Case 1: ZMC fracture with displaced ZS suture. A 33 y.o. male presented to the ED with a history of club-to-face assault. He was intoxicated with LOC. Upon presentation the ED noted increased left IOP and a lateral canthotomy was performed.  He was then evaluated and cleared by ophthalmology. On examination he denied blurry or double vision but reports malocclusion.  He denied salty taste in mouth but does report bilaterally intermittent clear rhinorrhea with walking. Physical examination was significant for a mobile and retruded maxilla and a depressed left zygoma. The left eye was swollen and decompressed by canthotomy. CT angiogram of the neck showed no evidence of blunt carotid or vertebral artery injury. CT and 3DCT review identified small left temporal lobe hemorrhagic contusions, extensive complex facial/orbital fractures. Left LeFort I, II, III and left zygomatic fracture. Right LeFort I and II fracture.  Hard palate fracture with extension to the alveolar ridge and traumatically absent right central maxillary incisor tooth. Left medial nasal lacrimal duct fracture. Nasal bone and nasal septal fractures. Cribriform plate fractures. Thickening of the left inferior and possible left lateral rectus muscles may suggest entrapment.  
Discussion: Reduction of the maxilla was aided by placing IMF screws anteriorly on the intact mandible and posteriorly on the maxilla allowing maxillary advancement with MMF wire tightening. Transoral vestibular and left transconjunctival approaches were made to access the midfacial skeleton and orbit.  The left ZS suture was accessed through the lateral canthotomy and separate blepharoplasty incision to help orient the zygoma during plating.  A displaced zygomaticosphenoid (ZS) suture (left photo) is seen in the left orbit.  A post-operative scan (right photo) shows the midface repair.  When available, intraoperative CT scanning can be a very helpful in positioning the zygoma. A separate horizontal incision was made over the nasion for the reduction and fixation of the nasofrontal fracture.  Following facial access and MMF the midface was plated and orbital floor repaired.   

Case 2: Right forehead trauma producing Lefort I-III and brain herniation into right eye. A 25 year old male was transferred from a community hospital where he underwent urgent decompressive craniotomy for right sided EDH. He arrived at our trauma center with a GCS of 3 after being therapeutically paralyzed and intubated. He was stabilized and placed in the SICU and initially sedated on Propofol and placed on Keppra prophylaxis and plan for craniotomy with neurosurgery.  Bilateral chemosis was found by ophthalmology with concern for left globe rupture. There was no evidence of ocular muscle entrapment. The only acute management issues were intubation for acute respiratory failure.  CT head showed severely comminuted fractures involving the frontal bones, orbits and mid face with moderate to large bilateral frontal contusions. Comminuted bilateral orbital roof fractures with herniation of a small amount of brain into the right orbit (left photo).  Fractures involved the left foramen ovale, left foramen spinosum, left carotid canal and right optic canal. Fractures involve the cribriform plates, ethmoid sinuses and sphenoid sinus with marked displacement of fracture fragments. Left temporal bone fracture was seen with ossicular disruption. Diffuse brain swelling with compression of third and lateral ventricles and basilar cisterns was noted and there was no evidence of cervical spine fracture or dislocation.
Discussion: The first considerations are acute management of the EDH and concern for ocular injury. CSF leak would be highly suspected. The midface fractures were produced from the force delivered at the right frontal cranium which is unusual.  His life-threatening issues required close cooperation with neurosurgery.  We delayed the cranial part of the procedure and took the patient in a staged fashion for tracheostomy, MMF and right zygomaticofrontal suture repair. The initial stage would allow for brain rest in anticipation for treating the cranium, cribriform and orbit. The second surgery was done 10 days later. The right photo shows a porous polyethylene/titanium implant placed to separate orbit and brain.  The cribriform area was severely traumatized and was covered with temporalis fascia to prevent CSF leak.  As expected the patient has not regained olfactory function and has not experienced CSF rhinorrhea. Vision and EOM’s were intact.