The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Brief Clinical Studies
and discussed at the oncology council, upon the recommendation of our oncologist and nuclear medicine physician. Upon the detection of hypermetabolic activity in the thyroid lodge via FDG, fine needle aspiration biopsy was performed on the nodule, and this was reported as follicular neoplasia. Strong immunoreactivity was observed in the TTF-1 and thyroglobulin stains applied on paraffin block directed at the thyroid origin of the neoplasm. In conclusion, the decision of the oncology council played a major role in diagnosing the subject with follicular thyroid carcinoma metastasis. Furthermore, 200-mCi I-131 was initiated with the decision of the oncology council, and no chemotherapeutic agent was administered. There is no consensus on the treatment of follicular carcinomas with metastasis to the skull base or the cavernous sinus.2 It is stated that multimodal therapeutic strategies composed of chemotherapy and/or tyrosine kinase inhibitors may provide improvement in overall survival especially in subjects with follicular thyroid carcinoma with distant metastases and poor prognostic factor.11 Considering that our patient, who was at an advanced age and presented with a tumor at a diameter of 68 mm displaying widely angioinvasion and extrathyroidal spreading, would have a poor prognosis, we are monitoring her closely to share her survival data in future studies. In conclusion, whereas the mass detected in the retro-orbital and paranasal region of the patient was initially monitored with the preliminary diagnosis of paranasal sinus tumor, we detected via wholebody PET/CT imaging that the primary tumor focus was the thyroid gland and that there were also lung and bone metastases. We presented considerably rare skull-base, cranial, retro-orbital, paranasal sinus, lung, and bone metastases of follicular thyroid carcinoma.
TAKE-HOME MESSAGES It is important for ear, nose, and throat specialists to perform USG as the first algorithm considering also the thyroid origin when assessing the patient in head-neck masses. Pathologists should keep in mind also the thyroid when searching for a primary focus in the head-neck region; include also the thyroid to the differential diagnosis in addition to the kidney, prostate, and liver in tumors displaying a clear cell morphology; and apply a relevant immunohistochemical panel. With regard to all physicians, it is important for clinical units dealing with oncology to work with a multidisciplinary approach in making a correct diagnosis and guiding the treatment. ACKNOWLEDGMENTS The authors thank associated professor Ümit Seza Tetikkurt, MD for her valuable comment and Esat Namal, MD for his critical opinions about the patient.
6. Anoop TM, Mini PN, Divya KP, et al. Clinical images. Thyroid follicular carcinoma presenting as intraorbital, intracranial, and subcutaneous metastasis. Am J Surg 2010;199:72–74 7. Patel TS, Desai SL, Trivedi PP, et al. Nasopharyngeal metastasis of follicular carcinoma of the thyroid with extensive clear cell change: a case report. Ear Nose Throat J 2012;91:16–18 8. Sugino K, Kameyama K, Nagahama M, et al. Follicular thyroid carcinoma with distant metastasis: outcome and prognostic factor. Endocr J 2014 9. Besic N, Luznik Z. Choroidal and orbital metastases from thyroid cancer. Thyroid 2013;23:543–551 10. Ropp BG, Solomides C, Palazzo J, et al. Follicular carcinoma of the thyroid with extensive clear-cell differentiation: a potential diagnostic pitfall. Diagn Cytopathol 2000;23:222–223 11. Carhill AA, Cabanillas ME, Jimenez C, et al. The noninvestigational use of tyrosine kinase inhibitors in thyroid cancer: establishing a standard for patient safety and monitoring. J Clin Endocrinol Metab 2013;98:31–42
Orbital Trapdoor Fracture: Can It Occur Also in Adults? Emanuele Zavattero, MD, Fabio Roccia, MD, Rodolfo Benech, MD, Giovanni Gerbino, MD, DDS, Guglielmo Ramieri, MD, DDS Abstract: We describe here a peculiar case of a 30-year-old woman presenting with an orbital trapdoor fracture. Preoperative and postoperative magnetic resonance images are provided to explain the mechanism of the injury. Key Words: Trapdoor orbital fracture, orbital, surgery
O
rbital floor blowout fractures of the trapdoor variety are pure orbital floor fractures. These fractures allow herniation and entrapment of the orbital contents, resulting in severely restricted eye movement and diplopia.1 Such fractures are thought to occur almost exclusively in the pediatric population because of the increased elasticity of the facial bones.2,3 The pattern of trapdoor fractures is generally divided into 2 models: linear or hinged medially. The literature has concentrated mainly on discussing trapdoor fractures in children, and early treatment is generally advocated.2,4,5 Here, we report a case of a 30-year-old woman with a trapdoor fracture entrapping the inferior rectus muscles sheath.
