Early Single-Stage Repair of Complex Craniofacial Trauma

Abstract

The traditional surgical management of complex craniofacial injuries is performed in three stages: immediate craniotomy, orbitofacial repair in 7 to 10 days, and cranioplasty delayed 6 to 12 months because of the perceived risks of infection and prolonged anesthesia in the head-injured patient. Cosmetic considerations have always played a secondary role; however, there are reports that suggest that bone fragments and grafts can be safely placed even in contaminated wounds. In addition, advances in neuroanesthetic technique allow for prolonged administration of anesthesia without untoward effects on the patient. The purpose of this prospective study was to determine if early single-stage repair of complex craniofacial injuries could be accomplished with acceptable morbidity and mortality. In this study, 13 patients (9 men, 4 women) ranging in age from 3 to 53 years, with Glascow Coma Scale scores of 10 to 15, all had a combined single-stage repair of their complex craniofacial injuries within 24 hours of their trauma. After initial assessment and resuscitation, all patients were evaluated with computerized tomography of the face and head before surgery. Bicoronal skin flaps were used for maximum exposure for frontal sinus exenteration as well as dural repair, cortical debridement, and calvarial reconstruction. Dural grafts were necessary in 12 of 13 patients (92%), and supplementary bone grafting was required in 9 of 13 patients (69%), of which 3 of the 9 (33%) had iliac bone grafts, whereas split calvarial grafts were used in the other 6 of 9 (67%). No artificial cranioplasty material was used. Neurosurgical outcome at both early and late evaluation was judged as good in 11 of 13 patients (85%) and moderate in 2 of the 13 (15%). No patient had a neurological outcome below that predicted by age and presenting Glascow Coma Scale score using the Jennett and Bond outcome scale, despite prolonged anesthesia required for single-stage craniofacial repair. No patient required late cranioplasty. Plastic surgical outcome at early evaluation showed 9 of 13 (69%) to be excellent, 2 of 13 (15%) to be good, and a single patient (8%) in each category to be fair and poor. At late reevaluation, the poor had improved to fair without further intervention and the fair had improved to good with just one additional reconstructive procedure. There were no wound infections and no osteomyelitis, graft resorption, or intracranial abscesses. Complications included 2 patients (15%) with delayed cerebrospinal fluid leaks, 1 with concurrent meningitis, both requiring delayed operative repair. Maxillary sinusitis developed in 2 of 13 patients (15%). These results compare favorably with historical data in which an overall infection rate for a staged repair would be 12.5 to 17.7%. We conclude that early single-stage repair of complex craniofacial injuries can be performed with an acceptable rate of morbidity and mortality, a decreased need for reoperation, and an improved cosmetic and functional outcome.