Dr. Sherman is a recognized expert in facial trauma, and has been teaching the repair and treatment of maxillofacial trauma for over 35 years at The New York Presbyterian Hospital Weill Cornell Medical Center. He is a member of The American Society of Maxillofacial Surgeons and is a co-author of a recognized textbook for the treatment of these injuries. Patients come to him from all over the country and around the world to help reconstruct their facial bones after fractures. Dr. Sherman works with a multi-specialty team to address all the issues and tissues involved within a simple or complex facial fracture: fractures of the maxilla, mid face, sinuses and orbits.
The spectrum of injuries range from the simple (nasal fractures, broken noses) to the repair of complex Le Fort fractures, which will be discussed below. Over the years treatment has evolved from the simple placement of wires to rigid fixation with titanium screws and plates. Imaging has also evolved from simple X-rays to CT scans and 3-D reconstructions which help the surgeon visualize injuries prior to surgery.
Nasal Fractures (Broken Nose)
The most commonly injured bone of the facial skeleton is the nasal bone. This occurs as a result of blunt trauma, auto accident, and sports injuries. Initially, the patient may notice only swelling, blood from nose (epistaxis), and pain. With swelling present, the actual fracture may easily be overlooked by the emergency room physician. Plain X-rays are not very useful in the diagnosis, often a CT scan should be seen to rule out more serious injuries.
Treatment of Nasal Fractures
Treatment is relatively easy, and must be performed on a timely basis. These fractures are rarely treated acutely because of the swelling that is present. Dr. Sherman usually prefers to perform a manipulation of the bones (closed reduction of the fracture). This is done after four days when the swelling has subsided, the nasal bones may be easily seen to set correctly and before two weeks at which time the fracture is mostly healed. The procedure may be performed under local anesthesia or sedation anesthesia by a board-certified anesthesiologist. A closed reduction can be performed in the office setting, or as an out-patient at the hospital.
If the reduction is necessary after the 2 to 3 week interval of healing post-trauma, the patient should wait for at least two months for swelling and the nasal bones to fully heal. At that time, an open reduction of the nasal fracture is performed. This is usually performed under sedation anesthesia with an anesthesiologist.
Whether the fracture is treated by open reduction, or closed reduction, the patient wears a splint for about 6 to 7 days. The swelling is modest, and the patient usually can return to work After two days. You should be aware that the nasal bones can shift until fully set which takes about three to four weeks.
Even after the reduction of the nasal fracture, the patient may have difficulty breathing months later because of changes to the septal cartilage (septum). At that time, this may also be corrected with a septoplasty.
Figure A, B. Preoperative picture showing displaced fracture of the nose.
Figure C, D. Patient after corrective surgery restoring appropriate alignment and structure of nose.
An orbital fracture is a traumatic injury to the bones of the eye socket – either the thicker, bony outer rim, the very thin orbital floor beneath the eye, the sides of the orbit, or all. These fractures are generally caused by blunt force, such as a car accident or sports injury, and can impede natural eye movement and functioning.
Symptoms of Orbital Fractures:
- Bruising around the eyes
- Double Vision (diplopia)
- Numbness around the eye socket and cheek area extending to upper lip
- Decreased ability to move eye normally (entrapment)
- Sunken appearance of the eye (enophthalmos)
Figure A. the patient’s left eye is able to gaze upward, and the right eye is unable to do so due to entrapment of the muscle.
Figure B. shows the orbital floor disparity of both eyes, so that the pupils are at different levels.
Figures C. and D. show the patient postoperatively with the ability to look upward without entrapment, and restoration of the floor so that the pupils are at the same level. Full restoration of ocular movement was obtained, and double vision eliminated.
Figure A. Pre-operative scan of 59-year-old patient. Arrow shows displaced orbital floor fracture, occurring in addition to fractures of the maxilla and zygoma.
Figure B, C. Restoration of normal anatomy with an orbital floor implant on the patient’s right side – highlighted and circled in blue. Additional plates are on the maxilla and zygoma (cheek bone) – highlighted in green.
Figure A. Arrows (red) indicate bilateral orbital floor fractures after this 37-year-old patient was assaulted. The patient also has fractures of the left maxilla (orange arrow).
