CLINICAL STUDY
Fixation of Fractured Anterior Wall of Maxillary Sinus Using Fibrin Glue in a Zygomaticomaxillary Complex Fracture Seung Han Song, MD,*‡ Hyunwoo Kyung, MD,†‡ Sang-Ha Oh, MD,*‡ and Nakheon Kang, MD* Background: Zygomaticomaxillary complex (ZMC) fracture occurs commonly, and restorations of facial shape and symmetry by 3dimensional reduction and ridged fixation are important. A severe ZMC fracture is accompanied by fractures to the anterior wall of maxillary sinus; thus, various complications can occur without appropriate restoration by surgery. Method: Of the patients with ZMC fracture from January 2008 to December 2012, 328 patients underwent surgery. Among them, 234 patients with severe fractures to the anterior wall of the maxillary sinus underwent restoration using fibrin glue (Tisseel; Baxter Healthcare, Norfolk, UK). Results: There were no major side effects in any of the 234 patients in whom Tisseel was used, and the bone fragments were fixed well in their original places according to postoperative CT findings. Conclusion: Grafted bone fragments can be maintained in their original places by fibrin clot layers with Tisseel. Using Tisseel, operation time is reduced, and the bleeding tendency is decreased by reduced shearing force with surrounding tissues and the hemostatic reaction of fibrin. Therefore, it can be concluded that using Tisseel is one effective method for the restoration of fractures on the anterior wall of the maxillary sinus. Key Words: Anterior wall of maxillary sinus, fibrin glue (J Craniofac Surg 2014;25: 919–921)
T
he zygomaticomaxillary complex (ZMC), which protrudes in an anterolateral direction from the face, decides the facial shape and symmetry by forming the malar eminence. Furthermore, the ZMC is anatomically involved with the orbital floor and lateral wall orbit, and it joins with the frontal, sphenoid, maxilla, and temporal bone. In addition, it is closely related to the nasal cavity and paranasal sinus.1
From the *Department of Plastic and Reconstructive Surgery, Chungnam National University Hospital, Daejeon; †Okcheon-gun Health Center, Chungbuk; and ‡Clinical Anatomy Institute, Chungnam National University Hospital, Daejeon, South Korea Received October 30, 2013. Accepted for publication December 27, 2013. Address correspondence and reprint requests to Hyunwoo Kyung, MD, Okcheon-gun Health Center, 161-45, Samyang-ri, Okcheon-eup, Okcheon-gun, Chungcheongbuk-do, South Korea; E-mail: [email protected] Ethical Disclosure: The authors have certified that the process of the research is in accordance with ethical standards of Helsinki declaration, and domestic and foreign committees that preside over human experiment. This work was supported by a research fund of Chungnam National University. The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000663
ZMC fractures occur mainly by trauma such as car accidents. Its nature varies from simple arch fractures to displacements and combined fractures. Among them, types of inferomedial displacement with disarticulation on the suture lines of 4 bones mentioned above (frontal, sphenoid, maxilla, and temporal bone) and palpable boney stepping on the malar sinus with crushing of the anterior wall of the maxillary sinus are most usual. In most of these cases, fractures of the anterior wall of the maxillary sinus are concomitant. For surgical treatment of ZMC fractures, open reduction and ridged fixation to the zygomaticomaxillary buttress, zygomaticofrontal buttress, and infraorbital rim are performed to maintain facial shape and symmetry. After that, for the restoration of fractures of the anterior wall of the maxillary sinus, large fragments are fixed with plates and screws or wires. Leftover or originally small-sized fragments are simply located in bony defect areas or removed. However, sinusitis, chronic purulent secretion, and rhinitis may occur by the inappropriate restoration of the anterior wall of the maxillary sinus.2,3 Therefore, we report here the effective fixation of fragments of the anterior wall of the maxillary sinus by fibrin glue (Tisseel; Baxter Healthcare).
PATIENTS AND METHODS Subjects The number of patients who underwent surgery with ZMC fractures was 328 in the Department of Plastic and Reconstructive Surgery of our institution (Chungnam National University Hospital) from January 2008 to December 2012. Among them, in 234 patients fractures on the anterior wall of the maxillary sinus were fixed by applying Tisseel. Because the remaining 94 patients had no fracture of anterior wall of maxillary sinus, either simple arch fractures, they did not require restoration.
