Combined injuries of the cranium and face

The neurosurgeon and plastic surgeon are increasingly called upon to manage the care of patients with combined injuries of the cranium and face. The authors briefly review the pathogenesis and classification of craniofacial fractures and outline historical approaches to them. Current principles of management are then discussed. Experience with 167 patients is presented with emphasis on surgical technique, the sequence of repair and early primary reconstruction. The controversial issue of fontal sinus fracture repair is addressed. The authors favour preservation of the frontal sinus cavity, where possible, and do not obliterate the nasofrontal duct. With injuries to the floor of the sinus, the base of the sinus and frontonasal duct are sealed with bone graft and a vascularised soft tissue flap and the sinus is cranialised. Immediate bone grafts, using split skull or rib, are used to reconstruct areas of bony destruction or loss. Ninety-eight patients required 402 grafts. Immediate bone grafting resulted in few complications and low incidence of secondary deformities needing correction.