1. Oral Maxillofacial Surg Clin N Am 17 (2005) 341 355 Maxillofacial Trauma Treatment Protocol David B. Powers, DMD, MDa,*, Michael J. Will, DDS, MDb,Sidney L. Bourgeois, Jr, DDSc, Holly D. Hatt, DMD, MDdaDepartment of Oral and Maxillofacial Surgery, Wilford Hall United States Air Force Medical Center, Lackland Air Force Base, 2200 Bergquist Drive, Suite 1, San Antonio, TX 78236-9908, USAb Department of Oral and Maxillofacial Surgery, Walter Reed Army Medical Center, Washington, DC 20327, USA cDepartment of Oral and Maxillofacial Surgery, National Naval Medical Center, Bethesda, MD 20889, USAdDepartment of Oral and Maxillofacial Surgery, National Naval Medical Center, San Diego, CA 92127, USAIn the early days of World War I, a young sur-have forced military surgeons to reinvent how we treatgeon from New Zealand stationed in Aldershot, maxillofacial trauma patients, much like the experi-England was inundated by horrendous wounds to ences that faced Sir Harold Gillies. Unfortunately, thethe head and neck of soldiers returning from the frontIsraeli experience shows us that terrorists possiblylines. Because of advances in ballistics and weaponry,could use the same tactics as the Iraqi insurgents andcoupled with the fact that trench warfare necessitatedexpose the American populace to IEDs.the soldiers to place their maxillofacial region at greatBefore September 11, 2001, the protocol designedrisk to monitor the status of the enemy, this surgeon by Robertson and Manson served as an excellentwas faced with injuries never before encountered. framework for the management of high-energy bal-His name was Harold Delf Gillies, and his contribu- listic injuries to the maxillofacial region [4]. Thetions to the medical community are universallycomplex nature of the wounds caused by IEDs andaccepted as the initiation of the discipline of plastic newer ballistics has rendered some portions of theirand reconstructive surgery [1,2]. Hippocrates oncetreatment plan ineffective and prone to secondaryfamously told his students, War is the only properinfection. IEDs are packed with dirt, glass, rocks,school for surgeons. Unfortunately, the experiences metal, bones from dead humans or animals, and otherundergone since September 11, 2001 have provided abody parts if detonated by suicide bombers. If thiswhole generation of military surgeons the opportunity technique of terrorism is used in the United States,to treat a new type of injury pattern never before seen civilian providers will be faced with the same dif-[3]. Improved body armor, which allows soldiers toficulties previously faced by the military. The chal-survive wounds that would have been fatal 2 to 3 yearslenge was to develop a system that could be used forearlier, and the catastrophic and new injury patterns conventional ballistic injuries and injuries that resultsustained by improvised explosive devices (IEDs)from IEDs. A new protocol has been developed thatserves as the current treatment regimen used by theoral and maxillofacial surgery departments at WilfordHall USAF Medical Center, the National NavalThe views presented in this article reflect those of theMedical Center Bethesda, Walter Reed Army Medi-authors and do not represent the official policies of thecal Center, and the National Naval Medical Center United States Air Force, the United States Army, the UnitedStates Navy, the Department of Defense, or any branchesSan Diego. In this article we present our treatmentof the United States government.algorithm for ballistic maxillofacial trauma based on* Corresponding author. the surgical experiences gained by performing 329E-mail address: David.Powers@Lackland.af.milprocedures on 109 patients since September 2001(D.B. Powers).(Box 1).1042-3699/05/$ see front matter. Published by Elsevier Inc.doi:10.1016/j.coms.2005.05.003oralmaxsurgery.theclinics.com

2. 342powers et alcolloids, or crystalloids as indicated. IdentificationBox 1. Treatment protocol forof potentially fatal situations, such as tension pneu-maxillofacial injuriesmothorax, cardiac tamponade, intraperitoneal hem-orrhage, or intracranial hemorrhage, should be 1. Stabilize patientaccomplished as soon as possible. 2. Identify injuries 3. Obtain radiographic studies andstereolithographic models 4. Initiate consultations (eg, psychia-Identification of injuriestry, physical therapy, speechtherapy)After initial stabilization of a patient, a thorough 5. Initiate cultures/sensitivitiesexamination should be performed to document all(infectious disease consultations)injuries. If a patient is comatose or intubated or the 6. Unidertake serial debridementevaluation is otherwise compromised, care should be(days 3 10) to remove necrotictaken to note clearly the limitations of the examina-tissuestion and the reasons for the difficulty. Detailed 7. Stabilize hard tissue base to sup-documentation of all injuries is necessary to coor-port soft tissue envelope and pre-dinate the sequence of treatment with all respectivevent scar contracture beforesurgical services (Figs. 1 and 2). Any opportunity toprimary reconstructionlimit exposure to general anesthesia should be taken, 8. Conduct comprehensive review ofas long as combined procedures do not affect thestereolithographic models andoutcome of planned surgical interventions. Physicalradiographs and determination ofexamination, radiographic studies, and laboratorytreatment goalstests are necessary components to identify correctly 9. Replace missing soft tissue com-all potential injuries.ponent (if necessary)10. Perform primary reconstructionand fracture management11. Incorporate aggressive physical/Obtaining radiographic studies andoccupational therapystereolithographic models12. Perform secondary reconstruction(eg, implants, vestibuloplasty) Adequate radiographs are essential for diagnosis of13. Perform tertiary reconstructionand treatment planning for complex maxillofacial(eg, cosmetic issues,scar revisions)Stabilization of the patientAlthough this should be intuitive, in a mass ca-sualty or acute trauma situation the basics of medi-cal care should be emphasized, because these actionsundoubtedly will save lives. Securing the airwayby whatever means necessary, including endotra-cheal intubation or surgical airway, should be per-formed immediately if there is any doubt about futurestability of the patient. A true disaster scenario eas-ily could overwhelm the ability of a medical carefacility to monitor the condition of victims with pos-Fig. 1. Drainage of left facial swelling. After fluid was sentsible or suspected future airway compromise. Bleed- to laboratory for evaluation, amylase level was noted to being should be controlled and volume expansion in excess of 3000, which is consistent with obstructedshould be accomplished to maintain perfusion of the parotid gland secondary to transection of Stensons ductvital organs by blood transfusion, blood substitutes, from shrapnel. 