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Orbital Floor Restoration Using the Transnasal Balloon Technique for Inferior Orbital Wall Fracture Nam Kyu Lim, MD, Dong Hee Kang, MD, PhD, Sang Ah Oh, MD, and Ja Hea Gu, MD, PhD
Background: Restoring the volume of orbital fracture is a challenge to the surgeons. We combined the transnasal balloon technique and the transorbital approach during orbital f loor reconstruction, and compared the outcomes of this technique with those of the conventional transorbital approach. Methods: Patients with unilateral pure orbital floor fracture were divided according to the surgical method: the direct transconjunctival approach (group A, 20 patients, control group) or the combination approach with the transnasal balloon technique (group B, 20 patients, experimental group). The orbital volume ratio (OVR) was measured with the use of computed tomographic scans, and enophthalmos was checked with a Hertel exophthalmometer. Results: The orbital volume ratios in both groups decreased after surgery: it was more effectively decreased in group B (7.88%) than that in group A (1.69%) (P G 0.05). Conclusions: A combination of transconjunctival exploration and transnasal restoration with balloon support was more effective in restoring the orbital volume than the conventional method. Key Words: blowout fracture, enophthalmos (Ann Plast Surg 2015;75: 522Y525)
M
ethods to approach the orbital f loor for the pure inferior orbital wall fracture have been either the direct transorbital approach from the eyelid or the indirect transantral approach from the maxillary sinus.1 Transorbital approaches such as the transconjunctival and transcutaneous incision are commonly used methods that provide a wide view of the inferior wall and sufficient exposure for implant placement.1 However, these eyelid approaches have caused some complications such as ectropion and lid shortening. Recently, the orbital f loor surgery through the maxillary sinus with an endoscope has become an alternative to the transorbital technique.2Y4 Use of an endoscope provides a clear view of the orbital f loor from the maxillary sinus and could be useful for achieving accurate reduction.1Y3 However, destruction of the anterior wall of the maxilla is inevitable when inserting an endoscope into the maxillary sinus, and it is difficult to place a large implant on the orbital side with this transantral approach.4 A combination of the transorbital and transantral method has been introduced by several surgeons to make up for the weakness of those approaches.1,5 With this dual approach, the prolapsed orbital contents and fractured orbital f loor can be easily restored to their prior position from the transantral side. The orbital f loor
Received December 4, 2013, and accepted for publication, after revision, January 28, 2014. From the Department of Plastic and Reconstructive Surgery, Dankook University Hospital, Cheonan, Chungnam, Republic of Korea. Conf licts of interest and sources of funding: Dr Kang conducted this study with the research fund of Dankook University in 2012. No disclosures for the remaining authors. Reprints: Dong Hee Kang, MD, PhD, Department of Plastic and Reconstructive surgery, Dankook University Hospital, 359 Manghyang-ro, Dongnam-gu, Cheonan, Chungnam 330-715, Republic of Korea. E-mail: [email protected]. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7505Y0522 DOI: 10.1097/SAP.0000000000000184
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restoration can be confirmed and an implant over the bony defect can be placed easily with the transorbital view. In this study, we combined the transnasal balloon technique and the transorbital approach during orbital floor surgery. We avoided an incision to the oral mucosa and maxillary ostectomy with the transnasal approach, and used transnasal inf lation of a Foley catheter to provide additional support to the restored orbital f loor. The aim of this study was to compare the outcomes of our technique with those of the conventional transorbital approach in inferior orbital wall fracture.
MATERIALS AND METHODS Subjects The retrospective study group consisted of 40 patients with a unilateral pure orbital f loor fracture who underwent orbit reconstruction surgery between March 2007 and September 2012. The study was approved by the institutional review board. The patients were divided into 2 groups according to the surgical methods used: the direct transconjunctival approach (group A, control group) or the combined approach with transnasal balloon technique (group B, experimental group). There were 36 men and 4 women, aged 16 to 45 years with a mean of 26.9 years. The average time of surgery was 7.4 days after injury (range, 3Y14 days). The most common cause was assault trauma (23 cases), followed by slipping (9 cases), traffic accidents (5 cases), and falling (3 cases). The surgical criteria were (1) limitation of extraocular movement, (2) radiographic evidence of extensive fracture [fracture size 9 2 cm2 on computed tomographic (CT) scans], (3) patient complaint of diplopia, or (4) enophthalmos (92 mm).
Ophthalmic Examination All surgical candidates underwent preoperative ophthalmic examinations for diplopia and extraocular muscle movement. The degree of enophthalmos was measured with a Hertel exophthalmometer (Inami Inc, Tokyo, Japan), and the scale was defined as the difference between both eyes by measuring from the lateral orbital rim to the apex of the cornea. To minimize error, a single surgeon measured 3 times in each patient consecutively, and the average value was calculated. Preoperative values were obtained 1 day before surgery to minimize the inf luence of facial edema. The clinical follow-up was performed at 1 week, 1 month, 6 months, and 1 year after treatment. Postoperative Hertel measurements were delayed until 1 year after surgery when the processes of atrophy and scarring of the orbital soft tissue were complete.
