On soft tissue reconstruction, he said, key steps include extensive irrigation, maintaining any tissue that has any chance of still being viable, and closing the face immediately. “Most important, you need to avoid the home run surgery,” he said. “Early in the war, we tried to reconstruct these people in one setting. And it doesn’t work.”
Explore This IssueMarch 2015
For mandible fractures, he again stressed “occlusion, occlusion, occlusion.” He also said he considers arch bars the gold standard in treatment and stressed the importance of preserving soft-tissue attachments and all bony fragments and using three-dimensional computed tomography for planning.
For midface fractures, again he stressed occlusion and suggested rebuilding from the stable to the unstable points toward the malar eminence. The malar eminence, he said, is the key, since it’s the most prominent projection in the midface.
In cases of secondary traumatic facial soft tissue deformities, it’s important not to let worries about scarring override placement considerations, said William Shockley, MD, chief of the division of facial plastic and reconstructive surgery at the University of North Carolina School of Medicine in Chapel Hill. “The facial and nasal contours are more important than facial scars,” he said. “And the position and orientation of these special facial structures are more important than facial scars.”
The tissues adjacent to the injury contract, causing a pull on the structure, so it’s critical to release or remove the scar that is causing the deformity to get the facial structure back to where it belongs. Once it’s back to its original position, the new defect must be reconstructed with a local flap or full thickness skin graft, for instance. “Don’t allow the secondary defect to deter you from repositioning the facial structure,” he said.
Robert Kellman, MD, professor and chair of otolaryngology and communication sciences at the State University of New York Upstate Medical University in Syracuse, questioned the value of using arch bars in mandibular fractures. He cited studies that concluded that there were no clear differences in outcomes whether or not arch bars were used.
At his institution, arch bars have been used less and less frequently in recent years in cases of non-subcondylar fractures. In 2013, he and his colleagues compared results and found no significant difference in complication rates in cases with arch bars compared to those without. In cases of a single angle fracture, there was no significant difference in the frequency of malocclusion. There was a significant difference, however, in cases with a single angle fracture and a non-angle fracture, with malocclusion in 2.5% of cases in which arch bars were used and in 19% of cases in which they were not.