Beruflich Dokumente
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Otolaryngology
Head and Neck Surgery
EDITORIAL BOARD
VIJAY K. ANAND, MD
HOWARD L. LEVINE, MD
New York, NY
Beachwood, OH
DAVID D. CALDARELLI, MD
MAHMOOD MAFEE, MD
Chicago, IL
Chicago, IL
JAMES CHOW, MD
ROBERT OSSOFF, MD
Maywood, IL
Nashville, TN
LAWRENCE DESANTO, MD
STEPHEN S. PARK, MD
Scottsdale, AZ
Charlottesville, VA
ISAAC ELIACHAR, MD
Cleveland, OH
Chapel Hill, NC
RAPHAEL FEINMESSER, MD
DALE H. RICE, MD
Petah-Tiqva, Israel
Los Angeles, CA
ALFIO FERLITO, MD
DAVID E. SCHULLER, MD
Udine, Italy
Columbus, OH
DAN M. FLISS, MD
JAMES STANKIEWICZ
Maywood, IL
ELLIOT STRONG, MD
Toronto, Canada
New York, NY
PHILLIP FRIEDMAN, MD
DAVID J. TERRIS
Southfield, MI
Augusta, GA
BRUCE J. GANTZ, MD
DEAN M. TORIUMI, MD
Iowa City, IA
Chicago, IL
JOSEPH JACOBS, MD
HARVEY TUCKER, MD
New York, NY
Cleveland, OH
YOSEF KRESPI, MD
B. TUCKER WOODSON, MD
New York, NY
Milwaukee, WI
ROEE LANDSBERG, MD
Tel Aviv, Israel
Operative Techniques in
Otolaryngology
Head and Neck Surgery
FUTURE ISSUES
THYROID-PARATHYROID SURGERY
David J. Terris, MD, FACS
March 2009, Vol 20, No 1
RECENT ISSUES
COSMETIC SURGERY
Raghu S. Athre, MD
September 2007, Vol 18, No 3
Operative Techniques in
Otolaryngology
Head and Neck Surgery
VOLUME 19, NUMBER 2, June 2008
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Operative Techniques in
Otolaryngology
Head and Neck Surgery
Editor: MICHAEL FRIEDMAN, MD
30 N. Michigan Avenue, Suite 1107, Chicago, Illinois 60602
Managing Editor: COLLEEN A. MARTIN
Editorials
feature articles: These articles are related to a featured
theme of the issue and will be related by anatomic area or
disease process, or both. Each feature article will include
indications and contraindications, work-up and preparation
of the patient, operative technique, and complications. These
articles will present new material related to the technique or
results of these procedures.
difficult decisions: This section focuses on a case related to
the central theme of the issue and will be presented with
patient photographs, diagnostic images, and/or other illustrations. The case is discussed by a panel of authorities and is
moderated by the editor of the section.
innovative techniques: This highly illustrated section combines two or three techniques on a topic possibly related to
the featured theme of the issue and concentrates on new
concepts, innovations, and alternatives relevant to the problem being discussed. Editorial comments may compare different approaches to the same problem.
complications: Although this section often discusses complications related to the central theme, it also presents other
interesting, unusual, and previously unpublished complications in otolaryngology head and neck surgery.
The contributions in the above sections may be invited; however, the Journal welcomes submissions for the following
sections:
original articles: These articles should center around a
technique which need not be a surgical technique. New techniques for diagnosis, treatment, or rehabilitation will all be
considered. The guidelines for authors that are presented
subsequently on this page all relate to original articles.
Original articles need not be theme-related.
letters to the editor: This correspondence should be brief
and embody a point of view. Content should relate either to
previously published material in the Journal or to other rel-
Abstracts
All feature articles and original articles must include an abstract. Abstracts should emphasize the topic investigated,
methods, results, and conclusions.
Review of Articles
Submitted manuscripts will be reviewed by the Guest Editor,
and also are subject to review by the Editor in Chief and/or
members of the Editorial Board.
References
Figures
All tables and figures must be cited in the text. The appropriate location of each table or figure should be indicated in
the margin of the manuscript in pencil.
Tables
Each table should be typed on a separate sheet and appropriately numbered. Each table must have a title. Tables must
be cited in numerical order in the text using arabic numbers
(Table 1, Table 2). Table legends should be typed on the same
sheets as the tables. Each table should have a legend in
sufficient detail to allow understanding without reference to
the text.
Authors contributing a manuscript do so on the understanding that, once it is accepted for publication, copyright in the
article including the right to reproduce the article in all forms
of media shall be assigned exclusively to the publisher.
Introduction
The management of facial trauma continues to evolve with
the development of improved techniques, surgical instrumentation, and implants. From the days of wiring the jaws and
closed reduction to precise open reduction and internal fixation, the otolaryngologist-head and neck surgeon has played a
critical role in the treatment of patients with facial trauma.
This edition brings together many of the leaders in the
fields of facial trauma, reconstructive surgery, and cosmetic
surgery to summarize the state of the art approach to many
different aspects of traumatic injuries of the craniofacial
region. It is my belief that the information provided here
1043-1810/$ -see front matter 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.otot.2008.05.001
Traumatic facial bony defects present one of the most challenging problems for the facial plastic
reconstructive surgeon. The most common mechanisms of trauma resulting in a bony defect of the
facial skeleton include gunshot injuries, motor vehicle accidents, and burns. These bony defects of the
facial skeleton resulting from trauma rarely occur in isolation. Rather, there is uniformly varying
degrees of soft-tissue trauma and/or loss, potential visual, neurological and spinal injuries, and other
associated life-altering implications. The application of free tissue transfer techniques to the management of these complex defects has allowed a significant change in paradigm, permitting early intervention and improved long-term outcomes.
2008 Published by Elsevier Inc.
Girod
81
Figure 1 (A) Mandible remnant after dbridment of traumatic loss of the anterior mandibular arch from a self-inflicted gunshot wound.
(B) Locking screw bridging reconstruction plate applied to maintain occlusive relationships and the soft tissue envelope thus avoiding
wound contracture while waiting for definitive repair. (C) Free tissue transfer of bone contoured with 2 wedge-shaped osteotomies and
secured to the reconstruction plate with locking screws. Excellent bone contact should be achieved with the native mandible and all segments
of flap bone to facilitate bone healing.
goals can be achieved. The use of free tissue transfer techniques has allowed the aggressive early management of
defects where large amounts of soft tissue and bone are
missing. The long-term goals of the reconstruction will
dictate the appropriate free tissue transfer flap(s) required to
provide the necessary amount of bone for mandibular and
maxillary reconstruction and soft tissue volume for bone
coverage, internal and external lining and cosmetic contouring. Additional free bone grafting may also be required for
the reconstruction of the midface, nose and orbit. Local
flaps are used in a limited fashion to avoid compromise of
the soft-tissue envelope.
Phase III of patient management consists of esthetic and
prosthetic refinement, which may occur over weeks to
years. Free flap debulking and contouring is often required.
Dental rehabilitation with tissue-borne or implant-borne
Technique
Once the initial phase of trauma management has been
completed as outlined in the previous section, the facial
plastic and reconstruction surgeon must begin the difficult
task of planning the definitive reconstruction. This often
requires a multidisciplinary team approach to define the
long term goals and objectives of the reconstruction.
Flap selection
The type of free tissue flap required will be dictated by
the defect and should be chosen to minimize the number of
82
nonviable tissues encountered at this time should be carefully dbrided. Care must be taken to preserve all nervous
structures, including the lingual and hypoglossal nerves and
the inferior alveolar nerve, if possible. The mandibular
remnant ends should be exposed and cut to provide a
smooth surface for the mandible-bone flap interface. Removal of the bridging plate is not required nor recommended as the loss of occlusal relationships should be
avoided. At this juncture the length of bone and size of the
skin paddle required for bone coverage can be readily determined.
For bony maxillary defects, the wound can generally be
approached through a transoral facial degloving approach.
If temporary bone grafts were previously placed to avoid
soft tissue contracture they should be removed at this time.
The anterior maxillary arch remnant should be exposed and
prepared to allow a smooth transition to the flap bone graft.
The posterior maxilla is often a more difficult issue and only
pterygoid plates may remain for flap abutment. The flap
bone graft will ultimately be secured using mini plates
anchored on the available remaining bone and must be
anticipated. The use of 3-dimensional models can be very
helpful in planning this aspect of the reconstruction. Access
to recipient vessels in the neck must also be anticipated and
an adequate tunnel created from the maxillary defect
through the cheek, over the mandible and into the neck.
Care must be taken to avoid facial nerve injury by using
blunt dissection. The tunnel must also be of adequate diameter to allow for the pedicle and soft tissue swelling without
venous compression and thrombosis.
Girod
ing plate will continue to bear the majority of the load with
chewing. It should also be recognized that the reconstruction of traumatic mandibular defects varies significantly
from similar reconstructions for defects, resulting from oncological resections, where much of the muscles of mastication have been resected or detached. These muscles are
largely intact in the setting of trauma and thus forces created
during chewing are much greater.
With bone contouring complete, the microvascular anastomosis of the flap artery and vein to the neck vessels can be
performed safely to minimize the ischemia time of the flap
tissues. This also allows time for observation of the microvascular anastomosis while the reconstruction continues. As
with tumor reconstruction of the mandible, the superior
thyroid artery and the internal jugular vein (or one of its
branches) are the most common recipient vessels. Vascular
pedicle length is rarely an issue in mandibular reconstruction so vein grafting can be avoided. Some prefer to perform
primary placement of osseointegrated dental implants. If so,
this is the appropriate time to place them while blood flow
to the bone has been reestablished and the bone is still
exposed.
Attention is now turned to the soft-tissue coverage of the
mandibular bone graft using the skin harvested with the flap.
Watertight closure over the graft is preferred to minimize
the risk of infection and salivary exposure of the flap vascular pedicle which can cause thrombosis and flap failure.
Soft-tissue swelling must again be anticipated; thus, the
closure should not be overly tight. The neck incision is then
closed after placement of adequate suction drains. The donor site is managed in the appropriate fashion.
The skin paddle provided by the fibula, radius and, in
particular, the scapula flap will be thicker and more redundant than desired for the alveolar ridge and thus will require
thinning in a delayed fashion. Dental implants also may be
placed at the time of flap revision if indicated. This may
require the removal of some locking screws which secure
the flap bone to the plate. If this procedure is delayed at least
3 months the bone will be healed and these screws are not
necessary. Removal of the reconstruction plate itself requires much more dissection and thus is typically avoided.
Maxillary reconstruction
Reconstruction of maxillary bony defects is similar to
that of the mandible with some important exceptions. Typically, there is no plate placed at the initial surgery to which
the flap bone can be contoured. A 3-dimensional model of
the skull created from the computed tomography scan is
very helpful in planning the flap size, contour and approach
necessary for the reconstruction.
Once wide exposure is obtained through the facial degloving approach the harvested flap is transferred into the
wound. The vascular pedicle is carefully passed through the
tunnel created in the cheek and over the mandible to reach
the neck. Vein grafts may be required to provide adequate
pedicle length to reach healthy vessels in the neck. The bone
is then contoured to fit the defect with shaped osteotomies
as with the mandible as described above. The bone is then
secured to the remaining maxilla with mini-plates. (Figure
2) Soft-tissue coverage of the bone is achieved using skin
83
from the flap folded on itself with a central area of deepithelialization. This allows skin to provide lining to the
oral palate defect and the nasal floor defect.
Premaxillary defects can be managed with the osteocutaneous radial forearm flap which provides an adequate
platform for a tissue-born prosthesis (partial denture) anchored off the remaining maxillary teeth.1,9 The fibula osteocutaneous flap will be more appropriate if dental implants are planned or the defect is more extensive.1
Perioperative management
Free tissue transfer for reconstruction of traumatic facial
bony defects is often a long operation (8 hours or longer)
that includes multiple operative sites (head and neck, flap
donor site, split-thickness skin graft site, calvarial bone graft
site). A team approach is generally preferred with one team
working in a clean-contaminated field preparing the recipient wound and neck vessels and the reconstructive team
working in a sterile field harvesting the free flap. The patient
must be positioned and prepped appropriately in anticipation of the expected surgical sites.
A tracheostomy is typically required and, depending on
the severity of the patients injury, a feeding tube or gastrostomy tube may also be indicated for preoperative nutrition. Intraoperative fluid management should be reviewed
with the anesthesia team to avoid excessive use of intravenous fluids that can contribute to postoperative soft tissue
edema. The use of vasoactive agents should also be avoided
during and after surgery as they may contribute to vasospasm of the microvascular pedicle after anastomosis resulting in flap failure.
Most patients will require at least one night in the surgical intensive care unit for hemodynamic monitoring and
to allow close observation of flap perfusion. Vascular compromise of the flap is most likely to occur in the first 72
hours, with the highest risk in the 24- to 48-hour time frame.
The most common problem encountered is in the low pressure venous system due to thrombosis of the venous anastomosis. This can occur from technical difficulties with the
microanastomosis, wound hematoma, unfavorable geometry of the pedicle resulting in kinking and obstruction or
from excessive soft tissue pressure from an overly tight
closure and soft-tissue edema. Several techniques have been
evaluated for the monitoring of free flap perfusion in the
postoperative period, including temperature probes, laser
Doppler probes, tissue oxygenation probes, and Doppler
monitoring of the vascular pedicle. Unfortunately, these
techniques are much more reliable for arterial inflow problems and do not detect venous problems until they progress
to include arterial thrombosis. We have found direct observation by trained personnel (resident, surgeon or experienced nurse) of flap color, turgor, capillary refill and bleeding to a prick created with a 30 gauge needle every 4 hours
to be most reliable.
At the first indication of vascular compromise of the flap,
a return to the operating room for wound exploration and
vascular pedicle revision will result in a satisfactory outcome in most instances. The tracheostomy tube can be
84
Figure 2 (A) Normal midface skeleton. (B) Defect caused in the premaxillary segment by a self-inflicted gun shot wound involving the
anterior maxillary arch, hard palate and nasal floor. (C) Reconstruction of the maxillary bony defect with free tissue transfer of bone using
a single osteotomy and fixation using miniplates. Excellent bone contact between all segments must be achieved for rapid bone healing.
intake can usually be resumed within 7 to 10 days. Evaluation for speech and swallow therapy is often required and
psychosocial issues should continue to be addressed.
Girod
Outcomes
Free tissue transfer for reconstruction of traumatic facial bony
defects is a highly reliable technique. Futran et al1 reported a
take back rate of almost 10% but no flap failures in a series of
54 free tissue transfers performed for facial trauma. This rate
compares favorably with free tissue transfer for reconstruction
of the head and neck following tumor ablation.1,8,9 Wound
infection rate was only 7% in these same 54 procedures,
despite the extensive contamination and tissue damage caused
by the soft tissue trauma seen in these cases.
