Facial Trauma - Sherdog Doctor Corner's Post
Article by Glenn Vallecillos, MD
Beverly Hills Plastic Surgeon
Welcome to Sherdog.com Doctor’s Corner. My name is Glenn Vallecillos and I am a Board Certified Plastic Surgeon. We are excited to provide Sherdog.com blog followers with the medical and surgical information which relates to Mixed Martial Arts combatants and injuries they may incur in competition. My first blog entry will review facial trauma and some of the more common facial injuries incurred in blunt force trauma, although the forum is open to cover any related surgical topics of interest. We encourage the readers to submit topic requests. We look forward to your response.
Facial Trauma in Mixed Martial Arts
By Glenn Vallecillos, MD, Diplomate, American Board of Plastic Surgery
Craniofacial trauma is a common occurrence in mixed martial arts competition as well as other combat sport injuries such as boxing. These injuries often require immediate medical attention. Facial reconstruction following trauma varies from individual to individual and is dependent on the location and nature of injury as well as acuity of other injuries.
The first and foremost priority in assessing any trauma patient is managing conditions which impede the normal functioning of the airway, breathing, and circulation, in addition to any other life-threatening emergency including massive bleeding. This occurs prior to treating facial injuries.
It is important to note that over 60% of patients who suffer a severe facial trauma injury will have other serious injuries in the head, chest, or abdomen. This concordance reflects the tremendous forces that are required to fracture human facial bones. Physicians examining a facial trauma patient also need to rule out, among other serious injuries, damage to the brain, spinal cord, and eyes.
Due to the complexities involved with multi-system trauma imaging studies of the face and cranium may need to be postponed for 24-72 hours in order to treat injuries to other organ systems. Once the patient has been cleared of more serious and life threatening injuries, computed tomography (CT) scans are taken of the craniofacial injuries. An increase in the accuracy of facial fracture diagnosis has been appreciated secondary to the advent of three-dimensional CT scans. Three-dimensional bony reconstruction has enhanced preoperative bony analysis and planning for reconstructive surgery.
FACIAL TRAUMA & RECONSTRUCTIVE SURGERY FACTS
FACIAL RECONSTRUCTION FOLLOWING BLUNT TRAUMA
Surgical repair of severe facial trauma can be extensive, sometimes lasting as long as14 hours. The basic tenets of management of craniofacial trauma are well accepted: Early identification and operative anatomic reduction of all fractures, followed by rigid internal fixation and primary bone grafting of significant skeletal defects. Failure to diagnose craniofacial injuries with consequent inappropriate application of internal fixation and bone grafting can lead to the establishment of post-traumatic secondary facial deformities. Despite various surgical advances and even in the face of appropriate and timely surgical management, patients with massive facial trauma may still end up with post-traumatic deformities following treatment.
Reconstruction may include the use of bone grafts, taking bone from other parts of the body to repair the facial bones, or fill in smaller areas of missing bone with prosthetic materials and implants. Repaired facial bones are held in place with mini-plates (titanium) as well as surgical screws.
Lacerations, or tears in the skin and soft-tissue of the face are typically closed in anatomic layers with stitches and in some cases, staples.
COMMON TRAUMATIC BONY INJURIES TO THE FACE
The zygomatic bone (cheek bone) is a paired bone of the skull. Its location makes it prone to severe blunt trauma such as blows to the face. The zygomatic bone occupies a prominent and important position in the facial skeleton. The zygoma is key in determining facial width as well as providing major support of the mid-facial region.
Mechanism of injury: Blows to the to the side of the face.
Moderate blunt trauma may result in minimally or non-displaced zygomatic fractures. More severe injuries result in a displaced zygoma.
Treatment of Zygomatic Fractures:
Historically, zygomatic fractures were repaired by reducing the fracture back into normal anatomic alignment, known as a “closed reduction”. With the exception of non-displaced and minimally displaced fractures, the results were often unsatisfactory, being fraught with complications including visual problems, non-healing of the fracture, and significant residual deformities. Treatment of zygomatic fractures has progressed over the past several decades to the more aggressive open repair using rigid mini-plate to stabilize a fracture and align the bones in their proper anatomic position. This is known as an “open reduction”.
The maxilla is the central keystone of the face. Fractures of the maxilla occur less frequently than those of the mandible or because of the strong structural support of this bone. Maxillary fractures can result from severe blows to the mid-facial region. Diagnosis is made by computerized tomographic (CT) scans and maxillary repair is aided by the use of 3-D CT reconstruction. The LeFort Classification System is used to describe the most common sites of maxillary fractures.
Treatment of Maxillary Fractures:
Management of maxillary fractures involves early one-stage repair, precise anatomic reduction with rigid fixation and immediate autogenous bone grafting when necessary, establishing the pre-injury bite and midface alignment. Simultaneous definitive soft-tissue management is performed when indicated. This more aggressive surgical approach has dramatically improved the aesthetic results now obtainable with fewer secondary deformities.
Nasal fractures are common following blunt trauma to the midface and may be one of the more common facial fractures experienced by MMA combatants. Nasal fractures may result from a lateral blow to the nose or from a frontal impact. Frontal impact injuries are more likely to result in significant injuries to the septum which must be repaired operatively.
Although nasal x-rays are frequently ordered, they are largely unnecessary. Nasal fractures should be detected on physical exam, which includes careful intranasal exploration. This is particularly important when examining the nasal septum. Septal hematomas (blood collections within the septal mucosa) require immediate drainage due to the risk of long-term cartilage desorption and subsequent loss of nasal support with subsequent potential development of a nasal deformity. Hence, all nasal fractures require immediate assessment by a medical professional.