CT Scans and Orbital Volume Measurements Three-dimensional CT scans (GE Lightspeed VCT; GE Healthcare, Milwaukee, Wis), which were useful to visualize the globe and extraocular muscles, were used to obtain continuous 2.5-mm-thick axial and coronal slices. All patients underwent CT scans within 1 week after trauma and at 6 months after surgery. The Rapidia Image Postprocessing System (Infinitt Co, Ltd, Seoul, Korea) was used to measure orbital volume by tracing the orbital boundary on each image. Orbital volume was calculated by summing the volumes of each slice, which involved averaging the areas of 2 adjacent scan sections and multiplying Annals of Plastic Surgery
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that average by the coronal section thickness. The contralateral orbital volume was used as a control to standardize the individual orbital volume differences. Orbital volume ratio (OVR) was obtained by dividing the volume of the traumatized orbit by that of the control side. The postoperative OVR was measured in the same manner.
Surgical Techniques Direct Transconjunctival Approach (Group A, Control Group) A forced duction test was first performed under general anesthesia to evaluate passive mobility of the globe. An incision was made from the precaruncular area to the lateral orbital fissure at 3 mm below the lower eyelid tarsal plate. A direct plane of dissection was then created and followed over the orbital septum to the inferior orbital rim. The incision was extended laterally with canthotomy. The orbital septum was separated from the inferior orbital rim. The fractured orbital f loor was revealed through the subperiosteal space. The herniated orbital contents were repositioned back into the orbit, and fractured orbital wall was reconstructed with Synpor (Synthes, Inc, West Chester, Pa). After the fracture was reconstructed, the dissected periosteum and the conjunctival incision were sutured in a standard fashion.
Transnasal Restoration With Balloon Support
Combination Approach With Transnasal Balloon Technique (Group B, Experimental Group) Under general anesthesia, a transconjunctival incision with lateral canthotomy incision was performed in the same manner mentioned previously, and the orbital f loor was dissected. After the nasal cavity was decongested with epinephrine pledgets, 2% lidocaine with 1:100,000 epinephrine was injected into the anterior root of the middle turbinate and the uncinate process. Through the maxillary ostium, a curved Freer elevator was passed into the sinus (Fig. 1). The bone fragment and the prolapsed orbital contents were gently raised from the antrum with the Freer elevator under the orbital view. After the herniated orbital contents were repositioned back into the orbital cavity, the fractured orbital floor was mobilized to its original position. Then, the balloon portion of the 16 Fr Foley catheter (Sewoon Medical Co, Ltd, Seoul, Korea) was held in a curved mosquito, passed through the nostril, and inserted into the maxillary ostium (Fig. 2). With the view from the orbit, a volume of physiologic saline solution appropriate for each patient ranging from 5 to 15 mL was injected into the balloon until the orbital floor was anatomically restored. During the injection, care was taken not to entrap the orbital contents between the bone fragments and not to increase orbital pressure by overinf lating the balloon. Synpor was shaped to the right size to bridge the defect, and it was adapted to the orbital f loor without
FIGURE 1. The fractured orbital f loor was restored to its original position with curved elevator and maintained using the transnasal balloon technique. A, An illustration shows a curved Freer elevator restoring the fractured orbital f loor transnasally. B, An illustration shows a ballooned Foley catheter supporting the restored inferior orbital wall. C, An intraoperative radiography of transnasal restoration of the fractured inferior wall with a curved elevator. D, An intraoperative radiography indicating that the Foley catheter held in a curved mosquito to introduce the maxillary ostium. E, Preoperative CT scan image. F, Postoperative CT scan image shows fractured orbital f loor was restored to prior position and supported with ballooned Foley catheter. * 2014 Wolters Kluwer Health, Inc. All rights reserved.
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FIGURE 2. The fractured left orbital f loor was restored with the transnasal balloon technique through the left maxillary ostium. A, An anatomical model shows the location of the maxillary ostium. B, An endoscopic image shows the Foley catheter entering through the maxillary ostium (white arrow) and inf lated with physiologic saline solution in maxillary sinus. C, A postoperative CT scan shows the Foley catheter entering through the maxillary ostium (white arrow).
fixation. A forced duction test was carried out to ensure free movement without entrapment. The tube of the Foley catheter was fixed on the cheek. The balloon support was kept in position for 7 to 8 days.
Statistical Analysis Measurements of OVR and Hertel scale were analyzed for statistically significant differences between groups using the MannWhitney test or Wilcoxon signed rank test. A P value less than 0.05 was considered significant. All analyses were performed using SPSS ver. 12.0 for Windows (SPSS, Inc, Chicago, Ill).
