Volume 14 • Number 1 • February 2006


Preface Robert M. Kellman and E. Bradley Strong Condylar Fracture Repair: Use of the Endoscope to Advance Traditional Treatment Philosophy Reid V. Mueller, Marcin Czerwinski, Chen Lee, and Robert M. Kellman Traditional treatment of subcondylar fractures with maxillomandibular fixation often results in a malreduction and significant functional and aesthetic sequelae, including facial asymmetry, decreased jaw opening, and potential for late derangements of the temporomandibular joint. When used selectively, based on preoperative CT scans, the endoscopic technique will reliably restore condylar anatomy in nearly 95% of patients, thus obviating the consequences of malunion. Furthermore, unlike traditional open techniques no significant facial scarring or permanent facial nerve palsies have resulted. Thus, the authors strongly advocate endoscopic repair of adult condylar neck and subcondylar fractures that demonstrate displacement or dislocation and have adequate proximal bone stock to accept miniplate fixation. Endoscopic Repair of Orbital Floor Fractures D. Gregory Farwell and E. Bradley Strong Significant orbital trauma can result in orbital floor fractures with subsequent prolapse of the orbital contents into the paranasal sinuses. Prolapse of the periorbita can result in extraocular muscle entrapment, diplopia, enophthalmos, and even visual loss. Management of orbital floor fractures traditionally has been accomplished through transconjunctival and subciliary incisions. These approaches provide adequate visualization and cosmetically acceptable scars. Unfortunately, post-operative lid malposition can occur in a small percentage of cases. Another limitation is easy visibility of the posterior orbit, which often is obscured by prolapsed orbital fat. In light of these limitations, some surgeons have begun to evaluate an endoscopic approach to orbital floor fractures. The endoscopic approach offers a hidden incision, improved fracture visualization, and avoidance of post-operative eyelid malposition. This article reviews the indications, technique, and potential complications of endoscopic orbital blow-out fracture repair.






Endoscopic Approach to Medial Orbital Wall Fractures John S. Rhee and Chien-Tzung Chen Repair of medial orbital wall fractures can be challenging with traditional open techniques. This article describes different endoscopic-assisted approaches—transcaruncular and intranasal—which have been used to successfully repair these fractures. Endoscopic Repair of Anterior Table—Frontal Sinus Fractures E. Bradley Strong and Robert M. Kellman Frontal sinus fractures account for 5% to 15% of all maxillofacial injuries. Historically, a large percentage of these injuries were treated aggressively because of the long term risk of mucocele formation. This required a coronal incision with the associated surgical sequelae including a large scar, alopecia, and paresthesias. In light of these sequelae and recent advances in CT diagnosis and endoscopic treatment of mucoceles, some surgeons are starting to manage isolated anterior table fractures through an endoscopic approach. The endoscopic repair significantly reduces patient morbidity because it requires only 2 small incisions behind the frontal hairline. The endoscopic approach can be divided into two types: acute fracture reduction (covered elsewhere in this issue) and fracture camouflage. This article reviews the indications, techniques, and advantages of frontal sinus fracture camouflage. Endoscopic Management of Frontal Sinus Fractures Kevin A. Shumrick Endoscopes have had a profound effect on nearly every surgical specialty over the past 20 years. Using endoscopic approaches, excellent visualization of the surgical site can be achieved while avoiding extensive external incisions, thus, dramatically reducing morbidity compared with traditional surgical approaches. This article outlines the state of the art with regard to the use of endoscopes for managing frontal sinus fractures, which are one of the most common fractures treated with endoscopic techniques. The Rationale and Technique of Endoscopic Approach to the Zygomatic Arch in Facial Trauma Marcin Czerwinski and Chen Lee The reliable form and strategic position of the zygomatic arch make it a valuable landmark in midfacial trauma management. The benefits of arch repair have been used infrequently, mainly because traditional coronal access to this structure is fraught with undesirable sequelae. Endoscope-assisted zygomatic arch realignment and fixation allow anatomic repair without sustaining the drawbacks of extensive access incisions. The relative importance of this approach increases with trauma complexity, being most useful in Le Fort III and complex zygoma injuries. Endoscopic Approach for Mandibular Orthognathic Surgery Maria J. Troulis, Jose L. Ramirez, and Leonard B. Kaban The field of minimally invasive surgery is defined as the combination of surgical innovation with modern technology. This article describes the history of surgery and newer developments in endoscopic surgery for mandibular orthognathic surgery.






L. Yeow Endoscopically assisted surgery has become an essential component in many fields of surgical specialties. Index 51 57 .Contents vii Endoscopic Approaches to Maxillary Orthognathic Surgery Dennis Rohner and Vincent K. The implementation of this technique to craniofacial and maxillofacial surgery is a recent development. Endoscopic approach to subcondylar mandible fractures has been established as reliable surgical method.

MD. MD. Park. Guest Editor Local Cutaneous Flaps Stephen S. Nassif. FACS. Guest Editor August 2006 Blepharoplasty Paul S.viii FORTHCOMING ISSUES May 2006 RECENT ISSUES November 2005 Auricular Otoplasty Steven R.com . Guest Editor May 2005 Upper Third of the Face Peter A. MD. MD. MD. Guest Editor THE CLINICS ARE NOW AVAILABLE ONLINE! Access your subscription at: www.theclinics. Mobley. Wang. Adamson. MD.H. Guest Editor August 2005 Revisional Rhinoplasty Russell W. Kridel. Guest Editor November 2006 The Aging Face Tom D.

edu (R. and facial endoscopy. Bradley Strong. MD Guest Editors Endoscopes for use in the head and neck were brought to the United States in the 1980s for use in endoscopic sinus surgery. The authors contributing to this issue of Facial Plastic Surgery Clinics of North America are recognized leaders in facial trauma. USA E. and elective orthognathic surgery. most recently in the area of facial trauma and reconstruction.M.fsc. and research into new techniques continues. This is a rapidly expanding area of clinical interest.ucdavis. Davis School of Medicine 2521 Stockton Blvd. MD Department of Otolaryngology and Communication Sciences State University of New York Upstate Medical University 750 E. This issue reviews the most up-todate endoscopic applications. frontal sinus.2005. Kellman. zygomaticomaxillary complex.edu (E.10. Strong) Robert M: Kellman. 1064-7406/06/$ – see front matter © 2006 Elsevier Inc.theclinics. NY 13210.ix FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 14 (2006) ix Preface Endoscopic Craniomaxillofacial Surgery Robert M. Adams Street Syracuse. doi:10.com . Ste 7200 Sacramento.. endoscopic applications in the head and neck have continued to grow. reconstructive surgery.1016/j. MD Department of Otolaryngology University of California. With this in mind.005 facialplastic. MD E: Bradley Strong. orbit. including fractures of the subcondylar region. USA E-mail addresses: kellmanr@upstate. All rights reserved. Since that time. this issue describes individual techniques used by various surgeons in applying endoscopes to the repair and repositioning of the bones of the craniomaxillofacial skeleton. CA 95817.strong@ucdmc. Kellman) edward.B.

Quebec. All rights reserved. 5000 boul. Mueller. C1139. Mail Code L352A. 1064-7406/06/$ – see front matter © 2006 Elsevier Inc. Until recently.com (R. USA * Corresponding author. OR 97201. NY 13210. Robert M.2005. Canada.10. Marcin Czerwinski. The results achieved using their techniques far surpassed the outcomes of closed reduction and nonrigid fixation. The best results have been achieved in skeletally immature children. rigid internal fixation. MDa. H3H 1P3 c Sacre-Coeur Hospital. Most show equal or better outcomes after open treat- Oregon Health Science University. Kellman. but it is not without significant morbidity. even in the face of little or no fracture reduction. Portland. Montreal. however. where condylar remodeling often can restore condylar anatomy to near normal. and primary bone grafting of critical size defects—introduced by these surgeons— revolutionized the field of craniomaxillofacial surgery.com . State University of New York Upstate Medical University. doi:10. Few studies exist comparing similar fractures treated by open versus closed methods. the outcomes in adults have not been uniform. MDd & & & MD b .theclinics. Chen Lee. visualized anatomic reduction.1016/j. this standard of care was not applied to all areas of facial trauma. MD c . & Regional anatomy and the effect of maxillomandibular fixation Role of the endoscope—treatment indications Preoperative planning Fracture anatomy Radiographic imaging Operative technique Endoscopic equipment Repair sequence Maxillomandibular fixation & & & Exposure Reduction Fixation Bailout Postoperative regime Results Fracture demographics Operative details Outcomes Summary References Treatment of facial fractures has progressed significantly over the last 25 years largely because of the pioneer efforts of Paul Manson and Joseph Gruss.fsc. E-mail address: reid@reidmueller. Canada.1 FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 14 (2006) 1–9 Condylar Fracture Repair: Use of the Endoscope to Advance Traditional Treatment Philosophy Reid V. 750 East Adams Street. USA b Montreal Children´s Hospital. 2300 Tupper Street.*. Despite almost miraculous condylar remodeling in children.V. Closed treatment of mandibular fractures with maxillomandibular fixation (MMF) has a long and successful history. Gouin West. and a significant percentage suffers long-term aesthetic and functional problems [1–5]. most notably omitted were the zygomatic arch and the mandibular condyle. Syracuse. Mueller). H4J 1C5 d Department of Otolaryngology and Communication Sciences. Montreal. Quebec. The systematic principles of wide exposure. 3181 Southwest Sam Jackson Park Road.004 a facialplastic.

Efforts to improve surgical access may result in either direct facial nerve injury or a traction injury during retraction. Studies in rhesus monkeys have demonstrated loss of interincisal opening and maximal stimulated bite force after MMF [32. reducing the risk to the facial nerve. Addition- . When assessing the shortcomings of closed treatment. abnormal orientation of the condylar fragment. A malunited condyle alters these precise relationships. As the fragments overlap. The use of the endoscope to treat condylar injuries was a natural extension of minimally invasive techniques for managing craniomaxillofacial trauma. Patients treated with an open approach had better restoration of facial symmetry. condylar movement. The complex relationships of the temporomandibular articulation allow only minimal imprecisions. This is exacerbated by the normal resting tone of masticatory.18–27]. as during chewing. Attachments of the lateral pterygoid muscle usually place the condylar fragment into a flexed posture. Endoscopic assistance allows the surgeon to produce anatomic fracture alignment. and alteration of temporomandibular joint biomechanics. the lateral ptygeroid often will cause inclination of the condylar head medially. all while embracing the accepted advantages of anatomic reduction and rigid fixation. This results in premature contact with the anterior wall of the glenoid fossa. The most important long-term complications of closed treatment are internal derangement and persistent malocclusion. the significant independent morbidities associated with MMF often are overlooked because of the surgical simplicity of its application. Extended experience and careful analysis of closed treatment of condylar injuries using MMF have shown that fracture reduction rarely occurs. Close proximity of the facial nerve to the condyle compromises access to the fracture segment and makes the dissection tedious. that fracture reduction and rigid fixation with restoration of anatomy are laudable goals if that can be achieved without undue morbidity. on an intellectual level. the latter reported in up to 28% of patients [15–17]. Instead. are proper occlusion and chin position forcefully restored [30].33]. An open intraoral approach. the mandible rotates such that there is premature posterior occlusal contact and an anterior open bite. This has been the case in 80% of adult condylar fractures in the authors’ experience. Most surgeons accept. and to avoid the negative sequelae of condylar malunion. In addition. but it rarely is used because of very poor visualization and difficult hardware fixation [28]. and less chronic pain. and infrahyoid musculature. comprising 455 patients. The reluctance to use open reduction and internal fixation of condylar fractures stemmed from the belief that these injuries do well with closed treatment using MMF and because the open technique was challenging and associated with significant morbidity. limiting interincisal opening to initial hingetype motion only. centric occlusion is forced through neuromuscular adaptation to the condylar malunion at the temporomandibular joint. suprahyoid. The prolonged period of immobilization using MMF necessitates a lengthy postoperative regimen of muscular and occlusal rehabilitation to improve muscle function. resulting in significant aberrations in joint dynamics that have a marked potential to produce late internal derangement. Regional anatomy and the effect of maxillomandibular fixation Any displaced fracture of the condyle will have some degree of fragment overlap resulting in shortening of the posterior ramal height [29]. all of which carry significant functional and aesthetic consequences. The risk of permanent facial nerve injury reported in 21 different series of open approaches. with up to 4% reporting an unsightly scar [7]. and nearly all will result in a perceptible scar [10]. because of the bilateral interdependence of the craniomandibular articulation.2 Mueller et al ment despite the fact that more severely injured patients tended to undergo open treatment [6–15]. and range of motion. Furthermore. The decrease in morbidity associated with the endoscopic approach may expand the indications for reduction and rigid fixation in the future. while the risk of transient palsy ranges from 0% to 46% (mean 12%) [11. In addition.14. The additional 15 to 20 mm of opening available through translational movement never is achieved fully. All surgical approaches for the open treatment of condylar fractures require a facial incision. designed to circumvent these drawbacks. ramal shortening causes a decreased radius of mandibular rotation that is visible as ipsilateral jaw deviation during motion [29]. faster recovery of jaw motion.15. this causes an unappealing loss of chin projection at the pogonion. The endoscopic approach described here has the potential to reduce morbidity by limiting scars. further shortening the ramal height. averages 1%. and eliminating the need for MMF. In addition. Only with effort. the contralateral condyle sustains excessive biomechanical loads and similarly is predisposed to early degenerative changes [31]. has been described. Malunion often results in shortening of the posterior ramus because of interfragmentary overlap.

and those who have seizure disorders or alcoholism are at risk for aspiration and death. Preoperative planning Fracture anatomy The endoscopic technique of condylar fracture repair relies on visual confirmation of fracture fragment reduction and sufficient length of the extracapsular segment for the placement of fixation hardware. degree of comminution. neck (below the capsular attachment and above the sigmoid notch). location of fracture. and subcondylar [Fig.and complex anatomical relationships of the temporomandibular articulation. and relationship of the condylar head to the fossa. Intracapsular fractures and high neck fractures are not treated using the endoscopic approach. The latter group forms the vast majority of adult condylar injuries treated at the authors’ centers.Condylar Fracture Repair 3 ally. manipulation. upright posture of the condylar head . and hard- Role of the endoscope—treatment indications The goals of condylar fracture treatment are: painfree mouth opening with interincisal distance beyond 40 mm. In addition. Fracture displacement Displacement refers to the position of the condylar fragment relative to the ascending ramus. It is difficult to maintain good oral hygiene with MMF. determination of the precise fracture geometry preoperatively is mandatory so that a decision can be reached whether an endoscopic approach is feasible. displacement. those where it is lateral. open treatment is not advocated for nondisplaced. nondislocated fractures. stable temporomandibular joints. In most circumstances. because there is no possibility of applying fixation. anatomic reduction and rigid fixation of the condyle are required to satisfy these objectives by restoring preinjury ramal height.15]. Endoscopic repair of subcondylar fractures is generally the easiest. Fractures of the condylar head generally do not demonstrate significant loss of posterior ramal height and can be expected to do relatively well with traditional methods. and who have dementia or psychiatric diagnosis simply may not tolerate the procedure. 2]. and patient choice. Fracture location Condylar fractures are classified as head (intracapsular). Fractures of the condylar neck are suitable for endoscopic treatment if sufficient bone stock is present proximally to accept two screws for miniplate fixation. Lateral override fractures are especially amenable to repair because of easier fragment visualization.0 mm plate are likewise not amenable to endoscopic repair. Consequently. and good symmetry [30]. dislocation of condylar head. orthodontic treatment must be delayed during the period of MMF. comminution. Displacement is an important variable guiding the initial approach to endoscopic treatment. Patients with condylar process fractures are selected for endoscopic-assisted reduction and fixation based on age. neck (below the head and above the sigmoid notch). as normal biomechanical relationships are unaltered. Fractures where the condylar segment is located medially are termed medial override. good excursion of the jaw in all directions. lateral override [Fig. tive. 1] [34]. 1. and subcondylar (passing through the nadir of the sigmoid notch). direction of proximal fragment displacement. and geometric constraints for instruments. restoration of preinjury occlusion. Endoscopic approaches by their very nature have a limited optical cavity. . comparisons of patients with condylar neck fractures randomized to open versus MMF treatment have demonstrated that patients after MMF have decreased range of motion necessitating long periods of physiotherapy to regain their premorbid function [7. Condylar fractures in prepubertal patients do not require anatomic reduction because of the great potential for rehabilitation through growth and remodeling. There are four specific fracture attributes that will help to make the decision: location. distorted perspec- Fig. Finally. Condylar fractures can be classified as head (intracapsular). Many patients find MMF uncomfortable. surgical exposure may lead to devascularization of the condylar head. Fractures that do not allow for the application of at least two holes of a 2. concomitant medical or surgical illness.

as the telescoped ascending ramus obscures visual access to the lateral surface of the condylar fragment and greatly impairs manipulation because of physical obstruction. Unfortunately. Wilson and colleagues compared helical CT scanning with panoramic tomography in detecting 73 mandibular fractures in 42 consecutive patients and correlated the results with known surgical findings. while panoramic tomography detected only 86%. Microcomminution will obscure the interdigitation of small irregularities along the fracture line that ordinarily assist in precise reduction. Generally lateral override fractures are the easiest to approach endoscopically. whereas medial override injuries are first reduced to lateral override to facilitate repair. During reduction. Nondisplaced. nondislocated fractures signify the presence of sufficient periosteal support for stability and do not require open treatment. those fractures with true dislocation of the condylar head are significantly more challenging. the visual limitations of endoscopy make reliable assessment of reduction deceptively challenging in the face of comminution. Comminuted fractures often will have fracture fragments that involve the border and thereby obscure these landmarks. 3]. in 2001. A minor degree of comminution is not considered a contraindication. A displaced condylar head without true dislocation usually can be relocated into anatomic position easily. The authors simplify the treatment of medial override injuries by first reducing them to the lateral override category. ware fixation. the anterior and posterior borders of the fracture line are used as anatomic landmarks to assess accurate reduction. In contrast. Using 1 mm collimated images (with a pitch of two) and 1 mm axial images reconstructed on every second image. In six missed frac- . Radiographic imaging Accurate radiographic imaging is necessary to reliably assess the feasibility of endoscopic repair and to formulate a precise treatment strategy by identifying fracture location. The fracture of the right condyle demonstrates lateral override.4 Mueller et al Fig. direction of displacement. Condyle–fossa relationship Fractures associated with nondislocated condylar heads are the most favorable for endoscopic repair. however. medial override injuries are more difficult to reduce endoscopically. that of the left. Fracture comminution Significant comminution is a relative contraindication to endoscopic repair as this technique relies largely on visualization of the fracture line for anatomic reduction and some degree of interfragmentary opposition for solid fixation. medial override. The accuracy of modern helical CT scans has surpassed panoramic tomography for detecting mandibular fractures. Helical CT scan detected 100% of the fractures. and degree of comminution [Fig. Coronal (above) and three-dimensional (below) CT reconstructions of a patient who sustained bilateral condylar fractures. 2.

no comminution. or a sufficient distance to place the fixation hardware. Exposure An intraoral incision along the oblique line of the mandible is made. then interfragmentary realignment is achieved by distracting the distal segment through mechanical traction at the mandibular angle or placement of a 3 mm posterior occlusal spacer. the surgical management was altered by the additional information provided from the CT scan. the subperiosteal dissection continues on the lateral surface up to the joint capsule. Three-dimensional CT scan of a left condylar fracture demonstrating characteristics amenable to the endoscopic repair technique: adequate proximal bone stock. The endoscopic cavity is created by elevating the periosteum off the lateral aspect of the ascending ramus. it is removed. and no dislocation out of the condylar fossa. Remember that the reduction of the fracture is a visual reduction and not based on occlusion. lateral override. Transcutaneous stab incisions for screw placement are made directly over the palpated fracture line at the posterior border of the mandible. the nature of a dental root fracture was seen better on panoramic tomography [35]. The proximal segment can be reduced by bringing the condylar fragment out if its flexed position and applying medially directed pressure using a trocar inserted through the stab incisions. The assistant may hold the endoscope while the surgeon uses the periosteal elevator and suction to continue the dissection proximally to reveal the condylar fragment. Once the proximal fragment is identified.000 epinephrine solution will decrease bleeding into the optical cavity. Fig. blunt hemostat dissection through the parotid gland and masseter muscle is performed to avoid injury to the facial nerve. and a video system. Gentle. Repair sequence If present. 3. 4]. If the fracture already is a lateral override. The use of tight wire maxillomandibular fixation will prevent distraction of the fracture and lock the displaced condyle in a malreduced position. This occurs because of a failure to appreciate the degree of lateral override and coronal plane angulation of the proximal fragment. tures. the authors use a 4 mm diameter 30o angle endoscope. extracondylar fractures are addressed first using standard open reduction and internal fixation techniques to restore an intact mandibular arch. fine cut axial computed tomography scans with three-dimensional reformatting provide the most precise illustration of these variables. which provides many specialized instruments facilitating the endoscopic technique. Pennsylvania). A common mistake is to inadvertently dissect under (or medial to) the proximal fragment. Injection at the intraoral incision site and along the lateral aspect of the ascending ramus with 1:200.Condylar Fracture Repair 5 Maxillomandibular fixation If MMF was used for repair of an extracondylar fracture. a 4 mm endoscopic brow lift sheath (Isse Dissector Retractor. Karl Storz. The three-dimensional reformatting is not accurate for detecting fracture detail but rather used to aid in the visualization of the fracture. Removal of traction or posterior occlusal wedge then will permit the rubber band fixation to temporarily impact the fracture interfaces together and often maintain reduction while fixation is applied [Fig. and forming a clear mental picture of what will be required for reduction. In one patient. Reduction To facilitate repair. The rigid arch is then helpful in manipulating fracture fragments to achieve adequate reduction. Germany) that maintains the optical cavity. medial override injuries are reduced initially into lateral override by placing a curved elevator medial to the proximal fragment while strongly distracting the fracture so as to allow the proximal fragment to be displaced to the lateral surface of the ascending ramus. In the authors’ experience. Standard mandible fracture repair instruments are used in addition to the Subcondylar Ramus fixation set from Synthes (Paoli. . Operative technique Endoscopic equipment At their centers. The authors routinely employ rubber band anterior MMF that facilitates fracture repair by maintaining occlusion but permitting realignment of fracture fragments.

