Not seeing eye-to-eye about septal grafts for orbital fractures

J Oral Maxillofac

56:906-907,

Surg

1998

NOT SEEING EYE-TO-EYE ABOUT SEPTALGRAFTS FOR ORBITALFRACTURES

quences of wasting septal cartilage for orbital defects and to seek alternative methods. DMD, MD Nashville, TN

JOHN R. WERTHER,

To the Editor-1 read Dr Ii’s paper “Repair of Traumatic Orbital Wall Defects With Nasal Septal Cartilage” OOMS 55:1098, 1997) with dismay over the thought that surgeons inexperienced with other uses of this cartilage might be tempted to adopt this technique. There are numerous theoretical and clinical objections to Ll’s recommendation to use septal cartilage for orbital defects, but I will mention just three. One of the major arguments that Li makes to support his recommendation to use septal cartilage for orbital defects is his interpretation that the complications of septal harvest “are all minor when compared to the potential compllcations of autogenous bone harvest.” CSF rhinorrhea, brain abscess, toxic shock syndrome, and death-all documented complications of septal surgery1x2-cannot be considered minor. I suspect that most surgeons would agree that there is no such thing as minor surgery, a minor complication, or an operation so simple that it cannot be screwed up. Ll is correct in pointing out that cartilage is neither biologically nor scientifically unsound as an orbital implant. In fact, cartilage grafts likely ossify over time when transplanted to a periosteal bed. Autogenous bone is a more natural choice for repair of orbital defects, but bone grafts can be diftlcult to contour to the confines of a complex, multi-vector orbital defect, particularly when the posterior stable ledge of bone is immediately adjacent to the optic canal. Li dismisses alloplastic implants but fails to reference newer materials, namely titanium mesh and polyethylene. These materials are biocompatible, easy to manipulate, can be contoured precisely to fit complex orbital defects and, like autogenous bone, bypass the potential problem of having a septal cartilage graft that is too small for the defect. However, the chief practical objection to using septal cartilage to repair an orbital defect is that it an unnecessary waste of a precious tissue that is in limited supply. Septal cartilage is uniquely suited to nasal reconstructive and aesthetic surgery and the alternatives, including ear cartilage, are less satisfactory from the standpoint of handling, strength, and appearance. Nasal reconstruction is a formidable task under ideal circumstances and more so in the septal cartllagedepleted patient. Just because a technique can be accomplished does not mean that it should be performed. I urge surgeons to consider carefully the conse-

References 1. Maniglia and sinus 2. Jacobson surgery. go1 Head

AJ: Fatal and major complications secondary to nasal surgery. Laryngoscope 99:276,1989 JA, Kasworm FM: Toxic shock syndrome after nasal Case reports and analysis of risk factors. Arch Otolaryn Neck Surg 112:329,1986

In Reply:-I wholeheartedly agree that “there is no such thing as minor surgery, a minor complication, or an operation so simple that it carmot be screwed up.” However, I contend that when properly performed by a competent surgeon, nasal septal cartilage harvest is associated with minimum complications. Dr Werther stated that “CSF rhlnorrhea, brain abscess, toxic shock syndrome, and death are all documented complications of septal surgery” and referenced Maniglia’ and Jacobson and Kasworn? to support his claims. In reality, almost all of the complications in Man&ha’s series were secondary to sinus surgery or anesthesia.l Of the complications noted by Dr Werther, only toxic shock syndrome was directly associated with septoplasty,1,2 with an incidence of 0.0165%.2 It should be emphasized that toxic shock syndrome is associated with the use of nasal splints and packings,1,2 which can be completely eliminated after septal cartilage harvest when septal mattress sutures are used.3 Certainly, either an autogenous or alloplastic implant can be used for an orbital defect. However, I suspect that most surgeons would agree that autogenous tissue is superior to any new alloplastic implant material regardless of how “biocompatible” the material may be. Alloplastic implants have a higher complication rate,* which is of particular Importance in the repair of defects near the orbital apex, where the intraorbital optic nerve is extremely vulnerable to implant migration, hemorrhage, infection, and capsular formation. The optic canal, on the other hand, is located within the contines of the sphenoid sinus,5x6 and is unrelated to the repair of traumatic orbital defects except under special circumstances.6-s The choice of an implant, whether it be alloplastic or autogenous, should be dictated by the circumstances of each individual case. When an autogenous graft is considered, the nasal septal cartilage offers easy accessibility with minimal donor site morbidity. This fact is supported by the literature,

including

the references

provided

by Dr Werther.

The elimination of this donor site simply for the remote chance that the patient may some day undergo a nasal procedure

requiring

septal

cartilage

graft

is irrational.

KASEY K. LI, DDS, MD Palo Alto, CA

References 1. Maniglia and sinus 2. Jacobson surgery. go1 Head

906

AJ: Fatal and major complications secondary to nasal surgery. Laryngoscope 99:276,1989 JA, Kasworm EM: Toxic shock syndrome after nasal Case reports and analysis of risk factors. Arch OtolarynNeck Surg 112:329,1986