RESULTS Ophthalmic Examinations This study included 40 patients (20 in each group). Nineteen of the patients had diplopia (6 patients in group A and 13 in group B) and 10 patients had limited extraocular movement (5 patients in each group) before surgery. All patients recovered completely after surgery from ocular dysfunctions such as diplopia and extraocular movement limitation. Preoperative enophthalmos measured with Hertel exophthalmometer averaged of j0.55 mm in group A and j1.00 mm in group B. The postoperative Hertel scale was j0.40 mm in group A and j0.55 mm in group B; the changes in the Hertel scale were 0.15 mm in group A and 0.45 mm in group B. Neither the difference between the preoperative and postoperative Hertel scale in each group nor a comparison between the 2 groups was statistically significant (P 9 0.05) (Table 1).
CT Scans and Orbital Volume Measurements The preoperative difference in the OVR between the 2 groups (j1.08%) was not significant (109.68% in group A and 110.76% in TABLE 1. Preoperative and Postoperative Hertel Scale in Each Group
Group A Group B
n
Preoperative Hertel Scale, mm
Postoperative Hertel Scale, mm
$Hertel Scale
20 20
j0.55 j1.00
j0.40 j0.55
0.15* 0.45*
*P 9 0.05, no significant difference. n indicates number of patients.
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group B). Postoperative CT scans taken 6 months after surgery showed a significantly decreased OVR in both groups by volumetric analysis (107.99% in group A and 102.87% in group B); the OVR had decreased more on average in group B (7.88%) than group A (1.69%) (P G 0.05) (Table 2).
DISCUSSION Reconstruction of orbital f loor fractures that are complicated or deeply located in the bony orbit is still a challenge to the surgeon, and various approaches with different paths have been reported. A transantral approach with the aid of an endoscope has been recently introduced to restore the fractured orbital f loor. In contrast to traditional transorbital methods, this approach produces a clear view of the orbital f loor from the maxillary sinus.1Y3 Although the endoscopic surgery provided magnified vision of the fracture from the maxillary sinus, the condition of the orbital cavity could not be checked and it was difficult to disengage the trapped orbital contents or extraocular muscles and to restore the orbital f loor exactly to its prior position. In addition, several authors who performed endoscopic orbital reconstruction with a transantral approach required a maxillary antrostomy to introduce the endoscope or alloplastic materials,4 and they encountered inevitable problems such as numbness of the alveolus after surgery.1 Furthermore, the maxillary ostectomy made it impossible to apply this method in pediatric patients with unerupted maxillary teeth.1 In this study, we use a transnasal approach to access the maxillary sinus instead of using a transantral approach to avoid the destruction of the maxillary anterior wall. Dissection through the transconjunctival approach provided an adequate space to insert the proper size implant and transnasal restoration allowed for repositioning the herniated soft tissue back into the orbit with minimal traction injury. Orbital fracture with large f loor defects often produce unfavorable results such as enophthalmos.4,6 The thin f lexible implant spanning the wide gap of f loor defect are often displaced back into the maxillary sinus and result in reherniation of orbital tissue after surgery. We mobilized the fractured orbital f loor to cover the defect from the sinus, expecting it to prevent the reherniation of implant after surgery. To maintain the restored bony floor in their prior position during the healing process, the Foley balloon held up the wall from the maxillary sinus in early period, and the implant was opposed as a barrier against intraorbital pressure from the orbital side until the healing was completed. Therefore, a combined approach with * 2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Transnasal Restoration With Balloon Support
TABLE 2. Preoperative and Postoperative Orbital Volume Ratio in Each Group Orbital Volume Ratio, % Unaffected Orbit
Affected Orbit
n Group A Group B AjB
20 20
Preoperative
Postoperative
Volume Change
109.68 110.76 Y1.08
107.99 102.87 5.12
1.69* 7.88* j6.19†
100 100
*Significant difference, P G 0.05 Wilcoxon signed rank test. †Significant difference, P G 0.05 Mann-Whitney test. n indicates number of patients.
