Sistemática en el Tratamiento Quirúrgico de las Fracturas Panfaciales Aplicado a un Caso Clínico De Alta Complejidad / Systematic in the Surgical Treatment of Panfacial Fractures Applied to a Highly Complex Clinical Case

RESUMEN: Las fracturas panfaciales son aquellas que afectan de forma simultánea al tejido óseo de dos o más tercios del rostro. El manejo inicial de estos pacientes es resolver o estabilizar las urgencias médico - quirúrgicas que puedan presentar, debido a que la gran mayoría de estas fracturas están asociadas a traumatismos de alta energía cinética, las que determinan la presencia de lesiones concomitantes que pueden comprometer la vida del paciente. El tratamiento quirúrgico de las fracturas panfaciales puede abarcar desde la intervención quirúrgica inicial de control de daños, estabilización, reducción y fijación quirúrgica de los segmentos fracturados mediante osteosíntesis hasta intervenciones mediatas para la reconstrucción de los tejidos afectados por el traumatismo. Para el tratamiento de las fracturas panfaciales existe una sistemática quirúrgica que tiene por objeto contener y/o minimizar daños agudos y permitir una reducción morfológica y funcional. Reportamos un caso clínico de fractura panfacial cuyo tratamiento siguió esta sistemática terapeútica.

ABSTRACT: Panfacial fractures affect bone tissue in two or more thirds of the face simultaneously. The initial management of these patients is to resolve or stabilize the medical-surgical emergencies that they may present. Most of these fractures are associated to trauma of high kinetic energy, which determine the presence of concomitant inju- ries that can compromise the life of the patient. The surgical treatment of panfacial fractures may include from the initial surgical intervention of damage control, stabilization, reduction and surgical fixation of fractured segments through osteosynthesis, to mediate the reconstruction of tissues affected by the trauma. For the treatment of panfacial fractures there is a surgical approach that aims to contain and/or minimize acute damage and allow for morphological and functional reduction. We report a clinical case of panfacial fracture whose treatment followed this therapeutic approach.

Tratamento de fraturas múltiplas da face associadas a ferimento extenso: relato de caso / Reconstruction of multiple face fractures associated with extensive injury: case report

As fraturas panfaciais acometem concomitantemente os terços superior, médio e inferior da face, decorrentes de acidentes automobilísticos, arma de fogo, atropelamento, agressão física, entre outros. Essas fraturas geralmente envolvem osso frontal, zigomático, maxila, mandíbula e ossos nasais, necessitando assim, fixação interna rígida através do uso de miniplacas e parafusos com o propósito de estabilizar as estruturas fraturadas, dar suporte aos tecidos moles e evitar deformidades estéticas da face. O objetivo deste trabalho é relatar o manejo cirúrgico de um caso clinico atendido em um hospital público de Salvador/BA, no qual a vítima apresenta ampla laceração na face e fratura exposta do terço médio da face. O tratamento executado sob anestesia geral foi redução dos cotos ósseos fraturados, fixação com miniplacas e parafusos, reconstrução imediata dos tecidos moles acometidos(AU)

Panfacial fractures affect concomitantly the upper, middle, lower third of the face, resulting from automobile accidents, firearms, hit-and-run, physical aggression, among others. These fractures usually involve frontal bone, zygomatic, maxilla, jaw and nasal bones, thus requiring rigid internal fixation through the use of miniplates and screws in order to stabilize fractured structures, support soft tissues avoiding aesthetic face deformities. The objective of this work is to report the surgical management of a clinical case attended in a public hospital in Salvador/BA, in which the victim has wide laceration of the face and exposed fracture of the middle third of the face. Treatment performed under general anesthesia was reduction of fractured bone stumps, fixation with miniplates and screws, immediate reconstruction of the affected soft tissues(AU)

Fracturas panfaciales: Oportunidad de tratamiento / Panfacial fractures: Treatment tming and strategy

