Extended Access/Internal Approaches for the Management of Facial Trauma Kevin A.
Shumrick, MD; Robert C. Kersten, MD; Dwight R. Kulwin, MD; Pradeep
K.
Sinha, MD; Timothy
L.
Smith,
MD
\s=b\ The two most significant recent developments in the treatment of facial trauma are the introduction of plating
systems, which provide rigid internal fixation and the
development of surgical approaches that allow wide exposure of the entire facial skeleton while minimizing external incisions. These approaches (referred to as extended access/ internal approaches) are hemicoronal and coronal flaps, the sublabial approach to the midface, the transconjunctival approach to the orbital floor and orbital rim, and the intraoral management of mandibular fractures. These ap-
proaches work well, and have become standard techniques for managing facial trauma; however, each one has definite technical points that need to be adhered to to assure their success. Additionally, there are situations where these approaches are not appropriate and, in fact, may even be detrimental. This article outlines our approach to facial trauma using these extended access/internal approaches and discusses the important technical factors of each approach. Our experience in treating 113 patients with 119 fractures and 161 approaches over the last 2 years is presented and the role extended access/internal approaches have played is reviewed. The indications, limitations, and possible complications associated with each approach are outlined. (Arch Otolaryngol Head Neck Surg. 1992;118:1105-1112) goal facial surgeon's The form and function, while minimizing any morbidity Until associated with the treatment
in
surgical repair.
trauma is to restore
relatively
re¬
the open reduction and internal fixation of facial fractures (LeFort, nasoethmoid, zygoma, and mandible) was a balancing act of making the smallest possible exter¬ nal incisions that were still sufficiently long to provide ex¬ posure for fracture reduction and fixation. Advances in craniofacial surgery, in conjunction with the development of plating systems that provide rigid internal fixation of facial fractures, have significantly advanced the treatment of facial fractures. It is now possible to expose the entire facial skeleton through internal or camouflaged incisions
cently,
Accepted for publication June 2, 1992. From the Departments of Otolaryngology (Dr Shumrick), Ophthalmology (Drs Kersten and Kulwin), and College of Medicine (Drs Shumrick, Sinha, and Smith), University of Cincinnati (Ohio). Presented at the fall meeting of the American Academy of Facial Plastic and Reconstructive Surgery, San Diego, Calif, September 7, 1990. Reprint requests to the Department of Otolaryngology, University of Cincinnati, 231 Bethesda Ave, Cincinnati, OH 45267 (Dr Shumrick). Arch
Otolaryngol Head Neck Surg\p=m-\Vol118, October
of the division of the facial skel¬ on the extended access/ that maximizes exposure, while minimizing external
Fig 1.—Diagrammatic representation eton into distinct anatomic
internal approach incisions to that region.
regions based
and
perform rigid, one-stage repair of fractures.1"8 Addi¬ tionally, the use of plates for rigid internal fixation of frac¬ tures has virtually eliminated the need for suspension wires and external traction devices, as well as significantly decreasing the requirements for intermaxillary fixation.7-9'10 The purpose of this article is to outline our approach to facial trauma utilizing extended access/internal ap¬ proaches, performed in a standardized fashion, to expose each portion of the facial skeleton. This systematic ap¬ proach to the facial skeleton can be used to treat isolated fractures or integrated into a treatment plan for exposing and treating virtually the entire facial skeleton. MATERIALS AND METHODS
Strategies for Approaching the
Extended Access/Internal
Facial Skeleton Via
Approaches
The facial skeleton can be divided into four major skeletal re¬ gions with one subregion. Each of these major regions has an ex¬ tended access/internal approach which, we believe, provides for optimal exposure while minimizing external scars. The four ma¬ jor skeletal regions are as follows (Fig 1): (1) The upper third of the facial skeleton that includes the zygomatic arches, lateral or¬ bital rims, supraorbital rims, medial orbital rims and medial can¬ titi, and the frontonasoethmoid region are approached through hemicoronal or coronal incisions. (2) The inferior orbital rim, or¬ bital floor, and upper maxilla are exposed with transconjunctival incisions. (3) The lower maxilla, zygomaticomaxillary buttress,
1992
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Dotted lines indicate coronal in¬ cision in individual where balding is a con¬ cern. In individuals where balding is not a concern the incision is placed 3 to 4 cm behind and parallel to the hairline. Right, Flap has been elevated in a supraperiosteal plane until 2 cm superior to the orbital rims where the dissection becomes subperiosteal. Note that the supraorbital nerves and vessels have been released from their foramen.
Fig 2.—Left,
Fig 3.—Lateral view of the dissection for coro¬ nal flaps. The initial dissection is just superfi¬ cial to the superficial layer of the deep tempo¬
ral fascia until the superficial temporal fat pad is visualized. (Note that for purposes of illus¬ tration the flap is shown elevated further ante¬ riorly than in actual surgery. The dissection should stop at the fat pad.)
Fig 4.—After exposing the fat pad, the overly¬
ing fascia is incised and the incision extended superiorly to join with the frontal subperiosteal dissection and inferiorly to the root of the zy¬
gomatic arch. The rest of the dissection is subfascial (but superficial to the fat pad) until the orbital rim and zygomatic arch are reached, at which point the dissection becomes subperi¬ osteal.
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and piriform aperture are exposed with either unilateral or bilat¬ eral sublabial incisions. (4) The mandible, including the symphy¬ sis, parasymphysis, and anterior half to two thirds of the mandibular body are exposed intraorally through incisions in the gingival buccal mucosa. We have separated mandible fractures of the posterior third of the body or angle into a subgroup that will be discussed separately.
Hemicoronal and Coronal Flaps: Region 1—Frontal, Nasoethmoid, Lateral Orbital Rims, Zygomatic Arches, and Body of Zygoma (Fig 1 ) Hemicoronal and coronal flaps have now become standardized technique and are routinely performed in neurosurgery, craniofacial surgery, skull base surgery, and frontal sinus surgery; as well as for facial trauma.311"13 They provide wide exposure of the zygomatic arches; zygomaticofrontal suture; lateral, superior, and medial orbital rims; frontal and nasofrontal suture; the nasoethmoid region; and may also be used for exposure of the mandibular ramus and condyle.14 Coronal incisions not only provide wide exposure of these areas, but are also better camouflaged than external or regional incisions by virtue of being placed in the hairline. We believe the scars re¬ sulting from coronal incisions, even in balding individuals, are preferable to glabellar scars that frequently widen and become depressed despite proper closure technique, often defying im¬ provement by revision. Hemicoronal incisions are used for uni¬ lateral fractures, where as full coronal incisions are used for bilat¬ eral fractures or when exposure of the frontal, nasoethmoid region is required. The keys to successfully performing either hemicoronal or coronal flaps are: (1) The lower portion of the in¬ cision is brought inferiorly in the preauricular crease to at least the level of the tragus. Failure to bring the incision sufficiently infe¬ rior will prevent access to the zygomatic arch and lower, lateral orbital rim. (2) The upper portion of the incision parallels the hairline and is placed 3 to 4 cm posterior to it. Individuals with male-pattern baldness should have the incisions brought straight across the top of the head from the root of one auricular helix to the root of the other helix (Fig 2). For hemicoronal flaps the inci¬ sion should come to at least the midline superiorly; failure to do so will prevent the flap from folding inferiorly enough to allow exposure of the superior and lateral orbital rims. (3) The incision is made with a scalpel blade in incremental sections 4 to 6 cm in length. We do not use the bovie along the incision to avoid injury to hair follicles; instead, Renne neurosurgical clamps are placed for hemostasis. (4) The initial plane of dissection is just above the periosteum superiorly over the skull and just superficial to the temporalis muscle fascia laterally. (5) In the superior portion of the dissection, over the frontal region, the periosteum is incised approximately 2 cm superior to the orbital rims and nasofrontal suture; the dissection is then continued inferiorly in a subperi¬ osteal plane over the orbital rims and root of the nose. This sub¬ periosteal dissection elevates the corrugator and procerus mus¬ cles and avoids injury to the supraorbital and supratrochlear arteries and nerves (Fig 2). (6) Laterally, over the temporalis muscle, the dissection is carried forward in a plane that is just su¬ perficial to the temporalis muscle fascia (this fascia is the super¬ ficial layer of the deep temporal fascia) until the superficial tem¬ poral fat pad is visualized under the fascia. An incision is then made through the temporalis fascia (superficial layer of the deep temporal fascia) extending from a point approximately 1.5 finger breadths superior to the orbital rim (connecting with the subpe¬ riosteal incision and dissection previously performed) and ex¬ tending inferiorly and posteriorly to the root of the zygoma. Af¬ ter incising the fascia, the dissection is continued in a subfasciai plane attempting to stay lateral to the fat pad; by doing so the frontalis branch of the facial nerve will be reflected later¬ ally.11'12'15-16 (Figs 3 and 4). When the lateral orbital rim and zygo¬ matic arch are reached, the fasciai attachments are incised and the dissection is continued subperiosteally. (7) In the nasofrontal re¬ gion, the dissection is continued subperiosteally down over the root of the nose and along the medial aspect of the orbit. (8) Frein their
Fig 5.—Diagrammatic representation transconjunctival approach.
