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Repair of traumatic orbital wall defects with nasal septal cartilage: Report of five cases
J Oral Maxillofac Surg 55:1098-l 102, 1997
Repair of Traumatic Orbital Wall Defects With Nasal Sep tal Cartilage: Report of Five Cases KASEY K. LI, DDS, MD* Purpose: This article reports the use of nasal septal cartilage for the repair of traumatic orbital wall defects. Patients and Methods: Five patients with disruption of the orbital wall after facial trauma were included in this retrospective review. All of the patients underwent open reduction with internal fixation of the fractures as well as repair of the orbital wall defect with autogenous septal cartilage. Results: Nasal septal cartilage was used in four cases of orbital floor defect and one case of orbital roof defect. All of the cases were successfully treated by restoration of the orbital wall continuity. Conclusion: Nasal septal cartilage is a readily accessible autogenous material that can be easily harvested with minimal donor site morbidity, and it should be considered when an autogenous orbital implant is needed for the repair of a traumatic orbital wall defect.
Unrepaired orbital wall defects after facial fractures can result in enophthalmos and diplopia because of increased orbital volume, herniation of orbital contents, and atrophy of herniated fat and muscle. Therefore, restoration of orbital wall defects is often recommended.lz2 When considering a grafting material for orbital reconstruction, autogenous bone remains the preferred choice for most oral and maxillofacial surgeons, despite the availability of various alloplastic materials,3-6 because of the potential risk of infection and extrusion with the latter. The ilium, rib, and calvarium are the preferred donor sites for autogenous bone. Although bone grafts can be easily harvested from these sites, each has associated morbidity. The procurement of iliac bone can result in adynamic ileus, prolonged postoperative pain, and restricted ambulation, as well as major complications such as arteriovenous fistula and ureteral injury.7-9 The rib is easy to work with because of its malleability;
however, rib harvesting can be associated with pleuritic pain and pneumothorax.93’0 The calvarium remains popular for bone grafting of the maxillofacial region because of its resistance to remodeling and resorption,” as well as the elimination of a second operative field. However, cranial bone harvesting can be associated with serious complications, including cerebral penetration, meningitis, subdural hematoma, laceration of the sagittal sinus, and permanent brain injury.‘2313 Cartilage from the ear concha and the nasal septum are excellent alternative sources of autogenous tissue. Autogenous cartilage has been shown both experimentally and clinically to incorporate with host tissue and resist resorption and deformation.‘4”5 Although the use of nasal septal cartilage and auricular cartilage for the reconstruction of the orbital floor has been previously described,16-19 they have received relatively little attention compared with bone grafts. This report describes five cases in which nasal septal cartilage was used in the reconstruction of traumatic orbital wall defects.
Received from the Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, CA. * Clinical Instructor. Address correspondence and reprint requests to Dr Li: Facial Reconstructive Surgery, 750 Welch Rd, Suite 317, Palo Alto, CA 94304. 0 1997 American
Association
of Oral and Maxillofacial
Patient
Selection
Ideally, the nasal septal cartilage graft should be harvested only in patients with minimal septal deviation and no spurs or turbinate hypertrophy to achieve rapid procurement of the graft. In patients with a his-
Surgeons
0278-2391/97/5510-0009$3.00/O
1098
KASEY
LI
tory of previous nasal surgery, septal perforation, and nasal symptoms such as crusting, obstruction, epistaxis, or discharge, septal cartilage harvest is contraindicated because the procedure may potentially complicate the patient’s preexisting nasal symptoms or future treatment. Concomitant facial injury involving the nasal structures, including Le Fort fractures and nasal/ nasoethmoidal fractures, are also contraindications. Patients
and Methods
