Post traumatic residual deformities

© Ramaiah University of Applied Sciences

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Faculty of Dental Sciences

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Post traumatic residual deformities

-ZEESHAN ARIF


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Contents

• Introduction

• Post traumatic scars

• Nasal deformities

• Naso – orbital deformities

• zygomatic complex

• Malocclusion(maxilla and mandible)

• Conclusion

• References


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Introduction

• For a variety of reasons, trauma patients can experience

unsuccessful initial management and the associated

morbidities of a post-traumatic craniofacial deformity that

would benefit from secondary correction.

• Experienced surgeons recognize the challenge of restoring

premorbid form and function to patients with established

deformities after craniofacial trauma


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The factors that lead to persistent deformities after craniofacial

trauma include

• severe comminution (especially that which requires bone

grafting)

• lack of definitive treatment

• excessively delayed initial treatment

• inadequate initial surgical repair


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Types of residual deformities

• Post traumatic scars

• Nasal deformities

• Naso – orbital deformities

• zygomatic complex

• Malocclusion(maxilla and mandible)


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Scar

• Scars are areas of fibrous tissue (fibrosis) that replace

normal skin after injury.

• A scar results from the biological process of wound repair in

the skin and other tissues of the body.


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Facial esthetic unitsRelaxed skin tension lines


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Assesment of existing scar

Types of scars

• Good scar- a desirable scar should be inscospicuous with the

face at rest as well as in the dynamic situation.

• It should be flat, the same color, as the surrounding skin,

soft, narrow, and oriented in the same direction as the

resting skin tension line

• Bad scar- is raised or depressed, hyper- or hypo pigmented,

wide and crossing the resting skin tension line


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• Depressed scar- runs

perpendicular to the resting skin

tension line as a result of wound

closure under tension

• Hematoma formation, wound

infection and inverted wound

closure are the common causes

of a depressed scar


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• Curved scar- healing of a curved scar will

produce contraction along the scar, causing a

purse string effect resulting in a trapdoor

appearance

• Stitch marks- tensionless

suturing;subcutaneous suturing; use of skin

hooks rather than forceps; fine sutures(7/0)

and early removal (3 days)


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• Step off deformities- result of inaccurate epidermal closure.

Dermal abrasion and resurfacing with the help of lasers.

• If the step is more than 1mm, resuturing is preferred

• Painful scar- entrapment of a nerve ending in the scar results

in a painful scar. If analgesics are not effective the scar should

be re-explored and the nerve should be cut and allowed to

retract to the muscle layer and sutured again


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Treatment options

Simple excision

• elliptical fashion

• peripherally undermined to facilitate

closure

• reapproximated with sufficient dermal

suturing to ensure wound-edge eversion.

• adequate eversion will help prevent

formation of a depressed scar following

wound contracture during healing.


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Subcision

• management of depressed scars that may have resulted

from insufficient wound-edge eversion or excessive scar

contraction during healing.

• circumferential insertion of a hypodermic needle into a

depressed scar, followed by a gentle lifting maneuver to

elevate the overlying epidermal tissue from the underlying

dermis.

• pain, swelling, bruising, hyperpigmentation, and hematoma

formation can occur if the procedure is carried out too

vigorously or if needle penetration traverses too deeply


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Preoperative anterior and bird’s-eye views. (C, D) The same views showing improvement in the early postoperative stage


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• Z-plasty -transposition of 2 triangular

flaps to reorientate a scar.

• It is ideal for scars that cause

functional impairment or are

perpendicular to the resting skin lines

because it changes the direction of the

scar band completely.

• The central component of the Z must

encompass the scar, and the other 2

limbs are designed so that the final

flaps are as parallel to the resting skin

lines as possible


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W-plasty

• The major indication for W-

plasty is a long scar that is

not orientated perpendicular

to the skin tension lines.

• The main advantage of W-

plasty is that it does not

increase the overall length of

the scar, unlike Z-plasty.


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Dermabrasion involves sanding of the scar using a high-speed

rotary device.

• It is performed down to the level of the papillary dermis, which is

recognized by looking for pinpoint bleeders.

• When dermabrading a raised scar, pinpoint bleeding occurs

almost instantaneously; therefore, care must be taken when

performing this procedure.

• treating raised scars as well as atrophic or pitted scars acne pits

• Dermabrasion in dark-skinned individuals can cause significant

dyspigmentation that may be permanent.


