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ENDOSCOPIC CRANIOMAXILLOFACIAL SURGERY

Volume 14 Number 1 February 2006

Contents

Preface Robert M. Kellman and E. Bradley Strong Condylar Fracture Repair: Use of the Endoscope to Advance Traditional Treatment Philosophy Reid V. Mueller, Marcin Czerwinski, Chen Lee, and Robert M. Kellman Traditional treatment of subcondylar fractures with maxillomandibular fixation often results in a malreduction and significant functional and aesthetic sequelae, including facial asymmetry, decreased jaw opening, and potential for late derangements of the temporomandibular joint. When used selectively, based on preoperative CT scans, the endoscopic technique will reliably restore condylar anatomy in nearly 95% of patients, thus obviating the consequences of malunion. Furthermore, unlike traditional open techniques no significant facial scarring or permanent facial nerve palsies have resulted. Thus, the authors strongly advocate endoscopic repair of adult condylar neck and subcondylar fractures that demonstrate displacement or dislocation and have adequate proximal bone stock to accept miniplate fixation. Endoscopic Repair of Orbital Floor Fractures D. Gregory Farwell and E. Bradley Strong Significant orbital trauma can result in orbital floor fractures with subsequent prolapse of the orbital contents into the paranasal sinuses. Prolapse of the periorbita can result in extraocular muscle entrapment, diplopia, enophthalmos, and even visual loss. Management of orbital floor fractures traditionally has been accomplished through transconjunctival and subciliary incisions. These approaches provide adequate visualization and cosmetically acceptable scars. Unfortunately, post-operative lid malposition can occur in a small percentage of cases. Another limitation is easy visibility of the posterior orbit, which often is obscured by prolapsed orbital fat. In light of these limitations, some surgeons have begun to evaluate an endoscopic approach to orbital floor fractures. The endoscopic approach offers a hidden incision, improved fracture visualization, and avoidance of post-operative eyelid malposition. This article reviews the indications, technique, and potential complications of endoscopic orbital blow-out fracture repair.

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Endoscopic Approach to Medial Orbital Wall Fractures John S. Rhee and Chien-Tzung Chen Repair of medial orbital wall fractures can be challenging with traditional open techniques. This article describes different endoscopic-assisted approachestranscaruncular and intranasalwhich have been used to successfully repair these fractures. Endoscopic Repair of Anterior TableFrontal Sinus Fractures E. Bradley Strong and Robert M. Kellman Frontal sinus fractures account for 5% to 15% of all maxillofacial injuries. Historically, a large percentage of these injuries were treated aggressively because of the long term risk of mucocele formation. This required a coronal incision with the associated surgical sequelae including a large scar, alopecia, and paresthesias. In light of these sequelae and recent advances in CT diagnosis and endoscopic treatment of mucoceles, some surgeons are starting to manage isolated anterior table fractures through an endoscopic approach. The endoscopic repair significantly reduces patient morbidity because it requires only 2 small incisions behind the frontal hairline. The endoscopic approach can be divided into two types: acute fracture reduction (covered elsewhere in this issue) and fracture camouflage. This article reviews the indications, techniques, and advantages of frontal sinus fracture camouflage. Endoscopic Management of Frontal Sinus Fractures Kevin A. Shumrick Endoscopes have had a profound effect on nearly every surgical specialty over the past 20 years. Using endoscopic approaches, excellent visualization of the surgical site can be achieved while avoiding extensive external incisions, thus, dramatically reducing morbidity compared with traditional surgical approaches. This article outlines the state of the art with regard to the use of endoscopes for managing frontal sinus fractures, which are one of the most common fractures treated with endoscopic techniques. The Rationale and Technique of Endoscopic Approach to the Zygomatic Arch in Facial Trauma Marcin Czerwinski and Chen Lee The reliable form and strategic position of the zygomatic arch make it a valuable landmark in midfacial trauma management. The benefits of arch repair have been used infrequently, mainly because traditional coronal access to this structure is fraught with undesirable sequelae. Endoscope-assisted zygomatic arch realignment and fixation allow anatomic repair without sustaining the drawbacks of extensive access incisions. The relative importance of this approach increases with trauma complexity, being most useful in Le Fort III and complex zygoma injuries. Endoscopic Approach for Mandibular Orthognathic Surgery Maria J. Troulis, Jose L. Ramirez, and Leonard B. Kaban The field of minimally invasive surgery is defined as the combination of surgical innovation with modern technology. This article describes the history of surgery and newer developments in endoscopic surgery for mandibular orthognathic surgery.

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Endoscopic Approaches to Maxillary Orthognathic Surgery Dennis Rohner and Vincent K.L. Yeow Endoscopically assisted surgery has become an essential component in many fields of surgical specialties. The implementation of this technique to craniofacial and maxillofacial surgery is a recent development. Endoscopic approach to subcondylar mandible fractures has been established as reliable surgical method. Index

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ix

FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA

Facial Plast Surg Clin N Am 14 (2006) ix

Preface

Endoscopic Craniomaxillofacial Surgery

Robert M. Kellman, MD Department of Otolaryngology and Communication Sciences State University of New York Upstate Medical University 750 E. Adams Street Syracuse, NY 13210, USA E. Bradley Strong, MD Department of Otolaryngology University of California, Davis School of Medicine 2521 Stockton Blvd., Ste 7200 Sacramento, CA 95817, USA E-mail addresses: kellmanr@upstate.edu (R.M. Kellman) edward.strong@ucdmc.ucdavis.edu (E.B. Strong)

Robert M: Kellman, MD E: Bradley Strong, MD Guest Editors

Endoscopes for use in the head and neck were brought to the United States in the 1980s for use in endoscopic sinus surgery. Since that time, endoscopic applications in the head and neck have continued to grow, most recently in the area of facial trauma and reconstruction. This is a rapidly expanding area of clinical interest, and research into new techniques continues. With this in mind, this issue describes individual techniques used by various surgeons in applying endoscopes

to the repair and repositioning of the bones of the craniomaxillofacial skeleton. The authors contributing to this issue of Facial Plastic Surgery Clinics of North America are recognized leaders in facial trauma, reconstructive surgery, and facial endoscopy. This issue reviews the most up-todate endoscopic applications, including fractures of the subcondylar region, orbit, frontal sinus, zygomaticomaxillary complex, and elective orthognathic surgery.

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FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA

Facial Plast Surg Clin N Am 14 (2006) 19

Condylar Fracture Repair: Use of the Endoscope to Advance Traditional Treatment Philosophy
Reid V. Mueller, MDa,*, Marcin Czerwinski, Robert M. Kellman, MDd
& & &

MD

, Chen Lee,

MD

&

Regional anatomy and the effect of maxillomandibular fixation Role of the endoscopetreatment indications Preoperative planning Fracture anatomy Radiographic imaging Operative technique Endoscopic equipment Repair sequence Maxillomandibular fixation

&

& &

Exposure Reduction Fixation Bailout Postoperative regime Results Fracture demographics Operative details Outcomes Summary References

Treatment of facial fractures has progressed significantly over the last 25 years largely because of the pioneer efforts of Paul Manson and Joseph Gruss. The systematic principles of wide exposure, visualized anatomic reduction, rigid internal fixation, and primary bone grafting of critical size defectsintroduced by these surgeons revolutionized the field of craniomaxillofacial surgery. The results achieved using their techniques far surpassed the outcomes of closed reduction and nonrigid fixation. Until recently, however, this standard of care was not applied to all areas of facial trauma; most notably omitted were the zygomatic arch and the mandibular condyle.

Closed treatment of mandibular fractures with maxillomandibular fixation (MMF) has a long and successful history, but it is not without significant morbidity. The best results have been achieved in skeletally immature children, where condylar remodeling often can restore condylar anatomy to near normal, even in the face of little or no fracture reduction. Despite almost miraculous condylar remodeling in children, the outcomes in adults have not been uniform, and a significant percentage suffers long-term aesthetic and functional problems [15]. Few studies exist comparing similar fractures treated by open versus closed methods. Most show equal or better outcomes after open treat-

Oregon Health Science University, Mail Code L352A, 3181 Southwest Sam Jackson Park Road, Portland, OR 97201, USA b Montreal Childrens Hospital, C1139, 2300 Tupper Street, Montreal, Quebec, Canada, H3H 1P3 c Sacre-Coeur Hospital, 5000 boul. Gouin West, Montreal, Quebec, Canada, H4J 1C5 d Department of Otolaryngology and Communication Sciences, State University of New York Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, USA * Corresponding author. E-mail address: reid@reidmueller.com (R.V. Mueller).
1064-7406/06/$ see front matter 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.fsc.2005.10.004

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Mueller et al

ment despite the fact that more severely injured patients tended to undergo open treatment [615]. Patients treated with an open approach had better restoration of facial symmetry, faster recovery of jaw motion, and less chronic pain. The most important long-term complications of closed treatment are internal derangement and persistent malocclusion, the latter reported in up to 28% of patients [1517]. The reluctance to use open reduction and internal fixation of condylar fractures stemmed from the belief that these injuries do well with closed treatment using MMF and because the open technique was challenging and associated with significant morbidity. All surgical approaches for the open treatment of condylar fractures require a facial incision, and nearly all will result in a perceptible scar [10], with up to 4% reporting an unsightly scar [7]. Close proximity of the facial nerve to the condyle compromises access to the fracture segment and makes the dissection tedious. Efforts to improve surgical access may result in either direct facial nerve injury or a traction injury during retraction. The risk of permanent facial nerve injury reported in 21 different series of open approaches, comprising 455 patients, averages 1%, while the risk of transient palsy ranges from 0% to 46% (mean 12%) [11,14,15,1827]. An open intraoral approach, designed to circumvent these drawbacks, has been described, but it rarely is used because of very poor visualization and difficult hardware fixation [28]. The use of the endoscope to treat condylar injuries was a natural extension of minimally invasive techniques for managing craniomaxillofacial trauma. Most surgeons accept, on an intellectual level, that fracture reduction and rigid fixation with restoration of anatomy are laudable goals if that can be achieved without undue morbidity. Endoscopic assistance allows the surgeon to produce anatomic fracture alignment, and to avoid the negative sequelae of condylar malunion. The endoscopic approach described here has the potential to reduce morbidity by limiting scars, reducing the risk to the facial nerve, and eliminating the need for MMF, all while embracing the accepted advantages of anatomic reduction and rigid fixation. The decrease in morbidity associated with the endoscopic approach may expand the indications for reduction and rigid fixation in the future.

Regional anatomy and the effect of maxillomandibular fixation

Any displaced fracture of the condyle will have some degree of fragment overlap resulting in shortening of the posterior ramal height [29]. This is

exacerbated by the normal resting tone of masticatory, suprahyoid, and infrahyoid musculature. As the fragments overlap, the mandible rotates such that there is premature posterior occlusal contact and an anterior open bite. In addition, this causes an unappealing loss of chin projection at the pogonion. Only with effort, as during chewing, are proper occlusion and chin position forcefully restored [30]. Furthermore, ramal shortening causes a decreased radius of mandibular rotation that is visible as ipsilateral jaw deviation during motion [29]. Attachments of the lateral pterygoid muscle usually place the condylar fragment into a flexed posture. This has been the case in 80% of adult condylar fractures in the authors experience. In addition, the lateral ptygeroid often will cause inclination of the condylar head medially, further shortening the ramal height. This results in premature contact with the anterior wall of the glenoid fossa, limiting interincisal opening to initial hingetype motion only. The additional 15 to 20 mm of opening available through translational movement never is achieved fully. The complex relationships of the temporomandibular articulation allow only minimal imprecisions. A malunited condyle alters these precise relationships, resulting in significant aberrations in joint dynamics that have a marked potential to produce late internal derangement. In addition, because of the bilateral interdependence of the craniomandibular articulation, the contralateral condyle sustains excessive biomechanical loads and similarly is predisposed to early degenerative changes [31]. Extended experience and careful analysis of closed treatment of condylar injuries using MMF have shown that fracture reduction rarely occurs. Instead, centric occlusion is forced through neuromuscular adaptation to the condylar malunion at the temporomandibular joint. Malunion often results in shortening of the posterior ramus because of interfragmentary overlap, abnormal orientation of the condylar fragment, and alteration of temporomandibular joint biomechanics, all of which carry significant functional and aesthetic consequences. When assessing the shortcomings of closed treatment, the significant independent morbidities associated with MMF often are overlooked because of the surgical simplicity of its application. The prolonged period of immobilization using MMF necessitates a lengthy postoperative regimen of muscular and occlusal rehabilitation to improve muscle function, condylar movement, and range of motion. Studies in rhesus monkeys have demonstrated loss of interincisal opening and maximal stimulated bite force after MMF [32,33]. Addition-

Condylar Fracture Repair

ally, comparisons of patients with condylar neck fractures randomized to open versus MMF treatment have demonstrated that patients after MMF have decreased range of motion necessitating long periods of physiotherapy to regain their premorbid function [7,15]. Many patients find MMF uncomfortable, and who have dementia or psychiatric diagnosis simply may not tolerate the procedure. It is difficult to maintain good oral hygiene with MMF; orthodontic treatment must be delayed during the period of MMF, and those who have seizure disorders or alcoholism are at risk for aspiration and death.

tive, and geometric constraints for instruments. Consequently, determination of the precise fracture geometry preoperatively is mandatory so that a decision can be reached whether an endoscopic approach is feasible. There are four specific fracture attributes that will help to make the decision: location, displacement, comminution, and relationship of the condylar head to the fossa. Fracture location Condylar fractures are classified as head (intracapsular), neck (below the head and above the sigmoid notch), and subcondylar [Fig. 1] [34]. Intracapsular fractures and high neck fractures are not treated using the endoscopic approach, because there is no possibility of applying fixation. In addition, surgical exposure may lead to devascularization of the condylar head. Fractures of the condylar neck are suitable for endoscopic treatment if sufficient bone stock is present proximally to accept two screws for miniplate fixation. Endoscopic repair of subcondylar fractures is generally the easiest. Fracture displacement Displacement refers to the position of the condylar fragment relative to the ascending ramus. Fractures where the condylar segment is located medially are termed medial override, those where it is lateral, lateral override [Fig. 2]. The latter group forms the vast majority of adult condylar injuries treated at the authors centers. Displacement is an important variable guiding the initial approach to endoscopic treatment. Lateral override fractures are especially amenable to repair because of easier fragment visualization, manipulation, and hard-

Role of the endoscopetreatment indications

The goals of condylar fracture treatment are: painfree mouth opening with interincisal distance beyond 40 mm, good excursion of the jaw in all directions, restoration of preinjury occlusion, stable temporomandibular joints, and good symmetry [30]. In most circumstances, anatomic reduction and rigid fixation of the condyle are required to satisfy these objectives by restoring preinjury ramal height, upright posture of the condylar head ,and complex anatomical relationships of the temporomandibular articulation. Patients with condylar process fractures are selected for endoscopic-assisted reduction and fixation based on age, location of fracture, degree of comminution, direction of proximal fragment displacement, dislocation of condylar head, concomitant medical or surgical illness, and patient choice. Condylar fractures in prepubertal patients do not require anatomic reduction because of the great potential for rehabilitation through growth and remodeling. Fractures of the condylar head generally do not demonstrate significant loss of posterior ramal height and can be expected to do relatively well with traditional methods. Fractures that do not allow for the application of at least two holes of a 2.0 mm plate are likewise not amenable to endoscopic repair. Finally, open treatment is not advocated for nondisplaced, nondislocated fractures, as normal biomechanical relationships are unaltered.

Preoperative planning Fracture anatomy

The endoscopic technique of condylar fracture repair relies on visual confirmation of fracture fragment reduction and sufficient length of the extracapsular segment for the placement of fixation hardware. Endoscopic approaches by their very nature have a limited optical cavity, distorted perspec-

Fig. 1. Condylar fractures can be classified as head (intracapsular), neck (below the capsular attachment and above the sigmoid notch), and subcondylar (passing through the nadir of the sigmoid notch).

Mueller et al

Fig. 2. Coronal (above) and three-dimensional (below) CT reconstructions of a patient who sustained bilateral condylar fractures. The fracture of the right condyle demonstrates lateral override, that of the left, medial override. Generally lateral override fractures are the easiest to approach endoscopically, whereas medial override injuries are first reduced to lateral override to facilitate repair.

ware fixation. In contrast, medial override injuries are more difficult to reduce endoscopically, as the telescoped ascending ramus obscures visual access to the lateral surface of the condylar fragment and greatly impairs manipulation because of physical obstruction. The authors simplify the treatment of medial override injuries by first reducing them to the lateral override category. Nondisplaced, nondislocated fractures signify the presence of sufficient periosteal support for stability and do not require open treatment. Fracture comminution Significant comminution is a relative contraindication to endoscopic repair as this technique relies largely on visualization of the fracture line for anatomic reduction and some degree of interfragmentary opposition for solid fixation. During reduction, the anterior and posterior borders of the fracture line are used as anatomic landmarks to assess accurate reduction. Comminuted fractures often will have fracture fragments that involve the border and thereby obscure these landmarks. Microcomminution will obscure the interdigitation of small irregularities along the fracture line that ordinarily assist in precise reduction. Unfortunately, the visual limitations of endoscopy make reliable assessment of reduction deceptively challenging in the face of comminution.

A minor degree of comminution is not considered a contraindication. Condylefossa relationship Fractures associated with nondislocated condylar heads are the most favorable for endoscopic repair. A displaced condylar head without true dislocation usually can be relocated into anatomic position easily; however, those fractures with true dislocation of the condylar head are significantly more challenging.

Radiographic imaging
Accurate radiographic imaging is necessary to reliably assess the feasibility of endoscopic repair and to formulate a precise treatment strategy by identifying fracture location, direction of displacement, and degree of comminution [Fig. 3]. The accuracy of modern helical CT scans has surpassed panoramic tomography for detecting mandibular fractures. Using 1 mm collimated images (with a pitch of two) and 1 mm axial images reconstructed on every second image, in 2001, Wilson and colleagues compared helical CT scanning with panoramic tomography in detecting 73 mandibular fractures in 42 consecutive patients and correlated the results with known surgical findings. Helical CT scan detected 100% of the fractures, while panoramic tomography detected only 86%. In six missed frac-

Condylar Fracture Repair

Maxillomandibular fixation
If MMF was used for repair of an extracondylar fracture, it is removed. The use of tight wire maxillomandibular fixation will prevent distraction of the fracture and lock the displaced condyle in a malreduced position. The authors routinely employ rubber band anterior MMF that facilitates fracture repair by maintaining occlusion but permitting realignment of fracture fragments. Remember that the reduction of the fracture is a visual reduction and not based on occlusion.

Fig. 3. Three-dimensional CT scan of a left condylar fracture demonstrating characteristics amenable to the endoscopic repair technique: adequate proximal bone stock, no comminution, lateral override, and no dislocation out of the condylar fossa.

Exposure
An intraoral incision along the oblique line of the mandible is made. The endoscopic cavity is created by elevating the periosteum off the lateral aspect of the ascending ramus. The assistant may hold the endoscope while the surgeon uses the periosteal elevator and suction to continue the dissection proximally to reveal the condylar fragment. A common mistake is to inadvertently dissect under (or medial to) the proximal fragment. This occurs because of a failure to appreciate the degree of lateral override and coronal plane angulation of the proximal fragment. Once the proximal fragment is identified, the subperiosteal dissection continues on the lateral surface up to the joint capsule, or a sufficient distance to place the fixation hardware. Transcutaneous stab incisions for screw placement are made directly over the palpated fracture line at the posterior border of the mandible. Gentle, blunt hemostat dissection through the parotid gland and masseter muscle is performed to avoid injury to the facial nerve.

tures, the surgical management was altered by the additional information provided from the CT scan. In one patient, the nature of a dental root fracture was seen better on panoramic tomography [35]. In the authors experience, fine cut axial computed tomography scans with three-dimensional reformatting provide the most precise illustration of these variables. The three-dimensional reformatting is not accurate for detecting fracture detail but rather used to aid in the visualization of the fracture, and forming a clear mental picture of what will be required for reduction.

Operative technique Endoscopic equipment

At their centers, the authors use a 4 mm diameter 30o angle endoscope, a 4 mm endoscopic brow lift sheath (Isse Dissector Retractor, Karl Storz, Germany) that maintains the optical cavity, and a video system. Standard mandible fracture repair instruments are used in addition to the Subcondylar Ramus fixation set from Synthes (Paoli, Pennsylvania), which provides many specialized instruments facilitating the endoscopic technique.

Reduction
To facilitate repair, medial override injuries are reduced initially into lateral override by placing a curved elevator medial to the proximal fragment while strongly distracting the fracture so as to allow the proximal fragment to be displaced to the lateral surface of the ascending ramus. If the fracture already is a lateral override, then interfragmentary realignment is achieved by distracting the distal segment through mechanical traction at the mandibular angle or placement of a 3 mm posterior occlusal spacer. The proximal segment can be reduced by bringing the condylar fragment out if its flexed position and applying medially directed pressure using a trocar inserted through the stab incisions. Removal of traction or posterior occlusal wedge then will permit the rubber band fixation to temporarily impact the fracture interfaces together and often maintain reduction while fixation is applied [Fig. 4].

