Skin Flaps

Local skin flaps contain tissue lying adjacent to the defect that usually matches the skin at the recipient site in color, texture, hair, and thickness. Flaps should be the same size and thickness as the defect and be designed to avoid distortion of local anatomic landmarks, such as the eyebrow or hairline. They can be planned so that the donor site can be closed directly and usually are elevated with incision lines placed in relaxed skin tension lines. Local flaps rely on the inherent elasticity of skin and are most useful in the older patient whose skin is looser. In some cases, the site from which the flap is raised is closed with a skin graft. Commonly used local skin flaps include the following:

Failure of a skin flap usually involves necrosis of the most distal portion of the transferred tissue. This could be caused by a flap design in which the size of the flap exceeds its inherent vascular supply, or could be a result of extrinsic mechanical compromise of the flap pedicle by pressure from a hematoma, compressive dressings, or twisting or kinking of the flap. Measures to optimize viability include proper flap design and avoiding extrinsic pedicle compression, undue tension with wound closure, and venous congestion caused by excessive flap dependency.

Muscle and Musculocutaneous Flaps

Consideration of a muscle as a potential flap is possible because muscles have independent, intrinsic blood supply. The motor nerves of a muscle are accompanied by an arteriovenous system that often is the major source of blood supply to that muscle. This vascular pedicle may be a dominant one, capable of sustaining the entire muscle independently. A minor pedicle, regardless of the size of the vessel, is defined as one that maintains only a lesser portion of the muscle. Many muscles have multiple unrelated sources of blood supply so that each nourishes only a segment of the muscle, thus called segmental pedicles. Some muscles have both a dominant pedicle and segmental blood supply. One example is the latissimus dorsi muscle with a dominant pedicle, the thoracodorsal artery in the axilla, and additional segmental perforating branches from the intercostal and lumbar vessels posteriorly. In these muscles, the dominant pedicle can be ligated and the muscle moved on the secondary vessels as a reverse muscle flap.

Muscle flaps are classified according to their principal means of blood supply and the patterns of vascular anatomy (Fig. 69-1):

FIGURE 69-1 Classification of muscle and musculocutaneous flaps according to their vascular supply: type I, one vascular pedicle; type II, dominant pedicle and minor pedicles; type III, two dominant pedicles; type IV, segmental vascular pedicles; type V, one dominant pedicle and secondary segmental pedicles.

(From Mathes SJ, Nahai F: Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg 67:177–187, 1981.)

In terms of reliability of the vascular anatomy and usefulness as a flap, large muscles with a recognized dominant pedicle supplying most of a flap (types I, III, and V) are most useful. The territory of the pedicles in type II muscles may vary, and type IV muscles are useful only when smaller flaps are needed. Connections between regions within a given muscle supplied by more than one pedicle are via small-caliber choke vessels with bidirectional flow. An example of a flap depending on these choke vessels is the transverse rectus abdominis musculocutaneous (TRAM) flap, in which the superior epigastric pedicle alone can support the lower half of the muscle normally supplied by the inferior epigastric vessels below the watershed level at the umbilicus. In muscle, venous territories are in parallel with arterial vessels. This means that venous outflow is adjacent to, and in a direction opposite from, flow in the major arterial pedicles. In a pattern analogous to that of the bidirectional choke vessels, venous flow from one territory to another occurs through oscillating veins that are devoid of valves.

Compared with skin flaps, muscle flaps are less bulky, less stiff, and more malleable to conform to wounds with irregular three-dimensional contours. They have more robust blood supply and demonstrate superiority in wounds compromised by irradiation or infection. The vascular anatomy is predictable and easily identifiable, and the muscle can be put into use as a functional unit for a dynamic tissue transfer. A major consideration with muscle flaps is whether the loss of function is acceptable. In an effort to limit the functional loss associated with use of an entire muscle, methods of functional preservation have been devised. If some portion of the muscle chosen as the flap is left innervated and attached at its insertion and origin, function is preserved after transfer of the remainder of the muscle. This can be done by splitting the muscle into segments, provided that each is supplied by a different dominant pedicle. An example is the gluteus maximus, which extends and rotates the thigh laterally. This is not an expendable muscle, but the superior or inferior half of the muscle can be elevated as a flap, with function of the intact half of the muscle preserved.

