Facial Trauma

A 35-year-old man is brought after a high-speed motor vehicle collision with severe panfacial trauma. He has active oropharyngeal bleeding, progressive facial swelling, gurgling respirations, and oxygen saturation of 82% despite supplemental oxygen. Two attempts at orotracheal intubation fail, and bag-mask ventilation is becoming ineffective. What is the most appropriate immediate next step?

A 42-year-old woman develops sudden orbital pain and rapid visual deterioration shortly after repair of a displaced zygomatic fracture. Examination shows proptosis, a tense orbit, restricted ocular movement, reduced visual acuity, and a relative afferent pupillary defect. What is the most appropriate immediate management?

A 7-year-old child is struck in the orbit by a ball. There is little external bruising, but the child has persistent vomiting, bradycardia, vertical diplopia, and severe limitation of upward gaze. Computed tomography shows a narrow orbital floor fracture with inferior rectus tissue trapped in the defect. What is the most appropriate management?

A 28-year-old man presents one week after blunt orbital trauma. Periorbital swelling has decreased, but he has persistent diplopia in primary gaze, 3 mm of enophthalmos, and computed tomography shows a large orbital floor defect with herniation of orbital contents into the maxillary sinus. What is the most appropriate definitive treatment?

A 33-year-old man sustains a displaced zygomaticomaxillary complex fracture. He has flattening of the malar prominence, infraorbital numbness, trismus, and widening of the lateral orbital contour. Computed tomography shows rotation of the zygoma with displacement at several facial buttresses. What is the most appropriate definitive management?

A 31-year-old woman sustains a comminuted naso-orbito-ethmoid fracture with marked telecanthus. Intraoperative assessment shows that the medial canthal tendon is detached from a fragmented central bony segment that cannot be reconstructed reliably. What is the most appropriate reconstructive step?

A 40-year-old construction worker sustains a frontal sinus fracture. Computed tomography demonstrates severe posterior-table comminution, displacement into the cranial cavity, persistent cerebrospinal fluid rhinorrhea, and disruption of the nasofrontal outflow tract. What is the most appropriate definitive management?

A 22-year-old man presents several hours after nasal trauma with increasing pain and complete bilateral nasal obstruction. Examination shows a soft fluctuant swelling on both sides of the septum that does not shrink after topical vasoconstrictor application. What is the most appropriate management?

A 30-year-old woman sustains a full-thickness lower eyelid laceration medial to the punctum. Saline irrigation through the punctum exits directly through the wound, and the globe is intact. What is the most appropriate treatment?

A 37-year-old man sustains a sharp preauricular laceration. Exploration reveals complete transection of the main extratemporal facial nerve trunk with a 20-mm segmental defect after debridement of damaged ends. The injury is recognized within 10 hours, and the distal branches are identifiable. What is the most appropriate reconstruction?

A 36-year-old man undergoes computed tomography after blunt frontal trauma. Imaging shows a minimally displaced posterior-table frontal sinus fracture involving less than 20% of the surface, a patent frontal sinus outflow tract, no intracranial air, and no cerebrospinal fluid leakage. Neurologic examination is normal. What is the most appropriate management?

A 28-year-old woman is struck in the forehead during a motor vehicle collision. She develops vertical diplopia, downward displacement of the globe, and pain with upward gaze. Computed tomography demonstrates a displaced orbital roof fragment projecting into the superior orbit and compressing the superior rectus-levator complex. What is the most appropriate management?

A 40-year-old man presents 10 days after blunt orbital trauma with persistent horizontal diplopia, restricted adduction, and progressive enophthalmos. Computed tomography shows a large medial orbital wall defect with herniation of orbital fat and tethering of the medial rectus muscle. What is the most appropriate definitive treatment?

A 26-year-old woman sustains a deep upper eyelid laceration from broken glass. After swelling subsides, she has complete ptosis despite preserved pupillary function and intact extraocular movements. Exploration shows transection of the levator aponeurosis with an intact superior rectus muscle and intact globe. What is the most appropriate treatment?

A 34-year-old man sustains a full-thickness laceration through the oral commissure. The orbicularis oris is divided, the upper and lower vermilion borders are displaced, and there is no tissue loss. What is the most important reconstructive step?

A 29-year-old woman sustains a near-total scalp avulsion when her hair is caught in industrial machinery. The avulsed scalp is intact, cooled appropriately, and arrives within a short ischemic interval. Recipient superficial temporal vessels are identifiable, and the patient is hemodynamically stable. What is the most appropriate reconstructive option?