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Laser resurfacing

• Carbon dioxide ultrapulse laser remains the gold standard.

• Laser resurfacing effectively removes the entire epidermis and upper

dermis and can stimulate significant neocollagen formation.

• Laser resurfacing is indicated in flat scars


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Posttraumatic facial soft-tissue volume deficiency

volume-restorative techniques include

• adjacent transfer of tissue

• free transfer of tissue

• prosthetic or alloplastic volume replacement


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Timing of Large or Composite DefectsRequiring Microvascular Free Tissue Transfer

• After initial management and stabilization, the first step is

establishment of the soft-tissue envelope with the best

possible soft-tissue closure.

• Debulking and vestibuloplasty may take place 6 weeks or

later following the initial flap placement.

• If a second debulking is required, the surgeon should wait at

least 6 months, and up to a year, after the first procedure to

allow for full contracture and atrophy, of both subcutaneous

fat and any accompanying muscle.


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Local rotational and advancementflaps

• Local flaps may be vascularized by specific vessels (ie, the supratrochlear

artery for the paramedian forehead flap)

• In general, the thickness and quality of the tissue adjacent to an avulsed

defect is similar to that of the missing tissue

• The lips and oral aperture are another location amenable to this type of

treatment when tissue is avulsed or necessarily surgically debrided early

on.

• In some cases, for example with cheek defects, a facial artery

musculomucosal flap may be indicated.


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Free Tissue Transfer

• When viable tissue is needed and local tissue is insufficient, not

indicated, or undesirable, free tissue may often restore volume

and structure in a lasting way.

• such as in radial forearm flaps for lip reconstruction

• these techniques restores form and function


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Full-Thickness Skin Grafting

• Grafting of free tissue may also take the form of full-thickness skin grafts and

fat grafting.

• Fullthickness skin grafting provides a good match for soft-tissue tone, quality,

and thickness.

• For skin replacement, if rotational flaps are not available or provide

incomplete coverage, a skin graft may be obtained.

• Excellent graft may be obtained from the preauricular and postauricular areas

in many individuals.


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Structural fat transfer

• Intermediate level soft tissue volume may be regained via fat

transfer

• Effective means of adding bulk to atrophied areas as well as

smoothing out irregularities.

• It may be used in conjunction with subcision of depressed scars

or in recontouring larger defects, such as temporal hollowing


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Complications of structural fat grafting

• Overcorrection

• Undercorrection

• surface irregularity

• graft migration

• infection.


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Soft-Tissue Fillers

• Examles -nonanimal stabilized hyaluronic acids, such as

Restylane and Juvederm.

• improve the appearance of scars

• sterile, and can be injected at various levels in the dermis and

subdermal level for the desired effect.

• Surgeons should consider these materials as adjuncts available

for use when contemplating minor revisional procedures


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A) Frontal scar that became depressed after healing. Treatment was injection of hyaluronic acid (B).


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Vascularized Free Tissue Transfer

• Composite volume deficit more commonly occurs secondary to

high-velocity ballistic injuries or high-energy trauma.

• In this case, skin as well as muscle and/ or bone may be lost.

• Free tissue transfer may be used only for soft tissue.

• Free flaps may be used to reconstruct the lips, especially the

lower lip.


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• The radial forearm flap with palmaris longus tendon transfer

may be used to create a new lower lip and restore oral

competence.

• Radial forearm flaps may also provide definitive orbital

coverage following enucleation.

• Similarly, anterolateral thigh flaps may be used when a larger

amount of soft tissue is required for coverage.


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Alloplastic and prostheticreconstruction of soft-tissue defects

Auricular prosthesis used for reconstruction following traumatically avulsed ear. The prosthesis is retained by 2 craniofacial implants


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• titanium mesh

• porous polyethylene (ie, Medpor)

• PEEK (poly ether ether ketone)

• implants such as Medpor, silicone, and PEEK may be custom-

modeled from computed tomography scans to match the

patient’s individual bony contours and provide a facial profile

mirroring the contralateral side.