A musculocutaneus flap, also called a myocutaneous flap, is a muscle flap designed with an attached skin paddle. Each superficial skeletal muscle carries blood supply to the skin lying directly over it through musculocutaneous perforators. The number and pattern of these musculocutaneous perforators varies with each specific muscle; this means that the extent of the skin territory is different for each muscle unit. Through dissection of injected cadaver specimens, the number, size, and location of musculocutaneous perforators have been described; this information, combined with clinical experience, is used to predict the cutaneous territories on the superficial muscles.

In addition to the musculocutaneous branches supplying the overlying skin, source vessels, also called mother vessels, branch within muscle into channels that perforate the deep fascia to anastomose within the subdermal plexus and nourish the skin. The source vessel and its perforating muscular branches can be dissected out of the muscle without jeopardizing skin perfusion. This requires intramuscular dissection to separate the perforators from the muscle and is the basis for the development of muscle perforator flaps. This makes the retention of muscle unnecessary for the survival of the skin paddle; thus, its inclusion serves a passive role, primarily to avoid tedious intramuscular dissection of the vascular tree. To spare the muscle unit, a growing number of muscle perforator flaps have been described, including the deep inferior epigastric perforator flap, which carries the same skin and subcutaneous tissue as the TRAM flap for breast reconstruction. By sparing the rectus muscle, abdominal wall bulging and other complications are less likely. The superior gluteal artery perforator flap (SGAP) carries the skin territory of the gluteus maximus musculocutaneous flap and preserves the muscle.

Fascia and Fasciocutaneous Flaps

Growing knowledge about musculocutaneous skin circulation has led to the identification of vascular pedicles emerging between muscles, traveling in the intermuscular septum, and entering the deep fascia. Termed septocutaneous perforators, these vessels supply the fascial plexus, which gives off branches to an overlying cutaneous territory. Some state that a fasciocutaneous flap, by definition, should include a specific known septocutaneous perforator. Others accept a less strict definition of a fasciocutaneous flap as a skin flap including the deep fascia.

The anatomic features of a fasciocutaneous flap are the fascial feeder vessels, also called the fascial perforators, which are branches of source vessels to a given angiosome. An angiosome is the three-dimensional block of tissue supplied by a source artery; the entire surface of the body is comprised of a multitude of angiosome units. The fascial feeder vessels do not perforate the deep fascia, but terminate within the fascial plexus. The fascial plexus is not a structure but is a confluence of multiple adjacent vascular intercommunications that exist at the subfascial, fascial, suprafascial, subcutaneous, and subdermal levels (Fig. 69-2).

FIGURE 69-2 Pathways of the various known cutaneous perforators that pierce the deep fascia to supply the fascial plexus. S, Source vessel; X, deep fascia.

(From Hallock GG: Direct and indirect perforator flaps: the history and the controversy. Plast Reconstr Surg 111:855–865, 2003.)

The concept of fasciocutaneous flaps arose from the observation that the size of a skin flap could be increased if it were oriented along a longitudinal axis on the extremity, and if the deep fascia were included. Subsequent anatomic studies have confirmed the presence of septocutaneous pedicles supplying a regional fascial vascular system. The larger septocutaneous pedicles tend to be fairly constant in location and a number of specific fasciocutaneous flaps have come into wide use (e.g., anterior lateral thigh flap, radial forearm flap, scapular flap).

