Orbit, 2014; 33(3): 189–192 ! Informa Healthcare USA, Inc. ISSN: 0167-6830 print / 1744-5108 online DOI: 10.3109/01676830.2014.900086
ORIGINAL ARTICLE
Microdebrider Use in Orbital Surgery Suzanne K. Freitag, Michael K. Yoon, Alison B. Callahan, N. Grace Lee, and Daniel R. Lefebvre Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts 02114, USA
ABSTRACT Purpose: To report the novel use of a sinus microdebrider for the removal of tissue during orbital surgery. Methods: This retrospective study reviewed the logs of 3 surgeons to identify patients who required orbital surgery during which the surgeon chose to use a sinus microdebrider with an open sky technique as a means of removing portions of the orbital tissue. Collected data included patient demographics, clinical examinations, pathologic diagnoses, radiologic studies, operative reports and, when available, photographs and intraoperative video. Results: Three patients were identified as having undergone orbital surgery assisted by the use of a sinus microdebrider. The first patient had an extensive, recurrent left orbital myxoid tumor. Debulking of this gelatinous, infiltrative mass was aided by the combined suction and cutting action of the microdebrider. Two cases involved orbital exenteration for infiltrative sino-orbital fungus infection resulting in a blind eye and frozen globe. Removal of orbital apical tissue during exenteration surgery was facilitated with the microdebrider. Conclusions: The characteristics of the sinus microdebrider make it a useful adjunct for orbital surgery, particularly in situations where tissue may be difficult to grasp and excise. Caution should be exercised whenever using this electrically powered tool due to its potential for rapid tissue destruction. Therefore, the microdebrider should only be used in cases in which there is little risk of damage to essential orbital structures. Keywords: Microdebrider, orbit, surgical technique
INTRODUCTION
METHODS
The microdebrider was patented in 1969 by Urban as a ‘‘vacuum rotary device.’’1 In its early years it was used in acoustic neuroma and arthroscopic surgeries, and in 1994 its use was reported in nasal surgery.2,3 New applications for this device continue to be developed, including recent reports in facial flap contouring4 and endoscopic dacryocystorhinostomy.5 Its use is now commonplace in endonasal surgery, although it has not previously been discussed in open orbital surgery. We report 3 cases in which the characteristics of the microdebrider were optimal to assist in the removal of difficult-to-handle orbital contents.
This retrospective chart review was performed with Institutional Review Board approval and in accordance with the tenets of the Declaration of Helsinki and the Health Insurance Portability and Accountability Act. Records were reviewed for patients who underwent orbitotomy assisted by the use of a sinus microdebrider in the practices of 3 surgeons from October 2009 to December 2012. Collected data included patient demographics, clinical examinations, pathologic diagnoses, radiologic studies, operative reports and, when available, photographs and intraoperative video.
Received 30 July 2013; Revised 22 January 2014; Accepted 17 February 2014; Published online 19 March 2014 Correspondence: Suzanne K. Freitag, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA. Tel: 617-573-5550. Fax: 617-573-5525. E-mail: [email protected]
189
190 S. K. Freitag et al.
RESULTS Case 1 A 79-year-old Caucasian woman presented with a 13-year history of a left orbital myxoid tumor. Because of pain and increasing tumor mass, she had required debulking surgeries every few years, with increasing frequency in recent years. It had not been possible to remove the lesion in its entirety because of its nonencapsulated, infiltrative nature and gelatinous texture. She was referred to our service for continued management. On examination, there was severe left afferent visual dysfunction with optic nerve pallor, negligible motility and changes consistent with severe chronic exposure of the ocular surface. Hertel exophthalmometry measured 20 mm on the right and greater than 35 mm on the left. The left globe
was laterally displaced, and there was tumor mass protruding beneath the skin of the lower lid greater than upper lid. (Figure 1A). Computed tomography (CT) demonstrated a lobulated mass filling the medial and posterior orbit (Figure 1B). The patient opted for aggressive surgical debulking and was not yet ready to consider orbital exenteration. The tumor was approached via a left lower eyelid infraciliary incision and a left medial upper lid crease incision. Intra-operatively, the loose, jelly-like composition of the tumor made it very difficult to grasp with forceps or dissect with a scissor or scalpel. The decision was made by the surgical team to employ a sinus microdebrider with a 4-mm Tricut blade set to oscillate at 5000/min (Straightshot M4 microdebrider, Medtronic Surgical Technologies, Minneapolis, MN) (Figure 2A–B). The tumor was isolated from the orbit with retractors and forceps while the microdebrider
FIGURE 1. External photograph of Patient 1 pre-operatively demonstrating severe proptosis and chemosis with tumor mass causing lower and medial upper eyelid fullness. Patient 1 axial CT slice demonstrating a lobulated mass filling the left medial and posterior orbit exerting mass effect on the abnormally contoured globe. There is disruption of the medial orbital wall secondary to previous orbital decompression surgery. External photograph of Patient 1 one week after microdebrider-assisted tumor debulking surgery demonstrating significantly reduced periorbital and eyelid fullness.
