2017-18 HSC Section 4 Green Book

Reprinted by permission of Facial Plast Surg Clin North Am. 2015; 23(3):335-345.

Evidence-Based Fac ial Fracture Management

Timothy D. Doerr, MD, FACS

KEYWORDS Facial fractures Trauma Evidence-based Surgery Mandible Nasal

KEY POINTS

The facial trauma literature primarily consists of lower-level evidence, including retrospective case series and case reports. There is strong clinical evidence from meta-analysis to guide antibiotic use in facial trauma. There is solid clinical evidence from meta-analysis of clinical trials supporting the use of general anesthesia for closed nasal reduction. There is no consensus from the literature on the best method of treating mandible fractures. Systematic review of the literature suggests improved patient outcomes with open reduction for displaced fractures of the mandibular condyle.

INTRODUCTION

surgeons adopted new techniques and approaches when they believed them to be better than what had been done. There certainly was no requirement to prove the superiority of a new tech- nique or instrument before adopting it. Innovators were not compelled to prove what they thought was inherently obvious. It is not surprising that the literature concerning facial fracture treatment is limited both in its quality and level of evidence. The predominant article types are retrospective case series and non- randomized trials. There is a scarcity of RCTs in all of facial plastic surgery; however, it is very glaring in facial trauma. This is not surprising given the obstacles inherent in conducting clinical studies in fracture treatment. Cost, ethical con- straints, and subject recruitment all deter random- ized studies. There are also challenges in conducting surgical trials given the significant vari- ability in facial fractures, the range of surgical pro- cedures to address the injuries, and the skills of surgeons performing those operations.

The demand for safe, cost-effective health care is increasing from the public, physicians, and third-party payers. Evidence-based practice is becoming an essential component of twenty-first century medicine and, increasingly, doctors must justify their work based on clinical effectiveness and cost. Physicians are being asked to show, us- ing higher level clinical research, the clinical bene- fits of accepted treatments. However, many of these treatments developed through technical ad- vances or surgical pioneering and were not vetted through the rigorous process of clinical trials. Facial fracture management, like most aspects of facial plastic and reconstructive surgery, has evolved through the collective experiences of its surgeons. The current surgical trends and tech- niques have been shaped through advances in di- agnostics, instrumentation, and hardware. In facial trauma, most current practices did not result from rigorous randomized clinical trials (RCTs). Instead,

Disclosures: AONA Faculty Member: receives honoraria and travel expenses for teaching educational courses. AO Foundation: Facial Trauma and Reconstructive Surgery Expert Group; receives per diem and travel expenses to attend working meetings. Depuy Synthes: paid consultant, material development. Department of Otolaryngology–Head and Neck Surgery, University of Rochester School of Medicine and Dentistry, 601 Elmwood, Box 629, Rochester, NY 14642, USA E-mail address: timothy_doerr@urmc.rochester.edu

Facial Plast Surg Clin N Am 23 (2015) 335–345 http://dx.doi.org/10.1016/j.fsc.2015.04.006

1064-7406/15/$ – see front matter

2015 Elsevier Inc. All rights reserved.

facialplastic.theclinics.com

243