Surgical Reconstruction Of Wide-Spread Soft-Tissue Defects Due To Complex Maxillofacial Trauma

Keywords

Complex M?xillof?ci?l Tr?um?; Wide-Spre?d Soft-Tissue Defects; Reconstruction.

Introduction

M?xill?f?ci?l injuries ?re frequent c?use ?f present?ti?ns in ?n emergency dep?rtment. V?rying fr?m simple, c?mm?n n?s?l fr?ctures t? gr?ss c?mmuniti?n ?f the f?ce, m?n?gement ?f such injuries c?n be extremely ch?llenging. The c?mplex m?xill?f?ci?l tr?um? with wide-spre?d s?ft-tissue defects h?s the p?tenti?l t? c?use disfigurement ?nd l?ss ?f functi?n; f?r ex?mple, blindness ?r difficulty m?ving the j?w c?n result [1-3]. Furtherm?re, the c?mplex m?xill?f?ci?l tr?um? usu?lly c?nnects cl?sely t? tr?um?tic br?in injury, th?r?cic tr?um? ?nd ne?rby ?rg?ns injury...[2, 4, 5].

The m?n?gement ?f m?xill?f?ci?l tr?um? inv?lves ?rg?ns ?nd regi?ns m?n?ged by v?ri?us well-est?blished he?lth c?re disciplines ?nd is theref?re multidisciplin?ry such ?s emergency, neur?l?gy, g?str?enter?l?gy, th?r?cic surgery, ?n?esthesi?l?gy, ?rth?pedic, ?phth?lm?l?gy, ?t?l?ryng?l?gy, h?em?t?l?gy, etc [1]. Theref?re, m?xill?f?ci?l surgic?l pr?cedures t? rec?nstruct the wide-spre?d s?ft-tissue defects ?ftentimes ? huge ch?llenge f?r ?r?l ?nd m?xill?f?ci?l surge?ns. We rep?rt 4 c?ses inv?lving c?mplex m?xill?f?ci?l tr?um? ?nd wide-spre?d s?ft-tissue defect wh? treated in ?d?nt?-st?m?t?l?gy center - Hue Centr?l H?spit?l.

Case Report

? t?t?l 4 p?tients with c?mplex m?xill?f?ci?l tr?um? wh? presented ?t ?d?nt?-st?m?t?l?gy center - Hue centr?l h?spit?l during the ye?r 2019. There were three m?les ?nd one fem?le. ?ge r?nge was 19-45 ye?rs. ?f these, three patients were tr?ffic ?ccidents victims, ?ne patient had w?rk-rel?ted ?ccident. ?ll c?ses h?d m?xill?f?ci?l fr?ctures ?nd wide-spre?d s?ft-tissue defects. The time t? h?spit?l w?s within 4 h?urs ?fter ?ccident ?ccuring. The p?tient ch?r?cteristics are sh?wed in t?ble 1.

?ll c?ses were surgic?lly m?n?ged by fix?ti?n ?nd f?ci?l rec?nstructi?n?t ?d?nt?-st?m?t?l?gy center - Hue centr?l h?spit?l; ?nd they were very well rec?very in functi?n ?nd ?esthetics. Facial ph?t?gr?phy fr?m ?ll p?tients bef?re ?nd ?fter surgery w?s obtained (as shown in Figure 1-4).

Disscusion

M?xill?f?ci?l tr?um? h?s bec?me ?ne ?f the m?j?r he?lth pr?blems w?rldwide, ?nd injury p?tterns v?ry in different s?cieties [6, 7]. The incidence v?ries ?cc?rding t? ge?gr?phic?l ?re? ?nd s?ci?ec?n?mic st?tus ?f the p?pul?ti?n investig?ted [8]. This gr?up ?f p?tient is ? huge burden ?nd w?rkl??d f?r m?xill?f?ci?l surge?ns [9], due t? m?ny vit?l structures ?nd signific?nt ?esthetic c?nsider?ti?n ?f the f?ci?l ?re?. Severe f?ci?l tr?um? c?n c?use signific?nt m?rbidity ?nd disfigur?ti?n ?nd p?ses ? unique ch?llenge t? the pl?stic surge?n, given the speci?lized n?ture ?f f?ci?l tissues ?nd imp?rt?nce ?f the f?ce f?r the p?tient's self-esteem ?nd pers?n?l identity. ?fter initi?l st?biliz?ti?n ?nd life-s?ving me?sures, f?cus turns t? ? rec?nstructive pr?cess th?t ?ims t? pr?vide ?ccept?ble functi?n?l ?nd ?esthetic ?utc?mes f?r the p?tient [10].

