Maxillofacial and neck trauma: a damage control approach.

Severe maxillofacial and neck trauma exposes patients to life threatening complications such as airway compromise and hemorrhagic shock. These conditions require rapid actions (diagnosis and management) and a strong interplay between surgeons and anesthesiologists. Effective airway management often makes the difference between life and death in severe maxillofacial and neck trauma and takes initial precedence over all other clinical considerations. Damage control strategies focus on physiological and biochemical stabilization prior to the comprehensive anatomical and functional repair of all injuries. Damage control surgery (DCS) can be defined as the rapid initial control of hemorrhage and contamination, temporary wound closure, resuscitation to normal physiology in the intensive care unit (ICU) and subsequent reexploration and definitive repair following restoration of normal physiology. Damage control resuscitation (DCR) consists mainly of hypotensive (permissive hypotension) and hemostatic (minimal use of crystalloid fluids and utilization of blood and blood products) resuscitation. Both strategies should be administered simultaneously in all of these patients.

Treatment protocol for high velocity/high energy gunshot injuries to the face.

Major causes of facial combat injuries include blasts, high-velocity/high-energy missiles, and low-velocity missiles. High-velocity bullets fired from assault rifles encompass special ballistic properties, creating a transient cavitation space with a small entrance wound and a much larger exit wound. There is no dispute regarding the fact that primary emergency treatment of ballistic injuries to the face commences in accordance with the current advanced trauma life support (ATLS) recommendations; the main areas in which disputes do exist concern the question of the timing, sequence, and modes of surgical treatment. The aim of the present study is to present the treatment outcome of high-velocity/high-energy gunshot injuries to the face, using a protocol based on the experience of a single level I trauma center. A group of 23 injured combat soldiers who sustained bullet and shrapnel injuries to the maxillofacial region during a 3-week regional military conflict were evaluated in this study. Nine patients met the inclusion criteria (high-velocity/high-energy injuries) and were included in the study. According to our protocol, upon arrival patients underwent endotracheal intubation and were hemodynamically stabilized in the shock-trauma unit and underwent total-body computed tomography with 3-D reconstruction of the head and neck and computed tomography angiography. All patients underwent maxillofacial surgery upon the day of arrival according to the protocol we present. In view of our treatment outcomes, results, and low complication rates, we conclude that strict adherence to a well-founded and structured treatment protocol based on clinical experience is mandatory in providing efficient, appropriate, and successful treatment to a relatively large group of patients who sustain various degrees of maxillofacial injuries during a short period of time.

Maxillofacial trauma patient: coping with the difficult airway.

Establishing a secure airway in a trauma patient is one of the primary essentials of treatment. Any flaw in airway management may lead to grave morbidity and mortality. Maxillofacial trauma presents a complex problem with regard to the patient's airway. By definition, the injury compromises the patient's airway and it is, therefore, must be protected. In most cases, the patient undergoes surgery for maxillofacial trauma or for other, more severe, life-threatening injuries, and securing the airway is the first step in the introduction of general anaesthesia. In such patients, we anticipate difficult endotracheal intubation and, often, also difficult mask ventilation. In addition, the patient is usually regarded as having a "full stomach" and has not been cleared of a C-spine injury, which may complicate airway management furthermore. The time available to accomplish the task is short and the patient's condition may deteriorate rapidly. Both decision-making and performance are impaired in such circumstances. In this review, we discuss the complexity of the situation and present a treatment approach.

Comparing the effects of V-Y advancement versus simple closure on upper lip aesthetics after Le Fort I advancement.

PURPOSE: The aim of this study was to compare upper lip movement and its dimensional changes after maxillary advancement via Le Fort I osteotomy, using V-Y advancement versus simple continuous closure. The study investigates dimensional changes in the superior and inferior portions of the upper lip, as well as changes in lip length, resulting from the procedure. PATIENTS AND METHODS: The study group consisted of 35 patients who had undergone 1-piece Le Fort I osteotomy for maxillary advancement of 3 to 6 mm with less than 3 mm of vertical changes. Fixation was performed by rigid monocortical plating. Closure of soft tissue was achieved using V-Y advancement in 17 patients and simple continuous suturing in 18 patients. Lateral cephalometric radiographs were taken and measured preoperatively and then 6 months after surgery. RESULTS: The magnitude of upper lip movement was 88.89% of the maxillary advancement in the simple continuous suturing group and 90.77% in the V-Y advancement group. The superior portion of the upper lip thickened by 2.08 mm and 2.35 mm in the 2 groups, respectively. The inferior portion of the upper lip thickened by -1.94 mm and -1.14 mm, respectively. The upper lip shortened by 0.79 mm in the simple continuous suturing group and lengthened by 1.10 mm in the V-Y advancement group. CONCLUSIONS: Upper lip movement and dimensional changes differ when simple continuous suturing and V-Y advancement closure are used.