The design of fasciocutaneous flaps has been learned by experience and the limits of these flaps still remain to be discovered. There are no set rules, because deep fascial perforators are frequently anomalous in caliber and location, not only among individuals but also on opposite sides of the same person. The expected range of flap size is learned through the experience of other surgeons.^1,2

One of the most useful features of a fasciocutaneous flap is that it can be distally based. Unlike a muscle flap, in which the dominant pedicle is closest to the heart, blood flow in the fascial plexus is multidirectional. The flow to the corresponding angiosome is equivalent for a distal fascial perforator and proximal facial perforator. This means that a flap pedicle can be distally based with a reliable skin territory and transposed to cover a defect located at the end of an extremity. For example, the distal-based sural flap uses the skin of the calf, based on a distal perforator of the peroneal artery, for transfer to cover the foot and ankle. Obviating the need for a free microvascular transfer, this has become a standard for foot coverage.

In addition to the advantages provided by a distally based flap design, a fasciocutaneous flap can confer sensibility if a sensory nerve is included. Compared with musculocutaneous flaps, they are accessible on the surface of the body, and have the great advantage that no functioning muscle is expended. The comparative disadvantages are the anatomic anomalies in the fascial vascular system and the unanswered question as to whether they are as effective as muscle in the radiated or infected wound.

Perforator Flaps

Perforator flaps evolved as an improvement over musculocutaneous and fasciocutaneous flaps. They rely on evidence that neither a passive muscle carrier nor the underlying fascial plexus of vessels is necessary for flap survival, provided that the musculocutaneous or fasciocutaneous vessel is carefully dissected out and preserved. Advantages of perforator flaps include preservation of functional muscle and fascia at the donor site and versatility of flap design with regard to including as little or as much bulk tissue as required. Disadvantages are the difficult dissection needed to isolate the perforator vessels, longer operating time associated with this dissection, anatomic variability of position and size of perforator vessels, short pedicle length available, and fragile nature of these small blood vessels.

A perforator is a blood vessel passing through the deep fascia and contributing blood supply to the fascial plexus. Perforators arise from a source, or mother, vessel to a given angiosome. There are direct and indirect perforators. Direct perforators are those that travel directly from the mother vessel to the plexus; these include septocutaneous and direct cutaneous branches. Indirect perforators supply other deep structures on their route from the mother vessel to plexus (e.g., the musculocutaneous perforator passing through muscle).

The nomenclature of perforation flaps is not yet standardized. They are named variably by location (anterolateral thigh flap), arterial supply (deep inferior epigastric artery perforator flap), and muscle of origin (the gastrocnemius perforator flap). They are described as cutaneous, musculocutaneous, septocutaneous, fasciocutaneous, composite, and chimeric; the last is a perforator flap with two separate muscular components with a common vascular source. Several suggestions for an ordering nomenclature have been made.

Because of the small size of the vessels and their anatomic variability, Doppler ultrasound is used routinely to locate the perforators before perforator flap elevation. This is not highly accurate and other technologies such as color flow duplex scanning and thermography may be useful in the future. Technical recommendations for harvesting a perforator flap include identification of at least one vessel with a diameter of 0.5 mm or more, inclusion of at least two or more perforators, sufficient pedicle length for the procedure, and preservation of a subcutaneous vein to use for venous outflow in situations in which the deep system of perforator veins proves anomalous.

The use of perforator flaps continues to evolve. Current work includes flap thinning, a technique for removing excess adipose tissue from the perforator flap as it is raised. This would provide a large delicate segment of vascularized skin for reconstruction in areas such as the ear, in which contour is important. Another innovation is the discovery of new flaps based on perforators smaller than 0.8 mm in diameter found superficial to the fascial plane. By eliminating the dissection needed to trace a perforator through the muscle, operating time is shortened and there is potential for developing a much larger number of suitable flaps. The challenge with these suprafascial free flaps is the supermicrosurgery needed for anastomoses in such small vessels.³