Antecedentes: las lesiones panfaciales son aquellas que involucran al menos dos de los tres segmentos faciales: frontal, tercio medio, tercio inferior o mandíbula. Este tpo de fracturas se acompaña comúnmente (18 a 45%) de lesiones en otras partes, como el neurocráneo, la columna cervical y el globo ocular. Objetivos: describir sus causas más frecuentes, las áreas faciales más afectadas, el momento y la oportunidad adecuados para iniciar la secuencia del tratamiento en 58 pacientes con lesiones panfaciales tratados en la División de Cirugía Plástica del Hospital Cosme Argerich entre los años 2000 y 2010. Material y métodos: de 720 pacientes con traumatismo facial, 68 (9,4%) presentaron fracturas pan-faciales; no obstante, el seguimiento de la evolución hasta los 2 años posoperatorios fue hecho en 58 (8%) pacientes, quienes fueron incluidos en este estudio. Resultados: las áreas más afectadas fueron las órbitas y la nariz (68%), el malarcigoma (60%), el maxilar superior (42%) y la mandíbula (28%). El cráneo estuvo directamente involucrado en 6 pacientes (15%). En todos los casos el método de tratamiento consistó en: 1) exploración a cielo abierto; 2) reducción y fijación de las fracturas con osteosíntesis mediante placas y tornillos, 3) reemplazo de huesos conminutados con autoinjertos óseos y material no biológico. Según el epicentro de las fracturas y las alteraciones estructurales faciales, la reconstrucción se inició desde el tercio superior hacia el inferior en 38 pacientes y en los 30 restantes de abajo hacia arriba. Conclusión: la biomecánica básica es obtener la recomposición de la línea media, mantener el ancho facial y la proyección lateral de la cara. Los resultados fueron aceptables en 48 casos (85%) y no aceptables en 9 (15%), teniendo en cuenta la recuperación de las formas y armonías faciales, las deformidades estéticas, las secuelas funcionales, las complicaciones y la complejidad de operaciones secundarias correctivas.

Background: panfacial fractures are those that involve at least two of the three facial segmentis: frontal, medial third and jaw o mandibular area. Concomitant injuries (18 to 45%) afecting the ocular globe, endocranium and cervical spine are associated with panfacial lesions. Objectives: to describe the most frequent causes, facial areas involved and the right tming to initate the treatment sequence in 58 patentis with panfacial injuries treated at the Plastic Surgery Division of the Cosme Argerich Hospital. Material and methods: between 2000 to 2010, 720 patentis with facial trauma were treated. Of them, 68 (9,4%) presented panfacial fractures and 58 were included in this study. Results: the most afected areas were orbit and nose (68%); zygoma-malar (60%); maxilla (42%) and jaw (28%). The cranium was directly involved in 6 patentis ) (15%). The reconstructive method used in all cases was; 1. Open fracture expositon; 2. Reducton and fxaton by means of plates and screws; 3. Replacement of the comminuted bones with iliac autograf and no biologic material. According to the epicenter of the fracture and structural alteraton, the reconstructon was done from superior to inferior thirds (up-botom), 38 patentis; and from inferior to superior third (botom-up), 30 patentis, respectively. Conclusions: the Results were acceptable in 48 cases (85%) and inadequate in 9 (9%) according to facial harmony, aesthetic deformity, functonal sequels, complicatons and severity of secondary corrective operatons. The basic biomechanic needs were to obtain the recompositon of the midline, maintain the facial width and the lateral projecton of the face.

Procedimiento quirúrgico en un paciente con múltiples fracturas faciales / Surgical procedure in a patient with multiple facial fract

Se describe el caso clínico de un paciente de 45 años de edad que fue asistido en la Unidad de Cuidados Intensivos Emergentes del Hospital Provincial Docente Clinicoquirúrgico "Saturnino Lora Torres" de Santiago de Cuba, luego de sufrir una caída de una altura aproximada de 6 metros por un impacto de alta energía, que le produjo fracturas en los tres tercios de la región facial. Fue intervenido quirúrgicamente de urgencia por un equipo multidisciplinario. Luego de varios procedimientos quirúrgicos y de ser intubado con ventilación mecánica por espacio de 72 horas, se le trasladó, por su estado muy grave, a la Unidad de Cuidados Intensivos, donde permaneció durante 21 días y su evolución fue favorable

The case report of a 45 years patient that was assisted in the Emergency Intensive Cares Unit of "Saturnino Lora Torres" Teaching Clinical Surgical Provincial Hospital in Santiago de Cuba is described, after falling down of an approximate height of 6 meters due to a high energy impact that provoked him fractures in the three thirds of the facial region. He was surgically treated as an emergency by a multidisciplinary team. After several surgical procedures and intubation with mechanical ventilation for 72 hours, he was referred to the Intensive Cares Unit due to his very serious state, where he stayed during 21 days and had a favorable clinical course

Evaluation of safety and usefulness of submental intubation in panfacial trauma surgery

OBJECTIVES: Submental intubation has been advocated as an alternative to classical tracheostomy for certain indicated panfacial trauma surgeries. Surgeons should have various options for airway management in maxillofacial trauma patients. Most maxillofacial injuries involve occlusal derangements, which might require intraoperative occlusal corrections; hence, orotracheal intubation is not ideal. Maxillofacial surgeons generally prefer nasotracheal intubation; however, in cases with concomitant skull base fracture or nasal bone fracture, nasotracheal intubation might not be suitable; in these situations, tracheostomy is typically performed. However, the possible complications of tracheostomy are well known. Due to trauma situations and to avoid the complications of tracheostomy, submental intubation would be an ideal alternative procedure in selected maxillofacial trauma surgery patients. This study aimed to evaluate the safety and usefulness of a submental intubation technique for panfacial trauma surgery. Moreover, we intended to share our experience of submental intubation and to recommend this simple, safe procedure for certain panfacial trauma surgeries. MATERIALS AND METHODS: In five panfacial trauma patients, we performed submental intubation for airway management; the mean time required for the procedure was only eight minutes. RESULTS: We were able to execute this procedure safely in a short time without any intraoperative or postoperative complications. CONCLUSION: Submental intubation is a safe and simple technique for airway management in indicated panfacial trauma surgery patients.

