-tissue laceration injuries to the face. Herein, a systematic approach for assessing facial lacerations is proposed based on location, depth of penetration, branching, directionality, size, presence of soft-tissue defect, and translation of such injuries into the current procedural terminology (CPT) code. Moreover, a new classification system for facial laceration injuries is presented that may serve as the basis for simplification of current billing codes. Prospective clinical application of this classification system may lead to standardization of facial injury assessment and improvement in the incomplete and inconsistent patient record. This system will establish a reliable database that may identify factors in soft-tissue injuries that contribute to poor aesthetic results or secondary functional deformities. These data will lead to the modification of established treatment plans.

Transverse glabellar flap for obliteration/isolation of the nasofrontal duct from the anterior cranial base.

Management of fractures involving the nasofrontal duct region of the frontal sinus has focused on preserving function when possible or obliterating the sinus and duct when fracture patterns potentiate ductal obstruction and possible transcranial seeding of bacteria. When frontal sinus preservation is in doubt, controversy surrounds the use of cranialization versus obliteration, and the method of obliteration. Perioperative and late postoperative infections are uncommon, but their occurrence jeopardizes an often complex reconstruction and can be life threatening. This paper describes the design and indications for a pedicled transverse glabellar muscle flap for obliteration of the nasofrontal duct, thereby isolating the anterior cranial base from the aerodigestive system. This vascularized muscle flap utilizes the corrugator supercilii and procerus muscles, which are introduced into the sinus via a small, surgically created window in the superomedial orbital wall without disturbing the central facial aesthetic contours. Six patients with comminuted fractures at the nasofrontal duct level associated with displaced posterior frontal sinus fractures have been treated with the transverse glabellar flap. Follow-up ranges from 8 to 30 months. There have been no early or late postoperative complications. The transverse glabellar flap is a reliable and versatile method of partitioning the upper aerodigestive tract from the anterior cranial base with vascularized tissue, thus minimizing the risk of infectious complications. The resulting donor site deformity is more acceptable than that seen with the traditional pedicled galeal frontalis flap.

The occipital bar and internal osteotomies in the treatment of lambdoidal synostosis.

Lambdoidal synostosis results in unilateral or bilateral deformities. Patients with this diagnosis often present with moderate to severe deformities at a relatively late period in development. This late presentation limits the options for treatment and methods for correction. Occipital bar advancement and internal osteotomies provide an accurate, reliable, and quantitative method to treat the deformity. This technique addresses the variable degree of asymmetry and the large flattened bony segments. It was performed in 12 patients over 18 months, with good to excellent results.

The edentulous Le Fort fracture.

A retrospective review of 328 Le Fort fractures has identified 20 (6.1%) of these fractures as edentulous. A review of treatment of the patients was conducted. Conservative (nonsurgical treatment methods) and classic open reductions produce aesthetic and functional results that lead to posterior and oblique positioning of the maxillary occlusal segment in comminuted fractures. Attention to positioning the maxilla by relating it to the mandible through maxillomandibular fixation minimized these deformities. Establishing maxillary-man-dibular relationships in edentulous fractures, therefore, seems to have the same importance as establishing occlusion in dentulous patients as an important initial step in the treatment of comminuted Le Fort fractures.