facial plastic surgery clinics of north america volume 14, issue 1, pages 1-62 (february 2006),...

Preface ix

Robert M. Kellman and E. Bradley Strong

Condylar Fracture Repair: Use of the Endoscope to Advance TraditionalTreatment Philosophy 1

Reid V. Mueller, Marcin Czerwinski, Chen Lee, and Robert M. Kellman

Traditional treatment of subcondylar fractures with maxillomandibular fixation oftenresults in a malreduction and significant functional and aesthetic sequelae, includingfacial asymmetry, decreased jaw opening, and potential for late derangements of thetemporomandibular joint. When used selectively, based on preoperative CT scans, theendoscopic technique will reliably restore condylar anatomy in nearly 95% of patients,thus obviating the consequences of malunion. Furthermore, unlike traditional opentechniques no significant facial scarring or permanent facial nerve palsies have resulted.Thus, the authors strongly advocate endoscopic repair of adult condylar neck and sub-condylar fractures that demonstrate displacement or dislocation and have adequateproximal bone stock to accept miniplate fixation.

Endoscopic Repair of Orbital Floor Fractures 11

D. Gregory Farwell and E. Bradley Strong

Significant orbital trauma can result in orbital floor fractures with subsequent prolapseof the orbital contents into the paranasal sinuses. Prolapse of the periorbita can resultin extraocular muscle entrapment, diplopia, enophthalmos, and even visual loss.Management of orbital floor fractures traditionally has been accomplished throughtransconjunctival and subciliary incisions. These approaches provide adequate visuali-zation and cosmetically acceptable scars. Unfortunately, post-operative lid malpositioncan occur in a small percentage of cases. Another limitation is easy visibility of the pos-terior orbit, which often is obscured by prolapsed orbital fat. In light of these limita-tions, some surgeons have begun to evaluate an endoscopic approach to orbital floorfractures. The endoscopic approach offers a hidden incision, improved fracture visuali-zation, and avoidance of post-operative eyelid malposition. This article reviews theindications, technique, and potential complications of endoscopic orbital blow-outfracture repair.

v

Contents

ENDOSCOPIC CRANIOMAXILLOFACIAL SURGERY

Volume 14 • Number 1 • February 2006

Contentsvi

Endoscopic Approach to Medial Orbital Wall Fractures 17

John S. Rhee and Chien-Tzung Chen

Repair of medial orbital wall fractures can be challenging with traditional open tech-niques. This article describes different endoscopic-assisted approaches—transcaruncularand intranasal—which have been used to successfully repair these fractures.

Endoscopic Repair of Anterior Table—Frontal Sinus Fractures 25

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 termrisk of mucocele formation. This required a coronal incision with the associated surgi-cal sequelae including a large scar, alopecia, and paresthesias. In light of these sequelaeand recent advances in CT diagnosis and endoscopic treatment of mucoceles, some sur-geons are starting to manage isolated anterior table fractures through an endoscopicapproach. The endoscopic repair significantly reduces patient morbidity because itrequires only 2 small incisions behind the frontal hairline. The endoscopic approachcan be divided into two types: acute fracture reduction (covered elsewhere in this issue)and fracture camouflage. This article reviews the indications, techniques, and advan-tages of frontal sinus fracture camouflage.

Endoscopic Management of Frontal Sinus Fractures 31

Kevin A. Shumrick

Endoscopes have had a profound effect on nearly every surgical specialty over the past20 years. Using endoscopic approaches, excellent visualization of the surgical site canbe achieved while avoiding extensive external incisions, thus, dramatically reducingmorbidity compared with traditional surgical approaches. This article outlines the stateof 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 inFacial Trauma 37

Marcin Czerwinski and Chen Lee

The reliable form and strategic position of the zygomatic arch make it a valuable land-mark in midfacial trauma management. The benefits of arch repair have been usedinfrequently, mainly because traditional coronal access to this structure is fraught withundesirable sequelae. Endoscope-assisted zygomatic arch realignment and fixationallow anatomic repair without sustaining the drawbacks of extensive access incisions.The relative importance of this approach increases with trauma complexity, being mostuseful in Le Fort III and complex zygoma injuries.

Endoscopic Approach for Mandibular Orthognathic Surgery 45

Maria J. Troulis, Jose L. Ramirez, and Leonard B. Kaban

The field of minimally invasive surgery is defined as the combination of surgical inno-vation with modern technology. This article describes the history of surgery and newerdevelopments in endoscopic surgery for mandibular orthognathic surgery.

Contents vii

Endoscopic Approaches to Maxillary Orthognathic Surgery 51

Dennis Rohner and Vincent K.L. Yeow

Endoscopically assisted surgery has become an essential component in many fields ofsurgical specialties. The implementation of this technique to craniofacial and maxillo-facial surgery is a recent development. Endoscopic approach to subcondylar mandiblefractures has been established as reliable surgical method.

Index 57

viii

FORTHCOMING ISSUES

May 2006

Auricular OtoplastySteven R. Mobley, MD, Guest Editor

August 2006

Revisional RhinoplastyRussell W.H. Kridel, MD, Guest Editor

November 2006

Upper Third of the FacePeter A. Adamson, MD, Guest Editor

RECENT ISSUES

November 2005

BlepharoplastyPaul S. Nassif, MD, Guest Editor

August 2005

The Aging FaceTom D. Wang, MD, Guest Editor

May 2005

Local Cutaneous FlapsStephen S. Park, MD, FACS, Guest Editor

THE CLINICS ARE NOW AVAILABLE ONLINE!

Access your subscription at:www.theclinics.com

F A C I A L P L A S T I CS U R G E R Y C L I N I C S

O F N O R T H A M E R I C A

Facial Plast Surg Clin N Am 14 (2006) ix

ix

Preface

Endoscopic CraniomaxillofacialSurgery

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

1064-7406/06/$ – see front matter © 2006 Elsevier Inc. All rightsfacialplastic.theclinics.com

Robert M. Kellman, MDDepartment of Otolaryngology andCommunication SciencesState University of New York UpstateMedical University750 E. Adams StreetSyracuse, NY 13210, USA

E. Bradley Strong, MDDepartment of OtolaryngologyUniversity of California, Davis School of Medicine2521 Stockton Blvd., Ste 7200Sacramento, CA 95817, USA

E-mail addresses:[email protected] (R.M. Kellman)[email protected] (E.B. Strong)

Endoscopes for use in the head and neck werebrought to the United States in the 1980s foruse in endoscopic sinus surgery. Since that time,endoscopic applications in the head and neckhave continued to grow, most recently in the areaof facial trauma and reconstruction. This is a rap-idly expanding area of clinical interest, and re-search into new techniques continues. With thisin mind, this issue describes individual techniquesused by various surgeons in applying endoscopes

to the repair and repositioning of the bonesof the craniomaxillofacial skeleton. The authorscontributing to this issue of Facial Plastic SurgeryClinics of North America are recognized leaders infacial trauma, reconstructive surgery, and facialendoscopy. This issue reviews the most up-to-date endoscopic applications, including fracturesof the subcondylar region, orbit, frontal sinus,zygomaticomaxillary complex, and elective ortho-gnathic surgery.

reserved. doi:10.1016/j.fsc.2005.10.005



Facial Plast Surg Clin N Am 14 (2006) 1–9

1

Condylar Fracture Repair: Use of theEndoscope to Advance TraditionalTreatment PhilosophyReid V. Mueller, MD

a,*, Marcin Czerwinski, MDb, Chen Lee, MD

c,Robert M. Kellman, MD

d

& Regional anatomy and the effect of Exposure
maxillomandibular fixation
& Role of the endoscope—treatmentindications

& Preoperative planningFracture anatomyRadiographic imaging

& Operative techniqueEndoscopic equipmentRepair sequenceMaxillomandibular fixation

a Oregon Health Science University, Mail Code L352A,OR 97201, USAb Montreal Children´s Hospital, C1139, 2300 Tupper Strec Sacre-Coeur Hospital, 5000 boul. Gouin West, Montread Department of Otolaryngology and Communication ScUniversity, 750 East Adams Street, Syracuse, NY 13210, U* Corresponding author.E-mail address: [email protected] (R.V. Mueller).


ReductionFixationBailoutPostoperative regime

& ResultsFracture demographicsOperative detailsOutcomes

& Summary& References

Treatment of facial fractures has progressed sig-nificantly over the last 25 years largely becauseof the pioneer efforts of Paul Manson and JosephGruss. The systematic principles of wide expo-sure, visualized anatomic reduction, rigid inter-nal fixation, and primary bone grafting of criticalsize defects—introduced by these surgeons—revolutionized the field of craniomaxillofacial sur-gery. The results achieved using their techniquesfar surpassed the outcomes of closed reductionand nonrigid fixation. Until recently, however,this standard of care was not applied to all areasof facial trauma; most notably omitted were thezygomatic arch and the mandibular condyle.

Closed treatment of mandibular fractures withmaxillomandibular fixation (MMF) has a longand successful history, but it is not without signifi-cant morbidity. The best results have been achievedin skeletally immature children, where condylarremodeling often can restore condylar anatomy tonear normal, even in the face of little or no fracturereduction. Despite almost miraculous condylar re-modeling in children, the outcomes in adults havenot been uniform, and a significant percentage suf-fers long-term aesthetic and functional problems[1–5]. Few studies exist comparing similar frac-tures treated by open versus closed methods. Mostshow equal or better outcomes after open treat-

3181 Southwest Sam Jackson Park Road, Portland,

et, Montreal, Quebec, Canada, H3H 1P3l, Quebec, Canada, H4J 1C5iences, State University of New York Upstate MedicalSA


2 Mueller et al

ment despite the fact that more severely injured pa-tients tended to undergo open treatment [6–15].Patients treated with an open approach had bet-ter restoration of facial symmetry, faster recoveryof jaw motion, and less chronic pain. The mostimportant long-term complications of closed treat-ment are internal derangement and persistentmalocclusion, the latter reported in up to 28% ofpatients [15–17].The reluctance to use open reduction and internal

fixation of condylar fractures stemmed from thebelief that these injuries do well with closed treat-ment using MMF and because the open techniquewas challenging and associated with significantmorbidity. All surgical approaches for the opentreatment of condylar fractures require a facialincision, and nearly all will result in a perceptiblescar [10], with up to 4% reporting an unsightly scar[7]. Close proximity of the facial nerve to the con-dyle compromises access to the fracture segmentand makes the dissection tedious. Efforts to im-prove surgical access may result in either directfacial nerve injury or a traction injury during retrac-tion. The risk of permanent facial nerve injuryreported in 21 different series of open approaches,comprising 455 patients, averages 1%, while therisk of transient palsy ranges from 0% to 46%(mean 12%) [11,14,15,18–27]. An open intraoralapproach, designed to circumvent these drawbacks,has been described, but it rarely is used becauseof very poor visualization and difficult hardwarefixation [28].The use of the endoscope to treat condylar inju-

ries was a natural extension of minimally inva-sive techniques for managing craniomaxillofacialtrauma. Most surgeons accept, on an intellectuallevel, that fracture reduction and rigid fixationwith restoration of anatomy are laudable goals ifthat can be achieved without undue morbidity. En-doscopic assistance allows the surgeon to produceanatomic fracture alignment, and to avoid the nega-tive sequelae of condylar malunion. The endo-scopic approach described here has the potentialto reduce morbidity by limiting scars, reducingthe risk to the facial nerve, and eliminating theneed for MMF, all while embracing the acceptedadvantages of anatomic reduction and rigid fixa-tion. The decrease in morbidity associated with theendoscopic approach may expand the indicationsfor reduction and rigid fixation in the future.

Regional anatomy and the effect ofmaxillomandibular fixation

Any displaced fracture of the condyle will havesome degree of fragment overlap resulting in short-ening of the posterior ramal height [29]. This is

exacerbated by the normal resting tone of mas-ticatory, suprahyoid, and infrahyoid musculature.As the fragments overlap, the mandible rotatessuch that there is premature posterior occlusal con-tact and an anterior open bite. In addition, thiscauses an unappealing loss of chin projection atthe pogonion. Only with effort, as during chew-ing, are proper occlusion and chin position force-fully restored [30]. Furthermore, ramal shorteningcauses a decreased radius of mandibular rotationthat is visible as ipsilateral jaw deviation duringmotion [29].Attachments of the lateral pterygoid muscle usu-

ally place the condylar fragment into a flexed pos-ture. This has been the case in 80% of adultcondylar fractures in the authors’ experience. Inaddition, the lateral ptygeroid often will cause in-clination of the condylar head medially, furthershortening the ramal height. This results in prema-ture contact with the anterior wall of the glenoidfossa, limiting interincisal opening to initial hinge-type motion only. The additional 15 to 20 mm ofopening available through translational movementnever is achieved fully.The complex relationships of the temporoman-

dibular articulation allow only minimal impreci-sions. A malunited condyle alters these preciserelationships, resulting in significant aberrationsin joint dynamics that have a marked potentialto produce late internal derangement. In addi-tion, because of the bilateral interdependence ofthe craniomandibular articulation, the contralateralcondyle sustains excessive biomechanical loadsand similarly is predisposed to early degenerativechanges [31].Extended experience and careful analysis of

closed treatment of condylar injuries using MMFhave shown that fracture reduction rarely occurs.Instead, centric occlusion is forced through neuro-muscular adaptation to the condylar malunion atthe temporomandibular joint. Malunion often re-sults in shortening of the posterior ramus becauseof interfragmentary overlap, abnormal orientationof the condylar fragment, and alteration of temporo-mandibular joint biomechanics, all of which carrysignificant functional and aesthetic consequences.When assessing the shortcomings of closed treat-

ment, the significant independent morbidities as-sociated with MMF often are overlooked becauseof the surgical simplicity of its application. Theprolonged period of immobilization using MMFnecessitates a lengthy postoperative regimen ofmuscular and occlusal rehabilitation to improvemuscle function, condylar movement, and rangeof motion. Studies in rhesus monkeys have demon-strated loss of interincisal opening and maximalstimulated bite force after MMF [32,33]. Addition-

3Condylar Fracture Repair

ally, comparisons of patients with condylar neckfractures randomized to open versus MMF treat-ment have demonstrated that patients after MMFhave decreased range of motion necessitating longperiods of physiotherapy to regain their premor-bid function [7,15]. Many patients find MMFuncomfortable, and who have dementia or psychi-atric diagnosis simply may not tolerate the proce-dure. It is difficult to maintain good oral hygienewith MMF; orthodontic treatment must be delayedduring the period of MMF, and those who haveseizure disorders or alcoholism are at risk for as-piration and death.

Role of the endoscope—treatmentindications

The goals of condylar fracture treatment are: pain-free mouth opening with interincisal distance be-yond 40 mm, good excursion of the jaw in alldirections, restoration of preinjury occlusion, stabletemporomandibular joints, and good symmetry[30]. In most circumstances, anatomic reductionand rigid fixation of the condyle are required tosatisfy these objectives by restoring preinjury ramalheight, upright posture of the condylar head ,andcomplex anatomical relationships of the temporo-mandibular articulation.Patients with condylar process fractures are se-

lected for endoscopic-assisted reduction and fixa-tion based on age, location of fracture, degree ofcomminution, direction of proximal fragment dis-placement, dislocation of condylar head, concomi-tant medical or surgical illness, and patient choice.Condylar fractures in prepubertal patients do notrequire anatomic reduction because of the greatpotential for rehabilitation through growth and re-modeling. Fractures of the condylar head generallydo not demonstrate significant loss of posteriorramal height and can be expected to do relativelywell with traditional methods. Fractures that do notallow for the application of at least two holes of a2.0 mm plate are likewise not amenable to endo-scopic repair. Finally, open treatment is not advo-cated for nondisplaced, nondislocated fractures, asnormal biomechanical relationships are unaltered.

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

Preoperative planning

Fracture anatomy

The endoscopic technique of condylar fracturerepair relies on visual confirmation of fracture frag-ment reduction and sufficient length of the extra-capsular segment for the placement of fixationhardware. Endoscopic approaches by their very na-ture have a limited optical cavity, distorted perspec-

tive, and geometric constraints for instruments.Consequently, determination of the precise frac-ture geometry preoperatively is mandatory so thata decision can be reached whether an endoscopicapproach is feasible. There are four specific frac-ture attributes that will help to make the deci-sion: location, displacement, comminution, andrelationship of the condylar head to the fossa.

Fracture locationCondylar fractures are classified as head (intra-capsular), neck (below the head and above thesigmoid notch), and subcondylar [Fig. 1] [34].Intracapsular fractures and high neck fractures arenot treated using the endoscopic approach, be-cause there is no possibility of applying fixation.In addition, surgical exposure may lead to devas-cularization of the condylar head. Fractures ofthe condylar neck are suitable for endoscopic treat-ment if sufficient bone stock is present proximallyto accept two screws for miniplate fixation. En-doscopic repair of subcondylar fractures is gener-ally the easiest.

Fracture displacementDisplacement refers to the position of the con-dylar fragment relative to the ascending ramus.Fractures where the condylar segment is locatedmedially are termed medial override, those whereit is lateral, lateral override [Fig. 2]. The latter groupforms the vast majority of adult condylar injuriestreated at the authors’ centers. Displacement is animportant variable guiding the initial approachto endoscopic treatment. Lateral override fracturesare especially amenable to repair because of easierfragment visualization, manipulation, and hard-

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

4 Mueller et al

ware fixation. In contrast, medial override injuriesare more difficult to reduce endoscopically, as thetelescoped ascending ramus obscures visual accessto the lateral surface of the condylar fragment andgreatly impairs manipulation because of physicalobstruction. The authors simplify the treatment ofmedial override injuries by first reducing them tothe lateral override category. Nondisplaced, nondis-located fractures signify the presence of sufficientperiosteal support for stability and do not requireopen treatment.

Fracture comminutionSignificant comminution is a relative contraindi-cation to endoscopic repair as this technique re-lies largely on visualization of the fracture linefor anatomic reduction and some degree of in-terfragmentary opposition for solid fixation. Dur-ing reduction, the anterior and posterior bordersof the fracture line are used as anatomic land-marks to assess accurate reduction. Comminutedfractures often will have fracture fragments thatinvolve the border and thereby obscure theselandmarks. Microcomminution will obscure theinterdigitation of small irregularities along the frac-ture line that ordinarily assist in precise reduction.Unfortunately, the visual limitations of endos-copy make reliable assessment of reduction de-ceptively challenging in the face of comminution.

A minor degree of comminution is not considereda contraindication.

Condyle–fossa relationshipFractures associated with nondislocated condylarheads are the most favorable for endoscopic re-pair. A displaced condylar head without true dis-location usually can be relocated into anatomicposition easily; however, those fractures with truedislocation of the condylar head are significantlymore challenging.

Radiographic imaging

Accurate radiographic imaging is necessary to re-liably assess the feasibility of endoscopic repair andto formulate a precise treatment strategy by identi-fying fracture location, direction of displacement,and degree of comminution [Fig. 3]. The accuracyof modern helical CT scans has surpassed pano-ramic tomography for detecting mandibular frac-tures. Using 1 mm collimated images (with a pitchof two) and 1 mm axial images reconstructed onevery second image, in 2001, Wilson and colleaguescompared helical CT scanning with panoramictomography in detecting 73 mandibular fracturesin 42 consecutive patients and correlated the re-sults with known surgical findings. Helical CT scandetected 100% of the fractures, while panoramictomography detected only 86%. In six missed frac-

Fig. 3. Three-dimensional CT scan of a left condylarfracture demonstrating characteristics amenable tothe endoscopic repair technique: adequate proximalbone stock, no comminution, lateral override, andno dislocation out of the condylar fossa.


tures, the surgical management was altered by theadditional information provided from the CT scan.In one patient, the nature of a dental root fracturewas seen better on panoramic tomography [35].In the authors’ experience, fine cut axial computedtomography scans with three-dimensional refor-matting provide the most precise illustration ofthese variables. The three-dimensional reformat-ting is not accurate for detecting fracture detailbut rather used to aid in the visualization of thefracture, and forming a clear mental picture of whatwill be required for reduction.

Operative technique

Endoscopic equipment

At their centers, the authors use a 4 mm diame-ter 30o angle endoscope, a 4 mm endoscopic browlift sheath (Isse Dissector Retractor, Karl Storz, Ger-many) that maintains the optical cavity, and avideo system. Standard mandible fracture repairinstruments are used in addition to the Subcon-dylar Ramus fixation set from Synthes (Paoli,Pennsylvania), which provides many specializedinstruments facilitating the endoscopic technique.

Repair sequence

If present, extracondylar fractures are addressedfirst using standard open reduction and internalfixation techniques to restore an intact mandibu-lar arch. The rigid arch is then helpful in ma-nipulating fracture fragments to achieve adequatereduction. Injection at the intraoral incision siteand along the lateral aspect of the ascending ra-mus with 1:200,000 epinephrine solution will de-crease bleeding into the optical cavity.