Panfacial Bone Fracture and Medial to Lateral Approach

Panfacial bone fracture is challenging. Even experienced surgeons find restoration of original facial architecture difficult because of the severe degree of fragmentation and loss of reference segments that could guide the start of facial reconstruction. To restore the facial contour, surgeons usually follow a general sequence for panfacial bone reduction. Among the sequences, the bottom-to-top and outside-in sequence is reported to be the most widely used in recent publications. However, a single sequence cannot be applied to all cases of panfacial fractures because of the variations in panfacial bone fracture patterns. In this article, we intend to find the reference and discuss the efficacy of inside-out sequence in facial bone fracture reconstruction.

Derivación submandibular para garantizar la vía respiratoria en la traumatologia facial / Submandibular bypass to secure the airway in facial trauma

Introducción: uno de los recursos más efectivos en traumatismos maxilofaciales es el empleo de la traqueostomía, esta se conoce desde hace más de doscientos años. Pocas intervenciones quirúrgicas han salvado tantas vidas como la traqueostomía pues esta, permite garantizar una vía respiratoria segura para el paciente, pero como todo proceder quirúrgico no está exenta de complicaciones. La derivación endotraqueal submandibular se presenta como una alternativa viable en los casos que se requiera una traqueostomía temporal, esta consiste en el paso del tubo endotraqueal de la boca para el exterior a través de una incisión en la región submandibular. Se denomina fractura panfacial cuando las lesiones comprometen los tercios superiores, medio e inferior da la cara y que resulta en una perturbación grave de la arquitectura facial. Objetivos: dar a conocer siete casos realizados desde el 2006 hasta la actualidad, cuatro en el Hospital General Docente "Abel Santamaría Cuadrado" de Pinar del Rio, Cuba, y tres en la Clínica Multiperfil de Luanda, Angola. Métodos: se exponen la técnica descrita por Altemir y detallada por Guevara Mantilla y cols en sus cuatro fases. Los pacientes fueron llevados al quirófano de forma urgente y electiva mediante coordinación con el Servicio de Anestesiología y Reanimación. Se realizó, primero la derivación submandibular y seguidamente el proceder programado para cada paciente. Conclusiones: el proceder permite un adecuado control de la vía respiratoria y constituye una alternativa segura y eficaz en pacientes con traumas complejos del tercio medio facial. No se han encontraron complicaciones ni durante ni en el posoperatorio.

Introduction: tracheostomy is one of the most effective resources in the treatment of facial trauma. This technique has been used for more than two hundred years. Few surgical interventions have saved as many lives as tracheostomy, since it makes it possible to secure a safe airway for the patient. However, as with all surgical procedures, tracheostomy may also have complications. Submandibular endotracheal bypass is a viable alternative when temporary tracheostomy is required. It consists in the passage of an endotracheal tube from the mouth outwards through an incision in the submandibular region. It is called panfacial fracture when the lesions compromise the upper, middle and lower thirds of the face, resulting in serious disturbance of the facial architecture. Objectives: present seven cases treated from 2006 to the present: four at Abel Santamaría Cuadrado General Teaching Hospital in Pinar del Río, Cuba, and three at the Multiprofile Clinic of Luanda, Angola. Methods: a presentation is provided of the four stages of the technique described by Altemir and detailed by Guevara Mantilla and cols. Patients were carried to the operating room for emergency and elective surgery prior coordination with the Anesthesiology and Resuscitation Service. Submandibular bypass was performed first, followed by the procedure scheduled for each patient. Conclusions: the procedure allows appropriate control of the airway and constitutes a safe, effective alternative for patients with complex trauma of the facial middle third. No complications were found during surgery or in the postoperative period.

Uso de guía de metil-metacrilato fabricados en biomodelo de poliuretano para el tratamiento tardío de fractura panfacial / The use of metil-metacrilate guide manufactured on biomodel of polyurethane for late treatment of panfacial fracture

El manejo de las secuelas faciales por fracturas no tratadas ha tenido un crecimiento importante debido al uso de los biomodelos. Estos permiten optimizar la cirugía, disminuir los tiempos quirúrgicos y mejorar los resultados. El presente articulo muestra un caso de secuela de fractura facial tratada con osteotomías con ayuda de guías quirúrgicos fabricados en base a un biomodelo operado; se presenta el resultado postoperatorio de 6 meses con una resolución adecuada.

