Transzygomatic Kirschner wire fixation for the treatment of blowout fracture

Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 875e882

Transzygomatic Kirschner wire fixation for the treatment of blowout fracture Kazunori Yasumura a,*, Taro Mikami a, Yuichiro Yabuki a, Kimie Ooishi a, Misato Hosono a, Yasushi Yamamoto a, Toshinori Iwai b, Jiro Maegawa a a

Department of Plastic and Reconstructive Surgery, Yokohama City University Hospital, 3e9 Fukuura Kanazawa-ku, Yokohama 236-0004, Japan b Department of Oral and Maxillofacial Surgery, Yokohama City University Hospital, Yokohama, Japan Received 9 September 2011; accepted 23 January 2012

KEYWORDS Blowout fracture; Surgical treatment; Minimally invasive surgery; Kirschner wire fixation; Autograft bone

Summary Background: Total orbital floor reconstruction with sheet-shape materials is available for the treatment of extensive and crushed-type blowout fractures. Simple blowout fractures, on the other hand, require only manual reduction without fixation. Although several types of blowout fractures do not require total reconstruction, some fixation is usually necessary. Methods: Eighteen cases of blowout fracture were treated with transzygomatic Kirschner wire fixation between 2002 and 2009. This technique was applied to simple fracture cases in which periorbital soft tissue re-herniated through the floor defect into the maxillary sinus after manual reduction, despite improvement of the extra-ocular muscle entrapment. The wire was used to directly support the fracture segment in five cases and used together with a maxillary sinus anterior wall bone graft in 13 cases. Results: Mean follow-up was 12.5 months. Mild diplopia remained as a subjective symptom in one case. None of the cases developed major complications or conspicuous scars on the cheek. Conclusions: Transzygomatic Kirschner wire fixation for blowout fracture has the advantages of precise and rigid fixation of all parts of the inferior floor, minimal morbidity without requiring an orbital approach and long-term safety without artificial remnants. This technique can be applied for the treatment of simple blowout fractures. ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

The goal of the treatment of blowout fracture is to improve diplopia and prevent enophthalmos. To improve diplopia, * Corresponding author. Tel.: þ81 0457872800; fax: þ81 0457835351. E-mail address: [email protected] (K. Yasumura).

functional reconstruction is performed to ensure smooth excursion of the extra-ocular muscle, which requires improvement in the intra-operative forced duction test, and, to prevent enophthalmos, cosmetic reconstruction is used to create a symmetrical eyeball and eyelid position and requires precise restoration of the broken orbital floor

1748-6815/$ - see front matter ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2012.01.025

876 and herniated periorbital soft tissue. Diplopia is not always present even in cases with conspicuous enophthalmos, because it mainly develops from entrapment of the extraocular muscle.1 Some cases with severe enophthalmos do not have diplopia. Therefore, results of a standard functional evaluation will not likely correspond with the level of producing patient satisfaction in every case. Regaining a natural facial image by symmetrical globe positioning, however, is as important to the patient as normal globe movement. Total floor reconstruction with alloplastic or autogenous materials through an orbital approach is the most popular strategy for treating complex and wide blowout fractures, leading to acceptable outcomes in both functional and cosmetic evaluations.2 The optimal materials and methods to use, however, are controversial.3e9 A simple inferior orbital wall fracture can sometimes be treated by manual reduction alone through a transantral approach and a forced duction test without fixation. In particular, this method should be applied first for a trapdoor-type fracture. The magnitude of surgical invasion, surgeon effort, donorsite morbidity, risk of complications and postoperative strain placed on the patient differs considerably between these two procedures. In most such cases, however, some stable fixation is necessary to prevent re-herniation of the periorbital soft tissue. To avoid total reconstruction, which might produce additional scars, several methods of simple fixation have been reported for a simple inferior wall fracture.10e12 When satisfactory reduction cannot be performed by intra-operative manual reduction alone, our group has applied transzygomatic Kirschner wire fixation. The surgeon who most often treats blowout fractures observed that, in several cases, periorbital soft tissue re-herniates into the maxillary sinus as soon as the elevator or forcep support of the hinged fracture segment edge is removed. We considered that a pinpoint support would be suitable to prevent tissue from re-herniating into the sinus. A Kirschner wire can effectively support most pinpoints of the fracture segment edge just as well as the tip of forceps or elevator, even in posterior areas that are difficult to fix using the appropriate materials with an orbital approach. Therefore, our group has adopted a three-step strategy: first, manual reduction alone, then transzygomatic Kirschner wire fixation and finally, total reconstruction with additional materials.

