J Oral
Maxillofac Surg 1, 1999
57: 199-20
Traumatic
Facial Artery Case Report
Zeljko
Orihovac MD, MSc, * Misdo Vi’irag, MD, PbD, f and Spomenka ManojloviL, MD, PbD# The blood loss was less than 10 ml. A suction drain was placed and the wound was closed using 3-O chromic gut sutures for the deep layers and 5-O nylon sutures for skin. The patient’s postoperative course was unremarkable, and he was discharged on the third postoperative day. Follow-up showed a well-healed incision with no recurrence of the swelling. The histologic section showed the wall of an extremely dilated facial artery (Fig 4), dilated vasa vasorum in the tunica media, inflammatory cells diffusely infiltrating all the layers of the artery wall (Fig 5), and edema, lymphocytes, plasma cells, and erythrocytes in the tunica media (Fig 6).
Traumatic arterial aneurysms are extremely uncommon in the facial region. When they do occur, the superficial temporal artery is the most frequently affected vessel,l but other branches of the external carotid, including the facial artery, also may be indescribes a patient with a vo1ved.l.9 This report traumatic facial artery aneurysm.
Report
of Case
A 30-year-old man was seen in our outpatient department because of a laceration in the right cheek. He reported having been struck with a wire over the right mandible and having the wound closed in layers under local anesthesia. Approximately 2 months later, the patient returned with edema of the right cheek. There was a palpable, movable mass in the right submandibular region measuring approximately 2.5 cm in diameter (Fig 1). Palpation of the lesion indicated a pulsation that corresponded to cardiac systole. Auscultation of the lesion showed a systolic bruit. Needle aspiration of the lesion produced blood under pressure. Because of the evident clinical findings, carotid angiography was not ordered. The patient was admitted to the hospital with a tentative diagnosis of a traumatic aneurysm of the facial artery. At the time of surgery, the patient was afebrile and his vital signs were normal. Laboratory studies also gave normal results. The patient was taken to the operating room for excision of the lesion and ligation of the facial artery. With the patient under general anesthesia, the aneurysm was approached by a submandibular incision (Fig 2). Special care was taken during the dissection to avoid the marginal mandibular branch of the facial nerve. The facial artery and aneurysm were exposed and isolated (Fig 3). Both ends of the artery were tied with a 2-O silk ligature, and the lesion was excised.
Received
from
the Medical
School,
Aneurysm:
University
of Zagreb,
Discussion Aneurysms can be classified into true and false types. True aneurysms are localized, abnormal dilations of arteries caused by a weakening of the vessel wall and containing all three layers. They are most
frequently associated with atherosclerosis, but also with trauma, congenital structural weakness, syphilis, and mycotic infections. False aneurysms are caused by a tangential laceration of an arterial wall by either blunt or penetrating trauma.* Such lacerations result in a persistent orifice secondary to partial retraction of the vessel. Extravasa-
Republic
of Croatia. *Attending gery. tProfessor
Surgeon, and
Department
Head,
of Maxillofacial
Department
and Oral
Sur-
and
Oral
of Maxillofacial
Surgery. *Associate Address Department Dubrava,
Professor,
Department
correspondence of Maxillofacial Avenija
izvidaza
of Pathology.
and reprint and Oral 6, 10000
requests Surgery,
Zagreb,
to Dr Orihovac: University
Republic
Hospital of Croatia;
e-mail:
[email protected]. o 1999Amerlcan
Associailon
of Oral and Maxillofacial
Surgeons
FIGURE
027%2391,‘99/5702-0018$3.00/O
submandibular
199
1.
Clinical region.
view
of patient
showing
a mass
in ihe
right
200
FIGURE
TRAUMATIC
2. View
of aneurysm
via the submandibular
incision.
tion of arterial blood into the surrounding tissues under pressure then will occur. When the pressure difference between the involved artery and the hematoma equalizes, further arterial flow will cease. The hematoma will liquify, with ensuing secondary hemorrhage from the previously injured artery. This can result in an increase in associated soft-tissue deformity and asymmetry. With liquefaction, a bruit and pulsation may develop. This would depend on the anatomic location of the injured artery as well as the nature of the covering tissues.tJ Besides inflammatory and neoplastic lesions, the differential diagnosis of soft tissue swellings should include the false aneurysm, arteriovenous (AV) fistula, and the true aneurysm. The false aneurysm may be differentiated from the AV fistula by several features.’ The AV fistula has a continuous vibratory thrill and bruit intensified during systole, with wide transmis-
3. View
of exposed
and
isolated
facial
artery
aneurysm.