A 43-year-old man presents with a complex auricular laceration after a fall onto glass. The cartilage is sharply divided, but most of the skin remains viable and there is no tissue loss. What is the most appropriate repair?

A 37-year-old woman develops a painless fluctuant cheek swelling one week after repair of a deep facial laceration. The swelling enlarges during meals, and aspiration yields clear amylase-rich fluid. There is no infection or facial nerve weakness. What is the most appropriate initial management?

A 25-year-old man presents within 6 hours of a dog bite to the cheek. The wound is irregular and contaminated but has viable edges, no gross tissue loss, and no injury to the facial nerve or parotid duct. What is the most appropriate management?

A 48-year-old man presents three months after an untreated depressed frontal bone and anterior-table frontal sinus fracture. He has a visible forehead contour defect, but there is no cerebrospinal fluid leakage, the posterior table is intact, and the frontal sinus outflow tract remains patent. What is the most appropriate reconstructive management?

A 36-year-old man with multiple displaced midface fractures continues to have brisk posterior nasal bleeding despite airway control, anterior and posterior nasal packing, correction of coagulopathy, and fluid resuscitation. Computed tomography angiography suggests active bleeding from branches of the internal maxillary artery. What is the most appropriate next management step?

A 42-year-old man sustains bilateral mandibular condylar neck fractures after falling from a height. He has severe shortening of both rami, an anterior open bite, and medial displacement of both condylar segments. A trial of closed reduction fails to restore stable mandibular alignment. What is the most appropriate definitive treatment?

A 69-year-old edentulous woman presents with a displaced mandibular body fracture through a severely atrophic mandible. There is minimal bony contact, marked fracture mobility, and insufficient bone stock for reliable load sharing. What is the most appropriate fixation strategy?

A 31-year-old woman develops immediate severe visual deterioration after orbital floor reconstruction. Examination shows a relative afferent pupillary defect and marked reduction in visual acuity, but the orbit is not tense and intraocular pressure is normal. Computed tomography shows the posterior edge of the implant extending into the orbital apex and compressing the optic nerve. What is the most appropriate management?

A 9-year-old child is struck in the medial orbit by a ball. There is minimal bruising, but the child has horizontal diplopia, severe limitation of abduction, nausea, vomiting, and bradycardia. Computed tomography shows a narrow medial orbital wall fracture with entrapment of the medial rectus and adjacent soft tissue. What is the most appropriate management?

A 39-year-old man sustains a displaced anterior-table frontal sinus fracture. Computed tomography shows complete obstruction of the frontal sinus outflow tract by comminuted fragments, but the posterior table and dura are intact. Endoscopic restoration of drainage is not feasible. What is the most appropriate definitive management?

A 35-year-old woman presents one year after a comminuted naso-orbito-ethmoid fracture with persistent telecanthus and loss of medial eyelid support. Computed tomography shows the central facial skeleton healed in a widened position, with both medial canthal tendons still attached to malpositioned bone fragments. What is the most appropriate definitive treatment?

A 28-year-old man loses approximately half of the right nasal ala in a machinery injury. The defect includes external skin, alar cartilage, and vestibular lining, and direct closure would severely narrow the external nasal valve. What is the most appropriate reconstructive plan?

A 58-year-old woman sustains a traumatic full-thickness defect involving 70% of the lower eyelid. The canaliculus and medial canthus are preserved, but insufficient local tissue remains for direct closure. The globe is intact. What is the most appropriate reconstruction?

A 33-year-old man presents within six hours of a facial abrasion sustained after sliding across asphalt. Numerous black particles are embedded deeply within the cheek and forehead dermis, but the skin remains viable and there is no significant tissue loss. What is the most appropriate management?

A 37-year-old man sustains a comminuted Le Fort II fracture with loss of a 2-cm segment of the left nasomaxillary buttress. The mandible and preinjury occlusal relationship have been restored, but the unsupported left maxilla collapses superiorly during reduction. What is the most appropriate reconstructive step?

A 28-year-old woman presents after blunt orbital trauma with isolated numbness of the cheek and upper lip. Visual acuity, globe position, ocular movements, and pupillary responses are normal. Computed tomography shows a small nondisplaced orbital floor fracture without soft-tissue entrapment or significant orbital-volume change. What is the most appropriate management?

A 42-year-old man presents with fever, increasing preauricular pain, purulent drainage, and progressive auricular deformity one week after an inadequately treated ear laceration. Examination shows a fluctuant collection separating the skin from exposed cartilage. What is the most appropriate management?

