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Operative Techniques in

Head and Neck Surgery



Elizabeth Blair, MD
September 2008, Vol 19, No 3


Raj Sindwani, MD, FRCS
December 2008, Vol 19, No 4

David J. Terris, MD, FACS
March 2009, Vol 20, No 1



Conrad Timon, MB, FRCSORL, MD
March 2008, Vol 19, No 1


Craig D. Friedman, MD, FACS
December 2007, Vol 18, No 4

Raghu S. Athre, MD
September 2007, Vol 18, No 3


David Goldenberg, MD
June 2007, Vol 18, No 2


B. Tucker Woodson, MD, FACS
March 2007, Vol 18, No 1

Operative Techniques in

Head and Neck Surgery
VOLUME 19, NUMBER 2, June 2008


D. Gregory Farwell, MD, FACS
Douglas A. Girod, MD, FACS




Stephen Maturo, MD, Manuel A. Lopez, MD



Krishna G. Patel, MD, PhD, Jonathan M. Sykes, MD



T.J. O-Lee, MD, Peter J. Koltai, MD



D. Gregory Farwell, MD, FACS



Neal D. Futran, MD, DMD



Johnathan D. McGinn, MD, Fred G. Fedok, MD



David M. Saito, MD, Andrew H. Murr, MD, FACS



Travis T. Tollefson, MD, FACS, Amir Rafii, MD,
J. David Kriet, MD



Clinton D. Humphrey, MD, J. David Kriet, MD



Terry Y. Shibuya, MD, FACS, Vincent Y. Chen, MD,
Young S. Oh, MD



Shri Nadig, MD, Wesley Schooler, MD, Mark K. Wax, MD
E. Bradley Strong, MD


Operative Techniques in

Head and Neck Surgery
30 N. Michigan Avenue, Suite 1107, Chicago, Illinois 60602
Managing Editor: COLLEEN A. MARTIN

Operative Techniques in OtolaryngologyHead and Neck Surgery

is dedicated to detailed, thorough, finest-quality illustrations
of new surgical procedures and techniques and to discussion
of issues in surgical management of problems in the areas of
otology, rhinology, laryngology, reconstructive head and
neck surgery, and facial plastic surgery. New techniques that
are nonoperative will also be featured.
Each issue of the journal typically includes the following

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
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
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evant issues in the surgical management of otolaryngology

head and neck surgery problems. Letters may include a short
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journal article: one to three authors

1. Arvvin AM: Herpes simplex infections during pregnancy
and in infants. Semin Dermatol 3:89-101, 1984
2. Bromberg K, Hammerschlag MR: Rapid diagnosis of
pneumonia in children. Semin Respir Infect 2:159-165, 1987
journal article: more than three authors
3. Hughes WT, Feldman S, Cox F, et al: Infectious diseases in
children with cancer. Pediatr Clin North Am 21:583-616,
journal article in press
4. OMalley JE, Eisenberg L: The hyperkinetic syndrome.
Semin Psychiatry (in press)
complete book
5. Adams DO, Edelson PJ, Koren HS: Methods for Studying
Mononuclear Phagocytes. San Diego, CA, Academic, 1981
chapter of book
6. Sallan SE, Weinstein HJ: Childhood acute leukemia, in
Nathan DG, Oski FA (eds): Hematology of Infancy and
Childhood, vol 2. Philadelphia, PA, Saunders, 1987, p 1028
book that is a new edition and is in volumes
7. Altman SM, Rozells G, Jaffe J: The human brain under
stress, in Caster W (ed): The Causes of Stress, vol 4 (ed 4).
San Diego, CA, Psychiatric Press, 1934, pp 109-199
chapter of book that is part of published meeting
8. Baron MH, Maniatis T: Stage-specific reprogramming of
globin gene expression, in Stamatoyannopoulos G, Nienhuis AW (eds): Developmental Control of Globin Gene
Expression, Proceedings of the Fifth Conference on Hemoglobin Switching, New York, NY, Alan R Liss, 1987
journal article in journal that is a supplement
9. Leach C, Roeder M, Cimino A: Genetic studies of lung
cancer. Semin Oncol 3:27-33, 1987 (suppl)
10. Garson G, Harris B, MacDonald J: Vericeal hemorrhage. J
Pediatr Surg 3:17, 1987 (abstr)
11. Reasoner PH, Smith LT: An argument against laetrile.
Semin Oncol 3:19-30, 1989 (editorial)

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Operative Techniques in Otolaryngology (2008) 19, 79

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.

will provide the reader with a broad overview of the proper

workup of the patient, the surgical goals, and techniques
that will optimize patient outcomes.
I would like to extend my gratitude to the authors of
these articles for their hard work and contributions to this
volume. It is my belief that the quality of the information in
these articles will make this a very useful reference edition
for Otolaryngologists for many years to come.
D. Gregory Farwell, MD, FACS
Guest Editor

Operative Techniques in Otolaryngology (2008) 19, 80-85

Free tissue reconstruction of traumatic facial bony defects

Douglas A. Girod, MD, FACS
From the Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Kansas City,
Facial reconstruction;
Free flap;
Bone defects

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.

Traumatic facial bony defects are most commonly the

result of self-inflicted gunshot wounds resulting from attempted suicide, followed by assault injuries (gun shot and
knife injuries) and motor vehicle accidents.1 These injuries
often include extensive soft-tissue damage, widespread contamination of the wounds with orosinonasal secretions,
bone fragments, and foreign body debris.1-3 Soft-tissue loss
often progresses over the course of 24-48 hours, further
complicating treatment planning. Immediate treatment of
these injuries requires a comprehensive systematic approach
to ensure all associated issues and injuries are addressed in
a timely fashion while preserving the soft-tissue envelope,
maintaining occlusive relationships and minimizing softtissue contracture.
Futran and colleagues1 have proposed a protocol of
phased management of these acute traumatic bony defects.
They describe a 3-phase approach consisting of (1) initial
management, (2) definitive reconstruction, and (3) esthetic
and prosthetic refinement. This approach allows the surgeon
to proceed through the many complex issues involved with
these patients in an organized fashion while accomplishing
all desired goals.
Phase I consists of the initial encounter where the ABCs
of trauma management are instituted, all life- and limbAddress reprint requests and correspondence: Douglas A. Girod,
MD, FACS, Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Mail Stop 3010, 3001 Eaton, Kansas
City, KS 66160.
E-mail address:
1043-1810/$ -see front matter 2008 Published by Elsevier Inc.

threatening injures are stabilized, and initial operating room

management is undertaken. Operative management should
include treatment of intracranial, ocular, and other major
injuries. Early management of the facial defect includes
establishing the occlusal relationships of the remaining
mandibular and maxillary segments and wound debridement of foreign material and obvious nonviable tissues. All
tissues of questionable viability should be preserved and
monitored for the need of further debridement. Major bony
segments should be repaired with the use of standard plating
techniques. Segmental mandible defects should be repaired
with bridging reconstruction plates to avoid soft-tissue
contracture. The use of locking screw reconstruction
plates of adequate size is preferable in this situation
(Figure 1A and B).4
Major maxillary, orbital, and nasal defects should be
addressed with cranial bone grafting if adequate soft tissue
exists. Because soft-tissue contracture is very difficult to
reverse, some surgeons prefer to also use temporary bone
grafting in the mid-face to maintain the soft-tissue envelope
even when adequate soft tissue is missing, with the intent of
subsequent replacement using free tissue transfer techniques. Once these early goals have been completed, planning can begin for the definitive reconstruction and prosthetic rehabilitation. Psychiatric and social services are
often required at this time as well.
Phase II consists of the definitive reconstruction, which
should occur as soon as reasonable after the initial injury, as
dictated by the patients other major issues. Careful planning
is required to ensure the major functional and cosmetic


Free Tissue Reconstruction of Traumatic Facial Bony Defects


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

prosthesis is undertaken. Additional cosmetic procedures,

facial prostheses, and tissue tattooing may also be required.

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


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

subsequent procedures and donor site morbidity. The use of

vascularized tissue allows these complex contaminated
wounds to heal rapidly without infection, with minimal
contracture and a high degree of reliability (95%). In one
study of 49 patients from 2 institutions, only 4 patients
required more than one free flap.1 Bone containing flaps
were most common (33 flaps), with fibula bone most frequently used, followed by radius bone, scapula, and iliac
crest, respectively. Soft tissue flaps (21 flaps) consisted of
forearm flaps followed by rectus, latissmus, and a gracilis
flap, respectively. These authors experience is similar to
the experience of other authors.2,3,5,6 One report describes
the use of 3 simultaneous free flaps (bilateral fibula flaps
and a radial forearm fasciocutaneous flap) for the singlestage reconstruction of a very large facial gunshot wound
involving the mandible, maxilla, and nose.5
Although flap selection is a multifactorial process, certain generalities exist. Segmental mandible defects are usually best managed by with the fibula osteocutaneous flap,
which provides more than 20 cm of bone length of adequate
stock to support osseointegrated dental implants7 and adequate soft tissue for bone coverage. For shorter defects (9
cm or less) in patients without the means for long-term
dental implantation, the osteocutaneous forearm flap can
provide bone and soft-tissue coverage capable of supporting
a tissue-borne prosthesis.8,9
Bony maxillary defects are more complex. The anterior
maxilla and orbital complex is usually best managed with
free calvarial bone grafts and a dental prosthesis for the intra
oral defect. Alternatively, the maxillary alveolar ridge may
be reconstructed with the fibula, radius, scapula, or iliac
crest bone flaps with appropriate soft-tissue coverage. The
use of 3-dimensional models prepared preoperatively from
computed scans can be very helpful in planning the reconstruction of the maxilla in particular.
Soft-tissue flaps are most often used when either a thin
lining is required (ie, nasal lining) when a radial forearm
flap is favored or when a large volume of bulk is required
for major soft tissue defects when a rectus or latissmus
muscle flap is used. A detailed description of free flap
anatomy, surgical harvest, and donor site morbidity is well
beyond the scope of this article; however, several excellent
texts are available for reference.10-12

Recipient site preparation

The facial wound is largely prepared for the definitive
reconstruction during the initial phase of wound management as previously outlined. Maximal preservation of bony
and soft tissues, plating of fractures, free bone grafts, and
segmental mandible defect management with bridging
plates sets the stage for the free tissue transfer. Tracheostomy is often required (and usually performed during initial
management) for airway protection and to allow the surgical
approach to oromandibular and maxillary defects without
interfering endotracheal tubes.
Mandibular reconstruction requires wide exposure of the
remnant mandible and the previously placed bridging plate.
This mandates an external approach, which also facilitates
exposure of the great vessels of the neck for the microvascular anastomoses required for free tissue transfer. Any

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.

Free flap inset

Mandible reconstruction
After harvest of the required free flap (eg, fibula flap for
mandible reconstruction), significant contouring of bone
must occur. Some surgeons prefer to perform this function
in the leg, with the flap still receiving the natural blood
supply or on the back table after flap harvest while the flap
is ischemic. The author prefers to transfer the isolated flap
into the neck and to contour the bone to the defect where the
vascular pedicle geometry can be assessed and anticipated.
Often, multiple osteotomies of the flap bone must be performed, particularly when reconstructing the anterior mandibular arch (Figure 1C). These osteotomies should be performed in a subperiosteal fashion to avoid disruption of
blood flow to the bone. Wedges of bone are removed to
allow the bending of the bone without any resultant gaps
between bone segments. Ideally, the individual bone segments should be 3 cm in length or longer. As this process is
critical to rapid bone healing and may be time consuming.
All contouring should occur before the microvascular anastomoses are performed to avoid unfavorable geometry and
undo tension or manipulation of the vascular pedicle.
Once the contouring is completed, the flap bone segments are secured to the bridging reconstruction plate with
locking screws to avoid bone mobility but with the recognition that these screws may interfere with future placement
of dental osseointegrated implants. The bone segments will
be only minimally load-bearing during healing as the bridg-


Free Tissue Reconstruction of Traumatic Facial Bony Defects

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
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


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


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

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.

removed as soon as soft-tissue edema has resolved enough

(assuming it will not be needed for the treatment of other
related injuries) for the patient to have a safe airway. Oral

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.


Free Tissue Reconstruction of Traumatic Facial Bony Defects

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.

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


2. Yuksel F, Celikoz B, Ergun O, et al: Management of maxillofacial

problems in self-inflicted rifle wounds. Ann Plast Surg 53:111-117,
3. Suominen E, Tukiainen E: Close-range shotgun and rifle injuries to the
face. Clin Plast Surg 28:323-337, 2001
4. Militskah ON, Wallace DI, Kriet JD, et al: Use of the 2.0-mm
locking reconstruction plate in primary oromandibular reconstruction after composite resection. Otolaryngol Head Neck Surg 131:
660-665, 2004
5. Nisanci M, Tegn M, Er E, et al: Reconstruction of the middle and
lower face with three simultaneous free flaps: Combined use of bilateral fibular flaps for maxillomandibular reconstruction. Ann Plast Surg
51:301-307, 2003
6. Duffy FJ, Gan BS, Israeli D, et al: Use of bilateral folded radial
forearm free flaps for reconstruction of a midface gunshot wound. J
Reconstr Microsurg 14:89-96, 1998
7. Frodel JL Jr., Funk GF, Capper DT, et al: Osseointegrated implants: a
comparative study of bone thickness in four vascularized bone flaps.
Plast Reconstr Surg 92:449-455, 1993
8. Militsakh ON, Werle A, Mohyuddin N, et al: Comparison of radial
forearm to fibula and scapula osteocutaneous free flaps for oromandibular reconstruction. Arch Otolaryngol Head Neck Surg 131:571575, 2005
9. Kim JH, Rosenthal EL, Ellis T, et al: Radial forearm osteocutaneous
free flap in maxillofacial and oromandibular reconstructions. Laryngoscope 115:1697-701, 2005
10. Strauch B, Yu HL: Atlas of Microvascular Surgery. New York, NY,
Thieme Medical Publishers, 1993
11. Urken ML, Cheney ML, Sullivan MJ, et al: Atlas of regional and free
flaps for head and neck reconstruction. New York, NY, Raven Press,
12. Day TA, Girod DA: Oral Cavity Reconstruction. New York, NY,
Taylor & Francis, Incorporated, 2006

Operative Techniques in Otolaryngology (2008) 19, 86-89

Zygomatico orbitomaxillary complex fractures

Stephen Maturo, MD, Manuel A. Lopez, MD
From the Facial Plastic and Reconstructive Surgery Service, Department of Otolaryngology,
Wilford Hall Medical Center, Lackland AFB, Texas.
Facial fracture;
Midface fracture;
Zygoma fracture;
Orbit fracture

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.

Zygoma and orbital fractures make up an estimated 15%

and 10%, respectively, of all facial fractures.1 Most zygomatico orbitomaxillary complex (ZOMC) fractures are
caused by violent assaults, followed by motor vehicle accidents The majority of patients are young males in their third
decade of life. Thirty to fifty percent of patients have associated concomitant facial fractures.2 Associated ocular injuries occur in 10% to 50% of midface fractures, with
greater rates in isolated orbital fractures.2
The zygoma attaches to the frontal, maxillary, temporal,
and sphenoid bones. The zygomatictemporal relationship
provides anterior facial projection whereas the zygomaticfrontal provides mid-face height. ZOMC fractures left untreated can result in cosmetic deformity, enophthalmos,
entrapment of ocular muscles, and persistent diplopia. Ophthalmology referral is usually recommended and clearance
from other injuries and medical issues is necessary. Although cervical spine injuries occur in less than 10% of
midface fractures it is optimal to have the spine cleared
before surgery.1 High-resolution computed tomography
scans of the face in both axial and coronal planes provide
the most detailed information for planning surgical approaches.
The goal of ZOMC reduction and fixation is 3-point
alignment (zygomatic-frontal, zygomatic-maxillary, and infraorbital rim) with at least a 2-point fixation.3,4 Specifically
with orbital floor involvement, the goals of repair are to
release entrapped ocular tissue and establish normal orbital
volume and globe position.5 The most important feature to

Address reprint requests and correspondence: Stephen Maturo,

MD, Facial Plastic and Reconstructive Surgery Service, Department of
Otolaryngology, Wilford Hall Medical Center, Lackland AFB, TX 78236.
E-mail address:
1043-1810/$ -see front matter Published by Elsevier Inc.

ensure proper reduction and alignment of ZOMC fractures

is excellent exposure. Improper alignment results in enophthalmos, orbital dystopia, and midface flattening. These
complications are difficult to revise making precise alignment imperative during the initial operation. The following
descriptions provide for optimal exposure needed in ZOMC

Transconjunctival approach with canthotomy

and cantholysis
The transconjunctival approach with canthotomy and cantholysis provides superb exposure to the inferior orbital rim,
the orbital floor, and the lateral orbital wall. Combining this
approach with a transcaruncular approach will allow exposure of the medial orbital wall.6 Canthotomy and cantholysis is not a requirement, but we have found that exposure is
significantly enhanced when lower eyelid tension is minimized. Advantages of the transconjuctival approach as opposed to the subciliary approach include lack of external
scar and decreased risk of ectropion.
The transconjunctival approach begins with placement of
a corneal shield protector impregnated with ophthalmic bacitracin. The contralateral face is included in the surgical
field so that facial projection, orbital projection, and lid
positioning can be compared. One cc of 1% lidocaine with
1/100,000 epinephrine is injected into the lateral canthus
and conjunctival region. Two 5-0 nylon sutures are placed
through the tarsus and used as stay sutures to help aid with
retraction. A 1 cm horizontal incision is made from the
lateral canthus and carried down to the lateral orbital rim
(Figure 1). Curved iris scissors are then used to carry out the
cantholysis where the result is complete lower lid laxity.