3. maxillofacial trauma treatment protocol 343 possible result while actually decreasing surgical time [5]. Early initiation of consultations Returning casualties from a war zone have many needs that must be addressed in concert to treat the entire patient. Not only is the treatment of a patients wounds of paramount importance but also are the treatment of a patients psychological status, facili- tation of speech and nutrition in maxillofacial injuries, management of centrally mediated pain syndromes, Fig. 2. Shrapnel injury to right upper extremity. and identification, evaluation, and involvement of a patients family or peer support system. This section attempts to identify consultants who may be deemed integral in the treatment of returning casualties withtrauma. Modern radiographic techniques allow for war injuries.three-dimensional visualization of the skeleton, helpidentify foreign bodies, and evaluate displaced fracturesegments. CT scans should be the minimum informa-Infectious diseasetion obtained before surgery (Fig. 3). The current CTscanner at Wilford Hall Medical Center is the GE The importance of this consultation cannot beLightspeed 16 (GE Health Care, Chalfont St. Giles, overemphasized. Patients returning from OIF/OEFUnited Kingdom), which allows rapid assimilation ofare well documented to be colonized by Acineto-data and manipulation of conventional coronal andbacter baumannii [6]. The nature of war injuriesaxial cuts to three-dimensional images via use of thealso provides an environment for the gross contami-GE Advantage Workstation AW 4.1 (GE Health Care; nation of wounds by staphylococci, enterococci,Chalfont St. Giles, United Kingdom) (Fig. 4).Klebsiella, and Clostridium perfringens and Clos-It is our opinion that complex panfacial trauma, tridium tetani. Further discussions of the infectioussuch as the injuries seen during Operations Iraqidisease consultation and the use of culture and sen-Freedom (OIF) and Enduring Freedom (OEF),sitivity testing to facilitate treatment are presentedabsolutely require the fabrication of stereolitho- in the following section.graphic (SL) models to plan treatment adequatelyand determine sequencing of fracture repair. The useof SL models allows preadaptation of surgical platesto obtain proper soft tissue projection and support thatotherwise would not be possible to the degree ofaccuracy obtained by this technique (Fig. 5). SLmodeling has the advantage of allowing customimplant fabrication to support the soft tissue envelopewhen the bony architecture is lost or irreversiblymisshapen. This has the advantage of reproducing apatients preoperative soft tissue profile as close aspossible to the preinjured state. Currently, WilfordHall Medical Center transfers conventional CT datavia the Materialise Mimics software program (Mate-rialise, Leuven, Belgium) for model fabrication bythe Viper SLA (3D Systems, Valencia, California).Depending on the size of the image being manufac-tured, most SL models can be completed by the ViperSLA within 6 to 24 hours. This relatively rapidFig. 3. Conventional CT scan indicates loss of soft tissueturnaround time does not impact patient care and isand anterior mandible extending bilaterally from the angleessential in our experience for obtaining the best to angle. 4. 344powers et alFig. 4. (A) Stereolithography model of case presented in Fig. 3. (B) Model used as template for prebending of reconstruction bar.Psychiatry consultationsand deglutition, and even if many of these structuresare salvaged or reconstructed, injury to cranial nervesInjured patients who return from a war zone may may make performing these functions next to im-present with a host of psychiatric challenges, all of possible. The ability to provide nutrition to a healingwhich must be addressed for appropriate treatment ofsurgical patient is of primary concern in healing andthe patient. These stressors include unrecognized maintenance of a patients immune system. Earlycombat stress, depression related to an injury, and consultation may lead to early placement of per-guilt related to leaving fellow unit members or cutaneous endoscopic gastrostomy feeding tubes,surviving. Facial appearance has been found to be central catheters, and evaluation of the digestivean important variable in how patients are perceived and respiratory tracts.by others, and maxillofacial injury patients mustdevelop the additional coping skills throughout their Physical therapytreatment to improve their self-esteem and ability tocontinue with reconstructive surgery.The physical therapy consultation is important inthe management of not only maxillofacial injuries butNutrition and speech therapy consultationsalso any orthopedic injuries. Maxillofacial physicaltherapy addresses the movement of the temporoman- Avulsive injuries to the maxillofacial regiondibular joint and should address electrical stimulationremove vital structures for phonation, mastication, of facial musculature, which has been effected by Fig. 5. (A, B) Examples of three-dimensional CT scans. 