- Email: [email protected]
An extended transcaruncular approach for naso-orbito-ethmoid and Le Fort II fracture repair
Accepted Manuscript An extended transcaruncular approach for naso-orbito-ethmoid and Le Fort II fracture repair Atsushi Imaizumi, MD, Kunihiro Ishida, MD, Osamu Nishizeki, MD PII:
S1010-5182(16)30211-6
DOI:
10.1016/j.jcms.2016.09.006
Reference:
YJCMS 2483
To appear in:
Journal of Cranio-Maxillo-Facial Surgery
Received Date: 14 February 2016 Revised Date:
9 August 2016
Accepted Date: 19 September 2016
Please cite this article as: Imaizumi A, Ishida K, Nishizeki O, An extended transcaruncular approach for naso-orbito-ethmoid and Le Fort II fracture repair, Journal of Cranio-Maxillofacial Surgery (2016), doi: 10.1016/j.jcms.2016.09.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title page
ACCEPTED MANUSCRIPT
An extended transcaruncular approach for naso-orbito-ethmoid and Le Fort II fracture repair
1
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Atsushi Imaizumi MD1, Kunihiro Ishida MD1, Osamu Nishizeki MD2
Department of Plastic Surgery, Prefectural Okinawa Chubu Hospital, Aza Miyazato 281,
Uruma City, Okinawa, Japan, 904-2243
Department of Plastic and Reconstructive Surgery, Prefectural Nanbu Medical Center/ Child
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2
Medical Center, Aza Arakawa 118-1, Haebaru Town, Shimajiri County, Okinawa, Japan,
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901-1193
Corresponding author: Atsushi Imaizumi, MD
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Department of Plastic Surgery, Prefectural Okinawa Chubu Hospital, Okinawa, Japan, Aza Miyazato 281, Uruma city, Okinawa, Japan, 904-2293 Tel: +81-98-973-4111, FAX: +81-98-974-5165
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e-mail:[email protected]
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Conflicts of interest: none
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INTRODUCTION
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Summary
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Naso-orbito-ethmoid (NOE) fractures are relatively rare fractures, representing less than 5% of pediatric and 15% of adult facial fractures (Liau et al., 2011; Rosenberger et al.,
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2013). Markowitz et al. classified NOE fractures into three types, based on the status of the medial canthal tendon, the tendon-bearing bone segment, and the fracture pattern (Markowitz et al., 1991). The vast majority are type I, with types II and III occurring much less frequently (Markowitz et al., 1991; Nguyen et al., 2010). Although recent
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advancements in computed tomography (CT) have enabled the diagnosis of these fracture types in greater detail, surgical access to the fracture around the upper nasofrontal buttress in NOE and Le Fort II fractures has remained unchanged over the past several decades. All
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of these approaches have required either local or coronal incisions (Lynch, 1921; Converse and Hogan, 1970; Bowerman et al., 1985; Manson, 1990; Manson, 2006), with resultant
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criticism due to the potential for scar formation, webbing, or other sequelae (Wolfley, 1985; Manson; 1990; Balch et al., 1998; Garcia et al., 1998; Shorr et al., 2000; Choi and Flores, 2012). For an uncomplicated NOE fracture, such as type I, a local incision around the medial orbit alone usually provides sufficient exposure of the fracture and operative field (Manson; 1990). In spite of several modifications, the above-mentioned resultant shortcomings of the cutaneous approach have remained unsolved, especially in our Oriental
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population with a broad and shallow nasal bridge (Wolfley, 1985; Katowitz et al., 1987; Neel et al., 1987; Choi and Flores, 2012).
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A transcaruncular approach was first introduced in 1997 as an approach for optic
canal decompression (Kuppersmith et al., 1997). Soon afterwards, it was also applied to
access the medial orbit and medial orbital wall fractures (Balch et al., 1998; Garcia et al.,
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1998). Subsequently this approach gained popularity for its direct and predictable access to the medial orbit, for eliminating cutaneous scars in the central area of the face, and for its
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limited morbidity (Shorr et al., 2000; Rodriguez et al., 2009; Choi and Flores, 2012; Morris et al., 2014).
With these drawbacks of cutaneous approaches in mind, the authors set out to apply the transcaruncular approach to the repair of upper nasofrontal buttress fractures. The
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purpose of this study is to report our experience and outcomes using an extended transcaruncular approach for the treatment of NOE and Le Fort II fractures.
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MATERIALS AND METHODS
We reviewed the clinical records of all patients seen between October 2012 and
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October 2015 who had undergone open reduction and internal fixation of NOE and Le Fort II fractures with the upper nasofrontal buttress repaired through an extended transcaruncular approach. Institutional review board approval was obtained. NOE and Le Fort II fractures that showed obvious displacement on CT scans were included. Clinical records were analyzed, looking for the occurrence of complications, CT scan findings of postoperative asymmetry in cases involving unilateral fractures, and any obvious
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deformities in cases involving bilateral fractures. Complications were defined as major if surgical intervention was required and minor if surgical intervention was not required.
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All surgeries were performed with the patients under general anesthesia. The
approach to the upper nasofrontal buttress via an extended transcaruncular incision is
similar to that of the medial orbital wall fractures up to the point of the periorbital incision.
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The technique of the transcaruncular approach has been well described previously (Shorr et al., 2000; Ellis and Zide, 2006). Therefore, our extension of the technique, starting from the
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point of the periorbital incision, will be delineated.