Maturo and Lopez

ZOMC Fractures


Figure 1 Canthotomy is demonstrated. A 1-cm incision is made

in the lateral canthus and carried down to the lateral orbital rim.
Wescott scissors or a knife may be used.

(Figure 2). Bishop Harmann forceps then retract the lower

eyelid inferior-medially and Wescott scissor is used to develop the plane lateral to medial between the orbital septum
and the anterior lamellae. The Wescott scissor is then used
to release the lower eyelid retractors from the inferior tarsal
border (Figure 3). We avoid using Bovie cautery on the
transconjunctival incision to decrease the risk of retraction
from septal scarring. Stay sutures (5-0 nylon) are then
placed through the conjunctival/septal flap to help provide
counter-traction as blunt dissection with a cotton tip applicator is performed preseptally. Preseptal dissection is carried down to the orbital rim. The orbital periosteum is
identified and then incised 3 to 5 mm inferior to the orbital
rim (Figure 4).
The periosteum of the orbital rim and orbital floor is then
raised as the orbital contents are gently retracted. The orbital
floor fracture is exposed in its entirety being aware that the
optic nerve is approximately 40 mm from the anterior lacrimal

Figure 3 Conjunctival incision is made at inferior tarsal border.

Stay suture through the tarsus aids with counter traction. Medial
extent of incision is lacrimal puncta. Notice complete laxity of
lower lid provided with canthotomy/cantholysis.

crest. Options for treatment of an orbital floor fracture are

numerous and include split-calvarial bone, titanium mesh, and
Medpor (Porex Surgical Products Group, Newnan, GA). The
implant used to reconstruct the floor should be fixed with
4-mm 1.0 titanium screws. The orbital rim is fixated with a
1.0 plate using 4- to 5-mm screws. Forced duction is then
performed to ensure that there is no entrapment.
The periosteum is then closed with interrupted 4-0 Vicryl
sutures. The conjunctival incision is generally not closed.
The canthus is resuspended to the medial portion of the
lateral orbital rim. Mild overcorrection is preferred as the
suture will loosen over the perioperative period. The importance of this suspension suture cannot be overemphasized as
lower lid laxity and ectropion can result in disastrous complications. The canthal incision is then closed with simple
interrupted skin sutures.

Sublabial approach

Figure 2 Cantholysis is demonstrated. Scissors are vertically

oriented and the lateral orbital rim is palpated with the scissor tip.
Result is total lower lid laxity.

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


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

the pupil. Conservative back elevation along the inferior

gingiva will help with final closure. Wide exposure of the
maxilla and zygoma is achievable with retraction of the soft
tissue (Figure 5). Access from superiorly and inferiorly is
achieved with combining the transconjunctival and sublabial approach. Accurate reduction of ZOMC fractures requires analysis of the three-dimensional plane to achieve
three point alignment. The Carroll-Girard or T-screw can
help with manipulation of the zygoma to achieve accurate
three dimensional reduction.
The zygoma and maxilla are usually plated with an
appropriately bent L-type plate using 5-mm screws. If a
nasomaxillary buttress fracture is evident this is easily
plated with a straight, appropriately bent 1.5 plate. The
overlying mucosa is closed with a running 4-0 Chromic

Lateral frontal fracture

A superior zygomatic-frontal fracture may not be easily
accessible through the transconjunctival approach with a
Figure 5 Exposure of the anterior face of the maxilla is demonstrated. Infraorbital nerve is identified and kept intact. Fractures
of the medial and lateral buttresses can now be reduced and plated.

canthotomy and cantholysis. Access is then obtained

through an extended upper lid blepharoplasty incision. The
most lateral aspect of the blepharoplasty incision is ex-

Figure 4 Preseptal dissection is completed and periosteum has

been incised on the anterior face of the orbital rim approximately
3 to 5 mm from its superior edge. The entire orbital rim is exposed.
Conjunctival-septal flap is retracted superiorly.

Figure 6 Extended upper lid blepharoplasty incision is demonstrated. Plating of the zygomatic-frontal, orbital rim, and lateral
buttress fractures are complete.

Maturo and Lopez

ZOMC Fractures

tended to just past the lateral orbital rim in a curvilinear

fashion. Needle tip cautery is then used to expose the bone.
Periosteal dissection is then used to expose the fracture in its
entirety. A 1.0 plate with 4-mm screws is used to plate the
fracture. Classical teaching dictates that the zygomatic frontal buttress should be plated first as it establishes midface
height, yet one should continue to be vigilant of the three
dimensional aspect of the zygoma to ensure acceptable post
operative cosmesis (Figure 6).4

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

fixations while the transconjunctival approach is used when
the orbital rim and/or floor needs repair.

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

Operative Techniques in Otolaryngology (2008) 19, 90-97

Management of soft-tissue trauma to the face

Krishna G. Patel, MD, PhD, Jonathan M. Sykes, MD
From the Department of OtolaryngologyHead and Neck Surgery, University of California, Davis Medical Center,
Sacramento, California.
Soft tissue trauma;
Facial trauma;
Facial injury

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.

In the United States, more than 146,000 patients per year

are treated for soft-tissue trauma in emergency centers.1 The
most common cause for soft-tissue trauma is motor vehicle
accidents. Other common etiologies of trauma include falls,
assault/altercations, sports, industrial accidents, self-inflicted trauma, and bites (both human and animal).1,2 The
appropriate initial management of soft-tissue trauma during
the acute phase can be invaluable for the long-term esthetic
and functional outcomes.
Given that many patients with soft-tissue trauma present
with multiple injuries, the patient must first undergo a thorough evaluation under the standard guidelines of the Advance Trauma Life Support (ATLS) system.3,4 This evaluation allows the trauma patient to be stabilized if there are
life-threatening injuries. However, soft-tissue trauma of the
face can contribute to airway compromise if there is significant edema or oral bleeding.4 Mandible fractures that
avulse the tongues attachment to the lingual mandible or
mobilize the central mandible, such as bilateral parasymphyseal fractures, can reposition the tongue base posteriorly
causing airway compromise. In addition to the airway, facial trauma can also play a role in circulatory compromise if

Address reprint requests and correspondence: Krishna G. Patel,

Department of OtolaryngologyHead and Neck Surgery, University of
California, Davis Medical Center, 2521 Stockton Blvd, Suite 7200, Sacramento, CA 95817.
E-mail address:
1043-1810/$ -see front matter 2008 Elsevier Inc. All rights reserved.

significant hemorrhage occurs. In the setting of hemorrhage,

initially packing and applying pressure allows for the temporary tamponade of the vascular injury until the lacerated
vessel can be identified and ligated, repaired, or embolized.
If epistaxis is present, temporary nasal packing often sufficiently manages the bleeding.

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

Tetanus prophylaxis in wound management

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

Recommendations are based upon the CDC, Department of Health

and Human Services Center for Disease Control and Prevention (www.
Td, diphtheria-tetanus toxoid; TIG, tetanus immune globulin.
*Yes, if 10 years since last dose.

Yes, if 5 years since last dose.

Patel and Sykes

Management of Soft-Tissue Trauma to the Face


Figure 1 A photograph displaying a lateral view of an intubated

patient involved in a motor vehicle accident. Note the extensive
asphalt tattooing over the cheek and multiple contaminated lacerations and abrasions. (Color version of figure is available online.)

of care. If the mechanism of injury involved armory often

there is deep tissue destruction and burn injury.5 Injuries
involving motor vehicles or gunshots often require exploration and removal of foreign body material. Human and
animal bites and contaminated wounds require extensive
irrigation to prevent wound infection. Obtaining past medical history and social history can help identify factors that
may affect wound healing. Comorbidities such as diabetes,

Figure 3 A postoperative photograph displaying a lateral view

of the patient from Figure 1 after high-pressure pulsatile irrigation,
debridement of necrotic tissue, and reapproximation of the wounds.
The tattooing of the cheek has significantly improved and will decrease the degree of permanent tattooing as well as the risk of posttrauma infection. (Color version of figure is available online.)

alcohol or tobacco abuse, or past radiation therapy may

negatively affect wound healing.1 Under circumstances of
deep penetrating injuries, patients should be questioned
regarding their tetanus immunization status and updated if

Figure 4 A Standard instrument set used for soft-tissue plastic

surgery including fine-tipped forceps, skin hooks, and fine-tipped
scissors. (Color version of figure is available online.)
Table 2

Local anesthetic maximal dosing concentrations

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
Bupivacaine 0.25%




3 to 4
5 to 7


1.5 to 2
2 to 6


2 to 4


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

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.

Initial wound management

Before any repair, the wound must be thoroughly cleansed.
Obtaining important facts regarding the mechanism of injury can help determine if there are significant foreign
bodies within the wound (Figure 1). If computed tomography scans had been obtained previously, these can reveal
radiopaque foreign bodies such as glass and can be helpful
in localizing deep foreign bodies. The best means for
cleansing the wound and removing foreign body material is
high-pressure irrigation (Figure 2). Multiple methods can be
used, such as high-pressure pulsatile irrigation or bulb syringe irrigation. This author prefers the use of high-pressure
pulsatile irrigation (Figure 3).7,8 Both methods should use
copious amounts of irrigant to remove contaminants and
bacteria. Irrigants commonly used include saline or antibiotic-infused saline (such as, 50,000 units of bacitracin to 1
liter of saline). Once the wound has been irrigated, the areas
of tissue revealing frank necrosis should be dbrided. If left,
the necrotic tissue can serve as a nidus for infection. However, any tissue that appears partially viable should be

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)

Patel and Sykes

Table 3

Management of Soft-Tissue Trauma to the Face


Suture caliber guidelines for facial subunits


Cutaneous suture

Subcutaneous/fascia suture


Eyelid and periorbital

#6-0, #7-0

#4-0, #5-0

Nose and pinna

#5-0, #6-0

#4-0, #5-0

Lip and vermilion


#3-0, #4-0

General facial and anterior neck

#4-0, #5-0 #6-0

#3-0, #4-0

Nasal and oral mucosa

#3-0, #4-0

#3-0, #4-0

Scalp and posterior neck

#3-0, #4-0

#2-0, #3-0

Minimal tensile strength requirements; aesthetic

concerns at a premium
Small tensile strength requirements; aesthetic
concerns at a premium
Moderate tensile strength requirements because
of highly active region; aesthetic concerns at
a premium
Moderate-to-high tensile strength requirements
because of regional mobility; significant
aesthetic concerns
Moderate tensile strength needed due to tissue
mobility; may select suture based on ease or
no need for removal; no aesthetic concern
Tensile strength needed for moderately heavy
tissue and very mobile region; minimal
aesthetic concern

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.

preserved to allow for the opportunity to revascularize and

to lessen the degree of tissue loss sustained. If the patient is
awake, the wound may need to be anesthetized before irrigation to thoroughly cleanse the wound without inflicting
too much pain.

Surgical repair

decision should depend on the severity of the injury and the

patients medical condition. The operating suite provides a
more controlled environment in terms of the patients airway and pain management. Additionally, operating rooms
have superior lighting and usually have access to better
instruments (Figure 4). If there is concern for nerve or
ductal injury, the operating suite should be used to allow for
the use of microscopic techniques. However, waiting for an
operating room may delay the closure of open wounds,

The setting for surgical repair of the injury may occur in

either the operating suite or in the emergency room. This

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.)

Figure 8 A photograph of the patient from Figure 7 at 1-month

follow-up revealing complete viability of the tissues repaired and
good contouring of the concha, antihelix and ear lobule. Mild
notching is noticed along the helical rim. (Color version of figure
is available online.)


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

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.)

which can allow for increased edema of the soft tissues.

Additionally, the severity of injury often does not warrant
use of the operating room facilities. Typically, 1% lidocaine
with 1:100,000 epinephrine provides anesthesia that is effective in the awake or intubated patient. The longevity of
the anesthetic can be increased by using a 1:1 mixture of 1%
lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine
(Table 2). The injection of the anesthesia can be painful for
the awake patient; this pain can be alleviated by buffering
the anesthetic with a ratio of 9:1 lidocaine to bicarbonate.
Additionally, waiting 10 to 15 minutes to allow for the
vasoconstrictive effects of the epinephrine in the patient
greatly aides one in visualization within the wound.
Techniques for wound closure depend on the location,
depth, and characteristics of the injury. Abrasions should be
kept clean and moist with application of a thin layer of
antibiotic ointment, such as bacitracin. If the wound is

Figure 10 A photograph of the patient from Figure 9 several

months postoperatively revealing excellent realignment of the vermilion cutaneous border. (Color version of figure is available

Figure 11

An illustration demonstrating the facial esthetic

significantly contaminated or inflicted by a human or animal

bite, loose closure helps prevent deep tissue abscess formation. Hematomas involving the ear and nasal septum should
be evacuated to prevent cartilage loss and subsequent future
deformities, such as a cauliflower ear or nasal dorsal collapse, respectively. After relieving the hematoma, the ear
should be bolstered or the septum bilaterally splinted to
prevent re-accumulation of blood with subsequent cartilage
The method of wound closure should be designed to
minimize wound tension and maximize eversion of the skin
edges (Figure 5).9 Any tension on the skin layer increases
risk of a widened scar or wound dehiscence. Employment of
a multi-layered closure most ably creates a tension-free
wound.10 In addition to eversion, placement of the sutures to
ensure the wound edges are even provides the best outcome
for wound healing (Figure 6).9 Table 3 provides a guideline
for the recommended suture selection for wound closure
(Table 3).9 Additional key elements include covering any
exposed cartilage or bone with soft tissue. If the cartilage
has been disrupted, such as the upper or lower lateral cartilages of the nose, or the helical cartilage of the ear, reapproximation of the cartilage edges with absorbable suture
helps regain structural support (Figures 7 and 8). If there is
interruption of muscle, such as the orbicularis oculi or
orbicularis oris muscles, these muscle edges should be realigned to maximize posttraumatic recovery of muscle function (Figures 9 and 10). Placement of horizontal mattress
sutures with absorbable suture helps to efface the muscle

Patel and Sykes

Management of Soft-Tissue Trauma to the Face


Figure 12 A photograph of the left forehead and eyebrow of a

patient involved in a motor vehicle accident. The complex laceration crossed the hair-bearing eyebrow subunit and exposed skull
on the forehead. (Color version of figure is available online.)
Figure 14 A postoperative photograph of the left forehead and
eyebrow from the patient in Figure 12 during a 6-month follow-up
visit. The patients subunits are well aligned but the soft tissue
trauma resulted in hair loss within the eyebrow subunit. (Color
version of figure is available online.)

edges in a tension-free manner. Failure to realign muscle

layers can lead to both esthetic and functional deficit that is
often later nonrepairable.
Meticulous realignment of skin edges is important, especially along the borders of esthetic subunits (Figure 11).
In closing the skin edges, a size 6.0 or smaller caliber suture
should be used. Special attention should be paid to realign
the vermilion-cutaneous border, eyelid margin, nasal rim,
brow or any hair-bearing borders (Figures 12-15). Using
vertical mattress suture technique is excellent for the realignment of esthetic borders such as the eyelid margin and
vermilion-cutaneous border of the lip. If the edges are not
well everted, notching will occur as the wound contracts,
which is particularly noticeable at esthetic subunit borders.
The traditional teachings for eyelid margin lacerations describe a three-layer closure realigning the lash line, gray

line, and meibomian glands with 7.0 silk vertical mattress

sutures that leave the tags long enough to secure more
peripherally to prevent corneal abrasions (Figure 16).8,11
However, more recent literature advocates the use of absorbable suture for the eyelid margin closure.12 In either
situation, the tarsal plate should be reapproximated with
absorbable suture to relieve tension from the skin closure.
With injuries near the medial canthus, secondary healing is
often preferred to prevent webbed scarring.10 In general,
concave surfaces heal well by secondary intention (Figures

Figure 13 An immediate postoperative photograph of the left

forehead and eyebrow from the patient in Figure 12. A layered
closure was performed, a drain was placed in the forehead to
prevent hematoma formation, and meticulous attention was paid in
realigning the eyebrow. (Color version of figure is available online.)

