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Archive for the ‘facial fractures’ Category

Improving Closed Reduction of Nasal Fracture Outcomes

Wednesday, February 1st, 2017


The broken nose is the most common facial fracture and references to its treatment date back a thousand years. It is usually viewed as a simple problem that is easily fixed by  trying to push back into place the displaced nasal bones. But the reality is that nasal fractures are underdiagnosed and untreated and there is a much higher incidence of secondary deformities from them that is appreciated.

In the January 2017 issue of the journal Plastic and Reconstructive Surgery a paper on this topic was published entitled ‘Improving Results in Closed Nasal Reduction: A Protocol for Reducing Secondary Deformity’. In this paper the authors looked retrospectively at 90 patients who underwent closed reduction of nasal fractures over a seven year period using a standard protocol. Postoperative deformities occurred in 16% of them with persistent displaced nasal bones and avulsion of the upper lateral cartilage as frequent secondary deformities.

Nasal fractures can be classified into four categories; type 1 unilateral bone fracture, type 2 bilateral nasal fractures, type 3 comminuted bone fractures and 4) combined nasal bone and septal fractures. Making the proper diagnosis is important and types 1 through 3 can be treated by closed reduction only. But a type 4 nasal fracture may require more of an open approach. Treatment of nasal fractures by closed reduction can be done under local anesthesia but many patients will find it more comfortable and better results may be obtained under deeper forms of anesthesia.

Closed Reduction Nasal Fracture Dr Barry Eppley IndianapolisThe closed reduction protocol initially consists of initial mucosal vasoconstriction with Afrin packing. The Boies straight elevator is used as a bimanual technique for elevation and repositioning the nasal bones. The Asch straightening forceps is used reposition the deviated septum followed by septal splinting. Once nasal bone and septum displacements have been reduced, nasal packing with vaseline gauze is done. Externally the nasal bridge is taped and splinted. Because of the nasal packing patients are placed on oral antibiotics. The nasal packing is removed by 3 days after surgery. The tapes and splint are removed after one week.

The closed treatment of nasal fractures is not complex. But it is also not as simple as just ‘popping the bone(s) back in place’. Most nasal fractures don’t have just one large piece of bone displaced, the bone fractures are typically comminuted. A more through bimanual reduction and applied support afterwards helps reduce the historic high incidence of secondary deformities and the need for further nasal surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Nasal Fracture Repair

Saturday, November 5th, 2016


nasal-bone-anatomyBackground: The nose is the most frequently fractured bone on the face. This is undoubtably because it is a very projecting structure that makes it easier to hit than other more recessed areas of the face. Even though the nose is two-thirds cartilage in composition, the small bones in the upper nose are highly prone to fracture with trauma.

While the nose can be struck from any angle, the most common cause of nasal fractures is from a side blow. The nasal bones are most frequently displaced in a lateral or side direction. Structurally this is the easiest direction for them to be displaced but also because most people turn their head to get away from the incoming force…resulting in the nose being struck from the side.

The treatment of most nasal fractures is often done acutely in the emergency room by closed reduction or delayed until a specialist is seen days to weeks later. The technique most commonly used is a closed reduction where instruments are used to push the bones back in place in a blind fashion. This can be a very successful procedure provided that the nasal derangement is not complex and involves substantial displacement of other structures such as the septum.

Case Study: This 28 year-old female was struck on the face and seen three days later with swollen and bruised eyes and an obviously deviated nose. The deflection of her nose to the right side of her nose demonstrated that the blow to her face came from the left side and probably from a right-handed assailant.

Two weeks later when most of the swelling had subsided, she underwent a closed reduction relocation of her nasal bones and an open reduction of her dislocated septum. The inwardly displaced nasal bone was moved back outward while the outwardly displaced right nasal bone was moved back inward. Through an internal hemitransfixion incision the fractured and displaced septum was removed, put back together to a resorbable PDS plate and then put back in the midline.

nasal-fracture-repair-dr-barry-eppley-indianapolisHer postoperative result six weeks later showed a straight nose, which presumably looked like it did before, and she had good air exchange through both sides of the nose.

Repair of nasal fractures is often perceived as simple but that is only so if only nasal bone is displaced. Once both right and left nasal bones are displaced the internal septal cartilage by definition is also fractured and malaligned. Treatment of such nasal fractures requires management of the septum as well as the nasal bones to get the best nasal alignment and function after repair.


1) Nasal bone fractures are common and usually treated by closed reduction techniques.

2) The timing of nasal fractures depends on specialist evaluation and the degree of nasal injury.

