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 units
Relaxed 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 Defects
Requiring 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 advancement
flaps
• 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 prosthetic
reconstruction 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- rieck
et al
• The Correction of Post-Traumatic Pan Facial Residual Deformity- K.
Ranganath et al

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Thank you

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