Rigid External Distractors in Midface Fractures

A Review of Relevant and Related Literature

Zachary Gala, MD; Jordan Halsey, MD; Samuel Kogan, MD; Ian Hoppe, MD; Frank S. Ciminello, MD; Mark S. Granick, MD


ePlasty. 2020;20(e11) 

In This Article

Abstract and Introduction


Introduction: Literature discussing the use of rigid external distraction devices in midfacial trauma is limited. Rigid external distraction devices have been described for use in craniofacial surgery, allowing for distraction and stabilization of bony segments. In complex facial trauma, bony fragments are often comminuted and unstable, making traditional approaches with internal fixation difficult. Moreover, these approaches require subperiosteal dissection, limiting blood supply that is important for bone healing.

Objective: The goal of this study was to evaluate the role of rigid external distraction devices for the treatment of complex facial trauma.

Methods: We performed a literature review of rigid external distraction devices, as relevant both for facial trauma and for other craniofacial indications, to better elucidate their use and efficacy in complex facial fractures.

Results: The review revealed only 2 articles explicitly describing rigid external distraction devices for facial trauma, while 6 other articles describing its use for other craniofacial cases. An important benefit associated with the use of rigid external distraction devices is their ability to provide controlled traction of bony segments while also allowing for movement as needed for fracture reduction. Various articles describe performing internal fixation following rigid external distraction device usage, while others emphasize that internal fixation is not necessarily indicated if the rigid external distraction device is left intact long enough to ensure bony healing. One potential setback described is unfamiliarity with using the rigid external distraction device, which can preclude its use by many surgeons. In addition, the literature review did not provide any uniform guidelines or recommendations about how long rigid external distraction devices should remain intact.

Conclusion: Based on relevant literature, rigid external distraction devices have been shown to be useful in the stabilization and treatment of complex facial fractures. Further studies should be conducted to better elucidate the specific indications for rigid external distraction devices in complex facial trauma.


Summary of Review:

Literature discussing the use of distraction ostogenesis (DO) and rigid external distraction (RED) devices in midfacial trauma is sparse. Our study seeks to analyze the available literature on these techniques, specifically as they are used in trauma rather than their traditional use in craniofacial surgery.

Distraction osteogenesis (DO) is the process by which bone is cut and separated, allowing for osteogenesis to occur. First proposed by Von Langenbeck in 1869 and first reported clinically by Cadivalla in 1905,[1] DO was historically utilized to correct lower extremity length discrepancies. Later, Ilizarov popularized the use of DO, describing the use of an external device to hold bony fracture segments in traction for osteogenesis to occur within the gap.[1] Later, its principles were applied to craniofacial surgery under McCarthy et al.[2] Now, this technique is employed in a wide variety of craniofacial clinical conditions, such as hemifacial microsomia, craniosynostosis, and micro/retrognathism.[1] In addition, rigid external distraction (RED) devices are used to assist with complex orthognathic and midface procedures.

RED devices have been described for use in severe facial fractures. However, there is a paucity of literature on the use of these RED devices, specifically for midfacial trauma. Often, facial fractures are treated with internal fixation using plates and screws. This technique requires extensive dissection, with plates placed in a subperiosteal plane. In severely comminuted fractures, this would eliminate the remaining blood supply, leading to bony resorption. Furthermore, in complex and comminuted fractures, there can be difficulty reducing fractured segments. RED devices do not violate the periosteum and could be useful in the treatment of severely comminuted, unstable injuries.

Our study reviews the available literature citing the use of RED devices in midfacial trauma in order to provide a framework for the indications and use of RED devices in these cases.