RECONSTRUCTIVE SURGERY
Orbital Floor Reconstruction With Ethyl-2-Cyanoacrylate Hitoshi Nemoto, MD, PhD, Yoshinori Ito, MD, PhD, Yoshiaki Kasai, MD, Naoki Maruyama, MD, Naohiro Kimura, MD, PhD, and Noriyoshi Sumiya, MD, PhD Abstract: The orbital f loor is one of the most frequently broken bones in maxillofacial fracture, and orbital reconstruction is needed in many cases. Various materials are used for orbital f loor reconstruction. We report here orbital reconstruction using autologous orbital bone with cyanoacrylate. Entrapped soft tissues were freed and repositioned intraorbitally and bone fragments were gathered with a microscope simultaneously. The bone fragments were fixed to a board of bone with ethyl-2-cyanoacrylate and returned to the orbital fracture site. Of 96 fresh orbital floor fractures, this method was used for 31 (32.3%) patients. Simple reduction was performed in 48 patients. Bone graft with iliac crest was performed in the other 12 patients. Reconstruction with alloplastic materials was performed in 5 patients. Diplopia was corrected in 26 patients on whom this method was performed. The reconstructed bone collapsed into the maxillary sinus in 1 patient who underwent iliac bone graft on reoperation. Another 4 patients did not show diplopia preoperatively. None of the patients showed enophthalmos, foreign body reaction, or infection postoperatively. We were able to perform orbital bone reconstruction with autologous orbital bone without another donor site in 30 (62.5%) of 48 cases that required grafting. The indications for this method are that a sufficient quantity of bone fragments can be obtained and returned on a board of bone which can be stabilized in the orbit without collapsing into the maxillary sinus. Good results were obtained, and we consider this to be a safe and useful method. Key Words: orbital floor fracture, blowout fracture, orbital floor reconstruction, cyanoacrylate, glue, ethyl-2-cyanoacrylate, autologous bone graft (Ann Plast Surg 2015;74: 195Y198)
BACKGROUND The orbital f loor fracture is one of the most common maxillofacial fractures. Treatment goals are the improvement of diplopia and enophthalmos, and functional and aesthetic results are demanded. Because orbital bone is very thin, the fragments of bone are often comminuted and orbital reconstruction requires various materials. The autologous materials most frequently used are bone obtained from the calvaria, iliac crest, or rib, and cartilage from the nasal septum, auricle, or rib.1Y4 The most common alloplastic materials used are porous polyethylene, hydroxyapatite, poly-L-lactic acid, polyglycolic acid, silicone, or titanium mesh.5 The use of autologous materials is associated with problems such as limited quantity of material, morbidity of the donor site, and extended operative time. On the other hand, there are risks of infection and foreign substance reaction when using alloplastic materials.6 Received October 21, 2012, and accepted for publication, after revision, April 3, 2013. From the Department of Plastic and Reconstructive Surgery, Fujigaoka Hospital, Showa University School of Medicine, Yokohama, Kanagawa, Japan. Conflicts of interest and sources of funding: none declared. Reprints: Hitoshi Nemoto, MD, PhD, Department of Plastic and Reconstructive Surgery, Fujigaoka Hospital, Showa University School of Medicine, 1-30 Fujigaoka, Aoba-ku, Yokohama, Kanagawa 227-8501, Japan. E-mail: [email protected]. Copyright * 2013 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7402-0195 DOI: 10.1097/SAP.0b013e3182956596
Annals of Plastic Surgery
& Volume 74, Number 2, February 2015
Ideally, if autologous orbital bone can be used, it will be the most physiologic option available and there will be no risk of foreign substance reaction or donor-site morbidity. Ethyl-2-cyanoacrylate (ECA) is a tissue adhesive used since the 1960s for skin closure, cartilage fixation, and blood vessel embolism material, among others.7 Cyanoacrylate (CA) has been used with orbital bone, in the maxillary sinus, and for mandible fixation8Y10 and, in our experience, we consider it to be most useful for orbital floor bone fixation, although there have been no published reports on its use in the orbital floor to date.
PATIENTS AND METHODS We analyzed patients on whom fresh orbital f loor fracture surgeries were performed between 2006 and 2011. Our first choice of procedure was orbital reconstruction with ECA when some kind of transplant of the orbit bone was required. Autologous iliac bone transplants were performed on patients whose obit bone could not be reconstructed with ECA. Orbital reconstruction with alloplastic material was performed on patients who did not consent to an iliac bone transplant. Patients were diagnosed by computed tomography (CT) and evaluated for trauma of the ocular globe by ophthalmologists. The ophthalmologic examination included a Hess chart and Goldmann perimeter. The indications for surgery included impaired eye movement (diplopia), enophthalmos, and predictable enophthalmos in the future. In cases of pure blowout fracture, the approach was through a subcilliary incision, and a gingivobuccal incision was added in cases of orbitozygomatic fracture. After reaching the orbital rim, subperiosteal dissection was performed to visualize the entire orbital fracture with the microscope, to minimize damage to nerve and muscle, and to retrieve the bone fragments. Entrapped soft tissues were freed and repositioned intraorbitally, and the bone fragments were gathered simultaneously. The decision to perform autologous grafting with recovered fragments was made intraoperatively, depending on whether the gathered bone fragments were sufficient to cover the bone defect in a stable manner. Unless these conditions were met, iliac bone or alloplastic material transplants were performed. Each fragment was fixed to a board of bone with ECA (Aron alpha A; Sankyo, Tokyo, Japan) (Figs. 1A, B). The board of bone surface was smoothly filed with a surgical bur if needed (Fig. 1C), and this was returned to the orbital fracture. It is not necessary to fix the board of bone to an orbital rim and we confirmed the board did not collapse into the maxillary sinus by the weight of the contents of the orbit. Ocular movement rehabilitation was performed with a pendulum from the first postoperative day. Patients were evaluated for diplopia, visual acuity, enophthalmos, eyelid deformity, and infraorbital sensation, and objective ocular movement testing was performed with a Hess chart and Goldmann perimeter.