of the exposure
possible with
a
quently, a limiting factor in exposing the nasoethmoid region is
the amount of inferior retraction one can achieve on the coronal flap due to tethering by the supraorbital nerves and vessels exit¬ ing the supraorbital foramen. It should be recognized that these vessels are not traveling in a true canal but, rather, a short fora¬ men of bone or, often, just a notch. Therefore, these nerves and vessels may be released inferiorly by carefully excising the infe¬ rior portion of the canal with a Kerrison punch, rongeur, osteotome, or drill (Fig 2). Continued subperiosteal dissection over the superior orbital rim and along the orbital roof will allow substantial additional inferior retraction of the flap. (9) While it is possible to use the coronal approach to expose the entire me¬ dial orbit and medial inferior rim we attempt to avoid dissecting the medial canthi from bony fragments because it is simpler to reposition the canthi if they retain their bony attachments.1718 (10) When closing, after this degloving approach, we place several tacking sutures of 2-0 polyglycolic acid suture (Dexon) to reapproximate the temporalis fascia, which is believed to provide support to the upper one third of the face. A 7-mm Jackson-Pratt drain is placed in a dependent position and brought out postauricularly. The rest of the incision is closed in a single layer with staples in the scalp and 6-0 running nylon sutures along the preauricular incision.
Transconjunctival Approach: Region 2—Inferior Orbital Rim, Orbital Floor, Superior Maxilla A transconjunctival approach offers excellent exposure of the infraorbital rim, orbital floor, inferior medial orbital wall, inferior lateral orbital rim, and superior face of the maxilla (Figs 1 and 5). Although this approach has been known for over half a century, it was not widely popularized until the early 1970s.19"23 Subse¬ quently, large series have shown it to be superior to the standard subciliary precutaneous approach, both from a cosmetic and from a functional standpoint.23-24 The keys to successfully performing a transconjunctival ap¬ proach to the inferior orbital rim and floor are as follows: (1) One must perform a lateral canthotomy and inferior cantholysis to disinsert the lower eyelid from the lateral orbital rim (Fig 6). Although Zingg et al25 state a canthotomy is not necessary, it is our experience that this simple step markedly increases distractibility of the lower lid and improves exposure of the rim and floor. (2) Dissection should be carried out in the preseptal plane. Initial studies on the transconjunctival approach described an incision in the inferior fornix entering the retroseptal space. This results in dissection through orbital fat to reach the infraorbital rim and
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Fig 6.—A lateral canthotomy is performed by placing a scissor blade on either side of the lateral canthal tendon at its apex and making a single cut. An inferior cantholysis is performed by making a single cut across the inferior portion of the tendon. Reattachment is via a single mattress suture (see text). risks
injury to the inferior oblique muscle as well as intraorbital
hemorrhage."'20'22'26 Instead of incising in the fornix, we prefer to
incise the conjunctiva immediately beneath the tarsal plate where the conjunctiva, lower lid retractors, and septum are fused and can be disinserted from the inferior tarsal border intact (Fig 7, left). The dissection then proceeds inferiorly in the avascular plane be¬ tween the orbital septum and overlying orbicularis muscle. Maintaining an intact septum prevents orbital fat from prolaps¬ ing into the operative field, protects extraocular muscles and in¬ traorbital tissue, and enhances hemostasis. (3) Cephalad retrac¬ tion on the lid must be maintained during dissection to the orbital rim. The tendency is to retract the lower lid in a caudad fashion, but this results in the lid being folded back over on itself and in¬ creases the risk of inadvertent penetration of the orbicularis mus¬ cle and "buttonholing" of the skin. When cephalad retraction is maintained the skin will not fold on itself and the plane of dissec¬ tion is more readily followed (Fig 7, left). (4) Care must be taken to avoid excessive lateral traction during exposure and manipu¬ lation of the orbital rim and floor. Laceration through the lacrimal canaliculi caused by excessive traction occurred in one of our pa¬ tients and has been described by others using the transconjunc¬ tival approach. If exposure is limited, then extension of the lateral canthotomy and dissection of the orbicularis muscle from the lat¬ eral zygoma will enhance medial exposure without requiring ex¬ cessive traction. (5) Following closure of the subtarsal incision with a continuous fine absorbable suture (we prefer 6-0 fast ab¬ sorbing chromic suture) the lateral canthal tendon is reapproxi-
mated with a horizontal mattress suture of 5-0 polyglycolic acid suture or polyglactin suture (Vicryl). This approximation is enhanced by the use of a double-armed suture that is passed through the superior and inferior portion of the cut lateral canthai tendon and then through the superior and inferior portion of the intact remnant at the lateral orbital rim (Fig 6).
Sublabial Approach: Region 3—The Inferior Maxilla, Piriform Aperture, and Zygomaticomaxillary Buttress The sublabial approach to the maxilla may be unilateral or bi¬ lateral and provides wide exposure of the zygomaticomaxillary buttress, inferior border of the body of the zygoma, the anterior face of the maxilla, and the piriform aperture27 (Fig 8). The tech¬ nical points are as follows: (1) The incision is placed sufficiently superior in the gingival buccal sulcus to ensure adequate soft tis¬ sue, on the inferior portion of the incision, to facilitate closure. (2) When performing a unilateral approach the anterior incision should come to at least the midline. (3) The posterior incisions (whether unilateral or bilateral) should extend to the posterior portion of the alveolar ridge to allow satisfactory exposure of the zygomaticomaxillary buttress. (4) Once the incision has been made it should be carried directly to the bone and the dissection completed in a subperiosteal plane. (5) As the dissection extends over the zygoma, it is often necessary to release a portion of the masseter from the inferior border of the zygoma with a knife or electrocautery. The upper limit of the dissection is usually just
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Fig 7.—Left, Cross section of lower lid showing proposed route (dotted line) of dissection through conjunctiva and lower lid retractors at the inferior border of the tarsus. The preseptal plane is entered and dissection continued to the orbital rim. At the orbital rim the periosteum is incised and the dissection continued subperiosteally. Right, Illustration of cephalad retraction on conjunctiva (arrow) and lower lid to aid in establishing and main¬ taining the preseptal plane.
parotid gland, and masseter with a drill sleeve to protect the soft no question that the intraoral treatment of pos¬
tissue.32 There is
Fig 8.—Demonstration of exposure possible with sublabial approach to the maxilla and transoral approach to mandibular fractures. Note that the use
of Hommon retractors, which hook underneath the mandible,
greatly facilitate exposure.
above the infraorbital nerve, but the inferior orbital rim may be exposed and viewed in its entirety, taking care to dissect around, and avoid damage to, the infraorbital nerve.