CLINICAL REPORT REFERENCES 1. Gilliland FD, Hunt WC, Morris DM, et al. Prognostic factors for thyroid carcinoma. A population-based study of 15,698 cases from the surveillance, epidemiology and end results (SEER) program 1973–1991. Cancer 1997;79:564–573 2. Matsuno A, Murakami M, Hoya K, et al. Clinicopathological and molecular histochemical review of skull base metastasis from differentiated thyroid carcinoma. Acta Histochem Cytochem 2013;46:129–136 3. Schlumberger MJ. Papillary and follicular thyroid carcinoma. N Engl J Med 1998;338:297–306 4. Sipos JA, Mazzaferri EL. Thyroid cancer epidemiology and prognostic variables. Clin Oncol (R Coll Radiol) 2010;22:395–404 5. Daumerie C, De Potter P, Godfraind C, et al. Orbital metastasis as primary manifestation of thyroid carcinoma. Thyroid 2000;10:189–192
e6
A 30-year-old woman was referred by another hospital to the maxillofacial department of Turin University Hospital, Italy, for management of an orbital blowout fracture with minimal displacement. From the Division of Maxillofacial Surgery, Department of Surgical Science, Città della Salute e della Scienza Hospital, University of Torino, Torino, Italy. Received April 23, 2014. Accepted for publication July 8, 2014. Address correspondence and reprint requests to Emanuele Zavattero, MD, Division of Maxillofacial Surgery, Department of Surgical Science, Città della Salute e della Scienza Hospital, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001215
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
FIGURE 1. Preoperative CT scan, coronal view: a linear fracture of the orbital floor with minimum displacement.
FIGURE 2. Preoperative CT scan, cross-sectional view: a linear fracture of the orbital floor with bone displacement less than the orbital floor thickness. The shape of the rectus inferior muscle may be altered.
Orbital computed tomography (CT) was provided and showed a linear nondisplaced bony defect without clear entrapment of soft tissue (Fig. 1). Cross-sectional imaging showed a possible change of the shape of the inferior rectus muscle (Fig. 2). On clinical examination, the patient reported to have diplopia as well as limited infraduction and supraduction of the right eye. Horizontal motility was intact. Results of neurologic examination and evaluation of visual acuity and pupils were normal. There were no signs of fracture to palpation of the inferior orbital rim. The Hess screen confirmed the limited infraduction and the diplopia (Fig. 3). Before surgery, a magnetic resonance (MR) image of the orbit was obtained and clearly confirmed the soft tissue entrapment in the linear fracture of the floor of the orbit (Fig. 4). Seventy-two hours after the trauma, the patient underwent surgery. The surgery was performed with the patient in the supine position under general anesthesia. The transconjunctival preseptal approach was used. On surgical exploration, a linear nondisplaced orbital floor fracture with entrapped orbital soft tissue was found. The herniated orbital contents were dissected gently and reduced into the orbit. To
FIGURE 3. Preoperative Hess screen confirmed the diplopia and the infraduction limitation.
FIGURE 4. Preoperative MR imaging: entrapment of the soft tissues including perimuscular tissue into a thin area of the orbital floor medial to the infraorbital nerve is clearly demonstrated.
