Surgery After Midfacial Trauma continues on p. 8
Surgery After Midfacial Trauma
Facial trauma is frequently encountered in the emergency de- partment and is often the result of motor vehicle accidents or interpersonal violence. Imaging with CT is the current
standard to diagnose fractures of the facial bones as well as to
assess for adequacy of repair following surgery.
The midface is composed of the maxilla, nasal bones, palatine
bone, medial orbital wall, and pterygoid processes, and fractures of
this skeletal unit present unique challenges for surgeons to manage. Le Fort and nasoorbitoethmoidal (NOE) complex fractures as
well as frontal sinus fractures are the most common injury patterns
resulting from midfacial trauma. The goal of repair is geared toward restoring the patient’s premorbid form and function.
There are several surgical disciplines that are involved in the
management of midfacial fractures. Otolaryngologists, oculo-plastic surgeons, facial plastic surgeons, and oral and maxillofa-cial surgeons may all function as lead physician for repair or as
assistants depending on the type and extent of the fracture. This
presents one of the difficulties for interpreting radiologists, as
these specialties all have slightly varying guidelines with respect
to how and when to intervene. Radiologists, therefore, will often
simply provide a laundry list of which facial bones are fractured
in the acute setting or a list of which bones have been repaired in
the postoperative setting on C T because there is confusion as to
what information is truly relevant to the treating surgeon.
Unfortunately, practicing in that manner diminishes the radiologist’s role. This piece provides meaningful information to the
surgeons when interpreting CT studies performed after midfacial fracture repair.
The facial buttress concept refers to struts of bone that are
thicker than the remainder of the facial skeleton and that serve as
a framework for muscles, ligaments, and smaller bones to attach
(Fig. 1). It is critical for these buttresses to be reconstructed appro-
priately following trauma so that the structure and the aesthetics of
the midface are reestablished. Another important consideration
for midfacial fractures is dental function. Diminished masticatory
function secondary to poor occlusal relationships could result if
alignment is not anatomic due to improper healing.
A systematic approach to interpreting postoperative facial
bone C T studies is necessary, identical to the practice of all other
aspects of radiology. For Le Fort fractures, internal fixation is
typically performed for any displaced or comminuted fractures.
Plating at the zygomaticomaxillary buttress and the infraorbital
rim are most commonly performed (Fig. 2). Although all Le Fort
fractures involve the pterygoid plates or pterygomaxillary buttress, this site is not repaired due to inability to obtain access,
and there is no effect on patient outcomes.
NOE fractures undergo surgical correction to prevent posttraumatic telecanthus and to reestablish continuity of the
lacrimal system. These fractures require varying methods of
Michael J. Reiter
Department of Radiology, Stony
Brook University Medical Center
A systematic approach to interpreting
postoperative facial bone CT studies is
necessary, identical to the practice of all
other aspects of radiology.
CT image of normal
adult facial skeleton
nasomaxillary or medial
maxillary (black arrow),
lateral maxillary (blue
or posterior maxillary
(pink arrow). Horizontal
orbital rim (white
arrow), infraorbital rim
or upper transverse
maxillary (yellow arrow),
and maxillary alveolar
rim or lower transverse
maxillary (red arrow).
Fig. 2—Repair of
Le Fort fracture.
A patient who
of bilateral Le Fort II
and right Le Fort III