Repair sequence
If present, extracondylar fractures are addressed first using standard open reduction and internal fixation techniques to restore an intact mandibular arch. The rigid arch is then helpful in manipulating fracture fragments to achieve adequate reduction. Injection at the intraoral incision site and along the lateral aspect of the ascending ramus with 1:200,000 epinephrine solution will decrease bleeding into the optical cavity.

Mueller et al

Fig. 4. (A,B) Preoperative coronal CT scan of a patient with bilateral condylar fractures and an endoscopic view of the left condylar fracture after reduction. (C,D) Postoperative coronal CT and a view of the anatomically reduced and rigidly fixated left condylar fracture using the endoscopic technique.

Fixation
Screws are introduced through the transcutaneous trocar. A miniplate is fixated along the posterior border of the ascending ramus, taking advantage of its thick cortical bone and flat surface [see Fig. 4]. At least two screws are placed in each fracture segment to ensure solid fixation. Self-drilling screws have not been useful and often are a significant liability. Several authors have reported fracture of single miniplates; the authors advocate placement of two miniplates whenever possible. In general, the fixation plate is attached to the condylar fragment first. This allows the plate to act as a handle to position the condylar fragment into reduction. After reduction is achieved, the screws are placed into the mandibular portion. Some groups have found that placing a plate near the sigmoid notch or anterior portion of the fracture first simplifies placement of the posterior border plate. Ultimately, each fracture will dictate the best approach. No matter the method, a meticulous inspection of the visual landmarks of anatomic reduction is imperative. The sigmoid notch and posterior border of the mandible must be visualized to ensure that reduction has occurred. If the reduction is not correct, then the distal screws should be removed and the condylar fragment repositioned. Following hardware placement, rubber band MMF is released and the mandible ranged in all excursions to ensure reproducible preinjury occlusion and stability of fixation.

Bailout
In a small number of attempted cases the endoscopic repair will not be possible because of inadequate proximal bone stock, excessive comminution, or inability to place fixation. In this circumstance, surgeons should resort to the method of condylar repair that they would use if the endoscopic technique was not available.

Postoperative regime
All patients leave the operating room without MMF and are kept on a soft diet for 6 weeks.

Results
The results depicted in the following sections represent the combined experience of the senior authors from three university medical centers: the Oregon Health and Science University Hospital Center, San Francisco General Hospital, and State University of New York Upstate Medical Center.

Fracture demographics
One hundred thirty-five patients were treated using primary endoscopic condylar fracture repair. The proportion of patients with bilateral, unilateral, and isolated fractures is shown in Fig. 5. Fractures involving bones other than the mandible were excluded; thus the term nonisolated fracture refers to involvement of the condyle and another mandibular site. In total, 150 condylar fractures were

Condylar Fracture Repair

Outcomes
Bailout procedure Fourteen of 150 attempted endoscopic fracture repairs were aborted. The bailout procedure used in nine fractures was MMF. In these nine fractures, fracture reduction was achieved, but plate fixation was not possible because of the short condylar pole. Despite endoscopic fracture reduction and postoperative MMF, follow-up radiographs revealed loss of fracture reduction in all cases. Traditional open reduction and internal fixation techniques were used as the bailout procedure in the other five aborted endoscopic fractures. These were found to be exceptionally challenging surgical repairs, with persisting malreduction found in two fractures treated with traditional ORIF following aborted endoscopic procedures. Radiographic fracture reduction Plate fixation was achieved at primary endoscopic repair in 136 of 150 condylar fractures. Malreduction in 6 of these 136 condylar fractures, however, was found on early postoperative CT imaging. Four malreduced fractures were revised using secondary endoscopic procedures with successful correction of the malreduction. The other two malreductions were judged as minor and acceptable. Hardware failure (broken plate) with late loss of reduction occurred in two of the remaining 130 primarily fixated condylar fractures; no secondary procedures were performed. Mandibular function Postoperative dental occlusion and interincisal jaw opening were documented in 102 patients. Mal-

Fig. 5. Primary endoscopic condylar repair was attempted in 135 patients. Percentages of bilateral, unilateral, and isolated injuries are shown.

attempted at primary endoscopic repair. Of those, 13 displayed medial override of the proximal fragment, and in eight fractures, the condylar head was dislocated completely out of the glenoid fossa.

Operative details
Of the 150 condylar fractures, plate fixation was achieved at primary endoscopic repair in 136 (91%) [Fig. 6]. In 27 patients presenting with bilateral condylar fractures, 13 had both sides repaired using the endoscopic approach. Fourteen had only one side treated endoscopically, as the bone stock in the proximal fragment on the contralateral side was deemed insufficient on preoperative CT images to achieve fixation. In 75% of the fractures, the mean time required to accomplish endoscopic repair was less than 2 hours. The average duration for the last 30 cases was approximately 70 minutes.

Fig. 6. Completion rate of primary endoscopic condylar repair according to the fracture type. Solid bars represent the number of cases, in each category, where fixation was achieved during primary repair. Cross-hatched bars signify the number of cases where fixation could not be achieved using the endoscopic approach.

Mueller et al

occlusion was found in 3 of 102 patients. Interincisal jaw opening exceeded 35 mm in 96% of patients (98/102). Aesthetic appearance Scarring from endoscopic access portals was minimal in all cases. Facial height, chin projection, and a symmetrical appearance of the jaw line were restored in cases where fracture reduction was achieved successfully. Soft tissue complications There were no permanent facial nerve palsies. Two temporary palsies (one full and one involving the frontal branch only) occurred; both resolved completely and spontaneously. One soft tissue abscess was identified at a trocar portal and was treated uneventfully by incisional drainage.

Summary
This compilation of a series of 150 attempts at endoscopic condylar fracture repair represents the early evolving experience from three centers. The comprehensive data presented delineate the advantages and potential pitfalls with this newly introduced technique. Analysis of the early results shows a high rate (9%) of bailout. Does this represent a failure of the technique? Critical scrutiny of the data suggests not. Specifically, a review of CT images of the 14 fractures where plate fixation could not be achieved by the endoscopic technique suggests that these belong to a subgroup of proximal injuries that are predictably difficult to manage regardless of the surgical method. These data confirm this notion, as bailout to traditional techniques showed successful anatomic repair in only 2 of the 14 aborted cases attempted initially using the endoscope. The incidence of bailout procedures can be reduced by careful analysis of CT images and subsequent exclusion of these proximal injuries. When endoscopic repair is used selectively to treat injuries that have been shown to be amenable to this approach, it can be expected to reliably produce anatomic reduction in 94% (128/136) of cases. Only 6 of 136 primarily endoscopically fixated fractures went on to malreduction. Four of those 6 were salvaged with successful secondary endoscopic procedure. Plate fracture accounted for only two failures in the 136 primarily endoscopically fixated condylar fractures. The substantial advantages of anatomic reduction have been delineated. Restoration of premorbid ramal height, upright posture of the condylar head, and complex temporomandibular joint relationships results in an aesthetic chin projection and occlusion, ade-

quate interincisal opening (96% of patients had opening greater than 35 mm). Additionally, the technique prevents the late sequelae of internal derangement. Furthermore, the drawbacks of open reduction had been avoided. No patients sustained significant facial scarring, and there were no cases of permanent facial nerve palsy and only two cases of temporary facial nerve palsy. The endoscopic approach is technically demanding, and the initial operative times are long. Following a period of adjustment, however, the authors have found the time required approximates that of transcutaneous open methods. In this series, the last 30 cases took an average of 70 minutes. The skills needed for condylar repair are also increasingly essential to complete various other facial plastic surgery procedures, and many instructional courses already have been organized. Furthermore, the development of specialized endoscopic instruments facilitates repair. In the treatment of condylar injuries, the endoscope is not only an aid; it alters the treatment philosophy, from the conservative MMF to anatomic repair. Each surgeon will have to decide on his or her indications for endoscopic repair, and indeed this may depend heavily on his or her experience and patient preference. The authors feel that anatomic reduction and fixation are the best way to restore preinjury facial aesthetics and mandibular motion dynamics and to prevent late sequelae of internal derangement. Thus, the authors strongly advocate endoscopic repair of adult condylar neck and subcondylar fractures that demonstrate displacement or dislocation. The authors look forward to future advancements of this and other endoscopic techniques.

References
[1] Feifel H, Risse G, Opheys A, et al. Conservative versus surgical therapy of unilateral fractures of the collum mandibulaeanatomic and functional results with special reference to computerassisted 3-dimensional axiographic registration of condylar paths. Fortschr Kiefer Gesichtschir 1996;41:1247. [2] Guven O, Keskin A. Remodeling following condylar fractures in children. J Craniomaxillofac Surg 2001;29(4):2327. [3] Hovinga J, Boering G, Stegenga B. Long-term results of nonsurgical management of condylar fractures in children. Int J Oral Maxillofac Surg 1999;28(6):42940. [4] Kellenberger M, von Arx T, Hardt N. Results of follow-up of temporomandibular joint fractures in 30 children. Fortschr Kiefer Gesichtschir 1996;41:13842. [5] Strobl H, Emshoff R, Rothler G. Conservative treatment of unilateral condylar fractures in chil-

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[6]

[7]

[8]

[9]

[10]

[11]

[12]

[13]

[14]

[15]

[16]

[17]

[18]

dren: a long-term clinical and radiologic followup of 55 patients. Int J Oral Maxillofac Surg 1999;28(2):958. de Amaratunga NA. Mouth opening after release of maxillomandibular fixation in fracture patients. J Oral Maxillofac Surg 1987;45(5):3835. Ellis III E, Simon P, Throckmorton GS. Occlusal results after open or closed treatment of fractures of the mandibular condylar process. J Oral Maxillofac Surg 2000;58(3):2608. Ellis III E, Throckmorton GS. Bite forces after open or closed treatment of mandibular condylar process fractures. J Oral Maxillofac Surg 2001; 59(4):38995. Ellis III E, Throckmorton GS, Palmieri C. Open treatment of condylar process fractures: assessment of adequacy of repositioning and maintenance of stability. J Oral Maxillofac Surg 2000; 58(1):2734 [discussion 35]. Haug RH, Assael LA. Outcomes of open versus closed treatment of mandibular subcondylar fractures. J Oral Maxillofac Surg 2001;59(4): 3705 [discussion 3756]. Konstantinovic VS, Dimitrijevic B. Surgical versus conservative treatment of unilateral condylar process fractures: clinical and radiographic evaluation of 80 patients. J Oral Maxillofac Surg 1992;50(4):34952 [discussion 3523]. Palmieri C, Ellis III E, Throckmorton G. Mandibular motion after closed and open treatment of unilateral mandibular condylar process fractures. J Oral Maxillofac Surg 1999;57(7):76475 [discussion 7756]. Throckmorton GS, Ellis III E. Recovery of mandibular motion after closed and open treatment of unilateral mandibular condylar process fractures. Int J Oral Maxillofac Surg 2000;29(6): 4217. Widmark G, Bagenholm T, Kahnberg KE, et al. Open reduction of subcondylar fractures. A study of functional rehabilitation. Int J Oral Maxillofac Surg 1996;25(2):10711. Worsaae N, Thorn JJ. Surgical versus nonsurgical treatment of unilateral dislocated low subcondylar fractures: a clinical study of 52 cases. J Oral Maxillofac Surg 1994;52(4):35360 [discussion 3601]. Silvennoinen U, Iizuka T, Oikarinen K, et al. Analysis of possible factors leading to problems after nonsurgical treatment of condylar fractures. J Oral Maxillofac Surg 1994;52(8):7939. Silvennoinen U, Raustia AM, Lindqvist C, et al. Occlusal and temporomandibular joint disorders in patients with unilateral condylar fracture. A prospective 1-year study. Int J Oral Maxillofac Surg 1998;27(4):2805. Chossegros C, Cheynet F, Blanc JL, et al. Short retromandibular approach of subcondylar fractures: clinical and radiologic long-term evaluation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82(3):24852.

[19] Eckelt U, Hlawitschka M. Clinical and radiological evaluation following surgical treatment of condylar neck fractures with lag screws. J Craniomaxillofac Surg 1999;27(4):23542. [20] Klotch DW, Lundy LB. Condylar neck fractures of the mandible. Otolaryngol Clin North Am 1991;24(1):18194. [21] MacArthur CJ, Donald PJ, Knowles J, et al. Open reduction-fixation of mandibular subcondylar fractures. A review. Arch Otolaryngol Head Neck Surg 1993;119(4):4036. [22] Mikkonen P, Lindqvist C, Pihakari A, et al. Osteotomy-osteosynthesis in displaced condylar fractures. Int J Oral Maxillofac Surg 1989;18(5): 26770. [23] Pereira MD, Marques A, Ishizuka M, et al. Surgical treatment of the fractured and dislocated condylar process of the mandible. J Craniomaxillofac Surg 1995;23(6):36976. [24] Raveh J, Vuillemin T, Ladrach K. Open reduction of the dislocated, fractured condylar process: indications and surgical procedures. J Oral Maxillofac Surg 1989;47(2):1207. [25] Takenoshita Y, Oka M, Tashiro H. Surgical treatment of fractures of the mandibular condylar neck. J Craniomaxillofac Surg 1989;17(3): 11924. [26] Tasanen A, Lamberg MA. Transosseous wiring in the treatment of condylar fractures of the mandible. J Maxillofac Surg 1976;4(4):2006. [27] Zide MF, Kent JN. Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 1983;41(2):8998. [28] Ellis III E, Dean J. Rigid fixation of mandibular condyle fractures. Oral Surg Oral Med Oral Path 1993;76:615. [29] Krenkel C. Biomechanics and osteosynthesis of condylar neck fractures of the mandible. Chicago: Quintessence Publishing; 1994. [30] Walker RV. Condylar fractures: nonsurgical management. J Oral Maxillofac Surg 1994;52:118592. [31] Dahlstrom L, Kahnberg KE, Lindahl L. 15-year follow-up on condylar fractures. Int J Oral Maxillofac Surg 1989;18:1823. [32] Ellis E, Carlson DS. The effects of mandibular immobilization on the masticatory system. A review. Clin Plast Surg 1989;16(1):13346. [33] Ellis ED, Dechow PC, Carlson DS. A comparison of stimulated bite force after mandibular advancement using rigid and nonrigid fixation. J Oral Maxillofac Surg 1988;46(1):2632. [34] Bos RR, Ward Booth RP, de Bont LG. Mandibular condyle fractures: a consensus. Br J Oral Maxillofac Surg 1999;37:879. [35] Wilson IF, Lokeh A, Benjamin CI, et al. Prospective comparison of panoramic tomography (zonography) and helical computed tomography in the diagnosis and operative management of mandibular fractures. Plast Reconstr Surg 2001;107(6):136975.

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FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA

Facial Plast Surg Clin N Am 14 (2006) 1116

Endoscopic Repair of Orbital Floor Fractures

D. Gregory Farwell,
& & &

MD*,

E. Bradley Strong,
& & &

MD

Indications Technique Discussion

Complications Summary References

When the periorbital region is injured with significant force, the bony orbital vault may be fractured. These fractures often involve the medial wall and floor of the orbit, resulting in prolapse of orbital contents into the paranasal sinuses [1]. This may result in extraocular muscle entrapment with diplopia and enophthalmos. Visual loss from optic neuropathy, retinal detachment, or hyphema also may occur. Management of orbital floor fractures traditionally has been accomplished through transconjunctival and subciliary incisions. These approaches provide adequate visualization and cosmetically acceptable scars. Unfortunately, postoperative lid malposition can occur in a small percentage of cases. The most common complications include entropion, ectropion, and lid shortening. Another limitation is easy visibility of the posterior orbit, which often is obscured by prolapsed orbital fat. The introduction of endoscopy and minimally invasive surgery has revolutionized the surgical treatment of many diseases. Endoscopy has become commonplace in urologic, laparoscopic, and sinus surgery. It offers magnified visualization, access through smaller incisions, less postoperative morbidity, and often greater patient acceptance. This concept now is being evaluated in orbital trauma. General requirements for endoscopic surgery include the ability to obtain an optical cavity, insert

an endoscope, maintain adequate hemostasis, and apply instrumentation. Although several authors have described access to the orbital floor by means of a transnasal approach [25], complete fracture visualization and reconstruction requires greater access through the maxillary sinus by means of a Caldwell Luc approach. It allows access to the maxillary sinus and excellent visualization of the entire orbital floor, including the stable posterior shelf, which can be difficult to visualize through traditional incisions. Walter described the Caldwell Luc approach for repair of orbital floor fractures in 1972 [6]. His technique involved direct visualization of the fracture with a headlight, blind fracture reduction, and short-term fixation with packing. Since Walters description, several authors have described an endoscopic Caldwell Luc approach to orbital floor fractures (Farwell and colleagues, unpublished data, 2004) [713]. This article reviews the indications, technique, and potential complications of endoscopic orbital blow-out fracture repair.

Indications
A preoperative CT scan should be obtained to document the location and extent of the orbital floor fracture. Patients with trap door [Fig. 1] and medial blow-out [Fig. 2] fractures are excellent candidates for endoscopic repair. Fractures that

Department of Otolaryngology, University of California, Davis School of Medicine 2521 Stockton Blvd. Ste 7200 Sacramento, CA 95817, USA * Corresponding author. E-mail address: dgfarwell@ucdavis.edu (D.G. Farwell).
1064-7406/06/$ see front matter 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.fsc.2005.11.001

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Fig. 1. Trap door fracture. Note that the fracture is hinged at the lamina papyracea and depressed along the junction with the infraorbital nerve. It is important to maintain the integrity of the hinge during the surgical repair.

Fig. 3. Lateral blow-out fracture. Note that the entire orbital floor is comminuted and depressed into the maxillary sinus. The fracture extends medially to the lamina papyracea and laterally to the lateral orbital wall. The infraorbital canal is disrupted.

extend lateral to the infraorbital nerve [Fig. 3] or involve the lamina papyracea are much more difficult to repair endoscopically and generally require an open approach.

Technique
Under general anesthesia, the patient is placed supine on the operating table. A right-handed surgeon is on the patients right side, and the assistant is on the left. The monitor is positioned at the head of the patient, so it can be seen by both surgeons. Two monitors are preferable. Local anesthetic and epinephrine are injected sublabially, and a 4 cm incision is made in the gingivobuccal sulcus, through the periosteum, and onto the max-

illa. The periosteum then is elevated, exposing the anterior wall of the maxilla up to the level of the infraorbital nerve. Care is taken to avoid excessive traction on the nerve. An approximate 1.0 cm 2.0 cm maxillary antrostomy is made in the thin bone of the maxillary face [Fig. 4]. This usually is performed with an osteotome and Kerrison rongeur, but the bone can be removed with a saw and replaced after the orbital floor repair. A small notch should be placed along the edge of the antrostomy to stabilize the endoscope and provide tactile feedback for the assistant surgeon. The notch can be placed inferiorly [see Fig. 4] or superior medially depending upon surgeon preference. The lip is retracted with a Greenberg self-retaining retractor, and oxymetazoline-soaked pledgets are placed into the maxillary sinus for decongestion. The orbital floor then is inspected with 0 or 30 sinus endoscopes. The defect is analyzed for size, location, soft tissue prolapse, soft tissue entrapment, and bony comminution. If a trap door in-

Fig. 2. Medial blow-out fracture. Note that the medial floor is comminuted and depressed into the maxillary sinus. The fracture extends medially to the lamina papyracea and laterally to the infraorbital nerve.

Fig. 4. Left maxillary sinus antrostomy. The cheek is retracted by a Greenberg retractor.

Orbital Floor Fractures

13

Fig. 5. Endoscopic repair of a medial blow out fracture. (A) Sagittal view; the primary support for the implant is anterior at the orbital rim and posterior at the stable bony shelf. (B) Coronal view; the pourous polyethylene implant is above the infraorbital nerve laterally. The medial support is very limited or nonexistent, because the lamina papyracea ends in a vertical plane.

jury is encountered with strangulated soft tissue, a small portion of mucosa is stripped away from the fracture. The fracture is opened with an angled retractor, and the orbital contents are reduced into the orbit. The bone flap is then allowed to snap back into place maintaining the reduction. Care must be used to avoid excessive medial dissection that might destabilize the hinge and require placement of an implant. When a medial blow-out fracture is present, the edges of the orbital defect are exposed by conservative elevation of the mucosa around the defect. The entire bony margin must be visualized well. Care must be used avoid injury to the maxillary sinus ostia or the infraorbital nerve. The orbital soft tissues then are reduced, and an attempt can be made to reposition the bony piece. More often there is comminution of the floor. In this case, all bone fragments should be removed before reconstruction. When bone is removed, the defect will appear larger, with greater prolapse of the orbital contents. An alloplastic implant (porous polyethylene, 0.85 mm thickness) should be fashioned to recreate the orbital floor and re-establish the orbital volume. The implant should be trimmed to a diameter approximately 1 mm bigger than the defect and inserted through the antrostomy just below the prolapsed orbital contents. Care should be used to assure that no bone fragments are pushed back into the orbital cavity. The implant then is inserted over the stable posterior shelf. A Fraser tip suction catheter and Freer elevator then are used to walk forward on the implant while maintaining the posterior positioning. Gentle force is applied

at the anterior portion of the implant (ie, below the posterior aspect of the orbital rim) until it slips over the orbital rim and is stabilized by downward pressure from the orbital contents [Fig. 5]. The primary area of support is anterior and posterior. If a medial shelf of bone is present, it can be used

Fig. 6. (A) Preoperative CT scan of a right-sided medial blow-out fracture. Note the depression and comminution of the entire medial segment of the orbital floor. (B) Postoperative CT scan after endoscopic repair of the medial blow-out fracture.