Brief Clinical Studies
FIGURE 5. Postoperative Hess screen shows complete recovery of the visual impairment.
prevent postoperative herniation and entrapment, the fractured orbital floor was patched. High-dose steroids were started before the surgical treatment and were continued for 72 hours postoperatively. The wound was closed using resorbable sutures. The postoperative course was uneventful, and the patient was discharged the following day. On the 1-month follow-up, extraocular motility had improved with no diplopia and without extraocular muscle limitation. The postoperative Hess screen confirmed the clinical findings (Fig. 5). On the six-month follow-up, an MR image was obtained, showing reduction of the orbital content and correct shape of the inferior rectus muscle referred to the unaffected side (Fig. 6).
DISCUSSION The trapdoor variety of blowout fracture was initially described by Soll and Poley1 in 1965, and it is thought to occur typically in children because of the different pattern of orbital injury and the increased elasticity of the facial bones.6,7 According to the CT images of the orbits and intraoperative findings, trapdoor fractures can be separated into linear (type 1a) and hinged (type 1b).8 The CT findings of linear fractures are characterized by the absence of orbital floor displacement and minimal or no soft tissue herniated in the maxillary sinus. These types of fractures are age-related and more frequent in patients younger than 12 years. Indeed, when a small part of the medial orbital floor is displaced into the maxillary sinus similar to a swinging door of bone with a medial hinge, the fracture is called hinged (type 1b). These types of fracture are more frequent when the mean age of the patient is close to 16 years.8 Although it has been suggested that these fracture patterns occur almost exclusively in children, Kwon et al6 showed that this injury can also occur in adults. In the case we are reporting on, intraoperatively, a greater amount of orbital soft tissue herniation within a small circular bone gap a few millimeters in diameter in the rear portion of the floor was found. On 1 side, according to CT classification, we can insert this case on type 1b fracture pattern. On the other side, we concur with Kwon et al6 that this pattern of injury can also occur in adults. Preoperative MR image clearly showed the tissue entrapped in the little bone gap and the mechanism of the injury. It has been suggested that the outcome after treatment of trapdoor fractures depends on the age of the patient and the timing of intervention.
FIGURE 6. Postoperative MR imaging at the 6-month follow-up showing complete freeing of the residual entrapped tissue.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e7
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Brief Clinical Studies
de Man et al9 and Cope et al10 reported worse outcomes in younger patients than in older patients. Some reports suggest that early intervention is associated with better outcome and quicker recovery.3,8,11,12 Smith et al13 believed that a small orbital fracture could incarcerate the extraocular muscles and might lead to a compartment syndrome. Conversely, Iliff et al14 reported that a compartment syndrome cannot be created in the extraocular muscles, and they demonstrated that it was interference with the longitudinal circulation within the muscle that became irreversible after a period of muscle incarceration. Regardless, early repair in the pediatric patient, who has marked motility restriction, might restore the circulation to the rectus muscle and perimuscular tissue, enhancing extraocular muscle recovery. Although this fracture pattern has been reported almost exclusively in children, the mechanism can be found in the same aspect also in adult cases even if rare. The linear bone defect in the trapdoor blowout fracture suggests that bulking of the thin orbital walls with entrapment of the soft tissue could be the mechanism responsible and it can easily shown by the MR imaging. In the case we are reporting on, CT cross-sectional imaging suggested the diagnosis, but MR clearly confirmed the entrapment of the soft tissues including perimuscular tissue into a thin area of the orbital floor medial to the infraorbital nerve. In conclusion, trapdoor blowout fracture is not an injury pattern restricted to children and can occur in adults as other authors previously reported.6 Commonly, the fracture pattern is type 1b according to CT classification.8 Bearing in mind that the mechanism of injury is probably the same in the adults as in the children, early intervention is recommended.
