Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_816_Библиотеки_им_академика_М_И_Перельмана.pdf
24 Midface Trauma Reconstruction
329
Studies have shown possible alopecia with the use of hemostatic clips. After hemostasis, the incision is carried down to the supraperiosteal plane. We routinely elevate
a pericranial ap as part of our dissection. If not utilized during the case, the pericranial ap can be sutured back in place for future use. We often raise the coronal
ap and pericranial ap as a single unit after making the lateral and inferior cuts of
the pericranial ap. The combo ap is then raised from posterior to anterior in the
subperiosteal plane as dissection is carried anteriorly until the superior orbital rims
are encountered. Care should be taken to protect the supraorbital and supratrochlear
neurovascular units. Dissection can be carried anteriorly along the midline down
over the root of the nose. The superior aspects of the orbits can also be entered with
this approach if the supraorbital complex enters the area through a foramen; a chisel
and blunt dissection may be required to free them from the foramen and elevate the
soft tissue unit of the coronal ap.
After carrying the incision down to the supraperiosteal plane, the surgeon should
begin the lateral component of the coronal ap just supercial to the temporalis
fascia and continue towards the level of the zygomatic arch. Soft tissue elevation
proceeds anteriorly and inferiorly along this plane until the supercial temporal fat
pad is seen through the supercial layer of the deep temporal fascia. The fascia is
transected at a 45-degree angle (in the same direction that the temporal branch of the
facial nerve runs) to enter the fat pad. The dissection is carried antero-inferiorly to
the arch by staying immediately deep to the supercial layer of the temporalis fascia. Staying in this plane will protect the temporal branch of the facial nerve. Care
is given to limit trauma to the fat pad itself, thereby limiting post-operative temporal
hallowing, which is caused by devascularization of the fat pad. If the reconstruction
necessitates the maximum midface exposure, the lateral subperiosteal dissection
can be continued from the lateral orbital rim downward over the body of the zygoma.
This exposure allows for direct reduction of the lateral half of the orbital oor. The
exposure necessary to reach the upper midface, medial orbital wall, infratemporal
fossa, temporomandibular joint, and mandibular condyle/ramus is covered in other
chapters of this text.
Site-Specific Surgical Techniques
1. Isolated ZMC
2. Le Fort 1
3. Le Fort II
Zygomaticomaxillary Complex Fractures
While there are always multiple fractures with any zygomatic complex fractures, a
signicant portion does not require multiple approaches. Often, depending on the
mechanism of injury, the force applied to the complex causes it to rotate medially,
posteriorly, and inferiorly without vertical separation of the ZF suture line or
330
D. A. Rengifo et al.
signicant disruption of the orbital oor. Often, this can be determined preoperatively through imaging and physical exam. In simple, straightforward injuries, the
appropriate reduction can often be achieved by simply disimpacting the complex
and reducing it by rotating the zygomatic complex anteriorly and laterally through
a transoral approach. In many cases, once the complex is reduced, it will not fall
back to its injury position. We routinely utilize an elevator for reduction. After elevation of the soft tissue envelope through a vestibular incision, the elevator is passed
through the comminuted bone of the anterior maxillary sinus into the sinus itself.
The elevator edge is then placed against the most anterior lateral edge of the maxillary sinus. Then, either lifting the elevator or cantilevering it off the nonfractured
portion of the maxilla, the ZMC complex can be rotated back into place. In these
cases, often, a single reconstructive plate placed along the ZM suture line is enough
to xate the fracture.
After reduction and xation, it is important to conrm that the ZF suture line is
still in correct alignment/reduction. This can be assessed by digital palpation along
the lateral orbital rim. If uncertain, then intraoperative imaging or direct assessment
of the suture line through a lateral blepharoplasty incision is warranted. The other
area that must be assessed is the orbital oor. It is possible that during the reduction
of the ZMC complex, the orbital oor fracture has shifted and is now of a signicant
size that requires treatment or shift, causing the inferior rectus muscle of the orbit to
become entrapped. We have found that it is possible to assess the quality of the
orbital oor after reduction by placing an elevator within the maxillary sinus along
the orbital oor and then gently pushing on the globe. The surgeon can feel if there
is signicant displacement of orbital contents. Similarly, an angled endoscope can
be passed into the sinus for direct observation of the oor. Once again, if there is any
doubt, imaging or direct surgical assessment and treatment may be performed.