the transnasal balloon support would be more effective for restoring the orbital f loor in large inferior orbital wall fracture without reherniation of soft tissue. Since supporting method of the restored orbital f loor with an antral balloon was first reported by Johnson in 1944, many authors introduced the surgical technique with the balloon for restoration and maintenance of the orbital f loor.7,8 A Foley balloon catheter is a durable, f lexible, and adjustable implant for temporary support that can be easily removed in the outpatient clinic.4 The antral ballooning technique allows simple and rapid restoration of orbital f loor fractures, but a complication of acute visual acuity loss after surgery by overinf lation of the balloon has been reported.7 To overcome these shortcomings, monitoring the bony restoration and the proper placement of the implant from the orbital side will make the ballooning technique safer and more precise. We used the maxillary ostium to pass a curved Freer elevator and Foley catheter into the maxillary sinus to restore and to support the orbit (Fig. 2). A working knowledge of the complex anatomy of the nasal cavity is required to insert the surgical instruments through the maxillary ostium successfully without inadvertent trauma to the surrounding structures. The width of the nasal cavity from the septum to the maxillary ostium has been previously measured as 11 mm.9 Although the location of the maxillary ostium varies, it occurs at an average of 12 mm from the medial anterior wall of the sinus.10 Instruments should be bent enough to pass the angled opening to enter the maxillary sinus from the nasal cavity.11 We use a Hertel exophthalmometer and CT volume measurements to evaluate our surgical results. The Hertel exophthalmometer is a tool used widely to measure enophthalmos, which is an indicator of the surgical outcome from blowout fractures.12 However, there are objections to its use based on its low reliability and poor repeatability.12Y14 Moreover, an accurate measurement of a globe depression cannot be made in patients with an orbital fracture who have undergone surgery within 7 to 10 days after injury due to posttraumatic edema. In our study, the improvements of Hertel values were 0.15 mm (group A) and 0.45 mm (group B). Although perioperative changes in the Hertel measurements were statistically insignificant, orbital volume decreased significantly in both groups. Relatively insignificant changes in the Hertel scale may have been caused by the periorbital edema, which can result in an underestimation of enophthalmos.13 If a convenient CT program to measure orbital volume is developed in the future, volume measurement could predict the enophthalmos, and it could be used as a surgical guideline for early reconstruction in patients with edema.13 Despite our encouraging results, this study had limitations as it was a retrospective chart review with a limited sample size. This study focused on the difference in the volumetric changes after surgery, which represents the surgical achievements in treating enophthalmos. In other ophthalmic symptoms such as diplopia, ocular movement should also be estimated for the functional recovery. Fortunately, ocular dysfunction was not observed in any of our patients in * 2014 Wolters Kluwer Health, Inc. All rights reserved.
the first year after surgery. We expect that further research with larger samples having such complications would allow for a more precise comparison between the 2 different surgical techniques.
CONCLUSIONS The authors performed surgical repair of orbital f loor fractures using a combined technique of transconjunctival exploration and transnasal reduction with balloon support through the maxillary ostium. This was demonstrated as more effective for restoring the OVR than that of the conventional transorbital method. We suggest that a combined approach with the transnasal balloon technique is useful for restoring the orbital volume in patients with inferior orbital wall fractures. REFERENCES 1. Kakibuchi M, Fukazawa K, Fukuda K, et al. Combination of transconjunctival and endonasal-transantral approach in the repair of blowout fractures involving the orbital floor. Br J Plast Surg. 2004;57:37Y44. 2. Chen CT, Chen YR. Application of endoscope in orbital fractures. Craniomaxillofac Trauma Reconstr. 2002;16:241Y250. 3. Saunders CJ, Whetzel TP, Strokes RG, et al. Transantral endoscopic orbital floor exploration: a cadaver and clinical study. Plast Reconstr Surg. 1997; 100:575Y581. 4. Farwell DG, Strong EB. Endoscopic repair of orbital floor fractures. Facial Plast Surg Clin North Am. 2006;14:11Y16. 5. Shi W, Jia R, Li Z, et al. Combination of transorbital and endoscopic transnasal approaches to repair orbital medial wall and floor fractures. J Craniofac Surg. 2012;23:71Y74. 6. Rodriguez ED, Dorafshar AH, Manson PN. Facial fractures. In: Neligan PC, ed. Plastic Surgery volume 3. Philadelphia, Pa: Saunders Elsevier; 2013: 53Y57. 7. Rosbe KW, Meredith SD, Holmes DK. Complication of maxillary sinus Foley balloon placement for orbital floor support. Otolaryngol Head Neck Surg. 1997;117:S148YS150. 8. Miki T, Wada J, Haraoka J, et al. Endoscopic transmaxillary reduction and balloon technique for blowout fractures of the orbital floor. Minim Invasive Neurosurg. 2004;47:359Y364. 9. Hall JE, Becker SS, Duncavage JA. Nasal cavity measurements using computed tomography scanning. Poster Session Presented at the Combined Otolaryngology Spring Meetings (COSM), Chicago, IL: 2011:94. 10. Moore CC, Bromwich M, Roth K, et al. Endoscopic anatomy of the orbital floor and maxillary sinus. J Craniofac Surg. 2008;19:271Y276. 11. Brodner D, Alexander I, Chandler S, et al. Accuracy of transnasal cannulation and dilation of the maxillary ostium in cadavers with intact uncinates. Am J Rhinol Allergy. 2013;27:58Y61. 12. Musch DC, Frueh BR, Landis JR. The reliability of Hertel exophthalmometry. Ophthalmology. 1985;92:1177Y1180. 13. Oh SA, Aum JH, Kang DH, et al. Change of the orbital volume ratio in pure blow-out fractures depending on fracture location. J Craniofac Surg. 2013; 24:1083Y1087. 14. Sung YS, Chung CM, Hong IP. The correlation between the degree of enophthalmos and the extent of fracture in medial orbital wall fracture left untreated for over six months: a retrospective analysis of 81 cases at a single institution. Arch Plast Surg. 2013;40:335Y340.