Figure 15 A postoperative photograph of the left forehead and

eyebrow from the patient in Figure 14 after undergoing a revision
w-plasty of the scarred tissue. Restoration of the natural contour of
the eyebrow camouflages the scar significantly. (Color version of
figure is available online.)


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

Figure 16 An illustration depicting the repair of a full-thickness

eyelid laceration. First, deep sutures are placed to reapproximate
the tarsal plate. At the eyelid margin, three vertical mattress sutures are placed at the lash line, gray line and meibomian glands
with 7.0 silk (A). The mattress suture tags are left long enough to
secure more peripherally to prevent corneal abrasions (B). (Reprinted with permission.18)

17 and 18). These concave surfaces include the lateral

forehead subunits, glabella, medial canthal subunit, depressed areas of the ear, supra-alar crease, soft tissue triangles, philtral subunit, and the perinasal melolabial crease
(Figure 19).13
Wound edges that are uneven in depth are both difficult
to realign and often create a pin-cushioning effect during the
healing period. Superiorly based wound flaps are particularly susceptible to pin-cushion defects.8 Sharply creating a
ninety-degree angle with the skin edge can help prevent this

Figure 17 A photograph of a patient who has a full-thickness

tissue defect exposing bone near the left medial canthus. (Color
version of figure is available online.)

Figure 18 A photograph of the patient from Figure 17, who

healed the full-thickness defect via secondary intention. Note the
significant wound contraction after 1 month of healing. (Color
version of figure is available online.)

complication; however, one must be careful not to remove

too much skin that would prevent closure of the wound
(Figure 20). If tissue loss is significant and inhibits wound
closure, as much of the wound as possible should be reapproximated. For the remaining open wound, wet-to-dry
dressings help dbride the wound and allow it to heal with
plans for later reconstruction.14 Immediate reconstruction
using soft tissue flaps is possible but discouraged given the
wound is not sterile. Thus, delayed reconstruction of gaping
wounds allows the edema and risk of infection to resolve.15
If there is suspicion that the facial nerve has been injured
and the penetrating injury lies lateral to a vertical line drawn
from the lateral canthus, the wound should be immediately
explored for transection of facial nerve branches. Identified
transected nerves should be repaired under microscopic

Figure 19 An illustration of the face. The shaded areas represent

concave regions of the face that heal well through secondary
intention. These concave surfaces include the lateral forehead
subunits, glabella, medial canthal subunit, depressed areas of the
ear, supra-alar crease, soft tissue triangles, philtral subunit, and the
perinasal melolabial crease. (Reprinted with permission.13) (Color
version of figure is available online.)

Patel and Sykes

Management of Soft-Tissue Trauma to the Face


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.


Figure 20 An illustration of an oblique skin laceration that

results in uneven dermal edges (A). These wounds are difficult to
reapproximate and often cause a pin-cushioning skin defect. Skin
edge eversion can be improved by sharply creating new edges with
90-degree angles (B); however, one must be careful not to remove
too much skin that would prevent closure of the wound. After
creating the new skin edges (C), reapproximation of the wound in
a layered closure helps to relieve tension off the skin edges (D).

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.

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-

1. Hochberg J, Ardenghy M, Toledo S, et al: Soft tissue injuries to face

and neck: Early assessment and repair. World J Surg 25:1023-1027,
2. MacBean CE, Taylor DM, Ashby K: Animal and human bite injuries
in Victoria, 1998-2004. Med J Aust 186:38-40, 2007
3. American College of Surgeons. Advanced Trauma Life Support. 2003.
Available at: Accessed
May 20, 2008
4. Perry M, Dancey A, Mireskandari K, et al: Emergency care in facial
traumaa maxillofacial and ophthalmic perspective. Injury 36:875896, 2005
5. Motamedi MH: Primary treatment of penetrating injuries to the face.
J Oral Maxillofac Surg 65:1215-1218, 2007
6. Halaas GW: Management of foreign bodies in the skin. Am Family
Physician 76:683-688, 2007
7. Svoboda SJ, Bice TG, Gooden HA, et al: Comparison of bulb syringe
and pulsed lavage irrigation with use of a bioluminescent musculoskeletal wound model. J Bone Joint Surg Am 88:2167-2174, 2006
8. Park S, Frodel J: Maxillofacial and soft tissue trauma, in Park SS (ed):
Facial Plastic Surgery, The Essential Guide. New York, Thieme, 2005,
pp 161-222
9. Sykes J, Byorth P: Suture needles and techniques for wound closure,
in: Baker SR, Swanson NA (eds): Local Flaps in Facial Reconstruction. New York, Mosby, 1995, pp 39-62
10. Key SJ, Thomas DW, Shepherd JP: The management of soft tissue
facial wounds. Br J Oral Maxillofac Surg 33:76-85, 1995
11. Mustarde J: Primary and secondary repair, in: Repair and Reconstruction in the Orbital Region. Baltimore, Williams & Wilkins, 1966
12. Perry JD, Aguilar CL, Kuchtey R: Modified vertical mattress technique for eyelid margin repair. Dermatol Surg 30:1580-1582, 2004
13. Larabee WF, Sherris DA: Principles of Facial Reconstruction (ed 1):
Philadelphia, Lippincott-Raven, 1995
14. Hogg NJ, Horswell BB: Soft tissue pediatric facial trauma: A review.
J Can Dent Assoc 72:549-552, 2006
15. Ueeck BA: Penetrating injuries to the face: Delayed versus primary
treatment considerations for delayed treatment. J Oral Maxillofac
Surg 65:1209-1214, 2007
16. Goslen JB: Wound healing for the dermatologic surgeon. J Dermatol
Surg Oncol 14:959-972, 1988
17. Hinman CD, Maibach H: Effect of air exposure and occlusion on
experimental human skin wounds. Nature 200:377-8, 1963
18. Lisman R, Spinelli H: Orbital adenexal injuries, in Sherman JE (ed):
Surgery with Facial Bone Fractures. New York, Churchill Livingstone,
1987, p 108

Operative Techniques in Otolaryngology (2008) 19, 98-107

Pediatric orbital roof fractures

T.J. O-Lee, MD,a,b Peter J. Koltai, MDa
From the aDepartment of Otolaryngology, Head and Neck Surgery, Division of Pediatric Otolaryngology, Head and Neck
Surgery, Stanford University School of Medicine, Stanford, California; and the
Department of Surgery, Division of OtolaryngologyHead and Neck Surgery, University of Nevada School of Medicine,
Las Vegas, Nevada.
Orbital fracture;
Orbital roof fracture;
Coronal approach;
Facial fracture;
Pediatric facial

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.

Orbital roof fractures are uncommon injuries. It has been

estimated that between 1% and 9% of facial fractures involve the orbital roof.1 Isolated orbital roof fractures are
rare in adults. Among pediatric patients, however, because
frontal sinuses are not significantly pneumatized before age
7, forces directed at the brow and superior orbital rim cannot
be distributed across the forehead and, therefore, orbital
roof fractures are more likely to occur.1-3 Greenwald and
coworkers found that all children with isolated orbital roof
fractures were younger than 7 years old,4 and the authors of
previous reports of orbital fractures in children found 35%
of cases involved the orbital roof.2
Although adult orbital roof fractures have a high male
predilection (89-93%),5,6 pediatric population does not exhibit similar trends, and the gender distribution appears
equal.1,2 This distribution is consistent with the accidental
nature of these injuries in children, with the most common
mechanisms being falls and motor vehicle accidents.1
The task of classifying orbital roof fractures has been undertaken by several authors in the past.7 However, the classification scheme is not yet uniform, and most studies continue
to describe fractures by their gross appearance.1,2 The first type
is the nondisplaced fracture. This is by far the most common
Address reprint requests and correspondence: Peter J. Koltai, MD,
Professor of Otolaryngology, Stanford University School of Medicine, Lucile
Packard Childrens Hospital, 801 Welch Road, Stanford, CA 94305-5739.
E-mail address:
1043-1810/$ -see front matter 2008 Elsevier Inc. All rights reserved.

type in the pediatric population.1,2,4,7 The fracture can involve

one or several bone fragments without displacement (Figure
1). The second type is the blow-out fracture. First coined by
Smith and Regan in 1957 to describe orbital floor injuries,8
these fractures involve bony fragments that are displaced away
from the globe. In the context of orbital roof fractures, the
fragments are displaced into the anterior cranial fossa, with
possible consequence of dural disruption (Figure 2). The third
type is the blow-in fracture. The bony fragments are displaced
inferiorly into the orbit (Figure 3). Possible consequences include orbital dystopia (vertical displacement of the globe) and
exophthalmos or proptosis.
The most common mechanism that causes orbital roof
fractures is from direct trauma to the orbital rim (Figure
4).2 As the force is delivered to the rim, pressure is
dissipated along the surrounding bony tissue around the
orbit, causing buckling of the orbital walls before the rim
itself eventually yields. When the amplitude of the wave
of deformation exceeds the compliance of the thin bone,
the walls are broken (Figure 5). This mechanism is applicable to floor and wall as well as roof fractures.

Orbital roof fractures may occur in conjunction with injuries
of other systems, particularly the central nervous system1,2

Lee and Koltai

Pediatric Orbital Roof Fractures

Figure 1


Left undisplaced orbital roof fracture in a 3-year-old child.

Figure 2 Left blow-out fracture of the orbital roof in a 15year-old patient.

Figure 3 Left blow-in fracture of the orbital roof in a 13-yearold patient.


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

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.

and, therefore, assessment of the entire patient needs to be

completed before focusing on orbital fractures. Indeed, most
orbital roof fractures are unexpectedly identified in children
who are having computed tomography (CT) scans performed for head trauma. The common physical counterpart
to these CT finding is a delayed upper eye lid ecchymosis
(Figure 6). In severe cases, periorbital edema, ecchymosis,

Figure 5 The thin orbital roof fractures as the amplitude of the

wave of deformation exceeds the compliance of the bone.

and subconjunctival edema/hemorrhage often obscure the

position of the globe and make it difficult for the surgeon to
open the eyelids to assess vision and integrity of the globe.9
The use of anesthetics or eyelid retractors is sometimes
helpful. The position of the globe is inspected for exophthalmos, enophthalmos, and vertical dystopia. Informal exophthalmometry, with the patient in chin-up position, is a
valuable tool to assess enophthalmos or exophthalmos at the
Ocular injuries associated with orbital fractures include
retinal edema, corneal abrasion, traumatic optic neuropathy,
ruptured globe, vitreous hemorrhage, subconjunctival hemorrhage, and conjunctival laceration (Figure 7).9 The potential for these injuries necessitates a detailed ophthalmology
examination in all orbital fractures. Patients with decreased
vision or afferent pupillary defect are at risk for traumatic
optic neuropathy. In those cases, CT scan is used to check
for fractures of the optic canal or optic nerve sheath hematoma. Controversy continues to surround the optimal treatment of traumatic optic neuropathy. Observation, corticosteroids, and possible decompression of the optic canal have
all been proposed and utilized with some success by various
Voluntary range of motion is a good assessment of ocular mobility. When deficits are detected, involuntary
forced-duction test is necessary to evaluate possible entrapment.9 Disruption of the orbital roof may also yield deficits
in trochlear and supraorbital nerve function, which is detectable as loss of sensation in the forehead and scalp.
Seventh nerve function is evaluated by voluntary movement
or grimace. These deficits need to be identified preopera-

Lee and Koltai

Pediatric Orbital Roof Fractures


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.


Figure 6 (A) Delayed upper lid ecchymosis in a 2-year-old child

with orbital roof fracture associated with frontal head trauma.
(B) Coronal CT of in a 2-year-old child with orbital roof fracture
(blow in) associated with frontal head trauma.

tively to minimize confusion after corrective surgery. The

intercanthal distance is assessed for traumatic hypertelorism. Naso-orbital-ethmoidal fractures may result in telecanthus with rounding of the medial canthal angle and displacement of the medial canthal ligaments.9
CT of the orbits with axial and coronal cuts has become
standard of care in evaluating facial fractures.1,9 Coronal
cuts are especially useful in assessing orbital roof integrity
and direction of bony fragment displacement, while axial
cuts demonstrate changes in orbital volume and globe position. Fine cuts in the range of 1.0 to 1.5 mm are needed to
fully assess the bony anatomy of the orbit (Figure 8). The
screening films of the head ordered as part of the trauma
workup are often 3 mm axial cuts, therefore are insufficient
to fully evaluate orbital injury.9

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
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


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

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.

Lee and Koltai

Pediatric Orbital Roof Fractures

Figure 8 A 1.5-mm cut axial CT scan of a left orbital roof

fracture extending from rim to apex in an 8-year-old patient.

location of the scar.11 Damages to the follicles within the

brow may also distort its appearance.
Blepharoplasty or upper-eyelid crease approach
This incision is hidden within the eyelid crease and is,
therefore, more cosmetically appealing. The accessible area
is identical to the brow incision. After a skin incision overlapping the upper eyelid crease is made, the orbicularis oculi
muscle is divided, and the dissection is carried superiorly
between the orbicularis muscle and the orbital septum until
the superior orbital rim is encountered, then the subperiosteal dissection is performed in the same fashion as the brow
incision. Both of theses approaches are able to access the
entire orbital roof, but if additional exposures are needed to
expose concomitant fractures of the frontal skull, frontal
sinus, or naso-orbital-ethmoidal fractures, theses incisions
may be too limiting.

Figure 9

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
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.


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

Figure 10

The incision is carried through the galea and stops above the calvarial periosteum.

pended to avoid hollowing over the zygomatic arch. The

galea is closed with large absorbable sutures over drains,
and staples are used for the scalp.
Complications of the coronal approach include temporary (10-15%) or permanent (2%) frontalis nerve injury,
scalp sensory loss or pain temporal fossa depression, hair
loss, and hematoma.13 Most frontal branch injuries are
thought to be secondary to excessive flap retraction over the
zygomatic arch. Inferior extension of the preauricular incision may improve flap mobility and alleviate the need for
retraction. Creating incisions parallel to the follicles and
limiting cautery and dissection in the subdermal plane help
to avoid permanent hair loss.
The subcranial approach is especially useful in repairing
large, inferiorly displaced fractures, while minimizing re-

Figure 11

traction of the frontal lobe. By removing the nasal bone and

the frontal bar, split cranial bone grafts harvested through
the coronal incision can be used to re-establish the continuity of anterior cranial fossa floor under direct vision.

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.


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

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.)

contiguous supraorbital rim fracture extending vertically

into a frontal skull fracture. This skull fracture component is
almost always of a green stick variety and as a consequence it can be very difficult to reduce (Figure 13). Slow,
steady reduction force to extract the displaced fragment
will usually succeed; the difficult part in this effort is
finding a purchase on the displaced fragment for the
application of such a force. Use the contiguous nondis-

placed portion of the supraorbital rim as a fulcrum is one

possible reduction strategy; alternatively, the placement
of a 2-mm diameter screw as a purchase point in the thick
portion of the displaced fragment can also be effective.
Once these skull fractures reduce at the orbital rim, the
friction at the fracture edges will buttress them in place
and internal fixation is commonly unnecessary. The supraorbital reduction will often result in the reduction of

Lee and Koltai

Pediatric Orbital Roof Fractures

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.

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

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.

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,
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

Operative Techniques in Otolaryngology (2008) 19, 108-112

Management of symphyseal and parasymphyseal

mandibular fractures
D. Gregory Farwell, MD, FACS
From the Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California.

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

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

Establishment of occlusion

Address reprint requests and correspondence: D. Gregory Farwell,

MD, FACS, Department of OtolaryngologyHead and Neck Surgery, University of California, Davis, 2521 Stockton Boulevard, Suite 7200, Sacramento, CA 95817.
E-mail address:
1043-1810/$ -see front matter 2008 Elsevier Inc. All rights reserved.