Maxillomandibular fixation

If MMF was used for repair of an extracondylarfracture, it is removed. The use of tight wire max-illomandibular fixation will prevent distraction ofthe fracture and lock the displaced condyle in amalreduced position. The authors routinely em-ploy rubber band anterior MMF that facilitatesfracture repair by maintaining occlusion but per-mitting realignment of fracture fragments. Remem-ber that the reduction of the fracture is a visualreduction and not based on occlusion.

Exposure

An intraoral incision along the oblique line of themandible is made. The endoscopic cavity is createdby elevating the periosteum off the lateral aspectof the ascending ramus. The assistant may holdthe endoscope while the surgeon uses the periostealelevator and suction to continue the dissectionproximally to reveal the condylar fragment. Acommon mistake is to inadvertently dissect under(or medial to) the proximal fragment. This occursbecause of a failure to appreciate the degree oflateral override and coronal plane angulation ofthe proximal fragment. Once the proximal frag-ment is identified, the subperiosteal dissection con-tinues on the lateral surface up to the joint capsule,or a sufficient distance to place the fixation hard-ware. Transcutaneous stab incisions for screw place-ment are made directly over the palpated fractureline at the posterior border of the mandible. Gen-tle, blunt hemostat dissection through the parotidgland and masseter muscle is performed to avoidinjury to the facial nerve.

Reduction

To facilitate repair, medial override injuries are re-duced initially into lateral override by placing acurved elevator medial to the proximal fragmentwhile strongly distracting the fracture so as toallow the proximal fragment to be displaced tothe lateral surface of the ascending ramus. If thefracture already is a lateral override, then inter-fragmentary realignment is achieved by distractingthe distal segment through mechanical tractionat the mandibular angle or placement of a 3 mmposterior occlusal spacer. The proximal segmentcan be reduced by bringing the condylar fragmentout if its flexed position and applying mediallydirected pressure using a trocar inserted throughthe stab incisions. Removal of traction or posteriorocclusal wedge then will permit the rubber bandfixation to temporarily impact the fracture inter-faces together and often maintain reduction whilefixation is applied [Fig. 4].

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

6 Mueller et al

Fixation

Screws are introduced through the transcutaneoustrocar. A miniplate is fixated along the posteriorborder of the ascending ramus, taking advantageof its thick cortical bone and flat surface [see Fig. 4].At least two screws are placed in each fracture seg-ment to ensure solid fixation. Self-drilling screwshave not been useful and often are a significantliability. Several authors have reported fracture ofsingle miniplates; the authors advocate placementof two miniplates whenever possible.In general, the fixation plate is attached to the

condylar fragment first. This allows the plate toact as a handle to position the condylar fragmentinto reduction. After reduction is achieved, thescrews are placed into the mandibular portion.Some groups have found that placing a plate nearthe sigmoid notch or anterior portion of the frac-ture first simplifies placement of the posteriorborder plate. Ultimately, each fracture will dictatethe best approach. No matter the method, a me-ticulous inspection of the visual landmarks of ana-tomic reduction is imperative. The sigmoid notchand posterior border of the mandible must bevisualized to ensure that reduction has occurred.If the reduction is not correct, then the distal screwsshould be removed and the condylar fragmentrepositioned. Following hardware placement, rub-ber band MMF is released and the mandible rangedin all excursions to ensure reproducible preinjuryocclusion and stability of fixation.

Bailout

In a small number of attempted cases the endo-scopic repair will not be possible because of inade-quate proximal bone stock, excessive comminution,or inability to place fixation. In this circumstance,surgeons should resort to the method of condylarrepair that they would use if the endoscopic tech-nique was not available.

Postoperative regime

All patients leave the operating room without MMFand are kept on a soft diet for 6 weeks.

Results

The results depicted in the following sections rep-resent the combined experience of the seniorauthors from three university medical centers: theOregon Health and Science University HospitalCenter, San Francisco General Hospital, and StateUniversity of New York Upstate Medical Center.

Fracture demographics

One hundred thirty-five patients were treated usingprimary endoscopic condylar fracture repair. Theproportion of patients with bilateral, unilateral,and isolated fractures is shown in Fig. 5. Fracturesinvolving bones other than the mandible wereexcluded; thus the term nonisolated fracture refersto involvement of the condyle and another man-dibular site. In total, 150 condylar fractures were

Fig. 5. Primary endoscopic condylar repair was at-tempted in 135 patients. Percentages of bilateral, uni-lateral, and isolated injuries are shown.


attempted at primary endoscopic repair. Of those,13 displayed medial override of the proximal frag-ment, and in eight fractures, the condylar head wasdislocated completely out of the glenoid fossa.

Operative details

Of the 150 condylar fractures, plate fixation wasachieved at primary endoscopic repair in 136 (91%)[Fig. 6].In 27 patients presenting with bilateral condylar

fractures, 13 had both sides repaired using theendoscopic approach. Fourteen had only one sidetreated endoscopically, as the bone stock in theproximal fragment on the contralateral side wasdeemed insufficient on preoperative CT imagesto achieve fixation.In 75% of the fractures, the mean time required

to accomplish endoscopic repair was less than2 hours. The average duration for the last 30 caseswas approximately 70 minutes.

Fig. 6. Completion rate of primary endoscopic condylar repthe number of cases, in each category, where fixation wasignify the number of cases where fixation could not be a

Outcomes

Bailout procedureFourteen of 150 attempted endoscopic fracture re-pairs were aborted. The bailout procedure usedin nine fractures was MMF. In these nine frac-tures, fracture reduction was achieved, but platefixation was not possible because of the shortcondylar pole. Despite endoscopic fracture reduc-tion and postoperative MMF, follow-up radio-graphs revealed loss of fracture reduction in allcases. Traditional open reduction and internal fixa-tion techniques were used as the bailout procedurein the other five aborted endoscopic fractures.These were found to be exceptionally challengingsurgical repairs, with persisting malreduction foundin two fractures treated with traditional ORIF fol-lowing aborted endoscopic procedures.

Radiographic fracture reductionPlate fixation was achieved at primary endoscopicrepair in 136 of 150 condylar fractures. Malreduc-tion in 6 of these 136 condylar fractures, however,was found on early postoperative CT imaging. Fourmalreduced fractures were revised using secondaryendoscopic procedures with successful correctionof the malreduction. The other two malreductionswere judged as minor and acceptable.Hardware failure (broken plate) with late loss

of reduction occurred in two of the remaining130 primarily fixated condylar fractures; no second-ary procedures were performed.

Mandibular functionPostoperative dental occlusion and interincisal jawopening were documented in 102 patients. Mal-

air according to the fracture type. Solid bars represents achieved during primary repair. Cross-hatched barschieved using the endoscopic approach.

8 Mueller et al

occlusion was found in 3 of 102 patients. Interinci-sal jaw opening exceeded 35 mm in 96% of pa-tients (98/102).

Aesthetic appearanceScarring from endoscopic access portals was mini-mal in all cases. Facial height, chin projection, anda symmetrical appearance of the jaw line wererestored in cases where fracture reduction wasachieved successfully.

Soft tissue complicationsThere were no permanent facial nerve palsies. Twotemporary palsies (one full and one involvingthe frontal branch only) occurred; both resolvedcompletely and spontaneously. One soft tissue ab-scess was identified at a trocar portal and wastreated uneventfully by incisional drainage.

Summary

This compilation of a series of 150 attempts atendoscopic condylar fracture repair represents theearly evolving experience from three centers. Thecomprehensive data presented delineate the advan-tages and potential pitfalls with this newly intro-duced technique. Analysis of the early results showsa high rate (9%) of bailout. Does this represent afailure of the technique? Critical scrutiny of thedata suggests not. Specifically, a review of CT im-ages of the 14 fractures where plate fixation couldnot be achieved by the endoscopic technique sug-gests that these belong to a subgroup of proximalinjuries that are predictably difficult to manageregardless of the surgical method. These data con-firm this notion, as bailout to traditional tech-niques showed successful anatomic repair in only2 of the 14 aborted cases attempted initially usingthe endoscope.The incidence of bailout procedures can be re-

duced by careful analysis of CT images and sub-sequent exclusion of these proximal injuries. Whenendoscopic repair is used selectively to treat inju-ries that have been shown to be amenable to thisapproach, it can be expected to reliably produceanatomic reduction in 94% (128/136) of cases.Only 6 of 136 primarily endoscopically fixatedfractures went on to malreduction. Four of those6 were salvaged with successful secondary endo-scopic procedure. Plate fracture accounted foronly two failures in the 136 primarily endoscopi-cally fixated condylar fractures. The substantialadvantages of anatomic reduction have been de-lineated. Restoration of premorbid ramal height,upright posture of the condylar head, and complextemporomandibular joint relationships results inan aesthetic chin projection and occlusion, ade-

quate interincisal opening (96% of patients hadopening greater than 35 mm). Additionally, thetechnique prevents the late sequelae of internalderangement. Furthermore, the drawbacks of openreduction had been avoided. No patients sustainedsignificant facial scarring, and there were no casesof permanent facial nerve palsy and only two casesof temporary facial nerve palsy.The endoscopic approach is technically demand-

ing, and the initial operative times are long. Follow-ing a period of adjustment, however, the authorshave found the time required approximates thatof transcutaneous open methods. In this series,the last 30 cases took an average of 70 minutes.The skills needed for condylar repair are also in-creasingly essential to complete various other facialplastic surgery procedures, and many instructionalcourses already have been organized. Furthermore,the development of specialized endoscopic instru-ments facilitates repair.In the treatment of condylar injuries, the endo-

scope is not only an aid; it alters the treatmentphilosophy, from the conservative MMF to ana-tomic repair. Each surgeon will have to decide onhis or her indications for endoscopic repair, andindeed this may depend heavily on his or her ex-perience and patient preference. The authors feelthat anatomic reduction and fixation are the bestway to restore preinjury facial aesthetics and man-dibular motion dynamics and to prevent late se-quelae of internal derangement. Thus, the authorsstrongly advocate endoscopic repair of adult con-dylar neck and subcondylar fractures that dem-onstrate displacement or dislocation. The authorslook forward to future advancements of this andother endoscopic techniques.

References

[1] Feifel H, Risse G, Opheys A, et al. Conservativeversus surgical therapy of unilateral fracturesof the collum mandibulae—anatomic and func-tional results with special reference to computer-assisted 3-dimensional axiographic registrationof condylar paths. Fortschr Kiefer Gesichtschir1996;41:124–7.

[2] Guven O, Keskin A. Remodeling following con-dylar fractures in children. J CraniomaxillofacSurg 2001;29(4):232–7.

[3] Hovinga J, Boering G, Stegenga B. Long-termresults of nonsurgical management of condylarfractures in children. Int J Oral Maxillofac Surg1999;28(6):429–40.

[4] Kellenberger M, von Arx T, Hardt N. Resultsof follow-up of temporomandibular joint frac-tures in 30 children. Fortschr Kiefer Gesichtschir1996;41:138–42.

[5] Strobl H, Emshoff R, Rothler G. Conservativetreatment of unilateral condylar fractures in chil-


dren: a long-term clinical and radiologic follow-up of 55 patients. Int J Oral Maxillofac Surg1999;28(2):95–8.

[6] de Amaratunga NA. Mouth opening after releaseof maxillomandibular fixation in fracture pa-tients. J Oral Maxillofac Surg 1987;45(5):383–5.

[7] Ellis III E, Simon P, Throckmorton GS. Occlu-sal results after open or closed treatment of frac-tures of the mandibular condylar process. J OralMaxillofac Surg 2000;58(3):260–8.

[8] Ellis III E, Throckmorton GS. Bite forces afteropen or closed treatment of mandibular condylarprocess fractures. J Oral Maxillofac Surg 2001;59(4):389–95.

[9] Ellis III E, Throckmorton GS, Palmieri C. Opentreatment of condylar process fractures: assess-ment of adequacy of repositioning and main-tenance of stability. J Oral Maxillofac Surg 2000;58(1):27–34 [discussion 35].

[10] Haug RH, Assael LA. Outcomes of open ver-sus closed treatment of mandibular subcondy-lar fractures. J Oral Maxillofac Surg 2001;59(4):370–5 [discussion 375–6].

[11] Konstantinovic VS, Dimitrijevic B. Surgical ver-sus conservative treatment of unilateral condylarprocess fractures: clinical and radiographic eval-uation of 80 patients. J Oral Maxillofac Surg1992;50(4):349–52 [discussion 352–3].

[12] Palmieri C, Ellis III E, Throckmorton G. Man-dibular motion after closed and open treatmentof unilateral mandibular condylar process frac-tures. J Oral Maxillofac Surg 1999;57(7):764–75[discussion 775–6].

[13] Throckmorton GS, Ellis III E. Recovery of man-dibular motion after closed and open treat-ment of unilateral mandibular condylar processfractures. Int J Oral Maxillofac Surg 2000;29(6):421–7.

[14] Widmark G, Bagenholm T, Kahnberg KE, et al.Open reduction of subcondylar fractures. Astudy of functional rehabilitation. Int J OralMaxillofac Surg 1996;25(2):107–11.

[15] Worsaae N, Thorn JJ. Surgical versus nonsurgi-cal treatment of unilateral dislocated low sub-condylar fractures: a clinical study of 52 cases.J Oral Maxillofac Surg 1994;52(4):353–60 [dis-cussion 360–1].

[16] Silvennoinen U, Iizuka T, Oikarinen K, et al.Analysis of possible factors leading to problemsafter nonsurgical treatment of condylar frac-tures. J Oral Maxillofac Surg 1994;52(8):793–9.

[17] Silvennoinen U, Raustia AM, Lindqvist C, et al.Occlusal and temporomandibular joint dis-orders in patients with unilateral condylar frac-ture. A prospective 1-year study. Int J OralMaxillofac Surg 1998;27(4):280–5.

[18] Chossegros C, Cheynet F, Blanc JL, et al. Shortretromandibular approach of subcondylar frac-tures: clinical and radiologic long-term evalua-tion. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 1996;82(3):248–52.

[19] Eckelt U, Hlawitschka M. Clinical and radiologi-cal evaluation following surgical treatment ofcondylar neck fractures with lag screws. J Cranio-maxillofac Surg 1999;27(4):235–42.

[20] Klotch DW, Lundy LB. Condylar neck fracturesof the mandible. Otolaryngol Clin North Am1991;24(1):181–94.

[21] MacArthur CJ, Donald PJ, Knowles J, et al. Openreduction-fixation of mandibular subcondylarfractures. A review. Arch Otolaryngol Head NeckSurg 1993;119(4):403–6.

[22] Mikkonen P, Lindqvist C, Pihakari A, et al.Osteotomy-osteosynthesis in displaced condylarfractures. Int J Oral Maxillofac Surg 1989;18(5):267–70.

[23] Pereira MD, Marques A, Ishizuka M, et al. Sur-gical treatment of the fractured and dislocatedcondylar process of the mandible. J Cranio-maxillofac Surg 1995;23(6):369–76.

[24] Raveh J, Vuillemin T, Ladrach K. Open reductionof the dislocated, fractured condylar process:indications and surgical procedures. J Oral Max-illofac Surg 1989;47(2):120–7.

[25] Takenoshita Y, Oka M, Tashiro H. Surgicaltreatment of fractures of the mandibular con-dylar neck. J Craniomaxillofac Surg 1989;17(3):119–24.

[26] Tasanen A, Lamberg MA. Transosseous wiringin the treatment of condylar fractures of themandible. J Maxillofac Surg 1976;4(4):200–6.

[27] Zide MF, Kent JN. Indications for open reductionof mandibular condyle fractures. J Oral Max-illofac Surg 1983;41(2):89–98.

[28] Ellis III E, Dean J. Rigid fixation of mandibularcondyle fractures. Oral Surg Oral Med Oral Path1993;76:6–15.

[29] Krenkel C. Biomechanics and osteosynthesis ofcondylar neck fractures of the mandible. Chi-cago: Quintessence Publishing; 1994.

[30] Walker RV. Condylar fractures: nonsurgical man-agement. J Oral Maxillofac Surg 1994;52:1185–92.

[31] Dahlstrom L, Kahnberg KE, Lindahl L. 15-yearfollow-up on condylar fractures. Int J Oral Max-illofac Surg 1989;18:18–23.

[32] Ellis E, Carlson DS. The effects of mandibularimmobilization on the masticatory system. A re-view. Clin Plast Surg 1989;16(1):133–46.

[33] Ellis ED, Dechow PC, Carlson DS. A comparisonof stimulated bite force after mandibular ad-vancement using rigid and nonrigid fixation.J Oral Maxillofac Surg 1988;46(1):26–32.

[34] Bos RR, Ward Booth RP, de Bont LG. Mandibularcondyle fractures: a consensus. Br J Oral Max-illofac Surg 1999;37:87–9.

[35] Wilson IF, Lokeh A, Benjamin CI, et al. Prospec-tive comparison of panoramic tomography(zonography) and helical computed tomogra-phy in the diagnosis and operative managementof mandibular fractures. Plast Reconstr Surg2001;107(6):1369–75.




11

Endoscopic Repair of OrbitalFloor FracturesD. Gregory Farwell, MD*, E. Bradley Strong, MD

& Indications & Complications
& Technique& Discussion
Department of Otolaryngology, University of California, DSacramento, CA 95817, USA* Corresponding author.E-mail address: [email protected] (D.G. Farwell).



When the periorbital region is injured with sig-nificant force, the bony orbital vault may be frac-tured. These fractures often involve the medial walland floor of the orbit, resulting in prolapse of or-bital contents into the paranasal sinuses [1]. Thismay result in extraocular muscle entrapment withdiplopia and enophthalmos. Visual loss from opticneuropathy, retinal detachment, or hyphema alsomay occur. Management of orbital floor frac-tures traditionally has been accomplished throughtransconjunctival and subciliary incisions. Theseapproaches provide adequate visualization and cos-metically acceptable scars. Unfortunately, post-operative lid malposition can occur in a smallpercentage of cases. The most common com-plications include entropion, ectropion, and lidshortening. Another limitation is easy visibility ofthe posterior orbit, which often is obscured byprolapsed orbital fat. The introduction of endos-copy and minimally invasive surgery has revolu-tionized the surgical treatment of many diseases.Endoscopy has become commonplace in urologic,laparoscopic, and sinus surgery. It offers magnifiedvisualization, access through smaller incisions, lesspostoperative morbidity, and often greater patientacceptance. This concept now is being evaluated inorbital trauma.General requirements for endoscopic surgery in-

clude the ability to obtain an optical cavity, insert

an endoscope, maintain adequate hemostasis, and ap-ply instrumentation. Although several authors havedescribed access to the orbital floor by means of atransnasal approach [2–5], complete fracture visu-alization and reconstruction require’s greater accessthrough the maxillary sinus by means of a CaldwellLuc approach. It allows access to the maxillary sinusand excellent visualization of the entire orbitalfloor, including the stable posterior shelf, whichcan be difficult to visualize through traditional in-cisions. Walter described the Caldwell Luc ap-proach for repair of orbital floor fractures in 1972[6]. His technique involved direct visualization ofthe fracture with a headlight, blind fracture reduc-tion, and short-term fixation with packing. SinceWalter’s description, several authors have describedan endoscopic Caldwell Luc approach to orbitalfloor fractures (Farwell and colleagues, unpublisheddata, 2004) [7–13]. This article reviews the indica-tions, technique, and potential complications of en-doscopic orbital blow-out fracture repair.

Indications

A preoperative CT scan should be obtained todocument the location and extent of the orbitalfloor fracture. Patients with trap door [Fig. 1] andmedial blow-out [Fig. 2] fractures are excellentcandidates for endoscopic repair. Fractures that

avis School of Medicine 2521 Stockton Blvd. Ste 7200


Fig. 1. Trap door fracture. Note that the fracture ishinged at the lamina papyracea and depressed alongthe junction with the infraorbital nerve. It is importantto maintain the integrity of the hinge during thesurgical repair.

Fig. 3. Lateral blow-out fracture. Note that the entireorbital floor is comminuted and depressed into themaxillary sinus. The fracture extends medially to thelamina papyracea and laterally to the lateral orbitalwall. The infraorbital canal is disrupted.

12 Farwell & Strong

extend lateral to the infraorbital nerve [Fig. 3] orinvolve the lamina papyracea are much more diffi-cult to repair endoscopically and generally requirean open approach.