RESULTS Ninety-six fresh orbital f loor fracture surgeries were performed between 2006 and 2011. Simple reduction was performed in 48 patients. Orbital reconstruction with ECA was performed in 31 patients. Bone graft with iliac crest was performed on 12 patients. www.annalsplasticsurgery.com
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FIGURE 1. A, Orbital bone fragments gathered under a microscope. B, Fixation of each bone fragment with ECA to make the board of bone. C, The board of bone was smoothly filed as needed.
Reconstruction with alloplastic materials was performed in 5 patients (calcium phosphate paste on 2 cases and absorbable plate in 3 cases). The average age of patients who underwent surgery with ECA was 40 years (range, 18Y76 years), 18 men and 13 women. The period
from injury to operation ranged from 2 to 27 days (mean, 10 days) in patients who underwent surgical repair of the orbital floor with ECA. Patient follow-up ranged from 2 to 16 months (mean, 7.5 months). Of 31 patients who underwent this method, 27 complained of double
TABLE 1. Patient Summary Patient Age, y Sex 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
46 28 44 25 38 38 68 33 48 41 68 20 36 22 43 18 27 36 37 33 44 52 53 33 76 39 20 48 33 53 30
F F F M F M M M F F F M M M M M F M M F M M F F F F M M M M M
Cause
Orbit
Fracture Type
MVA Left Pure orbital MVA Right Orbitozygomatic Kick Right Pure orbital Fall on face Left Pure orbital Fist blow Left Pure orbital Baseball Left Pure orbital Fall Left Pure orbital Fist blow Left Pure orbital Fall Left Pure orbital Fall Left Pure orbital MVA Right Pure orbital Unknown Left Pure orbital Fist blow Bilateral Pure orbital Fist blow Left Pure orbital Fist blow Left Pure orbital Rugby Right Pure orbital Snowboard Right Pure orbital Fist blow Left Pure orbital Fall Left Pure orbital Fall Left Pure orbital Judo Left Pure orbital Fall Left Pure orbital Fall on face Right Pure orbital Fall Right Pure orbital Fall Right Pure orbital Unknown Right Pure orbital Kick Right Pure orbital Fist blow Bilateral Pure orbital Fall Left Pure orbital MVA Left Orbitozygomatic Rugby Right Pure orbital
Preoperative Findings Diplopia, numbness Diplopia, numbness Diplopia, numbness Diplopia Diplopia, numbness Nothing Diplopia Diplopia Diplopia Diplopia Diplopia Noting Diplopia Noting Diplopia Diplopia Diplopia, numbness Diplopia, numbness Noting Diplopia, numbness Diplopia Diplopia Diplopia Diplopia Diplopia Diplopia, numbness Diplopia Diplopia Diplopia Diplopia Diplopia
Duration From Injury to Surgery, d Follow-up, mo 7 12 12 4 27 9 4 6 13 3 16 2 9 10 9 10 9 2 7 6 7 17 9 26 0 18 17 11 8 11 13
15 13 5 6 4 6 4 2 14 5 3 4 12 3 12 16 6 12 2 16 6 6 7 10 6 4 4 12 6 6 6
Postoperative Findings No impairment No impairment No impairment No impairment No impairment No impairment No impairment No impairment No impairment Numbness No impairment No impairment Bone fell again. Reoperation No impairment No impairment No impairment No impairment Numbness No impairment No impairment No impairment No impairment No impairment Numbness No impairment No impairment No impairment No impairment No impairment No impairment No impairment
MVA indicates motor vehicle accident.
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Annals of Plastic Surgery
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Orbital Floor Reconstruction With ECA
FIGURE 2. A, Preoperative coronal CT images show a right blowout fracture. B, Five months after surgery, coronal CT images show retention of the returned bone and good configuration of the orbitae.
vision before the operation. Nine patients had infraorbital nerve impairment preoperatively. None of the patients had any problems with visual acuity either preoperatively or postoperatively. Diplopia in daily life was corrected in 26 patients. One patient had collapse of the reconstructed bone into the maxillary sinus, determined on CT 1 week after the surgery. The patient underwent iliac bone graft repair. None of the patients showed enophthalmos, foreign body reaction to ECA, or infection postoperatively. In patients with infraorbital nerve impairment, 7 of 9 patients showed improvement postoperatively; the other 2 patients showed no change. Three patients experienced new impairment after the surgery. In total, the 30 patients who underwent this method have improved (Table 1).
Case Presentations Case 3 A 44-year-old woman was kicked in the face. She complained of diplopia and supraduction impairment of the right eye. A blowout fracture of the right eye was apparent on CT. Orbital reconstruction with ECA was performed on day 13 after injury. She had no double vision or enophthalmos at 5 postoperative months (Fig. 2).
Case 30 A 53-year-old man fell off his bicycle. Computed tomography revealed left orbitozygomatic fracture. He complained of double vision on upward gaze. The operation was performed on day 11 after injury. Open reduction and internal fixation of the zygoma and orbital reconstruction with ECA were performed simultaneously. He
had no double vision or enophthalmos at 6 postoperative months (Fig. 3).