Supermicrosurgery

The introduction of supermicrosurgery, which allows the anastomosis of smaller caliber vessels and microvascular dissection of vessels ranging from 0.3 to 0.8 mm in diameter, has led to the development of new reconstructive techniques. Free perforator-to-perforator flaps using suprafascial vessels can be transferred more quickly and the tissue can be obtained from better concealed parts of the body.⁵ If a discrete perforator can be identified anywhere on the body, a flap can be designed around it. This has been called a “freestyle flap.” The constraints of using only described territories can be disregarded and the donor site selected solely on the basis of the best possible match for color, contour, and texture at the recipient site. Disadvantages are the anatomic variation of the perforators and the need for supermicrosurgical technique. The latter includes the use of 12-0 nylon sutures with 50- to 30-µm needles; the surgeons who pioneered “freestyle reconstruction” have noted that it is difficult to learn and can be tedious.⁶

Congenital Ear Deformities

Congenital anomalies of the external ear may occur in isolation or as part of craniofacial microsomia. Common external ear deformities include prominent ears, constricted ears, cryptotia (failure of the upper pole of the ear to stand out from the head), and microtia (a small and/or abnormally formed outer ear). The most common type of microtia is a malformed vestigial cartilaginous structure associated with a soft tissue component of lobule. In cases of isolated microtia, there is often conductive hearing loss associated with absence of the external auditory canal. This is most important in bilateral cases in which a bone-anchored hearing aid is required.

Reconstruction of typical microtia can take two general approaches, autologous or nonautologous. Nonautologous reconstruction involves placement of a high-density polyethylene implant under the skin. This approach results in good form without the need to harvest tissue from another site or the requirement of shaping a framework. Disadvantages include the presence of a foreign body that may become exposed through the thin skin envelope, is susceptible to infection, and is difficult to salvage in case of complications. The second approach is preferred. This involves the use of autologous tissue (rib cartilage) to shape an ear framework, which is then buried in a subcutaneous pocket. The meticulous shaping of the framework, creation of a thin skin pocket, and use of drains allows the skin to contour around the intricate framework. The procedure requires multiple stages but results in a reconstructed ear that has good form and is capable of responding to trauma and infection like other parts of the body. The disadvantage is the need to harvest cartilage from the rib.

Craniofacial Microsomia

Craniofacial microsomia, also known as hemifacial microsomia, is a constellation of abnormalities involving deficient development of parts of the face related to the first and second branchial arches.⁸ Deformity can be unilateral or bilateral and can involve the orbit, mandible, external ear, facial nerve, and facial soft tissue. Each or all of the structures may be involved and to varying degrees. The cause is unknown but is thought to be related to in utero vascular compromise of the stapedial artery. Treatment of craniofacial microsomia is complex and the approach has to be tailored for individual patients. Functional problems such as airway compromise or eye exposure are treated in childhood; reconstruction of other structural defects is delayed until the patient is almost full-grown.

For patients with craniofacial anomalies such as those described, as well as those with cleft lip and palate, the current standard is team care at an established craniofacial center. With referral to a craniofacial center at birth, the craniofacial team can make a diagnosis, carry out genetic testing, educate the family, and outline short- and long-term plans in a coordinated manner, bringing in multiple specialists (e.g., plastic surgeons, neurosurgeons, oral surgeons, orthodontists, speech pathologists, otolaryngologists, ophthalmologists, social workers, nurse practitioners, developmental psychologists, pediatricians).

Cleft Lip and Palate

Cleft lip and palate are relatively common congenital anomalies. They may be unilateral or bilateral. Most are isolated anomalies, but many syndromes have clefts as one of the features. The genetics of cleft lip and palate is complex and the condition is multifactorial. The pathophysiology of cleft lip and palate is incompletely understood, but the deformity and its variations are well described. A minimum of three operations, and usually four, will be required to correct the deformity. These are performed at specific times corresponding to the developmental stage of the patient:

A cleft lip is characterized by a partial or complete lack of circumferential continuity of the lip. Most cleft lips occur at a typical location in the upper lip where one of the philtral columns normally lies, and they extend into the nose. The deformity involves the mucosa, orbicularis oris muscle, and skin. The nasal deformity is characterized by a slumped and widened ala (nostril) that is posteriorly misplaced at its base. The nasal floor is nonexistent in complete clefts and the nasal septum is deviated.

