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14. Lang B, Pohl Y, Filippi A. Knowledge and prevention of dental trauma in team handball in Switzerland and Germany. Dent Traumatol 2002;18:329–334 15. Persic R, Pohl Y, Filippi A. Dental squash injuries—a survey among players and coaches in Switzerland, Germany and France. Dent Traumatol 2006;22:231–236 16. Avila MM. A case study of the community health agents program in Uruburetama, Ceará (Brazil). Cien Saude Colet 2011;16:349–360 17. Sousa MF, Parreira CM. Green, healthy environments: training of community health agents in the city of São Paulo, Brazil. Rev Panam Salud Publica 2010;28:399–404 18. Shi L. Health care in China: a rural–urban comparison after the socioeconomic reforms. Bull World Health Organ 1993;71:723–736 19. Walker A, Brenchley J. It’s knockout: survey of the management of avulsed teeth. Accid Emerg Nurs 2000;8:66–70 20. Lin S, Levin L, Emodi O, et al. Physician and emergency medical technicians' knowledge and experience regarding dental trauma. Dent Traumatol 2006;22:124–126 21. Hamilton FA, Hill FJ, Mackie IC. Investigation of lay knowledge of management of avulsed permanent incisors. Endod Dent Traumatol 1997;13:19–23 22. Andreasen JO, Andreasen FM. Textbook and colour atlas of traumatic injuries to the teeth. 3rd ed. Copenhagen: Munksgaard, 1994 23. Pacheco LF, Garcia Filho PF, Letra A, et al. Evaluation of the knowledge of the treatment of avulsions in elementary school teachers in Rio de Janeiro, Brazil. Dent Traumatol 2003;19:76–78 24. Mori GG, Turcio KLH, Borro VPB, et al. Evaluation of knowledge of the tooth avulsion of schools professionals from Adamantina, São Paulo, Brazil. Dent Traumatol 2007;23:2–5 25. Sterenborg EM, van Hooft MJ, Frankenmolen FW, et al. What does the non-dentistry-trained person know about avulsion? Ned Tijdschr Tandheelkd 1999;106:42–45 26. Kinoshita S, Kojima R, Taguchi Y, et al. Tooth replantation after traumatic avulsion: a report of ten cases. Dent Traumatol 2002;18:153–156 27. Stokes AN, Anderson HK, Cowan TM. Lay and professional knowledge of methods for emergency management of avulsed teeth. Endod Dent Traumatol 1992;8:160–162 28. Cohenca N, Forrest JL, Rotstein I. Knowledge of oral health professionals of treatment of avulsed teeth. Dent Traumatol 2006;22:296–301 29. Flores MT, Andersson L, Andreasen JO, et al. International Association of Dental Traumatology. Guidelines for the management of traumatic dental injuries: II. Avulsion of permanent teeth. Dent Traumatol 2007;23:130–136 30. Andreasen JO, Ravn JJ. Epidemiology of traumatic dental injuries to primary and permanent teeth in a Danish population sample. Int J Oral Surg 1972;1:235–239
The Management of Pediatric Type 1 Nasoorbitoethmoidal Fractures With Resorbable Fixation Jose Rodriguez-Feliz, MD, Karan Mehta, BS, Ash Patel, MD From the Division of Plastic Surgery, Albany Medical College, ALbany, NY. Received October 17, 2013. Accepted for publication February 16, 2014. Address correspondence and reprint requests to Ash Patel, MD, Division of Plastic Surgery, Albany Medical College, 50 New Scotland Avenue, MC-190, 1st Floor, Albany, NY 12208; 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.0000000000000937
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Abstract: Nasoorbitoethmoid (NOE) fractures are rare in the pediatric population. A recent study reported that NOE fractures account for 1% to 8% of all pediatric craniofacial fractures based on the National Trauma Data Bank. Although infrequent, NOE fractures must be appropriately identified and treated because of potential severe esthetic and functional complications. In this report, we discuss our experience treating the uncommon case of a 9-year-old girl who was involved in a motor vehicle accident and had traumatic injuries to the midface, including a type 1 NOE fracture. We elected to use biodegradable plates to treat her left type 1 NOE fracture because of concerns of facial growth disturbances with the use of conventional rigid fixation techniques at her young age. At 1-year follow-up, the patient demonstrated an acceptable outcome with no functional problems reported. We have also incorporated in this article a thorough review of the literature relating the evolution of biodegradable plates for the treatment of pediatric facial fractures. Key Words: NOE fractures, nasoorbitoethmoid fractures, pediatric facial fractures, resorbable fixation, biodegradable fixation, bioabsorbable fixation, facial growth restriction, facial growth disturbances, telecanthus, midface fractures, craniofacial fractures, facial fractures