Four men and one woman with a mean age of 25 years (range, 18 to 34 years) and with facial fractures associated with orbital wall disruption were treated by using autogenous nasal septal cartilage. The graft was obtained by a hemitransfixation incision after injection with 1% lidocaine containing 1: 100,000 epinephrine for vasoconstriction. Mucoperichondrial flaps were elevated bilaterally to expose the quadrangular cartilage. Mucoperiosteal flaps were also elevated over the vomer and the maxillary crest to provide maximum exposure. A vertical incision was made at approximately 1.5 cm posterior to the caudal border of the quadrangular cartilage. A second cartilagenous incision was then made paralleling the nasal dorsum at 1.5 cm below the nasal dorsum. The septal cartilage was harvested by disarticulating it from the maxillary crest, the vomer, and the perpendicular plate of the ethmoid bone, while preserving an L-shaped strut for structural support of the nose (Fig 1). The hemitransfixation incision was closed with several interrupted 4-O chromic catgut sutures. The mucoperichondrial flaps were adapted using a 4-O plain septal catgut suture on a small straight needle in a mattress fashion, thus eliminating the need for nasal packing. There were two isolated zygomatic complex fractures (orbital floor defect), two pure blowout fractures (with an orbital floor defect), and one supraorbital rim fracture (orbital roof defect) treated. All of the orbital wall defects were larger than 1 X 1 cm. The indications for surgical repair of the fractures included facial asymmetry, diplopia, decreased extraocular movement, and enophthalmus. An existing laceration was used in one patient (supraorbital rim fracture) (Fig 2), a transconjunctival (preseptal) approach without lateral canthotomy was used in two patients (pure blowout fractures) (Fig 3), and a transconjunctival (preseptal) approach with lateral canthotomy was used in two patients (zygomatic complex fractures). The orbital floor defects were repaired by placing the graft so that the intact orbital wall served as a stable platform. The weight of the orbital contents provided stabilization of the graft, thus eliminating the need of fixation. In addition, being an autogenous graft, tissue ingrowth occurs within days, which further ensures stability of the graft. The orbital roof defect was reconstructed in
FIGURE 1. A, Area of septal cartilage harvest (arrow). It is important to preserve a minimum of 1.5 cm of dorsal and caudal cartilage to maintain nasal support. B, View of septal cartilage graft.
a similar fashion by placing the graft inside the orbit between the orbital contents and the roof to prevent herniation of the orbital content into the frontal sinus. A successful outcome was defined as a stable reduction of the fracture with repair of the orbital wall disruption and restoration of normal facial appearance and eye function. Results Five autogenous nasal septal cartilage grafts were placed in five patients with significant orbital wall defects (> 1 cm) resulting from trauma. The average follow-up was 4 months (range, 3 to 5 months). All patients were successfully reconstructed with restoration of the orbital wall continuity. There were no graft infections, exposures, or extrusions, and there were no donor site complications. The only complication encountered was mild scleral show in a patient with a zygomatic complex fracture and large orbital floor de-
1100
REPAIR OF ORBITAL
DEFECTS WITH NASAL
SEPTAL CARTILAGE
FIGURE 2. A, Coronal CT scan showing disruption of the orbital roof (arrow). B, Supraorbital rim fracture exposed through an existing laceration. Note the herniation of the periorbita through the orbital roof defect (arrow) and the nasal septal cartilage graft. C, Graft placed over the roof defect (arrow). D, Postoperative radiograph.
feet (2 x 2 cm) that was approached with a transconjunctival approach with lateral canthotomy. Discussion When an autogenousimplant is desiredfor reconstruction of traumatic orbital wall defects, nasal septal cartilage offers several advantages.It is readily accessibleby the standardsubmucousresectiontechnique and is easier to harvest than cranial bone. In addition, the harvesting of nasal septalcartilage is associatedwith minimal risks
when meticuloussurgicaltechnique is executed, although potential complications,including hemorrhage,infection, septalhematoma,septalperforation, and saddlenosedeformity, can occur. These complications are all minor when compared with the potential complications of autogenousbone harvest. Furthermore, septal cartilage harvest doesnot leave a visible scar or palpable donor site defect and, if a mattresssuture closure is used to adapt the septalmucosaafter the submucousresection,the need for nasalpacking is eliminated. Another advantage of nasal septal cartilage is that
KASEY
LI
1101
FIGURE 3. A, Coronal CT scan showing disruption of the orbital floor (an-ow). B, Orbital floor exposed by a transconjunctival (preseptal) approach. The nasal septal cartilage graft has been placed (arrow). C, Postoperative CT scan.
