**4. Surgical approaches in treatment of mid-face fractures**

### **4.1. Intraoral approaches**

Intraoral approach and vestibular incision is the most common technique used in treatment of Le Fort fractures (**Figure 14**). Circum-vestibular incision mesial to the second premolar is used to reach the nasal lateral walls and zygomatic buttresses. As mentioned earlier these buttresses are stable enough to maintain the maxilla at the right position following rigid fixation. Cinch suture and V-Y plasty is necessary when the incision involves the nasalis muscles.

### **4.2. Extraoral approaches**

**Figure 13.** A, fixation of the type I naso-orbital-ethmoid fracture. B, reconstruction of left type II naso-orbital-ethmoid

fracture.

64 Trauma Surgery

After decision-making of rigid fixation of the Le Fort III fracture, extraoral approaches to the zygomaticofrontal and nasofrontal sutures are applied (**Figure 15**). Bicoronal flap is the common approach to achieve all three sutures by one sing incision. Also this is a good approach in repairing the NOE fracture. The incision is made several centimeters behind the hair line between the upper origins of the temporal muscles from one superior temporal line to the other. Dissection of the flap is performed in the subgaleal plane up to 2 cm above the superior orbital rims. The periosteum is incised at this level and subperiosteal dissection is continued to expose the zygomaticofrontal and nasofrontal sutures. Using a suction drain is optional during closure.

When there is no displacement of nasofrontal suture, fixation of zygomaticofrontal sutures is applicable by lateral brow approach. The incision is made almost 2cm parallel to the hair follicles

of the lateral eyebrow (**Figure 16**). The advantages of this technique are least noticeable scar

Maxillofacial Fractures: From Diagnosis to Treatment http://dx.doi.org/10.5772/intechopen.76166 67

Glabellar and ethmoidal (known as Lynch approach) approaches are used in solitary NOE fracture. The latter technique is not recommended by AOCMF due to visible scar band (web) [23]. Glabellar incision is made in old patients in the glabellar furrows through the skin, sub-

Four kinds of periorbital approaches are represented in the literature for reconstruction of orbital fractures and Le Fort II fracture. The incisions on the lower lid are classified into three types based on the distance from the gray line (**Figure 17**). The periorbital approach is called subciliary incision when this distance is about 2–3 mm. When this distance is almost 3–4 mm to the gray line the incision is known as mid-lower lid or subtarsal approach. The dissection of these two techniques is in three fashions. The best dissection technique is to start a few millimeters subcutaneously followed by orbicularis oculi muscle dissection. Skin only or pre-orbicularis oculi muscle incision is not advocated by authors due to high possibility of ectropion rate. The third incision is called skin-muscle flap which involves both skin and

Another popular periorbital approach because of its invisible scar is the transconjunctival technique (**Figure 18**). The incision is made parallel to the gray line through the conjunctive. This approach is divided into preseptal and retroseptal techniques based on the dissection plane. Lateral canthotomy and inferior cantholysis are used in some cases when the surgeon

and no adjacent anatomical structure.

cutaneous layer, and the periosteum.

**4.3. Periorbital approaches**

orbicularis oculi muscle.

needs more access to the orbit.

**Figure 16.** Lateral brow approach.

**Figure 14.** Intraoral approach to expose the Le Fort I fracture line.

**Figure 15.** Coronal approach for management of Le Fort III fracture (courtesy of Dr. Fereydoun Pourdanesh).

of the lateral eyebrow (**Figure 16**). The advantages of this technique are least noticeable scar and no adjacent anatomical structure.

Glabellar and ethmoidal (known as Lynch approach) approaches are used in solitary NOE fracture. The latter technique is not recommended by AOCMF due to visible scar band (web) [23]. Glabellar incision is made in old patients in the glabellar furrows through the skin, subcutaneous layer, and the periosteum.