Long-term outcomes are mixed and largely dependent on
the severity of the injury at the outset. Not surprisingly, isolated
mandibular defects have the best cosmetic result and complex
mandibular, maxillary and nasal defects have the worst cosmetic results. Most patients will recover adequate speech and
swallow function. Dental rehabilitation remains critical to the
type of oral diet a patient can handle. All patients require
multiple procedures during the reconstructive process and
those with orbital and/or nasal defects are the most complex,
requiring the largest number of procedures.
References
1. Futran ND, Farwell DG, Smith RB, et al: Definitive management of
severe facial trauma utilizing free tissue transfer. Otolayrngol Head
Neck Surg 132:75-85, 2005
85
Zygomatico orbitomaxillary complex fractures are the second most common facial fracture. As with
all facial fractures, wide exposure and accurate fixation will lead to optimal functional and cosmetic
results. Surgical techniques to expose the orbital floor, zygoma, and maxilla are discussed.
Published by Elsevier Inc.
ZOMC Fractures
87
Sublabial approach
The sublabial approach provides access to the zygomaticmaxillary buttress and the naso-maxillary buttress. This
approach also provides access for inspection of the inferior
orbital rim, although reducing a rim fracture via the sublabial approach is extremely difficult.7 The sublabial approach
begins with injection of 1% lidocaine with 1/100,000 epinephrine into the gingival mucosa lying above the maxillary
teeth. The incision is made in the gingivobuccal sulcus
being cognizant to leave a cuff of 5- to 10-mm tissue above
the gum line to help aid with closure. Cautery is then used
to incise the submucosal, muscular and periosteum layers
down to bone. A periosteal elevator is used to elevate the
periosteum superiorly toward the inferior orbital rim. Care
is taken to preserve the infraorbital nerve, usually located 10
mm inferior to the orbital rim in a vertical plane in line with
88
Figure 6 Extended upper lid blepharoplasty incision is demonstrated. Plating of the zygomatic-frontal, orbital rim, and lateral
buttress fractures are complete.
ZOMC Fractures
Conclusion
ZOMC fractures are the second most encountered facial
fracture. Preoperative evaluation should include a comprehensive ophthalmologic evaluation as well as high resolution coronal and axial computed tomography scans. Attention to the accurate three dimensional reduction of the
zygoma and careful attention to the dissection planes in the
transconjunctival approach can help avoid poor postoperative cosmesis and ectropion complaints. The sublabial approach combined with an extended upper blepharoplasty/
lateral brow incision is usually adequate for two point
89
fixations while the transconjunctival approach is used when
the orbital rim and/or floor needs repair.
References
1. Kelley P, Crawford M, Higuera S, et al: Two hundred ninety four
consecutive facial fractures in an urban trauma center: Lessons learned.
Plast Reconstr Surg 116:42e-49e, 2005
2. Shere JL, Boole JR, Holter MR, et al: An analysis of 3599 midfacial and
1141 orbital blowout fractures among 4426 United States Army soldiers, 1980-2000. Otolaryngol Head Neck Surg 130:164-170, 2004
3. Shaw GY, Khan J: Precise repair of orbital maxillary zygomatic fractures. Arch Otolaryngol Head Neck Surg 120:613-619, 1994
4. Holmes KD, Matthews BL: Three-point alignment of zygoma fractures
with miniplate fixation. Arch Otolaryngol Head Neck Surg 115:961963, 1989
5. Patel BC, Hoffman J: Management of complex orbital fractures. Facial
Plast Surg 14:83-104, 1998
6. Garcia GH, Goldberg RA, Shorr N: The transcaruncular approach in
repair of orbital fractures: a retrospective study. J Craniomaxillofac
Trauma 4:7-12, 1998
7. Shumrick KA, Campbell AC: Management of the orbital rim and floor
in zygoma and midface fractures: Criteria for selective exploration.
Facial Plast Surg 14:77-81, 1998
The management of acute soft-tissue trauma can be very challenging for the facial plastic surgeon. The
goals of management of facial trauma are the preservation of form and function. These goals are
particularly important in facial soft-tissue trauma, where injuries can cause not only esthetic deformities
but also can affect neural function, normal mastication, visual fields, and salivary outflow. This article
outlines the evaluation and treatment of acute soft-tissue facial trauma. The key components include
allowing for the stabilization of the patient, complete examination of the injury and face, thorough
wound irrigation and debridement of necrotic tissue, preservation of all viable tissue, tension-free
closure, and realignment of important facial esthetic structures. Special consideration must be given to
injuries of functional structures such as the facial nerve, ductal systems or organs, and ensuring
appropriated management of these structures.
2008 Elsevier Inc. All rights reserved.
Evaluation
Once the initial assessment has been performed and the
patient stabilized, the soft-tissue facial trauma can be carefully evaluated. Obtaining the patients history, such as the
time and mechanism of the injury, aides in the management
Table 1
History of tetanus
immunization (doses)
Clean, minor
wounds, Td TIG
All other
wounds, Td TIG
Unknown or 3 doses
3 or more doses
Yes, No
No,* No
Yes, Yes
No, No
91
Anesthetic
Figure 2 An intraoperative photograph of the patient from Figure 1 demonstrating the use of high-pressure pulsatile irrigation to
clean and debride the contaminated facial wounds. (Color version
of figure is available online.)
Lidocaine 1%
Lidocaine 1% with epinephrine
1:100,000
Bupivacaine 0.25%
Dose
(mg/kg)
Onset
(min)
Duration
(hr)
3 to 4
5 to 7
2
2
1.5 to 2
2 to 6
2.5
2 to 4
92
Figure 5 An illustration depicting the use of deep sutures to reapproximate the wound edges (A) to allow for an even and everted skin
edge (B). Use of a layered closure relieves the tension on the epidermal sutures and minimizes scar widening during wound healing.
(Reprinted with permission.9)
necessary. Current tetanus prophylaxis is based on the recommendations by the Center for Disease Control and Prevention in Table 1.6
Physical examination
After obtaining the patients information, a thorough physical evaluation is imperative. This evaluation includes close
examination of the head and face for any signs of skeletal
instability, bony step-offs, or dental malocclusion. In the
event that there is suspicion of more than soft-tissue injury,
appropriate radiographic imaging should be obtained, such
as a computed tomography scan of the head or face or
radiographs of the facial skeleton. Injuries that involve the
eye should include ophthalmology consultation.4 A thorough examination of the skin, eyes, ears, nose, oral cavity,
oral pharynx, and cranial nerves should be performed. Early
recognition of any injury to the facial nerve, lacrimal ducts,
or Stensens ducts is important.
Figure 6 Illustration depicting the management of wounds when there is an uneven thickness of the dermal edges being reapproximated
(A). The use of a layered closure first involves placement of deep sutures to even realign the deep tissues (B). After closure of the deep
tissues, if the dermal edges are uneven (C), placing the dermal suture such that the suture is placed more deeply through the thinner dermal
edge and more superficially through the thicker dermal edge (D) will bring the epidermal edges together in an even manner (E). (Reprinted
with permission.9)
93
Region
Cutaneous suture
Subcutaneous/fascia suture
Comments
#6-0, #7-0
#4-0, #5-0
#5-0, #6-0
#4-0, #5-0
#6-0
#3-0, #4-0
#3-0, #4-0
#3-0, #4-0
#3-0, #4-0
#3-0, #4-0
#2-0, #3-0
Reprinted with permission from Baker S, Swanson N, Skyes J, et al: Suture needles and techniques for wound closure, in Local Flaps in Facial
Reconstruction. New York, Mosby, 1995.
Surgical repair
Figure 7 A photograph displaying a complex laceration involving the full-thickness of the skin and cartilage of the right ear.
Closure of this wound required a layered closure of the cartilage
and skin, as well as attempts to regain the original shape and
contour of the ear. Lacerations of the ear also require close evaluation of the external auditory canal and tympanic membrane. If
significant soft tissue edema is present within the external auditory
canal, a wick should be placed temporarily to prevent canal stenosis. Note the ischemic discoloration of the ear lobule, which was
later sutured to its original position. (Color version of figure is
available online.)
94
Figure 9 A photograph of a patient who sustained a full-thickness laceration through the left upper lip. To restore muscle function and improve esthetic outcome, a layered closure reapproximating the orbicularis oris muscle as well as a meticulous
realignment of the vermilion cutaneous border was performed.
(Color version of figure is available online.)
Figure 11
subunits.
95
96
97
biotic ointments, petroleum jelly is equally effective. Approximately 3 to 4 weeks after wound closure, massaging of
the wound can help soften scars and decrease hypertrophy
of the scar edges. If scarring becomes raised or uneven,
dermabrasion may be initiated as early as 4 weeks after
wound closure.
Summary
In summary, soft tissue trauma is often complex and requires thorough evaluation. The key for good wound healing includes repair of any injured functional structures,
copious irrigation, debridement of necrotic tissue, with meticulous tension-free closure. During the wound closure,
utmost attention should be paid to realigning all esthetic
subunit borders.
References
technique, usually with a 7.0 or smaller permanent monofilament suture to realign the epineurium. Using a nerve
stimulator can also be helpful in identifying the severed
nerve branches. Nerve injuries medial to a vertical line
drawn from the lateral canthus are thought to have enough
cross-innervation from surrounding branches to regain function. For this reason, nerve repair is usually not attempted
for medial injuries to the facial nerve. Injuries over the
buccal region should be carefully explored to rule out injury
to Stensons duct. Using lacrimal probes or silastic tubing
cannulated through the buccal orifice aides in identifying
the injured duct. Again, microscopic repair is warranted and
stenting the duct for 3 to 4 weeks with silastic tubing can
help prevent postoperative ductal stenosis.8,14
Key adjunctive treatments include providing antibiotic
prophylaxis to prevent wound infection. Often cefazolin or
cephalxin is appropriate, however, if the injury was from an
animal or human bite, broader spectrum antibiotic coverage
is advisable such as amoxicillin-clavulanate.14 If stents,
bolsters or nasal packing is used, the patient should be kept
on antibiotic prophylaxis as long as the packing is in place.
Tetanus immunization is important for all deep penetrating
wounds. For bites, infectious disease status of the offender
such as rabies, HIV, or hepatitis should be investigated and
the patient treated when question of exposure exists.14
Postoperative care
Diligent postoperative wound care is essential for good
healing of soft tissue wounds. Keeping the reapproximated
skin edges free of dried blood improves wound healing.
Open wounds or abrasions should be kept moist with a thin
layer of antibiotic ointment, such as bacitracin, to prevent
wound desiccation. Moist wounds have been shown to reepithelialize 50% faster compared with desiccated wound
beds.16,17 If the patient develops sensitivity to topical anti-
Isolated orbital roof fractures are rare. In the pediatric population, however, the lack of pneumatized frontal
sinuses makes them more susceptible to such injuries. In evaluating these injuries, maxillofacial computed
tomography is a necessary adjunct to a complete history and physical evaluation. Based on the relative
position of bone fragments, orbital roof fractures can be classified as non-displaced, blowout, or blow-in.
While many patients can be safely managed with careful observation. Symptoms such as extraocular
entrapment, vertical dystopia, diplopia, or cerebrospinal fluid leak may require surgery. Many different
approaches to the orbital roof are available; selection needs to be made based on surgeon experience and
location of injury. Cooperation between neurosurgery, ophthalmology and head and neck surgery are
essential to optimize the care for these patients.
2008 Elsevier Inc. All rights reserved.
Evaluation
Orbital roof fractures may occur in conjunction with injuries
of other systems, particularly the central nervous system1,2
Figure 1
99
100
Figure 4 Direct trauma to the orbital rim; as the force is delivered, pressure is dissipated into the surrounding bony tissue in a wave of
deformation causing buckling of the orbital walls.
101
Treatment
The treatment of orbital roof fracture needs to be tailored to
the degree of injury and clinical symptoms present. In general, treatment plans can be separated into 2 broad categories consisting of observation and surgery. The high frequency of concomitant neurological injuries means that the
initial focus of treatment need to be concentrated on stabilizing the neurological status, after which the orbital injuries
can be addressed.
Observation is appropriate for the nondisplaced fractures
and most of the blow-out orbital roof injuries.1-4,7 The
specific symptoms that need to be followed closely include
extraocular muscle entrapment, enophthalmos, vertical dystopia, diplopia and any suspicions of dural tear or cerebral
spinal fluid leak. The accuracy of the initial assessment
during the acute injury period may be questionable due to
edema, bleeding, and lack of patient cooperation.9 As the
injuries evolve over the following days, deficits may become more obvious and the need to switch from observation
to surgery becomes evident. For patients with significant
blow-out fractures that cannot be effectively followed by
clinical examination, a follow-up CT 24 hours after the
initial injury can be helpful in confirming the absence of
intracranial hematoma.7
Blow-in fractures are frequently associated with exophthalmos, vertical dystopia, and extraocular muscle entrapment.2 From an esthetic perspective, enophthalmos or exophthalmos of 2 mm will begin to be apparent in the
patients appearance.9 Unrepaired blow-in fractures have a
25% chance of developing late orbital encephalocele.7 For
these reasons, the threshold for surgery is much lower for
patients with blow-in type of orbital roof fracture.
Approaches
Numerous approaches to the orbital roof have been described,1-4,11 and the success of each technique is greatly
dependent on the location of each injury, as well as each
surgeons comfort level. We describe 3 different approaches
to the orbital roof and outline the salient points of each
procedure.
Brow or infra-brow approach
This is the most direct access to the antero-superior
orbit. It is capable of exposing the entire orbital roof from
the superior orbital rim all the way to the apex.11 The
incision is placed either within the brow or immediately
below it. Dissection is carried down to the periosteum,
which is incised and elevated at the superior orbital rim.
Orbital fat is retracted inferiorly and the area of interest
is exposed. A malleable retractor is often useful to keep
the orbital contents away from the surgical field. Care
needs to be taken to preserve the supraorbital and trochlear neurovascular bundles. The dissection over the lachrymal gland laterally needs to be subperiosteal to ensure
proper placement of the gland and the end of the procedure. The benefit of this approach is its direct pathway to
the area of interest, thus minimizing dissection of surrounding tissue. The disadvantage is the less desirable
102
Figure 7 (A) A 3-year-old child with complex bilateral orbital roof fracture from frontal trauma in a sledding accident. The child has
marked periorbital ecchymosis and conjunctival hemorrhage but no functional impairment. (B) Coronal CT of in a 3-year-old child with
bilateral orbital roof fracture (blow in) associated with frontal head trauma. (C) Same child 1 year later after only observation. (D) Coronal
CT of same child 1 year later after only observation with complete healing of bilateral orbital roof fractures.