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Farwell & Strong

also. Pressure laterally on the infraorbital nerve should be avoided. Once the fracture has been repaired, the endoscope is used to inspect the edges of the fracture looking for any entrapped orbital tissue. A pulse test is performed (ie, gentle external pressure is applied to the globe, and the pulsations are observed through the endoscope) to assure the implant is stable. Any mucosa or bone fragments overhanging the maxillary ostia are removed to minimize the chance of sinus obstruction and subsequent infection. Occasionally, a formal middle meatal antrostomy is required to ensure adequate maxillary sinus drainage. Finally, the wound is closed and a postreduction CT scan is obtained to confirm an adequate repair [Fig. 6].

Discussion
The use of endoscopes within the nasal cavity and paranasal sinuses has become the standard of care for endoscopic sinus surgery. In recent years, many sinus surgeons have begun performing sinusrelated procedures such as orbital decompression for Graves disease [14] and resection of certain sinus and skull base neoplasms [15]. As the realm of endoscopic surgery expands, the potential benefit of orbital floor fracture repair has become apparent. Traditional open approaches (ie, transconjunctival and transcutaneous) can result in lid malposition such as entropion and ectropion. Several large series reported complication rates of 5% [1619]. Careful review of these studies, however, demonstrates that lid complications were less common in patients with isolated orbital floor fractures. Eyelid malposition was more common in patients with more extensive dissection over the orbital rim for orbitozygomatic or Le Fort-type injuries. The endoscopic approach obviates the need for an eyelid incision and potential eyelid complications. An additional benefit is improved visualization of the posterior orbit and stable bony shelf. One of the major limitations of the open approaches is difficulty visualizing the posterior orbit because of the angle of attack and prolapsed orbital fat. This can result in improper implant placement along the stable posterior ledge and inadequate restoration of orbital volume with persistent enophthalmos. Using the endoscopic approach, the angle of inclination offers a more direct view of the posterior orbit, thereby reducing the risk of a poorly positioned implant. [Fig. 7]. Several surgeons have described a transnasal approach to orbital floor fractures [8,13]. They describe endoscopic placement of balloon catheters, threaded through the nose, to reduce the fracture and maintain reduction for up to 10 days.

Fig. 7. Sagittal CT scan of the orbital floor illustrating (black arrow) the less advantageous, tangential angle of attack using an open approach (ie, the surgeon is looking at the posterior bony shelf end on) and (white arrow) the more advantageous endoscopic approach in which the surgeon can visualize the posterior bony shelf from below.

These authors reported symptomatic resolution of diplopia in most patients. Follow-up data on orbital position were limited, and representative imaging in the article by Ikeda showed persistent increase in orbital volume. It is not certain that the goal of minimally invasive surgery was met in these patients. Despite the lack of an external incision, placement of a transnasal catheter for up to 10 days may not be considered minimally invasive. Subsequent reports of endoscopic orbital floor reconstruction by means of a transantral approach have demonstrated the feasibility of a pure endoscopic repair for accurate reestablishment of the premorbid orbital volume [7,9]. Different implant materials include porous polyethylene and resorbable and titanium mesh. These reports have demonstrated excellent patient tolerance with minimal incidence of infection or extrusion. Indications for the endoscopic repair vary, but most authors agree that isolated trap door and medial blow-out fractures as described by Strong and colleagues are indications for the technique [see Figs. 1, 2]. Larger lateral blow-out fractures involve the infraorbital nerve [see Fig. 3]. The use of the endoscopic approach in these cases is not recommended. Definitive repair requires significant manipulation of the infraorbital nerve and placement of an implant that spans medial and lateral to the infraorbital canal. An implant this large is difficult to insert and manipulate. Techniques for implant stabilization vary between authors. Most authors agree that hinged, trap door fractures can be snapped back into their premorbid position after reduction of the orbital contents. The interfragmentary friction alone will maintain the reduction. Intraoperative assessment

Orbital Floor Fractures

15

with forced duction testing and a pulse test (gentle external orbital pressure) should be performed to assure an adequate and stable repair. If comminution is present or occurs with manipulation of a trap door fracture, an implant is necessary to complete the reconstruction. Several techniques have been used to maintain the implant position. The most common approach is to place an implant slightly larger than the defect above the bony margin, within the orbital cavity, but below the orbital soft tissues [7]. The orbital contents then are allowed to fall down onto the implant holding it in place [see Fig. 5]. Chen and colleagues described a different technique in which the orbital contents are reduced and held in place by a piece of titanium mesh placed within the maxillary sinus [9]. This mesh is held into position with titanium screws placed into the residual orbital floor. Using this approach, care must be taken to avoid placing the drill hole too close to the infraorbital nerve or too deep into the orbital tissues. This could result in injury of the infraorbital nerve, extraocular muscles, or orbital hematoma. Caution also must be used to avoid obstruction of the maxillary sinus ostia. If the dissection is carried along the inferomedial aspect of the orbit, or the implant is placed near the ostia, the risk of postoperative maxillary sinusitis will increase. Time from injury is felt to influence the successful repair of orbital floor fractures, particularly with gross extraocular muscle entrapment. Patients with delayed surgical repair may be more likely to have persistent diplopia (Farwell and colleagues, unpublished data). For this reason, repair generally should be attempted as early as possible, particularly in patients with gross extraocular muscle entrapment. The endoscopic approach is advantageous in early repairs, because it offers excellent fracture visualization even in the face of marked periorbital edema. Another advantage of the endoscopic approach is that there is far less orbital retraction required. Hyphema is considered a contraindication to surgical repair of orbital floor fractures because of the potential risk of blindness secondary to globe retraction. By approaching these fractures from below, without significant orbital manipulation, urgent reduction of entrapped inferior rectus muscle can be accomplished, reducing the chance of permanent dysfunction from prolonged ischemia and pressure necrosis [7]. Even if the endoscopic approach is not chosen as the primary access for orbital floor fracture repair, it is useful in assessing the orbital floor in patients with other facial fractures [12]. An example of its utility is in evaluating the orbital floor in a patient with an orbitozygomatic fracture. Once the malar

portion of the fracture has been reduced, the orbital floor defect can be enlarged. Placing the endoscope through a small antrostomy or existing anterior maxillary fracture allows the surgeon to assess the integrity of the orbital floor without a lid incision. The authors recommend that surgeons considering learning the endoscopic technique have the equipment readily available for all traumas involving the orbit. The surgeon then can use existing incisions (ie, for zygoma or Le Fort fractures) to become comfortable with the technique. Once the surgeon gains confidence with the equipment, a pure endoscopic repair can be attempted.

Complications
Postoperative infraorbital paresthesias are common after this approach (Farwell and colleagues, unpublished data) [7]. The paresthesias may be caused by retraction or manipulation during the fracture exposure and implant placement. They generally resolve over 2 to 8 weeks. The surgeon also must avoid inadvertent displacement of a bone fragments into the orbital cavity [7]. All comminuted bone fragments must be removed before repair of medial blow-out fractures. Postoperative maxillary sinusitis is also a risk. The exact etiology is difficult to assess, because it may be caused by the surgical procedure or the fracture itself. Patients should be instructed on the importance of prompt evaluation of any sinus complaint. Failure to repair the fracture endoscopically will necessitate an alternative approach, either through a transconjunctival or subciliary incision. This should be discussed with the patient preoperatively in case a pure endoscopic repair cannot be achieved.

Summary
Endoscopic surgery is expanding rapidly, particularly within the field of otolaryngology. The repair of the orbital floor fractures through an endoscopic approach has been performed successfully by several centers. It is technically demanding and requires expertise in traditional repair of orbital floor fractures and endoscopy. The surgical technique, patient selection, instrumentation, and postoperative results will continue to evolve as more surgeons attempt this technique. As more data are obtained, it will be important to compare the results with the traditional open approach, which has a proven track record with low complication rates. The endoscopic approach, however, appears to be a promising new technique for isolated trap door and medial orbital floor fractures.

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Farwell & Strong

References
[1] Jones DE, Evans JN. Blow-out fractures of the orbit: an investigation into their anatomical basis. J Laryngol Otol 1967;81(10):110920. [2] Lee MJ, Kang YS, Yang JY, et al. Endoscopic transnasal approach for the treatment of medial orbital blow-out fracture: a technique for controlling the fractured wall with a balloon catheter and Merocel. Plast Reconstr Surg 2002;110(2): 41726 [discussion 4278]. [3] Yamaguchi N, Arai S, Mitani H, et al. Endoscopic endonasal technique of the blow-out fracture of the medial orbital wall. Operative Techniques in Otolaryngology Head and Neck Surgery 1991;2: 26974. [4] Michel O. Isolated medial orbital wall fractures: results of minimally invasive endoscopically controlled endonasal surgical technique. Laryngorhinootologie 1993;72(9):4504. [5] Rhee JS, Lynch J, Loehrl TA. Intranasal endoscopyassisted repair of medial orbital wall fractures. Arch Facial Plast Surg 2000;2(4):26973. [6] Walter WL. Early surgical repair of blowout fracture of the orbital floor by using the transantral approach. South Med J 1972;65(10):122943. [7] Strong EB, Kim KK, Diaz RC, et al. Endoscopic approach to orbital blowout fracture repair. Otolaryngol Head Neck Surg 2004;131(5):68395. [8] Ikeda K, Suzuki H, Oshima T, et al. Endoscopic endonasal repair of orbital floor fracture. Arch Otolaryngol Head Neck Surg 1999;125(1):5963. [9] Chen CT, Chen YR. Endoscopically assisted repair of orbital floor fractures. Plast Reconstr Surg 2001;108(7):20118 [discussion 2019]. [10] Saunders CJ, Whetzel TP, Stokes RB, et al. Transantral endoscopic orbital floor exploration: a cadaver and clinical study. Plast Reconstr Surg 1997;100(3):57581.

[11] Woog JJ, Hartstein ME, Glilich R, et al. Paranasal sinus endoscopy and orbital fracture repair. Arch Ophthalmol 1998;116(5):68891. [12] Forrest CR. Application of endoscope-assisted minimal-access techniques in orbitozygomatic complex, orbital floor, and frontal sinus fractures. J Craniomaxillofac Trauma 1999;5(4):712 [discussion 134]. [13] Otori N, Haruna S, Moriyam H, et al. Endoscopic endonasal or transmaxillary repair of orbital floor fracture: a study of 88 patients treated in our department. Acta Otolaryngol 2003;123(6): 71823. [14] Lund VJ, Larkin G, Fells P, et al. Orbital decompression for thyroid eye disease: a comparison of external and endoscopic techniques. J Laryngol Otol 1997;111(11):10515. [15] Al-Nashar IS, Carrau RL, Herrera A, et al. Endoscopic transnasal transpterygopalatine fossa approach to the lateral recess of the sphenoid sinus. Laryngoscope 2004;114(3):52832. [16] Zingg M, Chowdhury K, Ladsach K, et al. Treatment of 813 zygoma-lateral orbital complex fractures. New aspects. Arch Otolaryngol Head Neck Surg 1991;117(6):61120 [discussion 6212]. [17] Appling WD, Patrinely JR, Salzer TA, et al. Transconjunctival approach vs subciliary skinmuscle flap approach for orbital fracture repair. Arch Otolaryngol Head Neck Surg 1993;119(9): 10007. [18] Mullins JB, Holds JB, Branham GH, et al. Complications of the transconjunctival approach. A review of 400 cases. Arch Otolaryngol Head Neck Surg 1997;123(4):3858. [19] Lorenz HP, Longaker MT, Kawamoto HK, et al. Primary and secondary orbit surgery: the transconjunctival approach. Plast Reconstr Surg 1999; 103(4):11248.

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FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA

Facial Plast Surg Clin N Am 14 (2006) 1723

Endoscopic Approach to Medial Orbital Wall Fractures

John S. Rhee,
& & &

MD, MPH

a,b,*

, Chien-Tzung Chen,
& & &

MD

Preoperative evaluation Indications Surgical techniques Endoscopic transcaruncular approach Intranasal endoscopic-assisted technique

Complications Summary References

Historically, medial orbital wall fractures have been underappreciated in their incidence and importance. Recent studies have indicated that the incidence of medial orbital wall fractures may be higher than that of the floor [1]. In addition, studies have suggested that enophthalmos may be more significant from nonrepaired medial orbital wall fractures than from blowout fractures of any other orbital wall. Furthermore, because of the underappreciation of this injury, the incidence of delayed enophthalmos may be higher for this type of orbital fracture [2]. Biomechanical studies have suggested that that in the absence of orbital rim or facial skeleton trauma (pure hydraulic mechanism), isolated medial orbital wall fractures cannot occur without trauma to the surrounding bony framework (eg, orbital rim, nasal bone) [3]. These biomechanical findings are corroborated by reports in the clinical medical literature. In a large series of medial orbital fractures, Burm and colleagues [1] reported that nasal fractures were the most common fracture associated with the medial orbital wall fracture, suggesting that the force causing nasal fractures was a very important causative factor of pure medial orbital fractures by means of the buckling mechanism.

In the clinical realm, medial orbital fractures may occur by way of the buckling or hydraulic mechanism, with a combination of the two mechanisms the most likely scenario. It is also more common that the medial orbital wall is fractured in conjunction with the orbital floor, necessitating repair of both of these fractured walls. There are a multitude of approaches that have been used for repair of medial orbital wall fractures, each with their advantages and disadvantages. The medial brow incision has been described for access to the medial orbital wall [4]. This approach is limited to the anterior and superior medial orbital wall and fails to free the entrapped medial rectus muscle from the posterior medial wall fracture because of the close proximity of the optic nerve. A lid crease incision may offer a more cosmetically appealing result, but has the same limitations as the medial brow incision [5]. A direct medial canthal approach can be used to gain access to the medial and inferomedial aspects of the orbit, and this may be extended to the infraorbital rim to explore the floor. Drawbacks to this approach include the obvious external scar, webbing of the skin, and risk of telecanthus from surgical detachment of the medial canthal tendon [6].

a Department of Otolaryngology, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226, USA b Zablocki Veteran Affairs Medical Center, 5000 W. National Avenue, Milwaukee, WI 53295, USA c Division of Trauma Plastic Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Number199, Tunghwa Rd., Taipei, Taiwan, Republic of China * Corresponding author. Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, WI 53226. E-mail address: jrhee@mcw.edu (J.S. Rhee).

1064-7406/06/$ see front matter. Published by Elsevier Inc.

doi:10.1016/j.fsc.2005.10.006

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Indirect approaches to the medial orbital wall include the coronal incision, which usually is reserved for patients with multiple facial fractures. This approach offers wide exposure and reconstruction of the defect with calvarial bone through the same incision. Disadvantages include an external scar, scalp alopecia, significant surgical dissection, overnight hospitalization, and potential injury to cranial nerves VI and VII. The transcaruncular approach to the medial orbital wall has been described more recently and provides excellent access to the medial wall [68]. The main limitation of this approach is that a large graft cannot be placed through the small incision without connecting it to an orbital floor approach. Other potential disadvantages include the risk of injury to the lacrimal apparatus and difficulty assessing the posterior dissection. Endoscopic-assisted techniques have emerged as the next frontier for repair of medial orbital fractures. Recently, techniques have been described that allow for endoscopic assistance in reduction of the orbital contents and in placement of an alloplast or graft for reconstitution of the medial orbital wall. The two main techniques in which endoscopy has aided in the repair of these fractures have been either through the intranasal (transethmoidal) or the transcaruncular approaches [9,10]. Most endoscopic intranasal techniques involve partial ethmoidectomy and exposure of the fractured lamina papyracea. The herniated orbital contents are reduced, and some type of intranasal splint or packing is placed between the lamina and the middle turbinate for a period of time (approximately 2 months) until healing of the medial wall is completed [1113]. Alternatively, an intranasal endoscopic approach to assist in placement of an orbital implant by means of a periorbital incision has been described [14]. This article describes different endoscopic-assisted approachestranscaruncular and intranasalwhich have been used to successfully repair medial orbital wall fractures.

Nasal subconjunctival hemorrhage Horizontal diplopia Restriction of abduction Retraction syndrome Progressive enophthalmos Positive forced duction test [5,1518]

Preoperative evaluation
Medial orbital fractures, unlike blow-out fractures of the orbital floor, may be overlooked, because they present with clinical symptoms and signs in only a few instances, especially in the early acute trauma setting. The possible clinical symptoms and signs include:

Associated ocular injuries commonly occur in patients with midfacial trauma, which may result in decrease in visual acuity, or even complete vision loss, if early diagnosis and management are not initiated properly. The incidence of severe ocular disorders associated with an orbital blow-out fracture has been reported to be as high as 16.7% [19]. Therefore, early ophthalmology consultation routinely is sought in patients with suspected orbital fractures. The ocular examination should include an assessment of visual acuity, visual field, papillary function, extraocular muscle function, and slit lamp examination to rule out a corneal perforation or hyphema. A forced duction test is conducted if restriction of ocular movement is detected. The presence of diplopia may be associated with limitation of extraocular muscle movement. One must differentiate the causes of diplopia that may result from cranial nerve-induced injury, orbital soft tissue or muscle entrapment, mal-position of the globe, or intraorbital edema secondary to acute trauma. Imaging studies including CT scanning are essential before forming a surgical plan. Recently, the development of the helical CT scan has changed the type of studies needed to diagnose and evaluate orbital trauma. The helical CT scan allows for continuous acquisition of volumes of tissue, which permits multi-planar reconstructions of additional image planes. This technique reduces the number of examinations and radiation exposure of the patient and improves the quality of the image [20]. These fine-cut CT scan images are taken in coronal and axial planes, with soft tissue and bone windows. The reformatted sagittal sections that connect the midpoint of the globe and the apex of the orbit are particularly helpful to assess the concomitant orbital floor fractures. Three-dimensional CT images allow for a quick overview of the facial bone fractures, but they are seldom of value in the internal portion of the orbit. Occasionally, MRI can be used to differentiate the herniated muscle and orbital fat, and this may serve as a complement to CT scanning [5,21].

Epistaxis Eyelid emphysema, especially in the medial canthus Periorbital edema Narrowing of the palpebral fissure

Indications
There is some debate regarding the surgical treatment of an isolated orbital medial wall fracture. When a medial orbital wall fracture presents mini-

Medial Orbital Wall Fractures

19

mal displacement with no signs of herniation of the orbital content and minimal enophthalmos, conservative treatment is chosen. Surgical exploration and repair, however, are indicated if there is

Persistent symptomatic diplopia Pain during horizontal eye movement, A positive forced duction test with clear evidence of medial rectus muscle entrapment on a CT scan, Early enophthalmos more than 2 mm preoperatively A large defect likely causing secondary enophthalmos [5,21,22]

Both endoscopic-assisted techniques, through either the intranasal or transcaruncular approaches, can be applied to repair the variable sizes of the medial orbital wall fractures. The endoscopic techniques are especially valuable for those fractures involving the superior and posterior medial orbits, which are difficult to dissect and visualize through a lower eyelid approach. In general, these endoscopic techniques are used for primary repair of the medial orbital wall fractures. Recently, the transcaruncular endoscopic approach has been expanded in its use to correct late enophthalmos caused by uncorrected displacement of medial wall or previously inadequate reconstruction of medial wall defects [10]. One may use the coronal incision or existing lacerations to repair these fractures directly without the use of endoscopic approaches, however, if the medial orbital wall fracture is accompanied by periorbital fractures such as nasoethmoid, orbital roof, or supraorbital rim fractures.

