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Plastic Recon Help

drussotti

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New to plastics & this is BIG ask, but I would really appreciate any help anyone can provide on this one. Very overwhelming to me!!

Pre-operative diagnosis:
1. LeFort I, II, III fractures
2. Bilateral nasoorbitoethmoid fractures
3. Nasal bone fractures
4. Palatal fracture
5. Maxillary alveolar fractures
6. Mandibular alveolar fractures with extension to the right parasymphyseal region
7. Complex laceration of the nose
8. Full-thickness lacerations of the upper and lower lip

Post-operative diagnosis: same

Procedure performed:
1. Open reduction internal fixation of right NOE fracture
2. Open reduction of right orbital floor fracture
3. Open reduction internal fixation of right Lefort I and II fractures
4. Open reduction external fixation of palatal fracture with maxillomandibular fixation and internal fixation via plating the medial and lateral buttresses
5.  Maxillomandibular fixation for treatment of mandibular alveolar fracture extending into the right parasymphyseal region
6. Closed nasal bone reduction
7. Right infraorbital neurolysis
8. Washout and debridement of facial lacerations
9. Complex repair of right facial lacerations 10 cm
10. Full-thickness repair of upper lip laceration full lip height.
11. Full-thickness repair of lower lip laceration full lip height
The previously closed facial lacerations were opened once more. All wounds were irrigated with saline with notable debris within the wound.
An intraoral exam was performed with multiple unstable maxillary and mandibular dentition. At this time, Dr. Hartman from the OMFS service joined to address the dentition as well as assist in fixaiton of the mandibular and palatal fractures. Please refer to the separate operative note, detailing this portion of the case. In short, the unstable teeth were extracted with care to preserve any of the alveolus for possible bone graft. The mandibular parasymphyseal region appeared overall stable after dental extraction. Arch bars were then secured to the remaining segments of the maxillary and mandibular dentition with 24 G stainless steel wires. Occlusion was achieved with manipulation and this occlusion was secured with 26 G stainless steel wires to re-establish the posterior occlusion bilaterally. This was also used to provide stabilization of the palatal fracture.
After the occlusion had been established, the remainder of the fixation was built off of this stabilized construct. The left facial fractures were deemed minimally displaced and fairly stable constructs that could be built off of as well.
The existing facial lacerations were used as access for the midface fractures. Dissection was carried down to bone with electrocautery and subperiosteal dissection was performed across the orbital rim to stable zygoma, and to expose the nasion, injured nasal bone, and medial and lateral buttresses. The existing gingivobuccal incision was extended to provide further access to the right lateral buttress.
The right infraorbital nerve was adhered and somewhat twisted due to the heavy comminution of the anterior maxillary sinus wall that encased it. Neurolysis was performed to free the nerve of surrounding impinging tissue and to allow reduction of its attached bony segment.
With care to once more ensure that the palatal fracture was well-reduced, the lateral buttress was reduced and fixated with an L-shaped plate.
Next, the infraorbital rim and NOE was reconstructed. Using the stable zygoma as a base, the comminuted fragments were reduced, including a segment that extended towards the orbital floor. The NOE component was similarly reduced off of the stable nasion. Of note, the medial canthus was not disrupted and was left intact. Fixation of the orbital rim and NOE was then performed.
Finally, the medial buttress was reduced based off the surrounding stable constructs and fixated.
The intraoral lacerations and incisions were then closed. 3-0 vicryl was used to re-suspended any elevated muscle. The mucosal closure was then performed with 3-0 vicryl with care to obtain good bony coverage of the alveolus.
The lacerations were irrigated once more. Attention was then turned towards soft tissue repair. The right eyebrow and glabellar wounds were closed in layered fashion with 4-0 monocryl sutures to re-approximate the muscle and the skin was then closed with 5-0 monocryl in deep dermal fashion and overlying 5-0 prolene suture.
The complex laceration extending from the glabella across the nasal sidewall and alar rim was then addressed. Care was taken to first align the anatomic landmarks including the alar base, alar rim, and nasoalar groove. Layered closure was then performed with 4-0 monocryl in the deeper fibrofatty and muscle layers. The overlying skin was then closed with 5-0 monocryl in deep dermal fashion with overlying 5-0 prolene.
The upper lip laceration was noted to have a traumatic thinly-based flap that was dusky. Due to it's tenuous viability, this was excised to healthy tissue. The full-thickness upper lip laceration was then performed with care to re-align the anatomic landmarks including the vermilion border, white roll, and red line.4-0 PDS sutures were used to re-approximate the orbicularis oris muscle to restore competence. The mucosa was closed with 4-0 chromic sutures. The vermilion was closed with 5-0 FAST.
In similar fashion, the lower lip laceration was repaired in layered fashion with care to recreate the anatomic landmarks of the lip. The muscle was re-approximated with 4-0 PDS sutures, the mucosa was re-approximated with 4-0 chromic, and the dry vermilion was closed with 5-0 FAST.
Finally, a closed nasal bone reduction was performed and bilateral nares were packed with vaseline gauze for internal splinting.
The eye shields were carefully removed and the eyes irrigated with BSS. The incisions were dressed with ophthalmic antibiotic ointment. A moustache dressing was placed.
Thanks so much :)
 
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