Figure 9
103
Coronal and hemicoronal approaches
The coronal or hemicoronal scalp flaps have become
standard in neurosurgical and craniofacial surgical techniques. These approaches are able to access the entire upper
third of the face, including the nasoethmoid region, bilateral
superior orbital rim, zygoma, and temporomandibular
joints.12 With the addition of the subcranial approach developed by Raveh in 1992,13 the anterior skull base can also
be simultaneously accessed together with external facial
fractures.
The coronal incision begins with a preauricular incision
at the level of tragus and traverses the scalp 3 to 4 cm
behind the hairline to the contralateral side. The stealth
modification seems to camouflage the scalp scar better than
a straight incision (Figure 9).
The incision is carried through the galea and stops above
the calvarial periosteum (Figure 10). The subgaleal elevation is performed until approximately 2 cm above the superior orbital rims (Figure 11). The periosteum is incised at
this point, and elevation is carried forward in a subperiosteal
plane to protect the supraorbital neurovascular bundles and
preserving the pericranial flap (Figure 12). Alternatively,
the entire flap can also be raised in the subperiosteal plane
and leave the pericranial flap to be dissected out later if the
need arises. The supraorbital neurovascular bundles can be
released from their bony foramen with a small osteotome to
provide additional exposure.
Laterally, the dissection continues in the subgaleal plane
to 1 to 2 cm above the zygomatic arch, beyond the temporal
line of fusion. To protect the frontal branch of the facial
nerve, which runs within the temporoparietal fascia as it
crosses the zygomatic arch, the deep temporal fascia is
incised at this point; and the dissection continues deep to the
temporal fat pad over the temporalis muscle and investing
fascia (Figure 9 inset). Exposure of the lateral orbital wall
can be accomplished by elevating the temporalis muscle
from the greater wing of the sphenoid. Care should be given
not to interrupt deep temporal artery perforators to avoid
temporalis muscle wasting (Figure 10 inset). After fracture
repair, the deep temporal fascia should be carefully resus-
The stealth modification seems to camouflage the scalp scar better than a straight incision.
104
Figure 10
The incision is carried through the galea and stops above the calvarial periosteum.
Figure 11
Surgery
Once the supraorbital rim and orbital roof has been
exposed, the extent of reconstruction largely depends on the
severity of the injury. It is important to remember that
orbital roof fractures are a type of skull fracture and concomitant neurosurgical intervention may be necessary. In
our experience, most pediatric orbital roof fractures occur in
young children in whom the frontal sinuses have not developed. Those who have required reconstruction have had a
The subgaleal elevation is performed until approximately 2 cm above the superior orbital rims.
Figure 12
The supraorbital neurovascular bundles can be released from their bony foramen with a small osteotome to provide additional exposure.
Figure 13 (A) Axial CT of a 3-year-old patient with an orbital roof and rim fracture extending into a frontal skull fracture. (B) Surgical exposure
of a 3-year-old patient with a green stick orbital roof and rim fracture extending into a frontal skull fracture, before reduction. (C) Surgical
exposure of a 3-year-old patient with a green stick orbital roof and rim fracture extending into a frontal skull fracture, after reduction.
106
Figure 14 (A) Coronal CT of a 15-year-old child with complex outer facial frame fracture including left LeFort 3, orbital floor, lateral
wall and roof fracture extending into a frontal skull fracture. (B) Illustration from authors operative journal of 15-year-old child with
complex outer facial frame fracture before and after reconstruction with calvarial bone graft. (C) Coronal CT of 15-year-old child with
complex outer facial frame fracture after reconstruction with calvarial bone graft. (Color version of figure is available online.)
the orbital roof component as well, eliminating the necessity of further treatment.
Isolated blow-in fractures of the roof, where the bony
fragments of the roof impinge on the muscles of the superior
orbit resulting in loss of range of motion are quite uncommon. Once the fracture is exposed via a superior orbitotomy
in the subperiorbital plane, the offending bone fragments
can be either removed or teased back into position without
any need for rigid fixation. In the rare instance that the entire
roof is fragmented and there is concern about dura and brain
herniating into the orbit resulting in a traumatic encephalocele, a thin calvarial bone graft placed passively between the
superior periorbital and the shattered roof will mitigate this
possibility (Figure 14).
Comminuted orbital roof blow-out fractures will be
typically found in older children. These fractures can be
associated with frontal sinus fractures, dural tears, and frontal lobe injuries. Under these circumstances a combined
approach involving neurosurgery and the facial reconstructive surgeons is necessary. With the brain carefully retracted, the orbital roof can be rigidly reconstructed with
1-mm or 1.3-mm platting set and either the native bone
fragments or a thin calvarial bone graft secured to stable
portions of the floor of the anterior cranial fossa. The frontal
sinus can be cranialized, obliterated, or if its fracture is
favorable (lateral to the frontal recess) simply reconstructed
by rigidly stabilizing the fragments of the anterior and
posterior table. These complex injuries require long-term
follow up with annual CT scans to rule out orbital encephaloceles and frontal sinus mucoceles.
Conclusion
Pediatric orbital roof fractures are different than those of
adults. They occur more frequently due to the lack of frontal
sinus pneumatization. Children have a craniofacial ratio of
8:1 at birth, compared with 2:1 in adults, thus expose more
of their cranium and skull base to potential injuries.2 Most
orbital roof fractures can be safely observed in the acute
107
setting. Treatments should be directed by the presence of
symptoms, such as extraocular muscle entrapment, enophthalmos, exophthalmos, diplopia, vision changes or dystopia. Large fractures have a higher chance for late onset
complications; therefore surgical thresholds should be
lower. Depending on the extent and location of the orbital
roof fracture, various approaches are available to access the
area of interest. Cooperation between neurosurgery, ophthalmology, and head and neck surgery are essential to
optimize the care for these patients.
References
1. Haug RH, Van Sickles JE, Jenkins WS: Demographics and treatment
options for orbital roof fractures. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 93:238-245, 2002
2. Koltai PJ, Amjad I, Meyer D, et al: Orbital fractures in children. Arch
Otolaryngol Head Neck Surg 121:1375-1379, 1995
3. Clauser L, Dallera V, Sarti E, et al: Frontobasilar fractures in children.
Childs Nerv Syst 20:168-175, 2004
4. Greenwald MJ, Boston D, Pensler JM, et al: Orbital roof fractures in
childhood. Ophthalmology 96:491-496, 1989
5. Sullivan WG: Displaced orbital roof fractures: Presentation and treatment. Plast Reconstr Surg 87:657-61, 1991
6. Piotrowski WP, Beck-Mannagetta J: Surgical techniques in orbital
roof fractures: Early treatment in orbital roof fractures early treatment
and results. J Craniomaxillofac Surg 23:6-11, 1995
7. Messinger A, Radkowski MA, Greenwald MJ, et al: Orbital roof
fractures in the pediatric population. Plast Reconstr Surg 84:213-215,
1989
8. Smith B, Regan WF: Blowout fracture of the orbit: Mechanism and
correction of internal orbital fracture. Am J Ophthalmol 44:733, 1957
9. Foster JA, Holck DEE, Koltai PJ: Orbital fractures: Indications and
surgical techniques. Am Orthoptic Journal 54:13-23, 2004
10. Levin LA, Beck RW, Joseph MP, et al: The treatment of traumatic
optic neuropathy. Ophthalmology 106:1268-1277, 1999
11. Khan AM, Varvares MA: Traditional approaches to the orbit. Otolaryngol Clin N Am 39:895-909, 2006
12. Fritz MA, Koltai PJ: Surgical Approaches in the Management of
Facial Trauma. Management of Facial Trauma. New York, Elsevier,
2002, pp 254-260
13. Raveh JR, Laedrach K, Vuillemin T, et al: Management of combined
frontonaso-orbital/skull base fractures and telecanthus in 355 cases.
Arch Otolaryngol Head Neck Surg 118:605-614, 1992
The optimal management of symphyseal and parasymphyseal fractures continues to evolve. Fractures
in this area of the mandible predispose the patients to malocclusion and widening of the face if not
properly treated. The current understanding of the biomechanics and fracture healing of the mandible
has influenced the modern approach to the open reduction and internal fixation of these fractures. This
article will summarize the treatment approaches and the surgical caveats that will contribute to the
successful treatment of fractures of the mandibular symphysis and parasymphysis.
2008 Elsevier Inc. All rights reserved.
The treatment of symphyseal and parasymphyseal mandibular fractures has evolved significantly over the past few
years. Historically, mandibular fractures were treated with
closed reduction and a course of prolonged maxillomandibular fixation. The next phase of mandibular fracture
management involved open reduction and wire osteosynthesis. Wire osteosynthesis was subsequently supplanted as the
preferred treatment of fractures by open reduction and internal fixation with titanium hardware including lag screws
and plates. The approach to rigid plate fixation has likewise
been modified with progressively smaller plates and less
reliance on compression in the treatment of these fractures.
The work of Champy and others has allowed for reliable
fixation along lines of osteosynthesis through transoral approaches.1
Although the techniques of fracture management have
changed, the goals have not changed significantly. Accurate
reduction of the fractures, maintenance of premorbid occlusion, and early return to function are the keys to the successful management of these fractures. The technique of
fracture repair and hardware choice will depend on the
fracture pattern, fracture severity, and patient factors, such
as residual dentition, coexistent lacerations, and associated
injuries.
Indications
Fractures through the mandible at the level of the symphysis
and or parasymphysis are relatively common and account
for approximately 20% of mandibular fractures.2 These
fractures are often associated with a second fracture of the
mandible, especially in the subcondylar region.3 Most commonly, these fractures occur as the result of interpersonal
violence or motor vehicle accidents.2 Fractures of the symphyseal region are often associated with the clinical findings
of a widened intragonial distance with resultant malocclusion. It is essential for the proper management of these
patients to perform a careful preoperative examination to
diagnose and document occlusion, dental trauma, trigeminal
nerve function, lacerations, airway compromise, and associated injuries. Imaging is most commonly achieved with
multiplanar computed tomography. Panorex imaging is also
frequently used but is more likely to miss some symphyseal
fractures or associated subcondylar fractures if not carefully
analyzed.
Technique
Establishment of occlusion
Farwell
109
bars and wire loop maxillomandibular fixation are commonly used in this technique. Simple fractures may also be
managed with MMF via Ivey loops, maxillomandibular
fixation screws, or Ernst ligatures. However, care must be
taken to avoid overtightening the MMF, which can cause
flaring of the mandibular angles. If using the arch bar as the
tension band, care should be taken to ensure a solid bar
which can last for the period of fracture healing.
110
Figure 4 This diagram demonstrates the position of the lag screws and the proximity to the mental nerves. Care must be taken to avoid
injury of to those nerves during this technique. (A) Demonstrates the drilling of the glide hole through the proximal fragment.
(B) Demonstrates the placement of the drill guide through the glide hole to ensure the trajectory of the distal drill hole. (C) Demonstrates
the lag screw into position holding the fracture in correct anatomic reduction. (D) Demonstrates the trajectory of the lag screw technique
in the reduction of a symphyseal fracture. Please note that the buccal cortex drill hole must be counter synced to allow for a relative flat
position of the screw head.
Farwell
111
optimal choice to maximize the chances of stable fixation
and bone healing. With these fractures, 3 holes are desired
on each side of the affected segment for stable fixation.
Figure 5 These lines demonstrate the optimal location for osteosynthesis as describes by Champy. Plates and fixation placed in
this location allow for the optimal biomechanics for bone healing.
Plate technique
Once the fracture is reduced and the angles have been
squeezed together, plates may be applied for fixation of the
fracture. Historically, this involved a smaller monocortical
tension band along the upper mandible and a larger and
sometimes even a compression bicortical plate along the
lower border. Thanks to the work of Champy, the lines of
optimal osteosynthesis have been established (Figure 5).5
Several authors have shown that miniplate fixation along
these lines is a very effective way to fixate these fractures.6,7
The fracture is reduced with the bone reduction forceps
and manual compression of the mandibular angles to avoid
flaring. If the arch bars are going to be removed, a monocortical tension band is then applied to the upper Champy
line using a 4 to 5 hole, 2.0-mm plate, and 4- to 5-mm
screws. These short screws are used to avoid injury to the
underlying dental roots. The lower border bicortical plate is
than applied. Several authors have advocated overbending
the plate as yet another way to get accurate reduction of the
lingual cortex and overcome the tendency of the fracture to
remain splayed open (Figure 6A). The drill holes are made
adjacent to the fracture one at a time and the drill guide is
utilized to measure the thickness of the bone. The measurement allows the correct choice of screw length and the
screw is inserted. Once the holes on either side of the
fracture are filled, the remaining holes of the plate are filled
(Figure 6B). A minimum of 2 holes are needed on either
side of the fracture for stable fixation.
With severe comminution or an edentulous mandible,
larger, load-bearing hardware is required. In these circumstances, the larger locking, reconstruction plates are the
112
Discussion
Fractures of the symphysis and parasymphysis are common.
The key to successful management of these fractures is to
understand the principles of accurate reestablishment of occlusion, fracture reduction, and stable internal fixation. Newer
studies have demonstrated that appropriate placement of
smaller hardware along Champys lines of optimal osteosynthesis will result in good results in the vast majority of patients.
The demographics of mandibular trauma patients often complicate fracture management. Compliance with recommendations for soft diet and follow-up visits may be suboptimal. For
these reasons, making sure the first repair is accurate will
maximize the potential for excellent results.
References
Figure 7 This diagram demonstrates the appropriate technique
for closure. The periosteum and mentalis muscle are reapproximated first, followed by a watertight closure of the mucosa.
Complications
With any mandibular fracture repair, malocclusion, malunion, nonunion, infection, dental injury, would breakdown,
and nerve injury are possible. By using the aforementioned
techniques, one can minimize these complications. Postoperatively, the patients wounds are followed closely for
signs of breakdown, hardware exposure, inflammation that
might suggest nonunion or loose hardware, and frank infection. A postoperative panorex or computed tomography
scan is frequently obtained to confirm and document accurate reduction of the fractures. Patients should be followed
Comminuted mandible fractures generally are the result of a significant impact on a localized area of
the oromandibular complex and are defined as multiple lines of fracture in one region of the mandible.
These complex cases require careful diagnostic and radiographic workup, proper preoperative planning,
and technically excellent execution of fracture reduction and fixation. Treatment principles include
restoration of proper occlusion with maxillo-mandibular fixation, exposure and alignment of the
fracture segments, and ultimate fixation with a load-bearing locking reconstruction plate. Properly
executed rigid internal fixation is a great advance in the management of comminuted mandibular
fractures with reliable outcomes. The course of treatment is also significantly shortened and leads to
more rapid resumption of normal function.
