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In regard to the multiple problems of reconstruction concerning this fracture pattern, we developed various methods to achieve optimal results. As various vital regions, apart from the nasoethmoidal fractures and aesthetics, are involved, the proposed classification has direct implication for the surgical procedure. Even in intracranial fragment dislocations, cerebral contusion, and elevated intracranial pressure, the subcranial approach, in contrast with the transfrontal access, enables early definitive management of the skull base and the external facial frame in a one-stage procedure. Another method, the symmetrical centripetal compression of the canthal ligaments and naso-orbital bone fragments, enables correct reduction of the telecanthus. The significant reduction of morbidity and complication rate to a minimum confirms the efficiency of our treatment modalities.

In severe craniofacial-frontobasal injuries the optic nerve is quite often damaged. We report the findings and the visual outcome in 21 patients with severe mid-face fractures, who underwent primary optic nerve decompression after showing an afferent pupillary defect. During the subcranial exploration and the optic nerve decompression, fractures of the optic canal were found in 13 cases; a dislocated bone fragment could be removed in 6 patients. 9 eyes remained blind, but another 9 eyes regained good final visual acuity between 0.5 and 1.0. We conclude that fractures of the optic canal and dislocated bone fragments are often causes of optic nerve damage in mid-face injuries. The primary subcranial decompression of the optic nerve is a safe method to prevent secondary damage.

In severe craniofacial injuries, the involvement of the skull base with concomitant major dural tears is significantly high. Our methods and treatment plan are controversial compared with the conventional procedure: primary urgent neurosurgical exploration and repair with deferral of maxillofacial reconstruction. To avoid the disadvantages of the transfrontal intracranial management of the skull base, we modified the transethmoidal approach so as to enable the subcranial exposure of all the anterior fossa planes, including the sellar-sphenoidal region. The advantages rendered by this method are the feasibility of an early one-stage craniofacial reconstruction and avoiding retraction of the frontal lobes and damage to the olfactory filaments. The reduction of pseudohypertelorism, the decompression of the optic nerve, and the meticulous reconstruction of the midface and skull base are performed in one session and are regarded as one entity. The results of the surgical management of 395 craniofacial injuries and the low rate of complications emphasize the advantages of the methods described in this article.

The treatment modalities and results of 346 cases of frontobasal and midface fractures, 194 of which had to be managed by surgery, are reported, and the operative results are evaluated. The importance of an early one-stage operative repair of combined frontobasal-maxillofacial fractures is stressed. The indications for the pure transethmoidal, combined transethmoidal-transfrontal, and single neurosurgical handling of these patients are analyzed. Important surgical modifications that are decisive in the operative management of these fractures are described.

This paper deals with the management of 269 patients with frontobasal fractures of which 143 were treated operatively. The close interrelation between midface and base of skull and our operative modifications are discussed. The advantages and importance of the transethmoidal approach to the base of the skull is most adventageous for reconstruction of the midface pillars. Specially for comminuted fractures, avoiding complications such as pseudohypertelorism, telecanthus and frontobasal disturbances. This also enables an accurate reposition to be made with minimal use of foreign materials such as wire ligatures and miniplates. The operation should be performed by the same surgeon in a single sitting thus combining the transethmoidal approach with the midface reconstruction. The reduction of the rate of CSF recurrent leaking to only 3,5% is ascribed to these methods.

The aim of this paper is to emphasize the advantages of a one-stage, step by step repair of facial skeletal injuries as well as the dural tears and lesions of the anterior fossa, by one and the same team. The methods described permit optimal reduction of the pseudohypertelorism and major displacements in severe combined craniofacial injuries. The simultaneous subcranial exposure of the entire basal region of the anterior fossa obviates the intracranial approach or frontal lobe retraction thus making early stage surgical management feasible. The surgical treatment of these injuries as a single entity, as well as further modifications reduce complications such as recurrent CSF leakage, anosmia, mucocoele or secondary operations for inadequate fracture reduction. The significance of primary meticulous reconstruction of the combined cranial vault and midface fractures for the achievement of normal physiological function of the various systems is particularly highlighted.

BIOCEM is a recently developed material that consists of bisphenol-a-glycidyl methacrylate ("epoxide methacrylate") as the organic matrix and pentacalcium hydroxide triphosphate ("tricalcium phosphate") with or without bioceramic A2 as the filling particles. Previous animal experimentation has demonstrated that BIOCEM can establish and maintain direct contact with bone without compromising tissue vitality. Rather, it favors with time the ingrowth of, and coverage by, newly formed bone, thus creating interdigitations and strong fixation of the implant. This novel technique has now, for the first time, successfully been applied in humans, ie, for the fixation of frontal sinuses. Clinical, radiological, and histological findings are briefly reported, and it is also shown that the frontal sinus mucosa had recovered at the inside of the lesions filled with BIOCEM.

In the treatment of severe "dish-face" deformities which result from Le Fort II and III middle face fractures, reposition and fixation of the maxilla can be achieved by an extraoral cranial fixation apparatus. We describe a modification of the Georgiade head frame which achieves higher stability in fixing the maxilla and arch wires. The joints applied to the rigid wire connecting the arch bar to the head frame make an adaptation to the upper lip possible; traction of the maxilla to maintain its fixation can be applied extra-orally so that closure of the lips with correction of occlusion is possible, making easier the uptake of nourishment.