Intraoral Approaches to Mandibular Fractures: 4—Mandibular Symphysis, Parasymphysis, and Anterior Two Thirds of the Body
Region
The intraoral approach to mandibular fractures for rigid inter¬ nal fixation with mandibular plates has become our procedure of choice for the majority of mandibular fractures. The intraoral ap¬ proach provides excellent exposure of the mandibular symphy¬ sis, parasymphysis, and the anterior half to two thirds of the mandible body.28"31 However, intraoral exposure of the posterior third of the body and the angle is more difficult, usually requir¬ ing a percutaneous stab incision and working through the cheek,
terior mandible fractures is feasible and has most of the advan¬ tages of treating anterior mandible fractures, but it requires ad¬ ditional experience and equipment; individuals who are not performing these techniques on a regular basis may wish to con¬ sider restricting the intraoral approach for anterior fractures. For this article we have included only fractures of the anterior two thirds of the mandible. Several technical points should be noted regarding the intraoral approach to mandibular fractures: (1) The mucosal incisions are centered over the fracture with a 3- to 4-cm extension anteriorly and posteriorly. (2) Again, the incision is placed in the gingival buccal sulcus so as to leave adequate soft tissue on the gingival side for closure. (3) After the mucosal incision, the dissection is in a subperiosteal plane. (4) Particular care should be taken in the region of the first premolar to identify the inferior alveolar nerve and dissect around it. Most plates will be applied below the nerve and it is essential that the nerve be completely exposed and dis¬ sected free. Occasionally, it is necessary to dissect the nerve dis¬ tally onto the lip to provide further length for inferior retraction. It is also possible to remove a portion of the inferior alveolar nerve canal by drilling to allow greater mobility of the nerve, just as one would for the supraorbital nerves. (5) It is essential that the dis¬ section be carried inferiorly to, and around, the mandibular mar¬ gin, once the mandibular margin is exposed retraction is greatly facilitated by the use of Homman retractors that hook under the mandible and, by levering them inferiorly, help reduce the frac¬ ture as well as retracting the lips and cheeks out of the operative field. (6) The mandibular fracture is then stabilized with mandib¬ ular plates (we use Luhr Vitallium plates with bicortical selftapping screws) using compression when possible. (7) The plates are usually placed below the inferior alveolar nerve to avoid in¬ jury to the tooth roots with the drill and screws. Closure consists of a single layer of 3-0 chromic suture. If satisfactory rigid inter¬ nal fixation has been accomplished, then the intermaxillary fixa¬ tion is released at the end of the operation. We have reviewed facial trauma patients treated from January 1988 through June 1990, with extended access/internal ap¬ proaches. There were 161 extended access/internal approaches performed on 113 patients who had 119 separate classifiable frac¬ tures. The surgical approach or approaches to these fractures were determined by physical examination and roentgenographic find¬ ings. In simple zygomatic complex fractures, with minimal zygo¬ matic frontal suture displacement, a simple brow incision and wire or plate were used to approach the Z-F suture, with the ma-
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Table
Approaches
1.—Listing of Fractures and Approaches
Transconjunctival
Hemicoronal
23 2 2 9 0
0 13 0 10 0
Used to
Manage Them
Bicoronal
Sublabial
Intraoral Mandibular
0 41 2 25 0
0 0 0 0 21
Total
Fractures
Blowout
Zygomatic complex Nasoethmoid LeFort
Mandible
23 44 5 26 21
Total Fractures Total No. of Individual
Approaches
119 36
23
jor stabilization of the fracture being provided by a sublabial ap¬ proach to the maxilla and plating of the Z-M buttress. For delayed zygomatic fractures, fractures with significant displacement of or fractures involving the zygoma itself, a hemicoronal approach was used. For purposes of this article only fractures of
68
13
were
included.
Managed by Extended Access/Internal Approaches
Results of Patients
Review of the patient series showed the following fracture dis¬ tribution: 21 blowout fractures, five isolated nasoethmoid frac¬ tures, 26 LeFort type fractures, 44 isolated zygomatic complex fractures, and 21 mandible fractures. The types of incisions and approaches were as follows: 36 transconjunctival incisions, 23 hemicoronal flaps, 13 coronal flaps, 68 sublabial approaches to the maxilla, and 21 patients with intraoral repair of mandibular frac¬ tures (Table 1). Thirty-five patients had a combination of one or more approaches: 16 patients with hemicoronal and sublabial approaches, six patients with coronal and sublabial approaches, 10 patients with hemicoronal or coronal flaps with transconjunc¬ tival and sublabial approaches, and three patients with coronal, transconjunctival, sublabial, and intraoral mandibular ap¬ proaches (Table 2). Determination of the need for intermaxillary fixation was made on an individual basis depending on the severity of the injury, stability achieved, and associated fractures. Patients were followed up for a minimum of 6 weeks with an average follow-up of 12 weeks. Fracture reduction was believed to be adequate to excellent in all patients and there was no need for revisionai surgery. There were three patients with paralysis of the frontalis branch of the facial nerve following coronal or hemi¬ coronal flaps, two nerves recovered spontaneously within 4 weeks, and one remained paretic for 3 months and then recovered fully. The only complication associated with the transconjuncti¬ val approach was a lacrimal canalicular laceration due to exces¬ sive traction. This laceration was repaired by suture and stenting and is fully functional at 6 months. There were no ectropions or eyelid deformities associated with the transconjunctival ap¬ proach. The sublabial approach was associated with laceration of one infraorbital nerve with postoperative lip numbness; sensation has returned fully at 1 year. Three mandibular plates placed intraorally became exposed and were removed, but this did not af¬ fect the overall outcome. One mental nerve was lacerated during an intraoral reduction of a mandible fracture and was repaired primarily, the patient's lip remains numb at 1 year. A mental nerve was partially lacerated by retraction into a fracture that in¬ volved the mental foramen, but sensation recovered within 6 months postoperatively. There were no instances of infections, nonunions, or malunions associated with intraoral reduction of mandible fractures.
COMMENT Using the techniques described it is possible to expose virtually the entire facial skeleton with a subperiosteal dissection that provides wide exposure with camouflaged (in the hairline) or internal mucosal incisions. In this series
161
Table 2.—Fractures Managed by a Combination of Extended Access/Internal Approaches*
the arch,
the anterior two thirds of the mandible
21
No. of Patients
Approaches Hemicoronal and sublabial
16
Bicoronal and sublabial
6
Bicoronal, transconjunctival, and sublabial Hemicoronal or bicoronal, transconjunctival, sublabial, and intraoral
10
Total
35
mandibular
"Thirty-five patients had Table
two or more
3
approaches.