REFERENCES 1. Soll DB, Poley BJ. Trapdoor variety of blowout fracture of the orbital floor. Am J Ophthalmol 1965;60:269 2. Koltai PJ, Amjad I, Meyer D, et al. Orbital fractures in children. Arch Otolaryngol Head Neck Surg 1995;121:1375 3. Criden MR, Ellis FJ. Linear nondisplaced orbital fractures with muscle entrapment. J AAPOS 2007;11:142 4. Grant JH, Patrinely JR, Weiss AH, et al. Trapdoor fracture of the orbit in a pediatric population. Plast Reconstr Surg 2002;109:482 5. Koltai PJ, Foster JA, Papay FC, et al. Pediatric orbital fractures. In: Holck DEE, Ng JD, eds. Evaluation and Treatment of Orbital Fractures: A Multidisciplinary Approach. Philadelphia, PA: Elsevier Saunders; 2006:209–224 6. Kwon JH, Moon JH, Kwon MS, et al. The differences of blowout fracture of the inferior orbital wall between children and adults. Arch Otolaryngol Head Neck Surg 2005;131:723 7. McGraw BL, Cole RR. Pediatric maxillofacial trauma: age-related variations in injury. Arch Otolaryngol Head Neck Surg 1990;116:41 8. Gerbino G, Roccia F, Bianchi FA, et al. Surgical management of orbital trapdoor fracture in a pediatric population. J Oral Maxillofac Surg 2010;68:1310–1316 9. de Man K, Wijngaarde R, Hes J, et al. Influence of age on the management of blow-out fractures of the orbital floor fractures: the white-eyed blowout. Ophthal Plast Reconstr Surg 1998;14:379–390 10. Cope MR, Moos KF, Speculand B. Does diplopia persist after blow-out fractures of the orbital floor in children? Br J Oral Maxillofac Surg 1999;37:46–51 11. Losee JE, Afifi A, Jiang S, et al. Pediatric orbital fractures: classification, management and early follow up. Plast Reconstr Surg 2008;122:886 12. Manson PN, Iliff N, Robertson B. Trapdoor fracture of the orbit in a pediatric population. Plast Reconstr Surg 2002;109:490 13. Smith B, Lisman RD, Simonton J, et al. Volkmann's contracture of the extraocular muscles following blowout fracture. Plast Reconstr Surg 1984;74:200 14. Iliff N, Manson PN, Katz J, et al. Mechanisms of extraocular muscle injury in orbital fractures. Plast Reconstr Surg 1999;103:787
e8
The Hybrid Approach for Reconstruction of Severely Destructed Lower Eyelids: Combination of Skin Grafting, Temporary Tarsorrhaphy, and Autologous Fat Grafting for Cicatricial Ectropion After Injection of Commercial Grade Silicone Sebastian Voigt, MD, Peter Niclas Broer, MD, Sarah Lorenz, MD, Milomir Ninkovic, MD, Felix von Spiegel, MD Background: Although silicone injections for permanent soft tissue augmentation were popular in the past, their use has become unduly controversial because of severe complications, mainly caused by injection of illegal silicones by unlicensed practitioners. The delicate local anatomy of the lower eyelid region makes this region particularly susceptible for complications after silicone augmentation including local inflammation, tissue retraction, and consecutive cicatricial ectropion leading to lagophthalmus and ocular surface irritation. Clinical Report: This is a case of a 47-year-old patient demonstrating severe lower eyelid destruction with consecutive ectropion after injection of commercial grade silicone in Thailand 5 years prior, leading to chronic granulomatous infections requiring multiple surgical interventions. Our hybrid approach included radical debridement with complete elimination of silicone residues, lateral canthopexy, reconstruction of the entire lower eyelid esthetic unit using a supraclavicular fullthickness skin graft, and temporary tarsorrhaphy followed by 2 sessions of autologous fat graft injections. Although many previous publications mainly focus on individual aspects of lower eyelid reconstruction, we describe a staged reconstructive approach for correction of severely destructed lower eyelid defects with consecutive lower eyelid ectropion. Conclusions: The hybrid approach presented here has proven to be a viable surgical strategy for lower eyelid reconstruction, with esthetically appealing results. Key Words: Lower eyelid, ectropion, silicone injection, fat grafting From the Departments of Plastic-, Reconstructive-, Hand-, and Burn-Surgery, Klinikum Bogenhausen Academic Teaching Hospital, Technical University Munich, Munich, Germany. Received May 3, 2014. Accepted for publication July 14, 2014. Address correspondence and reprint requests to Sebastian Voigt, MD, Departments of Plastic-, Reconstructive-, Hand-, and Burn-Surgery, Klinikum Bogenhausen Academic Teaching Hospital, Technical University Munich, Englschalkingerstr. 77,81925 Munich, Germany; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001218
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