surgeons should resort to the method of condylar repair that they would use if the endoscopic technique was not available. After reduction is achieved. and isolated fractures is shown in Fig. unilateral. Postoperative regime All patients leave the operating room without MMF and are kept on a soft diet for 6 weeks. The proportion of patients with bilateral. Fractures involving bones other than the mandible were excluded.B) Preoperative coronal CT scan of a patient with bilateral condylar fractures and an endoscopic view of the left condylar fracture after reduction. (A. In this circumstance. each fracture will dictate the best approach. Several authors have reported fracture of single miniplates. then the distal screws should be removed and the condylar fragment repositioned. and State University of New York Upstate Medical Center. This allows the plate to act as a handle to position the condylar fragment into reduction. the screws are placed into the mandibular portion. In general. the authors advocate placement of two miniplates whenever possible. Bailout In a small number of attempted cases the endoscopic repair will not be possible because of inadequate proximal bone stock. If the reduction is not correct. Following hardware placement. The sigmoid notch and posterior border of the mandible must be visualized to ensure that reduction has occurred. the fixation plate is attached to the condylar fragment first. Results The results depicted in the following sections represent the combined experience of the senior authors from three university medical centers: the Oregon Health and Science University Hospital Center. Ultimately. thus the term nonisolated fracture refers to involvement of the condyle and another mandibular site. 4]. San Francisco General Hospital. Some groups have found that placing a plate near the sigmoid notch or anterior portion of the fracture first simplifies placement of the posterior border plate. (C. taking advantage of its thick cortical bone and flat surface [see Fig.D) Postoperative coronal CT and a view of the anatomically reduced and rigidly fixated left condylar fracture using the endoscopic technique. rubber band MMF is released and the mandible ranged in all excursions to ensure reproducible preinjury occlusion and stability of fixation. A miniplate is fixated along the posterior border of the ascending ramus. or inability to place fixation. At least two screws are placed in each fracture segment to ensure solid fixation. 150 condylar fractures were . 5. 4. No matter the method. In total. Self-drilling screws have not been useful and often are a significant liability. excessive comminution. a meticulous inspection of the visual landmarks of anatomic reduction is imperative.6 Mueller et al Fig. Fixation Screws are introduced through the transcutaneous trocar. Fracture demographics One hundred thirty-five patients were treated using primary endoscopic condylar fracture repair.

Mandibular function Postoperative dental occlusion and interincisal jaw opening were documented in 102 patients. 13 displayed medial override of the proximal fragment.Condylar Fracture Repair 7 Outcomes Bailout procedure Fourteen of 150 attempted endoscopic fracture repairs were aborted. Percentages of bilateral. where fixation was achieved during primary repair. with persisting malreduction found in two fractures treated with traditional ORIF following aborted endoscopic procedures. fracture reduction was achieved. Solid bars represent the number of cases. Fourteen had only one side treated endoscopically. and isolated injuries are shown. Four malreduced fractures were revised using secondary endoscopic procedures with successful correction of the malreduction. 5. 6. no secondary procedures were performed. the condylar head was dislocated completely out of the glenoid fossa. Of those. Mal- Fig. In 75% of the fractures. in each category. Radiographic fracture reduction Plate fixation was achieved at primary endoscopic repair in 136 of 150 condylar fractures. and in eight fractures. In these nine fractures. . Fig. follow-up radiographs revealed loss of fracture reduction in all cases. Primary endoscopic condylar repair was attempted in 135 patients. 13 had both sides repaired using the endoscopic approach. The bailout procedure used in nine fractures was MMF. The average duration for the last 30 cases was approximately 70 minutes. attempted at primary endoscopic repair. 6]. the mean time required to accomplish endoscopic repair was less than 2 hours. Despite endoscopic fracture reduction and postoperative MMF. In 27 patients presenting with bilateral condylar fractures. Traditional open reduction and internal fixation techniques were used as the bailout procedure in the other five aborted endoscopic fractures. however. but plate fixation was not possible because of the short condylar pole. Cross-hatched bars signify the number of cases where fixation could not be achieved using the endoscopic approach. unilateral. as the bone stock in the proximal fragment on the contralateral side was deemed insufficient on preoperative CT images to achieve fixation. plate fixation was achieved at primary endoscopic repair in 136 (91%) [Fig. The other two malreductions were judged as minor and acceptable. Completion rate of primary endoscopic condylar repair according to the fracture type. Hardware failure (broken plate) with late loss of reduction occurred in two of the remaining 130 primarily fixated condylar fractures. These were found to be exceptionally challenging surgical repairs. was found on early postoperative CT imaging. Malreduction in 6 of these 136 condylar fractures. Operative details Of the 150 condylar fractures.

The authors look forward to future advancements of this and other endoscopic techniques. and indeed this may depend heavily on his or her experience and patient preference. Two temporary palsies (one full and one involving the frontal branch only) occurred. Emshoff R. In this series. Fortschr Kiefer Gesichtschir 1996. No patients sustained significant facial scarring. Aesthetic appearance Scarring from endoscopic access portals was minimal in all cases. however. the technique prevents the late sequelae of internal derangement. et al. Long-term results of nonsurgical management of condylar fractures in children. and the initial operative times are long. The endoscopic approach is technically demanding. the authors have found the time required approximates that of transcutaneous open methods. In the treatment of condylar injuries. Summary This compilation of a series of 150 attempts at endoscopic condylar fracture repair represents the early evolving experience from three centers. Thus.8 Mueller et al occlusion was found in 3 of 102 patients. and many instructional courses already have been organized. Stegenga B. Furthermore. Does this represent a failure of the technique? Critical scrutiny of the data suggests not. J Craniomaxillofac Surg 2001. Following a period of adjustment. and a symmetrical appearance of the jaw line were restored in cases where fracture reduction was achieved successfully.41:124–7.41:138–42. Int J Oral Maxillofac Surg 1999. The skills needed for condylar repair are also increasingly essential to complete various other facial plastic surgery procedures. [4] Kellenberger M. Fortschr Kiefer Gesichtschir 1996. The comprehensive data presented delineate the advantages and potential pitfalls with this newly introduced technique. The incidence of bailout procedures can be reduced by careful analysis of CT images and subsequent exclusion of these proximal injuries. The authors feel that anatomic reduction and fixation are the best way to restore preinjury facial aesthetics and mandibular motion dynamics and to prevent late sequelae of internal derangement. Risse G. Hardt N. von Arx T. Conservative versus surgical therapy of unilateral fractures of the collum mandibulae—anatomic and functional results with special reference to computerassisted 3-dimensional axiographic registration of condylar paths. it alters the treatment philosophy. Each surgeon will have to decide on his or her indications for endoscopic repair. References [1] Feifel H. Boering G. upright posture of the condylar head. the drawbacks of open reduction had been avoided.28(6):429–40. Furthermore. Additionally. Keskin A. [5] Strobl H. Restoration of premorbid ramal height. the endoscope is not only an aid. and complex temporomandibular joint relationships results in an aesthetic chin projection and occlusion. ade- quate interincisal opening (96% of patients had opening greater than 35 mm). Interincisal jaw opening exceeded 35 mm in 96% of patients (98/102). These data confirm this notion.29(4):232–7. the authors strongly advocate endoscopic repair of adult condylar neck and subcondylar fractures that demonstrate displacement or dislocation. When endoscopic repair is used selectively to treat injuries that have been shown to be amenable to this approach. Specifically. Remodeling following condylar fractures in children. as bailout to traditional techniques showed successful anatomic repair in only 2 of the 14 aborted cases attempted initially using the endoscope. the development of specialized endoscopic instruments facilitates repair. chin projection. a review of CT images of the 14 fractures where plate fixation could not be achieved by the endoscopic technique suggests that these belong to a subgroup of proximal injuries that are predictably difficult to manage regardless of the surgical method. The substantial advantages of anatomic reduction have been delineated. both resolved completely and spontaneously. it can be expected to reliably produce anatomic reduction in 94% (128/136) of cases. [3] Hovinga J. from the conservative MMF to anatomic repair. Plate fracture accounted for only two failures in the 136 primarily endoscopically fixated condylar fractures. Analysis of the early results shows a high rate (9%) of bailout. Opheys A. Four of those 6 were salvaged with successful secondary endoscopic procedure. Results of follow-up of temporomandibular joint fractures in 30 children. and there were no cases of permanent facial nerve palsy and only two cases of temporary facial nerve palsy. Soft tissue complications There were no permanent facial nerve palsies. the last 30 cases took an average of 70 minutes. One soft tissue abscess was identified at a trocar portal and was treated uneventfully by incisional drainage. Facial height. Rothler G. Only 6 of 136 primarily endoscopically fixated fractures went on to malreduction. [2] Guven O. Conservative treatment of unilateral condylar fractures in chil- .

A review. Open reduction of subcondylar fractures. 1994. [21] MacArthur CJ. J Oral Maxillofac Surg 2001. Surgical treatment of fractures of the mandibular condylar neck. J Oral Maxillofac Surg 1994. Hlawitschka M. Ishizuka M.24(1):181–94.17(3): 119–24. Occlusal results after open or closed treatment of fractures of the mandibular condylar process. Konstantinovic VS. Dechow PC. J Craniomaxillofac Surg 1999. Silvennoinen U. J Maxillofac Surg 1976. et al. et al. Biomechanics and osteosynthesis of condylar neck fractures of the mandible. de Bont LG. Recovery of mandibular motion after closed and open treatment of unilateral mandibular condylar process fractures. et al. Carlson DS. 59(4):389–95. Throckmorton GS. Donald PJ. Lundy LB. et al. Surgical versus nonsurgical treatment of unilateral dislocated low subcondylar fractures: a clinical study of 52 cases. Vuillemin T. Thorn JJ. [23] Pereira MD. Ward Booth RP. Silvennoinen U. .28(2):95–8. fractured condylar process: indications and surgical procedures. A comparison of stimulated bite force after mandibular advancement using rigid and nonrigid fixation.25(2):107–11. Chossegros C. J Oral Maxillofac Surg 1992.41(2):89–98. Ellis III E. [32] Ellis E. J Oral Maxillofac Surg 1983. J Oral Maxillofac Surg 1989. J Oral Maxillofac Surg 2000. [31] Dahlstrom L. Oikarinen K. Mandibular condyle fractures: a consensus.Condylar Fracture Repair 9 [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] dren: a long-term clinical and radiologic followup of 55 patients. Lindahl L. Assael LA. J Oral Maxillofac Surg 1994. A review. Iizuka T. Chicago: Quintessence Publishing.29(6): 421–7.50(4):349–52 [discussion 352–3]. Dimitrijevic B. Outcomes of open versus closed treatment of mandibular subcondylar fractures. Ellis III E. Rigid fixation of mandibular condyle fractures. Indications for open reduction of mandibular condyle fractures.59(4): 370–5 [discussion 375–6].18:18–23. [28] Ellis III E. Throckmorton GS. Condylar neck fractures of the mandible. Open reduction of the dislocated. [33] Ellis ED. Open treatment of condylar process fractures: assessment of adequacy of repositioning and maintenance of stability. Int J Oral Maxillofac Surg 1999.82(3):248–52. et al. Int J Oral Maxillofac Surg 1998. et al.45(5):383–5. A prospective 1-year study. Prospective comparison of panoramic tomography (zonography) and helical computed tomography in the diagnosis and operative management of mandibular fractures.27(4):235–42. Mouth opening after release of maxillomandibular fixation in fracture patients. Tashiro H. Ladrach K. Oka M. Oral Surg Oral Med Oral Path 1993. Osteotomy-osteosynthesis in displaced condylar fractures. [19] Eckelt U. J Oral Maxillofac Surg 1987. Ellis III E. Int J Oral Maxillofac Surg 2000.46(1):26–32. Arch Otolaryngol Head Neck Surg 1993.76:6–15. [29] Krenkel C.37:87–9. J Oral Maxillofac Surg 1988. Throckmorton GS. Int J Oral Maxillofac Surg 1989.119(4):403–6.16(1):133–46.4(4):200–6. J Oral Maxillofac Surg 1994. Marques A. Otolaryngol Clin North Am 1991. Clinical and radiological evaluation following surgical treatment of condylar neck fractures with lag screws. The effects of mandibular immobilization on the masticatory system. Widmark G. Analysis of possible factors leading to problems after nonsurgical treatment of condylar fractures. Kahnberg KE. Open reduction-fixation of mandibular subcondylar fractures.47(2):120–7. Kahnberg KE.52:1185–92. [24] Raveh J. de Amaratunga NA. Clin Plast Surg 1989. [35] Wilson IF. J Craniomaxillofac Surg 1995. Short retromandibular approach of subcondylar fractures: clinical and radiologic long-term evaluation. Occlusal and temporomandibular joint disorders in patients with unilateral condylar fracture. Knowles J.52(4):353–60 [discussion 360–1]. [20] Klotch DW. Bagenholm T. Surgical versus conservative treatment of unilateral condylar process fractures: clinical and radiographic evaluation of 80 patients. [22] Mikkonen P. Raustia AM. Ellis III E.27(4):280–5. Carlson DS. J Oral Maxillofac Surg 2000. [34] Bos RR. Transosseous wiring in the treatment of condylar fractures of the mandible. Pihakari A. J Oral Maxillofac Surg 2001. Int J Oral Maxillofac Surg 1996. Surgical treatment of the fractured and dislocated condylar process of the mandible. Int J Oral Maxillofac Surg 1989. Throckmorton G. Lamberg MA. [25] Takenoshita Y. Br J Oral Maxillofac Surg 1999. Dean J. et al.18(5): 267–70. Cheynet F. Condylar fractures: nonsurgical management. Palmieri C.107(6):1369–75. J Oral Maxillofac Surg 1999. Mandibular motion after closed and open treatment of unilateral mandibular condylar process fractures.58(3):260–8. Blanc JL. [26] Tasanen A.23(6):369–76. Throckmorton GS. Ellis III E. et al. Plast Reconstr Surg 2001.57(7):764–75 [discussion 775–6]. 15-year follow-up on condylar fractures. Palmieri C. A study of functional rehabilitation. Lokeh A. Benjamin CI. Lindqvist C. J Craniomaxillofac Surg 1989. Simon P. Worsaae N. Lindqvist C.52(8):793–9. Haug RH. Bite forces after open or closed treatment of mandibular condylar process fractures. [27] Zide MF. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996. [30] Walker RV. 58(1):27–34 [discussion 35]. Kent JN.

Patients with trap door [Fig. doi:10. laparoscopic. USA * Corresponding author. The introduction of endoscopy and minimally invasive surgery has revolutionized the surgical treatment of many diseases. His technique involved direct visualization of the fracture with a headlight. This may result in extraocular muscle entrapment with diplopia and enophthalmos. Walter described the Caldwell Luc approach for repair of orbital floor fractures in 1972 [6].G. which can be difficult to visualize through traditional incisions. which often is obscured by prolapsed orbital fat. It offers magnified visualization. 1] and medial blow-out [Fig. postoperative lid malposition can occur in a small percentage of cases. E.theclinics. Ste 7200 Sacramento. The most common complications include entropion.001 facialplastic. Endoscopy has become commonplace in urologic. technique. 1064-7406/06/$ – see front matter © 2006 Elsevier Inc. and sinus surgery. This concept now is being evaluated in orbital trauma. less postoperative morbidity. and potential complications of endoscopic orbital blow-out fracture repair. Visual loss from optic neuropathy. Farwell). Bradley Strong. or hyphema also may occur. access through smaller incisions.11. unpublished data.com . 2] fractures are excellent candidates for endoscopic repair. and often greater patient acceptance. Another limitation is easy visibility of the posterior orbit. & & & MD*.11 FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 14 (2006) 11–16 Endoscopic Repair of Orbital Floor Fractures D. Gregory Farwell. University of California. These approaches provide adequate visualization and cosmetically acceptable scars. Indications A preoperative CT scan should be obtained to document the location and extent of the orbital floor fracture. and lid shortening.fsc. blind fracture reduction. All rights reserved. Davis School of Medicine 2521 Stockton Blvd. insert an endoscope. 2004) [7–13]. Although several authors have described access to the orbital floor by means of a transnasal approach [2–5]. several authors have described an endoscopic Caldwell Luc approach to orbital floor fractures (Farwell and colleagues. resulting in prolapse of orbital contents into the paranasal sinuses [1]. retinal detachment. Unfortunately. E-mail address: dgfarwell@ucdavis.1016/j.2005. Management of orbital floor fractures traditionally has been accomplished through transconjunctival and subciliary incisions. ectropion. and apply instrumentation. complete fracture visualization and reconstruction require’s greater access through the maxillary sinus by means of a Caldwell Luc approach. maintain adequate hemostasis. This article reviews the indications. and short-term fixation with packing.edu (D. General requirements for endoscopic surgery include the ability to obtain an optical cavity. These fractures often involve the medial wall and floor of the orbit. including the stable posterior shelf. the bony orbital vault may be fractured. & & & MD Indications Technique Discussion Complications Summary References When the periorbital region is injured with significant force. Fractures that Department of Otolaryngology. Since Walter’s description. It allows access to the maxillary sinus and excellent visualization of the entire orbital floor. CA 95817.

3. 3] or involve the lamina papyracea are much more difficult to repair endoscopically and generally require an open approach. The infraorbital canal is disrupted. 1. Trap door fracture. Two monitors are preferable. Note that the entire orbital floor is comminuted and depressed into the maxillary sinus. Local anesthetic and epinephrine are injected sublabially. An approximate 1. 4] or superior– medially depending upon surgeon preference. soft tissue entrapment. The fracture extends medially to the lamina papyracea and laterally to the infraorbital nerve. so it can be seen by both surgeons. and the assistant is on the left. 4]. Note that the medial floor is comminuted and depressed into the maxillary sinus. the patient is placed supine on the operating table. 2. The monitor is positioned at the head of the patient. Lateral blow-out fracture. location.12 Farwell & Strong Fig. A small notch should be placed along the edge of the antrostomy to stabilize the endoscope and provide tactile feedback for the assistant surgeon. The fracture extends medially to the lamina papyracea and laterally to the lateral orbital wall. The cheek is retracted by a Greenberg retractor. The periosteum then is elevated. exposing the anterior wall of the maxilla up to the level of the infraorbital nerve. Technique Under general anesthesia. extend lateral to the infraorbital nerve [Fig. The defect is analyzed for size. Medial blow-out fracture. Note that the fracture is hinged at the lamina papyracea and depressed along the junction with the infraorbital nerve. Fig. Care is taken to avoid excessive traction on the nerve. and bony comminution. The notch can be placed inferiorly [see Fig. and a 4 cm incision is made in the gingivobuccal sulcus. through the periosteum.0 cm maxillary antrostomy is made in the thin bone of the maxillary face [Fig. but the bone can be removed with a saw and replaced after the orbital floor repair. 4. . A right-handed surgeon is on the patient’s right side. Fig. Left maxillary sinus antrostomy. and oxymetazoline-soaked pledgets are placed into the maxillary sinus for decongestion. This usually is performed with an osteotome and Kerrison rongeur. soft tissue prolapse. The lip is retracted with a Greenberg self-retaining retractor.0 cm × 2. If a trap door in- Fig. and onto the max- illa. It is important to maintain the integrity of the hinge during the surgical repair. The orbital floor then is inspected with 0° or 30° sinus endoscopes.