it is easily manipulated, and its inherent resilience can be used for firm support or contouring. By placing partial-thickness cuts over its surface, it can be shaped into the natural curvature of the orbital wall within
minutes. This is considerably simpler than shaping a bone graft, where osteotomies and fixation of the segments with microplates are often needed to create the desired curvature. Furthermore, nasal septal cartilage
1102
REPAIR
grafts measuring 2 X 2.5 cm can be reliably obtained, which is usually a sufficient size to repair the orbital wall defect. The use of an autogenous cartilage graft in traumatic orbital wall repair is also scientifically sound. Experimental evidence suggests that such a graft is rapidly incorporated by the host tissue, especially when the perichondrium is left intact, and it maintains most of its initial volume and integrity years after transplantation.14 Clinically, the success of its use in nasal reconstruction is irrefutable. When compared with auricular cartilage, nasal septal cartilage is easier to harvest, offers a slightly larger graft, is easier to shape and contour, and provides better structural support. Therefore, this donor site should be considered when an autogenous graft is needed for reconstruction of traumatic orbital wall defects. References 1, Manson PN, Clifford CM, Su CT, et al: Mechanisms of global support and posttraumatic enophthalmos: I. The anatomy of the ligament sling and its relation to intramuscular cone orbital fat. Plast Reconstr Surg 77:193, 1986 2. Manson PN, Grivas A, Rosenbaum A, et al: Studies on enophthalmos: II. The measurement of orbital injuries and their treatment by quantitative computed tomography. Plast Reconstr Surg 77:203, 1986 3. Burres SA, Cohn AM, Mathog RH: Repair of orbital blowout fractures with Marlex mesh and Gelfilm. Laryngoscope 91:1881, 1981 4. Morrison AD, Sanderson RC, Moos DF: The use of silastic as an orbital implant for reconstruction of orbital wall defects: Review of 3 11 cases treated over 20 years. J Oral Maxillofac Surg 53:412, 1995
OF ORBITAL
DEFECTS
WITH
NASAL
SEPTAL
CARTILAGE
5. Rozema FR, Bos RRM, Pennings AJ, et al: Poly (L-Lactide) implants in repair of defects of the orbital floor. J Oral Maxillofac Surg 48:1305, 1990 6. Sargent LS, Fulks KD: Reconstruction of internal orbital fractures with vitallium mesh. Plast Reconstr Surg 88:31, 1991 7. James JD, Geist ET, Gross BD: Adynamic ileus as a complication of iliac bone removal: Report of two cases. .I Oral Surg 39:289, 1981 8. Marx ER, Morales MJ: Morbidity from bone harvest in major jaw reconstruction: A randomized trial comparing the lateral anterior and posterior approaches to the ilium. J Oral Maxillofat Surg 46:196, 1988 9. Laurie SW, Kaban LB, Mulliken JB: Donor site morbidity after harvesting rib and iliac bone. Plast Reconstr Surg 73:933, 1984 10. Whitaker LS, Munro IR, Saler KE, et al: Combined report of problems and complications in 793 craniofacial operations. Plast Reconstr Surg 64:198, 1979 11. Zins JE, Whitaker LA: Membranous versus endochondral bone: Implications for cranial facial reconstruction. Plast Reconstr Surg 72:778, 1983 12. Kline RM, Wolfe SA: Complications associated with the harvesting of cranial bone grafts. Plast Reconstr Surg 95:5, 1995 13. Frodel JL, Marentette LJ, Quatela VC, et al: Calvarial bone graft harvest: Techniques, considerations, and morbidity. Arch Otolaryngol Head Neck Surg 119:17, 1993 14. Motoki DS, Mulliken JB: The healing of bone and cartilage. Clin Plast Surg 17:527, 1990 15. Sheen JH: Secondary rhinoplasty. Plast Reconstr Surg 56:137, 1975 16. Stark RB, Frileck SP: Conchal cartilage grafts in augmentation rhinoplasty and orbital floor fractures. Plast Reconstr Surg 43:591, 1969 17. Constantian MB: Use of auricular cartilage in orbital floor reconstruction. Plast Reconstr Surg 69:951, 1982 18. Hendler BH, Gateno J, Smith BM: Use of auricular cartilage in the repair of orbital floor defects. Oral Surg Oral Med Oral Path01 74:719, 1992 19. Wiesenbaugh JM, Beil MC: Orbital floor repair with nasal septal cartilage, in Kaye LW (ed): Transactions of the Fourth International Conference on Oral Surgery. Copenhagen, Munskgaard, 1973, pp 308-309
Repair of Traumatic Orbital Wall Defects With Nasal Sep tal Cartilage: Report of Five Cases KASEY K. LI, DDS, MD* Purpose: This article reports the use of nasal septal cartilage for the repair of traumatic orbital wall defects. Patients and Methods: Five patients with disruption of the orbital wall after facial trauma were included in this retrospective review. All of the patients underwent open reduction with internal fixation of the fractures as well as repair of the orbital wall defect with autogenous septal cartilage. Results: Nasal septal cartilage was used in four cases of orbital floor defect and one case of orbital roof defect. All of the cases were successfully treated by restoration of the orbital wall continuity. Conclusion: Nasal septal cartilage is a readily accessible autogenous material that can be easily harvested with minimal donor site morbidity, and it should be considered when an autogenous orbital implant is needed for the repair of a traumatic orbital wall defect.