After establishing the preseptal route between the orbital septum and Horner’s muscle through the caruncle toward the posterior side of the posterior lacrimal crest, a Ragnell and a malleable retractor were inserted to retract the incised caruncle medially and the orbital
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contents laterally. The periorbita behind the posterior lacrimal crest was incised vertically with a scalpel (Fig. 1 and Fig.2, above, left). This incision was extended superomedially along the medial orbital rim by repeating the following procedure: elevating the periorbita
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of the medial orbital rim with a sharp-tipped periosteal elevator, then cutting it with a sharp pointed scissors, thereby obtaining a sufficient operative field extending from the posterior
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lacrimal crest where the posterior limb of the medial canthal tendon inserts, superiorly up to an 11 o’clock position of the left globe or up to a 1 o’clock position of the right globe along the medial orbital rim (Fig. 1, Fig. 2, above, right, below, left). While establishing exposure of the fracture site, care was taken not to pull the upper eyelid too much in order not to violate the insertion of the posterior limb of the medial canthal tendon. Combined with a transconjunctival lower eyelid and an upper gingival buccal sulcus incision, the fracture
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was reduced and fixed with plates (Fig. 2, below, right). Medial continuation of the superior orbital ridge served as a guide for alignment of the upper nasofrontal buttress (Fig. 1).
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Adequate fixation of the fracture in the upper nasofrontal buttress was accomplished with a plate holding at least one screw on one side of fracture and two on the other side. When an absorbable plate was used in the pediatric case, only one screw on each side of fracture was
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able to be placed. The following combinations of plates and screws were used for repair of the upper nasofrontal buttress: 0.6-mm-thick titanium plates and 1.5-mm-diameter screws
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in the adult cases and 0.9-mm-thick absorbable plates and 1.5-mm-diameter screws in the pediatric case. The periorbita was closed with 5-0 polydioxanone suture where possible, and the conjunctiva was closed with 7-0 polyglactin suture.
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RESULTS
Eight patients (six male and two female), with a mean age of 32 years, underwent NOE and Le Fort II fracture repairs using an extended transcaruncular approach. Two of
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the patients had Le Fort II fractures and six had NOE fractures. Of the six NOE fractures, all were classified as type I, two were bilateral, and four were unilateral. Therefore, this
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approach was applied to a total of 12 orbits. The inferior oblique muscle was left untouched in all cases. Concomitant fractures and injuries are summarized in Table 1. All but one fracture repair was accomplished via an extended transcaruncular
approach without making any skin incision. Because the right medial orbital rim was comminuted and unstable, case 7 required an additional small skin incision on the glabella to fix the cranial part of the plate on the frontal bone.
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The types of plates used for the upper nasofrontal buttress fixation were as follows: a three-hole absorbable plate for the pediatric NOE fracture (case 1), five-hole titanium plates
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for two of the NOE fractures (cases 3 and 5), seven-hole and four-hole titanium plates in one of the Le Fort II fractures (case 7), and three-hole titanium plates in the rest of the cases.
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The mean follow-up period was 248 days, with a range of 21 to 537 days. The final postoperative CT scan was taken an average of 170 days after surgery, with a range of 2 to
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274 days. On postoperative CT scan, all cases showed excellent alignment of the fracture repair with no deformity along the upper nasofrontal buttress or inferior orbital rim. One minor and five major complications occurred in five orbits of three cases. Of these, one minor and two major complications in two cases (case 1 and 6) were attributed to
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the extended transcaruncular approach. Case patient 1 developed trichiasis on the center of her right lower eyelid (Fig. 3, below, right). Case patient 6 experienced asymptomatic granulomas over the bilateral caruncles. These were excised concurrently with removal of
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the exposed plate for palatal fracture repair (Fig. 4). Case patient 3 experienced inadvertent right lower eyelid lacrimal canalicular transection during the repair of a severe
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zygomaticomaxillary complex fracture and also developed bilateral cicatricial entropion over the transconjunctival lower eyelid incisions. These were considered to be a consequence of excessive traction over the lower eyelids when repairing the fractures around the fronto-zygomatic sutures via the extended transconjunctival incision (see Slideshow, Supplemental Digital Content 1, describing details of case 3).
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Case 1 A 7-year-old girl was referred to us for treatment of bilateral type I NOE fractures
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(Fig. 3, above, left). Using the extended transcaruncular approach combined with
transconjunctival lower eyelid and upper gingival buccal sulcus incisions, the bilateral NOE fractures on the upper nasofrontal buttress were adequately exposed. Displacement of the
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fracture on the upper nasofrontal buttress on the left side was minimal and stable after
reduction. Therefore, only the inferior orbital rim required fixation (Fig. 2, above, right).
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The right upper nasofrontal buttress fracture and the right inferior orbital rim fracture were reduced and fixed (Fig. 2, below, left and right). Because an absorbable plate is larger than a titanium one, and because of the relatively narrow operative field, a three-hole absorbable plate was used for the upper nasofrontal buttress fixation with only a single screw on each
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side of the fracture, with the middle hole above the fracture remaining empty. Similarly, fractures of the inferior orbital rim and the piriform aperture were fixed with absorbable plates. Postoperative CT showed good alignment of both NOE fracture sites (Fig. 3, above,
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right). Although she developed mild trichiasis on the right lower eyelid, which did not require any treatment, the clinical appearance of her medial canthal area 1 year after
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surgery appeared symmetric and natural (Fig. 3, below, left, right).
