Craniofacial Reconstruction in the Polytrauma Patient

Care of complex battlefield injuries has evolved since the last major conflict in Vietnam. Survivability of severe injuries is significantly improved due to far forward complex surgical and ICU care, efficient transport, and increased sophistication of body armor. Consequently, soldiers with complex craniofacial injuries, mainly from blast trauma, went on to receive definitive care at Stateside, Level 1 Military Treatment Facilities (MTFs). Many of these patients underwent decompressive craniectomy near the battlefield. Once the patient was stabilized back in the US, care coordination was undertaken in a multidisciplinary approach. Through coordination of the efforts of neurosurgery and craniofacial surgery, severe craniofacial trauma patients were able to be treated with improved with refinement of protocols. Acute facial fractures were often treated 3 weeks after injury due to complexity and prolonged swelling. Craniofacial infections were problematic until there was recognition of the pathogen Acinetobacter Baumanii. Composite craniofacial injuries were common, necessitating soft tissue coverage (usually free flaps) in the acute setting. Once patients were free of infection, and had stable soft tissue coverage, secondary craniofacial reconstruction could be undertaken. Attention was given to definitive separation of brain and nasal cavities through bone grafting and vascularized soft tissue. Autologous orbital reconstruction provided a successful foundation for alloplastic cranial reconstruction. Syndrome of the trephined was a recognized phenomenon, necessitating urgent reconstruction in some patients. The planning for and production of patient-specific 3D prefabricated cranial implants was developed as an intrinsic mechanism to treat a high volume of cranial defects. Patient CT data was used to generated custom implants within the Military’s 3D Medical Applications Lab. Most frequently, prefabricated patient-specific methylmethacrylate was utilized. Adequate soft tissue coverage and intracranial dead space management was key to cranial implant retention. Liberal use of free tissue transfer was incorporated to aid in reconstruction of composite defects.