DISCUSSION Cyanoacrylate, developed in 1949 by Ardis,11 solidifies in a very short time and provides firm adherence.9 It demonstrates the ability to bond under moisture.9 Cyanoacrylate is a biodegradable and biocompatible substance12 and was first applied to surgery by Coover in 1959.13 Thereafter, CA has been used in many surgical situations, including skin closure,14 bone cartilage bonding,8,15 tendon repair,16 control of bleeding in cardiac surgery,17 sealing of retinal tears,18 closing leaking blebs after trabulectomy,19 anastomosis of blood vessels,20 and cartilaginous nasal support in rhinoplasty.15 In craniomaxillofacial surgeries, CA has been used in surgeries of orbital roof, anterior maxillary wall, frontal sinus fracture, and cranial bone defect and good results were reported.9,21,22 The glue was useful for small thin bone segments like those of the anterior maxillary wall.9 There are several CAs available: ECA, N-butyl-2-cyanoacrylate, and octyl-2-cyanoacrylate are the most well known. Ethyl-2cyanoacrylate was one of the first adhesives to be tested for medical use and exhibits excellent adhesive strength.23 However, in the presence of water or blood, CA ionizes and degrades to form cyanoacetate and formaldehyde. Both are cleared by the tissues and have tissue toxicity.13 The smaller the ester chain, the higher the adhesive strength and histotoxicity.13,24 Ethyl-2-cyanoacrylate has a smaller lateral chain than the others and therefore has greater adhesive strength and a short setting time.12 For this reason, when firm
FIGURE 3. A, Preoperative coronal CT images show left orbitozygomatic fracture. B, Three months after surgery, coronal CT images show retention of the returned bone and good configuration of the orbitae. * 2013 Wolters Kluwer Health, Inc. All rights reserved.
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fixation is required, ECA is preferred. Although the histotoxicity of ECA has been noted, no adverse effects were reported for its use as an adhesive with expanded polytetraf luoroethlane patches in the myocardium, aorta, and lung of rats25 or for anastomosis in the peripheral nerve of pigs.26 Some animal experiments have examined bone healing after using CA for bone fixation. Saska et al12 compared using ECA with screws for fixation of bone grafts to the calvaria of rabbits. Ethyl-2cyanoacrylate gradually degraded with time and bone healing started to arise with this degradation. The area of transplant bone in the ECA group was significantly larger than in the screw group because the stability of ECA was good. These findings suggest that completion of bone healing depends on the degradation rate and the amount of CA used. Ethyl-2-cyanoacrylate degrades more quickly than N-butyl-2cyanoacrylate, up to a period of 1 year.27 It is preferable to use the minimum quantity from which good fixation can be obtained. Although plates and screws are standard bone fixation tools in the repair of facial bone fracture, they cannot be used for orbital fracture repair due to the thinness and pulverization of the bone fragments. An ideal orbital bone reconstruction material would be one that has a structure similar to orbital bone, has similar contours, is displaced by bone, is easily broken to absorb shock to the ocular globe at second trauma to the orbit, can be handled easily, does not need a donor site, has no restriction on quantity, does not instigate foreign body reaction, is insusceptible, and is inexpensive. Although a material that fulfills all of these conditions does not exist at present, the method we performed in this study does fulfill most of these conditions. In addition, the glue does not interfere with magnetic resonance imaging or CT. Our method does not prolong operation time. It is easy to gather the bone fragments and reposition orbital contents under a microscope simultaneously. It takes only 5 to 10 minutes to fix bone fragments to make a board. In this study, 48 (50%) of 96 patients were treated by simple reduction and the remaining 48 (50%) required some kind of orbital bone reconstruction. It is significant that orbital bone reconstruction using autologous orbital bone could be performed without a donor in 30 (62.5%) of the 48 patients who had needed some kind of transplantation. The indications for this method are that a sufficient quantity of bone fragments can be recovered and returned fixed on a board of bone stabilized in the orbit without collapsing into the maxillary sinus. In particular, if a fracture is in the boundary region of the medial wall and f loor, the returned bone is often unstable. Naturally, the procedure is contraindicated when there is a history of allergic reactions to ECA. Although contact dermatitis28Y30 and asthma31,32 have been reported as allergic reactions to ECA, it is extremely rare.33
CONCLUSIONS Orbital bone reconstruction was feasible using the described method in 62.5% patients with fresh orbital f loor fracture requiring some kind of transplantation. Good results were obtained, and we considered the described method to be physiologic, useful, and safe. REFERENCES 1. Harsha BC, Turvey TA, Powers SK. Use of autogenous cranial bone grafts in maxillofacial surgery: a preliminary report. J Oral Maxillofac Surg. 1986; 44:11Y15. 2. Kontio RK, Laine P, Salo A, et al. Reconstruction of internal orbital wall fracture with iliac crest free bone graft: clinical, computed tomography, and magnetic resonance imaging follow-up study. Plast Reconstr Surg. 2006; 118:1365Y1374. 3. Johnson PE, Raftopoulos I. In situ splitting of a rib graft for reconstruction of the orbital floor. Plast Reconstr Surg. 1999;103:1709Y1711. 4. Manson PN. Facial fracture. In: Mathes SJ, ed. Mathes Plastic Surgery. Vol.3, 2nd ed. Philadelphia, Pa: Saunders Elsevier; 2006:77Y381.