Finally, a forced duction test should be performed at the conclusion of any ZMC
case to rule out entrapment of the inferior rectus muscle.
In cases that are more complex with signicant disruption of the ZMC complex,
a single transoral approach will not sufce. These cases typically require multiple
approaches, including lateral upper blepharoplasty to assess the ZF and ZS suture
lines and a transconjunctival approach to examine and treat the orbital oor and rim.
We have found in complex cases, it is best to utilize multiple approaches early in the
surgery to identify fractures, assess their reduction, and, when needed, xate. When
reducing the ZMC in multiple vectors at the same time, it is not uncommon to correctly reduce and xate one fracture line while misaligning the other.
Once the soft tissue is elevated and the fractures are exposed, the surgeon needs
to determine the best manner in which to reduce the fracture. As with simple ZMC
fractures, reduction with periosteal elevator or bone hook, may be enough to reduce
the complex and hold it place. In other cases, the amount of malar deformity is too
substantial, or adequate torque to reduce the fracture cannot be generated by the use
of an elevator or hook. In such cases, a Carroll-Girard screw can be used. The instrument can either be placed transcutaneous through a small stab incision through the
24 Midface Trauma Reconstruction
331
overlying skin or the soft tissue can be elevated and the instrument placed through
the trans vestibular incision. When utilizing a Carroll-Girard screw, it is important
to place it in an area of adequate bone stock so that it does not become dislodged
when manipulating the malar complex. Once placed, this instrument cannot be
removed and replaced multiple times. A disadvantage of the Carroll-Girard screw is
that its overall size and placement can often make it difcult to observe the skeleton
directly behind the instrument. This can also make the placement of screws and
plates markedly more difcult. To circumvent these drawbacks, we often utilize the
placement of a longer midface or mandible recon screw in the same location as we
would normally place the Carroll-Girard. The midface screw is not completely
tightened, with a signicant portion of the screw left exposed above the bone edge.
A clamp or hemostat can then be used to grab onto the screw, and the new construct
can be manipulated like the Carroll-Girard. The hemostat can also be removed or
replaced depending on necessity.
It is not unusual in complex cases to nd that the fractures remain mobile after
reduction, making it difcult to maintain ZMC reduction in all directions while plating. As each fracture line is xated, the amount of mobility in the other directions
decreases, thereby making each subsequent reduction easier to hold in place.
Unfortunately, it is quite easy to plate one fracture in appropriate reduction, only to
nd that the other fracture lines have shifted out of correct reduction, and that the
plate that was placed, will not allow the rest of the complex to be reduced accurately. Therefore, the order of xation that that the surgeon chooses has its own
benets and limitations. While each surgeon has an order that they prefer to xate
fractures, we nd that with a mobile ZMC, we routinely xate the ZF fracture rst.
By doing this, we have corrected the vertical height of the midface. Fixation of the
ZF suture line rst still allows manipulation of the ZMC in some directions. The
medial portion of the complex can be rotated in the superior-inferior direction as
well as in the anterior-posterior direction. This limited mobility lets us rotate the
ZMC complex and reset the zygomatico-sphenoid (ZS) suture line correctly, thereby
correcting the orbital volume. We do not nd that the ZS suture line routinely needs
xation, though some surgeons prefer to place a small plate there. With the persistent mobility allowed by ZF xation, we can also correctly reduce the infraorbital
(IO) rim, which is the fracture line we xate second. Finally, after conrming that
the ZF, ZS, and IO lines are reduced correctly, we xate the zygomatic maxillary
(ZM) suture line. Of all the fracture lines, it is the easiest to access and plate. Also,
slight malposition of the ZM has a limited impact on malar projection and overall
appearance. We rarely nd that the zygomatic arch (ZA) requires plating unless
there is a signicant palpable step-off noted on palpation. After xation of the ZF,
IO and ZM fractures, we then treat the orbital oor fracture if necessary. Occasionally,
when there is signicant comminution of the infraorbital rim along with an orbital
oor fracture, we will next place an orbital oor plate that extends over the rim to
treat both the oor and IO areas simultaneously.
