Facial injuries most commonly result from fights and road traffic accidents: about two-thirds of people involved in road accidents suffer head and/or neck injuries, many of which create functional, anaesthetic and reconstructive problems. These patients are cared for by plastic surgeons and those specializing in otorhinolaryngology; a brief review of the subject is appropriate here.

The establishment and maintenance of any airway is the primary concern during the initial examination of a patient with severe facial injury. The airway may be compromised following blunt cervical trauma, lacerations of the oropharynx, foreign bodies in the oropharynx, fractures of the larynx, or uncontrolled cervical bleeding. Swelling associated with unstable fractures of the mandible and midface may also compromise the airway. The physician should assess the likelihood of respiratory obstruction and should perform either a prophylactic endotracheal intubation or a tracheostomy to establish the airway. The cervical spine is also often damaged in patients with severe head injuries, and must be protected until adequate radiological examination has been completed.

The identification of cerebrospinal fluid (CSF) leaks is an important part of the examination of patients with midfacial and skull base injuries. Fractures involving the temporal fossa can produce leaks into the frontal and ethmoid sinuses or through the cribriform plate. Temporal bone fractures are also a possible source of CSF leaks. Most leaks resolve spontaneously; they must, however, be identified so that surgical repair can be undertaken if they fail to resolve.

Facial trauma frequently results in severe bleeding and soft tissue injury. Most bleeding can be controlled initially by the application of direct pressure. Definitive control can be gained once the airway is secure. Major nasal bleeding can be controlled by anterior or posterior packing. Open soft tissue injuries should be closed immediately after adequate photographic documentation, inspection for foreign bodies, and debridement has been completed.

The nasal bone is the most frequently fractured bone in the facial skeleton. Patients with nasal fractures present with epistaxis, swelling, external changes of the bony framework, nasal congestion, and periorbital ecchymosis. Physical examination reveals tenderness, mobility, and crepitus on palpation of the bony and cartilaginous framework.

Radiographic images, including anteroposterior, lateral, and submental vertex exposures, confirm the extent of injury and the existence of any injury to the surrounding midfacial bones. Radiological studies should not be used as a substitute for a good nasal examination, and normal results should not over-ride clinical signs and symptoms of fracture. Intranasal examination requires irrigation and suctioning of the nose, to allow diagnosis of common post-traumatic problems such as mucosal tears, fracture dislocations of the nasal septum, and septal haematomas.

Nasal fractures can be treated by either closed or open reduction. Closed reduction is appropriate in patients with minimal displacement and mild swelling. A nasal elevator is used to lift and reduce the fractured bones after administration of appropriate local anaesthetic, including field blocks of the infraorbital nerves. Intranasal packing and extranasal stabilization are required to maintain nasal bone position for 7 to 10 days. Open reduction is indicated for treatment of severe fractures associated with extensive swelling and distortion of the cartilaginous and bony framework. It is also used for the treatment of septal fractures, comminuted nasal fractures, and fractures which have not responded to closed reduction.

Open reduction should normally be delayed until 6 or 8 weeks after the injury, or after the attempt at closed reduction, to allow swelling to subside and to provide time for the evaluation of possible CSF leaks and other injuries. Surgery aims to repair the nasal septum, providing proper elevation and stabilization in a midline position. Once the septum has been appropriately realigned, attention is directed to the nasal dorsum. Osteotomies may be required to allow mobilization of the bony pyramid and adequate fracture reduction. The nasal vault is packed with Surgicel, and an external cast is applied to prevent displacement of the fractures. No attempt to refine the shape of the nasal tip is made immediately after injury; this can be undertaken after 6 to 9 months. Alternatively, nasal repair may be delayed for 6 to 9 months, when traditional rhinoplasty techniques can be used to repair deformity.

The nasoethmoidal region is the weakest part of the facial skeleton, and injuries to this area often result in dislocation of important anatomical landmarks. Characteristic signs and symptoms of nasoethmoidal fracture include depression and widening of the bony nasal pyramid (sometimes in association with a laceration in the same area), infraorbital anaesthesia, subcutaneous emphysema of the cheek and eyelids, diplopia, flattening of the central third of the face, subconjunctival haemorrhage, CSF leaks, and intranasal septal fractures. The clinical suspicion of such fractures must be confirmed by CT scans.