Arch bars and maxillomandibular fixation (MMF) are

almost always necessary to establish the premorbid relationship of the mandibular and maxillary teeth. Although there
are many ways to establish occlusion, standard Ernst arch


Symphyseal and Parasymphyseal Mandibular Fractures


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.

Approach and exposure

The most common approach to the symphysis and parasymphysis is the transoral gingivolabial and gingivobuccal
incision. The key to the design of the incision is to stay
approximately a centimeter away from the attached gingival
to allow enough tissue for a watertight closure at the end of
the procedure (Figure 1). Care must be taken to avoid
injuring the mental nerves because they exit the mandible
and supply sensation for the lower third of the middle
portion of the face. After incising through the mucosa, the
mentalis muscle is divided and the periosteum is elevated
off of the mandible, exposing all of the fractures and enough
of the adjacent mandible for placement of the hardware. If
necessary to provide sufficient access, the mental nerves
may be exposed. Care is taken when dissecting around the
mental foramen, to not cut or stretch the nerves. The periosteum is circumferentially elevated away from the foramen, allowing the soft tissue to be retracted away from the
foramen for improved exposure. On occasion, the periosteum may need to be incised radially in the direction of the
nerve to further increase exposure. With larger, comminuted
fractures, an external approach may be necessary to accurately and rigidly fixate the mandible. In this approach a
standard cervical incision may be made approximately 2
fingerbreadths below the mandible to avoid injury to the
marginal mandibular nerve. After elevating the submandibular gland fascia to protect the nerve, the inferior border of
the mandible may be approached. The periosteum is incised
and elevated in the same fashion as the transoral approach to

Figure 1 This diagram demonstrates the surgical approach to

the anterior mandible. Note the generous cuff of the mucosa that is
left attached to the gingiva to allow for accurate and watertight
closure at the end of the case. The arrows denote the location of the
mental nerve which exits near the first or second premolar.

Figure 2 The mandibular reduction forceps are applied to the

mandible by drilling oblique monocortical holes and placing the
ends of the reduction forceps into those holes. This allows the
fracture to be preloaded before the application of mandibular

expose the fracture and allow for the placement of the

appropriate hardware.

Fracture reduction and fixation

Once the occlusion has been established with the arch
bars and MMF and the fracture has been exposed, attention
is turned to reduction and fixation of the fracture. Reducing
the fracture is usually straightforward in this technique.
However, with severely comminuted fractures, care must be
taken to ensure the viability of the segments with careful
periosteal dissection and fragment manipulation. Once the
fracture has been reduced to the anatomic position, the
fixation is applied. The classic approach to fractures has
been to place an upper border, monocortical tension band
and a large lower border bicortical (often compression)
plate. When properly performed, this AO-ASIF (i.e., Association for the Study of Internal Fixation) technique has
resulted in very successful fracture management. However,

Figure 3 This diagram demonstrates the technique of manual

compression of the angles to reduce the lingual splay of the
fracture. Tight compression is applied by the assistant to squeeze
the mandible and the lingual aspect of the fracture shut.


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

over the years, many other excellent alternative approaches

have been shown to be equally effective with similar results.
Currently, smaller plates (miniplates) or lag screw fixation
are most commonly used for repair of symphyseal and
parasymphyseal fractures.

Lag screw technique

As with all fractures, the key to successful repair is
accurate fracture reduction. This is especially true of symphyseal and parasymphyseal fractures, where there is a
strong tendency for the mandible to flair at the angles. Lag
screw fixation is a very useful technique in the symphysis
and parasymphysis.4 In this description, references to screw
size and instruments are to the AO/ASIF 2.4-mm mandibular trauma system although most mandibular plating systems will have the necessary equipment. It is imperative to

have a wide variety of screw lengths to make sure the

appropriate length is available for every fracture. Monocortical drill holes are placed on each side of the fracture and
a bone reduction forcep is applied to hold the fracture in
reduction (Figure 2). When the lag screws are applied, it is
imperative to reduce the lingual border of the fracture and
reestablish the appropriate intragonial distance by squeezing
the mandibular angles together (Figure 3). While holding
the reduction, the lag screws may be applied. This is accomplished by drilling a gliding hole with the 2.4-mm
(larger drill bit) through the proximal bone to the level of
the fracture line. Then, by sliding a drill guide into the
gliding hole, the trajectory of the distal hole may be maintained. The drill bit is then changed to the 1.8 mm (smaller
drill bit), and the distal bone is drilled until the drill exits the
cortex (Figure 4A and B). Care is taken to insure that the
trajectory of the drill bit is away from the mental nerves and

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.


Symphyseal and Parasymphyseal Mandibular Fractures

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.

Closure and postoperative care

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.

below the level of the tooth roots (Figure 4C). A countersink

is then used to allow for flush placement of the screw, and
the screw is inserted into the hole (Figure 4D). For optimal
strength a second lag screw is placed in a similar fashion.
The bone reduction forceps are removed and the occlusion
is checked.

Once the hardware has been placed, the occlusion is

checked and attention is turned to closure. After copious
irrigation, the intraoral incision is closed with care taken to
reattach the mentalis muscle. A watertight closure of the
mucosa is then performed with absorbable sutures (Figure 7).
A decision is then made to either leave the arch bars in place
or to remove them. In most cases, with accurate reduction
and appropriate fixation the arch bars can be removed and
the patient can start to function immediately after surgery.
Before leaving the operating room, the skin is washed and
a splint of foam tape may be used to reapproximate the
mental soft tissue over the bony mentum. Patients are instructed on oral care with frequent mouth rinses utilizing
peroxide or chlorhexidine rinses. A soft diet is recommended for the 4 to 6 weeks of fracture healing. The
patients are followed postoperatively for signs of malocclusion, wound breakdown, and infection.

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

Figure 6 This figure demonstrates the principle of overbending

to insure reduction of the lingual border of the mandible. Please
note by overbending the plate (A); the lingual border is squeezed
shut as the screws are tightened down, pulling the mandible up
against the plate (B). This is only appropriate in a nonlocking


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

for at least 6 weeks to insure accurate reduction and occlusion during the fracture healing.

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.

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.

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

1. Champy M, Lodde JP, Jaeger JH, et al: Mandibular osteosynthesis

according to the Michelet technic. I. Biomechanical bases [in French].
Rev Stomatol Chir Maxillofac 77:569-576, 1976
2. Boole JR, Holtel M, Amoroso P, et al: 5196 mandible fractures amount
4381 active duty army soldiers 1980 to 1998. Laryngoscope 111:16911696, 2001
3. Zachariades N, Mezitis M, Mourouzis C, et al. Fractures of the mandibular condyle: a review of 466 cases. Literature review, reflections on
treatment and proposals. J Craniomaxillofac Surg 34:421-432, 2006
4. Ellis E 3rd: Lag screw fixation of mandibular fractures. J Craniomaxillofac Trauma 3:16-26, 1997
5. Champy M: Mandibular osteosynthesis by miniature screwed plates via
buccal approach. J Maxillofac Surg 6:14-21, 1978
6. Chritah A, Lazow SK, Berger JR: Transoral 2.0-mm locking miniplate
fixation of mandibular fractures plus 1 week of maxillomandibular
fixation: A prospective study. J Oral Maxillofac Surg 63:1737-1741,
7. Boulourian R, Lazow S, Berger J: Transoral 2.0-mm miniplate fixation
of mandibular fractures plus 2 weeks maxillomandibular fixation: A
prospective study. J Oral Maxillofac Surg 60:167-170, 2002

Operative Techniques in Otolaryngology (2008) 19, 113-116

Management of comminuted mandible fractures

Neal D. Futran, MD, DMD
From the Department of OtolaryngologyHead and Neck Surgery, University of Washington School of Medicine, Seattle,
Mandible fracture;
Reconstruction plate;

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.

Comminuted mandible fractures generally are the result

of a significant impact on a localized area of the oromandibular complex. Most of these fractures are open. Under
any circumstances, these fractures are difficult to treat and
have a greater complication rate than more simple ones.
Traditional treatment of comminuted mandibular fractures
has involved closed techniques in an effort to avoid stripping periosteum from the comminuted bony segments. This
would avoid potentially devitalizing the bone fragments
with resulting sequestration. Closed reduction was performed with a variety of techniques, including maxillomandibular fixation (MMF), splints, and extraoral skeletal
pins. In many cases, infection still ensued resulting in significant bone loss and associated morbidity.
However, this theory was challenged more than 60 years
ago by Kazanjian, based on his treatment of war injuries.1,2
Concerning the management of mandibular gunshot
wounds, he stated that the majority of nonunited fractures
are due to inadequate immobilization of comminuted fragments of bone, and subsequent infection, rather than to
initial loss of bone.2 To Kazanjian, it was clear. Stabilization of the fragments was the most important requirement to
obtain osseous union of comminuted fragments. He devel-

Address reprint requests and correspondence: Neal D. Futran, MD,

DMD, Department of OtolaryngologyHead and Neck Surgery, University
of Washington School of Medicine, 1959 NE Pacific Street, Room BB
1165, Seattle WA 98195-6515.
E-mail address:
1043-1810/$ -see front matter 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-


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

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-


Management of Comminuted Mandible Fractures


tention as made to malocclusion, number of fragments,

lacerations, fifth nerve parathesias and other facial skeleton
fractures. Although panoramic and plain radiographs give a
good general view of the fractures, axial and coronal CT
scans (Figure 1A) provide the optimal 3-dimensional aspects of these complex injuries. Prophylactic antibiotics
covering oral flora are administered, as these fractures by
definition are open.
Emergent treatment of these fractures is not necessary.
Once the patient is stabilized and appropriate studies are
obtained, definitive surgical intervention is planned. In the
event a patient is undergoing urgent operative intervention,
maxillomandibular fixation can be applied and then definitive reduction of fractures can proceed in a more convenient
Figure 2 Anatomic model demonstrating proper placement and
contour of the locking reconstruction plate across a comminuted
fracture, as well as placement of a lower arch bar.

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
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.

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


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

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.

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.

These include mechanism of injury, delay between injury and

treatment, and surgical expertise.
Properly executed rigid internal fixation is a great advance in the management of comminuted mandibular fractures.10-12 With proper assessment of the injuries, adequate
reduction and stabilization of the fractures, and good surgical
technique, the outcomes are better. The course of treatment is
also significantly shortened utilizing these techniques and leads
to more rapid resumption of normal function.

1. Kazanjian VH: An outline of the treatment of extensive comminuted
fractures of the mandible. Am J Orthod Oral Surg 28:B265-B274,
2. Kazanjian VH: Immobilization of wartime, compound, comminuted
fractures of the mandible. Am J Orthod Oral Surg 28:B551-B560,
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,
11. Ellis E 3rd, Muniz O, Anand K: Treatment considerations for comminuted mandibular fractures. J Oral Maxillofac Surg 61:861-870,
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

Operative Techniques in Otolaryngology (2008) 19, 117-122

Techniques of maxillarymandibular fixation

Johnathan D. McGinn, MD, Fred G. Fedok, MD
From the Division of OtolaryngologyHead and Neck Surgery, Department of Surgery, Penn State University College of
Medicine, Hershey, Pennsylvania
Mandible fracture;
Ivy loops;
Ernst ligatures

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.

elective orthognathic surgery. Stabilization, immobilization,

and maintenance of occlusion are the primary goals accomplished in placing the patient into MMF.
Historically, many different methods have been used to
accomplish this immobilization and alignment. Barton
dressings, wire arch bars, Essig wiring, Erich arch bars,
Ernst ligatures, Ivy loops, IMF fixation screws, bonded
dental lugs, and plastic circumdental lugs (Rapid IMF, Synthes, West Chester, PA) are but a few of the fixation methods that have been used. In this article, we will focus on a
number of the currently popularized methods.

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

Address reprint requests and correspondence: Johnathan D. McGinn,

MD, Penn State College of Medicine, 500 University Drive, PO Box 850,
H091, Hershey, PA 17033.
E-mail address:
1043-1810/$ -see front matter 2008 Elsevier Inc. All rights reserved.

There are several key principles guiding the surgeon who is

considering the placement of a patient into maxillary-mandibular fixation: (1) occlusion, which is the maintenance or
establishment of an optimal occlusive relationship between
the upper and lower jaws is the dominant ideal behind and
the main goal of MMF. Depending on the clinical situation
this may be class I occlusion,2 or optimal may be the
patients less-than-perfect premorbid occlusion; (2) immobilization of fractures, which is the reduction of motion
along a bone disruption, whether it is a traumatic fracture or
an iatrogenic elective osteotomy, is important to promote
timely healing, or union. Motion across a healing bone
interface is a key factor in malunion and nonunion3; (3) the
viability of teeth, which depends on intact vascularity and
stability. MMF techniques must support these factors, and
not disrupt either through the very placement of the MMF


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

materials; and finally; and (4) early functioning. In certain

clinical situations, particularly in the case of condylar and
condylar neck fractures, provisions for the option of a degree of mobilization should be insured by the MMF technique used. In these circumstances, the period of immobilization should be relatively brief to facilitate successful
rehabilitation and minimize the risk of ankylosis of the
temporomandibular joint.

Erich arch bars

For many, Erich arch bars represent the most reliable method
of placing a patient in MMF. The arch bars themselves provide
a semirigid bar scaffold to which each dental arch is wired. The
arch bars are then wired together, securing the occlusal relationship. The sequence of application is as follows (Figure 1):
(1) the skeleton and dental arch is reduced as well as possible

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

McGinn and Fedok

Techniques of MaxillaryMandibular Fixation

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


multiple avulsed or unstable teeth. Dentoalveolar fractures and

comminuted fractures may also make placement more challenging.

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.


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

similarities to the technique used in the creation and placement

of Ivy loops. The Ernst ligatures are best used for temporary
fixation and simple fractures. In some clinical situations, such
as comminuted or unstable fractures, they may not be sufficient
to fully stabilize the fracture segments. The teeth used for the
wiring must be secure and not fractured or luxed. The Ernst
ligatures are placed as follows (Figure 3): (1) premolar teeth
are typically selected for securing the ligature; (2) a 24-gauge
wire is placed between the canine and first premolar from a
buccal to palatal direction; (3) this wire is then placed in a
reverse direction back through the interdental space of the
premolars (Figure 3A); (4) the other end of the wire is passed
behind the second premolar in a similar fashion (Figure 3B);
(5) the second end is also passed back between the premolar
interdental space; (6) one end of the wire should be on top and
one below the wire loop created on the buccal side of the teeth
(Figure 3C); (7) the wire ends are then twisted tight and cut off
4 to 5 cm long (Figure 3D); (8) an identical wire placement is
performed on the opposite jaw and a similar pair on the contralateral side (Figure 3E); (9) the ends of these 2 matching
pairs are then twisted together after placing the patient in
occlusion (Figure 3F); (10) alternatively, the wire ends can be
folded over several times creating hooks, which can then be
used for elastics.

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.

McGinn and Fedok

Techniques of MaxillaryMandibular Fixation


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.

Complications and limitations

Dental care becomes an important part of postoperative care.
Dental caries may develop if regular dental care with a soft

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


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

in MMF provides a closed-method to stabilize the jaw into an

occlusive relationship. For the surgeon to use many of the
described methods, the patient must have enough stable teeth
to apply the fixation apparatus.

The authors wish to thank Synthes, Inc., for their generous
donation of supplies used in the photographs for this article.

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.

Operative Techniques in Otolaryngology (2008) 19, 123-127

Internal fixation of mandibular angle fractures with the

Champy technique
David M. Saito, MD, Andrew H. Murr, MD, FACS
From the Department of OtolaryngologyHead & Neck Surgery, University of California, San Francisco, California.
Mono-cortical miniplate;
Load sharing

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
2008 Elsevier Inc. All rights reserved.

