Resident Manual of Trauma to the Face, Head and Neck

CHAPTER 3: Upper Facial Trauma

v. Bifrontal (Coronal) Forehead Flap For severe NOE fractures that involve the anterior skull base, nasal process of the frontal bone, inferior/anterior/posterior frontal sinus or that extend into the cribriform plate, it is usually necessary to approach the reconstruction through a bifrontal (coronal) forehead flap, elevating in the subperiosteal plane. This exposure will also allow for repair of an avulsed trochlea, and obliteration of the frontal sinus, if indicated. 4. Reconstructive Options The reconstruction of NOE injuries usually involves the reduction and fixation of the nasal bones, medial orbit, nasolacrimal system, and medial canthal tendons, with the goals to obtain near-normal appear- ance and function, as well as to reduce immediate and late complications. a. NOE Fracture Reduction Reduction of the NOE fractures in the operating room is normally a simple maneuver of manually compressing the splayed fractures at the level of the medial canthi to obtain a more normal intercanthal distance, based on half of the patient’s interpupillary distance. Often, this reduction sufficiently produces adequate NOE anterior/profile projec- tion, and the bones maintain their position without internal fixation. Only an external nasal cast may be required in most patients. Typically, the nasal bones will also be fractured inferior to the NOE complex, so these need to be reduced properly, as well, as described in Chapter 4 of this Resident Manual. It is also helpful to have decongested the nasal mucosa with topical oxymetazoline hydrochloride (0.25 percent), with or without 4 percent lidocaine hydrochloride, prior to the closed reduction. b. Nasal Bone Reduction During the closed reduction process, if the nasal and ethmoid processes of the frontal and maxillary bones have also been compressed posteri- orly, it might be necessary to insert the blades of an Asch forceps into the superior nasal region to assist with the anterior distraction of the fragments. If the cribriform plate has been fractured, great care must be exerted during proper insertion of the forceps and the gentle distraction process, so as not to further violate this critical area. c. Techniques for Fracture Fixation If the NOE fractures are unstable, requiring internal stabilization—par- ticularly to maintain the proper intercanthal distance—then several fixation options are commonly used.

66

Resident Manual of Trauma to the Face, Head, and Neck