The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015

FIGURE 3. Osteoma is being resected after wide subperiostic exposition.

(scissors), with curved dissectors by means of delicate maneuvers of liberation from the surrounding tissues permitting complete tumor extirpation.

DISCUSSION The recent advent of endoscopic procedures has compelled the plastic surgeon to reconsider the conventional methods of excision of different types of tumors placed in the head and neck areas, which are then classically achieved.6 Lipomas and osteomas of the frontal area are current pathologies, which can be successfully treated by endoscopic surgery; video-assisted technique offers both good illumination and excellent magnification, permitting easier surgical maneuvers. Lipomas are usually located above the fibers of frontal muscle into the subcutaneous plane; in some cases, these tumors can be under the muscular fibers or in subperiostic position. Anatomically, the most important element is the frontal branch of the facial nerve reaching the deep surface of the muscular fiber going from the temporal region to the frontal area. The approach of the tumor is always subperiostic until it reaches the tumoral area. When it is placed above the muscular fibers in the subcutaneous plane, complete resection is obtained after periosteal and frontal muscles are divided; if they are in both the subperiostic or submuscular planes, direct extirpation is made. The surgery of either tumor in the frontal area has traditionally been a challenge for head and neck surgeons for many reasons; residual and hidden scar is the most important among them. On the other hand, a good illumination and magnification supported by endoscopic surgery providing clear and sharp vision permits not only a safe anatomic dissection but also surgical maneuvers in avascular planes that contribute to avoid injuries in the frontal branch of the facial nerve.7 Although the optical cavity is the subcutaneous cavity within the soft tissue of the frontal area, the support may be provided by surrounding bony surface where additional illumination is obtained when the endoscopic light is reflected on the frontal bone during subperiostic undermining. In all 26 patients, minimal or no pain was reported, and analgesic drugs were only necessary in the first postoperative hours; any kind of discomfort was claimed by patients. Three complications (18%) were detected in all 26 patients operated with this technique: 2 hematomas and 1 paresis of the frontal nerve with spontaneous recuperation 5 months later. Soft and lax tissue of the frontal area is ideal for the application of endoscopic principles; its anatomic areas can transform in an expandable cavity with avascular plane of dissection. In conclusion, the outcome achieved with endoscopic techniques in other surgical areas has permitted to considerer it like the first

FIGURE 4. A, Periosteal is divided permitting the tumor exposition after muscular dissection. B, Lipoma resection is carried out after complete liberation.

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election in the surgical treatment in tumors in the frontal region, offering more advantages than the classic approaches. The advantages of endoscopic resection are as follows: (1) avoidance of visible scar, with inconspicuous and invisible scar hidden from the view (inside the hair) as the only sequel of the surgery; (2) better visualization and magnified view of the dissection areas, which result in the injury of the important anatomic landmarks, nerves and vessel, being avoided; (3) excellent postoperative comfort; and (4) short hospital stay. Its disadvantage is that it is necessary to have (1) an endoscope and other special instruments and also (2) specific surgical training. This article not only describes the endoscopic techniques used in the surgery for the resection of the mentioned tumors but also projects the use of incisions behind the hairline. With the arrival of the new surgical techniques, surgeon experience, and advanced endoscopic instruments, the video-assisted surgery can be a safe method of choice in the treatment of several diseases of the head and neck using natural orifice approaches.

