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Mandibular Fractures
P30
Otolaryngology-Head and Neck Surgery, Vol 139, No 2S1, August 2008
Facial Plastic and Reconstructive Surgery 3D CT for Diagnosis of Facial/Mandibular Fractures Paul Schalch, MD (presenter); Jason H Kim, MD OBJECTIVE: To describe how the use of 3-D reformatted computer tomographic (CT) images increases the accuracy of diagnosis of facial and mandibular fractures and influences surgical planning. METHODS: Retrospective review of 20 patients with facial and/or mandibular fractures between 2005 and 2006, diagnosed with CT facial bones (axial and coronal images and 3-D renderings). The study was conducted at a university- affiliated institution. Standard CT facial bones protocol consisting of 1.5mm contiguous axial and coronal sections were performed on a 40-slice scanner (Philips Medical Systems, Cleveland, OH). 3-D reconstructions were then obtained. Scans were reviewed by the consulting surgeon. Pre-operative diagnoses were confirmed intraoperatively. RESULTS: Patient mean age was 31 years (17-46). Preoperative diagnoses included: 18 mandible fractures, 8 zygomatico-maxillary/orbital floor, and 4 midface fractures. Mechanisms of injury included assault, motor-vehicle accidents, sports- and work-related injuries, and falls. Diagnosis and surgical planning was influenced in 1/3 of fractures after reviewing 3-D reformatted images. 3-D reformatting did not add any cost to the CT scans performed, did not expose patients to additional radiation, nor did it significantly increase the time to obtain the study. CONCLUSIONS: 3-D CT reformatting is an inexpensive, easy-to-obtain diagnostic imaging modality that increases the accuracy of diagnosis and helps improve planning of surgical repair of facial and mandibular fractures. Anterolateral Thigh Flap for Skull Base Reconstruction Matthew M Hanasono, MD (presenter); Neha Goel MD; Martina Ayad, MD; Roman Skoracki; Justin Michael Sacks, MD OBJECTIVE: 1) Review our experience with the anterolateral thigh (ALT) free flap in skull base reconstruction. 2) Describe reconstructive techniques for skull base defects and dural coverage with simultaneous facial reanimation. METHODS: A retrospective review was performed for 25 consecutive patients with defects of the skull base who were reconstructed with the ALT free flap. RESULTS: Reconstructed sites consisted of 2 anterior, 7 lateral, and 16 posterior skull base defects. Neoadjuvant and adjuvant radiotherapy (RT) was administered to 32% and 36% of the patients, respectively. The overall complication rate was 36% (66% recipient site and 34% donor site). One patient developed a CSF leak and one a nasocutaneous fistula. RT was
associated with a two-fold increase in wound complications relative to controls. There were no flap losses and no long-term donor site probleMS 3 nerve grafts using the lateral femoral cutaneous nerve and 12 static slings for facial reanimation using the tensor fascia lata were performed simultaneously with free flap reconstruction from the same donor site. 4 gold eyelid weights, 2 lateral canthoplasties, and 3 direct browlifts were also performed simultaneously. CONCLUSIONS: The ALT free flap provides reliable and versatile reconstruction of skull base defects. Primary advantages of this flap reside in the ability to harvest variable amounts of skin and vastus lateralis muscle along with nerve and fascial grafts from the same operative site, minimizing operative time and donor site morbidity. In our practice, the ALT flap represents a first-line option for composite skull base defects. Endonasal Access to the Orbital Floor for Blowout Fractures Yasuyuki Hinohira, MD, PhD (presenter); Atsushi Shiraishi, MD, PhD; Naohito Hato, MD; Masahiro Komori, MD OBJECTIVE: 1) Describe how to endonasally access the inferior orbital wall for the reduction surgery using endoscope. 2) Show the usefulness of the endoscopic endonasal approach for alternative to the current approaches. METHODS: Between 1997 and 2007, 41 patients with isolated inferior blowout fractures not involving the medial wall underwent surgery. The surgical treatment was determined due to persisting diplopia for 2 to 4 weeks after the trauma. In 38 of the 41 patients the reduction surgery was completed using only the endoscopic endonasal approach. To achieve the endoscopic endonasal reduction surgery, via the middle nasal meatus, septoplasty was supplemented in 7 patients and submucous conchotomy in 36. In 16 patients the inferior antrostomy was additionally required to reach the fracture site. The bone fragments entrapping the orbital content were carefully removed. An ophthalmologist verified the ocular motility improvement by eye traction test. No permanent supporting material except temporary balloon fixation was used. RESULTS: No surgical complications were encountered in any of the patients. Postoperatively, diplopia disappeared in 32 of the 35 patients (91.4%) followed over 6 months. No patients complained of postoperative buccal paresthesia or enophthalmos. CONCLUSIONS: An endoscopic endonasal reduction surgery for isolated blowout fractures has so far been considered as technically difficult. Our procedure to access the inferior orbital wall comprise sinonasal surgery techniques that have been conventionally used. We conclude that the endoscopic endonasal approach can be an alternative to the extranasal methods because of safety and usefulness.
