TECHNICAL STRAREGY

Repair of Orbital Fracture: The Antral Balloon With Implantable Reservoir Technique Masanobu Yamashita, MD, Akiko Nishio, MD, Haruhisa Daizo, MD, Miyuki Kishibe, MD, and Kenichi Shimada, MD Abstract: The antral balloon technique is a useful procedure for the treatment of orbital fracture. Its advantages include being able to apply it without any donor-site morbidity. However, the saline injection catheter, which is inserted nasally from the natural ostium, sometimes causes discomfort. We present our new antral balloon technique with an implantable reservoir dome. This technique did not cause patient discomfort because no saline injection catheter was inserted nasally. It contributed to long-term placement of the antral balloon. Of 30 patients, satisfactory symmetries were achieved in 27 patients and the others required subsequent calvarial bone grafting for correction because of residual enophthalmos. Key Words: Antral balloon, orbital fracture, facial injury, enophthalmos (J Craniofac Surg 2014;25: 554Y556)

Bunkyo City, Japan) (Fig. 1) at Kanazawa Medical University Hospital between January 2005 and August 2011.

Operative Technique The procedure involved direct observation via a transconjunctival approach7 and reduction of the orbital floor from inside the maxillary antrum. All of the orbital contents were separated from the bone fragments, infraorbital nerve, and mucosa of the maxillary antrum. Next, the anterior wall of the maxillary antrum was exposed via a maxillary vestibular incision, and a 15  15-mm bone window was made in the anterior wall with a bone saw (Fig. 2). The antral balloon was placed in the maxillary antrum, and a bone piece was positioned and fixed with a titanium microplate and screws. The antral balloon was inflated under direct vision from inside the orbit. This prevents the orbital contents from being entrapped by bone fragments. After fracture reduction, the reservoir dome was placed in the subcutaneous layer of the postauricular region (Fig. 3). After a consolidation period, the patient underwent antral balloon removal.

F

or many years, various techniques have been applied to repair the orbital floor in orbital fracture. These are divided into a few categories. One is reconstruction of the orbital floor using autogenous bone. Calvarial bone grafting1 is always useful for orbital wall reconstruction. Artificial materials, such as titanium meshes, silicon plates,2 or porous high-density polyethylenes,3 are also used. On the other hand, the antral balloon technique is an alternative.4,5 Its advantages include being able to apply it without any donor-site morbidity. The antral balloon should be placed in the maxillary antrum for a period. However, the saline injection catheter, which is inserted nasally from the natural ostium, sometimes causes discomfort.6 From 2005, we have used the modified antral balloon to avoid this problem. The aim of this study was to introduce our new antral balloon and treatment protocol for orbital floor fractures at our institution.

RESULTS A total of 30 patients required the reconstruction of orbital floor fractures using an antral balloon with implantable reservoir. Their mean follow-up was 12 months (range, 6Y27 mo). The results of preoperative examination showed diplopia in 20 patients. Of the 30 patients, 24 were males. Their mean age at surgery was 28 years, with a range from 7 to 57 years. The mean antral balloon placement period was 95 days, with a range from 39 to 149 days. Diagnoses are summarized in Table 1. No intraoperative and only 3 postoperative complications (2 infections and 1 reservoir dome exposure during the consolidation period) were observed.

PATIENTS AND METHODS A retrospective review of patients’ photographs and medical charts was completed for all patients who underwent orbital floor repair using the antral balloon with reservoir dome (Koken Co, Ltd,

From the Department of Plastic and Reconstructive Surgery, Kanazawa Medical University, Uchinada, Ishikawa, Japan. Received June 28, 2013. Accepted for publication September 30, 2013. Address correspondence and reprint requests to Masanobu Yamashita, MD, Department of Plastic and Reconstructive Surgery, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Ishikawa 9200293, Japan; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/01.scs.0000436747.56470.ef

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FIGURE 1. Antral balloon with implantable reservoir dome.

The Journal of Craniofacial Surgery

& Volume 25, Number 2, March 2014

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

The Journal of Craniofacial Surgery

& Volume 25, Number 2, March 2014

Repair of Orbital Fracture

TABLE 1. Diagnoses No. Orbital fracture Zygomaticomaxillary complex fracture Le Fort fracture Naso-orbito-ethmoidal fracture Total

19 6 3 2 30

FIGURE 2. Bone window made in the anterior wall of the maxillary antrum.

Satisfactory symmetries were achieved in 27 patients, and the others required subsequent calvarial bone grafting for correction because of residual enophthalmos. Two of them had residual symptomatic diplopia after the surgery.

FIGURE 4. Patient 1. Computed tomographic scans showing right orbital floor fracture (left) and the consolidation period with antral balloon (right).