Treatment of Nasal Fractures:
Ideally, nasal fractures are reduced in the first 2 hours after trauma, before nasal swelling becomes severe. More typically, nasal fractures are reduced 3 to 5 days following the injury, allowing swelling to subside.
An external nasal splint should always be placed to help protect the nose from further trauma for approximately 1 week.
Patients undergoing closed reduction for nasal injuries should always be counseled that subsequent open rhinoplasty might be necessary. This is typically performed a year out from the injury.
Nasoethmoid Orbital Skeletal Fractures
Trauma to the central midface frequently results in fractures of the nasoethmoid orbital (NOE) skeleton. This is a complex area consisting of a union of bones that include the nose, orbits, maxilla, and cranium. These fractures are among the most difficult and challenging of all facial fractures to diagnose and treat.
Failure to diagnose these injuries or inadequate treatment will result in both functional and cosmetic deformities that are extremely difficult to correct secondarily. The best results of the NOE fracture are obtained with early diagnosis and aggressive surgical treatment.
Complications from NOE fractures occur when this injury has been misdiagnosed or inadequately treated. Successful surgical treatment of these complex injuries consist of early open reduction and stabilization of bone fragments. Bone grafts are used to restore contour and support to areas of severely fractured or missing bone. Unstable or displaced fractures that are left untreated result in permanent deformities once healed. Late reconstruction is a difficult task that requires repositioning of both bone and soft tissue. Although late reconstruction of these deformities is possible, in general, the best aesthetic results are obtained with definitive repair at the time of injury, avoiding the common pitfalls.
Orbit al Fractures
Orbital Fractures are seen in all professional contact sports including Mixed Martial Arts competition, and occur subsequent to blunt trauma to the eye region (fist, elbow, knee, etc). Depending on the force of the blow, injury to the eye is possible; therefore a complete ocular evaluation is necessary to rule out injury to the globe (eyeball) and optic nerve. This examination should occur without delay if a globe injury is suspected.
An orbital “blow-out” fracture consists of a fracture of the bones of the eye "socket". This may involve a number of bones along the orbital floor, wall, or roof. Most cases or orbital fractures typically involve the orbital floor. Most patients will present with pain, tenderness around the eye, swelling, subconjunctival hemorrhage, and double vision.
The bony orbits play a critical role in establishing eye aesthetics and proper function; therefore reconstruction of the bony orbit is essential to maintain normal aesthetics and function of the eyes.
Treatment of Orbital Fractures:
The goals of orbital reconstructive surgery following trauma include orbital volume restoration, with subsequent correct positioning of the eye within the orbit. Correction of soft-tissue entrapment is also a pivotal in ensuring proper functioning of eye movement. Diagnosis is generally made by CT Scan with 3-Dimensional reconstruction.
The general approach for orbital floor defect reconstruction involves the utilization of bone or alloplast (silicone, Teflon, titanium mesh, methyl methacrylate). Additionally, mini- or micro plates may be used in combination with bone grafts to improve stabilization and enhance the healing.
The mandible has a complex role in the aesthetics of the face as well as the functional occlusion (bite). Due to the prominent position of the jaw, mandible fractures are the most common fracture of the facial skeleton, and are a common injury in MMA, boxing as well as other contact sports. Fractures of the mandible will present with a malocclusion (inability to bite down), pain at fracture site, significant internal bruising, or laceration with bleeding between teeth at the fracture site. Reduction and stabilization of the mandible fracture is the key to successful treatment to avoid long-term morbidity.
Treatment of Mandibular Fractures:
The fundamental goal of mandibular fracture repair is to restore the pre-injury anatomy, hence preserving the pre-injury occlusion (bite) and aesthetics. Imaging techniques to evaluate suspected mandibular fractures include CT scans with 3-D reconstruction and panoramic radiographs (panorex – see below).
The method of management may vary based on the severity, location of the fracture and presence or absence of teeth and is bifurcated into open and closed techniques. Many simple mandibular fractures can be managed by conventional “closed” techniques with maxillomandibular fixation (MMF) or “wiring of the teeth”, for a period typically lasting 4 to 6 weeks. Plate and screw fixation of mandibular fractures provide unparalleled stability when compared to other modes of fracture therapy.
RISKS OF SURGERY AND COMPLICATIONS
Craniofacial reconstructive surgery has intrinsic risks, which are common to all surgical procedures done under general anesthesia. These risks include, but are not limited to: bleeding, infection, breathing problems, bruises underneath the skin, reactions to the anesthesia, need for re-operation, and death.
Risks specific to craniofacial reconstruction include but are not limited to:
o Motor and sensory (numbness/alteration in sensation) deficits
Decrease in height of the face
Decrease in facial projection
Increase in width of face
Enophthalmos or posterior displacement of the eye into the orbit
Traumatic telecanthus or abnormal widening between the medial aspects of the eyelids
Misalignment of teeth or “malocclusion”
Nasal obstruction and associated deformities
Cerebrospinal fluid leak
Anosmia or lack of ability to perceive odors
Risk factors that can affect the long-term results of craniofacial reconstruction include:
A weakened immune system or immmunocompromised state such as HIV
A history of smoking
A history of diabetes
Poor nutrition both before the injury and during the recover period
Damage to the skin from previous radiation therapy
A connective tissue disorder. Examples include lupus or scleroderma
The time elapsed between a traumatic injury and surgical management
Poor blood circulation in the affected area
Disclaimer: This information is intended only as an introduction to facial trauma and its management. This information should not be used to determine whether you will have the procedure performed nor does it guarantee results of your specific trauma. Further details regarding surgical standards and procedures should be discussed with your physician.