2008 Elsevier Inc. All rights reserved.
oped elaborate techniques for maintaining the reduced fracture fragments in position during healing. Other investigators then recommended open reduction of comminuted
mandibular fractures. Bromiage3 described a technique for
open reduction with internal fixation of the comminuted
segments using a threaded Kirschner wire placed near the
inferior border via an extraoral approach. Coniglio and
Norante4 later demonstrated good results in several cases
using a modification of this technique, placing a K-wire
at the inferior border of the mandible and securing it to
the stable segments with wire. Cohen and coworkers5
discussed management of comminuted mandibular fractures by extraoral open reduction, with removal of the
comminuted segments, stripping them of soft tissue,
crushing them into chips, and then replacing them in the
wound as a free graft.
More recently, open reduction and stable internal fixation
with plates and/or screws has been advocated for comminuted fractures.6-12 The aforementioned authors suggest that
stripping some of the blood supply does not lead to increased incidence of infection as long as stabilization of the
bony fragments is achieved. Rigid fixation of the fragments
minimizes sequestration. Further, open reduction and internal fixation of these comminuted mandible fractures with
load bearing osteosynthesis allows for rapid healing and
reduces the risk of nonunion and mal-union.13 Spiessl and
Prein stressed 2 fundamental principles to obtain adequate
rigid internal fixation for comminuted mandibular frac-
114
Figure 1 (A) Axial computed tomography scan of a comminuted anterior mandible fracture. (B) Fixation of dento-alveolar segments with
wiring and arch bars. (C) Exposure of the entire fracture through a submandibular extra-oral approach before plating. (D) Simplification of
the fracture by plating larger fragments together with 2.0 miniplates with monocortical fixation. (E) Application of a load bearing 2.4 locking
reconstruction plate to bridge and fixate the entire fracture. (F) Postoperative axial computed tomography scan confirming accurate anatomic
reduction of the fracture.
tures.7,8 First, the fixation needs to support the full functional loads (load-bearing osteosynthesis). Second, absolute stability of the fracture construct must be achieved.
This is the prerequisite for sound bone healing and a low
rate of infection. These principles can be adhered to using
titanium reconstruction plates. In comminuted fractures,
the bone fragments cannot take part in the functional
load, and therefore load-sharing osteosynthesis between
implant and bone is not possible, so a load-bearing plate
must be used.
Preoperative planning
Comminution is defined as multiple lines of fracture in one
region of the mandible.9,11 The mechanism of injury should
be determined as impacts, such as gunshot wounds, can
create additional soft tissue damage and contamination than
blunt trauma.
After assessment and stabilization of any life-threatening
or critical systemic conditions, careful clinical assessment
of the oromandibular complex is mandatory. Particular at-
Futran
115
Surgical technique
Rigid fixation of the teeth and alveolar segments is performed with arch bars and MMF is established before open
reduction of the fractures (Figure 1B). Acrylic, wiring, and
lingual splinting is applicable to certain cases. Gunning type
splints may be fabricated in the edentulous setting to establish MMF. Unstable, unsalvageable teeth should be extracted. Minimal debridement of fractured bone is done to
maintain as much bone bulk as possible to avoid bone
grafting.
An extraoral approach is used in the vast majority of
cases to properly apply fixation. The fractures are exposed
through generous incisions, low in the neck. The marginal
mandibular nerve is protected and maintained in the superior flap. All mandibular fractures must be exposed before
the reduction and fixation of the fragments is done (Figure
1C). The fracture should first be simplified before application of the load bearing locking reconstruction plate. It is
essential to maintain the lingual periosteum if at all possible.
Larger fragments should be fixed first. This can be performed either with lag screws or with 1.5 or 2.0 miniplates
(Figure 1D).
The entire fracture is then completely bridged with a
locking reconstruction plate with 3 or 4 screws on either
side of the fractures (Figure 1E).14 The plate must be strong
enough to withstand the fracture and forces of the mandible
and generally the 2.4 mm size is used (Figure 2). Whenever
possible, additional screws should be placed into the thicker
comminuted fragments to stabilize them. Care must always
be taken not to use screws too close to a fracture line.
Locking reconstruction plates have the advantage over
traditional plates in that the screw heads lock to threads in
the holes of the plate. This prevents compression of the bone
which can compromise blood supply. Intimate adaptation of
the plate to the bone is not critical (Figure 2).
Meticulous closure of the tissues is necessary and drainage of the wounds indicated. Final intraoperative supervision of occlusion is compulsory. If there are not associated
maxillary fractures and the alveolar segments have good
mucosal coverage and are not mobile, maxillomandibular
fixation can be released. In many cases the lower arch bar is
left on for 2 to 4 weeks to act as a tension band and provides
enhanced stabilization of the occlusal segments. Postoperative imaging should be performed to document proper
reduction and fixation of the fractures (Figure 1F).
Special attention must be given to the condylar area since
many of these comminuted fractures are observed in combination with condylar or subcondylar fractures. Especially
when bilateral or in combination with panfacial fractures,
these fractures should be internally stabilized, if anatomically possible.
Complications
Reasons for failure are almost always the fault of the surgeon, rather than to the hardware used. It is very important
to reanalyze failures in order recognize and understand the
reason for the complication. The aim is to carry out a safe
and quick repair. To avoid nerve and tooth root damage
the plate must be placed adequately, for example, not at
the level of the mandibular nerve channel or the tooth
roots. If this is not possible, the direction of the screw
holes must be in such a way that the screw bypasses these
structures or it must be placed in a monocortical manner.
Comminution means a lack of bony support. Compression in comminuted areas is impossible and leads to dislocation of the fragments. As described previously, it is necessary at first to simplify the fracture via reduction of the
small bone pieces and fixation with small plates and screws
and to bridge the whole area thereafter with a reconstruction
plate. The screws of the reconstruction plate should not
engage the small bone pieces in the comminuted area. In
addition, repeated insertion and removal of screws is to be
avoided. Good visibility helps to avoid the positioning of a
screw in a fracture gap. Nevertheless, in oblique fractures,
the postoperative radiograph may reveal poor position of a
screw, ie, in the fracture gap, which was not realized during
the operative procedure. Therefore, it is necessary to supervise also the lingual aspect of the fracture before drilling the
screw holes.
Infection and osteomyelitis can occur and must be
treated as soon as possible. It is not advisable to manage
116
local infection with fistulation by using antibiotics. Antibiotics play only a supporting role. The reason of infection/
osteomyelitis in the majority of the cases is instability of the
fracture and loose hardware.15 Therefore, the only effective
measure to manage the situation is reoperation, cleaning of the
infected area and application of a new locking reconstruction
plate. It is important to use at least 3 screws on each side of the
fracture and they must not be placed in the infected area.
Malocclusion may be seen postoperatively as a result of
an insufficient intermaxillary fixation during surgery. Although slight occlusal interferences after open reduction and
internal fixation of mandibular fractures may eventually be
corrected by grinding the occlusal surfaces of the teeth,
serious malocclusion requires reosteosynthesis in the correct position of the fragments. Hardware fractures require
removal and in the case of instability reosteosynthesis.
Discussion
Ellis and coworkers11 had an overall complication rate of
13% in 198 comminuted fractures. Patients treated with
external pin fixation and a 35.2% complication rate compared with a 17.1% complication rate for patients undergoing closed treatment with MMF, or patients treated with
open reduction and stable internal fixation (10.3%). Smith
and Johnson9 evaluated 16 comminuted mandible fractures
treated with rigid fixation All patients fractures healed in a
bony union without bone grafting. The mean maximum
incisal opening at longest follow-up was 40 mm (range, 20
to 50 mm). All patients had a satisfactory facial form and
none required further surgery for facial recon touring or
malocclusion. Complications were observed in three patients. Two patients (13%) developed infections. The low
incidence of major complications in this group corroborates
one of the most important principles of the Arbeitgemeinshaft fur Osteosynthesefragen/Association for the Study of
Internal Fixation group, that is, susceptibility to infection is
related to mobility of the bone fragments. Lack of adequate
stabilization leads to chronic inflammation, which impairs the
normal healing process and can result in delayed union, nonunion, or infection. Multiple, displaced, and comminuted fractures are especially prone to develop such problems because of
the difficulty in obtaining sufficient immobilization of the fragments. Other important factors, however, also affect outcome.
References
1. Kazanjian VH: An outline of the treatment of extensive comminuted
fractures of the mandible. Am J Orthod Oral Surg 28:B265-B274,
1942
2. Kazanjian VH: Immobilization of wartime, compound, comminuted
fractures of the mandible. Am J Orthod Oral Surg 28:B551-B560,
1942
3. Bromige MR: Severe compound comminuted fracture of the mandible.
Br J Oral Surg 9:29-32, 1971
4. Coniglio JU, Norante JD: Augmented fixation of mandibular fractures
with a threaded Kirschner wire. Arch Otolaryngol Head Neck Surg
115:699-704, 1989
5. Cohen BM, Feig H, Freeman NC: Management of comminuted mandibular fractures: Report of case. J Oral Surg 26:537-541, 1968
6. Prein J: Manual of Internal Fixation in the Craniofacial Skeleton.
Berlin-Heidelberg, Germany, Springer-Verlag, 1998, p 57
7. Spiessl B: Internal Fixation of the Mandible. Berlin-Heidelberg, Germany, Springer-Verlag, 1989, p 235
8. Klotch D: Use of rigid internal fixation in the repair of complex and
comminuted mandible fractures. Otolaryngol Clin North Am 20:495518, 1987
9. Smith BR, Johnson JV: Rigid fixation of comminuted mandibular
fractures. J Oral Maxillofac Surg 51:1320-1326, 1993
10. Scolozzi P, Richter M: Treatment of severe mandibular fractures
using AO reconstruction plates. J Oral Maxillofac Surg 61:458-461,
2003
11. Ellis E 3rd, Muniz O, Anand K: Treatment considerations for comminuted mandibular fractures. J Oral Maxillofac Surg 61:861-870,
2003
12. Smith BR, Teenier TJ: Treatment of comminuted mandibular fractures
by open reduction and rigid internal fixation. J Oral Maxillofac Surg
54:328-331, 1996
13. Herford AS, Ellis E 3rd: Use of a locking reconstruction bone plate/
screw system for mandibular surgery. J Oral Maxillofac Surg 56:12611265, 1998
14. Haug RH: Effect of screw number on reconstruction plating. Oral Surg
Oral Med Oral Pathol 75:664-668, 1993
15. Stone IE, Dodson TB, Bays RA: Risk factors for infection following
operative treatment of mandibular fractures: A multivariate analysis.
Plast Reconstr Surg 91:64-68, 1993
Maxillary-mandibular fixation (MMF) methods are important in the surgical management of the lower
facial skeleton. Various techniques have been described to fixate these bones during treatment of facial
trauma, reconstruction, and orthognathic surgery. The utilization and technique of placement for Erich
arch bars, Ivy loops, Ernst ligatures, and fixation screws are reviewed.
2008 Elsevier Inc. All rights reserved.
Maxillarymandibular fixation (MMF) methods are important techniques to master for the otolaryngologist, plastic
surgeon, and oromaxillofacial surgeon who is caring for
patients with jaw fractures and reconstruction needs. The
concept of MMF has been used for the treatment of jaw and
dental issues for more than 2000 years. The first documented use of MMF dates to Hippocrates, who in 460 B.C.
described a closed reduction of mandible fractures via external manipulation, with gold wire placement to secure the
surrounding teeth in occlusion.1 During the course of the
last 100 years, multiple methods have been developed and
some remain in use today.
Principles
Purpose
The purpose of MMF is to immobilize the upper and lower
jaws in an occlusal relationship by securing them to each
other via one of the many accepted fixation methods. Properly applied, the fixation method will maintain the jaws in
the desired occlusive relationship. Maxillarymandibular,
or intermaxillary fixation, is used in a variety of clinical
situations, including the management of mandible and midface fractures, the maintenance of occlusion during mandible reconstruction, and the maintenance of occlusion after
118
Figure 1 Erich arch bars. (A) After the arch bar material is cut to the length of each dental arch, the bar is placed along the buccal surface
of the dental arch, lugs oriented apically. A 24- or 26-gauge wire is passed interdentally around each tooth, such that one end of the wire
is positioned occlusal and the other apical of the arch bar. (B) Each wire is twisted clockwise, thus tightening it around the tooth, apical
to the crown. (C) The twisted ends are then trimmed and then rosetted down toward the gingival, also in a clockwise direction. (D) The
patient should be placed into occlusion, and the 2 arch bars secured to each other, either with a wire loops or rubber bands. (E) Arch bars
completed.
into the desired position, or occlusion, depending on the clinical situation. (2) The arch bar material is cut to the length of
each dental arch. One should avoid extending the arch bar
beyond the last tooth to reduce soft tissue injury, or alternatively, one may bend the arch bar around the back of the last
tooth. (3) The arch bar is then secured to stable teeth using
circumdental 24- or 26-gauge wire, insuring that the lugs of the
arch bars are oriented away from the occlusal plane (apically).
A wire is placed around each tooth, such that one end of the
wire is positioned occlusal and the other apical of the arch bar
(Figure 1A). Consistency in wire placement (eg, mesial wire
always apical) may be helpful in dealing with these wires
during placement and even during the period of MMF. Each
wire is twisted clockwise, thus tightening it around the tooth,
apical to the contact point or around the base of the crown
(Figure 1B). If the jaw on which the surgeon is working
contains a fracture, it may be helpful to initially tighten the
wires on the greater segment (segment with more teeth) and
loosely place the wires on the lesser.
After all wires are in place, the fracture may be reduced
and held in reduction, while the lesser segment wires are
then tightened. This action may prevent the arch bar placement from interfering with fracture reduction. During tightening, it is important to use a wire push to insure that the
circumdental wire is set below the widest portion of the tooth
crown, to minimize wire loosening through slippage of the
wire occlusally. (4) The twisted ends are then trimmed and
then rosetted down toward the gingival, also in a clockwise
direction (Figure 1C). (5) After both dental arches are completed, the patient should be placed into occlusion, and the two
arch bars secured to each other, either with a wire loops or
rubber bands (Figure 1D and E). Erich arch bar placement may
be difficult if the patient has poor dentition, or if there are
119
Ivy loops
Ivy loops were among the earliest methods used to provide
intermaxillary fixation, but they are still frequently used
today. Ivy loops allow the patient to be placed in intermaxillary fixation and allow the stabilization of adjacent teeth to
one another. Some authors feel they have advantages that
allow them to be used in children with mixed and primary
dentition.4 Ivy loops are made and placed as follows
(Figure 2): (1) a small loop is created in a 24-gauge wire
(Figure 2A); (2) the 2 free ends are placed between 2 stable
teeth (Figure 2B); (3) the wire is wrapped around each tooth
and the wire fed back through the next dental interspace
(Figure 2C); (4) the distal wire is passed through the original loop (Figure 2D) and tightened; (5) the same procedure
is performed for the other dental arch, directly opposite the
first Ivy loop (Figure 2E); (6) the loops may each be tightened further over the wire to decrease the loop size and
length; finally, (7) a second wire should be used through the
2 opposing Ivy loops and tightened clockwise, as in Erich
arch bars (Figure 2F). Elastic bands may also be placed over
the loops if preferred.