Clinical Reports Patient 1 A 40-year-old man received a blow to his right orbit during a fight. The results of clinical examination showed eyelid ecchymosis and moderate enophthalmos of the right orbit. No diplopia was observed. A coronal view on computed tomography revealed an orbital floor fracture. Orbital floor reduction with the antral balloon was performed at 11 days after the injury. After the orbital content swelling reduced, slight enophthalmos remained. Therefore, we injected additional saline (1.5 mL) from the reservoir dome, which was connected to the balloon. The antral balloon was in place for 84 days without any discomfort. The enophthalmos resolved completely (Figs. 4, 5).

Patient 2 A 45-year-old man received a blow to his right orbit during a fight. The results of clinical examination showed subconjunctival hemorrhage and mild enophthalmos of the right orbit. No diplopia

FIGURE 5. Patient 1. Preoperative (left) and postoperative (right) appearances.

was observed. A coronal view on computed tomography revealed an open door-type orbital floor fracture and that the orbital contents had herniated into the antrum. Orbital floor reduction was performed in the same fashion 18 days after the injury. The enophthalmos improved, and the antral balloon was removed 93 days after the reduction without the recurrence of enophthalmos (Figs. 6, 7).

FIGURE 3. Three-dimensional computed tomographic scan showing the reservoir dome connected to antral balloon (inside of the antrum) and placed in the postauricular region.

FIGURE 6. Patient 2. Computed tomographic scans showing left orbital floor fracture (left) and the consolidation period with antral balloon (right).

* 2014 Mutaz B. Habal, MD

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

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The Journal of Craniofacial Surgery

Yamashita et al

& Volume 25, Number 2, March 2014

and subsequent enophthalmos,9 so we prefer to place the antral balloon for as long as possible. There are some disadvantages of our technique. Secondary surgery is required for antral balloon removal. A scar behind the earis acceptable but noticeable. Unsatisfactory aesthetic results were achieved in patients with Le Fort fracture and severe zygomaticomaxillary complex fracture. All of these patients showed remaining enophthalmos despite a long consolidation period. The antral balloon technique may be limited regarding its indication forisolated orbital floor fractures or mild zygomaticomaxillary complex fractures.

ACKNOWLEDGMENTS The authors thank Professor Shigehiko Kawakami, who provided helpful comments and suggestions. FIGURE 7. Patient 2. Preoperative (left) and postoperative (right) appearances.

Patient 3 A 24-year-old man, who was physically assaulted, presented to our institution. The results of clinical examination showed subconjunctival hemorrhage and malar flattening. No diplopia was observed. Computed tomographic findings showed a zygomaticomaxillary complex fracture and an associated orbital floor fracture. Reduction of the zygomaticomaxillary complex fracture with antral balloon placement was performed at 16 days after the injury. The patient showed a favorable postoperative course, and the antral balloon was removed 135 days after the reduction.

DISCUSSION The extent of antral balloon inflation was easily adjusted by transcutaneous saline injection into the implantable reservoir dome to compensate for undercorrection after the orbital content swelling had gone down. Our technique did not cause any discomfort because no saline injection catheter was nasally inserted. It contributed to long-term placement of the antral balloon. Previous reports suggested various periods of antral balloon placement,8 but a suitable period is unclear. A shorter period of placement resulted in the collapse of the orbital contents

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REFERENCES 1. Tessier P. Autogenous bone grafts taken from the calvarium for facial and cranial applications. Clin Plast Surg 1982;9:531Y538 2. Prowse SJ, Hold PM, Gilmour RF, et al. Orbital floor reconstruction: a case for silicone. A 12 year experience. J Plast Reconstr Aesthet Surg 2012;63:1105Y1109 3. Ozturk S, Sengezer M, Isik S, et al. Long-term outcomes of ultra-thin porous polyethylene implants used for reconstruction of orbital floor defects. J Craniofac Surg 2005;16:973Y977 4. Kirkegaard J, Greisen O, Højslet PE. Orbital floor fractures: early repair and results. Clin Otolaryngol Allied Sci 1986;11:69Y73 5. Tovi F, Rosenberg L, Gatot A. Alternative surgical method for repair of the fractured orbital floor. Laryngoscope 1985;95:1004Y1005 6. Batchvarova Z, Athmani B. The antral balloon catheter: a simple, fast, and inexpensive method for reconstruction of the orbital floor fracture. Plast Reconstr Surg 2005;116:2048Y2049 7. Tessier P. The conjunctival approach to the orbital floor and maxilla in congenital malformation and trauma. J Maxillofac Surg 1973;1:3Y8 8. Jeon SY, Kwon JH, Kim JP, et al. Endoscopic intranasal reduction of the orbit in isolated blowout fractures. Acta Otolaryngol Suppl 2007;127:102Y109 9. Hinohira Y, Yumoto E, Shimamura I. Endoscopic endonasal reduction of blowout fractures of the orbital floor. Otolaryngol Head Neck Surg 2005;133:741Y747

* 2014 Mutaz B. Habal, MD

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

Repair of orbital fracture: the antral balloon with implantable reservoir technique.

The antral balloon technique is a useful procedure for the treatment of orbital fracture. Its advantages include being able to apply it without any do...
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