There are many techniques for repair of a cleft lip, but most are a variation of the rotation advancement repair. Millard introduced this technique of downward rotation of the medial portion of the lip and advancement of the lateral portion into the defect created by the rotation. The repair is based on the principle that existing elements need to be returned to their normal position to restore the normal anatomy while remaining cognizant of future growth and the effects of surgery on growth (Fig. 69-4).⁹

FIGURE 69-4 Infant girl with a wide, left-sided, unilateral complete cleft lip and palate. A, Preoperative view shows the deformity—a wide cleft and absence of the nasal floor, malrotated central lip element, twisted premaxilla, and nasal deformity. B, Intraoperative markings for rotation-advancement cleft lip repair at age 3 months. C, Immediate postoperative views. D, Postoperative views at 11 months of age taken at the time of cleft palate repair.

Cleft palate can also be complete or incomplete. The goals of palatal repair are the development of normal speech and prevention of regurgitation of food into the nose. Normal speech requires velopharyngeal competence to close the oral cavity off from the nasal cavity to produce pressure consonants. This requires static physical separation of the two cavities in the region of the hard palate and dynamic closure of the soft palate against the posterior pharyngeal wall with a functioning levator veli palatini muscle. In a cleft palate, the levator veli palatini muscle fibers are oriented abnormally along the cleft. Thus, all modern techniques of cleft palate repair involve repair of the nasal lining, oral mucosa, and reorientation and repair of the levator veli palatini muscle. The primary measure of outcome of cleft palate repair is normal speech. The third procedure necessary in most cases is alveolar bone grafting. Cancellous bone, usually from the ilium, is used to restore bony continuity along the dental arch as a foundation for dental implants for missing teeth associated with the cleft, close a nasolabial fistula, if present, and produce support for the nose.

Other procedures are indicated for some patients, but this generally cannot be predicted in infancy. Approximately 15% of patients will continue to demonstrate velopharyngeal insufficiency after initial palate repair and secondary palatal lengthening or other approaches to promote velopharyngeal closure are indicated, typically after 3 years of age.¹⁰ Septorhinoplasty is usually necessary to correct residual nasal deformity in the teenage years after final dental restoration and orthodontics. A subset of unilateral cleft lip and palate patients will develop maxillary hypoplasia that is iatrogenic and related to scarring and growth retardation from lip and palate surgery. Depending on the degree of maxillary hypoplasia, LeFort I maxillary advancement in the teenage years may be indicated. In sum, treatment of a child born with a cleft lip and palate does not end after palate repair, but rather requires observation by a craniofacial team throughout development into adulthood and must be tailored for each individual.

Emergent Management

Surgical emergencies in the facial trauma patient include airway compromise, life-threatening hemorrhage, and reversible structural injury to the eye or optic nerve. Other injuries such as lacerations or extraocular muscle entrapment are treated within the first 24 hours. Fractures are treated within the first 2 weeks. Evaluation of the facial trauma patient follows advanced trauma life support (ATLS) protocol and includes looking for intracranial trauma and cervical spine injury. Acute airway compromise usually occurs in the setting of combined mandibular-maxillary trauma, with hemorrhage and soft tissue swelling. Endotracheal intubation should be attempted and need not be avoided because of concern about the facial injury. Nasotracheal intubation is contraindicated in the case of severe naso-orbitoethmoid and skull base fractures. Cricothyroidotomy is performed if oral or nasal endotracheal intubation is unsuccessful, and should be converted to tracheostomy after the patient has been stabilized. Maxillomandibular fixation by itself is not an indication for tracheostomy because endotracheal intubation may be maintained via the nasal or oral route using an armored tube that can be routed behind the molars without kinking. An alternative technique is to exit the endotracheal tube through a submental incision, which alleviates some of the practical difficulties of working around an oral tube.

