Concomittant dislocations of the face and skull

Abstract

Summary Cranial lesions associated with facial fractures are sometimes so severe that they have to be classified as dislocation by reason of their extensive displacement. The examination of such patients reveals situations which have to be classified in two different groups presenting different diagnostic and therapeutic problems. 1. Dislocations of the base associated with those of the face first present a diagnostic problem. They therefore should be systematically evaluated by tomography. The treatment calls for a neuro-surgical approach by elevating a frontal bone flap. This gives satisfactory access to all lesions of the base and good conditions for reconstruction. The dura mater is sutured and grafted with epicranium. The bony structures arc either repositioned and fixed or — if they are small — removed and repaired by a bone graft. The posterior wall of the frontal sinus is resected, and the ducts arc closed. The facial dislocations are treated as usual. The treatment of these lesions has to be performed by a neuro-surgical and maxillo-facial team working together in the same operative session. The cranial reconstruction usually precedes that of the face. However, it may be advisable with certain types of lesions that the fronto-orbital area is reconstructed before the cranial area to avoid the risk of damaging the cranial reconstruction while dealing with the facial dislocation. 2. The dislocations of the vault associated with those of the face have a less concealed symptomatology. Cranial and facial reconstructions are undertaken during the same session. The base of the cranial fossa is also inspected. The reconstruction of the vault always precedes the reconstruction of the face in order to have stable reference points for the suspension of the facial skeleton. The therapeutic problem is that of the shape and size of the cranial bone flap. It depends on two factors: the suspected lesions of the base and the topography of the facial lesions. A total once-for-all reconstruction performed by two teams during a single operative session seems to be the best solution for the problem of how to deal with such inter-related lesions from the neuro-surgical and the maxillo-facial point of view.