332
D. A. Rengifo et al.
Le Fort IFractures
Le Fort I fracture treatment aims to restore normal occlusion and vertical height to
the midface. Treatment begins by conrming occlusion. If there is no malocclusion,
then the patient is placed in maxilla-mandibular xation (MMF) prior to performing
a vestibular incision. This is done so that the reduction of the midface fractures does
not alter the patient’s occlusion. When the patient does not easily go back into
occlusion, reduction of the maxilla may be required. Often, this can be done with a
simple periosteal elevator after exposure of the fracture lines. In cases where greater
traumatic forces were applied to the maxilla, Rowe disimpaction forceps may be
required to mobilize the maxilla prior to MMF utilization. After occlusion is reestablished with MMF and the fractures are exposed, stabilization is required. While
all four vertical buttresses can be xated, a minimum of two are required so that the
maxilla does not shift or rotate when the patient chews. When placing midface
plates, at least two screws must be placed on either side of the fracture line. L- or
T-shaped plates are very useful in this area because they allow the placement of
enough screws along the inferior aspect of the fracture while simultaneously avoiding the tooth roots. If there is bone loss within the vertical buttress, bone grafts
should be used. Bridging gaps with plate xation alone may lead to an alteration of
the achieved occlusion or plate exposure. Generally, if bone grafting is not required
and when reduction is rigid, the surgeon may elect to discontinue MMF at the end
of the case.
Le Fort II Fractures
Le Fort II fracture reconstruction begins with the sequence as a Le Fort I fracture;
however, the surgeon may need to expose the orbital rim and oor. The rim may be
repaired with low-prole miniplates, and bone loss can be addressed via bone grafting to avoid cosmetic deformities. The reconstruction of the orbital oor is further
explained in the orbital trauma chapter of this text. In cases where there are bilateral
midface fractures, we once again address occlusion rst. From there, treatment
begins on the side of the face that is less comminuted and, therefore, easier to correctly reduce and xate fracture. As variables become reestablished, they can be
used to help conrm the correct reduction on the more comminuted side. Minimizing
the number of variables gives the best chance of a successful outcome.
Pan Facial Fractures
Determining the order of reduction and xation varies greatly from case to case in
pan facial fractures. There is no denitive order of reconstruction. At best, general
guidelines can be given. Function is the main concern, and therefore, reestablishing
24 Midface Trauma Reconstruction
333
occlusion when possible is paramount. From there, the literature describes various
directional reconstructions, such as a bottom-to-top or inside-to-out reconstruction,
for example. As with bilateral midface fractures, after establishing occlusion, we
start with the areas of least comminution and move on to progressively more complex areas. Experience also teaches us to monitor for common mistakes such as
over-widening of the lateral face. This can be caused by something as seemingly
innocuous as overly curving the zygomatic arches, which, despite their name, are
mostly a straight structure in the anterior-posterior direction. Beyond just falling
back on previous experience, the use of modern technology has made these exceptionally tough cases easier. Liberal utilization of intraoperative navigation and
imaging allows the surgical team to assess their work in real time and adjust quickly.
Ever increasing ease of use and application of surgical planning software with
patient specic hardware is quickly taking the guesswork out of these cases and
optimizing outcomes.
Pediatric Midface Fracture Management
Midface fractures in the pediatric population, while uncommon, are often the result
of blunt trauma from sports injuries, falls, transportation incidents, and assault and
tend to occur in the older pediatric population. The pediatric facial bones have more
elasticity and cartilage framework when compared to the adult facial skeleton. Also,
late aeration of the maxillary sinus, along with unerupted teeth in younger children,
act as buttresses and limit displaced fracture occurrence. The majority of ZMC fractures occur with limited displacement and are best treated with observation and a
soft diet. Fractures of the zygomatic complex with signicant displacement, comminution or diplopia should be treated with open reduction and internal xation.