METHODS To reduce bleeding during surgery, 2% lidocaine mixed with epinephrine at a ratio of 1:100,000 was injected into the surgical areas, and then incisions were performed. By a transconjunctival or transcutaneous approach, the infraorbital rim and orbital floor were exposed. In case of accompanying fractures on the orbital floors, reduction was conducted, and an implant was performed if necessary. The zygomaticofrontal suture was exposed by transcutaneous lateral brow incision. To expose the zygomaticomaxillary suture, an intraoral upper buccal sulcus incision was performed. Taking into account bleeding, an incision of the periosteum was performed by exfoliation. After confirming fracture areas, accurate 3-dimensional reduction was performed. With special attention to the alignment of the sphenozygomatic suture, reduction was carried out for facial shape and symmetry, and then 3-point (zygomaticofrontal suture, infraorbital rim, and zygomaticomaxillary suture) fixation was implemented. After plate and screw fixation, for restoration of anterior wall of maxillary sinus, large-sized fragments preferentially were fixed on unimpaired bones with microplates and screws. For the remaining
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
919
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
Song et al
defects, fragments were collected and the maximum effort was made to return them to their original places, and then Tisseel was sprayed to fix them (Fig. 1). Taking care not to move the fixed layer of fibrin glue, the incisions, including the intraoral incision, were closed.
Postoperative Evaluation To investigate the surgical outcomes and complications, the progress records, physical examinations, and radiological findings were reviewed in the 234 patients who had undergone surgery with the application of Tisseel among all of the ZMC patients.
RESULTS Among the 328 patients who were diagnosed with ZMC fractures, the number of males was 256 (78%) and females was 72 (22%). The number of group III by the classification of Knight and North was the greatest, at 150 (46%), and the next was Group II, at 90 (27%) (Table 1). In ZMC fracture patients, there were no facial asymmetry requiring surgical revision. Postoperative wound infection and enophthalmos with diplopia were treated with conservative methods. Other complications were associated with anterior maxillary sinus wall fractures. In patients for whom Tisseel had been applied, some complications occurred and improved spontaneously. However, no complications caused by Tisseel itself such as infection or permanent swelling occurred (Table 2). Fixation maintained the fragments well in their original positions according to radiological examinations (Figs. 2 and 3).
DISCUSSION ZMC fracture is one in which the malar eminence is separated from 4 main buttresses, including the zygomaticomaxillary, frontozygomatic, zygomaticosphenoid, and zygomaticotemporal, by a certain degree of external force. The malar eminence protrudes in an anterolateral position; thus, it is easily fractured by trauma such as traffic and industrial accidents. In fact, malar eminence fractures occur second only to nasal bone fractures in frequency.1,2 Symptoms of malar eminence fractures are periorbital, buccal, and conjunctival ecchymoses, epistaxis, malar flattening, palpable bony steps over the inferior and lateral orbital rims and the zygomaticomaxillary buttress under the lip, numbness over the cheek, trismus, and enophthalmos. Without surgical treatment, ongoing symptoms, non-union, mal-union, and facial asymmetry may occur; thus, surgery is needed.3,4 Knight and North classified ZMC fracture into 6 groups according to fragment dislocation and its severity. They reported that the number in group III, in which the ZMC was displaced by the inferomedial position without rotation, was the largest.5 Like this, the number in group III was the greatest, at 150 (46%), and that of group II was next in this study. Regarding surgical methods, reduction was performed by a temporal approach of Gillies if there was only an arch fracture, that is, a group II fracture by the Knight and North classification. Severe fractures were fixed by applying plates and screws after open reduction.6 Considering the importance
TABLE 1. Knight and North’s ZMC Fracture Classification System Group I
4 (1)
Group II
90 (27) 150 (46) 75 (23) 4 (1) 5 (2) Undisplaced fracture Isolated, displaced arch fracture Downward and inward displaced, unrotated Medially rotated Laterally rotated Additional fracture line across main fragment
Group Group Group Group Group Group Group Group Group Group
III IV V VI I II III IV V VI
Values are presented as number (%).