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NASAL DEFORMITIES

• Saddle nose

• Short nose

• Nasal deviation

• Columellar retaction

• Management


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Common traumatic nasal deformities

Saddle nose

• Lack of structure in nasal

dorsum (bone/cartilage)

• Scooped out appearance –

lateral view

• Flat nasal bridge – frontal

view


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Short nose

• Reduced distance from nasion to

tip

• Obtuse nasolabial angle

• Over-rotated nose

• Weakning of the lower cartilages,

detachment of the upper lateral

cartilages from the nasal bone


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Nasal deviation

• Nasal dorsum or deviated tip

• Deviation from the glabella

to the tip of the cupids bow

• Because of deviation of one

or both nasal bone

• Collapse of an ipsilateral

lateral cartilage


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Columellar retraction

• Normal distance from ala to base of

the columella is 2mm

• With trauma the columellar show can

decrease due to the retrodisplacement

of the caudal septum

• Direct blow at the base of the nose

• Increased columellar show- upper and

middle vault collpase


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Grafting of nasal dorsum

• Repair of saddle nose deofmity

• Bone/cartilage grafts

• Cartilage grafts- smaller deformities- septum, ear or rib

• Septal cartilage has the advantage of being right in the

surgical field and offers a larger amount of graft material as

only a cm of dorsal and caudal cartilage must be retained for

adequate dorsal support in traditional septal harvest


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• Auricular cartilage- harvesting of the concha

through a postauricular incision is rapid

and produces less morbidity

• The curved shape of this cartilage may or

may not be beneficial depending on the

defect

• For nasal tip this is most useful

• For long straight grafts of the dorsum this is

not the first choice


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• Costal cartilage offers large amount of

donor tissue

• 8th and the 9th rib harvest sites are curved

and cannot provide a long straight graft

• Bending the graft by scoring the

perichondrium or completely removing it

makes it straight intraoperatively but

postopertively memory and recoil

• A K wire can be placed in the grafts to

make it straight post operatively

• Unpredictable Resorption


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• Autogenous bone grafts

offer greater support and

augmentation that is used

in larger defects

• Rib

• iliac crest

• calvarium


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• Alloplastic materials- silicone

rubber, mersiline mesh, Gore-Tex,

medpore

• Silicone rubber- high excrusion

rate and not used these days

• Mersiline – resorb over the years

• Gore – Tex- most commonly used


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Spreader grafts

• Deformity of the middle nasal vault will lead to nasal

obstruction as well as airway obstruction due to the collapse of

the internal nasal valve

• With significant dorsal septal deflections where scoring of the

septum is inadequate, spreader grafts are used unilaterally


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Osteotomies

• Correction of deformities of the

nasal bone

• Closure of an open roof deformity,

straightening of a deviated nasal

dorsum and narrowing of the nasal

side walls

• Infracture one or both nasal bones

(more stable)


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NASO – ORBITAL DEFORMITY

Residual deformities due to NOE

Reconstruction of nasal base and orbito nasal angle

Bone grafting

Canthopexy

Reconstruction of nasal passage

Dacryocystorhinostomy


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• If untreated or inadequately

treated NOE injury not only

leads to residual deformity of

nasal crest but also:

• Orbito nasal angle

• Dystophy to medial canthus

• Alteration to continuity of

lacrimal passage

• Reduction in the patency of

nasal airway


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Reconstruction of the deformity


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Bone graft

• existence of many

multiple fragments makes

it impossible to divide

these by osteotomy

• complete resection

• bone graft


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Canthopexy

• Whether the MCL been cut across, avulsed or displaced with

the frontal process, it must be reinserted or repositioned

• Technique by Tessier et al 1962


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Dacryocystorhinostomy

• Repositioning of the medial

canthal-bearing fragment is the

first step in any reconstruction of

the lacrimal system.

• Once this has been

accomplished, reconstruction of

the lacrimal system can be

performed.


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ZYGOMATIC COMPLEX RESIDUAL DEFORMITIES

Signs and symptoms

Enopthalmous

Epiphora

Removal Or Reposition of malunited fragments

Inlays and onlays


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Symptoms and clinical findings

• In case of trauma the zygomatic complex bone may be:

Broken or dislocated

Soft tissue torn ,squeezed, strangulated

Clinical sign and symptoms

Facial asymmetry

Dislocation of eyeball

Diplopia

Enopthalmous

Paresthesia of infraorbital nerve


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• Enophthalmos is common due to increased orbital volume or

herniation of orbital contents through defects in the orbital

walls, usually inferior or medial


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Enopthalmous management

• Expose the fracture sites

• Reduce/refracture

• Rigidly fix ZMC (3 point fixation)

• Free any herniated tissue

• Graft/plate any defects

• Perform FDT before closure

• Close in layers


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Removal Or Reposition of malunited fragments