Patients and methods Patients There were 162 cases of blowout fractures from 2002 to 2009 in our institute. We applied surgical treatment to 92 cases and conservative treatment to 70 cases. Nineteen cases of single blowout fracture and 14 cases of blowout fracture complicated by another facial fracture were treated by manual reduction without any materials. Fortyone cases of extensive blowout fracture were treated by total reconstruction with some materials. Eighteen cases of inferior orbital blowout fracture were treated with a Kirschner wire. The patient group comprised 10 men and 8

K. Yasumura et al. women between 13 and 72 years of age (mean age, 35 years; Table 1). A complicated, mild dislocated medial wall fracture was present on the left in three cases and on the right in two cases. In these five cases, reduction of the medial wall fracture was not performed because the fracture segments were not severely displaced based on the computed tomography (CT) images.

Protocol The indication for surgical treatment in the patients developing less than 5% herniation of the periorbital soft tissue in preoperative CT images depends on the severity of the diplopia. Kirschner wire fixation is applied to patients developing an obvious trapdoor-type fracture with more than 5% herniation of the periorbital soft tissue in preoperative CT images. Fracture location and diplopia complications are not considered except in the case of medial wall fracture. Patients developing a typical trapdoor-type fracture or having a less than 5% herniation are also informed of manual reduction without additional materials. Patients developing a complicated or extensive trapdoor-type fracture are also informed of total reconstruction with additional materials.

Surgical technique When manual reduction is successfully performed for a simple fracture, the repositioned periorbital soft tissue and bony segment might remain stable in the orbit and reherniation might not occur. In this case, the surgeon may determine that fixation is not necessary. In many cases, however, the periorbital soft tissue and bony segment reherniate into the maxillary sinus as soon as the support device is removed, even if an intra-operative forced duction test is successful. Such a situation is a good indication for wire fixation. This technique does not require a subciliary approach, only a transantral approach and a stab incision in the cheek. A Kirschner wire is inserted from the stab incision into the maxillary sinus through the zygomatic body. The stab incision is only 2e3 mm in length (Figure 1(a) and (b)). A forced duction test must be performed to ensure that the entrapped extra-ocular muscle is released. In cases in which several forced duction tests or minimal isolation between the bony crack indicate that muscle entrapment remains, a subciliary approach must be added to release the muscle. Occasionally, stripping the floor bone of the periorbital soft tissue through a subciliary approach will show that fracture is more complex than observed on the CT images or the surgeon’s impression based on palpation of the maxillary sinus mucoperiosteum. In these cases, total reconstruction with the appropriate materials should be performed. In cases in which reduction by pinpoint support and improvement of the muscle entrapment appears to be successful, we first apply a transzygomatic Kirschner wire for fixation. A Kirschner wire should be run into the sinus close to the sinus roof (i.e., the orbital floor) for rigid

Patient data.

No.

Sex

Age

Cause of fracture

Location of fracture

Herniation volume (%)

Waiting period (days)

Approach

Bone graft

Postoperative CT (months)

Globe projection difference on last CT (mm)

Postoperative diplopia

Postoperative enophthalmos

Follow-up (months)