of both aesthetic and function, 3-dimensional reduction is necessary to restore the facial shape, position of the infraorbital nerve and eyes, and mouth opening. In addition, complications such as recurrences of symptoms and facial asymmetry can be prevented by ridged 3-point fixation including the zygomaticofrontal suture, infraorbital rim, and zygomaticomaxillary suture. In addition, the condition of the zygomaticosphenoid suture on the lateral orbital wall is a very useful indicator of anatomical displacement and rotation of the zygoma.1 According to the classification of Knight and North, in group III and above the fracture of the anterior wall of the maxillary sinus accompanies, and it should be appropriately restored to prevent disorders of sinusitis and rhinitis and prolapsed soft tissues from the cheeks into the sinus, intrusion of bone fragments, and irritation of the mucosa. If the defect is too large to close with bone fragments, the traditional method has been the restoration by titanium meshes and resorbable materials7; however, the damaged mucosa is directly exposed to the foreign material and the soft tissue, and the occurrence of complication is possible. In fact, after reconstruction with a titanium or resorbable mesh, rhinitis, purulence, pain, and swelling were reported.7 Thus, in this study, large fragments were fixed by plates and screws, and small fragments were effectively fixed by spraying Tisseel after bone grafting. Balallon et al reported that ZMC fracture with anterior maxillary sinus wall has a high complication rate: rhinitis, purulence, pain, and swelling. So, with appropriate craniofacial suspension, reconstruction of anterior sinus wall is a way to reduce complications.7 Our patients in whom the anterior sinus wall was restored showed symptoms after the operation: 3 (1.2%) cases of rhinitis, 2 (0.8%) cases of purulence, 4 (1.7%) cases of pain, and 2 (8.0%) cases of swelling. This complication rate was slightly lower compared to Ballon A et al’s result. While the conventional method used titanium or absorbable plates, we used Tisseel that reduced operation time and exposure of sinus mucosa, so we were able to reduce the complications. TABLE 2. Clinical Findings of Patient Whit Sinus Anterior Wall Restoration by Tisseel Rhinitis
3 (1.2)
Purulence
2 (0.8) 4 (1.7) 2 (0.8) 0 (0) 0 (0)
Pain swelling Infection Permanent swelling FIGURE 1. Left: fibrin glue being applied to the surgical field by a dual syringe method. Right: surgical field with a layer of fibrin glue applied.
920
Values are presented as number (%).
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
FIGURE 2. A 55-year-old woman with Lt. ZMC fracture. Left: preoperative, right: postoperative CT image—the bone fragment is located in its original position after reconstruction.
The fibrin glue consisted of 2 syringes for fibrinogen, plasmatic protein, and factor XIII on the one hand, and thrombin, calcium chloride, and aprotinin on the other. Mixing these components, a fibrin clot is formed. Fibrin glue has been used for gastroenteroanastomosis, breast surgery, facial lifting, and neurosurgery because the shearing force is reduced by increased adhesion to the surrounding tissues and the bleeding tendency is decreased with a similar reaction in the last step of the physiological hemostatic reaction.8 The use of fibrin was once limited because of the risk of blood-borne diseases and the insufficient amount and inappropriate quality of fibrin being extracted from donated plasma.9 However, fibrin glue such as Tisseel was developed and has been used for various purposes. The structural integrity of a fibrin clot has been maintained for 3 weeks by antifibrinolytic components including aprotinin,10 and then the restoration stability is maintained over time because the surgical wounds have recovered during the 3-week period. During
FIGURE 3. A 37-year-old man with Rt. ZMC fracture. Left: preoperative, right: postoperative CT image.
Fixing Maxillary Sinus Using Fibrin Glue
wound recovery, no fibroses or foreign body reactions to Tisseel occurred. In addition, there was no increase in volume from Tisseel itself because it was absorbed over time.11 Besides, Tisseel did not show toxicities or the possibilities of mutation and deformity.12 As in previous studies, there were no infections or permanent swellings due to the Tisseel in this study. Also, there were no complications such as rhinitis, purulence, pain, and swelling. The reason considered is that soft tissue is healed and mucosa of sinus is regenerated while maintaining the fibrin clot. The possibility of viral infection theoretically exists; however, no actual occurrences of viral infection have been reported.12 Thus, it is considered that Tisseel did not have its own side effects. However, Tanemoto et al suggested the possibility of bacterial colonization from the outside during surgery,13 and Thompson et al also noted the possibility of infection.14 Therefore, special consideration is necessary in fracture surgeries with a high possibility of contamination such as open fractures connected with the inside of the mouth.