Different eti?l?gies ?f m?xill?f?ci?l injuries h?d been rep?rted in the liter?ture, which include m?t?r vehicle ?ccident (MV?), ?ss?ult, d?mestic injury, sp?rt injuries, ?nd ?thers. Due t? the differences in s?ci?l, culture, envir?nment?l, ?nd risk f?ct?rs, b?th the incidence ?nd the eti?l?gy ?f the tr?um? v?ry fr?m ?ne c?untry t? ?n?ther.

?ss?ult ?nd MV? ?re the tw? m?in c?uses ?f m?xill?f?ci?l injury w?rldwide [11]. Injuries ?t m?xill?f?ci?l regi?ns stemming fr?m MV? c?ntinue t? be the le?ding c?use in m?ny c?untries [7, 12]. It is kn?wn th?t the incidence ?f MV? is even higher in devel?ping c?untries, which r?nged fr?m 55.2 t? 91% ?s rep?rted in the liter?ture [13, 18]. MV? is the m?in eti?l?gy ?nd the sec?nd c?use ?f m?rt?lity, p?rticul?rly in S?uthe?st ?si?. Vietn?m is n?t sp?red fr?m the m?xill?f?ci?l tr?um? c?used by MV?, with the m?j?rity inv?lved m?t?rcyclists, ?s m?t?rcycles c?nstitute h?lf ?f ?ll vehicles ?nd c?ntributed t? m?re th?n 70% ?f c?su?lties in Vietn?m. The key findings ?f this study were m?les c?nstituted the higher tr?um? in the study ?f Lee et ?l [19], it w?s sh?wn th?t m?xill?f?ci?l fr?ctures were signific?ntly m?re prev?lent in men (538 m?les, 85.4%) c?mp?red with w?men (92 fem?les, 14.6%). M?le-t?-fem?le r?ti? w?s 5.8:1. The r?ti? ?f ?ur study w?s l?wer th?n 13:1 ?s described by M??fi?n et ?l in ? study perf?rmed in Ir?n [20]. These findings dem?nstr?te ? l?ck ?f est?blished p?ttern ?cr?ss cultures [7]. The cultur?l ?nd s?ci?ec?n?mic v?lues ?f p?pul?ti?n studied might influence the r?tes ?f f?ci?l fr?ctures in w?men [11]. F?r ?ccidents, men tend t? h?ve ? higher-risk j?b ?s c?mp?red with w?men. ?ccup?ti?n inv?lving physic?l str?in ?r the use ?f t??ls ?nd m?chine tend t? be m?re d?nger?us [8]. Highest incidence ?f m?xill?f?ci?l tr?um? w?s fr?m p?tients within the ?ge gr?up ?f 19 t? 38 ye?rs. B?th gender ?nd ?ge gr?up predilecti?ns were simil?r t? the d?t? rep?rted in different rese?rches d?ne in ?ther p?rts ?f the w?rld [7, 8, 11, 13-18]. It h?s been suggested th?t m?les, ?ged between 21 ?nd 30 ye?rs, were m?re susceptible t? m?xill?f?ci?l tr?um? due t? their high r?te ?f c?mmuting [11].

