The gold standard of management of facial fractures is based on the principle that only by an “open” approach can access be gained to the fracture to precisely reduce and stabilize the fragments. Only by this aggressive approach can full form and function be most reliably achieved. An “open” approach demands great ingenuity to provide, as far as possible, access utilizing pre-existing lacerations,transmucosal incisions or carefully placed skin incisions in the hair line. Presently, transmucosal incisions, via oral and conjunctival mucosae, should be seen as the “ideal “. although the latter may have complications in 25% of cases,particularly excessive scleral show.
Skin incisions should be placed with esthetics in mind and should if possible, avoid visible facial skin. Even the best placed incision, in the most skilled hands, can form a bad scar. Typically these non facial skin incisions are the Gilles temporal approach and coronal flaps. Both these approaches should confine the incisions to the hair bearing area. To be successful, these incisions must be placed at right angles to the hair follicles to prevent hair loss and, in case of coronal incisions, high and posteriorly in male pationts to avoid exposure in the event of male-pattern hair loss.
Only on rare occasions should it be necessary to either extend on to or place the incision on the exposed skin. Periorbital fractures are the most common reason for visible skin incisions. There is accumulating evidence that the transconjunctival approach, with or without lateral canthotomy, gives excellent access to all parts of periorbita. The lateral canthotomy extension provides excellent exposure of the frontozygomatic suture when extended from a transconjunctival incision. Only superior wall or medial superior rim fractures cannot be accessed by this approach. The short skin extension into the so-called ‘crowfoot’ area appears not to have any significant morbidity and is rarely visible. Another option is to combine transconjunctival approach with a superior blepharoplasty incision. The latter has very few complications and is of course hidden when the eyes are open.