REFERENCES 1. Evans BG, Evans GR. MOC-PS SM CME article: zygomatic fractures. Plast Reconstr Surg 2008;121:1–11 2. Hollier LH, Thornton J, Pzamino P, et al. The management of orbitozygomatic fractures. Plast Reconstr Surg 2003;111:2386–2392 3. Blondel JH, Legros M. Post-traumatic maxillary sinusitis. J Fr Otorhinolaryngol Audiophonol Chir Maxillofac 1980;29:633–634, 637–638 4. Gasparini G, Brunelli A, Rivaroli A, et al. Maxillofacial traumas. J Craniofac Surg 2002;13:645–649 5. Knight JS, North JF. Fracture of the facial skeleton. 2nd ed. Baltimore: William & Wilkins Company, 1968 6. Ellis E3rd, Kittidumkerng W. Analysis of treatment for isolated zygomaticomaxillary complex fracture. J Oral Maxillofac Surg 1996;54:386–400 7. Ballon A, Landes CA, Zeilhofer HF, et al. The importance of the primary reconstruction of the traumatized anterior maxillary sinus wall. J Craniofac Surg 2008;19:505–509 8. Grossman JA, Capraro PA. Long term experience with the use of fibrin sealant in aesthetic surgery. Aesthet Surg J 2007;27:558–562 9. Gibble JW, Ness PM. Fibrin glue: the perfect operative sealant? Transfusion 1990;30:741–747 10. Radosevich M, Goubran HI, Burnouf T. Fibrin sealant: scientific rationale, production methods, properties, and current clinical use. Vox Sang 1997;72:133–143 11. Brennan M. Fibrin glue. Blood Rev 1991;5:240–244 12. Ali SN, Gill P, Oikonomou D, et al. The combination of fibrin glue and quilting reduces drainage in the extended latissimus dorsi flap donor site. Plast Reconstr Surg 2010;125:1615–1619 13. Tanemoto K, Fujinami H. Experimental study on bacterial colonization of fibrin glue and its prevention. Clin Ther 1994;16:1016–1027 14. Thompson DF, Davis TW, The addition of antibiotics to fibrin glue. South Med J 1997;90:681–684
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
921
Fixation of Fractured Anterior Wall of Maxillary Sinus Using Fibrin Glue in a Zygomaticomaxillary Complex Fracture Seung Han Song, MD,*‡ Hyunwoo Kyung, MD,†‡ Sang-Ha Oh, MD,*‡ and Nakheon Kang, MD* Background: Zygomaticomaxillary complex (ZMC) fracture occurs commonly, and restorations of facial shape and symmetry by 3dimensional reduction and ridged fixation are important. A severe ZMC fracture is accompanied by fractures to the anterior wall of maxillary sinus; thus, various complications can occur without appropriate restoration by surgery. Method: Of the patients with ZMC fracture from January 2008 to December 2012, 328 patients underwent surgery. Among them, 234 patients with severe fractures to the anterior wall of the maxillary sinus underwent restoration using fibrin glue (Tisseel; Baxter Healthcare, Norfolk, UK). Results: There were no major side effects in any of the 234 patients in whom Tisseel was used, and the bone fragments were fixed well in their original places according to postoperative CT findings. Conclusion: Grafted bone fragments can be maintained in their original places by fibrin clot layers with Tisseel. Using Tisseel, operation time is reduced, and the bleeding tendency is decreased by reduced shearing force with surrounding tissues and the hemostatic reaction of fibrin. Therefore, it can be concluded that using Tisseel is one effective method for the restoration of fractures on the anterior wall of the maxillary sinus. Key Words: Anterior wall of maxillary sinus, fibrin glue (J Craniofac Surg 2014;25: 919–921)
T
he zygomaticomaxillary complex (ZMC), which protrudes in an anterolateral direction from the face, decides the facial shape and symmetry by forming the malar eminence. Furthermore, the ZMC is anatomically involved with the orbital floor and lateral wall orbit, and it joins with the frontal, sphenoid, maxilla, and temporal bone. In addition, it is closely related to the nasal cavity and paranasal sinus.1
From the *Department of Plastic and Reconstructive Surgery, Chungnam National University Hospital, Daejeon; †Okcheon-gun Health Center, Chungbuk; and ‡Clinical Anatomy Institute, Chungnam National University Hospital, Daejeon, South Korea Received October 30, 2013. Accepted for publication December 27, 2013. Address correspondence and reprint requests to Hyunwoo Kyung, MD, Okcheon-gun Health Center, 161-45, Samyang-ri, Okcheon-eup, Okcheon-gun, Chungcheongbuk-do, South Korea; E-mail: [email protected] Ethical Disclosure: The authors have certified that the process of the research is in accordance with ethical standards of Helsinki declaration, and domestic and foreign committees that preside over human experiment. This work was supported by a research fund of Chungnam National University. The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000663