Surgical techniques Endoscopic transcaruncular approach

The surgery is performed under general anesthesia. An injection of 1:100,000 epinephrine solution is placed in the medial conjunctiva using a fine needle. The cornea is protected with a scleral shield during the procedure. Two parallel traction sutures using 4-0 silk are placed in the medial conjunctiva posterior to the caruncle to facilitate the conjunctival incision. A slight curvilinear incision approximately 1 cm in length is made between the two sutures, and then a scissors is used to bluntly dissect toward the medial orbital wall immediately posterior to the lacrimal apparatus [Fig. 1]. With progressive blunt dissection, the periorbita is incised behind the posterior lacrimal crest to avoid severance of the medial canthal ligament and injury to the lacrimal sac. The periorbita is elevated further superiorly and inferiorly with a Freer elevator; then the dissection proceeds posteriorly, thereby

creating a periosteal opening wider than the conjunctival incision. Initially, the anterior part of the medial wall is dissected under direct vision with the aid of a headlight. Because the orbital roof is intact in most cases, the authors prefer starting the dissection from the superior medial wall near the orbital roof and then proceeding downward to the inferior portion of the orbital medial wall. The optical cavity is created and maintained with insertion of a baby retractor medially and a narrow malleable retractor laterally to retract the orbital contents gently. A 2.7 mm diameter, 0 endoscope is introduced through the transcaruncular approach. With the aid of endoscope, the posterior dissection of the medial wall is performed using an orbital periosteal elevator. The first important structure that is encountered is the anterior ethmoid vessels coming out from the anterior ethmoid foramen, which is on average 24 mm behind the anterior lacrimal crest. The vessels should be cauterized meticulously to avoid any undue bleeding and facilitate further posterior dissection. Subsequently, the posterior ethmoid vessels appear in the surgical field and indicate the limit of safe dissection along the medial wall. This landmark is on average 36 mm away from the anterior lacrimal crest. One should keep in mind that the optic nerve is located on average 7 mm posterior to the posterior ethmoid vessels. A horizontal line connecting the anterior and posterior ethmoid vessels indicates the superior limit of the ethmoid sinus. Generally, the medial wall fractures rarely extend above this horizontal line. The entrapped orbital contents gradually are reduced from the ethmoid sinus into the orbital cavity, and the fracture fragments of the medial wall are removed. After that, the whole boundary of the medial wall defect is defined clearly [see Fig. 1]. To reconstruct the bony defect, the authors use the synthetic implants titanium micromesh or Medpor (Porex Surgical, Incorporated, Newnan, Georgia) in most cases. The orbital implant is trimmed to proper size and shape, with the dimension no greater than 1.5 cm in width and 3 cm in length, because the small incision prevents placement of a larger graft. The implant is inserted through the transcaruncular incision to cover the bony defect in the subperiosteal space and fixated with a microscrew [see Fig. 1]. In the scenario of a larger bony defect extending onto the inferior medial wall, additional implant is required, with one overlapping the other, to completely cover the bony defect. Finally, the proper position of these implant areas is rechecked and adjusted under endoscopic visualization. A forced duction test is performed after placement of these implants to confirm the mobility of the globe in any direction. The conjunctival wound is closed with a 6-0 plain

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Rhee & Chen

Fig. 1. (A) Transcaruncular incision made posterior to the caruncle with two parallel traction sutures. (B) Endoscopic view of the bone defect of the orbital medial wall. Arrow points to the boundary of the bone defect; O indicates periorbital tissue. (C ) Endoscopic view of Medpor implant placed across the defect with microscrew fixation.

catgut suture. A clinical case using this technique is illustrated in Fig. 2.

Intranasal endoscopic-assisted technique

The operation is performed under general anesthesia with the patient in a supine position. The orbital floor is approached through a transconjunctival incision with a canthotomy and cantholysis. A preseptal dissection is carried down to the orbital rim. The arcus marginalis then is incised sharply at the orbital rim. Dissection continues along the orbital floor, deep to the periorbita. A concomitant orbital floor fracture can be addressed with reduction of the orbital contents. Before the manipulation of the medial orbital contents, the medial orbital wall is approached intranasally. After proper nasal decongestion is accomplished, a 4.0 mm 0 endoscope is introduced into the nostril. The uncinate is identified and resected. Approximately 3 to 4 mm of uncinate is left intact superiorly to prevent frontal recess stenosis. This exposes the natural ostium of the maxillary sinus.

The bulla ethmoidalis then is entered medially and resected to expose the lamina papyracea defect. The herniated orbital contents are usually apparent at this stage, and great care is taken to prevent further injury. The dissection is carried posteriorly through the ground lamella to fully expose the defect in the lamina papyracea. Next, from the periorbital incision, the orbital contents are reduced and held in place with a malleable retractor. Adequate reduction is confirmed from the intranasal endoscopic and external approaches. The orbital implant then is cut to the appropriate shape and size to cover the floor and lamina papyracea defect. The implant is introduced through the periorbital incision and guided into position using the endoscopes for visualization. While an assistant holds the endoscope in proper position, the implant is manipulated bimanually from the sinonasal and periorbital approaches into proper position. A clinical case illustrating this technique is described in Figs. 3 and 4. No nasal packing is necessary, in contrast to the temporary intranasal stent placement procedures.

Medial Orbital Wall Fractures

21

Fig. 2. (A) 40-year-old patient with left orbital medial wall blow-out fracture. Preoperative submental view showing left upper eyelid ecchymosis and enophthalmos (1.5 mm). (B) Preoperative CT scan revealing a blowout fracture of the left orbital medial wall with soft tissue prolapse. (C ) Postoperative submental view 5 months following correction of the orbital medial wall defect with symmetric projection of the globe. (D) Properly reconstructed medial wall with titanium mesh implant shown in postoperative CT scan.

Fig. 3. Patient with a combined fracture of the orbital floor and medial wall without evidence of entrapment, as seen on (A) coronal and (B) axial CT. Intranasal endoscopy-assisted repair of medial orbital wall fractures. (From Rhee JS, Lynch J, Loehrl TA. Intranasal endoscopy-assisted repair of medial orbital wall fracture. Arch Facial Plast Surg 2000;2(4):26973; with permission.)

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Rhee & Chen

Fig. 4. (A) Intranasal endoscopic view of right medial orbital wall fracture. Asterisk indicates bony defect of the lamina papyracea. Arrow delineates the intact posterior medial wall. (B) Intranasal endoscopic view of the Medpor implant in proper position. (From Rhee JS, Lynch J, Loehrl TA. Intranasal endoscopy-assisted repair of medial orbital wall fractures. Arch Facial Plast Surg 2000;2(4):26973; with permission.)

The periorbital incision is closed in standard fashion. Postoperatively, the patient is placed on nasal saline irrigations and is seen every 7 to 14 days with endoscopic debridement performed until the ethmoid cavity is mucosalized.

Complications
In the authors experience, postoperative complications with either transcaruncular or intranasal approaches have been minimal. There have been no cases of infection or sinusitis using an implant to repair the medial wall defect. One minor complication related to the transcaruncular incision was reported by Graham and colleagues [23], in which excessive medial canthal scarring caused diplopia that resolved after revision conjunctivoplasty surgery. Other potential intraoperative complications include optic nerve injury, cerebrospinal fluid rhinorrhea, intraorbital or nasal hemorrhage, damage to extraocular muscle, lacrimal sac and cornea, inadequate reduction of herniated orbital tissue, or incomplete coverage of the medial wall defect. When a transcaruncular approach is adopted, one should avoid too much anterior or posterior dissection causing injury to the lacrimal sac and to the medial rectus muscle, respectively. The use of a corneal shield during the procedure is essential to prevent incidental injury to the cornea. Displacement of the bone grafts [10,21] or implants [22] has been reported, especially when repairing a large bony defect through the transcaruncular incision. To prevent displacement of grafts, one of the authors usually fixates the material used for repairing the medial wall defect with microscrews [10]. Mun and colleagues [21] reported an alternative bone graft-shaping method, a combination of an inlayonlay graft, which is

thinned at the edge and set on the edge of the intact medial wall in the onlay position, to minimize the risk of graft migration. Transient diplopia and exophthalmos can be expected as in other orbital reconstructive surgeries, with usual resolution by 3 months. Residual enophthalmos caused by reherniation of the orbital contents has been reported when using a temporary intranasal stenting procedure [24]. The authors advocate using a permanent implant placed either by means of the transcaruncular or intranasal endoscopic-assisted approach to decrease the likelihood of reherniation of orbital contents into the ethmoid cavity.

Summary
Fractures of the medial orbital wall are more common than previously thought and pose unique challenges to the reconstructive surgeon. The use of endoscopes can facilitate visualization, reduction, and placement of grafts to reconstruct this area. The authors advocate using either the endoscopic-assisted transcaruncular approach or an intranasal endoscopic-assisted approach combined with a periorbital incision to place a permanent graft or implant to repair the medial orbital wall. Both techniques have been successful in treating this difficult fracture without the need for longterm intranasal stenting or external skin incisions.

References
[1] Burm JS, Chung CH, Oh SJ. Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture. Plast Reconstr Surg 1999;103:183949. [2] Whitehouse RW, Batterbury M, Jackson A, et al. Prediction of enophthalmos by computed tomog-

Medial Orbital Wall Fractures

23

[3]

[4]

[5]

[6]

[7]

[8]

[9]

[10]

[11]

[12]

[13]

raphy after blow out orbital fracture. Br J Ophthalmol 1994;78:61820. Rhee JS, Kilde J, Yoganadan N, et al. Orbital blowout fractures: experimental evidence for the pure hydraulic theory. Arch Facial Plast Surg 2002;4:98101. Rumelt MB, Ernest JT. Isolated blowout fracture of the medial orbital wall with medial rectus muscle entrapment. Am J Ophthalmol 1972; 73:4513. Leone Jr CR, Lloyd III WC, Rylander G. Surgical repair of medial wall fractures. Am J Ophthalmol 1984;97:34956. Chen CT, Chen YR, Tung TC, et al. Endoscopically assisted reconstruction of orbital medial wall fractures. Plast Reconstr Surg 1999;103:71420. Baumann A, Ewers R. Transcaruncular approach for reconstruction of medial orbital wall fracture. Int J Oral Maxillofac Surg 2000;29:2647. Oh JY, Rah SH, Kim YH. Transcaruncular approach to blowout fractures of the medial orbital wall. Korean J Ophthalmol 2003;17:504. Chen CT, Chen YR. Endoscopically assisted repair of orbital floor fractures. Plast Reconstr Surg 2001;108:20118. Chen CT, Chen YR. Endoscopic orbital surgery. Atlas Oral Maxillofac Surg Clin North Am 2003; 11:179208. Lee HM, Han SK, Chae SW, et al. Endoscopic endonasal reconstruction of blowout fractures of the medial orbital walls. Plast Reconstr Surg 2002;109:8726. Otori N, Haruna S, Moriyama H. Endoscopic endonasal or transmaxillary repair of orbital floor fracture: a study of 88 patients treated in our department. Acta Otolaryngol 2003;123:71823. Sanno T, Tahara S, Nomura T, et al. Endoscopic endonasal reduction for blowout fracture of the medial orbital wall. Plast Reconstr Surg 2003; 112:122837 [discussion 1238].

[14] Rhee JS, Lynch J, Loehrl TA. Intranasal endoscopyassisted repair of medial orbital wall fractures. Arch Facial Plast Surg 2000;2:26973. [15] Edwards WC, Ridley RW. Blowout fracture of medial orbital wall. Am J Ophthalmol 1968;65: 2489. [16] Thering HR, Bogart JN. Blowout fracture of the medial orbital wall, with entrapment of the medial rectus muscle. Plast Reconstr Surg 1979; 63:84852. [17] Merle H, Gerard M, Raynaud M. Isolated medial orbital blow-out fracture with medial rectus entrapment. Acta Ophthalmol Scand 1998;76: 3789. [18] Naraghi M, Kashfi A. Endonasal endoscopic treatment of medial orbital wall fracture via rotational repositioning. Am J Otolaryngol 2002; 23:3125. [19] al-Qurainy IA, Stassen LF, Dutton GN. The characteristics of midfacial fractures and the association with ocular injury: a prospective study. Br J Oral Maxillofac Surg 1991;29:291301. [20] Lakits A, Prokesch R, Scholda C, et al. Helical and conventional ct in the imaging of metallic foreign bodies in the orbit. Acta Ophthalmol Scand 2000;78:7983. [21] Mun GH, Song YH, Bang SI. Endoscopically assisted transconjunctival approach in orbital medial wall fractures. Ann Plast Surg 2002;49: 33743 [discussion 344]. [22] Kim S, Helen Lew M, Chung SH, et al. Repair of medial orbital wall fracture: transcaruncular approach. Orbit 2005;24:19. [23] Graham SM, Thomas RD, Carter KD, et al. The transcaruncular approach to the medial orbital wall. Laryngoscope 2002;112:9869. [24] Jin HR, Shin SO, Choo MJ, et al. Endonasal endoscopic reduction of blowout fractures of the medial orbital wall. J Oral Maxillofac Surg 2000;58:84751.

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FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA

Facial Plast Surg Clin N Am 14 (2006) 2529

Endoscopic Repair of Anterior TableFrontal Sinus Fractures

E. Bradley Strong,
& & &

MD

a,*

, Robert M. Kellman,
& &

MD

Indications Technique Discussion

Summary References

Frontal sinus fractures account for 5% to 15% of all maxillofacial injuries [1]. The treatment algorithm for fractures involving the frontal recess or posterior table is complex because of the associated risks of brain injury, meningitis, cerebrospinal fluid fistula, and mucocele formation [2]. Mild-tomoderately displaced anterior table fractures, however, carry a low risk of long-term morbidity and generally are treated as aesthetic deformities. Traditional repair of isolated anterior table fractures requires a coronal incision, bony reduction, and rigid fixation. Surgical sequelae of this procedure include a large scar, alopecia, paresthesias, and uncommonly facial nerve injury. Consequently, some surgeons are starting to manage isolated anterior table fractures through an endoscopic approach. General requirements for endoscopic surgery include: the ability to surgically obtain/maintain an optical cavity, insert a fiberoptic endoscope, sustain adequate hemostasis, and apply instrumentation [3]. At least two points of access generally are required. The advantages of endoscopic surgery include more accurate visualization, minimal external incisions, visualization around corners, reduced soft tissue dissection, reduced hospital stay, and improved teaching. Disadvantages include a moderate learning curve, narrow field of view, poor

depth perception, current lack of dedicated instrumentation, and the fact that the surgeon cannot operate bimanually without an assistant. Endoscopic sinus surgery came to the United States in the late 1970s and became the standard of care in the 1980s. The indications for endoscopic head and neck surgery continue to expand. Current applications include otology (middle ear endoscopy), skull base surgery (pituitary, cerebral spinal fluid leak, optic nerve decompression), ophthalmology (dacrocystorhinostomy), facial plastic surgery (brow lift), neck surgery (thyroid, parathyroid, node biopsy), and facial trauma. Specific facial trauma applications include subcondylar, orbital, and frontal sinus fractures. This article reviews the indications and technique for endoscopic repair of anterior table frontal sinus fractures.

Indications
Not all isolated anterior table fractures are appropriate for this technique. Injuries with severe comminution and marked mucosal injury require open reduction or even frontal sinus obliteration. Fractures that extend over the orbital rim may be difficult or impossible to visualize endoscopically and may require an open approach. The ideal candi-

Department of Otolaryngology, University of California Davis School of Medicine, 2521 Stockton Blvd. Ste 7200 Sacramento, CA 95817, USA b Department of Otolaryngology and Communication Sciences, State University of New York Upstate Medical University, 750 E. Adams St., Syracuse, NY 13210, USA * Corresponding author. E-mail address: edward.strong@ucdmc.ucdavis.edu (E.B. Strong).
1064-7406/06/$ see front matter 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.fsc.2005.10.003

facialplastic.theclinics.com

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Strong & Kellman

dates for the endoscopic approach are reliable patients who have isolated anterior table fractures limited to the vertical face of the frontal bone.

Technique
Preoperative photographs and CT scans should be obtained to document the injury [Figs. 1, 2]. Informed consented is obtained for the procedure, including the risks of bleeding, infection, paresthesia, alopecia, poor aesthetic result, and possible need for open approach if an endoscopic repair cannot be performed. The patients head is prepared and draped from the orbits to the vertex of the head. After injection of local anesthetic, a 3 to 5 cm parasagittal working incision is placed above the fracture and 3 cm behind the hair line [Fig. 3]. In patients with a prominent forehead or receding hair line, the incision may need to be closer to the hairline to allow visualization around the intrinsic curvature of the forehead. The incision length will vary depending on the size of the implant to be inserted. Care should be taken to avoid trauma to the hair follicles, and cautery should be avoided if possible. A second 1 to 2 cm endoscope incision then is placed at the same height, but 4 to 6 cm medial to the working incision [see Fig. 3]. A blind subperiosteal dissection is performed through the working incision down to the level of the fracture. Care should be used to maintain the integrity of the

Fig. 2. Preoperative axial CT scan of patient in Fig. 1 demonstrating an anterior table frontal sinus fracture.

periosteum, because periosteal tears will catch the endoscope when it is inserted. A 4.0 mm, 30 endoscope (with rigid endosheath and camera) then is inserted through the smaller, medial incision, and the optical cavity is visualized. Dissection over the fracture is performed under direct vision to the level of the orbital rims. Caution must be used to avoid injury to the supratrochlear and supraorbital neurovascular pedicles. The elevation is generally easy, because the procedure is performed 3 months after the injury, and there is a fibrous layer preventing entry into the sinus. Once the entire fracture is exposed, an implant is inserted to fill the defect. The authors have evaluated hydroxyapatite bone cement for this purpose but found it difficult to apply and manipulate endoscopically. A 0.85 mm thick Medpor (Porex Surgical - Newnan, Georgia) sheet is the preferred implant. The implant is trimmed to approximate the defect [Fig. 4]. The implant is inserted through the working incision and manipulated over the defect. The superior edge of the implant is marked with a pen to maintain the orientation endoscopi-

Fig. 1. Anterior table frontal sinus fracture.

Fig. 3. Scalp incisions used for endoscopic repair of frontal sinus fractures.

Frontal Sinus Fracture Repair

27

Fig. 4. Intraoperative photograph of a 0.85 mm Medpor implant trimmed to camouflage the anterior table frontal sinus fracture.

cally [Fig. 5]. At times, the author has sutured two to three layers of Medpor together to fill the defect more accurately [Fig. 6]. A 25 gauge needle then is passed through the skin over the fracture site and endoscopically visualized to determine the best site for percutaneous screw placement [see Fig. 5]. The ideal site will allow placement of two screws at opposite edges of the implant. A #11 blade is used to make a 2 mm, through-and-through stab incision. A 1.7 mm self-drilling screw (length 4 to 7 mm) is passed through the stab incision, through the edge of the implant, and into the frontal bone. If the implant is not completely stable, a second screw is placed on the contralateral side. The selfdrilling screw must be placed at least 0.5 to 1.0 mm away from the implant edge or the implant may tear. An alternative to the standard 0.85 mm Medpor sheeting is a prefabricated Medpor implant that is generated from a CT scan and completely fills the volume of the defect. The major advantage is a tight-fitting implant with little dead space. The dis-

Fig. 6. Intraoperative photograph of a layered Medpor implant. Two 0.85 mm thick Medpor implants were sutured together to fill dead space in the anterior table defect.

advantage is that prefabricated implants cost approximately $4000 and require 6 weeks for fabrication, as opposed to standard sheets which cost $250 to $450. Both types of implant are palpable through the skin, but are not visible upon inspection [Fig. 7]. After completion of the procedure,

Fig. 5. Endoscopic view of Medpor sheeting inserted over a frontal sinus fracture. Note the 25 gauge needle being passed through the skin to localize the site of percutaneous screw placement, and the marking line on the superior aspect of the implant used for orientation.

Fig. 7. Postoperative photograph of endoscopically repaired anterior table frontal sinus fracture seen in Fig. 1.

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Strong & Kellman

the scalp incisions are closed in layers, and a head dressing is applied for 48 hours. No drains are used.

Discussion
Historically, almost all frontal sinus fractures were treated aggressively because of the long term risk of mucocele formation. Although the success rates for open reduction and internal fixation are very high, the procedure results in postsurgical stigmata, including a large scar, paresthesias, possible alopecia, and uncommonly facial nerve injury. Advances in endoscopic surgery and CT have provided more effective options for diagnosis and treatment of frontal sinus mucoceles. Consequently, more conservative endoscopic approaches are being investigated. Several authors have described an endoscopic approach to frontal sinus fractures, eliminating the need for a coronal incision [46]. The endoscopic repair can be divided into two types: acute fracture reduction with or without fixation, and fracture camouflage. The fracture reduction technique involves exposure of the fracture in the acute setting, reduction of the bone fragments, and application of internal fixation as needed to maintain stability. This technique is covered elsewhere in this issue. The fracture camouflage technique involves an observation period to allow resolution of facial edema, followed by recontouring of the defect with an alloplastic implant. Strong and colleagues compared the fracture reduction and camouflage techniques [3]. They found that both approaches were feasible. Fracture reduction, however, was technically more challenging, because it required mobilization and reduction of small bone fragments that may be under great compressive forces [Fig. 8]. If the interfragmentary resistance is too great, the reduction

Fig. 9. (A) Coronal CT scan of a patient with an anterior table frontal sinus fracture with enough displacement to be considered for traditional open repair in the acute setting. (B) 4-month postinjury photograph of the same patient without any visible cosmetic deformity. The patient received no treatment for the injury.

cannot be performed. If the interfragmentary resistance is too little, it may be difficult to maintain the reduction, because the bone fragments are free floating. The fracture camouflage technique was found to have several advantages:

The exposure is easier, because the bone fragments are not mobile. The repair is technically less challenging, because it does not require manipulation of bone fragments. The repair need not be done in the acute setting.

