Subunit Principles in Midface Fractures: The Importance of Sagittal Buttresses, Soft-Tissue Reductions, and Sequencing Treatment of Segmental Fractures

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Learning Objectives:

After studying this article, the partcipant should be able to: 1. Categorize the patterns of midface fractures and the frequency of associated mandibular and frontal bone and nasoethmoid factures. 2. Assess the patterns for treatment by either anterior or combined anterior and posterior approaches according to the need for facial width correction. 3. Evaluate the most frequent problems and complications observed following complicated facial injury repair and to identify areas where improvement is necessary. 4. Evaluate the kinds of soft-tissue deformity seen following creation of exposures for facial fracture repair and suggest how these deformities may be minimized. 5. Emphasize the frontal bone, the mandible, and intermaxillary fixation as indispensable structures for maintaining stability in complicated facial fracture repairs.

The patterns of midface fractures were related to postoperative computed tomography scans and clinical results to assess the value of ordering fracture assembly in success of treatment methods. A total of 550 midface fractures were studied for their midface components and the presence of fractures in the adjacent frontal bone or mandible. Preoperative and postoperative computed tomography scans were analyzed to generate recommendations regarding exposure and postoperative stability related to fracture pattern and treatment sequence, both within the midface alone and when combined with frontal bone and mandibular fractures. Large segment (Le Fort I, II, and III) fractures were seen in 68 patients (12 percent); more comminuted midface fracture combinations were seen in 93 patients (17 percent). Midface and mandibular fractures were seen in 166 patients (30 percent). Midface, mandible, and nasoethmoid fractures were seen in 38 patients (7 percent). Frontal bone and midface fractures were seen in 131 patients (24 percent). Split-palate fractures accompanied 8 percent of midface fractures. Frontal bone, midface, and mandibular fractures were seen in 54 patients (10 percent).

The midface, because of weak bone structure and comminuted fracture pattern, must therefore be considered a dependent, less stable structure. Its injuries more commonly occur with fractures of the frontal bone or mandible (two-thirds of cases) and, more often than not (>60 percent), are comminuted. Comminuted and pan-facial (multiple area) fractures deserve individualized consideration regarding the length of intermaxillary immobilization. Examples of common errors are described from this patient experience. (Plast. Reconstr. Surg. 103: 1287, 1999.)

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