Maxillary fractures with malocclusion are often best managed with a short course
of MMF with elastics for no longer than 1–2weeks. If the ZMC is signicantly
displaced, xation with miniplates should be performed. Great care should be taken
to avoid placing screws into the undescended tooth buds. There continues to be a
lack of consensus regarding internal xation plate management because of the controversial risk of halting facial growth. Some surgeons will elect to remove plates
around 3–6months after xation, while others do not believe permanent plates signicantly impact facial growth. Unfortunately, there is no signicant evidence to
sway the decision towards a standard of care. Literature does suggest for consideration of plate removal in the setting of highly complex and involved facial fractures,
younger patients, and the presence of facial deformity. Absorbable plates are another
option; however, there is no signicant evidence to prove their superiority over nonabsorbable plating. There is also a learning curve to their correct placement; therefore, they have not become the standard of care. Overall, a thorough discussion with
the parents or guardians should include the potential risks and benets of surgical
management, absorbable and nonabsorbable plates, as well as temporary and permanent plating.
334
D. A. Rengifo et al.
Complications
Complications of midface trauma may result from sequelae of injury, delayed therapy, infection, and improper surgical technique. It is important to keep in mind that
the severity of injury and incidence of complications have a direct relationship.
Severely comminuted fractures may often exhibit associated bone loss, which further complicates appropriate xation. The vast vascular supply of the midface aids
in decreased risk of nonunion and infection, and the feared complication of osteomyelitis is thankfully rarely encountered due to this vascularity.
While nasal bone fractures are covered in more detail in other chapters of this
text, it should be noted that they are the most common fractures of the midface.
Minimal displacement of the nasal bones and septum may result in epistaxis, septal
hematoma, cosmetic deformity, and nasal obstruction. Proper initial management
and subsequent septo-rhinoplasty are important to address these risks.
Postoperatively, residual deformities and continual nasal obstruction are the most
common complications. Sufcient time to heal after initial repair is important to
keep in mind, even with suboptimal results. This time allows edema and inammation, making for a proper facial analysis to consider revision.
A full review of orbital fractures and associated complications is beyond the
scope of this chapter; however, it is important to briey cover the basics of these
complications. When orbital fractures are included in ZMC injury, symptoms may
include periorbital bruising, swelling, diplopia, enophthalmos, and hypoesthesia of
the inferior orbital (V2) nerve. Entrapment of the inferior rectus can also limit extraocular movement, while traumatic palsy of CN III can present in a similar or more
severe fashion. Oculocardiac reex is the one true emergency complication of
orbital fractures and should be addressed in a timely fashion. Postoperative complications include inferior orbital nerve paresthesia, as well as diplopia and enophthalmos due to malposition of the reconstructed zygoma. Persistent diplopia may,
unfortunately, be a relatively common complication, with literature noting up to 7%
incidence postoperatively. Long-term enophthalmos may be due to perioperative
edema and orbital fat atrophy.
Complications of ZMC fractures can include loss of facial lateral projection,
trismus due to impingement of depressed zygomatic arch on the coronoid process
or direct compression of the temporalis by the zygomatic arch. As discussed previously, several orbital complications may present as sequelae of ZMC injury.
Common complication from improperly repaired ZMC fractures include facial
asymmetry, poor aesthetics, and cheek ptosis. The subciliary approach can lead to
persistent lower lid edema. Likewise, ectropion may also present as a complication
of the transconjunctival approach. Daily massage of the area postoperatively may
result in the spontaneous resolution of these complications.
Le Fort I fractures result in mobile palatomaxillary segment, mucosal lacerations
and palatal ecchymosis. Le Fort II fractures often result in infraorbital nerve paresthesia, with these patients exhibiting reduced sensitivity in the frontal teeth, upper
lip, cheeks, and skin of the lateral nose. Le Fort III fractures may exhibit epistaxis,
massive swelling of oral mucosa and orbit, cerebrospinal uid rhinorrhea. All Le
24 Midface Trauma Reconstruction
335
Fort fractures may additionally present in malocclusion after reconstruction despite
the surgeon’s best attempts. This may be caused by early mobilization and subsequent malunion. This complication may be addressed by orthognathic reconstruction at a later time.