Fractures of the angle account for 23% to 42% of all

mandibular fractures.1-3 These fractures generate the highest frequency of complications relative to all other mandible
fractures, with reported rates from 0% to 32%.4 There are
several unique properties of the mandibular angle that pertain to fracture management. The cross-section of bone at
the angle is less than that in more anterior locations, providing less surface contact area to allow stabilization between fragments. The angle is less surgically accessible than
parasymphyseal or body fractures via a transoral approach.
Fractures are generally posterior to the molar dentition,
which prevents optimal stabilization by maxillomandibular
fixation. Also, the presence of a third molar has been linked
to an increased risk of angle fractures,5,6 and may hinder
fracture reduction, decrease bony surface contact area, disrupt the vascularity to the fracture site, and be a source of
pathogenic organisms.7 The angle fracture can be further
complicated by distraction and rotation by opposing forces
of the elevator muscles (masseter, medial and lateral pterygoids, temporalis) and the depressor muscles (geniohyoid,
genioglossus, mylohyoid, digastric). The angle is subject to
forces up to 60 DN during mastication, which any successful fixation method must be able to withstand.
The standard options for treatment of angle fractures
Address reprint requests and correspondence: Andrew H. Murr,
MD, FACS, Department of OtolaryngologyHead & Neck Surgery, University of California, San Francisco, Box 0342, 400 Parnassus Ave, UC
Clinics 730, University of California, San Francisco, San Francisco, CA
E-mail address:
1043-1810/$ -see front matter 2008 Elsevier Inc. All rights reserved.

include maxillomandibular fixation (MMF) for 4 to 6 weeks

versus open reduction and internal fixation with or without
MMF. The application of MMF creates several well-known
and significant problems for both patient and surgeon. The
patients inability to open the mouth leads to nutritional
deficits, suboptimal wound healing, and weight loss. The
MMF hardware often creates painful abrasions and ulcers in
the oral mucosa. Also, prolonged immobilization of the
temporomandibular joint leads to ankylosis and bone resorption. MMF can even lead to life-threatening complications, as when patients with nausea and/or substance abuse
aspirate gastric contents during episodes of emesis.
Because of such problems, the use of rigid fixation is
appealing as it allows early recovery of mandible function
with limited or no need for postoperative maxillomandibular fixation. In the 1960s, the Schenk studies illustrated how
bone healing could be accelerated with compression of the
fragments.8 For decades, the AO/ASIF (Arbeitgemeinshaft
fur Osteosynthesefragen/Association for the Study of Internal Fixation) has stressed the need of rigid fixation with
fragment compression to promote primary bone healing and
has provided guidelines for its application at the mandibular
angle.9 The AO recommends placement of internal fixation
plates in such a fashion that avoids injury to the underlying
mandibular canal and tooth roots. This can be accomplished
with a 6-hole compression plate or reconstruction plate with
bicortical screws inserted along the inferior border of the
mandible. Alternatively, a 2-plate technique can be employed with a bicortical compression plate or reconstruction
plate along the inferior border and a four-hole monocortical


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

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.

Monocortical screws pose very little risk to the mandibular

canal and inferior alveolar nerve. By using a transoral approach, the surgeon can avoid a large external skin incision
and minimize risk to the facial nerve. The transoral approach is also technically easier than an external approach,
can be swiftly performed, and requires minimal tissue dissection with less tissue devitalization.
Although the Champy technique forgoes fragment compression and primary bone healing, its success rate for
treating angle fractures has been proven through many clinical studies with complication rates as low as 3.8%.10 The
successful clinical experience is seemingly at odds with the
results of numerous in vitro studies on the biomechanics of
angle fracture fixation, all of which conclude that monocortical miniplates offer insufficient resistance to the displacing
forces of mastication.12-14 This may be partly explained by
the fact that patients bite forces are subnormal for many
weeks after sustaining a fracture, so that a less rigid form of
fixation is adequate for fragment stability during the healing
The Champy technique does have its limitations in practice and is not well-suited for all angle fractures. Because
the use of monocortical plates does not allow primary bone
healing, it is critical to follow patients in the outpatient
setting to ensure that secondary bone healing occurs. This
may be challenging or impossible in the setting of homelessness, substance abuse, and other socioeconomic barriers. Reduction of a displaced or unfavorable fracture can be
challenging via a transoral approach. These fractures are
better visualized and reduced via an external approach and
using reduction forceps. Similarly, a comminuted fracture
should be adequately exposed and fixated with a reconstruction plate via a transcervical approach.
There are current topics of discussion regarding the details of the Champy technique, especially whether it is
preferable to use one or two miniplates along the superior
mandible border. In 1996, Ellis and Walker16 noted that the
use of a single 2-mm monocortical plate was associated
with a low complication rate (16%), most frequently local
infection that was treated with outpatient incision and drainage
and later removal of the miniplate under local anesthesia. In
contrast, these authors reported a much higher complication

Figure 2 Four-hole fixation for maxillomandibular fixation.

(Color version of figure is available online.)

Saito and Murr

Champy Technique

Figure 3 Diagram depiction of Champys lines of osteosynthesis at the mandibular angle. (Reprinted with permission.20)

rate of 29% when paired miniplates were employed.17 Ellis

speculates that using one miniplate avoids unnecessary dissection and preserves blood supply to the fracture site. However,
other studies would indicate that two miniplates lead to better
stability and lower complication rates. Fox and Kellman found
a low 18% complication rate in 68 patients treated with paired
2-mm miniplates.18 Similarly, Levy and coworkers19 found a
very low complication rate of 3% in fractures treated with
paired miniplates compared with a 26% complication rate in
fractures fixed with a single miniplate.

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).

Figure 4 A 2-mm miniplate precurved in 90 orientation, shown

with drill guide screwed into place. (Color version of figure is
available online.)


Figure 5 An Obwegeser retractor is used to expose the plate and

ensure proper positioning. The drill guide is then screwed into the
miniplate and used as a guide for drilling. (Color version of figure
is available online.)

Care must be taken to avoid drilling into the tooth roots.

Premorbid occlusion is thus restored and attention can be
turned to exposing the angle fracture. The gingivo-buccal
sulcus over the angle and along the ipsilateral alveolar ridge
is infiltrated with 1% lidocaine with 1:100,000 epinephrine
for hemostasis. The planned incision is marked at intervals
with pinpoint marks using needle-point electrocautery. At
least 5 mm of gingiva should be left attached to the alveolar
ridge to allow adequate tissue for closure at the end of the
case. The electrocautery is then used to incise the mucosa
and dissect down the periosteum of the mandible. The
dissection proceeds with a Freer or Cottle elevator to expose
the fracture and the surrounding periosteum. The use of
Sewall or Obwegeser toe-in retractors can greatly aid in
adequate exposure. In Champys model of mandible biomechanics, the ideal lines of fixation are located along the
alveolar portion of the angle of the mandible posterior to the
third molar (see Figure 3).
With the fracture adequately exposed and reduced, a
4-hole 2-mm monocortical miniplate is positioned spanning
the fracture line over the superior ridge of the mandible
angle. Miniplates are now available that are prebent in a 90
orientation to aid in optimal coaptation to the mandible
angle (Figure 4). Otherwise, bending of the miniplate
should be performed to allow two screw holes on either side
of the fracture.
The drill hole must be performed absolutely perpendicular to the periosteum and should only proceed through the
outer cortex. A drill guide can be screwed into the hole of
the plate to ensure correct drilling orientation (Figure 5).
A 6-mm screw is used to secure the plate. The remaining
3 holes are drilled with the plate in situ. A transbuccal
trochar may be necessary to drill the holes into the distal
fracture segment in a true perpendicular fashion and secure
the bone screws (Figure 6).
This is performed by making a 5-mm incision through
the skin overlying the mandible angle with a scalpel. Then,
focused blunt dissection proceeds through the soft tissues
with a clamp until the tips protrude through the buccal
mucosa. The clamp is removed and the trochar can be


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

Figure 6 A transbuccal trochar may be necessary to drill perpendicular holes in the distal fracture segment. (Color version of
figure is available online.)

Figure 8 Paired miniplates for internal fixation of left angle

fracture. (Color version of figure is available online.)

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).

Figure 7 After drilling, the screwdriver is inserted into the

transbuccal trochar and used to secure the bone screws. (Color
version of figure is available online.)

Early recovery of mandibular function is a clear benefit in

the treatment of mandible fractures. Both the AO/ASIF and
the Champy technique are acceptable options for internal
fixation of an angle fracture and offer different profiles of
advantages and disadvantages. For fractures that are distracted or comminuted, and for patients in whom weekly
follow-up is not likely, the AO/ASIF compression technique is preferred for its superior exposure, fragment reduction, and rigid stability. However, for simple angle fractures, the Champy technique is an elegant and effective
method of internal fixation that reduces surgical time and

Figure 9 Anteriorposterior plain film of mandible with miniplate

spanning fracture line.

Saito and Murr

Champy Technique

dissection, minimizes risk to the facial and inferior alveolar

nerves, and allows early return of function with acceptable
complication rates.

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

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,
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

Operative Techniques in Otolaryngology (2008) 19, 128-131

Tracheostomy scar revision

Travis T. Tollefson, MD, FACS,a Amir Rafii, MD,a J. David Kriet, MDb
From the aDepartment of Otolaryngology Head and Neck Surgery, University of California, Davis Medical Center,
Sacramento, California; and the
Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas.
Hypertropic scar;
Facial fracture;
Strap muscle

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.

Tracheostomy tube placement is a common procedure

for patients with severe maxillofacial trauma, airway
compromise, or head and neck cancer. After decanulation, the resulting tracheotomy scar is commonly unsightly both at rest and during swallowing. Typically, the
vertical movement of the scar with the trachea is termed
tracheocutaneous tethering (or tug). The scar develops
during secondary intention wound healing after the tracheostomy tube is removed. The tracheocutaneous fistula
is filled in with granulation tissue and subsequent wound
contraction leads to scar depression. The patient may
complain of dysphagia and discomfort with neck movement due to the adherence of the subcutaneous tissue to
the trachea.
Tracheostomy scar revision is a commonly performed
procedure to improve both the appearance and symptoms
of tracheocutaneous tethering. A variety of tracheostomy
scar revision techniques have been described and will be
reviewed in the context of the authors preferred method.
The objectives are to minimize the visibility of the external scar both at rest and during swallowing by (1)
filling the depressed scar and (2) allowing the skin to
glide over the underlying scar. A graft may be placed

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:
1043-1810/$ -see front matter 2008 Elsevier Inc. All rights reserved.

between the scar and the trachea to augment the scar


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

Tracheostomy Scar Revision

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
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.)

not seen complications such as infection, seroma, or

acellular dermis extrusion. Although standard postoperative scar management using scar massage and silicone
gel or sheeting is encouraged, occasionally triamcinolone
10 mg/mL is injected into the scar to treat hypertrophic
scarring. Superficial injection of steroids is contraindicated as dermal atrophy and hypopigmentation may

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-

Figure 2 The technique of Kubler and Passy is shown.4 The

strap muscles are mobilized and suspended in the midline with
three interrupted 3-0 absorbable sutures. (Color version of figure is
available online.)


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

Figure 3 Intraoperative photograph of human acellular dermis

(Alloderm, LifeCell Corp, Branchberg, NJ) sutured to the surface
of the medialized strap muscles with 4-0 Vicryl sutures. (Color
version of figure is available online.)

burg, NJ) was originally introduced as a cadaveric skin graft

substitute for the treatment of burns.8 Other reported uses of
acellular dermis in the head and neck include static facial
slings,9 parotidectomy defects,10 nasal septal perforations,11
palatal fistulas,12 and salivary fistulas.13 The use of acellular
dermis in tracheostomy scar revision has been reported in a
single case report.14
The authors have placed acellular human dermis as an
interpositional graft during tracheostomy scar revision under the hypothesis that the formation of adhesions between
the trachea and skin can be prevented; but is it necessary?
Some disadvantages of using acellular human dermis in
tracheostomy scar revision could include the additional cost
for the material, risk of viral transmission from the donor,
and the potential for seroma in the dead space that is created
between the graft and the soft tissues.
The techniques chosen by the authors during tracheostomy scar revision are based on the characteristics of
the scar. In severely depressed scars, soft tissue augmentation with surrounding muscle is necessary to fill the
concavity. In tracheocutaneous tethering, the skin can be
separated from the trachea using strap muscles and/or an
interpositional graft. Presently, the authors preferred
technique does not routinely include using acellular human dermis.

Figure 4 (A) Preoperative photograph of tracheostomy scar

illustrating the characteristic features, including (1) widened and
erythematous; (2) retracted and depressed; and (3) tracheocutaneous tethering. (B) Postoperative photograph of the same patient 6
months after scar revision using acellular dermis. (Color version of
figure is available online.)

Tollefson et al

Tracheostomy Scar Revision

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.


Figure 5 Illustration of Pressmans rotation of separated sternal

heads of the sternocleidomastoid muscle into the tracheostomy
scar depression.3 (Color version of figure is available online.)

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,
2. Poulard A: Traitement de cicatrices faciales. Presse Med 26:221-225,
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,
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

Operative Techniques in Otolaryngology (2008) 19, 132-139

Surgical approaches to the orbit

Clinton D. Humphrey, MD, J. David Kriet, MD
From the Department of Otolaryngology, University of Kansas Medical Center, Kansas City, Kansas
Orbital blowout
Orbital trauma;

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:
1043-1810/$ -see front matter 2008 Elsevier Inc. All rights reserved.

moid artery foramina, and orbital fissures are shown in Figure 1.

Moving posteriorly, the anterior ethmoid artery, posterior ethmoid artery, and optic nerve are located approximately 24 mm,
36 mm, and 42 mm, respectively, from the anterior lacrimal
crest. Upper and lower eyelid layers are detailed in Figure 2.3
The medial canthal tendon attaches via a thicker limb to the
anterior lacrimal crest and a thinner limb containing Horners
muscle to the posterior lacrimal crest. The lateral canthal tendon also consists of 2 limbs. A thin anterior limb blends with
the orbicularis oculi muscle fibers and periosteum of the lateral
orbital rim, and a thicker posterior limb attaches to Whitnalls
tubercle of the zygoma. Intimately related to the medial canthal
tendon is the lacrimal system. Upper and lower puncta begin 5
to 7 mm lateral to the canthus and continue as a common
canaliculus into the lacrimal sac located between the anterior
and posterior limbs of the medial canthal tendon within the
lacrimal fossa. The sac empties into the inferior meatus via the
nasolacrimal duct. The lacrimal gland is located within the
lateral upper lid and divided into a larger orbital portion and a
smaller palpebral portion by the lateral horn of the levator
aponeurosis. Anteriorly, the glands orbital portion is in contact
with the orbital septum.4,5
Extraocular muscles include the 2 oblique and 4 rectus
muscles. The course of the superior oblique muscle brings it
into nearly direct contact with the periorbita of the orbital roof
and medial wall at the trochlea. The inferior oblique is in
proximity to the orbit at its origin just posterior to the inferomedial orbital rim, lateral to the superior end of the nasolacrimal canal, and occasionally from the fascia over the lacrimal
sac. The superior, inferior, lateral, and medial rectus muscles
originate from the annulus of Zinn and insert onto the sclera.

Humphrey and Kriet

Surgical Approaches to the Orbit


Figure 1 The lacrimal, maxillary, zygomatic, greater and lesser

wings of the sphenoid, frontal, and ethmoid contributions to the
orbital skeleton are as shown. As measured from the anterior lacrimal
crest, the anterior ethmoid artery, posterior ethmoid artery, and optic
foramina are located at 24, 36, and 42 mm, respectively.

Approaches to the lateral orbit and orbital

Lateral brow
The lateral brow and upper blepharoplasty approaches
are useful for accessing the zygomaticofrontal and zygomaticosphenoid sutures. The lateral portion of the superior

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)

orbital rim can be exposed as well. Incision placement for

each of these approaches is shown in Figure 3.
For the lateral brow approach, local anesthetic with epinephrine is infiltrated just inferior and parallel to the hair

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.)


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

sary, the superolateral orbital wall can be dissected to assess
zygomaticosphenoid suture alignment (Figure 4). Closure is
performed in layers, with the surgeon reapproximating the
periosteum by using a 5-0 polydioxanone suture followed
by skin closure with a 6-0 polypropylene or fast absorbing
gut suture in a running fashion. The advantage of the upper
blepharoplasty approach is a cosmetically favorable scar
that is barely discernable once healed.6,7

Coronal approach

Figure 4 Zygomaticofrontal and zygomaticosphenoid sutures

are exposed after subperiosteal elevation through an upper blepharoplasty approach.

follicles of the lateral 2 to 3 cm of the inferior brow. Some

clinicians advocate making this incision within the brow,
but this may result in undesirable alopecia. The incision is
carried through both the skin and orbicularis oculi with a
#15 blade. The periosteum over the lateral orbital rim is
sharply incised and raised with a Freer elevator to obtain the
desired exposure. Closure is performed in layers, with the
surgeon reapproximating the periosteum and then orbicularis oculi with 5-0 polydioxanone suture in an interrupted
fashion. The skin is closed with either a 6-0 polypropylene
or fast-absorbing gut in a running fashion.
The primary advantage of this approach is the simplicity
of the technique. Disadvantages include the possibility of
visible scarring and brow alopecia. It is because of this
scarring that this approach has largely been replaced by the
upper blepharoplasty 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.