1

F

32

12

Ttransantral

þ

15

1.2

Excellent

Good

14

M

25

16.3

3

Ttransantral



1

0.4

Good

Excellent

3

M

37

Assault

19.4

5

7

1.6

Good

Good

14

F

33

16.1

8

þ

3

1.3

Good

Good

12

5

M

15

17.6

14

Transantral

þ

1

0.0

Excellent

Excellent

36

6

M

16

16.6

9

3

1.1

Excellent

Good

14

F

28

16.6

12

Transantral, subciliary Transantral

þ

7

Hit by accident Hit by accident Sports related Assault

Transantral, subciliary Transantral

þ

4

þ

3

1.3

Good

Good

5

8

M

29

Assault

16.4

6

Transantral

þ

3

1.4

Good

Good

11

9

F

45

14.6

11

Transantral



4

0.2

Excellent

Excellent

7

10

M

30

Sports related Assault

16.1

5

Transantral



3

1.4

Good

Good

5

11

F

46

14.4

9

1

0.0

Good

Excellent

7

F

29

10.0

6

Transantral, subciliary Transantral

þ

12

þ

4

0.1

Fair

Excellent

12

13

F

28

9.6

17

Transantral



13

0.5

Excellent

Excellent

14

14

M

30

11.1

13

Transantral



6

1.2

Excellent

Good

7

15

F

72

18.0

9

Transantral

þ

3

1.0

Good

Good

18

16

M

13

Inferior, left Inferior & medial, right Inferior, right Inferior, left Inferior, right Inferior, left Inferior & medial, left Inferior, left Inferior, right Inferior & medial, left Inferior, right Inferior, left Inferior, left Inferior & medial, right Inferior, left Inferior, left

14.7

2

Hit by accident Sports related

7.6

5

Transantral

þ

12

0.6

Good

Excellent

31

Hit by accident Traffic accident Hit by accident Assault

Traffic accident Assault

5

877

(continued on next page)

Transzygomatic Kirschner wire fixation for the treatment of blowout fracture

Table 1

12.5

6 Excellent

0.83

Excellent 1

9 14.5

14.3

7

Transantral

þ

0.9

Excellent Excellent 0.7 3 þ Transantral 8 11.7

Figure 1 Case 13. (a) A typical trapdoor fracture can be seen. (b) A Kirschner wire is inserted from the stab incision in the cheek. The Kirschner wire provides pinpoint support for a fracture segment.

35 Average

M 18

64

Sports related

Inferior & medial, left Inferior, right Traffic accident M 17

51

Postoperative enophthalmos Postoperative diplopia Globe projection difference on last CT (mm) Postoperative CT (months) Bone graft Approach Waiting period (days) Herniation volume (%) Location of fracture Cause of fracture Age Sex No.

Table 1 (continued )

7

K. Yasumura et al. Follow-up (months)

878

fixation. Use of a wire 1.2e1.5 mm in diameter is important because a wire that is too fine and easy to bend may enter the orbit. If the tip of the wire cannot be guided effectively to the bony segment edge, gently curving and rotating the wire with pliers after insertion into the sinus makes the fixation more precise and rigid. Over-bending of the wire is contraindicated, however, because manoeuvering the tip of the wire and its removal will be difficult after surgery. We show the typical case in which we applied single Kirschner wire fixation in Figure 2(a) and (b). Furthermore, in cases in which pinpoint support of fracture segment edge is effective, but not adequate for accurate repositioning, we also apply a bone graft within the anterior wall of the maxillary sinus from the maxillary sinus side. The tip of the wire then supports the grafted bone as a pinpoint, and the grafted bone supports the dislocated bony segments. A bone graft makes it possible to apply Kirschner wire fixation to an atypical trapdoor fracture with some small segment and easy to prevent reherniation without over-bending of the wire. An atypical case in which Kirschner wire fixation was applied with bone graft is shown in Figure 3(a) and (b). Whether or not a bone graft was applied, the wire was removed under local anaesthesia in the outpatient clinic 3 months after surgery.

Transzygomatic Kirschner wire fixation for the treatment of blowout fracture

Figure 2 Case 9. A subciliary approach and bone graft were not applied. (a) Preoperative CT image. (b) 4-Month postoperative CT image.

Evaluation of diplopia and enophthalmos In our evaluation of diplopia, a rating of ‘excellent’ was considered perfect recovery to the level prior to surgery in ordinary use and in a complete work-up, such as based on the Hess chart (Table 2). A rating of ‘good’ included cases with only a small, double visual field after a complete workup. A rating of ‘fair’ included cases experiencing diplopia in ordinary use without serious trouble due to local fields of double vision. In our evaluation of postoperative enophthalmos, a rating of ‘excellent’ included cases in which measurement of the front and rear eyeball position on CT images differed by less than 1 mm between the right and left eyeball. A rating of ‘good’ included cases in which the same measurement differed by between 1 and 2 mm. The patients in this group were divided according to whether they felt that their orbital appearance was asymmetrical, though most of the evaluators recognised enophthalmos based on direct examination or standardised photographs taken of the patient looking up and from above. A rating of ‘fair’ included cases in which the measurement differed by more than 2 mm. To evaluate the severity of the fracture preoperatively, orbital volume and herniated periorbital soft tissue volume were measured on coronal CT images.13 The ratio of herniated tissue to the orbital volume ratio is shown in Table 1.