Ernst ligatures
Ernst ligatures are another time-honored method of placing a
patient into maxillary-mandibular fixation. There are some
Figure 2 Ivy loops. (A) A small loop is created in a 24-gauge wire. (B) Both free ends are placed between 2 stable teeth. (C) The wire
is then passed around the each neighboring tooth and fed back through the next dental interspace. (D) The distal wire is passed through the
original loop. (E) The wire ends are twisted together and then the excess if cut off. The same procedure should be performed for the other
dental arch, directly opposite the first Ivy loop. Note that the loop can also be further twisted to decrease its size. (F) A second wire is placed
through the 2 opposing Ivy loops and tightened clockwise.
120
Fixation screws
This is one of the more recently introduced techniques for
the placement of patients into MMF. Several companies
now manufacture specific kits for this technique. The advantages are that it is more rapidly applied than most other
techniques. Disadvantages include that it provides no toothto-tooth stabilization within the dental arch, and there is
notable risk of tooth injury. The mental nerve and infraorbital nerves must be located and preserved with this technique. The technique is probably best applied in short-term
situations. In general, the fixation screws are placed as
follows (Figure 4): (1) the canine roots are identified on
both dental arches, with plans made to place the screws
either mesially or distally to the canine root on both dental
arches and two points that are 5 mm apical from the dental
root are identified. It should be noted that some systems
require drilling before screw placement; others are selfdrilling, self-tapping screws. Directions should be followed
for the set being used. A small cut in the mucosa at the
screw placement site may be helpful to minimize mucosa
being caught by screw threads and wrapped around the
screw as it is placed. (2) The screw should be fully inserted,
with a minimum of 2 on the maxilla and 2 on the mandible
(Figure 4B). (3) A 24-gauge wire in a loop fashion should
be placed (similar to Erich arch bars) over the screw shoulder on each opposing jaw and tightened (Figure 4C).
Some screws have through holes on the screw head,
through which the wire may also be placed. (4) Cross
wires may be placed to create force vectors that can aid
in fracture stabilization (Figure 4D). (5) If the patient
develops a posterior bite deformity when the wires are
tightened, further MMF screws, Ernst ligatures, or Ivy
loops may be used posteriorly to correct it. If predesigned
MMF screws are not available, short 2.0-mm plates can
be used by fixing the plate to the jaw with monocortical
6-mm screws. Wires may then be placed through a plate
screw hole after establishing occlusion and tightened.
Figure 3 Ernst ligatures. (A) A 24-gauge wire is placed between the canine and first premolar from a buccal to palatal direction and then
passed in a reverse direction back through the interdental space of the premolars. (B) The other end of the wire is passed behind the second
premolar in a similar fashion. (C) The second end is also passed back between the premolar interdental space, such that one end of the wire
should be on top and one below the wire loop created on the buccal side of the teeth. (D) The wire ends are then twisted tight and cut off
4 to 5 cm long. (E) Identical wire placement is performed on the opposite jaw and a similar pair on the contralateral side. (F) The ends of
these 2 matching pairs are then twisted together after placing the patient in occlusion.
121
Figure 4 Fixation screws. (A) The canine roots are identified on both dental arches. A screw is placed either mesially or distally to the
canine root and 5 mm apical from the dental root. (B) A minimum of 2 screws are secured on the maxilla and two on the mandible. (C) After
reducing the patient into desired occlusion, a 24 gauge wire is used to fashion a loop, which is placed over the screw shoulder on each
opposing jaw and tightened. (D) Cross wires may be added to create force vectors, which can aid in fracture stabilization.
Other techniques
Some attempts to make placement of MMF less traumatic
for the patient, more rapid in placement, and safer for the
surgeon (eg, reduced wire sticks) have been made. The
primary modification involved in these techniques is
the lack of circumdental wires. Bonded dental lugs and
Rapid IMF (Synthes Inc, West Chester, PA) are products
in which the maxillomandibular fixation is based on lugs
either fixed to the enamel of the teeth or by a plastic circumdental device. These techniques are likely best utilized for
short term MMF.
Splinting materials can become necessary in the edentulous mandible. These custom acrylic splints are fixed to the
mandible and then serve as a dental arch for maxillarymandibular reduction immobilization. In the setting of
trauma, the patients dentures may be used in this fashion if
they are intact after the trauma.
toothbrush and/or water pick device is not used. Caries may still
be an issue beneath the arch bars despite good care techniques.
Complications include infection, malunion, nonunion, malocclusion, periodontitis, and tooth-related problems. Many
complications are the result of an inability to achieve a stable
and appropriate occlusive relationship between the upper and
lower jaws or the inability to achieve fracture stability and
reduction. Nutritional concerns while the patient is in MMF
should be considered. Patients should be given instructions on
liquid diets and nutritional counseling to avoid malnutrition, if
MMF is to be maintained. Emesis or airway problems may
arise in the immediate postoperative period, or in a delayed
fashion. Patients who have wires between dental arches should
be provided a wire cutter on discharge, with instructions in its
use if it should be necessary, as well as instructions to keep the
cutters on them at all times. Patients in tight elastic band MMF
may benefit from carrying simple scissors to allow for rapid
removal of MMF if necessary. Some surgeons may keep a
nasogastric tube in place for a short period after MMF placement under general anesthesia, to provide gastric decompression and reduce the risk of emesis postoperatively. The nasogastric tube may also be utilized for enteral feeding if the
patient is unable to take oral nutrition. The placement of patient
122
Acknowledgments
The authors wish to thank Synthes, Inc., for their generous
donation of supplies used in the photographs for this article.
References
1. Hippocrates: Oiuvres Completes. The Loeb Classical Library. Cambridge, 1928
2. Angle E: Classification of malocclusion. Dent Cosmos 412:248-264,
350-357, 1899
3. Bruno JR, Kempers KG, Silverstein K: Treatment of traumatic mandibular nonunion. J Craniomaxillofac Trauma 5:27-32, 1999
4. Smartt JM Jr., Low DW, Bartlett SP: The pediatric mandible: II.
Management of traumatic injury or fracture. Plast Reconstr Surg 116:
28e-41e, 2005.
Fractures of the angle of the mandible are prone to complications including malocclusion and nonunion. Although a standard rigid fixation technique allowing immediate load bearing using large plates
and tension bands has a long track record, the non-rigid mono-cortical plate technique using load
sharing engineering principles popularized by Champy has gained the confidence of many surgeons.
This article describes the Champy technique in detail in contrast to the technique of load bearing
fixation.
2008 Elsevier Inc. All rights reserved.
124
Figure 1 AO technique with inferior compression plate and superior tension band. Note the holes drilled on either side of the fracture for
use of reduction forceps. (Color version of figure is available online.)
tension band just inferior to the tooth roots (see Figure 1).
The tension band may be substituted with a set of arch bars
to counteract tension along the alveolar ridge.
In practice, however, the AO technique is challenging to
perform correctly at the mandibular angle. Surgical accessibility through a transoral route may be challenging and
many surgeons prefer an external transbuccal approach,
which carries the risk of damaging the marginal branch of
the facial nerve and the possibility of infection and prominent scarring. Furthermore, when bending the compression
plate, failure to precisely coapt the plate to the outer cortex
of the mandible will create a gap on the lingual surface of
the fracture. Also, a fracture that is oriented in a sagittal
direction cannot be effectively compressed and may actually be distracted by applying a compression plate. In fact,
compression at the angle is not currently recommended at
the angle because of this factor. Finally, the thinness of the
bone at the inferior border of the angle leads to less available surface area for fragment approximation and somewhat
less toleration of fracture compression.
In the late 1970s and early 1980s, Champy and colleagues developed an internal fixation technique using only
1 or 2 monocortical plates inserted along the superior ridge
of the mandibular angle.10,11 This method was born from
the realization, through a series of elegant experiments, that
there existed ideal lines of osteosynthesis across the mandibular angle where the compressive and tensile forces from
mastication could be countered with only monocortical fixation. The plates can be applied via a transoral approach.
Maxillomandibular fixation may be applied for a short period after fixation or forgone completely.
The Champy technique offers advantages over the AO
standard method of internal fixation and is a viable option
for appropriate patients. A recent survey of the practices of
110 AO faculty members revealed that 51% usually use the
Champy technique for a simple fracture of the angle, and it is
used more commonly by more experienced surgeons.4 By
precise application of these low-profile monocortical plates,
the surgeon uses only the minimal amount of hardware necessary to fixate the fracture against predictable force patterns.
The thin plates can be easily coapted to the surface of the bone.
Champy Technique
Figure 3 Diagram depiction of Champys lines of osteosynthesis at the mandibular angle. (Reprinted with permission.20)
Champy technique
The patient is brought to the operating room and intubated
with a nasal RAE tube. The patients occlusion is first
placed into MMF. This can be achieved using either arch
bars and intermaxillary wires or four-hole fixation with
screws placed into the mandible and the maxilla at the nasal
maxillary buttress (see Figure 2).
125
126
Figure 6 A transbuccal trochar may be necessary to drill perpendicular holes in the distal fracture segment. (Color version of
figure is available online.)
Conclusion
inserted into the wound, so that the tip is lined up with the
plate holes of interest. The drill guide is then threaded
through the trochar and screwed into the miniplate screw
hole, allowing drilling to take place in the correct perpendicular trajectory. The drill guide is then removed and the
screwdriver, with 6 mm screw attached, is threaded through
the trochar to secure the screw into the newly drilled hole
(Figure 7). A second 4-hole miniplate can then be secured,
if desired, along the superior lateral border of the angle
(Figure 8).
The surgical wound is irrigated with Bacitracin irrigation. The wound is closed with 0-chromic in a running
locking fashion. No surgical drain is necessary. The IMF
wires are removed with the arch bars left in place to allow
placement of guiding elastic bands if deemed necessary in
the postoperative period. Postoperative plain films of the
mandible will demonstrate placement of the hardware and
reduction of the fracture line (Figure 9).
Champy Technique
References
1. Schierle HP, Schmelzeisen R, Rahn B, et al: One- or two-plate fixation of
mandibular angle fractures? J Craniomaxillofac Surg 25:162-168, 1997
2. Safdar N, Meechan JG: Relationship between fractures of the mandibular
angle and the presence and state of eruption of the lower third molar. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 799:680-684, 1995
3. Pape HD, Herzog M, Gerlach KC: Der Wandel der Unterkieferfrakturversorgung von 1950-1980 am Beispiel der Kelner Klinik. Dtsch
Zahnrztl Z 38:301-303, 1983
4. Gear AJL, Apasova E, Schmitz JP, et al: Treatment modalities for
mandibular angle fractures. J Oral Maxillofac Surg 63:655-663, 2005
5. Halmos DR, Ellis E 3rd, Dodson TB: Mandibular third molars and
angle fractures. J Oral Maxillofac Surg 62:1076-1081, 2004
6. Lee JT, Dodson TB: The effect of mandibular third molar presence and
position on the risk of an angle fracture. J Oral Maxillofac Surg
58:394-398, 2000
7. Assael LA: Treatment of mandibular angle fractures: Plate and screw
fixation. J Oral Maxillofac Surg 52:757-761, 1994
8. Schenk R. Biology of fracture repair, in Browner B, Jupiter JB, Levine
AM, et al (eds): Skeletal Trauma. Philadelphia, PA, Saunders, 1991,
pp 31-75
9. Prein J (ed): Manual of Internal Fixation in the Cranio-facial Skeleton.
Berlin, Springer-Verlag, 1998
127
10. Champy M, Lodd JP, Schmitt R, et al: Mandibular osteosynthesis by
miniature screwed plates via a buccal approach. J Maxillofac Surg
6:14-21, 1978
11. Worthington P, Champy M: Monocortical miniplate osteosynthesis.
Otolaryngol Clin North Am 20:607-620, 1987
12. Kroon FHM, Mathisson M, Cordey JR, et al: The use of miniplates in
mandibular fractures: An in vitro study. J Craniomaxillofac Surg
19:199-204, 1991
13. Choi BH, Yoo JH, Kim KN, et al: Stability testing of a two miniplate
fixation technique for mandibular angle fractures. An in vitro study. J
Craniomaxillofac Surg 23:123-125, 1995
14. Shetty V, McBrearty D, Fourney M, et al: Fracture line stability as a
function of the internal fixation system. An in vitro comparison using
a mandibular angle fracture model. J Oral Maxillofac Surg 53:791801, 1995
15. Gerlach KL, Pape HD, Nussbaum P: Untersuchungen zur Belastbarkeit nach der Miniplattenosteosynthese von Unterkieferfrakturen.
Dtsch Z Mund Kiefer Gesichtschir 8:363, 1984
16. Ellis E 3rd, Walker LR: Treatment of mandibular angle fractures using
one noncompression miniplate. J Oral Maxillofac Surg 54:864-871,
1996
17. Ellis E 3rd, Walker LR: Treatment of mandibular angle fractures using
two noncompression miniplates. J Oral Maxillofac Surg 52:10321036, 1994
18. Fox AJ, Kellman RM: Mandibular angle fractures: Two-miniplate
fixation and complications. Arch Facial Plast Surg 5:464-469, 2003
19. Levy FE, Smith RW, Odland RM, et al: Monocortical miniplate
fixation of mandibular angle fractures. Arch Otolaryngol Head neck
Surg 117:149-154, 1991
20. Murr AH: Operative techniques: Innovations in facial trauma. Alternative techniques of fixation for mandibular angle fractures. Oper Tech
Otolaryngol Head Neck Surg 13:273-276, 2002
Tracheostomy tube placement is a common procedure performed in patients with severe maxillofacial
trauma. Many patients that do not require emergent intubation will require an elective tracheostomy at
the time of maxillomandibular fixation and fracture repair due to oropharyngeal edema. After recovery
and decanulation, these patients often have a resulting tracheostomy scar that is hypertrophy and
discolored. The scar may be adherent (or tethered) to the underlying trachea which can be uncomfortable during swallowing. The objectives of surgical revision of a tracheostomy scar are to improve the
appearance and symptoms of tracheocutaneous tethering. A variety of standard scar revision techniques
are employed to fill the depressed scar and to separate the skin from the tracheal scar with mobilized
strap muscles or grafting material, such as cadaveric acellular dermis.