Case 4
A 52-year-old woman presented with a left NOE type I, left inferior orbital rim and
orbital floor fractures (Fig. 5, center, left). An extended transcaruncular approach was used for the NOE fracture repair. The upper nasofrontal buttress was fixed using a three-hole
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titanium plate, with two screws for the cranial side of the fracture and one screw for the caudal side harboring the medial canthal tendon (Fig. 5, above, left, and right). The other
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fractures were also repaired with titanium plates, but an absorbable plate was used for the orbital floor. Postoperative CT showed good alignment of the left upper nasofrontal
buttress. The clinical appearance of the medial canthal area was symmetric without any
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apparent complications (Fig. 5, center, right, and below).
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Case 7
A 35-year-old man presented with Le Fort I and II fractures as well as a fracture of the anterior wall of the frontal sinus (Fig. 6, above, left). Fracture repair of the left upper nasofrontal buttress was accomplished via an extended transcaruncular approach using a
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four-hole titanium plate. However, because of comminution of the right medial orbital rim at the 1 o’clock position, in addition to the extended transcaruncular incision, a small skin incision on the glabella was necessary to fix the cranial part of the plate onto the stable part
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of the frontal bone (Fig. 6, center, left). The short limb of the L-shaped plate was fixed to the caudal segment with two screws via the extended transcaruncular approach (Fig. 6,
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center, right). The long limb of the L-shaped plate was fixed to the stable frontal bone with two screws using this small skin incision on the glabella. Postoperative CT scan showed natural alignment of the upper nasofrontal buttress (Fig. 6, above, right). A small incision on the glabella was inconspicuous (Fig. 6, below).
DISCUSSION
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NOE fracture is a relatively rare facial fracture, which, if not treated properly, runs a risk of leaving an obvious deformity over the central part of the face (Manson, 1990; Liau
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et al., 2011; Rosenberger et al., 2013). Markowitz et al classified NOE fractures into three types and assigned approaches accordingly (Markowitz et al., 1991). Recent advancements in CT scan have enabled us to diagnose these fracture types in greater detail, allowing the
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most appropriate mode of treatment to be chosen. However, despite these advancements in CT, surgical approaches to the areas around the upper nasofrontal buttress in the NOE or Le
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Fort II fractures have remained largely unchanged. All of these approaches require skin incisions and have been criticized due to resultant scar formation, webbing, or other sequelae (Wolfley, 1985; Manson, 1990; Balch et al., 1998; Garcia et al., 1998; Shorr et al., 2000; Choi and Flores, 2012). Among the various cutaneous approaches, a local incision
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around the medial orbit is indicated for uncomplicated NOE fractures, whereas a coronal incision remains the gold standard. Although a coronal approach provides a wide surgical field with the potential for simultaneous calvarial bone graft harvest for associated nasal
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deformity correction, we regard this approach as too invasive for repair of simple NOE fractures because it requires a large incision; it risks leaving scalp numbness, hair loss, flap
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hematoma, and frontalis palsy; and it is time consuming (Manson, 2006). In spite of several modifications, local cutaneous approaches to the upper nasofrontal buttress are also not free of drawbacks, and carry the risk of disfiguring scar formation, webbing, and other sequelae. This is especially a problem in our Oriental population with a broad, shallow nasal bridge (Wolfley, 1985; Katowitz et al., 1987; Neel et al., 1987; Manson, 1990; Balch et al., 1998; Garcia et al., 1998; Shorr et al., 2000; Choi and Flores, 2012).
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A transcaruncular approach is free of these drawbacks of cutaneous approaches. A transcaruncular approach is now widely used in surgery of the medial orbit. Furthermore, it
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can be easily combined with a lower eyelid transconjunctival incision to provide continuous uninterrupted access to both the inferior and medial orbit (Balch et al., 1998; Garcia et al., 1998; Shorr et al., 2000; Rodriguez et al., 2009; Choi and Flores, 2012; Morris et al.,
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2014). When applying a transcaruncular approach to the repair of the upper nasofrontal
buttress in NOE or Le Fort II fractures, four possible concerns arise. The first is whether an
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adequate surgical field can be obtained without violating the posterior limb of the medial canthal tendon. The second is whether rigid fixation can be achieved. The third is the potential morbidity of this approach, and the fourth is whether this approach can be applied to complex NOE fractures, such as type II and III.
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Regarding the first concern, Kakizaki et al showed that dissection via a transcaruncular incision could be safely performed up to the 11 o’clock position (the location of the trochlea) (Kakizaki et al., 2007). Most of the fractures in our cases were
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located around the fronto-maxillary suture (approximately 10 o’clock on the left globe and 2 o’clock on the right globe). Even the superior-most fracture in our cases (case 3), which
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was around the 11 o’clock position of the left globe, was satisfactorily repaired via the extended transcaruncular approach. Our approach enabled repair of fractures along the nasofrontal buttress as high as 11 o’clock on the left globe and 1 o’clock on the right without compromising the integrity of the medial canthal tendon, as long as the medial orbital rims around 11 o’clock on the left globe or 1 o’clock on the right were not comminuted. Case 7 required a small additional skin incision on the glabella because of
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instability for plate fixation on the comminuted right medial orbital rim at the 1 o’clock position. As most of the procedure had already been accomplished via the extended
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transcaruncular approach at that point, it was believed that it would be least invasive just to make a small incision in order to drill and place screws into the frontal bone. Although an additional small skin incision was required, compared to conventional skin incisions for
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NOE fracture repair, it was very small and inconspicuous (Fig. 6, below).