REFERENCES 1. Mangnan J, Chays A, Lepetre C, et al. Surgical perspective of endoscopic of the cerebellopontine angle. Am J Otolaryngol 1994;15:366–370 2. Breant AS. Endoscopic approach to benign tumors of the paranasal sinuses. In Wackym PA, Rice DH, Schaefer SD, eds. In Minimally Invasive Surgery of the Head and Neck and Cranial Base. Philadelphia: Lippincott Williams & Wilkins, 2002:297–310 3. Litynski GS. Endoscopic surgery: the history, the pioneers. World J Surg 1999;23:745–753 4. Davis CJ. A history of endoscopic surgery. Surg Laparosc Endosc 1992;2:16–23 5. Guerrissi JO. Innovation and surgical technique. endoscopic resection of cervical branchiogenic cysts. J Craniofac Surg 2002;13:478–482 6. Guerrissi JO, Taborda G. Endoscopic excision of the submandibular gland by an intraoral approach. J Craniofac Surg 2001;13:299–303 7. Rhee JS, Gallo JF, Constantino PD. Endoscopic facial rejuvenation. In Wackym PA, Rice DH, Schaefer SD, eds. In Minimally Invasive Surgery of the Head and Neck and Cranial Base. Philadelphia: Lippincott Williams & Wilkins, 2002:356–366

Fixation of Fractured Inferior Orbital Wall Using Fibrin Glue in Inferior Blowout Fracture Surgery Eun Jun Jo, MD, Ho Jik Yang, MD, Jong Hwan Kim, MD Abstract: The objectives of surgical treatment for orbital fracture are to return soft tissue to its original position as well as reduce and fix the bone fragments properly. Reduction of the orbital bone From the Department of Plastic and Reconstructive Surgery, College of Medicine, Eulji University, Daejeon, Korea. Received June 30, 2014. Accepted for publication August 19, 2014 Address correspondence and reprint requests to Ho Jik Yang, MD, Department of Plastic and Reconstructive Surgery, College of Medicine, Eulji University, 95 Dunsanseo-ro, Seo-gu, Daejeon 302-799, Korea; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001293

© 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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through a subciliary or conjunctival incision and reduction using a urinary balloon catheter were simultaneously performed on 53 patients between 2010 and 2013. Fibrin glue was used to attach the reduced bone fragments. These patients had less than 2 cm2 of bone defect and showed diplopia, eye movement limitation, and enophthalmos. Diplopia, eye movement limitation, and enophthalmos were each reduced to 3/32, 2/25, and 2/48, respectively. There were no adverse effects, such as infection or hematoma, and because implants were not used, there was no possibility of its extrusion or foreign body reaction. The operation time decreased compared with when using an implant, and the bone fragments remained in a fixed position even after removing the urinary balloon catheter. Therefore, the use of fibrin glue proved to be effective in orbital floor fractures. Key Words: Fibrin glue, blowout fracture

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xcessive pressure on the orbital bone from traffic accidents or falling is a common cause of orbital fractures.1 Fracture usually occurs in the medial or inferior wall because they are composed of thin bone. Complications such as enophthalmos, eye movement limitation, and diplopia can occur in orbital floor fractures, so there is emphasis on an early and accurate diagnosis of location and extent of fracture using computed tomography (CT), which leads to an appropriate surgical strategy.2 In order to obtain an optimal surgical result, soft tissue and bone fragments of the orbital that are extruding in the maxillary sinus must be returned back to the orbital. At the same time, the orbital floor must be reconstructed back to its anatomical position as well as fixed firmly enough to be immobilized. Because the orbital bone is one of the thinnest bones in the body, there are difficulties in performing internal fixation using metal plates and screws.3 Also, implants, such as porous polyethylene (Medpor), might be needed in cases of bone defect that occur when bone fragments extruding in the maxillary sinus are not fixed in place. However, when using an implant, there is risk of infection, foreign body reaction, and the need for reoperation because of implant extrusion.4 Choi et al5 demonstrated a technique using a urinary balloon catheter to reduce and fix extruded bone fragments. However, when using this technique, reduced bone fragments may move from their original positions after removing the catheter.6 Therefore, we report the orbital floor fracture fixation using fibrin glue.

MATERIALS AND METHODS This study was conducted in patients diagnosed with orbital fracture from our hospital between 2010 and 2013. To be included, the patients should have bone defect of 2 cm2 or less on CT with eye movement limitation, diplopia, or enophthalmos of 2 mm or greater on exophthalmometer. Finally, a total of 53 patients were included in this study.