FIGURE 2. Image of straightshot M4 microdebrider (Medtronic Surgical Technologies). Rotating cutting tip implemented in described surgical technique. Orbit
Microdebrider Use in Orbital Surgery efficiently debulked the gelatinous tumor lobules. The microdebrider was used only in this open-sky technique with the plane of cutting above the orbital tissues. Continuous direct visualization of the tip was maintained during its use (video). Post-operatively, she had significant improvement in her pain and proptosis (Figure 1C).
Case 2 A 52-year-old man with a history of diabetes mellitus was transferred with suspicion for invasive fungal disease of the orbit, sinuses and face. He had a oneweek history of rapidly progressive ptosis, decreased extraocular motility and loss of facial sensation on the right. On examination, visual acuity was no light perception OD with complete right blepharoptosis, a frozen globe, right optic nerve pallor and edema, and retinal whitening. Radiographic imaging showed extensive right-sided mucosal thickening of the ethmoid and maxillary sinuses, and enhancement of the orbital fat, extraocular muscles, optic nerve and preseptal tissues. Nasal endoscopy revealed an anesthetic right nasopharynx with ulceration and necrosis of the middle turbinate. Biopsies of this mucosa revealed necrotic tissue with branching hyphae invading vasculature consistent with rhino-orbital mucormycosis. Emergent surgery combined with otolaryngology consisted of right orbital exenteration, maxillectomy and facial debridement of necrotic tissue. Eyelidsparing exenteration was initiated.6 After subperiosteal dissection in the orbit was completed, the anterior two-thirds of the orbital soft tissue was excised by transecting soft tissue with electrocautery. The remaining apical tissue was avascular and friable precluding purchase with forceps. Therefore, the microdebrider (Straightshot M4 microdebrider, Medtronic Surgical Technologies, Minneapolis, MN) and Xomed Power Source (XPS 3000, Medtronics/ Xomed, Jacksonville, FL, USA) with a 2 mm cutting blade set to oscillate at 3000/minute was used to excise this tissue. While using the device with an open sky, non-endoscopic technique, continuous visualization of the side port was maintained to prevent inadvertent damage to surrounding bone. Once the optic canal and superior and inferior orbital fissures were reached, a final margin of tissue was excised with scissors. The patient recovered well from his infection.
Case 3 A 64-year-old man with a history of diabetes mellitus and renal transplantation for IgA-related nephropathy reported binocular diplopia followed by severe visual !
2014 Informa Healthcare USA, Inc.
191
loss OD with right-sided retrobulbar headache, nausea and vomiting. On examination, visual acuity was no light perception OD with an afferent pupillary defect, and there was moderate dysmotility in all directions without proptosis. Dilated funduscopic examination revealed a cherry red spot and boxcarring within the retinal vasculature consistent with central retinal artery occlusion. MRI showed soft tissue enhancement in the right ethmoid sinus and right orbital apex with possible extension intracranially. Nasal endoscopy revealed a black but sensate middle turbinate. Surgical biopsy with endoscopic sinus debridement revealed Rhizopus species; the orbital apex biopsy did not contain fungal elements. Despite initiation of liposomal amphotericin and posaconazole with discontinuation of immunosuppresion, the patient continued to worsen, prompting the decision to exenterate the right orbit. An eyelid-sparing technique6 was employed for orbital exenteration. Necrotic lamina papyracea was removed with Kerrison rongeurs. For maximal apical debridement, the microdebrider (Straightshot M4 microdebrider, Medtronic Surgical Technologies, Minneapolis, MN) and Xomed Power Source (XPS 3000, Medtronics/Xomed, Jacksonville, FL, USA) with a 2 mm cutting blade set to oscillate at 3000/min was successfully employed via an open sky technique. Careful and continuous visualization of the side port was maintained to prevent inadvertent damage to tissues beyond the confines of the orbit. Despite aggressive surgical and medical intervention, the patient succumbed to complications of his infection.
