Immediate Single-Stage Reconstruction of Complex Frontofaciobasal Injuries: Part I

Abstract

Objective To determine if immediate (within 6 hours of adequate resuscitation) single-stage repair of complex craniofacial injuries could be accomplished with acceptable morbidity and mortality taking into consideration the cosmetic appearance of the patient.

Patients and Methods A total of 26 patients (19 men, 7 women) ranging in age from 8 to 58 years with Glasgow Coma Scale scores of 5 to 15 all had a combined single-stage repair of their complex craniofacial injuries within 6 hours of their admission. After initial assessment and adequate resuscitation, they were evaluated with three-dimensional computed tomography of the face and head. Coronal skin flap was used for maximum exposure for frontal sinus exenteration as well as dural repair, cortical debridement, calvarial reconstruction, and titanium mesh placement.

Results Neurosurgical outcome at both the early and late evaluations was judged as good in 22 of 26 patients (85%), moderate in 3 of 26 (11%), and poor in 1 of the 26 (3.8%). Cosmetic surgical outcome at the early evaluation showed 17 of 26 (65%) to be excellent, 4 of 26 (15.5%) to be good, 4 patients (15.5%) to be fair, and 1 patient (3.8%) to be poor. At the late reevaluation, the fair had improved to good with an additional reconstructive procedure, and the poor had improved to fair with another surgery. There was no calvarial osteomyelitis, graft resorption, or intracranial abscess. Complications included three patients (11%): one (3.8%) had tension pneumocephaly and meningitis, one (3.8%) had delayed cerebrospinal fluid leak with recurrent attacks of meningitis, and one had a maxillary sinus infection (3.8%) secondary to front maxillary fistula.

Conclusion The immediate single-stage repair of complex craniofacial injuries can be performed with acceptable results, a decreased need for reoperation, and improved cosmetic and functional outcomes.