3) In complex nasal fractures with significant osteocartilaginous displacement, a delayed open nasal fracture repair is usually best.

Dr. Barry Eppley

Indianapolis, Indiana

Zygomatic Arch Fractures and Their Repair

Sunday, March 1st, 2015


NBA player cheekbone fractureFacial fractures are common injuries and sporting activities are a common source of them. This was well illustrated by a well chronicled facial injury sustained recently in the NBA. Oklahoma City’s Russell Westbrook was injured in a game last Friday in Portland when his teammate’s knee collided into the right side of his face in the last minute of the game. This left an immediate imprint in the side of his face between the eye and the ear. The next day he had surgery to repair a ‘cheekbone’ fracture.

Understanding the anatomy of the cheek bone, technically known as the zygomatico-orbital complex, will explain the specific type of facial fracture this NBA player sustained. The distinct imprint on the side of his face was caused by a zygomatic arch fracture. This is the very thin stick of bone that goes from the main body of the cheekbone (zygoma) back to its attachment to the temporal bone in front of the ear. It is like an arched bridge that spans the cheek and skull to let the large temporal muscle go underneath it.

zygomatic arch fracture Dr Barry Eppley Indianapoliscomminuted zygomatic arch fracture dr barry eppley indianapolisBecause the zygomatic arch is so thin, it is one of the most easily fractured bones on the face. But it requires a direct blow to the height of the arch to create a displaced fracture. It usually fractures inward like a V with two collapsing spans of a bridge. But it can also be a comminuted type zygomatic arch fracture where it breaks into multiple pieces and the entire ‘span of the bridge’ falls inward.

Zygomatic Arch Fracture Repair Dr Barry Eppley IndianapolisRepair of a displaced zygomatic arch fracture is unlike just about every other facial fracture other than that of the nasal bones. It is located in an area where direct surgical access is impossible due to branches of the facial nerve. Without direct access it is not possible to rigidly fix the fracture with plates and screws. (at least not very easily) Thus zygomatic arch fractures are repaired from a remote incision in the temporal scalp and are elecated back up into position off of the temporalis muscle.

Zygomatic arch fracture repairs are, by definition, unstable since they are not rigidly fixed back into place. This is why you will usually see some type of protective device over the side of the face to prevent secondary inward displacement while it heals.

Dr. Barry Eppley

Indianapolis, Indiana

Sports-Related Facial Fractures in Children and Teenagers

Thursday, July 11th, 2013


Facial fractures in children are not nearly as common as that in adults for a variety of reasons. Undeveloped bones that bend but do not break and less exposure to differing methods of trauma are the main reasons. But the one trauma exposure that children and teenagers are exposed is that of sports. When it comes to sports, the flying object of some form of ball that makes inadvertent facial contact is likely.

In the June 2013 issue of the journal Plastic and Reconstructive Surgery, a paper was published entitled ‘Non-Fatal Sport-Related Craniofacial Fractures: Characteristics, Mechanisms, and Demographic Data in the Pediatric Population’. This study examined how and when facial fractures occur in various sports using 167 children and teens seen over a five year period for sports-related fractures. To no surprise, 80% of those injured were boys. Most were between the ages of 12 and 15 years old. The most common fracture was to the nose (40%) followed by orbital fractures (34%) and skull fractures. (31%) Many of the children were injured by a sports ball and about half involved attempting to catch a baseball or softball. Only 10% occurred with a basketball or football. Collisons with other players, most often seen in soccer, accounted for 25% of the injuries. Falls accounted for nearly 20% of the injuries.

Facial fractures from sports like skiing or snowboarding occurred in children who were not wearing helmets. Horseback riding injuries were the result of being kicked. Although horseback and skateboarding injuries were not common, they were often much more serious.  Almost half of the children injured were admitted to the hospital for either surgery or observation. Really significant facial fracture injuries that resulted in an unstable airway or spinal cord injury were uncommon, occurring in less than 5% of the patients.

What this study shows is that some facial injuries can be prevented by the use of protective equipment. Wearing helmets in the most risk-prone sports such as skateboarding and skiers and googles and nasal protectors in other smaller ball-related sports can be very helpful.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Delayed Cheekbone Fracture Repair

Thursday, July 11th, 2013


Background:  Fractures of the cheek bone, like the nose, are common due to the prominence of these bones on the face. They are frequently exposed to trauma from sporting activities to fisticuffs. It fractures along the numerous legs of its bony attachments which is where it gets its common name, tripod fracture. It also goes by many other names such as zygoma fractures, trimalar fractures, and orbitozygomatic fractures.