The m?in c?use ?f m?xill?f?ci?l tr?um? in ?ur study w?s MV? f?ll?wed by w?rk-rel?ted ?ccident. The result w?s c?mp?r?ble t? ?ther studies, rep?rting th?t devel?ping c?untries h?ve higher incidence ?f MV?, r?nging fr?m 55.2 t? 91% [13-18]. Vietn?m sh?res simil?r pr?files ?f cr?sh p?tterns with ?ther devel?ping n?ti?ns in the w?rld in the p?st dec?de. The tremend?us incre?se ?f m?t?rized vehicles ?n r??ds h?s inv?ri?bly led t? signific?nt rise in the number ?f tr?ffic ?ccidents. H?wever, the eti?l?gy ?f m?xill?f?ci?l tr?um? h?s ch?nged dr?stic?lly in devel?ped c?untries in the p?st dec?de; pers?n?l ?ss?ult h?s ?vert?ken MV? ?s the m?in c?use [21]. These findings h?ve been rep?rted in c?untries such ?s Denm?rk, Sweden, United Kingd?m, Fr?nce, Finl?nd, ?nd New Ze?l?nd [21-25].

?ll ?f ?ur p?tients h?d s?ft-tissue injury with wide-spre?d defects. S?ft-tissue injuries included l?cer?ti?n w?und, ?br?si?n ?r c?ntusi?n ?n the f?ci?l regi?n. D?t? ?f the ex?ct ?n?t?mic?l l?c?ti?n ?nd severity ?f the s?ft-tissue injuries were n?t c?llected in this study. D?m?ged p?r?tid gl?nds were n?rm?lly referred t? ?nd m?n?ged by ?t?rhin?l?ryng?l?gy (?RL) te?m. The m?st c?mm?nly fr?ctured site ?t the f?ce w?s the m?ndible f?ll?wed by m?xill? ?nd zyg?m?. M?ndible's pr?minence m?de it ? f?v?r?ble site f?r fr?cture. P?r?symphysis w?s the m?st frequent site f?r m?ndibul?r fr?cture f?ll?wed by c?ndyle ?nd b?dy ?f m?ndible. P?r?symphysis fr?cture is ? fr?cture th?t ?ccurs between the ment?l f?r?men ?nd the dist?l ?spect ?f the m?ndibul?r l?ter?l incis?rs. The ?n?t?mic?l l?c?ti?n ?f p?r?symphysis ?r?und the curv?ture ?f the m?ndible m?kes it ? pr?minent site f?r fr?cture. The thin c?ndyl?r neck tends t? fr?cture e?sily during ?n imp?ct ?nd this mech?nism prevents it fr?m being pushed int? the middle cr?ni?l f?ss?. Sever?l studies rep?rted simil?r findings with ?ur study, which menti?ned th?t the m?st frequent site ?f m?xill?f?ci?l fr?cture w?s m?ndible [11, 18, 26], ?nd the m?st frequent m?ndibul?r fr?cture sites were symphysis–p?r?symphysis ?nd c?ndyl?r regi?n f?r r??d-tr?ffic ?ccident c?ses.

There ?re m?ny meth?ds ?v?il?ble t? imp?rt tissue t? the he?d ?nd neck regi?n; the m?n?gement pl?n is individu?lized t? the c?se ?t h?nd. L?c?l tissue fl?ps h?ve limited ?m?unts ?f tissue ?nd ? m?dest v?scul?r supply, ?nd thus ?re ?ften s?ved f?r the fin?l st?ges ?f rec?nstructi?n f?r min?r c?nt?uring. Pedicled my?cut?ne?us fl?ps ?ffer l?rge ?m?unts ?f tissue with reli?ble v?scul?rity f?r s?ft tissue c?ver?ge, but ?re ?ften bulky ?nd ?re limited by the length ?f the v?scul?r pedicle. Free tissue tr?nsfer ?ll?ws the e?rly rec?nstructi?n ?f d?m?ged b?nes ?nd pr?vides s?ft tissue c?ver?ge s??n ?fter injury [27]. ?dditi?n?l rec?nstructive techniques ?nd t??ls include impl?nts, tissue exp?nders, ?nd epiderm?l skin gr?fting, ?lth?ugh these ?re n?t frequently used in the ?cute setting [10].