FIGURE 1. Surgical field with a layer of fibrin glue applied.

to make a 5-mm hole to insert a urinary balloon catheter within the maxillary sinus. While inflating the balloon by injecting 10 to 15 mL of normal saline into a 12F balloon catheter, reduction of displaced bone fragments was observed through the subciliary or conjunctival incision. Fibrin glue was sprayed between the reduced bone fragments and orbital tissue (Fig. 1). Then, ocular movement was monitored using the forced duction test. Vicryl 5-0 and black silk 6-0 were used to suture the periosteum and the subciliary or conjunctival incision, respectively.

RESULTS The age of patients ranged from 12 to 67 years: 4 cases in their teens, 18 cases in their 20s, 16 cases in their 30s, 9 cases in their 40s, 5 cases in their 50s, and 1 case in his/her 60s. Thirty-five patients were male, and 18 were female. The cause of orbital fracture was traffic accident (n = 21), falling down (n = 14), violence damage (n = 10), falling from a height (n = 5), injury during exercise (n = 2), and industrial accident (n = 1) (Table 1). The mean operation time was 106 minutes. Preoperative physical examinations revealed 48 cases of enophthalmos, 32 cases of diplopia, and 25 cases of eye movement limitation. Postoperative physical examinations showed 4 cases of enophthalmos, 3 cases of diplopia, and 2 cases of eye movement limitation, and most symptoms were alleviated with conservational treatment (Table 2). There were no cases of infection or hematoma as well as subsequent extrusion or foreign body reaction because implants were not used. The balloon catheter was removed 7 to 10 days later, and after 3 months, CT showed no signs of movement of the bone fragments (Fig. 2).

DISCUSSION Direct trauma on the orbital area can cause an orbital wall fracture, which leads to the extrusion of the orbital content.7 In cases of medial and inferior wall fractures, there is no difference in eye movement limitations; however, diplopia occurs more commonly in inferior wall fractures.8 These symptoms can be improved by surgically exposing the fracture site and restoring the extruded orbital tissue. The objective of surgical treatment of an orbital fracture is to reconstruct the orbital walls back to their original anatomical positions and thereby restoring the shape and volume of the orbital cavity. An ideal surgical method to achieve this objective is appropriately reducing and firmly fixing the bone fragments. However,

Surgical Methods In order to minimize bleeding, a solution of 2% lidocaine with epinephrine in the ratio of 1:1,000,000 was injected into the surgical site. Ablation was performed through subciliary or conjunctival incisions until the periosteum was exposed. The periosteum was incised 3 mm below and parallel to the orbital margin and ablated to expose the fracture site. Soft tissue extruding in the maxillary sinus was completely reduced, and bone fragments were partly reduced. Then, using the Caldwell-Luc approach, a 2-cm mucosal incision on the canine fossa was done to expose the maxillary sinus. This was located in the anterior wall and on the side of the fracture of the maxillary sinus. After that, an electric drill was used

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TABLE 1. Cause of blowout fracture Cause

Patients, n (%)

Traffic accident

21 (40) 14 (26) 10 (19) 5 (9) 2 (4) 1 (2) 53 (100)

Slip down Violence Sports Fall down Industrial Total

© 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015

TABLE 2. Incidence of complications

Enophthalmos Diplopia Eye movement limitation

Preoperative, n (%)

Postoperative, n (%)

48/53 (91) 32/53 (60) 25/53 (47)