Care should be used to assure that no bone fragments are pushed back into the orbital cavity. Note the depression and comminution of the entire medial segment of the orbital floor. Care must be used avoid injury to the maxillary sinus ostia or the infraorbital nerve. it can be used Fig.85 mm thickness) should be fashioned to recreate the orbital floor and re-establish the orbital volume. the pourous polyethylene implant is above the infraorbital nerve laterally. a small portion of mucosa is stripped away from the fracture. 6. The medial support is very limited or nonexistent. If a medial shelf of bone is present. In this case. (B) Coronal view. the defect will appear larger. The orbital soft tissues then are reduced. When bone is removed. the primary support for the implant is anterior at the orbital rim and posterior at the stable bony shelf. all bone fragments should be removed before reconstruction. The implant should be trimmed to a diameter approximately 1 mm bigger than the defect and inserted through the antrostomy just below the prolapsed orbital contents. 0. and the orbital contents are reduced into the orbit. jury is encountered with strangulated soft tissue. (A) Sagittal view. The entire bony margin must be visualized well. The fracture is opened with an angled retractor. and an attempt can be made to reposition the bony piece. . 5. because the lamina papyracea ends in a vertical plane. with greater prolapse of the orbital contents. Care must be used to avoid excessive medial dissection that might destabilize the hinge and require placement of an implant. (B) Postoperative CT scan after endoscopic repair of the medial blow-out fracture. The bone flap is then allowed to snap back into place maintaining the reduction. An alloplastic implant (porous polyethylene. A Fraser tip suction catheter and Freer elevator then are used to walk forward on the implant while maintaining the posterior positioning. Gentle force is applied at the anterior portion of the implant (ie. The primary area of support is anterior and posterior. the edges of the orbital defect are exposed by conservative elevation of the mucosa around the defect. The implant then is inserted over the stable posterior shelf. below the posterior aspect of the orbital rim) until it slips over the orbital rim and is stabilized by downward pressure from the orbital contents [Fig. When a medial blow-out fracture is present. Endoscopic repair of a medial blow out fracture. More often there is comminution of the floor. (A) Preoperative CT scan of a right-sided medial blow-out fracture. 5].Orbital Floor Fractures 13 Fig.

Using the endoscopic approach. but most authors agree that isolated trap door and medial blow-out fractures as described by Strong and colleagues are indications for the technique [see Figs. Several large series reported complication rates of 5% [16–19]. Careful review of these studies. Definitive repair requires significant manipulation of the infraorbital nerve and placement of an implant that spans medial and lateral to the infraorbital canal. Occasionally. Follow-up data on orbital position were limited. trap door fractures can be snapped back into their premorbid position after reduction of the orbital contents. a formal middle meatal antrostomy is required to ensure adequate maxillary sinus drainage.13]. One of the major limitations of the open approaches is difficulty visualizing the posterior orbit because of the angle of attack and prolapsed orbital fat.14 Farwell & Strong also. A pulse test is performed (ie. and the pulsations are observed through the endoscope) to assure the implant is stable. Once the fracture has been repaired. In recent years. many sinus surgeons have begun performing sinusrelated procedures such as orbital decompression for Graves’ disease [14] and resection of certain sinus and skull base neoplasms [15]. 6]. and representative imaging in the article by Ikeda showed persistent increase in orbital volume. the surgeon is looking at the posterior bony shelf end on) and (white arrow) the more advantageous endoscopic approach in which the surgeon can visualize the posterior bony shelf from below. the angle of inclination offers a more direct view of the posterior orbit. Discussion The use of endoscopes within the nasal cavity and paranasal sinuses has become the standard of care for endoscopic sinus surgery. Fig. threaded through the nose. Eyelid malposition was more common in patients with more extensive dissection over the orbital rim for orbitozygomatic or Le Fort-type injuries. An additional benefit is improved visualization of the posterior orbit and stable bony shelf. As the realm of endoscopic surgery expands. An implant this large is difficult to insert and manipulate. These authors reported symptomatic resolution of diplopia in most patients. placement of a transnasal catheter for up to 10 days may not be considered minimally invasive. These reports have demonstrated excellent patient tolerance with minimal incidence of infection or extrusion. They describe endoscopic placement of balloon catheters. gentle external pressure is applied to the globe. demonstrates that lid complications were less common in patients with isolated orbital floor fractures. 3]. Several surgeons have described a transnasal approach to orbital floor fractures [8. The endoscopic approach obviates the need for an eyelid incision and potential eyelid complications. thereby reducing the risk of a poorly positioned implant. 7]. [Fig. tangential angle of attack using an open approach (ie. the endoscope is used to inspect the edges of the fracture looking for any entrapped orbital tissue. 2]. Sagittal CT scan of the orbital floor illustrating (black arrow) the less advantageous. Finally. 7. This can result in improper implant placement along the stable posterior ledge and inadequate restoration of orbital volume with persistent enophthalmos. 1.9]. Techniques for implant stabilization vary between authors. Subsequent reports of endoscopic orbital floor reconstruction by means of a transantral approach have demonstrated the feasibility of a pure endoscopic repair for accurate reestablishment of the premorbid orbital volume [7. The use of the endoscopic approach in these cases is not recommended. transconjunctival and transcutaneous) can result in lid malposition such as entropion and ectropion. Larger lateral blow-out fractures involve the infraorbital nerve [see Fig. Traditional open approaches (ie. The interfragmentary friction alone will maintain the reduction. Intraoperative assessment . Pressure laterally on the infraorbital nerve should be avoided. Any mucosa or bone fragments overhanging the maxillary ostia are removed to minimize the chance of sinus obstruction and subsequent infection. to reduce the fracture and maintain reduction for up to 10 days. Indications for the endoscopic repair vary. however. the wound is closed and a postreduction CT scan is obtained to confirm an adequate repair [Fig. Most authors agree that hinged. the potential benefit of orbital floor fracture repair has become apparent. Despite the lack of an external incision. It is not certain that the goal of minimally invasive surgery was met in these patients. Different implant materials include porous polyethylene and resorbable and titanium mesh.

urgent reduction of entrapped inferior rectus muscle can be accomplished. Another advantage of the endoscopic approach is that there is far less orbital retraction required. Complications Postoperative infraorbital paresthesias are common after this approach (Farwell and colleagues. For this reason. within the orbital cavity. or orbital hematoma. Once the surgeon gains confidence with the equipment.Orbital Floor Fractures 15 with forced duction testing and a pulse test (gentle external orbital pressure) should be performed to assure an adequate and stable repair. particularly with gross extraocular muscle entrapment. The endoscopic approach is advantageous in early repairs. instrumentation. it is useful in assessing the orbital floor in patients with other facial fractures [12]. care must be taken to avoid placing the drill hole too close to the infraorbital nerve or too deep into the orbital tissues. but below the orbital soft tissues [7]. Patients with delayed surgical repair may be more likely to have persistent diplopia (Farwell and colleagues. it will be important to compare the results with the traditional open approach. The surgeon then can use existing incisions (ie. The repair of the orbital floor fractures through an endoscopic approach has been performed successfully by several centers. reducing the chance of permanent dysfunction from prolonged ischemia and pressure necrosis [7]. All comminuted bone fragments must be removed before repair of medial blow-out fractures. Patients should be instructed on the importance of prompt evaluation of any sinus complaint. Chen and colleagues described a different technique in which the orbital contents are reduced and held in place by a piece of titanium mesh placed within the maxillary sinus [9]. Even if the endoscopic approach is not chosen as the primary access for orbital floor fracture repair. An example of its utility is in evaluating the orbital floor in a patient with an orbitozygomatic fracture. the orbital floor defect can be enlarged. Postoperative maxillary sinusitis is also a risk. They generally resolve over 2 to 8 weeks. Once the malar portion of the fracture has been reduced. unpublished data) [7]. Summary Endoscopic surgery is expanding rapidly. and postoperative results will continue to evolve as more surgeons attempt this technique. because it offers excellent fracture visualization even in the face of marked periorbital edema. repair generally should be attempted as early as possible. Several techniques have been used to maintain the implant position. 5]. an implant is necessary to complete the reconstruction. The most common approach is to place an implant slightly larger than the defect above the bony margin. The endoscopic approach. appears to be a promising new technique for isolated trap door and medial orbital floor fractures. extraocular muscles. Placing the endoscope through a small antrostomy or existing anterior maxillary fracture allows the surgeon to assess the integrity of the orbital floor without a lid incision. If the dissection is carried along the infero–medial aspect of the orbit. This could result in injury of the infraorbital nerve. This should be discussed with the patient preoperatively in case a pure endoscopic repair cannot be achieved. This mesh is held into position with titanium screws placed into the residual orbital floor. for zygoma or Le Fort fractures) to become comfortable with the technique. Using this approach. the risk of postoperative maxillary sinusitis will increase. The surgeon also must avoid inadvertent displacement of a bone fragments into the orbital cavity [7]. The authors recommend that surgeons considering learning the endoscopic technique have the equipment readily available for all traumas involving the orbit. patient selection. The exact etiology is difficult to assess. Failure to repair the fracture endoscopically will necessitate an alternative approach. however. unpublished data). The orbital contents then are allowed to fall down onto the implant holding it in place [see Fig. The surgical technique. Hyphema is considered a contraindication to surgical repair of orbital floor fractures because of the potential risk of blindness secondary to globe retraction. without significant orbital manipulation. Time from injury is felt to influence the successful repair of orbital floor fractures. a pure endoscopic repair can be attempted. . As more data are obtained. which has a proven track record with low complication rates. Caution also must be used to avoid obstruction of the maxillary sinus ostia. particularly within the field of otolaryngology. If comminution is present or occurs with manipulation of a trap door fracture. It is technically demanding and requires expertise in traditional repair of orbital floor fractures and endoscopy. because it may be caused by the surgical procedure or the fracture itself. or the implant is placed near the ostia. The paresthesias may be caused by retraction or manipulation during the fracture exposure and implant placement. either through a transconjunctival or subciliary incision. By approaching these fractures from below. particularly in patients with gross extraocular muscle entrapment.

[15] Al-Nashar IS. Arch Otolaryngol Head Neck Surg 1997. Kang YS. Ladsach K. Chowdhury K. Longaker MT.100(3):575–81. et al. Isolated medial orbital wall fractures: results of minimally invasive endoscopically controlled endonasal surgical technique.72(9):450–4. Endoscopic approach to orbital blowout fracture repair. et al. [18] Mullins JB. South Med J 1972. Laryngoscope 2004. Arch Facial Plast Surg 2000. Kawamoto HK. Fells P. Suzuki H. Arch Otolaryngol Head Neck Surg 1991.125(1):59–63.111(11):1051–5. et al. Patrinely JR.2: 269–74. Chen YR. Otolaryngol Head Neck Surg 2004.123(4):385–8.131(5):683–95.2(4):269–73. [2] Lee MJ. Kim KK. Endoscopically assisted repair of orbital floor fractures. Plast Reconstr Surg 1997. et al. [6] Walter WL. Blow-out fractures of the orbit: an investigation into their anatomical basis.81(10):1109–20.108(7):2011–8 [discussion 2019]. Salzer TA. Holds JB. [3] Yamaguchi N.114(3):528–32. [10] Saunders CJ. Yang JY. et al. Endoscopic endonasal repair of orbital floor fracture. Treatment of 813 zygoma-lateral orbital complex fractures.123(6): 718–23. J Laryngol Otol 1997. Carrau RL.117(6):611–20 [discussion 621–2]. Plast Reconstr Surg 2001.110(2): 417–26 [discussion 427–8]. Arch Otolaryngol Head Neck Surg 1993. Oshima T. [8] Ikeda K. Transantral endoscopic orbital floor exploration: a cadaver and clinical study. [5] Rhee JS. Haruna S. Transconjunctival approach vs subciliary skinmuscle flap approach for orbital fracture repair. Evans JN. orbital floor. Whetzel TP. et al. Orbital decompression for thyroid eye disease: a comparison of external and endoscopic techniques. 103(4):1124–8. Lynch J. . [13] Otori N. Intranasal endoscopyassisted repair of medial orbital wall fractures. Mitani H. [14] Lund VJ.119(9): 1000–7. Endoscopic endonasal or transmaxillary repair of orbital floor fracture: a study of 88 patients treated in our department.5(4):7–12 [discussion 13–4]. New aspects. Larkin G. [19] Lorenz HP. [17] Appling WD. [16] Zingg M. Primary and secondary orbit surgery: the transconjunctival approach. [4] Michel O. Operative Techniques in Otolaryngology Head and Neck Surgery 1991. Arch Ophthalmol 1998. et al. Hartstein ME. A review of 400 cases. Stokes RB.116(5):688–91. Moriyam H. J Craniomaxillofac Trauma 1999. [9] Chen CT. Acta Otolaryngol 2003. Glilich R.16 Farwell & Strong References [1] Jones DE. et al. Endoscopic endonasal technique of the blow-out fracture of the medial orbital wall.65(10):1229–43. Laryngorhinootologie 1993. Herrera A. Application of endoscope-assisted minimal-access techniques in orbitozygomatic complex. [12] Forrest CR. Paranasal sinus endoscopy and orbital fracture repair. Branham GH. Arai S. Early surgical repair of blowout fracture of the orbital floor by using the transantral approach. and frontal sinus fractures. et al. Complications of the transconjunctival approach. J Laryngol Otol 1967. et al. Plast Reconstr Surg 2002. [7] Strong EB. et al. Endoscopic transnasal approach for the treatment of medial orbital blow-out fracture: a technique for controlling the fractured wall with a balloon catheter and Merocel. et al. Endoscopic transnasal transpterygopalatine fossa approach to the lateral recess of the sphenoid sinus. Arch Otolaryngol Head Neck Surg 1999. Plast Reconstr Surg 1999. Loehrl TA. et al. [11] Woog JJ. Diaz RC.


Facial Plast Surg Clin N Am 14 (2006) 17–23

Endoscopic Approach to Medial Orbital Wall Fractures
John S. Rhee,
& & &



, Chien-Tzung Chen,
& & &



Preoperative evaluation Indications Surgical techniques Endoscopic transcaruncular approach Intranasal endoscopic-assisted technique

Complications Summary References

Historically, medial orbital wall fractures have been underappreciated in their incidence and importance. Recent studies have indicated that the incidence of medial orbital wall fractures may be higher than that of the floor [1]. In addition, studies have suggested that enophthalmos may be more significant from nonrepaired medial orbital wall fractures than from blowout fractures of any other orbital wall. Furthermore, because of the underappreciation of this injury, the incidence of delayed enophthalmos may be higher for this type of orbital fracture [2]. Biomechanical studies have suggested that that in the absence of orbital rim or facial skeleton trauma (pure hydraulic mechanism), isolated medial orbital wall fractures cannot occur without trauma to the surrounding bony framework (eg, orbital rim, nasal bone) [3]. These biomechanical findings are corroborated by reports in the clinical medical literature. In a large series of medial orbital fractures, Burm and colleagues [1] reported that nasal fractures were the most common fracture associated with the medial orbital wall fracture, suggesting that the force causing nasal fractures was a very important causative factor of pure medial orbital fractures by means of the buckling mechanism.

In the clinical realm, medial orbital fractures may occur by way of the buckling or hydraulic mechanism, with a combination of the two mechanisms the most likely scenario. It is also more common that the medial orbital wall is fractured in conjunction with the orbital floor, necessitating repair of both of these fractured walls. There are a multitude of approaches that have been used for repair of medial orbital wall fractures, each with their advantages and disadvantages. The medial brow incision has been described for access to the medial orbital wall [4]. This approach is limited to the anterior and superior medial orbital wall and fails to free the entrapped medial rectus muscle from the posterior medial wall fracture because of the close proximity of the optic nerve. A lid crease incision may offer a more cosmetically appealing result, but has the same limitations as the medial brow incision [5]. A direct medial canthal approach can be used to gain access to the medial and inferomedial aspects of the orbit, and this may be extended to the infraorbital rim to explore the floor. Drawbacks to this approach include the obvious external scar, webbing of the skin, and risk of telecanthus from surgical detachment of the medial canthal tendon [6].

a Department of Otolaryngology, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226, USA b Zablocki Veteran Affairs Medical Center, 5000 W. National Avenue, Milwaukee, WI 53295, USA c Division of Trauma Plastic Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Number199, Tunghwa Rd., Taipei, Taiwan, Republic of China * Corresponding author. Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, WI 53226. E-mail address: jrhee@mcw.edu (J.S. Rhee).

1064-7406/06/$ – see front matter. Published by Elsevier Inc.




Rhee & Chen

Indirect approaches to the medial orbital wall include the coronal incision, which usually is reserved for patients with multiple facial fractures. This approach offers wide exposure and reconstruction of the defect with calvarial bone through the same incision. Disadvantages include an external scar, scalp alopecia, significant surgical dissection, overnight hospitalization, and potential injury to cranial nerves VI and VII. The transcaruncular approach to the medial orbital wall has been described more recently and provides excellent access to the medial wall [6–8]. The main limitation of this approach is that a large graft cannot be placed through the small incision without connecting it to an orbital floor approach. Other potential disadvantages include the risk of injury to the lacrimal apparatus and difficulty assessing the posterior dissection. Endoscopic-assisted techniques have emerged as the next frontier for repair of medial orbital fractures. Recently, techniques have been described that allow for endoscopic assistance in reduction of the orbital contents and in placement of an alloplast or graft for reconstitution of the medial orbital wall. The two main techniques in which endoscopy has aided in the repair of these fractures have been either through the intranasal (transethmoidal) or the transcaruncular approaches [9,10]. Most endoscopic intranasal techniques involve partial ethmoidectomy and exposure of the fractured lamina papyracea. The herniated orbital contents are reduced, and some type of intranasal splint or packing is placed between the lamina and the middle turbinate for a period of time (approximately 2 months) until healing of the medial wall is completed [11–13]. Alternatively, an intranasal endoscopic approach to assist in placement of an orbital implant by means of a periorbital incision has been described [14]. This article describes different endoscopic-assisted approaches—transcaruncular and intranasal—which have been used to successfully repair medial orbital wall fractures.

• • • • • •

Nasal subconjunctival hemorrhage Horizontal diplopia Restriction of abduction Retraction syndrome Progressive enophthalmos Positive forced duction test [5,15–18]

Preoperative evaluation
Medial orbital fractures, unlike blow-out fractures of the orbital floor, may be overlooked, because they present with clinical symptoms and signs in only a few instances, especially in the early acute trauma setting. The possible clinical symptoms and signs include:

Associated ocular injuries commonly occur in patients with midfacial trauma, which may result in decrease in visual acuity, or even complete vision loss, if early diagnosis and management are not initiated properly. The incidence of severe ocular disorders associated with an orbital blow-out fracture has been reported to be as high as 16.7% [19]. Therefore, early ophthalmology consultation routinely is sought in patients with suspected orbital fractures. The ocular examination should include an assessment of visual acuity, visual field, papillary function, extraocular muscle function, and slit lamp examination to rule out a corneal perforation or hyphema. A forced duction test is conducted if restriction of ocular movement is detected. The presence of diplopia may be associated with limitation of extraocular muscle movement. One must differentiate the causes of diplopia that may result from cranial nerve-induced injury, orbital soft tissue or muscle entrapment, mal-position of the globe, or intraorbital edema secondary to acute trauma. Imaging studies including CT scanning are essential before forming a surgical plan. Recently, the development of the helical CT scan has changed the type of studies needed to diagnose and evaluate orbital trauma. The helical CT scan allows for continuous acquisition of volumes of tissue, which permits multi-planar reconstructions of additional image planes. This technique reduces the number of examinations and radiation exposure of the patient and improves the quality of the image [20]. These fine-cut CT scan images are taken in coronal and axial planes, with soft tissue and bone windows. The reformatted sagittal sections that connect the midpoint of the globe and the apex of the orbit are particularly helpful to assess the concomitant orbital floor fractures. Three-dimensional CT images allow for a quick overview of the facial bone fractures, but they are seldom of value in the internal portion of the orbit. Occasionally, MRI can be used to differentiate the herniated muscle and orbital fat, and this may serve as a complement to CT scanning [5,21].

• • • •

Epistaxis Eyelid emphysema, especially in the medial canthus Periorbital edema Narrowing of the palpebral fissure

There is some debate regarding the surgical treatment of an isolated orbital medial wall fracture. When a medial orbital wall fracture presents mini-

Medial Orbital Wall Fractures


mal displacement with no signs of herniation of the orbital content and minimal enophthalmos, conservative treatment is chosen. Surgical exploration and repair, however, are indicated if there is

• • • • •

Persistent symptomatic diplopia Pain during horizontal eye movement, A positive forced duction test with clear evidence of medial rectus muscle entrapment on a CT scan, Early enophthalmos more than 2 mm preoperatively A large defect likely causing secondary enophthalmos [5,21,22]

Both endoscopic-assisted techniques, through either the intranasal or transcaruncular approaches, can be applied to repair the variable sizes of the medial orbital wall fractures. The endoscopic techniques are especially valuable for those fractures involving the superior and posterior medial orbits, which are difficult to dissect and visualize through a lower eyelid approach. In general, these endoscopic techniques are used for primary repair of the medial orbital wall fractures. Recently, the transcaruncular endoscopic approach has been expanded in its use to correct late enophthalmos caused by uncorrected displacement of medial wall or previously inadequate reconstruction of medial wall defects [10]. One may use the coronal incision or existing lacerations to repair these fractures directly without the use of endoscopic approaches, however, if the medial orbital wall fracture is accompanied by periorbital fractures such as nasoethmoid, orbital roof, or supraorbital rim fractures.