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5. Magana FG, Arzac RM, De Hilario Aviles L. Combined use of titanium mesh and resorbable PLLA-PGA implant in the treatment of large orbital floor fractures. J Craniofac Surg. 2011;22:1991Y1995. 6. Courtney DJ, Thomas S, Whitfield PH. Isolated orbital blowout fractures: survey and review. Br J Oral Maxillofac Surg. 2000;38:496Y504. 7. Gul R, Khan F, Maher Y, et al. Osteochondral fractures in the knee treated with butyl-2-cyanoacrylate glue. A case report. Acta Orthop Belg. 2006;72: 641Y643. 8. Amarante MT, Constantinescu MA, O’Connor D, et al. Cyanoacrylate fixation of the craniofacial skeleton: an experimental study. Plast Reconstr Surg. 1995;95:639Y646. 9. Kim YO. Use of cyanoacrylate in facial bone fractures. J Craniofac Surg. 1997;8:229Y234; discussion 235. 10. Mehta MJ, Shah KH, Bhatt RG. Osteosynthesis of mandibular fractures with N-butyl cyanoacrylate: a pilot study. J Oral Maxillofac Surg. 1987;45: 393Y396. 11. Ardis AE. U.S. Patents No.2467926 and 2467927 (1949). 12. Saska S, Hochuli-Vieira E, Minarelli-Gaspar AM, et al. Fixation of autogenous bone grafts with ethyl-cyanoacrylate glue or titanium screws in the calvaria of rabbits. Int J Oral Maxillofac Surg. 2009;38:180Y186. 13. Shermak MA, Wong L, Inoue N, et al. Butyl-2-cyanoacrylate fixation of mandibular osteotomies. Plast Reconstr Surg. 1998;102:319Y324. 14. Kamer FM, Joseph JH. Histoacryl. Its use in aesthetic facial plastic surgery. Arch Otolaryngol Head Neck Surg. 1989;115:193Y197. 15. Sachs ME. Enbucrilate as cartilage adhesive in augmentation rhinoplasty. Arch Otolaryngol. 1985;111:389Y393. 16. Trail IA, Powell ES, Noble J, et al. The role of an adhesive (Histoacryl) in tendon repair. J Hand Surg Br. 1992;17:544Y549. 17. Robicsek F, Rielly JP, Marroum MC. The use of cyanoacrylate adhesive (Krazy Glue) in cardiac surgery. J Card Surg. 1994;9:353Y356. 18. Bovino JA, Marcus DF. Cyanoacrylate tissue adhesive in the management of recurrent retinal detachment caused by macular hole. Am J Ophthalmol. 1990;109:616. 19. Zalta AH, Wieder RH. Closure of leaking filtering blebs with cyanoacrylate tissue adhesive. Br J Ophthalmol. 1991;75:170Y173. 20. Takenaka H, Esato K, Ohara M, et al. Sutureless anastomosis of blood vessels using cyanoacrylate adhesives. Surg Today. 1992;22:46Y54. 21. Wiecko J, Karasiewicz P, Fruba J. Use of tissue adhesives in the reconstruction of the frontal sinus. Polim Med. 1980;10:165Y170. 22. Gonzalez E, Orta J, Quero C, et al. Ethyl-2-cyanoacrylate fixation of the cranial bone flap after craniotomy. Surg Neurol. 2000;53:288Y289. 23. Esteves JC, Borrasca AG, Aranega AM, et al. Histomorphometric analysis of the repair process of autogenous bone grafts fixed at rat calvaria with cyanoacrylate. J Appl Oral Sci. 2011;19:529Y534. 24. Farion KJ, Osmond MH, Hartling L, et al. Tissue adhesives for traumatic lacerations: a systematic review of randomized controlled trials. Acad Emerg Med. 2003;10:110Y118. 25. Kaplan M, Bozkurt S, Kut MS, et al. Histopathological effects of ethyl 2cyanoacrylate tissue adhesive following surgical application: an experimental study. Eur J Cardiothorac Surg. 2004;25:167Y172. 26. Rickett T, Li J, Patel M, et al. Ethyl-cyanoacrylate is acutely nontoxic and provides sufficient bond strength for anastomosis of peripheral nerves. J Biomed Mater Res A. 2009;90:750Y754. 27. Toriumi DM, Raslan WF, Friedman M, et al. Histotoxicity of cyanoacrylate tissue adhesives. A comparative study. Arch Otolaryngol Head Neck Surg. 1990;116:546Y550. 28. Belsito DV. Contact dermatitis to ethyl-cyanoacrylate-containing glue. Contact Dermatitis. 1987;17:234Y236. 29. Bruze M, Bjo¨rkner B, Lepoittevin JP. Occupational allergic contact dermatitis from ethyl cyanoacrylate. Contact Dermatitis. 1995;32:156Y159. 30. Conde-Salazar L, Rojo S, Guimaraens D. Occupational allergic contact dermatitis from cyanoacrylate. Am J Contact Dermat. 1998;9:188Y189. 31. Thomsen GF. Occupational asthma induced by cyanoacrylate glue [in Danish]. Ugeskr Laeger. 1994;156:5131Y5132. 32. Kopp SK, McKay RT, Moller DR, et al. Asthma and rhinitis due to ethylcyanoacrylate instant glue. Ann Intern Med. 1985;102:613Y615. 33. Isaksson M, Siemund I, Bruze M. Allergic contact dermatitis from ethylcyanoacrylate in an office worker with artificial nails led to months of sick leave. Contact Dermatitis. 2007;57:346Y347.