Life-threatening hemorrhage, defined as 3 U of blood loss or hematocrit below 29%, occurs in a small percentage of facial trauma patients. In most cases, bleeding is effectively controlled with pressure, packing and, in the case of significant soft tissue avulsion, the rapid placement of temporary bolster sutures. Blind attempts to clamp and ligate vessels should be avoided because this is usually unnecessary and may result in injury to critical structures, such as the facial nerve. With penetrating trauma, hemorrhage is controlled in the operating room with vessel identification and ligation and, if unsuccessful, by angiographic selective embolization. With blunt trauma, severe hemorrhage is usually from the internal maxillary artery. The most effective way to control bleeding, especially when it is associated with midfacial fractures, is fracture reduction and stabilization. This can be accomplished quickly by temporary placement in maxillomandibular fixation using rapid techniques such as fixation screws. Severe hemorrhage from skull base and nasoethmoid fractures can often be controlled with anteroposterior nasal packing. Placement of Foley balloon catheters in each nasal airway serves to tamponade the bleeding and also stabilizes the packing. Current protocols for control of hemorrhage in blunt facial trauma settings involve selective angiography if these measures fail (Fig. 69-5).¹² Angiographic embolization is effective but is associated with significant morbidity, including the possibility of stroke or necrosis of midfacial structures such as the palate. In unstable patients, fracture reduction and nasal packing may be attempted on the angiography table to be followed immediately with embolization, if necessary.

FIGURE 69-5 Algorithm for the management of life-threatening hemorrhage in the setting of blunt facial trauma.

(Adapted from Ho K, Hutter JJ, Eskridge J, et al: The management of life-threatening haemorrhage following blunt facial trauma. J Plast Reconstr Aesthet Surg 59:1257–1262, 2006.)

Injuries to the orbit and contents can result in blindness; it is critical to recognize promptly and treat reversible injuries that are vision-threatening. Conditions that require emergent intervention include increased intraocular pressure, globe rupture, and optic nerve impingement. Acute increased ICP is manifested by pain and vision loss and can result from causes such as hematoma or decreased orbital volume because of fracture or a foreign body. Treatment involves rapid alleviation of intraocular hypertension by lateral canthotomy and administration of mannitol, acetazolamide (Diamox), and steroids. Urgent ophthalmology consultation is indicated. Vision loss may result from mechanical compression of the optic nerve. Computed tomography (CT) will diagnose the presence of a bone fragment or foreign body; such a finding should prompt emergent surgical decompression to preserve vision. Extraocular muscle entrapment presents as the inability to move the eye on the trajectory controlled by the entrapped muscle and is associated with pain on attempted motion. Especially in children, the pain may be severe and accompanied by nausea or vomiting. Muscle entrapment should be treated by surgical release of the entrapped contents. This should be done fairly soon after injury because delaying the treatment of entrapment for 1 week or longer after injury typically results in failure of the entrapped muscle to regain excursion.

Evaluation and Diagnosis

The primary diagnostic studies for facial injury are physical examination and CT. Systematic physical examination can detect deformity, soft tissue injury, cerebrospinal fluid (CSF) leak, and facial nerve injury. Palpation is used to identify bony stepoffs or midface instability. The eyes are examined for proptosis or enophthalmos, extraocular muscle function, and visual acuity. In patients who cannot cooperate with a physical examination and for whom there is reasonable suspicion of periorbital injury, a forced duction test should be performed. The occlusion is evaluated for subjective or objective malocclusion. Extraocular muscle entrapment, acute enophthalmos, and malocclusion are indications that surgical treatment of facial fractures will be required. Fine-cut CT of the face with direct or reformatted coronal and sagittal views is used to diagnose facial trauma and direct nonsurgical and surgical treatment (Fig. 69-6). With current CT scanning technology, plain films are not necessary and provide less information. An exception is the Panorex, which is used by many physicians as an adjunct or primary study for mandible fractures and to assess teeth and their roots in particular.