Technique

Under general anesthesia, the patient is placedsupine on the operating table. A right-handed sur-geon is on the patient’s right side, and the assis-tant is on the left. The monitor is positioned at thehead of the patient, so it can be seen by both sur-geons. Two monitors are preferable. Local anes-thetic and epinephrine are injected sublabially,and a 4 cm incision is made in the gingivobuccalsulcus, through the periosteum, and onto the max-

Fig. 2. Medial blow-out fracture. Note that the medialfloor is comminuted and depressed into the maxillarysinus. The fracture extends medially to the laminapapyracea and laterally to the infraorbital nerve.

illa. The periosteum then is elevated, exposingthe anterior wall of the maxilla up to the level ofthe infraorbital nerve. Care is taken to avoid ex-cessive traction on the nerve. An approximate1.0 cm × 2.0 cm maxillary antrostomy is made inthe thin bone of the maxillary face [Fig. 4]. Thisusually is performed with an osteotome and Kerri-son rongeur, but the bone can be removed with asaw and replaced after the orbital floor repair. Asmall notch should be placed along the edge of theantrostomy to stabilize the endoscope and providetactile feedback for the assistant surgeon. The notchcan be placed inferiorly [see Fig. 4] or superior–medially depending upon surgeon preference. Thelip is retracted with a Greenberg self-retainingretractor, and oxymetazoline-soaked pledgets areplaced 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 entrap-ment, and bony comminution. If a trap door in-

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

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

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

13Orbital Floor Fractures

jury is encountered with strangulated soft tissue,a small portion of mucosa is stripped away fromthe fracture. The fracture is opened with an angledretractor, and the orbital contents are reduced intothe orbit. The bone flap is then allowed to snapback into place maintaining the reduction. Caremust be used to avoid excessive medial dissectionthat might destabilize the hinge and require place-ment of an implant.When a medial blow-out fracture is present, the

edges of the orbital defect are exposed by conserva-tive elevation of the mucosa around the defect. Theentire bony margin must be visualized well. Caremust be used avoid injury to the maxillary sinusostia or the infraorbital nerve. The orbital soft tis-sues then are reduced, and an attempt can be madeto reposition the bony piece. More often there iscomminution of the floor. In this case, all bonefragments should be removed before reconstruc-tion. When bone is removed, the defect will ap-pear larger, with greater prolapse of the orbitalcontents. An alloplastic implant (porous polyeth-ylene, 0.85 mm thickness) should be fashioned torecreate the orbital floor and re-establish the orbitalvolume. The implant should be trimmed to a di-ameter approximately 1 mm bigger than the defectand inserted through the antrostomy just belowthe prolapsed orbital contents. Care should beused to assure that no bone fragments are pushedback into the orbital cavity. The implant then isinserted over the stable posterior shelf. A Fraser tipsuction catheter and Freer elevator then are usedto walk forward on the implant while maintainingthe posterior positioning. Gentle force is applied

at the anterior portion of the implant (ie, belowthe posterior aspect of the orbital rim) until it slipsover the orbital rim and is stabilized by downwardpressure from the orbital contents [Fig. 5]. Theprimary area of support is anterior and posterior.If a medial shelf of bone is present, it can be used

Fig. 7. Sagittal CT scan of the orbital floor illustrating(black arrow) the less advantageous, tangential angleof attack using an open approach (ie, the surgeon islooking at the posterior bony shelf end on) and (white

14 Farwell & Strong

also. Pressure laterally on the infraorbital nerveshould be avoided.Once the fracture has been repaired, the endo-

scope is used to inspect the edges of the fracturelooking for any entrapped orbital tissue. A pulsetest is performed (ie, gentle external pressure isapplied to the globe, and the pulsations are ob-served through the endoscope) to assure the im-plant is stable. Any mucosa or bone fragmentsoverhanging the maxillary ostia are removed tominimize the chance of sinus obstruction and sub-sequent infection. Occasionally, a formal middlemeatal antrostomy is required to ensure adequatemaxillary sinus drainage. Finally, the wound isclosed and a postreduction CT scan is obtained toconfirm an adequate repair [Fig. 6].

arrow) the more advantageous endoscopic approachin which the surgeon can visualize the posterior bonyshelf from below.

Discussion

The use of endoscopes within the nasal cavity andparanasal sinuses has become the standard of carefor endoscopic sinus surgery. In recent years, manysinus surgeons have begun performing sinus-related procedures such as orbital decompressionfor Graves’ disease [14] and resection of certain sinusand skull base neoplasms [15]. As the realm ofendoscopic surgery expands, the potential benefitof orbital floor fracture repair has become apparent.Traditional open approaches (ie, transconjuncti-

val and transcutaneous) can result in lid malposi-tion such as entropion and ectropion. Several largeseries reported complication rates of 5% [16–19].Careful review of these studies, however, demon-strates that lid complications were less common inpatients with isolated orbital floor fractures. Eyelidmalposition was more common in patients withmore extensive dissection over the orbital rim fororbitozygomatic or Le Fort-type injuries. The endo-scopic approach obviates the need for an eyelidincision and potential eyelid complications. Anadditional benefit is improved visualization of theposterior orbit and stable bony shelf. One of themajor limitations of the open approaches is diffi-culty visualizing the posterior orbit because of theangle of attack and prolapsed orbital fat. This canresult in improper implant placement along thestable posterior ledge and inadequate restorationof orbital volume with persistent enophthalmos.Using the endoscopic approach, the angle of incli-nation offers a more direct view of the posteriororbit, thereby reducing the risk of a poorly posi-tioned implant. [Fig. 7].Several surgeons have described a transnasal

approach to orbital floor fractures [8,13]. Theydescribe endoscopic placement of balloon cathe-ters, threaded through the nose, to reduce the frac-ture and maintain reduction for up to 10 days.

These authors reported symptomatic resolution ofdiplopia in most patients. Follow-up data on or-bital position were limited, and representative im-aging in the article by Ikeda showed persistentincrease in orbital volume. It is not certain thatthe goal of minimally invasive surgery was met inthese patients. Despite the lack of an external inci-sion, placement of a transnasal catheter for up to10 days may not be considered minimally invasive.Subsequent reports of endoscopic orbital floor

reconstruction by means of a transantral approachhave demonstrated the feasibility of a pure endo-scopic repair for accurate reestablishment of thepremorbid orbital volume [7,9]. Different implantmaterials include porous polyethylene and resorb-able and titanium mesh. These reports have dem-onstrated excellent patient tolerance with minimalincidence of infection or extrusion. Indications forthe endoscopic repair vary, but most authors agreethat isolated trap door and medial blow-out frac-tures as described by Strong and colleagues areindications for the technique [see Figs. 1, 2]. Largerlateral blow-out fractures involve the infraorbitalnerve [see Fig. 3]. The use of the endoscopic ap-proach in these cases is not recommended. De-finitive repair requires significant manipulationof the infraorbital nerve and placement of animplant that spans medial and lateral to the infra-orbital canal. An implant this large is difficult toinsert and manipulate.Techniques for implant stabilization vary be-

tween authors. Most authors agree that hinged,trap door fractures can be snapped back into theirpremorbid position after reduction of the orbitalcontents. The interfragmentary friction alone willmaintain the reduction. Intraoperative assessment

15Orbital Floor Fractures

with forced duction testing and a pulse test (gentleexternal orbital pressure) should be performed toassure an adequate and stable repair. If comminu-tion is present or occurs with manipulation of atrap door fracture, an implant is necessary to com-plete the reconstruction. Several techniques havebeen used to maintain the implant position. Themost common approach is to place an implantslightly larger than the defect above the bony mar-gin, within the orbital cavity, but below the orbitalsoft tissues [7]. The orbital contents then are al-lowed to fall down onto the implant holding it inplace [see Fig. 5]. Chen and colleagues describeda different technique in which the orbital contentsare reduced and held in place by a piece of tita-nium mesh placed within the maxillary sinus [9].This mesh is held into position with titaniumscrews placed into the residual orbital floor.Using this approach, care must be taken to avoidplacing the drill hole too close to the infraorbitalnerve or too deep into the orbital tissues. Thiscould result in injury of the infraorbital nerve,extraocular muscles, or orbital hematoma. Cautionalso must be used to avoid obstruction of the max-illary sinus ostia. If the dissection is carried alongthe infero–medial aspect of the orbit, or the im-plant is placed near the ostia, the risk of postopera-tive maxillary sinusitis will increase.Time from injury is felt to influence the success-

ful repair of orbital floor fractures, particularlywith gross extraocular muscle entrapment. Patientswith delayed surgical repair may be more likelyto have persistent diplopia (Farwell and colleagues,unpublished data). For this reason, repair gener-ally should be attempted as early as possible, par-ticularly in patients with gross extraocular muscleentrapment. The endoscopic approach is advan-tageous in early repairs, because it offers excel-lent fracture visualization even in the face ofmarked periorbital edema. Another advantage ofthe endoscopic approach is that there is far lessorbital retraction required. Hyphema is consid-ered a contraindication to surgical repair of orbitalfloor fractures because of the potential risk ofblindness secondary to globe retraction. By ap-proaching these fractures from below, without sig-nificant orbital manipulation, urgent reduction ofentrapped inferior rectus muscle can be accom-plished, reducing the chance of permanent dys-function from prolonged ischemia and pressurenecrosis [7].Even if the endoscopic approach is not chosen as

the primary access for orbital floor fracture repair, itis useful in assessing the orbital floor in patientswith other facial fractures [12]. An example of itsutility is in evaluating the orbital floor in a patientwith an orbitozygomatic fracture. Once the malar

portion of the fracture has been reduced, the orbitalfloor defect can be enlarged. Placing the endoscopethrough a small antrostomy or existing anteriormaxillary fracture allows the surgeon to assess theintegrity of the orbital floor without a lid incision.The authors recommend that surgeons consideringlearning the endoscopic technique have the equip-ment readily available for all traumas involving theorbit. The surgeon then can use existing incisions(ie, for zygoma or Le Fort fractures) to becomecomfortable with the technique. Once the surgeongains confidence with the equipment, a pure endo-scopic repair can be attempted.

Complications

Postoperative infraorbital paresthesias are commonafter this approach (Farwell and colleagues, unpub-lished data) [7]. The paresthesias may be caused byretraction or manipulation during the fractureexposure and implant placement. They generallyresolve over 2 to 8 weeks. The surgeon also mustavoid inadvertent displacement of a bone frag-ments into the orbital cavity [7]. All comminutedbone fragments must be removed before repair ofmedial blow-out fractures. Postoperative maxillarysinusitis is also a risk. The exact etiology is difficultto assess, because it may be caused by the surgicalprocedure or the fracture itself. Patients should beinstructed on the importance of prompt evaluationof any sinus complaint. Failure to repair the frac-ture endoscopically will necessitate an alternativeapproach, either through a transconjunctival orsubciliary incision. This should be discussed withthe patient preoperatively in case a pure endoscopicrepair cannot be achieved.

Summary

Endoscopic surgery is expanding rapidly, particu-larly within the field of otolaryngology. The repairof the orbital floor fractures through an endoscopicapproach has been performed successfully by sev-eral centers. It is technically demanding andrequires expertise in traditional repair of orbitalfloor fractures and endoscopy. The surgical tech-nique, patient selection, instrumentation, and post-operative results will continue to evolve as moresurgeons attempt this technique. As more data areobtained, it will be important to compare theresults with the traditional open approach, whichhas a proven track record with low complicationrates. The endoscopic approach, however, appearsto be a promising new technique for isolated trapdoor and medial orbital floor fractures.

16 Farwell & Strong

References

[1] Jones DE, Evans JN. Blow-out fractures of the or-bit: an investigation into their anatomical basis.J Laryngol Otol 1967;81(10):1109–20.

[2] Lee MJ, Kang YS, Yang JY, et al. Endoscopictransnasal approach for the treatment of medialorbital blow-out fracture: a technique for con-trolling the fractured wall with a balloon catheterand Merocel. Plast Reconstr Surg 2002;110(2):417–26 [discussion 427–8].

[3] Yamaguchi N, Arai S, Mitani H, et al. Endoscopicendonasal technique of the blow-out fracture ofthe medial orbital wall. Operative Techniques inOtolaryngology Head and Neck Surgery 1991;2:269–74.

[4] Michel O. Isolated medial orbital wall fractures:results of minimally invasive endoscopically con-trolled endonasal surgical technique. Laryngo-rhinootologie 1993;72(9):450–4.

[5] Rhee JS, Lynch J, Loehrl TA. Intranasal endoscopy-assisted repair of medial orbital wall fractures.Arch Facial Plast Surg 2000;2(4):269–73.

[6] Walter WL. Early surgical repair of blowout frac-ture of the orbital floor by using the transantralapproach. South Med J 1972;65(10):1229–43.

[7] Strong EB, Kim KK, Diaz RC, et al. Endoscopic ap-proach to orbital blowout fracture repair. Otolar-yngol Head Neck Surg 2004;131(5):683–95.

[8] Ikeda K, Suzuki H, Oshima T, et al. Endoscopicendonasal repair of orbital floor fracture. ArchOtolaryngol Head Neck Surg 1999;125(1):59–63.

[9] Chen CT, Chen YR. Endoscopically assisted re-pair of orbital floor fractures. Plast Reconstr Surg2001;108(7):2011–8 [discussion 2019].

[10] Saunders CJ, Whetzel TP, Stokes RB, et al.Transantral endoscopic orbital floor exploration:a cadaver and clinical study. Plast Reconstr Surg1997;100(3):575–81.

[11] Woog JJ, Hartstein ME, Glilich R, et al. Paranasalsinus endoscopy and orbital fracture repair. ArchOphthalmol 1998;116(5):688–91.

[12] Forrest CR. Application of endoscope-assistedminimal-access techniques in orbitozygomaticcomplex, orbital floor, and frontal sinus fractures.J Craniomaxillofac Trauma 1999;5(4):7–12 [dis-cussion 13–4].

[13] Otori N, Haruna S, Moriyam H, et al. Endoscopicendonasal or transmaxillary repair of orbitalfloor fracture: a study of 88 patients treated inour department. Acta Otolaryngol 2003;123(6):718–23.

[14] Lund VJ, Larkin G, Fells P, et al. Orbital decom-pression for thyroid eye disease: a comparisonof external and endoscopic techniques. J Laryn-gol Otol 1997;111(11):1051–5.

[15] Al-Nashar IS, Carrau RL, Herrera A, et al. En-doscopic transnasal transpterygopalatine fossaapproach to the lateral recess of the sphenoidsinus. Laryngoscope 2004;114(3):528–32.

[16] Zingg M, Chowdhury K, Ladsach K, et al. Treat-ment of 813 zygoma-lateral orbital complex frac-tures. New aspects. Arch Otolaryngol Head NeckSurg 1991;117(6):611–20 [discussion 621–2].

[17] Appling WD, Patrinely JR, Salzer TA, et al.Transconjunctival approach vs subciliary skin-muscle flap approach for orbital fracture repair.Arch Otolaryngol Head Neck Surg 1993;119(9):1000–7.

[18] Mullins JB, Holds JB, Branham GH, et al. Com-plications of the transconjunctival approach.A review of 400 cases. Arch Otolaryngol HeadNeck Surg 1997;123(4):385–8.

[19] Lorenz HP, Longaker MT, Kawamoto HK, et al.Primary and secondary orbit surgery: the trans-conjunctival approach. Plast Reconstr Surg 1999;103(4):1124–8.




17

Endoscopic Approach to MedialOrbital Wall FracturesJohn S. Rhee, MD, MPH

a,b,*, Chien-Tzung Chen, MDc

& Preoperative evaluation & Complications
& Indications& Surgical techniques
Endoscopic transcaruncular approachIntranasal endoscopic-assisted technique

a Department of Otolaryngology, Medical College of WWI 53226, USAb Zablocki Veteran Affairs Medical Center, 5000 W. Natic Division of Trauma Plastic Surgery, Department of PlastHospital, Number199, Tunghwa Rd., Taipei, Taiwan, Rep* Corresponding author. Department of Otolaryngology,E-mail address: [email protected] (J.S. Rhee).

1064-7406/06/$ – see front matter. Published by Elsevier Inc.facialplastic.theclinics.com


Historically, medial orbital wall fractures havebeen underappreciated in their incidence and im-portance. Recent studies have indicated that theincidence of medial orbital wall fractures may behigher than that of the floor [1]. In addition, stud-ies have suggested that enophthalmos may bemore significant from nonrepaired medial orbitalwall fractures than from blowout fractures of anyother orbital wall. Furthermore, because of theunderappreciation of this injury, the incidence ofdelayed enophthalmos may be higher for this typeof orbital fracture [2].Biomechanical studies have suggested that that in

the absence of orbital rim or facial skeleton trauma(pure hydraulic mechanism), isolated medial or-bital wall fractures cannot occur without traumato the surrounding bony framework (eg, orbitalrim, nasal bone) [3]. These biomechanical findingsare corroborated by reports in the clinical medicalliterature. In a large series of medial orbital frac-tures, Burm and colleagues [1] reported that nasalfractures were the most common fracture associatedwith the medial orbital wall fracture, suggestingthat the force causing nasal fractures was a veryimportant causative factor of pure medial orbitalfractures by means of the buckling mechanism.

In the clinical realm, medial orbital fractures mayoccur by way of the buckling or hydraulic mecha-nism, with a combination of the two mechanismsthe most likely scenario. It is also more commonthat the medial orbital wall is fractured in conjunc-tion with the orbital floor, necessitating repair ofboth 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. Themedial brow incision has been described for accessto the medial orbital wall [4]. This approach islimited to the anterior and superior medial orbitalwall and fails to free the entrapped medial rectusmuscle from the posterior medial wall fracturebecause of the close proximity of the optic nerve.A lid crease incision may offer a more cosmeticallyappealing result, but has the same limitations as themedial brow incision [5].A direct medial canthal approach can be used to

gain access to the medial and inferomedial aspectsof the orbit, and this may be extended to the infra-orbital rim to explore the floor. Drawbacks to thisapproach include the obvious external scar, web-bing of the skin, and risk of telecanthus from sur-gical detachment of the medial canthal tendon [6].

isconsin, 9200 W. Wisconsin Avenue, Milwaukee,

onal Avenue, Milwaukee, WI 53295, USAic and Reconstructive Surgery, Chang Gung Memorialublic of ChinaMedical College of Wisconsin, Milwaukee, WI 53226.

doi:10.1016/j.fsc.2005.10.006

18 Rhee & Chen

Indirect approaches to the medial orbital wallinclude the coronal incision, which usually is re-served for patients with multiple facial fractures.This approach offers wide exposure and reconstruc-tion of the defect with calvarial bone through thesame incision. Disadvantages include an externalscar, scalp alopecia, significant surgical dissection,overnight hospitalization, and potential injury tocranial nerves VI and VII.The transcaruncular approach to the medial or-

bital wall has been described more recently andprovides excellent access to the medial wall [6–8].The main limitation of this approach is that a largegraft cannot be placed through the small incisionwithout connecting it to an orbital floor approach.Other potential disadvantages include the risk ofinjury to the lacrimal apparatus and difficulty as-sessing the posterior dissection.Endoscopic-assisted techniques have emerged as

the next frontier for repair of medial orbital frac-tures. Recently, techniques have been describedthat allow for endoscopic assistance in reductionof the orbital contents and in placement of analloplast or graft for reconstitution of the medialorbital wall. The two main techniques in which en-doscopy has aided in the repair of these fractureshave been either through the intranasal (transeth-moidal) or the transcaruncular approaches [9,10].Most endoscopic intranasal techniques involve

partial ethmoidectomy and exposure of the frac-tured lamina papyracea. The herniated orbital con-tents are reduced, and some type of intranasalsplint or packing is placed between the laminaand the middle turbinate for a period of time(approximately 2 months) until healing of themedial wall is completed [11–13]. Alternatively, anintranasal endoscopic approach to assist in place-ment of an orbital implant by means of a peri-orbital incision has been described [14].This article describes different endoscopic-assisted

approaches—transcaruncular and intranasal—whichhave been used to successfully repair medial orbitalwall fractures.

Preoperative evaluation

Medial orbital fractures, unlike blow-out fracturesof the orbital floor, may be overlooked, becausethey present with clinical symptoms and signs inonly a few instances, especially in the early acutetrauma setting. The possible clinical symptoms andsigns include:

• Epistaxis

• Eyelid emphysema, especially in themedial canthus

• Periorbital edema

• Narrowing of the palpebral fissure

• Nasal subconjunctival hemorrhage

• Horizontal diplopia

• Restriction of abduction

• Retraction syndrome

• Progressive enophthalmos

• Positive forced duction test [5,15–18]

Associated ocular injuries commonly occur inpatients with midfacial trauma, which may resultin decrease in visual acuity, or even complete visionloss, if early diagnosis and management are notinitiated properly. The incidence of severe oculardisorders associated with an orbital blow-out frac-ture has been reported to be as high as 16.7%[19]. Therefore, early ophthalmology consultationroutinely is sought in patients with suspected or-bital fractures. The ocular examination should in-clude an assessment of visual acuity, visual field,papillary function, extraocular muscle function, andslit lamp examination to rule out a corneal perfo-ration or hyphema. A forced duction test is con-ducted if restriction of ocular movement is detected.The presence of diplopia may be associated withlimitation of extraocular muscle movement. Onemust differentiate the causes of diplopia that mayresult from cranial nerve-induced injury, orbitalsoft tissue or muscle entrapment, mal-positionof the globe, or intraorbital edema secondary toacute trauma.Imaging studies including CT scanning are essen-

tial before forming a surgical plan. Recently, thedevelopment of the helical CT scan has changed thetype of studies needed to diagnose and evaluateorbital trauma. The helical CT scan allows for con-tinuous acquisition of volumes of tissue, whichpermits multi-planar reconstructions of additionalimage planes. This technique reduces the numberof examinations and radiation exposure of thepatient and improves the quality of the image[20]. These fine-cut CT scan images are taken incoronal and axial planes, with soft tissue and bonewindows. The reformatted sagittal sections thatconnect the midpoint of the globe and the apexof the orbit are particularly helpful to assess the con-comitant orbital floor fractures. Three-dimensionalCT images allow for a quick overview of the facialbone fractures, but they are seldom of value in theinternal portion of the orbit. Occasionally, MRI canbe used to differentiate the herniated muscleand orbital fat, and this may serve as a complementto CT scanning [5,21].