Unrepaired orbital wall defects after facial fractures can result in enophthalmos and diplopia because of increased orbital volume, herniation of orbital contents, and atrophy of herniated fat and muscle. Therefore, restoration of orbital wall defects is often recommended.lz2 When considering a grafting material for orbital reconstruction, autogenous bone remains the preferred choice for most oral and maxillofacial surgeons, despite the availability of various alloplastic materials,3-6 because of the potential risk of infection and extrusion with the latter. The ilium, rib, and calvarium are the preferred donor sites for autogenous bone. Although bone grafts can be easily harvested from these sites, each has associated morbidity. The procurement of iliac bone can result in adynamic ileus, prolonged postoperative pain, and restricted ambulation, as well as major complications such as arteriovenous fistula and ureteral injury.7-9 The rib is easy to work with because of its malleability;
however, rib harvesting can be associated with pleuritic pain and pneumothorax.93’0 The calvarium remains popular for bone grafting of the maxillofacial region because of its resistance to remodeling and resorption,” as well as the elimination of a second operative field. However, cranial bone harvesting can be associated with serious complications, including cerebral penetration, meningitis, subdural hematoma, laceration of the sagittal sinus, and permanent brain injury.‘2313 Cartilage from the ear concha and the nasal septum are excellent alternative sources of autogenous tissue. Autogenous cartilage has been shown both experimentally and clinically to incorporate with host tissue and resist resorption and deformation.‘4”5 Although the use of nasal septal cartilage and auricular cartilage for the reconstruction of the orbital floor has been previously described,16-19 they have received relatively little attention compared with bone grafts. This report describes five cases in which nasal septal cartilage was used in the reconstruction of traumatic orbital wall defects.
Received from the Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, CA. * Clinical Instructor. Address correspondence and reprint requests to Dr Li: Facial Reconstructive Surgery, 750 Welch Rd, Suite 317, Palo Alto, CA 94304. 0 1997 American
Association
of Oral and Maxillofacial
Patient
Selection
Ideally, the nasal septal cartilage graft should be harvested only in patients with minimal septal deviation and no spurs or turbinate hypertrophy to achieve rapid procurement of the graft. In patients with a his-
Surgeons
0278-2391/97/5510-0009$3.00/O
1098
KASEY
LI
tory of previous nasal surgery, septal perforation, and nasal symptoms such as crusting, obstruction, epistaxis, or discharge, septal cartilage harvest is contraindicated because the procedure may potentially complicate the patient’s preexisting nasal symptoms or future treatment. Concomitant facial injury involving the nasal structures, including Le Fort fractures and nasal/ nasoethmoidal fractures, are also contraindications. Patients
and Methods
Four men and one woman with a mean age of 25 years (range, 18 to 34 years) and with facial fractures associated with orbital wall disruption were treated by using autogenous nasal septal cartilage. The graft was obtained by a hemitransfixation incision after injection with 1% lidocaine containing 1: 100,000 epinephrine for vasoconstriction. Mucoperichondrial flaps were elevated bilaterally to expose the quadrangular cartilage. Mucoperiosteal flaps were also elevated over the vomer and the maxillary crest to provide maximum exposure. A vertical incision was made at approximately 1.5 cm posterior to the caudal border of the quadrangular cartilage. A second cartilagenous incision was then made paralleling the nasal dorsum at 1.5 cm below the nasal dorsum. The septal cartilage was harvested by disarticulating it from the maxillary crest, the vomer, and the perpendicular plate of the ethmoid bone, while preserving an L-shaped strut for structural support of the nose (Fig 1). The hemitransfixation