ZMC fractures occur mainly by trauma such as car accidents. Its nature varies from simple arch fractures to displacements and combined fractures. Among them, types of inferomedial displacement with disarticulation on the suture lines of 4 bones mentioned above (frontal, sphenoid, maxilla, and temporal bone) and palpable boney stepping on the malar sinus with crushing of the anterior wall of the maxillary sinus are most usual. In most of these cases, fractures of the anterior wall of the maxillary sinus are concomitant. For surgical treatment of ZMC fractures, open reduction and ridged fixation to the zygomaticomaxillary buttress, zygomaticofrontal buttress, and infraorbital rim are performed to maintain facial shape and symmetry. After that, for the restoration of fractures of the anterior wall of the maxillary sinus, large fragments are fixed with plates and screws or wires. Leftover or originally small-sized fragments are simply located in bony defect areas or removed. However, sinusitis, chronic purulent secretion, and rhinitis may occur by the inappropriate restoration of the anterior wall of the maxillary sinus.2,3 Therefore, we report here the effective fixation of fragments of the anterior wall of the maxillary sinus by fibrin glue (Tisseel; Baxter Healthcare).
PATIENTS AND METHODS Subjects The number of patients who underwent surgery with ZMC fractures was 328 in the Department of Plastic and Reconstructive Surgery of our institution (Chungnam National University Hospital) from January 2008 to December 2012. Among them, in 234 patients fractures on the anterior wall of the maxillary sinus were fixed by applying Tisseel. Because the remaining 94 patients had no fracture of anterior wall of maxillary sinus, either simple arch fractures, they did not require restoration.
METHODS To reduce bleeding during surgery, 2% lidocaine mixed with epinephrine at a ratio of 1:100,000 was injected into the surgical areas, and then incisions were performed. By a transconjunctival or transcutaneous approach, the infraorbital rim and orbital floor were exposed. In case of accompanying fractures on the orbital floors, reduction was conducted, and an implant was performed if necessary. The zygomaticofrontal suture was exposed by transcutaneous lateral brow incision. To expose the zygomaticomaxillary suture, an intraoral upper buccal sulcus incision was performed. Taking into account bleeding, an incision of the periosteum was performed by exfoliation. After confirming fracture areas, accurate 3-dimensional reduction was performed. With special attention to the alignment of the sphenozygomatic suture, reduction was carried out for facial shape and symmetry, and then 3-point (zygomaticofrontal suture, infraorbital rim, and zygomaticomaxillary suture) fixation was implemented. After plate and screw fixation, for restoration of anterior wall of maxillary sinus, large-sized fragments preferentially were fixed on unimpaired bones with microplates and screws. For the remaining
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
919
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
Song et al
defects, fragments were collected and the maximum effort was made to return them to their original places, and then Tisseel was sprayed to fix them (Fig. 1). Taking care not to move the fixed layer of fibrin glue, the incisions, including the intraoral incision, were closed.
Postoperative Evaluation To investigate the surgical outcomes and complications, the progress records, physical examinations, and radiological findings were reviewed in the 234 patients who had undergone surgery with the application of Tisseel among all of the ZMC patients.
RESULTS Among the 328 patients who were diagnosed with ZMC fractures, the number of males was 256 (78%) and females was 72 (22%). The number of group III by the classification of Knight and North was the greatest, at 150 (46%), and the next was Group II, at 90 (27%) (Table 1). In ZMC fracture patients, there were no facial asymmetry requiring surgical revision. Postoperative wound infection and enophthalmos with diplopia were treated with conservative methods. Other complications were associated with anterior maxillary sinus wall fractures. In patients for whom Tisseel had been applied, some complications occurred and improved spontaneously. However, no complications caused by Tisseel itself such as infection or permanent swelling occurred (Table 2). Fixation maintained the fragments well in their original positions according to radiological examinations (Figs. 2 and 3).