Indications

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

19Medial Orbital Wall Fractures

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

• Persistent symptomatic diplopia

• Pain during horizontal eye movement,

• A positive forced duction test with clear evi-dence of medial rectus muscle entrapment ona CT scan,

• Early enophthalmosmore than 2mmpreoperatively

• A large defect likely causing secondary enoph-thalmos [5,21,22]

Both endoscopic-assisted techniques, through ei-ther the intranasal or transcaruncular approaches,can be applied to repair the variable sizes of themedial orbital wall fractures. The endoscopic tech-niques are especially valuable for those fracturesinvolving the superior and posterior medial or-bits, which are difficult to dissect and visualizethrough a lower eyelid approach. In general, theseendoscopic techniques are used for primary repairof the medial orbital wall fractures. Recently, thetranscaruncular endoscopic approach has beenexpanded in its use to correct late enophthalmoscaused by uncorrected displacement of medialwall or previously inadequate reconstruction ofmedial wall defects [10]. One may use the coro-nal incision or existing lacerations to repair thesefractures directly without the use of endoscopicapproaches, however, if the medial orbital wallfracture is accompanied by periorbital fracturessuch as nasoethmoid, orbital roof, or supraorbitalrim fractures.

Surgical techniques

Endoscopic transcaruncular approach

The surgery is performed under general anesthesia.An injection of 1:100,000 epinephrine solution isplaced in the medial conjunctiva using a fine nee-dle. The cornea is protected with a scleral shieldduring the procedure. Two parallel traction suturesusing 4-0 silk are placed in the medial conjunctivaposterior to the caruncle to facilitate the conjunc-tival incision. A slight curvilinear incision approxi-mately 1 cm in length is made between the twosutures, and then a scissors is used to bluntly dis-sect toward the medial orbital wall immediatelyposterior to the lacrimal apparatus [Fig. 1]. Withprogressive blunt dissection, the periorbita is in-cised behind the posterior lacrimal crest to avoidseverance of the medial canthal ligament and injuryto the lacrimal sac. The periorbita is elevated fur-ther superiorly and inferiorly with a Freer elevator;then the dissection proceeds posteriorly, thereby

creating a periosteal opening wider than the con-junctival incision. Initially, the anterior part of themedial wall is dissected under direct vision with theaid of a headlight. Because the orbital roof is intactin most cases, the authors prefer starting the dis-section from the superior medial wall near theorbital roof and then proceeding downward tothe inferior portion of the orbital medial wall.The optical cavity is created and maintained with

insertion of a baby retractor medially and a narrowmalleable retractor laterally to retract the orbitalcontents gently. A 2.7 mm diameter, 0° endoscopeis introduced through the transcaruncular ap-proach. With the aid of endoscope, the posteriordissection of the medial wall is performed using anorbital periosteal elevator. The first important struc-ture that is encountered is the anterior ethmoidvessels coming out from the anterior ethmoid fora-men, which is on average 24 mm behind the ante-rior lacrimal crest. The vessels should be cauterizedmeticulously to avoid any undue bleeding andfacilitate further posterior dissection. Subsequently,the posterior ethmoid vessels appear in the surgi-cal field and indicate the limit of safe dissectionalong the medial wall. This landmark is on average36 mm away from the anterior lacrimal crest. Oneshould keep in mind that the optic nerve is locatedon average 7 mm posterior to the posterior ethmoidvessels. A horizontal line connecting the anteriorand posterior ethmoid vessels indicates the superiorlimit of the ethmoid sinus. Generally, the medialwall fractures rarely extend above this horizontalline. The entrapped orbital contents gradually arereduced from the ethmoid sinus into the orbitalcavity, and the fracture fragments of the medialwall are removed. After that, the whole boundary ofthe medial wall defect is defined clearly [see Fig. 1].To reconstruct the bony defect, the authors

use the synthetic implants titanium micromeshor Medpor (Porex Surgical, Incorporated, Newnan,Georgia) in most cases. The orbital implant istrimmed to proper size and shape, with the dimen-sion no greater than 1.5 cm in width and 3 cm inlength, because the small incision prevents place-ment of a larger graft. The implant is insertedthrough the transcaruncular incision to cover thebony defect in the subperiosteal space and fixatedwith a microscrew [see Fig. 1]. In the scenario of alarger bony defect extending onto the inferior me-dial wall, additional implant is required, with oneoverlapping the other, to completely cover thebony defect. Finally, the proper position of theseimplant areas is rechecked and adjusted underendoscopic visualization. A forced duction test isperformed after placement of these implants toconfirm the mobility of the globe in any direction.The conjunctival wound is closed with a 6-0 plain

Fig. 1. (A) Transcaruncular incision made posterior to the caruncle with two parallel traction sutures. (B) Endo-scopic 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 micro-screw fixation.

20 Rhee & Chen

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

Intranasal endoscopic-assisted technique

The operation is performed under general anesthe-sia with the patient in a supine position. The orbitalfloor is approached through a transconjunctivalincision with a canthotomy and cantholysis. A pre-septal dissection is carried down to the orbital rim.The arcus marginalis then is incised sharply at theorbital rim. Dissection continues along the orbitalfloor, deep to the periorbita. A concomitant orbitalfloor fracture can be addressed with reduction ofthe orbital contents. Before the manipulation ofthe medial orbital contents, the medial orbitalwall is approached intranasally.After proper nasal decongestion is accomplished,

a 4.0 mm 0° endoscope is introduced into the nos-tril. The uncinate is identified and resected. Ap-proximately 3 to 4 mm of uncinate is left intactsuperiorly to prevent frontal recess stenosis. Thisexposes the natural ostium of the maxillary sinus.

The bulla ethmoidalis then is entered mediallyand resected to expose the lamina papyracea defect.The herniated orbital contents are usually apparentat this stage, and great care is taken to preventfurther injury. The dissection is carried posteriorlythrough the ground lamella to fully expose thedefect in the lamina papyracea.Next, from the periorbital incision, the orbital

contents are reduced and held in place with a mal-leable retractor. Adequate reduction is confirmedfrom the intranasal endoscopic and external ap-proaches. The orbital implant then is cut to theappropriate shape and size to cover the floor andlamina papyracea defect. The implant is introducedthrough the periorbital incision and guided intoposition using the endoscopes for visualization.While an assistant holds the endoscope in properposition, the implant is manipulated bimanuallyfrom the sinonasal and periorbital approachesinto proper position. A clinical case illustratingthis technique is described in Figs. 3 and 4.No nasal packing is necessary, in contrast to the

temporary intranasal stent placement procedures.

Fig. 2. (A) 40-year-old patient with left orbital medial wall blow-out fracture. Preoperative submental viewshowing left upper eyelid ecchymosis and enophthalmos (1.5 mm). (B) Preoperative CT scan revealing a blowoutfracture of the left orbital medial wall with soft tissue prolapse. (C ) Postoperative submental view 5 monthsfollowing correction of the orbital medial wall defect with symmetric projection of the globe. (D) Properlyreconstructed 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 FacialPlast Surg 2000;2(4):269–73; with permission.)


Fig. 4. (A) Intranasal endoscopic view of right medial orbital wall fracture. Asterisk indicates bony defect of thelamina papyracea. Arrow delineates the intact posterior medial wall. (B) Intranasal endoscopic view of theMedpor implant in proper position. (From Rhee JS, Lynch J, Loehrl TA. Intranasal endoscopy-assisted repair ofmedial orbital wall fractures. Arch Facial Plast Surg 2000;2(4):269–73; with permission.)

22 Rhee & Chen

The periorbital incision is closed in standard fash-ion. Postoperatively, the patient is placed on nasalsaline irrigations and is seen every 7 to 14 days withendoscopic debridement performed until the eth-moid cavity is mucosalized.

Complications

In the authors’ experience, postoperative complica-tions with either transcaruncular or intranasal ap-proaches have been minimal. There have been nocases of infection or sinusitis using an implant torepair the medial wall defect. One minor complica-tion related to the transcaruncular incision was re-ported by Graham and colleagues [23], in whichexcessive medial canthal scarring caused diplopiathat resolved after revision conjunctivoplasty surgery.Other potential intraoperative complications in-

clude optic nerve injury, cerebrospinal fluid rhino-rrhea, intraorbital or nasal hemorrhage, damage toextraocular muscle, lacrimal sac and cornea, in-adequate reduction of herniated orbital tissue, orincomplete coverage of the medial wall defect.When a transcaruncular approach is adopted, oneshould avoid too much anterior or posterior dis-section causing injury to the lacrimal sac and to themedial rectus muscle, respectively. The use of acorneal shield during the procedure is essential toprevent incidental injury to the cornea.Displacement of the bone grafts [10,21] or im-

plants [22] has been reported, especially whenrepairing a large bony defect through the trans-caruncular incision. To prevent displacement ofgrafts, one of the authors usually fixates the ma-terial used for repairing the medial wall defectwith microscrews [10]. Mun and colleagues [21]reported an alternative bone graft-shaping method,a combination of an inlay–onlay graft, which is

thinned at the edge and set on the edge of theintact medial wall in the onlay position, to mini-mize the risk of graft migration. Transient diplopiaand exophthalmos can be expected as in other or-bital reconstructive surgeries, with usual resolu-tion by 3 months. Residual enophthalmos causedby reherniation of the orbital contents has beenreported when using a temporary intranasal stent-ing procedure [24]. The authors advocate using apermanent implant placed either by means of thetranscaruncular or intranasal endoscopic-assistedapproach to decrease the likelihood of reherniationof orbital contents into the ethmoid cavity.

Summary

Fractures of the medial orbital wall are more com-mon than previously thought and pose uniquechallenges to the reconstructive surgeon. Theuse of endoscopes can facilitate visualization, re-duction, and placement of grafts to reconstructthis area. The authors advocate using either theendoscopic-assisted transcaruncular approach or anintranasal endoscopic-assisted approach combinedwith a periorbital incision to place a permanentgraft or implant to repair the medial orbital wall.Both techniques have been successful in treatingthis difficult fracture without the need for long-term intranasal stenting or external skin incisions.

References

[1] Burm JS, Chung CH, Oh SJ. Pure orbital blow-out fracture: new concepts and importance ofmedial orbital blowout fracture. Plast ReconstrSurg 1999;103:1839–49.

[2] Whitehouse RW, Batterbury M, Jackson A, et al.Prediction of enophthalmos by computed tomog-


raphy after blow out orbital fracture. Br J Oph-thalmol 1994;78:618–20.

[3] Rhee JS, Kilde J, Yoganadan N, et al. Orbitalblowout fractures: experimental evidence forthe pure hydraulic theory. Arch Facial Plast Surg2002;4:98–101.

[4] Rumelt MB, Ernest JT. Isolated blowout frac-ture of the medial orbital wall with medial rec-tus muscle entrapment. Am J Ophthalmol 1972;73:451–3.

[5] Leone Jr CR, Lloyd III WC, Rylander G. Surgicalrepair of medial wall fractures. Am J Ophthalmol1984;97:349–56.

[6] Chen CT, Chen YR, Tung TC, et al. Endoscopi-cally assisted reconstruction of orbital medial wallfractures. Plast Reconstr Surg 1999;103:714–20.

[7] Baumann A, Ewers R. Transcaruncular approachfor reconstruction of medial orbital wall frac-ture. Int J Oral Maxillofac Surg 2000;29:264–7.

[8] Oh JY, Rah SH, Kim YH. Transcaruncular ap-proach to blowout fractures of the medial orbitalwall. Korean J Ophthalmol 2003;17:50–4.

[9] Chen CT, Chen YR. Endoscopically assisted re-pair of orbital floor fractures. Plast Reconstr Surg2001;108:2011–8.

[10] Chen CT, Chen YR. Endoscopic orbital surgery.Atlas Oral Maxillofac Surg Clin North Am 2003;11:179–208.

[11] Lee HM, Han SK, Chae SW, et al. Endoscopicendonasal reconstruction of blowout fracturesof the medial orbital walls. Plast Reconstr Surg2002;109:872–6.

[12] Otori N, Haruna S, Moriyama H. Endoscopic en-donasal or transmaxillary repair of orbital floorfracture: a study of 88 patients treated in ourdepartment. Acta Otolaryngol 2003;123:718–23.

[13] Sanno T, Tahara S, Nomura T, et al. Endoscopicendonasal reduction for blowout fracture of themedial orbital wall. Plast Reconstr Surg 2003;112:1228–37 [discussion 1238].

[14] Rhee JS, Lynch J, Loehrl TA. Intranasal endoscopy-assisted repair of medial orbital wall fractures.Arch Facial Plast Surg 2000;2:269–73.

[15] Edwards WC, Ridley RW. Blowout fracture ofmedial orbital wall. Am J Ophthalmol 1968;65:248–9.

[16] Thering HR, Bogart JN. Blowout fracture ofthe medial orbital wall, with entrapment of themedial rectus muscle. Plast Reconstr Surg 1979;63:848–52.

[17] Merle H, Gerard M, Raynaud M. Isolated medialorbital blow-out fracture with medial rectusentrapment. Acta Ophthalmol Scand 1998;76:378–9.

[18] Naraghi M, Kashfi A. Endonasal endoscopictreatment of medial orbital wall fracture viarotational repositioning. Am J Otolaryngol 2002;23:312–5.

[19] al-Qurainy IA, Stassen LF, Dutton GN. The char-acteristics of midfacial fractures and the asso-ciation with ocular injury: a prospective study.Br J Oral Maxillofac Surg 1991;29:291–301.

[20] Lakits A, Prokesch R, Scholda C, et al. Helicaland conventional ct in the imaging of metallicforeign bodies in the orbit. Acta OphthalmolScand 2000;78:79–83.

[21] Mun GH, Song YH, Bang SI. Endoscopicallyassisted transconjunctival approach in orbitalmedial wall fractures. Ann Plast Surg 2002;49:337–43 [discussion 344].

[22] Kim S, Helen Lew M, Chung SH, et al. Repairof medial orbital wall fracture: transcaruncularapproach. Orbit 2005;24:1–9.

[23] Graham SM, Thomas RD, Carter KD, et al. Thetranscaruncular approach to the medial orbitalwall. Laryngoscope 2002;112:986–9.

[24] Jin HR, Shin SO, Choo MJ, et al. Endonasalendoscopic reduction of blowout fractures ofthe medial orbital wall. J Oral Maxillofac Surg2000;58:847–51.




25

Endoscopic Repair of AnteriorTable—Frontal Sinus FracturesE. Bradley Strong, MD

a,*, Robert M. Kellman, MDb

& Indications & Summary
& Technique& Discussion
a Department of Otolaryngology, University of CaliforSte 7200 Sacramento, CA 95817, USAb Department of Otolaryngology and Communication ScUniversity, 750 E. Adams St., Syracuse, NY 13210, USA* Corresponding author.E-mail address: [email protected] (E.B. S


& References

Frontal sinus fractures account for 5% to 15% ofall maxillofacial injuries [1]. The treatment algo-rithm for fractures involving the frontal recess orposterior table is complex because of the asso-ciated risks of brain injury, meningitis, cerebrospinalfluid fistula, and mucocele formation [2]. Mild-to-moderately displaced anterior table fractures, how-ever, carry a low risk of long-term morbidity andgenerally are treated as aesthetic deformities. Tradi-tional repair of isolated anterior table fracturesrequires a coronal incision, bony reduction, andrigid fixation. Surgical sequelae of this procedureinclude a large scar, alopecia, paresthesias, anduncommonly facial nerve injury. Consequently,some surgeons are starting to manage isolated ante-rior table fractures through an endoscopic approach.General requirements for endoscopic surgery

include: the ability to surgically obtain/maintainan optical cavity, insert a fiberoptic endoscope,sustain adequate hemostasis, and apply instrumen-tation [3]. At least two points of access generally arerequired. The advantages of endoscopic surgeryinclude more accurate visualization, minimal exter-nal incisions, visualization around corners, reducedsoft tissue dissection, reduced hospital stay, andimproved teaching. Disadvantages include a mod-erate learning curve, narrow field of view, poor

depth perception, current lack of dedicated instru-mentation, and the fact that the surgeon cannotoperate bimanually without an assistant.Endoscopic sinus surgery came to the United

States in the late 1970s and became the standardof care in the 1980s. The indications for endoscopichead and neck surgery continue to expand. Currentapplications include otology (middle ear endos-copy), skull base surgery (pituitary, cerebral spinalfluid leak, optic nerve decompression), ophthal-mology (dacrocystorhinostomy), facial plastic sur-gery (brow lift), neck surgery (thyroid, parathyroid,node biopsy), and facial trauma. Specific facialtrauma applications include subcondylar, orbital,and frontal sinus fractures. This article reviews theindications and technique for endoscopic repair ofanterior table frontal sinus fractures.

Indications

Not all isolated anterior table fractures are appro-priate for this technique. Injuries with severe com-minution and marked mucosal injury require openreduction or even frontal sinus obliteration. Frac-tures that extend over the orbital rim may be diffi-cult or impossible to visualize endoscopically andmay require an open approach. The ideal candi-

nia Davis School of Medicine, 2521 Stockton Blvd.

iences, State University of New York Upstate Medical

trong).


26 Strong & Kellman

dates for the endoscopic approach are reliablepatients who have isolated anterior table fractureslimited to the vertical face of the frontal bone.

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

Technique

Preoperative photographs and CT scans should beobtained to document the injury [Figs. 1, 2].Informed consented is obtained for the procedure,including the risks of bleeding, infection, paresthe-sia, alopecia, poor aesthetic result, and possibleneed for open approach if an endoscopic repaircannot be performed. The patient’s head is pre-pared and draped from the orbits to the vertex ofthe head. After injection of local anesthetic, a 3 to5 cm parasagittal working incision is placed abovethe fracture and 3 cm behind the hair line [Fig. 3].In patients with a prominent forehead or recedinghair line, the incision may need to be closer to thehairline to allow visualization around the intrinsiccurvature of the forehead. The incision length willvary depending on the size of the implant to be in-serted. Care should be taken to avoid trauma to thehair follicles, and cautery should be avoided if pos-sible. A second 1 to 2 cm endoscope incision thenis placed at the same height, but 4 to 6 cm medialto the working incision [see Fig. 3]. A blind sub-periosteal dissection is performed through theworking incision down to the level of the fracture.Care should be used to maintain the integrity of the

Fig. 1. Anterior table frontal sinus fracture.

periosteum, because periosteal tears will catch theendoscope when it is inserted. A 4.0 mm, 30° endo-scope (with rigid endosheath and camera) then isinserted through the smaller, medial incision, andthe optical cavity is visualized. Dissection over thefracture is performed under direct vision to thelevel of the orbital rims. Caution must be used toavoid injury to the supratrochlear and supraorbitalneurovascular pedicles. The elevation is generallyeasy, because the procedure is performed 3 monthsafter the injury, and there is a fibrous layer prevent-ing entry into the sinus.Once the entire fracture is exposed, an implant

is inserted to fill the defect. The authors have evalu-ated hydroxyapatite bone cement for this purposebut found it difficult to apply and manipulateendoscopically. A 0.85 mm thick Medpor (PorexSurgical - Newnan, Georgia) sheet is the preferredimplant. The implant is trimmed to approximatethe defect [Fig. 4]. The implant is inserted throughthe working incision and manipulated over thedefect. The superior edge of the implant is markedwith a pen to maintain the orientation endoscopi-

Fig. 3. Scalp incisions used for endoscopic repair offrontal sinus fractures.

Fig. 4. Intraoperative photograph of a 0.85 mm Med-por implant trimmed to camouflage the anterior tablefrontal sinus fracture.

Fig. 6. Intraoperative photograph of a layered Medporimplant. Two 0.85 mm thick Medpor implants weresutured together to fill dead space in the anteriortable defect.