5. maxillofacial trauma treatment protocol 345facial nerve injury. This stimulation prevents facialShould a battlefield wound become infected,muscle atrophy and encourages facial nerve regrowthtreatment should be definitive, with removal ofin the area of deficit.foreign bodies and necrotic and infected tissue. Empiric broad-spectrum antibiotics are initiated against likely pathogens for 7 to 10 days. Table 1Pain management services provides an overview of the various antibiotics and spectrum of coverage [7,8]. Gram stains, cultures, Many patients who have returned from theaterand sensitivities are obtained to direct antibioticwith severe injuries manage their pain with largetherapy. Because Clostridium and Bacteroides spe-amounts of opiate analgesics. Centrally mediated paincies are difficult to culture, antibiotic therapy shouldsyndrome has been identified in a small number ofbe directed to cover these organisms.patients whose pain issues have been addressed It is also important for clinicians to realize thatinadequately. For both of these subgroups of patients, battlefield wounds are prone to tetanus because ofconsulting the pain management service assists inhigh levels of contamination with C tetani. Everyfacilitating the comfort of patients and supports in the effort should be made to investigate a patientswithdrawal from opiate analgesics to an appropriatecurrent tetanus immunization status and initiatelevel of pain medications. appropriate treatment or immunization. Necrotizing soft tissue infections from clostridial myonecrosis or polymicrobial infections can be the most dangerousCultures and sensitivities (infectious disease)and lethal infections that are encountered. All layers of tissue may be involved, and the treatment involvesCasualties from OEF/OIF who have been treatedaggressive surgical debridement combined with anti-in multiple health care settings, including austerebiotic therapy.combat situations, bring with them complex infec-Finally, clinicians must remember that patientstious disease issues related to multiple resistant may present with a confusing picture because oforganisms. Patients with open wounds automatically infection of various other wounds or a progression toshould be started on prophylactic antibiotics forsepsis. Following the previously mentioned princi-24 hours, with the cornerstone of treatment beingples and maintaining vigilant monitoring duringsurgical serial debridement. The decision regardingmedical evacuation should allow a patient to arriveantibiotic use should be based on the area of injury at a large tertiary care facility for more definitiveand degree of wound contamination. treatment and reconstruction.Table 1Spectrum of selected antibiotic agents [16,17]AgentAntibacterial spectrumPenicillin G Streptococcus pyogenes, penicillin-sensitive Streptococcus pneumonia, Clostridium spAmpicillin Enterococcal sp, streptococcal sp, Proteus, some Escherichia coli, KlebsiellaAmpicillin/sulbactam Enterococcal sp, streptococcal sp, Staphylococcus (not MRSA), Escherichia coli, Proteus, Klebsiella, Clostridium sp, Bacteroides/Prevotella spNafcillinStaphylococcal sp (not MRSA), streptococcal spPiperacillin/tazobactamEnterococcal sp, streptococcal sp, Staphylococcus (not MRSA), Escherichia coli, Pseudomonas and other enterobacteriaceae, Clostridium sp, Bacteroides/Prevotella spImipenem Enterococcal sp, streptococcal sp, Staphylococcus(not MRSA), Escherichia coli, Pseudomonas and other enterobacteriaceae, Clostridium sp, Bacteroides/Prevotella spCefazolinStaphylcoccal sp(not MRSA), streptococcal sp, Escherichia coli, Klebsiella, ProteusCiprofloxacinE coli, Pseudomonas and other enterobacteriaceaeGentamycin E coli, Pseudomonas and other enterobacteriaceaeVancomycin Streptococcal, enterococcal, and staphylococcal species (incl MRSA); not VREClindamycinStreptococcus sp, Staphylococcus sp, Clostridium sp, Bacteriodes/Prevotella spMetronidazoleClostridium sp, Bacteroides/Prevotella spAbbreviations: MRSA, methicillin resistant Staphylococcus aureus; VRE, vancomycin resistant Enterococcus.Data from Schuster GS. The microbiology of oral and maxillofacial infections. In: Topazian RG, Goldberg MH, editors. Oraland maxillofacial infections. 3rd edition. Philadelphia: WB Saunders; 1994. p. 39 78; and Gilbert DN, Moellering Jr RC,Sande MA. The Sanford guide to antimicrobial therapy. 34th edition. Hyde Park (VT): Antimicrobial Therapy, Inc.; 2004. 6. 346powers et alUpon receipt of casualties in our facilities, cultureand sensitivity for A baumannii automatically areinitiated. A patient usually is placed in contact andairborne isolation pending results, a process that cantake up to 48 hours. If this resistant organism has beencultured in patients who have returned from OIF,aggressive antibiotic therapy is initiated to includecoverage with ticarcillin and an aminoglycoside. Ingeneral, comprehensive wound care managementcoupled with appropriate antibiotic coverage andconsultation with infectious disease specialists forchallenging cases can prevent life-threatening sepsis.Fig. 7. Following pulsatile irrigation. (Courtesy of D.Clifford, DMD, MD; Bethesda, MD)Serial debridementThe role of serial debridement cannot be over- purposes. Tacking sutures may aid in securing gauzestated in dealing with patients injured in combat orpacking, but they should not be placed for reap-terrorist activities. The injury patterns seen differ inproximation of wound margins. After evacuation toseveral ways from those seen in a civilian trauma a higher echelon treatment facility out of theatersetting: (1) the devastating destruction of soft and hard (eg, Europe, United States), the entire wound is re-tissues caused by high velocity, fragmentation-type explored and debridement of grossly necrotic tissue injury patterns leads to compromised tissue beyondis completed. Unless contraindicated because ofthe visibly damaged tissue; (2) the battlefield environ-concomitant injuries, aggressive irrigation with copi-ment in which patients are injured is grossly con-ous saline and antibiotic solution (eg, clindamycin) istaminated; (3) wound care on the battlefield and whileperformed with a pulsatile irrigation system (Pulsa-in transport is less than ideal; and (4) evacuation off vac, Zimmer, Warsaw, Indiana). After the firstthe battlefield is not always expeditious, which leadspulsatile irrigation, superficial wet-to-dry dressingto increased wound contamination. Initial wound changes are performed three times per day. Aftermanagement involves hemostasis, dressing, awaiting48 to 72 hours, the procedure is repeated. At thatevacuation to an aid station, and ultimately, a higherpoint, the surgeon is faced with the decision of whenlevel facility in the combat theater. to perform the primary closure [9,10]. It has been ourUpon presentation at a higher echelon facility, experience that definitive closure should not beaggressive irrigation and foreign body removal andperformed