2/53 (4) 3/53 (6) 2/53 (4)

many surgeons prefer removing the bone fragments and replacing them with autologous and alloplastic material.9 This is because orbital wall fractures tend to be more comminuted than other facial bone fractures. In addition, performing internal fixation using the conventional technique is difficult because of the thin orbital wall, the narrow surgical space, and the possibility of orbital tissue damage. When bone defects are caused by unfixed bone fragments, synthetic material can be used to replace the defect. Synthetic materials, such as silastic sheets, polyamide mesh, polytetrafluoroethylene, Teflon, and porous polyethylene, are used, porous polyethylene (Medpor) being the most common.10–12 When using alloplastic materials for orbital wall reconstruction, the closure of the mucosal defect is delayed by 4 weeks when using Medpor and by 8 to 12 weeks when using silicon.13 As a result, reformation of the mucosa is markedly late. On the other hand, when using only the bone fragments, the original orbital wall is conserved, and the sinus mucoperiosteum is conserved as well using the osteomucoperiosteal flap. This allows the wound to heal rapidly. The reconstructed mucosa of the sinus wall is close to a U-shaped lacerated normal mucosa with sufficient blood supply. In conclusion, the mucus drainage function of the sinus is intact, and there is little chance of postoperational sinus complications. Through a simple surgical procedure, the operation time is shortened with no complications, such as bone resorption, orbital infection, fistula formation, implant displacement, herniation relapse, globe elevation, proptosis, sinusitis, and donor-site morbidity. Another method of reducing fractured bone fragments is using a urinary balloon catheter.5 This is a method using the Caldwell-Luc approach, where a 2-cm mucosal incision on the canine fossa is done to expose the maxillary sinus. This is located on the anterior wall and on the side of the fracture of the maxillary sinus. Then, an electric drill is used to make a 5-mm hole in order to insert a balloon catheter within the maxillary sinus. While inflating the balloon by injecting 10 to 15 mL of normal saline into a 12F balloon catheter, reduction of displaced bone fragments is observed through the subciliary or conjunctival incision, which is made beforehand. The catheter is removed 7 to 10 days later when using this method,

Brief Clinical Studies

which creates a risk of the bone fragments moving from their initial reduced positions. To overcome this problem, the authors used fibrin glue to fix in place the bone fragments that were reduced using a balloon catheter. After the surgery, appropriate orbital fracture reduction in patients in whom fibrin glue was used was confirmed using CT. The urinary balloon catheter was removed after 7 to 10 days, and 3 months later, CT was performed, once again confirming that the bone fragments were still fixed in place. For postoperative complications, there were 6% of diplopia, 4% of enophthalmos, and 4% eye movement limitation. This shows significant improvement compared with the orbital fracture complications that Eun et al14 reported. In Eun and colleagues’14 report, there were 14% of diplopia, 8% of enophthalmos, and 7% of eye movement limitation. Moreover, 6 cases underwent reoperations because of implant extrusion. In contrast, in this research, no implants were used, so there was no risk of reoperation because of its extrusion. Fibrin glue is composed of fibrinogen, plasmatic protein, and factor XIII contained in 1 syringe and thrombin, calcium chloride, and aprotinin contained in another, and when the 2 are mixed, they form fibrin clots. This glue decreases the shear force by increasing the adherence among the surrounding tissue, and it undergoes a reaction similar to the last stage of a physiological hemostatic process. For these reasons, it has been used in gastrointestinal anastomosis, breast implant surgery, facelift surgery, neurological surgery, and so on.15 Initially, the use of this product was limited because of the small amount and low quality. Fibrin glue was produced from donated plasma and had the risk of containing blood-mediated diseases. However, newly released fibrin glue has lower risk of infection, and its applications gradually increased.16 A fibrin clot can maintain its structural bond for 3 weeks through its antifibrinolytic components, such as aprotinin. Fibrosis and foreign body reactions do not occur during the recovery period.17 Fibrin glue does not increase the volume because after a certain amount of time the clot is completely reabsorbed. Animal testing did not show any evidence of deformity or toxicity due to fibrin glue.15 Theoretically, transmission of viral disease is possible, but there are no cases of this observed. Therefore, there are no actual adverse effects for fibrin glue, and the authors could not observe any adverse effects during this research. However, caution is needed when this is used during a fracture surgery for a highly contaminated wound because fibrin glue can increase the risk of infection.