incision was closed with several interrupted 4-O chromic catgut sutures. The mucoperichondrial flaps were adapted using a 4-O plain septal catgut suture on a small straight needle in a mattress fashion, thus eliminating the need for nasal packing. There were two isolated zygomatic complex fractures (orbital floor defect), two pure blowout fractures (with an orbital floor defect), and one supraorbital rim fracture (orbital roof defect) treated. All of the orbital wall defects were larger than 1 X 1 cm. The indications for surgical repair of the fractures included facial asymmetry, diplopia, decreased extraocular movement, and enophthalmus. An existing laceration was used in one patient (supraorbital rim fracture) (Fig 2), a transconjunctival (preseptal) approach without lateral canthotomy was used in two patients (pure blowout fractures) (Fig 3), and a transconjunctival (preseptal) approach with lateral canthotomy was used in two patients (zygomatic complex fractures). The orbital floor defects were repaired by placing the graft so that the intact orbital wall served as a stable platform. The weight of the orbital contents provided stabilization of the graft, thus eliminating the need of fixation. In addition, being an autogenous graft, tissue ingrowth occurs within days, which further ensures stability of the graft. The orbital roof defect was reconstructed in
FIGURE 1. A, Area of septal cartilage harvest (arrow). It is important to preserve a minimum of 1.5 cm of dorsal and caudal cartilage to maintain nasal support. B, View of septal cartilage graft.
a similar fashion by placing the graft inside the orbit between the orbital contents and the roof to prevent herniation of the orbital content into the frontal sinus. A successful outcome was defined as a stable reduction of the fracture with repair of the orbital wall disruption and restoration of normal facial appearance and eye function. Results Five autogenous nasal septal cartilage grafts were placed in five patients with significant orbital wall defects (> 1 cm) resulting from trauma. The average follow-up was 4 months (range, 3 to 5 months). All patients were successfully reconstructed with restoration of the orbital wall continuity. There were no graft infections, exposures, or extrusions, and there were no donor site complications. The only complication encountered was mild scleral show in a patient with a zygomatic complex fracture and large orbital floor de-
1100
REPAIR OF ORBITAL
DEFECTS WITH NASAL
SEPTAL CARTILAGE
FIGURE 2. A, Coronal CT scan showing disruption of the orbital roof (arrow). B, Supraorbital rim fracture exposed through an existing laceration. Note the herniation of the periorbita through the orbital roof defect (arrow) and the nasal septal cartilage graft. C, Graft placed over the roof defect (arrow). D, Postoperative radiograph.
feet (2 x 2 cm) that was approached with a transconjunctival approach with lateral canthotomy. Discussion When an autogenousimplant is desiredfor reconstruction of traumatic orbital wall defects, nasal septal cartilage offers several advantages.It is readily accessibleby the standardsubmucousresectiontechnique and is easier to harvest than cranial bone. In addition, the harvesting of nasal septalcartilage is associatedwith minimal risks
when meticuloussurgicaltechnique is executed, although potential complications,including hemorrhage,infection, septalhematoma,septalperforation, and saddlenosedeformity, can occur. These complications are all minor when compared with the potential complications of autogenousbone harvest. Furthermore, septal cartilage harvest doesnot leave a visible scar or palpable donor site defect and, if a mattresssuture closure is used to adapt the septalmucosaafter the submucousresection,the need for nasalpacking is eliminated. Another advantage of nasal septal cartilage is that
KASEY
LI
1101
FIGURE 3. A, Coronal CT scan showing disruption of the orbital floor (an-ow). B, Orbital floor exposed by a transconjunctival (preseptal) approach. The nasal septal cartilage graft has been placed (arrow). C, Postoperative CT scan.