if any sign of nonviable tissue is presentlimited soft tissue debridement are completed; the upon exploration of the wound (Figs. 6 and 7).wounds should be left open or packed for hemostatic Delayed primary closure of the wound is generallyperformed after the second washout, although thethreshold for continuing the debridement is low Fig. 6. Initial presentation with irrigation and debridement;tacking sutures placed. (Courtesy of D. Clifford, DMD, MD;Fig. 8. Healthy appearance of tissue at time of primaryBethesda, MD) closure. (Courtesy of D. Clifford, DMD, MD; Bethesda, MD) 7. maxillofacial trauma treatment protocol 347(Fig. 8). Generally the hard tissue base is stabilized atthe time of primary closure.Stabilization of hard tissue base to support softtissue envelope and prevent scar contracturebefore primary reconstructionBecause of the high risk of infection and extensivesoft tissue injury in these patients, definitive recon-struction is often deferred to a secondary phase. Ourexperience has demonstrated that with a lack of bonyFig. 10. Stereolithographic model demonstrates avulsivesupport, fibrous tissue and scar contracture compro-defect of midface region seen in Fig. 9. (Courtesy of D.mise the eventual functional and aesthetic result ofClifford, DMD, MD; Bethesda, MD)any reconstruction. In the routine trauma setting,bone grafting or alloplastic implants may be placed atthe initial surgery with immediate soft tissue cover-age. We have opted to use standard rigid fixation tion can be undertaken. Such support also maintains asystems to span bony gaps and give support to tissue plane, which provides easier dissection uponoverlying soft tissue with only limited bone grafting secondary reconstruction with either autogenous oror other alloplast use (eg, Medpor Porex, Newnan, alloplastic materials.Georgia) as necessary to reduce scar contracture.Complete reconstruction is often deferred to a sec-ondary phase. The placement of rigid fixation fol-Comprehensive review of stereolithographylows standard trauma protocol to provide supportmodels and radiographs and determination ofof the facial pillars. One of the risks of using titanium treatment goalsplates in this manner is that of plate exposure.Although it occurred in some patients, the associated The ultimate treatment goal for our combatmorbidity was low, the area was excised, and primarycasualties with facial injuries is the restoration ofclosure was performed with minimal cosmetic defect. function and cosmesis. Most injured patients haveAnother option for supporting the soft tissue is thesignificant avulsive defects of facial structures. CTapplication of an external fixator, which has provedscans are the gold standard for imaging of facialsuccessful in projecting the mandible and zygomat-fractures (Fig. 9). Three-dimensional reconstructedicomaxillary complexes until the primary reconstruc-CT scans and stereolithographic models are essentialadjunctive elements in preparing a treatment plan foravulsive-type defects (Fig. 10). The most importantaspect of treating avulsive defects is using appro-priate imaging to develop a staged reconstructionplan with the final endpoint in mind before any re-construction begins. Items for consideration in view-ing the studies and models are (1) which structuresare missing, (2) which structures remain, (3) theeffect of each on the reconstruction goals, (4) whichstructures require replacement, (5) how those struc-tures will be replaced (nonvascularized versus vas-cularized tissue), (6) identifying stabilization pointsfor replacement structures, (7) soft tissue consider-ations, (8) choice of grafting material, and (9) theeffect of grafting plan on future implant reconstruc-tion or dental rehabilitation. The choice of graftingor replacement material includes (1) bone (eg, cra-Fig. 9. CT scan demonstrates avulsive defect of midface nial, iliac crest [block versus particulate], osteomyo-region. (Courtesy of D. Clifford, DMD, MD; Bethesda, MD)cutnaeous vascularized flaps), (2) myocutaneous 8. 348powers et alFig. 13. Custom Medpor implant for avulsive midface defectFig. 11. Replacement of avulsed tissue with wax for seen in Figs. 9 and 10. (Courtesy of D. Clifford, DMD, MD;template formation. (Courtesy of J. Solomon, DMD andBethesda, MD)G. Waskewicz, DDS; Bethesda, MD)bacteria from the oral cavity or external environmentvascularized flaps, and (3) alloplast. Stereolitho-(Fig. 14). Once scar contractures develop, it isgraphic models allow for wax replacement of avulsedessentially impossible to recover from this and createstructures (Fig. 11) or generation of mirror-imagea normal soft tissue appearance. In our experience,structures, prebending of plates (Fig. 12), fabricationvascularized tissue is more resistant to secondaryof templates for contouring of bone grafts, fabrica-infection and scar contracture and gives the mosttion of custom implants (Fig. 13) (Medpor Porex,ideal result. Patients who present with injuriesNewnan, Georgia, titanium, or polymethylmethacry-sustained by IED blasts usually are already contami-late), or use of stock alloplasts (eg, Medpor) [5].nated with multiple bacterial species and are highlysusceptible to recurrent infections and secondaryscarring. The use of vascularized tissue has helpedReplacement of missing soft tissue componentminimize complications in these cases. When facedwith the dilemma of using a local rotational flapIf soft tissue has been avulsed or is lost over theversus free flap, the reconstructive surgeon shouldcourse of serial debridement, it is absolutely criticaldetermine whether a satisfactory result can beto replace this tissue with some form of vascularizedobtained in one surgical procedure or if severalflapeither rotational flap or free flapbefore therevision surgeries are necessary (Fig. 15). If a singledevelopment of scar contractures or colonization withsurgery is planned, rotation of a local flap may beindicated because of the similarities in tissue colo-ration, consistency, and appearance. If the need forfuture surgical intervention is necessary, considera-tion should be given to using the free tissue transferinitially to inhibit scar contracture and finalize treat-ment at the secondary and tertiary surgeries with thelocal flap (Fig. 16). We recommend waiting a mini-mum of 8 to 12 weeks after placement of a graft toallow for maturation before the next surgical proce-dure at that site (Fig. 17).Primary reconstruction and fracture management The goal of primary reconstruction should beFig. 