Fronto-orbito-nasal dislocations. Secondary treatment of sequelae

Fronto-orbito-nasal dislocation untreated or maltreated can have many important sequelae for both function and aesthetics. Two types of cases may be observed, those with: -extensive bone loss -malunited fracture. The treatment of sequelae caused by bone loss in order to be rational, logical and complete necessitates: 1. protection of the underlying elements = eye and meningo-cerebral tissues, 2. reconstitution of an harmonious cranio-facial profile, 3. definitive isolation of cranial contents from the facial cavities. 4. repair of nasal and orbital walls and the necessary ligamentous re-insertions on them. The best material for such a repair remains the autogenous bone graft. The treatment of sequelae caused by malunited fractures necessitates repositioning osteotomies. In addition to rotation, elevation and translation osteotomies the following may be required: -either a monoblock advancement osteotomy, -or an "expansion" osteotomy. They require solid fixation. This may be obtained by: -either superior fixation to a previously conserved intermediate frontal strut -or a rebuilding of the shape of the vault, laterally fixed to sound bone parts, and an interposed bone graft to act as a "keystone" of the vault. Such repairs seem to be better than simple onlay bone grafts which are useful from an aesthetic point of view, but which neglect the underlying injuries with their concomitant functional sequelae, and which expose the patient to secondary sinus or cerebro-meningeal complications. They permit a single, total, simultaneous, and definitive repair of all the sequelae both functional and aesthetic; an approach which is more rational than successive surgical sessions. But they require: 1. Dura mater repair by suture and pericranial grafting. 2. Total isolation of cranial contents from the face. 3. Obliteration of the frontal sinus. It is therefore necessary to work with a combined neuro- and maxillo-facial team. Four cases are described to illustrate these proposed procedures, one case with very extensive bone loss, three with malunited fractures: the first orbito-frontal, the second with a fronto-zygomatic lateral component, the third with a fronto-nasal medical component.