Approaches to the orbital floor

Converse9 originally described the subciliary approach to
the orbit in 1944. He and others have also advocated a
subtarsal variation of this approach. Both are transcutaneous
approaches that provide access to most of the orbital floor.
The orbital rim incision is an alternative transcutaneous
approach, which we do not use or recommend because of
the potential for visible scarring.

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

Humphrey and Kriet

Surgical Approaches to the Orbit

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
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


Figure 6 Paths traversed by the pre- and postseptal variations of

the transconjunctival approach are shown. (Reprinted with permission.3) (Color version of figure is available online.)

lower eyelid malposition. With a Jaeger lid plate placed

over the globe and one finger on the skin inferior to the
tarsal plate to evert the lid, an incision is made through the
conjunctiva of the lower lid 2 mm inferior to the tarsal plate
using a Colorado dissector. The incision is continued
through the lower lid retractors taking care to violate neither
the thin lower lid skin nor the orbital septum. Blunt dissection between the orbicularis oculi and orbital septuma
preseptal approachthen proceeds using a cotton tipped
applicator. A 5-0 silk suture is placed through the orbital
septum and pulled superiorly to further protect the globe.
Alternatively, the orbital septum can be incised to reveal a
dissection plane between the orbital septum and periorbital
fata postseptal approach (Figure 6). Blunt dissection with
a malleable retractor over the septum or orbital fat and a
Ragnel retractor on the lower lid and orbicularis oculi
will reveal the periosteum of the inferior orbital rim. The
Colorado dissector is used to incise the periosteum on the
anterior surface of the rim. Elevation of the periosteum is
performed with a Freer elevator, and the malleable retractor
can be used to continually retract the orbital contents and
expose the desired portion of the orbital floor (Figure 7). No
closure of the conjunctiva is needed so long as it is properly
repositioned at the conclusion of the procedure. If canthotomy and cantholysis are performed, the tarsal plate is
resuspended to the orbital periosteum near Whitnalls tubercle with a single 5-0 polydioxanone suture. The canthus
is reapproximated by the surgeon using a single 6-0 fast
absorbing gut suture placed through the gray line of the
lateral upper and lower lids. Interrupted sutures are used as
needed to close any remaining canthotomy defect laterally.


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

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

Figure 8 A right orbital blow-out fracture as identified with

computed tomography (A) and as visualized endocopically via a
transantral endoscopic approach with herniation of bone fragments, periorbita, and orbital fat into the maxillary sinus (B).
(Color version of figure is available online.)

Figure 9 Orbital blow-out fracture shown in Figure 8 following

reduction of herniated orbital fat and placement of a Medpor
linear high density polyethylene implant (Porex Surgical Inc,
Newnan, GA) supported by the anterior and posterior shelves of
the floor defect. (Color version of figure is available online.)

Humphrey and Kriet

Surgical Approaches to the Orbit

retract the lip, and a Freer elevator is used to expose the

anterior wall of the maxillary sinus up to the level of the
infraorbital nerve. An osteotome and Kerrison rongeur are
used to make a 10 by 20 mm defect in the anterior wall of
the sinus (Figure 7). Zero- and 30-degree 4-mm telescopes
are then inserted through the antrostomy to visualize the
orbital floor (Figure 8). The floor defect is usually obvious and
mucosa can be elevated adjacent to the defect for visualization
and reduction of the orbital contents. Trap door or greenstick
type fractures can occasionally be reduced using this approach
alone without need for fixation if the bony shelf once reduced
is stable. An implant can also be inserted if necessary by
placing it first onto the posterior shelf and then sliding it up
onto the anterior shelf (Figure 9). Closure proceeds by the
surgeon reapproximating the gingivolabial sulcus mucosa using interrupted 3-0 polyglactin suture.
Advantages to this approach include improved visibility
of the posterior orbit and especially the posterior shelf of a
floor defect. Disadvantages include difficulty in reconstructing the orbital floor lateral to the infraorbital nerve, the need
to violate the anterior maxillary face, and the need for
specialized endoscopic instrumentation.

Approaches to the medial orbit

Lynch16 described his transcutaneous approach to the
medial orbit and frontal sinus for sinusitis in 1921. Access
to most of the medial orbital wall is achievable through this
approach. Local anesthetic with epinephrine is injected
down to the ipsilateral nasal bone and the medial orbital rim.
An incision is made with a #15 blade over the superomedial
orbital rim from a point inferior to the medial brow to the
superior aspect of the nasofacial junction. This incision is
carried down through periosteum using the Colorado dissector. A Freer elevator is used to expose the medial orbital
wall, staying superior to the canthal tendons and lacrimal
apparatus until posterior to these structures. If exposing the
superomedial orbit, care should be taken to identify and
cauterize or ligate the ethmoid arteries. Closure is performed by reapproximating the skin using running 6-0
polypropylene or fast absorbing gut suture. Simplicity and
exposure are the primary advantages to this approach. A
significant disadvantage is the risk of medial canthal web
formation and visible scarring which can be decreased by
incorporating a z-plasty at the time of closure.

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


Figure 10 The transcaruncular incision is placed either over or

just posterior to the caruncle in the sulcus between the caruncle
and the semilunar fold. (Reprinted with permission.17)

retracted with Demares retractors and the orbital contents

protected using a small or medium malleable retractor. A
plane posterior to Horners muscle is developed with iris
scissors until the posterior lacrimal crest is palpable or
clearly anterior to plane of dissection. The orbital contents
are retracted with a malleable retractor to expose the periosteum posterior to the crest. The Colorado dissector is used
to incise the periosteum posterior to all medial canthal
attachments and the lacrimal apparatus (Figure 11). A Freer
elevator is used to gain the desired exposure of the medial
orbital wall, and the anterior and posterior ethmoid arteries
are ligated as necessary. Figure 11 shows the typical access
obtained with this technique. If exposure of both the medial
wall and floor of the orbit is desired, one can sharply free the
attachment of the inferior oblique, allowing broad unobstructed access to the floor and medial wall. Care must be
taken to identify the inferior oblique at its bony attachment
if it is to be released as injury to the belly of the muscle may
result in a functional deficit.
This approach has replaced Lynchs technique as the
standard for access to the medial orbital wall because it
eliminates the potential for visible scarring and webbing
associated with the transcutaneous Lynch incision. One
disadvantage to this approach is that it can be difficult to
insert and manipulate an implant through the relatively
small incision. Combining the transcaruncular approach
with either a transconjunctival or transnasal approach can
be helpful in this situation. Care must be used to avoid
injury to lacrimal apparatus by following the proper dissection plane to the posterior lacrimal crest.

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.


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

leaving 3 to 4 mm superiorly to prevent formation of nasofrontal recess synechiae. The ethmoid bulla and maxillary
os are identified. The majority of medial orbital injuries are
associated with nasal trauma and there may be significant
intranasal damage in addition to the prolapsing orbital contents. Care must be taken to bluntly dissect the tissues and
definitively identify landmarks as one proceeds to avoid
creating or enlarging an orbital or skull base defect. The
bulla ethmoidalis is entered using a small Frazier suction
and the ethmoid cells are opened back to the ground lamella,
exposing the lamina papyracea and medial orbital defect.
Orbital contents can be carefully reduced using both the
transorbital and transnasal approaches at this point. An
implant can be better visualized and manipulated using the
combined approaches as well.
Advantages to this approach include the excellent visualization it provides of the extent of the bony defect and the
limited risk it poses to intraorbital structures when the
surgeon is experienced with intranasal endoscopic surgical
techniques. Easier identification of the orbital defect and
skull base can be facilitated with the use of a computed
tomography image guidance system when available. A disadvantage to the transnasal approach is the potential increased risk of skull base injury and cerebral spinal fluid
leak. This approach also lacks utility as a single approach
because of both limited space for implant introduction and
the need to insert an implant toward rather than away from
orbital structures in an area that can potentially place pressure on the optic nerve. No increased morbidity from sinus
disease postoperatively has been described in the literature.

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,

Forced duction testing should be performed in the operating

room after any orbital approach with bony manipulation or
implant placement. There should be unrestricted ocular mobility. After surgery, it is our belief that all patients undergoing orbital approaches for traumatic injury should be
observed in an inpatient facility overnight. The prompt
recognition and attention that orbital complications deserve
can best be offered when the patients are observed in this
setting. Vision checks for light perception are performed
every 2 to 4 hours. Color discrimination is a very sensitive
indicator of optic nerve injury, and the ability of the patient
to perceive the color red is a useful bedside test as well.
Patients that have impaired color perception will see a
brownish hue rather than bright red. Pain should also be
monitored closely. Corneal abrasion is the most common
cause of pain in the early postoperative period, but patients
with increasing pain should be immediately assessed for
light and color perception. If light or color perception
changes with increasing pain or proptosis, the patient should

Humphrey and Kriet

Surgical Approaches to the Orbit

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


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 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-

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

Operative Techniques in Otolaryngology (2008) 19, 140-144

Naso-orbito-ethmoid fracture management

Terry Y. Shibuya, MD, FACS, Vincent Y. Chen, MD, Young S. Oh, MD
From the Department of Head and Neck Surgery, Southern California Permanente Medical Group, Anaheim, California.
Naso-orbito ethmoid
Facial fracture repair

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.

Naso-orbito-ethmoid (NOE) fractures involve injury to

the central mid-face. Anatomically, the region is composed
of the frontal bone, nasal bones, lacrimal bones, frontal
process of the maxillae, ethmoids, and lesser wings of the
sphenoid. The horizontal buttresses run along the superior
and inferior orbital rims. Although the vertical buttresses
run along the frontal process of the maxilla, nasal bone, and
frontal bone, damage to this region represents the meeting
point of the anterior cranial fossa, frontal bones, orbits,
maxillae, and nasal bones. Injury often results in telecanthus, orbital dystopia, cerebrospinal fluid leak (CSF), and
frontobasilar skull fracture.
Injuries to the NOE region may be very difficult to diagnose. A thorough physical examination and radiographic imaging are standard for assessing injury to this region. A highresolution computed tomography scan of the facial bones and
orbits with axial and coronal cuts are recommended. If available, 3-deminsional computed tomography scan image reconstruction can be a helpful adjunct.
An accurate physical assessment of the patient often is
impaired from the facial and soft-tissue edema. Characteristic finds on physical examination include retrusion of the
nasal bridge, telecanthus, enophthalmos, and shortened palpebral fissure. The normal intercanthal distance is approximately half the width of the interpupillary distance, whereas
an intercanthal width greater than this suggests a fracture.
An intercanthal distance of 35 mm is suggestive of a displaced fracture, and a distance of 40 mm or more is considered diagnostic.1 Bimanual palpation of this region is
Address reprint requests and correspondence: Terry Y. Shibuya,
MD, FACS, Department of Head and Neck Surgery, 411 Lakeview Ave,
Anaheim, CA 92807.
E-mail address:
1043-1810/$ -see front matter 2008 Elsevier Inc. All rights reserved.

performed by placing a Kelly clamp into the nose, under the

frontal process of the maxilla, and then externally palpating
the medial canthal tendon between the clamp (intranasal)
and index finger (external) to physically determine whether
a fracture is present.2 If there is mobility, then an injury to
the NOE region is present. Direct palpation of the medial
canthus and the eyelid retraction test are other methods
for physically examining this region, but these examination
techniques often miss an injury.3 In addition, one should
look for signs of a CSF leak. The leak may be suggested by
the demonstration of a double ringing/haloing of nasal fluid
found on the patients bed sheets or paper towels. Sampling
some of the nasal fluid for beta-2-transferrin can confirm the
presence of CSF. CSF leaks occur in up to 10% to 30% of
basilar skull fractures and will frequently resolve with fracture reduction and repair.4
NOE fractures have been classified by a number of
authors, one the most widely accepted classification system
was established by Markowitz et al.5 They classify fractures
into 3 types based on the medial canthal tendons relationship to the central bony fracture fragment. For a type I
injury, there is a single central fragment with the medial
canthal tendon attached (Figure 1A). For a type II injury,
there is comminution of the central fragment with the fracture external to the medial canthal tendon-bone insertion
(Figure 1B). For a type III injury, there is comminution of
the central fragment with the medial canthal tendon disrupted from its bony insertion (Figure 1C).

The technique we use to repair NOE fractures has been
developed during the past decade as the result of repairing

Shibuya et al

Naso-Orbito-Ethmoid Fracture Management

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.

Figure 1 (A) Type I NOE fracture, single central fragment

with the medial canthal tendon attached. (B) Type II, comminution
of the central fragment with the fracture external to the medial
canthal tendon-bone insertion. (C) Type III comminution of the
central fragment with the medial canthal tendon disrupted from its
bony insertion.

fractures and reconstructing the anterior skull base after

tumor ablative surgery. Sequentially, we start with reconstructing the medial orbital walls, resetting the nasal dorsum, and we finish with reattaching the medial canthal
tendons. Our technique varies for unilateral and bilateral
injuries. For type I and II injuries, the medial orbital wall(s)
are reconstructed with the use of microplates or titanium
mesh and the canthal tendon(s) are repositioned while attached to the bony fragments. Therefore, an accurate reduction of the medial orbital wall bony fragments into proper
position simultaneously results in proper reduction of the
medial canthi. The more-complex surgical repair occurs
with type III injuries and the techniques further described in
this article will address our repair strategy for unilateral and
bilateral type III injuries.
For a unilateral or bilateral injury, a bicoronal incision
may or may not be necessary. If there is extensive injury to
the anterior skull base, forehead, superior orbital rim, or
nasal dorsum, a bicoronal incision is usually recommended
to enhance surgical exposure and access for possible split

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
10. Mosquito forceps are used to bluntly dissect, in a horizontal direction, down through the soft tissue to identify the medial canthal tendon.


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

Figure 4 The medial canthus tendon is identified with blunt

dissection. The wires are twisted to seat the medial canthus against
the orbital wall.

Bilateral repair

Figure 2 28-gauge wires are passed thru the preselected holes,

grasped in the nose, and twisted together (lower arrow).

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
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).

Figure 3 18-gauge needles are passed from the skin surface

above and below the medial canthal tendon, and wires are passed
through the needles.

In cases of a bilateral 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, from one side thru to the
opposite side. At this point, the wire should be entering
one medial orbital wall and exiting the opposite medial
orbital wall (Figure 5).
5. An 18-gauge needle is passed from the skin surface
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. This is done on each side, so that on
each side the wire is now located above and below the
medial canthal tendon region (Figure 6).
6. On one side, the wires are twisted together to form a
tight bond and then bent to hide the sharp edge (Figure
7. A 15 blade is used to make an incision between the 2
8. Mosquito forceps are used to bluntly dissect, in a horizontal direction, down through the soft tissue to identify the medial canthal tendon.
9. The wire is pulled in a lateral direction, so that the
twisted wire pulled in a medial direction and seats the
medial canthal tendon onto the surface of the medial
orbital wall (lacrimal region).
10. A 15 blade is used to make an incision between the 2
wires that have not been twisted together (Figure 7).
11. Mosquito forceps are used to bluntly dissect, in a horizontal direction, down through the soft tissue to identify the medial canthal tendon.
12. Skin hooks and Ragnell retractors are used to retract the
soft tissue around the medial canthal tendon and medial

Shibuya et al

Naso-Orbito-Ethmoid Fracture Management


Figure 7 The medial canthus tendon is identified with blunt

dissection. The wires are twisted to seat the medial canthus against
the orbital wall.


Figure 5 Bilateral repair: wires are passed through pre selected

holes from one side across to the opposite side.

canthal tendon is pushed into the bone with a Freer

13. The 28-gauge wire is twisted down to seat the medial
canthal tendon into its position on the medial orbital
wall. Now, both tendons have been reinserted onto the
new medial orbital walls.

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.