Figure B. Placement of orbital implants (highlighted in blue), correcting the medial wall defects as well as the orbital floors. Additional plate is on the left maxilla (green).
Stryker® Contour Medpor titanium implants that are often used to reconstruct the orbital floor.
A small (4mm) screw is secured to the orbital rim for fixation.
Facial Fractures and Cheekbone Surgery (zygoma)
Fractures of the zygoma occur from blunt force trauma either from a fall, motor vehicle accident, or assault. The zygoma (cheekbone) fracture occurs at the maxilla, the zygomatic arch and superior orbital rim articulating in three places.
Fracture of the left cheekbone (zygoma). (Illus. from Surgery of Facial Bone Fractures by John E. Sherman MD)
The illustration above shows a typical cheekbone fracture (fracture of the zygoma) causing downward displacement of the bone. This is often called a tripod fracture because of the three locations of the fractures. The bone is usually displaced downward, which may impinge on the movement of the upper jaw (maxilla).
Facial Anatomy of the Cheekbones
The cheekbones are bones that involve the area around the orbit of the eye (beneath and around the eye socket), the zygoma, zygomatic arch, and the maxilla. The zygomatic arch is the bone area that connects the under-bone of the eye to the area below the temple just before (anterior to) the ear. A tripod fracture is a facial fracture that involves the zygoma, which is displaced. It may involve the arch and the orbit.
Symptoms of Fractures of the Zygoma
Cheekbone fractures often are painful if they are displaced. Often the individual that has the cheekbone fracture will find that chewing, talking, yawning or anything having to do with the movement of the face in that area will be painful. The additional fracture pain is due to the compression of the zygoma (cheekbone area) on the muscles that are below.
The area of the cheek extending to the teeth of the maxilla (upper jaw) may also be numb. This is due to the injury to the infraorbital nerve which is often involved at the fracture site. Sensation usually returns up to nine months later.
Diagnosis of these injures is made after a CT scan. If you have an orbital injury, an ophthalmologist should also examine the eye to make sure that there is no damage to the globe.
Preoperative scan of 29 year old male victim of assault, who sustained fracture of the zygoma. Fracture lines are highlighted in red.
Postoperative view showing reduction of the fracture with titanium plates, restoring normal anatomy (highlighted in blue).
A fracture may often only involve the arch of the zygoma. The most significant symptom is trismus, pain caused by opening the mouth. The treatment for this is different than full fractures of the zygoma. A small incision is made behind the hairline, and an instrument is inserted to simply elevate the displaced fragment.
A temporal (Gillies) approach for reduction of fractures of the zygoma and zygomatic arch. (Illus. from Surgery of Facial Bone Fractures by John E. Sherman MD)
Complex Facial Fractures
25 year old male who fell from second story window, sustaining Le Fort III multiple facial fractures of the maxilla, mandible, midface and both orbits. Dr. John Sherman led his multispecialty team in reestablishing normal facial anatomy.
Figure A. Red arrows show size of fractures throughout maxilla, mandible, orbit and zygoma.
Figure B, C. Reduction and occlusion were restored after the fixation with multiple screws and plates. Images show position of plates (highlighted in blue) after complex surgery to repair Le Fort III fracture, restoring normal facial anatomy.
Above images depict severe facial bone trauma and subsequent repair in a 39-year-old patient who suffered a four-story fall.
Post-operative images of above patient after successful bone reconstruction following severe trauma.
Treatment of Complex Facial Fractures
The patient must be evaluated to ensure that no other injuries are present. Orthopedic surgeons, critical care physicians, and neurosurgeons are often involved in the treatment of the more complex injuries.
Surgery is usually performed after hospital admission and the patient is stabilized. Remarkably, after the fractures are stabilized, pain is modest and the patient feels better because there is no more movement of the involved bones.
Access incisions may be made in the mouth, eyelid (transconjunctival) and the brow. More complex fractures may involve incisions behind the hairline.
If you have suffered from a cheek fracture, facial trauma, or have previous facial injury, contact our office to schedule your consultation with Dr. Sherman, a world renowned facial trauma specialist, today. If you are hospitalized, transfer to the New York Presbyterian hospital can be arranged.