2008 Elsevier Inc. All rights reserved.
Address reprint requests and correspondence: Travis T. Tollefson, MD, FACS, Facial Plastic and Reconstructive Surgery, University
of California, Davis Medical Center, Department of Otolaryngology
Head and Neck Surgery, 2521 Stockton Blvd, Suite 7200, Sacramento,
CA 95817.
E-mail address: travis.tollefson@yahoo.com.
1043-1810/$ -see front matter 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.otot.2008.04.002
Surgical technique
A modification of the surgical technique described by
Lewin and Keunen may be used.1 The tracheostomy scar is
incised in an ellipse, and then, de-epithelialized (Figure 1).
The surrounding skin is circumferentially undermined for 2
to 3 cm. Bilateral sternohyoid and sternothyroid muscles are
mobilized both superior and inferior to the scar. The deepithelialized scars are then imbricated to fill in the depression. The strap muscles are approximated in the midline
with three interrupted, absorbable sutures (Figure 2). In
severely depressed scars or recalcitrant tracheocutaneous
tethering cases, acellular human dermis may be used. A
sheet of 0.045- to 0.070-inch thick Alloderm (Lifecell
Corp, Branchburg, NJ) is soaked in saline, cut to fit the
exposed area, and secured over the midline strap muscles
(Figure 3). The skin is then closed in 2 layers with 5-0
polydiaxone for the dermal closure and 6-0 nylon suture or
topical skin glue.
Postoperative care
Using these local tissue transfer techniques, successful
resolution of tracheocutaneous tethering and improved
scar appearance can be seen (Figure 4). The authors have
Tollefson et al
129
bilization of the sternal heads of the sternocleidomastoid
to fill depression in the suprasternal notch (Figure 5).3
Lewin and Keunen modified Poulards procedure by suggesting a de-epithelialization of the scar with dermabrasion and rolling the deep scar into a tube with sutures to
compensate for scar depression (see Figure 1).1 In 1972,
Kulber and Passy suggested medializing the strap muscles and emphasized that the intact muscle fascia would
help prevent tracheocutaneous adhesions (see Figure 2).
This technique not only added fullness to the depressed
scar, but also separated the tracheal from the more superficial scar.4 Standard camouflage techniques that reorient the scar, such as Z-plasty, have been suggested.5
However, this does not address the tracheocutaneous
tethering.
Since the introduction as a grafting material, the safety
and applicability of acellular human dermis has been examined in a variety of surgical areas. In 1999, reports of the
successful use of lyophilized dura in tracheostomy scar
revision stimulated our consideration of using acellular human dermis as an alternative interpositional material.6,7
Acellular human dermis (Alloderm, Lifecell Corp, Branch-
Figure 1 An illustration of the tracheostomy scar revision technique described by Lewen and Keunen is shown. (A) The scar is
incised with an ellipse. (B) The scar is de-epithelialized. (C) Imbrication of the scar edges with suture adds tissue volume to the scar
depression.1 (D) Sutured deep closure of imbricated flaps. (Color
version of figure is available online.)
Discussion
The authors preferred tracheostomy scar revision techniques are a combination of several traditional techniques. The first description of the correction of depressed scars was in 1918 by Poulard, who described the
de-epithelization of the cicatricial island after incision
around the scar, mobilization of surrounding skin flaps,
and skin closure.2 In 1961, Pressman recommended mo-
130
Tollefson et al
131
separating the skin from the tracheal scar with strap
muscle or grafting material. The criteria for grafting
material have not been established and will require further comparative studies.
References
Conclusions
Patients with disfiguring tracheostomy scars can be treated
with traditional scar revision techniques. The surgeon must
not only be attentive to improving the scar appearance but
also to treatment of the tracheocutaneous tethering by
1. Lewin ML, Keunen HF: Revision of the posttracheotomy scar. Correction of the depressed, retracted scar. Arch Otolaryngol 91:395-397,
1970
2. Poulard A: Traitement de cicatrices faciales. Presse Med 26:221-225,
1918
3. Pressman JJ: The repair of depressed tracheotomy scars. Arch Otolaryngol 74:150-152, 1961
4. Kulber H, Passy V: Tracheostomy closure and scar revisions. Arch
Otolaryngol 96:22-26, 1972
5. Vecchione TR, Pickering PP: The subcutaneous Z-plasty. Case report.
Plast Reconstr Surg 56:579-580, 1975
6. Carlson ER, Marx RE, Jones GM: Tracheostomy scar revision using
allogenic dura. J Oral Maxillofac Surg 49:315-318, 1991
7. Skigen AL, Bedrock R, Stopperich PS: Correction of the depressed,
retracted, post-tracheostomy scar. Plast Reconstr Surg 103:1703-1705,
1999
8. Wainwright DJ: Use of an acellular allograft dermal matrix (AlloDerm) in
the management of full-thickness burns. Burns 21:243-248, 1995
9. Fisher E, Frodel JL: Facial suspension with acellular human dermal
allograft. Arch Facial Plast Surg 1:195-199, 1999
10. Sinha UK, Saadat D, Doherty CM, et al: Use of Alloderm implant to
prevent Frey Syndrome after parotidectomy. Arch Facial Plast Surg
5:109-112, 2003
11. Kridel RW, Foda H, Lunde KC: Septal perforation repair with acellular human dermal allograft. Arch Otolaryngol Head Neck Surg
124:73-78, 1998
12. Clark JM, Saffold SH, Israel JM: Decellularized dermal grafting in
cleft palate repair. Arch Facial Plast Surg 5:40-44, 2003
13. Abenavoli FM, Giordano L: Other uses of Alloderm: Case reports.
Ann Plast Surg 46:354-355, 2001
14. Lu V, Johnson MA: Tracheostomy scar revision using acellular dermal
matrix allograft. Plast Reconst Surg 113:2217-2219, 2004
Orbital injuries can only be treated most effectively, aesthetically, and safely when the surgeons armamentarium includes all contemporary orbital approaches. The lateral orbit, orbital floor, and medial orbit are
useful anatomic divisions that are each exposed best through distinct approaches. Lateral brow, upper
blepharoplasty, and coronal approaches provide access to the lateral orbit. The orbital floor is accessible
through subciliary, subtarsal, transconjunctival, or transantral approaches. Lynch, transcaruncular, transnasal, and coronal approaches are useful for medial orbital exposure. When the surgeon utilizes these
approaches appropriately with meticulous surgical technique and close postoperative observation for rare
potential complications, excellent outcomes can be achieved following orbital trauma.
2008 Elsevier Inc. All rights reserved.
Orbital injuries frequently require surgical treatment. Zygomaticomaxillary, nasoorbitalethmoid, orbital rim, and
blow-out fractures are among the injuries requiring intervention. Modern approaches are safe and esthetically acceptable when performed properly. Selecting the most appropriate surgical approach will optimize exposure and
increase the likelihood of successful treatment.
Immediate intervention in the treatment of orbital floor
fractures is indicated only when orbital soft-tissue entrapment
is associated with the oculocardiac reflex. This situation is
most commonly observed in younger patients with a closed
trap-door fracture. Most orbital fractures can be repaired within
2 weeks when edema has resolved adequately but significant
fibrosis has not yet developed.1 We obtain ophthalmology
consultation after complex orbital trauma and if any ocular
injury is suspected before surgical intervention. Evidence of
hyphema or ocular rupture should delay internal orbital approaches until these injuries can be addressed by an ophthalmologist and surgically treated if necessary.2
Relevant anatomy
The orbital skeleton contains contributions from the lacrimal,
maxillary, zygomatic, greater and lesser wings of the sphenoid,
frontal, and ethmoid bones. Locations of the optic foramen, ethAddress reprint requests and correspondence: J. David Kriet, MD,
Department of Otolaryngology, Eaton Hall, Mail Stop 3010, 3901 Rainbow
Boulevard, Kansas City, KS 66160-7380.
E-mail address: DKriet@kumc.edu.
1043-1810/$ -see front matter 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.otot.2008.07.002
133
Figure 3 The brow incision is placed within or just below the hair
follicles of the lateral 2 to 3 cm of the eyebrow. An upper blepharoplasty incision is placed in the lateral one third to one half of the
supratarsal fold and can be extended as necessary, following a horizontal crease above the lateral canthus. (Reprinted with permission.6)
Figure 2 Lower eyelid components include skin, orbicularis, oculi, tarsal plate, conjunctiva, and orbital septum (A). Upper eyelid
components include skin, orbicularis oculi, levator palpebral superioris aponeurosis, Mller muscle, tarsal plate, conjunctiva, and orbital
septum (B). C, palpebral conjunctiva; IO, inferior oblique muscle; IR, inferior rectus muscle; LA, levator palpebral susperioris aponeurosis;
MM, Mller muscle, OO, orbicularis muscle; OS, orbital septum; P, periosteum/periorbita; TP, tarsal plate. (Reprinted with permission.3)
(Color version of figure is available online.)
134
Coronal approach
The coronal approach is a workhorse for craniomaxillofacial surgery and can be used for broad access to the
medial, superior, and lateral orbit as well as the zygomatic
arch. Access to the lateral aspect of the infraorbital rims is
also possible by extending the incision along the preauricular creases. The coronal approach has been well-described
in the literature. For further reading, Frodel and Marantette8
provide an excellent discussion of anatomical considerations and surgical technique for this approach.
The primary advantage of the coronal flap is broad exposure and access to both orbits and the nasal skeleton that
is unparalleled by any other approach. Disadvantages include incision length, extensive dissection, and potential
morbidity including alopecia, forehead numbness, and injury to the temporal branch of the facial nerve.
Upper blepharoplasty
For the upper blepharoplasty approach, the supratarsal
fold is marked (typically 7-9 mm above the ciliary line). The
incision is extended within the fold and horizontally beyond
the lateral canthus in a skin crease as needed for exposure
(Figure 3). Local anesthetic with epinephrine is injected
subcutaneously and down to the lateral orbital rim at the
zygomaticofrontal suture. The skin is incised and scissors or
a Colorado dissector can then be used to traverse the orbicularis oculi, dividing the muscle parallel to the fibers. Dissection then proceeds to the lateral orbital rim and zygomaticofrontal suture in a plane superficial to the orbital
septum and lacrimal gland. The periosteum is elevated over
the rim and zygomaticofrontal suture as needed. If neces-
Figure 5 Paths traversed by the subciliary and subtarsal approaches through the lower eyelid are shown. It is important to step
the incisions as shown to preserve lid integrity and avoid scar
inversion.
For the subciliary and subtarsal approaches, local anesthetic with epinephrine is infiltrated subcutaneously in the
lower eyelid and along the inferior orbital rim. A lateral
temporary tarsorrhaphy is performed on the operative eye
for protection and retraction. The subciliary cutaneous incision is made 2 mm below and parallel to the lash line with
the use of a #15 blade (Figure 5). The incision should be
carried no further medially than the lower lid punctum.
Laterally, the incision can be extended up to 15 mm beyond
the lateral canthus. If this lateral extension is performed, it
should be directed horizontally and not inferiorly to promote an esthetically acceptable scar. A subcutaneous dissection superficial to the orbicularis oculi is followed inferiorly by the surgeon using either sharp dissection or the
Colorado dissector until just inferior to the tarsal plate
where the orbicularis is divided parallel to its fibers. It is
crucial to preserve this rim of orbicularis over the tarsal
plate to maintain lower lid structure and support. A preseptal plane is then followed down to the orbital rim. The
periosteum is incised on the anterior aspect of the inferior
orbital rim and elevation proceeds posteriorly onto the orbital floor using a Freer elevator. For the subtarsal variation
of this approach, the skin incision is made in the subtarsal
fold or 5 to 7 mm below the lash line when the fold is
obscured by edema (Figure 5). The orbicularis oculi is
divided a few millimeters below the level of the skin incision to discourage scar inversion. For either approach, closure is performed by the surgeon reapproximating the skin
with a running 6-0 polypropylene or fast absorbing gut
suture. A Frost suture is sometimes used to support the lid
in the early postoperative period.
Advantages to the subciliary and subtarsal approaches
are that they are easy to learn and offer broad access to the
orbital floor. Disadvantages are greater rates of postoperative lower lid malposition and visible scarring when compared with the transconjunctival approach.10,11 Technique
in a transcutaneous lower lid approach must be flawless to
minimize the risk of scleral show and ectropion. Rohrich et
al12 argue that the subtarsal variation of this approach produces less risk of vertical lid shortening, scleral show, and
ectropion but slightly greater risk of visible scarring. Innervation to the pretarsal and much of the preseptal orbicularis
is better preserved through the subtarsal variant which may
help maintain the preoperative lower lid position.
Transconjunctival approach
Bourquett first described the inferior fornix conjunctival
or transconjunctival approach for blepharoplasty in 1924.13
Tenzel and Miller later used this approach in the 1970s for
the repair of orbital floor defects.14 Exposure of most of the
orbital floor can be achieved through the transconjunctival
approach.
Local anesthetic with epinephrine is infiltrated at the
lateral canthus, just under the conjunctiva of the lower lid,
and transcutaneously down to the orbital rim. Lateral canthotomy and cantholysis using a curved iris scissor is optional for greater retraction and exposure. If the canthal
release is not performed, great care must be taken to avoid
excessive retraction or abrasion of the tarsal plate mucosa as
these conditions are associated with a higher incidence of
135
136
Figure 7 A Davida malleable neurosurgical retractor (Flexbar Machine Corporation, Islandia, NY) is positioned to retract the ipsilateral
cheek (A). A 10- by 20-mm defect is then created in the anterior wall of the maxillary sinus for access to the orbital floor. As shown, the
medial buttress, lateral buttress, and inferior orbital rim remain intact (B). (Color version of figure is available online.)
The advantages of this approach include no visible scarring and decreased risk of ectropion when compared with
the subciliary approach.10,11 Although the continually protruding periorbital fat can be an annoyance, a theoretical
advantage of the postseptal technique is decreased incidence
of postoperative lower lid malposition since the plane between the orbicularis oculi and orbital septum is not violated.
Transantral approach
Farwell and Strong have described the endoscopically
assisted transantral approach to orbital floor fractures.15 The
approach may be used as an isolated technique or combined
with a more traditional approach to assist in fracture visualization and reduction.