A 33-year-old woman sustains a full-thickness upper-eyelid avulsion involving 60% of the lid, including the lateral canthal tendon. The medial canthus and lacrimal system remain intact, and the globe is uninjured. What is the most appropriate reconstructive principle?

A 40-year-old man presents five days after fixation of a mandibular angle fracture with increasing facial swelling, fever, trismus, and purulent drainage from the intraoral incision. Computed tomography shows a localized abscess, but the fracture reduction is anatomical and the fixation remains stable. What is the most appropriate management?

A 10-year-old boy sustains a displaced nasal septal fracture with severe unilateral obstruction and visible columellar deviation. Closed reduction fails, and the caudal septum is dislocated from the anterior nasal spine. What is the most appropriate management?

A 30-year-old woman sustains traumatic loss of approximately 80% of the lower lip, including both oral commissures, with preservation of the mandible. Local lip tissue is insufficient to restore oral aperture and sphincter function. What is the most appropriate reconstruction?

A 36-year-old man sustains a through-and-through central cheek injury with loss of oral lining, facial muscle, and external skin. The oral commissure is intact, local facial tissue is unavailable, and the mandibular skeleton has been stabilized. What is the most appropriate definitive reconstruction?

A 44-year-old woman presents six months after orbital fracture repair with persistent diplopia and progressive enophthalmos. Computed tomography shows that the implant covers only the anterior floor and fails to support a large posterior defect near the orbital strut. There is no active infection. What is the most appropriate management?

A 35-year-old man presents three months after a forehead laceration with complete loss of sensation over the ipsilateral forehead and scalp and a painful trigger point at the superior orbital rim. Ultrasound shows a focal supraorbital nerve neuroma with no useful distal sensory recovery. Conservative desensitization and medication have failed. What is the most appropriate operative treatment?

A 34-year-old carpenter presents four days after a penetrating orbital injury caused by a wooden fragment. He has increasing orbital pain, fever, proptosis, and restricted ocular movements. Visual acuity is preserved. Computed tomography shows an irregular low-density object extending through the inferomedial orbit with a surrounding fluid collection. What is the most appropriate management?

A 29-year-old man sustains an isolated displaced mandibular coronoid process fracture after blunt facial trauma. He has severe persistent trismus, and computed tomography shows the displaced fragment mechanically impinging beneath the zygomatic arch. There is no condylar fracture or mandibular instability. What is the most appropriate definitive treatment?

A 38-year-old woman presents eight months after a blast laceration involving the left oral commissure. She has a markedly narrowed oral aperture, difficulty eating, and distortion of the mouth corner. Examination shows a dense circumferential commissural scar, but adequate upper and lower lip tissue remains. What is the most appropriate reconstruction?

A 46-year-old man presents nine months after reconstruction of a naso-orbito-ethmoid fracture. The central facial skeleton is stable and the medial canthi are well positioned, but he has persistent unilateral tearing and recurrent swelling near the lacrimal sac. Imaging confirms complete post-traumatic nasolacrimal duct obstruction. What is the most appropriate definitive management?

A 25-year-old man sustains complete traumatic amputation of the lower lip from one commissure to the other. The amputated segment is well preserved, the ischemia time is short, and identifiable labial vessels are present. The mandible is intact. What is the most appropriate reconstructive option?

A 32-year-old woman sustains a full-thickness traumatic loss of the central columella. The nasal tip and alae remain viable, but the defect includes external skin, vestibular lining, and the caudal septal support. What is the most appropriate reconstructive principle?

A 40-year-old man undergoes open reduction of a mandibular symphyseal fracture through a lower vestibular incision. The mentalis muscle has been divided to expose the fracture, and fixation is stable. What is the most important step during soft-tissue closure?

A 35-year-old woman sustains a deep cheek laceration from shattered glass. Computed tomography shows a 2-cm glass fragment lying adjacent to a major facial nerve branch. Facial movement is intact, and there is no active hemorrhage. What is the most appropriate management?

A 48-year-old man develops marked temporal hollowing and weakness of mastication six months after a coronal approach for repair of upper facial fractures. Imaging shows inferior displacement and scarring of the temporalis muscle from its temporal attachment, without recurrent skeletal deformity. What is the most appropriate corrective treatment?

A 30-year-old woman sustains traumatic loss of approximately 40% of the central upper-lip vermilion. The cutaneous lip, orbicularis oris, and oral commissures remain intact, and there is no full-thickness defect. What is the most appropriate reconstruction?