3.—Complications of Extended
Access/Internal Approaches Bicoronal and hemicoronal flaps: three frontalis nerves paretic postoperatively, two recovered spontaneously, one remains paralyzed at 10 wk Transconjunctival approach: one canalicular laceration due to excessive traction, repaired primarily Sublabial approach: one infraorbital nerve lacerated, completely recovered at 1 yr Intraoral approach to mandibular fractures: one mental nerve surgically lacerated, repaired primarily, no function at 1 y, one mental nerve partially lacerated at fracture site, full function at 6 mo
of 119 patients, 35 patients had a combination of extended access/internal approaches. In fact, three patients had the entire facial skeleton exposed with coronal flaps, bilateral transconjunctival incisions, bilateral sublabial incisions, and intraoral reduction of mandibular fractures. Because the incisions used for extended access/internal approaches are made in the mucosa or in the scalp, the inflammation and edema encountered in external, muscle-splitting inci¬ sions is greatly reduced. Additionally, the dissections are performed in a subperiosteal plane so that there is no dis¬ ruption of blood supply, lymphatic drainage, nerve func¬ tion, or muscle function. A further advantage to extended access approaches is that exposure of the entire facial skel¬ eton is possible allowing much more complete visualiza¬ tion of the fractured bone or bones when compared with traditional external incisions where only a small portion of the fracture is seen. This improved exposure allows for more accurate fracture reduction and is necessary to take full advantage of the various plating systems that are now an integral part of managing facial trauma. While these extended access/internal approaches offer
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significant advantages they are technically somewhat more demanding than simple external approaches and they each have certain potential complications and con¬ traindications. The coronal and hemicoronal flaps carry the possibility of injury to the frontalis branch of the seventh cranial nerve and the supraorbital nerves. In this series we encountered three paralyses of the frontalis nerve in the postoperative period, all of which completely recovered. This complete recovery suggests that the paresis occurred secondary to traction, rather than as a direct injury to the nerve. There have been no long-term supraorbital nerve
deficits that we attribute to careful release of the supraor¬ bital nerves from their foramens. The transconjunctival approach to the orbital floor and rim has been a safe and reliable technique. It replaces the longer, visible subciliary incision with a very fine lateral canthotomy incision that is hidden in the lateral commis¬ sure and remains virtually imperceptible. In addition to improved cosmesis, the transconjunctival approach has essentially eliminated the complications of ectropion and scierai show, which frequently occur following the percu¬ taneous, subciliary approach.24-33-34 Some authors have suggested the need for a tarsal suture and pressure dress¬ ings in the postoperative period; however, these have not been required in our cases and, in fact, we believe they are contraindicated in the immediate postoperative period when it is important to monitor visual status. We also be¬ lieve that a lateral canthotomy and inferior cantholysis significantly improves exposure of the orbital rim and floor and minimizes complications due to excessive traction on the eyelid. A key to enhancing this exposure is to extend the canthotomy laterally up to 1 cm, or as necessary, and to bluntly dissect the orbicularis from its attachment to the zygoma. Manson et al35 have described a technique of ex¬ tending this dissection superiorly to expose the zygomaticofrontal suture through a single incision, but we do not have experience with this technique. Initially, there was concern that the exposure achieved with the transconjunctival approach might require more retraction on the globe with the possibility of globe rupture or hyphema, but we have had no indications that this is the case. Additionally, because one is working within the eye¬ lid there is the potential for corneal abrasions, but if the conjunctival flap is retracted superiorly, it should protect the cornea. Early in our series we had one patient develop a laceration of the inferior lacrimal canaliculus that was believed to be secondary to excessive traction. This was managed by microscopic repair over an underlying sili¬ cone stent and has healed without sequelae. With greater awareness of possible traction injuries, this complication has not been encountered subsequently. The sublabial approach to the midface provides consis¬ tently excellent exposure with minimal morbidity. The only complication encountered with this approach to date was the inadvertent severing of an infraorbital nerve. Oneyear follow-up shows the patient has essentially normal sensation in the distribution of that nerve and this compli¬ cation should be easily avoidable. The intraoral approach to mandibular fractures has pro¬ vided excellent exposure for fractures of the anterior half to two thirds of the mandible. Despite concerns over the possibility of increased risk of infections, there have been no infections or nonunions associated with this approach. There was an inadvertent severing of the mental nerve that was repaired intraoperatively. Follow-up on this repaired
is too short to determine turn or not. There was also one
whether sensation will re¬ mental nerve partially lac¬ erated by retraction into a fracture involving the mental foramen. Fractures involving the mental foramen may be a relative contraindication to the intraoral approach be¬ cause there is no way to avoid retraction on the lip and drawing the nerve into the fracture line. Intraoral reduc¬ tion and plating is more difficult for the posterior one third of the mandibular body and angle requiring considerable experience with fractures and plating techniques. While we routinely treat these posterior fractures transorally one should thoroughly master the treatment of anterior frac¬ tures before attempting these. We have presented a plan for managing facial fractures that minimizes external incisions. This system relies on a series of extended access/internal approaches specific for each region of the facial skeleton. These approaches are through scalp or mucosa and not only avoid visible exter¬ nal scars, but also provide wider exposure than conven¬ tional external incisions. The use of these extended access/ internal approaches has allowed excellent fracture exposure, reduction, and fixation, while being associated with minimal morbidity. nerve
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10. Gruss JS, Mackinnon SE. Complex maxillary fractures: role of buttress reconstruction and immediate bone grafts. Plast Reconstr Surg. 1986;78:9\x=req-\ 22. 11. Gruss JS, VanWyck L, Phillips JH, Antonyohn O. The importance of the zygomatic arch in complex midfacial fracture repair and correction of posttraumatic orbitozygomatic deformities. Plast Reconstr Surg. 1990;85: 878-890. 12. Yasargil MG, Reichman MV, Kubik S. Preservation of the frontotem-
poral branch of the facial nerve using the interfascial temporalis flap for pterional craniotomy. J Neurosurg. 1987;67:463-446. 13. Stanley RB. The temporal approach to impacted lateral orbital wall fractures. Arch Otolaryngol Head Neck Surg. 1988;114:550-553. 14. Schwartz HC, Liebel P. Use of a hemicoronal scalp flap to approach an osteochondroma of the coronoid process. Oral Maxillofac Surg. 1987;45: 545-547. 15. Stuzin
JM, Wagstrom L, Kawamoto HK, Wolfe SA. Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg. 1989;83:265-271. 16. Stuzin JM, Wagstrom L, Kawamoto HK, Baker TJ, Wolfe AS. The anatomy and clinical applications of the buccal fat pad. Plast Reconstr Surg. 1990;85:29-37. 17. Glassman RD, Manson PN, Vander Kolk CA, et al. Rigid fixation of internal orbital fractures. Plast Reconstr Surg. 1990;86:1103-1109. 18. Markowitz BL, Manson PN, Sargent L, et al. Management of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central fragmentation, classification and treatment. Plast Reconstr Surg. 1991;87:843-853. 19. Tenzel RR, Miller GR. Orbital blowout fracture repair, conjunctival approach. Am J Ophthalmol. 1971;71:1141-1142. 20. Tessier P. The conjunctival approach to the orbital floor and maxilla and congenital malformation and trauma. J Maxillofac Surg. 1973;1:3-7. 21. Habal MB, Chaset RB. Infra-ciliary trans-conjunctival approach to the
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orbital floor for correction of traumatic lesions. Surg Gynecol Obstet. 1974;
139:420-425. 22. Lynch D, Lamp JC, Royster HP. The conjunctival approach for exploration of the orbital floor. Plast Reconstr Surg. 1974;54:153-157. 23. Habal MB. Experience in the application of the trans-conjunctival route for surgical exposure in the orbital region. Surg Gynecol Obstet. 1976; 143:437-439. 24. Wray RC, Holtmann B, Ribaudo JM, Keiter J, Weeks PM. A comparison of conjunctival and sub-ciliary incisions for orbital fractures. Br J Plast
Surg. 1977;30:142-145.