DISCUSSION The microdebrider is an electrically powered device with a design and action analogous to a cutting vitrectomy probe (Figure 2A–B). It consists of an outer shaft with an oscillating or rotating inner cannula. Continuous suction pulls soft tissue into a side port near the tip, and the rotation of the serrated blade of the inner cannula cuts the tissue into small pieces which are then aspirated through plastic tubing by a stream of saline irrigation. The device is quite powerful and can excise soft tissue and thin bone in seconds. The combined cutting and suction action of the microdebrider was ideal for the cases in our series. In Case 1, where forceps and sharp dissection allowed only marginal purchase of the tumor, the microdebrider’s combined suction and cutting proved well-suited for removal of this gelatinous tissue. In the subsequent two cases involving exenteration for invasive fungal infection, after elevation of the periorbita, tissue in the orbital apex could be safely and efficiently aspirated by the microdebrider.
192 S. K. Freitag et al. By angling the side port away from the orbital walls, the opening could be directly visualized and risk of damage to the orbital bones or surrounding structures was minimized. Unlike previous reports of combined functional endoscopic sinus surgery and orbital exenteration via an endonasal approach,8 we utilized an open sky technique without an endoscope. Although not performed in the above cases, histopathologic examination of tissue excised with the microdebrider has been shown to be comparable to piece meal resected specimens using conventional instrumentation.7 An additional advantage of the microdebrider is its ability to improve visibility in the surgical field by continuously suctioning blood and tissue fragments. This allows the surgeon to expeditiously remove large amounts of tissue, thereby decreasing operative time. There are, however, disadvantages to using the microdebrider system. The initial capital expense and ongoing cost of disposable components is high compared with conventional instruments. There is much less tactile feedback when using the microdebrider compared with non-powered instruments. In addition, the sinus microdebrider, with its 11–13 cm shaft, is designed to be used in a deeper orifice than the orbit. This length in the comparably shallow space of the orbit can make instrument handling somewhat unwieldy. Although complications of microdebrider use are uncommon, they may occur rapidly because of the powerful nature of the device. Damage to orbital structures from endonasal use of the microdebrider, including extensive irreparable extraocular muscle damage,9,10 is well known to sinus and orbital surgeons and underscores the caution that must be exercised when using this device. The use of the microdebrider; therefore, should be employed in select situations such as profound visual loss in an
orbit with a large volume of tissue that is difficult or time-consuming to remove or cannot be removed with traditional means.
DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES 1. Urban, JC. Vacuum rotary dissector. US patent 3,618,611. November 9, 1971. 2. Setliff III RC. The hummer: a remedy for apprehension in functional endoscopic sinus surgery. Otolaryngol Clin North Am 1996;29:95–104. 3. Parsons DS. Rhinologic uses of powered instrumentation in children beyond sinus surgery. Otolaryngol Clin North Am 1996;29(1):105–114. 4. Poore SO, Mahajan AY, Israel JS, et al. Facial flap contouring using a sinus microdebrider. Plast Reconstr Surg 2013; 131(4):653e–655e. 5. Yoon SW, Yoon YS, Lee SH. Clinical results of endoscopic dacryocystorhinostomy using a microdebrider. Korean J Ophthalmol 2006;20(1):1–6. 6. Shields JA, Shields CL, Suvarnamani C, et al. Orbital extenteration with eyelid sparing: indications, technique, and results. Ophthalmic Surg 1991;22:292–297. 7. Zweig JL, Schaitkin BM, Fan CY, Barnes EL. Histopathology of tissue samples removed using the microdebrider technique: implications for endoscopic sinus surgery. Am J Rhinol 2000;14(1):27–32. 8. Batra PS, Lanza DC. Endoscopic power-assisted orbital exenteration. Am J Rhinology 2005;19:297–301. 9. Thacker NM, Velez FG, Demer JL, et al. Extraocular muscle damage associated with endoscopic sinus surgery: an ophthalmology perspective. Am J Rhinol 2005;19(4):400–405. 10. Bleier BS, Schlosser RJ. Prevention and management of medial rectus injury. Otolaryngol Clin North Am 2010; 43(4):901–907.