879

Figure 3 Case 12. A bone graft was applied. (a) 2-Week postoperative CT image shows a Kirschner wire (small arrow) supporting the bone graft (large arrow). (b) CT image at 6months postoperatively shows that the bone graft (large arrow) was incorporated into the orbital floor.

Results The average follow-up period was 12.5 months. The transantral approach was used in 15 cases. To release muscle entrapment, the subciliary approach was used in three cases. Bone grafts were applied in 13 cases because we applied single Kirschner wire fixation to the typical trapdoor fracture. There were no complications concerning the bone graft. Only one minor complication occurred in which the wire poked through the skin 2 months after surgery. This case, however, had no noticeable scar after the revision together with wire removal. In all cases, the stab incision on the cheek healed well. No other complications resulting from Kirschner wire fixation were observed. After surgery, 17 cases had diplopia ratings of ‘excellent’ or ‘good’. One case that developed severe diplopia in the primary gaze had a diplopia rating of ‘fair’. In this case, there was no difference between sides in the intraoperative forced duction test just after reduction. Surgical treatment improved the condition immediately, but diplopia in the downgaze persisted for more than a year after surgery. All of the cases had enophthalmos ratings of ‘excellent’ or ‘good’. A bone graft was applied in 13 cases. Bone grafts were applied in these cases because there were fewer typicaltype fractures than atypical-type fractures, and the fracture type rarely conformed to the CT images, which revealed only local and simple fractures. Moreover, additional approaches were not required to perform the bone graft, because the graft could be achieved using the

880 Table 2 surgery.

K. Yasumura et al. Evaluation of diplopia and enophthalmos after

Evaluation of diplopia 1. Excellent: no double vision within any visual field both with normal use and on examination with a Hess chart. 2. Good; no double vision within the central visual field but in some peripheral double vision detected with the Hess chart. 3. Fair: some double vision detected within the central visual field, but not readily appreciated by the patient because the double visual field is small or not in the main visual field. 4. Poor: obstructive double vision within the central visual field. Evaluation of enophthalmos 1. Excellent: no enophthalmos in subjective or objective findings. 2. Good: slight enophthalmos with less than a 1-mm discrepancy in both globe positions on CT image. 3. Fair: mild enophthalmos that is noted as a change in appearance in a mirror or less than 2 mm discrepancy in both globe positions on CT image. 4. Poor: remarkable enophthalmos with over a 2-mm discrepancy in both globe positions on CT image.

transantral approach. Postoperative CT showed that the grafted bone was incorporated into the bottom of the orbital floor and was not displaced after the Kirschner wire removal.

Discussion A number of minimally invasive treatments for blowout fractures and other facial fractures have been reported. These surgical interventions are broadly classifiable as closed reduction and open reduction methods. Although open reduction and internal fixation have been the gold standard treatment for zygomatic bone fracture for almost a half century,14,15 closed reduction and external fixation are still considered useful methods.16e18 Surgeons who prefer this traditional style argue that the cosmetic outcomes do not differ from those of the open method19,20 Most surgeons claim that the use of this technique results in little scar formation at the wire insertion site. Our wire fixation technique for blowout fracture is similar to the technique for zygomatic bone fracture, and we also did not observe soft tissue morbidity on the cheek. For blowout fracture, the approaches used for each treatment are not distinguished as either a closed or an open method. The most suitable closed method is the endoscopic method,21e23 because the aim is identical to that of the closed method used for other facial fractures with minimal morbidity and a smaller facial incision. An orbital approach with a subciliary or conjunctival incision carries a risk of cosmetic complications in the lower eyelid, conspicuous scarring, entropion, lid retraction and lid malposition, among others.24,25 This risk is one of the main