CONCLUSIONS The objective of an orbital fracture surgery is to retrieve the extruded orbital contents to their original place in order to maintain the orbital volume. Compared with the method using an implant, this method has the advantage of shortening the operation time, in turn decreasing the risk of infection, complications of anesthesia, and edema.

REFERENCES

FIGURE 2. Facial bone CT finding of a 54-year-old man with right inferior blowout fracture. Preoperative coronal CT scan (above, left). Preoperative sagittal CT scan (below, left). Immediate postoperative coronal CT scan (above, center). Immediate postoperative sagittal CT scan (below, center). Postoperative 3 months’ coronal CT scan (above, right). Postoperative 3 months sagittal CT scan (below, right).

1. Morton WR, Turnbull W. Blowout fractures of the floor of the orbit. Can Med Assoc J 1964;90:58–61 2. Kim YJ, Kim IJ, Lim P. A clinical analysis of the pure blowout fracture. J Korean Soc Plast Reconstr Surg 1994;21:736–744 3. Jones DEP, Evans JNG. “Blow-out” fractures of the orbit; an investigation into their anatomical basis. J Laryngol Otol 1967;81:1109–1113 4. Morrison AD, Sanderson RC, Moos KF. The use of silastic as an orbital implant for reconstruction of orbital wall defects: review of 311 cases treated over 20 years. J Oral Maxillofac Surg 1995;53:412–417

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Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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5. Choi HJ, Kim MS, Lee YM. The endoscopic treatment of blow-out fracture. J Korean Cleft Palate Craniofac Assoc 2002;3:173–178 6. Saunders CJ, Whetzel TP, Stokes RB, et al. Transantral endoscopic orbital floor exploration: a cadaver and clinical study. Plast Reconstr Surg 1997;100:575–581 7. Smith B, Regan WF Jr. Blow out fracture of the orbit: mechanism and correction of internal orbital fracture. Am J Ophthalmol 1957; 44:733–739 8. Park MS, Kim YJ, Kim H, et al. Prevalence of diplopia and extraocular movement limitation according to the location of isolated pure blowout fractures. Arch Plast Surg 2012;39:204–208 9. Glassman RD, Manson PN, Vanderkolk CA, et al. Rigid fixation of internal orbital fractures. Plast Reconstr Surg 1990;86:1103–1106 10. Polley JW, Ringler SL. The use of Teflon in orbital floor reconstruction following blunt facial trauma: a 20-year experience. Plast Reconstr Surg 1987;79:39–42 11. Rubin PAD, Bilyk RJ, Shore JW. Orbital reconstruction using porous polyethylene sheets. Ophthalmology 1994;101:1697–1704 12. Geer AJ, Lokeh A, Aldridge JH, et al. Safety of titanium mesh for orbital reconstruction. Ann Plast Surg 2002;48:1–7 13. Dougherty WR, Wellisz T. The natural history of alloplastic implant in orbital floor reconstruction: an animal model. J Craniofac Surg 1994;5:26–30 14. Eun SC, Heo CY, Baek RM, et al. Survey and review of blow out fracture. J Korean Soc Plast Reconstr Surg 2007;34:600–605 15. Ali SN, Gill P, Oikonomou D, et al. The combination of fibrin glue and quilting reduces drainage in the extended latissimus dorsi flap donorsite. Plast Reconstr Surg 2010;125:1615–1619 16. Man D, Plosker H, Winland-Brown JE. The use of autologous platelet-rich plasma (platelet gel) and autologous platelet-poor plasma (fibrin glue) in cosmetic surgery. Plast Reconstr Surg 2001; 107:229–237 17. Radosevich M, Goubran HI, Burnouf T. Fibrin sealant: scientific rationale, production methods, properties, and current clinical use. Vox Sang 1997;72:133–143