FIGURE 69-6 Three-dimensional reconstruction of a fine-cut facial CT scan of a patient who sustained severe injuries in a sledding accident. A, Arrows clockwise from top show (1) massive orbital floor blowout fracture, (2) severely displaced zygoma, (3) displaced LeFort I fracture causing malocclusion. B, Lateral preoperative view showing the presence of a naso-orbitoethmoid fracture as well (arrow). C, D, Postoperative CT scan shows reduction of the fractures and fixation with titanium plates and screws. Cranial bone grafts were used to reconstruct the left lateral maxillary buttress. The orbital floor was repaired using a Medpor implant (Stryker, Newnan, Ga) containing embedded titanium mesh.

Soft Tissue Injuries

Because of its rich blood supply, even questionable tissue should be salvaged when treating facial lacerations and avulsions. The robust perfusion of facial tissue provides resistance to infection and repair can be done after a longer delay than would be safe elsewhere on the body. Although there is no strict cutoff, generally primary repair is done up to 24 hours after injury. Even grossly contaminated wounds or those from animal bites are irrigated extensively, débrided, and closed primarily. If there is the possibility of facial nerve injury, this is confirmed by the physical examination revealing weakness or absence of function of a portion of the muscles of facial expression. It is important to recognize a facial nerve laceration so that the distal cut ends can be identified with a nerve stimulator and tagged if they are not to be repaired immediately. Identification of distal stumps by nerve stimulation is not possible after a few days because conduction ceases. Parotid duct injuries should be identified and treated acutely to prevent the formation of sialocele or salivary fistula. In a sharp laceration or penetrating injury to the cheek, a parotid duct injury can be confirmed by direct visualization or injection of dye. This is done by cannulating Stensen’s duct on the mucosal surface of the cheek and injecting a small amount of methylene blue dye. Extravasation of the dye into the wound indicates a parotid duct laceration and repair over a stent should be done in the operating room.

Craniofacial Fractures

Current concepts in facial fracture treatment rest on craniofacial techniques to provide surgical exposure of the craniofacial skeleton, anatomic reduction of fractures, rigid bony fixation with low profile, titanium plates, and bone-grafting techniques. Failure to reconstruct the bony facial skeleton invariably results in shrinkage and tightening of the facial soft tissue envelope, a sequela that is almost impossible to correct secondarily.

Treatment of forehead fractures involves assessment of the frontal sinus and cranial base. The approach is dictated by injury to the anterior or posterior table of the frontal bone or skull base, and whether there is a dural injury or injury to the nasofrontal ducts that drain the frontal sinuses into the nose. Fractures of the upper midface include malar (zygoma) fractures, naso-orbitoethmoid fractures, and orbital fractures. There is considerable overlap in this region. For example, malar fractures occur in association with orbital fractures to a varying degree because the zygoma, in addition to producing cheek projection and determining facial width, is also part of the orbit. Treatment of fractures of the lower midface, the maxilla, focuses on the restoration of the preinjury dental occlusion. It is important to determine the patient’s preoperative occlusion; the relationship of the upper and lower teeth is described by the Angle classification.

Maxillary fractures are classified using the LeFort system based on the level at which the midface is separated from the rest of the craniofacial skeleton. Repairs focus on the restoration of facial height and projection. With significant comminution or bone loss, bone grafting may be required to maintain the appropriate position of the maxilla in space. Rigid plate and screw fixation obviates the need for prolonged maxillomandibular fixation. Fractures of the mandible are treated by reduction and rigid fixation using restoration of occlusion as the principle intraoperative and postoperative goal. Many mandibular fractures are treated with open reduction and internal fixation, which may make maxillomandibular fixation unnecessary.¹³ Certain fractures, however, are best treated closed, and the decision to pursue an open or closed approach depends on the fracture location and orientation.

The same principles of fracture repair apply in the pediatric patient, with some differences; early treatment within 1 week is necessary given the rapid healing in children, and fixation is complicated by the presence of permanent teeth embedded in the maxilla and mandible that are easily damaged by hardware. Resorbable hardware is frequently used for children but does not have the mechanical strength required for the most adult fractures.