and discussed at the oncology council, upon the recommendation of our oncologist and nuclear medicine physician. Upon the detection of hypermetabolic activity in the thyroid lodge via FDG, fine needle aspiration biopsy was performed on the nodule, and this was reported as follicular neoplasia. Strong immunoreactivity was observed in the TTF-1 and thyroglobulin stains applied on paraffin block directed at the thyroid origin of the neoplasm. In conclusion, the decision of the oncology council played a major role in diagnosing the subject with follicular thyroid carcinoma metastasis. Furthermore, 200-mCi I-131 was initiated with the decision of the oncology council, and no chemotherapeutic agent was administered. There is no consensus on the treatment of follicular carcinomas with metastasis to the skull base or the cavernous sinus.2 It is stated that multimodal therapeutic strategies composed of chemotherapy and/or tyrosine kinase inhibitors may provide improvement in overall survival especially in subjects with follicular thyroid carcinoma with distant metastases and poor prognostic factor.11 Considering that our patient, who was at an advanced age and presented with a tumor at a diameter of 68 mm displaying widely angioinvasion and extrathyroidal spreading, would have a poor prognosis, we are monitoring her closely to share her survival data in future studies. In conclusion, whereas the mass detected in the retro-orbital and paranasal region of the patient was initially monitored with the preliminary diagnosis of paranasal sinus tumor, we detected via wholebody PET/CT imaging that the primary tumor focus was the thyroid gland and that there were also lung and bone metastases. We presented considerably rare skull-base, cranial, retro-orbital, paranasal sinus, lung, and bone metastases of follicular thyroid carcinoma.
TAKE-HOME MESSAGES It is important for ear, nose, and throat specialists to perform USG as the first algorithm considering also the thyroid origin when assessing the patient in head-neck masses. Pathologists should keep in mind also the thyroid when searching for a primary focus in the head-neck region; include also the thyroid to the differential diagnosis in addition to the kidney, prostate, and liver in tumors displaying a clear cell morphology; and apply a relevant immunohistochemical panel. With regard to all physicians, it is important for clinical units dealing with oncology to work with a multidisciplinary approach in making a correct diagnosis and guiding the treatment. ACKNOWLEDGMENTS The authors thank associated professor Ümit Seza Tetikkurt, MD for her valuable comment and Esat Namal, MD for his critical opinions about the patient.
6. Anoop TM, Mini PN, Divya KP, et al. Clinical images. Thyroid follicular carcinoma presenting as intraorbital, intracranial, and subcutaneous metastasis. Am J Surg 2010;199:72–74 7. Patel TS, Desai SL, Trivedi PP, et al. Nasopharyngeal metastasis of follicular carcinoma of the thyroid with extensive clear cell change: a case report. Ear Nose Throat J 2012;91:16–18 8. Sugino K, Kameyama K, Nagahama M, et al. Follicular thyroid carcinoma with distant metastasis: outcome and prognostic factor. Endocr J 2014 9. Besic N, Luznik Z. Choroidal and orbital metastases from thyroid cancer. Thyroid 2013;23:543–551 10. Ropp BG, Solomides C, Palazzo J, et al. Follicular carcinoma of the thyroid with extensive clear-cell differentiation: a potential diagnostic pitfall. Diagn Cytopathol 2000;23:222–223 11. Carhill AA, Cabanillas ME, Jimenez C, et al. The noninvestigational use of tyrosine kinase inhibitors in thyroid cancer: establishing a standard for patient safety and monitoring. J Clin Endocrinol Metab 2013;98:31–42
Orbital Trapdoor Fracture: Can It Occur Also in Adults? Emanuele Zavattero, MD, Fabio Roccia, MD, Rodolfo Benech, MD, Giovanni Gerbino, MD, DDS, Guglielmo Ramieri, MD, DDS Abstract: We describe here a peculiar case of a 30-year-old woman presenting with an orbital trapdoor fracture. Preoperative and postoperative magnetic resonance images are provided to explain the mechanism of the injury. Key Words: Trapdoor orbital fracture, orbital, surgery
O
rbital floor blowout fractures of the trapdoor variety are pure orbital floor fractures. These fractures allow herniation and entrapment of the orbital contents, resulting in severely restricted eye movement and diplopia.1 Such fractures are thought to occur almost exclusively in the pediatric population because of the increased elasticity of the facial bones.2,3 The pattern of trapdoor fractures is generally divided into 2 models: linear or hinged medially. The literature has concentrated mainly on discussing trapdoor fractures in children, and early treatment is generally advocated.2,4,5 Here, we report a case of a 30-year-old woman with a trapdoor fracture entrapping the inferior rectus muscles sheath.