DISCUSSION ZMC fracture is one in which the malar eminence is separated from 4 main buttresses, including the zygomaticomaxillary, frontozygomatic, zygomaticosphenoid, and zygomaticotemporal, by a certain degree of external force. The malar eminence protrudes in an anterolateral position; thus, it is easily fractured by trauma such as traffic and industrial accidents. In fact, malar eminence fractures occur second only to nasal bone fractures in frequency.1,2 Symptoms of malar eminence fractures are periorbital, buccal, and conjunctival ecchymoses, epistaxis, malar flattening, palpable bony steps over the inferior and lateral orbital rims and the zygomaticomaxillary buttress under the lip, numbness over the cheek, trismus, and enophthalmos. Without surgical treatment, ongoing symptoms, non-union, mal-union, and facial asymmetry may occur; thus, surgery is needed.3,4 Knight and North classified ZMC fracture into 6 groups according to fragment dislocation and its severity. They reported that the number in group III, in which the ZMC was displaced by the inferomedial position without rotation, was the largest.5 Like this, the number in group III was the greatest, at 150 (46%), and that of group II was next in this study. Regarding surgical methods, reduction was performed by a temporal approach of Gillies if there was only an arch fracture, that is, a group II fracture by the Knight and North classification. Severe fractures were fixed by applying plates and screws after open reduction.6 Considering the importance
TABLE 1. Knight and North’s ZMC Fracture Classification System Group I
4 (1)
Group II
90 (27) 150 (46) 75 (23) 4 (1) 5 (2) Undisplaced fracture Isolated, displaced arch fracture Downward and inward displaced, unrotated Medially rotated Laterally rotated Additional fracture line across main fragment
Group Group Group Group Group Group Group Group Group Group
III IV V VI I II III IV V VI
Values are presented as number (%).
of both aesthetic and function, 3-dimensional reduction is necessary to restore the facial shape, position of the infraorbital nerve and eyes, and mouth opening. In addition, complications such as recurrences of symptoms and facial asymmetry can be prevented by ridged 3-point fixation including the zygomaticofrontal suture, infraorbital rim, and zygomaticomaxillary suture. In addition, the condition of the zygomaticosphenoid suture on the lateral orbital wall is a very useful indicator of anatomical displacement and rotation of the zygoma.1 According to the classification of Knight and North, in group III and above the fracture of the anterior wall of the maxillary sinus accompanies, and it should be appropriately restored to prevent disorders of sinusitis and rhinitis and prolapsed soft tissues from the cheeks into the sinus, intrusion of bone fragments, and irritation of the mucosa. If the defect is too large to close with bone fragments, the traditional method has been the restoration by titanium meshes and resorbable materials7; however, the damaged mucosa is directly exposed to the foreign material and the soft tissue, and the occurrence of complication is possible. In fact, after reconstruction with a titanium or resorbable mesh, rhinitis, purulence, pain, and swelling were reported.7 Thus, in this study, large fragments were fixed by plates and screws, and small fragments were effectively fixed by spraying Tisseel after bone grafting. Balallon et al reported that ZMC fracture with anterior maxillary sinus wall has a high complication rate: rhinitis, purulence, pain, and swelling. So, with appropriate craniofacial suspension, reconstruction of anterior sinus wall is a way to reduce complications.7 Our patients in whom the anterior sinus wall was restored showed symptoms after the operation: 3 (1.2%) cases of rhinitis, 2 (0.8%) cases of purulence, 4 (1.7%) cases of pain, and 2 (8.0%) cases of swelling. This complication rate was slightly lower compared to Ballon A et al’s result. While the conventional method used titanium or absorbable plates, we used Tisseel that reduced operation time and exposure of sinus mucosa, so we were able to reduce the complications. TABLE 2. Clinical Findings of Patient Whit Sinus Anterior Wall Restoration by Tisseel Rhinitis
3 (1.2)
Purulence
2 (0.8) 4 (1.7) 2 (0.8) 0 (0) 0 (0)
Pain swelling Infection Permanent swelling FIGURE 1. Left: fibrin glue being applied to the surgical field by a dual syringe method. Right: surgical field with a layer of fibrin glue applied.
920
Values are presented as number (%).