A 32-year-old man sustains a high-energy shearing injury to the right cheek. Exploration shows that a broad skin and subcutaneous flap has been separated from the underlying superficial musculoaponeurotic system, creating a large dead space. The skin remains warm and bleeds at its edges, and no facial nerve or parotid duct injury is identified. What is the most appropriate management?

A 29-year-old woman sustains a sharp laceration across the anterior border of the masseter. Exploration demonstrates complete transection of the parotid duct near its oral end. The proximal duct is identifiable and produces clear saliva, but the distal segment is too short and damaged for end-to-end repair. Facial nerve function is intact. What is the most appropriate reconstruction?

A 41-year-old man presents three days after a human bite caused a partial lower-lip avulsion. The wound is swollen, erythematous, and draining pus, with several clearly necrotic skin and muscle edges. He is febrile but hemodynamically stable. What is the most appropriate next management step?

A 48-year-old man presents six weeks after fixation of an open frontal bone fracture. He has an exposed plate, purulent drainage, and tenderness over the forehead. Computed tomography shows sequestrated frontal bone and localized osteomyelitis, while the dura remains intact and there is no intracranial abscess. What is the most appropriate management?

A 36-year-old woman presents eight months after nonoperative treatment of a displaced zygomaticomaxillary complex fracture. She has malar flattening, increased facial width, 3 mm of enophthalmos, and persistent diplopia. Computed tomography shows the zygoma healed in a posteriorly rotated position with enlargement of the orbital cavity. What is the most appropriate definitive treatment?

A 44-year-old man presents one year after inadequately reduced central midface fractures. He has severe midfacial retrusion, loss of nasal support, shortening of the lower midface, and marked facial imbalance. Computed tomography shows healed Le Fort-level fractures in a posterior and superior position. What is the most appropriate reconstructive approach?

A 52-year-old woman presents six months after repair of an orbital and lower-eyelid injury. She has painful corneal irritation, inward rotation of the lower-eyelid margin, and lashes rubbing against the globe. Examination shows posterior lamellar scarring with adequate external skin and normal horizontal lid tension. What is the most appropriate reconstruction?

A 27-year-old man sustains a sharp avulsion of the lateral eyelid attachments without globe injury or orbital fracture. The upper and lower eyelid margins remain intact, but the lateral canthal tendon is completely detached, producing rounding and medial displacement of the lateral commissure. What is the most appropriate repair?

A 39-year-old woman sustains a 3-cm traumatic skin loss over the nasal dorsum and upper sidewall. The nasal lining and cartilaginous framework are intact, but bone and cartilage are exposed and the surrounding nasal skin cannot be advanced without distortion. What is the most appropriate reconstruction?

A 45-year-old man develops sudden swelling, severe flap tension, and rapidly worsening venous congestion two hours after cervicofacial flap reconstruction of a traumatic cheek defect. A drain has stopped functioning, and the flap remains warm but becomes increasingly dusky. What is the most appropriate next management step?

A 10-year-old boy presents 14 months after an untreated displaced mandibular condylar fracture. He has progressive facial asymmetry, maximal mouth opening of 9 mm, and almost no translation of the affected temporomandibular joint. Computed tomography shows a mature bony bridge between the mandibular condyle and temporal bone. What is the most appropriate definitive management?

A 47-year-old man presents seven months after fixation of a mandibular body fracture with persistent pain and mobility at the fracture site. There is no drainage, erythema, or fever. Computed tomography shows an atrophic nonunion with a 12-mm gap, sclerotic bone ends, and intact but mechanically insufficient fixation. What is the most appropriate treatment?

A 35-year-old woman develops immediate severe numbness and burning pain of the lower lip after open reduction of a mandibular fracture. Postoperative computed tomography shows that a fixation screw penetrates the inferior alveolar canal, while fracture alignment is satisfactory. What is the most appropriate next step?

A 29-year-old man sustains an isolated frontal sinus anterior-table fracture. Computed tomography shows a 6-mm depressed segment producing a visible forehead contour defect. The posterior table is intact, the frontal sinus outflow tract is patent, and there is no cerebrospinal fluid leak. What is the most appropriate management?

A 38-year-old woman sustains a displaced medial orbital wall blow-in fracture. She has nonprogressive proptosis, horizontal diplopia, and restriction of adduction. Visual acuity and pupillary responses are normal, and the orbit is not tense. Computed tomography shows medial wall fragments displaced into the orbit, reducing orbital volume and compressing the medial rectus without muscle entrapment in a fracture gap. What is the most appropriate definitive management?