CLINICAL REPORT REFERENCES 1. Gilliland FD, Hunt WC, Morris DM, et al. Prognostic factors for thyroid carcinoma. A population-based study of 15,698 cases from the surveillance, epidemiology and end results (SEER) program 1973–1991. Cancer 1997;79:564–573 2. Matsuno A, Murakami M, Hoya K, et al. Clinicopathological and molecular histochemical review of skull base metastasis from differentiated thyroid carcinoma. Acta Histochem Cytochem 2013;46:129–136 3. Schlumberger MJ. Papillary and follicular thyroid carcinoma. N Engl J Med 1998;338:297–306 4. Sipos JA, Mazzaferri EL. Thyroid cancer epidemiology and prognostic variables. Clin Oncol (R Coll Radiol) 2010;22:395–404 5. Daumerie C, De Potter P, Godfraind C, et al. Orbital metastasis as primary manifestation of thyroid carcinoma. Thyroid 2000;10:189–192
e6
A 30-year-old woman was referred by another hospital to the maxillofacial department of Turin University Hospital, Italy, for management of an orbital blowout fracture with minimal displacement. From the Division of Maxillofacial Surgery, Department of Surgical Science, Città della Salute e della Scienza Hospital, University of Torino, Torino, Italy. Received April 23, 2014. Accepted for publication July 8, 2014. Address correspondence and reprint requests to Emanuele Zavattero, MD, Division of Maxillofacial Surgery, Department of Surgical Science, Città della Salute e della Scienza Hospital, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001215
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
FIGURE 1. Preoperative CT scan, coronal view: a linear fracture of the orbital floor with minimum displacement.
FIGURE 2. Preoperative CT scan, cross-sectional view: a linear fracture of the orbital floor with bone displacement less than the orbital floor thickness. The shape of the rectus inferior muscle may be altered.
Orbital computed tomography (CT) was provided and showed a linear nondisplaced bony defect without clear entrapment of soft tissue (Fig. 1). Cross-sectional imaging showed a possible change of the shape of the inferior rectus muscle (Fig. 2). On clinical examination, the patient reported to have diplopia as well as limited infraduction and supraduction of the right eye. Horizontal motility was intact. Results of neurologic examination and evaluation of visual acuity and pupils were normal. There were no signs of fracture to palpation of the inferior orbital rim. The Hess screen confirmed the limited infraduction and the diplopia (Fig. 3). Before surgery, a magnetic resonance (MR) image of the orbit was obtained and clearly confirmed the soft tissue entrapment in the linear fracture of the floor of the orbit (Fig. 4). Seventy-two hours after the trauma, the patient underwent surgery. The surgery was performed with the patient in the supine position under general anesthesia. The transconjunctival preseptal approach was used. On surgical exploration, a linear nondisplaced orbital floor fracture with entrapped orbital soft tissue was found. The herniated orbital contents were dissected gently and reduced into the orbit. To
FIGURE 3. Preoperative Hess screen confirmed the diplopia and the infraduction limitation.
FIGURE 4. Preoperative MR imaging: entrapment of the soft tissues including perimuscular tissue into a thin area of the orbital floor medial to the infraorbital nerve is clearly demonstrated.
Brief Clinical Studies
FIGURE 5. Postoperative Hess screen shows complete recovery of the visual impairment.
prevent postoperative herniation and entrapment, the fractured orbital floor was patched. High-dose steroids were started before the surgical treatment and were continued for 72 hours postoperatively. The wound was closed using resorbable sutures. The postoperative course was uneventful, and the patient was discharged the following day. On the 1-month follow-up, extraocular motility had improved with no diplopia and without extraocular muscle limitation. The postoperative Hess screen confirmed the clinical findings (Fig. 5). On the six-month follow-up, an MR image was obtained, showing reduction of the orbital content and correct shape of the inferior rectus muscle referred to the unaffected side (Fig. 6).