All of our cases of NOE fracture were type I, the uncomplicated type. Accurate
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three-dimensional repositioning of the fractures was achieved without difficulty in all cases, leading to successful results. Since the vast majority of NOE fractures are type I (Markowitz et al., 1991; Nguyen et al., 2010), we therefore believe that most NOE fractures can be successfully repaired using our approach instead of conventional cutaneous
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approaches.
Similarly, our approach can be successfully applied to cases with Le Fort II fractures (see Figure, Supplemental Digital Content 2, which shows details of case 6 with Le Fort II
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fracture (above, left and right), CT scan findings before and after surgery (below, left), and intraoperative ultrasonographic findings showing accurate reduction of the fracture
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(arrowhead) between the frontal (*) and the nasal bone (#) in the mid-sagittal plane (below, right). Clinical results 11 months after surgery are shown. It should be noted that the caruncular granulations have been resected. As for the second concern, rigid fixation appears to be well achieved using the
extended transcaruncular approach. This is supported by the postoperative CT findings, which show no displacement of any fracture segment, even in case 1 in which only two
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screws were used for the nasofrontal buttress fracture plate. The only functional force acting on the fracture segment bearing the medial canthal tendon is that exerted by the
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obicularis oculi muscle (Antonyshyn and Hurwitz, 1996). Therefore, microplate systems
with one screw on one fragment and two screws on the other are considered sufficient for fixation in this area, which has little torque load.
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As to the third concern, the potential for morbidity with this approach, among
repairs to 12 orbits in eight patients we experienced two major and one minor complication
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in three orbits of two patients, which directly related to the extended transcaruncular approach. Case 6 developed asymptomatic bilateral granulomas over the caruncles requiring excision. This might be caused by some inflammatory response due to the suture material. We also saw mild trichiasis in case 2, which was considered to be a result of
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retraction of the lower eyelid with suture material. As we described, it is considered that the extended transcaruncular approach was not responsible for the complications that occurred in case 3.
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In their article on the transcaruncular approach, Choi et al. summarized 11 studies involving 228 cases and reported an overall incidence of complications of 2.6% after the
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transcaruncular approach (Choi and Flores, 2012). Of these complications, half were reported as minor, whereas the remaining half did require a procedure. Of the six complications in total, inferior oblique muscle injury and conjunctival scar occurred most commonly. The three major complications included one due to a cicatrix that affected lacrimal duct function, one due to a cicatrix with resultant reduced ocular motility, and one due to a suture granuloma requiring excision and revision. Malhotra et al. reported that,
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“although overall, there were very few long-term complications related to transcaruncular approach; there were many short-term ophthalmic problems that required ophthalmic
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assessment and conservative treatment” (Malhotra et al., 2007). They noted that the
conjunctiva is vulnerable to ophthalmic problems after surgery and that special care should be exerted to avoid any complications, such as granulomas as developed in case 6.
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Finally, regarding whether this approach can be applied to complex type II and type III NOE fractures, although we have no experience so far, it may be worth attempting. This
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approach offers a wide surgical field over the medial orbital wall, including the area posterior to the posterior lacrimal crest where transnasal wiring would be placed. Even in cases in which a cantilever bone graft is required simultaneously with fracture repair, only an additional local scalp incision for calvarial bone graft harvest, and an additional small
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skin incision on the nasal root for bone graft insertion and fixation, would be required.
CONCLUSION
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Combined with a transconjunctival lower eyelid and gingival buccal sulcus approach, an extended transcaruncular approach enabled accurate repair of NOE type I and Le Fort II
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fractures without making any skin incisions in all but one of the cases. This approach can be a superior alternative to conventional ones.
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Patient consent
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Patients, parents, or guardians provided written consent for the use of patients’ images.
Conflict of interest None.
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Acknowledgement
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The authors sincerely thank Thomas Lynn Hurt, MD, for English proofreading.
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REFERENCES Antonyshyn OH, Hurwitz JJ: Lacrimal trauma: injuries and management. In: Hurwitz
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JJ (ed.), The Lacrimal System. Philadelphia: Lippincott-Raven, 211-235, 1996.
Balch KC, Goldberg RA, Green JP, Shorr N: The transcaruncular approach to the
medial orbit and ethmoid sinus. A cosmetically superior option to the cutaneous
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(Lynch) incision. Facial Plast Surg Clin North Am 6:71-77, 1998.
Bowerman JE, Fordyce GL, Levant BA: Fractures of the middle third of the facial
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Choi M, Flores RL: Medial orbital wall fractures and the transcaruncular approach. J Craniofac Surg 23:696-701, 2012.
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Converse JM, Hogan VM: Open-sky approach for reduction of naso-orbital fractures. Case report. Plast Reconstr Surg 46:396-398, 1970. Ellis E 3rd, Zide MF: Periorbital incisions─transconjunctival approaches. In: Ellis E
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3rd, Zide MF (eds.), Surgical Approaches to the Facial Skeleton. Philadelphia: Lippincott Williams & Wilkins, 41-64, 2006.
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Garcia GH, Goldberg RA, Shorr N: The transcaruncular approach in repair of orbital fractures: a retrospective study. J Craniomaxillofac Trauma 4:7-12, 1998.
Kakizaki H, Nakano T, Asamoto K: Safe limits for the incisional area in a transcaruncular approach to the medial orbit and ethmoid sinus. Ophthal Plast Reconstr Surg 23:497-498, 2007.
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Katowitz JA, Welsh MG, Bersani TA: Lid crease approach for medial wall fracture repair. Ophthalm Surg 18:288-290, 1987.