?t the initi?l enc?unter, ?fter st?biliz?ti?n ?nd the m?n?gement ?f life-thre?tening injuries, the initi?l rec?nstructi?n in the ?per?ting r??m serves t? debride the w?und, est?blish pr?per ?cclusi?n, ?nd cl?se the w?und in the best w?y p?ssible. The timing ?f definitive rec?nstructi?n is currently ? t?pic ?f deb?te. S?me ?uth?rs suggest th?t, when p?ssible, p?tients requiring free-tissue tr?nsfer sh?uld h?ve their definitive tre?tment perf?rmed immedi?tely (within 24-48 h?urs) [28]. Immedi?te definitive rec?nstructi?n le?ds t? fewer revisi?n?ry pr?cedures ?nd impr?ved results, where?s del?yed rec?nstructi?n h?s ?n incre?sed incidence ?f w?und c?ntr?cture [29-31]. ?thers suggest pr?viding c?nserv?tive c?ver?ge in the ?cute setting, then perf?rming m?re lengthy definitive rec?nstructi?ns ?fter the p?tient h?s been st?bilized [27, 32].

?f ?ll c?ses, tw? p?tients ch?se t? be tre?ted with ?pen reducti?n ?nd intern?l fix?ti?n (?RIF), ?ne c?se by cl?sed reducti?n, ?nd ?ne c?se by either c?nserv?tive m?n?gement ?r n? tre?tment. ?RIF w?s m?inly ?chieved vi? tit?nium ?ste?synthesis pl?tes. ?ll ?ur ?RIF c?ses were tre?ted with l??d sh?ring mini pl?tes with excepti?n t? c?mminuted m?ndibul?r fr?ctures where l??dbe?ring pl?tes were used. Cl?sed reducti?n w?s m?inly ?chieved vi? interm?xill?ry fix?ti?n either using ?rch b?r ?r eyelet wiring. With reg?rd t? tre?tment meth?ds, s?me rese?rch h?d rep?rted th?t ?ppr?xim?tely 98% ?f ?ll p?tients with m?ndibul?r ?nd middle third f?ci?l fr?ctures were tre?ted by cl?sed reducti?n, f?ll?wed by ?RIF ?nd c?nserv?tive m?n?gement (?ctive j?w exercises ?fter sh?rt peri?d ?f imm?biliz?ti?n f?r c?ndyl?r fr?ctures) [18].

?RIF m?y le?d t? e?rly rec?very, segment st?bility, m?re r?pid return ?f functi?n, ?nd ?ls? impr?vement ?f p?tient's c?mf?rt [11]. Indic?ti?ns f?r ?RIF ?f zyg?m?tic c?mplex fr?ctures include dipl?pi?, en?phth?lmus, p??r ?esthetic, ?nd limited m?uth ?pening. We tre?t c?ndyl?r fr?cture with cl?sed reducti?n with excepti?n f?r c?ses indic?ted f?r ?pen reducti?n such ?s fr?ctured l?ter?lly, displ?cement ?f c?ndyle int? middle cr?ni?l f?ss?, ?nd the presence ?f f?reign b?dy. Nevertheless, p?tients refused ?RIF tre?tment bec?use ?f the he?lthc?re c?st. S?me ?f the simple fr?ctures were m?n?ged c?nserv?tively.

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Table 1:

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T?ble 1. Baseline ch?r?cteristics ?f the patients..

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Figure 1:

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Figure 1. C?se 1 (m?le, 30 ye?rs ?ld).

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Figure 2:

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Figure 2. C?se 2 (fem?les, 23 ye?rs ?ld).

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Figure 3:

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Figure 3. C?se 3 (m?le, 19 ye?rs ?ld).

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Figure 4:

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Figure 4. C?se 4 (m?le, 45 ye?rs ?ld).

?cknowledgments

The ?uthors ?re gr?teful to physici?ns, ?dministr?tive st?ff ?t Odonto-Stom?tology Center of Hue Centr?l Hospit?l for ?llowing us to undert?ke this rese?rch.

Conclusion

C?mplex m?xill?f?ci?l injuries c?n be ? dev?st?ting ?rde?l f?r p?tients ?nd f?milies. The v?st impr?vement in preh?spit?l c?re h?s resulted in typic?lly m?re-severe m?xill?f?ci?l injuries being m?n?ged by the pl?stic surge?n. The m?n?gement ?f f?ci?l fr?ctures ?nd wide-spre?d s?ft-tissue defects h?s ev?lved s? th?t ? multidisciplin?ry te?m is best equipped t? de?l with ?ng?ing issues.