A 42-year-old man presents six months after nasal trauma with severe unilateral obstruction. Endoscopy shows a dense scar band connecting the septum to the lateral nasal wall, completely narrowing the airway. The septal framework is stable, and there is no active infection. What is the most appropriate treatment?

A 27-year-old woman sustains an open septal fracture with opposing lacerations of both mucoperichondrial flaps and exposed septal cartilage. The dorsal and caudal support remain adequate after reduction. What is the most important reconstructive step to prevent a delayed septal perforation?

A 33-year-old man sustains a sharp laceration of the lower face with complete transection of the mental nerve. He has dense numbness of the ipsilateral lower lip and chin. Exploration shows healthy proximal and distal nerve ends separated by a 15-mm gap after debridement, and direct repair would be under tension. What is the most appropriate reconstruction?

A 24-year-old wrestler presents eight months after repeated untreated auricular hematomas. The upper ear is thickened and deformed, with an organized fibrous-cartilaginous mass and loss of the normal antihelical contour. There is no active infection. What is the most appropriate corrective treatment?

A 45-year-old woman presents one year after a cheek crush injury with a stable facial skeleton but a pronounced soft-tissue depression and tethered scar over the malar region. Facial nerve function is normal, and computed tomography shows no residual bone defect. What is the most appropriate reconstructive approach?

A 34-year-old man presents after a high-speed collision with bilateral condylar fractures and a displaced mandibular symphyseal fracture. The mandibular arch is widened, the lower face appears broadened, and posterior ramal height is reduced on both sides. What is the most appropriate operative sequence?

A 37-year-old woman sustains a displaced zygomaticomaxillary complex fracture. She has malar flattening, a palpable infraorbital rim step, widening of the lateral orbital wall, and restricted mouth opening. Computed tomography confirms displacement at the zygomaticofrontal suture, infraorbital rim, and zygomaticomaxillary buttress. What is the most appropriate definitive management?

A 29-year-old man presents three days after an orbital floor fracture. He has mild diplopia only at extreme upward gaze, normal visual acuity, normal globe position, no nausea or bradycardia, and no clinical enophthalmos. Computed tomography shows a small defect without muscle entrapment or substantial soft-tissue herniation. What is the most appropriate management?

A 46-year-old woman sustains an isolated anterior-table frontal sinus fracture. Computed tomography shows 2 mm of displacement, a smooth forehead contour, an intact posterior table, and a patent frontal sinus outflow tract. There is no cerebrospinal fluid leak. What is the most appropriate management?

A 32-year-old man sustains an open nasal fracture with a laceration extending through the vestibular lining, lower lateral cartilage, and external skin. The tissue is viable, there is no major tissue loss, and the septum remains structurally stable. What is the most appropriate operative management?

A 40-year-old woman sustains a full-thickness upper-eyelid defect involving approximately 30% of the horizontal lid length. The medial and lateral canthal tendons are intact, the globe is uninjured, and the remaining eyelid tissue is viable but direct closure is moderately tight. What is the most appropriate reconstruction?

A 27-year-old man presents after a human bite removed a 1.5-cm segment of the upper helical rim. The wound is recent, thoroughly irrigated, and free of established infection. The remaining auricular cartilage and skin are viable, and primary closure would produce significant shortening. What is the most appropriate reconstruction?

A 35-year-old woman sustains a near-complete lower-eyelid avulsion. The avulsed eyelid remains attached by a narrow viable lateral skin-muscle pedicle, while the medial canthal tendon and lower canaliculus are disrupted. The globe is intact. What is the most appropriate repair?

A 43-year-old man sustains a stellate scalp laceration with brisk bleeding from a divided superficial temporal artery branch. The wound extends through the galea, but there is no tissue loss or skull fracture. What is the most appropriate management?

A 38-year-old woman develops persistent clear salivary drainage from a small cheek wound three weeks after repair of a parotid injury. Imaging shows a patent main parotid duct draining into the mouth, and there is no abscess or retained foreign body. What is the most appropriate initial management?

A 29-year-old man has displaced Le Fort II and bilateral zygomaticomaxillary complex fractures after a motor vehicle collision. He also has an evolving intracranial hemorrhage, elevated intracranial pressure, and unstable hemodynamics requiring vasopressor support. The facial airway is secure and there is no uncontrolled facial bleeding. What is the most appropriate management of the facial fractures at this stage?