Delayed repair can be important, because once the soft tissue edema resolves, there may be no esthetic deformity, and the patient may not require any surgical intervention. This determination, however, cannot be made until 3 to 4 months after the injury. Using the camouflage approach, only those patients with a true aesthetic deformity will require surgery [Fig. 9]. The main disadvantage of

Fig. 8. External forces applied to the frontal bone during (A) fracture and (B) surgical repair.

Frontal Sinus Fracture Repair

29

the camouflage technique is the need for an alloplastic implant. The authors currently use the camouflage technique with 0.85 mm thick Medpor sheeting to treat isolated, moderate displacement (2 to 6 mm) fractures of the anterior table. Medpor has a long track record for maxillofacial reconstruction. It is relatively cheap, easy to handle and insert, and well-tolerated. Additionally, it can be removed in one piece should it be necessary.

standardized sheeting is equally effective and significantly cheaper.

References
[1] Strong EB, Sykes JM. Frontal sinus and nasoorbitoethmoid complex fractures. In: Papel ID, editor. Facial plastic reconstructive surgery. 2nd edition. New York, NY. 2002. p. 74758. [2] McGraw-Wall B. Frontal sinus fractures. Facial Plast Surg 1998;14(1):5966. [3] Strong EB, Buchalter G, Moultrop T. Endoscopic repair of isolated anterior table frontal sinus fractures. Arch Facial Plast Surg 2003;5(6):51421. [4] Forrest CR, et al. Application of endoscopicassisted minimal-access techniques in orbitozygomatic complex orbital floor and frontal sinus fractures. J Craniomaxillofac Trauma 1999;5(4): 712. [5] Graham III DH, Spring P. Endoscopic repair of frontal sinus fracture: case report. 1996. p. 525. [6] Lappert P. Treatment of an isolated outer table frontal sinus fracture using endoscopic reduction and fixation. Plast Reconstr Surg 1999;102(5): 16425.

Summary
Endoscopic repair (ie, camouflage) of anterior table frontal sinus fractures is an efficacious technique that significantly reduces patient morbidity. It also has the added advantage of being a secondary procedure. Therefore, only those patients with a true aesthetic deformity require surgery. Surgeons considering this technique should be very comfortable with endoscopic equipment and techniques. The skill set is very similar to that of an endoscopic brow lift. Prefabricated implants can be used, but

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FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA

Facial Plast Surg Clin N Am 14 (2006) 3135

Endoscopic Management of Frontal Sinus Fractures

Kevin A. Shumrick,
&

MD

Endoscopic management of frontal sinus fractures

&

References

Management of facial trauma always has been a balancing act between achieving accurate fracture reduction and stabilization, while causing as little morbidity as possible. Until roughly the 1930s, management of facial fractures consisted of external splints and bandages, which simply immobilized the fractures and allowed them to heal. Although external splints imparted little morbidity, the fractures rarely were reduced anatomically. Later, interfragment wires and suspension wires were developed, somewhat improving reduction and stabilization. Wire placement and fracture reduction, however, required multiple small keyhole incisions, and the reductions rarely were completely accurate or rigidly stabilized. In the late 1980s and early 1990s, the development of plate and screw fixation placed by means of extendedaccess approaches provided excellent fracture reduction and fixation but required long incisions and extensive soft tissue elevation [116]. As surgeons continued to refine their management of facial trauma, it was only natural that a less invasive approach to fractures would be found. Endoscopes have had a profound effect on nearly every surgical specialty over the past 20 years. Using endoscopic approaches, excellent visualization of the surgical site can be achieved while avoiding ex-

tensive external incisions, thus, dramatically reducing morbidity compared with traditional surgical approaches. The specialties of orthopedics, gynecology, abdominal surgery, thoracic surgery, and paranasal sinus surgery have been enhanced by the ability to perform accurate endoscopic surgery while virtually eliminating the long surgical scars and pain of surgical approaches. To perform effective endoscopic surgery, a cavity is required to keep soft tissue from draping over the endoscope and obscuring visualization of the surgical site. The use of endoscopes for facial surgery has lagged behind these other specialties primarily because of the lack of a readily usable optical cavity, but also difficulty working around the curve of the skull. In the aforementioned surgical specialties, the optical cavities are either natural (as with sinus and thoracic surgery) or created by infusing gas (abdominal surgery) or saline (orthopedic surgery). Unfortunately, for most facial skeletal surgery, there is no readily available cavity in which an endoscope can function. To overcome this deficiency, special sheaths have been designed for the scopes with extensions that hold soft tissue away from the surgical site. Typically, a 30 scope is used in conjunction with the sheath and extension. These tent the soft tissues away from the surgical site. This tenting of the soft

Division of Facial Plastic Surgery, Department of Otolaryngology, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267, USA E-mail address: shumrika@ucmail.uc.edu
1064-7406/06/$ see front matter 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.fsc.2005.11.004

facialplastic.theclinics.com

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Shumrick

Fig. 3. Endoscopic sheath.

Fig. 1. Various endoscopic instruments.

tissue creates an optical cavity, allowing the surgeon to look down on the surgical site using a 30 scope. [Figs. 14]. This article outlines the state of the art with regard to the use of endoscopes for managing frontal sinus fractures, which are one of the most common fractures treated with endoscopic techniques.

Endoscopic management of frontal sinus fractures

Endoscopic forehead lifting has been accepted for the past 10 years and has provided significant experience with endoscopic management of the frontal region for aesthetic purposes [1723]. With this experience has come well-developed exposures and instrumentation. Using endoscopic techniques, several authors have reported case reports detailing successful management of anterior wall fractures of the frontal sinus [2429]. These reports have dealt exclusively with eggshell fractures of the anterior wall that simply are popped back into position and allowed to heal without fixation. Strong and colleagues reported on a cadaver study looking at the feasibility of performing endoscopic reduction and fixation. They found that the fractures could be visualized, but they encountered difficulty with complete reduction and were unable to perform rigid fixation in a noninvasive manner. As an alternative, Stronge and colleagues recommended camouflaging

the anterior wall depression by endoscopically applying hydroxyapatite bone cement. At the University of Cincinnati, the author and colleagues have attempted endoscopic reduction of frontal sinus fractures on 19 patients and have been successful in 12 of them. Success is defined as a reduction sufficiently anatomic and stable that no further treatment was felt to be necessary (by the physician or patient) The authors technique is similar to endoscopic forehead lifting, with one central and two lateral hairline incisions [Figs. 4 and 5]. It is preferred to work through separate ports for the endoscope and instruments to avoid crowding of the instruments and scope at the anterior portion of the incision. The forehead soft tissues are elevated subperiosteally, and the fractures are visualized by means of a 30 endoscope with an external sheath for soft tissue retraction [Figs. 6 and 7]. Once the fracture site is visualized, one attempts to elevate the fragments with endoscopic elevators. The author, however, has found that it is usually necessary to approach the fragments directly through small forehead incisions (preferably hidden in the brow). Using small external incisions directly over the fractures allows the surgeon to apply anterior force for anatomic reduction of the fracture segments. This approach has been more successful than trying to work within the forehead skin envelope, which requires more of a prying motion to elevate the fractures; this tips the fragments. The fractures are elevated using percutaneous nerve hooks, or by drilling into the fragments and grabbing them with threaded Stein-

Fig. 2. 30 and 70 scopes. Most frequently the 30 scope is used.

Fig. 4. Endoscope inside endoscopic sheath.

Frontal Sinus Fractures

33

Fig. 5. (A) Endoscopic view of frontal sinus anterior wall fracture. (B) Direct percutaneous approach with threaded Steinman pin and nerve hook to elevate bone fragments. (C ) Combination of nerve hook and threaded Steinman. (D) Instruments in midline and paramedian incisions.

mann pins [see Figs. 57]. With gentle retraction, the fragments often elevate into a reduced position and are frequently stable without the need for rigid fixation. Given the fact that the fracture segments are not approached directly, it is common to have residual surface irregularities. These irregularities are considered a trade off for avoiding long, approach incisions, and they are camouflaged with patches of Vicril Mesh (Ethicon, Inc., Somerville, New Jersey) [Fig. 7].

Fig. 6. The surgeon sits at the head of the table, and the monitor is at the foot.

In the four patients whose endoscopic fracture repair was felt to be unsuccessful, the reason was that the fracture segments were unstable after endoscopic reduction. The fragments continued to collapse despite having been reduced. In retrospect, these unsuccessful reductions were more extensively comminuted then was appreciated on the initial review of the coronal and axial CT scans. This highlights the importance of careful patient selection and the need for fully informing patients that the endoscopic approach may not reduce their fractures fully. Cases with unstable anterior walls after endoscopic reduction were converted to an open approach with coronal incisions and rigid fixation in the standard fashion [Fig. 8]. Based on this experience, the author feels that the endoscopic technique is appropriate only for anterior wall frontal sinus fractures that have several large segments without extensive comminution. It goes without saying that more extensive fractures with involvement of the nasofrontal ducts or posterior wall should have open approaches . Additionally, the surgeon should be prepared to camouflage any residual irregularities with the material of choice. As mentioned, the author prefers Vicril mesh, but alternatives would include bone cement, Gore-Tex, Alloderm, or Surgicell.

34

Shumrick

Fig. 7. (A) Frontal sinus anterior wall fracture. This is a good candidate for endoscopic reduction, because it is not comminuted. (B) Incisions planned. (C ) Threaded Steinman pin used to reduce fracture fragments while the endoscope is used to monitor the reduction. (D) Endoscopic view of Vicryl mesh placement for camouflage of residual irregularities. (E ) Six-week postreduction photo.

Fig. 8. (A) Unsuccessful attempt at endoscopic reduction. The fracture was too comminuted and unstable. (B) Fracture was managed with a coronal approach and rigid fixation with titanium mesh.

Frontal Sinus Fractures

35

References
[1] Yaremchuk MJ, Gruss JS, Manson PN, editors. Rigid fixation of the craniomaxillofacial skeleton. Boston: Butterworth-Heinemann; 1992. [2] Manson PN. Midface fractures: advantages of immediate extended open reduction and bone grafting. Plast Reconstr Surg 1985;76:110. [3] Manson PN, et al. Toward CT based facial fracture treatment. Plast Reconstr Surg 1990;85:20212. [4] Barone CM, Gigantelli JW. Endoscopic repair of posttraumatic enophthalmos using medial transconjunctival approach: a case report. J Craniomaxillofac Trauma 1998;4(1):226. [5] Barone CM, Boschert MT, Jimenez DF. Usefulness of endoscopy in craniofacial trauma. J Craniomaxillofac Trauma 1998;4(3):3641. [6] Bell RB, et al. Management of cerebrospinal fluid leak associated with craniomaxillofacial trauma. J Oral Maxillofac Surg 2004;62(6):67684. [7] Chen CT, et al. Endoscopically assisted mandibular subcondylar fracture repair. Plast Reconstr Surg 1999;103(1):605. [8] Czerwinski M, Lee C. Traumatic arch injury: indications and an endoscopic method of repair. Facial Plast Surg 2004;20(3):2318. [9] Honda T, et al. Endoscope-assisted facial fracture repair. World J Surg 2001;25(8):107583. [10] Krimmel M, Cornelius CP, Reinert S. Endoscopically assisted zygomatic fracture reduction and osteosynthesis revisited. Int J Oral Maxillofac Surg 2002;31(5):4858. [11] Lee CH, Lee C, Trabulsy PP. Endoscopic-assisted repair of a malar fracture. Ann Plast Surg 1996; 37(2):17883. [12] Lee C, Jacobovicz J, Mueller RV. Endoscopic repair of a complex midfacial fracture. J Craniofac Surg 1997;8(3):1705. [13] Lee CH, et al. A cadaveric and clinical evaluation of endoscopically assisted zygomatic fracture repair. Plast Reconstr Surg 1998;101(2):33345 [discussion 3467]. [14] Rhee JS, Lynch J, Loehrl TA. Intranasal endoscopyassisted repair of medial orbital wall fractures. Arch Facial Plast Surg 2000;2(4):26973.

[15] Schon R, Gellrich NC, Schmelzeisen R. Frontiers in maxillofacial endoscopic surgery. Atlas Oral Maxillofac Surg Clin North Am 2003;11(2): 20938. [16] Schon R, Schmelzeisen R. Endoscopic fracture treatment. Ann R Australas Coll Dent Surg 2002; 16:405. [17] Aly A, Avila E, Cram AE. Endoscopic plastic surgery. Surg Clin North Am 2000;80(5):137382. [18] Chajchir A. Endoscopic subperiosteal forehead lift. Aesthetic Plast Surg 1994;18(3):26974. [19] Daniel RK, Tirkanits B. Endoscopic forehead lift. Aesthetics and analysis. Clin Plast Surg 1995; 22(4):60518. [20] Daniel RK, Tirkanits B. Endoscopic forehead lift: an operative technique. Plast Reconstr Surg 1996; 98(7):114857 [discussion 1158]. [21] Dayan SH, et al. The forehead lift: endoscopic versus coronal approaches. Aesthetic Plast Surg 2001;25(1):359. [22] Marchac D, Goni S. Endoscopic forehead lift. Acta Chir Belg 2001;101(5):2107. [23] Ramirez OM. Endoscopic full facelift. Aesthetic Plast Surg 1994;18(4):36371. [24] Chen DJ, et al. Endoscopically assisted repair of frontal sinus fracture. J Trauma 2003;55(2): 37882. [25] Graham III HD, Spring P. Endoscopic repair of frontal sinus fracture: case report. J Craniomaxillofac Trauma 1996;2(4):525. [26] Lappert PW, Lee JW. Treatment of an isolated outer table frontal sinus fracture using endoscopic reduction and fixation. Plast Reconstr Surg 1998;102(5):16425. [27] Rice DH. Management of frontal sinus fractures. Curr Opin Otolaryngol Head Neck Surg 2004; 12(1):468. [28] Shumrick KA, Ryzenman JM. Endoscopic management of facial fractures. Facial Plast Surg Clin North Am 2001;9(3):46974. [29] Strong EB, Buchalter GM, Moulthrop TH. Endoscopic repair of isolated anterior table frontal sinus fractures. Arch Facial Plast Surg 2003;5(6): 51421.

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FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA

Facial Plast Surg Clin N Am 14 (2006) 3743

The Rationale and Technique of Endoscopic Approach to the Zygomatic Arch in Facial Trauma
Marcin Czerwinski,
& & & &

MD

, Chen Lee,

MD, FRCSC

b,*

&

The role of arch anatomy and use of endoscopy to minimize treatment pitfalls Arch injury patterns Endoscopic indications and rationale for repairs Repair sequencing Le Fort III Complex zygoma Surgical technique Equipment

&

& &

Exposure Reduction Fixation Case presentations Le Fort III Complex zygoma Discussion References

Endoscopy was introduced to the field of facial plastic surgery relatively late by Vasconez and colleagues [1], who were the first to perform an endoscopic brow lift in 1994. This initial delay in the assimilation of the endoscope in the head and neck region likely was caused by the absence of naturally occurring body cavities, such as the abdomen or a joint space, which greatly facilitate its application in general and orthopedic surgeries. In addition, initial endoscopic instruments lacked specificity to the facial region. Despite this late introduction, the use of endoscopy rapidly progressed as the advantages of minimal access were realized. Sakai and colleagues [2] extended endoscopic applications to the management of craniofacial disorders, performing a Le Fort I level osteotomy. Lee and colleagues [3,4] and Kobayashi and colleagues [5] pioneered the

use of endoscopy in the area of the zygomatic arch. Since their original descriptions, several modifications to their techniques have been proposed. These vary in placement of incisions, planes of dissection and methods of fixation [6,7]. The endoscope currently is considered by many to have an integral role for managing injuries in this region. This article presents the authors experience with the endoscopic technique of zygomatic arch repair, the evolution and advantages of its present indications, and future directions.

The role of arch anatomy and use of endoscopy to minimize treatment pitfalls
The zygomatic arch is a narrow skeletal element spanning from the temporal bone to the zygoma body. In the axial plane, the arch is curved in the

, Montreal Children s Hospital, C1139 2300 Tupper Street, Montreal, Quebec, Canada, H3H 1P3 Sacre-Coeur Hospital, 5400 boul. Gouin West, Montreal, Quebec, Canada, H4J 1C5 PH * Corresponding author. E-mail address: chenlee@sympatico.ca (C. Lee).
a b

1064-7406/06/$ see front matter 2006 Elsevier Inc. All rights reserved.

doi:10.1016/j.fsc.2005.11.002

facialplastic.theclinics.com

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Czerwinski & Lee

reduction and rigid internal fixation, standard in other facial trauma repair, has been applied infrequently to the zygomatic arch. The use of endoscopy allows the surgeon to fully benefit from the role of arch repair while minimizing the negative sequelae of traditional access. This technique also offers other advantages, including magnified direct visualization, and in the longterm, a potential for increased quickness [11] and cost-effectiveness.

Arch injury patterns

Fractures of the zygomatic arch can occur in isolation or with midfacial injuries. The individual pattern depends mainly on the magnitude and direction of the trauma force vector applied to the craniofacial skeleton. Isolated arch fractures can be of three types. First, direct lateral force displaces the arch medially [Fig. 1]. Second, an anterior force vector focused on the malar prominence usually will cause a posterior telescoping pattern of injury [Fig. 2]. At times, however, a posteriorly directed force can result in an explosive burst with displacement of the arch fragments laterally [Fig. 3]. Recognition of the latter two injury patterns is important, as a nonvisualized reduction attempt, using an elevator inserted under the arch, will be unsuccessful and exacerbate fracture displacement. A displaced zygoma fracture results from disruption of all its bony attachments, of which the zygomatic arch is a necessary component. Most frequently, it arises because of a force applied directly to the malar prominence with dissipation

Fig. 1. Medial arch displacement occurs following direct lateral force. (From Czerwinski M, Lee C. Traumatic arch injury: indications and an endoscopic method of repair. Facial Plast Surg 2004;20(3):2318, with permission.)

posterior third of its course and straight in the anterior two thirds. In the sagittal plane, it is parallel to the Frankfort horizontal. The arch also occupies a strategic position, joining the midface, which frequently is displaced in facial trauma, to the stable skull base. Numerous authors have taken advantage of these properties, using the archs bony attachments and consistent shape as a guide to anatomically repairing it and the midface without the necessity of exposing the contralateral, uninjured part of the skull as a control [8,9]. The role of the arch in midfacial repair can be viewed threefold. First, it can be used as a guide to precise fracture realignment, to accurately restore midfacial projection and transverse width. Second, it can serve as an anchor point of the midface because of its sturdy skull base attachment. Last, its anatomic reduction is paramount to aesthetic appearance in individuals with prominent preinjury lateral facial contour. Despite its key role, the advantages of arch repair have not been used sufficiently, as access to it is fraught with difficulties. Incisions cannot be placed directly over the arch because of high risk of facial nerve injury. The facial nerve pierces the superficial musculoaponeurotic system at its lower border and courses superficially to the temporoparietal fascia in an anterosuperior direction [10]. Instead, the coronal approach designed to avoid injury to the facial nerve traditionally has been used. The latter has its own drawbacks, however, including alopecia, anesthesia posterior to the incision, risks of traction injury to the frontal branch of the facial nerve and temporal hollowing, and excessive blood loss [4]. Consequently, the principle of anatomic

Fig. 2. Posterior telescoping fracture of the arch results when energy applied anteriorly to the malar prominence is transmitted to the arch segment. (From Czerwinski M, Lee C. Traumatic arch injury: indications and an endoscopic method of repair. Facial Plast Surg 2004;20(3):2318, with permission.)

Zygomatic Arch in Facial Trauma

39

Fig. 3. (A) Zygomatic arch fragmentation with lateral displacement of the segments occurs when a high energy force is applied anteriorly at the zygoma and dissipates posteriorly at the arch. (B) Successful anatomic repositioning of the lateralized arch fragments. (From Czerwinski M, Lee C. Traumatic arch injury: indications and an endoscopic method of repair. Facial Plast Surg 2004;20(3):2318, with permission.)

of much of the energy at the anterior, zygomaticomaxillary, and infraorbital buttresses. Only higher energy mechanisms will have a sufficient portion of the force transmitted posteriorly to cause arch disruption. The magnitude of energy determines the degrees of displacement and comminution [12]. A displaced zygoma fracture results in malar prominence depression and may cause enophthalmos because of orbital enlargement. A Le Fort III-level fracture is defined in part by separation of the maxilla from the cranial base at the zygomatic arch. It occurs in high-energy injuries in which the force vector fractures across the alveolus and the pterygoid plates, resulting in a mobile maxilla and its attached dentition. Disruption of the stable arch attachment causes occlusal instability in addition to midfacial flattening, widening, and asymmetry.