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Orbital Floor Reconstruction With Ethyl-2-Cyanoacrylate Hitoshi Nemoto, MD, PhD, Yoshinori Ito, MD, PhD, Yoshiaki Kasai, MD, Naoki Maruyama, MD, Naohiro Kimura, MD, PhD, and Noriyoshi Sumiya, MD, PhD Abstract: The orbital f loor is one of the most frequently broken bones in maxillofacial fracture, and orbital reconstruction is needed in many cases. Various materials are used for orbital f loor reconstruction. We report here orbital reconstruction using autologous orbital bone with cyanoacrylate. Entrapped soft tissues were freed and repositioned intraorbitally and bone fragments were gathered with a microscope simultaneously. The bone fragments were fixed to a board of bone with ethyl-2-cyanoacrylate and returned to the orbital fracture site. Of 96 fresh orbital floor fractures, this method was used for 31 (32.3%) patients. Simple reduction was performed in 48 patients. Bone graft with iliac crest was performed in the other 12 patients. Reconstruction with alloplastic materials was performed in 5 patients. Diplopia was corrected in 26 patients on whom this method was performed. The reconstructed bone collapsed into the maxillary sinus in 1 patient who underwent iliac bone graft on reoperation. Another 4 patients did not show diplopia preoperatively. None of the patients showed enophthalmos, foreign body reaction, or infection postoperatively. We were able to perform orbital bone reconstruction with autologous orbital bone without another donor site in 30 (62.5%) of 48 cases that required grafting. The indications for this method are that a sufficient quantity of bone fragments can be obtained and returned on a board of bone which can be stabilized in the orbit without collapsing into the maxillary sinus. Good results were obtained, and we consider this to be a safe and useful method. Key Words: orbital floor fracture, blowout fracture, orbital floor reconstruction, cyanoacrylate, glue, ethyl-2-cyanoacrylate, autologous bone graft (Ann Plast Surg 2015;74: 195Y198)
BACKGROUND The orbital f loor fracture is one of the most common maxillofacial fractures. Treatment goals are the improvement of diplopia and enophthalmos, and functional and aesthetic results are demanded. Because orbital bone is very thin, the fragments of bone are often comminuted and orbital reconstruction requires various materials. The autologous materials most frequently used are bone obtained from the calvaria, iliac crest, or rib, and cartilage from the nasal septum, auricle, or rib.1Y4 The most common alloplastic materials used are porous polyethylene, hydroxyapatite, poly-L-lactic acid, polyglycolic acid, silicone, or titanium mesh.5 The use of autologous materials is associated with problems such as limited quantity of material, morbidity of the donor site, and extended operative time. On the other hand, there are risks of infection and foreign substance reaction when using alloplastic materials.6 Received October 21, 2012, and accepted for publication, after revision, April 3, 2013. From the Department of Plastic and Reconstructive Surgery, Fujigaoka Hospital, Showa University School of Medicine, Yokohama, Kanagawa, Japan. Conflicts of interest and sources of funding: none declared. Reprints: Hitoshi Nemoto, MD, PhD, Department of Plastic and Reconstructive Surgery, Fujigaoka Hospital, Showa University School of Medicine, 1-30 Fujigaoka, Aoba-ku, Yokohama, Kanagawa 227-8501, Japan. E-mail: [email protected]. Copyright * 2013 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7402-0195 DOI: 10.1097/SAP.0b013e3182956596
Annals of Plastic Surgery
& Volume 74, Number 2, February 2015
Ideally, if autologous orbital bone can be used, it will be the most physiologic option available and there will be no risk of foreign substance reaction or donor-site morbidity. Ethyl-2-cyanoacrylate (ECA) is a tissue adhesive used since the 1960s for skin closure, cartilage fixation, and blood vessel embolism material, among others.7 Cyanoacrylate (CA) has been used with orbital bone, in the maxillary sinus, and for mandible fixation8Y10 and, in our experience, we consider it to be most useful for orbital floor bone fixation, although there have been no published reports on its use in the orbital floor to date.
PATIENTS AND METHODS We analyzed patients on whom fresh orbital f loor fracture surgeries were performed between 2006 and 2011. Our first choice of procedure was orbital reconstruction with ECA when some kind of transplant of the orbit bone was required. Autologous iliac bone transplants were performed on patients whose obit bone could not be reconstructed with ECA. Orbital reconstruction with alloplastic material was performed on patients who did not consent to an iliac bone transplant. Patients were diagnosed by computed tomography (CT) and evaluated for trauma of the ocular globe by ophthalmologists. The ophthalmologic examination included a Hess chart and Goldmann perimeter. The indications for surgery included impaired eye movement (diplopia), enophthalmos, and predictable enophthalmos in the future. In cases of pure blowout fracture, the approach was through a subcilliary incision, and a gingivobuccal incision was added in cases of orbitozygomatic fracture. After reaching the orbital rim, subperiosteal dissection was performed to visualize the entire orbital fracture with the microscope, to minimize damage to nerve and muscle, and to retrieve the bone fragments. Entrapped soft tissues were freed and repositioned intraorbitally, and the bone fragments were gathered simultaneously. The decision to perform autologous grafting with recovered fragments was made intraoperatively, depending on whether the gathered bone fragments were sufficient to cover the bone defect in a stable manner. Unless these conditions were met, iliac bone or alloplastic material transplants were performed. Each fragment was fixed to a board of bone with ECA (Aron alpha A; Sankyo, Tokyo, Japan) (Figs. 1A, B). The board of bone surface was smoothly filed with a surgical bur if needed (Fig. 1C), and this was returned to the orbital fracture. It is not necessary to fix the board of bone to an orbital rim and we confirmed the board did not collapse into the maxillary sinus by the weight of the contents of the orbit. Ocular movement rehabilitation was performed with a pendulum from the first postoperative day. Patients were evaluated for diplopia, visual acuity, enophthalmos, eyelid deformity, and infraorbital sensation, and objective ocular movement testing was performed with a Hess chart and Goldmann perimeter.