25. Zingg M, Chowdhurg K, Ladrach K, Vuillemin T, Sutter F, Raveh J. Treatment of 813 zygoma-lateral orbital complex fractures. Arch Otolaryn-
gol Head Neck Surg. 1991;117:611-620.
26. Converse JM, Firman F, Wood-Smith DA, Friedland JA. The conjunctival approach and orbital fractures. Plast Reconstr Surg. 1973;52:656-658. 27. Casson PR, Bonanno PC, Converse JM. The midface degloving procedure. Plast Reconstr Surg. 1974;53:102-103. 28. Chuong R, Donoff RB. Intraoral open reduction of mandibular fractures. Int J Oral Surg. 1985;14:22-28.
29. Wald RM, Abemayor E, Zemplenyi J, Mannai C, Lesavoy MA. The transoral treatment of mandibular fractures using noncompression miniplates: a prospective study. Ann Plast Surg. 1988;20:409-413. 30. Dierks EJ. Transoral approach to fractures of the mandible. Laryngoscope. 1987;97:4-6. 31. Raveh J, Vuillemin T, Ladrach K, Roux M, Sutter F. Plate osteosynthesis of 367 mandibular fractures: the unrestricted indication for intraoral approach. J Craniomaxillofac Surg. 1987;15:244-253. 32. Nishioka GJ, Van Sickels JE. Transoral plating of mandibular angle fractures: a technique. Oral Surg. 1988;66:531-535. 33. Lacy MF, Pospisil OA. Lower blepharoplasty, post orbicularis approach to the orbit: a prospective study. Br J Oral Maxillofac Surg. 1987;25:
398-401. 34. Pospisil OA, Fernando TD. Review of the lower blepharoplasty incision as a surgical approach to zygomatic-orbital fractures. Br J Oral Maxil-
lofac
Surg. 1984;22:261-168.
35. Manson PN, Ruos E, Iliff N, Yaremchuk M. Single eyelid incision for exposure of the zygomatic bone and orbital reconstruction. Plast Reconstr
Surg. 1987;79:120-126.
NEWS AND COMMENT
Jerusalem Symposium on Surgery of the Skull Base and Adjacent Midline Region.—The Organizing Committee is pleased to announce that the Jerusalem Symposium on Surgery of the Skull Base and Adjacent Midline Region will be held from March 21 through 26, 1993, in Jerusalem, Israel. For further information, contact F. Umansky, Chairman, Organizing Com¬ mittee, PO Box 50006, Tel Aviv 61500, Israel; telephone, 972-35174571; fax, 972-3655674.
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Shumrick, MD; Robert C. Kersten, MD; Dwight R. Kulwin, MD; Pradeep
K.
Sinha, MD; Timothy
L.
Smith,
MD
\s=b\ The two most significant recent developments in the treatment of facial trauma are the introduction of plating
systems, which provide rigid internal fixation and the
development of surgical approaches that allow wide exposure of the entire facial skeleton while minimizing external incisions. These approaches (referred to as extended access/ internal approaches) are hemicoronal and coronal flaps, the sublabial approach to the midface, the transconjunctival approach to the orbital floor and orbital rim, and the intraoral management of mandibular fractures. These ap-
proaches work well, and have become standard techniques for managing facial trauma; however, each one has definite technical points that need to be adhered to to assure their success. Additionally, there are situations where these approaches are not appropriate and, in fact, may even be detrimental. This article outlines our approach to facial trauma using these extended access/internal approaches and discusses the important technical factors of each approach. Our experience in treating 113 patients with 119 fractures and 161 approaches over the last 2 years is presented and the role extended access/internal approaches have played is reviewed. The indications, limitations, and possible complications associated with each approach are outlined. (Arch Otolaryngol Head Neck Surg. 1992;118:1105-1112) goal facial surgeon's The form and function, while minimizing any morbidity Until associated with the treatment
in
surgical repair.
trauma is to restore
relatively
re¬
the open reduction and internal fixation of facial fractures (LeFort, nasoethmoid, zygoma, and mandible) was a balancing act of making the smallest possible exter¬ nal incisions that were still sufficiently long to provide ex¬ posure for fracture reduction and fixation. Advances in craniofacial surgery, in conjunction with the development of plating systems that provide rigid internal fixation of facial fractures, have significantly advanced the treatment of facial fractures. It is now possible to expose the entire facial skeleton through internal or camouflaged incisions
cently,
Accepted for publication June 2, 1992. From the Departments of Otolaryngology (Dr Shumrick), Ophthalmology (Drs Kersten and Kulwin), and College of Medicine (Drs Shumrick, Sinha, and Smith), University of Cincinnati (Ohio). Presented at the fall meeting of the American Academy of Facial Plastic and Reconstructive Surgery, San Diego, Calif, September 7, 1990. Reprint requests to the Department of Otolaryngology, University of Cincinnati, 231 Bethesda Ave, Cincinnati, OH 45267 (Dr Shumrick). Arch
Otolaryngol Head Neck Surg\p=m-\Vol118, October
of the division of the facial skel¬ on the extended access/ that maximizes exposure, while minimizing external
Fig 1.—Diagrammatic representation eton into distinct anatomic
internal approach incisions to that region.
regions based
and
perform rigid, one-stage repair of fractures.1"8 Addi¬ tionally, the use of plates for rigid internal fixation of frac¬ tures has virtually eliminated the need for suspension wires and external traction devices, as well as significantly decreasing the requirements for intermaxillary fixation.7-9'10 The purpose of this article is to outline our approach to facial trauma utilizing extended access/internal ap¬ proaches, performed in a standardized fashion, to expose each portion of the facial skeleton. This systematic ap¬ proach to the facial skeleton can be used to treat isolated fractures or integrated into a treatment plan for exposing and treating virtually the entire facial skeleton. MATERIALS AND METHODS
Strategies for Approaching the
Extended Access/Internal
Facial Skeleton Via
Approaches
The facial skeleton can be divided into four major skeletal re¬ gions with one subregion. Each of these major regions has an ex¬ tended access/internal approach which, we believe, provides for optimal exposure while minimizing external scars. The four ma¬ jor skeletal regions are as follows (Fig 1): (1) The upper third of the facial skeleton that includes the zygomatic arches, lateral or¬ bital rims, supraorbital rims, medial orbital rims and medial can¬ titi, and the frontonasoethmoid region are approached through hemicoronal or coronal incisions. (2) The inferior orbital rim, or¬ bital floor, and upper maxilla are exposed with transconjunctival incisions. (3) The lower maxilla, zygomaticomaxillary buttress,
1992
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Dotted lines indicate coronal in¬ cision in individual where balding is a con¬ cern. In individuals where balding is not a concern the incision is placed 3 to 4 cm behind and parallel to the hairline. Right, Flap has been elevated in a supraperiosteal plane until 2 cm superior to the orbital rims where the dissection becomes subperiosteal. Note that the supraorbital nerves and vessels have been released from their foramen.
Fig 2.—Left,
Fig 3.—Lateral view of the dissection for coro¬ nal flaps. The initial dissection is just superfi¬ cial to the superficial layer of the deep tempo¬
ral fascia until the superficial temporal fat pad is visualized. (Note that for purposes of illus¬ tration the flap is shown elevated further ante¬ riorly than in actual surgery. The dissection should stop at the fat pad.)
Fig 4.—After exposing the fat pad, the overly¬
ing fascia is incised and the incision extended superiorly to join with the frontal subperiosteal dissection and inferiorly to the root of the zy¬
gomatic arch. The rest of the dissection is subfascial (but superficial to the fat pad) until the orbital rim and zygomatic arch are reached, at which point the dissection becomes subperi¬ osteal.