Open exposure and direct wiring or plating are the mainstays of treatment of these fractures. Fresh injuries can be manipulated intranasally or through an existing laceration, and stabilized by direct wiring. Stabilization of the fracture can be combined with exploration of the frontal sinus, and its obliteration if the nasofrontal ducts have been damaged. Attention must be paid to the integrity and stability of the medial canthus, which is commonly detached by fractures in this area.

Fractures of the zygomatic bone (trimalar fractures) usually result from a direct blow to the midfacial region. The zygoma articulates with the frontal bone superiorly, the greater wing of the sphenoid posteriorly, the maxilla medially and inferiorly, and the temporal bone laterally. Clinical signs of zygomatic fracture include infraorbital hypoaesthesia, periorbital ecchymosis, loss of malar prominence, trismus, limitation of eye movement, diplopia, and palpable fractures of the rim of the orbit (Fig. 2) 2399. Ophthalmological examination should be performed to exclude the possibility of associated ocular injuries.

Surgical reduction of zygoma fractures should be undertaken 5 to 7 days after the injury, by which time swelling has subsided and any question of intracranial injury has been resolved. A brow incision allows inspection of the frontozygomatic suture line, a lower lid incision is used to expose the inferior orbital rim, and a gingivobuccal incision is made through which the lateral facial buttress can be examined. The fracture can be manipulated by an elevator placed under the medial zygomatic arch. The reduced fracture should be stabilized with wire or compression plates at three points: the orbital rim, the frontozygomatic suture, and the lateral maxillary buttress. Radiographs taken 2 to 3 days after surgery confirm proper bony alignment and fracture stabilization.

Midfacial fractures can be classified as LeFort types I, II, or III, on the basis of the mobility of the midfacial skeleton. Mobility is assessed by lifting the anterior maxillary arch and observing the movement of the lower maxilla (LeFort I, transverse maxillary), maxilla and nose (LeFort II, pyramidal), or the entire midface (LeFort III, complete craniofacial separation). Although this classification scheme is useful in management and preoperative planning, fractures corresponding to the classic descriptions of each type are rare. CT scans should be obtained as soon as possible after injury to clarify the location of the fractures and to confirm the clinical findings.

Most patients with midfacial fractures have been involved in major road traffic accidents, and concomitant intracranial, intra-abdominal, and airway injuries are common. Many important anatomical areas, including the orbit, skull base, and dental arches, may be affected. The timing of repair of midfacial fractures depends on the general condition of the patient and the degree of facial oedema. Most patients are observed for 3 to 5 days, during which associated neurological, thoracic, ophthalmological and thoracic injuries can be assessed, and a combined surgical approach can be established.

The basic principle of management of midfacial fractures is that the surgeon works from areas of stability superiorly to areas of instability. The key to controlled facial reconstruction is adequate exposure. An incision across the gingivobuccal sulcus provides excellent exposure of the midfacial bones, the nasal spine, and the infraorbital rims. In addition, the frontozygomatic suture can be explored via a brow incision, and the orbital rims and floor can be examined through a subciliary or transconjunctival incision. Initially, occlusion should be established by aligning the lower maxillary dentition in proper relationship to the mandibular dentition. The upper maxilla is stabilized to the cranial base and to the frontal bone superiorly, and inferiorly to the mandibular-maxillary complex. Attention given to these landmarks preserves both the superior-inferior and the anterior-posterior dimensions of the face.

The general plan followed in the reduction and fixation of midfacial fractures is the application of arch bars to the lower and upper oral dentition, the reduction of alveolar ridge fractures, intermaxillary fixation to establish occlusion, the reduction of mandibular fractures, and the realignment and stabilization of midfacial fractures to the craniofrontal skeleton with stabilization of the mandibulomaxillary complex.

The treatment of LeFort I fractures involves placement of arch bars and stabilization of the maxillary segment to the zygometric buttress using miniplates or 24-gauge stainless steel wire. Maxillary fixation for 2 to 4 weeks is recommended, but compression of the maxilla against the cranial base appears to be unnecessary.

LeFort II fractures involve the orbital floors as well as the zygomaticomaxillary buttress and nasofrontal area. Exposure is through a gingivobuccal incision in conjunction with a subciliary incision. Telescoping of the middle third of the face is common, and is reduced by realigning the fracture sites with disimpacting forceps prior to their stabilization. Three-point fixation is required to prevent rotation of the bony fragments.