The tripod fracture, more anatomically described as a zygomaticomaxillary complex (ZMC) fracture, is comprised of three (technically four) bone fracture lines. The first portion of the fracture involves the maxillary sinus which includes the anterior and posterior buttresses or supports of the maxilla as well as an overlying floor of the eye socket. (orbit) The second portion involves the zygomatic arch which attaches to the main body of the zygoma. (cheek bone) The third portion involves the  outside bone of the eye socket (lateral orbital rim) up to the zygomaticofrontal suture line. The fourth fracture line, often overlooked, is the sphenozygomatic suture which is located deeper in the eye socket.

When the cheekbone sustains trauma, the impact force disrupts all four legs of the bone. When this happens the cheek bone tilts downward into the maxillary sinus causing a loss of cheek projection and the appearance of a lopsided face. Depending upon the severity of the impact force will determine how far the bone settles into the sinus and the degree of flattening of the cheek. If severe enough the eyeball will also drop down if the bone of the floor of the eye is sufficiently broken. This may cause a tilt downward of the corner of the eye also.

Case Study: This 28 year-old male was struck on the left side of his face in an altercation in a bar. His face became very swollen and bruised days later and he had persistent numbness of his upper teeth and lip. The swelling and bruising went down weeks later but the numbness continued. By a month after the injury he noticed his face was flat and sunken over his cheek area.

The sunken cheek area was obvious and it was painful to touch below the lower eye socket rim. A CT scan showed a severely displaced ZMC fracture with near complete rotation into the maxillary sinus. Compared to the opposite normal side, the degree of cheek bone displacement was considerable.

Under general anesthesia, a combined intraoral and transconjunctival lower eyelid incisions were used to approach the fracture. The cheek bone was disimpacted and rotated back upward into anatomic position and secured into place with multiple 1.5mm plates and screws. Any loose bone fragments were attached to the metal mesh. A fine metal mesh was used to rebuild the lower orbital rim. The large infraorbital nerve was entrapped in the fracture but not severed. Both mucosal incisions were closed with dissolveable sutures.

His postoperative recovery was just like the original injury, taking nearly three weeks for all swelling and any bruising to subside. At six weeks after surgery, he had much improved facial symmetry from all angles of viewing. His lip and teeth were still numb but hope remained for a full nerve recovery which could take up to a year to occur.

Delayed repair of cheekbone fractures can be done months after the initial injury as these thinner facial bones take a long time to heal. They initially heal by fibrous union as they can relatively easily be moved around even 3 to 6 months after being displaced.

Case Highlights:

1) Cheek bone fractures almost always cause a loss of cheek projection and lowering of the floor of the eye as the bone rotates into the maxillary sinus.

2) The key to good results from cheek bone fracture repair is to disimpact the bone from the sinus and re-establish the maxillary buttress and infraorbital rim contours with rigid miniature plate and screw fixation.

3) Delayed repair of cheek bone fractures can be successfully done even as late as 6 months after the initial injury.

Dr. Barry Eppley

Indianapolis, Indiana

‘Unwrapping’ Cheekbone (ZMC) Fractures

Thursday, August 23rd, 2012


Facial fractures are a common injury and occur to the most prominent portions of the face in the vast majority of cases. These include the nose, cheeks, and jaw as frequent sites of facial fractures.. Blunt trauma is the most common cause with fists, falls, sporting activities and automobile accidents being the most common causes.

Cheek bone fractures, technically known as zygomatico-maxillary complex (ZMC) fractures, happen frequently. The cheek bone is less prominent than the centrally positioned nose but it is the most protruding structure on the side of the face and there are two of them.  The cheek bones are a unique facial bone because, although it is a sturdy stock of bone, it is attached to the eye superiorly, the upper jaw inferiorly and the temple posteriorly by relatively thin legs of bone. This is why it is often called a tripod fracture when it becomes broken. (even though technically there are four legs or attachments) Once impacted by enough force, the thinner legs break causing the body of the cheek bone to be pushed inward and usually downward as well. This flattens the cheek bone and causes a tremendous amount swelling and bruising, particularly around the eye area.

This appears to be the exact injury suffered recently by Food Network TV host, Marc Summers, in Philadelphia. This story drew my attention not only because of the recognizeable facial injury pattern but because I have always liked his well known show, ‘Unwrapped’. So to ‘unwrap’ his facial injury, the mechanism as he described the events of his injury is a classic example of what can cause a ZMC fracture. Rapid deceleration with his face planted right up against the glass partition of a cab in a rainstorm is how the accident happened.

