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Laterally based cervicofacial advancement flaps that follow the borders of facial aesthetic subunits provide a more aesthetic solution to the reconstruction of anterior cheek defects than do standard cervicofacial flaps or skin grafts. The circulation in these laterally and inferiorly based flaps is improved, because the transverse facial artery is spared. These flaps also provide better contour and possess more aesthetic scar placement than do anteriorly and inferiorly based flaps.

The surgical correction of post-traumatic enophthalmos is among the most challenging problems for the surgeon. A thorough understanding of orbital anatomy and the purposed mechanisms of enophthalmos is crucial to the ultimate success or failure of the procedures. The successful orbital reconstruction begins with a careful physical examination of the patient that is attentive to ocular function, soft-tissue position, and visible or palpable defects of the facial skeleton. The physical examination combined with thin section CT scanning in the axial and coronal planes provides the basis of the operative plan. The anatomy of the deformity should dictate the anatomy and shape in the surgical correction. In many cases, multiple surgical incisions will be required; therefore, care must be taken to maximize exposure and minimize the cosmetic problems associated with large incisions. We advocate a step-wise approach consisting of mobilization of the soft tissues in the area of the fracture, repositioning of the anterior and middle sections of the bony orbit, and reattachment of the soft tissue to the bone at the proper location. The approach to reconstruction of the bony orbit that we advocate is to first sequentially reposition each segment of the rim, carefully examining each articulation. Once rim reconstruction is complete, reconstruction of the internal wall is performed. Recall that the largest source of error is in inadequate reduction of the orbital rim, owing to the fact that this error is "squared" (according to the model) in the computation of the orbital volume. Through the application of these principles, the cosmetic and functional sequelae of post-traumatic enophthalmos can be improved greatly with minimal complications.

The physiology of bone healing, regeneration, and bone transfer is discussed from the dual perspectives of basic physiology and the application to clinical situations of bone transfer. Recommendations are made regarding clinical applications for the site, orientation, and fixation of grated materials. Rationale for the use of vascularized transfers is presented.

The proper management of nasoethmoid orbital fractures relies upon early accurate diagnosis and treatment. A surgical plan must be established after careful review of the physical examination and CT scans. Identification of the extent and type of fracture pattern determines the operative approach. Extended (wide) exposure, using craniofacial techniques, facilitates precise reduction and rigid fixation of all bone fragments. Transnasal reduction of the canthus-bearing central segment (medial orbital rim) is the critical operative maneuver required to achieve normal intercanthal distance. Immediate bone grafting replaces severely comminuted or missing bone fragments. The skin overlying the nasoethmoid area is carefully redraped by gentle pressure from padded external compression bolsters. These principles form the basis for superior aesthetic and functional results.

Complications, unfortunately, arise as a result of traumatic or iatrogenic injuries. The sequelae can range from the most insignificant to the most debilitating. The most common complications noted in the diagnosis and treatment of orbital fractures are outlined as well as discussed as appropriate to their appearance during the healing process. With better understanding and better management, complications can be prevented.

Recent advances in facial trauma management have enabled the surgeon to perceive and successfully reconstruct complex panfacial injuries. Restoration of both preinjury facial aesthetics and function is now the goal. An organized approach to these injuries begins at the maxillary and mandibular arches with progression to the vertical mandible. The nasoorbital ethmoidal complex is stabilized to the cranium and bone grafted when indicated. The zygomatic complex is related medially, and orbital reconstruction performed. The facial architectural restoration is completed at the Lefort I level. Adherence to this protocol enables the surgeon to obtain reproducibly good results, even with the most extensive facial dislocations.

Post-traumatic enophthalmos is a complex orbital deformity resulting from an injury disrupting orbital bone and ligament support, allowing displacement and a change in shape of the orbital soft-tissue contents. Clinically, this is manifested by inferior and posterior displacement of the globe, pseudoptosis, and deepening of the supratarsal fold. Soft-tissue changes such as canthal malposition and shortening of the horizontal dimension of the palpebral fissure are present when unreduced nasoethmoidal orbital fractures exist. The essential principles of surgical correction include full dissection of the bony orbital soft tissues including the posterior orbit with restoration of bony orbital volume by the judicious insertion of bone grafts to correct the vertical as well as the anteroposterior position of the ocular globe. The combination of techniques of craniofacial exposure, osteotomy, and bone grafting allow the condition of post-traumatic enophthalmos to be greatly improved with minimal complications.

It is helpful to consider fractures of the orbit both in terms of their location and fracture pattern. CT scanning is an invaluable aid to the diagnosis and treatment of all orbital fractures. Early operative intervention, wide exposure, and accurate and stable fixation accompanied by immediate bone grafting provide the most successful treatment of fractures of the orbit.

Safe anesthetic management of head and neck surgery and maxillofacial trauma depends on an accurate identification of ancillary problems, precise intraoperative monitoring, and treatment. Protocols facilitate thorough management, and a discussion is provided.