Orbit
Copyright of Orbit is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
ORIGINAL ARTICLE
Microdebrider Use in Orbital Surgery Suzanne K. Freitag, Michael K. Yoon, Alison B. Callahan, N. Grace Lee, and Daniel R. Lefebvre Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts 02114, USA
ABSTRACT Purpose: To report the novel use of a sinus microdebrider for the removal of tissue during orbital surgery. Methods: This retrospective study reviewed the logs of 3 surgeons to identify patients who required orbital surgery during which the surgeon chose to use a sinus microdebrider with an open sky technique as a means of removing portions of the orbital tissue. Collected data included patient demographics, clinical examinations, pathologic diagnoses, radiologic studies, operative reports and, when available, photographs and intraoperative video. Results: Three patients were identified as having undergone orbital surgery assisted by the use of a sinus microdebrider. The first patient had an extensive, recurrent left orbital myxoid tumor. Debulking of this gelatinous, infiltrative mass was aided by the combined suction and cutting action of the microdebrider. Two cases involved orbital exenteration for infiltrative sino-orbital fungus infection resulting in a blind eye and frozen globe. Removal of orbital apical tissue during exenteration surgery was facilitated with the microdebrider. Conclusions: The characteristics of the sinus microdebrider make it a useful adjunct for orbital surgery, particularly in situations where tissue may be difficult to grasp and excise. Caution should be exercised whenever using this electrically powered tool due to its potential for rapid tissue destruction. Therefore, the microdebrider should only be used in cases in which there is little risk of damage to essential orbital structures. Keywords: Microdebrider, orbit, surgical technique
INTRODUCTION
METHODS
The microdebrider was patented in 1969 by Urban as a ‘‘vacuum rotary device.’’1 In its early years it was used in acoustic neuroma and arthroscopic surgeries, and in 1994 its use was reported in nasal surgery.2,3 New applications for this device continue to be developed, including recent reports in facial flap contouring4 and endoscopic dacryocystorhinostomy.5 Its use is now commonplace in endonasal surgery, although it has not previously been discussed in open orbital surgery. We report 3 cases in which the characteristics of the microdebrider were optimal to assist in the removal of difficult-to-handle orbital contents.
This retrospective chart review was performed with Institutional Review Board approval and in accordance with the tenets of the Declaration of Helsinki and the Health Insurance Portability and Accountability Act. Records were reviewed for patients who underwent orbitotomy assisted by the use of a sinus microdebrider in the practices of 3 surgeons from October 2009 to December 2012. Collected data included patient demographics, clinical examinations, pathologic diagnoses, radiologic studies, operative reports and, when available, photographs and intraoperative video.
Received 30 July 2013; Revised 22 January 2014; Accepted 17 February 2014; Published online 19 March 2014 Correspondence: Suzanne K. Freitag, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA. Tel: 617-573-5550. Fax: 617-573-5525. E-mail: [email protected]
189
190 S. K. Freitag et al.
RESULTS Case 1 A 79-year-old Caucasian woman presented with a 13-year history of a left orbital myxoid tumor. Because of pain and increasing tumor mass, she had required debulking surgeries every few years, with increasing frequency in recent years. It had not been possible to remove the lesion in its entirety because of its nonencapsulated, infiltrative nature and gelatinous texture. She was referred to our service for continued management. On examination, there was severe left afferent visual dysfunction with optic nerve pallor, negligible motility and changes consistent with severe chronic exposure of the ocular surface. Hertel exophthalmometry measured 20 mm on the right and greater than 35 mm on the left. The left globe
was laterally displaced, and there was tumor mass protruding beneath the skin of the lower lid greater than upper lid. (Figure 1A). Computed tomography (CT) demonstrated a lobulated mass filling the medial and posterior orbit (Figure 1B). The patient opted for aggressive surgical debulking and was not yet ready to consider orbital exenteration. The tumor was approached via a left lower eyelid infraciliary incision and a left medial upper lid crease incision. Intra-operatively, the loose, jelly-like composition of the tumor made it very difficult to grasp with forceps or dissect with a scissor or scalpel. The decision was made by the surgical team to employ a sinus microdebrider with a 4-mm Tricut blade set to oscillate at 5000/min (Straightshot M4 microdebrider, Medtronic Surgical Technologies, Minneapolis, MN) (Figure 2A–B). The tumor was isolated from the orbit with retractors and forceps while the microdebrider
FIGURE 1. External photograph of Patient 1 pre-operatively demonstrating severe proptosis and chemosis with tumor mass causing lower and medial upper eyelid fullness. Patient 1 axial CT slice demonstrating a lobulated mass filling the left medial and posterior orbit exerting mass effect on the abnormally contoured globe. There is disruption of the medial orbital wall secondary to previous orbital decompression surgery. External photograph of Patient 1 one week after microdebrider-assisted tumor debulking surgery demonstrating significantly reduced periorbital and eyelid fullness.