Endoscopic indications and rationale for repairs

In the authors experience, endoscopic approach to the arch should be considered in all cases where precise arch repair is deemed an integral part of the treatment plan. Thus, when the zygomatic arch is thought to contribute to proper reduction or enhanced stability of other facial fractures, or when the arch itself is considered an important aesthetic landmark, the surgeon should attempt endoscopic reduction and fixation. This approach allows effective fracture management while minimizing the stigmata of extensive incisions. In Le Fort III-level injuries, the principal benefit of rigid arch fixation is to stabilize the mobile maxilla and its attached dentition to the skull base. This ensures a secure maxillomandibular occlu-

sal relationship. The arch is a particularly valuable point, as the other anterior buttresses frequently are comminuted. The secondary role of the arch in Le Fort III fractures is to enhance accurate midface realignment. In displaced zygoma fractures, arch reduction is a valuable tool for anatomic repositioning of the malar prominence to recreate preinjury facial width and projection. It may, in addition, restore adequate orbital volume. This is paramount in complex zygoma fractures when there is extensive comminution of at least two of the anterior three zygoma buttresses. In these injuries, the arch also serves as an additional point of rigid fixation. In isolated arch fractures, repair is particularly important in individuals with prominent preinjury lateral facial contour. Failure of realignment will lead to an unsightly temporal depression and asymmetry. In addition, miniplate placement will prevent subsequent arch redisplacement caused by reinjury or pull by the masseter muscle, an issue not addressed by the Gillies approach.

Repair sequencing
In the authors experience, when the complexity of facial trauma necessitates incorporation of arch repair into a comprehensive management plan, the following sequences are most effective.

Le Fort III
The authors approach the repair of these fractures by individually treating the cranioorbital and maxillomandibular units, subsequently uniting them at the Le Fort I level. The cranioorbital unit is addressed by first reducing and fixating the external orbital frame at the infraorbital and zygo-

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Czerwinski & Lee

maticofrontal interfaces. The arch then is repaired to provide appropriate projection and width to the midface. Premorbid occlusion is restored using maxillomandibular fixation. Next, the two functional units are joined using miniplates at the zygomaticomaxillary and nasomaxillary buttresses.

Dissector Retractor, Karl Storz, Germany), which maintains the optical cavity, and a video system (Olympus America, Lake Success, New York) to project the endoscopic image onto a monitor display.

Exposure
A scalp extension of the preauricular incision is carried through the skin and the temporoparietal fascia to expose the deep temporal fascia. A periosteal elevator then is inserted, and an optical cavity is created by dissecting superficial to the deep temporal fascia. This nonvisualized part of the dissection is performed only superior to an imaginary line extending from the helical crus to the superior orbital rim. This minimizes the risk of injury to the frontal branch of the facial nerve. Following dissection of the optical cavity, a retractor-mounted endoscope is inserted, and directly visualized dissection in the same plane is performed down to the zygomatic arch. Maintenance of integrity of the deep temporal fascia helps to avoid unsightly temporal hollowing. Once the arch is reached, its periosteum is incised, and the sites of fracture are exposed in the subperiosteal plane [Fig. 4].

Complex zygoma
Complex zygoma fracture may require repair of all the anterior buttresses, including: zygomaticofrontal, infraorbital and zygomaticomaxillary, along with the zygomatic arch. Repair is accomplished most expediently by first restoring the external orbital frame, then reducing and fixating the zygomatic arch. The zygomaticomaxillary buttress is addressed last.

Surgical technique Equipment

The equipment used at the authors center includes: a 4 mm diameter 30 angle scope (Karl Storz, Germany), a 4 mm endoscope mounted retractor (Isse

Fig. 4. (A) Endoscopic repair of the arch is performed using a small incision hidden in the temporal hairline. The retractor-mounted endoscope is inserted, and directly visualized dissection is performed in a plane superficial to the deep temporal fascia down to the zygomatic arch. (B) Endoscopic view demonstrates medially displaced arch segments. (C ) Following repair, arch fragments are seen in their anatomic position. (From Czerwinski M, Lee C. Traumatic arch injury: indications and an endoscopic method of repair. Facial Plast Surg 2004;20(3):2318, with permission.)

Zygomatic Arch in Facial Trauma

41

Reduction
Following exposure, arch fragments are reduced according to the fragmentation pattern to restore preinjury arch form. This is preferably done in situ. If excessive comminution prevents stability and does not allow in situ reduction, the fragments can be removed and precisely realigned on a side table. This, however, carries a significant risk of bony resorption, as the periosteal blood supply is interrupted [13].

Fixation
Selection of appropriate fixation hardware depends on the type of fracture. A short miniplate is used in isolated arch injuries, whereas a long miniadaptation plate is preferred in associated midfacial trauma. The long mini-adaptation plate extends onto the lateral orbital rim, restoring and rigidly stabilizing the midface. Following fixation of the plate to an arch segment, either in situ or on a side table, accurate reduction is confirmed, and the plate is stabilized to other fracture segments using the endoscope [see Fig. 4].

revealed left Le Fort III and right Le Fort II facial fractures. In the operating room, premorbid occlusion initially was restored using maxillomandibular fixation. Access for repairs was achieved using preauricular (endoscopic arch fixation), lateral extension of upper blepharoplasty (zygomaticofrontal buttress), and upper buccal sulcus incisions (inferior orbital rim and zygomaticomaxillary buttress). The arch component of the Le Fort III fracture was plated rigidly as a free graft ex vivo and then repositioned accurately to help stabilize and reduce the midfacial injury [Figs. 5, 6].

Complex zygoma
A male involved in a motor vehicle collision was brought to the hospital. During the trauma, the left side of his face struck the steering wheel. He complained of left cheek flatness and pain, and anesthesia in the left infraorbital nerve distribution. In addition, he sustained a left lateral orbital laceration. CT imaging demonstrated a left zygoma fracture with lateral displacement of the comminuted arch. Access for fracture repair was by means of preauricular (endoscopic arch fixation), lateral orbital laceration (zygomaticofrontal buttress), and upper buccal sulcus incisions (inferior orbital rim and zygomaticomaxillary buttress). The significantly comminuted arch component was plated ex vivo and then repositioned anatomically as the arch element of four-point zygoma fracture reduction and fixation [Figs. 3, 7].

Case presentations Le Fort III

A young male was assaulted with a baseball bat. On examination, the left side of his face was visibly flattened; the entire maxillary segment was mobile, and he complained of malocclusion. CT imaging

Fig. 5. (A) Preoperative photograph of a patient who sustained a left Le Fort III and right Le Fort II facial fractures. Midfacial flattening and malocclusion are evident. (B) Photograph several months following endoscope-assisted repair. (From Czerwinski M, Lee C. Traumatic arch injury: indications and an endoscopic method of repair. Facial Plast Surg 2004;20(3):2318, with permission.)

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Czerwinski & Lee

Fig. 6. (A) Coronal and axial CT images demonstrating left Le Fort III and right Le Fort II level injuries with severe left zygomatic arch comminution. (B) Following endoscope-assisted repair, anatomic realignment of midfacial anatomy and restoration of preinjury occlusion can be seen. (From Czerwinski M, Lee C. Traumatic arch injury: indications and an endoscopic method of repair. Facial Plast Surg 2004;20(3):2318, with permission.)

Fig. 7. (A) Preoperative photograph of a patient with a complex zygoma fracture. Severe decrease in malar prominence projection and increased facial width can be appreciated. (B) Photograph several months following surgery shows restoration of normal facial topography. The arch component of four-point zygoma fracture repair was performed using the endoscopic technique. (From Czerwinski M, Lee C. Traumatic arch injury: indications and an endoscopic method of repair. Facial Plast Surg 2004;20(3):2318, with permission.)

Zygomatic Arch in Facial Trauma

43

Discussion
The reliable form and strategic position of the zygomatic arch make it a valuable landmark in midfacial trauma management [8,9]. In isolated arch fractures, its repair restores lateral contour of the face and prevents subsequent displacement caused by reinjury or pull by the masseter muscle. In complex fractures of the zygoma, restoration of arch anatomy is an essential guide to recreating preinjury malar prominence projection and transverse facial width. In Le Fort III-level fractures, rigid arch repair is the most stable point of fixation that anchors the mobile maxillary dentition to the skull base. The relative importance of arch repair increases as the complexity of trauma rises, being most important in Le Fort III injuries and least so in isolated fractures. Open zygomatic arch repair has been used infrequently, mainly because traditional access to this structure is fraught with undesirable sequelae, namely: alopecia, loss, of scalp sensation posterior to the incision, excessive blood loss, temporal hollowing and potential injury to the frontal branch of the facial nerve [4]. Thus for many years, the standard of anatomic reduction and rigid internal fixation used in facial trauma management did not apply to the arch. The authors believe the endoscopic approach allows the surgeon to fully appreciate the role of zygomatic arch in facial fracture management without having to suffer the consequences of coronal access. The endoscope-assisted approach necessitates only small, well-concealed incisions and allows in situ reduction and fixation under direct, magnified visualization. The authors encourage the use of the endoscope-assisted zygomatic arch repair in Le Fort III, complex zygoma, and isolated arch fractures, all of which previously had been considered to be indications for a coronal incision. The endoscopic method of zygomatic arch repair does have some disadvantages. It requires the acquisition of a different set of surgical skills. This technical challenge arises, because the separation in the usual hand-eye coordination results in the loss of tactile perception. In addition, perception of depth is lost as the three-dimensional image is reformatted on a flat screen. Furthermore, there is an associated steep learning curve resulting in initially long operative times. Finally, purchase of required surgical instruments and electronic devices represents a significant initial expense.

Being aware of its difficulties, the authors believe endoscope-assisted zygomatic arch repair represents a significant advance in midfacial trauma management. In the future, implementation of specialized training programs into surgical program curricula and further improvements in endoscopic instruments will promote this technique further.

References
[1] Vasconez LO, Core GB, Gamboa-Bobadilla M, et al. Endoscopic techniques in coronal brow lifting. Plast Reconstr Surg 1994;94:78893. [2] Sakai Y, Kobayashi S, Ohmori K. An endoscopic Le Fort I osteotomy: clinical results. Jpn J Plast Reconstr Surg 1995;38:875. [3] Lee C, Jacobovicz J, Mueller RV. Endoscopic repair of a complex midfacial fracture. J Craniofac Surg 1997;8:1705. [4] Lee CH, Lee C, Trabulsy PP, et al. A cadaveric and clinical evaluation of endoscopically assisted zygomatic fracture repair. Plast Reconstr Surg 1998;101:33345. [5] Kobayashi S, Sakai Y, Yamada A, et al. Approaching the zygoma with an endoscope. J Craniofac Surg 1995;6:51924. [6] Lee SS, Lin SD, Chiu YT, et al. Deep dissection plane for endoscopic-assisted comminuted malar fracture repair. Ann Plast Surg 2002;49: 4529. [7] Lee JS, Kang S, Kim YW. Endoscopically assisted malarplasty: one incision and two dissection planes. Plast Reconstr Surg 2003;111:4617. [8] Stanley Jr RB. The zygomatic arch as a guide to reconstruction of comminuted malar fractures. Arch Otolaryngol Head Neck Surg 1989;115: 145962. [9] Gruss JS, Van Wyck L, Phillips JH, et al. The importance of the zygomatic arch in complex midfacial fracture repair and correction of posttraumatic orbitozygomatic deformities. Plast Reconstr Surg 1990;85:87890. [10] Ellis EI, Zide MF. Surgical approaches to the facial skeleton. Williams and Wilkins; 1995. [11] Lee C, Stiebel M, Young DM. Cranial nerve VII region of the traumatized facial skeleton: optimizing fracture repair with the endoscope. J Trauma 2000;48:42330. [12] Manson PN, Markowitz B, Mirvis S, et al. Toward CT-based facial fracture treatment. Plast Reconstr Surg 1990;85:20212. [13] Krimmel M, Cornelius CP, Reinert S. Endoscopically assisted zygomatic fracture reduction and osteosynthesis revisited. Int J Oral Maxillofac Surg 2002;31:4858.

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FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA

Facial Plast Surg Clin N Am 14 (2006) 4550

Endoscopic Approach for Mandibular Orthognathic Surgery

Maria J. Troulis, DDS, MSc*, Jose L. Ramirez, Leonard B. Kaban, DMD, MD
&

DMD, MD,

Overview of endoscopic procedures Endoscopic vertical ramus osteotomy Condylectomy Mandibular retrognathism

&

References

The field of minimally invasive surgery (MIS) is defined as the combination of surgical innovation with modern technology [1]. It is the discipline of surgery that aims to minimize morbidity and complications usually associated with traditional procedures. MIS focuses on reducing tissue trauma and the resultant bleeding, edema, and injury to maximize the rate and quality of healing. This results in a faster recovery for the patient [2]. Until the mid 1800s, infection and the inability to effectively control hemorrhage, shock, and pain, limited the practice of surgery to the treatment of life-threatening conditions [3]. The use of aseptic technique, the discovery and widespread use of anesthesia, and improvements in perioperative patient management created an environment in which the art and science of surgery could flourish. The introduction of antibiotics after World War II allowed surgeons to carry out a greater variety of elective procedures to improve quality of life. During the last decade, craniomaxillofacial surgeons have begun to develop endoscopic techniques to treat soft tissue and skeletal defects [4] with decreased morbidity. The first orthognathic surgical procedure was reported by Simon Hullihen in 1849, in the American Journal of Dental Science. The procedure de-

scribed was a mandibular body ostectomy for correcting retrognathism and an anterior open bite resulting from a burn scar contracture of the neck. Hullihen realized that the constricting scar had to be released to facilitate the corrective jaw movement and to improve the long-term stability of the procedure. A collaborative effort between the orthodontist Edward Angle and the surgeon V. P. Blair led to the development of the St. Louis procedure. This technique involved bilateral ramus osteotomies for treating mandibular prognathism [5]. Schuchardt, in the German literature, was the first to describe a mandibular osteotomy resembling the current sagittal split. This approach to mandibular surgery first was discussed in the English literature by Trauner and Obwegeser in 1955. The technique proved to be quite versatile. It was used to treat various deformities including prognathism, retrognathism, asymmetries, and open bite. Another significant advantage of the sagittal split osteotomy was that a bone graft was not needed in cases where advancement of the mandible was required. The bilateral split osteotomy (BSSO) has been modified and improved over the years [6,7] to minimize morbidity and improve stability. The procedure, however, continues to be associated with significant swelling and potential injury to the inferior alveolar nerve.

Massachusetts General Hospital, Warren Building, Suite 1201, Boston MA 02114, USA * Corresponding author. E-mail address: mtroulis@partners.org (M.J. Troulis).
1064-7406/06/$ see front matter 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.fsc.2005.11.003

facialplastic.theclinics.com

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Troulis et al

Minimizing morbidity associated with mandibular surgery continues to be a central issue in craniomaxillofacial surgery. The development of rigid internal fixation has improved short- and longterm skeletal stability and has eliminated the need for prolonged periods of maxillomandibular fixation. Controlled hypotensive anesthesia has decreased blood loss, thus minimizing the risk of transfusion [8,9]. Administration of perioperative corticosteroids has contributed to a decrease in perioperative edema and discomfort [10]. The combination of improvements in all of these areas has decreased the length of stay associated with mandibular orthognathic surgery [11]. Recent advances in imaging, instrumentation, and fiberoptic technology have allowed surgeons to develop and refine minimally invasive access for orthognathic surgical procedures. These techniques eventually may replace traditional open procedures and further decrease morbidity. The endoscopic approach to the mandibular ramus/condyle unit (RCU) is a minimally invasive access technique. It is used to perform osteotomies and reconstructive procedures such as vertical ramus osteotomies with rigid fixation, condylectomy and costochondral grafts, and placement of miniature distraction devices. A combination of endoscopic access, rigid fixation, and in cases requiring skeletal expansion, distraction osteogenesis, will decrease the morbidity associated with orthognathic and reconstructive procedures. In the future, these procedures may be performed predominantly in an outpatient setting. Ultimately, this will have profound impacts on cost, availability, morbidity, and patient acceptance.

be the minimally invasive alternative to the sagittal split osteotomy.

Endoscopic vertical ramus osteotomy

Background For patients with mandibular prognathism (with or without asymmetry), the standard treatment options are the intraoral vertical ramus osteotomy (IVRO) or BSSO. IVRO offers the advantage of a lower incidence of inferior alveolar neurosensory disturbance when compared with BSSO. The osteotomy, however, generally is performed with poor visibility. It is not possible to use rigid fixation; therefore, the jaw must be immobilized by maxillomandibular fixation. The complication of condylar sag may result in postoperative open bite in a small percentage of patients. The BSSO is a more complicated osteotomy than the IVRO and requires more soft tissue dissection (medial and lateral ramus). The distinct advantage of the BSSO is that it can be used with rigid internal fixation. There is, however, a significant risk of inferior alveolar nerve (IAN) damage [13,14]. The endoscopic vertical ramus osteotomy (EVRO) is a minimally invasive alternative to the IVRO and BSSO. It can be accomplished with minimal risk to the IAN, and it allows the use of rigid internal fixation. The EVRO is indicated for those patients with mandibular prognathism or asymmetry who refuse maxillomandibular fixation and who are not willing to accept the risks of inferior alveolar nerve injury. This procedure also allows for mandibular setback without the need for extraction of welldeveloped mandibular third molars, which are associated intimately with the IAN [12] [Fig 1]. The surgical technique for the EVRO begins with careful marking of the zygoma, temporomandibular joint, ramus, angle, anterior border, and condyle on the skin. Then, a 1.5 cm incision is made one finger-breadth below the inferior border of the mandible, parallel to existing neck creases. The dissection is carried bluntly to the masseter muscle, which is incised with a needlepoint electrocautery. The bone is exposed and the dissection completed, in the subperiosteal plane, using endoscopic elevators with a suction port. This dissection creates an optical cavity that allows for excellent visualization of the operative field. A 30 endoscope is placed into the wound and oriented parallel to the posterior border. This dissection provides direct access to the entire RCU [4,12]. With the endoscope the next step is to identify the anatomic landmarks of the RCU: posterior border, sigmoid notch, coronoid process, anterior border, and posterior mandibular body. An osteotomy is created, under direct endoscopic visualization,

Overview of endoscopic procedures

The benefits of endoscopy include small and remotely placed incisions, inconspicuous scars, and direct visualization of a magnified and illuminated operative field for the surgeon. Tissue dissection and manipulation are minimized, resulting in less pain, edema, and overall morbidity [2,7,12]. Length of hospital stay is shortened, and there is a quicker return to normal activity [2,4,12,1921]. Endoscopic access can be used for orthognathic surgical correction of three types of mandibular deformities. In cases of mandibular prognathism or asymmetry, the endoscopic vertical ramus osteotomy is a minimally invasive alternative to the traditional vertical ramus osteotomy or sagittal split osteotomy. It also can be used for congenital or acquired temporomandibular joint conditions requiring either condylectomy and costochondral grafting or RCU construction. In cases of mandibular retrognathia, the endoscopic approach, when combined with a miniature distraction device, will

Minimally Invasive Surgery

47

Fig. 1. Vertical ramus osteotomy. (A) Endoscopic view of right lateral ramus with completed osteotomy, extending from sigmoid notch to angle. (B) Close-up panoramic view showing vertical ramus osteotomy with setback and rigid fixation. (C ) Lateral facial photograph of patient. Note healed incision.

from the sigmoid notch to the mandibular angle using a long-shaft reciprocating blade. The medial pterygoid muscle is stripped partially to allow for overlap of the proximal and distal segments. The patient is placed into maxillomandibular fixation in the preplanned occlusion. Rigid fixation is achieved with three 12 to 14 mm long, 2.0 mm diameter screws. The screw holes are drilled and the screws placed through the incision or with the aid of a percutaneous trocar. If there is minimal overlap of the proximal and distal segments, plate fixation may be used as an alternative [12]. Troulis and Kaban reported a retrospective study of 14 patients treated with EVRO [12]. The mean operating time was 37 minutes per side. A single patient suffered transient weakness of the marginal mandibular nerve, and this lasted less than 1 week. No patients required maxillomandibular fixation. One patient with concurrent medical problems had a hospital stay of 2 days. All other patients were discharged within 23 hours. The stability of bone positioning was documented at a mean of 1.7 years postoperatively with lateral cephalograms.