NOE fractures can be very difficulty to repair. There have

been a number of approaches reported by authors in the past
for reconstructing these very difficult injuries.4-9 Unfortunately, there is no universally accepted or fool-proof technique that consistently works. However, there are a number
of steps that are consistently performed with most techniques that optimize results. Wide exposure, usually with a
bicoronal incision, is preferred. Evaluation of the medial
orbital walls and nasal dorsum injury is necessary to visualize and assess the injury. Reconstruction of the medial
orbital walls and nasal dorsum with bone grafts are recommended; alternatively, allograft materials also may be used.
A canthopexy usually is performed with a transnasal wiring
For unilateral type III injuries, we usually fixate the
medial canthal tendon to the newly established medial orbital wall with a 28-gauge wire. For bilateral type III injuries, we usually perform bilateral transnasal wire fixation to
the medial orbital walls. This similar technique has been
used frequently for reconstructing the anterior skull base
after ablative surgery. We believe that the key to optimal
cosmetic results is securing the disrupted medial canthi to
the newly created medial orbital wall and positioning the
new wall into a correct anatomical location. This step results
in the medial canthal tendon being placed into proper position. Once the tendon is fixated to the bone, there will be
minimal to no change in position of the canthi, regardless of
whatever pulling vector is place on the tendon via transnasal
wiring. Others have suggested that transnasal wiring with a
pulling vector in the posterior superior direction can enhance cosmetic results. We agree with this concept in principle; however, we believe proper tendon fixation is the key
to best results.
Although this technique is not fool-proof, we have had a
high degree of success in repositioning the medial canthal
tendons and reconstruction the central mid-face region. We
have encountered only a few cases in which the medial
canthi have drifted laterally. We believe that this problem of


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

canthal migrating overtime is difficult to prevent, regardless

of whatever technique is used. The key from our perspective
is fixating the medial canthal tendon to the newly reconstructed medial orbital wall and allowing enough time for
the tendon to scar and secure itself to the newly reconstructed medial orbital wall.

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,

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

Operative Techniques in Otolaryngology (2008) 19, 145-150

Free tissue reconstruction of traumatic soft-tissue defects

Shri Nadig, MD, Wesley Schooler, MD, Mark K. Wax, MD
From the Department of Otolaryngology/Head and Neck Surgery, Oregon Health & Science University, Portland,
Free flap;

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.

In social interaction, the face is the most important

physical cue, facilitating recognition of individuals. Facial expressions and gestures convey subtle and overt
nonverbal communications and are an important component of daily interpersonal interactions. As a result, deformities of the head and neck resulting from trauma are
devastating, and patients encountering significant alterations of their physical appearance often experience feelings of maladjustment and social isolation. Functional
limitations as a consequence of these traumatic injuries
may also be significant, particularly those that result in
oromandibular defects. When possible, these complex
defects should be reconstructed in a manner that restores
form and function as completely as possible.
Traumatic soft-tissue defects result from projectile injury
from civilian or military conflict and avulsive or burn injuries from agricultural or industrial accidents. They have
added new dimensions to the type, complexity, and severity
of defects of the face, head, and neck confronting the reconstructive surgeon. Ballistic or avulsive facial injuries
result in missing or severely damaged soft tissue. These
injuries, in contrast to blunt soft-tissue injury, produce an
evolving pattern of soft-tissue loss resulting in devascularization of bone.
Address reprint requests and correspondence: Mark K. Wax,
MD, Department of Otolaryngology/Head and Neck Surgery, Oregon
Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239.
E-mail address: E-mail:
1043-1810/$ -see front matter 2008 Elsevier Inc. All rights reserved.

Primary repair of these defects with bony reconstruction

is the ideal goal; unfortunately, as with blunt injury, poorly
vascularized nonviable soft tissue, hematoma, dead space,
foreign material, and ischemia with consequent infection
compromise and complicate such primary repair.1,2
Primary repair with local advancement flaps is always
the desirable goal because they provide the best color
match. The role of local cutaneous and soft-tissue flaps may
be limited in major defect reconstruction because of limited
available volume, limited contourability, poor adaptability
to complex defects, multiple stages, and a compromised
vascular supply. Under these circumstances, extensive and
composite tissue loss can only be repaired with tissue replacement from regional or distant sites. The exponential
advances in the variety and complexity of tissues available
for importing into the field have significantly empowered
the reconstructive facial plastic surgeon.
Before the advent of free tissue transfer, prosthetic rehabilitation was one of the only methods of rehabilitating or
reconstructing these individuals. Although beyond the
scope of this article, prosthetic rehabilitation in the hands of
a well-trained prosthodontist is an excellent modality for
reconstruction. The ability to achieve a cosmetic contour
that is acceptable to the patient and the family is exceedingly high. Patient satisfaction begins to deteriorate when
the work involvedsuch as using a tissue adhesive to keep
the prosthesis in place or the cleansing of the prosthesis to
keep it odor freeis added into the equation. Further, these
services are not often available in a location close to the
patients home.


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

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.


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.

The most innovative technique in the field of imaging is

stereolithography. The development of rapid prototyping to
build 3-dimensional medical models with the use of CT
scan information has evolved from the crude milled models
to the laser-polymerized stereolithographic models today
(Figure 1).
This concept of using a 3D model was first applied to
grafting a skull defect in 1995. Rapid prototyping is a
process. These 3D models allow preoperative analysis of
facial defects, enhancing implant precontouring, screw selection/location, technique simulation to reduce operating

Figure 2 This 3-dimensional mold made from the CT scan

demonstrates the site and 3-dimensional relationship of the soft
tissue and bony defects. (Color version of figure is available

Nadig et al

Free Tissue Reconstruction of Soft-Tissue Defects


time, enhance physician communication, patient information, and consequently improve patient outcomes (Figure 2).

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

Early and appropriate surgical debridement of nonviable

tissues and foreign matter;
copious irrigation;
fixation and immobilization of injured tissues;
detailed wound closure;
maintenance of clean dressings;
nutrition; and
circulating fluid volume

Hemodynamics of the patient must also be addressed, as

the oxygen-carrying capacity is influential in both wound
healing and prevention of infection with extensive blood

Figure 3 The radial forearm fasciocutaneous free flap is one of

the most common flaps used in head and neck reconstruction. It is
thin, pliable and can adapt to 3-dimensional molding. (Color version of figure is available online.)

Free tissue reconstruction by

anatomic subsite
The various subsites of the face that may need to be reconstructed can be grouped as follows: (1) lips and chin; (2)
oral cavity, including floor of mouth, palate, and buccal
cheek; and the (3) midface, including the nose.

Lips and chin

Free tissue transfer

Modern head and neck reconstruction relies heavily on the
use of free tissue flaps. These are defined as skin and
subcutaneous tissue (and/or bone) fed by a distinct vascular
supply (pedicle). The most common flap used in these
circumstances is the fasciocutaneous flap. It is a composite
flap that includes skin, subcutaneous tissue, and fascia. The
blood supply to the fasciocutaneous flap typically consists
of perforating vessels arising from regional arteries coursing
through fascial septa. Cadaveric studies have demonstrated
that the fasciocutaneous perforators and their fascial plexus
lie in the longitudinal axis, and therefore the length-tobreadth ratio is dictated by a longitudinally-oriented pattern
of blood flow. Fasciocutaneous flaps have the advantage of
being thin and pliable, and function well for reconstruction
of low volume, moderate surface defects (Figure 3).
Many different areas of the body are suitable for the
harvesting of a fasciocutaneous free flap. The anatomy of
these structures is consistent, providing a technical advantage for the reconstructive surgeon. The characteristics of
the vascular pedicle contribute to the versatility of these
flaps, as the flap may be positioned in a variety of orientations while maintaining adequate pedicle length for vascular
anastomosis to the larger caliber external carotid branch
vessels in the neck (facial, superior thyroid, or lingual vessel). Further contributing to the versatility of this flap are its
pliability and low volume, allowing the flap to be positioned
in various 3-dimensional orientations in the recipient site.

The principles of perioral reconstruction are underpinned

by the priority to maintain oral competence. A deep enough
labiogingival sulcus allowing good denture fit and a freely
mobile sensate normal-looking lower lip facilitate competence and good articulation. A shallow sulcus and a numb
lower lip may cause drooling and give rise to physiological
problems. Reconstruction using the following therapeutic
ladder depends on the amount of tissue loss: (1) primary
closure, (2) use of the uninjured part of the same side of the
lip, (3) use of the opposite lip if the same side is not
available, (4) use of the local flaps from the sides of the
defect, if the tissue is insufficient, and (5) free tissue transfer
as a last resort for defects 80%.
The radial forearm or the ulnar flaps are optimal for lip
reconstruction. Although the flaps do not usually include
any muscle, incorporating the palmaris longus tendon reconstructs the oral sphincter and restores facial movements
to the newly formed lip (Figure 4A and B). Mucosal grafts
can be used for vermilion reconstruction and to provide a
sensate flap (lateral cutaneous nerve of the forearm) giving
superior esthetic end results. The vascularized palmaris longus tendon may be fixed to the muscle, nasolabial dermis,
the modiolus, the lateral malar eminence, for static suspension. Dynamic suspension of the reconstructed lower lip is
achieved by looping the tendon around the modiolus or
suturing it to transferred masseter muscle11 or orbicularis
oris.12 More recently, functional (innervated) gracilis free
muscle transfer has been used to replace the missing orbic-


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

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.

ularis oris muscle.13 These reconstructions often will need

subsequent commissurotomy to obtain symmetry or a commissuroplasty.

Oral cavity including floor of mouth, palate, and

buccal cheek
Reconstruction is centered on the principle of maintaining oral competence, maximizing oral function and esthetics
while preserving speech and swallowing. The newly formed
oral aperture must be large enough so that a dental prosthesis may be easily used. A shallow sulcus and a numb lower
lip may cause drooling (Figure 5A and C).
The free radial forearm flap or the ulnar flap is the first
choice to restore soft tissue of the oral cavity. The flaps
epidermal lining can be used to reconstruct mucosal defects,
with particular attention paid to a watertight closure to
isolate the oral cavity from other tissues of the neck to
prevent salivary fistulas. Through and through, defects of
the cheek may require the use of doubling a single flap,
double free flaps, or can be combined with pedicled flaps to
provide both mucosal and skin cover (Figure 5).

Midface, including nose

Reconstruction of the midface, particularly the nose, is
complicated by the fact that esthetic and functional rehabilitation involves recreating the projection, highlights, and
shadows that reflect the three-dimensional or layer characteristic of the nose. Cover alone does not recreate these
unique structures. These subunits are the external skin
cover, supporting cartilage or bone, and the inner lining.
Consequently, nasal reconstruction is one of the biggest
challenges to the facial plastic surgeon.
The radial forearm free flap is thin, pliable vascularized
tissue well suited for internal cover. When multiple nasal
subunits have been lost, it can be used to provide internal
lining which is often lost extensively. Costal cartilage is
well suited for reconstruction of the nasal dorsum and caudal strut, with septal or auricular cartilage for lower lateral
cartilage reconstruction. The outer lamella is best reconstructed
with a hinged paramedian or nasolabial flap (Figure 6). The
paramedian flap is particularly reliable as both supratrochlear
arteries are rarely damaged together. Secondary procedures
after initial flap insetting include thinning or debulking, carti-

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

Free Tissue Reconstruction of Soft-Tissue Defects


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

lage or bony framework reconstruction, and external skin

cover from other local or free flap transfers as the posterior
auricular flap.

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.

Revisions and secondary operations are often necessary;
Motamedi14 reported a 48% rate for his patients in the

final phase. Volume and contour are the most common

reasons for flap revision. Reconstructed flaps undergo
dynamic involution of soft tissue with change in both
parameters. Revision must not be planned for at least 9
months. Function of the area reconstructed may necessitate secondary procedures. Revisions are usually needed
for oral commissures and the vermilion border of the lips,
reduction of bulk for oral function, facial contour, nasal
refinement and near the eyes. In nasal reconstruction,
refining alar volume and restoration of nasal airway are
most often required.

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).

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


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

4. Futran ND, Farwell DG, Smith RB, et al: Definitive management of

severe facial trauma utilizing free tissue transfer. Otolaryngol Head
Neck Surg 132:75-85, 2005
5. Dolin J, Scalea T, Mannor L, et al: The management of gunshot
wounds to the face. J Trauma 33:508-515, 1992
6. Cole RD, Browne JF, Phipps CD: Gunshot wounds to the mandible
and midface: evaluation, treatment and avoidance of complications.
Otolaryngol Head Neck Surg 111:739-745, 1994
7. Kihtir T, Ivatury RR, Simon RJ, et al: Early management of civilian
gunshot wounds to the face. J Trauma 35:569-577, 1993
8. Chen AY, Stewart MG, Raup G: Penetrating injuries of the face.
Otolaryngol Head Neck Surg 115:464-470, 1996
9. Vasconez HC, Shockley ME, Luce EA: High-energy gunshot wounds
to the face. Ann Plast Surg 36:18-25, 1996

10. Suominen E, Tukiainen E: Close-range shotgun and rifle injuries to the

face. Clin Plast Surg 28:323-337, 2001
11. Sawhney CP: Reanimation of lower lip reconstructed by flaps. Br J
Plast Surg 39:114-117, 1986
12. Jeng SF, Kuo YR, Wei FC, et al: Total lower lip reconstruction with
a composite radial forearm-palmaris longus tendon flap: A clinical
series. Plast Reconstr Surg 113:19-23, 2004
13. Ninkovic M, di Spilimbergo SS, Ninkovic M: Lower lip reconstruction: Introduction of a new procedure using a functioning gracilis
muscle free flap. Plast Reconstr Surg 119:1472-1480, 2007
14. Motamedi MH: Primary management of maxillofacial hard and soft
tissue gunshot and shrapnel injuries. J Oral Maxillofac Surg 61:13901398, 2003

Operative Techniques in Otolaryngology (2008) 19, 151-160

Frontal sinus fractures

E. Bradley Strong, MD
From the Department of Otolaryngology, University of California, Davis School of Medicine, Sacramento, California.
Frontal sinus;
Minimally invasive
surgical procedures;
Maxillofacial injuries;
Facial injuries;

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.

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

Address reprint requests and correspondence: E. Bradley Strong,

MD, Department of Otolaryngology, University of California, Davis
School of Medicine, 2521 Stockton Boulevard, Suite 7200, Sacramento,
CA 95817.
E-mail address:
1043-1810/$ -see front matter 2008 Elsevier Inc. All rights reserved.

reconstructions may help to visualize the external contour

deformity seen less clearly with 2D cuts alone.

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.

Frontal recess fractures (Figure 1)

Frontal recess fractures result in disruption of the only
frontal sinus outflow tract. Regardless of anterior or posterior table injuries, frontal recess fractures that result in sinus
outflow obstruction will require frontal sinus obliteration.
However, one recent article has described some success


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

Figure 1

Algorithm of frontal sinus fractures.

with expectant observation of frontal sinus fractures, after

open reduction and internal fixation of anterior table frontal
sinus and naso-orbito-ethmoid fractures.5 They reported
spontaneous ventilation of the sinus in five of seven patients. Two patients had persistent obstruction requiring an
endoscopic frontal sinusotomy. At the time of publication,
these two patients had adequate sinus ventilation (at 21 and
25 months), and no patients had recurrent infection or mucocele formation (mean follow-up, 17 months). However,
endoscopic frontal sinusotomy following frontal recess
trauma is technically challenging. This approach should
only be considered in reliable patients and should be reserved for surgeons with extensive experience in both endoscopic sinus surgery as well as open approaches to frontal
sinus fractures.

Anterior table fractures (Figure 1)

Nondisplaced (1-2 mm) anterior table fractures can be
observed with little risk of long-term morbidity. Fractures
with greater displacement (2-6 mm) present little risk of
mucocele formation; however, the risk of an esthetic deformity increases. Although a surgical repair may be necessary, a traditional coronal approach may result in an iatrogenic deformity (alopecia) more severe than the injury

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.

Posterior table fractures (Figure 1)

The treatment algorithm for posterior table fractures is
complex due to the risk of CSF leak, meningitis, and mucocele formation.4,8 If the posterior table is minimally displaced (less than one table width) and no CSF leak is


Frontal Sinus Fractures

Figure 2 Surgical approach for frontal sinus trephination. (Inset)

Cutting burr used to enter the frontal sinus. (Color version of figure
is available online.)

present, the patient may be observed. If a CSF leak is

present, 1 week of observation is indicated; approximately
50% will resolve spontaneously.4 If the leak is persistent,
open reduction, repair of the leak, and sinus obliteration is
indicated. Fractures with significant posterior table displacement (greater than 1 table width), no CSF leak, and
mild comminution should be treated with sinus obliteration.
The most severe injuries are those with a frank CSF leak
and moderate to severe comminution. In these instances,
sinus obliteration is indicated. If the injury results in disruption of more than 25% to 30% of the posterior table,
sinus cranialization should be considered.8

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

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.