Local anesthetic with epinephrine is injected in the maxillary gingivolabial sulcus. An incision is made in the sulcus
using cautery while preserving a 4- to 5-mm cuff of mucosa
on the gingival side for closure. The periosteum is incised
on the maxilla. A Longenbeck retractor should be used to
Transcaruncular approach
The transcaruncular approach was first described by
Shorr et al.17 It allows access to the entire medial orbital
wall posterior to the lacrimal fossa. Local anesthetic with
epinephrine is injected transcutaneously down to the medial
orbital rim. The injection to the caruncle should be minimized to avoid distortion of the tissue planes. A Colorado
dissector to is used to make a 12- to 15-mm incision either
through or just posterior to the caruncle and anterior to the
semilunar fold (Figure 10). The upper and lower lids are
137
Transnasal approach
Rhee and Chen18 have described using a transnasal approach to either place stenting material between the middle
turbinate and a medial orbital defect or in conjunction with a
transcaruncular or transconjunctival approach to facilitate precise placement of an implant for medial orbital wall reconstruction.
138
Coronal approach
The coronal approach has already been discussed and is
useful when broad access to both the nasal bones and
bilateral medial orbital walls is needed for repair of nasoorbitalethmoid fractures.
Postoperative care
Figure 11 The transcaruncular approach follows a plane immediately posterior to Horners muscle down to the periosteum of the
medial orbital wall posterior to both the canthal attachments and
lacrimal apparatus (A). Periosteal elevation can then proceed without disturbing these structures (B). (Reprinted with permission.17)
The nose is decongested using oxymetazoline on cottonoid pledgets. A 4-mm 0-degree endoscope is advanced into
the nasal cavity. The middle turbinate is gently medialized
with a Frazier suction or blunt tipped right angle probe to
visualize the uncinate process. Local anesthetic with epinephrine is injected along the uncinate process. A Kerrison
rongeur is then used by the surgeon to remove the uncinate,
be examined by a physician for evidence of increased intraocular pressure. A determination can then be made
whether intervention or further observation is warranted.
Gauze pads soaked in an ice water bath should be applied
to the operative eye for 36 to 48 hours after surgery to
decrease swelling and promote vasoconstriction. Tobramycin and dexamethasone ointment is applied to the eye twice
daily for one week to maintain lubrication and decrease
inflammation.
Complications
139
cisions or thermal cautery injury may damage the tarsal
plate and increase the risk of entropion and scleral show.
There is also potential for symblepharon, or scar formation
between the tarsal and bulbar conjunctival surfaces. A theoretical and controversial increased risk of lower lid malposition exists using a preseptal rather than a postseptal
approach because of scar which may form between the
orbital septum and orbicularis oculi following a preseptal
dissection. Some cases of postoperative ectropion and entropion are transient and will resolve with massage and
observation over a few weeks. If persistent, surgery including lower lid tightening in conjunction with other procedures may be required for correction.
Diplopia
Diplopia may be the most common complication after
surgical approaches for orbital trauma. In many cases, it is
preexisting and will persist because of unilateral posttraumatic and postoperative swelling. Forced duction testing
with good ocular mobility in the operating suite at the
conclusion of the procedure can give the surgeon confidence
that there is no persistent entrapment or adherence of orbital
contents to the implant. In cases of entrapped rectus muscles
which have been released, recovery of function can take
many months and may not be complete. If the diplopia is
persistent and bothersome to the patient, referral to ophthalmology is indicated for evaluation and treatment.
Vision loss
Vision loss can occur with direct injury to the optic nerve
or its vascular supply. Intraoperative mydriasis is a sign of
pressure on the ciliary ganglion located 1 cm anterior to the
annulus of Zinn between the lateral rectus and optic nerve.
When mydriasis develops, it should serve as a warning that
excess pressure is being applied to the intraorbital contents
but is not a direct indication that the optic nerve has been
damaged. Postoperative hemorrhage can result in blindness
if not treated immediately. If the patient develops visual
changes, such as decreased color discrimination or loss of
acuity associated with increased intraocular pressure and
proptosis, retroorbital hematoma must be suspected. Canthotomy and cantholysis should be performed immediately at
the bedside to decrease intraocular pressure. Wound exploration, removal of the implant, and hematoma evacuation in the
operating room are also indicated. Immediate ophthalmology
consultation should be obtained in any case of decreasing
visual acuity but should not delay initial treatment.
Lid malposition
Lower lid malposition in the form of shortening or ectropion is a complication that develops at least temporarily
in 28% to 42% of transcutaneous approaches to the orbital
floor.10,11 In transconjunctival approaches, the combined
incidence of ectropion, entropion, and scleral show has been
reported at less than 0.5%.19,20 Misplaced conjunctival in-
References
1. Burnstine MA: Clinical recommendations for repair of orbital facial
fractures. Curr Opin Ophthalmol 14:236-240, 2003
2. Holt JE, Holt R, Blodgett JM: Ocular injuries sustained during blunt
facial trauma. Ophthalmology 90:14-18, 1983
3. Ellis E, Zide MF: Surgical Approaches to the Facial Skeleton (ed 2).
Baltimore, Lippincott Williams and Wilkins, 2006
4. Larrabee WF, Makielski KH: Surgical Anatomy of the Face. New
York, Raven, 1993
5. Zide BM: Surgical Anatomy Around the Orbit. Philadelphia, Lippincott Williams and Wilkins, 2006
6. Kung DS, Kaban LB: Supratarsal fold incision for approach to the
superior lateral orbit. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 81:522-525, 1996
7. Rega AJ, Ziccardi VB, Granick M: Cosmetically favorable scars using
the upper blepharoplasty incision. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 98:627-628, 2004
8. Frodel JL, Marentette LJ: The coronal approach: Anatomic and technical considerations and morbidity. Arch Otolaryngol Head Neck Surg
119:201-207, 1993
9. Converse J: Two plastic operations for repair of orbit following severe trauma
and extensive comminuted fracture. Arch Ophthalmol 31:323, 1944
10. Appling WD, Patrinely JR, Salzer TA: Transconjunctival approach vs
subciliary skin-muscle flap approach for orbital fracture repair. Arch
Otolaryngol Head Neck Surg 119:1000-1007, 1993
11. Wray RC Jr, Holtmann B, Ribaudo JM, et al: A comparison of
conjunctival and subcilliary incisions for orbital fracture. Br J Plast
Surg 30:142-145, 1977
12. Rohrich RJ, Janis JE, Adams WP Jr: Subciliary versus subtarsal
approaches to orbitozygomatic fractures. Plast Reconstr Surg 111:
1708-1713, 2003
13. Tessier P: The conjunctival approach to the orbital floor and maxilla in
congenital malformation and trauma. J Maxillofac Surg 1:3-8, 1973
14. Tenzel RR, Miller GR: Orbital blow-out fracture repair, a conjunctival
approach. Am J Opthalmol 71:1141-1142, 1971
15. Farwell DG, Strong EB: Endoscopic repair of orbital floor fractures.
Facial Plastic Surg Clin N Am 14:11-16, 2006
16. Lynch RC: The technique of a radical frontal sinus operation which
has given me the best results. Laryngoscope 31:1-5, 1921
17. Shorr N, Baylis HI, Goldberg RA, et al: Transcaruncular approach to the
medial orbit and orbital apex. Ophthalmology 107:1459-1463, 2000
18. Rhee JS, Chen CT: Endoscopic approach to medial orbital wall fractures. Facial Plastic Surg Clin N Am 14:17-23, 2006
19. Westfall CT, Shore JW, Nunery WR, et al: Operative complications of
the transconjunctival inferior fornix approach. Ophthalmology 98:
1525-1528, 1991
20. Mullins JB, Holds JB, Branham GH, et al: Complications of the
transconjunctival approach: A review of 400 cases. Arch Otolaryngol
Head Neck Surg 123:385-388, 1997
Naso-orbito-ethmoid fractures involve injury to the central mid-face, resulting in significant cosmetic
and functional deformities. Management of this fracture is considered one of the most challenging
because diagnosis may be difficult and surgical outcomes can be variable. In this article, we present our
surgical approach for repairing this challenging injury. We have developed and refined our technique
during the past decade while repairing central mid-face defects secondary to trauma or anterior skull
base tumor ablation.
2008 Elsevier Inc. All rights reserved.
Technique
The technique we use to repair NOE fractures has been
developed during the past decade as the result of repairing
Shibuya et al
141
calvarial bone graft harvesting. For most type III NOE
fractures, we commonly performed a coronal incision. Thru
the coronal approach, the dissection is carried all the way
down over the nasal dorsum, exposing the medial, superior
and lateral orbital walls. Dissecting into the orbital surface
1 to 2 cm is necessary to allow mobilization of the soft
tissue. Frequently ligation of the anterior ethmoid artery is
necessary. The severity of the medial orbital wall(s) and
nasal dorsum injuries are then assessed.
1. If the medial orbital wall is completely missing, a split
calvarial bone graft is harvested and shaped to create a
new medial orbital wall. Titanium mesh may also be
used as a substitute, preferably with some bone graft or
fragments attached to the mesh. The bone, mesh, or
bone/mesh is then used to reconstruct a new medial
orbital wall.
2. If there is a significant nasal deformity, a bone graft is
harvested from the calvarium, and it is cantilever
grafted to create a new nasal dorsum. An open rhinoplasty approach is used to position the bone graft into
proper position and length. If necessary, a columellar
bone strut is placed between the lower lateral cartilages
to help stabilize the graft into proper position.
3. Additionally, 2 holes will be drilled into the bone or
selected in the mesh for placement of 28-gauge wires to
reattach the medial canthal tendon. The position on the
new medial orbital wall is selected that would simulate
the position of the lacrimal bone, because this is the
normal location where the medial canthal tendons insert. For bilateral injuries, the holes are drilled into both
new medial orbital walls.
Unilateral injury
In cases of unilateral injury, the following steps should
be taken:
4. After the medial orbital wall is reconstructed, two 28gauge wires, 8 to 10 inches in length, are passed
through the preselected holes (Figure 2).
5. The wires are then grasped in the nose with the use of
a nasal speculum and bayonet forceps.
6. The wires are the twisted together to form a tight bond,
which is cut and bent to hide the sharp edge (Figure 2).
7. An 18-gauge needle is passed from the skin surface
(external) above and below the medial canthal tendon,
through the skin and soft tissue to the bone of the
medial orbital wall. The superior wire is passed through
the needle superior to the medial canthal tendon and the
inferior wire is passed through the needle inferior to
the medial canthal tendon (Figure 3).
8. The wire is pulled in a lateral direction (toward the
lateral orbital wall), so that the twisted nasal side of
wire is seated on the medial (nasal) surface of the
medial orbital wall (Figure 4).
9. A 15 blade is used to make an incision between the 2
wires.
10. Mosquito forceps are used to bluntly dissect, in a horizontal direction, down through the soft tissue to identify the medial canthal tendon.
142
Bilateral repair
11. Skin hooks and Ragnell retractors are used to retract the
soft tissue around the medial canthal tendon and medial
canthal tendon is pushed into the bone with a Freer
elevator.
12. The 28-gauge wire is twisted down to seat the medial
canthal tendon into its position on the medial orbital
wall. Now, the tendon has been reinserted onto the new
medial orbital wall (Figure 4).
13. The incision on the medial orbital skin is closed with a
6-0 fast absorbing gut suture (Figure 4).
Shibuya et al
143
Discussion
Figure 6 Wires are passed through the soft tissue via 18-gauge
needles, placed above and below the medial canthus tendon. This
step is performed on both sides.
144
References
1. Paskert JP, Manson PN, Iliff NT: Nasoethmoidal and orbital fractures.
Clin Plast Surg 15:209-223, 1988
2. Paskert JP, Manson PN: The bimanual examination for assessing instability in naso-orbitoethmoidal injuries. Plast Reconstr Surg 83:165-167,
1989
3. Furnas DW, Bircoll MJ: Eyelash traction test to determine if the medial
canthal ligament is detached. Plast Reconstr Surg 52:315-317, 1973
4. Ellis E 3rd: Sequencing treatment for naso-orbital-ethmoid fractures.
J Oral Maxillofac Surg 51:543-558, 1993
5. Markowitz BL, Manson PN, Sargent L, et al: Management of the medial
canthal tendon in nasoeithmoid orbital fractures: The importance of the
central fragment in classification and treatment. Plast Reconstr Surg
87:843-853, 1991
6. Meleca RJ, Mathog RH: Diagnosis and treatment of naso-orbital fractures, in Mathog RH, Arden RL, Marks SC (eds): Trauma of the Nose
and Paranasal Sinuses. New York, Thieme Med Pub, 1995. pp 65-98
7. Jackson IT: Classification and treatment of orbitozygomatic and orbitoethmoid fractures. Clin Plast Surg 16:77-91, 1989
8. Grass JS: Naso-ethmoid-orbital fractures: Classification and role of
primary bone grafting. Plast Reconstr Surg 75:303-317, 1985
9. Duvall AJ, Banovetz JD: Nasoethmoidal fractures. Otolaryngol Clin
North Am 9:506-515, 1976
Soft tissue trauma to the head and neck is most often managed by local tissue debridement and
rearrangement. In rare instances it may require free tissue transfer to bring composite tissue into the
field. In cases of massive composite tissue loss, a free tissue transfer may be the only method of
reconstructing the patient. Traumatic injuries to the head and neck can be one of those instances that
requires major tissue rearrangement. The loss of vital structures results in severe malfunction of speech
and deglutition with cosmetic sequelae. This article demonstrates the utility of free tissue transfer in the
reconstruction of massive composite defects in the head and neck following trauma.
2008 Elsevier Inc. All rights reserved.
146
Imaging
An angiogram or computed tomography (CT) angiogram is
used to evaluate the vascular system to facilitate a diagnosis
of vascular injury. This diagnosis will impact decisions
about vessel availability for the microvascular reconstruction. The incidence of major vascular injury in facial gunshot wounds is 10% to 50%, depending on the entry site,
and the indications for angiographic evaluation can be
found in a number of references.6-10 CT and magnetic resonance imaging evaluation is also necessary to evaluate
more urgent life-threatening neurovascular or concomitant
tissue injuries during Phase 1.
Stereolithography
Figure 1 This 3-dimensional CT scan reconstruction demonstrates a bony-soft tissue defect of the mandible lesion. (Color
version of figure is available online.)
Pedicled myocutaneous flaps are reliable for both coverage and volume. However, they are bulky flaps tht have
poor contourability, have a limited vascular pedicle length,
and are unreliable for the bony reconstruction that often
accompanies these defects.
The arrival of free tissue transfer has allowed reconstructive surgeons to reconstruct composite tissue defects with
similar composite tissue.3 This reconstructive paradigm was
first described for mucosal disease in the head and neck, and
this experience can be translated and transposed to reconstruction of large defects of the integumentary system. As
time has gone on, surgeons have been able to replace and
match the tissue characteristics for both its composition (ie,
bony, soft tissue, cartilaginous) and its volume. The ability
to bring well-vascularized bone and soft tissue into a hostile
wound environment with excellent survival allows for rapid
replacement of the lost structures. Neuroanastomosis with
reinnervation of the tissue that is being transferred allows
restoration of sensation. The ability to restore muscular
function may be more problematic.