it is easily manipulated, and its inherent resilience can be used for firm support or contouring. By placing partial-thickness cuts over its surface, it can be shaped into the natural curvature of the orbital wall within
minutes. This is considerably simpler than shaping a bone graft, where osteotomies and fixation of the segments with microplates are often needed to create the desired curvature. Furthermore, nasal septal cartilage
1102
REPAIR
grafts measuring 2 X 2.5 cm can be reliably obtained, which is usually a sufficient size to repair the orbital wall defect. The use of an autogenous cartilage graft in traumatic orbital wall repair is also scientifically sound. Experimental evidence suggests that such a graft is rapidly incorporated by the host tissue, especially when the perichondrium is left intact, and it maintains most of its initial volume and integrity years after transplantation.14 Clinically, the success of its use in nasal reconstruction is irrefutable. When compared with auricular cartilage, nasal septal cartilage is easier to harvest, offers a slightly larger graft, is easier to shape and contour, and provides better structural support. Therefore, this donor site should be considered when an autogenous graft is needed for reconstruction of traumatic orbital wall defects. References 1, Manson PN, Clifford CM, Su CT, et al: Mechanisms of global support and posttraumatic enophthalmos: I. The anatomy of the ligament sling and its relation to intramuscular cone orbital fat. Plast Reconstr Surg 77:193, 1986 2. Manson PN, Grivas A, Rosenbaum A, et al: Studies on enophthalmos: II. The measurement of orbital injuries and their treatment by quantitative computed tomography. Plast Reconstr Surg 77:203, 1986 3. Burres SA, Cohn AM, Mathog RH: Repair of orbital blowout fractures with Marlex mesh and Gelfilm. Laryngoscope 91:1881, 1981 4. Morrison AD, Sanderson RC, Moos DF: The use of silastic as an orbital implant for reconstruction of orbital wall defects: Review of 3 11 cases treated over 20 years. J Oral Maxillofac Surg 53:412, 1995
OF ORBITAL
DEFECTS
WITH
NASAL
SEPTAL
CARTILAGE
5. Rozema FR, Bos RRM, Pennings AJ, et al: Poly (L-Lactide) implants in repair of defects of the orbital floor. J Oral Maxillofac Surg 48:1305, 1990 6. Sargent LS, Fulks KD: Reconstruction of internal orbital fractures with vitallium mesh. Plast Reconstr Surg 88:31, 1991 7. James JD, Geist ET, Gross BD: Adynamic ileus as a complication of iliac bone removal: Report of two cases. .I Oral Surg 39:289, 1981 8. Marx ER, Morales MJ: Morbidity from bone harvest in major jaw reconstruction: A randomized trial comparing the lateral anterior and posterior approaches to the ilium. J Oral Maxillofat Surg 46:196, 1988 9. Laurie SW, Kaban LB, Mulliken JB: Donor site morbidity after harvesting rib and iliac bone. Plast Reconstr Surg 73:933, 1984 10. Whitaker LS, Munro IR, Saler KE, et al: Combined report of problems and complications in 793 craniofacial operations. Plast Reconstr Surg 64:198, 1979 11. Zins JE, Whitaker LA: Membranous versus endochondral bone: Implications for cranial facial reconstruction. Plast Reconstr Surg 72:778, 1983 12. Kline RM, Wolfe SA: Complications associated with the harvesting of cranial bone grafts. Plast Reconstr Surg 95:5, 1995 13. Frodel JL, Marentette LJ, Quatela VC, et al: Calvarial bone graft harvest: Techniques, considerations, and morbidity. Arch Otolaryngol Head Neck Surg 119:17, 1993 14. Motoki DS, Mulliken JB: The healing of bone and cartilage. Clin Plast Surg 17:527, 1990 15. Sheen JH: Secondary rhinoplasty. Plast Reconstr Surg 56:137, 1975 16. Stark RB, Frileck SP: Conchal cartilage grafts in augmentation rhinoplasty and orbital floor fractures. Plast Reconstr Surg 43:591, 1969 17. Constantian MB: Use of auricular cartilage in orbital floor reconstruction. Plast Reconstr Surg 69:951, 1982 18. Hendler BH, Gateno J, Smith BM: Use of auricular cartilage in the repair of orbital floor defects. Oral Surg Oral Med Oral Path01 74:719, 1992 19. Wiesenbaugh JM, Beil MC: Orbital floor repair with nasal septal cartilage, in Kaye LW (ed): Transactions of the Fourth International Conference on Oral Surgery. Copenhagen, Munskgaard, 1973, pp 308-309