12. Plates prebent to wax template replacing avulsed to obtain the best functional and cosmetic resultstissue. (Courtesy of J. Solomon, DMD and G. Waskewicz,possible, because the tissues injured by explosiveDDS; Bethesda, MD)projectiles may have significant scar contracture at 9. maxillofacial trauma treatment protocol 349Fig. 14. (A) Presurgical appearance. Soft tissue closure accomplished at field hospital. (B) Avulsive injury with significant loss ofsoft tissue.any future procedure and the opportunity to obtain aReplacement of missing bone should be included insatisfactory result will be decreased. Preoperative this treatment planning, because support of the softplanning is of paramount importance, with support oftissue envelope is important. A strong recommenda-the soft tissue envelope being a priority for main- tion is to consider exhausting native bone grafttaining as normal a facial contour as possible. options before resorting to other choices. If theFig. 15. (A) Location of latissimus dorsi free flap donor site. (B) Mobilization of the flap and preservation of vascular access.(C) Latissimus dorsi free tissue transfer to the mandibular region. The vascular supply is from the superior thyroid artery.Note presence of reconstruction bar to provide support to the free flap and assist with prevention of scar contracture.Osseous reconstruction is attempted at secondary surgery with corticocancellous bone graft. (D) Reconstruction of the floor ofmouth with the muscular component of the latissimus dorsi flap. 10. 350powers et aldures also allows for dental impressions and splintfabrication to occur to a known reference point, thenewly reconstructed mandible.One of the more common errors associated withpanfacial trauma reconstruction is inadequate re-duction of the mandibular archform, which resultsin excessive facial width secondary to splaying ofthe mandibular angles [12]. Excessive width of themandibular angles results in the appearance ofretrognathia because of posterior positioning of themandibular symphysis. If the mandible is plated in thewrong position, ultimately the maxilla and zygo- Fig. 16. Appearance of flap immediately postoperatively. maticomaxillary complex also are improperly posi-tioned, which results in excessive width to the faceand the appearance of midfacial deficiency. This com-recipient site is contaminated or infected, which is notplication can be prevented by using prebent surgicalunlikely in cases of IED blasts, our experiences have plates made from stereolithographic or cadaveric/shown that allogeneic bone has a high propensity foranatomic models to ensure accurate gonial width andresorption and chronic foreign body reaction. Nativeanterior projection of the mandibular symphysisbone, particularly bone transferred with periosteal (Fig. 18).coverage, has been less likely to show evidence ofAfter proper fixation of the mandible, attention islate infection and better maintains the soft tissue directed to zygomaticomaxillary complex and archprojection obtained. In cases of significant panfacialprojection. Our experience has been that accuratetrauma that involves the maxilla and mandible, we positioning of the malar prominence and zygomaticrecommend sequencing of treatment as previously arch is best accomplished by direct visualization ofpublished by Wong and Johnson (Box 2) [11]. the zygomaticomaxillary and zygomaticotemporalOur clinical experience has been to secure theairway and reconstruct the mandible as a first stage insurgery. In most cases of panfacial fractures, accom-plishing these procedures takes several hours at aBox 2. Sequencing of treatment forminimum, and proceeding immediately to a lengthypanfacial traumareconstruction of the midface and orbital fracturesmay not be advised because of potential fatigue of theSecure definitive airwaysurgical team. Breaking after the mandibular proce- Obain reduction and fixation of man-dibular fracturesObtain mandibular arch impressions forfabrication of occlusal/palatalsplints as necessary using the fixedmandible as templatePosition LeFort fractures into occlusionwith mandibular dentition usingmaxillomandibular fixationObtain reproducible seating of man-dibular condyles into fossaRepair frontal sinus fractures if presentReduce zygomatic complexes and re-construct nasofrontal junctionReduce naso-orbital-ethmoid complexfractures and medial canthopexiesReduce infraorbital rimsReduce LeFort I level fracturesReduce orbital floor fracturesUndertake nasal grafting Fig. 17. Appearance of patient 4 months after free flap. 11. maxillofacial trauma treatment protocol351Fig. 18. (A) Three-dimensional CT scan shows excessive widening of the mandibular angles before definitive treatment ofmandibular fractures. Anterior symphysis plate currently serves to stabilize fracture segments. Note open lingual cortical plate.(B) Stereolithography model of radiograph shown in (A). (C) Stereolithography model is sectioned and repositioned inaccordance with accepted anatomic norms for gonial distance and ramus distance. Reconstruction bar is prebent to newdimensions to correctly position the segments intraoperatively. Condylar fracture reduction occurs during the same operation tocorrect vertical and anteroposterior position of the mandible before treatment of maxillary fractures. (D) Intraoperative view ofmandibular fracture reduction and positioning of reconstruction bar. Proper positioning of mandibular angles is obtained by thesurgical assistant, who places pressure in the region of the mandibular angles until fractured segments passively fit thereconstruction bar. The gonial distance was reduced 2.5 cm in this case from the presurgical dimensions. (E) Postoperative three-dimensional CT scan shows improved dimensions of gonial distance and mandibular contour and shape. Proper reduction ofmidfacial fractures can occur at this time to optimize aesthetic and functional result. 12. 