Condylectomy
Idiopathic condylar resorption For those patients with mandibular retrognathism and open bite secondary to idiopathic condylar resorption or degenerative joint disease, endoscopic condylectomy and costochondral graft reconstruction are minimally invasive alternatives to the standard open-access approaches. The standard technique for condylectomy and costochondral graft RCU reconstruction involves preauricular and submandibular incisions [15,16] with potential risk for facial

nerve paresis. The standard open approach also is associated with considerable bleeding and edema. Alternatively, condylectomy and RCU reconstruction can be achieved through the same 1.5 cm incision and dissection used for the EVRO. This approach results in a single, small and well-concealed facial scar. It also significantly decreases the risk to the facial nerve and the amount of bleeding and swelling. The incision, dissection, creation of the optical cavity, and landmark identification are the same as described for the EVRO. However, dissection of the condylar head and neck, however, is extended into the lower compartment of the temporomandibular joint until the bone is skeletonized. The condyle then can be atraumatically removed and the undersurface of the articular disc visualized [4,20]. The patient is placed in maxillomandibular fixation, with a splint, producing a 2 3 mm posterior open bite on the sides to be reconstructed. This compensates for the loss of vertical height of the costochondral graft during healing [15]. Costochondral grafts are harvested in the standard fashion through an inframammary incision. Then, using the endoscope, the disc is identified, and the graft is placed into the glenoid fossa. The graft is fixed into position using a 2.0 mm titanium miniplate (as a washer) with multiple screws. A retrospective evaluation of 10 patients revealed a mean operating time of 57 minutes per side exclusive of the rib harvesting procedure. Average hospital stay was 2.5 days [20]. There were no long-term neurologic changes associated with the IAN or lingual or facial nerves. All patients demonstrated a good range of motion, with maximal incisal opening returning to preoperative values by 1 year. In all patients, the desired occlusion

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Troulis et al

Fig. 2. Uncompensated left condylar hyperplasia, vertical pattern. Frontal (A) and submental (B) views of a 15-year-old patient with elongated left mandibular ramus indicative of condylar hyperplasia. (C) Intraoral view shows the left posterior open bite before the development of dental compensations, (D) SPECT scan showing the increased uptake of the left condyle. (E) Similarly, the left condyle is hyperactive. (F ) Patient underwent endoscopic high condylectomy and vertical ramus osteotomy with rigid fixation. (G, H) Postoperative patients symmetry and left open bite have been corrected. (From Kaban LB, Troulis MJ. Pediatric oral and maxillofacial surgery. Philadelphia, PA: W.B. Saunders; 2004;343; with permission.)

was maintained at the latest follow up (longer than 1 year). Condylar hyperplasia For patients with mandibular asymmetry secondary to condylar hyperplasia, the previously described approach to the RCU also can be used to perform

a growth-arresting procedure or high condylectomy. After exposing the condylar head and neck, the hyperplastic segment is marked, osteotomized, and removed. Then the normal condylar stump is smoothed and contoured. This procedure is performed best early in the disease cycle, before the development of dental compensations, to avoid

Minimally Invasive Surgery

49

Fig. 2 (continued).

the need for mandibular or bimaxillary orthognathic surgery. Patients who suffer from active condylar hyperplasia with secondary deformities of the maxilla and mandible are treated best by a combination of high condylectomy and bimaxillary orthognathic surgery. In patients who are clinically stable, orthodontic decompensation and standard orthognathic surgery are the treatment of choice [Fig. 2] [22].

Mandibular retrognathism
Patients with mandibular retrognathism account for approximately one third of all orthognathic surgical cases. The standard operation for the correction of this deformity is BSSO. Considerable research has been performed to minimize the morbidity and complications associated with this procedure. Despite these efforts, there are limitations associated with the sagittal split osteotomy. Sensory disturbance of the inferior alveolar nerve occurs in a high percentage of patients. This is mostly a result of the anatomy of the mandible and nerve canal rather than a specific surgical complication. IAN parethesia may occur because of stretch, when the jaw is advanced, trauma from retraction of the nerve on the medial side of the ramus, and compression or direct injury by bicortical screws used for rigid internal fixation. Sensory disturbance may range from paresthesia to anesthesia but is often transient and exhibits spontaneous resolution within 2 to 6 months in most cases. Up to 25% of the affected patients, however, have some persistent nerve deficit. The rate of this complication is even higher among patients over 40 years of age [13,14]. Another potential limitation is skeletal relapse, especially with advancements greater than 8 mm [6,7]. Distraction osteogenesis (DO) is a surgical technique that makes use of the bodys healing poten-

tial to form new bone in response to tension forces placed across an osteotomy. A corticotomy is made, and a device is placed across the cut. The device is activated gradually to produce the desired amount of bone lengthening. Gradual expansion of bone and associated soft tissues allows for correction of the deformity. Skeletal expansion is tolerated better than soft tissue, risk to the inferior alveolar nerve and risk of relapse potentially are diminished as compared to acute movements [17]. In a recent retrospective evaluation of 20 consecutive patients with mandibular retrognathism, treated with either BSSO (n = 10) or DO (n = 10), 36% of the BSSO versus 21% of the DO patients had dense paresthesia postoperatively. This difference suggests that paresthesia is less frequent in DO, but further studies are needed to confirm this. Subjectively, the DO patients also recovered normal sensation in greater numbers and more quickly [18]. Currently, the placement of distraction devices for mandibular advancement is achieved with an incision and dissection similar to that for BSSO, but with significantly less dissection. The third molar is removed, if present, and a corticotomy is made through the third molar tooth region. The distracter is fixed across the gap between proximal and distal segments. The wound is closed, leaving the activation mechanism exposed transmucosally. After a latency period ranging from 2 to 4 days, distraction begins at a rate of 1 mm a day to the desired amount [23]. The development and refinement of endoscopic techniques for access to the maxillofacial skeleton will allow surgeons in the near future to perform complex osteotomies and place distraction devices, creating additional minimally invasive options for correcting skeletal deformities. In particular, a miniaturized DO device, totally buried, remotely activated and capable of three-dimensional movements is

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desirable. This device also could be placed endoscopically in either the maxilla or the mandible, thus combining the benefits of both techniques. The combination of endoscopic techniques with a CT-based, three-dimensional navigation system will allow for more accurate execution of complex skeletal treatment plans. It is possible that with the minimally invasive techniques described in this article, treatment of skeletal defects will be performed in the future in an outpatient setting with local anesthesia and intravenous sedation. This would impact cost, patient morbidity, and availability of treatment significantly.

[11]

[12]

[13]

[14]

References
[1] Hunter JG, Sackier JM. Minimally invasive high tech surgery: Into the 21st century. In: Hunter JG, Sackier JM, editors. Minimally Invasive Surgery. Columbus, Ohio: McGraw Hill; 1993. p. 36. [2] Williams BW, Abukawa H, Shuster V, et al. A comparison of postoperative edema after intraoral vs. endoscopic mandibular ramus osteotomy. J Oral Maxillofac Surg 2003;61(8 Suppl):61a62. [3] Kaban LB. Biomedical technology revolution: opportunities and challenges for oral and maxillofacial surgeons. Int J Oral Maxillofac Surg 2002;31(1):112. [4] Troulis MJ, Kaban LB. Endoscopic approach to the ramus/condyle unit: clinical applications. J Oral Maxillofac Surg 2001;59(5):5039. [5] Pandya NJ, Stuteville OH. Vertical wedge ostectomy in the mandibular rami for correction of prognathism. Plast Reconstr Surg 1971;48(2): 14054. [6] Lake SL, McNeil RW, Little RM, et al. Surgical mandibular advancement: a cephalometric analysis of treatment response. Am J Orthod 1981; 80:37694. [7] Bhatia N, Yan B, Behbehanit I, et al. Nature of relapse after surgical mandibular advancement. Br J Orthod 1985;12:58. [8] Dolman RM, Bentley KC, Head TW, et al. The effect of hypotensive anesthesia on blood loss and operative time during Le Fort osteotomy. J Oral Maxillofac Surg 2000;58(8):8349. [9] Precious DS, Splinter W, Bosco D. Induced hypotensive anesthesia for adolescent orthognathic surgery patients. J Oral Maxillofac Surg 1996;54(6): 6803. [10] Gersema L, Baker K. Use of corticosteroids in

[15]

[16]

[17]

[18]

[19]

[20]

[21]

[22]

[23]

oral surgery. J Oral Maxillofac Surg 1992;50(3): 2707. Juvet LM, Denman KL, Nastri A, et al. Variable affecting hospital length of stay in orthognathic surgery patients. J Dent Res. Troulis MJ, Kaban LB. Endoscopic vertical ramus osteotomy: early clinical results. J Oral Maxillofac Surg 2004;62(7):8248. August M, Marchena J, Donady J, et al. Neurosensory deficit and functional impairment after sagittal ramus osteotomy: a long-term followup study. J Oral Maxillofac Surg 1998;56(11): 12315. MacIntosh RB. Experience with the sagittal osteotomy of the mandibular ramus: a 13-year review. J Maxillofac Surg 1981;8:151. Perrott DH, Umeda H, Kaban LB. Costochondral graft construction/reconstruction of the ramus/ condyle unit: long-term follow-up. Int J Oral Maxillofac Surg 1994;23(6):3218. Ko EW, Huang CS, Chen YR, et al. Temporomandibular joint reconstruction in children using costochondral grafts. J Oral Maxillofac Surg 1998;57(7):78998. McCarthy J, Schreiber J, Karp N, et al. Lengthening the human mandible by gradual distraction. Plast Reconstr Surg 1992;89(1):110. Bendahan G. Distraction osteogenesis versus bilateral split osteotomy for mandibular advancement. Masters of Science Thesis. Harvard School of Dental Medicine, April 2005. Trauner R, Obwegeser H. The surgical correction of mandibular prognathism and retrognathia with consideration of genioplasty. Oral Surg 1957; 899909. Troulis MJ, Williams WB, Kaban LB. Endoscopic mandibular condylectomy and reconstruction: early clinical results. J Oral Maxillofac Surg 2004; 62(4):4605. Troulis MJ, Perrott DH, Kaban LB. Endoscopic mandibular osteotomy, and placement and activation of a semiburied distractor. J Oral Maxillofac Surg 1999;57:1110. Kaban LB. Acquired abnormalities of the temporomandibular joint. In: Kaban LB, Troulis MJ, editors. Pediatric oral and maxillofacial surgery. Elsevier; 2004. p. 34076. Padwz BL. Orthognathic surgery in the growing child. In: Kaban LB, Troulis MJ, editors. Pediatric oral and maxillofacial surgery. Elsevier; 2004. p. 377400.

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Facial Plast Surg Clin N Am 14 (2006) 5155

Endoscopic Approaches to Maxillary Orthognathic Surgery

Dennis Rohner, MD, DMD, PhDa,*, Vincent K.L. Yeow, MBBS, FRCS, FAMSb,c
&

&

Material and methods Endoscopic equipment Surgical technique Results

& & &

Discussion Summary References

Endoscopically assisted surgery has become an essential component in many fields of surgical specialties. The implementation of this technique to craniofacial and maxillofacial surgery is a recent development. Endoscopic approach to subcondylar mandible fractures has been established as reliable surgical method [14]. The endoscopic repair of midfacial and malar fractures, of traumatic arch injury, of frontal sinus fracture, and of orbital fractures is described in the recent literature also [510]. The use of endoscopic techniques in the field of orthognathic surgery must be addressed separately for the sagittal split osteotomy and the Le Fort l osteotomy. Troulis and colleagues [11,12] have described the endoscopic vertical ramus osteotomy followed by rigid fixation for treating mandibular prognathism. There are only a few articles published that present endoscopic approaches to the midface and Le Fort l level with regard to orthognathic surgery [1315]. What could be the benefit of an endoscopically assisted Le Fort l osteotomy? First, there is need to describe the commonly used technique with an open approach. Through a horizontal incision of the mucosal soft tissue in the Le Fort l plane, the osteotomy is performed using an oscillating saw. The pterygomaxillary junction, the lateral nasal wall,
a

and the nasal septum can be osteotomized using different chisels. The downfracture of the Le Fort l plane completes this procedure after an average operation time of about 30 minutes. In most of the cases, the le Fort I osteotomy as mono-segment or multi-segment procedure is performed to correct congenital and acquired deformities of the jaws. The overall complication rate of Le Fort l osteotomies varies between 6% and 9% [16,17]. Hemorrhage, infection, and maxillary necrosis represent the majority of these complications. Some authors reported ischemic problems because of the decreased vascularization of mostly anterior maxillary segments [18,19]. Different cadaveric studies showed that the commonly performed le Fort l osteotomy carries the risk of injury to the descending palatal artery [20,21]. Only the ascending palatal artery and the pharyngeal branch arising from the ascending pharyngeal artery can be preserved routinely. Quejada and colleagues [22] could show in an animal study that the maintenance of vascular pedicles to the palate and labiobuccal area was sufficient to support total maxillary osteotomy despite trans-section of both descending palatinal vessels. Lanigan and colleagues [23,24], however, suggested total maxillary osteotomy using vertical incisions from the buccal approach with tun-

Cranio Facial Center, Hirslanden Clinic Aarau, CH-5000 Aarau, Switzerland K.K. Womens and Childrens Hospital, 100 Baskit Timah Road, Singapore 223899 c Department of Plastic Surgery, Singapore General Hospital, Outram Road, Singapore 169608, Singapore * Corresponding author. E-mail address: dennis.rohner@hirslanden.ch (D. Rohner).
b

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Rohner & Yeow

Fig. 1. Subperiostal dissection of the lateral buttress.

Fig. 3. Dissection of the nasal floor.

neling as technically difficult and time-consuming, but possible. Therefore, the use of an endoscopic technique in combination with basic techniques for Le Fort l osteotomies to minimize the access and to optimize the vascularization should be the aim of future treatments. Nevertheless, a well-documented and standardized treatment as the Le Fort l osteotomy should not turn out to be a difficult endoscopicassisted treatment. This was the reason to initiate and perform a cadaveric study for the endoscopically assisted Le Fort l osteotomy.

project the endoscopic image to a video display (Sony Videocassette Recorder SVT-S3050P).

Surgical technique
Six fresh cadaver specimens were used to perform this study. Two of the cadavers were edentulous; three were partial, and one was completely dentated. Two vertical incisions were done bilaterally between the roots of the second incisors and the canines, starting 1 to 2 mm above the attached gingiva and performed to the depth of the vestibule [Fig. 1]. Using a periosteal elevator, the lateral wall of the maxilla was exposed subperiosteally. The scope could be inserted into the tunnel, and it visualized the lateral buttress [Figs. 2, 3]. A second vertical incision was accomplished between the roots of the first and second molar, again starting 1 to 2 mm above the attached gingiva. This was performed to the depth of the vestibule [Fig. 4]. Visually controlled by the scope, the mucosa was tunneled to the distal portion of the tuberosity and the pterygomaxillary junction using a periosteal elevator. Subperiosteal tunneling with an ele-

Material and methods Endoscopic equipment

The endoscope used was a 2.7mm diameter, 30-degree angle scope. A video system composed of a camera, light source (Coldlight Fountain, Karl Storz, Germany), camera converter and monitor (Sony Trinitron [Sony], Singapore) was used to

Fig. 2. Endoscope and periosteal elevator inserted to the nasal floor through the paranasal vertical incision.

Fig. 4. Identified and intact descending palatal artery.

Maxillary Orthognathic Surgery

53

intact in all tested specimens. The nasal soft tissue tube was in all cadavers complete and without laceration. The soft tissue bridge on both buccal sides could be preserved. The longitudinal branches of the facial artery within the gingival mucosa were intact. In all the specimens, maxillary movements up to 5 mm in any direction could be accomplished. The plate fixation was performed at the typical locations paranasal and at the lateral buttress under direct view through the vertical incisions on both sides.
Fig. 5. Prototype of a reciprocal saw presenting an elongated but thinner shaft (Medicon Company, Tbingen, Germany).

Discussion
The Le Fort l osteotomy is a standard technique for corrections of dentofacial deformities. In experienced hands, a mono-segment osteotomy including osteosynthesis lasts on an average 60 minutes. The cadaver dissection could be accomplished between 30 and 45 minutes. One has to consider, however, that permanent bleeding is a major disturbance of visibility in an endoscopic treatment. This could prolongate an endoscopically assisted surgery dramatically. One possible solution could be injection of vasoactive agents preoperatively into the nasal and buccal mucosa to minimize bleeding during the dissection. Hemorrhageone of the major problems in the pastnow is almost negligible. Improved technical skills, controlled anesthesia in relative hypotension, stable osteosynthesis, and reduced time of surgery led to this positive development. There remains, however, the risk of bleeding resulting from an injury to the maxillary artery or its branches, with the descending palatine artery being the most common source of bleeding. Recent studies showed that the average blood loss stood in correlation to mode of anesthesia, position of the patient, maxillary or bimaxillary osteotomies, and length of operation [2527]. The cadaveric dissection allowed a controllable dissection of the nasal and buccal mucosa with the use of endoscopic assistance. The limited approaches resulted in more physiological wounds of the buccal mucosa. The vertical direction of the incisions preserved the anastomotic network between branches of the facial artery and branches of the maxillary artery on the gingiva and buccal mucosa. Therefore, one could expect a further decrease in blood loss, which might be one advantage in clinical applications. An avulsion or interruption of the posterior descending palatal artery during downfracture of the maxillary segment is possible. Osteotomy of the lateral nasal wall using a straight osteotome can disrupt this vessel. The use of the endoscope could visualize the position of the vessel and al-

vator connected the two vertical incisions in the anterior maxilla. The dissection then extended into the nasal cavity, lifting the nasal mucosa from the floor of the nose and from the lateral nasal walls up to the inferior turbinate. This dissection was monitored with the scope. The scope inserted into the lateral tunnel could visualize the performance of straight horizontal osteotomy cuts on both sides through the lateral antral wall, extending from the piriform aperture to the pterygomaxillary junction using a 4 mm osteotome with a mallet [Fig. 5]. With the scope inserted into the nasal cavity between nasal mucosa and floor, a horizontal cut through the medial antral wall and nasal septum was made using the 4 mm osteotome also. A curved osteotome inserted through the posterior vertical incision was placed into the pterygomaxillary junction under visual control with the scope. Osteotomy was accomplished when the blade could be palpated on the palatal aspect. The maxilla then was downfractured using finger pressure. In the first two cadaver dissections, the Le Fort procedure was performed without fixating the osteotomized segment. In cadavers three to six, rigid fixation was accomplished using self-drilling screws and titanium mini-plates (Compact Stardrive 1.5 mm, Mathys Bettlach, Switzerland). The osteotomized segments were fixed first at the nasal buttress using straight five-hole plates. At the lateral buttress, L-plates were used, positioned through the posterior vertical incision under endoscopic visualization through the lateral tunnel. The fixation of the plates was done manually with the self-drilling screws using a screwdriver.

Results
In all six cadavers, the Le Fort l osteotomy could be performed successfully. The downfractured maxilla offered enough space to insert the scope to identify the descending palatal arteries that were

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Rohner & Yeow

lowed for precise osteotomy of the lateral nasal wall with controllable preservation of the vessel in this cadaver study. Siebert and colleagues [21] mentioned that in their cadaver study with open Le Fort l procedure, the descending palatine arteries were interrupted in all their specimens. Another important issue is the postoperative edema and swelling. The horizontal incision applied for the open Le Fort l osteotomy extending from first molar to first molar creates a wound surface that causes postoperative swelling and edema. Limited approaches with controlled elevation and reduced lesion of the periosteum prevent swelling and edema, which will decrease the risk for postoperative infection and accelerate the recovery. Often when the open Le Fort l technique has been performed, the patient presents a slight soft tissue sagging in the cheek area on both sides. One reason could be the wide elevation of the periosteum at the buccal side. The limited elevation and intact periosteum in the endoscopic technique prevent the soft tissue from slumping and allow for correct reattachment. The osteotomies could be performed in this study using chisels. During the open Le Fort l procedure, the reciprocal saw was a commonly used instrumentation that allowed for fast and proper osteotomy. Medicon in Tubingen, Germany, has produced a prototype of a reciprocal saw with a slim but elongated shaft that enables a tunneled osteotomy. There is a need to prove such new instruments to evaluate their qualities and benefits for endoscopic techniques. It is essential to value the advantages against the disadvantages. Limited approach, reduced bleeding, less edema, and shorter time of recovery might be the advantages. Extended time of surgery, disturbed visibility, higher technical challenge, and more expensive costs could be disadvantageous. The use of this technique for the surgically assisted rapid palatal expansion (SARPE) could one of the main indications. Complete osteotomy without downfracture but sagittal split of the maxilla is the condition for a palatal widening using a distracter. The SARPE turns, with help of the endoscopically assisted technique, more and more into an outpatient treatment. Further experimental work, however, should help to improve the performance of this technique. Finally, only extensive clinical work could prove the feasibility and value of this technique.

proved only in clinical use. In a first prospective study, patients with the need of SARPE may benefit from this technique. Minimal access, reduced periosteal elevation, and lessened edema could shorten the time of recovery. The introduction of specifically adapted instruments for endoscopic approaches could improve this technique further.