reasons why many surgeons prefer an endoscopic approach as the closed method for other facial fractures. The technique for the endoscopic approach was developed mainly in the field of otolaryngology as an endoscopic transantral or transnasal approach for early-phase and local area orbital wall fracture.26e29 Reconstruction using sheet-shape materials through the transantral approach under endoscopic assistance is now more common.10,21,30,31,32 The application has become widespread and excellent outcomes are reported, even for large floor reconstruction or delayed complex repair cases.33 Not all surgeons, however, are able to reconstruct the orbital floor of a wide and complex blowout fracture using the transantral approach, even with the use of an endoscope. There are limitations to the present blowout fracture repair method. One of the most difficult problems is the use of artificial materials. Artificial materials do not cause donorsite morbidity, but do carry a risk of infection or reaction in viable tissue.34e37 Although the risk of infection eventually disappears with the use of resorbable plates, a residual resorbable plate can cause gaze restriction because of its high reactivity with viable tissue.38 This is why some surgeons prefer autologous bone or cartilage grafts despite the time and effort needed to harvest them. At the very least, the use of autologous materials should not be completely ruled out, even with the risk of donor-site morbidity. Another problem is the safety of each approach. The orbital approach has the great advantage that surgeons can observe not only the entrapment area, but also the surrounding normal periorbital soft tissue, widely and directly. The principle that good visualisation leads to good results holds true for any surgery. In other words, it may be difficult for the surgeon to obtain a clear view with the transantral approach when an endoscope cannot be used. Besides reduction, vertical insertion of the devices or materials for fixation and reconstruction into the orbit through a crack in the hard bony floor under inadequate direct vision carries a higher risk of orbital soft tissue complications compared to other approaches. Extra caution must be taken for procedures in the posterior region of the orbital floor because the optic nerve is closer to the orbital floor here than in the anterior region. Thus, even simple endoscopic transantral reconstruction of the orbital floor may lead to grave complications. The tip of the device should always be directed towards the orbital basilicus organs when using this approach. The posterior region, however, never comes into view through the orbital approach because it locates deep in the orbit and slopes up towards the optic canal. Therefore, the transantral approach has the advantage of being the easiest method of accessing the posterior region. The endoscopic transantral approach is considered to be the most suitable approach for accessing the posterior region.14,39,40 A temporal sinus packing technique with a balloon catheter seems to avoid these limitations without leaving behind permanent artificial remnants or producing morbidity of orbital soft tissue.41,42 This method too, however, has limitations. One limitation is the absence of pinpoint support of the fracture segment edge, such as the tip of the surgeon’s finger, elevator or forceps. An inflated balloon peak may not always attach to the segment edge efficiently. Moreover, soft material is unsuitable for a rigid and stable fixation.

Transzygomatic Kirschner wire fixation for the treatment of blowout fracture Another limitation is that a long period of fixation is not possible extension of the lumen of the balloon from the maxillary sinus to the extra-body space causes patient discomfort. Inadequate repositioning and a short period of unstable fixation may result in enophthalmos after surgery. The concept of our wire fixation technique is similar to this technique in that it has minimal morbidity without requiring an orbital approach or the use of permanent artificial materials. The wire fixation technique has the great advantage of providing higher quality fixation, which decreases the risk of enophthalmos after surgery because the most effective bone segment for fast support can be used. Every effort should be made to confirm that the reduction is accurate and the fixation is rigid during surgery. We experienced one case with severe diplopia in the primary gaze that continues to have mild diplopia in ordinary use, even 1 year after surgery. This is not likely due to insufficient release of the muscle entrapment, based on the intra-operative findings and the postoperative course. It is likely that the diplopia remains mostly due to nerve or muscle injury occurring at the time of the primary injury. We found no evidence of a causal relation between the residual diplopia and the wire fixation technique.

Conclusion Transzygomatic Kirschner wire fixation for blowout fracture has several advantages for the repair of simple inferior orbital floor fractures: (1) precise, rigid and long-term fixation of any part of the anterior or posterior floor; (2) applicability for grafted bone fixation; (3) high quality of life after surgery without subciliary or conjunctival incision; and (4) safety without remnant artificial materials. This technique can be applied for the treatment of simple blowout fractures.

Ethics approval This study was carried out in Yokohama City University Hospital (Yokohama, Japan) with approval of the institutional review board and permission from the ethics committee. All patients received preoperative explanation of the difference between standard treatment and treatment with a Kirschner wire.

Funding None declared.

Conflicts of interest None declared.

