eMedicine Specialties > Plastic Surgery > Facial Fractures

Facial Trauma, Management of Panfacial Fractures

Author: Kris S Moe, MD, FACS, Chief, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine; Clinical Associate Professor of Surgery, Division of Head and Neck Surgery, University of California, San Diego
Contributor Information and Disclosures

Updated: Sep 9, 2009

Introduction

History of the Procedure

The management of panfacial fractures has undergone several changes in the last decade. Plate-and-screw fixation has completely revolutionized the sequence with which panfacial injuries can be managed. The "inside-out, bottom-to-top" approach has been the guiding principle in the management of panfacial trauma. With the advent of rigid fixation, midface reconstruction can precede the fixation of the mandible if adequate bony keys or pillars are restored to ensure proper maxillary positioning.

Initial clinical presentation of a patient with p...

Initial clinical presentation of a patient with panfacial fracture.

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Initial clinical presentation of a patient with p...

Initial clinical presentation of a patient with panfacial fracture.



Postoperative frontal view of patient, demonstrat...

Postoperative frontal view of patient, demonstrating good facial symmetry.

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Postoperative frontal view of patient, demonstrat...

Postoperative frontal view of patient, demonstrating good facial symmetry.

Problem

Panfacial injuries involve trauma to the upper, middle, and lower facial bones. Because such injuries are commonly associated with multisystem injury or polytrauma, treatment often requires a team approach.1,2 After the patient is stabilized, the maxillofacial surgeon’s goals are early and total restoration of the form and function of the patient’s face.1

For information on treatment of more isolated facial fractures, see eMedicine articles Mandible Fractures, General Principles and Occlusion; Mandible Fractures in Children; Maxillary Zygomatic Fractures; and Nasal Fracture Reduction. For additional specific fractures, see related topics in the Facial Fractures section of the Plastic Surgery journal and the Trauma section of the Otolaryngology and Facial Plastic Surgery journal.

Etiology

Panfacial fractures can be caused by various traumatic injuries to the face. According to a 2008 retrospective analysis, the most common causes of facial fractures are assault (36%), motor vehicle collision (32%), fall (18%), sports (11%), occupational (3%), and gunshot wound (2%).3 Motor vehicle collisions and gunshot wounds were found to be significant predictors of panfacial fractures.3

Pathophysiology

In the treatment of a patient with multiple maxillofacial injuries, differentiating injuries that require immediate operative management from those for which the operation can be delayed is critical.2 An immediate operation may be indicated to initially stabilize a patient rather than to provide definitive treatment; therefore, those procedures that require more extensive evaluation are delayed to a later date when the patient is systemically stable. Occasionally, the immediate operation can be the definitive procedure. Immediate initial treatment in patients with maxillofacial injuries is indicated when the following are present:

  • Airway compromise:4,5,6 Airway compromise is common in persons with severe maxillofacial injuries and may require an immediate operation to temporarily reduce the fractured facial bones encroaching on the airway. A surgical airway may be necessary to facilitate later surgical procedures.
  • Severe hemorrhage: Severe bleeding from fractured bony segments also may necessitate immediate surgery to ligate associated major vessels or to reduce the segments and thus control the hemorrhage.
  • Large open wounds: Debride and close large open wounds in a layered fashion early. Wounds that are to be used later for access to repair fractures may be closed in a temporary manner.
  • Coincidental surgical procedure being performed: Occasionally, patients with multiple injuries undergo surgery immediately by another service to treat a concomitant injury. Performing a complete examination, debriding and stabilizing maxillofacial injuries, and even taking dental impressions while the patient is anesthetized may be advantageous. Impressions are taken for study models and may be used to fabricate surgical splints for use in definitive surgery.

Presentation

The surgeon presented with such complex maxillofacial injuries should be alert to the potential for both obvious injuries and occult injuries to other systems of the body. The force necessary to create such severe facial injuries is usually significant enough to cause concomitant injury to the central nervous system, chest, abdomen, pelvis, or extremities.

Start with a detailed systemic examination, using the advanced trauma life support protocol. Proceed to a written description of all maxillofacial injuries, with drawings of both soft and hard tissue injuries. Photographs are an excellent means of documenting the preoperative soft tissue injuries. Once the patient is stabilized systemically, perform a more thorough systematic maxillofacial examination. The clinical findings should correlate with diagnostic radiographic images.

Indications

The indications for surgery in a panfacial trauma are the same as those outlined for each facial unit. Restoration of preinjury facial aesthetics and function is the goal of treatment. Early and total restoration of facial form and function prevents latent cosmetic and functional deficits.

Contraindications

Definitive treatment of maxillofacial injuries can be delayed if the patient has severe, compromising, concomitant systemic trauma. Treatment of facial fractures can be delayed as many as 2 weeks after injury if the fractures do not involve cranial structures.

Operate on patients with neurologic or cranial injuries when they are stable. This allows for correction of blood volume, electrolyte, and nutritional deficits while giving the surgeon time for an accurate evaluation and proper planning of the surgical procedure.