RESULTS Ninety-six fresh orbital f loor fracture surgeries were performed between 2006 and 2011. Simple reduction was performed in 48 patients. Orbital reconstruction with ECA was performed in 31 patients. Bone graft with iliac crest was performed on 12 patients. www.annalsplasticsurgery.com
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FIGURE 1. A, Orbital bone fragments gathered under a microscope. B, Fixation of each bone fragment with ECA to make the board of bone. C, The board of bone was smoothly filed as needed.
Reconstruction with alloplastic materials was performed in 5 patients (calcium phosphate paste on 2 cases and absorbable plate in 3 cases). The average age of patients who underwent surgery with ECA was 40 years (range, 18Y76 years), 18 men and 13 women. The period
from injury to operation ranged from 2 to 27 days (mean, 10 days) in patients who underwent surgical repair of the orbital floor with ECA. Patient follow-up ranged from 2 to 16 months (mean, 7.5 months). Of 31 patients who underwent this method, 27 complained of double
TABLE 1. Patient Summary Patient Age, y Sex 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
46 28 44 25 38 38 68 33 48 41 68 20 36 22 43 18 27 36 37 33 44 52 53 33 76 39 20 48 33 53 30
F F F M F M M M F F F M M M M M F M M F M M F F F F M M M M M
Cause
Orbit
Fracture Type
MVA Left Pure orbital MVA Right Orbitozygomatic Kick Right Pure orbital Fall on face Left Pure orbital Fist blow Left Pure orbital Baseball Left Pure orbital Fall Left Pure orbital Fist blow Left Pure orbital Fall Left Pure orbital Fall Left Pure orbital MVA Right Pure orbital Unknown Left Pure orbital Fist blow Bilateral Pure orbital Fist blow Left Pure orbital Fist blow Left Pure orbital Rugby Right Pure orbital Snowboard Right Pure orbital Fist blow Left Pure orbital Fall Left Pure orbital Fall Left Pure orbital Judo Left Pure orbital Fall Left Pure orbital Fall on face Right Pure orbital Fall Right Pure orbital Fall Right Pure orbital Unknown Right Pure orbital Kick Right Pure orbital Fist blow Bilateral Pure orbital Fall Left Pure orbital MVA Left Orbitozygomatic Rugby Right Pure orbital
Preoperative Findings Diplopia, numbness Diplopia, numbness Diplopia, numbness Diplopia Diplopia, numbness Nothing Diplopia Diplopia Diplopia Diplopia Diplopia Noting Diplopia Noting Diplopia Diplopia Diplopia, numbness Diplopia, numbness Noting Diplopia, numbness Diplopia Diplopia Diplopia Diplopia Diplopia Diplopia, numbness Diplopia Diplopia Diplopia Diplopia Diplopia
Duration From Injury to Surgery, d Follow-up, mo 7 12 12 4 27 9 4 6 13 3 16 2 9 10 9 10 9 2 7 6 7 17 9 26 0 18 17 11 8 11 13
15 13 5 6 4 6 4 2 14 5 3 4 12 3 12 16 6 12 2 16 6 6 7 10 6 4 4 12 6 6 6
Postoperative Findings No impairment No impairment No impairment No impairment No impairment No impairment No impairment No impairment No impairment Numbness No impairment No impairment Bone fell again. Reoperation No impairment No impairment No impairment No impairment Numbness No impairment No impairment No impairment No impairment No impairment Numbness No impairment No impairment No impairment No impairment No impairment No impairment No impairment
MVA indicates motor vehicle accident.
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Orbital Floor Reconstruction With ECA
FIGURE 2. A, Preoperative coronal CT images show a right blowout fracture. B, Five months after surgery, coronal CT images show retention of the returned bone and good configuration of the orbitae.
vision before the operation. Nine patients had infraorbital nerve impairment preoperatively. None of the patients had any problems with visual acuity either preoperatively or postoperatively. Diplopia in daily life was corrected in 26 patients. One patient had collapse of the reconstructed bone into the maxillary sinus, determined on CT 1 week after the surgery. The patient underwent iliac bone graft repair. None of the patients showed enophthalmos, foreign body reaction to ECA, or infection postoperatively. In patients with infraorbital nerve impairment, 7 of 9 patients showed improvement postoperatively; the other 2 patients showed no change. Three patients experienced new impairment after the surgery. In total, the 30 patients who underwent this method have improved (Table 1).
Case Presentations Case 3 A 44-year-old woman was kicked in the face. She complained of diplopia and supraduction impairment of the right eye. A blowout fracture of the right eye was apparent on CT. Orbital reconstruction with ECA was performed on day 13 after injury. She had no double vision or enophthalmos at 5 postoperative months (Fig. 2).
Case 30 A 53-year-old man fell off his bicycle. Computed tomography revealed left orbitozygomatic fracture. He complained of double vision on upward gaze. The operation was performed on day 11 after injury. Open reduction and internal fixation of the zygoma and orbital reconstruction with ECA were performed simultaneously. He
had no double vision or enophthalmos at 6 postoperative months (Fig. 3).