References 1. Fujino T, Makino K. Entrapment mechanism and ocular injury in orbital blowout fracture. Plast Reconstr Surg 1980;65(5): 571e4. 2. Kaufman Y, Stal D, Cole P, Hollier Jr L. Orbitozygomatic fracture management. Plast Reconstr Surg 2008;121(4):1370e4.

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3. Guo L, Tian W, Feng F, Long J, Li P, Tang W. Reconstruction of orbital floor fractures: comparison of individual prefabricated titanium implants and calvarial bone grafts. Ann Plast Surg 2009;63(6):624e31. 4. Al-Sukhun J, Lindqvist C. A comparative study of 2 implants used to repair inferior orbital wall bony defects: autogenous bone graft versus bioresorbable poly-L/DL-Lactide [P(L/DL)LA 70/30] plate. J Oral Maxillofac Surg 2006;64(7): 1038e48. 5. Garibaldi DC, Iliff NT, Grant MP, Merbs SL. Use of porous polyethylene with embedded titanium in orbital reconstruction: a review of 106 patients. Ophthal Plast Reconstr Surg 2007;23(6):439e44. 6. Prowse SJ, Hold PM, Gilmour RF, Pratap U, Mah E, Kimble FW. Orbital floor reconstruction: a case for silicone. A 12 year experience. J Plast Reconstr Aesthet Surg 2010;63(7): 1105e9. 7. Park DJ, Garibaldi DC, Iliff NT, Grant MP, Merbs SL. Smooth nylon foil (SupraFOIL) orbital implants in orbital fractures: a case series of 181 patients. Ophthal Plast Reconstr Surg 2008; 24(4):266e70. 8. Sakakibara S, Hashikawa K, Terashi H, Tahara S. Reconstruction of the orbital floor with sheets of autogenous iliac cancellous bone. J Oral Maxillofac Surg 2009;67(5): 957e61. 9. Talesh KT, Babaee S, Vahdati SA, Tabeshfar SH. Effectiveness of a nasoseptal cartilaginous graft for repairing traumatic fractures of the inferior orbital wall. Br J Oral Maxillofac Surg 2009;47(1):10e3. 10. Kim JH, Kook MS, Ryu SY, Oh HK, Park HJ. A simple technique for the treatment of inferior orbital blow-out fracture: a transantral approach, open reduction, and internal fixation with miniplate and screws. J Oral Maxillofac Surg 2008;66(12): 2488e92. 11. Burm JS. Internal fixation in trapdoor-type orbital blowout fracture. Plast Reconstr Surg 2005;116(4):962e70. 12. Strong EB. Endoscopic repair of orbital blow-out fractures. Facial Plast Surg 2004;20(3):223. 13. Furuta M. Measurement of orbital volume by computed tomography: especially on the growth of orbit. Jpn J Opthalmol 2001;45:600e6. 14. Adams VM. Internal wiring fixation of facial fractures. Surgery 1942;12:523e40. 15. Michelet FX, Deymes J, Dessus B. Osteosynthesis with miniaturized screw plants in maxillofacial surgery. J Maxillofac Surg 1973;1:79e8416. 16. Mavili ME, Canter HI, Tuncbilek G. Treatment of noncomminuted zygomatic fractures with percutaneous screw reduction and fixation. J Craniofac Surg 2007;18(1):67e73. 17. Bezuhhly M, Lalonde J, Lalonde DH. Gillies elevation and percutaneous Kirschner wire fixation in the treatment of simple zygoma fractures: long-term quantitative outcomes. Plast Reconstr Surg 2008;121(3):948e55. 18. Soejima K, Sakurai H, Kono T, et al. Semi-closed reduction of tripod fractures of zygoma under intraoperative assessment using ultrasonography. J Plast Reconstr Aesthet Surg 2009; 62(4):499e505. 19. Lothrop HA. Fractures of the superior maxillary bone caused by direct blows over the malar bone. Boston Med Surg J 1906;154: 8e11. 20. Gillies HD, Kilner TP, Stone D. fractures of the malar zygomatic compound, with a description of a new X-ray position. Br J Surg 1927;14(56):651e6. 21. Ducic Y, Verret DJ. Endoscopic transantral repair of orbital floor fractures. Otolaryngol Head Neck Surg 2009;140(6): 849e54. 22. Chen CT, Chen YR. Endoscopically assisted repair of orbital floor fractures. Plast Reconstr Surg 2001;108(7):2011e8.