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Kuppersmith RB, Alford EL, Patrinely JR, Lee AG, Parke RB, Holds JB: Combined transconjunctival/intranasal endoscopic approach to the optic canal in traumatic optic neuropathy. Laryngoscope 107:311-315, 1997.
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Liau JY, Woodlief J, van Aalst JA: Pediatric nasoorbitoethmoid fractures. J Craniofac Surg 22:1834-1838, 2011.
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Lynch RC: The technique of a radical sinus operation which has given me the best result. Laryngoscope 31:1-5, 1921.
Malhotra R, Saleh GM, de Sousa JL, Sneddon K, Selva D: The transcaruncular approach to orbital fracture repair: ophthalmic sequelae. J Craniofac Surg
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18:420-426, 2007.
Manson PN: Facial injuries. In: McCarthy JG (ed.), Plastic Surgery. Philadelphia: W.B. Saunders, 867-1141, 1990.
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Manson PN: Facial fractures. In: Mathes SJ (ed.), Plastic Surgery, 2nd edition. Philadelphia: PA: Saunders Elsevier, 77-380, 2006.
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Markowitz BL, Manson PN, Sargent L, Kolk CAV, Yaremchuk M, Glassman D, Crawley WA: Management of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central fragment in classification and treatment. Plast Reconstr Surg 87:843-853, 1991.
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Morris DE, Liliav B, Cohen MN: Transcaruncular approach to the isolated medial orbital wall fracture: technical perspective and cadaveric dissection. J Craniofac
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Surg 25:1047-1049, 2014.
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97:1274-1279, 1987.
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Craniomaxillofac Trauma Reconstr 2:35-40, 2009.
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Shorr N, Baylis HI, Goldberg RA, Perry JD: Transcaruncular approach to the medial orbit and orbital apex. Ophthalmology 107:1459-1463, 2000.
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< NOE = naso-orbito-ethmoid.
S1010-5182(16)30211-6
DOI:
10.1016/j.jcms.2016.09.006
Reference:
YJCMS 2483
To appear in:
Journal of Cranio-Maxillo-Facial Surgery
Received Date: 14 February 2016 Revised Date:
9 August 2016
Accepted Date: 19 September 2016
Please cite this article as: Imaizumi A, Ishida K, Nishizeki O, An extended transcaruncular approach for naso-orbito-ethmoid and Le Fort II fracture repair, Journal of Cranio-Maxillofacial Surgery (2016), doi: 10.1016/j.jcms.2016.09.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title page
ACCEPTED MANUSCRIPT
An extended transcaruncular approach for naso-orbito-ethmoid and Le Fort II fracture repair
1
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Atsushi Imaizumi MD1, Kunihiro Ishida MD1, Osamu Nishizeki MD2
Department of Plastic Surgery, Prefectural Okinawa Chubu Hospital, Aza Miyazato 281,
Uruma City, Okinawa, Japan, 904-2243
Department of Plastic and Reconstructive Surgery, Prefectural Nanbu Medical Center/ Child
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2
Medical Center, Aza Arakawa 118-1, Haebaru Town, Shimajiri County, Okinawa, Japan,
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901-1193
Corresponding author: Atsushi Imaizumi, MD
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Department of Plastic Surgery, Prefectural Okinawa Chubu Hospital, Okinawa, Japan, Aza Miyazato 281, Uruma city, Okinawa, Japan, 904-2293 Tel: +81-98-973-4111, FAX: +81-98-974-5165
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e-mail:[email protected]
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Conflicts of interest: none
ACCEPTED MANUSCRIPT
INTRODUCTION
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Summary
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Naso-orbito-ethmoid (NOE) fractures are relatively rare fractures, representing less than 5% of pediatric and 15% of adult facial fractures (Liau et al., 2011; Rosenberger et al.,
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2013). Markowitz et al. classified NOE fractures into three types, based on the status of the medial canthal tendon, the tendon-bearing bone segment, and the fracture pattern (Markowitz et al., 1991). The vast majority are type I, with types II and III occurring much less frequently (Markowitz et al., 1991; Nguyen et al., 2010). Although recent
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advancements in computed tomography (CT) have enabled the diagnosis of these fracture types in greater detail, surgical access to the fracture around the upper nasofrontal buttress in NOE and Le Fort II fractures has remained unchanged over the past several decades. All
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of these approaches have required either local or coronal incisions (Lynch, 1921; Converse and Hogan, 1970; Bowerman et al., 1985; Manson, 1990; Manson, 2006), with resultant
AC C
criticism due to the potential for scar formation, webbing, or other sequelae (Wolfley, 1985; Manson; 1990; Balch et al., 1998; Garcia et al., 1998; Shorr et al., 2000; Choi and Flores, 2012). For an uncomplicated NOE fracture, such as type I, a local incision around the medial orbit alone usually provides sufficient exposure of the fracture and operative field (Manson; 1990). In spite of several modifications, the above-mentioned resultant shortcomings of the cutaneous approach have remained unsolved, especially in our Oriental
ACCEPTED MANUSCRIPT
population with a broad and shallow nasal bridge (Wolfley, 1985; Katowitz et al., 1987; Neel et al., 1987; Choi and Flores, 2012).