352 powers et aljunctions by the use of the coronal flap (Fig. 19).possible formation of traumatic alopecia that canSome surgeons may argue that the scar from the occur during prolonged reconstruction cases.coronal flap is unsightly and an acceptableposition of the zygomaticomaxillary complex canbe obtained by other approaches. In cases of minimalor isolated fractures of the zygomaticomaxillary Aggressive physical and occupational therapycomplex we would agree. Our bias in cases ofsignificant midfacial destruction or gross comminu-Oral and maxillofacial disability can result fromtion of the maxilla is that proper projection of the scar contracture, soft or hard tissue fibrosis, andmidface cannot occur without direct visualization, muscle atrophy caused by prolonged maxilloman-and ultimately secondary scar contracture continuesdibular fixation. Injured soldiers returning from OIF/to displace the segments and results in the previously OEF often present with some degree of maxillofacialacceptable appearance ultimately becoming un-disability. The injuries sustained typically involveacceptable. Our technique is to use the stereolitho- soft tissue and hard tissue loss and comminution ofgraphic model as a template for plate adaptation. If the facial bony structure.the contralateral side is unaffected, we bend surgical Soft tissue fibrosis and scar contracture areplates to that side of the model and place them on the typically seen weeks to months after injury repairaffected side whenever possible to reproduce accu- [13,14]. Initial management after adequate healingrately a patients preinjury skeletal contours and involves mandibular opening exercises with lateralmaximize the potential for an accurate zygomatic excursive movements. The patients also performwidth and good soft tissue projection after healing. manual massage of the injured area in an effort toWhen properly designed and positioned, the soften fibrosis and contracture bands. The goal ofcoronal flap can be aesthetically pleasing. Ourthis modality is to reduce the soft tissue tensiontechnique involves placing approximately 10 cc ofand allow a full range of mandibular movement2% lidocaine with 1:100,000 epinephrine along the[15]. If this conservative therapy is not successful, aproposed incision site. We place the local anesthesiamore aggressive regimen is followed to include abefore performing the surgical scrub and address any commercially available mandibular functional de-obvious sources of vascular bleeding with cautious vice. Our institutions use the Therabite device (Atosapplication of electrocautery. After reflection of the Medical AB, Horby, Sweden) for cases that requireflap, a moist surgical sponge is placed over the cut further therapy. The protocol for this device is sevenedges to prevent desiccation at the incision edge andmandibular stretches held at maximum openingassist with control of bleeding. Blood loss in all cases for 7 seconds. This routine is repeated seven timeshas been minimal. This technique has been used indaily until a patient achieves a maximum incisalmore than 20 cases by one of the authors and opening larger than 35 mm or improvement is noeliminates the need for scalp clips, which preventslonger achieved. Another modality of therapy for soft tissue fibrosis involves injection of steroids into the fibrotic area. This approach promotes the re- configuration of collagen fibrils and softening of the scar, which releases the tension of the soft tis- sue. Mandibular function is reassessed after 4 to 6 months of healing and therapy. For areas with high tension that have not responded to prior inter- ventions, scar revision is considered with excision of fibrotic tissue and soft tissue release using rotational flaps or undermining procedures. Emphasis is placed on tension-free closure to allow optimal healing with minimal scarring. Hard tissue fibrosis is seen in patients who sustain maxillofacial injuries caused by the degree of boneFig. 19. Accurate reproduction of zygomaticomaxillarydestruction and secondary blast effects. Patients withcomplex and zygomatic arch accomplished by prebendingsevere comminution of the mandible or maxilla typi-surgical plates on contralateral side of stereolithography cally undergo maxillomandibular fixation for 6 weeks.model to reproduce preinjury facial projection and use ofAfter the release of fixation, patients typically dem-coronal flap for access. onstrate a maximum incisal opening smaller than 13. maxillofacial trauma treatment protocol35315 mm [13,14]. Patients are instructed on activeindications, such as vestibuloplasty, ridge augmenta-mandibular range-of-motion exercises and manual tion, alveolar distraction, or orthognathic surgery totechniques to aid in opening. These exercises are correct maxillary-mandibular arch discrepancies.performed with minimal pressure so as not to affect In dealing with soft tissue injuries as seen inthe healing fracture. For patients who do not respond terrorist attacks or warfare, a surgeon must show someto mandibular opening or manual manipulation, the creativity while maintaining basic surgical principles.Therabite device is introduced to their routine and the Replacement of soft tissue can be as simple as skinstandard protocol is used. For patients with man- grafting or local flap advancement, or it can be asdibular disability secondary to temporalis fibrosis advanced as tissue expansion or free flaps. Micro-who do not respond to conservative therapy, coro- stomia secondary to tissue loss or scarring may benoidectomies may be considered. The goal of thisaddressed initially to give better access for intraoralintervention is to release the temporalis muscleprocedures, which may be a necessity for dentalattachment to the mandible and allow normal man-impressions to be taken. Intraoral fibrous scar bandsdibular function. can be excised and grafts placed. In areas that haveBecause of the destructive nature of the injuries suffered from avulsive injuries, local recruitment ofsustained by soldiers in support of OIF/OEF, many tissues should be the first option, with regional or freecasualties with oral and maxillofacial injuries pre-flaps used when the local tissues are inadequate. Freesent with mandibular disability secondary to either gingival grafts or connective tissue grafts are per-soft tissue or hard tissue fibrosis. The management formed to restore an adequate amount of attachedapproach to these patientsafter all injuries are