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and piriform aperture are exposed with either unilateral or bilat¬ eral sublabial incisions. (4) The mandible, including the symphy¬ sis, parasymphysis, and anterior half to two thirds of the mandibular body are exposed intraorally through incisions in the gingival buccal mucosa. We have separated mandible fractures of the posterior third of the body or angle into a subgroup that will be discussed separately.
Hemicoronal and Coronal Flaps: Region 1—Frontal, Nasoethmoid, Lateral Orbital Rims, Zygomatic Arches, and Body of Zygoma (Fig 1 ) Hemicoronal and coronal flaps have now become standardized technique and are routinely performed in neurosurgery, craniofacial surgery, skull base surgery, and frontal sinus surgery; as well as for facial trauma.311"13 They provide wide exposure of the zygomatic arches; zygomaticofrontal suture; lateral, superior, and medial orbital rims; frontal and nasofrontal suture; the nasoethmoid region; and may also be used for exposure of the mandibular ramus and condyle.14 Coronal incisions not only provide wide exposure of these areas, but are also better camouflaged than external or regional incisions by virtue of being placed in the hairline. We believe the scars re¬ sulting from coronal incisions, even in balding individuals, are preferable to glabellar scars that frequently widen and become depressed despite proper closure technique, often defying im¬ provement by revision. Hemicoronal incisions are used for uni¬ lateral fractures, where as full coronal incisions are used for bilat¬ eral fractures or when exposure of the frontal, nasoethmoid region is required. The keys to successfully performing either hemicoronal or coronal flaps are: (1) The lower portion of the in¬ cision is brought inferiorly in the preauricular crease to at least the level of the tragus. Failure to bring the incision sufficiently infe¬ rior will prevent access to the zygomatic arch and lower, lateral orbital rim. (2) The upper portion of the incision parallels the hairline and is placed 3 to 4 cm posterior to it. Individuals with male-pattern baldness should have the incisions brought straight across the top of the head from the root of one auricular helix to the root of the other helix (Fig 2). For hemicoronal flaps the inci¬ sion should come to at least the midline superiorly; failure to do so will prevent the flap from folding inferiorly enough to allow exposure of the superior and lateral orbital rims. (3) The incision is made with a scalpel blade in incremental sections 4 to 6 cm in length. We do not use the bovie along the incision to avoid injury to hair follicles; instead, Renne neurosurgical clamps are placed for hemostasis. (4) The initial plane of dissection is just above the periosteum superiorly over the skull and just superficial to the temporalis muscle fascia laterally. (5) In the superior portion of the dissection, over the frontal region, the periosteum is incised approximately 2 cm superior to the orbital rims and nasofrontal suture; the dissection is then continued inferiorly in a subperi¬ osteal plane over the orbital rims and root of the nose. This sub¬ periosteal dissection elevates the corrugator and procerus mus¬ cles and avoids injury to the supraorbital and supratrochlear arteries and nerves (Fig 2). (6) Laterally, over the temporalis muscle, the dissection is carried forward in a plane that is just su¬ perficial to the temporalis muscle fascia (this fascia is the super¬ ficial layer of the deep temporal fascia) until the superficial tem¬ poral fat pad is visualized under the fascia. An incision is then made through the temporalis fascia (superficial layer of the deep temporal fascia) extending from a point approximately 1.5 finger breadths superior to the orbital rim (connecting with the subpe¬ riosteal incision and dissection previously performed) and ex¬ tending inferiorly and posteriorly to the root of the zygoma. Af¬ ter incising the fascia, the dissection is continued in a subfasciai plane attempting to stay lateral to the fat pad; by doing so the frontalis branch of the facial nerve will be reflected later¬ ally.11'12'15-16 (Figs 3 and 4). When the lateral orbital rim and zygo¬ matic arch are reached, the fasciai attachments are incised and the dissection is continued subperiosteally. (7) In the nasofrontal re¬ gion, the dissection is continued subperiosteally down over the root of the nose and along the medial aspect of the orbit. (8) Frein their
Fig 5.—Diagrammatic representation transconjunctival approach.
of the exposure
possible with
a
quently, a limiting factor in exposing the nasoethmoid region is
the amount of inferior retraction one can achieve on the coronal flap due to tethering by the supraorbital nerves and vessels exit¬ ing the supraorbital foramen. It should be recognized that these vessels are not traveling in a true canal but, rather, a short fora¬ men of bone or, often, just a notch. Therefore, these nerves and vessels may be released inferiorly by carefully excising the infe¬ rior portion of the canal with a Kerrison punch, rongeur, osteotome, or drill (Fig 2). Continued subperiosteal dissection over the superior orbital rim and along the orbital roof will allow substantial additional inferior retraction of the flap. (9) While it is possible to use the coronal approach to expose the entire me¬ dial orbit and medial inferior rim we attempt to avoid dissecting the medial canthi from bony fragments because it is simpler to reposition the canthi if they retain their bony attachments.1718 (10) When closing, after this degloving approach, we place several tacking sutures of 2-0 polyglycolic acid suture (Dexon) to reapproximate the temporalis fascia, which is believed to provide support to the upper one third of the face. A 7-mm Jackson-Pratt drain is placed in a dependent position and brought out postauricularly. The rest of the incision is closed in a single layer with staples in the scalp and 6-0 running nylon sutures along the preauricular incision.
Transconjunctival Approach: Region 2—Inferior Orbital Rim, Orbital Floor, Superior Maxilla A transconjunctival approach offers excellent exposure of the infraorbital rim, orbital floor, inferior medial orbital wall, inferior lateral orbital rim, and superior face of the maxilla (Figs 1 and 5). Although this approach has been known for over half a century, it was not widely popularized until the early 1970s.19"23 Subse¬ quently, large series have shown it to be superior to the standard subciliary precutaneous approach, both from a cosmetic and from a functional standpoint.23-24 The keys to successfully performing a transconjunctival ap¬ proach to the inferior orbital rim and floor are as follows: (1) One must perform a lateral canthotomy and inferior cantholysis to disinsert the lower eyelid from the lateral orbital rim (Fig 6). Although Zingg et al25 state a canthotomy is not necessary, it is our experience that this simple step markedly increases distractibility of the lower lid and improves exposure of the rim and floor. (2) Dissection should be carried out in the preseptal plane. Initial studies on the transconjunctival approach described an incision in the inferior fornix entering the retroseptal space. This results in dissection through orbital fat to reach the infraorbital rim and
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Fig 6.—A lateral canthotomy is performed by placing a scissor blade on either side of the lateral canthal tendon at its apex and making a single cut. An inferior cantholysis is performed by making a single cut across the inferior portion of the tendon. Reattachment is via a single mattress suture (see text). risks
injury to the inferior oblique muscle as well as intraorbital
hemorrhage."'20'22'26 Instead of incising in the fornix, we prefer to
incise the conjunctiva immediately beneath the tarsal plate where the conjunctiva, lower lid retractors, and septum are fused and can be disinserted from the inferior tarsal border intact (Fig 7, left). The dissection then proceeds inferiorly in the avascular plane be¬ tween the orbital septum and overlying orbicularis muscle. Maintaining an intact septum prevents orbital fat from prolaps¬ ing into the operative field, protects extraocular muscles and in¬ traorbital tissue, and enhances hemostasis. (3) Cephalad retrac¬ tion on the lid must be maintained during dissection to the orbital rim. The tendency is to retract the lower lid in a caudad fashion, but this results in the lid being folded back over on itself and in¬ creases the risk of inadvertent penetration of the orbicularis mus¬ cle and "buttonholing" of the skin. When cephalad retraction is maintained the skin will not fold on itself and the plane of dissec¬ tion is more readily followed (Fig 7, left). (4) Care must be taken to avoid excessive lateral traction during exposure and manipu¬ lation of the orbital rim and floor. Laceration through the lacrimal canaliculi caused by excessive traction occurred in one of our pa¬ tients and has been described by others using the transconjunc¬ tival approach. If exposure is limited, then extension of the lateral canthotomy and dissection of the orbicularis muscle from the lat¬ eral zygoma will enhance medial exposure without requiring ex¬ cessive traction. (5) Following closure of the subtarsal incision with a continuous fine absorbable suture (we prefer 6-0 fast ab¬ sorbing chromic suture) the lateral canthal tendon is reapproxi-
mated with a horizontal mattress suture of 5-0 polyglycolic acid suture or polyglactin suture (Vicryl). This approximation is enhanced by the use of a double-armed suture that is passed through the superior and inferior portion of the cut lateral canthai tendon and then through the superior and inferior portion of the intact remnant at the lateral orbital rim (Fig 6).