DISCUSSION Cyanoacrylate, developed in 1949 by Ardis,11 solidifies in a very short time and provides firm adherence.9 It demonstrates the ability to bond under moisture.9 Cyanoacrylate is a biodegradable and biocompatible substance12 and was first applied to surgery by Coover in 1959.13 Thereafter, CA has been used in many surgical situations, including skin closure,14 bone cartilage bonding,8,15 tendon repair,16 control of bleeding in cardiac surgery,17 sealing of retinal tears,18 closing leaking blebs after trabulectomy,19 anastomosis of blood vessels,20 and cartilaginous nasal support in rhinoplasty.15 In craniomaxillofacial surgeries, CA has been used in surgeries of orbital roof, anterior maxillary wall, frontal sinus fracture, and cranial bone defect and good results were reported.9,21,22 The glue was useful for small thin bone segments like those of the anterior maxillary wall.9 There are several CAs available: ECA, N-butyl-2-cyanoacrylate, and octyl-2-cyanoacrylate are the most well known. Ethyl-2cyanoacrylate was one of the first adhesives to be tested for medical use and exhibits excellent adhesive strength.23 However, in the presence of water or blood, CA ionizes and degrades to form cyanoacetate and formaldehyde. Both are cleared by the tissues and have tissue toxicity.13 The smaller the ester chain, the higher the adhesive strength and histotoxicity.13,24 Ethyl-2-cyanoacrylate has a smaller lateral chain than the others and therefore has greater adhesive strength and a short setting time.12 For this reason, when firm
FIGURE 3. A, Preoperative coronal CT images show left orbitozygomatic fracture. B, Three months after surgery, coronal CT images show retention of the returned bone and good configuration of the orbitae. * 2013 Wolters Kluwer Health, Inc. All rights reserved.
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fixation is required, ECA is preferred. Although the histotoxicity of ECA has been noted, no adverse effects were reported for its use as an adhesive with expanded polytetraf luoroethlane patches in the myocardium, aorta, and lung of rats25 or for anastomosis in the peripheral nerve of pigs.26 Some animal experiments have examined bone healing after using CA for bone fixation. Saska et al12 compared using ECA with screws for fixation of bone grafts to the calvaria of rabbits. Ethyl-2cyanoacrylate gradually degraded with time and bone healing started to arise with this degradation. The area of transplant bone in the ECA group was significantly larger than in the screw group because the stability of ECA was good. These findings suggest that completion of bone healing depends on the degradation rate and the amount of CA used. Ethyl-2-cyanoacrylate degrades more quickly than N-butyl-2cyanoacrylate, up to a period of 1 year.27 It is preferable to use the minimum quantity from which good fixation can be obtained. Although plates and screws are standard bone fixation tools in the repair of facial bone fracture, they cannot be used for orbital fracture repair due to the thinness and pulverization of the bone fragments. An ideal orbital bone reconstruction material would be one that has a structure similar to orbital bone, has similar contours, is displaced by bone, is easily broken to absorb shock to the ocular globe at second trauma to the orbit, can be handled easily, does not need a donor site, has no restriction on quantity, does not instigate foreign body reaction, is insusceptible, and is inexpensive. Although a material that fulfills all of these conditions does not exist at present, the method we performed in this study does fulfill most of these conditions. In addition, the glue does not interfere with magnetic resonance imaging or CT. Our method does not prolong operation time. It is easy to gather the bone fragments and reposition orbital contents under a microscope simultaneously. It takes only 5 to 10 minutes to fix bone fragments to make a board. In this study, 48 (50%) of 96 patients were treated by simple reduction and the remaining 48 (50%) required some kind of orbital bone reconstruction. It is significant that orbital bone reconstruction using autologous orbital bone could be performed without a donor in 30 (62.5%) of the 48 patients who had needed some kind of transplantation. The indications for this method are that a sufficient quantity of bone fragments can be recovered and returned fixed on a board of bone stabilized in the orbit without collapsing into the maxillary sinus. In particular, if a fracture is in the boundary region of the medial wall and f loor, the returned bone is often unstable. Naturally, the procedure is contraindicated when there is a history of allergic reactions to ECA. Although contact dermatitis28Y30 and asthma31,32 have been reported as allergic reactions to ECA, it is extremely rare.33
CONCLUSIONS Orbital bone reconstruction was feasible using the described method in 62.5% patients with fresh orbital f loor fracture requiring some kind of transplantation. Good results were obtained, and we considered the described method to be physiologic, useful, and safe. REFERENCES 1. Harsha BC, Turvey TA, Powers SK. Use of autogenous cranial bone grafts in maxillofacial surgery: a preliminary report. J Oral Maxillofac Surg. 1986; 44:11Y15. 2. Kontio RK, Laine P, Salo A, et al. Reconstruction of internal orbital wall fracture with iliac crest free bone graft: clinical, computed tomography, and magnetic resonance imaging follow-up study. Plast Reconstr Surg. 2006; 118:1365Y1374. 3. Johnson PE, Raftopoulos I. In situ splitting of a rib graft for reconstruction of the orbital floor. Plast Reconstr Surg. 1999;103:1709Y1711. 4. Manson PN. Facial fracture. In: Mathes SJ, ed. Mathes Plastic Surgery. Vol.3, 2nd ed. Philadelphia, Pa: Saunders Elsevier; 2006:77Y381.