Comprehensive management of severe facial trauma is
facilitated by a phased approach, within which definitive
free tissue transfer reconstruction of the anatomic defect is
incorporated. These are: Phase 1, initial encounter; Phase 2,
definitive reconstruction; and Phase 3, esthetic and prosthetic refinement.4,5
Phase 1 involves the golden hour of resuscitation (ie,
ABCs), stabilization, debridement, and closure by trauma
services. Neurosurgical consultation and clearance may be
necessary. These injuries often result in bony injuries or
defects that will require stabilization. Stabilization during
this initial phase is critical to prevent collapse of the remaining facial soft tissue. Phase 2 involves the essential
phase of reconstruction of soft tissue that can happen a few
weeks after Phase 1. This is followed by Phase 3, which can
last months to several years.
Nadig et al
147
time, enhance physician communication, patient information, and consequently improve patient outcomes (Figure 2).
Antibiotics
The wound environment after a severe open facial injury is
hostile. The defect may be contaminated with oral or sinonasal secretions or foreign material and frequently contain nonviable soft tissue and bone. It has been reported that
close-range shotgun injuries to the face cause infection
100% of the time.10 Important treatment steps include the
following:
148
Figure 4 This schematic demonstrates reconstruction of loss of parts of the lower and upper lip. (A) The defect consists of complete loss
of one commissure. A significant soft-tissue defect of the upper and lower lips is present. (B) The Palmaris longus tendon has been connected
to the remaining orbicularis oris muscle of the upper and lower lip. The forearm tissue is draped over the tendon to create inner and outer
lining. (C) The final result is a rounded commissure that will require revision. Oral competence is maintained.
Figure 5 Reconstruction of a floor of mouth and internal lip defect. This patient suffered a gunshot injury to the face that destroyed the
floor of mouth, ventral tongue, and buccal mucosa. (A) Initial management was with debridement and primary closure. The bone has healed
and the tongue is tethered to the lower lip. (B) The lip has been released from the lower lip and a sulcus created. (C) A radial forearm flap
has been inset into the defect to recreate the lower lip buccal mucosa, floor of mouth. This allows for better mobility of the tongue
(articulation, swallowing) and the formation of a gingival buccal sulcas (deglutition, dental rehabilitation).
Nadig et al
149
Figure 6 Reconstruction of nasal defect. This patient suffered a gunshot injury to the face that destroyed the full thickness (all 3 layers)
of the nose. (A) This rendition demonstrates total loss of the nose. (B) Reconstruction of the Inner, middle and outer lining of the nose is
required. The radial forearm flap is used to reconstruct the interior lining. Cartilage for the middle lamella and a forehead flap for the outer
layer.
Complications
Complications can be functional or esthetic. The most frequent esthetic complications include poor nasal projection
and shape, traumatic telecanthus, apparent asymmetry of the
position of the eyes, unsatisfactory facial contour due to
underlying bone or overlying soft tissue bulk, and poor
color match to surrounding tissue.
Functional complications of the flap include vascular
failure, infection, impairment of vision, mastication, oral
competence, speech, or swallowing. Vascular failure is not
common in skilled hands with a recent review of our series
with a 96% success rate and return to the operating room for
potential vascular compromise at a rate of 5%. An aggressive approach to flap management and care to create a
generous tunnel into the neck ensures that the pedicle is not
compressed and remains tension free. Mucosal and flap
closures in the floor of the mouth must be watertight. If
infection does occur in the neck, prompt drainage and diversion away from the vascular pedicle should be undertaken. If the vascular pedicle is exposed to the infection, it
should be covered with a pectoralis myofascial flap. Gunshot wounds lead to progressive extensive soft tissue damage, which can increase the risk of vessel thrombosis, particularly venous, if free tissue transfer reconstruction is
performed too early. The incidence of wound healing complications from even low energy gunshot wounds that traverse the oral cavity is 39%.14 In suspect cases, returning to
the operating room after reconstruction for wound irrigation
reduced the risk of free flap compromise and potential loss.
Revision
Revisions and secondary operations are often necessary;
Motamedi14 reported a 48% rate for his patients in the
Conclusion
The advent of early free tissue transfer has widely expanded
the capabilities of the reconstructive surgeon to recreate
acceptable form and function following extensive tissue loss
(Phase I). Selection of a flap for reconstruction is dependent
on the characteristics of both the donor and the recipient
sites, and should be individually tailored to suit each case.
The advantages of each flap are weighed against potential
morbidity, and ultimately, a flap is chosen based on its
overall suitability for reconstruction of the recipient site.
Detailed knowledge of reconstructive options enables the
surgeon to select an appropriate reconstructive modality that
will achieve an acceptable functional and esthetic outcome
for each patient (Phase III).
References
1. Thorne CH: Gunshot wounds to the face. Current concepts. Clin Plast
Surg 19:233-244, 1992
2. Clark N, Birely B, Manson PN, et al: High-energy ballistic and
avulsive facial injuries: Classification, patterns, and an algorithm for
primary reconstruction. Plast Reconstr Surg 98:583-601, 1996
3. Funk GF, Laurenzo JF, Valentino J, et al: Free-tissue transfer reconstruction of midfacial and cranio-orbito-facial defects. Arch Otolaryngol Head Neck Surg 121:293-303, 1995
150
The majority of frontal sinus fractures are the result of high-velocity injuries, such as motor vehicle
accidents, assaults, and sporting events. Patients often have associated injuries. The initial evaluation
should focus on airway control and hemodynamic stability. The head and neck examination should
focus on injuries to brain, spine, orbits, and facial skeleton. This requires a team approach involving the
otolaryngologist, neurosurgeon, and ophthalmologist. The treatment goals for repair of frontal sinus
fractures include avoidance of short- and long-term complications, the return of normal sinus function,
and reestablishment of an esthetic facial contour. A treatment algorithm and surgical approach to the
management of frontal sinus fractures will be presented.
2008 Elsevier Inc. All rights reserved.
Diagnosis
Physical findings suggestive of a frontal sinus fracture include forehead abrasions/lacerations, contour irregularities,
tenderness, paresthesias, and hematoma. Forehead lacerations should be examined sterily to assess the integrity of
the anterior and posterior tables. Through-and-through injuries of the frontal sinus have high morbidity, and prompt
surgical treatment is indicated.1 Conscious patients should
be questioned regarding the presence of watery rhinorrhea
or salty-tasting postnasal drainage suspicious of a cerebrospinal fluid (CSF) leak. Any fluid collected can be grossly
evaluated for CSF using a halo test, whereby the bloody
fluid is allowed to drip onto filter paper. If CSF is present,
it will diffuse faster than blood and result in a clear halo
around the blood. Beta-2 transferrin is the definitive test to
confirm a CSF leak; however, it is generally a send-out test
and takes 5 to 7 working days to get results. A thin-cut (1.5
mm) axial computed tomography (CT) scan with coronal,
sagittal, and 3-dimensional reconstructions is the radiologic
gold standard for diagnosis of frontal sinus fractures. Axial
images provide the best information about the anterior and
posterior tables; coronal images are used to assess the sinus
floor and orbital roof. Sagittal reconstructions can be useful
in assessing the patency of the frontal recess, whereas 3D
Treatment
Treatment of frontal sinus fractures is complex and sometimes controversial. However, appropriate treatment decisions can be made by assessing five anatomic parameters;
these include the presence of: (1) an anterior table fracture,
(2) a posterior table fracture, (3) a nasofrontal recess fracture, (4) a dural tear (CSF leak), and (5) fracture comminution. These findings can be applied to the algorithm presented in Figure 1 to determine appropriate treatment
options. These options include: observation, endoscopic repair, open reduction and internal fixation, sinus obliteration,
and sinus cranialization. A full discussion of all the complexities related to surgical decision making in frontal sinus
fracture repair is beyond the scope of this article and is well
documented elsewhere in the literature.2-4 However, the
author will present a brief summary to support the proposed
treatment algorithm.
152
Figure 1
itself. This author and others have studied endoscopic fracture reduction in the acute setting. It is very challenging
because of the extreme ranges of interfragmentary resistance between bone fragments. If the interfragmentary resistance is too high, the fracture cannot be reduced; if it is
too low, the fragments will not stay in place without the
application of hardware. Therefore, the author currently
prefers to observe these patients and perform an endoscopic
camouflage of the fracture if an esthetic deformity develops.6,7 This avoids the need for a coronal incision and also
allows the patient to assess the degree of deformity after all
of the facial edema has resolved. The patient can then make
an educated decision as to whether he/she desires surgical
intervention. In the authors experience, a significant number of these patients will have minimal or no deformity and
will require no surgical intervention. More complex anterior
table fractures with marked depression may require open
reduction or, on rare occasions, obliteration.
Strong
Surgical treatment
Frontal sinus trephination
Trephination and endoscopic evaluation of the frontal
sinus can be useful to assess the frontal recess and extent of
any posterior table injury. Appropriate consent is obtained
for the procedure, including the risks of bleeding, infection,
paresthesias, and poor esthetic result. After infiltration of
local anesthesia, a 1.0- to 1.5-cm skin incision is placed
midway between the medial canthus and the glabella, approximately 1 cm inferior to the brow (Figure 2). The
incision is best hidden by placing it inferior and deep to the
curve of the forehead. A small V-shaped relaxing incision
can be added to reduce the risk of scar contracture and
webbing. The supratrochlear neurovascular pedicle is located deep to the medial aspect of the brow and should be
protected while the dissection is carried through the periosteum. The incision should not be placed within the eyebrow
itself. This increases the risk to the supratrochlear neurovascular pedicle and may result in injury of the hair follicles
leading to an obvious deformity. Sharp dissection can be
used to expose the bone; however, the author prefers to use
a guarded micropoint monopolar electrocautery on a low
setting to reduce bleeding. The location of the frontal sinus
is confirmed on the CT scan (or with navigation), and a
153
small cutting burr is used to open a 4- to 5-mm frontal
sinusotomy approximately 1 cm medial and inferior to the
medial brow (Figure 2, inset). The mucosa is incised
sharply, and the sinus can be suctioned free of any blood or
mucous. The posterior table and nasofrontal recess can be
examined with a 0 and/or 30 endoscope for any evidence
of mucosal laceration or hematoma. A valsalva maneuver
can assist with the diagnosis of a CSF leak. On rare occasions, the author has used a flexible pediatric bronchoscope
to visualize the lateral aspects of the frontal sinus. Other
authors have described instillation of methylene blue or
fluorescein into the frontal recess to assess patency into the
nasal cavity.2 Unfortunately this does not rule out the presence of a fracture or assess the long-term risk of frontal
recess stenosis. The author is aware of no studies to confirm
efficacy of this technique. Once the examination has been
completed, the skin and soft tissue are closed meticulously
in layers.
154
Figure 5 (A) Insertion of porous polyethylene implant over anterior table frontal sinus fracture. (B) Application of a self-drilling screw
to fixate the implant.
Strong
155
Figure 6 (A) Illustration of a zig-zag scalp incision used to help camouflage the coronal scar. (B) Technique for braiding hair to expose
incision line.
156
Strong
Figure 11 Subperiosteal dissection of the supraorbital neurovascular pedicle from the supraorbital notch. (Inset) Release of the
supraorbital neurovascular pedicle from the supraorbital foramina
using an osteotome.
157
then reduced and plated with 1.0- to 1.3-mm microplates.
Missing bone is uncommon; however, high-velocity injuries may result in small, comminuted fragments, which
cannot be reapproximated. Small gaps (4-10 mm) can be
reconstructed with titanium mesh. Although hydroxyappatite bone cement has been recommended to fill bone
defects, the author believes this should be avoided due to an
unacceptably high risk of infection and extrusion. However,
bone pate, burred from intact calvarium, can be used in
combination with a pericranial flap to smooth surface irregularities.
After the bony reconstruction, it is important to resuspend the temporal soft tissues to avoid long-term ptosis of
the forehead and upper midface. Two, 2-0 monofilament
sutures are passed through the temporoparietal fascia and
suspended up to the temporalis muscle fascia. The stitch is
placed as an air knot, and a needle driver is used to
maintain the first throw, while the second throw is applied
(Figure 13). To reduce blood loss during the closure, the
Rainey clips are removed in thirds and a tight galeal closure
is performed with interrupted 3-0 pop-off sutures. Electrocautery is kept to a minimum, reducing the risk of postop
alopecia. Bilateral -inch Penrose drains are placed beneath
the scalp, exiting the coronal incision above each ear, and
sutured to the skin. Staples are used to close the skin. A
pressure dressing is applied. Care should be taken to
assure that the ears are not rolled forward under the
pressure dressing. The Penrose drains are removed at 24
hours, the pressure dressing at 3 days, and the skin
staples at 10 days.
158
After the limits of the sinus have been drawn out, two
microplates (1.0-1.3 mm) are applied on opposite sides of
sinus. Each plate is preapplied with 3- to 4-mm screws,
spanning the proposed osteotomy site. This allows the surgeon to accurately reapproximate the bone fragments despite the fact that a bone defect (or kerf) will be formed with
the osteotomy. One screw is left in place on the upper
border of each plate, and they are rotated superiorly out of
the surgical field (Figure 15). Although a sagittal saw can be
used to perform the sinusotomy, the author prefers a Midas
Rex drill (Medtronic, Fort Worth, TX) with a B-1 bit, which
has both drilling and side-cutting capabilities. The surgeon
should initially use the bit to drill postage stamp perforations around the periphery of the sinus (Figure 16A). The
drill must be angled toward the sinus cavity to avoid intracranial penetration and injury (Figure 16B). The side-cut-
Strong
159
poralis muscle plug is then placed into the frontal recess to
obliterate the ostea. Finally, a 5-mm osteotome is used to
obtain two 5 5-mm bone chips from the calvarium (Figure 18A). These are inserted to seal off the frontal sinus
infundibulum (Figure 18B).
A fat graft is obtained through a left lower quadrant (or
periumbilical) incision using a separate, sterile instrument
set. An attempt should be made to harvest the fat graft in a
single piece, with minimal trauma and avoiding electrocautery when possible. The fat graft is then inserted into the
sinus cavity, and the anterior table fragments are replaced.
The fat should meet but not extrude into the saw kerf.
Anterior table stabilization is achieved by rotating the preapplied microplates inferiorly and reapplication of the
screws. Mesh and/or bone pat can be used to camouflage
surface irregularities, if necessary.
Figure 17 Illustration highlighting the deepest areas at the periphery of the frontal sinus that can be difficult to access with a
drill. Eradication of sinus mucosa in these areas can be challenging
and requires extra effort.
160
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