DISCUSSION The trapdoor variety of blowout fracture was initially described by Soll and Poley1 in 1965, and it is thought to occur typically in children because of the different pattern of orbital injury and the increased elasticity of the facial bones.6,7 According to the CT images of the orbits and intraoperative findings, trapdoor fractures can be separated into linear (type 1a) and hinged (type 1b).8 The CT findings of linear fractures are characterized by the absence of orbital floor displacement and minimal or no soft tissue herniated in the maxillary sinus. These types of fractures are age-related and more frequent in patients younger than 12 years. Indeed, when a small part of the medial orbital floor is displaced into the maxillary sinus similar to a swinging door of bone with a medial hinge, the fracture is called hinged (type 1b). These types of fracture are more frequent when the mean age of the patient is close to 16 years.8 Although it has been suggested that these fracture patterns occur almost exclusively in children, Kwon et al6 showed that this injury can also occur in adults. In the case we are reporting on, intraoperatively, a greater amount of orbital soft tissue herniation within a small circular bone gap a few millimeters in diameter in the rear portion of the floor was found. On 1 side, according to CT classification, we can insert this case on type 1b fracture pattern. On the other side, we concur with Kwon et al6 that this pattern of injury can also occur in adults. Preoperative MR image clearly showed the tissue entrapped in the little bone gap and the mechanism of the injury. It has been suggested that the outcome after treatment of trapdoor fractures depends on the age of the patient and the timing of intervention.
FIGURE 6. Postoperative MR imaging at the 6-month follow-up showing complete freeing of the residual entrapped tissue.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e7
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Brief Clinical Studies
de Man et al9 and Cope et al10 reported worse outcomes in younger patients than in older patients. Some reports suggest that early intervention is associated with better outcome and quicker recovery.3,8,11,12 Smith et al13 believed that a small orbital fracture could incarcerate the extraocular muscles and might lead to a compartment syndrome. Conversely, Iliff et al14 reported that a compartment syndrome cannot be created in the extraocular muscles, and they demonstrated that it was interference with the longitudinal circulation within the muscle that became irreversible after a period of muscle incarceration. Regardless, early repair in the pediatric patient, who has marked motility restriction, might restore the circulation to the rectus muscle and perimuscular tissue, enhancing extraocular muscle recovery. Although this fracture pattern has been reported almost exclusively in children, the mechanism can be found in the same aspect also in adult cases even if rare. The linear bone defect in the trapdoor blowout fracture suggests that bulking of the thin orbital walls with entrapment of the soft tissue could be the mechanism responsible and it can easily shown by the MR imaging. In the case we are reporting on, CT cross-sectional imaging suggested the diagnosis, but MR clearly confirmed the entrapment of the soft tissues including perimuscular tissue into a thin area of the orbital floor medial to the infraorbital nerve. In conclusion, trapdoor blowout fracture is not an injury pattern restricted to children and can occur in adults as other authors previously reported.6 Commonly, the fracture pattern is type 1b according to CT classification.8 Bearing in mind that the mechanism of injury is probably the same in the adults as in the children, early intervention is recommended.