A 36-year-old man presents with complete craniofacial separation after a high-energy injury. The entire midface moves independently from the frontal bone, with bilateral zygomatic arch disruption, orbital wall fractures, nasal root mobility, and marked facial elongation. The mandible has been anatomically reconstructed and can provide a stable lower facial reference. What is the most appropriate definitive reconstructive strategy?

A 42-year-old man sustains a unilateral intracapsular mandibular condylar fracture. He has mild preauricular pain, preserved ramal height, stable preinjury mandibular alignment, and no mechanical block to movement. Computed tomography shows a comminuted condylar head fracture confined within the joint capsule. What is the most appropriate management?

A 33-year-old woman requires open reduction of an isolated orbital floor and infraorbital rim fracture. She has no existing lower-eyelid scar, and adequate exposure can be obtained without an external skin incision. Which operative approach best minimizes the risk of a visible scar and postoperative lower-eyelid retraction?

A 45-year-old woman develops mild lower-eyelid retraction and scleral show two weeks after transconjunctival repair of an orbital fracture. The globe is protected, there is no implant malposition, and examination suggests postoperative edema and early scar contracture without a fixed skin shortage. What is the most appropriate initial management?

A 27-year-old man sustains a short superficial laceration medial to the lateral canthus. He has slight weakness of the adjacent upper-lip elevator, but exploration shows injury only to very distal facial nerve twigs within the densely interconnected medial facial plexus. No major named branch or muscle is transected. What is the most appropriate management?

A 19-year-old woman has complete traumatic loss of the external ear after a machinery injury. The amputated part is unavailable, the wound is clean after debridement, and the mastoid skin is viable but insufficient to recreate an auricular framework. What is the most appropriate definitive reconstructive plan?

A 63-year-old man has a 7-cm traumatic scalp skin defect after debridement. The pericranium is intact and well vascularized, the calvarium is not exposed, and local flap surgery would carry significant risk because of severe cardiopulmonary disease. What is the most appropriate reconstruction?

A 30-year-old man develops periorbital swelling and crepitus after blowing his nose following a small orbital wall fracture. Visual acuity, pupillary responses, ocular movements, globe position, and intraocular pressure are normal. The orbit is soft, and computed tomography shows noncompressive orbital emphysema without retrobulbar hemorrhage. What is the most appropriate management?

A 40-year-old woman has a contaminated open midfacial fracture with loss of cheek skin and muscle over newly stabilized zygomatic and maxillary buttresses. After serial debridement, the remaining wound is clean, but fixation plates and bone remain exposed and local facial tissue is insufficient for closure. What is the most appropriate definitive soft-tissue management?

A 36-year-old man arrives after falling onto a metal rod that entered the left cheek and remains impaled. The rod crosses the deep facial spaces and terminates near the carotid sheath on computed tomography. He is hemodynamically stable, the airway is secure, and there is no active external hemorrhage. What is the most appropriate next management step?

A 27-year-old woman sustains complete amputation of the nasal tip and columella from a sharp machinery injury. The amputated segment is intact, appropriately cooled, and reaches the hospital after a short ischemic interval. Suitable vessels are identified in both the amputated part and recipient wound. What is the most appropriate reconstructive option?

A 33-year-old man sustains a deep stellate injury at the oral commissure. The skin and mucosa can be approximated, but the orbicularis oris, buccinator, and modiolus are disrupted. After superficial closure at another facility, he develops drooling, commissural displacement, and inability to maintain oral competence. What is the most appropriate definitive reconstruction?

A 41-year-old woman presents after a high-energy nasal injury with severe dorsal comminution, collapse of the middle vault, loss of tip support, and bilateral airway obstruction. Closed manipulation cannot maintain reduction, but the nasal lining remains viable and there is no established infection. What is the most appropriate definitive management?

A 48-year-old man presents one year after orbital fracture reconstruction with foreign-body sensation, conjunctival inflammation, and visible exposure of the anterior edge of a titanium mesh implant. Computed tomography confirms solid fracture healing, normal globe position, and no abscess or recurrent orbital defect. What is the most appropriate management?

A 35-year-old woman presents six months after a blunt midfacial injury with persistent downward displacement of the cheek soft tissues despite anatomically healed zygomatic fractures. She has deepening of the nasolabial fold, loss of malar fullness, and lower-eyelid support weakness. Imaging confirms correct skeletal alignment but detachment of the malar soft-tissue envelope from its periosteal attachments. What is the most appropriate reconstruction?