■ Part 1. Surgical Anatomy and General Considerations

The 22 bones of the craniofacial skeleton are remarkably resilient and able to tolerate and instantly distribute a wide range of load forces (facial flow equilibrium circuits) during normal function and after untoward impact (see Chapter 2). As isolated structures yield, fractures limited in scope and clinical measure are manifest. As even greater thresholds are breached, however, the injury takes on disarray, as organized buttresses and platforms are put asunder into an osseous paradigm of derangement and dislocation.

The frontal, ethmoid, lacrimal, sphenoid, and temporal bones form a major aggregate at the intersection of the midfacial skeleton and the cranium (see Chapter 6). Involvement of this complex and the adjacent bone establishes the pattern of pancraniofacial injury. Combined injuries of the cranium and face may be limited to the craniomalar, nasomaxillary, and orbitoethmoid regions, or more likely extend to the lower midface and palate or coinvolve the sphenoid, occiput, mandible, or cervical spine.1 ^– 10 Patients with pancraniofacial injury should be held, for this reason, in the chariest regard.

The pancranioface assumes a distorted reconfiguration, typically splayed, broadened, and flattened (lacking projection). The buttresses and microbuttresses of dependent cavities (cranium, orbits, sinuses, nasal vaults, pterygopalatine fossae, and oral cavity) reflect the alteration of three-dimensional form and the altered cavities settle into a new, deranged architecture with altered volumes.

The extent of injury of the pancraniofacial injury may be broadly cast, as depicted, with a myriad of variation from side-to-side and level-to-level ( Fig. 9.1 ).