• POST TRAUMATIC SECONDARY DEFECTS

    The unavailability of proper timely treatment to patients with facial trauma for various reasons can create critical secondary defects in them. Successful repair of skeletal injuries require proper understanding of mechanics of injury and the macro and micro anatomy of facial region. Only a maxillo facial surgeon, due to his extensive and vast training in this part of the body, can thoroughly understand the intricacies of facial skeleton which is more complicated than many other parts of the body can set together this jig saw puzzle satisfactorily without compromising on function and facial esthetics.

    Orbital Fractures

    Orbital fractures are extremely complicated and can result from direct or indirect facial trauma. Sudden increase of pressure on the orbit walls due to an impact can lead to the fracture of orbital floor.

    Post Traumatic Secondary Defects

    Orbital fractures need surgical treatment if:

    1. The fractures cause entrapment of the extra ocular muscles of the eye, which leads to diplopia or double vision.
    2. The fracture causes sagging of orbital contents, causing enophthalmos, a condition of backward or downward recession of the eyeball within the orbit.
    3. The fracture causes changes in visual acuity or loss of vision.

    Treatment of these fractures should be performed at the earliest possible for better results. Orbital contents would be accessed through subciliary or transconjunctival incisions which leave no scar on the face and the impaired orbital contents are raised out of fracture line. If required, any graft material like bone, cartilage, titanium plate or others is implanted on to the defect site to provide firm support to the sagging orbital contents.

    Nasoethmoid Complex Fractures

    Nasoethmoid complex is a structure of paired nasal bones in which ethmoid labyrinth separates the orbits from the nasal cavity. This kind of facial fracture is characterized by clinical symptoms such as flattened nasal bridge, epistaxis (bleeding from the nose), double vision, CSF rhinorrhea (leaking of brain’s liquid through nose) and nasal swelling and forehead lacerations. After direct examination of the complex, fracture site is exposed to repair cranial base, frontal sinus, nasal dorsum and other injured structures like medial canthal ligament of the eye (the support structure of the eye which maintains the shape of the medial corner of the eye). The identification and repositioning of medial canthal ligament into its actual position is mandatory.

    Zygomatic Complex Fractures

    Zygomatic complex fractures include zygomatic arch fracture, infraorbital rim fracture, frontozygomatic buttress and zygomaticomaxillary buttress.

    It is also referred to as tripod fracture. Its symptoms and indications for surgery include periorbiatal edema, flattening over arch, deformed zygomatic buttress, enophthalmos, orbital floor recession, restricted mandibular movements, fracture displacement etc.

    The goals of surgical treatments are to restore normal shape of face, stable fixation of reduced fragments, remove mandibular interferences, diplopia or double vision correction and to remove infraorbital nerve pressure.

    Towel clip reduction, endoscopic management and gillie's approach are advanced surgical strategies found effective for zygomatic complex fractures. In gillie's approach, an incision is made behind the temporal hairline and temporal fascia is exposed. The advantage is the incision will stay hidden in the hairline leaving no visible facial scar. Then an elevator is placed very deep in fascia to reduce arch fracture.

    Maxillary Fractures / Upper Jaw Fractures

    These fractures are also called Le Fort fractures or midface fractures. They usually arise from high-velocity trauma like road traffic accidents. Maxillary fractures are classified into three, namely, Le Fort I, Le Fort II and Le Fort III. These fractures result in loss of facial dimensions in all three planes of space resulting in flattening of mid face region. The entire upper jaw can be pulled backwards and downwards due to unopposed muscle pull and this results in severe changes in the bite position of the teeth making it impossible for the patient to open his mouth or chew the food. Maxillary fractures can cause severe airway compromise and blindness also. It causes the separation of maxilla from the skull base. Fracture of the pterygoid plate is common to all kinds of Le Fort fractures. The aim of the treatment is to restore original contour of the facial skeleton and reestablish the dental occlusion and other facial functions. Open reduction and fixation is needed for treating maxillary fractures.

    Mandibular Fractures / Lower Jaw Fractures

    Fractures of lower jaw are one of the most common among facial bone injuries and can occur as an isolated fracture or as a part of multiple facial bone fractures (Pan facial fractures). These fractures can be quite devastating in terms of acute pain and limitations of functions like inability to chew, speak and swallow. Sometimes they might cause airway obstruction too. The earlier these fractures are managed the better would be the outcome. The fractures will be treated by open reduction and internal fixation methods.

    How facial bone fractures are managed or what is open reduction and internal fixation?

    Unlike other parts of the body which is generally covered by clothing or hidden, the face is exposed and therefore any minor scar or deformity on the face is quite visible. Face stands for our identity and reflects our state of mind with its various expressions and movements. Derangement of any of these due to trauma can be extremely distressing and psychologically depressing.

    While managing facial bone fractures the maxillofacial surgeons are trained not to inflict any further scars on the face with their incisions. They approach most of the facial skeleton by placing the incisions in the hidden parts of the face like from inside the mouth, inside the eye or within the hair line. Once the fracture site is opened, the bones will be aligned to their proper position and fixed using titanium plates which are minute in nature. These plates will remain on face for the rest of the life of the patient and generally not to be removed. They can be neither seen externally nor felt when face is touched.

    Salivary Gland Tumors

    Salivary glands are responsible for producing saliva which is very important for food digestion, maintaining oral hygiene and lubrication and protection of oral cavity. There are major and minor salivary glands located around oral cavity which ultimately opens into mouth through various ducts. Like any other gland or organ, salivary glands can also be afflicted by tumors. These tumors can be either malignant or benign. Mostly they are benign in nature and will present as a slow growing mass on the face just below the ear lobule or in the upper part of the neck below the lower jaw or in the palate. When identified and diagnosed in time, they can be surgically treated by removing the diseased portion of the gland. If neglected they can overgrow or can spread to other parts of the body and can become life threatening or locally extremely disfiguring.

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