gingiva. After the primary bone grafting is complete, ahealedfollows a conservative algorithm with esca-prosthodontic consultation should be obtained forlation as needed to achieve normal mandibular definitive treatment planning. A maxillofacial pros-function. For this approach to be successful, patient thodontist should be involved early in the treatment ofcompliance is necessary with diligence in following large avulsive injuries, notably when an obturator forinstructions as prescribed. maxillary defects is proposed.Secondary reconstructionPosttraumatic scarring and cosmetic managementThe primary purposes of secondary reconstructiveComplex maxillofacial penetrating trauma relatedprocedures should be to increase functional activityto blast and ballistic injuries frequently results inof the maxillofacial complex, correct obvious errorsaggressive, disfiguring scars. The combination of aor bony relapses from the primary surgical interven-high degree of wound contamination, wound avul-tion, and improve the cosmetic appearance of asion, and loss of tissue vitality contributes to sig-patient. As with any trauma patient, a surgeon should nificant cicatrix formation and facial disfigurement.begin to formulate the long-term reconstruction plans Our experiences managing these complex woundsbefore any surgical treatment to avoid performing sustained by servicemen and servicewomen in sup-procedures that may limit definitive reconstruction.port of OIF and OEF have served as a basis for theAs many authors have expressed and we havefollowing discussion according to the lessons learnedemphasized repeatedly in this article, the success of by our surgeons.long-term reconstruction depends greatly on initial The key to a successful cosmetic outcome afterwound management and the prevention of scar these devastating injuries is based on interveningcontracture. The ideal end result of the reconstructive procedures designed to prevent cicatrix formationprocess is to restore a patient to a functional dentition rather than strictly addressing wound scarring as awith optimal cosmesis. With avulsion of tissuesecondary procedure. Initial management of theseassociated with high-energy injury patterns, we haveinjuries must include early, extensive wound debride-found that definitive reconstruction of the jaws is ment of contamination through serial wash outslimited by the hard and soft tissue defect and thewith copious antibiotic-containing irrigation solutionsassociated scarring, which often requires numerousand obtaining wound cultures along the way tosecondary procedures. Common procedures per-identify infective organisms and their appropriateformed during this phase from the maxillofacial sensitivities. Assessment of the degree of missingsurgery perspective include placement of ocular,tissue present after these blast injuries is imperative.auricular, or dental implants for prosthetic replace- Patients who present with tissue loss or avulsion thatment or preprosthetic surgery wholly for dental is left to heal secondarily will develop severe 14. 354 powers et aldisfiguring scar formation. Early identification oftattooing: the Nd Yag (1064 nm) infrared laser andtissue loss followed by procedures to bring vascular-the red Alexandrite laser (755 nm). We are convincedized tissue through local rotation flaps or distant free that persistence of these foreign particles within theflaps is essential to minimize scarring and maximize soft tissues provides the impetus and etiology forform and function. Early reduction and fixation of significant hypertophic scar formation. Prompt scarunderlying bony fractures and replacement of missing excision and revision coupled with laser-assistedosseous structures with bone grafts or alloplastic phagocytosis and elimination of metallic particlesaugmentation also are essential for a favorable return provide the greatest likelihood of a favorableof form and function and minimization of cicatrixcosmetic soft tissue wound result [17].formation. Early intervention regarding reconstruc-Facial scarring secondary to ballistic and blast-tion of the underling bony defects and overlying related injuries is a significant cosmetic concern. Thecutaneous defects should b accomplished within 10 to outcome can be made more predictable and cosmeti-14 days of injury to avoid extensive wound contrac-cally pleasing if certain treatment protocols andture and aggressive scarring. This is certainly amodalities are used. Essential considerations mustreasonable time period to initiate these surgicalinclude early fixation and reconstitution of the facialprocedures once appropriate consultations have beenskeleton, followed by passive soft tissue woundaccomplished and wound infection has been ruled outclosure through use of local rotational flaps or distantor appropriately treated. If this protocol is followed,free flaps. In our experience, early scar excision andthe resultant scar formation should be minimized and revision along with early program dermabrasion andamenable to the following treatment options to use of laser technology to remove tattooing of softaccomplish a cosmetically acceptable outcome.tissue seem to provide the most favorable cosmeticScarring associated with ballistic and blast injuriesoutcome for these devastating facial injuries. Mea-usually presents with tattooing of the penetratedsures used to prevent or eliminate wound contami-tissues secondary to impregnation of the skin by nation and contraction provide the foundation for themetallic fragments. In addition to the tattoo effect,most favorable cosmetic outcome. Preventive mea-there is usually hypertophic cicatrix formation. Early sures always outweigh the benefits of secondaryprogram dermabrasion of these scars 4 to 6 weeks management of posttraumatic scarring.after soft tissue closure or scar excision/revision hasproved to be beneficial to leveling the skin andimproving cosmesis. Injecting subcutaneous kenalogto reduce hypertrophic scarring is also beneficial asSummarylong as long as low doses are used so as not to causesignificant dermal atrophy or liponecrosis. TopicalThe management of complex maxillofacial inju-application of silastic gel or sheets through a relatively ries sustained in modern warfare or terrorist attackunknown mechanism also improves wound