Surgical techniques Endoscopic transcaruncular approach
The surgery is performed under general anesthesia. An injection of 1:100,000 epinephrine solution is placed in the medial conjunctiva using a fine needle. The cornea is protected with a scleral shield during the procedure. Two parallel traction sutures using 4-0 silk are placed in the medial conjunctiva posterior to the caruncle to facilitate the conjunctival incision. A slight curvilinear incision approximately 1 cm in length is made between the two sutures, and then a scissors is used to bluntly dissect toward the medial orbital wall immediately posterior to the lacrimal apparatus [Fig. 1]. With progressive blunt dissection, the periorbita is incised behind the posterior lacrimal crest to avoid severance of the medial canthal ligament and injury to the lacrimal sac. The periorbita is elevated further superiorly and inferiorly with a Freer elevator; then the dissection proceeds posteriorly, thereby

creating a periosteal opening wider than the conjunctival incision. Initially, the anterior part of the medial wall is dissected under direct vision with the aid of a headlight. Because the orbital roof is intact in most cases, the authors prefer starting the dissection from the superior medial wall near the orbital roof and then proceeding downward to the inferior portion of the orbital medial wall. The optical cavity is created and maintained with insertion of a baby retractor medially and a narrow malleable retractor laterally to retract the orbital contents gently. A 2.7 mm diameter, 0° endoscope is introduced through the transcaruncular approach. With the aid of endoscope, the posterior dissection of the medial wall is performed using an orbital periosteal elevator. The first important structure that is encountered is the anterior ethmoid vessels coming out from the anterior ethmoid foramen, which is on average 24 mm behind the anterior lacrimal crest. The vessels should be cauterized meticulously to avoid any undue bleeding and facilitate further posterior dissection. Subsequently, the posterior ethmoid vessels appear in the surgical field and indicate the limit of safe dissection along the medial wall. This landmark is on average 36 mm away from the anterior lacrimal crest. One should keep in mind that the optic nerve is located on average 7 mm posterior to the posterior ethmoid vessels. A horizontal line connecting the anterior and posterior ethmoid vessels indicates the superior limit of the ethmoid sinus. Generally, the medial wall fractures rarely extend above this horizontal line. The entrapped orbital contents gradually are reduced from the ethmoid sinus into the orbital cavity, and the fracture fragments of the medial wall are removed. After that, the whole boundary of the medial wall defect is defined clearly [see Fig. 1]. To reconstruct the bony defect, the authors use the synthetic implants titanium micromesh or Medpor (Porex Surgical, Incorporated, Newnan, Georgia) in most cases. The orbital implant is trimmed to proper size and shape, with the dimension no greater than 1.5 cm in width and 3 cm in length, because the small incision prevents placement of a larger graft. The implant is inserted through the transcaruncular incision to cover the bony defect in the subperiosteal space and fixated with a microscrew [see Fig. 1]. In the scenario of a larger bony defect extending onto the inferior medial wall, additional implant is required, with one overlapping the other, to completely cover the bony defect. Finally, the proper position of these implant areas is rechecked and adjusted under endoscopic visualization. A forced duction test is performed after placement of these implants to confirm the mobility of the globe in any direction. The conjunctival wound is closed with a 6-0 plain

Before the manipulation of the medial orbital contents. deep to the periorbita. in contrast to the temporary intranasal stent placement procedures. The orbital implant then is cut to the appropriate shape and size to cover the floor and lamina papyracea defect. A concomitant orbital floor fracture can be addressed with reduction of the orbital contents. The orbital floor is approached through a transconjunctival incision with a canthotomy and cantholysis. . a 4. No nasal packing is necessary. After proper nasal decongestion is accomplished. A clinical case using this technique is illustrated in Fig. 3 and 4. the orbital contents are reduced and held in place with a malleable retractor. the medial orbital wall is approached intranasally. Dissection continues along the orbital floor. Adequate reduction is confirmed from the intranasal endoscopic and external approaches. The herniated orbital contents are usually apparent at this stage. (A) Transcaruncular incision made posterior to the caruncle with two parallel traction sutures. from the periorbital incision. (B) Endoscopic view of the bone defect of the orbital medial wall. Approximately 3 to 4 mm of uncinate is left intact superiorly to prevent frontal recess stenosis. While an assistant holds the endoscope in proper position. Next. A clinical case illustrating this technique is described in Figs. Intranasal endoscopic-assisted technique The operation is performed under general anesthesia with the patient in a supine position. “O” indicates periorbital tissue. catgut suture. The arcus marginalis then is incised sharply at the orbital rim. The implant is introduced through the periorbital incision and guided into position using the endoscopes for visualization. The dissection is carried posteriorly through the ground lamella to fully expose the defect in the lamina papyracea.0 mm 0° endoscope is introduced into the nostril. The bulla ethmoidalis then is entered medially and resected to expose the lamina papyracea defect. 1.20 Rhee & Chen Fig. (C ) Endoscopic view of Medpor implant placed across the defect with microscrew fixation. the implant is manipulated bimanually from the sinonasal and periorbital approaches into proper position. This exposes the natural ostium of the maxillary sinus. 2. and great care is taken to prevent further injury. A preseptal dissection is carried down to the orbital rim. The uncinate is identified and resected. Arrow points to the boundary of the bone defect.

5 mm).Medial Orbital Wall Fractures 21 Fig. (C ) Postoperative submental view 5 months following correction of the orbital medial wall defect with symmetric projection of the globe.2(4):269–73. Lynch J. (B) Preoperative CT scan revealing a blowout fracture of the left orbital medial wall with soft tissue prolapse. with permission. Patient with a combined fracture of the orbital floor and medial wall without evidence of entrapment. Fig. Loehrl TA. (D) Properly reconstructed medial wall with titanium mesh implant shown in postoperative CT scan. (From Rhee JS. Preoperative submental view showing left upper eyelid ecchymosis and enophthalmos (1. 2. as seen on (A) coronal and (B) axial CT. Intranasal endoscopy-assisted repair of medial orbital wall fracture.) . 3. Intranasal endoscopy-assisted repair of medial orbital wall fractures. Arch Facial Plast Surg 2000. (A) 40-year-old patient with left orbital medial wall blow-out fracture.

Chung CH. Complications In the authors’ experience. intraorbital or nasal hemorrhage. There have been no cases of infection or sinusitis using an implant to repair the medial wall defect. especially when repairing a large bony defect through the transcaruncular incision. inadequate reduction of herniated orbital tissue. Arch Facial Plast Surg 2000. Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture.2(4):269–73. Asterisk indicates bony defect of the lamina papyracea. 4. (A) Intranasal endoscopic view of right medial orbital wall fracture. Mun and colleagues [21] reported an alternative bone graft-shaping method. To prevent displacement of grafts. with permission. lacrimal sac and cornea. (From Rhee JS. Oh SJ. Jackson A. Other potential intraoperative complications include optic nerve injury. respectively. Prediction of enophthalmos by computed tomog- .) The periorbital incision is closed in standard fashion. The authors advocate using a permanent implant placed either by means of the transcaruncular or intranasal endoscopic-assisted approach to decrease the likelihood of reherniation of orbital contents into the ethmoid cavity. cerebrospinal fluid rhinorrhea. and placement of grafts to reconstruct this area. one should avoid too much anterior or posterior dissection causing injury to the lacrimal sac and to the medial rectus muscle. one of the authors usually fixates the material used for repairing the medial wall defect with microscrews [10]. with usual resolution by 3 months. which is thinned at the edge and set on the edge of the intact medial wall in the onlay position.103:1839–49. Residual enophthalmos caused by reherniation of the orbital contents has been reported when using a temporary intranasal stenting procedure [24]. The use of a corneal shield during the procedure is essential to prevent incidental injury to the cornea. in which excessive medial canthal scarring caused diplopia that resolved after revision conjunctivoplasty surgery. Arrow delineates the intact posterior medial wall. Postoperatively. to minimize the risk of graft migration. [2] Whitehouse RW. or incomplete coverage of the medial wall defect. (B) Intranasal endoscopic view of the Medpor implant in proper position. Batterbury M. postoperative complications with either transcaruncular or intranasal approaches have been minimal. One minor complication related to the transcaruncular incision was reported by Graham and colleagues [23]. Intranasal endoscopy-assisted repair of medial orbital wall fractures. When a transcaruncular approach is adopted. Displacement of the bone grafts [10. a combination of an inlay–onlay graft. Both techniques have been successful in treating this difficult fracture without the need for longterm intranasal stenting or external skin incisions. Plast Reconstr Surg 1999. damage to extraocular muscle. reduction. Transient diplopia and exophthalmos can be expected as in other orbital reconstructive surgeries. Lynch J. The use of endoscopes can facilitate visualization. Summary Fractures of the medial orbital wall are more common than previously thought and pose unique challenges to the reconstructive surgeon.21] or implants [22] has been reported. et al. Loehrl TA. References [1] Burm JS. The authors advocate using either the endoscopic-assisted transcaruncular approach or an intranasal endoscopic-assisted approach combined with a periorbital incision to place a permanent graft or implant to repair the medial orbital wall.22 Rhee & Chen Fig. the patient is placed on nasal saline irrigations and is seen every 7 to 14 days with endoscopic debridement performed until the ethmoid cavity is mucosalized.

Orbital blowout fractures: experimental evidence for the pure hydraulic theory. Am J Ophthalmol 1984. The characteristics of midfacial fractures and the association with ocular injury: a prospective study. et al. Chen CT.109:872–6. Endoscopic endonasal or transmaxillary repair of orbital floor fracture: a study of 88 patients treated in our department. Kilde J.103:714–20.76: 378–9. et al. [20] Lakits A.4:98–101. 112:1228–37 [discussion 1238]. Am J Otolaryngol 2002. Plast Reconstr Surg 1999. [23] Graham SM. Ridley RW. Isolated blowout fracture of the medial orbital wall with medial rectus muscle entrapment. Transcaruncular approach to blowout fractures of the medial orbital wall. [22] Kim S. et al. Chen YR. Ernest JT.2:269–73. Scholda C. Endoscopic orbital surgery. Blowout fracture of the medial orbital wall. with entrapment of the medial rectus muscle. Oh JY. Thomas RD. Sanno T. Surgical repair of medial wall fractures. Bogart JN.97:349–56. Stassen LF. Bang SI. 73:451–3. Endonasal endoscopic reduction of blowout fractures of the medial orbital wall. et al. 23:312–5. Helen Lew M. Rhee JS. et al. [21] Mun GH. Repair of medial orbital wall fracture: transcaruncular approach.49: 337–43 [discussion 344]. Tahara S. Blowout fracture of medial orbital wall. Br J Ophthalmol 1994. Prokesch R.17:50–4. Lynch J. Leone Jr CR. Yoganadan N. et al. 11:179–208. [14] Rhee JS.24:1–9. Am J Ophthalmol 1968. Transcaruncular approach for reconstruction of medial orbital wall fracture. Choo MJ. [17] Merle H. Endoscopically assisted reconstruction of orbital medial wall fractures. . Han SK. 63:848–52. Endoscopically assisted transconjunctival approach in orbital medial wall fractures. Chen CT. Raynaud M. Endoscopic endonasal reconstruction of blowout fractures of the medial orbital walls. Tung TC. Chen YR. Acta Ophthalmol Scand 1998. [19] al-Qurainy IA. Arch Facial Plast Surg 2002. Carter KD. Plast Reconstr Surg 2002. Lloyd III WC. Otori N.108:2011–8. Kim YH. Atlas Oral Maxillofac Surg Clin North Am 2003. Kashfi A. Endoscopic endonasal reduction for blowout fracture of the medial orbital wall. Arch Facial Plast Surg 2000. Rumelt MB. Orbit 2005. Nomura T. Ann Plast Surg 2002.123:718–23.78:618–20. J Oral Maxillofac Surg 2000. Plast Reconstr Surg 2001.58:847–51. Ewers R. Dutton GN. Chen CT. Plast Reconstr Surg 2003.29:291–301. Intranasal endoscopyassisted repair of medial orbital wall fractures. [16] Thering HR. Laryngoscope 2002. [24] Jin HR.29:264–7. Song YH. Endonasal endoscopic treatment of medial orbital wall fracture via rotational repositioning. Lee HM. Acta Otolaryngol 2003. Korean J Ophthalmol 2003. Int J Oral Maxillofac Surg 2000. Rah SH. Gerard M. Rylander G. Chae SW. Chung SH. Chen YR. Haruna S. et al. Br J Oral Maxillofac Surg 1991. Endoscopically assisted repair of orbital floor fractures. [18] Naraghi M. Moriyama H. et al. Loehrl TA. Baumann A. Shin SO.112:986–9. The transcaruncular approach to the medial orbital wall.65: 248–9. [15] Edwards WC. Am J Ophthalmol 1972.78:79–83. Plast Reconstr Surg 1979. Helical and conventional ct in the imaging of metallic foreign bodies in the orbit. Isolated medial orbital blow-out fracture with medial rectus entrapment. Acta Ophthalmol Scand 2000.Medial Orbital Wall Fractures 23 [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] raphy after blow out orbital fracture.

alopecia.edu (E. orbital. Endoscopic sinus surgery came to the United States in the late 1970s and became the standard of care in the 1980s.1016/j. University of California Davis School of Medicine.B. Current applications include otology (middle ear endoscopy). NY 13210. however. 2521 Stockton Blvd. and apply instrumentation [3]. and improved teaching.25 FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 14 (2006) 25–29 Endoscopic Repair of Anterior Table—Frontal Sinus Fractures E. Specific facial trauma applications include subcondylar. facial plastic surgery (brow lift). Syracuse. reduced soft tissue dissection. visualization around corners. State University of New York Upstate Medical University. USA b Department of Otolaryngology and Communication Sciences. sustain adequate hemostasis. skull base surgery (pituitary. and the fact that the surgeon cannot operate bimanually without an assistant. Consequently. some surgeons are starting to manage isolated anterior table fractures through an endoscopic approach. insert a fiberoptic endoscope. Surgical sequelae of this procedure include a large scar. Injuries with severe comminution and marked mucosal injury require open reduction or even frontal sinus obliteration.fsc. Mild-tomoderately displaced anterior table fractures. Robert M. optic nerve decompression). At least two points of access generally are required.2005. Adams St. Kellman. CA 95817. The indications for endoscopic head and neck surgery continue to expand. narrow field of view. bony reduction. Indications Not all isolated anterior table fractures are appropriate for this technique. and uncommonly facial nerve injury. Ste 7200 Sacramento. current lack of dedicated instrumentation. This article reviews the indications and technique for endoscopic repair of anterior table frontal sinus fractures. Traditional repair of isolated anterior table fractures requires a coronal incision. doi:10. All rights reserved. The treatment algorithm for fractures involving the frontal recess or posterior table is complex because of the associated risks of brain injury.10. The ideal candi- Department of Otolaryngology.com . minimal external incisions. 750 E. neck surgery (thyroid. reduced hospital stay. and mucocele formation [2].* . Disadvantages include a moderate learning curve. meningitis. poor depth perception. carry a low risk of long-term morbidity and generally are treated as aesthetic deformities. & & & MD a. USA * Corresponding author. and rigid fixation. and facial trauma. parathyroid. General requirements for endoscopic surgery include: the ability to surgically obtain/maintain an optical cavity. E-mail address: edward. node biopsy).. Fractures that extend over the orbital rim may be difficult or impossible to visualize endoscopically and may require an open approach. 1064-7406/06/$ – see front matter © 2006 Elsevier Inc.strong@ucdmc. and frontal sinus fractures. ophthalmology (dacrocystorhinostomy).theclinics.ucdavis. paresthesias. Bradley Strong. The advantages of endoscopic surgery include more accurate visualization. cerebral spinal fluid leak. Strong). cerebrospinal fluid fistula. & & MD b Indications Technique Discussion Summary References Frontal sinus fractures account for 5% to 15% of all maxillofacial injuries [1].003 a facialplastic.

because the procedure is performed 3 months after the injury. 2]. and cautery should be avoided if possible. paresthesia. Once the entire fracture is exposed. and the optical cavity is visualized. After injection of local anesthetic. Technique Preoperative photographs and CT scans should be obtained to document the injury [Figs. Dissection over the fracture is performed under direct vision to the level of the orbital rims. Anterior table frontal sinus fracture. Care should be used to maintain the integrity of the Fig. The elevation is generally easy. 2. The implant is trimmed to approximate the defect [Fig.0 mm. alopecia. 1. A 4. The implant is inserted through the working incision and manipulated over the defect. poor aesthetic result. 1. a 3 to 5 cm parasagittal working incision is placed above the fracture and 3 cm behind the hair line [Fig. Informed consented is obtained for the procedure. A 0. . In patients with a prominent forehead or receding hair line. Fig. periosteum. The superior edge of the implant is marked with a pen to maintain the orientation endoscopi- Fig. an implant is inserted to fill the defect. The incision length will vary depending on the size of the implant to be inserted. Preoperative axial CT scan of patient in Fig. 3]. medial incision. 3.85 mm thick Medpor (Porex Surgical . 4]. 3]. The patient’s head is prepared and draped from the orbits to the vertex of the head. and there is a fibrous layer preventing entry into the sinus.Newnan. Scalp incisions used for endoscopic repair of frontal sinus fractures. 1 demonstrating an anterior table frontal sinus fracture. and possible need for open approach if an endoscopic repair cannot be performed.26 Strong & Kellman dates for the endoscopic approach are reliable patients who have isolated anterior table fractures limited to the vertical face of the frontal bone. infection. Caution must be used to avoid injury to the supratrochlear and supraorbital neurovascular pedicles. A second 1 to 2 cm endoscope incision then is placed at the same height. including the risks of bleeding. A blind subperiosteal dissection is performed through the working incision down to the level of the fracture. the incision may need to be closer to the hairline to allow visualization around the intrinsic curvature of the forehead. Georgia) sheet is the preferred implant. The authors have evaluated hydroxyapatite bone cement for this purpose but found it difficult to apply and manipulate endoscopically. Care should be taken to avoid trauma to the hair follicles. because periosteal tears will catch the endoscope when it is inserted. but 4 to 6 cm medial to the working incision [see Fig. 30° endoscope (with rigid endosheath and camera) then is inserted through the smaller.

Both types of implant are palpable through the skin. Endoscopic view of Medpor sheeting inserted over a frontal sinus fracture. through the edge of the implant. 5]. The major advantage is a tight-fitting implant with little dead space. After completion of the procedure. 5. Fig. Postoperative photograph of endoscopically repaired anterior table frontal sinus fracture seen in Fig. 7]. The selfdrilling screw must be placed at least 0. through-and-through stab incision.0 mm away from the implant edge or the implant may tear. cally [Fig. A 1. An alternative to the standard 0. advantage is that prefabricated implants cost approximately $4000 and require 6 weeks for fabrication. 6]. Intraoperative photograph of a 0. Fig.85 mm Medpor implant trimmed to camouflage the anterior table frontal sinus fracture. and the marking line on the superior aspect of the implant used for orientation. The ideal site will allow placement of two screws at opposite edges of the implant.85 mm thick Medpor implants were sutured together to fill dead space in the anterior table defect. 7. The dis- Fig. 4. . If the implant is not completely stable. the author has sutured two to three layers of Medpor together to fill the defect more accurately [Fig. 1. At times.5 to 1. Intraoperative photograph of a layered Medpor implant.7 mm self-drilling screw (length 4 to 7 mm) is passed through the stab incision.85 mm Medpor sheeting is a prefabricated Medpor implant that is generated from a CT scan and completely fills the volume of the defect. 5]. A #11 blade is used to make a 2 mm. A 25 gauge needle then is passed through the skin over the fracture site and endoscopically visualized to determine the best site for percutaneous screw placement [see Fig. a second screw is placed on the contralateral side.Frontal Sinus Fracture Repair 27 Fig. 6. but are not visible upon inspection [Fig. as opposed to standard sheets which cost $250 to $450. Two 0. Note the 25 gauge needle being passed through the skin to localize the site of percutaneous screw placement. and into the frontal bone.

No drains are used. The repair need not be done in the acute setting. was technically more challenging. however. The fracture reduction technique involves exposure of the fracture in the acute setting. Discussion Historically. If the interfragmentary resistance is too little. only those patients with a true aesthetic deformity will require surgery [Fig. and the patient may not require any surgical intervention. 8. 8]. paresthesias. cannot be made until 3 to 4 months after the injury. 9].28 Strong & Kellman the scalp incisions are closed in layers. The patient received no treatment for the injury. because once the soft tissue edema resolves. and application of internal fixation as needed to maintain stability. including a large scar. Fracture reduction. (A) Coronal CT scan of a patient with an anterior table frontal sinus fracture with enough displacement to be considered for traditional open repair in the acute setting. . and a head dressing is applied for 48 hours. (B) 4-month postinjury photograph of the same patient without any visible cosmetic deformity. Delayed repair can be important. The fracture camouflage technique involves an observation period to allow resolution of facial edema. eliminating the need for a coronal incision [4–6]. This technique is covered elsewhere in this issue. Advances in endoscopic surgery and CT have provided more effective options for diagnosis and treatment of frontal sinus mucoceles. If the interfragmentary resistance is too great. reduction of the bone fragments. the procedure results in postsurgical stigmata. because the bone fragments are not mobile. it may be difficult to maintain the reduction. however. cannot be performed. The endoscopic repair can be divided into two types: acute fracture reduction with or without fixation. because it does not require manipulation of bone fragments. This determination. They found that both approaches were feasible. Using the camouflage approach. Several authors have described an endoscopic approach to frontal sinus fractures. Consequently. The fracture camouflage technique was found to have several advantages: • • • The exposure is easier. followed by recontouring of the defect with an alloplastic implant. possible alopecia. The main disadvantage of Fig. because the bone fragments are free floating. almost all frontal sinus fractures were treated aggressively because of the long term risk of mucocele formation. more conservative endoscopic approaches are being investigated. the reduction Fig. The repair is technically less challenging. and fracture camouflage. and uncommonly facial nerve injury. there may be no esthetic deformity. External forces applied to the frontal bone during (A) fracture and (B) surgical repair. Strong and colleagues compared the fracture reduction and camouflage techniques [3]. 9. because it required mobilization and reduction of small bone fragments that may be under great compressive forces [Fig. Although the success rates for open reduction and internal fixation are very high.