FIGURE 2. Image of straightshot M4 microdebrider (Medtronic Surgical Technologies). Rotating cutting tip implemented in described surgical technique. Orbit
Microdebrider Use in Orbital Surgery efficiently debulked the gelatinous tumor lobules. The microdebrider was used only in this open-sky technique with the plane of cutting above the orbital tissues. Continuous direct visualization of the tip was maintained during its use (video). Post-operatively, she had significant improvement in her pain and proptosis (Figure 1C).
Case 2 A 52-year-old man with a history of diabetes mellitus was transferred with suspicion for invasive fungal disease of the orbit, sinuses and face. He had a oneweek history of rapidly progressive ptosis, decreased extraocular motility and loss of facial sensation on the right. On examination, visual acuity was no light perception OD with complete right blepharoptosis, a frozen globe, right optic nerve pallor and edema, and retinal whitening. Radiographic imaging showed extensive right-sided mucosal thickening of the ethmoid and maxillary sinuses, and enhancement of the orbital fat, extraocular muscles, optic nerve and preseptal tissues. Nasal endoscopy revealed an anesthetic right nasopharynx with ulceration and necrosis of the middle turbinate. Biopsies of this mucosa revealed necrotic tissue with branching hyphae invading vasculature consistent with rhino-orbital mucormycosis. Emergent surgery combined with otolaryngology consisted of right orbital exenteration, maxillectomy and facial debridement of necrotic tissue. Eyelidsparing exenteration was initiated.6 After subperiosteal dissection in the orbit was completed, the anterior two-thirds of the orbital soft tissue was excised by transecting soft tissue with electrocautery. The remaining apical tissue was avascular and friable precluding purchase with forceps. Therefore, the microdebrider (Straightshot M4 microdebrider, Medtronic Surgical Technologies, Minneapolis, MN) and Xomed Power Source (XPS 3000, Medtronics/ Xomed, Jacksonville, FL, USA) with a 2 mm cutting blade set to oscillate at 3000/minute was used to excise this tissue. While using the device with an open sky, non-endoscopic technique, continuous visualization of the side port was maintained to prevent inadvertent damage to surrounding bone. Once the optic canal and superior and inferior orbital fissures were reached, a final margin of tissue was excised with scissors. The patient recovered well from his infection.
Case 3 A 64-year-old man with a history of diabetes mellitus and renal transplantation for IgA-related nephropathy reported binocular diplopia followed by severe visual !
2014 Informa Healthcare USA, Inc.
191
loss OD with right-sided retrobulbar headache, nausea and vomiting. On examination, visual acuity was no light perception OD with an afferent pupillary defect, and there was moderate dysmotility in all directions without proptosis. Dilated funduscopic examination revealed a cherry red spot and boxcarring within the retinal vasculature consistent with central retinal artery occlusion. MRI showed soft tissue enhancement in the right ethmoid sinus and right orbital apex with possible extension intracranially. Nasal endoscopy revealed a black but sensate middle turbinate. Surgical biopsy with endoscopic sinus debridement revealed Rhizopus species; the orbital apex biopsy did not contain fungal elements. Despite initiation of liposomal amphotericin and posaconazole with discontinuation of immunosuppresion, the patient continued to worsen, prompting the decision to exenterate the right orbit. An eyelid-sparing technique6 was employed for orbital exenteration. Necrotic lamina papyracea was removed with Kerrison rongeurs. For maximal apical debridement, the microdebrider (Straightshot M4 microdebrider, Medtronic Surgical Technologies, Minneapolis, MN) and Xomed Power Source (XPS 3000, Medtronics/Xomed, Jacksonville, FL, USA) with a 2 mm cutting blade set to oscillate at 3000/min was successfully employed via an open sky technique. Careful and continuous visualization of the side port was maintained to prevent inadvertent damage to tissues beyond the confines of the orbit. Despite aggressive surgical and medical intervention, the patient succumbed to complications of his infection.