Because it is a natural reaction to turn one’s head even in the split-second of the event, the side of the face where the cheekbone is prominent slams into an immoveable object. The legs of the cheekbone fracture, pushing it inward and down into the maxillary sinus. This was described as ‘wiping out half of my face’ which is somewhat accurate. Fortunately this is a blunt injury where the bone is fractured but no soft tissue is lost. Despite the magnitude of this facial fracture, it can be successfully repaired through an incision inside the mouth with or without an external lower eyelid incision. It requires the cheek bone to be repositioned and then held there to heal with small titanium plates and screws.

Many ZMC fractures can be very successfully repaired and patients can have a complete recovery with no long-term sequelae or facial deformity. It will takes about six weeks for the cheek and eye area to resolve all of its swelling and up to three months for all feeling to return to the skin and teeth. May we wish March Summers a speedy and full recovery and look forward to seeing him again on the show later this year.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Craniofacial Reconstruction of a Severe Zygomatico-Maxillary Complex (ZMC) Fracture

Wednesday, August 1st, 2012

Background:  Facial fractures occur from a wide variety of mechanisms, most commonly blunt trauma. The cheekbone or zygomatico-maxillary complex (ZMC) is one of the facial bones that is commonly broken due to its prominence on the face. Usually blunt trauma such as being hit by a sporting ball or a fist causes the cheekbone to be knocked out of place, down and into the maxillary sinus. The legs or attachments of the cheek bone behind its frontal prominence are fourfold, being attached superiorly to the tail end of the brow, medially to the lower rim of the eye socket, inferiorly to the maxilla and out laterally to the arch process/temporal bone. To displace the cheekbone, all four legs must be fractured.

Gunshot injuries to facial bones are unique because they have a blast effect, similar to the forces of blunt trauma, but also have a penetrating disruptive force of a high-velocity bullet. The path of the bullet slices the bones creating a wedge effect in its path. When bullets penetrate the face, they are frequently deflected from their path by the initial bone that they hit. This creates non-straight line bullet paths that can be completely unpredictable. The facial fracture pattern of each bullet wound injury is unique.

Case Study: This 39 year-old female has sustained a severe facial injury from a gunshot wound. The bullet entered her right temple and angled through her cheekbone area downward, incredulously exiting out her mouth. She retained her right eye but became blind due to optic nerve impingement from the blast effect and bony displacement. When seen for reconstruction four months after her injury, she had a severely displaced ZMC fracture pattern with impingement and fibrosis to the coronoid process of the lower jaw and temporalis muscle. As a result she had more than a centimeter of orbital dystopia, very significant facial asymmetry and she could not open her mouth.

A 3-D model made from a CT scan shows the severe amount of ZMC bony displacement.

She subsequently underwent a craniofacial reconstructive procedure that was done through a combined coronal (scalp), lower eyelid and intraoral incisions. The entire ZMC complex (or what remained of it, was displaced downward into the maxillary sinus and well scarred into the temporalis muscle. It was osteotomized and repositioned along the lateral orbital rim, zygomatic arch and the underlying maxilla. The bones were stabilized with titanium plates and bone gaps repaired with split-thickness cranial bone grafts. The orbital floor was also built up with cranial bone grafts in layers until the eye position was at the same level as the normal size. Her lower jaw was remobilized by removing the coronoid process and releasing it from the scarred muscle.

After six weeks of healing, she could be seen to have substantial improvement in her facial symmetry with better eye position and cheek projection. Equally important she could open her mouth to almost a normal amount. While she will need further refinements, such as temporal augmentation, the underlying facial skeleton has been anatomically restored.

Case Highlights:

1) ZMC facial fractures can affect the position of the eye and eyelid, the prominence of the cheek bone, opening of the lower jaw and the integrity of the maxillary sinus.

2) Severe ZMC fractures require extensive osteotomies using a multiple incisional approach, cranial bone grafts and rigid titanium plate and screw fixation.

3) Orbito-zygomatic bone and eye symmetry is a main objective of extensive ZMC reconstruction.

Dr. Barry Eppley

Indianapolis, Indiana

Secondary Revisions of Soft Tissue Problems of Cheekbone (Zygomatic) and Orbital Facial Fracture Repairs

Thursday, December 10th, 2009

Cheekbone (zygomatic) and orbital fractures are very common results of blunt trauma to the face. Methods to put the displaced bones back in place and secure them with plates and screws so they can heal properly are well known. But even when these facial bones are put back into perfect anatomic position and the operation has been scored as a complete success, the facial appearance may still not be completely normal.