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Orbital Floor Restoration Using the Transnasal Balloon Technique for Inferior Orbital Wall Fracture Nam Kyu Lim, MD, Dong Hee Kang, MD, PhD, Sang Ah Oh, MD, and Ja Hea Gu, MD, PhD
Background: Restoring the volume of orbital fracture is a challenge to the surgeons. We combined the transnasal balloon technique and the transorbital approach during orbital f loor reconstruction, and compared the outcomes of this technique with those of the conventional transorbital approach. Methods: Patients with unilateral pure orbital floor fracture were divided according to the surgical method: the direct transconjunctival approach (group A, 20 patients, control group) or the combination approach with the transnasal balloon technique (group B, 20 patients, experimental group). The orbital volume ratio (OVR) was measured with the use of computed tomographic scans, and enophthalmos was checked with a Hertel exophthalmometer. Results: The orbital volume ratios in both groups decreased after surgery: it was more effectively decreased in group B (7.88%) than that in group A (1.69%) (P G 0.05). Conclusions: A combination of transconjunctival exploration and transnasal restoration with balloon support was more effective in restoring the orbital volume than the conventional method. Key Words: blowout fracture, enophthalmos (Ann Plast Surg 2015;75: 522Y525)
M
ethods to approach the orbital f loor for the pure inferior orbital wall fracture have been either the direct transorbital approach from the eyelid or the indirect transantral approach from the maxillary sinus.1 Transorbital approaches such as the transconjunctival and transcutaneous incision are commonly used methods that provide a wide view of the inferior wall and sufficient exposure for implant placement.1 However, these eyelid approaches have caused some complications such as ectropion and lid shortening. Recently, the orbital f loor surgery through the maxillary sinus with an endoscope has become an alternative to the transorbital technique.2Y4 Use of an endoscope provides a clear view of the orbital f loor from the maxillary sinus and could be useful for achieving accurate reduction.1Y3 However, destruction of the anterior wall of the maxilla is inevitable when inserting an endoscope into the maxillary sinus, and it is difficult to place a large implant on the orbital side with this transantral approach.4 A combination of the transorbital and transantral method has been introduced by several surgeons to make up for the weakness of those approaches.1,5 With this dual approach, the prolapsed orbital contents and fractured orbital f loor can be easily restored to their prior position from the transantral side. The orbital f loor
Received December 4, 2013, and accepted for publication, after revision, January 28, 2014. From the Department of Plastic and Reconstructive Surgery, Dankook University Hospital, Cheonan, Chungnam, Republic of Korea. Conf licts of interest and sources of funding: Dr Kang conducted this study with the research fund of Dankook University in 2012. No disclosures for the remaining authors. Reprints: Dong Hee Kang, MD, PhD, Department of Plastic and Reconstructive surgery, Dankook University Hospital, 359 Manghyang-ro, Dongnam-gu, Cheonan, Chungnam 330-715, Republic of Korea. E-mail: [email protected]. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7505Y0522 DOI: 10.1097/SAP.0000000000000184
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restoration can be confirmed and an implant over the bony defect can be placed easily with the transorbital view. In this study, we combined the transnasal balloon technique and the transorbital approach during orbital floor surgery. We avoided an incision to the oral mucosa and maxillary ostectomy with the transnasal approach, and used transnasal inf lation of a Foley catheter to provide additional support to the restored orbital f loor. The aim of this study was to compare the outcomes of our technique with those of the conventional transorbital approach in inferior orbital wall fracture.
MATERIALS AND METHODS Subjects The retrospective study group consisted of 40 patients with a unilateral pure orbital f loor fracture who underwent orbit reconstruction surgery between March 2007 and September 2012. The study was approved by the institutional review board. The patients were divided into 2 groups according to the surgical methods used: the direct transconjunctival approach (group A, control group) or the combined approach with transnasal balloon technique (group B, experimental group). There were 36 men and 4 women, aged 16 to 45 years with a mean of 26.9 years. The average time of surgery was 7.4 days after injury (range, 3Y14 days). The most common cause was assault trauma (23 cases), followed by slipping (9 cases), traffic accidents (5 cases), and falling (3 cases). The surgical criteria were (1) limitation of extraocular movement, (2) radiographic evidence of extensive fracture [fracture size 9 2 cm2 on computed tomographic (CT) scans], (3) patient complaint of diplopia, or (4) enophthalmos (92 mm).
Ophthalmic Examination All surgical candidates underwent preoperative ophthalmic examinations for diplopia and extraocular muscle movement. The degree of enophthalmos was measured with a Hertel exophthalmometer (Inami Inc, Tokyo, Japan), and the scale was defined as the difference between both eyes by measuring from the lateral orbital rim to the apex of the cornea. To minimize error, a single surgeon measured 3 times in each patient consecutively, and the average value was calculated. Preoperative values were obtained 1 day before surgery to minimize the inf luence of facial edema. The clinical follow-up was performed at 1 week, 1 month, 6 months, and 1 year after treatment. Postoperative Hertel measurements were delayed until 1 year after surgery when the processes of atrophy and scarring of the orbital soft tissue were complete.