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
FIGURE 2. A 55-year-old woman with Lt. ZMC fracture. Left: preoperative, right: postoperative CT image—the bone fragment is located in its original position after reconstruction.
The fibrin glue consisted of 2 syringes for fibrinogen, plasmatic protein, and factor XIII on the one hand, and thrombin, calcium chloride, and aprotinin on the other. Mixing these components, a fibrin clot is formed. Fibrin glue has been used for gastroenteroanastomosis, breast surgery, facial lifting, and neurosurgery because the shearing force is reduced by increased adhesion to the surrounding tissues and the bleeding tendency is decreased with a similar reaction in the last step of the physiological hemostatic reaction.8 The use of fibrin was once limited because of the risk of blood-borne diseases and the insufficient amount and inappropriate quality of fibrin being extracted from donated plasma.9 However, fibrin glue such as Tisseel was developed and has been used for various purposes. The structural integrity of a fibrin clot has been maintained for 3 weeks by antifibrinolytic components including aprotinin,10 and then the restoration stability is maintained over time because the surgical wounds have recovered during the 3-week period. During
FIGURE 3. A 37-year-old man with Rt. ZMC fracture. Left: preoperative, right: postoperative CT image.
Fixing Maxillary Sinus Using Fibrin Glue
wound recovery, no fibroses or foreign body reactions to Tisseel occurred. In addition, there was no increase in volume from Tisseel itself because it was absorbed over time.11 Besides, Tisseel did not show toxicities or the possibilities of mutation and deformity.12 As in previous studies, there were no infections or permanent swellings due to the Tisseel in this study. Also, there were no complications such as rhinitis, purulence, pain, and swelling. The reason considered is that soft tissue is healed and mucosa of sinus is regenerated while maintaining the fibrin clot. The possibility of viral infection theoretically exists; however, no actual occurrences of viral infection have been reported.12 Thus, it is considered that Tisseel did not have its own side effects. However, Tanemoto et al suggested the possibility of bacterial colonization from the outside during surgery,13 and Thompson et al also noted the possibility of infection.14 Therefore, special consideration is necessary in fracture surgeries with a high possibility of contamination such as open fractures connected with the inside of the mouth.
REFERENCES 1. Evans BG, Evans GR. MOC-PS SM CME article: zygomatic fractures. Plast Reconstr Surg 2008;121:1–11 2. Hollier LH, Thornton J, Pzamino P, et al. The management of orbitozygomatic fractures. Plast Reconstr Surg 2003;111:2386–2392 3. Blondel JH, Legros M. Post-traumatic maxillary sinusitis. J Fr Otorhinolaryngol Audiophonol Chir Maxillofac 1980;29:633–634, 637–638 4. Gasparini G, Brunelli A, Rivaroli A, et al. Maxillofacial traumas. J Craniofac Surg 2002;13:645–649 5. Knight JS, North JF. Fracture of the facial skeleton. 2nd ed. Baltimore: William & Wilkins Company, 1968 6. Ellis E3rd, Kittidumkerng W. Analysis of treatment for isolated zygomaticomaxillary complex fracture. J Oral Maxillofac Surg 1996;54:386–400 7. Ballon A, Landes CA, Zeilhofer HF, et al. The importance of the primary reconstruction of the traumatized anterior maxillary sinus wall. J Craniofac Surg 2008;19:505–509 8. Grossman JA, Capraro PA. Long term experience with the use of fibrin sealant in aesthetic surgery. Aesthet Surg J 2007;27:558–562 9. Gibble JW, Ness PM. Fibrin glue: the perfect operative sealant? Transfusion 1990;30:741–747 10. Radosevich M, Goubran HI, Burnouf T. Fibrin sealant: scientific rationale, production methods, properties, and current clinical use. Vox Sang 1997;72:133–143 11. Brennan M. Fibrin glue. Blood Rev 1991;5:240–244 12. Ali SN, Gill P, Oikonomou D, et al. The combination of fibrin glue and quilting reduces drainage in the extended latissimus dorsi flap donor site. Plast Reconstr Surg 2010;125:1615–1619 13. Tanemoto K, Fujinami H. Experimental study on bacterial colonization of fibrin glue and its prevention. Clin Ther 1994;16:1016–1027 14. Thompson DF, Davis TW, The addition of antibiotics to fibrin glue. South Med J 1997;90:681–684
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
921