levels and has presented military surgeons with a new form ofcosmesis. Topical application of imiquimod 5% creaminjury pattern previously not discussed in the medicalalso has been reported to reduce hypertrophic scar literature. The unique wounding characteristics of theformation by activating cellular cytokines and alpha IED, the portability of the weapon platform, and theinterferon. This agent is helpful if initiated by therelative low cost of development make it an idealsecond week after the wound repair [16]. weapon for potential terrorist attacks. If potentialTattooing of the skin with gray-blue pigmentationfuture terrorist attacks in the United States follow theafter penetrating metallic injury can be reduced same pattern as the incidents currently unfolding insignificantly or eliminated with treatments using thethe Middle East, civilian practitioners will be requiredpulsed-dye laser. The pulsed dye laser (595 nm,to manage these wounds early for primary surgicalyellow light laser) provides collagen rebuilding and intervention and late for secondary and tertiaryreorganization while normalizing neovascularization. reconstructive efforts.These treatments can be repeated on a monthly basisThe use of stereolithographic models in presur-for eight to ten applications. The tattooing isgical planning of complex maxillofacial injuries issecondary to implanted metallic fragments that critical and should be considered the standard of care.consist of copper, zinc, graphite, and other metals. These models can be manufactured during the initialThe metallic fragments can be disrupted through48- to 72-hour period of serial debridement and photo acoustic shattering of the pigmented par-surgical washouts. They are invaluable in visualizingticles using a Q-switched laser. Two other lasersthe bony architecture of the skeletal framework. Ourhave been effective in our experience in reducingexperiences with patients injured by IED blasts 15. maxillofacial trauma treatment protocol 355indicate that they are highly likely to become infected [5] Powers DB, Edgin WA, Tabatchnick L. Stereolitho-by some type of organism, the only variable being graphy: a historical review and indications for use inwhen the infection will develop over the course ofthe management of trauma. J Craniomaxillofac Trauma1998;4(3):16 23.treatment. Scar contracture that occurs either sec-[6] Scott PT, Peterson K, Fishbain J, et al. Acinetobacterondary to infection or as a consequence of improperbaumannii infections among patients at military medi-positioning of the bony substructure of the face is cal facilities treating injured US service members,almost impossible to recover from if inadequate 2002 2004. MMWR Morb Mortal Wkly Rep 2004;projection of the soft tissue envelope is not main- 53(45):1063 6.tained. The treating surgeon should not fall victim to[7] Schuster GS. The microbiology of oral and maxillo-the mistake of rushing these patients to the operatingfacial infections. In: Topazian RG, Goldberg MH,room for definitive treatment before gathering theeditors. Oral and maxillofacial infections. 3rd edition.appropriate preoperative data. Projection and support Philadelphia7 WB Saunders; 1994. p. 39 78.of the soft tissue envelope is critical to the success of [8] Gilbert DN, Moellering Jr RC, Sande MA. TheSanford guide to antimicrobial therapy. 34th edition.any surgical treatment initially performed. We alsoHyde Park (VT)7 Antimicrobial Therapy, Inc.; 2004.have used this treatment protocol on civilian pan-[9] Eppley BL, Bhuller A. Principles of facial soft tissuefacial trauma casualties, such as victims of automo-repair. In: Booth PW, Eppley B, Schmelzheisen R,bile accidents or isolated gunshot wounds, and have editors. Maxillofacial trauma and esthetic facial recon-found it to be successful. Whereas our wish is that the struction. Edinburgh7 Churchill-Livingstone; 2003.information presented in this article never will be p. 107 20.used in the United States for the treatment of patients[10] Clark N, Birely B, Manson PN, et al. High-energyinjured in another terrorist attack, the lessons learnedballistic and avulsive facial injuries: classification,in the management of modern ballistic injuries andpatterns, and an algorithm for primary reconstruction.wounds sustained in warfare should be shared with Plast Reconstr Surg 1996;98(4):583 601. [11] Wong MEK, Johnson JV. Management of midfacethe civilian community so that if that day ever comes,injuries. In: Fonseca RJ, editor. Oral and maxillofacialwe shall all be prepared.surgery. 1st edition. Philadelphia7 WB Saunders; 2000.p. 245 99. [12] Ellis E, Tharanon W. Facial width problems associatedAcknowledgments with rigid fixation of mandibular fractures: casereports. J Oral Maxillofac Surg 1992;50(1):87 94.The authors would like to acknowledge the chief[13] Dolwick MF, Armstrong JW. Complications in tem-residents of the National Capitol Consortium Oral poromandibular joint surgery. In: Kaban LB, Pogreland Maxillofacial Surgery Training Program, Michael MA, Perrott DH, editors. Complications in oral andJ. Doherty, DDS, and Charles G. Stone, Jr, DDS, for maxillofacial surgery. Philadelphia7 WB Saunders;1997. p. 98 9.their assistance with the research and preparation of [14] Keith DA. The long-term unfavorable result inthis article.temporomandibular joint surgery. In: Kaban LB,Pogrel MA, Perrott DH, editors. Complications in oraland maxillofacial surgery. Philadelphia7 WB Saunders;References1997. p. 301 2. [15] Van Sickles JE, Parks Jr WJ. Temporomandibular joint [1] Sakula A. Sir Harold Gillies, FRCS (1882 1960).region injuries. In: Fonseca RJ, editor. Oral and J Med Biogr 2004;12(2):65. maxillofacial surgery. 1st edition. Philadelphia7 WB [2] Triana Jr RJ. Sir Harold Gillies. Arch Facial PlastSaunders; 2000. p. 146 7. Surg 1999;1(2):142 3. [16] Berman B. Pilot study of the effect of postoperative [3] Shaolin Wahnam Institute. Quotes from famous imiquimod 5% cream on the recurrence rate of excised warriors. Available at: http://wongkiewkit.com/forum/keloids. J Am Acad Dermatol 2002;47:S209 11. showthread.php?t=642. Accessed April 18, 2005.[17] Maggio K. Clinical experience, laser and cutaneous [4] Robertson BC, Manson PN. High-energy ballistic surgery center. 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