Evidence-Based Medicine in Facial Trauma

Perioperative Management of Patients with Craniomaxillofacial Trauma

Successful surgical management of patients with facial fractures requires a detailed preoperative evaluation and postoperative management that differs from elective surgical patients. This review presents evidence-based recommendations from the surgical and anesthesiology literature that address many of the clinical questions that arise during the perioperative management of this group of patients. Surgeons and anesthesiologists must work together at numerous points and make joint decisions, especially where airway and pain management challenges may arise. The multidisciplinary nature of the decision-making process is emphasized.

Facial Fractures Have Similar Outcomes When Managed by Either Otolaryngology or Plastic Surgery: Encounters From a Single Level I Trauma Center

Study Design:

Retrospective cohort.

Objective:

Traumatic facial fractures (FFs) often require specialty consultation with Plastic Surgery (PS) or Otolaryngology (ENT); however, referral patterns are often non-standardized and institution specific. Therefore, we sought to compare management patterns and outcomes between PS and ENT, hypothesizing no difference in operative rates, complications, or mortality.

Methods:

We performed a retrospective analysis of patients with FFs at a single Level I trauma center from 2014 to 2017. Patients were compared by consulting service: PS vs. ENT. Chi-square and Mann-Whitney-U tests were performed.

Results:

Of the 755 patients with FFs, 378 were consulted by PS and 377 by ENT. There was no difference in demographic data ( P > 0.05). Patients managed by ENT received a longer mean course of antibiotics (9.4 vs 7.0 days, P = 0.008) and had a lower rate of open reduction internal fixation (ORIF) (9.8% vs. 15.3%, P = 0.017), compared to PS patients. No difference was observed in overall operative rate (15.1% vs. 19.8%), use of computed tomography (CT) imaging (99% vs. 99%), time to surgery (65 vs. 55 hours, P = 0.198), length of stay (LOS) (4 vs. 4 days), 30-day complication rate (10.6% vs. 7.1%), or mortality (4.5% vs. 2.6%) (all P > 0.05).

Conclusion:

Our study demonstrated similar baseline characteristics, operative rates, complications, and mortality between FFs patients who had consultation by ENT and PS. This supports the practice of allowing both ENT and PS to care for trauma FFs patients, as there appears to be similar standardized care and outcomes. Future studies are needed to evaluate the generalizability of our findings.

A Novel Approach to the Treatment of Le Fort Fractures Using Internal Fixation to Achieve Mandibulomaxillary Fixation

Background:

We aimed to determine the minimum effective period of mandibulomaxillary fixation after the inadequate internal fixation of Le Fort I or Le Fort II fracture.

Objective:

The aim of this study was to investigate the stability of the skeleton after the treatment of Le Fort I or Le Fort II fractures by measuring bite forces and to determine the minimum time required for effective mandibulomaxillary fixation following treatment with internal fixation and mandibulomaxillary fixation.

Method:

A prospective study was performed to examine the treatment of Le Fort I or Le Fort II fracture in the Department of Maxillofacial Surgery at the National Hospital of Odonto-Stomatology in Ho Chi Minh City, Vietnam. A total of 31 patients were included, with up to 1 month of follow-up after discharge from the hospital. Midface bone stability and the mandibulomaxillary fixation time were evaluated using bite force criteria after 1, 2, and 4 weeks.

Results:

Midface bone stability values 1, 2, and 4 weeks after treatment were 87.1%, 100%, and 100%, respectively. After 1 week, 87.1% of patients achieved intermaxillary fixation, and 96.3% of these patients were treated with at least three rigid plates. The remaining 12.9% of patients achieved fixation after 2 weeks, and all of these patients were fixed only at zygomaticomaxillary sutures (p < 0.05). Bite forces increased significantly at 2 weeks compared with 1 week and at 4 weeks compared with 2 weeks (p < 0.05).

Conclusion:

When treated using only rigid fixation, through the placement of plates and screws at zygomaticomaxillary buttresses, patients with Le Fort I and Le Fort II fractures can achieve mandibulomaxillary fixation after 2 weeks. For Le Fort I fractures, rigid fixation using plates and screws at zygomaticomaxillary buttresses and canine buttress at three positions can achieve mandibulomaxillary fixation after only 1 week (p = 0.0001).

Evaluation of Bite Force After Treatment of Le Fort Fractures by Internal Fixation and Mandibulomaxillary Fixation

Objectives:

Evaluation of bite force one, two, and four weeks after discharge following treatment of Le Fort I and/or Le Fort II fracture by rigid fixation and mandibulomaxillary fixation.

Objective:

The aim of this study was to evaluate bite force following treatment of Le Fort I and/or Le Fort II fractures by rigid fixation and mandibulomaxillary fixation at one, two, and four weeks after discharge. This provides valuable results to guide the development of a treatment protocol for Le Fort fractures.

Method:

This was a prospective study including 31 patients who underwent followup examination three times after being discharged from hospital. The examination evaluated bite force using a bite force meter in the right molar, left molar, and incisor regions.

Results:

One week after discharge, bite forces in the right molar, left molar, and incisor regions were 94.29 ± 58.80 N, 95.42 ± 57.34 N, and 39,94 ± 30,29 N, respectively. Two weeks after discharge, bite forces in the right molar, left molar, and incisor regions were 153.84 ± 89.14 N, 153.00 ± 78.55 N, and 65,9 ± 43.89 N, respectively. Four weeks after discharge, bite forces in the right molar, left molar, and incisor regions were 279.77 ± 95.46 N, 285.00 ± 90,47 N, and 123.42 ± 54.04 N, respectively.

Conclusions:

Bite forces in the right molar, left molar, and incisor regions were significantly increased one week, two weeks, and four weeks after discharge. Bite force may be a helpful parameter to confirm the stability of the midface bone after treatment of Le Fort fractures.

Antibiotic prophylaxis for traumatic facial fractures

WHAT IS KNOWN AND OBJECTIVE

The purpose of this paper is to discuss the limitations of the evidence supporting the SIS recommendations for antibiotic prescribing in patients with traumatic facial fractures and to provide suggestions for clinical decision-making and further research in this area given the wide variation in prescribing practices.

COMMENT

The Surgical Infection Society (SIS) recently published guidelines on antibiotic use in patients with traumatic facial fractures. The guidelines recommend against the use of prophylactic antibiotics for all adult patients with mandibular or non-mandibular facial fractures undergoing non-operative or operative procedures. Despite the available evidence, surveys conducted in the United States and the United Kingdom prior to the publication of the SIS guidelines demonstrate substantial preoperative, intraoperative and postoperative prophylactic prescribing of antibiotics for patients with facial fractures undergoing surgery.

WHAT IS NEW AND CONCLUSION

With the exception of strong recommendations based on moderate-quality evidence to avoid prolonged postoperative antibiotic prophylaxis, the weak recommendations in the guidelines are a function of low-quality evidence. A logical choice for a narrow-spectrum antibiotic is cefazolin administered within 1 h of surgery and no longer than 24 h after surgery, since it is the gold standard of comparison based on clinical practice guidelines concerning antibiotic prophylaxis.