facial plastic and reconstructive surgery in Winston Salem North carolina
Facial fractures occur most commonly from blunt trauma to the face, predominantly from motor vehicle accidents, sporting accidents, and domestic violence. When facial bones are fractured our primary goal is to return them back to a state where they can function. It is most important, therefore, that we consider vision, dentition, hearing, and nasal airway when we repair facial fractures. Secondary to function is scar, cosmesis, and sensation.
The most common facial fracture is a nasal fracture. When nasal bones are broken by themselves they can be fixed in the first two to three weeks with an outpatient surgery. This procedure for repairing nasal fractures soon after an injury is called a closed nasal reduction. We tend to do our closed nasal reductions in the outpatient center giving our patients anesthesia through an IV, which makes them comfortable and relaxed so that the process can go as smoothly as possible for them. After we have completed a closed nasal reduction we place a small cast made of white plastic on the nose. This cast stays on for one week. We will place some packing on one side or the other of the nose. About seven days later we remove the cast and at that point there may be a small amount of bruising or swelling but it is okay to wear makeup, to shower, and to get back to lighter activities. We like to wait three weeks for aerobic activities and six weeks for contact sports. About 80% of the time patients do not require more treatment than this. About 20% of the time, even when we get the nose as straight as possible in the operating room, it settles when patients are at home. This can happen while sleeping or from even gentle contact before the bones have healed. If this happens we let the nose completely heal for approximately six months to a year and then we can fix the nose through a procedure called rhinoplasty.
The next most common facial fracture is a mandible, or jaw, fracture. The key to reconstruction of a mandible fracture is achieving a good bite and occlusal relationship after surgery. We do everything we can to avoid making incisions anywhere on the face. Occasionally we can repair a fracture simply by wiring the teeth together with temporary wires that look like braces. This requires a person to be wired shut for four to six weeks. While this does avoid incisions, it makes it very hard to eat anything but pureed food and most patients will lose up to 15 pounds over four to six weeks.
In some cases incisions can avoid the need to wire the teeth together. Incisions can be made inside the lip at the gum line or on the neck to approach fractures that are on the back edge of the mandible. Sometimes an incision can be placed underneath the chin as well. A titanium plate and titanium screws are placed in the incisions to stabilize the fracture. Many mandible fractures result in postoperative problems even after a good repair, which include a slightly changed bite and numbness or pain in the nerves that go to the teeth or lips.
Midface fractures and fractures of the orbit are significant because they can involve the upper jaws, the sinuses, the eyes, and the nerves that go to the eyes. The most critical issue in dealing with these fractures is usually to obtain correct orbital function. Sometimes the bones around the eyes can be so broken that the eye will sink into the cheek and not move together with the other eye. This can result in double vision. Sometimes when the bones are replaced a space where the globe can fall can cause double vision. Often therefore, even in patients who don't appear to have double vision before surgery, some type of corrective or preventive procedure may be needed to help support the globe after replacement of the cheek and sinus bones. Our approaches to facial fractures are designed to avoid cheek scars. The most common approach to the upper jaws is from the inside of the mouth between the upper lip and the gums. The most common approach to the bones around the eye is hidden in the eyebrow or through the eyelid. We tend to hide the incision on the inside of the eyelid as in cosmetic eyelid surgery or blepharoplasty, since we believe that there is a lower risk of causing ectropion. ( eyelid reconstruction). Patients with fractures around the eyes may need to spend the night in the hospital. We recommend they intermittently ice their eyes and notify us of any vision changes. Any sutures in the eyebrow or corner of the eyelid, are generally removed in 5-7 days.
Fractures of the skull and frontal sinus can be significant since they allow a connection between the nose, sinus cavity, and brain tissue. These can also leave dents in the foreheadand lead to infections, such as meningitis. Some fractures don't need significant repair but can be followed with CT scans to make sure they are healing well. Some fractures, on the other hand, require repair or occasionally destruction of the frontal sinus to make it safe. If the back wall is relatively intact, it can be destroyed and filled with fat, which is usually harvested from the belly. In some cases, where there are many tares and breaks, the safest thing to do is to actually remove the whole sinus and separate the nasal contents from the brain cavity with flaps from underneath the hair. This surgery requires a long incision across the top of the head, which may result in forehead numbness after surgery. No aerobic activity or nose blowing is allowed at all for 3-6 weeks. |