The management of facial sequel by facial fractures non-treated nowadays presents an important expansion by the use of biomodels. This system can be used for reduce surgical time, optimize surgical protocol and improve outcomes. This paper presents a sequel case for facial fracture treated with bone osteotomy using surgical guide manufactured base on biomodels operated; is showing the postoperative 6 month follow-up with good results.

Modified Submental Intubation in Panfacial Bone Fracture Patients

PURPOSE: Nasotracheal or oral intubation procedure is widely used for facial bone fractures. However, during the operation intubated tube can interfere or obstruct the view of the operator. We authors used a modified submental intubation method in panfacial bone fracture patients for intact airway and the operation view. METHODS: After intravenous induction of anaesthesia, traditional orotracheal tubation was done. A horizontal incision was made 2cm from the midline, 2cm medial to and parallel with the mandible in the submental region.1 In order to approach to the floor of the oral cavity, a haemostat was pushed through the soft tissues. A chest tube front cover was applied to the intubation tube and the tube was inserted through the submental tunnel. Orotracheal tube was disconnected and pulled back through the soft tissue and secured with a suture. RESULTS: The procedure took about 30 minutes and there were no problems during the intubation. Intraoral manipulation and occlusal checks were free without any interference. Extubation was also easily done without any complications such as lung aspiration, infection, hematoma, or fistula. CONCLUSION: Submental endotracheal intubation is fast, safe, easy to use and free from the concern about the tube being pull back again. Conventional submental intubations are being held without any coverage of the tip. We authors applied the modified method to the trauma patients and obtained satisfactory results. From the above advantages, modified submental intubation can be widely available not only in fractured patients, but also in aesthetic or orthognathic surgeries.

Delayed visual loss by indirect traumatic optic neuropathy related to panfacial fracture: A case report

The Usefulness of Transcatheter Arterial Embolization for Panfacial Injury

PURPOSE: A life-threatening hemorrhage resulting from a severe facial fracture is rare, but it needs a prompt and aggressive treatment. Especially, a massive oronasal bleeding combined with midfacial fracture which may result from the rupture of the internal maxillary artery. With the recent advances in the radiologic intervention, its use has increased for managing these life threatening case. We reviewed its usefulness with our experiences and literatures. METHODS: A retrospective review was performed to determine the usefulness of the transcatheter arterial embolization in patients with panfacial trauma. If the vital signs were unstable, cardiopulmonary resuscitation was performed. Oronasal bleeding was controlled with nasal packing and electrocautery. All injured regions were studied by radiologic study including CT. Even after primary management, if the oronasal bleeding was persistent, radiologic intervention was performed 10 patients were treated with transcatheter arterial embolization and the bleeding focus controlled by embolization with polyvinyl alcohol and gelfoam. RESULTS: After the intervention, the vital signs became stable and there were no complications from embolization in the follow-up for 6 months. Also patients could recover through appropriate operations. CONCLUSION: Transcatheter arterial embolization for maxillofacial injury has many advantages for both, the doctor and the patient. First, less pain is induced than a compression device or an operation, which is another way to treat oronasal bleeding. Second, it does not need general anesthesia. And through a single procedure not only we can know the accurate bleeding point, but we can also bleeding by embolization.

Modified submental approach to oroendotracheal intubation in patients with panfacial bone fractures

A Clinical Experience and Treatment of Panfacial Fracture

Panfacial fracture defines that fractures include all upper face, midface, and lower face. But clinically it means fracture more than two areas including midface. Many panfacial fracture patients have injury of cranium and face. Serious soft tissue damage and bony defect are frequent, normal anatomical reconstruction is difficult. After primary treatment many patients have sequelae of functional and aesthetic deformities, which are difficult to restore by secondary reconstruction. Patients with panfacial fracture are 75 cases among 1138 facial bone fractures who received treatment in department of plastic and reconstructive surgery of our university. We followed up survey from January, 1997 to December, 2001 by retrospective study and came to a conclusion. First, interconnection between skull base and nasal cavity must be seperated perfectly. Second, telecanthus can be prevented by anatomical bone fixation. Third, surgeon reconstruct zygomatic area exactly for facial width and projection. Forth, surgeon restore normal occlusion by anatomic reduction of maxilla and mandible. Fifth, soft tissue must be repaired layer by layer for prevention of secondary contour deformity. In conclusion, surgeon decides operation methods and time after discuss with related departments for with patient's condition. And treatment plans are based on patients mental and physical state. Proper primary treatment can reduce complications and necessity of secondary operation.