27Frontal Sinus Fracture Repair

cally [Fig. 5]. At times, the author has sutured twoto three layers of Medpor together to fill the defectmore accurately [Fig. 6]. A 25 gauge needle then ispassed through the skin over the fracture site andendoscopically visualized to determine the best sitefor percutaneous screw placement [see Fig. 5]. Theideal site will allow placement of two screws atopposite edges of the implant. A #11 blade isused to make a 2 mm, through-and-through stabincision. A 1.7 mm self-drilling screw (length 4 to7 mm) is passed through the stab incision, throughthe edge of the implant, and into the frontal bone.If the implant is not completely stable, a secondscrew is placed on the contralateral side. The self-drilling screw must be placed at least 0.5 to 1.0 mmaway from the implant edge or the implant maytear. An alternative to the standard 0.85 mm Med-por sheeting is a prefabricated Medpor implant thatis generated from a CT scan and completely fillsthe volume of the defect. The major advantage is atight-fitting implant with little dead space. The dis-

Fig. 5. Endoscopic view of Medpor sheeting insertedover a frontal sinus fracture. Note the 25 gauge nee-dle being passed through the skin to localize thesite of percutaneous screw placement, and the mark-ing line on the superior aspect of the implant usedfor orientation.

advantage is that prefabricated implants cost ap-proximately $4000 and require 6 weeks for fab-rication, as opposed to standard sheets which cost$250 to $450. Both types of implant are palpablethrough the skin, but are not visible upon inspec-tion [Fig. 7]. After completion of the procedure,

Fig. 7. Postoperative photograph of endoscopicallyrepaired anterior table frontal sinus fracture seen inFig. 1.

28 Strong & Kellman

the scalp incisions are closed in layers, and ahead dressing is applied for 48 hours. No drainsare used.

Fig. 9. (A) Coronal CT scan of a patient with an ante-rior table frontal sinus fracture with enough displace-ment to be considered for traditional open repair inthe acute setting. (B) 4-month postinjury photographof the same patient without any visible cosmeticdeformity. The patient received no treatment forthe injury.

Discussion

Historically, almost all frontal sinus fractures weretreated aggressively because of the long term riskof mucocele formation. Although the success ratesfor open reduction and internal fixation are veryhigh, the procedure results in postsurgical stig-mata, including a large scar, paresthesias, possi-ble alopecia, and uncommonly facial nerve injury.Advances in endoscopic surgery and CT have pro-vided more effective options for diagnosis andtreatment of frontal sinus mucoceles. Conse-quently, more conservative endoscopic approachesare being investigated.Several authors have described an endoscopic ap-

proach to frontal sinus fractures, eliminating theneed for a coronal incision [4–6]. The endoscopicrepair can be divided into two types: acute fracturereduction with or without fixation, and fracturecamouflage. The fracture reduction technique in-volves exposure of the fracture in the acute setting,reduction of the bone fragments, and applicationof internal fixation as needed to maintain stability.This technique is covered elsewhere in this issue.The fracture camouflage technique involves anobservation period to allow resolution of facialedema, followed by recontouring of the defectwith an alloplastic implant.Strong and colleagues compared the fracture

reduction and camouflage techniques [3]. Theyfound that both approaches were feasible. Fracturereduction, however, was technically more challeng-ing, because it required mobilization and reduc-tion of small bone fragments that may be undergreat compressive forces [Fig. 8]. If the inter-fragmentary resistance is too great, the reduction

Fig. 8. External forces applied to the frontal bone

cannot be performed. If the interfragmentary resis-tance is too little, it may be difficult to maintainthe reduction, because the bone fragments are freefloating. The fracture camouflage technique wasfound to have several advantages:

• The exposure is easier, because the bone frag-ments are not mobile.

• The repair is technically less challenging, be-cause it does not require manipulation ofbone fragments.

• The repair need not be done in the acute setting.

Delayed repair can be important, because oncethe soft tissue edema resolves, there may be noesthetic deformity, and the patient may not requireany surgical intervention. This determination, how-ever, cannot be made until 3 to 4 months afterthe injury. Using the camouflage approach, onlythose patients with a true aesthetic deformity willrequire surgery [Fig. 9]. The main disadvantage of

during (A) fracture and (B) surgical repair.

29Frontal Sinus Fracture Repair

the camouflage technique is the need for an allo-plastic implant. The authors currently use the cam-ouflage technique with 0.85 mm thick Medporsheeting to treat isolated, moderate displacement(2 to 6 mm) fractures of the anterior table. Medporhas a long track record for maxillofacial reconstruc-tion. It is relatively cheap, easy to handle and insert,and well-tolerated. Additionally, it can be removedin one piece should it be necessary.

Summary

Endoscopic repair (ie, camouflage) of anterior tablefrontal sinus fractures is an efficacious techniquethat significantly reduces patient morbidity. It alsohas the added advantage of being a secondary pro-cedure. Therefore, only those patients with a trueaesthetic deformity require surgery. Surgeons con-sidering this technique should be very comfortablewith endoscopic equipment and techniques. Theskill set is very similar to that of an endoscopicbrow lift. Prefabricated implants can be used, but

standardized sheeting is equally effective and sig-nificantly cheaper.

References

[1] Strong EB, Sykes JM. Frontal sinus and nasoorbito-ethmoid complex fractures. In: Papel ID, editor.Facial plastic reconstructive surgery. 2nd edition.New York, NY. 2002. p. 747–58.

[2] McGraw-Wall B. Frontal sinus fractures. Facial PlastSurg 1998;14(1):59–66.

[3] Strong EB, Buchalter G, Moultrop T. Endoscopicrepair of isolated anterior table frontal sinus frac-tures. Arch Facial Plast Surg 2003;5(6):514–21.

[4] Forrest CR, et al. Application of endoscopic-assisted minimal-access techniques in orbito-zygomatic complex orbital floor and frontal sinusfractures. J Craniomaxillofac Trauma 1999;5(4):7–12.

[5] Graham III DH, Spring P. Endoscopic repair offrontal sinus fracture: case report. 1996. p. 52–5.

[6] Lappert P. Treatment of an isolated outer tablefrontal sinus fracture using endoscopic reductionand fixation. Plast Reconstr Surg 1999;102(5):1642–5.




31

Endoscopic Management of FrontalSinus FracturesKevin A. Shumrick, MD

& Endoscopic management of frontal sinus & References
fractures
Division of Facial Plastic Surgery, Department of OtolarWay, Cincinnati, OH 45267, USAE-mail address: [email protected]


Management of facial trauma always has been abalancing act between achieving accurate fracturereduction and stabilization, while causing as littlemorbidity as possible. Until roughly the 1930s,management of facial fractures consisted of exter-nal splints and bandages, which simply immo-bilized the fractures and allowed them to heal.Although external splints imparted little morbidity,the fractures rarely were reduced anatomically.Later, interfragment wires and suspension wireswere developed, somewhat improving reductionand stabilization. Wire placement and fracture re-duction, however, required multiple small keyholeincisions, and the reductions rarely were com-pletely accurate or rigidly stabilized. In the late1980s and early 1990s, the development of plateand screw fixation placed by means of extended-access approaches provided excellent fracturereduction and fixation but required long incisionsand extensive soft tissue elevation [1–16]. As sur-geons continued to refine their management offacial trauma, it was only natural that a less invasiveapproach to fractures would be found.Endoscopes have had a profound effect on nearly

every surgical specialty over the past 20 years. Usingendoscopic approaches, excellent visualization ofthe surgical site can be achieved while avoiding ex-

tensive external incisions, thus, dramatically reduc-ing morbidity compared with traditional surgicalapproaches. The specialties of orthopedics, gyne-cology, abdominal surgery, thoracic surgery, andparanasal sinus surgery have been enhanced bythe ability to perform accurate endoscopic surgerywhile virtually eliminating the long surgical scarsand pain of surgical approaches. To perform effec-tive endoscopic surgery, a cavity is required to keepsoft tissue from draping over the endoscope andobscuring visualization of the surgical site. The useof endoscopes for facial surgery has lagged behindthese other specialties primarily because of the lackof a readily usable optical cavity, but also difficultyworking around the curve of the skull. In the afore-mentioned surgical specialties, the optical cavitiesare either natural (as with sinus and thoracic sur-gery) or created by infusing gas (abdominal sur-gery) or saline (orthopedic surgery). Unfortunately,for most facial skeletal surgery, there is no readilyavailable cavity in which an endoscope can func-tion. To overcome this deficiency, special sheathshave been designed for the scopes with extensionsthat hold soft tissue away from the surgical site.Typically, a 30° scope is used in conjunction withthe sheath and extension. These tent the soft tissuesaway from the surgical site. This tenting of the soft

yngology, University of Cincinnati, 231 Albert Sabin


Fig. 1. Various endoscopic instruments.

Fig. 3. Endoscopic sheath.

32 Shumrick

tissue creates an optical cavity, allowing the sur-geon to look down on the surgical site using a 30°scope. [Figs. 1–4]. This article outlines the state ofthe art with regard to the use of endoscopes formanaging frontal sinus fractures, which are oneof the most common fractures treated with endo-scopic techniques.

Endoscopic management of frontal sinusfractures

Endoscopic forehead lifting has been accepted forthe past 10 years and has provided significant ex-perience with endoscopic management of the fron-tal region for aesthetic purposes [17–23]. With thisexperience has come well-developed exposures andinstrumentation. Using endoscopic techniques, sev-eral authors have reported case reports detailingsuccessful management of anterior wall fracturesof the frontal sinus [24–29]. These reports havedealt exclusively with eggshell fractures of the ante-rior wall that simply are popped back into positionand allowed to heal without fixation. Strong andcolleagues reported on a cadaver study looking atthe feasibility of performing endoscopic reductionand fixation. They found that the fractures couldbe visualized, but they encountered difficulty withcomplete reduction and were unable to perform rigidfixation in a noninvasive manner. As an alternative,Stronge and colleagues recommended camouflaging

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

the anterior wall depression by endoscopically apply-ing hydroxyapatite bone cement.At the University of Cincinnati, the author and

colleagues have attempted endoscopic reduction offrontal sinus fractures on 19 patients and have beensuccessful in 12 of them. Success is defined as areduction sufficiently anatomic and stable that nofurther treatment was felt to be necessary (by thephysician or patient) The author’s technique issimilar to endoscopic forehead lifting, with onecentral and two lateral hairline incisions [Figs. 4and 5]. It is preferred to work through separateports for the endoscope and instruments to avoidcrowding of the instruments and scope at the ante-rior portion of the incision. The forehead soft tis-sues are elevated subperiosteally, and the fracturesare visualized by means of a 30° endoscope withan external sheath for soft tissue retraction [Figs. 6and 7]. Once the fracture site is visualized, oneattempts to elevate the fragments with endoscopicelevators. The author, however, has found that it isusually necessary to approach the fragmentsdirectly through small forehead incisions (prefera-bly hidden in the brow). Using small externalincisions directly over the fractures allows the sur-geon to apply anterior force for anatomic reduc-tion of the fracture segments. This approach hasbeen more successful than trying to work withinthe forehead skin envelope, which requires moreof a prying motion to elevate the fractures; this tipsthe fragments. The fractures are elevated using per-cutaneous nerve hooks, or by drilling into thefragments and grabbing them with threaded Stein-

Fig. 4. Endoscope inside endoscopic sheath.

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

33Frontal Sinus Fractures

mann pins [see Figs. 5–7]. With gentle retraction,the fragments often elevate into a reduced posi-tion and are frequently stable without the need forrigid fixation. Given the fact that the fracture seg-ments are not approached directly, it is commonto have residual surface irregularities. These irregu-larities are considered a trade off for avoiding long,approach incisions, and they are camouflaged withpatches of Vicril Mesh (Ethicon, Inc., Somerville,New Jersey) [Fig. 7].

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

In the four patients whose endoscopic fracturerepair was felt to be unsuccessful, the reason wasthat the fracture segments were unstable after en-doscopic reduction. The fragments continued to col-lapse despite having been reduced. In retrospect,these unsuccessful reductions were more exten-sively comminuted then was appreciated on theinitial review of the coronal and axial CT scans.This highlights the importance of careful patientselection and the need for fully informing patientsthat the endoscopic approach may not reduce theirfractures fully. Cases with unstable anterior wallsafter endoscopic reduction were converted to anopen approach with coronal incisions and rigidfixation in the standard fashion [Fig. 8]. Based onthis experience, the author feels that the endo-scopic technique is appropriate only for anteriorwall frontal sinus fractures that have several largesegments without extensive comminution. It goeswithout saying that more extensive fractures withinvolvement of the nasofrontal ducts or posteriorwall should have open approaches . Additionally,the surgeon should be prepared to camouflage anyresidual irregularities with the material of choice.As mentioned, the author prefers Vicril mesh, butalternatives would include bone cement, Gore-Tex,Alloderm, or Surgicell.

Fig. 7. (A) Frontal sinus anterior wall fracture. This is a good candidate for endoscopic reduction, because it is notcomminuted. (B) Incisions planned. (C ) Threaded Steinman pin used to reduce fracture fragments while theendoscope is used to monitor the reduction. (D) Endoscopic view of Vicryl mesh placement for camouflage ofresidual 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.

34 Shumrick

35Frontal Sinus Fractures

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 im-mediate extended open reduction and bone graft-ing. Plast Reconstr Surg 1985;76:1–10.

[3] Manson PN, et al. Toward CT based facial fracturetreatment. Plast Reconstr Surg 1990;85:202–12.

[4] Barone CM, Gigantelli JW. Endoscopic repair ofposttraumatic enophthalmos using medial trans-conjunctival approach: a case report. J Cranio-maxillofac Trauma 1998;4(1):22–6.

[5] Barone CM, Boschert MT, Jimenez DF. Useful-ness of endoscopy in craniofacial trauma.J Craniomaxillofac Trauma 1998;4(3):36–41.

[6] Bell RB, et al. Management of cerebrospinal fluidleak associated with craniomaxillofacial trauma.J Oral Maxillofac Surg 2004;62(6):676–84.

[7] Chen CT, et al. Endoscopically assisted mandibu-lar subcondylar fracture repair. Plast ReconstrSurg 1999;103(1):60–5.

[8] Czerwinski M, Lee C. Traumatic arch injury:indications and an endoscopic method of repair.Facial Plast Surg 2004;20(3):231–8.

[9] Honda T, et al. Endoscope-assisted facial fracturerepair. World J Surg 2001;25(8):1075–83.

[10] Krimmel M, Cornelius CP, Reinert S. Endoscopi-cally assisted zygomatic fracture reduction andosteosynthesis revisited. Int J Oral MaxillofacSurg 2002;31(5):485–8.

[11] Lee CH, Lee C, Trabulsy PP. Endoscopic-assistedrepair of a malar fracture. Ann Plast Surg 1996;37(2):178–83.

[12] Lee C, Jacobovicz J, Mueller RV. Endoscopicrepair of a complex midfacial fracture. J Cranio-fac Surg 1997;8(3):170–5.

[13] Lee CH, et al. A cadaveric and clinical evaluationof endoscopically assisted zygomatic fracture re-pair. Plast Reconstr Surg 1998;101(2):333–45[discussion 346–7].

[14] Rhee JS, Lynch J, Loehrl TA. Intranasal endoscopy-assisted repair of medial orbital wall fractures.Arch Facial Plast Surg 2000;2(4):269–73.

[15] Schon R, Gellrich NC, Schmelzeisen R. Fron-tiers in maxillofacial endoscopic surgery. AtlasOral Maxillofac Surg Clin North Am 2003;11(2):209–38.

[16] Schon R, Schmelzeisen R. Endoscopic fracturetreatment. Ann R Australas Coll Dent Surg 2002;16:40–5.

[17] Aly A, Avila E, Cram AE. Endoscopic plastic sur-gery. Surg Clin North Am 2000;80(5):1373–82.

[18] Chajchir A. Endoscopic subperiosteal foreheadlift. Aesthetic Plast Surg 1994;18(3):269–74.

[19] Daniel RK, Tirkanits B. Endoscopic forehead lift.Aesthetics and analysis. Clin Plast Surg 1995;22(4):605–18.

[20] Daniel RK, Tirkanits B. Endoscopic forehead lift:an operative technique. Plast Reconstr Surg 1996;98(7):1148–57 [discussion 1158].

[21] Dayan SH, et al. The forehead lift: endoscopicversus coronal approaches. Aesthetic Plast Surg2001;25(1):35–9.

[22] Marchac D, Goni S. Endoscopic forehead lift.Acta Chir Belg 2001;101(5):210–7.

[23] Ramirez OM. Endoscopic full facelift. AestheticPlast Surg 1994;18(4):363–71.

[24] Chen DJ, et al. Endoscopically assisted repairof frontal sinus fracture. J Trauma 2003;55(2):378–82.

[25] Graham III HD, Spring P. Endoscopic repair offrontal sinus fracture: case report. J Craniomax-illofac Trauma 1996;2(4):52–5.

[26] Lappert PW, Lee JW. Treatment of an isolatedouter table frontal sinus fracture using endo-scopic reduction and fixation. Plast Reconstr Surg1998;102(5):1642–5.

[27] Rice DH. Management of frontal sinus fractures.Curr Opin Otolaryngol Head Neck Surg 2004;12(1):46–8.

[28] Shumrick KA, Ryzenman JM. Endoscopic man-agement of facial fractures. Facial Plast Surg ClinNorth Am 2001;9(3):469–74.

[29] Strong EB, Buchalter GM, Moulthrop TH. Endo-scopic repair of isolated anterior table frontalsinus fractures. Arch Facial Plast Surg 2003;5(6):514–21.




37

The Rationale and Technique ofEndoscopic Approach to theZygomatic Arch in Facial TraumaMarcin Czerwinski, MD

a, Chen Lee, MD, FRCSCb,*

& The role of arch anatomy and use of Exposure
endoscopy to minimize treatment pitfalls
& Arch injury patterns& Endoscopic indications and rationale for

repairs& Repair sequencing

Le Fort IIIComplex zygoma

& Surgical techniqueEquipment

a Montreal Children,s Hospital, C1139 2300 Tupper Streeb Sacre-Coeur Hospital, 5400 boul. Gouin West, Montrea* Corresponding author.E-mail address: [email protected] (C. Lee).


ReductionFixation

& Case presentationsLe Fort IIIComplex zygoma

& Discussion& References

Endoscopy was introduced to the field of facialplastic surgery relatively late by Vasconez and col-leagues [1], who were the first to perform an endo-scopic brow lift in 1994. This initial delay in theassimilation of the endoscope in the head and neckregion likely was caused by the absence of naturallyoccurring body cavities, such as the abdomen or ajoint space, which greatly facilitate its applicationin general and orthopedic surgeries. In addition,initial endoscopic instruments lacked specificity tothe facial region.Despite this late introduction, the use of endos-

copy rapidly progressed as the advantages of mini-mal access were realized. Sakai and colleagues [2]extended endoscopic applications to the man-agement of craniofacial disorders, performing aLe Fort I level osteotomy. Lee and colleagues [3,4]and Kobayashi and colleagues [5] pioneered the

use of endoscopy in the area of the zygomaticarch. Since their original descriptions, several modi-fications to their techniques have been proposed.These vary in placement of incisions, planes ofdissection and methods of fixation [6,7]. The endo-scope currently is considered by many to have anintegral 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 indica-tions, and future directions.

The role of arch anatomy and use ofendoscopy to minimize treatment pitfalls

The zygomatic arch is a narrow skeletal elementspanning from the temporal bone to the zygomabody. In the axial plane, the arch is curved in the

t, Montreal, Quebec, Canada, H3H 1P3l, Quebec, Canada, H4J 1C5 PH


Fig. 1. Medial arch displacement occurs following di-rect lateral force. (From Czerwinski M, Lee C. Trau-matic arch injury: indications and an endoscopicmethod of repair. Facial Plast Surg 2004;20(3):231–8,with permission.)

Fig. 2. Posterior telescoping fracture of the arch re-sults when energy applied anteriorly to the malarprominence is transmitted to the arch segment.(From Czerwinski M, Lee C. Traumatic arch injury: indi-cations and an endoscopic method of repair. FacialPlast Surg 2004;20(3):231–8, with permission.)

38 Czerwinski & Lee

posterior third of its course and straight in theanterior two thirds. In the sagittal plane, it is par-allel to the Frankfort horizontal. The arch alsooccupies a strategic position, joining the midface,which frequently is displaced in facial trauma, tothe stable skull base. Numerous authors have takenadvantage of these properties, using the arch’s bonyattachments and consistent shape as a guide toanatomically repairing it and the midface withoutthe necessity of exposing the contralateral, un-injured 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 toprecise fracture realignment, to accurately restoremidfacial projection and transverse width. Second,it can serve as an anchor point of the midfacebecause of its sturdy skull base attachment. Last,its anatomic reduction is paramount to aestheticappearance in individuals with prominent pre-injury lateral facial contour.Despite its key role, the advantages of arch repair

have not been used sufficiently, as access to it isfraught with difficulties. Incisions cannot be placeddirectly over the arch because of high risk of facialnerve injury. The facial nerve pierces the superficialmusculoaponeurotic system at its lower border andcourses superficially to the temporoparietal fasciain an anterosuperior direction [10]. Instead, thecoronal approach designed to avoid injury to thefacial nerve traditionally has been used. The latterhas its own drawbacks, however, including alope-cia, anesthesia posterior to the incision, risks oftraction injury to the frontal branch of the facialnerve and temporal hollowing, and excessive bloodloss [4]. Consequently, the principle of anatomic

reduction and rigid internal fixation, standard inother facial trauma repair, has been applied in-frequently to the zygomatic arch.The use of endoscopy allows the surgeon to fully

benefit from the role of arch repair while minimiz-ing the negative sequelae of traditional access. Thistechnique also offers other advantages, includingmagnified direct visualization, and in the long-term, a potential for increased quickness [11] andcost-effectiveness.