ediatric facial fractures are uncommon. Imahara et al1 described the epidemiology of pediatric facial injuries using data from the American College of Surgeons National Trauma Data Bank. Of the 277,008 pediatric trauma admissions, only 4.6% (12,739) were associated with facial fractures.1 The most commonly reported pediatric facial fractures occurred in the mandible and nasal bones. 1,2 Midfacial fractures are exceedingly rare in children3; moreover, nasoorbitoethmoid (NOE) fractures are responsible for only 1% to 8% of all pediatric facial fractures.1 This can be explained by the difference between a child's facial anatomy and an adult's facial anatomy. The volume occupied by the skull in comparison with that by the face shifts from 8:1 to 2:1 between infancy and adulthood.2 As a result, in infants, the cranium is much more vulnerable to injury than the face. As a child develops and the face enlarges, the incidence of midfacial fractures also increases eventually reaching adult levels.4 The presence of immature cancellous bone and greater elasticity of the pediatric skeleton also protects children against facial fractures by incorporating an additional degree of flexibility to bone.4 The lack of complete development of the sinuses and, therefore, decreased pneumatization of facial bones could also explain the lower incidence of pediatric NOE fractures. 3 The NOE area lies at the intersection of the forehead, nose, orbits, and upper portion of the midface. This area is near the chondrocranial sphenoethmoidonasal growth center. Its appearance is dictated by the active interaction and development of all these surrounding structures. Therefore, injury to this area and operative intervention make subsequent growth of the region difficult to predict and an important concern in the management of these fractures in the pediatric patient. The NOE fractures yield a typical facie characterized by a shortened width of the palpebral fissures, telecanthus from lateral migration of the medial canthus, and a saddle nose deformity. 4 Although pediatric NOE fractures occur rarely, they must be appropriately identified and treated because of a potential for severe esthetic and functional complications.2 The NOE fractures in adults are treated according to wellestablished protocols that call for rigid fixation using miniplates and screws. The use of rigid fixation in the treatment of pediatric facial fractures poses a unique problem due to the active growth of
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the craniomaxillofacial skeleton during childhood. Persing et al5. reported that immobilization of the coronal suture in 9-day-old rabbits with methylcyanoacrylate adhesive resulted in significantly decreased growth across the suture. A later study by Resnick and colleagues6 showed a reduction in growth across plated coronal sutures in 6-week-old rabbits. Similar findings were later reported by a number of other animal studies. We believe that treating a pediatric NOE fracture with rigid titanium fixation has the potential for a higher chance of growth disturbances in the midface considering the multiple growth centers in the vicinity. In light of the limitations posed by rigid titanium fixation, the use of resorbable fixation seems promising for the treatment of NOE fractures in pediatric patients that have not reached facial growth plateau. Moe and Weisman7 (2001) reported on their experience in 30 patients and 35 procedures (cosmetic and reconstructive) using polylactic acid resorbable fixation plates. They reported good outcomes in different clinical scenarios including craniofacial fractures, craniomaxillofacial osteotomies (Le Fort 1/Le Fort 2), and soft tissue suspension for endoscopic brown lift. There were no reported cases of wound infections, malunion, delayed fracture healing, or plate extrusion. Eppley8 reported on 44 pediatric facial fractures effectively treated using resorbable plates and screws with no long-term complications. Bell and Kindsfater9 also reported effective healing in 59 patients who received resorbable fixation for a variety of pediatric facial fractures. In 2010, Ahn et al10 found resorbable fixation to be so effective that they recommended that resorbable fixation be the standard of care for the fixation of pediatric facial fractures. Although the use of biodegradable internal fixation techniques has been increasing in popularity in the management of pediatric facial fractures, we did not find any reported cases in the literature for its use in the treatment of pediatric NOE fractures. This clinical report aims to describe our experience using resorbable plates and screws for the treatment of a pediatric patient with a type 1 NOE fracture after a motor vehicle accident. We will discuss the scientific data that suggested the potential for growth disturbances in the pediatric craniofacial skeleton with the use of rigid titanium fixation and those studies that led to an era of research, development, and application of biodegradable plates and screws for the treatment of not only pediatric facial fractures but also adult craniomaxillofacial trauma.
CASE PRESENTATION The patient is a 9-year-old girl who was a restrained back-seat passenger in a multivehicle car accident. She presented to our institution as hemodynamically stable, with a reported temporary loss of consciousness. As part of her trauma assessment, she underwent imaging including computed tomography scans of the head and face. She was found to have facial bone fractures, including a right minimally displaced frontal bone fracture extending caudally toward the nasal bones, bilateral nasal bone fractures, a left type 1 NOE fracture with comminution at the left nasomaxillary buttress, left inferior
FIGURE 1. Axial CT scan image demonstrating the left nasomaxillary buttress fractured and significantly displaced, with associated bilateral nasal bone fractures and deviation of the nasal bones to the left.