Cheeks can look flat, the orbital area may look hollowed, and the lower eyelid may be uneven or retracted downward. All of these are not rare sequelae from this type of facial fracture repair and are a reflection of soft tissue problems. Periorbital soft tissues can be affected by three factors; incisional problems, soft tissue retraction from surgical elevation, and traumatic fat atrophy.

Lower eyelid incisions are needed for exposure and treatment of cheek (zygomatic) and eyebone (orbital) fractures. There are three types of these incisions which can  be done from the skin on the outside of the eyelid to the lining on the inside. Each of these approaches has its surgical advocates but eyelid complications can occur with any of them. By far, the most common problem is that of ectropion or the lower eyelid margin being pulled downward away from the eyeball. Besides causing problems with irritation and tearing, it causes a very noticeable aesthetic distraction as more white of the eye is seen and has horizontal eyelid margin asymmetry compared the opposite side. The other eyelid problem is entropion, where scarring causes the eyelid margin to turn inward. This changes the direction of the eyelashes which now rub against one’s cornea rather than pointing outward. Either eyelid problem can be successfully improved by revisional surgery and can make for a significant aesthetic improvement and elimination of uncomfortable symptoms.

Many cheekbone fractures use a combined lower eyelid and intraoral approach for access. This requires the soft tissues of the cheek to be lifted off during the dissection. If they are not put back at the end of the procedure, soft tissue retraction occurs. This can make the cheek area look flat even though the underlying bone may be properly positioned. This can be improved by revisional surgery through either a cheek resuspension technique (midface lift) or a cheek implant. Each treatment approach can be successful and which one is appropriate for any patient must be determined on an individual basis.

The trauma to the soft tissues, either from the initial injury or from the surgical bone repair, can cause fat around the eye and cheek to shrink and resorb. Fat atrophy from trauma and hematomas (blood collections) is a well known phenomenon. I have seen it not uncommonly in my Indianapolis plastic surgery practice and the cheek area seems to be particularly prone to this soft tissue problem. Fat injections to the cheek and strip fat grafts to the eyelids and orbital rim can be used to help partially restore the lost soft tissue volume.

Secondary reconstruction of soft tissue problems from fractures around the eye and cheek may be needed to treat complications from these injuries. A perfect bone repair does not always lead to a complete restoration of facial appearance.

Dr. Barry Eppley

Indianapolis, Indiana





Sports-Related Facial Fractures – Early Return to Activity after Treatment

Tuesday, November 24th, 2009

Over the past two decades, I have treated many hundreds of facial fractures from a wide variety of mechanisms. By far, domestic interactions and motor vehicle accidents make up the reason that almost two-thirds of these facial injuries as the cause. Facial fractures from sporting events make up a small (less than 10%) number and they often are less severe.

After reviewing numerous research studies on sport-related maxillofacial fractures, several trends are seen. First, males sustain the largest percent of these types of injuries as compared to women. Reports range from 10 to 15:1. This is no surprise given that there are more males than females who participate in contact sports at all age levels. Often, only a single facial bone is fractured with the nose, cheek, orbit, and mandible making up most of the isolated injuries. Dentoalveolar fractures (teeth loosening and avulsions), while still occurring, have decreased in the past decade as the availability and use of mouthguards have become more widely used.

Most of the facial fractures, in my Indianapolis plastic surgery experience, come from soccer, baseball, basketball and hockey…contact sports in which there is little to no facial protection. Flying objects are the main source in baseball and hockey due to the speed and small size of the baseball and puck. Head and upper extremity contact cause most soccer and basketball facial injuries.

With contemporary facial fracture repair methods, many athletes can return to training and competition sooner than in days past. Three-dimensional CT scans provide an immediate assessment of the injury so the need for surgery can be promptly determined. With knowing what to do, surgical repair can be done as soon as possible. With the exception of certain types of nasal fractures, most facial fractures can be promptly treated without waiting for swelling to subside.

Modern low-profile titanium plates and screws enable most facial fractures to be repositioned and secured quite accurately. They are strong enough to not only hold the bones in place but can resist repeat trauma during the bone healing period. They rarely need to be removed as titanium has superb biocompatibility with bone and often becomes overgrown with new healing bone. Resorbable plates and screws are also available but if one is interested in returning to sporting activities as soon as possible, metal fixation is a better choice for earlier return to activities.

Nasal fractures are the one exception to early treatment and bone plating. It is hard to know the full extent of nasal structure displacement since much of the nose is cartilage and not bone. It is usually better to let the swelling go down before attempting surgical repair. The small and thin size of the nasal bones do not permit rigid bone fixation to be done. This is why splinting and protection of the nose is critical for a long time even after returning to sports activity.

Dr. Barry Eppley

Indianapolis, Indiana




Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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