Otolaryngology-Head and Neck Surgery, Vol 139, No 2S1, August 2008
Facial Plastic and Reconstructive Surgery 3D CT for Diagnosis of Facial/Mandibular Fractures Paul Schalch, MD (presenter); Jason H Kim, MD OBJECTIVE: To describe how the use of 3-D reformatted computer tomographic (CT) images increases the accuracy of diagnosis of facial and mandibular fractures and influences surgical planning. METHODS: Retrospective review of 20 patients with facial and/or mandibular fractures between 2005 and 2006, diagnosed with CT facial bones (axial and coronal images and 3-D renderings). The study was conducted at a university- affiliated institution. Standard CT facial bones protocol consisting of 1.5mm contiguous axial and coronal sections were performed on a 40-slice scanner (Philips Medical Systems, Cleveland, OH). 3-D reconstructions were then obtained. Scans were reviewed by the consulting surgeon. Pre-operative diagnoses were confirmed intraoperatively. RESULTS: Patient mean age was 31 years (17-46). Preoperative diagnoses included: 18 mandible fractures, 8 zygomatico-maxillary/orbital floor, and 4 midface fractures. Mechanisms of injury included assault, motor-vehicle accidents, sports- and work-related injuries, and falls. Diagnosis and surgical planning was influenced in 1/3 of fractures after reviewing 3-D reformatted images. 3-D reformatting did not add any cost to the CT scans performed, did not expose patients to additional radiation, nor did it significantly increase the time to obtain the study. CONCLUSIONS: 3-D CT reformatting is an inexpensive, easy-to-obtain diagnostic imaging modality that increases the accuracy of diagnosis and helps improve planning of surgical repair of facial and mandibular fractures. Anterolateral Thigh Flap for Skull Base Reconstruction Matthew M Hanasono, MD (presenter); Neha Goel MD; Martina Ayad, MD; Roman Skoracki; Justin Michael Sacks, MD OBJECTIVE: 1) Review our experience with the anterolateral thigh (ALT) free flap in skull base reconstruction. 2) Describe reconstructive techniques for skull base defects and dural coverage with simultaneous facial reanimation. METHODS: A retrospective review was performed for 25 consecutive patients with defects of the skull base who were reconstructed with the ALT free flap. RESULTS: Reconstructed sites consisted of 2 anterior, 7 lateral, and 16 posterior skull base defects. Neoadjuvant and adjuvant radiotherapy (RT) was administered to 32% and 36% of the patients, respectively. The overall complication rate was 36% (66% recipient site and 34% donor site). One patient developed a CSF leak and one a nasocutaneous fistula. RT was
associated with a two-fold increase in wound complications relative to controls. There were no flap losses and no long-term donor site probleMS 3 nerve grafts using the lateral femoral cutaneous nerve and 12 static slings for facial reanimation using the tensor fascia lata were performed simultaneously with free flap reconstruction from the same donor site. 4 gold eyelid weights, 2 lateral canthoplasties, and 3 direct browlifts were also performed simultaneously. CONCLUSIONS: The ALT free flap provides reliable and versatile reconstruction of skull base defects. Primary advantages of this flap reside in the ability to harvest variable amounts of skin and vastus lateralis muscle along with nerve and fascial grafts from the same operative site, minimizing operative time and donor site morbidity. In our practice, the ALT flap represents a first-line option for composite skull base defects. Endonasal Access to the Orbital Floor for Blowout Fractures Yasuyuki Hinohira, MD, PhD (presenter); Atsushi Shiraishi, MD, PhD; Naohito Hato, MD; Masahiro Komori, MD OBJECTIVE: 1) Describe how to endonasally access the inferior orbital wall for the reduction surgery using endoscope. 2) Show the usefulness of the endoscopic endonasal approach for alternative to the current approaches. METHODS: Between 1997 and 2007, 41 patients with isolated inferior blowout fractures not involving the medial wall underwent surgery. The surgical treatment was determined due to persisting diplopia for 2 to 4 weeks after the trauma. In 38 of the 41 patients the reduction surgery was completed using only the endoscopic endonasal approach. To achieve the endoscopic endonasal reduction surgery, via the middle nasal meatus, septoplasty was supplemented in 7 patients and submucous conchotomy in 36. In 16 patients the inferior antrostomy was additionally required to reach the fracture site. The bone fragments entrapping the orbital content were carefully removed. An ophthalmologist verified the ocular motility improvement by eye traction test. No permanent supporting material except temporary balloon fixation was used. RESULTS: No surgical complications were encountered in any of the patients. Postoperatively, diplopia disappeared in 32 of the 35 patients (91.4%) followed over 6 months. No patients complained of postoperative buccal paresthesia or enophthalmos. CONCLUSIONS: An endoscopic endonasal reduction surgery for isolated blowout fractures has so far been considered as technically difficult. Our procedure to access the inferior orbital wall comprise sinonasal surgery techniques that have been conventionally used. We conclude that the endoscopic endonasal approach can be an alternative to the extranasal methods because of safety and usefulness.