ABSTRACT
Modern techniques of exposing the facial skeleton evolved in the last half of the 20th century from the combined experiences of several surgical disciplines including otolaryngology-head and neck surgery, plastic surgery, maxillofacial surgery, and neurosurgery. Exposure of facial fractures previously consisted of making several small incisions over fracture sites, with little concern for visible scars or sensorimotor deficits. Although limited surgical access is often all that is required for selected simple facial fractures, complex or comminuted fractures demand more extensive exposure for accurate reduction and fixation. The modern approach to complex facial fractures (which represent the majority of facial fractures) is wide surgical exposure that facilitates a three-dimensional assessment of fracture displacement and application of rigid internal fixation appliances and bone grafts (1). These surgical approaches emphasize minimally invasive techniques that spare neurosensory structures while maximizing exposure of the facial skeleton. Craniofacial incisions are hidden in areas such as behind the hairline, within the oral cavity, in the conjunctiva, or under the eyelids. Incisions camouflaged by placement within a border of a topographical subunit or natural skin crease are also acceptable (e.g., subciliary). Examples include
Coronal approach to the upper and midface Transcutaneous approach to the orbital floor Transconjunctival approach to the orbital floor Endoscopic subcondylar approach for the condylar neck Subcranial approach for the deep upper and midface Open sky approach for the naso-orbital complex Extracranial transsphenoethmoidal approach for the optic foramen and
canal
CORONAL APPROACH
Description and Indications
The coronal approach provides the greatest potential surface exposure of the craniofacial skeleton including the frontal bone and calvaria, the superior and upper lateral orbital rims, the zygomatic arches, the temporomandibular joints, and the nasal bones. This approach is useful for the open treatment of severely comminuted zygomatic fractures (2). It also provides ample exposure for the zygomaticofacial suture, lateral orbit, malar eminence, and nasoethmoid complex. Most important is that the coronal approach provides wide exposure of the anterior cranial fossa including the frontal sinuses, frontal lobe, cribriform plate, orbital roofs, and orbital apices.