References
1. Motamedi MH, Dadgar E, Ebrahimi A, Shirani G, Haghighat A, Jamalpour MR. Pattern
of maxillofacial fractures: a 5-year analysis of 8,818 patients. J Trauma Acute Care Surg.
2014;77(4):630–4. https://doi.org/10.1097/TA.0000000000000369. PMID: 25250606.
2. Nahum AM.The biomechanics of maxillofacial trauma. Clin Plast Surg. 1975;2:59.
3. Le Fort R.Etude expérimentale sur les fractures de la mâchoire inférieure. I, II, III.Rev Chir
Paris. 1901;23:208.
4. Jackson IT.Classication and treatment of orbitozygomatic and orbitoethmoid fractures. The
place of bone grafting and plate xation. Clin Plast Surg. 1989;16(1):77–91. PMID: 2647349.
Frontal Sinus Reconstruction
25
LauraPetrauskas, EliGordin, andDavidChan
Introduction
Disruption of the frontal sinus is usually the result of oncologic ablative surgery,
blunt or penetrating trauma, and chronic infection [1, 2]. Frontal sinus fractures
account for 5–15% of facial fractures. Approximately two-thirds of frontal sinus
fractures involve both the anterior and posterior table, while isolated anterior table
fractures occur in one-third of cases, and isolated posterior table fractures are the
least common (7–11%) [3]. The frontal sinuses may function as a “crumple zone”
for protection of the cranial vault [4, 5]. Neoplasms affecting the frontal sinus are
rare, with osteomas being the most common, and are present in up to 3% of all CT
scans [6]. While inverted papillomas are benign and usually originate from the lateral nasal wall, they can rarely present in the frontal sinus and carry a 5–15% risk of
malignant transformation. Malignant neoplasms of the frontal sinus are rare and
only account for 2% of all sinonasal malignancies [7].
Frontal sinus injury, whether iatrogenic or traumatic, can lead to signicant morbidity and mortality if not properly diagnosed and repaired. Obstruction of the frontal sinus outow tract impairs mucociliary ow, leading to mucocele formation in
up to 33% of anterior table fractures and 60% of combined anterior/posterior table
fractures. Depressed anterior table fractures may lead to cosmetic deformity of the
forehead, while posterior table fractures may result in cerebrospinal uid leak and
L. Petrauskas · D. Chan (*)
Section of Otolaryngology—Head and Neck Surgery, University of Chicago,
Chicago, IL, USA
e-mail: Laura.petrauskas@vumc.org
E. Gordin
Department of Otolaryngology—Head and Neck Surgery, UT Southwestern Medical Center,
Dallas, TX, USA
e-mail: Eli.Gordin@UTSouthwestern.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
F. Sokoya, A. G. Vincent (eds.), Manual of Head and Neck Reconstruction,
https://doi.org/10.1007/978-3-031-65999-7_25
337
338
intracranial infection (e.g. meningitis, extra or intradural abscess, osteomyelitis) [2, 3].
Therefore, the goals of frontal sinus reconstruction, regardless of cause, are to (1)
create a safe sinus by reopening or eliminating the frontal sinus drainage system, (2)
separate the sterile intracranial compartment from the contaminated sinonasal
space, (3) create a watertight dural seal if there is a CSF leak, (4) provide an acceptable cosmetic outcome, and (5) minimize long-term complications. Failure to properly address the frontal sinus may result in chronic sinusitis, forehead deformity,
mucocele, mucopyocele, meningitis, or brain abscess [8].