The resolution in facial edema during this time allows for more accurate clinical evaluation and simplifies the surgical procedure. Necessary radiographic imaging studies and consultations can also be obtained during this time. For more information on imaging studies, see Orbit, Fractures in eMedicine's Radiology journal.

More on Facial Trauma, Management of Panfacial Fractures

Overview: Facial Trauma, Management of Panfacial Fractures
Workup: Facial Trauma, Management of Panfacial Fractures
Treatment: Facial Trauma, Management of Panfacial Fractures
Follow-up: Facial Trauma, Management of Panfacial Fractures
Multimedia: Facial Trauma, Management of Panfacial Fractures
References
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References

  1. Wenig BL. Management of panfacial fractures. Otolaryngol Clin North Am. Feb 1991;24(1):93-101. [Medline].

  2. Follmar KE, Debruijn M, Baccarani A, et al. Concomitant injuries in patients with panfacial fractures. J Trauma. Oct 2007;63(4):831-5. [Medline].

  3. Erdmann D, Follmar KE, Debruijn M, et al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg. Apr 2008;60(4):398-403. [Medline].

  4. Caron G, Paquin R, Lessard MR, et al. Submental endotracheal intubation: an alternative to tracheotomy in patients with midfacial and panfacial fractures. J Trauma. Feb 2000;48(2):235-40. [Medline].

  5. Stoll P, Galli C, Wachter R, Bahr W. Submandibular endotracheal intubation in panfacial fractures. J Clin Anesth. Jan-Feb 1994;6(1):83-6. [Medline].

  6. Babu I, Sagtani A, Jain N, Bawa SN. Submental tracheal intubation in a case of panfacial trauma. Kathmandu Univ Med J (KUMJ). Jan-Mar 2008;6(1):102-4. [Medline].

  7. Berardo N, Leban SG, Williams FA. A comparison of radiographic treatment methods for evaluation of the orbit. J Oral Maxillofac Surg. Oct 1988;46(10):844-9. [Medline].

  8. DeMarino DP, Steiner E, Poster RB, et al. Three-dimensional computed tomography in maxillofacial trauma. Arch Otolaryngol Head Neck Surg. Feb 1986;112(2):146-50. [Medline].

  9. Gillespie JE, Quayle AA, Barker G, Isherwood I. Three-dimensional CT reformations in the assessment of congenital and traumatic cranio-facial deformities. Br J Oral Maxillofac Surg. Apr 1987;25(2):171-7. [Medline].

  10. Zide MF, Kent JN. Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg. Feb 1983;41(2):89-98. [Medline].

  11. Kelly KJ, Manson PN, Vander Kolk CA, et al. Sequencing LeFort fracture treatment (Organization of treatment for a panfacial fracture). J Craniofac Surg. Oct 1990;1(4):168-78. [Medline].

  12. Tang W, Feng F, Long J, et al. Sequential surgical treatment for panfacial fractures and significance of biological osteosynthesis. Dent Traumatol. Apr 2009;25(2):171-5. [Medline].

  13. Irby WB. Facial Trauma and Concomitant Problems: Evaluation and Treatment. 2nd ed. St. Louis, Mo: CV Mosby; 1979.

  14. Tullio A, Sesenna E. Role of surgical reduction of condylar fractures in the management of panfacial fractures. Br J Oral Maxillofac Surg. Oct 2000;38(5):472-6. [Medline].

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Further Reading

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Keywords

facial trauma, panfacial fractures, facial fracture, plate and screw fixation, plate-and-screw fixation, facial trauma pictures, facial fracture pictures, facial fracture treatment, facial fracture repair, rigid fixation, midface injury, mid-face injury, midface reconstruction, mid-face reconstruction, panfacial injury, complex maxillofacial injury, panfacial trauma, facial fracture, face fracture, maxillofacial surgery, maxillofacial reconstruction, maxillofacial repair, maxillofacial injury, maxillomandibular fixation, MMF, panfacial fracture, facial trauma, facial fracture management

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Contributor Information and Disclosures

Author

Kris S Moe, MD, FACS, Chief, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine; Clinical Associate Professor of Surgery, Division of Head and Neck Surgery, University of California, San Diego
Kris S Moe, MD, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Society for Head and Neck Surgery, and North American Skull Base Society
Disclosure: Nothing to disclose.

Medical Editor

James F Thornton, MD, Assistant Professor, Department of Plastic and Reconstructive Surgery, University of Texas Southwestern
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Jaime R Garza, MD, DDS, FACS, Consulting Staff, Private Practice
Jaime R Garza, MD, DDS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, Texas Medical Association, and Texas Society of Plastic Surgeons
Disclosure: Allergan Honoraria Consulting

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Deepak Narayan, MD, FRCS, Associate Professor of Surgery (Plastic), Yale University School of Medicine; Chief of Plastic Surgery, West Haven Veterans Affairs Medical Center
Deepak Narayan, MD, FRCS is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Medical Association, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Indian Medical Association, Plastic Surgery Research Council, Royal College of Surgeons of Edinburgh, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

 
 
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