Arch injury patterns

Fractures of the zygomatic arch can occur in iso-lation or with midfacial injuries. The individualpattern depends mainly on the magnitude anddirection of the trauma force vector applied to thecraniofacial skeleton.Isolated arch fractures can be of three types. First,

direct lateral force displaces the arch medially[Fig. 1]. Second, an anterior force vector focusedon the malar prominence usually will cause a pos-terior telescoping pattern of injury [Fig. 2]. Attimes, however, a posteriorly directed force canresult in an explosive burst with displacement ofthe arch fragments laterally [Fig. 3]. Recognition ofthe latter two injury patterns is important, as anonvisualized reduction attempt, using an elevatorinserted under the arch, will be unsuccessful andexacerbate fracture displacement.A displaced zygoma fracture results from dis-

ruption of all its bony attachments, of which thezygomatic arch is a necessary component. Mostfrequently, it arises because of a force applieddirectly to the malar prominence with dissipation

Fig. 3. (A) Zygomatic arch fragmentation with lateral displacement of the segments occurs when a high energyforce is applied anteriorly at the zygoma and dissipates posteriorly at the arch. (B) Successful anatomic reposi-tioning of the lateralized arch fragments. (From Czerwinski M, Lee C. Traumatic arch injury: indications and anendoscopic method of repair. Facial Plast Surg 2004;20(3):231–8, with permission.)

39Zygomatic Arch in Facial Trauma

of much of the energy at the anterior, zygomatico-maxillary, and infraorbital buttresses. Only higherenergy mechanisms will have a sufficient portionof the force transmitted posteriorly to cause archdisruption. The magnitude of energy determinesthe degrees of displacement and comminution[12]. A displaced zygoma fracture results in malarprominence depression and may cause enophthal-mos because of orbital enlargement.A Le Fort III-level fracture is defined in part by

separation of the maxilla from the cranial base atthe zygomatic arch. It occurs in high-energy injuriesin which the force vector fractures across the alveo-lus and the pterygoid plates, resulting in a mobilemaxilla and its attached dentition. Disruption ofthe stable arch attachment causes occlusal instabil-ity in addition to midfacial flattening, widening,and asymmetry.

Endoscopic indications and rationale forrepairs

In the authors’ experience, endoscopic approach tothe arch should be considered in all cases whereprecise arch repair is deemed an integral part ofthe treatment plan. Thus, when the zygomatic archis thought to contribute to proper reduction or en-hanced stability of other facial fractures, or whenthe arch itself is considered an important aestheticlandmark, the surgeon should attempt endoscopicreduction and fixation. This approach allows effec-tive fracture management while minimizing thestigmata of extensive incisions.In Le Fort III-level injuries, the principal benefit

of rigid arch fixation is to stabilize the mobile max-illa and its attached dentition to the skull base.This ensures a secure maxillomandibular occlu-

sal relationship. The arch is a particularly valuablepoint, as the other anterior buttresses frequentlyare comminuted. The secondary role of the archin Le Fort III fractures is to enhance accurate mid-face realignment.In displaced zygoma fractures, arch reduction is

a valuable tool for anatomic repositioning of themalar prominence to recreate preinjury facial widthand projection. It may, in addition, restore ade-quate orbital volume. This is paramount in com-plex zygoma fractures when there is extensivecomminution of at least two of the anterior threezygoma buttresses. In these injuries, the arch alsoserves as an additional point of rigid fixation.In isolated arch fractures, repair is particularly

important in individuals with prominent preinjurylateral facial contour. Failure of realignment willlead to an unsightly temporal depression and asym-metry. In addition, miniplate placement will pre-vent subsequent arch redisplacement caused byreinjury or pull by the masseter muscle, an issuenot addressed by the Gillie’s approach.

Repair sequencing

In the authors’ experience, when the complexity offacial trauma necessitates incorporation of arch re-pair into a comprehensive management plan, thefollowing sequences are most effective.

Le Fort III

The authors approach the repair of these fracturesby individually treating the cranio–orbital and max-illomandibular units, subsequently uniting themat the Le Fort I level. The cranio–orbital unit isaddressed by first reducing and fixating the exter-nal orbital frame at the infraorbital and zygo-

40 Czerwinski & Lee

maticofrontal interfaces. The arch then is repairedto provide appropriate projection and width tothe midface. Premorbid occlusion is restored usingmaxillomandibular fixation. Next, the two func-tional units are joined using miniplates at thezygomaticomaxillary and nasomaxillary buttresses.

Complex zygoma

Complex zygoma fracture may require repair ofall the anterior buttresses, including: zygomatico-frontal, infraorbital and zygomaticomaxillary, alongwith the zygomatic arch. Repair is accomplishedmost expediently by first restoring the external or-bital frame, then reducing and fixating the zygo-matic arch. The zygomaticomaxillary buttress isaddressed last.

Surgical technique

Equipment

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

Fig. 4. (A) Endoscopic repair of the arch is performed usThe retractor-mounted endoscope is inserted, and directlyto the deep temporal fascia down to the zygomatic arch.arch segments. (C ) Following repair, arch fragments areLee C. Traumatic arch injury: indications and an endoscopiwith permission.)

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

Exposure

A scalp extension of the preauricular incision iscarried through the skin and the temporoparietalfascia to expose the deep temporal fascia. A peri-osteal elevator then is inserted, and an optical cav-ity is created by dissecting superficial to the deeptemporal fascia. This nonvisualized part of the dis-section is performed only superior to an imaginaryline extending from the helical crus to the superiororbital rim. This minimizes the risk of injury to thefrontal branch of the facial nerve. Following dis-section of the optical cavity, a retractor-mountedendoscope is inserted, and directly visualized dis-section in the same plane is performed down tothe zygomatic arch. Maintenance of integrity of thedeep temporal fascia helps to avoid unsightly tem-poral hollowing. Once the arch is reached, its peri-osteum is incised, and the sites of fracture areexposed in the subperiosteal plane [Fig. 4].

ing a small incision hidden in the temporal hairline.visualized dissection is performed in a plane superficial(B) Endoscopic view demonstrates medially displacedseen in their anatomic position. (From Czerwinski M,c method of repair. Facial Plast Surg 2004;20(3):231–8,


Reduction

Following exposure, arch fragments are reduced ac-cording to the fragmentation pattern to restore pre-injury arch form. This is preferably done in situ. Ifexcessive comminution prevents stability and doesnot allow in situ reduction, the fragments can be re-moved 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 dependson the type of fracture. A short miniplate is usedin isolated arch injuries, whereas a long mini-adaptation plate is preferred in associated midfacialtrauma. The long mini-adaptation plate extendsonto the lateral orbital rim, restoring and rigidlystabilizing the midface. Following fixation of theplate to an arch segment, either in situ or on a sidetable, accurate reduction is confirmed, and theplate is stabilized to other fracture segments usingthe endoscope [see Fig. 4].

Case presentations

Le Fort III

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

Fig. 5. (A) Preoperative photograph of a patient who sustaiMidfacial flattening and malocclusion are evident. (B) Phorepair. (From Czerwinski M, Lee C. Traumatic arch injury: iPlast Surg 2004;20(3):231–8, with permission.)

revealed left Le Fort III and right Le Fort II facialfractures. In the operating room, premorbid occlu-sion initially was restored using maxillomandibularfixation. Access for repairs was achieved using pre-auricular (endoscopic arch fixation), lateral exten-sion of upper blepharoplasty (zygomaticofrontalbuttress), and upper buccal sulcus incisions (infe-rior orbital rim and zygomaticomaxillary buttress).The arch component of the Le Fort III fracturewas plated rigidly as a free graft ex vivo and thenrepositioned accurately to help stabilize and reducethe midfacial injury [Figs. 5, 6].

Complex zygoma

A male involved in a motor vehicle collision wasbrought to the hospital. During the trauma, theleft side of his face struck the steering wheel. Hecomplained of left cheek flatness and pain, andanesthesia in the left infraorbital nerve distribu-tion. In addition, he sustained a left lateral orbitallaceration. CT imaging demonstrated a left zygomafracture with lateral displacement of the commi-nuted arch. Access for fracture repair was bymeans of preauricular (endoscopic arch fixation),lateral orbital laceration (zygomaticofrontal but-tress), and upper buccal sulcus incisions (inferiororbital rim and zygomaticomaxillary buttress). Thesignificantly comminuted arch component wasplated ex vivo and then repositioned anatomicallyas the arch element of four-point zygoma fracturereduction and fixation [Figs. 3, 7].

ned a left Le Fort III and right Le Fort II facial fractures.tograph several months following endoscope-assistedndications and an endoscopic method of repair. Facial

Fig. 7. (A) Preoperative photograph of a patient with a complex zygoma fracture. Severe decrease in malarprominence projection and increased facial width can be appreciated. (B) Photograph several months follow-ing surgery shows restoration of normal facial topography. The arch component of four-point zygoma fracturerepair 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):231–8, with permission.)

Fig. 6. (A) Coronal and axial CT images demonstrating left Le Fort III and right Le Fort II level injuries with severeleft zygomatic arch comminution. (B) Following endoscope-assisted repair, anatomic realignment of midfacialanatomy 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):231–8, with permission.)

42 Czerwinski & Lee


Discussion

The reliable form and strategic position of the zygo-matic arch make it a valuable landmark in mid-facial trauma management [8,9]. In isolated archfractures, its repair restores lateral contour of theface and prevents subsequent displacement causedby reinjury or pull by the masseter muscle. In com-plex fractures of the zygoma, restoration of archanatomy is an essential guide to recreating pre-injury malar prominence projection and trans-verse facial width. In Le Fort III-level fractures,rigid arch repair is the most stable point of fixationthat anchors the mobile maxillary dentition tothe skull base. The relative importance of arch re-pair increases as the complexity of trauma rises,being most important in Le Fort III injuries andleast so in isolated fractures.Open zygomatic arch repair has been used in-

frequently, mainly because traditional access tothis structure is fraught with undesirable sequelae,namely: alopecia, loss, of scalp sensation posteriorto the incision, excessive blood loss, temporal hol-lowing and potential injury to the frontal branchof the facial nerve [4]. Thus for many years, thestandard of anatomic reduction and rigid internalfixation used in facial trauma management did notapply to the arch. The authors believe the endo-scopic approach allows the surgeon to fully appreci-ate the role of zygomatic arch in facial fracturemanagement without having to suffer the conse-quences of coronal access. The endoscope-assistedapproach necessitates only small, well-concealedincisions and allows in situ reduction and fixa-tion under direct, magnified visualization. The au-thors encourage the use of the endoscope-assistedzygomatic arch repair in Le Fort III, complex zy-goma, and isolated arch fractures, all of which pre-viously had been considered to be indications fora coronal incision.The endoscopic method of zygomatic arch repair

does have some disadvantages. It requires the ac-quisition of a different set of surgical skills. Thistechnical challenge arises, because the separationin the usual hand-eye coordination results in theloss of tactile perception. In addition, perceptionof depth is lost as the three-dimensional image isreformatted on a flat screen. Furthermore, there isan associated steep learning curve resulting in ini-tially long operative times. Finally, purchase of re-quired surgical instruments and electronic devicesrepresents a significant initial expense.

Being aware of its difficulties, the authors believeendoscope-assisted zygomatic arch repair repre-sents a significant advance in midfacial traumamanagement. In the future, implementation of spe-cialized training programs into surgical programcurricula and further improvements in endoscopicinstruments will promote this technique further.

References

[1] Vasconez LO, Core GB, Gamboa-Bobadilla M,et al. Endoscopic techniques in coronal browlifting. Plast Reconstr Surg 1994;94:788–93.

[2] Sakai Y, Kobayashi S, Ohmori K. An endoscopicLe Fort I osteotomy: clinical results. Jpn J PlastReconstr Surg 1995;38:875.

[3] Lee C, Jacobovicz J, Mueller RV. Endoscopicrepair of a complex midfacial fracture. J Cranio-fac Surg 1997;8:170–5.

[4] Lee CH, Lee C, Trabulsy PP, et al. A cadavericand clinical evaluation of endoscopically assistedzygomatic fracture repair. Plast Reconstr Surg1998;101:333–45.

[5] Kobayashi S, Sakai Y, Yamada A, et al. Approach-ing the zygoma with an endoscope. J CraniofacSurg 1995;6:519–24.

[6] Lee SS, Lin SD, Chiu YT, et al. Deep dissec-tion plane for endoscopic-assisted comminutedmalar fracture repair. Ann Plast Surg 2002;49:452–9.

[7] Lee JS, Kang S, Kim YW. Endoscopically assistedmalarplasty: one incision and two dissectionplanes. Plast Reconstr Surg 2003;111:461–7.

[8] Stanley Jr RB. The zygomatic arch as a guide toreconstruction of comminuted malar fractures.Arch Otolaryngol Head Neck Surg 1989;115:1459–62.

[9] Gruss JS, Van Wyck L, Phillips JH, et al. The im-portance of the zygomatic arch in complexmidfacial fracture repair and correction of post-traumatic orbitozygomatic deformities. PlastReconstr Surg 1990;85:878–90.

[10] Ellis EI, Zide MF. Surgical approaches to thefacial skeleton. Williams and Wilkins; 1995.

[11] Lee C, Stiebel M, Young DM. Cranial nerve VIIregion of the traumatized facial skeleton: opti-mizing fracture repair with the endoscope.J Trauma 2000;48:423–30.

[12] Manson PN, Markowitz B, Mirvis S, et al. To-ward CT-based facial fracture treatment. PlastReconstr Surg 1990;85:202–12.

[13] Krimmel M, Cornelius CP, Reinert S. Endo-scopically assisted zygomatic fracture reductionand osteosynthesis revisited. Int J Oral MaxillofacSurg 2002;31:485–8.




45

Endoscopic Approach forMandibular Orthognathic SurgeryMaria J. Troulis, DDS, MSc*, Jose L. Ramirez, DMD, MD,Leonard B. Kaban, DMD, MD

& Overview of endoscopic procedures & References
Endoscopic vertical ramus osteotomyCondylectomyMandibular retrognathism
Massachusetts General Hospital, Warren Building, Suite* Corresponding author.E-mail address: [email protected] (M.J. Troulis).


The field of minimally invasive surgery (MIS)is defined as the combination of surgical innova-tion with modern technology [1]. It is the disci-pline of surgery that aims to minimize morbidityand complications usually associated with tradi-tional procedures. MIS focuses on reducing tis-sue trauma and the resultant bleeding, edema,and injury to maximize the rate and quality ofhealing. This results in a faster recovery for thepatient [2].Until the mid 1800s, infection and the inability

to effectively control hemorrhage, shock, and pain,limited the practice of surgery to the treatmentof life-threatening conditions [3]. The use of asep-tic technique, the discovery and widespread useof anesthesia, and improvements in perioperativepatient management created an environment inwhich the art and science of surgery could flourish.The introduction of antibiotics after World War IIallowed surgeons to carry out a greater variety ofelective procedures to improve quality of life. Dur-ing the last decade, craniomaxillofacial surgeonshave begun to develop endoscopic techniques totreat soft tissue and skeletal defects [4] with de-creased morbidity.The first orthognathic surgical procedure was

reported by Simon Hullihen in 1849, in the Ameri-can Journal of Dental Science. The procedure de-

scribed was a mandibular body ostectomy for cor-recting retrognathism and an anterior open bite re-sulting from a burn scar contracture of the neck.Hullihen realized that the constricting scar had tobe released to facilitate the corrective jaw move-ment and to improve the long-term stability ofthe procedure. A collaborative effort between theorthodontist Edward Angle and the surgeon V. P.Blair led to the development of the St. Louis pro-cedure. This technique involved bilateral ramusosteotomies for treating mandibular prognathism[5]. Schuchardt, in the German literature, was thefirst to describe a mandibular osteotomy resem-bling the current sagittal split. This approach tomandibular surgery first was discussed in the En-glish literature by Trauner and Obwegeser in 1955.The technique proved to be quite versatile. It wasused to treat various deformities including progna-thism, retrognathism, asymmetries, and open bite.Another significant advantage of the sagittal splitosteotomy was that a bone graft was not neededin cases where advancement of the mandible wasrequired. The bilateral split osteotomy (BSSO) hasbeen modified and improved over the years [6,7] tominimize morbidity and improve stability. The pro-cedure, however, continues to be associated withsignificant swelling and potential injury to the in-ferior alveolar nerve.

1201, Boston MA 02114, USA


46 Troulis et al

Minimizing morbidity associated with mandibu-lar surgery continues to be a central issue in cranio-maxillofacial surgery. The development of rigidinternal fixation has improved short- and long-term skeletal stability and has eliminated the needfor prolonged periods of maxillomandibular fixa-tion. Controlled hypotensive anesthesia has de-creased blood loss, thus minimizing the risk oftransfusion [8,9]. Administration of perioperativecorticosteroids has contributed to a decrease inperioperative edema and discomfort [10]. The com-bination of improvements in all of these areas hasdecreased the length of stay associated with man-dibular orthognathic surgery [11]. Recent advancesin imaging, instrumentation, and fiberoptic tech-nology have allowed surgeons to develop andrefine minimally invasive access for orthognathicsurgical procedures. These techniques eventuallymay replace traditional open procedures and fur-ther decrease morbidity. The endoscopic approachto the mandibular ramus/condyle unit (RCU) is aminimally invasive access technique. It is used toperform osteotomies and reconstructive proceduressuch as vertical ramus osteotomies with rigid fixa-tion, condylectomy and costochondral grafts, andplacement of miniature distraction devices. A com-bination of endoscopic access, rigid fixation, andin cases requiring skeletal expansion, distractionosteogenesis, will decrease the morbidity associatedwith orthognathic and reconstructive procedures.In the future, these procedures may be performedpredominantly in an outpatient setting. Ultimately,this will have profound impacts on cost, availabil-ity, morbidity, and patient acceptance.

Overview of endoscopic procedures

The benefits of endoscopy include small and re-motely placed incisions, inconspicuous scars, anddirect visualization of a magnified and illuminatedoperative field for the surgeon. Tissue dissectionand manipulation are minimized, resulting in lesspain, edema, and overall morbidity [2,7,12]. Lengthof hospital stay is shortened, and there is a quickerreturn to normal activity [2,4,12,19–21].Endoscopic access can be used for orthognathic

surgical correction of three types of mandibulardeformities. In cases of mandibular prognathismor asymmetry, the endoscopic vertical ramus osteo-tomy is a minimally invasive alternative to thetraditional vertical ramus osteotomy or sagittalsplit osteotomy. It also can be used for congenitalor acquired temporomandibular joint conditionsrequiring either condylectomy and costochondralgrafting or RCU construction. In cases of mandibu-lar retrognathia, the endoscopic approach, whencombined with a miniature distraction device, will

be the minimally invasive alternative to the sagittalsplit osteotomy.

Endoscopic vertical ramus osteotomy

BackgroundFor patients with mandibular prognathism (withor without asymmetry), the standard treatmentoptions are the intraoral vertical ramus osteotomy(IVRO) or BSSO. IVRO offers the advantage of alower incidence of inferior alveolar neurosensory dis-turbance when compared with BSSO. The osteotomy,however, generally is performed with poor visibil-ity. It is not possible to use rigid fixation; therefore,the jaw must be immobilized by maxillomandibu-lar fixation. The complication of condylar sag mayresult in postoperative open bite in a small percent-age of patients.The BSSO is a more complicated osteotomy than

the IVRO and requires more soft tissue dissection(medial and lateral ramus). The distinct advantageof the BSSO is that it can be used with rigid inter-nal fixation. There is, however, a significant risk ofinferior alveolar nerve (IAN) damage [13,14].The endoscopic vertical ramus osteotomy (EVRO)

is a minimally invasive alternative to the IVRO andBSSO. It can be accomplished with minimal risk tothe IAN, and it allows the use of rigid internalfixation. The EVRO is indicated for those patientswith mandibular prognathism or asymmetry whorefuse maxillomandibular fixation and who are notwilling to accept the risks of inferior alveolar nerveinjury. This procedure also allows for mandibularsetback without the need for extraction of well-developed mandibular third molars, which areassociated intimately with the IAN [12] [Fig 1].The surgical technique for the EVRO begins with

careful marking of the zygoma, temporomandibu-lar joint, ramus, angle, anterior border, and con-dyle on the skin. Then, a 1.5 cm incision is madeone finger-breadth below the inferior border of themandible, parallel to existing neck creases. Thedissection 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 eleva-tors with a suction port. This dissection creates anoptical cavity that allows for excellent visualizationof the operative field. A 30° endoscope is placed intothe wound and oriented parallel to the posteriorborder. This dissection provides direct access to theentire RCU [4,12].With the endoscope the next step is to identify

the anatomic landmarks of the RCU: posterior bor-der, sigmoid notch, coronoid process, anterior bor-der, and posterior mandibular body. An osteotomyis created, under direct endoscopic visualization,

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

47Minimally Invasive Surgery

from the sigmoid notch to the mandibular angleusing a long-shaft reciprocating blade. The medialpterygoid muscle is stripped partially to allow foroverlap of the proximal and distal segments. Thepatient is placed into maxillomandibular fixation inthe preplanned occlusion. Rigid fixation is achievedwith three 12 to 14 mm long, 2.0 mm diameterscrews. The screw holes are drilled and the screwsplaced through the incision or with the aid of apercutaneous trocar. If there is minimal overlapof the proximal and distal segments, plate fixationmay be used as an alternative [12]. Troulis andKaban reported a retrospective study of 14 patientstreated with EVRO [12]. The mean operating timewas 37 minutes per side. A single patient sufferedtransient weakness of the marginal mandibularnerve, and this lasted less than 1 week. No patientsrequired maxillomandibular fixation. One patientwith concurrent medical problems had a hospitalstay of 2 days. All other patients were dischargedwithin 23 hours. The stability of bone positioningwas documented at a mean of 1.7 years postopera-tively with lateral cephalograms.