CT Scans and Orbital Volume Measurements Three-dimensional CT scans (GE Lightspeed VCT; GE Healthcare, Milwaukee, Wis), which were useful to visualize the globe and extraocular muscles, were used to obtain continuous 2.5-mm-thick axial and coronal slices. All patients underwent CT scans within 1 week after trauma and at 6 months after surgery. The Rapidia Image Postprocessing System (Infinitt Co, Ltd, Seoul, Korea) was used to measure orbital volume by tracing the orbital boundary on each image. Orbital volume was calculated by summing the volumes of each slice, which involved averaging the areas of 2 adjacent scan sections and multiplying Annals of Plastic Surgery
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Annals of Plastic Surgery
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that average by the coronal section thickness. The contralateral orbital volume was used as a control to standardize the individual orbital volume differences. Orbital volume ratio (OVR) was obtained by dividing the volume of the traumatized orbit by that of the control side. The postoperative OVR was measured in the same manner.
Surgical Techniques Direct Transconjunctival Approach (Group A, Control Group) A forced duction test was first performed under general anesthesia to evaluate passive mobility of the globe. An incision was made from the precaruncular area to the lateral orbital fissure at 3 mm below the lower eyelid tarsal plate. A direct plane of dissection was then created and followed over the orbital septum to the inferior orbital rim. The incision was extended laterally with canthotomy. The orbital septum was separated from the inferior orbital rim. The fractured orbital f loor was revealed through the subperiosteal space. The herniated orbital contents were repositioned back into the orbit, and fractured orbital wall was reconstructed with Synpor (Synthes, Inc, West Chester, Pa). After the fracture was reconstructed, the dissected periosteum and the conjunctival incision were sutured in a standard fashion.
Transnasal Restoration With Balloon Support
Combination Approach With Transnasal Balloon Technique (Group B, Experimental Group) Under general anesthesia, a transconjunctival incision with lateral canthotomy incision was performed in the same manner mentioned previously, and the orbital f loor was dissected. After the nasal cavity was decongested with epinephrine pledgets, 2% lidocaine with 1:100,000 epinephrine was injected into the anterior root of the middle turbinate and the uncinate process. Through the maxillary ostium, a curved Freer elevator was passed into the sinus (Fig. 1). The bone fragment and the prolapsed orbital contents were gently raised from the antrum with the Freer elevator under the orbital view. After the herniated orbital contents were repositioned back into the orbital cavity, the fractured orbital floor was mobilized to its original position. Then, the balloon portion of the 16 Fr Foley catheter (Sewoon Medical Co, Ltd, Seoul, Korea) was held in a curved mosquito, passed through the nostril, and inserted into the maxillary ostium (Fig. 2). With the view from the orbit, a volume of physiologic saline solution appropriate for each patient ranging from 5 to 15 mL was injected into the balloon until the orbital floor was anatomically restored. During the injection, care was taken not to entrap the orbital contents between the bone fragments and not to increase orbital pressure by overinf lating the balloon. Synpor was shaped to the right size to bridge the defect, and it was adapted to the orbital f loor without
FIGURE 1. The fractured orbital f loor was restored to its original position with curved elevator and maintained using the transnasal balloon technique. A, An illustration shows a curved Freer elevator restoring the fractured orbital f loor transnasally. B, An illustration shows a ballooned Foley catheter supporting the restored inferior orbital wall. C, An intraoperative radiography of transnasal restoration of the fractured inferior wall with a curved elevator. D, An intraoperative radiography indicating that the Foley catheter held in a curved mosquito to introduce the maxillary ostium. E, Preoperative CT scan image. F, Postoperative CT scan image shows fractured orbital f loor was restored to prior position and supported with ballooned Foley catheter. * 2014 Wolters Kluwer Health, Inc. All rights reserved.
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FIGURE 2. The fractured left orbital f loor was restored with the transnasal balloon technique through the left maxillary ostium. A, An anatomical model shows the location of the maxillary ostium. B, An endoscopic image shows the Foley catheter entering through the maxillary ostium (white arrow) and inf lated with physiologic saline solution in maxillary sinus. C, A postoperative CT scan shows the Foley catheter entering through the maxillary ostium (white arrow).
fixation. A forced duction test was carried out to ensure free movement without entrapment. The tube of the Foley catheter was fixed on the cheek. The balloon support was kept in position for 7 to 8 days.
Statistical Analysis Measurements of OVR and Hertel scale were analyzed for statistically significant differences between groups using the MannWhitney test or Wilcoxon signed rank test. A P value less than 0.05 was considered significant. All analyses were performed using SPSS ver. 12.0 for Windows (SPSS, Inc, Chicago, Ill).
