Abstract
The reconstruction of complex facial trauma poses a significant challenge for plastic surgeons, as it requires a multidisciplinary approach to achieve both functional and aesthetic outcomes. Moreover, it represents a substantial burden on public health. In severe facial trauma, initial management to rule out life-threatening conditions through Advanced Trauma Life Support (ATLS) is crucial. Expertise in soft tissue reconstruction and facial fracture management is essential to achieve good results. New reconstruction techniques include free flaps, grafts, expanders, and epidermal grafts.
Here, we present the case of a 68-year-old male who suffered facial trauma from an aircraft propeller managed through staged reconstructive surgical techniques. We will describe surgical management, emphasizing the methods and outcomes. The primary objective of this study is to provide insights into the clinical challenges and therapeutic strategies in managing severe facial trauma, underscoring the critical importance of an interdisciplinary approach to achieve successful and functional facial reconstruction.
A 68-year-old male patient presented to the plastic and reconstructive surgery department at a secondary-level hospital following facial trauma from an aircraft propeller blade.
Upon arrival at the emergency department, a Computed Tomography (CT) scan was performed, revealing a comminuted exposed displaced fracture of the maxilla, a multifragmented transverse exposed fracture of the palate, a fracture of the right orbit, frontal sinus, ethmoid sinus, sphenoid bone, the bilateral anterior wall of the maxillary sinus, displaced avulsion of the maxilla, composite defect in the floor of the mouth, combined mandibular fracture with bone loss, fracture of the left condyle, loss of the right nose, and traumatic amputation detachment of the central facial structures (Figure 1).
Figure 1. Physical examination upon arrival at the emergency department.
The diagnosis included “comminuted displaced exposed fracture of the maxilla, multi fragmented transverse exposed fracture of the palate, fracture of the right orbit, frontal sinus, ethmoid sinus, sphenoid bone, bilateral anterior wall of the maxillary sinus, displaced avulsion of the maxilla, loss of upper and lower lips, composite defect in the floor of the mouth, combined mandibular fracture with bone loss, fracture of the left condyle, loss of right nose and right medial canthus.”
Initially, a mandibular reconstruction was performed, along with reduction and osteosynthesis of the right and left maxillary para fissure fractures and the palate. Additionally, a fasciocutaneous forehead flap was used for frontal closure, a flap from the right cheek for defect closure and upper-side reconstruction, bilateral fasciocutaneous neck flaps, and a mucosal flap for oral cavity reconstruction (Figure 2).
Figure 2. Fasciocutaneous forehead flap for frontal closure and right cheek flap for facial defect closure with upper side reconstruction.
During his follow-up, he required six additional interventions, including rib grafts on the dorsum of the nose, nasal septum, and nasal wings. Mucosal flaps for internal coverage of the nasal floor and reconstruction of a LeFort III fracture with costal graft in the upper maxillary arch. Also, during his interventions, the medial and posterior walls of the orbital floor were reconstructed with a costal graft fixed with osteosynthesis material. A fasciocutaneous advancement flap was placed on the right cheek, a muscle advancement flap to cover the palate, and a medial lower eyelid flap. For the sixth surgery, the forehead flap pedicle was separated, a nasal dorsum plasty with forehead flap and TAI over in the forehead region (Figure 3).
Figure 3. Forehead flap plasty with right nasal ala plasty, right oral commissure opening comisuroplasty, and upper lip plasty.
At the 4-month follow-up, the patient was scheduled for evaluation to assess the results, as shown in Figure 4.
Figure 4. Results 4 months after discharge.
Discussion
Facial traumas are a common issue in emergency services worldwide. The most common causes include motor vehicle accidents, interpersonal violence, and sports-related injuries, with traffic accidents being the most frequent of the three.1 Bone injuries affect men more (ratio 2:1), while soft tissue injuries are equally distributed between genders.3 Current reconstruction techniques include free flaps, grafts, expanders, and epidermal grafts. Subsequently, a thorough physical examination is essential, considering the location of soft tissue or bone injuries. Tools like trauma protocol computed tomography (CT) scans can help us to determine the non-visible damage.
Initial management of severe facial trauma
The treatment of facial fractures involves restoring and optimizing the facial aesthetic appearance. In most cases, realigning displaced structures and performing interfragmentary osteosynthesis are essential.4
Delayed primary closure
Whenever feasible, primary closure is the preferred treatment for non-complex wounds. It has been demonstrated that delayed closure beyond 24 h is more likely to result in structural and functional deformities. Ideally, closure should occur within 6 h of the initial injury. To minimize infection risk, local wound care and adequate debridement are essential.5 On the other hand, when talking about primary repair, for example, we should consider the primary repair of nasal soft tissues when there is no significant tissue or cartilage loss. Individual layer approximation of nasal layers should be performed separately. When repairing nasal cartilaginous structures, using a longer-acting absorbable suture on a tapered needle, such as polydioxanone, is ideal.
Post-repair management
Appropriate post-repair care is crucial to maintain the integrity of the repair and should be closely monitored to prevent additional tissue loss. Regarding facial fractures and trauma, there is limited evidence on the use of prophylactic antibiotics. Commonly cited indications include open fractures, penetrating injuries, and mandibular fractures.6
Skin grafts
Both partial-thickness and full-thickness skin grafts are viable options for reconstruction. However, this technique has its limitations, as improper use can lead to color mismatch or graft failure. The upper two-thirds of the nose tend to achieve better aesthetic outcomes with skin grafts compared to the highly sebaceous lower third. Ideal donor sites include postauricular, nasolabial, supraclavicular, upper eyelid, and preauricular skin, with the latter being particularly suitable for full-thickness reconstruction of the lower third of the nose.3
Composite grafts
For patients with more profound and full-thickness defects, composite grafts can be used to repair alar rim defects that require vestibular and cartilaginous support. These grafts are seldom used alone and are often combined with other local or regional flaps.
Local flaps
Advancement flaps are most suitable for the nasal dorsum and supra-tip region due to this area's degree of skin laxity. More complex tunneled advancement flaps can also be used for repairing the nasal dorsum, lateral walls, and even supra-tip and tip regions. A key-perforator island flap has been described for reconstructing small (<2 cm) dorsum nasal defects.7
A V-Y advancement flap, when pedicled, has been described as an appropriate repair technique for the tip and supra-tip regions.8 It can also repair nasal root/glabellar defects with good outcomes. A bilobed flap is preferred for nasal defects less than 1.5 cm, as it is ideal for the nasal tip.
Interpolated flaps
The interpolated flap is a reliable technique for addressing defects larger than 1.5 cm and complex defects involving the nasal lining.7 On the other hand, the nasolabial flap is preferred for nasal defects requiring reconstruction of the entire alar subunit, lateral wall, and nasal dorsum.3
Conclusion
Reconstruction of massive facial defects necessitates not only a healthy wound but also the restoration of a normal appearance. Reconstruction focuses on understanding the wound's nature, identifying anatomical layers requiring replacement, and selecting a transfer method to move tissue from donor to recipient sites efficiently. The varied presentations and severity of facial traumas demand plastic surgeons to possess technical skills and conceptual knowledge to effectively address these scenarios, emphasizing the importance of multidisciplinary support.
Additionally, plastic surgeons must manage patient compliance and expectations while providing reliable and cost-effective care.
Yusef Jiménez-Murat, Kevin Fuentes-Calvo, Kenzo A. Fukumoto-Inukai, Rogelio Martínez-Wagner,
Severe facial trauma secondary to aircraft propeller injury: The art of facial reconstruction,