REFERENCES 1. Soll DB, Poley BJ. Trapdoor variety of blowout fracture of the orbital floor. Am J Ophthalmol 1965;60:269 2. Koltai PJ, Amjad I, Meyer D, et al. Orbital fractures in children. Arch Otolaryngol Head Neck Surg 1995;121:1375 3. Criden MR, Ellis FJ. Linear nondisplaced orbital fractures with muscle entrapment. J AAPOS 2007;11:142 4. Grant JH, Patrinely JR, Weiss AH, et al. Trapdoor fracture of the orbit in a pediatric population. Plast Reconstr Surg 2002;109:482 5. Koltai PJ, Foster JA, Papay FC, et al. Pediatric orbital fractures. In: Holck DEE, Ng JD, eds. Evaluation and Treatment of Orbital Fractures: A Multidisciplinary Approach. Philadelphia, PA: Elsevier Saunders; 2006:209–224 6. Kwon JH, Moon JH, Kwon MS, et al. The differences of blowout fracture of the inferior orbital wall between children and adults. Arch Otolaryngol Head Neck Surg 2005;131:723 7. McGraw BL, Cole RR. Pediatric maxillofacial trauma: age-related variations in injury. Arch Otolaryngol Head Neck Surg 1990;116:41 8. Gerbino G, Roccia F, Bianchi FA, et al. Surgical management of orbital trapdoor fracture in a pediatric population. J Oral Maxillofac Surg 2010;68:1310–1316 9. de Man K, Wijngaarde R, Hes J, et al. Influence of age on the management of blow-out fractures of the orbital floor fractures: the white-eyed blowout. Ophthal Plast Reconstr Surg 1998;14:379–390 10. Cope MR, Moos KF, Speculand B. Does diplopia persist after blow-out fractures of the orbital floor in children? Br J Oral Maxillofac Surg 1999;37:46–51 11. Losee JE, Afifi A, Jiang S, et al. Pediatric orbital fractures: classification, management and early follow up. Plast Reconstr Surg 2008;122:886 12. Manson PN, Iliff N, Robertson B. Trapdoor fracture of the orbit in a pediatric population. Plast Reconstr Surg 2002;109:490 13. Smith B, Lisman RD, Simonton J, et al. Volkmann's contracture of the extraocular muscles following blowout fracture. Plast Reconstr Surg 1984;74:200 14. Iliff N, Manson PN, Katz J, et al. Mechanisms of extraocular muscle injury in orbital fractures. Plast Reconstr Surg 1999;103:787
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The Hybrid Approach for Reconstruction of Severely Destructed Lower Eyelids: Combination of Skin Grafting, Temporary Tarsorrhaphy, and Autologous Fat Grafting for Cicatricial Ectropion After Injection of Commercial Grade Silicone Sebastian Voigt, MD, Peter Niclas Broer, MD, Sarah Lorenz, MD, Milomir Ninkovic, MD, Felix von Spiegel, MD Background: Although silicone injections for permanent soft tissue augmentation were popular in the past, their use has become unduly controversial because of severe complications, mainly caused by injection of illegal silicones by unlicensed practitioners. The delicate local anatomy of the lower eyelid region makes this region particularly susceptible for complications after silicone augmentation including local inflammation, tissue retraction, and consecutive cicatricial ectropion leading to lagophthalmus and ocular surface irritation. Clinical Report: This is a case of a 47-year-old patient demonstrating severe lower eyelid destruction with consecutive ectropion after injection of commercial grade silicone in Thailand 5 years prior, leading to chronic granulomatous infections requiring multiple surgical interventions. Our hybrid approach included radical debridement with complete elimination of silicone residues, lateral canthopexy, reconstruction of the entire lower eyelid esthetic unit using a supraclavicular fullthickness skin graft, and temporary tarsorrhaphy followed by 2 sessions of autologous fat graft injections. Although many previous publications mainly focus on individual aspects of lower eyelid reconstruction, we describe a staged reconstructive approach for correction of severely destructed lower eyelid defects with consecutive lower eyelid ectropion. Conclusions: The hybrid approach presented here has proven to be a viable surgical strategy for lower eyelid reconstruction, with esthetically appealing results. Key Words: Lower eyelid, ectropion, silicone injection, fat grafting From the Departments of Plastic-, Reconstructive-, Hand-, and Burn-Surgery, Klinikum Bogenhausen Academic Teaching Hospital, Technical University Munich, Munich, Germany. Received May 3, 2014. Accepted for publication July 14, 2014. Address correspondence and reprint requests to Sebastian Voigt, MD, Departments of Plastic-, Reconstructive-, Hand-, and Burn-Surgery, Klinikum Bogenhausen Academic Teaching Hospital, Technical University Munich, Englschalkingerstr. 77,81925 Munich, Germany; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001218
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