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A transcaruncular approach was first introduced in 1997 as an approach for optic
canal decompression (Kuppersmith et al., 1997). Soon afterwards, it was also applied to
access the medial orbit and medial orbital wall fractures (Balch et al., 1998; Garcia et al.,
SC
1998). Subsequently this approach gained popularity for its direct and predictable access to the medial orbit, for eliminating cutaneous scars in the central area of the face, and for its
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limited morbidity (Shorr et al., 2000; Rodriguez et al., 2009; Choi and Flores, 2012; Morris et al., 2014).
With these drawbacks of cutaneous approaches in mind, the authors set out to apply the transcaruncular approach to the repair of upper nasofrontal buttress fractures. The
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purpose of this study is to report our experience and outcomes using an extended transcaruncular approach for the treatment of NOE and Le Fort II fractures.
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MATERIALS AND METHODS
We reviewed the clinical records of all patients seen between October 2012 and
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October 2015 who had undergone open reduction and internal fixation of NOE and Le Fort II fractures with the upper nasofrontal buttress repaired through an extended transcaruncular approach. Institutional review board approval was obtained. NOE and Le Fort II fractures that showed obvious displacement on CT scans were included. Clinical records were analyzed, looking for the occurrence of complications, CT scan findings of postoperative asymmetry in cases involving unilateral fractures, and any obvious
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deformities in cases involving bilateral fractures. Complications were defined as major if surgical intervention was required and minor if surgical intervention was not required.
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All surgeries were performed with the patients under general anesthesia. The
approach to the upper nasofrontal buttress via an extended transcaruncular incision is
similar to that of the medial orbital wall fractures up to the point of the periorbital incision.
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The technique of the transcaruncular approach has been well described previously (Shorr et al., 2000; Ellis and Zide, 2006). Therefore, our extension of the technique, starting from the
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point of the periorbital incision, will be delineated.
After establishing the preseptal route between the orbital septum and Horner’s muscle through the caruncle toward the posterior side of the posterior lacrimal crest, a Ragnell and a malleable retractor were inserted to retract the incised caruncle medially and the orbital
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contents laterally. The periorbita behind the posterior lacrimal crest was incised vertically with a scalpel (Fig. 1 and Fig.2, above, left). This incision was extended superomedially along the medial orbital rim by repeating the following procedure: elevating the periorbita
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of the medial orbital rim with a sharp-tipped periosteal elevator, then cutting it with a sharp pointed scissors, thereby obtaining a sufficient operative field extending from the posterior
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lacrimal crest where the posterior limb of the medial canthal tendon inserts, superiorly up to an 11 o’clock position of the left globe or up to a 1 o’clock position of the right globe along the medial orbital rim (Fig. 1, Fig. 2, above, right, below, left). While establishing exposure of the fracture site, care was taken not to pull the upper eyelid too much in order not to violate the insertion of the posterior limb of the medial canthal tendon. Combined with a transconjunctival lower eyelid and an upper gingival buccal sulcus incision, the fracture
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was reduced and fixed with plates (Fig. 2, below, right). Medial continuation of the superior orbital ridge served as a guide for alignment of the upper nasofrontal buttress (Fig. 1).
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Adequate fixation of the fracture in the upper nasofrontal buttress was accomplished with a plate holding at least one screw on one side of fracture and two on the other side. When an absorbable plate was used in the pediatric case, only one screw on each side of fracture was
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able to be placed. The following combinations of plates and screws were used for repair of the upper nasofrontal buttress: 0.6-mm-thick titanium plates and 1.5-mm-diameter screws
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in the adult cases and 0.9-mm-thick absorbable plates and 1.5-mm-diameter screws in the pediatric case. The periorbita was closed with 5-0 polydioxanone suture where possible, and the conjunctiva was closed with 7-0 polyglactin suture.
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RESULTS
Eight patients (six male and two female), with a mean age of 32 years, underwent NOE and Le Fort II fracture repairs using an extended transcaruncular approach. Two of
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the patients had Le Fort II fractures and six had NOE fractures. Of the six NOE fractures, all were classified as type I, two were bilateral, and four were unilateral. Therefore, this
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approach was applied to a total of 12 orbits. The inferior oblique muscle was left untouched in all cases. Concomitant fractures and injuries are summarized in Table 1. All but one fracture repair was accomplished via an extended transcaruncular
approach without making any skin incision. Because the right medial orbital rim was comminuted and unstable, case 7 required an additional small skin incision on the glabella to fix the cranial part of the plate on the frontal bone.
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The types of plates used for the upper nasofrontal buttress fixation were as follows: a three-hole absorbable plate for the pediatric NOE fracture (case 1), five-hole titanium plates
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for two of the NOE fractures (cases 3 and 5), seven-hole and four-hole titanium plates in one of the Le Fort II fractures (case 7), and three-hole titanium plates in the rest of the cases.
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The mean follow-up period was 248 days, with a range of 21 to 537 days. The final postoperative CT scan was taken an average of 170 days after surgery, with a range of 2 to
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274 days. On postoperative CT scan, all cases showed excellent alignment of the fracture repair with no deformity along the upper nasofrontal buttress or inferior orbital rim. One minor and five major complications occurred in five orbits of three cases. Of these, one minor and two major complications in two cases (case 1 and 6) were attributed to
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the extended transcaruncular approach. Case patient 1 developed trichiasis on the center of her right lower eyelid (Fig. 3, below, right). Case patient 6 experienced asymptomatic granulomas over the bilateral caruncles. These were excised concurrently with removal of
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the exposed plate for palatal fracture repair (Fig. 4). Case patient 3 experienced inadvertent right lower eyelid lacrimal canalicular transection during the repair of a severe
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zygomaticomaxillary complex fracture and also developed bilateral cicatricial entropion over the transconjunctival lower eyelid incisions. These were considered to be a consequence of excessive traction over the lower eyelids when repairing the fractures around the fronto-zygomatic sutures via the extended transconjunctival incision (see Slideshow, Supplemental Digital Content 1, describing details of case 3).
