Cranial nerve VII region of the traumatized facial skeleton: optimizing fracture repair with the endoscope.
OBJECTIVE
Cranial nerve VII (CN VII) is anatomically positioned adjacent to the condylar neck of the mandible and arch of the midface. Fracture treatment of this region of the facial skeleton remains controversial because of difficult surgical access. Conservative management rarely achieves anatomic fracture repair and can result in irreversible structural deformity and dysfunction. Traditional operative methods require access through very visible facial incisions and risk injury to the facial nerve. We report endoscopic methods of facial fracture repair in the region of CN VII that achieve excellent fracture reduction and stabilization, with minimal risk of facial nerve injury by using hidden incisions.


METHODS
A consecutive series of 65 endoscopically assisted facial fracture repairs were analyzed. Endoscopic repairs of the condylar neck (n = 40) of the mandible were performed through an intraoral incision. Endoscopic arch repairs (n = 25) of the midface were performed through a preauricular incision. Outcomes were evaluated by postoperative fracture reduction on radiographs, occlusion, interincisal jaw opening, and facial nerve function.


RESULTS
Thirty-seven of 40 condylar neck mandible fractures went on to anatomic bone union, whereas 3 of 40 had either incomplete fracture reduction or re-fracture through the plate. There was one temporary palsy of CN VII that completely resolved spontaneously. Jaw opening exceeded 40 mm by the 8th postoperative week. Computed tomographic images demonstrated anatomic arch repair in all 25 endoscopically repaired cases. Six of seven endoscopically repaired Le Fort III facial fractures went on to restoration of their premorbid occlusion. One of seven had an excellent restoration of the occlusal interface but a cant to the occlusal plane. Two of seven had improved but incomplete restoration of the malar prominence and enopthalmos ipsilateral to the side of endoscopic arch repair. Eight of 25 endoscopic arch repairs developed temporary paralysis of the frontal branch of CN VII that recovered completely by the 10th postoperative week.


CONCLUSIONS
We have developed novel endoscopically assisted techniques to facilitate repair of facial fractures in the region of CN VII. These techniques have been successfully applied to accurately restore the facial skeleton to its preinjury anatomic position in the region of CN VII with minimal risk of facial paralysis by using limited and well-hidden incisions.
Lee
C
C
Department of Surgery, San Francisco General Hospital, University of California, 94110, USA.
Stiebel
M
M
Young
D M
DM
D000293:Adolescent; D000328:Adult; D019723:Endoscopes; D020220:Facial Nerve Injuries / Q000517:prevention & control*; D005260:Female; D005593:Fracture Fixation, Internal; D017102:Fracture Healing; D006801:Humans; D007431:Intraoperative Complications / Q000517:prevention & control*; D008335:Mandibular Condyle / Q000293:injuries* / Q000601:surgery; D008337:Mandibular Fractures / Q000601:surgery*; D008875:Middle Aged; D012307:Risk Factors; D016896:Treatment Outcome