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5. Magana FG, Arzac RM, De Hilario Aviles L. Combined use of titanium mesh and resorbable PLLA-PGA implant in the treatment of large orbital floor fractures. J Craniofac Surg. 2011;22:1991Y1995. 6. Courtney DJ, Thomas S, Whitfield PH. Isolated orbital blowout fractures: survey and review. Br J Oral Maxillofac Surg. 2000;38:496Y504. 7. Gul R, Khan F, Maher Y, et al. Osteochondral fractures in the knee treated with butyl-2-cyanoacrylate glue. A case report. Acta Orthop Belg. 2006;72: 641Y643. 8. Amarante MT, Constantinescu MA, O’Connor D, et al. Cyanoacrylate fixation of the craniofacial skeleton: an experimental study. Plast Reconstr Surg. 1995;95:639Y646. 9. Kim YO. Use of cyanoacrylate in facial bone fractures. J Craniofac Surg. 1997;8:229Y234; discussion 235. 10. Mehta MJ, Shah KH, Bhatt RG. Osteosynthesis of mandibular fractures with N-butyl cyanoacrylate: a pilot study. J Oral Maxillofac Surg. 1987;45: 393Y396. 11. Ardis AE. U.S. Patents No.2467926 and 2467927 (1949). 12. Saska S, Hochuli-Vieira E, Minarelli-Gaspar AM, et al. Fixation of autogenous bone grafts with ethyl-cyanoacrylate glue or titanium screws in the calvaria of rabbits. Int J Oral Maxillofac Surg. 2009;38:180Y186. 13. Shermak MA, Wong L, Inoue N, et al. Butyl-2-cyanoacrylate fixation of mandibular osteotomies. Plast Reconstr Surg. 1998;102:319Y324. 14. Kamer FM, Joseph JH. Histoacryl. Its use in aesthetic facial plastic surgery. Arch Otolaryngol Head Neck Surg. 1989;115:193Y197. 15. Sachs ME. Enbucrilate as cartilage adhesive in augmentation rhinoplasty. Arch Otolaryngol. 1985;111:389Y393. 16. Trail IA, Powell ES, Noble J, et al. The role of an adhesive (Histoacryl) in tendon repair. J Hand Surg Br. 1992;17:544Y549. 17. Robicsek F, Rielly JP, Marroum MC. The use of cyanoacrylate adhesive (Krazy Glue) in cardiac surgery. J Card Surg. 1994;9:353Y356. 18. Bovino JA, Marcus DF. Cyanoacrylate tissue adhesive in the management of recurrent retinal detachment caused by macular hole. Am J Ophthalmol. 1990;109:616. 19. Zalta AH, Wieder RH. Closure of leaking filtering blebs with cyanoacrylate tissue adhesive. Br J Ophthalmol. 1991;75:170Y173. 20. Takenaka H, Esato K, Ohara M, et al. Sutureless anastomosis of blood vessels using cyanoacrylate adhesives. Surg Today. 1992;22:46Y54. 21. Wiecko J, Karasiewicz P, Fruba J. Use of tissue adhesives in the reconstruction of the frontal sinus. Polim Med. 1980;10:165Y170. 22. Gonzalez E, Orta J, Quero C, et al. Ethyl-2-cyanoacrylate fixation of the cranial bone flap after craniotomy. Surg Neurol. 2000;53:288Y289. 23. Esteves JC, Borrasca AG, Aranega AM, et al. Histomorphometric analysis of the repair process of autogenous bone grafts fixed at rat calvaria with cyanoacrylate. J Appl Oral Sci. 2011;19:529Y534. 24. Farion KJ, Osmond MH, Hartling L, et al. Tissue adhesives for traumatic lacerations: a systematic review of randomized controlled trials. Acad Emerg Med. 2003;10:110Y118. 25. Kaplan M, Bozkurt S, Kut MS, et al. Histopathological effects of ethyl 2cyanoacrylate tissue adhesive following surgical application: an experimental study. Eur J Cardiothorac Surg. 2004;25:167Y172. 26. Rickett T, Li J, Patel M, et al. Ethyl-cyanoacrylate is acutely nontoxic and provides sufficient bond strength for anastomosis of peripheral nerves. J Biomed Mater Res A. 2009;90:750Y754. 27. Toriumi DM, Raslan WF, Friedman M, et al. Histotoxicity of cyanoacrylate tissue adhesives. A comparative study. Arch Otolaryngol Head Neck Surg. 1990;116:546Y550. 28. Belsito DV. Contact dermatitis to ethyl-cyanoacrylate-containing glue. Contact Dermatitis. 1987;17:234Y236. 29. Bruze M, Bjo¨rkner B, Lepoittevin JP. Occupational allergic contact dermatitis from ethyl cyanoacrylate. Contact Dermatitis. 1995;32:156Y159. 30. Conde-Salazar L, Rojo S, Guimaraens D. Occupational allergic contact dermatitis from cyanoacrylate. Am J Contact Dermat. 1998;9:188Y189. 31. Thomsen GF. Occupational asthma induced by cyanoacrylate glue [in Danish]. Ugeskr Laeger. 1994;156:5131Y5132. 32. Kopp SK, McKay RT, Moller DR, et al. Asthma and rhinitis due to ethylcyanoacrylate instant glue. Ann Intern Med. 1985;102:613Y615. 33. Isaksson M, Siemund I, Bruze M. Allergic contact dermatitis from ethylcyanoacrylate in an office worker with artificial nails led to months of sick leave. Contact Dermatitis. 2007;57:346Y347.
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