DISCUSSION The microdebrider is an electrically powered device with a design and action analogous to a cutting vitrectomy probe (Figure 2A–B). It consists of an outer shaft with an oscillating or rotating inner cannula. Continuous suction pulls soft tissue into a side port near the tip, and the rotation of the serrated blade of the inner cannula cuts the tissue into small pieces which are then aspirated through plastic tubing by a stream of saline irrigation. The device is quite powerful and can excise soft tissue and thin bone in seconds. The combined cutting and suction action of the microdebrider was ideal for the cases in our series. In Case 1, where forceps and sharp dissection allowed only marginal purchase of the tumor, the microdebrider’s combined suction and cutting proved well-suited for removal of this gelatinous tissue. In the subsequent two cases involving exenteration for invasive fungal infection, after elevation of the periorbita, tissue in the orbital apex could be safely and efficiently aspirated by the microdebrider.
192 S. K. Freitag et al. By angling the side port away from the orbital walls, the opening could be directly visualized and risk of damage to the orbital bones or surrounding structures was minimized. Unlike previous reports of combined functional endoscopic sinus surgery and orbital exenteration via an endonasal approach,8 we utilized an open sky technique without an endoscope. Although not performed in the above cases, histopathologic examination of tissue excised with the microdebrider has been shown to be comparable to piece meal resected specimens using conventional instrumentation.7 An additional advantage of the microdebrider is its ability to improve visibility in the surgical field by continuously suctioning blood and tissue fragments. This allows the surgeon to expeditiously remove large amounts of tissue, thereby decreasing operative time. There are, however, disadvantages to using the microdebrider system. The initial capital expense and ongoing cost of disposable components is high compared with conventional instruments. There is much less tactile feedback when using the microdebrider compared with non-powered instruments. In addition, the sinus microdebrider, with its 11–13 cm shaft, is designed to be used in a deeper orifice than the orbit. This length in the comparably shallow space of the orbit can make instrument handling somewhat unwieldy. Although complications of microdebrider use are uncommon, they may occur rapidly because of the powerful nature of the device. Damage to orbital structures from endonasal use of the microdebrider, including extensive irreparable extraocular muscle damage,9,10 is well known to sinus and orbital surgeons and underscores the caution that must be exercised when using this device. The use of the microdebrider; therefore, should be employed in select situations such as profound visual loss in an
orbit with a large volume of tissue that is difficult or time-consuming to remove or cannot be removed with traditional means.
DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES 1. Urban, JC. Vacuum rotary dissector. US patent 3,618,611. November 9, 1971. 2. Setliff III RC. The hummer: a remedy for apprehension in functional endoscopic sinus surgery. Otolaryngol Clin North Am 1996;29:95–104. 3. Parsons DS. Rhinologic uses of powered instrumentation in children beyond sinus surgery. Otolaryngol Clin North Am 1996;29(1):105–114. 4. Poore SO, Mahajan AY, Israel JS, et al. Facial flap contouring using a sinus microdebrider. Plast Reconstr Surg 2013; 131(4):653e–655e. 5. Yoon SW, Yoon YS, Lee SH. Clinical results of endoscopic dacryocystorhinostomy using a microdebrider. Korean J Ophthalmol 2006;20(1):1–6. 6. Shields JA, Shields CL, Suvarnamani C, et al. Orbital extenteration with eyelid sparing: indications, technique, and results. Ophthalmic Surg 1991;22:292–297. 7. Zweig JL, Schaitkin BM, Fan CY, Barnes EL. Histopathology of tissue samples removed using the microdebrider technique: implications for endoscopic sinus surgery. Am J Rhinol 2000;14(1):27–32. 8. Batra PS, Lanza DC. Endoscopic power-assisted orbital exenteration. Am J Rhinology 2005;19:297–301. 9. Thacker NM, Velez FG, Demer JL, et al. Extraocular muscle damage associated with endoscopic sinus surgery: an ophthalmology perspective. Am J Rhinol 2005;19(4):400–405. 10. Bleier BS, Schlosser RJ. Prevention and management of medial rectus injury. Otolaryngol Clin North Am 2010; 43(4):901–907.
Orbit
Copyright of Orbit is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