Keywords

craniofacial trauma - orbital fracture - titanium mesh

• References

• 1 Theogaraj SD. Management of facial injuries following craniofacial trauma. In: Becker DP, Gudeman SK, , eds. Head Injury. Philadelphia, PA: WB Saunders; 1989: 348
• 2 Gruss JS, Phillips JH. Complex facial trauma: the evolving role of rigid fixation and immediate bone graft reconstruction. Clin Plast Surg 1989; 16 (1) 93-104
• 3 Lauritzen C, Lilja J, Vällfors B. The craniofacial approach to trauma. Ann Plast Surg 1986; 17 (6) 503-512
• 4 Gruss JS. Naso-ethmoid-orbital fractures: classification and role of primary bone grafting. Plast Reconstr Surg 1985; 75 (3) 303-317
• 5 Friedman JA, Ebersold MJ, Quast LM. Post-traumatic cerebrospinal fluid leakage. World J Surg 2001; 25 (8) 1062-1066
• 6 Yilmazlar S, Arslan E, Kocaeli H , et al. Cerebrospinal fluid leakage complicating skull base fractures: analysis of 81 cases. Neurosurg Rev 2006; 29 (1) 64-71
• 7 Dandy WE. Pneumocephalus. Arch Surg 1926; 12: 949
• 8 Wakhloo AK, van Velthoven V, Schumacher M, Krauss JK. Evaluation of MR imaging, digital subtraction cisternography, and CT cisternography in diagnosing CSF fistula. Acta Neurochir (Wien) 1991; 111 (3–4) 119-127
• 9 Nachtigal D, Frenkiel S, Yoskovitch A, Mohr G. Endoscopic repair of cerebrospinal fluid rhinorrhea: is it the treatment of choice?. J Otolaryngol 1999; 28 (3) 129-133
• 10 Patel MR, Shah RN, Snyderman CH , et al. Pericranial flap for endoscopic anterior skull-base reconstruction: clinical outcomes and radioanatomic analysis of preoperative planning. Neurosurgery 2010; 66 (3) 506-512 ; discussion 512
• 11 Burstein F, Cohen S, Hudgins R, Boydston W. Frontal basilar trauma: classification and treatment. Plast Reconstr Surg 1997; 99 (5) 1314-1321 ; discussion 1322–1323
• 12 Francel PC, Persing JA. Microplating and screw systems for cranial bone fixation. Clin Neurosurg Instrumentation, Technique, and Technology 1993; 32 (4) 683-686
• 13 Manson PN, Stanwix MG, Yaremchuk MJ, Nam AJ, Hui-Chou H, Rodriguez ED. Frontobasal fractures: anatomical classification and clinical significance. Plast Reconstr Surg 2009; 124 (6) 2096-2106
• 14 Benzil DL, Robotti E, Dagi TF, Sullivan P, Bevivino JR, Knuckey NW. Early single-stage repair of complex craniofacial trauma. Neurosurgery 1992; 30 (2) 166-171 ; discussion 171–172
• 15 Asano T, Ohno K, Takada Y, Suzuki R, Hirakawa K, Monma S. Fractures of the floor of the anterior cranial fossa. J Trauma 1995; 39 (4) 702-706
• 16 Eftekhar B, Ghodsi M, Nejat F, Ketabchi E, Esmaeeli B. Prophylactic administration of ceftriaxone for the prevention of meningitis after traumatic pneumocephalus: results of a clinical trial. J Neurosurg 2004; 101 (5) 757-761
• 17 Derdyn C, Persing JA, Broaddus WC , et al. Craniofacial trauma: an assessment of risk related to timing of surgery. Plast Reconstr Surg 1990; 86 (2) 238-245 ; discussion 246–247
• 18 Sakas DE, Beale DJ, Ameen AA , et al. Compound anterior cranial base fractures: classification using computerized tomography scanning as a basis for selection of patients for dural repair. J Neurosurg 1998; 88 (3) 471-477
• 19 Katzen JT, Jarrahy R, Eby JB, Mathiasen RA, Margulies DR, Shahinian HK. Craniofacial and skull base trauma. J Trauma 2003; 54 (5) 1026-1034
• 20 Antonelli V, Cremonini AM, Campobassi A, Pascarella R, Zofrea G, Servadei F. Traumatic encephalocele related to orbital roof fractures: report of six cases and literature review. Surg Neurol 2002; 57 (2) 117-125
• 21 Madhusudan G, Sharma RK, Khandelwal N, Tewari MK. Nomenclature of frontobasal trauma: a new clinicoradiographic classification. Plast Reconstr Surg 2006; 117 (7) 2382-2388
• 22 Poole MD, Briggs M. Cranio-orbital trauma: a team approach to management. Ann R Coll Surg Engl 1989; 71 (3) 187-194
• 23 Glover LE, Tajiri N, Lau T, Kaneko Y, van Loveren H, Borlongan CV. Immediate, but not delayed, microsurgical skull reconstruction exacerbates brain damage in experimental traumatic brain injury model. PLoS ONE 2012; 7 (3) e33646
• 24 Miyake H, Ohta T, Tanaka H. A new technique for cranioplasty with L-shaped titanium plates and combination ceramic implants composed of hydroxyapatite and tricalcium phosphate (Ceratite). Neurosurgery 2000; 46 (2) 414-418
• 25 Gear AJL, Lokeh A, Aldridge JH, Migliori MR, Benjamin CI, Schubert W. Safety of titanium mesh for orbital reconstruction. Ann Plast Surg 2002; 48 (1) 1-7 ; discussion 7–9
• 26 Imola MJ, Hamlar DD, Shao W, Chowdhury K, Tatum S. Resorbable plate fixation in pediatric craniofacial surgery: long-term outcome. Arch Facial Plast Surg 2001; 3 (2) 79-90
• 27 Kosaka M, Uemura F, Tomemori S, Kamiishi H. Scanning electron microscopic observations of ‘fractured’ biodegradable plates and screws. J Craniomaxillofac Surg 2003; 31 (1) 10-14
• 28 Mathur N. Orbital fractures: otolaryngology and facial plastic surgery - e medicine, 2007.
• 29 Cohen AJ. Orbital floor fractures (blowout) Treatment and Management, Medscape 2014.
• 30 Bell RB, Markiewicz MR. Computer-assisted planning, stereolithographic modeling, and intraoperative navigation for complex orbital reconstruction: a descriptive study in a preliminary cohort. J Oral Maxillofac Surg 2009; 67 (12) 2559-2570
• 31 Hegazy HM, Carrau RL, Snyderman CH, Kassam A, Zweig J. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. Laryngoscope 2000; 110 (7) 1166-1172
• 32 Scholsem M, Scholtes F, Collignon F , et al. Surgical management of anterior cranial base fractures with cerebrospinal fluid fistulae: a single-institution experience. Neurosurgery 2008; 62 (2) 463-469 ; discussion 469–471
• 33 Casiano RR, Jassir D. Endoscopic cerebrospinal fluid rhinorrhea repair: is a lumbar drain necessary?. Otolaryngol Head Neck Surg 1999; 121 (6) 745-750