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FIGURE 2. Axial CT scan image demonstrating the fractured left frontal process of the maxilla (NOE segment) with involvement of the left inferior orbital rim.
orbital rim fracture, left medial orbital wall fracture, and left orbital floor fracture (Figs. 1–4). She had a full-thickness laceration of the right forehead extending across the glabella that was repaired at the bedside (Fig. 5). The patient also had pneumocephalus and a subdural hematoma in the left fronto-orbital region. She was evaluated and cleared by neurosurgery and ophthalmology and scheduled for surgical management of her facial fractures. The patient was taken to the operating room 6 days after her initial injury. The most significant injury was a left type 1 NOE fracture with comminution of the left nasomaxillary buttress and telecanthus on the left (Figs. 5–8). She also had bilateral nasal bone fractures with an associated fracture/deviation of the nasal septum, a left medial orbital wall fracture, and a left orbital floor fracture involving the inferior orbital rim. The right frontal bone fracture was minimally displaced, and repair was not required. The procedure was performed under general anesthesia. The traumatic laceration was used for direct access to the NOE region (Fig. 9). A subperiosteal dissection was performed on the left NOE region preserving the left canthal tendon and the lacrimal apparatus (Fig. 10). The left canthal tendon was found to be attached to the fractured NOE segment confirming a type 1 NOE fracture. We then performed a left transconjunctival incision to expose the left orbital rim and orbital floor (Fig. 11). Via the left nostril, the intranasal laceration gave us direct access to the fractured nasomaxillary buttress (Fig. 12). After reducing the fractures, a resorbable plate was placed on the orbital rim as our first point of fixation. A second point of fixation was achieved by placing a resorbable box plate at the left nasomaxillary buttress through the traumatic intranasal laceration (Fig. 13). The medial orbital wall and orbital floor were repaired with a resorbable mesh implant.
RESULTS The patient was discharged on the second postoperative day without signs of early complication. She was seen as an outpatient 2 weeks postoperative (Figs. 14, 15). A slight deviation of the nasal tip to the left was noted. There was also edema of the left periorbital region and the left cheek. Healing of the forehead scar was appropriate. There was no evidence of telecanthus. In Figures 16 and 17, there is markedly improvement of the periorbital edema with a satisfactory result at 5 weeks postoperative. At 1-year follow-up, there is persistence of nasal tip deviation to the left and fullness of the left
FIGURE 3. Coronal CT scan image demonstrating a significant fracture of the entire medial left orbit and left nasomaxillary buttress.
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FIGURE 4. Three-dimensional reconstruction. Despite artifact from an oxygen mask, fractures of the nasal bones and left type 1 NOE fracture are demonstrated.
FIGURE 5. Preoperative frontal view illustrating the traumatic laceration in the right forehead/glabella region that was used to access the fractured NOE segment. Left-sided telecanthus is visible.
cheek. The patient also shows some rounding of the left medial canthus along with a slight degree of enophthalmos visible only on the worm’s eye view (Figs. 18–21). There is no evidence of telecanthus. The forehead scar has matured appropriately. There is asymmetry of the nares (Fig. 19) secondary to scar contracture on the left nasal sill at the site of traumatic laceration. Her visual acuity was normal, and she did not complain of diplopia. The patient has returned to her baseline activities. There have not been any psychologic disturbances reported secondary to her appearance. Despite the results at her 1-year follow-up, the mother was counseled regarding the importance of close follow-up until the patient becomes adolescent to identify any growth disturbances that may occur as the patient’s craniofacial skeleton continues to develop.
DISCUSSION The Evolution of Biodegradable Fixation Plates and Screws The case of a pediatric patient in the midst of her facial growth and development with a type 1 NOE fracture requiring operative management is presented here. The challenges of this particular case included not only the complex nature of the fracture itself but also the fact that we were confronted with an uncommon problem in which plastic surgeons have had limited clinical experience. Here, we discuss the literature that supports our management of this patient. Internal fixation of facial fractures was not popular until after the antibiotic era. Before the advent of antibiotics, it was thought
FIGURE 6. Worm’s eye view demonstrating deviation of the tip of the nose to the left. The nasal sill and intranasal lacerations were used for access to the fractured nasomaxillary buttress.