Endoscopic anterior table repair

This technique is limited to isolated anterior table frontal
sinus fractures. The repair is generally performed 2 to 4
months after the injury, when all forehead swelling has
resolved and an accurate assessment of any esthetic deformity can be made. Not all anterior table fractures are appropriate for this technique. Injuries with severe comminution and marked mucosal injury may require open reduction
or even obliteration. Fractures that extend inferiorly over the
orbital rim can be difficult to visualize endoscopically, and
may also require an open repair.
If the patient is seen acutely, the reasoning and indications for a delayed repair must be explained (i.e., observation to confirm that an esthetic deformity is present and the
fact that an endoscopic repair can avoid a coronal incision).
It should be articulated to the patient that a traditional open
reduction cannot be performed secondarily. Although the

Figure 3 Scalp incisions used for endoscopic repair of frontal

sinus fractures. The working incision is larger and located directly
above the injury. The endoscope incision is smaller and located
approximately 6 cm medially. (Reprinted with permission.7)
(Color version of figure is available online.)


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

Figure 4 Illustration of an endoscopic, subperisteal dissection

for exposure of a frontal sinus fracture.

risk of mucocele is very low, this should also be discussed.

Appropriate consent is obtained for the procedure including
the risks of bleeding, infection, paresthesias, alopecia, poor
esthetic result, and possible need for open approach if an
endoscopic repair cannot be performed.
The surgical technique is similar to a brow lift.9 A 3to 5-cm parasagittal working incision should be placed
above the fracture, 3 cm behind the hairline, and carried
through the periosteum onto bone (Figure 3). Care should be
taken to avoid excessive trauma to the hair follicles. Local
vasoconstriction agents should be used, and electrocautery
should be avoided if possible. The incision length should be
kept to a minimum, but this will vary depending on the size
of the fracture and implant to be inserted. A 1- to 2-cm
subperiosteal endoscope incision is then placed at the
same height, 4 to 6 cm medial to the working incision. In
patients with a prominent forehead or receding hairline, the
incisions may need to be closer to the hairline to allow
visualization around the forehead curvature.
Using endoscopic brow lift instrumentation and external
palpation, a directed subperiosteal dissection is performed
down to the level of the fracture. A 4.0-mm, 30-degree
endoscope (with rigid endosheath and camera) is inserted
through the endoscope incision to visualize the optical cavity. A large endosheath guard is recommended to maintain
a generous optical cavity. Under direct visualization, the
periosteum is then carefully elevated over the defect using
an endoscopic brow lift elevator (Figure 4). The supraorbital
and supratrochlear neurovascular pedicles may be visible at
the orbital rim. Caution should be used to avoid excessive

traction, which can result in postoperative paresthesias. The

dissection is generally easy, and there is little risk of entry
into the sinus because the fracture has healed. Once the
limits of the fracture have been visualized, a 0.85-mm-thick
porous polyethylene sheet is trimmed to approximate the
defect. The superior edge is then marked with a pen to
maintain orientation endoscopically during insertion. The
implant is inserted through the working incision and manipulated both internally (with instruments) and externally
(with fingers) above the defect (Figure 5A). Once the implant is in place over the fracture, the size and shape are
evaluated and it is removed to be trimmed and refined. The
process is repeated until the diameter of the implant is
approximately 2.0 to 3.0 mm larger than the defect. At
times, the author has sutured two to three layers of polyethylene sheeting together in an inverted pyramid shape to
more accurately fill deeper defects. Once the implant is appropriately fashioned, a 25-gauge needle is passed through the
skin over the fracture and endoscopically visualized to determine the best site for a percutaneous incision and screw
placement. Optimal incision placement will allow for
screws to be placed on either side of the implant through a
single incision. Larger implants may require two stab incisions. Once the appropriate site has been determined, a #11
blade is used to make a 2-mm, through-and-through stab
incision. A 1.7-mm, self-drilling screw (length 4-7 mm) is
passed through the stab incision, through the edge of the
implant, and into stable bone peripheral to the fracture edge
(Figure 5B). The screw must be securely attached to the
screwdriver to avoid dislodging the screw as it passes
through the soft tissue. The screw must be placed at least 1.0
mm away from the implant edge or it may tear. If the
implant remains unstable after the first screw, a second
screw is placed on the contralateral side. The scalp incisions
are then closed in layers, and a pressure dressing is applied.

Open reduction and internal fixation

Anterior table fractures that cannot be observed or managed endoscopically may require open reduction and internal fixation. The patient is consented for the procedure,
including the risks of bleeding, infection, paresthesias,
headache, CSF leak, orbital injury, diplopia, meningitis,

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.


Frontal Sinus Fractures


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.

external deformity, and late mucocele formation. In patients

with longer hair (at least 3-4 cm), the author prefers a
zig-zag incision placed 4 to 6 cm behind the hairline (Figure
6A). The zig-zag pattern allows gravity to pull the hair
down and cover the transverse arms of the incision. The hair
need not be shaved but can be banded instead. The application of a water-based lubricant to the hair facilitates separating the hair and rapid application of the rubber bands
(Figure 6B). If the patient wears very short hair, the zig-zag
pattern only lengthens and accentuates the incision. In these
patients the traditional straight line, coronal incision works
equally well and is easier to perform (Figure 7). If a straightline incision is used, some type of marker should be placed
along the incision to assist with symmetric closure of the
scalp. Some options include small methylene blue tattoos
placed on opposite sides of the incision with a 21-guage
needle or placement of a small widows peak in the
midline (Figure 7). In patients with male pattern baldness,

Figure 7 Illustration of a traditional coronal incision, with a

widows peak to assist with symmetric wound closure.

the incision can be moved posteriorly to camouflage it

within the hair. This may necessitate a slightly more extensive longer lateral dissection to allow forward rotation of the
scalp flap. Mid-forehead, brow, and gull wing incisions
should be avoided due to the prominent scar and associated
forehead anesthesia. Whichever incision is chosen, the technique should be described to the patient in detail; particularly to those with male pattern baldness.
In the operating room, the bed is turned 180 away from
anesthesia, and corneal shields or temporary tarsoraphies
are placed. Towels are stapled to the scalp just behind the
incision line. An adherent plastic suction pouch is applied at
the leading edge of the towel to collect blood and minimize
spillage onto the surgeons. If large lacerations are present on
the forehead, they should be explored and used to assist with
fracture repair. Significant extension of forehead lacerations
should be avoided. The greatest blood loss occurs with the
initial incision and wound closure. When possible, generous
amounts of a vasoconstrictor agent should be injected in a
subgaleal plane before surgery. The scalp is then incised
from one temporal line to the other. The incision passes
through the skin and subcutaneous tissues. Two doubleprong skin hooks are used to retract the skin away from the
skull. This elevation will protect the underlying pericranium
from inadvertent injury. A scalpel is used to incise the galea.
Once the galea is violated, air will rapidly enter into the
subgaleal plane, and there will be an obvious separation
between the galea and the pericranium. The skin hooks are
then moved medial and lateral as the skin incision is completed. Bleeding from larger vessels should be tied off
individually. Electrocautery should be used sparingly as it
may injure hair follicles. Rainey clips can be used for
hemostasis. Finger dissection can then be used to elevate
2 to 3 cm on either sides of the incision, taking care to
maintain the integrity of the pericranium.
The lateral dissection demands a thorough understanding
of temporal anatomy. The initial incision is extended below
the temporal line and behind the helix on one side (Figures
6A and 7). The incision should be carried through the


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

temporoparietal fascia (superficial temporal fascia) and onto

the temporalis muscle fascia (deep temporal fascia). This
incision traverses the temporal artery and vein, which
should be controlled by using a suture ligature or Rainey
clips. The appropriate depth can be confirmed by placing a
small (1-2 mm) nick in the temporalis muscle fascia and
confirming the presence of dark red temporalis muscle beneath. The flap is then elevated anteriorly using blunt finger
dissection or gauze, with intermittent use of the scalpel. The
integrity of the temporoparietal fascia must be maintained, as it
contains the frontal branch of the facial nerve (Figure 8). As
the temporal flap is elevated, it is joined with the central
dissection (medial to the temporal line) by sharply incising
the fibers along the temporal line. Once again, special attention must be used to avoid injury to the temporal nerve.
If necessary to help ease tension on the flap and gain lateral
exposure, sharp dissection can be performed over the posterior aspect of the frontozygomatic suture line toward the
zygomatic arch. Finally, the temporal dissection is completed on the contralateral side.
The scalp is then rotated forward, and blunt or sharp
dissection can be used to elevate the subgaleal flap to a level
3 to 4 cm above the orbital rims. Care is taken to avoid
injury to the supraorbital and supratrochlear neurovascular
pedicles. The frontal bone can then be exposed by incising
the periosteum directly above the fracture. However, it is
generally wise to maintain the integrity of the vascularized
pericranial flap, as it can be used for frontal recontouring,
dural repair, or obliteration of the sinus. The pericranial flap
can be elevated by placing an incision through the periosteum, parallel and 2 cm behind the initial scalp incision.
This is then joined with lateral incisions 2 cm cephalad to
the temporal line (Figure 9). Although periosteal lacerations

Figure 8 Illustration of a coronal flap in the temporal region.

The temporal branch of the facial nerve lies within the temporoparietal fascia and must be protected.

Figure 9 Illustration of pericranial flap being incised. Note that

the extra length can be obtained by starting the flap behind the
scalp incision.

may exist at the fracture site, a careful dissection will

usually maintain an intact vascular supply and provide a
lengthy flap for reconstruction (Figure 10). More extensive
inferior dissection exposing the orbital rims and roof necessitates release of the supraorbital neurovascular pedicle.
Release of the neurovascular pedicle from the supraorbital
notch requires a methodical subperiosteal dissection to
avoid nerve injury or exposure of orbital fat. If a true
foramina is present, it is necessary to use an osteotome to
release the pedicle. A 2- to 3-mm osteotome is placed
laterally in the foramina and angled toward the lateral orbital wall. A malleable retractor protects the orbit, and
mallet is used to fracture out the notch (Figure 11, inset).
This is repeated on the medial side of the foramina. A
careful subperisteal dissection across the orbital roof will
allow release of the neurovascular pedicle.

Figure 10 Photograph of a pericranial flap after elevation.

(Color version of figure is available online.)


Frontal Sinus Fractures

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.

After complete exposure of the frontal bone, attention

should be turned to fracture reduction. Reduction of noncomminuted, compressed fractures can be extremely challenging. When the convex surface of the frontal bone is
fractured, it goes through a compression phase before it
becomes concave (Figure 12A). Fracture reduction will
require enough force to pull the bone fragments back
through the compression phase (Figure 12B). It may be
necessary to remove a bone fragment, release the tension,
and make room for reduction. If comminution exists or bone
segments overlap at the fracture site, a small bone hook can
be insinuated between the fragments to assist with fracture
elevation. Another technique is to place a 1.5- to 2.0-mm
screw in the depressed segment, grasp the screw with a
heavy hemostat, and pull upward to reduce the segment.
Every attempt should be made to keep the majority of the
fragments in place, as this will allow for a more accurate
Once the bone fragments are mobilized, the sinus mucosa should be evaluated. A 30 endoscope can be helpful to
visualize the sinus and the nasofrontal recess through a
limited bone defect. Mucosa involved in a fracture line
should be removed to avoid entrapment. The fragments are

Figure 12 (A) Illustration of frontal sinus fracture dynamics.

(B) Illustration of frontal sinus fracture repair. Note that the
bone fragments must be pulled back through the compression
phase to complete the reduction. (Reprinted with permission.7)
(Color version of figure is available online.)

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.

Frontal sinus obliteration

More severe injuries may require frontal sinus obliteration. This involves exposure of the entire sinus, fastidious
removal of all sinus mucosa, and obliteration of the cavity
with autologous materials. Many different materials have
been used for sinus obliteration, including abdominal fat,
cancellous bone, muscle, pericranium, and spontaneous osteoneogenesis with auto-obliteration.4 The author prefers

Figure 13 Photograph of technique used for resuspension of the

temporal soft tissues. This avoids late ptosis of the forehead and
upper midface. (Color version of figure is available online.)


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

Figure 14 Use of a bipolar to demarcate the boundary of the

frontal sinus.

abdominal fat. As previously mentioned, hydroxyappatite

cement should be avoided due to the unacceptably high risk
of infection and extrusion.
The patient is given informed consent, including the risks
of bleeding, infection, paresthesias, brain injury, CSF leak,
meningitis, diplopia, visual loss, external deformity, and
late mucocele formation. A coronal flap is used to expose
the fracture as previously described. The full pericranial flap
should be maintained to repair any CSF leak, dural defect,
or obliterate the sinus (Figure 10). After complete exposure,
all anterior table bone fragments should be removed and
kept moist. Placing the fragments atop a drawing of the
fracture will help maintain the anatomic orientation of each
segment before the repair. With isolated fractures, it is often
necessary to perform a frontal sinusotomy or remove the
remainder of the anterior table. Localization of the sinusotomy cuts can be performed in several ways. Historically a
6 foot penny Caldwell x-ray was used (i.e., anterior
posterior Caldwell x-ray with the patient placed 6 feet from
the x-ray tube). However, current digital radiograph technology has made this x-ray very difficult to obtain. Intraoperative navigation is accurate but requires a specialized
scan and navigation hardware. Alternatively, one tine of a
bipolar cautery can be placed on each side of the anterior
table. The internal tine is then used to walk around the
periphery of the sinus, while the outer tine is used to mark
an outline the sinus using a bovie electrocautery (Figure 14).
A third technique involves application of a light source into
a fracture line; this transilluminates the periphery of the

Figure 15 Preapplication of hardware, spanning the proposed

osteotomy site. This allows for accurate repositioning of the bone
flap despite the bone loss from the osteotomy. The plates are then
rotated out of the osteotomy site.

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-

Figure 16 Illustration of a frontal sinusotomy performed with a

router bit. (A) Initially, perforations are made into the sinus. These
are then joined into a long osteotomy. (B) Note that the drill must
be held at an angle to reduce the risk of intracranial entry.


Frontal Sinus Fractures

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.

Frontal sinus cranialization

The most severe injuries with disruption of the posterior
table will require frontal sinus cranialization. Consultation
with a neurosurgical colleague is recommended. The surgical approach is identical to that described under frontal
sinus obliteration; however, maintaining the integrity of
the pericranial flap becomes more critical for dural repair
and control of CSF leaks. All free bone fragments from the

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.

ting capability of the bit can then be used to join the

perforations and complete the osteotomy (Figure 16A).
Care should be taken to avoid obliteration of the predrilled
miniplate holes while performing the osteotomy. Particular
attention should be paid to osteotomize the lateral orbital
rims and the glabella without injury to the supraorbital/
supratrochlear neurovascular pedicles. These osteotomies
can be performed with a B-1 bit or a 2- to 4-mm osteotome.
A curved 4-mm osteotome is then inserted obliquely through
the frontal osteotomy and used to break down any intersinus
septations. Finally, the anterior table is out-fractured and
hinged anteriorly.
After complete exposure of the sinus, the posterior table
integrity is evaluated. If it is stable and free of large defects,
sinus obliteration is acceptable. However, all sinus mucosa
must be meticulously removed from both the posterior and
anterior tables. The author prefers to start with a large (4-6
mm) cutting burr and move to small diamond burrs for
deeper in the sinus. Access to the deepest portions of the
sinus can be extremely challenging in patients with pronounced pnuematization. Special attention must be paid to
the deepest areas at the periphery of the sinus to assure
complete mucosal removal (Figure 17). After complete removal of the sinus mucosa, attention is turned to the frontal
recess. The mucosa of the frontal sinus infundibulum is
elevated and inverted into the frontal recess. A small tem-

Figure 18 (A) Photograph of an outer table calvarial bone graft

harvest with an osteotome. (B) Photograph of bone graft placed
into the frontal recess bilaterally. (Color version of figure is available online.)


Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

anterior and posterior table are removed and drilled free of

mucosa. Once the sinus is fully exposed, the dura should be
carefully dissected from the posterior table remnant with
Penfield elevators. The brain should be gently retracted and
any remaining portion of the posterior table removed using
straight and angled rongeurs. A drill is then used to smooth
the posterior table edge flush with the anterior sinus walls,
floor, and anterior cranial fossa. The frontal recess is occluded as previously described in frontal sinus obliteration. Simple lacerations of the dura can be repaired with
interrupted 5-0 nylon sutures and tissue glue. More complex
injuries may require neurosurgical debridement and closure
with a pericranial flap. When a pericranial flap is used, a
small bony defect must be fashioned just above the orbital
rims. This allows the flap to pass intracranially without
cutting off the blood supply. The anterior table is then
reconstructed using 1.0- to 1.3-mm microplates and mesh.
The bony disruption may be so severe that posterior table
fragments are required to reconstruction the anterior table. The
incision is closed as described under anterior table fractures.

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