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Case 1 A 7-year-old girl was referred to us for treatment of bilateral type I NOE fractures
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(Fig. 3, above, left). Using the extended transcaruncular approach combined with
transconjunctival lower eyelid and upper gingival buccal sulcus incisions, the bilateral NOE fractures on the upper nasofrontal buttress were adequately exposed. Displacement of the
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fracture on the upper nasofrontal buttress on the left side was minimal and stable after
reduction. Therefore, only the inferior orbital rim required fixation (Fig. 2, above, right).
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The right upper nasofrontal buttress fracture and the right inferior orbital rim fracture were reduced and fixed (Fig. 2, below, left and right). Because an absorbable plate is larger than a titanium one, and because of the relatively narrow operative field, a three-hole absorbable plate was used for the upper nasofrontal buttress fixation with only a single screw on each
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side of the fracture, with the middle hole above the fracture remaining empty. Similarly, fractures of the inferior orbital rim and the piriform aperture were fixed with absorbable plates. Postoperative CT showed good alignment of both NOE fracture sites (Fig. 3, above,
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right). Although she developed mild trichiasis on the right lower eyelid, which did not require any treatment, the clinical appearance of her medial canthal area 1 year after
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surgery appeared symmetric and natural (Fig. 3, below, left, right).
Case 4
A 52-year-old woman presented with a left NOE type I, left inferior orbital rim and
orbital floor fractures (Fig. 5, center, left). An extended transcaruncular approach was used for the NOE fracture repair. The upper nasofrontal buttress was fixed using a three-hole
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titanium plate, with two screws for the cranial side of the fracture and one screw for the caudal side harboring the medial canthal tendon (Fig. 5, above, left, and right). The other
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fractures were also repaired with titanium plates, but an absorbable plate was used for the orbital floor. Postoperative CT showed good alignment of the left upper nasofrontal
buttress. The clinical appearance of the medial canthal area was symmetric without any
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apparent complications (Fig. 5, center, right, and below).
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Case 7
A 35-year-old man presented with Le Fort I and II fractures as well as a fracture of the anterior wall of the frontal sinus (Fig. 6, above, left). Fracture repair of the left upper nasofrontal buttress was accomplished via an extended transcaruncular approach using a
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four-hole titanium plate. However, because of comminution of the right medial orbital rim at the 1 o’clock position, in addition to the extended transcaruncular incision, a small skin incision on the glabella was necessary to fix the cranial part of the plate onto the stable part
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of the frontal bone (Fig. 6, center, left). The short limb of the L-shaped plate was fixed to the caudal segment with two screws via the extended transcaruncular approach (Fig. 6,
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center, right). The long limb of the L-shaped plate was fixed to the stable frontal bone with two screws using this small skin incision on the glabella. Postoperative CT scan showed natural alignment of the upper nasofrontal buttress (Fig. 6, above, right). A small incision on the glabella was inconspicuous (Fig. 6, below).
DISCUSSION
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NOE fracture is a relatively rare facial fracture, which, if not treated properly, runs a risk of leaving an obvious deformity over the central part of the face (Manson, 1990; Liau
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et al., 2011; Rosenberger et al., 2013). Markowitz et al classified NOE fractures into three types and assigned approaches accordingly (Markowitz et al., 1991). Recent advancements in CT scan have enabled us to diagnose these fracture types in greater detail, allowing the
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most appropriate mode of treatment to be chosen. However, despite these advancements in CT, surgical approaches to the areas around the upper nasofrontal buttress in the NOE or Le
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Fort II fractures have remained largely unchanged. All of these approaches require skin incisions and have been criticized due to resultant scar formation, webbing, or other sequelae (Wolfley, 1985; Manson, 1990; Balch et al., 1998; Garcia et al., 1998; Shorr et al., 2000; Choi and Flores, 2012). Among the various cutaneous approaches, a local incision
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around the medial orbit is indicated for uncomplicated NOE fractures, whereas a coronal incision remains the gold standard. Although a coronal approach provides a wide surgical field with the potential for simultaneous calvarial bone graft harvest for associated nasal
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deformity correction, we regard this approach as too invasive for repair of simple NOE fractures because it requires a large incision; it risks leaving scalp numbness, hair loss, flap
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hematoma, and frontalis palsy; and it is time consuming (Manson, 2006). In spite of several modifications, local cutaneous approaches to the upper nasofrontal buttress are also not free of drawbacks, and carry the risk of disfiguring scar formation, webbing, and other sequelae. This is especially a problem in our Oriental population with a broad, shallow nasal bridge (Wolfley, 1985; Katowitz et al., 1987; Neel et al., 1987; Manson, 1990; Balch et al., 1998; Garcia et al., 1998; Shorr et al., 2000; Choi and Flores, 2012).
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A transcaruncular approach is free of these drawbacks of cutaneous approaches. A transcaruncular approach is now widely used in surgery of the medial orbit. Furthermore, it
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can be easily combined with a lower eyelid transconjunctival incision to provide continuous uninterrupted access to both the inferior and medial orbit (Balch et al., 1998; Garcia et al., 1998; Shorr et al., 2000; Rodriguez et al., 2009; Choi and Flores, 2012; Morris et al.,
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2014). When applying a transcaruncular approach to the repair of the upper nasofrontal
buttress in NOE or Le Fort II fractures, four possible concerns arise. The first is whether an
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adequate surgical field can be obtained without violating the posterior limb of the medial canthal tendon. The second is whether rigid fixation can be achieved. The third is the potential morbidity of this approach, and the fourth is whether this approach can be applied to complex NOE fractures, such as type II and III.