L. Petrauskas et al.
Anatomy
The frontal sinus is absent at birth; by 2years, the anterior ethmoid cells invade the
frontal bone and continue to develop to adult size by the age of 15 [9]. The frontal
sinuses usually take the shape of a pyramid. The borders of the frontal sinus are as
follows: anteriorly, the frontal sinus is bounded by the nasofrontal suture line and
extends to below the frontal protuberance. Laterally, it extends to the angular prominence of the frontal bones. Inferiorly, it forms the roof of the orbit. The superior
border of the frontal sinus is the frontal bone [10]. The anterior table (2–12mm) is
usually signicantly thicker than the posterior (0.1–4mm), which protects the anterior cranial fossa [4]. The shape of the frontal sinus is variable and, in some cases,
may be unilateral (10%), rudimentary (5%), or absent (4%) [11]. The frontal sinus
outow tract is traditionally described as an hourglass shape with the infundibulum
superiorly. The ostium is usually the narrowest portion (3–4mm), leading to the
inferior frontal recess [4]. The boundaries of the frontal recess include the middle
turbinate (medially), lamina papyracea (laterally), posterior wall of agger nasi
(anteriorly), and the ethmoid bulla (posteriorly) [12]. The frontal sinus drainage
pathway is dependent on the location of the attachment of the uncinate process.
Most commonly, the uncinate process attaches to the skull base, and the frontal
sinus drains into the ethmoid infundibulum. When the uncinate attaches to the lamina, the frontal sinus drains into the middle meatus [13].
The frontal bone is one of the strongest of the facial bones, tolerating forces up
to 800–1600 lbs [14]. Thus, injury is most commonly caused by high velocity
impacts such as motor vehicle accidents, assaults, industrial accidents, and sports
injuries [15]. Frontal injuries are often associated with other facial fractures (65%)
[16], ophthalmologic and intracranial injuries. Long-term sequelae include mucocele, chronic sinusitis, and mucopyocele [17].
Evaluation andManagement
Evaluation of frontal sinus defects is usually performed by physical exam and imaging. The anterior table, posterior table, and frontal sinus outow tracts should be
carefully assessed to determine the extent of injury, anticipate sequelae, and plan
25 Frontal Sinus Reconstruction
339
surgery. Soft tissue injures should be noted, as well as lacerations that may accommodate sufcient surgical exposure. The presence of CSF rhinorrhea should also be
noted, as this will inuence the extent of repair. CT imaging is essential. Axial
images are useful to evaluate displacement of the anterior and posterior tables,
while coronal and sagittal images are useful for assessing the frontal sinus outow tract.
Anterior Table
Anterior table fractures account for 18–27% of frontal sinus fractures. If the outow
tract and posterior table are not affected, an isolated anterior table fracture represents a purely cosmetic issue, and observation can be considered depending on the
degree of deformity [4]. Unfortunately, there is no consensus regarding indications
for anterior table repair, as this depends on what is considered acceptable between
the surgeon and the patient. Small, depressed fractures of 4mm or less may heal
without signicant cosmetic deformity once scarring and bone remodeling occur
[18, 19].Multiple approaches to the frontal sinus are available. The coronal approach
offers the best exposure but carries some morbidity, including scalp paresthesia,
alopecia, scarring, and facial nerve injury. This approach is best reserved for severe
depressions, severely comminuted fractures, the need to obliterate or cranialize the
frontal sinus, or in cases where a craniotomy is needed to address neurologic
injuries.
Less invasive approaches include the upper eyelid incision, suprabrow approach,
endoscopic brow, and transnasal endoscopic approach [20–23]. The endoscopic
approach is unique in that it can address both depressed anterior table fractures,
CSF leaks, and the frontal sinus outow tract in well-selected patients [3, 24].
Posterior Table
Fractures of the posterior table can be associated with intracranial injuries or dural
tears, which predispose the patient to intracranial infections, mucoceles, and CSF
leaks. Historically, cranialization was the recommended treatment for signicantly
displaced posterior table fractures (greater than one table width or 2mm) or persistent CSF leaks. However, Choi etal. showed that even displaced, comminuted posterior table fractures can be managed without cranialization, regardless of the
presence of CSF leak, in their 10-year, retrospective review of 59 patients [25].
Furthermore, for persistent CSF leaks, an endoscopic approach can be attempted
prior to committing to an open procedure. Complication rates after cranialization or
obliteration range from 10 to 17%, including headache, wound infection, persistent
CSF leak, mucocele formation, intracranial infection, and cosmetic deformity [26].
Therefore, it may be prudent to observe mild to moderate posterior table fractures
prior to surgical intervention. In cases with persistent CSF leak, persistent obstruction of the frontal outow tract, signicant posterior table disruption or