Osteoplastic Flap Approach Versus Orbitotomy in Case of Orbitofrontal Cholesterol Granuloma Abdulkadir Imre, MD,* Ercan Pinar, MD,* Irem Paker, MD,† Seher Saritepe Imre, MD,‡ Ridvan Duran, MD,* Sedat Ozturkcan, MD* Abstract: A 44-year-old man developed a slow-growing painless left superolateral orbital mass that extended into the frontal sinus with a complaint of ptosis. Magnetic resonance imaging revealed a heterogenous hyperintense lesion confined to the left frontal bone From the Departments of *Otorhinolaryngology, †Pathology, ‡Ophtalmology, Izmir Katip Çelebi University Ataturk Training and Research Hospital, Izmir, Turkey. Received July 4, 2014. Accepted for publication August 19, 2014. Address correspondence and reprint requests to Abdulkadir Imre, MD, Department of Otorhinolaryngology, Izmir Katip Çelebi University Ataturk Training and Research Hospital, 9200/1 sk No. 5 D:10 Camlikent Sitesi Karabaglar/Izmir, 35150 Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001296

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and superior orbit. The osteoplastic frontal sinus approach was performed to drain supraorbital cholesterol granuloma cyst and for curetting the capsule. Orbitofrontal cholesterol granuloma characteristically arises in the diploe of the superolateral frontal bone. The traditional approach for a primarily orbitofrontal cholesterol granuloma is the transorbital approach including anterior orbitotomy or lateral orbitotomy.However, the osteoplastic approach should be kept in mind as an alternative aprroach for the management of supraorbital lesions in patients with well-pneumatized frontal sinus. Key Words: Cholesterol granuloma, pneumosinus dilatans, frontal sinus, osteoplastic flap, orbitotomy

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holesterol granuloma is a chronic inflammatory process associated with foreign body reaction to hemorrhage-related cholesterol crystals. In the head and neck region, cholesterol granuloma most frequently arises in the pneumatized air cell of temporal bone, particularly in the petrous apex and middle ear cavity. However, it has been reported less frequently in several locations, such as the paranasal sinuses, orbit, frontal bone, breast, lungs, and peritoneum.1 Cholesterol granuloma is a benign lesion, but lesions involving the frontal bone erode adjacent facial skeleton and this slowly expanding lesion eventually breaks into the orbit, frontal sinus, skull base, or intracranial structures.2 Significant percentage of these lesions are treated by the ophthalmologist alone as other orbital tumors. However, collaboration with a neurosurgeon or a surgeon of eyes, nose, and throat may be required for larger and intracranial extended tumors. Here, we present a case of orbitofrontal cholesterol granuloma in a patient with pneumosinus dilatans frontalis, which enables surgical access to the orbital roof through an osteoplastic flap approach. The diagnosis and management of this lesion were discussed.

CASE REPORT A 44-year-old man was referred to our clinic with a complaint of left supraorbital mass and ptosis for the past 3 months. The patient reported a 2-year history of left upper eyelid fullness. His vision was 20/20, right eye and left eye, respectively. Ptosis and inferior vertical dystopia were noted on the left eye (Fig. 1). Ocular movement was completely restricted in the superior direction, whereas it is normal in other directions. There was no proptosis or enophthalmos noted. A 2  2-cm firm mass was palpable in the superolateral orbital region. The remaining ophthalmologic and otolaryngologic examinations were unremarkable. A computed tomographic scan revealed a well-defined supraorbital mass measuring 2.7  2.8  3.7 cm in the well-aerated frontal sinus with superior orbital wall erosion. Magnetic resonance imaging (MRI) demonstrated a predominantly hyperintense and heterogenous lesion on both T1-weighted and T2-weighted images, with inferior displacement of the ocular globe and intraconal contents. In T2 sequences, a thick hypointense ring around the lesion was noted

FIGURE 1. Preoperative and postoperative view of the patient. Ptosis and inferior vertical dystopia of the globe (left) as well as the scar of the brow incision at postoperative 1 month (right) are shown.

© 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

Fixation of fractured inferior orbital wall using fibrin glue in inferior blowout fracture surgery.

The objectives of surgical treatment for orbital fracture are to return soft tissue to its original position as well as reduce and fix the bone fragme...
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