Condylectomy

Idiopathic condylar resorptionFor those patients with mandibular retrognathismand open bite secondary to idiopathic condylar re-sorption or degenerative joint disease, endoscopiccondylectomy and costochondral graft reconstruc-tion are minimally invasive alternatives to the stan-dard open-access approaches. The standard techniquefor condylectomy and costochondral graft RCU rec-onstruction involves preauricular and submandibu-lar incisions [15,16] with potential risk for facial

nerve paresis. The standard open approach also isassociated with considerable bleeding and edema. Al-ternatively, condylectomy and RCU reconstructioncan be achieved through the same 1.5 cm incisionand dissection used for the EVRO. This approachresults in a single, small and well-concealed facialscar. It also significantly decreases the risk to the fa-cial nerve and the amount of bleeding and swelling.The incision, dissection, creation of the optical

cavity, and landmark identification are the sameas described for the EVRO. However, dissection ofthe condylar head and neck, however, is extendedinto the lower compartment of the temporoman-dibular joint until the bone is skeletonized. Thecondyle then can be atraumatically removed andthe undersurface of the articular disc visualized[4,20]. The patient is placed in maxillomandibularfixation, with a splint, producing a 2 3 mm poste-rior open bite on the sides to be reconstructed. Thiscompensates for the loss of vertical height of thecostochondral graft during healing [15].Costochondral grafts are harvested in the stan-

dard fashion through an inframammary incision.Then, using the endoscope, the disc is identified,and the graft is placed into the glenoid fossa. Thegraft is fixed into position using a 2.0 mm titaniumminiplate (as a washer) with multiple screws.A retrospective evaluation of 10 patients revealed

a mean operating time of 57 minutes per sideexclusive of the rib harvesting procedure. Aver-age hospital stay was 2.5 days [20]. There were nolong-term neurologic changes associated with theIAN or lingual or facial nerves. All patients demon-strated a good range of motion, with maximalincisal opening returning to preoperative valuesby 1 year. In all patients, the desired occlusion

Fig. 2. Uncompensated left condylar hyperplasia, vertical pattern. Frontal (A) and submental (B) views of a 15-year-oldpatient with elongated left mandibular ramus indicative of condylar hyperplasia. (C) Intraoral view showsthe left posterior open bite before the development of dental compensations, (D) SPECT scan showing theincreased uptake of the left condyle. (E) Similarly, the left condyle is hyperactive. (F ) Patient underwent endo-scopic high condylectomy and vertical ramus osteotomy with rigid fixation. (G, H) Postoperative patients sym-metry 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.)

48 Troulis et al

was maintained at the latest follow up (longer than1 year).

Condylar hyperplasiaFor patients with mandibular asymmetry secondaryto condylar hyperplasia, the previously describedapproach to the RCU also can be used to perform

a growth-arresting procedure or high condylec-tomy. After exposing the condylar head and neck,the hyperplastic segment is marked, osteotomized,and removed. Then the normal condylar stump issmoothed and contoured. This procedure is per-formed best early in the disease cycle, before thedevelopment of dental compensations, to avoid

Fig. 2 (continued).

49Minimally Invasive Surgery

the need for mandibular or bimaxillary orthognathicsurgery. Patients who suffer from active condylarhyperplasia with secondary deformities of the max-illa and mandible are treated best by a combinationof high condylectomy and bimaxillary orthognathicsurgery. In patients who are clinically stable, ortho-dontic decompensation and standard orthognathicsurgery are the treatment of choice [Fig. 2] [22].

Mandibular retrognathism

Patients with mandibular retrognathism accountfor approximately one third of all orthognathicsurgical cases. The standard operation for the cor-rection of this deformity is BSSO. Considerableresearch has been performed to minimize the mor-bidity and complications associated with this pro-cedure. Despite these efforts, there are limitationsassociated with the sagittal split osteotomy. Sensorydisturbance of the inferior alveolar nerve occurs ina high percentage of patients. This is mostly a re-sult of the anatomy of the mandible and nervecanal rather than a specific surgical complication.IAN parethesia may occur because of stretch, whenthe jaw is advanced, trauma from retraction ofthe nerve on the medial side of the ramus, andcompression or direct injury by bicortical screwsused for rigid internal fixation. Sensory disturbancemay range from paresthesia to anesthesia but isoften transient and exhibits spontaneous resolu-tion within 2 to 6 months in most cases. Up to25% of the affected patients, however, have somepersistent nerve deficit. The rate of this complica-tion is even higher among patients over 40 yearsof age [13,14]. Another potential limitation is skele-tal relapse, especially with advancements greaterthan 8 mm [6,7].Distraction osteogenesis (DO) is a surgical tech-

nique that makes use of the body’s healing poten-

tial to form new bone in response to tension forcesplaced across an osteotomy. A corticotomy is made,and a device is placed across the cut. The device isactivated gradually to produce the desired amountof bone lengthening. Gradual expansion of boneand associated soft tissues allows for correction ofthe deformity. Skeletal expansion is tolerated betterthan soft tissue, risk to the inferior alveolar nerveand risk of relapse potentially are diminished ascompared to acute movements [17]. In a recent ret-rospective evaluation of 20 consecutive patientswith mandibular retrognathism, treated with eitherBSSO (n = 10) or DO (n =10), 36% of the BSSOversus 21% of the DO patients had dense paresthe-sia postoperatively. This difference suggests thatparesthesia is less frequent in DO, but further stud-ies are needed to confirm this. Subjectively, theDO patients also recovered normal sensation ingreater numbers and more quickly [18]. Currently,the placement of distraction devices for mandibularadvancement is achieved with an incision and dis-section similar to that for BSSO, but with signifi-cantly less dissection. The third molar is removed, ifpresent, and a corticotomy is made through thethird molar tooth region. The distracter is fixedacross the gap between proximal and distal seg-ments. The wound is closed, leaving the activationmechanism exposed transmucosally. After a latencyperiod ranging from 2 to 4 days, distraction beginsat a rate of 1 mm a day to the desired amount [23].The development and refinement of endoscopic

techniques for access to the maxillofacial skeletonwill allow surgeons in the near future to performcomplex osteotomies and place distraction devices,creating additional minimally invasive options forcorrecting skeletal deformities. In particular, a minia-turized DO device, totally buried, remotely activa-ted and capable of three-dimensional movements is

50 Troulis et al

desirable. This device also could be placed endo-scopically 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 systemwill allow for more accurate execution of complexskeletal treatment plans. It is possible that with theminimally invasive techniques described in thisarticle, treatment of skeletal defects will be per-formed in the future in an outpatient setting withlocal anesthesia and intravenous sedation. Thiswould impact cost, patient morbidity, and avail-ability of treatment significantly.

References

[1] Hunter JG, Sackier JM. Minimally invasive hightech surgery: Into the 21st century. In: Hunter JG,Sackier JM, editors. Minimally Invasive Surgery.Columbus, Ohio: McGraw Hill; 1993. p. 3–6.

[2] Williams BW, Abukawa H, Shuster V, et al. Acomparison of postoperative edema after intra-oral vs. endoscopic mandibular ramus osteotomy.J Oral Maxillofac Surg 2003;61(8 Suppl):61a–62.

[3] Kaban LB. Biomedical technology revolution:opportunities and challenges for oral and max-illofacial surgeons. Int J Oral Maxillofac Surg2002;31(1):1–12.

[4] Troulis MJ, Kaban LB. Endoscopic approach tothe ramus/condyle unit: clinical applications.J Oral Maxillofac Surg 2001;59(5):503–9.

[5] Pandya NJ, Stuteville OH. Vertical wedge ostectomyin the mandibular rami for correction of progna-thism. Plast Reconstr Surg 1971;48(2): 140–54.

[6] Lake SL, McNeil RW, Little RM, et al. Surgicalmandibular advancement: a cephalometric analy-sis of treatment response. Am J Orthod 1981;80:376–94.

[7] Bhatia N, Yan B, Behbehanit I, et al. Nature ofrelapse after surgical mandibular advancement.Br J Orthod 1985;12:58.

[8] Dolman RM, Bentley KC, Head TW, et al. Theeffect of hypotensive anesthesia on blood lossand operative time during Le Fort osteotomy.J Oral Maxillofac Surg 2000;58(8):834–9.

[9] Precious DS, Splinter W, Bosco D. Induced hypo-tensive anesthesia for adolescent orthognathic sur-gery patients. J Oral Maxillofac Surg 1996;54(6):680–3.

[10] Gersema L, Baker K. Use of corticosteroids in

oral surgery. J Oral Maxillofac Surg 1992;50(3):270–7.

[11] Juvet LM, Denman KL, Nastri A, et al. Variableaffecting hospital length of stay in orthognathicsurgery patients. J Dent Res.

[12] Troulis MJ, Kaban LB. Endoscopic vertical ramusosteotomy: early clinical results. J Oral MaxillofacSurg 2004;62(7):824–8.

[13] August M, Marchena J, Donady J, et al. Neuro-sensory deficit and functional impairment aftersagittal ramus osteotomy: a long-term follow-up study. J Oral Maxillofac Surg 1998;56(11):1231–5.

[14] MacIntosh RB. Experience with the sagittalosteotomy of the mandibular ramus: a 13-yearreview. J Maxillofac Surg 1981;8:151.

[15] Perrott DH, Umeda H, Kaban LB. Costochondralgraft construction/reconstruction of the ramus/condyle unit: long-term follow-up. Int J OralMaxillofac Surg 1994;23(6):321–8.

[16] Ko EW, Huang CS, Chen YR, et al. Temporo-mandibular joint reconstruction in children us-ing costochondral grafts. J Oral Maxillofac Surg1998;57(7):789–98.

[17] McCarthy J, Schreiber J, Karp N, et al. Lengthen-ing the human mandible by gradual distraction.Plast Reconstr Surg 1992;89(1):1–10.

[18] Bendahan G. Distraction osteogenesis versus bi-lateral split osteotomy for mandibular advance-ment. Master’s of Science Thesis. Harvard Schoolof Dental Medicine, April 2005.

[19] Trauner R, Obwegeser H. The surgical correctionof mandibular prognathism and retrognathiawith consideration of genioplasty. Oral Surg 1957;899–909.

[20] Troulis MJ, Williams WB, Kaban LB. Endoscopicmandibular condylectomy and reconstruction:early clinical results. J Oral Maxillofac Surg 2004;62(4):460–5.

[21] Troulis MJ, Perrott DH, Kaban LB. Endoscopicmandibular osteotomy, and placement and ac-tivation of a semiburied distractor. J Oral Maxil-lofac Surg 1999;57:1110.

[22] Kaban LB. Acquired abnormalities of the tem-poromandibular joint. In: Kaban LB, Troulis MJ,editors. Pediatric oral and maxillofacial surgery.Elsevier; 2004. p. 340–76.

[23] Padwz BL. Orthognathic surgery in the growingchild. In: Kaban LB, Troulis MJ, editors. Pediat-ric oral and maxillofacial surgery. Elsevier; 2004.p. 377–400.




51

Endoscopic Approaches to MaxillaryOrthognathic SurgeryDennis Rohner, MD, DMD, PhD

a,*,Vincent K.L. Yeow, MBBS, FRCS, FAMS

b,c

& Material and methods & Discussion
Endoscopic equipmentSurgical technique
& Results

a Cranio Facial Center, Hirslanden Clinic Aarau, CH-5000b K.K. Womens and Childrens Hospital, 100 Baskit Timahc Department of Plastic Surgery, Singapore General Hosp* Corresponding author.E-mail address: [email protected] (D. Rohner)



Endoscopically assisted surgery has become anessential component in many fields of surgical spe-cialties. The implementation of this technique tocraniofacial and maxillofacial surgery is a recentdevelopment. Endoscopic approach to subcondylarmandible fractures has been established as reliablesurgical method [1–4]. The endoscopic repair ofmidfacial and malar fractures, of traumatic archinjury, of frontal sinus fracture, and of orbital frac-tures is described in the recent literature also [5–10].The use of endoscopic techniques in the field of

orthognathic surgery must be addressed separatelyfor the sagittal split osteotomy and the Le Fort losteotomy. Troulis and colleagues [11,12] havedescribed the endoscopic vertical ramus osteotomyfollowed by rigid fixation for treating mandibu-lar prognathism. There are only a few articles pub-lished that present endoscopic approaches to themidface and Le Fort l level with regard to or-thognathic surgery [13–15].What could be the benefit of an endoscopically

assisted Le Fort l osteotomy? First, there is need todescribe the commonly used technique with anopen approach. Through a horizontal incision ofthe mucosal soft tissue in the Le Fort l plane, theosteotomy is performed using an oscillating saw.The pterygomaxillary junction, the lateral nasal wall,

and the nasal septum can be osteotomized usingdifferent chisels. The downfracture of the Le Fort lplane completes this procedure after an averageoperation time of about 30 minutes. In most ofthe cases, the le Fort I osteotomy as mono-segmentor multi-segment procedure is performed to correctcongenital and acquired deformities of the jaws.The overall complication rate of Le Fort l osteo-tomies varies between 6% and 9% [16,17]. Hemor-rhage, infection, and maxillary necrosis representthe majority of these complications. Some authorsreported ischemic problems because of the de-creased vascularization of mostly anterior maxil-lary segments [18,19]. Different cadaveric studiesshowed that the commonly performed le Fort losteotomy carries the risk of injury to the descend-ing palatal artery [20,21]. Only the ascending pala-tal artery and the pharyngeal branch arising fromthe ascending pharyngeal artery can be preservedroutinely. Quejada and colleagues [22] could showin an animal study that the maintenance of vascu-lar pedicles to the palate and labiobuccal area wassufficient to support total maxillary osteotomy de-spite trans-section of both descending palatinalvessels. Lanigan and colleagues [23,24], however,suggested total maxillary osteotomy using verti-cal incisions from the buccal approach with tun-

Aarau, SwitzerlandRoad, Singapore 223899ital, Outram Road, Singapore 169608, Singapore

.


Fig. 1. Subperiostal dissection of the lateral buttress. Fig. 3. Dissection of the nasal floor.

52 Rohner & Yeow

neling as technically difficult and time-consuming,but possible.Therefore, the use of an endoscopic technique in

combination with basic techniques for Le Fort losteotomies to minimize the access and to opti-mize the vascularization should be the aim of fu-ture treatments. Nevertheless, a well-documented andstandardized treatment as the Le Fort l osteotomyshould not turn out to be a difficult endoscopic-assisted treatment. This was the reason to initiateand perform a cadaveric study for the endoscopicallyassisted Le Fort l osteotomy.

Material and methods

Endoscopic equipment

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

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

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

Surgical technique

Six fresh cadaver specimens were used to performthis study. Two of the cadavers were edentulous;three were partial, and one was completely den-tated. Two vertical incisions were done bilaterallybetween the roots of the second incisors andthe canines, starting 1 to 2 mm above the attachedgingiva and performed to the depth of the vestibule[Fig. 1]. Using a periosteal elevator, the lateral wallof the maxilla was exposed subperiosteally. Thescope could be inserted into the tunnel, and itvisualized the lateral buttress [Figs. 2, 3]. A secondvertical incision was accomplished between theroots of the first and second molar, again starting1 to 2 mm above the attached gingiva. This wasperformed to the depth of the vestibule [Fig. 4].Visually controlled by the scope, the mucosa wastunneled to the distal portion of the tuberosityand the pterygomaxillary junction using a perios-teal elevator. Subperiosteal tunneling with an ele-

Fig. 4. Identified and intact descending palatal artery.

Fig. 5. Prototype of a reciprocal saw presenting anelongated but thinner shaft (Medicon Company,Tübingen, Germany).

53Maxillary Orthognathic Surgery

vator connected the two vertical incisions in theanterior maxilla. The dissection then extended intothe nasal cavity, lifting the nasal mucosa from thefloor of the nose and from the lateral nasal wallsup to the inferior turbinate. This dissection wasmonitored with the scope. The scope insertedinto the lateral tunnel could visualize the perfor-mance of straight horizontal osteotomy cuts onboth sides through the lateral antral wall, extendingfrom the piriform aperture to the pterygomaxillaryjunction using a 4 mm osteotome with a mallet[Fig. 5]. With the scope inserted into the nasalcavity between nasal mucosa and floor, a horizon-tal cut through the medial antral wall and nasalseptum was made using the 4 mm osteotome also.A curved osteotome inserted through the posteriorvertical incision was placed into the pterygomaxil-lary junction under visual control with the scope.Osteotomy was accomplished when the bladecould be palpated on the palatal aspect. The max-illa then was downfractured using finger pressure.In the first two cadaver dissections, the Le Fort

procedure was performed without fixating theosteotomized segment. In cadavers three to six,rigid fixation was accomplished using self-drillingscrews and titanium mini-plates (Compact Star-drive 1.5 mm, Mathys Bettlach, Switzerland). Theosteotomized segments were fixed first at the nasalbuttress using straight five-hole plates. At the lateralbuttress, L-plates were used, positioned through theposterior vertical incision under endoscopic visu-alization through the lateral tunnel. The fixation ofthe plates was done manually with the self-drillingscrews using a screwdriver.

Results

In all six cadavers, the Le Fort l osteotomy couldbe performed successfully. The downfractured max-illa offered enough space to insert the scope toidentify the descending palatal arteries that were

intact in all tested specimens. The nasal soft tissuetube was in all cadavers complete and withoutlaceration. The soft tissue bridge on both buccalsides could be preserved. The longitudinal branchesof the facial artery within the gingival mucosa wereintact. In all the specimens, maxillary movementsup to 5 mm in any direction could be accom-plished. The plate fixation was performed at thetypical locations paranasal and at the lateral but-tress under direct view through the vertical inci-sions on both sides.

Discussion

The Le Fort l osteotomy is a standard techniquefor corrections of dentofacial deformities. In experi-enced hands, a mono-segment osteotomy includ-ing osteosynthesis lasts on an average 60 minutes.The cadaver dissection could be accomplished be-tween 30 and 45 minutes. One has to consider,however, that permanent bleeding is a major dis-turbance of visibility in an endoscopic treatment.This could prolongate an endoscopically assistedsurgery dramatically. One possible solution couldbe injection of vasoactive agents preoperativelyinto the nasal and buccal mucosa to minimizebleeding during the dissection.Hemorrhage—one of the major problems in the

past—now is almost negligible. Improved techni-cal skills, controlled anesthesia in relative hypoten-sion, stable osteosynthesis, and reduced time ofsurgery led to this positive development. There re-mains, however, the risk of bleeding resulting froman injury to the maxillary artery or its branches,with the descending palatine artery being the mostcommon source of bleeding. Recent studies showedthat the average blood loss stood in correlation tomode of anesthesia, position of the patient, max-illary or bimaxillary osteotomies, and length of op-eration [25–27].The cadaveric dissection allowed a controllable

dissection of the nasal and buccal mucosa withthe use of endoscopic assistance. The limited ap-proaches resulted in more physiological wounds ofthe buccal mucosa. The vertical direction of theincisions preserved the anastomotic network be-tween branches of the facial artery and branchesof the maxillary artery on the gingiva and buccalmucosa. Therefore, one could expect a further de-crease in blood loss, which might be one advantagein clinical applications.An avulsion or interruption of the posterior de-

scending palatal artery during downfracture ofthe maxillary segment is possible. Osteotomy ofthe lateral nasal wall using a straight osteotomecan disrupt this vessel. The use of the endoscopecould visualize the position of the vessel and al-

54 Rohner & Yeow

lowed for precise osteotomy of the lateral nasalwall with controllable preservation of the vesselin this cadaver study. Siebert and colleagues [21]mentioned that in their cadaver study with openLe Fort l procedure, the descending palatine ar-teries were interrupted in all their specimens.Another important issue is the postoperative

edema and swelling. The horizontal incision ap-plied for the open Le Fort l osteotomy extendingfrom first molar to first molar creates a wound sur-face that causes postoperative swelling and edema.Limited approaches with controlled elevation andreduced lesion of the periosteum prevent swellingand edema, which will decrease the risk for post-operative infection and accelerate the recovery.Often when the open Le Fort l technique has

been performed, the patient presents a slight softtissue sagging in the cheek area on both sides. Onereason could be the wide elevation of the peri-osteum at the buccal side. The limited elevationand intact periosteum in the endoscopic techniqueprevent the soft tissue from slumping and allowfor 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 instru-mentation that allowed for fast and proper os-teotomy. Medicon in Tubingen, Germany, hasproduced a prototype of a reciprocal saw with aslim but elongated shaft that enables a tunneledosteotomy. There is a need to prove such new in-struments to evaluate their qualities and benefitsfor endoscopic techniques. It is essential to valuethe advantages against the disadvantages.Limited approach, reduced bleeding, less edema,

and shorter time of recovery might be the advan-tages. Extended time of surgery, disturbed visibil-ity, higher technical challenge, and more expensivecosts could be disadvantageous. The use of thistechnique for the surgically assisted rapid palatalexpansion (SARPE) could one of the main indica-tions. Complete osteotomy without downfracturebut sagittal split of the maxilla is the condition fora palatal widening using a distracter. The SARPEturns, with help of the endoscopically assisted tech-nique, 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 provethe feasibility and value of this technique.

