Maxillofacial trauma

Facial trauma in Birmingham, Solihull and Sutton Coldfield

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I was more than completely satisfied with the surgery and reconstruction.
Patient satisfaction survey, Solihull Hospital 2019

In my NHS role, I work in a Major Trauma Centre and am well placed to deal with the full remit of maxillofacial trauma, having been involved in over 500 cases to date. As part of a busy on call, I am often involved in decision-making and operating on facial fractures. I am well placed to understand the nuances of post-traumatic deformity management as well, in restoring form and function to patients who have suffered injuries. In addition I have used my transferable skills to provide reconstruction of orbital defects following endoscopically removed paranasal osteomas in my NHS practice in the recent past.

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Bespoke orbital implant placed with stereotactic navigation assistance via endoscopically assisted minimal access approach to recreate orbital floor and medial wall defect following removal of a paranasal osteoma.

What are the common causes of facial trauma?

Facial trauma may happen for a range of reasons. Sadly the most common of these is interpersonal violence and injuries sustained during the course of an assault. Less common reasons may include road traffic accidents (RTAs) and sporting injuries. I researched the aetiologies in an international study previously (Elledge et al, 2011) and have developed online learning environments for junior staff in Emergency Medicine and my own specialty to ensure that patients receive the very best possible care from the outset (Elledge et al, 2015; Elledge et al, 2016; Elledge et al, 2018).

Sustaining facial fractures can be life-changing and tied up with the psychological impact of how the injuries occurred. I try to make sure that all patients are treated holistically and feel cared for at the beginning of their journey to recover and all the way through. Regardless of the aetiology, I am meticulous in my approach to planning and execution and am exacting in the standards that I set out to achieve in any Maxillofacial Trauma operation.

What operations do you perform routinely?

I work in a busy Major Trauma Centre and military hospital, the internationally recognised Queen Elizabeth Hospital in Birmingham. Any given on call week will see me perform and supervise tracheostomies, surgical management of fascial space infections, multidisciplinary management of polytrauma patients, mandible (lower jaw) fractures, Le Fort (midface) and zygomatic (cheekbone) complex fractures, orbital (eye socket) fractures and craniofacial trauma.

As someone with a subspecialty interest in temporomandibular joint (TMJ) surgery, I regularly also undertake open repairs of mandibular condyle fractures to a high standard, as this plays on the approaches used in my elective surgery.

What are the signs and symptoms of facial fractures?

Facial fractures of the lower jaw (mandible) can give rise to symptoms including an altered occlusion (bite) with teeth feeling like they no longer contact properly. Other symptoms include pain, steps in the bone, bruising (including bleeding underneath the tongue) and altered sensation to the lip, chin and/or tongue. Fractures of the mid face (zygoma and/or Le Fort fractures and/or orbital fractures) can cause altered vision (including diplopia or double vision), flattening of the cheekbones and altered facial projection.

I am the Chief Investigator for the Birmingham Mandible and Midface (BruMM) Rules study at University Hospitals Birmingham NHS Foundation Trust that aims to develop a clinical predictor rule for facial fractures on plain film radiographs.

Will my teeth need to be wired together?

No! This is a common misconception that some patients have that is based on outdated treatments. Modern management of Maxillofacial Trauma aims to rehabilitate patients and get them back to function as quickly as possible. With this in mind, most injuries can be managed with mini-plate fixation, whereby small titanium plates are placed across fractures to hold them together and allow them to heal.

The plates stay in for life, are non-ferromagnetic and biocompatible, being made of titanium. They have little inherent strength so patients will need to have a soft diet for a few weeks after surgery but then can build back up to a normal diet within two months in the vast majority of cases.

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Titanium miniplate used for fracture fixation in the Maxillofacial region.

How do you treat orbital (eye socket) fractures?

Orbital fractures can be complex and require a fine eye for detail (no pun intended). I was trained in a range of minimal access approaches around the orbit to approach defects in a safe and cosmetically sensitive manner. For many patients, a stock (off the shelf) titanium plate will be used to replace the paper thin bone that has fractured. In more challenging cases, I will ask for a bespoke or custom plate that precisely recreates the lost anatomy.

Patients will need to have a full work up before surgery that includes an orthoptics assessment checking for double vision due to mechanical restriction in a formal and reproducible way.

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Post-operative imaging with bespoke (custom) orbital plate.

What is a post-traumatic deformity?

Post-traumatic deformity refers to a lasting deformity following traumatic injuries and may be the result of a number of things. Treatment may have been delayed (e.g. patients may not have been well enough for surgery at the time of the initial injury) or the initial surgery may have achieved compromised results. Ultimately, these causes culminate in a "malunion" whereby the bones "fix themselves" in the "wrong place".

Managing such deformities can be challenging and can require either masking the deformity (e.g. with MEDPOR onlays) or re-breaking (osteotomising) the fractures to "set" them in the correct position.