RESULTS Ophthalmic Examinations This study included 40 patients (20 in each group). Nineteen of the patients had diplopia (6 patients in group A and 13 in group B) and 10 patients had limited extraocular movement (5 patients in each group) before surgery. All patients recovered completely after surgery from ocular dysfunctions such as diplopia and extraocular movement limitation. Preoperative enophthalmos measured with Hertel exophthalmometer averaged of j0.55 mm in group A and j1.00 mm in group B. The postoperative Hertel scale was j0.40 mm in group A and j0.55 mm in group B; the changes in the Hertel scale were 0.15 mm in group A and 0.45 mm in group B. Neither the difference between the preoperative and postoperative Hertel scale in each group nor a comparison between the 2 groups was statistically significant (P 9 0.05) (Table 1).
CT Scans and Orbital Volume Measurements The preoperative difference in the OVR between the 2 groups (j1.08%) was not significant (109.68% in group A and 110.76% in TABLE 1. Preoperative and Postoperative Hertel Scale in Each Group
Group A Group B
n
Preoperative Hertel Scale, mm
Postoperative Hertel Scale, mm
$Hertel Scale
20 20
j0.55 j1.00
j0.40 j0.55
0.15* 0.45*
*P 9 0.05, no significant difference. n indicates number of patients.
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group B). Postoperative CT scans taken 6 months after surgery showed a significantly decreased OVR in both groups by volumetric analysis (107.99% in group A and 102.87% in group B); the OVR had decreased more on average in group B (7.88%) than group A (1.69%) (P G 0.05) (Table 2).
DISCUSSION Reconstruction of orbital f loor fractures that are complicated or deeply located in the bony orbit is still a challenge to the surgeon, and various approaches with different paths have been reported. A transantral approach with the aid of an endoscope has been recently introduced to restore the fractured orbital f loor. In contrast to traditional transorbital methods, this approach produces a clear view of the orbital f loor from the maxillary sinus.1Y3 Although the endoscopic surgery provided magnified vision of the fracture from the maxillary sinus, the condition of the orbital cavity could not be checked and it was difficult to disengage the trapped orbital contents or extraocular muscles and to restore the orbital f loor exactly to its prior position. In addition, several authors who performed endoscopic orbital reconstruction with a transantral approach required a maxillary antrostomy to introduce the endoscope or alloplastic materials,4 and they encountered inevitable problems such as numbness of the alveolus after surgery.1 Furthermore, the maxillary ostectomy made it impossible to apply this method in pediatric patients with unerupted maxillary teeth.1 In this study, we use a transnasal approach to access the maxillary sinus instead of using a transantral approach to avoid the destruction of the maxillary anterior wall. Dissection through the transconjunctival approach provided an adequate space to insert the proper size implant and transnasal restoration allowed for repositioning the herniated soft tissue back into the orbit with minimal traction injury. Orbital fracture with large f loor defects often produce unfavorable results such as enophthalmos.4,6 The thin f lexible implant spanning the wide gap of f loor defect are often displaced back into the maxillary sinus and result in reherniation of orbital tissue after surgery. We mobilized the fractured orbital f loor to cover the defect from the sinus, expecting it to prevent the reherniation of implant after surgery. To maintain the restored bony floor in their prior position during the healing process, the Foley balloon held up the wall from the maxillary sinus in early period, and the implant was opposed as a barrier against intraorbital pressure from the orbital side until the healing was completed. Therefore, a combined approach with * 2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery
& Volume 75, Number 5, November 2015
Transnasal Restoration With Balloon Support
TABLE 2. Preoperative and Postoperative Orbital Volume Ratio in Each Group Orbital Volume Ratio, % Unaffected Orbit
Affected Orbit
n Group A Group B AjB
20 20
Preoperative
Postoperative
Volume Change
109.68 110.76 Y1.08
107.99 102.87 5.12
1.69* 7.88* j6.19†
100 100
*Significant difference, P G 0.05 Wilcoxon signed rank test. †Significant difference, P G 0.05 Mann-Whitney test. n indicates number of patients.