Additionally. Surgeons considering this technique should be very comfortable with endoscopic equipment and techniques.102(5): 1642–5. Arch Facial Plast Surg 2003. Plast Reconstr Surg 1999. Application of endoscopicassisted minimal-access techniques in orbitozygomatic complex orbital floor and frontal sinus fractures. but . and well-tolerated. Frontal sinus and nasoorbitoethmoid complex fractures. The authors currently use the camouflage technique with 0. Frontal sinus fractures. 2nd edition. Moultrop T. Treatment of an isolated outer table frontal sinus fracture using endoscopic reduction and fixation. Spring P. 1996. [5] Graham III DH. J Craniomaxillofac Trauma 1999. It also has the added advantage of being a secondary procedure. [2] McGraw-Wall B.85 mm thick Medpor sheeting to treat isolated. Facial plastic reconstructive surgery.5(4): 7–12. [3] Strong EB. Therefore. 2002. Endoscopic repair of isolated anterior table frontal sinus fractures. Buchalter G. In: Papel ID.14(1):59–66. editor. 52–5. [6] Lappert P. NY. It is relatively cheap.5(6):514–21. camouflage) of anterior table frontal sinus fractures is an efficacious technique that significantly reduces patient morbidity. [4] Forrest CR. standardized sheeting is equally effective and significantly cheaper. et al.Frontal Sinus Fracture Repair 29 the camouflage technique is the need for an alloplastic implant. moderate displacement (2 to 6 mm) fractures of the anterior table. Endoscopic repair of frontal sinus fracture: case report. Medpor has a long track record for maxillofacial reconstruction. Summary Endoscopic repair (ie. p. easy to handle and insert. Prefabricated implants can be used. The skill set is very similar to that of an endoscopic brow lift. p. Facial Plast Surg 1998. New York. it can be removed in one piece should it be necessary. only those patients with a true aesthetic deformity require surgery. Sykes JM. References [1] Strong EB. 747–58.

however.theclinics.004 facialplastic. which simply immobilized the fractures and allowed them to heal.2005. Until roughly the 1930s.fsc. thoracic surgery. doi:10. In the aforementioned surgical specialties. Cincinnati.11. To overcome this deficiency. Shumrick. for most facial skeletal surgery. and paranasal sinus surgery have been enhanced by the ability to perform accurate endoscopic surgery while virtually eliminating the long surgical scars and pain of surgical approaches. gynecology. dramatically reducing morbidity compared with traditional surgical approaches.uc. To perform effective endoscopic surgery. Although external splints imparted little morbidity. Department of Otolaryngology. interfragment wires and suspension wires were developed. it was only natural that a less invasive approach to fractures would be found. Later. special sheaths have been designed for the scopes with extensions that hold soft tissue away from the surgical site. Using endoscopic approaches. required multiple small keyhole incisions. OH 45267. the development of plate and screw fixation placed by means of extendedaccess approaches provided excellent fracture reduction and fixation but required long incisions and extensive soft tissue elevation [1–16]. and the reductions rarely were completely accurate or rigidly stabilized.31 FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 14 (2006) 31–35 Endoscopic Management of Frontal Sinus Fractures Kevin A. As surgeons continued to refine their management of facial trauma. Wire placement and fracture reduction. & MD Endoscopic management of frontal sinus fractures & References Management of facial trauma always has been a balancing act between achieving accurate fracture reduction and stabilization. thus. somewhat improving reduction and stabilization. while causing as little morbidity as possible. abdominal surgery. a cavity is required to keep soft tissue from draping over the endoscope and obscuring visualization of the surgical site. University of Cincinnati. 231 Albert Sabin Way. In the late 1980s and early 1990s. management of facial fractures consisted of external splints and bandages.com . there is no readily available cavity in which an endoscope can function. excellent visualization of the surgical site can be achieved while avoiding ex- tensive external incisions. The use of endoscopes for facial surgery has lagged behind these other specialties primarily because of the lack of a readily usable optical cavity. The specialties of orthopedics. but also difficulty working around the curve of the skull. Unfortunately. the fractures rarely were reduced anatomically. All rights reserved.1016/j.edu 1064-7406/06/$ – see front matter © 2006 Elsevier Inc. USA E-mail address: shumrika@ucmail. the optical cavities are either natural (as with sinus and thoracic surgery) or created by infusing gas (abdominal surgery) or saline (orthopedic surgery). Endoscopes have had a profound effect on nearly every surgical specialty over the past 20 years. This tenting of the soft Division of Facial Plastic Surgery. These tent the soft tissues away from the surgical site. Typically. a 30° scope is used in conjunction with the sheath and extension.

Success is defined as a reduction sufficiently anatomic and stable that no further treatment was felt to be necessary (by the physician or patient) The author’s technique is similar to endoscopic forehead lifting. and the fractures are visualized by means of a 30° endoscope with an external sheath for soft tissue retraction [Figs. 30° and 70° scopes. however. This approach has been more successful than trying to work within the forehead skin envelope. The forehead soft tissues are elevated subperiosteally. It is preferred to work through separate ports for the endoscope and instruments to avoid crowding of the instruments and scope at the anterior portion of the incision. 1–4]. has found that it is usually necessary to approach the fragments directly through small forehead incisions (preferably hidden in the brow). which requires more of a prying motion to elevate the fractures. With this experience has come well-developed exposures and instrumentation. . The author. the author and colleagues have attempted endoscopic reduction of frontal sinus fractures on 19 patients and have been successful in 12 of them. with one central and two lateral hairline incisions [Figs. They found that the fractures could be visualized. Endoscope inside endoscopic sheath. This article outlines the state of the art with regard to the use of endoscopes for managing frontal sinus fractures. tissue creates an optical cavity. Fig. Strong and colleagues reported on a cadaver study looking at the feasibility of performing endoscopic reduction and fixation. Once the fracture site is visualized. Fig. one attempts to elevate the fragments with endoscopic elevators. 3. At the University of Cincinnati.32 Shumrick Fig. 4. [Figs. Using endoscopic techniques. this tips the fragments. Stronge and colleagues recommended camouflaging the anterior wall depression by endoscopically applying hydroxyapatite bone cement. but they encountered difficulty with complete reduction and were unable to perform rigid fixation in a noninvasive manner. 4 and 5]. which are one of the most common fractures treated with endoscopic techniques. 6 and 7]. Using small external incisions directly over the fractures allows the surgeon to apply anterior force for anatomic reduction of the fracture segments. As an alternative. Endoscopic sheath. 2. The fractures are elevated using percutaneous nerve hooks. Endoscopic management of frontal sinus fractures Endoscopic forehead lifting has been accepted for the past 10 years and has provided significant experience with endoscopic management of the frontal region for aesthetic purposes [17–23]. Various endoscopic instruments. Most frequently the 30° scope is used. 1. allowing the surgeon to look down on the surgical site using a 30° scope. These reports have dealt exclusively with eggshell fractures of the anterior wall that simply are popped back into position and allowed to heal without fixation. several authors have reported case reports detailing successful management of anterior wall fractures of the frontal sinus [24–29]. or by drilling into the fragments and grabbing them with threaded Stein- Fig.

mann pins [see Figs. Alloderm. The fragments continued to collapse despite having been reduced. the author feels that the endoscopic technique is appropriate only for anterior wall frontal sinus fractures that have several large segments without extensive comminution. In retrospect. Based on this experience.. 7]. This highlights the importance of careful patient selection and the need for fully informing patients that the endoscopic approach may not reduce their fractures fully. the reason was that the fracture segments were unstable after endoscopic reduction. (D) Instruments in midline and paramedian incisions. and the monitor is at the foot. (B) Direct percutaneous approach with threaded Steinman pin and nerve hook to elevate bone fragments. Gore-Tex. Given the fact that the fracture segments are not approached directly. As mentioned. It goes without saying that more extensive fractures with involvement of the nasofrontal ducts or posterior wall should have open approaches . but alternatives would include bone cement. 8]. These irregularities are considered a trade off for avoiding long. Somerville. approach incisions. and they are camouflaged with patches of Vicril Mesh (Ethicon. (C ) Combination of nerve hook and threaded Steinman. these unsuccessful reductions were more extensively comminuted then was appreciated on the initial review of the coronal and axial CT scans. . The surgeon sits at the head of the table. Fig. 5. With gentle retraction. the author prefers Vicril mesh. New Jersey) [Fig. it is common to have residual surface irregularities. or Surgicell. (A) Endoscopic view of frontal sinus anterior wall fracture. the fragments often elevate into a reduced position and are frequently stable without the need for rigid fixation. In the four patients whose endoscopic fracture repair was felt to be unsuccessful. 6. Cases with unstable anterior walls after endoscopic reduction were converted to an open approach with coronal incisions and rigid fixation in the standard fashion [Fig. 5–7]. Inc. Additionally.Frontal Sinus Fractures 33 Fig. the surgeon should be prepared to camouflage any residual irregularities with the material of choice.

. (B) Fracture was managed with a coronal approach and rigid fixation with titanium mesh. (B) Incisions planned. 8. (E ) Six-week postreduction photo. Fig. because it is not comminuted. (D) Endoscopic view of Vicryl mesh placement for camouflage of residual irregularities. 7. (A) Frontal sinus anterior wall fracture.34 Shumrick Fig. (A) Unsuccessful attempt at endoscopic reduction. (C ) Threaded Steinman pin used to reduce fracture fragments while the endoscope is used to monitor the reduction. This is a good candidate for endoscopic reduction. The fracture was too comminuted and unstable.

Endoscope-assisted facial fracture repair. Plast Reconstr Surg 1985. [5] Barone CM. Arch Facial Plast Surg 2003.101(2):333–45 [discussion 346–7].9(3):469–74. Aesthetic Plast Surg 1994. Ryzenman JM. Gellrich NC. Clin Plast Surg 1995.18(3):269–74. Traumatic arch injury: indications and an endoscopic method of repair. et al. Endoscopic repair of a complex midfacial fracture.5(6): 514–21. Plast Reconstr Surg 1990. Plast Reconstr Surg 1998.4(3):36–41. editors. [9] Honda T. [7] Chen CT.25(8):1075–83. Management of cerebrospinal fluid leak associated with craniomaxillofacial trauma.Frontal Sinus Fractures 35 References [1] Yaremchuk MJ. Endoscopic management of facial fractures. Endoscopic forehead lift. Lynch J. [17] Aly A. [25] Graham III HD. Frontiers in maxillofacial endoscopic surgery. Endoscopic-assisted repair of a malar fracture.2(4):269–73. et al. Aesthetics and analysis. Endoscopically assisted repair of frontal sinus fracture.20(3):231–8. Endoscopic subperiosteal forehead lift. [11] Lee CH. J Craniomaxillofac Trauma 1998. et al. [2] Manson PN. [15] Schon R. J Craniomaxillofac Trauma 1998. et al. Treatment of an isolated outer table frontal sinus fracture using endoscopic reduction and fixation. [6] Bell RB. Facial Plast Surg Clin North Am 2001. Endoscopic repair of posttraumatic enophthalmos using medial transconjunctival approach: a case report. Trabulsy PP. Plast Reconstr Surg 1998. 12(1):46–8. [28] Shumrick KA.85:202–12. Int J Oral Maxillofac Surg 2002. Intranasal endoscopyassisted repair of medial orbital wall fractures. [21] Dayan SH. Schmelzeisen R. [16] Schon R. Management of frontal sinus fractures. et al. Usefulness of endoscopy in craniofacial trauma. Reinert S. . 22(4):605–18.103(1):60–5. Tirkanits B. [18] Chajchir A. [8] Czerwinski M. Avila E. Endoscopically assisted mandibular subcondylar fracture repair. [3] Manson PN. Schmelzeisen R. 16:40–5. The forehead lift: endoscopic versus coronal approaches. Mueller RV. Boschert MT. Plast Reconstr Surg 1996. [4] Barone CM. J Trauma 2003. Gigantelli JW. et al. J Craniofac Surg 1997.76:1–10. Endoscopic full facelift.4(1):22–6.31(5):485–8. Lee JW. Atlas Oral Maxillofac Surg Clin North Am 2003. Arch Facial Plast Surg 2000. Moulthrop TH.18(4):363–71. Curr Opin Otolaryngol Head Neck Surg 2004. Surg Clin North Am 2000. Jimenez DF. [24] Chen DJ. Aesthetic Plast Surg 1994.102(5):1642–5. [23] Ramirez OM. Endoscopic repair of isolated anterior table frontal sinus fractures.2(4):52–5.101(5):210–7. Endoscopic fracture treatment. 98(7):1148–57 [discussion 1158]. Endoscopic plastic surgery. 37(2):178–83. Jacobovicz J. [26] Lappert PW. Endoscopic forehead lift.25(1):35–9.8(3):170–5. [27] Rice DH. Goni S. et al.55(2): 378–82. 1992. Rigid fixation of the craniomaxillofacial skeleton. Facial Plast Surg 2004.80(5):1373–82. Tirkanits B. World J Surg 2001. [13] Lee CH. [19] Daniel RK. [12] Lee C. Buchalter GM. [14] Rhee JS. Endoscopic repair of frontal sinus fracture: case report. J Oral Maxillofac Surg 2004.11(2): 209–38. Cornelius CP. A cadaveric and clinical evaluation of endoscopically assisted zygomatic fracture repair. Lee C. Gruss JS. Cram AE. Toward CT based facial fracture treatment. Midface fractures: advantages of immediate extended open reduction and bone grafting. [29] Strong EB. Endoscopically assisted zygomatic fracture reduction and osteosynthesis revisited. Loehrl TA. Spring P. [22] Marchac D.62(6):676–84. Lee C. [20] Daniel RK. Ann R Australas Coll Dent Surg 2002. [10] Krimmel M. Boston: Butterworth-Heinemann. Ann Plast Surg 1996. Plast Reconstr Surg 1999. J Craniomaxillofac Trauma 1996. Manson PN. Aesthetic Plast Surg 2001. Endoscopic forehead lift: an operative technique. Acta Chir Belg 2001.

4] and Kobayashi and colleagues [5] pioneered the use of endoscopy in the area of the zygomatic arch. the evolution and advantages of its present indications. several modifications to their techniques have been proposed. Sakai and colleagues [2] extended endoscopic applications to the management of craniofacial disorders. 5400 boul. Lee). Montreal Children s Hospital. Canada.ca (C. C1139 2300 Tupper Street.1016/j. planes of dissection and methods of fixation [6. Chen Lee. E-mail address: chenlee@sympatico. This article presents the authors’ experience with the endoscopic technique of zygomatic arch repair. a b 1064-7406/06/$ – see front matter © 2006 Elsevier Inc. Montreal.fsc. The role of arch anatomy and use of endoscopy to minimize treatment pitfalls The zygomatic arch is a narrow skeletal element spanning from the temporal bone to the zygoma body. and future directions. H4J 1C5 PH * Corresponding author. Since their original descriptions. Quebec. the use of endoscopy rapidly progressed as the advantages of minimal access were realized.* & The role of arch anatomy and use of endoscopy to minimize treatment pitfalls Arch injury patterns Endoscopic indications and rationale for repairs Repair sequencing Le Fort III Complex zygoma Surgical technique Equipment & & & Exposure Reduction Fixation Case presentations Le Fort III Complex zygoma Discussion References Endoscopy was introduced to the field of facial plastic surgery relatively late by Vasconez and colleagues [1]. All rights reserved.11. & & & & MD a . Montreal. which greatly facilitate its application in general and orthopedic surgeries. doi:10. FRCSC b.002 facialplastic. H3H 1P3 Sacre-Coeur Hospital. such as the abdomen or a joint space. MD.37 FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 14 (2006) 37–43 The Rationale and Technique of Endoscopic Approach to the Zygomatic Arch in Facial Trauma Marcin Czerwinski. In addition. who were the first to perform an endoscopic brow lift in 1994.2005. performing a Le Fort I level osteotomy. Despite this late introduction. This initial delay in the assimilation of the endoscope in the head and neck region likely was caused by the absence of naturally occurring body cavities. Canada.theclinics. Quebec. In the axial plane.7]. These vary in placement of incisions. Lee and colleagues [3. The endoscope currently is considered by many to have an integral role for managing injuries in this region. the arch is curved in the . Gouin West. initial endoscopic instruments lacked specificity to the facial region.com .

to the stable skull base. (From Czerwinski M. however. the coronal approach designed to avoid injury to the facial nerve traditionally has been used. an anterior force vector focused on the malar prominence usually will cause a posterior telescoping pattern of injury [Fig. 1]. Medial arch displacement occurs following direct lateral force.20(3):231–8. to accurately restore midfacial projection and transverse width. including alopecia. First. it can be used as a guide to precise fracture realignment. it can serve as an anchor point of the midface because of its sturdy skull base attachment. Lee C. Traumatic arch injury: indications and an endoscopic method of repair. Isolated arch fractures can be of three types. At times. with permission. the principle of anatomic Fig. with permission. Incisions cannot be placed directly over the arch because of high risk of facial nerve injury. Recognition of the latter two injury patterns is important. its anatomic reduction is paramount to aesthetic appearance in individuals with prominent preinjury lateral facial contour. it arises because of a force applied directly to the malar prominence with dissipation Fig. The use of endoscopy allows the surgeon to fully benefit from the role of arch repair while minimizing the negative sequelae of traditional access. and excessive blood loss [4]. The role of the arch in midfacial repair can be viewed threefold.9]. In the sagittal plane. joining the midface.) . The latter has its own drawbacks. which frequently is displaced in facial trauma. of which the zygomatic arch is a necessary component. 2]. the advantages of arch repair have not been used sufficiently. First. Posterior telescoping fracture of the arch results when energy applied anteriorly to the malar prominence is transmitted to the arch segment. Facial Plast Surg 2004. it is parallel to the Frankfort horizontal. Traumatic arch injury: indications and an endoscopic method of repair. 3]. Arch injury patterns Fractures of the zygomatic arch can occur in isolation or with midfacial injuries. direct lateral force displaces the arch medially [Fig. Second. Consequently. uninjured part of the skull as a control [8. risks of traction injury to the frontal branch of the facial nerve and temporal hollowing. standard in other facial trauma repair. 1. The individual pattern depends mainly on the magnitude and direction of the trauma force vector applied to the craniofacial skeleton. Facial Plast Surg 2004.20(3):231–8. Second. Instead. as a nonvisualized reduction attempt. using an elevator inserted under the arch. will be unsuccessful and exacerbate fracture displacement. Numerous authors have taken advantage of these properties. (From Czerwinski M. however. Despite its key role. Lee C. Last. Most frequently. a potential for increased quickness [11] and cost-effectiveness. a posteriorly directed force can result in an explosive burst with displacement of the arch fragments laterally [Fig. 2. has been applied infrequently to the zygomatic arch.) posterior third of its course and straight in the anterior two thirds. A displaced zygoma fracture results from disruption of all its bony attachments. as access to it is fraught with difficulties. including magnified direct visualization. anesthesia posterior to the incision. The facial nerve pierces the superficial musculoaponeurotic system at its lower border and courses superficially to the temporoparietal fascia in an anterosuperior direction [10]. and in the longterm. The arch also occupies a strategic position. This technique also offers other advantages. using the arch’s bony attachments and consistent shape as a guide to anatomically repairing it and the midface without the necessity of exposing the contralateral.38 Czerwinski & Lee reduction and rigid internal fixation.

Lee C. It occurs in high-energy injuries in which the force vector fractures across the alveolus and the pterygoid plates. Endoscopic indications and rationale for repairs In the authors’ experience. Repair sequencing In the authors’ experience. as the other anterior buttresses frequently are comminuted. in addition. or when the arch itself is considered an important aesthetic landmark. In addition. The magnitude of energy determines the degrees of displacement and comminution [12]. Traumatic arch injury: indications and an endoscopic method of repair. subsequently uniting them at the Le Fort I level. 3.20(3):231–8. arch reduction is a valuable tool for anatomic repositioning of the malar prominence to recreate preinjury facial width and projection. Disruption of the stable arch attachment causes occlusal instability in addition to midfacial flattening. and asymmetry. In Le Fort III-level injuries. Only higher energy mechanisms will have a sufficient portion of the force transmitted posteriorly to cause arch disruption. In these injuries. and infraorbital buttresses. Thus. when the zygomatic arch is thought to contribute to proper reduction or enhanced stability of other facial fractures. This is paramount in complex zygoma fractures when there is extensive comminution of at least two of the anterior three zygoma buttresses. when the complexity of facial trauma necessitates incorporation of arch repair into a comprehensive management plan. with permission. It may.) of much of the energy at the anterior. zygomaticomaxillary. the following sequences are most effective. an issue not addressed by the Gillie’s approach. (B) Successful anatomic repositioning of the lateralized arch fragments. endoscopic approach to the arch should be considered in all cases where precise arch repair is deemed an integral part of the treatment plan. the principal benefit of rigid arch fixation is to stabilize the mobile maxilla and its attached dentition to the skull base. The arch is a particularly valuable point. A Le Fort III-level fracture is defined in part by separation of the maxilla from the cranial base at the zygomatic arch. repair is particularly important in individuals with prominent preinjury lateral facial contour. the surgeon should attempt endoscopic reduction and fixation. The cranio–orbital unit is addressed by first reducing and fixating the external orbital frame at the infraorbital and zygo- . Failure of realignment will lead to an unsightly temporal depression and asymmetry. This approach allows effective fracture management while minimizing the stigmata of extensive incisions. miniplate placement will prevent subsequent arch redisplacement caused by reinjury or pull by the masseter muscle. In displaced zygoma fractures. (A) Zygomatic arch fragmentation with lateral displacement of the segments occurs when a high energy force is applied anteriorly at the zygoma and dissipates posteriorly at the arch. widening. This ensures a secure maxillomandibular occlu- sal relationship. Facial Plast Surg 2004. A displaced zygoma fracture results in malar prominence depression and may cause enophthalmos because of orbital enlargement. Le Fort III The authors approach the repair of these fractures by individually treating the cranio–orbital and maxillomandibular units. The secondary role of the arch in Le Fort III fractures is to enhance accurate midface realignment. restore adequate orbital volume. resulting in a mobile maxilla and its attached dentition. (From Czerwinski M.Zygomatic Arch in Facial Trauma 39 Fig. the arch also serves as an additional point of rigid fixation. In isolated arch fractures.