882 23. Farewell DG, Sires BS, Kriet JD, Stanley Jr RB. Endoscopic repair of orbital blowout fracture: Use or misuse of a new approach? Arch Facial Plast Surg 2007;9(6):427e33. 24. Ridgway EB, Chen C, Colakoglu S, Gautam S, Lee BT. The Incidence of lower eyelid malposition after facial fracture repair: a retrospective study and meta-analysis comparing subtarsal, subciliary, and transconjunctival incisions. Plast Reconstr Surg 2009;124(5):1578e86. 25. Kim YK, Kim JW. Evaluation of subciliary incision used in blowout fracture treatment: pretarsal flattening after lower eyelid surgery. Plast Reconstr Surg 2010;125(5):1479e84. 26. Kennedy DW, Goodstein ML, Miller NR, Zinreich SJ. Endoscopic transnasal orbital decompression. Arch Otolaryngol Head Neck Surg 1990;116(3):275e82. 27. Yamaguchi N, Arai S, Mitani H, Uchida Y. Endoscopic endonasal technique of the blowout fracture of the medial orbital wall. Op Tech Otolaryngol Head Neck Surg 1992;2(4):269e74. 28. Lee HH, Alcaraz N, Reino A, et al. Reconstruction of orbital floor fractures with maxillary bone. Arch Otolaryngol Head Neck Surg 1998;124(1):56e5929. 29. Folkestad L, Westin T. Long-term sequelae after surgery for orbital floor fractures. Otolaryngol Head Neck Surg 1999; 120(6):914e21. 30. Nishiike S, Nagai M, Nakagawa A, Harada T. Endoscopic transantral orbital floor repair with antral bone grafts. Arch Otolaryngol Head Neck Surg 2005;131(10):911e915,. 31. Nahlieli O, Bar-Droma E, Zagury A, et al. Endoscopic intraoral plating of orbital floor fractures. J Oral Maxillofac Surg 2007; 65(9):1751e7. 32. Persons BL, Wong GB. Transantral endoscopic orbital floor repair using resorbable plate. J Craniofac Surg 2002;13(3):483e8.

K. Yasumura et al. 33. Cheong EC, Chen CT, Chen YR. Broad application of the endoscope for orbital floor reconstruction: long-term follow-up results. Plast Reconstr Surg 2010;125(3):969e78. 34. Thore ´n H, Sna ¨ll J, Kormi E, Lindqvist C, Suominen-Taipale L, To ¨rnwall J. Symptomatic plate removal after treatment of facial fractures. J Craniomaxillofac Surg 2010;38(7):505e10. 35. Nagase DY, Courtemanche DJ, Peters DA. Plate removal in traumatic facial fractures: 13-year practice review. Ann Plast Surg 2005;55(6):608e11. 36. Lee HB, Nunery WR. Orbital adherence syndrome secondary to titanium implant material. Ophthal Plast Reconstr Surg 2009; 25(1):33e6. 37. Warrier S, Prabhakaran VC, Davis G, Selva D. Delayed complications of silicone implants used in orbital fracture repairs. Orbit 2008;27(3):147e51. 38. Uygur S, Cukurluoglu O, Ozmen S, Guclu TH, Sezgin B. Resorbable mesh plate in the treatment of blow-out fracture might cause gaze restriction. J Craniofac Surg 2009;20(1): 71e2. 39. Mohadjer Y, Hartstein ME. Endoscopic orbital fracture repair. Otolaryngol Clin North Am 2006;39(5):1049e57. 40. Woog JJ, Hartstein ME, Gliklich R. Paranasal sinus endoscopy and orbital fracture repair. Arch Ophthalmol 1998;116(5): 688e91. 41. Hinohira Y, Yumoto E, Shimamura I. Endoscopic endonasal reduction of blowout fractures of the orbital floor. Otolaryngol Head Neck Surg 2005;133(5):741e7. 42. Miki T, Wada J, Haraoka J, Inaba I. Endoscopic transmaxillary reduction and balloon technique for blowout fractures of the orbital floor. Minim Invasive Neurosurg 2004;47(6):359e64.