Sublabial Approach: Region 3—The Inferior Maxilla, Piriform Aperture, and Zygomaticomaxillary Buttress The sublabial approach to the maxilla may be unilateral or bi¬ lateral and provides wide exposure of the zygomaticomaxillary buttress, inferior border of the body of the zygoma, the anterior face of the maxilla, and the piriform aperture27 (Fig 8). The tech¬ nical points are as follows: (1) The incision is placed sufficiently superior in the gingival buccal sulcus to ensure adequate soft tis¬ sue, on the inferior portion of the incision, to facilitate closure. (2) When performing a unilateral approach the anterior incision should come to at least the midline. (3) The posterior incisions (whether unilateral or bilateral) should extend to the posterior portion of the alveolar ridge to allow satisfactory exposure of the zygomaticomaxillary buttress. (4) Once the incision has been made it should be carried directly to the bone and the dissection completed in a subperiosteal plane. (5) As the dissection extends over the zygoma, it is often necessary to release a portion of the masseter from the inferior border of the zygoma with a knife or electrocautery. The upper limit of the dissection is usually just
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Fig 7.—Left, Cross section of lower lid showing proposed route (dotted line) of dissection through conjunctiva and lower lid retractors at the inferior border of the tarsus. The preseptal plane is entered and dissection continued to the orbital rim. At the orbital rim the periosteum is incised and the dissection continued subperiosteally. Right, Illustration of cephalad retraction on conjunctiva (arrow) and lower lid to aid in establishing and main¬ taining the preseptal plane.
parotid gland, and masseter with a drill sleeve to protect the soft no question that the intraoral treatment of pos¬
tissue.32 There is
Fig 8.—Demonstration of exposure possible with sublabial approach to the maxilla and transoral approach to mandibular fractures. Note that the use
of Hommon retractors, which hook underneath the mandible,
greatly facilitate exposure.
above the infraorbital nerve, but the inferior orbital rim may be exposed and viewed in its entirety, taking care to dissect around, and avoid damage to, the infraorbital nerve.
Intraoral Approaches to Mandibular Fractures: 4—Mandibular Symphysis, Parasymphysis, and Anterior Two Thirds of the Body
Region
The intraoral approach to mandibular fractures for rigid inter¬ nal fixation with mandibular plates has become our procedure of choice for the majority of mandibular fractures. The intraoral ap¬ proach provides excellent exposure of the mandibular symphy¬ sis, parasymphysis, and the anterior half to two thirds of the mandible body.28"31 However, intraoral exposure of the posterior third of the body and the angle is more difficult, usually requir¬ ing a percutaneous stab incision and working through the cheek,
terior mandible fractures is feasible and has most of the advan¬ tages of treating anterior mandible fractures, but it requires ad¬ ditional experience and equipment; individuals who are not performing these techniques on a regular basis may wish to con¬ sider restricting the intraoral approach for anterior fractures. For this article we have included only fractures of the anterior two thirds of the mandible. Several technical points should be noted regarding the intraoral approach to mandibular fractures: (1) The mucosal incisions are centered over the fracture with a 3- to 4-cm extension anteriorly and posteriorly. (2) Again, the incision is placed in the gingival buccal sulcus so as to leave adequate soft tissue on the gingival side for closure. (3) After the mucosal incision, the dissection is in a subperiosteal plane. (4) Particular care should be taken in the region of the first premolar to identify the inferior alveolar nerve and dissect around it. Most plates will be applied below the nerve and it is essential that the nerve be completely exposed and dis¬ sected free. Occasionally, it is necessary to dissect the nerve dis¬ tally onto the lip to provide further length for inferior retraction. It is also possible to remove a portion of the inferior alveolar nerve canal by drilling to allow greater mobility of the nerve, just as one would for the supraorbital nerves. (5) It is essential that the dis¬ section be carried inferiorly to, and around, the mandibular mar¬ gin, once the mandibular margin is exposed retraction is greatly facilitated by the use of Homman retractors that hook under the mandible and, by levering them inferiorly, help reduce the frac¬ ture as well as retracting the lips and cheeks out of the operative field. (6) The mandibular fracture is then stabilized with mandib¬ ular plates (we use Luhr Vitallium plates with bicortical selftapping screws) using compression when possible. (7) The plates are usually placed below the inferior alveolar nerve to avoid in¬ jury to the tooth roots with the drill and screws. Closure consists of a single layer of 3-0 chromic suture. If satisfactory rigid inter¬ nal fixation has been accomplished, then the intermaxillary fixa¬ tion is released at the end of the operation. We have reviewed facial trauma patients treated from January 1988 through June 1990, with extended access/internal ap¬ proaches. There were 161 extended access/internal approaches performed on 113 patients who had 119 separate classifiable frac¬ tures. The surgical approach or approaches to these fractures were determined by physical examination and roentgenographic find¬ ings. In simple zygomatic complex fractures, with minimal zygo¬ matic frontal suture displacement, a simple brow incision and wire or plate were used to approach the Z-F suture, with the ma-
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Table
Approaches
1.—Listing of Fractures and Approaches
Transconjunctival
Hemicoronal
23 2 2 9 0
0 13 0 10 0
Used to
Manage Them
Bicoronal
Sublabial
Intraoral Mandibular
0 41 2 25 0
0 0 0 0 21
Total
Fractures
Blowout
Zygomatic complex Nasoethmoid LeFort
Mandible
23 44 5 26 21
Total Fractures Total No. of Individual
Approaches
119 36
23
jor stabilization of the fracture being provided by a sublabial ap¬ proach to the maxilla and plating of the Z-M buttress. For delayed zygomatic fractures, fractures with significant displacement of or fractures involving the zygoma itself, a hemicoronal approach was used. For purposes of this article only fractures of
68
13
were
included.