(From Czerwinski M. The retractor-mounted endoscope is inserted. Following dissection of the optical cavity.20(3):231–8. infraorbital and zygomaticomaxillary. Lee C. the two functional units are joined using miniplates at the zygomaticomaxillary and nasomaxillary buttresses. a 4 mm endoscope mounted retractor (Isse Fig. and a video system (Olympus America. arch fragments are seen in their anatomic position. and the sites of fracture are exposed in the subperiosteal plane [Fig. The zygomaticomaxillary buttress is addressed last. Germany). (C ) Following repair. Facial Plast Surg 2004. with permission. Lake Success. including: zygomaticofrontal. Traumatic arch injury: indications and an endoscopic method of repair. which maintains the optical cavity. A periosteal elevator then is inserted. Germany). Next. New York) to project the endoscopic image onto a monitor display. along with the zygomatic arch. Once the arch is reached. Premorbid occlusion is restored using maxillomandibular fixation. Karl Storz.) . (B) Endoscopic view demonstrates medially displaced arch segments.40 Czerwinski & Lee maticofrontal interfaces. Complex zygoma Complex zygoma fracture may require repair of all the anterior buttresses. Exposure A scalp extension of the preauricular incision is carried through the skin and the temporoparietal fascia to expose the deep temporal fascia. and an optical cavity is created by dissecting superficial to the deep temporal fascia. Maintenance of integrity of the deep temporal fascia helps to avoid unsightly temporal hollowing. its periosteum is incised. This minimizes the risk of injury to the frontal branch of the facial nerve. Repair is accomplished most expediently by first restoring the external orbital frame. This nonvisualized part of the dissection is performed only superior to an imaginary line extending from the helical crus to the superior orbital rim. then reducing and fixating the zygomatic arch. and directly visualized dissection in the same plane is performed down to the zygomatic arch. a retractor-mounted endoscope is inserted. The arch then is repaired to provide appropriate projection and width to the midface. 4. (A) Endoscopic repair of the arch is performed using a small incision hidden in the temporal hairline. and directly visualized dissection is performed in a plane superficial to the deep temporal fascia down to the zygomatic arch. Dissector Retractor. Surgical technique Equipment The equipment used at the authors’ center includes: a 4 mm diameter 30° angle scope (Karl Storz. 4].

He complained of left cheek flatness and pain.20(3):231–8. and upper buccal sulcus incisions (inferior orbital rim and zygomaticomaxillary buttress). and the plate is stabilized to other fracture segments using the endoscope [see Fig. Access for repairs was achieved using preauricular (endoscopic arch fixation). CT imaging demonstrated a left zygoma fracture with lateral displacement of the comminuted arch. Complex zygoma A male involved in a motor vehicle collision was brought to the hospital. with permission. CT imaging Fig. the left side of his face was visibly flattened. lateral orbital laceration (zygomaticofrontal buttress). and upper buccal sulcus incisions (inferior orbital rim and zygomaticomaxillary buttress). whereas a long miniadaptation plate is preferred in associated midfacial trauma. as the periosteal blood supply is interrupted [13]. and anesthesia in the left infraorbital nerve distribution. (From Czerwinski M. Access for fracture repair was by means of preauricular (endoscopic arch fixation). the left side of his face struck the steering wheel. he sustained a left lateral orbital laceration. The arch component of the Le Fort III fracture was plated rigidly as a free graft ex vivo and then repositioned accurately to help stabilize and reduce the midfacial injury [Figs. 5. If excessive comminution prevents stability and does not allow in situ reduction. Lee C. This. arch fragments are reduced according to the fragmentation pattern to restore preinjury arch form. The significantly comminuted arch component was plated ex vivo and then repositioned anatomically as the arch element of four-point zygoma fracture reduction and fixation [Figs. either in situ or on a side table. revealed left Le Fort III and right Le Fort II facial fractures. This is preferably done in situ. During the trauma. 3. however. In addition. (A) Preoperative photograph of a patient who sustained a left Le Fort III and right Le Fort II facial fractures. carries a significant risk of bony resorption. restoring and rigidly stabilizing the midface. lateral extension of upper blepharoplasty (zygomaticofrontal buttress). premorbid occlusion initially was restored using maxillomandibular fixation. On examination. Midfacial flattening and malocclusion are evident. 4]. Case presentations Le Fort III A young male was assaulted with a baseball bat. A short miniplate is used in isolated arch injuries. the entire maxillary segment was mobile. 7]. Following fixation of the plate to an arch segment.Zygomatic Arch in Facial Trauma 41 Reduction Following exposure. and he complained of malocclusion. accurate reduction is confirmed. Facial Plast Surg 2004. Fixation Selection of appropriate fixation hardware depends on the type of fracture. 5. The long mini-adaptation plate extends onto the lateral orbital rim. the fragments can be removed and precisely realigned on a side table. 6]. In the operating room.) . Traumatic arch injury: indications and an endoscopic method of repair. (B) Photograph several months following endoscope-assisted repair.

(B) Photograph several months following surgery shows restoration of normal facial topography. anatomic realignment of midfacial anatomy and restoration of preinjury occlusion can be seen.20(3):231–8. 6.) . Traumatic arch injury: indications and an endoscopic method of repair. Lee C. Facial Plast Surg 2004. (From Czerwinski M. Traumatic arch injury: indications and an endoscopic method of repair. The arch component of four-point zygoma fracture repair was performed using the endoscopic technique. (From Czerwinski M. Facial Plast Surg 2004. with permission.42 Czerwinski & Lee Fig. Lee C. Severe decrease in malar prominence projection and increased facial width can be appreciated. (B) Following endoscope-assisted repair. with permission. (A) Coronal and axial CT images demonstrating left Le Fort III and right Le Fort II level injuries with severe left zygomatic arch comminution.) Fig. 7. (A) Preoperative photograph of a patient with a complex zygoma fracture.20(3):231–8.

of scalp sensation posterior to the incision. Yamada A. Lee C. restoration of arch anatomy is an essential guide to recreating preinjury malar prominence projection and transverse facial width.48:423–30.85:202–12. Kim YW. all of which previously had been considered to be indications for a coronal incision. Endoscopically assisted malarplasty: one incision and two dissection planes.8:170–5. Being aware of its difficulties. Phillips JH. Plast Reconstr Surg 1994.85:878–90. rigid arch repair is the most stable point of fixation that anchors the mobile maxillary dentition to the skull base. perception of depth is lost as the three-dimensional image is reformatted on a flat screen. Plast Reconstr Surg 1990. J Trauma 2000. In complex fractures of the zygoma. Furthermore. Plast Reconstr Surg 1990. Jpn J Plast Reconstr Surg 1995. Sakai Y. [6] Lee SS. . excessive blood loss. the authors believe endoscope-assisted zygomatic arch repair represents a significant advance in midfacial trauma management. 1995. Core GB. Jacobovicz J. Williams and Wilkins.94:788–93. Arch Otolaryngol Head Neck Surg 1989. [4] Lee CH. [12] Manson PN. In addition. [10] Ellis EI. Endoscopic techniques in coronal brow lifting. Thus for many years. [11] Lee C. Int J Oral Maxillofac Surg 2002. implementation of specialized training programs into surgical program curricula and further improvements in endoscopic instruments will promote this technique further. Plast Reconstr Surg 2003. its repair restores lateral contour of the face and prevents subsequent displacement caused by reinjury or pull by the masseter muscle. Trabulsy PP. et al. A cadaveric and clinical evaluation of endoscopically assisted zygomatic fracture repair.Zygomatic Arch in Facial Trauma 43 Discussion The reliable form and strategic position of the zygomatic arch make it a valuable landmark in midfacial trauma management [8.38:875. Kobayashi S. Ann Plast Surg 2002. et al. This technical challenge arises. et al. Stiebel M. et al. Lin SD. Van Wyck L. [8] Stanley Jr RB. Plast Reconstr Surg 1998.115: 1459–62. Toward CT-based facial fracture treatment. magnified visualization. because the separation in the usual hand-eye coordination results in the loss of tactile perception. [7] Lee JS. The relative importance of arch repair increases as the complexity of trauma rises. Cornelius CP. Finally.9]. the standard of anatomic reduction and rigid internal fixation used in facial trauma management did not apply to the arch. Markowitz B. J Craniofac Surg 1997. The endoscope-assisted approach necessitates only small. temporal hollowing and potential injury to the frontal branch of the facial nerve [4]. J Craniofac Surg 1995. The authors believe the endoscopic approach allows the surgeon to fully appreciate the role of zygomatic arch in facial fracture management without having to suffer the consequences of coronal access. Cranial nerve VII region of the traumatized facial skeleton: optimizing fracture repair with the endoscope. Gamboa-Bobadilla M.101:333–45. being most important in Le Fort III injuries and least so in isolated fractures. Kang S. References [1] Vasconez LO.49: 452–9. In Le Fort III-level fractures. loss. An endoscopic Le Fort I osteotomy: clinical results. The authors encourage the use of the endoscope-assisted zygomatic arch repair in Le Fort III. Chiu YT. Mueller RV.6:519–24. In isolated arch fractures. et al. Young DM. Surgical approaches to the facial skeleton. Zide MF. [13] Krimmel M. Ohmori K. The zygomatic arch as a guide to reconstruction of comminuted malar fractures. Endoscopically assisted zygomatic fracture reduction and osteosynthesis revisited. In the future. there is an associated steep learning curve resulting in initially long operative times. The endoscopic method of zygomatic arch repair does have some disadvantages.31:485–8. Mirvis S. Endoscopic repair of a complex midfacial fracture. purchase of required surgical instruments and electronic devices represents a significant initial expense. and isolated arch fractures. Reinert S. [9] Gruss JS. It requires the acquisition of a different set of surgical skills. Open zygomatic arch repair has been used infrequently. complex zygoma. [5] Kobayashi S. well-concealed incisions and allows in situ reduction and fixation under direct. The importance of the zygomatic arch in complex midfacial fracture repair and correction of posttraumatic orbitozygomatic deformities. Approaching the zygoma with an endoscope. Deep dissection plane for endoscopic-assisted comminuted malar fracture repair. [2] Sakai Y.111:461–7. mainly because traditional access to this structure is fraught with undesirable sequelae. et al. [3] Lee C. namely: alopecia.

however. Troulis. and injury to maximize the rate and quality of healing. and improvements in perioperative patient management created an environment in which the art and science of surgery could flourish. This approach to mandibular surgery first was discussed in the English literature by Trauner and Obwegeser in 1955. During the last decade. The technique proved to be quite versatile. This results in a faster recovery for the patient [2]. craniomaxillofacial surgeons have begun to develop endoscopic techniques to treat soft tissue and skeletal defects [4] with decreased morbidity. in the German literature. DMD. limited the practice of surgery to the treatment of life-threatening conditions [3]. continues to be associated with significant swelling and potential injury to the inferior alveolar nerve. Overview of endoscopic procedures Endoscopic vertical ramus osteotomy Condylectomy Mandibular retrognathism & References The field of minimally invasive surgery (MIS) is defined as the combination of surgical innovation with modern technology [1]. Louis procedure. This technique involved bilateral ramus osteotomies for treating mandibular prognathism [5]. infection and the inability to effectively control hemorrhage. 1064-7406/06/$ – see front matter © 2006 Elsevier Inc. Warren Building.J. It is the discipline of surgery that aims to minimize morbidity and complications usually associated with traditional procedures. asymmetries. Hullihen realized that the constricting scar had to be released to facilitate the corrective jaw movement and to improve the long-term stability of the procedure. in the American Journal of Dental Science. The use of aseptic technique.com .7] to minimize morbidity and improve stability. DDS. Blair led to the development of the St.theclinics. The bilateral split osteotomy (BSSO) has been modified and improved over the years [6. The procedure.1016/j. Suite 1201. Schuchardt. Another significant advantage of the sagittal split osteotomy was that a bone graft was not needed in cases where advancement of the mandible was required. It was used to treat various deformities including prognathism. Troulis). Boston MA 02114. shock. Until the mid 1800s.003 facialplastic. MD. edema. USA * Corresponding author. MIS focuses on reducing tissue trauma and the resultant bleeding. doi:10. The introduction of antibiotics after World War II allowed surgeons to carry out a greater variety of elective procedures to improve quality of life. the discovery and widespread use of anesthesia.org (M. Massachusetts General Hospital.45 FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 14 (2006) 45–50 Endoscopic Approach for Mandibular Orthognathic Surgery Maria J. was the first to describe a mandibular osteotomy resembling the current sagittal split. Ramirez. A collaborative effort between the orthodontist Edward Angle and the surgeon V. and open bite. MD & DMD. The procedure de- scribed was a mandibular body ostectomy for correcting retrognathism and an anterior open bite resulting from a burn scar contracture of the neck. All rights reserved.fsc. Leonard B. retrognathism. MSc*. Jose L. Kaban. P.2005. and pain.11. The first orthognathic surgical procedure was reported by Simon Hullihen in 1849. E-mail address: mtroulis@partners.

19–21]. It also can be used for congenital or acquired temporomandibular joint conditions requiring either condylectomy and costochondral grafting or RCU construction.12]. ramus. Ultimately. The surgical technique for the EVRO begins with careful marking of the zygoma. Recent advances in imaging. and it allows the use of rigid internal fixation.12. anterior border. and direct visualization of a magnified and illuminated operative field for the surgeon. instrumentation. Length of hospital stay is shortened. a 1. The development of rigid internal fixation has improved short. generally is performed with poor visibility. Tissue dissection and manipulation are minimized. and posterior mandibular body. It is used to perform osteotomies and reconstructive procedures such as vertical ramus osteotomies with rigid fixation. inconspicuous scars. Endoscopic vertical ramus osteotomy Background For patients with mandibular prognathism (with or without asymmetry). These techniques eventually may replace traditional open procedures and further decrease morbidity. Administration of perioperative corticosteroids has contributed to a decrease in perioperative edema and discomfort [10]. This dissection provides direct access to the entire RCU [4. An osteotomy is created. will . condylectomy and costochondral grafts. The BSSO is a more complicated osteotomy than the IVRO and requires more soft tissue dissection (medial and lateral ramus). This procedure also allows for mandibular setback without the need for extraction of welldeveloped mandibular third molars. resulting in less pain. and fiberoptic technology have allowed surgeons to develop and refine minimally invasive access for orthognathic surgical procedures. The bone is exposed and the dissection completed.46 Troulis et al Minimizing morbidity associated with mandibular surgery continues to be a central issue in craniomaxillofacial surgery. parallel to existing neck creases. however. and condyle on the skin. In cases of mandibular prognathism or asymmetry. distraction osteogenesis. temporomandibular joint. under direct endoscopic visualization. in the subperiosteal plane. morbidity.9]. Then. This dissection creates an optical cavity that allows for excellent visualization of the operative field. and patient acceptance. With the endoscope the next step is to identify the anatomic landmarks of the RCU: posterior border. Endoscopic access can be used for orthognathic surgical correction of three types of mandibular deformities. Controlled hypotensive anesthesia has decreased blood loss. anterior border. a significant risk of inferior alveolar nerve (IAN) damage [13. coronoid process. and in cases requiring skeletal expansion.4. therefore. this will have profound impacts on cost. the jaw must be immobilized by maxillomandibular fixation. The endoscopic vertical ramus osteotomy (EVRO) is a minimally invasive alternative to the IVRO and BSSO.14]. The endoscopic approach to the mandibular ramus/condyle unit (RCU) is a minimally invasive access technique. There is. which are associated intimately with the IAN [12] [Fig 1]. and there is a quicker return to normal activity [2. It can be accomplished with minimal risk to the IAN. which is incised with a needlepoint electrocautery. Overview of endoscopic procedures The benefits of endoscopy include small and remotely placed incisions. will decrease the morbidity associated with orthognathic and reconstructive procedures. The EVRO is indicated for those patients with mandibular prognathism or asymmetry who refuse maxillomandibular fixation and who are not willing to accept the risks of inferior alveolar nerve injury. however. the endoscopic vertical ramus osteotomy is a minimally invasive alternative to the traditional vertical ramus osteotomy or sagittal split osteotomy. these procedures may be performed predominantly in an outpatient setting. The osteotomy. rigid fixation.and longterm skeletal stability and has eliminated the need for prolonged periods of maxillomandibular fixation. In cases of mandibular retrognathia. using endoscopic elevators with a suction port. the standard treatment options are the intraoral vertical ramus osteotomy (IVRO) or BSSO.7.5 cm incision is made one finger-breadth below the inferior border of the mandible. It is not possible to use rigid fixation. In the future. IVRO offers the advantage of a lower incidence of inferior alveolar neurosensory disturbance when compared with BSSO. and overall morbidity [2. the endoscopic approach. thus minimizing the risk of transfusion [8. The dissection is carried bluntly to the masseter muscle. availability. A 30° endoscope is placed into the wound and oriented parallel to the posterior border. The distinct advantage of the BSSO is that it can be used with rigid internal fixation. The complication of condylar sag may result in postoperative open bite in a small percentage of patients. The combination of improvements in all of these areas has decreased the length of stay associated with mandibular orthognathic surgery [11]. sigmoid notch. and placement of miniature distraction devices. when combined with a miniature distraction device. be the minimally invasive alternative to the sagittal split osteotomy. edema.12]. A combination of endoscopic access. angle.

The condyle then can be atraumatically removed and the undersurface of the articular disc visualized [4. Troulis and Kaban reported a retrospective study of 14 patients treated with EVRO [12]. Alternatively. A single patient suffered transient weakness of the marginal mandibular nerve. endoscopic condylectomy and costochondral graft reconstruction are minimally invasive alternatives to the standard open-access approaches. (B) Close-up panoramic view showing vertical ramus osteotomy with setback and rigid fixation. Condylectomy Idiopathic condylar resorption For those patients with mandibular retrognathism and open bite secondary to idiopathic condylar resorption or degenerative joint disease. The patient is placed into maxillomandibular fixation in the preplanned occlusion. Costochondral grafts are harvested in the standard fashion through an inframammary incision. The screw holes are drilled and the screws placed through the incision or with the aid of a percutaneous trocar. Rigid fixation is achieved with three 12 to 14 mm long.5 cm incision and dissection used for the EVRO. The mean operating time was 37 minutes per side. One patient with concurrent medical problems had a hospital stay of 2 days. from the sigmoid notch to the mandibular angle using a long-shaft reciprocating blade. condylectomy and RCU reconstruction can be achieved through the same 1. extending from sigmoid notch to angle. and this lasted less than 1 week. Vertical ramus osteotomy.0 mm titanium miniplate (as a washer) with multiple screws.5 days [20].7 years postoperatively with lateral cephalograms.0 mm diameter screws. The standard open approach also is associated with considerable bleeding and edema. the disc is identified. 1. (C ) Lateral facial photograph of patient. producing a 2 3 mm posterior open bite on the sides to be reconstructed. The graft is fixed into position using a 2. Then. with a splint. dissection of the condylar head and neck. No patients required maxillomandibular fixation. is extended into the lower compartment of the temporomandibular joint until the bone is skeletonized. The medial pterygoid muscle is stripped partially to allow for overlap of the proximal and distal segments. creation of the optical cavity.Minimally Invasive Surgery 47 Fig. the desired occlusion . This compensates for the loss of vertical height of the costochondral graft during healing [15]. plate fixation may be used as an alternative [12]. (A) Endoscopic view of right lateral ramus with completed osteotomy. In all patients. using the endoscope. and the graft is placed into the glenoid fossa. There were no long-term neurologic changes associated with the IAN or lingual or facial nerves. The patient is placed in maxillomandibular fixation. All other patients were discharged within 23 hours. small and well-concealed facial scar.16] with potential risk for facial nerve paresis. This approach results in a single. The incision. Average hospital stay was 2. The standard technique for condylectomy and costochondral graft RCU reconstruction involves preauricular and submandibular incisions [15. However. dissection. All patients demonstrated a good range of motion. Note healed incision. with maximal incisal opening returning to preoperative values by 1 year. It also significantly decreases the risk to the facial nerve and the amount of bleeding and swelling. 2. however. If there is minimal overlap of the proximal and distal segments. A retrospective evaluation of 10 patients revealed a mean operating time of 57 minutes per side exclusive of the rib harvesting procedure. and landmark identification are the same as described for the EVRO.20]. The stability of bone positioning was documented at a mean of 1.

the hyperplastic segment is marked. Saunders. to avoid . with permission. (From Kaban LB. Condylar hyperplasia For patients with mandibular asymmetry secondary to condylar hyperplasia.B. and removed. H) Postoperative patients symmetry and left open bite have been corrected. 2004. Pediatric oral and maxillofacial surgery. PA: W. (G. (D) SPECT scan showing the increased uptake of the left condyle. 2. Philadelphia. After exposing the condylar head and neck.343.) was maintained at the latest follow up (longer than 1 year). Then the normal condylar stump is smoothed and contoured. (F ) Patient underwent endoscopic high condylectomy and vertical ramus osteotomy with rigid fixation. (E) Similarly.48 Troulis et al Fig. the previously described approach to the RCU also can be used to perform a growth-arresting procedure or high condylectomy. (C) Intraoral view shows the left posterior open bite before the development of dental compensations. osteotomized. vertical pattern. Frontal (A) and submental (B) views of a 15-year-old patient with elongated left mandibular ramus indicative of condylar hyperplasia. before the development of dental compensations. This procedure is performed best early in the disease cycle. Uncompensated left condylar hyperplasia. Troulis MJ. the left condyle is hyperactive.