LeFort III fractures involve the maxilla, zygoma, orbital rims, nasofrontal areas, and the base of the skull. The telescoped midface must be disimpacted and the fractures fixed via exposures through gingivobuccal, subciliary, and brow incisions. The fractures are stabilized with miniplates or 24-gauge wire. If midfacial fractures are not stable from the mandible to the zygomatic suture, suspension wires are necessary to stabilize the midface to the cranial base (Fig. 4) 2401.

Antibiotics should be administered for 7 to 10 days following surgery because of the risk of sinusitis. Tracheostomy may be required when the reconstruction is complete if there is extensive oral and tissue swelling. Arch bars are left in place for 3 to 6 weeks and removed when adequate stabilization has been achieved.

Frontal sinus fractures result from a direct blow to the forehead. Associated injuries include neurological trauma, orbital fractures, LeFort fractures, and nasoethmoid fractures. The anterior, posterior, or inferior walls of the frontal sinuses may be fractured individually, but a combination of fractures is most common. Fractures of the inferior walls often affect the nasofrontal duct. Complications arising from frontal sinus fractures include CSF leaks, meningitis, recurrent sinusitis, mucocele, pyocele, and osteomyelitis of the frontal bone.

The site and extent of injury must be determined. A thorough neurological examination is mandatory, and CSF leaks should be suspected. Plain radiographs should be used as a primary screening method, followed by CT scans to evaluate fully the frontal sinus injury as well as any concomitant intracranial injuries.

Treatment depends on the extent and location of the fracture. Broad-spectrum antibiotics should be administered, and the patient should be observed in hospital for at least 24 h. Non-displaced fractures of the anterior wall can be treated by careful observation. If serial radiographs show a persistent air–fluid level or opacification the sinus should be explored surgically to investigate the integrity of the nasofrontal duct and to exclude the possibility of a CSF leak.

Comminuted, depressed fractures of the anterior wall require open reduction and internal fixation. Fractured fragments can be realigned and stabilized with wire or miniplates at the time of exploration. Autogenous calvarial bone from the temporoparietal area of the outer calvarium can be used as an autograft to reconstruct missing bone.

Fractures of the posterior wall occur in association with injuries to the anterior wall and to the floor of the sinus. Patients often have significant neurological injury. An apparently isolated, non-displaced fracture of the posterior wall with no evidence of CSF leak can be treated by simple observation and serial radiographs.

Extensive injury to the posterior wall, with depressed fragments or a CSF leak, requires surgical exploration. Damage to the nasofrontal duct should be explored through an osteoplastic flap, with careful removal of all injured membrane, packing of the duct, and obliteration of the sinus with abdominal fat. Cranialization of the frontal sinus is indicated when large portions of the posterior wall are missing: the full extent of the posterior wall is removed, allowing the frontal lobe to obliterate the sinus.

Mucoceles and pyoceles often develop following frontal and sinus fractures, sometimes months or years after injury (Fig. 5) 2402,2403. These are treated by osteoplastic flap obliteration.

Initial clinical findings in a patient with mandibular fracture include tenderness over the mandible, a change in dental occlusion, and trismus and hypoaesthesia in the distribution of the inferior alveolar nerve.

Principles of treatment include anatomical reduction of the fracture, attainment of acceptable dental occlusion, and mandibular immobilization. Intermaxillary fixation stabilizes the mandible to the midface, maintains occlusion, and prevents disruption of the fracture line by the force exerted by the muscles of mastication.

Mandibular fractures are classified according to their location, the direction of the fracture line, and the presence or absence of teeth. The direction and angle of a mandibular fracture are rated as either favourable or unfavourable, depending on their relationship with muscle forces acting upon the bone (Fig. 6) 2404. Fractures that run downwards and anteriorly are favourable, because the fragments are pulled together. For the same reason, those running from the lateral surface inwards and posteriorly do not become displaced. Fractures that run downwards in a posterior direction are unfavourable, since the posterior fragment is further displaced by the muscles of mastication. The posterior fragment of fractures that run behind anteriorly and medially tend to be displaced as a result of the medial pull on the proximal segment by the posterior muscle group. A vertical fracture may show a different pattern of displacement.

Compression plating systems are the primary means of correcting mandibular fractures. Compression plates are designed to produce maximum contact and stabilization of the fractures: the need for intermaxillary compression is eliminated, allowing continued motion of the temporomandibular joints. If plating systems are not available, open exposure of the fracture and direct wiring and intermaxillary fixation for 6 weeks is required.