Managed by Extended Access/Internal Approaches
Results of Patients
Review of the patient series showed the following fracture dis¬ tribution: 21 blowout fractures, five isolated nasoethmoid frac¬ tures, 26 LeFort type fractures, 44 isolated zygomatic complex fractures, and 21 mandible fractures. The types of incisions and approaches were as follows: 36 transconjunctival incisions, 23 hemicoronal flaps, 13 coronal flaps, 68 sublabial approaches to the maxilla, and 21 patients with intraoral repair of mandibular frac¬ tures (Table 1). Thirty-five patients had a combination of one or more approaches: 16 patients with hemicoronal and sublabial approaches, six patients with coronal and sublabial approaches, 10 patients with hemicoronal or coronal flaps with transconjunc¬ tival and sublabial approaches, and three patients with coronal, transconjunctival, sublabial, and intraoral mandibular ap¬ proaches (Table 2). Determination of the need for intermaxillary fixation was made on an individual basis depending on the severity of the injury, stability achieved, and associated fractures. Patients were followed up for a minimum of 6 weeks with an average follow-up of 12 weeks. Fracture reduction was believed to be adequate to excellent in all patients and there was no need for revisionai surgery. There were three patients with paralysis of the frontalis branch of the facial nerve following coronal or hemi¬ coronal flaps, two nerves recovered spontaneously within 4 weeks, and one remained paretic for 3 months and then recovered fully. The only complication associated with the transconjuncti¬ val approach was a lacrimal canalicular laceration due to exces¬ sive traction. This laceration was repaired by suture and stenting and is fully functional at 6 months. There were no ectropions or eyelid deformities associated with the transconjunctival ap¬ proach. The sublabial approach was associated with laceration of one infraorbital nerve with postoperative lip numbness; sensation has returned fully at 1 year. Three mandibular plates placed intraorally became exposed and were removed, but this did not af¬ fect the overall outcome. One mental nerve was lacerated during an intraoral reduction of a mandible fracture and was repaired primarily, the patient's lip remains numb at 1 year. A mental nerve was partially lacerated by retraction into a fracture that in¬ volved the mental foramen, but sensation recovered within 6 months postoperatively. There were no instances of infections, nonunions, or malunions associated with intraoral reduction of mandible fractures.
COMMENT Using the techniques described it is possible to expose virtually the entire facial skeleton with a subperiosteal dissection that provides wide exposure with camouflaged (in the hairline) or internal mucosal incisions. In this series
161
Table 2.—Fractures Managed by a Combination of Extended Access/Internal Approaches*
the arch,
the anterior two thirds of the mandible
21
No. of Patients
Approaches Hemicoronal and sublabial
16
Bicoronal and sublabial
6
Bicoronal, transconjunctival, and sublabial Hemicoronal or bicoronal, transconjunctival, sublabial, and intraoral
10
Total
35
mandibular
"Thirty-five patients had Table
two or more
3
approaches.
3.—Complications of Extended
Access/Internal Approaches Bicoronal and hemicoronal flaps: three frontalis nerves paretic postoperatively, two recovered spontaneously, one remains paralyzed at 10 wk Transconjunctival approach: one canalicular laceration due to excessive traction, repaired primarily Sublabial approach: one infraorbital nerve lacerated, completely recovered at 1 yr Intraoral approach to mandibular fractures: one mental nerve surgically lacerated, repaired primarily, no function at 1 y, one mental nerve partially lacerated at fracture site, full function at 6 mo
of 119 patients, 35 patients had a combination of extended access/internal approaches. In fact, three patients had the entire facial skeleton exposed with coronal flaps, bilateral transconjunctival incisions, bilateral sublabial incisions, and intraoral reduction of mandibular fractures. Because the incisions used for extended access/internal approaches are made in the mucosa or in the scalp, the inflammation and edema encountered in external, muscle-splitting inci¬ sions is greatly reduced. Additionally, the dissections are performed in a subperiosteal plane so that there is no dis¬ ruption of blood supply, lymphatic drainage, nerve func¬ tion, or muscle function. A further advantage to extended access approaches is that exposure of the entire facial skel¬ eton is possible allowing much more complete visualiza¬ tion of the fractured bone or bones when compared with traditional external incisions where only a small portion of the fracture is seen. This improved exposure allows for more accurate fracture reduction and is necessary to take full advantage of the various plating systems that are now an integral part of managing facial trauma. While these extended access/internal approaches offer
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significant advantages they are technically somewhat more demanding than simple external approaches and they each have certain potential complications and con¬ traindications. The coronal and hemicoronal flaps carry the possibility of injury to the frontalis branch of the seventh cranial nerve and the supraorbital nerves. In this series we encountered three paralyses of the frontalis nerve in the postoperative period, all of which completely recovered. This complete recovery suggests that the paresis occurred secondary to traction, rather than as a direct injury to the nerve. There have been no long-term supraorbital nerve
deficits that we attribute to careful release of the supraor¬ bital nerves from their foramens. The transconjunctival approach to the orbital floor and rim has been a safe and reliable technique. It replaces the longer, visible subciliary incision with a very fine lateral canthotomy incision that is hidden in the lateral commis¬ sure and remains virtually imperceptible. In addition to improved cosmesis, the transconjunctival approach has essentially eliminated the complications of ectropion and scierai show, which frequently occur following the percu¬ taneous, subciliary approach.24-33-34 Some authors have suggested the need for a tarsal suture and pressure dress¬ ings in the postoperative period; however, these have not been required in our cases and, in fact, we believe they are contraindicated in the immediate postoperative period when it is important to monitor visual status. We also be¬ lieve that a lateral canthotomy and inferior cantholysis significantly improves exposure of the orbital rim and floor and minimizes complications due to excessive traction on the eyelid. A key to enhancing this exposure is to extend the canthotomy laterally up to 1 cm, or as necessary, and to bluntly dissect the orbicularis from its attachment to the zygoma. Manson et al35 have described a technique of ex¬ tending this dissection superiorly to expose the zygomaticofrontal suture through a single incision, but we do not have experience with this technique. Initially, there was concern that the exposure achieved with the transconjunctival approach might require more retraction on the globe with the possibility of globe rupture or hyphema, but we have had no indications that this is the case. Additionally, because one is working within the eye¬ lid there is the potential for corneal abrasions, but if the conjunctival flap is retracted superiorly, it should protect the cornea. Early in our series we had one patient develop a laceration of the inferior lacrimal canaliculus that was believed to be secondary to excessive traction. This was managed by microscopic repair over an underlying sili¬ cone stent and has healed without sequelae. With greater awareness of possible traction injuries, this complication has not been encountered subsequently. The sublabial approach to the midface provides consis¬ tently excellent exposure with minimal morbidity. The only complication encountered with this approach to date was the inadvertent severing of an infraorbital nerve. Oneyear follow-up shows the patient has essentially normal sensation in the distribution of that nerve and this compli¬ cation should be easily avoidable. The intraoral approach to mandibular fractures has pro¬ vided excellent exposure for fractures of the anterior half to two thirds of the mandible. Despite concerns over the possibility of increased risk of infections, there have been no infections or nonunions associated with this approach. There was an inadvertent severing of the mental nerve that was repaired intraoperatively. Follow-up on this repaired
is too short to determine turn or not. There was also one
whether sensation will re¬ mental nerve partially lac¬ erated by retraction into a fracture involving the mental foramen. Fractures involving the mental foramen may be a relative contraindication to the intraoral approach be¬ cause there is no way to avoid retraction on the lip and drawing the nerve into the fracture line. Intraoral reduc¬ tion and plating is more difficult for the posterior one third of the mandibular body and angle requiring considerable experience with fractures and plating techniques. While we routinely treat these posterior fractures transorally one should thoroughly master the treatment of anterior frac¬ tures before attempting these. We have presented a plan for managing facial fractures that minimizes external incisions. This system relies on a series of extended access/internal approaches specific for each region of the facial skeleton. These approaches are through scalp or mucosa and not only avoid visible exter¬ nal scars, but also provide wider exposure than conven¬ tional external incisions. The use of these extended access/ internal approaches has allowed excellent fracture exposure, reduction, and fixation, while being associated with minimal morbidity. nerve
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NEWS AND COMMENT
Jerusalem Symposium on Surgery of the Skull Base and Adjacent Midline Region.—The Organizing Committee is pleased to announce that the Jerusalem Symposium on Surgery of the Skull Base and Adjacent Midline Region will be held from March 21 through 26, 1993, in Jerusalem, Israel. For further information, contact F. Umansky, Chairman, Organizing Com¬ mittee, PO Box 50006, Tel Aviv 61500, Israel; telephone, 972-35174571; fax, 972-3655674.
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