References
[1] Kellman RM. Endoscopic approach to subcondylar mandible fractures. Facial Plast Surg 2004; 20(3):23947. [2] Schon R, Schramm A, Gellrich NC, et al. Followup of condylar fractures of the mandible in eight patients at 18 months after transoral endoscopicassisted open treatment. J Oral Maxillofac Surg 2003;61(1):4954. [3] Chen CT, Lai JP, Tung TC, et al. Endoscopically assisted mandibular subcondylar fracture repair. Plast Reconstr Surg 1999;103(1):605. [4] Lee C, Mueller RV, Lee K, et al. Endoscopic subcondylar fracture repair: functional, aesthetic, and radiographic outcomes. Plast Reconstr Surg 1998;102(5):143443 [discussion 14445]. [5] Shumrick KA, Ryzenman JM. Endoscopic management of facial fractures. Facial Plast Surg Clin North Am 2001;9(3):46974. [6] Czerwinski M, Lee C. Traumatic arch injury: indications and an endoscopic method of repair. Facial Plast Surg 2004;20(3):2318. [7] Chen DJ, Chen CT, Chen YR, et al. Endoscopically assisted repair of frontal sinus fracture. J Trauma 2003;55(2):37882. [8] Strong EB. Endoscopic repair of orbital blow-out fractures. Facial Plast Surg 2004;20(3):22330. [9] Strong EB, Kim KK, Diaz RC. Endoscopic approach to orbital blowout fracture repair. Otolaryngol Head Neck Surg 2004;131(5):68395. [10] Chen CT, Chen YR. Endoscopically assisted repair of orbital floor fractures. Plast Reconstr Surg 2001;108(7):20118 [discussion 2019]. [11] Troulis MJ, Nahlieli O, Castano F, et al. Minimally invasive orthognathic surgery: endoscopic vertical ramus osteotomy. Int J Oral Maxillofac Surg 2000;29(4):23942. [12] Troulis MJ, Kaban LB. Endoscopic vertical ramus osteotomy: early clinical results. J Oral Maxillofac Surg 2004;62(7):8248. [13] Rohner D, Yeow V, Hammer B. Endoscopically assisted Le Fort l osteotomy. J Craniomaxillofac Surg 2001;29(6):3605. [14] Wiltfang J, Kessler P. Endoscopically assisted Le Fort I osteotomy to correct transverse and sagittal discrepancies of the maxilla. J Oral Maxillofac Surg 2002;60(10):11425 [discussion 1146]. [15] Levine JP, Rowe NM, Bradley JP, et al. The combination of endoscopy and distraction osteogenesis in the development of a canine midface advancement model. J Craniofac Surg 1998; 9(5):42332. [16] el Deeb M, Wolford L, Bevis R. Complications of

Summary
Endoscopically assisted Le Fort l osteotomy could be performed in a cadaver study successfully. The feasibility of this technique, especially the handling with an irrigation/suction system, can be

Maxillary Orthognathic Surgery

55

[17]

[18]

[19]

[20]

[21]

[22]

orthognathic surgery. Clin Plast Surg 1989;16(4): 82540. Bendor-Samuel R, Chen YR, Chen PK. Unusual complications of the Le Fort I osteotomy. Plast Reconstr Surg 1995;96(6):128996. Bell WH. Immediate surgical repositioning of one- and two-tooth dento-osseous segments. Int J Oral Surg 1973;2(6):26572. Burk Jr JL, Provencher RF, McKean TW. Small segmental and unitooth osteotomies to correct dentoalveolar deformities. J Oral Surg 1977; 35(6):45360. Gauthier A, Lezy JP, Vacher C. Vascularization of the palate in maxillary osteotomies: anatomical study. Surg Radiol Anat 2002;24(1):137. Siebert JW, Angrigiani C, McCarthy JG, et al. Blood supply of the Le Fort l maxillary segment: an anatomic study. Plast Reconstr Surg 1997; 100(4):84351. Quejada JG, Kawamura H, Finn RA, et al. Wound healing associated with segmental total maxillary osteotomy. J Oral Maxillofac Surg 1986;44(5): 36677.

[23] Lanigan DT, Hey JH, West RA. Aseptic necrosis following maxillary osteotomies: report of 36 cases. J Oral Maxillofac Surg 1990;48(2): 14256. [24] Lanigan DT, Hey JH, West RA. Major vascular complications of orthognathic surgery: hemorrhage associated with Le Fort I osteotomies. J Oral Maxillofac Surg 1990;48(6):56173. [25] Dolman RM, Bentley KC, Head TW, et al. The effect of hypotensive anesthesia on blood loss and operative time during Le Fort l osteotomies. J Oral Maxillofac Surg 2000;58(8):8349 [discussion 840]. [26] Moenning JE, Bussard DA, Lapp TH, et al. Average blood loss and the risk of requiring perioperative blood transfusion in 506 orthognathic surgical procedures. J Oral Maxillofac Surg 1995;53(8):8802. [27] Rohling RG, Zimmermann AP, Biro P, et al. Alternative methods for reduction of blood loss during elective orthognathic surgery. Int J Adult Orthodon Orthognath Surg 1999;14(1):7782.

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Facial Plast Surg Clin N Am 14 (2006) 5762

Index
Note: Page numbers of article titles are in boldface type.

A
aesthetics, postoperative, of maxillomandibular fixation, 8 alloplastic implants, for orbital floor fracture repair, 1314 stabilization techniques for, 1415 anterior table fractures, of frontal sinus, endoscopic repair of, 2529 compressive forces and, 28 computed tomography of, 2628 discussion on, 2829 fracture camouflage technique, 2829 general requirements for, 25 indications for, 2526, 29 Medpor sheeting implant for, 2627 photographs of, intraoperative, 2627 postoperative, 27 preoperative, 26 scalp incisions used for, 26, 28 technique for, 2628 treatment algorithm for, 25 antrostomies, for orbital floor fracture repair, maxillary sinus, 12 middle meatal, 1314

buccal mucosa dissection, for endoscopic orthognathic surgery, 5354

C
Caldwell Luc approach, to orbital floor fracture repair, 11 camouflage technique, of frontal sinus fracture repair, 3234 with anterior table, 2829 closed reduction, of condylar fractures, 12 computed tomography (CT) scan, in mandibular orthognathic surgery, 48, 50 of anterior table-frontal sinus fracture repair, 2628 of frontal sinus fracture repair, 3334 of maxillomandibular fixation, for preoperative planning, 45 of postoperative results, 78 of orbital floor fracture repair, 11, 1314 of zygomatic arch fractures, 39, 41 condylar fractures, endoscopic repair of, 19 as closed treatment, 12 bailout procedure for, 6, 7 condyle-fossa relationship and, 4 equipment for, 5 exposure step for, 5 fixation technique for, 56 fracture anatomy impact on, 3 fracture comminution impact on, 4 fracture displacement impact on, 34 fracture location impact on, 3 indications for, 3 open reduction and internal fixation versus, 2 operative technique for, 56 pioneering trends, 1, 2 postoperative regime for, 6

B
bailout procedure, for maxillomandibular fixation, 6, 7 bilateral split osteotomy (BSSO), for mandibular retrognathism, 49 vertical ramus osteotomy versus, 4546 bone cement, hydroxyapatite, for frontal sinus fracture repair, 3233 bone flaps, for orbital floor fracture repair, 13 bone grafts, for medial orbital wall fracture repair, 19, 22

1064-7406/06/$ see front matter 2006 Elsevier Inc. All rights reserved.

doi:10.1016/S1064-7406(06)00016-2

facialplastic.theclinics.com

58

Index

preoperative planning for, 35 radiographic imaging in, 45 reduction step for, 5 regional anatomy and, 23 repair sequence for, 5 results of, 68 demographics, 67 operative details, 78 summary of, 8 condylar hyperplasia, endoscopic condylectomy for, 4849 condylar resorption, idiopathic, endoscopic condylectomy for, 4748 condyle-fossa relationship, in maxillomandibular fixation, 4 condylectomy, endoscopic, for condylar hyperplasia, 4849 for idiopathic condylar resorption, 4748 for mandibular conditions, 46 costochondral grafting, endoscopic, for mandibular conditions, 4647

D
deformity(ies), mandibular, 4550 (See also mandibular orthognathic surgery) endoscopic approach to, 4550 (See also endoscopic approach) displacement patterns, of zygomatic arch fractures, 3839 distraction osteogenesis (DO), for mandibular retrognathism, 4950

E
edema, postoperative, with Le Fort I osteotomy, 54 endoscope(s), for maxillomandibular fixation, 5 for orbital floor fracture repair, 14 for orthognathic surgery, 52 for zygomatic arch fracture repair, 40 optical cavity requirement for use of, 3132 surgical specialty impact of, 31 various, 32 endoscopic approach, to orthognathic surgery, 5155 advantages of, 5354 discussion on, 5354 equipment for, 52 for Le Fort I osteotomy, 5152 mandibular, 4550 advantages of, 46 as minimally invasive, 45 decreased morbidity with, 46

costochondral grafts for, 4647 current application/usage trends, 46 for prognathism (asymmetry), 4647 for retrognathism, 46, 4950 historical perspectives of, 45 morbidity minimization with, 4546 with condylectomy, for condylar hyperplasia, 4849 for idiopathic condylar resorption, 4748 for mandibular conditions, 46 with distraction osteogenesis, 4950 with vertical ramus osteotomy, 4647 midface applications of, 51 results of, 53 surgical technique for, 5253 surgically assisted rapid palatal expansion and, 54 endoscopic repair, of condylar fractures, 19 as closed treatment, 12 bailout procedure for, 6, 7 condyle-fossa relationship and, 4 equipment for, 5 exposure step for, 5 fixation technique for, 56 fracture anatomy impact on, 3 fracture comminution impact on, 4 fracture displacement impact on, 34 fracture location impact on, 3 indications for, 3 open reduction and internal fixation versus, 2 operative technique for, 56 pioneering trends, 1, 2 postoperative regime for, 6 preoperative planning for, 35 radiographic imaging in, 45 reduction step for, 5 regional anatomy and, 23 repair sequence for, 5 results of, 68 demographics, 67 operative details, 78 summary of, 8 of frontal sinus-anterior table fractures, 2529 compressive forces and, 28 computed tomography of, 2628 discussion on, 2829 fracture camouflage technique, 2829 general requirements for, 25 indications for, 2526, 29 Medpor sheeting implant for, 2627 photographs of, intraoperative, 2627 postoperative, 27 preoperative, 26 scalp incisions used for, 26, 28 technique for, 2628 treatment algorithm for, 25

Index

59

of frontal sinus fractures, 3135 camouflage technique for, 3234 compressive forces and, 28 computed tomography of, 2628, 3334 discussion on, 2829 equipment for, 3132 external techniques versus, 31 fracture camouflage technique, 2829 general requirements for, 25 indications for, 2526, 29 Medpor sheeting implant for, 2627 optical cavity requirement for, 3132 patient selection for, 3334 photographs of, intraoperative, 2627 postoperative, 27 preoperative, 26 scalp incisions used for, 26, 28 technique for, 2628 treatment algorithm for, 25 trends in, 32 unsuccessful, conversion to open approach, 3334 of orbital floor fractures, 1116 Caldwell Luc approach versus, 11 complications of, 11, 15 computed tomography of, 11, 1314 discussion on, 1415 general requirements of, 11 indications for, 1112, 14 Le Fort-type injuries and, 1415 medial blow out, 1113, 15 orbitozygomatic injuries and, 1415 technique for, 1214 traditional techniques versus, 11, 14 transantral approach to, 14 transnasal approach to, 14 trap door, 1113 trend summary, 15 of orbital wall fractures, medial, 1723 biomechanical studies of, 17 bone grafts for, 19, 22 complications of, 22 direct vs. indirect approach to, 1718 implants for, 1920, 22 indications for, 1819 injury mechanisms, 17 intranasal technique, 18, 2022 miscellaneous approaches versus, 1718 preoperative evaluation for, 18 surgical techniques for, 1922 transcaruncular technique, 1821 trend summary, 1718, 22 of zygomatic arch fractures, 3743 advantages of, 38 arch anatomy role in, 3738, 42 case presentations of, 42 computed tomography of, 39, 41

disadvantages of, 43 discussion on, 4243 equipment for, 40 exposure incisions for, 40, 43 fixation for, 4142 indications for, 39 injury patterns and, 3839 lateral displacement and, 3839 Le Fort I level, 37, 40 Le Fort II level, 41 Le Fort III level, 3942 medial arch displacement and, 3839 pioneering trends, 37, 43 reduction for, 40 sequencing for, 3940 surgical technique for, 4042 telescoping pattern considerations, 38 with complex zygoma injury, 40, 42 endoscopic sheaths, various, 3132 endoscopic vertical ramus osteotomy (EVRO), 4647 external forces, compressive, in anterior table-frontal sinus fracture repair, 28 in zygomatic arch fracture patterns, 3839

F
facial artery, in endoscopic orthognathic surgery, 5354 facial trauma, fractures from (See fracture(s)) forces, as fracture factor (See external forces) forehead lifting, endoscopic technique for, 3234 fracture(s), anterior table, 2529 (See also anterior table fractures) endoscopic repair of, 2529 condylar, 19 (See also condylar fractures) endoscopic repair of, 19 (See also endoscopic repair) maxillomandibular fixation for, 19 (See also maxillomandibular fixation (MMF)) frontal sinus, 3135 (See also frontal sinus fractures) endoscopic repair of, 3135 (See also endoscopic repair) with anterior table, 2529 mandibular, 4550 (See also mandibular orthognathic surgery) endoscopic approach to, 4550 (See also endoscopic approach) medial orbital wall, 1723 (See also orbital wall fractures) endoscopic approach to, 1723 (See also endoscopic repair) midface, orthognathic surgery for, 5155 (See also orthognathic surgery) orbital floor, 1116 (See also orbital floor fractures)

60

Index

endoscopic repair of, 1116 (See also endoscopic repair) zygomatic arch, 3743 (See also zygomatic arch fractures) endoscopic repair of, 3743 (See also endoscopic repair) Fraser tip suction catheter, for orbital floor fracture repair, 13 Freer elevator, for orbital floor fracture repair, 13 frontal sinus fractures, endoscopic repair of, 3135 camouflage technique for, 3234 computed tomography of, 3334 equipment for, 3132 external techniques versus, 31 optical cavity requirement for, 3132 patient selection for, 3334 trends in, 32 unsuccessful, conversion to open approach, 3334 with anterior table, 2529 compressive forces and, 28 computed tomography of, 2628 discussion on, 2829 fracture camouflage technique, 2829 general requirements for, 25 indications for, 2526, 29 Medpor sheeting implant for, 2627 photographs of, intraoperative, 2627 postoperative, 27 preoperative, 26 scalp incisions used for, 26, 28 technique for, 2628 treatment algorithm for, 25

internal fixation, in endoscopic orthognathic surgery, 53 of condylar fractures, 2 of frontal sinus fractures, with anterior table, 28 with failed endoscopic approach, 3334 of maxillomandibular injuries, 4647, 49 intranasal approach, endoscopic, to medial orbital wall fracture repair, 18, 2022 intraoral vertical ramus osteotomy (IVRO), 46

K
Kerrison rongeur, for orbital floor fracture repair, 12

L
lateral buttress dissection, for endoscopic orthognathic surgery, 5253 Le Fort I osteotomy, endoscopic approach to, advantages of, 5354 applications of, 5152 discussion on, 5354 equipment for, 52 palatal artery cautions, 5254 results of, 53 surgical technique for, 5253 surgically assisted rapid palatal expansion and, 54 Le Fort I zygomatic arch fractures, endoscopic repair of, 37, 40 Le Fort II zygomatic arch fractures, endoscopic repair of, 41 Le Fort III zygomatic arch fractures, endoscopic repair of, 3942 Le Fort-type injuries. See also specific fracture endoscopic repair of, 1415

G
grafts and grafting, bone, for medial orbital wall fracture repair, 19, 22 costochondral, for mandibular conditions, 4647 Greenberg retractor, for orbital floor fracture repair, 12

M
mandibular orthognathic surgery, endoscopic approach to, 4550 advantages of, 46 as minimally invasive, 45 decreased morbidity with, 46 costochondral grafts for, 4647 current application/usage trends, 46 for prognathism (asymmetry), 4647 for retrognathism, 46, 4950 historical perspectives of, 45 with condylectomy, for condylar hyperplasia, 4849 for idiopathic condylar resorption, 4748 for mandibular conditions, 46 with distraction osteogenesis, 4950 with vertical ramus osteotomy, 4647

H
hemorrhage, with Le Fort I osteotomy, 53

I
implant(s), alloplastic, for orbital floor fracture repair, 1314 stabilization techniques for, 1415 Medpor sheeting, for anterior table-frontal sinus fracture repair, 2627 synthetic, for medial orbital wall fracture repair, 1920, 22 Vicryl mesh, for frontal sinus fracture repair, 3433

Index

61

mandibular prognathism (asymmetry), endoscopic orthognathic correction of, 4647 mandibular ramus/condyle unit (RCU), endoscopic approach to, 46 (See also mandibular orthognathic surgery) mandibular retrognathism, endoscopic orthognathic correction of, 46, 4950 maxillomandibular fixation (MMF), for condylar fractures, bailout procedure for, 6, 7 condyle-fossa relationship and, 4 endoscopic equipment for, 5 endoscopy indications, 3 exposure step for, 5 fixation technique for, 56 fracture anatomy impact on, 3 fracture comminution impact on, 4 fracture displacement impact on, 34 fracture location impact on, 3 open reduction and internal fixation versus, 2 operative technique for, 56 pioneering trends, 1, 2 postoperative regime for, 6 preoperative planning for, 35 radiographic imaging in, 45 reduction step for, 5 regional anatomy and, 23 repair sequence for, 5 results of, 68 demographics, 67 operative details, 78 summary of, 8 Medpor sheeting implants, for anterior table-frontal sinus fracture repair, 2627 midface orthognathic surgery, endoscopic approach to, 5155 (See also orthognathic surgery) minimally invasive surgery (MIS), 45 for facial injuries (See endoscopic approach; endoscopic repair) morbidity, with condylar fractures, and closed treatment, 12 with frontal sinus fractures, 31 with mandibular orthognathic surgery, 46 mucocele, with anterior table-frontal sinus fracture repair, 28

of frontal sinus fractures, with anterior table, 28 with failed endoscopic approach, 3334 orbital floor fractures, endoscopic repair of, 1116 Caldwell Luc approach versus, 11 complications of, 11, 15 computed tomography of, 11, 1314 discussion on, 1415 general requirements of, 11 indications for, 1112, 14 lateral blow out, 12 Le Fort-type injuries and, 1415 medial blow out, 1113, 15 orbitozygomatic injuries and, 1415 technique for, 1214 traditional techniques versus, 11, 14 transantral approach to, 14 transnasal approach to, 14 trap door, 1113 trend summary, 15 orbital wall fractures, medial, endoscopic repair of, 1723 biomechanical studies of, 17 bone grafts for, 19, 22 complications of, 22 direct vs. indirect approach to, 1718 implants for, 1920, 22 indications for, 1819 injury mechanisms, 17 intranasal technique, 18, 2022 miscellaneous approaches versus, 1718 preoperative evaluation for, 18 surgical techniques for, 1922 transcaruncular technique, 1821 trend summary, 1718, 22 orbitozygomatic fractures, endoscopic repair of, 1415 orthognathic surgery, endoscopic approach to, 5155 advantages of, 5354 discussion on, 5354 equipment for, 52 for Le Fort I osteotomy, 5152 mandibular, 4550 advantages of, 46 as minimally invasive, 45 decreased morbidity with, 46 costochondral grafts for, 4647 current application/usage trends, 46 for prognathism (asymmetry), 4647 for retrognathism, 46, 4950 historical perspectives of, 45 with condylectomy, for condylar hyperplasia, 4849 for idiopathic condylar resorption, 4748 for mandibular conditions, 46 with distraction osteogenesis, 4950 with vertical ramus osteotomy, 4647

N
nasal floor dissection, for endoscopic orthognathic surgery, 52

O
open reduction and internal fixation, of condylar fractures, 2

62

Index

midface applications of, 51 palatal artery cautions, 5254 results of, 53 surgical technique for, 5253 surgically assisted rapid palatal expansion and, 54 osteotome, for endoscopic orthognathic surgery, 53 for orbital floor fracture repair, 12

transantral approach, endoscopic, to orbital floor fracture repair, 14 transcaruncular approach, endoscopic, to medial orbital wall fractures, 1821 transnasal approach, endoscopic, to orbital floor fracture repair, 14 trauma, facial, fractures from (See fracture(s))

P
palatal artery, in endoscopic orthognathic surgery, 5254 periosteal elevator, for endoscopic orthognathic surgery, 52 pulse test, for orbital floor fracture repair, 14

V
vertical ramus osteotomy, bilateral split osteotomy versus, 4546 endoscopic, 4647 intraoral, 46 Vicryl mesh implants, for frontal sinus fracture repair, 3433

R
radiography, of maxillomandibular fixation, for preoperative planning, 45 of postoperative results, 78 reciprocal saw, for endoscopic orthognathic surgery, 53

Z
zygomatic arch fractures, endoscopic repair of, 3743 advantages of, 38 arch anatomy role in, 3738, 42 case presentations of, 42 computed tomography of, 39, 41 disadvantages of, 43 discussion on, 4243 displacement patterns and, lateral, 3839 medial arch, 3839 equipment for, 40 exposure incisions for, 40, 43 fixation for, 4142 indications for, 39 injury patterns and, 3839 Le Fort I level, 37, 40 Le Fort II level, 41 Le Fort III level, 3942 pioneering trends, 37, 43 reduction for, 40 sequencing for, 3940 surgical technique for, 4042 telescoping pattern of, 38 with complex zygoma injury, 40, 42

S
soft tissue, complications of, with maxillomandibular fixation, 8 Steinmann pins, for frontal sinus fracture repair, 3234 surgically assisted rapid palatal expansion (SARPE), in endoscopic orthognathic surgery, 54 synthetic implants, for medial orbital wall fracture repair, 1920, 22

T
telescoping pattern, of zygomatic arch fractures, 38 temporomandibular joint conditions, endoscopic orthognathic correction of, 46