Mandibular retrognathism Patients with mandibular retrognathism account for approximately one third of all orthognathic surgical cases. totally buried. Sensory disturbance may range from paresthesia to anesthesia but is often transient and exhibits spontaneous resolution within 2 to 6 months in most cases. creating additional minimally invasive options for correcting skeletal deformities. a miniaturized DO device.14]. but with significantly less dissection. Up to 25% of the affected patients. Sensory disturbance of the inferior alveolar nerve occurs in a high percentage of patients. but further studies are needed to confirm this. distraction begins at a rate of 1 mm a day to the desired amount [23]. and a corticotomy is made through the third molar tooth region. In a recent retrospective evaluation of 20 consecutive patients with mandibular retrognathism. The development and refinement of endoscopic techniques for access to the maxillofacial skeleton will allow surgeons in the near future to perform complex osteotomies and place distraction devices. 2 (continued). the placement of distraction devices for mandibular advancement is achieved with an incision and dissection similar to that for BSSO. Distraction osteogenesis (DO) is a surgical technique that makes use of the body’s healing poten- tial to form new bone in response to tension forces placed across an osteotomy. Considerable research has been performed to minimize the morbidity and complications associated with this procedure. Gradual expansion of bone and associated soft tissues allows for correction of the deformity. leaving the activation mechanism exposed transmucosally. After a latency period ranging from 2 to 4 days. Skeletal expansion is tolerated better than soft tissue. and a device is placed across the cut. trauma from retraction of the nerve on the medial side of the ramus. The rate of this complication is even higher among patients over 40 years of age [13. This difference suggests that paresthesia is less frequent in DO. IAN parethesia may occur because of stretch. orthodontic decompensation and standard orthognathic surgery are the treatment of choice [Fig.7]. 2] [22]. have some persistent nerve deficit. the DO patients also recovered normal sensation in greater numbers and more quickly [18]. there are limitations associated with the sagittal split osteotomy. 36% of the BSSO versus 21% of the DO patients had dense paresthesia postoperatively. Subjectively. The third molar is removed. The device is activated gradually to produce the desired amount of bone lengthening. This is mostly a result of the anatomy of the mandible and nerve canal rather than a specific surgical complication. the need for mandibular or bimaxillary orthognathic surgery. treated with either BSSO (n = 10) or DO (n = 10). The standard operation for the correction of this deformity is BSSO. and compression or direct injury by bicortical screws used for rigid internal fixation. Patients who suffer from active condylar hyperplasia with secondary deformities of the maxilla and mandible are treated best by a combination of high condylectomy and bimaxillary orthognathic surgery. when the jaw is advanced. however. remotely activated and capable of three-dimensional movements is . especially with advancements greater than 8 mm [6. Despite these efforts. In particular. if present. The distracter is fixed across the gap between proximal and distal segments.Minimally Invasive Surgery 49 Fig. The wound is closed. Another potential limitation is skeletal relapse. risk to the inferior alveolar nerve and risk of relapse potentially are diminished as compared to acute movements [17]. Currently. In patients who are clinically stable. A corticotomy is made.

61(8 Suppl):61a–62. et al. Karp N. Padwz BL.50 Troulis et al desirable. [11] [12] [13] [14] References [1] Hunter JG. J Oral Maxillofac Surg 1999. A comparison of postoperative edema after intraoral vs. Am J Orthod 1981. Williams WB. MacIntosh RB.48(2): 140–54. Neurosensory deficit and functional impairment after sagittal ramus osteotomy: a long-term followup study. This device also could be placed endoscopically in either the maxilla or the mandible. Troulis MJ. August M. p. Troulis MJ. McNeil RW. Costochondral graft construction/reconstruction of the ramus/ condyle unit: long-term follow-up. et al. editors. [3] Kaban LB. J Oral Maxillofac Surg 1998. Kaban LB. 80:376–94.54(6): 680–3. Chen YR. [6] Lake SL. Baker K. J Oral Maxillofac Surg 2004. In: Kaban LB. et al. 899–909. Huang CS. Pediatric oral and maxillofacial surgery.56(11): 1231–5. Marchena J. endoscopic mandibular ramus osteotomy. Umeda H. Juvet LM. [10] Gersema L. J Oral Maxillofac Surg 2000. The effect of hypotensive anesthesia on blood loss and operative time during Le Fort osteotomy. [7] Bhatia N. Endoscopic mandibular osteotomy. 340–76. J Oral Maxillofac Surg 1996. Orthognathic surgery in the growing child. Kaban LB. Int J Oral Maxillofac Surg 1994. Columbus. Elsevier. Troulis MJ. . et al. April 2005. Master’s of Science Thesis.59(5):503–9. Nastri A.8:151. Endoscopic vertical ramus osteotomy: early clinical results. editors. Induced hypotensive anesthesia for adolescent orthognathic surgery patients. Br J Orthod 1985.57:1110. [4] Troulis MJ. Pediatric oral and maxillofacial surgery. It is possible that with the minimally invasive techniques described in this article. [5] Pandya NJ. Stuteville OH. Troulis MJ. Head TW. This would impact cost. Bendahan G.89(1):1–10. Temporomandibular joint reconstruction in children using costochondral grafts. 1993. Vertical wedge ostectomy in the mandibular rami for correction of prognathism. Bentley KC. Elsevier. The surgical correction of mandibular prognathism and retrognathia with consideration of genioplasty. Behbehanit I. 377–400. The combination of endoscopic techniques with a CT-based. Abukawa H. Kaban LB. et al. [2] Williams BW. treatment of skeletal defects will be performed in the future in an outpatient setting with local anesthesia and intravenous sedation. Variable affecting hospital length of stay in orthognathic surgery patients. Obwegeser H. Sackier JM. 2004. Perrott DH. Oral Surg 1957. Little RM. Kaban LB. Biomedical technology revolution: opportunities and challenges for oral and maxillofacial surgeons. Minimally invasive high tech surgery: Into the 21st century. thus combining the benefits of both techniques. Use of corticosteroids in [15] [16] [17] [18] [19] [20] [21] [22] [23] oral surgery. Sackier JM. Yan B. 2004. Denman KL.57(7):789–98. Plast Reconstr Surg 1971. and placement and activation of a semiburied distractor. three-dimensional navigation system will allow for more accurate execution of complex skeletal treatment plans. Int J Oral Maxillofac Surg 2002. J Oral Maxillofac Surg 2004. Trauner R. and availability of treatment significantly. Harvard School of Dental Medicine. Troulis MJ. Endoscopic approach to the ramus/condyle unit: clinical applications. et al. Shuster V. 3–6. Lengthening the human mandible by gradual distraction. Perrott DH. In: Hunter JG. [8] Dolman RM. editors. p.50(3): 270–7. Kaban LB. Schreiber J. p. In: Kaban LB. J Oral Maxillofac Surg 1992. Minimally Invasive Surgery.62(7):824–8. Splinter W.12:58. Donady J. Surgical mandibular advancement: a cephalometric analysis of treatment response. Plast Reconstr Surg 1992. Ohio: McGraw Hill. 62(4):460–5.58(8):834–9. J Dent Res. et al. et al. Nature of relapse after surgical mandibular advancement. J Oral Maxillofac Surg 2001. Acquired abnormalities of the temporomandibular joint. Endoscopic mandibular condylectomy and reconstruction: early clinical results. J Oral Maxillofac Surg 1998. Experience with the sagittal osteotomy of the mandibular ramus: a 13-year review. Kaban LB.31(1):1–12. Bosco D. McCarthy J. J Oral Maxillofac Surg 2003. Distraction osteogenesis versus bilateral split osteotomy for mandibular advancement.23(6):321–8. J Maxillofac Surg 1981. [9] Precious DS. patient morbidity. Ko EW.

Womens and Childrens Hospital. suggested total maxillary osteotomy using vertical incisions from the buccal approach with tun- Cranio Facial Center. the le Fort I osteotomy as mono-segment or multi-segment procedure is performed to correct congenital and acquired deformities of the jaws. Singapore 223899 c Department of Plastic Surgery. MBBS. The implementation of this technique to craniofacial and maxillofacial surgery is a recent development. however. Endoscopic approach to subcondylar mandible fractures has been established as reliable surgical method [1–4].002 facialplastic. of frontal sinus fracture. The overall complication rate of Le Fort l osteotomies varies between 6% and 9% [16. and of orbital fractures is described in the recent literature also [5–10]. The use of endoscopic techniques in the field of orthognathic surgery must be addressed separately for the sagittal split osteotomy and the Le Fort l osteotomy. Different cadaveric studies showed that the commonly performed le Fort l osteotomy carries the risk of injury to the descending palatal artery [20. MD.ch (D.1016/j.10. CH-5000 Aarau. FRCS.51 FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 14 (2006) 51–55 Endoscopic Approaches to Maxillary Orthognathic Surgery Dennis Rohner.K. the lateral nasal wall. Rohner). Vincent K. In most of the cases. a and the nasal septum can be osteotomized using different chisels. Singapore 169608.19].com . Lanigan and colleagues [23. All rights reserved. The pterygomaxillary junction. there is need to describe the commonly used technique with an open approach. Hemorrhage. Hirslanden Clinic Aarau. the osteotomy is performed using an oscillating saw. Singapore * Corresponding author. Yeow.fsc. Singapore General Hospital. and maxillary necrosis represent the majority of these complications. The downfracture of the Le Fort l plane completes this procedure after an average operation time of about 30 minutes.theclinics. DMD. Some authors reported ischemic problems because of the decreased vascularization of mostly anterior maxillary segments [18.2005. FAMSb. Through a horizontal incision of the mucosal soft tissue in the Le Fort l plane. infection. of traumatic arch injury. Switzerland K.12] have described the endoscopic vertical ramus osteotomy followed by rigid fixation for treating mandibular prognathism.rohner@hirslanden. There are only a few articles published that present endoscopic approaches to the midface and Le Fort l level with regard to orthognathic surgery [13–15].c & & Material and methods Endoscopic equipment Surgical technique Results & & & Discussion Summary References Endoscopically assisted surgery has become an essential component in many fields of surgical specialties. 100 Baskit Timah Road.*.L. Outram Road. PhDa.24]. b 1064-7406/06/$ – see front matter © 2006 Elsevier Inc. doi:10. The endoscopic repair of midfacial and malar fractures.17]. Quejada and colleagues [22] could show in an animal study that the maintenance of vascular pedicles to the palate and labiobuccal area was sufficient to support total maxillary osteotomy despite trans-section of both descending palatinal vessels. Only the ascending palatal artery and the pharyngeal branch arising from the ascending pharyngeal artery can be preserved routinely. Troulis and colleagues [11.21]. What could be the benefit of an endoscopically assisted Le Fort l osteotomy? First. E-mail address: dennis.

the lateral wall of the maxilla was exposed subperiosteally. Subperiosteal tunneling with an ele- Material and methods Endoscopic equipment The endoscope used was a 2. Germany). Fig.52 Rohner & Yeow Fig. 2. camera converter and monitor (Sony Trinitron [Sony]. This was the reason to initiate and perform a cadaveric study for the endoscopically assisted Le Fort l osteotomy. the mucosa was tunneled to the distal portion of the tuberosity and the pterygomaxillary junction using a periosteal elevator. 1. Karl Storz. Surgical technique Six fresh cadaver specimens were used to perform this study. 3. project the endoscopic image to a video display (Sony Videocassette Recorder SVT-S3050P). Dissection of the nasal floor. and it visualized the lateral buttress [Figs.7mm diameter. A second vertical incision was accomplished between the roots of the first and second molar. Nevertheless. the use of an endoscopic technique in combination with basic techniques for Le Fort l osteotomies to minimize the access and to optimize the vascularization should be the aim of future treatments. Singapore) was used to Fig. 4. Using a periosteal elevator. The scope could be inserted into the tunnel. . 2. Two of the cadavers were edentulous. Visually controlled by the scope. but possible. 30-degree angle scope. Fig. three were partial. Subperiostal dissection of the lateral buttress. Endoscope and periosteal elevator inserted to the nasal floor through the paranasal vertical incision. 4]. 3]. again starting 1 to 2 mm above the attached gingiva. light source (Coldlight Fountain. starting 1 to 2 mm above the attached gingiva and performed to the depth of the vestibule [Fig. Therefore. A video system composed of a camera. Two vertical incisions were done bilaterally between the roots of the second incisors and the canines. This was performed to the depth of the vestibule [Fig. 1]. Identified and intact descending palatal artery. a well-documented and standardized treatment as the Le Fort l osteotomy should not turn out to be a difficult endoscopicassisted treatment. and one was completely dentated. neling as technically difficult and time-consuming.

Hemorrhage—one of the major problems in the past—now is almost negligible. In experienced hands. A curved osteotome inserted through the posterior vertical incision was placed into the pterygomaxillary junction under visual control with the scope. Improved technical skills. Germany). In the first two cadaver dissections. Discussion The Le Fort l osteotomy is a standard technique for corrections of dentofacial deformities. This dissection was monitored with the scope. Tübingen. One possible solution could be injection of vasoactive agents preoperatively into the nasal and buccal mucosa to minimize bleeding during the dissection. The scope inserted into the lateral tunnel could visualize the performance of straight horizontal osteotomy cuts on both sides through the lateral antral wall. Fig. The nasal soft tissue tube was in all cadavers complete and without laceration. and length of operation [25–27]. Therefore. the Le Fort l osteotomy could be performed successfully. The osteotomized segments were fixed first at the nasal buttress using straight five-hole plates. In cadavers three to six. L-plates were used. extending from the piriform aperture to the pterygomaxillary junction using a 4 mm osteotome with a mallet [Fig. 5. positioned through the posterior vertical incision under endoscopic visualization through the lateral tunnel. which might be one advantage in clinical applications. The cadaver dissection could be accomplished between 30 and 45 minutes. Recent studies showed that the average blood loss stood in correlation to mode of anesthesia. that permanent bleeding is a major disturbance of visibility in an endoscopic treatment. With the scope inserted into the nasal cavity between nasal mucosa and floor. controlled anesthesia in relative hypotension. position of the patient. There remains. At the lateral buttress. The downfractured maxilla offered enough space to insert the scope to identify the descending palatal arteries that were . Mathys Bettlach. one could expect a further decrease in blood loss. and reduced time of surgery led to this positive development. An avulsion or interruption of the posterior descending palatal artery during downfracture of the maxillary segment is possible. One has to consider.Maxillary Orthognathic Surgery 53 intact in all tested specimens. however. Osteotomy of the lateral nasal wall using a straight osteotome can disrupt this vessel. The limited approaches resulted in more physiological wounds of the buccal mucosa. This could prolongate an endoscopically assisted surgery dramatically. Results In all six cadavers. the risk of bleeding resulting from an injury to the maxillary artery or its branches. The maxilla then was downfractured using finger pressure. maxillary or bimaxillary osteotomies. stable osteosynthesis. The use of the endoscope could visualize the position of the vessel and al- vator connected the two vertical incisions in the anterior maxilla.5 mm. a horizontal cut through the medial antral wall and nasal septum was made using the 4 mm osteotome also. The vertical direction of the incisions preserved the anastomotic network between branches of the facial artery and branches of the maxillary artery on the gingiva and buccal mucosa. however. Prototype of a reciprocal saw presenting an elongated but thinner shaft (Medicon Company. with the descending palatine artery being the most common source of bleeding. The soft tissue bridge on both buccal sides could be preserved. In all the specimens. The longitudinal branches of the facial artery within the gingival mucosa were intact. The cadaveric dissection allowed a controllable dissection of the nasal and buccal mucosa with the use of endoscopic assistance. The dissection then extended into the nasal cavity. Switzerland). lifting the nasal mucosa from the floor of the nose and from the lateral nasal walls up to the inferior turbinate. 5]. a mono-segment osteotomy including osteosynthesis lasts on an average 60 minutes. The fixation of the plates was done manually with the self-drilling screws using a screwdriver. the Le Fort procedure was performed without fixating the osteotomized segment. maxillary movements up to 5 mm in any direction could be accomplished. rigid fixation was accomplished using self-drilling screws and titanium mini-plates (Compact Stardrive 1. Osteotomy was accomplished when the blade could be palpated on the palatal aspect. The plate fixation was performed at the typical locations paranasal and at the lateral buttress under direct view through the vertical incisions on both sides.

Mueller RV. Schramm A. with help of the endoscopically assisted technique. [11] Troulis MJ. the patient presents a slight soft tissue sagging in the cheek area on both sides. [5] Shumrick KA. [13] Rohner D. Yeow V. Facial Plast Surg 2004. patients with the need of SARPE may benefit from this technique. et al. reduced bleeding. proved only in clinical use. Endoscopically assisted repair of frontal sinus fracture. less edema. Plast Reconstr Surg 1998. Complete osteotomy without downfracture but sagittal split of the maxilla is the condition for a palatal widening using a distracter. Facial Plast Surg Clin North Am 2001. Gellrich NC. disturbed visibility. Chen YR. [4] Lee C. J Craniomaxillofac Surg 2001.60(10):1142–5 [discussion 1146].29(6):360–5. Facial Plast Surg 2004.9(3):469–74. Nahlieli O.20(3):231–8. The osteotomies could be performed in this study using chisels. Plast Reconstr Surg 1999. Bradley JP. Kaban LB. Endoscopic repair of orbital blow-out fractures. Finally. J Oral Maxillofac Surg 2004. et al. Otolaryngol Head Neck Surg 2004.29(4):239–42. Endoscopic approach to orbital blowout fracture repair. [8] Strong EB. [2] Schon R. References [1] Kellman RM. The introduction of specifically adapted instruments for endoscopic approaches could improve this technique further. Siebert and colleagues [21] mentioned that in their cadaver study with open Le Fort l procedure. Extended time of surgery. and lessened edema could shorten the time of recovery. Germany.62(7):824–8. the descending palatine arteries were interrupted in all their specimens. Endoscopic vertical ramus osteotomy: early clinical results. more and more into an outpatient treatment. Followup of condylar fractures of the mandible in eight patients at 18 months after transoral endoscopicassisted open treatment. Endoscopically assisted repair of orbital floor fractures.20(3):223–30. [9] Strong EB. One reason could be the wide elevation of the periosteum at the buccal side. Lee K. Endoscopically assisted Le Fort I osteotomy to correct transverse and sagittal discrepancies of the maxilla. et al. In a first prospective study. Kim KK. and shorter time of recovery might be the advantages. 9(5):423–32. has ¨ produced a prototype of a reciprocal saw with a slim but elongated shaft that enables a tunneled osteotomy. The feasibility of this technique. Hammer B.131(5):683–95. The limited elevation and intact periosteum in the endoscopic technique prevent the soft tissue from slumping and allow for correct reattachment. Further experimental work. Tung TC. It is essential to value the advantages against the disadvantages. Plast Reconstr Surg 2001. Diaz RC. Traumatic arch injury: indications and an endoscopic method of repair. which will decrease the risk for postoperative infection and accelerate the recovery. et al.55(2):378–82. J Oral Maxillofac Surg 2003. Int J Oral Maxillofac Surg 2000. The horizontal incision applied for the open Le Fort l osteotomy extending from first molar to first molar creates a wound surface that causes postoperative swelling and edema. Endoscopic subcondylar fracture repair: functional. higher technical challenge. [3] Chen CT. J Craniofac Surg 1998. Limited approach. Endoscopic management of facial fractures. Bevis R. J Trauma 2003. the reciprocal saw was a commonly used instrumentation that allowed for fast and proper osteotomy. Chen CT.102(5):1434–43 [discussion 1444–5]. Lee C. [6] Czerwinski M. Complications of Summary Endoscopically assisted Le Fort l osteotomy could be performed in a cadaver study successfully. Limited approaches with controlled elevation and reduced lesion of the periosteum prevent swelling and edema. and more expensive costs could be disadvantageous. however. should help to improve the performance of this technique. et al. can be . [10] Chen CT. especially the handling with an irrigation/suction system. Wolford L. reduced periosteal elevation. Kessler P. The combination of endoscopy and distraction osteogenesis in the development of a canine midface advancement model. Often when the open Le Fort l technique has been performed. 20(3):239–47. [12] Troulis MJ. The use of this technique for the surgically assisted rapid palatal expansion (SARPE) could one of the main indications.108(7):2011–8 [discussion 2019]. Facial Plast Surg 2004. Minimally invasive orthognathic surgery: endoscopic vertical ramus osteotomy. [16] el Deeb M. Another important issue is the postoperative edema and swelling. Minimal access. Endoscopically assisted Le Fort l osteotomy. and radiographic outcomes. Rowe NM. et al. Lai JP. The SARPE turns. [7] Chen DJ.103(1):60–5.54 Rohner & Yeow lowed for precise osteotomy of the lateral nasal wall with controllable preservation of the vessel in this cadaver study. During the open Le Fort l procedure. only extensive clinical work could prove the feasibility and value of this technique.61(1):49–54. Medicon in Tubingen. Endoscopically assisted mandibular subcondylar fracture repair. Ryzenman JM. [15] Levine JP. There is a need to prove such new instruments to evaluate their qualities and benefits for endoscopic techniques. Endoscopic approach to subcondylar mandible fractures. Chen YR. Castano F. J Oral Maxillofac Surg 2002. [14] Wiltfang J. aesthetic.

