This was a 20 year old male involved in a severe road traffic accident with a number of fractures of skull, facial and jaw bones. The challenge was that there was no single site that was stable to get anchor for fixing the fracture or plates to screw. In addition, there was a cerebrospinal leakage.
The surgery was handled in two stages. The first stage was to correct the cranial and facial fractures and then the jaw bone fractures. The first stage was corrected by carefully raising the bicoronal flap leaving behind an intact pericranium and care exercised not to damage it. After raising it, the fracture site along the forehead bone was visualized, all the fragments approximated, plated together. Frontal sinus was thoroughly debrided and all lining removed. The sinus was packed with thick packs of fat and muscle harvested from thigh. This would ensure that the cerebrospinal fluid do not leak further. Rarely such situation may need a cranialization which was not required in this case. The Le Fort III fracture was next attended to. Next the naso Ethomoidal fractures was visualized, debrided, secured, reduced, approximated and fixed with a modified canthoplexy with the stable frontal bone. The fat graft was used to cover potential areas of depression and ensured normal appearance of face. Nasal bridge was recreated and a calvaraial graft used to replace the defective areas. After this using the rebuilt bone, the cheek bone or the zygoma was reduced with approximation and plating. After this stage, the bicoronal flap was closed.
In this stage, all procedure and approach was done through mouth itself. The next step was to create a stable upper jaw and reducing the split upper jaw. The fracture jaw was visualized and wired. The split was plated. Diathermy was used to keep the area blood free. In stage wise, all areas of fractures were approximated, reduced and plate using the realigned palate and cheek bone as stable landmark. Layered closure of nose was performed. Three layered sutures were placed in areas of severe trauma. No wires or jaw closures or IMFixatures were placed.