Summary

Endoscopically assisted Le Fort l osteotomy couldbe performed in a cadaver study successfully. Thefeasibility of this technique, especially the han-dling with an irrigation/suction system, can be

proved only in clinical use. In a first prospectivestudy, patients with the need of SARPE may bene-fit from this technique. Minimal access, reducedperiosteal elevation, and lessened edema couldshorten the time of recovery. The introductionof specifically adapted instruments for endoscopicapproaches could improve this technique further.

References

[1] Kellman RM. Endoscopic approach to subcondy-lar mandible fractures. Facial Plast Surg 2004;20(3):239–47.

[2] Schon R, Schramm A, Gellrich NC, et al. Follow-up of condylar fractures of the mandible in eightpatients at 18 months after transoral endoscopic-assisted open treatment. J Oral Maxillofac Surg2003;61(1):49–54.

[3] Chen CT, Lai JP, Tung TC, et al. Endoscopicallyassisted mandibular subcondylar fracture re-pair. Plast Reconstr Surg 1999;103(1):60–5.

[4] Lee C, Mueller RV, Lee K, et al. Endoscopic sub-condylar fracture repair: functional, aesthetic,and radiographic outcomes. Plast Reconstr Surg1998;102(5):1434–43 [discussion 1444–5].

[5] Shumrick KA, Ryzenman JM. Endoscopic man-agement of facial fractures. Facial Plast Surg ClinNorth Am 2001;9(3):469–74.

[6] Czerwinski M, Lee C. Traumatic arch injury: in-dications and an endoscopic method of repair.Facial Plast Surg 2004;20(3):231–8.

[7] Chen DJ, Chen CT, Chen YR, et al. Endoscopi-cally assisted repair of frontal sinus fracture.J Trauma 2003;55(2):378–82.

[8] Strong EB. Endoscopic repair of orbital blow-outfractures. Facial Plast Surg 2004;20(3):223–30.

[9] Strong EB, Kim KK, Diaz RC. Endoscopic ap-proach to orbital blowout fracture repair. Oto-laryngol Head Neck Surg 2004;131(5):683–95.

[10] Chen CT, Chen YR. Endoscopically assisted re-pair of orbital floor fractures. Plast Reconstr Surg2001;108(7):2011–8 [discussion 2019].

[11] Troulis MJ, Nahlieli O, Castano F, et al. Mini-mally invasive orthognathic surgery: endoscopicvertical ramus osteotomy. Int J Oral MaxillofacSurg 2000;29(4):239–42.

[12] Troulis MJ, Kaban LB. Endoscopic vertical ramusosteotomy: early clinical results. J Oral MaxillofacSurg 2004;62(7):824–8.

[13] Rohner D, Yeow V, Hammer B. Endoscopicallyassisted Le Fort l osteotomy. J CraniomaxillofacSurg 2001;29(6):360–5.

[14] Wiltfang J, Kessler P. Endoscopically assistedLe Fort I osteotomy to correct transverse and sag-ittal discrepancies of the maxilla. J Oral Maxillo-fac Surg 2002;60(10):1142–5 [discussion 1146].

[15] Levine JP, Rowe NM, Bradley JP, et al. Thecombination of endoscopy and distraction osteo-genesis in the development of a canine midfaceadvancement model. J Craniofac Surg 1998;9(5):423–32.

[16] el Deeb M, Wolford L, Bevis R. Complications of

55Maxillary Orthognathic Surgery

orthognathic surgery. Clin Plast Surg 1989;16(4):825–40.

[17] Bendor-Samuel R, Chen YR, Chen PK. Unusualcomplications of the Le Fort I osteotomy. PlastReconstr Surg 1995;96(6):1289–96.

[18] Bell WH. Immediate surgical repositioning ofone- and two-tooth dento-osseous segments. IntJ Oral Surg 1973;2(6):265–72.

[19] Burk Jr JL, Provencher RF, McKean TW. Smallsegmental and unitooth osteotomies to correctdentoalveolar deformities. J Oral Surg 1977;35(6):453–60.

[20] Gauthier A, Lezy JP, Vacher C. Vascularizationof the palate in maxillary osteotomies: anatom-ical study. Surg Radiol Anat 2002;24(1):13–7.

[21] 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):843–51.

[22] Quejada JG, Kawamura H, Finn RA, et al. Woundhealing associated with segmental total maxillaryosteotomy. J Oral Maxillofac Surg 1986;44(5):366–77.

[23] Lanigan DT, Hey JH, West RA. Aseptic necro-sis following maxillary osteotomies: report of36 cases. J Oral Maxillofac Surg 1990;48(2):142–56.

[24] Lanigan DT, Hey JH, West RA. Major vascularcomplications of orthognathic surgery: hemor-rhage associated with Le Fort I osteotomies.J Oral Maxillofac Surg 1990;48(6):561–73.

[25] Dolman RM, Bentley KC, Head TW, et al. Theeffect of hypotensive anesthesia on blood lossand operative time during Le Fort l osteotomies.J Oral Maxillofac Surg 2000;58(8):834–9 [dis-cussion 840].

[26] Moenning JE, Bussard DA, Lapp TH, et al.Average blood loss and the risk of requiringperioperative blood transfusion in 506 or-thognathic surgical procedures. J Oral MaxillofacSurg 1995;53(8):880–2.

[27] Rohling RG, Zimmermann AP, Biro P, et al.Alternative methods for reduction of blood lossduring elective orthognathic surgery. Int J AdultOrthodon Orthognath Surg 1999;14(1):77–82.




57

IndexNote: Page numbers of article titles are in boldface type.

A

aesthetics, postoperative, of maxillomandibular

fixation, 8

alloplastic implants, for orbital floor fracture repair,

13–14

stabilization techniques for, 14–15

anterior table fractures, of frontal sinus, endoscopic

repair of, 25–29

compressive forces and, 28

1064facia

computed tomography of, 26–28

discussion on, 28–29

fracture camouflage technique, 28–29

general requirements for, 25

indications for, 25–26, 29

Medpor sheeting implant for, 26–27

photographs of, intraoperative, 26–27

-7406/0lplast

postoperative, 27

preoperative, 26

scalp incisions used for, 26, 28

technique for, 26–28

treatment algorithm for, 25

antrostomies, for orbital floor fracture repair,

maxillary sinus, 12

middle meatal, 13–14

B

bailout procedure, for maxillomandibular fixation,

6, 7

bilateral split osteotomy (BSSO), for mandibular

retrognathism, 49

vertical ramus osteotomy versus, 45–46

bone cement, hydroxyapatite, for frontal sinus fracture

repair, 32–33

bone flaps, for orbital floor fracture repair, 13

bone grafts, for medial orbital wall fracture repair,

19, 22

6/$ – see front matter © 2006 Elsevier Inc. All rightsic.theclinics.com

buccal mucosa dissection, for endoscopic

orthognathic surgery, 53–54

C

Caldwell Luc approach, to orbital floor fracture

repair, 11

camouflage technique, of frontal sinus fracture repair,

32–34

with anterior table, 28–29

closed reduction, of condylar fractures, 1–2

computed tomography (CT) scan, in mandibular

orthognathic surgery, 48, 50

of anterior table-frontal sinus fracture repair,

26–28

of frontal sinus fracture repair, 33–34

of maxillomandibular fixation, for preoperative

planning, 4–5

reserve

of postoperative results, 7–8

of orbital floor fracture repair, 11, 13–14

of zygomatic arch fractures, 39, 41

condylar fractures, endoscopic repair of, 1–9

as closed treatment, 1–2

bailout procedure for, 6, 7

condyle-fossa relationship and, 4

equipment for, 5

exposure step for, 5

fixation technique for, 5–6

fracture anatomy impact on, 3

fracture comminution impact on, 4

fracture displacement impact on, 3–4

fracture location impact on, 3

indications for, 3

open reduction and internal fixation versus, 2

operative technique for, 5–6

pioneering trends, 1, 2

postoperative regime for, 6

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

58 Index

preoperative planning for, 3–5

radiographic imaging in, 4–5

reduction step for, 5

regional anatomy and, 2–3

repair sequence for, 5

results of, 6–8

demographics, 6–7

operative details, 7–8

summary of, 8

condylar hyperplasia, endoscopic condylectomy for,

48–49

condylar resorption, idiopathic, endoscopic

condylectomy for, 47–48

condyle-fossa relationship, in maxillomandibular

fixation, 4

condylectomy, endoscopic, for condylar hyperplasia,

48–49

for idiopathic condylar resorption, 47–48

for mandibular conditions, 46

costochondral grafting, endoscopic, for mandibular

conditions, 46–47

D

deformity(ies), mandibular, 45–50 (See also

mandibular orthognathic surgery)

endoscopic approach to, 45–50 (See also

endoscopic approach)

displacement patterns, of zygomatic arch fractures,

38–39

distraction osteogenesis (DO), for mandibular

retrognathism, 49–50

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, 31–32

surgical specialty impact of, 31

various, 32

endoscopic approach, to orthognathic surgery,

51–55

advantages of, 53–54


equipment for, 52

for Le Fort I osteotomy, 51–52

mandibular, 45–50

advantages of, 46

as minimally invasive, 45

decreased morbidity with, 46

costochondral grafts for, 46–47

current application/usage trends, 46

for prognathism (asymmetry), 46–47

for retrognathism, 46, 49–50

historical perspectives of, 45

morbidity minimization with, 45–46

with condylectomy, for condylar hyperpla-

sia, 48–49

for idiopathic condylar resorption,

47–48


with distraction osteogenesis, 49–50

with vertical ramus osteotomy, 46–47

midface applications of, 51

results of, 53

surgical technique for, 52–53

surgically assisted rapid palatal expansion

and, 54

endoscopic repair, of condylar fractures, 1–9

as closed treatment, 1–2

bailout procedure for, 6, 7


equipment for, 5







indications for, 3










results of, 6–8

demographics, 6–7


summary of, 8

of frontal sinus-anterior table fractures, 25–29









postoperative, 27

preoperative, 26




59Index

of frontal sinus fractures, 31–35

camouflage technique for, 32–34


computed tomography of, 26–28, 33–34


equipment for, 31–32

external techniques versus, 31





optical cavity requirement for, 31–32

patient selection for, 33–34


postoperative, 27

preoperative, 26




trends in, 32

unsuccessful, conversion to open approach,

33–34

of orbital floor fractures, 11–16

Caldwell Luc approach versus, 11

complications of, 11, 15

computed tomography of, 11, 13–14


general requirements of, 11


Le Fort-type injuries and, 14–15

medial blow out, 11–13, 15

orbitozygomatic injuries and, 14–15


traditional techniques versus, 11, 14

transantral approach to, 14

transnasal approach to, 14

trap door, 11–13

trend summary, 15

of orbital wall fractures, medial, 17–23

biomechanical studies of, 17

bone grafts for, 19, 22

complications of, 22

direct vs. indirect approach to, 17–18

implants for, 19–20, 22

indications for, 18–19

injury mechanisms, 17

intranasal technique, 18, 20–22

miscellaneous approaches versus, 17–18

preoperative evaluation for, 18

surgical techniques for, 19–22

transcaruncular technique, 18–21

trend summary, 17–18, 22

of zygomatic arch fractures, 37–43

advantages of, 38

arch anatomy role in, 37–38, 42

case presentations of, 42

computed tomography of, 39, 41

disadvantages of, 43


equipment for, 40

exposure incisions for, 40, 43

fixation for, 41–42

indications for, 39

injury patterns and, 38–39

lateral displacement and, 38–39

Le Fort I level, 37, 40

Le Fort II level, 41

Le Fort III level, 39–42

medial arch displacement and, 38–39


reduction for, 40

sequencing for, 39–40


telescoping pattern considerations, 38

with complex zygoma injury, 40, 42

endoscopic sheaths, various, 31–32

endoscopic vertical ramus osteotomy (EVRO), 46–47

external forces, compressive, in anterior table-frontal

sinus fracture repair, 28

in zygomatic arch fracture patterns, 38–39

F

facial artery, in endoscopic orthognathic surgery,

53–54

facial trauma, fractures from (See fracture(s))

forces, as fracture factor (See external forces)

forehead lifting, endoscopic technique for, 32–34

fracture(s), anterior table, 25–29 (See also anterior

table fractures)

endoscopic repair of, 25–29

condylar, 1–9 (See also condylar fractures)

endoscopic repair of, 1–9 (See also

endoscopic repair)

maxillomandibular fixation for, 1–9 (See also

maxillomandibular fixation (MMF))

frontal sinus, 31–35 (See also frontal sinus fractures)


endoscopic repair)


mandibular, 45–50 (See also mandibular

orthognathic surgery)


endoscopic approach)

medial orbital wall, 17–23 (See also orbital

wall fractures)


endoscopic repair)

midface, orthognathic surgery for, 51–55 (See also


orbital floor, 11–16 (See also orbital floor fractures)

60 Index


endoscopic repair)

zygomatic arch, 37–43 (See also zygomatic

arch fractures)


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, 31–35

camouflage technique for, 32–34


equipment for, 31–32

external techniques versus, 31

optical cavity requirement for, 31–32

patient selection for, 33–34

trends in, 32

unsuccessful, conversion to open approach,

33–34










postoperative, 27

preoperative, 26




G

grafts and grafting, bone, for medial orbital wall

fracture repair, 19, 22

costochondral, for mandibular conditions, 46–47

Greenberg retractor, for orbital floor fracture repair, 12

H

hemorrhage, with Le Fort I osteotomy, 53

I

implant(s), alloplastic, for orbital floor fracture repair,

13–14

stabilization techniques for, 14–15

Medpor sheeting, for anterior table-frontal sinus

fracture repair, 26–27

synthetic, for medial orbital wall fracture repair,

19–20, 22

Vicryl mesh, for frontal sinus fracture repair, 34–33

internal fixation, in endoscopic orthognathic

surgery, 53

of condylar fractures, 2

of frontal sinus fractures, with anterior table, 28

with failed endoscopic approach, 33–34

of maxillomandibular injuries, 46–47, 49

intranasal approach, endoscopic, to medial orbital

wall fracture repair, 18, 20–22

intraoral vertical ramus osteotomy (IVRO), 46

K

Kerrison rongeur, for orbital floor fracture repair, 12

L

lateral buttress dissection, for endoscopic orthognathic

surgery, 52–53

Le Fort I osteotomy, endoscopic approach to,


applications of, 51–52


equipment for, 52

palatal artery cautions, 52–54

results of, 53



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, 39–42

Le Fort-type injuries. See also specific fracture

endoscopic repair of, 14–15

M

mandibular orthognathic surgery, endoscopic

approach to, 45–50

advantages of, 46








with condylectomy, for condylar hyperplasia,

48–49

for idiopathic condylar resorption, 47–48




61Index

mandibular prognathism (asymmetry), endoscopic

orthognathic correction of, 46–47

mandibular ramus/condyle unit (RCU), endoscopic

approach to, 46 (See also mandibular


mandibular retrognathism, endoscopic orthognathic

correction of, 46, 49–50

maxillomandibular fixation (MMF), for condylar

fractures, bailout procedure for, 6, 7


endoscopic equipment for, 5

endoscopy indications, 3
















results of, 6–8

demographics, 6–7


summary of, 8

Medpor sheeting implants, for anterior table-frontal

sinus fracture repair, 26–27

midface orthognathic surgery, endoscopic approach

to, 51–55 (See also orthognathic surgery)

minimally invasive surgery (MIS), 45

for facial injuries (See endoscopic approach;

endoscopic repair)

morbidity, with condylar fractures, and closed

treatment, 1–2

with frontal sinus fractures, 31

with mandibular orthognathic surgery, 46

mucocele, with anterior table-frontal sinus fracture

repair, 28

N

nasal floor dissection, for endoscopic orthognathic

surgery, 52

O

open reduction and internal fixation, of condylar

fractures, 2

of frontal sinus fractures, with anterior table, 28

with failed endoscopic approach, 33–34

orbital floor fractures, endoscopic repair of, 11–16

Caldwell Luc approach versus, 11

complications of, 11, 15

computed tomography of, 11, 13–14


general requirements of, 11


lateral blow out, 12

Le Fort-type injuries and, 14–15

medial blow out, 11–13, 15

orbitozygomatic injuries and, 14–15


traditional techniques versus, 11, 14

transantral approach to, 14

transnasal approach to, 14

trap door, 11–13

trend summary, 15

orbital wall fractures, medial, endoscopic repair of,

17–23

biomechanical studies of, 17

bone grafts for, 19, 22

complications of, 22

direct vs. indirect approach to, 17–18

implants for, 19–20, 22

indications for, 18–19

injury mechanisms, 17

intranasal technique, 18, 20–22

miscellaneous approaches versus, 17–18

preoperative evaluation for, 18

surgical techniques for, 19–22

transcaruncular technique, 18–21

trend summary, 17–18, 22

orbitozygomatic fractures, endoscopic repair of, 14–15

orthognathic surgery, endoscopic approach to, 51–55



equipment for, 52

for Le Fort I osteotomy, 51–52

mandibular, 45–50

advantages of, 46








with condylectomy, for condylar hyperpla-

sia, 48–49

for idiopathic condylar resorption,

47–48




62 Index

midface applications of, 51

palatal artery cautions, 52–54

results of, 53



and, 54

osteotome, for endoscopic orthognathic surgery, 53

for orbital floor fracture repair, 12

P

palatal artery, in endoscopic orthognathic surgery,

52–54

periosteal elevator, for endoscopic orthognathic

surgery, 52

pulse test, for orbital floor fracture repair, 14

R

radiography, of maxillomandibular fixation, for

preoperative planning, 4–5

of postoperative results, 7–8

reciprocal saw, for endoscopic orthognathic

surgery, 53

S

soft tissue, complications of, with maxillomandibular

fixation, 8

Steinmann pins, for frontal sinus fracture repair,

32–34

surgically assisted rapid palatal expansion (SARPE), in

endoscopic orthognathic surgery, 54

synthetic implants, for medial orbital wall fracture

repair, 19–20, 22

T

telescoping pattern, of zygomatic arch fractures, 38

temporomandibular joint conditions, endoscopic

orthognathic correction of, 46

transantral approach, endoscopic, to orbital floor

fracture repair, 14

transcaruncular approach, endoscopic, to medial

orbital wall fractures, 18–21

transnasal approach, endoscopic, to orbital floor

fracture repair, 14

trauma, facial, fractures from (See fracture(s))

V

vertical ramus osteotomy, bilateral split osteotomy

versus, 45–46

endoscopic, 46–47

intraoral, 46

Vicryl mesh implants, for frontal sinus fracture repair,

34–33

Z

zygomatic arch fractures, endoscopic repair of, 37–43

advantages of, 38

arch anatomy role in, 37–38, 42

case presentations of, 42

computed tomography of, 39, 41

disadvantages of, 43


displacement patterns and, lateral, 38–39

medial arch, 38–39

equipment for, 40

exposure incisions for, 40, 43

fixation for, 41–42

indications for, 39

injury patterns and, 38–39

Le Fort I level, 37, 40

Le Fort II level, 41

Le Fort III level, 39–42


reduction for, 40

sequencing for, 39–40


telescoping pattern of, 38

with complex zygoma injury, 40, 42

facial plastic surgery clinics of north america volume 14, issue 1, pages 1-62 (february 2006),...

Documents

endoscopic techniques

endoscopic approaches

contents endoscopic

common fractures

orbital contents

orbital fat

anatomic repair

benefits of arch repair