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Regarding the first concern, Kakizaki et al showed that dissection via a transcaruncular incision could be safely performed up to the 11 o’clock position (the location of the trochlea) (Kakizaki et al., 2007). Most of the fractures in our cases were
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located around the fronto-maxillary suture (approximately 10 o’clock on the left globe and 2 o’clock on the right globe). Even the superior-most fracture in our cases (case 3), which
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was around the 11 o’clock position of the left globe, was satisfactorily repaired via the extended transcaruncular approach. Our approach enabled repair of fractures along the nasofrontal buttress as high as 11 o’clock on the left globe and 1 o’clock on the right without compromising the integrity of the medial canthal tendon, as long as the medial orbital rims around 11 o’clock on the left globe or 1 o’clock on the right were not comminuted. Case 7 required a small additional skin incision on the glabella because of
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instability for plate fixation on the comminuted right medial orbital rim at the 1 o’clock position. As most of the procedure had already been accomplished via the extended
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transcaruncular approach at that point, it was believed that it would be least invasive just to make a small incision in order to drill and place screws into the frontal bone. Although an additional small skin incision was required, compared to conventional skin incisions for
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NOE fracture repair, it was very small and inconspicuous (Fig. 6, below).
All of our cases of NOE fracture were type I, the uncomplicated type. Accurate
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three-dimensional repositioning of the fractures was achieved without difficulty in all cases, leading to successful results. Since the vast majority of NOE fractures are type I (Markowitz et al., 1991; Nguyen et al., 2010), we therefore believe that most NOE fractures can be successfully repaired using our approach instead of conventional cutaneous
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approaches.
Similarly, our approach can be successfully applied to cases with Le Fort II fractures (see Figure, Supplemental Digital Content 2, which shows details of case 6 with Le Fort II
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fracture (above, left and right), CT scan findings before and after surgery (below, left), and intraoperative ultrasonographic findings showing accurate reduction of the fracture
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(arrowhead) between the frontal (*) and the nasal bone (#) in the mid-sagittal plane (below, right). Clinical results 11 months after surgery are shown. It should be noted that the caruncular granulations have been resected. As for the second concern, rigid fixation appears to be well achieved using the
extended transcaruncular approach. This is supported by the postoperative CT findings, which show no displacement of any fracture segment, even in case 1 in which only two
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screws were used for the nasofrontal buttress fracture plate. The only functional force acting on the fracture segment bearing the medial canthal tendon is that exerted by the
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obicularis oculi muscle (Antonyshyn and Hurwitz, 1996). Therefore, microplate systems
with one screw on one fragment and two screws on the other are considered sufficient for fixation in this area, which has little torque load.
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As to the third concern, the potential for morbidity with this approach, among
repairs to 12 orbits in eight patients we experienced two major and one minor complication
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in three orbits of two patients, which directly related to the extended transcaruncular approach. Case 6 developed asymptomatic bilateral granulomas over the caruncles requiring excision. This might be caused by some inflammatory response due to the suture material. We also saw mild trichiasis in case 2, which was considered to be a result of
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retraction of the lower eyelid with suture material. As we described, it is considered that the extended transcaruncular approach was not responsible for the complications that occurred in case 3.
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In their article on the transcaruncular approach, Choi et al. summarized 11 studies involving 228 cases and reported an overall incidence of complications of 2.6% after the
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transcaruncular approach (Choi and Flores, 2012). Of these complications, half were reported as minor, whereas the remaining half did require a procedure. Of the six complications in total, inferior oblique muscle injury and conjunctival scar occurred most commonly. The three major complications included one due to a cicatrix that affected lacrimal duct function, one due to a cicatrix with resultant reduced ocular motility, and one due to a suture granuloma requiring excision and revision. Malhotra et al. reported that,
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“although overall, there were very few long-term complications related to transcaruncular approach; there were many short-term ophthalmic problems that required ophthalmic
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assessment and conservative treatment” (Malhotra et al., 2007). They noted that the
conjunctiva is vulnerable to ophthalmic problems after surgery and that special care should be exerted to avoid any complications, such as granulomas as developed in case 6.
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Finally, regarding whether this approach can be applied to complex type II and type III NOE fractures, although we have no experience so far, it may be worth attempting. This
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approach offers a wide surgical field over the medial orbital wall, including the area posterior to the posterior lacrimal crest where transnasal wiring would be placed. Even in cases in which a cantilever bone graft is required simultaneously with fracture repair, only an additional local scalp incision for calvarial bone graft harvest, and an additional small
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skin incision on the nasal root for bone graft insertion and fixation, would be required.
CONCLUSION
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Combined with a transconjunctival lower eyelid and gingival buccal sulcus approach, an extended transcaruncular approach enabled accurate repair of NOE type I and Le Fort II
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fractures without making any skin incisions in all but one of the cases. This approach can be a superior alternative to conventional ones.
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Patient consent
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Patients, parents, or guardians provided written consent for the use of patients’ images.
Conflict of interest None.
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Acknowledgement
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The authors sincerely thank Thomas Lynn Hurt, MD, for English proofreading.
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