Orbital sonography: a valuable investigation in midface trauma

327 post-traumatic and congenital periorbital deformities. First, Dr H. P. M. Freihofer spoke on the effectiveness of secondary post-traumatic periorbital reconstructions, concluding that corrections after fractures of the zygoma showed good results in 80% of cases, while midfacial reconstructions had only acceptable results upgraded by tertiary operations. Dr S. Morax presented the general principles of treatment of the congenital malformations of the eye and its adnexa, which are multiple and can affect the whole eyeball or any part of it, as well as the orbit, eyelids, lacrimal ducts, extraocular muscles, and conjunctiva. In his second presentation, Dr S. A. Wolfe reviewed the technical points of congenital orbital hypertelorism reconstruction with particular reference to the nasal bridge and the management of the medial cantal tendon. In his last contribution, Dr H. P. M. Freihofer proposed a new, individually tailored, three-stage correction of Treacher Collins' syndrome. The first stage is osteotomized reconstruction of the malar bones and genioplasty, followed by reorientation of the maxillomandibular complex in a second stage. Small tertiary corrections of skeletal contour or soft tissues may be desirable. Dr M. Y. Mommaerts (Bruges, Belgium) emphasized the role o f malar "sandwich" osteotomy in developmental, post-traumatic, and congenital deformities. In a video demonstration, he explained the surgical steps. Dr S. A. Wolfe completed this topic by speaking on corrections of craniofacial dysostosis (Crouzon's syndrome and Apert's syndrome). In general, he still performs early synosteotomy and fronto-orbital advancement, although this may be a debatable procedure in Apert's syndrome. The best result generally comes from intracranial monobloc fronto-orbital advancement with or without facial bipartition, performed ideally at 4--8 years of age. The fourth session was dedicated to free papers submitted by members (see the following abstracts). The sixth symposium will take place in Zurich, Switzerland, in 1997. W e hope that it will be of the same standard, scientifically as well as socially, as the Amsterdam meeting. M. A. W. MERKX J. C. BEI~'qE A. W. P. J. ROOSErqBER~

Abstracts Classification and treatment of orbital fractures J. Kleinheinz, U. Joos

In a retrospective study, 326 orbital fractures treated in our department between 1992 and 1995 were analyzed to devise a new classification of orbital fractures and to demonstrate our treatments of the various types. The patients were assigned to a new classification according to the number of invoh'ed walls, type of fracture, and involvement of the periorbita. In addition, concomitant injuries of the periorbital tissues were listed. Bony defects were reconstructed either with autologous bone transplants (iliac crest or tabula extema) or with allogenic materials (PDS membranes or hydroxyapatite blocks). The ethmoid cells and the frontal sinus were not operated on except when decompression of the optic nerve was necessary. The results showed that central and centrolateral midface fractures of two orbital wails are predominant, 85.4% of all fractures having orbital involvement. The best functional and aesthetic results were achieved after complete primary reconstruction of soft tissue and bone. Secondary reconstructions were more difficult and showed worse results than primary reconstruction. Avoidance of transethmoidal operations resulted in fewer cases of postoperative diplopia or enophthalmos. A classification of medial canthal injuries R R. Ayliffe, B. T. Evans

Historically, the classification of midface trauma has concentrated on bony injuries; e.g., those of the maxilla, zygomatic complex, nose, and nasoethmoid complex. On the basis of the observation of over 50 patients with midface trauma, the senior author (B. T. E.) proposes a classification of medial canthal injuries. This classification allows the management of the injury to be based on a more diagnostic approach, and successful functional and cosmetic results can be obtained in a more predictable manner in this challenging area of craniofacial trauma.

use, lack of radiation, and low cost are arguments for routine use of sonography in orbital trauma. A radiologic and anatomic study of the lateral orbital wall osteotomy in orbital surgery M. S. Dover, T. K. Mellor

Accurate reconstruction of the orbital walls depends on visualization of the entire bony defect. A lower eyelid approach, with preservation of the orbital rim, can limit surgical exposure and compromise repair, particularly of larger defects. For these larger orbital wall defects, we have used a bicoronal flap and lateral wall osteotomy to approach the orbit laterally. Surgical exposure is thereby much improved, and the calvarium is available as a bone graft donor side. Assessment of 50 axial CT scans of adult patients has shown the anterior limit of the temporal lobe to be relatively constant with respect to the orbit. These results, together with dried skull examination and model surgery, have shown that it is safe to place the vertical osteotomy cut 15 mm behind the orbital rim. The dura and temporal lobe are then not at risk. A self-stabilizing osteotomy can be used, with a microplate and reattachment of the temporalis muscle for stability. This approach has been successfully used over the past 18 months on eight patients for correction of early and late enophthalmos. The theoretic and practical implications of this study are discussed. Transorbital penetrating injuries of the skull base J. Birbe, X. Rodrlguez, C. Bassas, G. Raspall

Transorbital penetrating injuries of the anterior or medial fossae of the skull base are not common. For appropriate treatment, a multidisciplinary team approach is mandatory. We present three cases treated in our service. The etiology, presentation, therapeutic approach, and prophylaxis of complications are analyzed and discussed. Reconstruction techniques and aesthetic repercussions are emphasized. We propose a diagnostic and therapeutic protocol for these patients.

Orbital sonography: a valuable Investigation in mtdface trauma H. Thuau

Therapeutic concept and management of complex midfaee trauma N. D. Kalavrezos, C. K. Oechslin, K. W. Gr~itz, H. F. Sailer

Orbital sonography has significantly benefited from recent advances in ultrasound imaging. High-resolution ultrasound offers the major advantage of aUowing static as well as dynamic scanning. It enables the surgeon to assess the integrity of the orbital walls, and also to visualize the soft tissues during ocular movement. Standardization of the orbital scanning planes is proposed, and the first results of a prospective study comparing computed tomography/surgical exposure and ultrasound imaging, with a 7.5-MHz curvilinear array probe and a closed-eyelid technique, is discussed. Accuracy, simplicity of

Severe trauma to the midface often results in fractures of the naso-orbito-ethmoidal (NOE) complex. Early surgical management is the only therapy by which to avoid post-traumatic defects in the fragile periorbital region that may lead to inadequate secondary procedures. Fifty-five patients with major midface trauma, treated in the University Hospital of Zurich from January 1990 to December 1994, are reviewed. The fractures were mainly caused by traffic and work accidents, but also by gunshot wounds and sports accidents. The therapeutic planning included wide exposure of the fractured area by a coronal incision,