the transnasal balloon support would be more effective for restoring the orbital f loor in large inferior orbital wall fracture without reherniation of soft tissue. Since supporting method of the restored orbital f loor with an antral balloon was first reported by Johnson in 1944, many authors introduced the surgical technique with the balloon for restoration and maintenance of the orbital f loor.7,8 A Foley balloon catheter is a durable, f lexible, and adjustable implant for temporary support that can be easily removed in the outpatient clinic.4 The antral ballooning technique allows simple and rapid restoration of orbital f loor fractures, but a complication of acute visual acuity loss after surgery by overinf lation of the balloon has been reported.7 To overcome these shortcomings, monitoring the bony restoration and the proper placement of the implant from the orbital side will make the ballooning technique safer and more precise. We used the maxillary ostium to pass a curved Freer elevator and Foley catheter into the maxillary sinus to restore and to support the orbit (Fig. 2). A working knowledge of the complex anatomy of the nasal cavity is required to insert the surgical instruments through the maxillary ostium successfully without inadvertent trauma to the surrounding structures. The width of the nasal cavity from the septum to the maxillary ostium has been previously measured as 11 mm.9 Although the location of the maxillary ostium varies, it occurs at an average of 12 mm from the medial anterior wall of the sinus.10 Instruments should be bent enough to pass the angled opening to enter the maxillary sinus from the nasal cavity.11 We use a Hertel exophthalmometer and CT volume measurements to evaluate our surgical results. The Hertel exophthalmometer is a tool used widely to measure enophthalmos, which is an indicator of the surgical outcome from blowout fractures.12 However, there are objections to its use based on its low reliability and poor repeatability.12Y14 Moreover, an accurate measurement of a globe depression cannot be made in patients with an orbital fracture who have undergone surgery within 7 to 10 days after injury due to posttraumatic edema. In our study, the improvements of Hertel values were 0.15 mm (group A) and 0.45 mm (group B). Although perioperative changes in the Hertel measurements were statistically insignificant, orbital volume decreased significantly in both groups. Relatively insignificant changes in the Hertel scale may have been caused by the periorbital edema, which can result in an underestimation of enophthalmos.13 If a convenient CT program to measure orbital volume is developed in the future, volume measurement could predict the enophthalmos, and it could be used as a surgical guideline for early reconstruction in patients with edema.13 Despite our encouraging results, this study had limitations as it was a retrospective chart review with a limited sample size. This study focused on the difference in the volumetric changes after surgery, which represents the surgical achievements in treating enophthalmos. In other ophthalmic symptoms such as diplopia, ocular movement should also be estimated for the functional recovery. Fortunately, ocular dysfunction was not observed in any of our patients in * 2014 Wolters Kluwer Health, Inc. All rights reserved.
the first year after surgery. We expect that further research with larger samples having such complications would allow for a more precise comparison between the 2 different surgical techniques.
CONCLUSIONS The authors performed surgical repair of orbital f loor fractures using a combined technique of transconjunctival exploration and transnasal reduction with balloon support through the maxillary ostium. This was demonstrated as more effective for restoring the OVR than that of the conventional transorbital method. We suggest that a combined approach with the transnasal balloon technique is useful for restoring the orbital volume in patients with inferior orbital wall fractures. REFERENCES 1. Kakibuchi M, Fukazawa K, Fukuda K, et al. Combination of transconjunctival and endonasal-transantral approach in the repair of blowout fractures involving the orbital floor. Br J Plast Surg. 2004;57:37Y44. 2. Chen CT, Chen YR. Application of endoscope in orbital fractures. Craniomaxillofac Trauma Reconstr. 2002;16:241Y250. 3. Saunders CJ, Whetzel TP, Strokes RG, et al. Transantral endoscopic orbital floor exploration: a cadaver and clinical study. Plast Reconstr Surg. 1997; 100:575Y581. 4. Farwell DG, Strong EB. Endoscopic repair of orbital floor fractures. Facial Plast Surg Clin North Am. 2006;14:11Y16. 5. Shi W, Jia R, Li Z, et al. Combination of transorbital and endoscopic transnasal approaches to repair orbital medial wall and floor fractures. J Craniofac Surg. 2012;23:71Y74. 6. Rodriguez ED, Dorafshar AH, Manson PN. Facial fractures. In: Neligan PC, ed. Plastic Surgery volume 3. Philadelphia, Pa: Saunders Elsevier; 2013: 53Y57. 7. Rosbe KW, Meredith SD, Holmes DK. Complication of maxillary sinus Foley balloon placement for orbital floor support. Otolaryngol Head Neck Surg. 1997;117:S148YS150. 8. Miki T, Wada J, Haraoka J, et al. Endoscopic transmaxillary reduction and balloon technique for blowout fractures of the orbital floor. Minim Invasive Neurosurg. 2004;47:359Y364. 9. Hall JE, Becker SS, Duncavage JA. Nasal cavity measurements using computed tomography scanning. Poster Session Presented at the Combined Otolaryngology Spring Meetings (COSM), Chicago, IL: 2011:94. 10. Moore CC, Bromwich M, Roth K, et al. Endoscopic anatomy of the orbital floor and maxillary sinus. J Craniofac Surg. 2008;19:271Y276. 11. Brodner D, Alexander I, Chandler S, et al. Accuracy of transnasal cannulation and dilation of the maxillary ostium in cadavers with intact uncinates. Am J Rhinol Allergy. 2013;27:58Y61. 12. Musch DC, Frueh BR, Landis JR. The reliability of Hertel exophthalmometry. Ophthalmology. 1985;92:1177Y1180. 13. Oh SA, Aum JH, Kang DH, et al. Change of the orbital volume ratio in pure blow-out fractures depending on fracture location. J Craniofac Surg. 2013; 24:1083Y1087. 14. Sung YS, Chung CM, Hong IP. The correlation between the degree of enophthalmos and the extent of fracture in medial orbital wall fracture left untreated for over six months: a retrospective analysis of 81 cases at a single institution. Arch Plast Surg. 2013;40:335Y340.
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