J Oral Maxillofac Surg 1990. Chen PK. Clin Plast Surg 1989. Vacher C. The effect of hypotensive anesthesia on blood loss and operative time during Le Fort l osteotomies. Int J Oral Surg 1973. Chen YR. [27] Rohling RG. Bell WH. Gauthier A.24(1):13–7.53(8):880–2. Biro P. Vascularization of the palate in maxillary osteotomies: anatomical study.48(6):561–73. Plast Reconstr Surg 1995. Finn RA. [24] Lanigan DT. J Oral Maxillofac Surg 1995. [23] Lanigan DT. Zimmermann AP. Surg Radiol Anat 2002. Hey JH. et al.48(2): 142–56. Head TW. Bussard DA. Bentley KC. J Oral Surg 1977. . Lapp TH. McKean TW.Maxillary Orthognathic Surgery 55 [17] [18] [19] [20] [21] [22] orthognathic surgery. J Oral Maxillofac Surg 1990. et al. West RA. West RA. Average blood loss and the risk of requiring perioperative blood transfusion in 506 orthognathic surgical procedures. Wound healing associated with segmental total maxillary osteotomy.58(8):834–9 [discussion 840]. Major vascular complications of orthognathic surgery: hemorrhage associated with Le Fort I osteotomies. Lezy JP. J Oral Maxillofac Surg 2000. Bendor-Samuel R. Blood supply of the Le Fort l maxillary segment: an anatomic study. Quejada JG. Aseptic necrosis following maxillary osteotomies: report of 36 cases. Provencher RF. [26] Moenning JE. Angrigiani C. Int J Adult Orthodon Orthognath Surg 1999. 100(4):843–51. Hey JH. McCarthy JG.2(6):265–72. 35(6):453–60.44(5): 366–77. Unusual complications of the Le Fort I osteotomy. J Oral Maxillofac Surg 1986. Siebert JW.96(6):1289–96. Plast Reconstr Surg 1997.14(1):77–82.16(4): 825–40. Immediate surgical repositioning of one. Small segmental and unitooth osteotomies to correct dentoalveolar deformities. [25] Dolman RM.and two-tooth dento-osseous segments. Kawamura H. et al. Alternative methods for reduction of blood loss during elective orthognathic surgery. Burk Jr JL. et al. et al.

A aesthetics. 28–29 closed reduction. 4–5 of postoperative results. 26 scalp incisions used for.theclinics. for orbital floor fracture repair. to orbital floor fracture repair. for preoperative planning. 33–34 of maxillomandibular fixation. endoscopic repair of. 25 antrostomies. of maxillomandibular fixation. 53–54 C Caldwell Luc approach. 26–28 treatment algorithm for. 6. 5–6 pioneering trends. of frontal sinus fracture repair. 1–2 bailout procedure for. for mandibular retrognathism. 7 condyle-fossa relationship and. of condylar fractures. 22 1064-7406/06/$ – see front matter © 2006 Elsevier Inc.57 FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 14 (2006) 57–62 Index Note: Page numbers of article titles are in boldface type. 48. 1. 26–28 of frontal sinus fracture repair. intraoperative. 45–46 bone cement. 8 alloplastic implants. 13–14 of zygomatic arch fractures. All rights reserved. 6 B bailout procedure. for orbital floor fracture repair. 3–4 fracture location impact on. 50 of anterior table-frontal sinus fracture repair. 41 condylar fractures. 11. maxillary sinus. 13–14 stabilization techniques for. for frontal sinus fracture repair. 25 indications for. 19. 5 fixation technique for. 6. 13–14 buccal mucosa dissection. 1–9 as closed treatment. 32–34 with anterior table.com . 28 computed tomography of. 5–6 fracture anatomy impact on. 5 exposure step for. doi:10. 32–33 bone flaps. of frontal sinus.1016/S1064-7406(06)00016-2 facialplastic. 26–27 postoperative. 13 bone grafts. 3 open reduction and internal fixation versus. 12 middle meatal. 25–29 compressive forces and. 1–2 computed tomography (CT) scan. 26–27 photographs of. 11 camouflage technique. endoscopic repair of. 3 indications for. 3 fracture comminution impact on. 7 bilateral split osteotomy (BSSO). 49 vertical ramus osteotomy versus. 29 Medpor sheeting implant for. 26. 39. in mandibular orthognathic surgery. 28–29 general requirements for. postoperative. for maxillomandibular fixation. 28–29 fracture camouflage technique. for medial orbital wall fracture repair. 26–28 discussion on. 2 operative technique for. 4 equipment for. 2 postoperative regime for. 28 technique for. 27 preoperative. 25–26. for orbital floor fracture repair. 14–15 anterior table fractures. hydroxyapatite. 4 fracture displacement impact on. 7–8 of orbital floor fracture repair. for endoscopic orthognathic surgery.

48–49 condylar resorption. 49–50 historical perspectives of. 7–8 summary of. 28 technique for. for mandibular retrognathism. 32 endoscopic approach. 7 condyle-fossa relationship and. 28 computed tomography of. mandibular. 6–8 demographics. 45–50 advantages of. in maxillomandibular fixation. 6–7 operative details. of zygomatic arch fractures. 46 for prognathism (asymmetry). intraoperative. 51–55 advantages of. 46 with distraction osteogenesis. 46 costochondral grafts for. 40 optical cavity requirement for use of. 6–8 demographics. 45–46 with condylectomy. 26–28 treatment algorithm for. 1. 47–48 for mandibular conditions. 4 condylectomy. for mandibular conditions. 47–48 condyle-fossa relationship. 26–27 postoperative. for condylar hyperplasia. 4–5 reduction step for. 25 . for condylar hyperplasia. of condylar fractures. 46–47 current application/usage trends. endoscopic. 54 endoscopic repair. 26. 26 scalp incisions used for. 46–47 midface applications of. idiopathic. postoperative. 8 condylar hyperplasia. 52 for zygomatic arch fracture repair. 51–52 mandibular. to orthognathic surgery. 6. 52–53 surgically assisted rapid palatal expansion and. 6 preoperative planning for. 26–27 photographs of. 25 indications for. 26–28 discussion on. 47–48 for mandibular conditions. 25–26. 53 surgical technique for. 52 for Le Fort I osteotomy. 48–49 for idiopathic condylar resorption. 5 fixation technique for. 25–29 compressive forces and. 2 postoperative regime for. 31–32 surgical specialty impact of. 46. 14 for orthognathic surgery. 28–29 fracture camouflage technique. 3–5 radiographic imaging in. endoscopic. 5 exposure step for. 6–7 operative details. 46 as minimally invasive. 5 regional anatomy and. 38–39 distraction osteogenesis (DO). 5 regional anatomy and. 8 of frontal sinus-anterior table fractures. 49–50 with vertical ramus osteotomy. 5 results of. 53–54 discussion on. 1–2 bailout procedure for. 5–6 fracture anatomy impact on. 45–50 (See also mandibular orthognathic surgery) endoscopic approach to. 54 endoscope(s). endoscopic condylectomy for. 4 fracture displacement impact on. 49–50 E edema. 4–5 reduction step for. 5 results of. 2–3 repair sequence for. 3–5 radiographic imaging in. 1–9 as closed treatment. 48–49 for idiopathic condylar resorption. 7–8 summary of. 27 preoperative. 45–50 (See also endoscopic approach) displacement patterns. 5–6 pioneering trends. 3 fracture comminution impact on. 46 costochondral grafting. 29 Medpor sheeting implant for. for maxillomandibular fixation. endoscopic condylectomy for. 31 various. 46–47 D deformity(ies). 46–47 for retrognathism. 4 equipment for. 3 indications for. 3 open reduction and internal fixation versus. 3–4 fracture location impact on. 28–29 general requirements for. 45 morbidity minimization with.58 Index preoperative planning for. 5 for orbital floor fracture repair. 53–54 equipment for. 2 operative technique for. 51 results of. 2–3 repair sequence for. 45 decreased morbidity with. with Le Fort I osteotomy.

19. 39–42 medial arch displacement and. 28–29 general requirements for. 15 of orbital wall fractures. medial. 17 bone grafts for. 11–12. 1–9 (See also condylar fractures) endoscopic repair of. 18 surgical techniques for. 28 technique for. 14–15 general requirements of. 19–22 transcaruncular technique. indirect approach to. 26–27 postoperative. 11–16 Caldwell Luc approach versus. 45–50 (See also endoscopic approach) medial orbital wall. in anterior table-frontal sinus fracture repair. 26 scalp incisions used for. 1–9 (See also maxillomandibular fixation (MMF)) frontal sinus. 32–34 fracture(s). various. 51–55 (See also orthognathic surgery) orbital floor. 13–14 discussion on. 22 indications for. 11. 28–29 equipment for. 22 direct vs. 14 trap door. 37. fractures from (See fracture(s)) forces. intraoperative. 31–32 external techniques versus. 26–27 optical cavity requirement for. 53–54 facial trauma. 1–9 (See also endoscopic repair) maxillomandibular fixation for. as fracture factor (See external forces) forehead lifting. 26–28 treatment algorithm for. 14 transnasal approach to. anterior table. 18–21 trend summary. 22 complications of. 41 Le Fort III level. conversion to open approach. 40 sequencing for. 38–39 lateral displacement and. 32 unsuccessful. in endoscopic orthognathic surgery. 11 indications for. 15 orbitozygomatic injuries and. 41 disadvantages of. 28 in zygomatic arch fracture patterns. 41–42 indications for. orthognathic surgery for. 40. 14 Le Fort-type injuries and. 22 of zygomatic arch fractures. 43 discussion on. 25–29 mandibular. 17–23 (See also endoscopic repair) midface. compressive. 45–50 (See also mandibular orthognathic surgery) endoscopic approach to. 33–34 of orbital floor fractures. 40–42 telescoping pattern considerations. 38–39 F facial artery. 42–43 equipment for. 40 Le Fort II level. 11. 46–47 external forces. 42 computed tomography of. 27 preoperative. 39–40 surgical technique for. 31–32 patient selection for. 31–35 (See also endoscopic repair) with anterior table. 26. 40. 37–43 advantages of. endoscopic technique for. 19–20. 31–32 endoscopic vertical ramus osteotomy (EVRO). 17–23 biomechanical studies of. 37. 29 Medpor sheeting implant for. 14 transantral approach to. 26–28. 17–18. 20–22 miscellaneous approaches versus. 11–16 (See also orbital floor fractures) . 11–13 trend summary. 42 case presentations of. 12–14 traditional techniques versus. 43 fixation for. 25 indications for. 40 exposure incisions for.Index 59 of frontal sinus fractures. 18–19 injury mechanisms. 11 complications of. 17 intranasal technique. 28 computed tomography of. 42 endoscopic sheaths. 25 trends in. 17–23 (See also orbital wall fractures) endoscopic approach to. 38 with complex zygoma injury. 14–15 technique for. 25–29 (See also anterior table fractures) endoscopic repair of. 11–13. 43 reduction for. 18. 31–35 (See also frontal sinus fractures) endoscopic repair of. 25–26. 31–35 camouflage technique for. 31 fracture camouflage technique. 38–39 Le Fort I level. 15 computed tomography of. 38–39 pioneering trends. 11. 17–18 preoperative evaluation for. 39. 39 injury patterns and. 37–38. 38 arch anatomy role in. 25–29 condylar. 33–34 discussion on. 17–18 implants for. 32–34 compressive forces and. 33–34 photographs of. 14–15 medial blow out.

52–54 results of. for mandibular conditions. 20–22 intraoral vertical ramus osteotomy (IVRO). 33–34 trends in. 12 L lateral buttress dissection. 53–54 equipment for. 32–34 computed tomography of. 53 of condylar fractures. 25 indications for. 26 scalp incisions used for. 33–34 with anterior table. 46 with distraction osteogenesis. with Le Fort I osteotomy. 45 with condylectomy. advantages of. 46–47 for retrognathism. endoscopic repair of. endoscopic repair of. 34–33 . alloplastic. for anterior table-frontal sinus fracture repair. 25–29 compressive forces and. 48–49 for idiopathic condylar resorption. 46 K Kerrison rongeur. 45 decreased morbidity with. 26–27 photographs of. 31–32 external techniques versus. 28–29 fracture camouflage technique. 49 intranasal approach. 52–53 Le Fort I osteotomy. in endoscopic orthognathic surgery. for orbital floor fracture repair. 14–15 Medpor sheeting. 46–47 H hemorrhage. 22 costochondral. for condylar hyperplasia. 53–54 applications of. 37. 22 Vicryl mesh. 14–15 G grafts and grafting. for orbital floor fracture repair. 13–14 stabilization techniques for. 46–47 Greenberg retractor. to medial orbital wall fracture repair. 37–43 (See also zygomatic arch fractures) endoscopic repair of. 12 M mandibular orthognathic surgery. 32 unsuccessful. 51–52 discussion on. 18. 26–27 postoperative. 33–34 equipment for. 46. conversion to open approach. for frontal sinus fracture repair. 25–26. bone. endoscopic approach to. 52–53 surgically assisted rapid palatal expansion and. 39–42 Le Fort-type injuries. 53 I implant(s). with anterior table. 47–48 for mandibular conditions. 28 technique for. 28 with failed endoscopic approach. 52 palatal artery cautions. 26–28 treatment algorithm for. See also specific fracture endoscopic repair of. for orbital floor fracture repair. 40 Le Fort II zygomatic arch fractures. for orbital floor fracture repair. 46–47. endoscopic. 46 for prognathism (asymmetry). 53 surgical technique for. 19–20.60 Index endoscopic repair of. 46 as minimally invasive. for medial orbital wall fracture repair. 28 computed tomography of. 2 of frontal sinus fractures. 26–28 discussion on. 13 Freer elevator. 46 costochondral grafts for. 54 Le Fort I zygomatic arch fractures. 26–27 synthetic. 28–29 general requirements for. 31–35 camouflage technique for. 19. 49–50 with vertical ramus osteotomy. 31–32 patient selection for. for orbital floor fracture repair. for endoscopic orthognathic surgery. endoscopic repair of. 13 frontal sinus fractures. 26. intraoperative. 46–47 current application/usage trends. 33–34 of maxillomandibular injuries. endoscopic repair of. 27 preoperative. 25 internal fixation. 41 Le Fort III zygomatic arch fractures. for medial orbital wall fracture repair. 45–50 advantages of. 49–50 historical perspectives of. 31 optical cavity requirement for. 29 Medpor sheeting implant for. 37–43 (See also endoscopic repair) Fraser tip suction catheter. 11–16 (See also endoscopic repair) zygomatic arch. endoscopic approach to.

11–13. 11–16 Caldwell Luc approach versus. 2 postoperative regime for. 46 as minimally invasive. 17–18 preoperative evaluation for. bailout procedure for. 19–22 transcaruncular technique. 11. 46 with distraction osteogenesis. 17–23 biomechanical studies of. medial. 5 results of. 51–55 (See also orthognathic surgery) minimally invasive surgery (MIS). 13–14 discussion on. 15 orbitozygomatic injuries and. endoscopic repair) morbidity. 4–5 reduction step for. 51–55 advantages of. 46–47 mandibular ramus/condyle unit (RCU). endoscopic orthognathic correction of. 7–8 summary of. 28 of frontal sinus fractures. 11. 14–15 general requirements of. 5 endoscopy indications. 6–8 demographics. 4 fracture displacement impact on. 48–49 for idiopathic condylar resorption. 47–48 for mandibular conditions. 14 transantral approach to. 14 lateral blow out. 46. 49–50 historical perspectives of. endoscopic orthognathic correction of. 2 operative technique for. 3–4 fracture location impact on. 18 surgical techniques for. 12 Le Fort-type injuries and. with condylar fractures. 52 O open reduction and internal fixation. of condylar fractures. 20–22 miscellaneous approaches versus. 15 computed tomography of. 22 orbitozygomatic fractures. 45 with condylectomy. 3 exposure step for. 7 condyle-fossa relationship and. 31 with mandibular orthognathic surgery. 12–14 traditional techniques versus. 11 complications of. 5 fixation technique for. 8 Medpor sheeting implants. 11–12. 1. 53–54 discussion on. for condylar hyperplasia. 2 . endoscopic repair of. 46 mucocele. endoscopic repair of. 46 costochondral grafts for. 18–21 trend summary. 3–5 radiographic imaging in. 49–50 maxillomandibular fixation (MMF). 17 bone grafts for. 14–15 technique for. 18–19 injury mechanisms. 28 with failed endoscopic approach. endoscopic repair of.Index 61 mandibular prognathism (asymmetry). 17–18 implants for. 15 orbital wall fractures. 22 indications for. 46–47 for retrognathism. 2–3 repair sequence for. 45 decreased morbidity with. 11–13 trend summary. 46. 46 (See also mandibular orthognathic surgery) mandibular retrognathism. 45 for facial injuries (See endoscopic approach. 14–15 orthognathic surgery. indirect approach to. for condylar fractures. 14–15 medial blow out. endoscopic approach to. 1–2 with frontal sinus fractures. 18. with anterior table-frontal sinus fracture repair. 51–52 mandibular. 14 trap door. 53–54 equipment for. 52 for Le Fort I osteotomy. 22 complications of. 6. 22 direct vs. endoscopic approach to. with anterior table. 46–47 N nasal floor dissection. for anterior table-frontal sinus fracture repair. 17 intranasal technique. 45–50 advantages of. 5–6 fracture anatomy impact on. 19. 26–27 midface orthognathic surgery. 11. and closed treatment. 46 for prognathism (asymmetry). 19–20. 3 fracture comminution impact on. 14 transnasal approach to. endoscopic approach to. 6–7 operative details. for endoscopic orthognathic surgery. 3 open reduction and internal fixation versus. 5–6 pioneering trends. 11 indications for. 49–50 with vertical ramus osteotomy. 46–47 current application/usage trends. 5 regional anatomy and. 17–18. 4 endoscopic equipment for. 6 preoperative planning for. 33–34 orbital floor fractures.

complications of. 54 synthetic implants. 40 sequencing for. 4–5 of postoperative results. 51 palatal artery cautions. 42 case presentations of. 39. 19–20. 46 . 38–39 Le Fort I level. 39–42 pioneering trends. endoscopic orthognathic correction of. bilateral split osteotomy versus. 40. 7–8 reciprocal saw. 37–43 advantages of. 38 temporomandibular joint conditions. to medial orbital wall fractures. 42–43 displacement patterns and. for endoscopic orthognathic surgery. for endoscopic orthognathic surgery. of maxillomandibular fixation. 41 Le Fort III level. 45–46 endoscopic. for frontal sinus fracture repair. 32–34 surgically assisted rapid palatal expansion (SARPE). 40 Le Fort II level. 40 exposure incisions for. 14 trauma. lateral. 52–54 periosteal elevator. 8 Steinmann pins. 39–40 surgical technique for. to orbital floor fracture repair. 14 transcaruncular approach. 38 with complex zygoma injury.62 Index midface applications of. for frontal sinus fracture repair. 41 disadvantages of. for endoscopic orthognathic surgery. 38–39 equipment for. of zygomatic arch fractures. for orbital floor fracture repair. 43 reduction for. endoscopic. 34–33 R radiography. 37. in endoscopic orthognathic surgery. 53 for orbital floor fracture repair. endoscopic. fractures from (See fracture(s)) P palatal artery. 43 fixation for. 40. in endoscopic orthognathic surgery. 53 Z zygomatic arch fractures. 42 computed tomography of. 22 T telescoping pattern. 52–54 results of. endoscopic. 14 V vertical ramus osteotomy. with maxillomandibular fixation. 52–53 surgically assisted rapid palatal expansion and. 40–42 telescoping pattern of. 43 discussion on. 53 surgical technique for. facial. 39 injury patterns and. 46 Vicryl mesh implants. for preoperative planning. 46–47 intraoral. 38–39 medial arch. 37. 18–21 transnasal approach. 52 pulse test. endoscopic repair of. to orbital floor fracture repair. 41–42 indications for. 42 S soft tissue. for medial orbital wall fracture repair. 12 transantral approach. 54 osteotome. 38 arch anatomy role in. 37–38.

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