ARTERY
ANEURYSM:
FIGURE 4. Part of the wall of the extremely dilated fills the lumen, and all layers of the wall are infiltrated cells. (HE stain, original magnification x20)
CASE
REPORT
artery. Blood clot with inflammatory
sion of the murmur, whereas in a false aneurysm the bruit is heard only during systole and remains localized. Another distinction between the two is that usually the false aneurysm produces a relentlessly expanding aneurysmal sac that compresses collateral vessels, whereas an AV shunt does not. The possibility of a vascular lesion should be considered in the differential diagnosis of soft tissue trauma (penetrating and nonpenetrating wounds),3 facial fracand iatrogenic trauma from tures,loJ1 atherosclerosis,l* surgery or arterial catheterization13 Vascular lesions that go undetected may be injured accidentally and easily ruptured, with the possibility of the hemorrhage. Treatment options discussed in the literature include excision, ligation, and arterial embolization. We do not believe there is any indication for embolization of aneurysms within the facial region. Furthermore, for lesions such a the one described, we do not believe that even angiography is necessary, because it is evident that such lesions have to be
FIGURE FIGURE
FACIAL
cells diffusely magnification
5.
Dilated infiltrate X50)
vasa vasorum all the layers
in the tunica media. Inflammatory of the artery wall. [HE stain, original
MEHRA ET AL
FIGURE iunica
201
6. Edema, lymphocytes, plasma media. (HE, original magnification
cells, x200)
and
erythrocyies
in the
explored and excised. If the decision to operate is made on the grounds of the clinical examination, even a low complication risk of 1% to 1 .5%‘*J5 with angiography seems too high.
References 1. Cooperband BR, Friedel W, Bhatt GM, et al: False aneurysm the facial artery. J Oral MaxilIofac Surg 47:1327, 1989 J Oral
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2. Lutcavage GJ: Traumatic facial artery aneurysm and arteriovenous fistula: Case report. J Oral Maxillofac Surg 50:402, 1992 of the 3. Wineland PL, Topazian RG, Marble HB Jr: False aneurysm facial artery. J Oral Surg 34:642, 1976 4. Akker HP van den, Lijn F van der: A false aneurysm of the facial artery as a complication of circumferential wiring. Oral Surg Oral Med Oral Path01 37:514,1974 5. Schwartz SH, Blankenship BJ, Stout RA: False aneurysm of the facial artery: Report of case. J Oral Surg 29:672,1971 6. Bresner M, Brekke J, Dubit J, et al: False aneurysm of the facial region. J Oral Surg 30:307, 1972 7. Cohen SM: Vascular surgery and reticuloendothelium system, in Rob C, Smith R (eds): Clinical Surgery, vol 14. Philadelphia, PA, Lippincott, 1967, pp 140-141 8. Schwartz HC, Kendrick RW, Pogrel BS: False aneurysm of the matiary artery: An unusual complication of closed facial trauma. Arch Otolaryngol109:616, 1983 aneurysm of the facial artery 9. Cohen MA: False (traumatic) caused by a foreign body. Int J Oral Maxillofac Surg 15:336, 1986 JW, Kent JN: False aneurysm and a partial facial 10. Kennedy paralysis secondary to mandibuiar fracture: Report of case. J Oral Surg 28:854, 1970 11 Taylor DV: Traumatic aneurysm and facial palsy as complication of a mandibular fracture. Br J Oral Surg 4:202, 1967 (false) aneurysm of the terminal portion 12 Calem WS: Traumatic of the external carotid artery. Am J Surg 106:522, 1963 A complication of percutaneous 13 Wagner M: Pseudoaneurysm. angiography and angiocardiography. JAMA 186:427, 1963 CP, Moran CJ, Cross DT, et al: Intraoperative digital 14 Derdeyn subtraction angiography: a review of 112 consecutive examinations. AJNR 16:307, 1995 complica15 Heiserman JE, Dean BL, Hodak JA, et al: Neurologic tions of cerebral angiography. AJNR 15:1401, 1994
Surg 1999
Life-Threatening, Delayed Epistaxis After Surgically Assisted Rapid Palatal Expansion: A Case Report Pushkar Me&-a, BDS, DMD, * David A. Cottrell, DMD, f Avonso Caiazzo, DDS,f and Robert Lincoln, DMDJ
*Chief Boston
Resident, University
tAssistant ment
School
Professor
Medicine,
*Resident, University
of Dental
§Assistant Address Department University
of Oral
MA.
Training, University
correspondence
and MaxiIlofaciaI
Medicine,
Professor,
Surgery,
School
Boston,
Department
Boston
Medical
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to Dr
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Surgery,
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o 1999
of Oral
of Oral & Maxillofacial
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Boston,
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Surgeons
St,
Transverse maxillary deficiencies are routinely corrected in growing patients with appliances that help in separation of the median palatal and associated maxillary sutures. However, this technique is not feasible in skeletally mature individuals. Alternatives in these cases include the use of surgically assisted rapid palatal expansion (SARPE) or a segmental Le Fort I osteotomy in an attempt to overcome the resistance of the closed sutures. Major intraoperative or postoperative bleeding associated with maxillary surgery is an infrequent complication relative to the number of these procedures performed. Most of the reported cases of hemorrhage involve Le Fort 1 osteotomies. Treatment options to manage hemorrhagic complications of maxillary or-