• If intercuspation and occlusion appear to be unaltered by the

trauma , if no abnormal ophthalmological findings can be

detected and the overall symmetry and harmony of face is

undisturbed , no major osteotomy is indicated

• If a visible bony step at the orbital rim is present it should be

removed surgically through an lower eyelid incision

• Orbital floor is explored subsequently so as not to overlook any

undiagnosed adhesions


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Inlays and onlays

• If the only pathological finding in a patient is either a downward

displacement of the globe or asymmetry of the malar

prominences, contour restoration with implants is preferred

• Depending on the size of the graft, this is placed on zygoma using

infraorbital or an intra oral approach


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• Onlay grafting-mild cases of

malar asymmetry and can

usually be carried out easily

through a lower eyelid incision.

• Calvarial bone, bone substitutes

or alloplastic implants may be

used


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POST TRAUMATIC MALOCCLUSION

• It is present following malunion of any fracture that directly or

indirectly involves the alveolar segments of the maxilla or

mandible.

• The introduction of ORIF makes direct anatomical segment

reduction the primary aim.

• If this is achieved, a normal occlusion should automatically follow.

• Infection of mandibular fractures, particularly those involving the

tooth-bearing segment of the mandible or angle, may result in

non-union, malunion and segment displacement with

malocclusion.


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Maxilla

Indications

• In order to correct occlusal abnormalities due to maxillary

malunion, Le Fort I osteotomy is indicated.

• Osteotomy at Le Fort II or III level, or variations of these

procedures tailored to the individual needs of the patient,

may be required in some instances where simultaneous

correction of midface deformity is necessary.

• Le Fort I osteotomy is therefore indicated for most cases of

maxillary occlusal abnormality, when segmental or one-

piece maxillary repositioning is necessary.


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• Once the correct maxillary position is established, any

significant bony gaps or deficiencies are bone grafted.

• These insure union, stability and support for the overlying

soft tissues of the cheek.

• the use of bone grafts in Le Fort I osteotomies to correct

posttraumatic occlusion is uncommon due to the relatively

small movements involved


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Mandible

• Malunion of fractures behind the tooth-bearing segment of the

mandible result in displacement of the whole dentoalveolar

arch.

• Severe condylar malposition with dislocation allows vertical

shortening of the ascending ramus and this may be associated

with restricted mouth opening or deviation on opening due to

mechanical disruption of the temporomandibular joint.


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Unilateral condylar malunion

• The aim of treatment in unilateral cases is to restore the

pretraumatic ramus height and correct posterior mandibular

displacement if present.

• This corrects the occlusal plane cant and restores a normal occlusion

• an osteotomy at the site of the original fracture, repositioning and if

necessary interpositional bone grafting to maintain lengthening of

the ramus

• a ramus osteotomy distant from the fracture site


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Bilateral condylar malunion

• results in anterior open bite and class II jaw relationship.

• The correction is achieved by adjusting the maxilla to

accommodate this reduced posterior face height by carrying

out a posterior maxillary impaction.

• This results in an increase of the occlusal plane angle, but

this is of little significance and will result in a stable

correction of the anterior open bite component of the

deformity, as a consequence of mandibular autorotation.


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Conclusion

• The basic principles of treatment of post-traumatic residual

deformities include an initial major osseous reconstructive surgery to

restore an anatomically correct craniofacial architecture followed by

selective procedures to address soft tissue deficits and functional

deformities.

• Preservation of essential and basic functions will be the primary goal

followed by the creation of form/function and esthetics.

• Careful preoperative assessment, establishment of reasonable

reconstructive goals and detailed surgical planning are critical to

ensure the best possible outcome


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References

• Rowe and Williams’ Maxillofacial Injuries 2nd edition

• Maxillofacial trauma and esthetic facial reconstruction -Peterwardbooth

• Managementof Naso-Orbito-EthmoidFractures: A10-YearReview MiladEtemadi

• Medial canthopexy of old unrepaired naso-orbital ethmoid traumatic telecanthus – amir et al

• External Dacryocystorhinostomy and Transnasal Canthopexy: New Details of Combined Surgery-Marco Sales-Sanz et al

• Late revision or correction of facial truma – related soft tissue injuries- riecket al

• The Correction of Post-Traumatic Pan Facial Residual Deformity- K. Ranganath et al


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Thank you

Post traumatic residual deformities

Health & Medicine

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