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FIGURE 7. Lateral view from the right.
that an open operation for the reduction or fixation of fractures of the jaws too often resulted in osteomyelitis and that, as a result, intraoral and external appliances should be used to adequately immobilize the fragments of the jaw.11,12 In the United States, the treatment of facial fractures continued to evolve since the first reported use of intraosseous wire for the fixation of a mandibular fracture in 1846 to 1847. 11,13 In 1942, Adams14 described the use of internal fixation for midface fractures using wires after his dissatisfaction with the outcomes of nonoperative treatment of midface fractures. 11 This landmark study revolutionized the treatment of facial fractures and opened the path for further studies and the development of better fixation techniques that evolved from wires to rigid fixation devices. Rigid fixation has become the standard of care in the treatment of craniomaxillofacial trauma. Because of its success in the adult population, craniofacial surgeons have extended its application to treat craniomaxillofacial deformities and trauma in children. 15,16 Many immediate postoperative advantages were attributed to the use of rigid fixation techniques in pediatric craniofacial reconstruction such as (1) the ability to create stable three-dimensional shapes, (2) prevention of osteotomy and/or bone graft collapse, (3) facilitation of primary bone healing, (4) reduced bone graft mobility decreasing the rate of infection and graft resorption, and (5) elimination of problems caused by wires under the skin.17 Despite these advantages, the long-term effects of rigid fixation on the growth of the craniofacial skeleton led to a number of experimental animal studies in the late 1980s and early 1990s. Lin and colleagues18 evaluated the effect of compression miniplates in craniofacial growth in 12-week-old kittens. In this study, the surgical group with osteotomy (fronto-orbital craniectomy) and either wire or rigid fixation revealed a statistically significant growth restriction on the operated side when compared with the control group. They also found compensatory growth disturbances on adjacent craniometric measurements in the surgical group with rigid
FIGURE 8. Lateral view from the left.
FIGURE 9. The traumatic laceration in the forehead/glabella region was used for direct exposure of the fracture.
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FIGURE 10. View of the medial left orbit.
FIGURE 11. Transconjunctival exposure of the left orbital rim.
FIGURE 12. Intranasal exposure of the fractured nasomaxillary buttress.
fixation, leading to the idea that rigid fixation techniques might affect the dynamic growth of adjacent bones that could also result in deformities of the craniofacial skeleton. In addition, the group that had a plate placed across the coronal suture without an osteotomy did not show any significant evidence of growth restriction. This may have been related to having rigid fixation across an area that had minimal growth at that time or that the osteotomy was what caused growth restriction as opposed to the type of fixation. The study was limited by an animal model in which kittens had reached 70% of their adult craniofacial size, making it more difficult to compare the effect that similar techniques would have had in humans. To our knowledge, we consider this study to be the first one to provide evidence on the potential long-term effects of rigid fixation on the restriction and dynamic compensatory mechanisms in craniofacial growth, as well as the implications of early surgical interventions during times of faster growth rates in the craniofacial skeleton. They provided the basis for others to improve the design of experimental animal models that would isolate the effect of rigid fixation and resemble the growth of the human craniofacial skeleton. Resnick et al6 were the first ones to document in the American literature a reduction in growth across the plated coronal suture group of New Zealand white male rabbits. They created an experimental model consisting of twelve 6-week-old rabbits (brain was 75% of
FIGURE 13. Reduction and fixation of the left nasomaxillary buttress with a biodegradable plate.
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FIGURE 14. Two weeks postoperative: frontal view. Persistent left periorbital and left cheek swelling.
its adult size by weight) in an attempt to approximate conditions similar to early childhood in humans. They reported a 9% reduction in growth across the coronal suture in the plated group, but in contrast to previous studies, they did not observe an increased growth in the contralateral frontonasal area. Their findings supported the concept presented earlier by Lin et al, suggesting that the age of the rabbit at the time of the operation does influence the degree of subsequent growth disturbance. Eppley et al19 were interested in knowing if the type of rigid fixation had a difference in the growth restriction. They investigated the effect of noncompressive miniplate and microplate fixation techniques in an animal model consisting of 28-day-old New Zealand white rabbits. Their results showed regional alteration of the skeletal growth pattern in association with the fixation plate but did not show any change in the overall symmetry or craniomaxillofacial morphology due to more distant (frontonasal) growth compensation. Yaremchuk et al20 were able to create an animal model consisting of infant rhesus monkeys (Macaca mulatta), which has a facial skeletal anatomy as well as growth and development similar to those of humans. They compared growth effect on the craniofacial skeleton caused by left frontal osteotomy (not involving the coronal
FIGURE 15. Two weeks postoperative: worm's eye view. Slight nasal tip deviation to the left.
FIGURE 16. Five weeks postoperative: frontal view. Correction of the telecanthus.
FIGURE 17. Five weeks postoperative: worm's eye view.
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FIGURE 18. One year postoperative: frontal view.
FIGURE 20. One year postoperative: left lateral.
suture) and repair with 1 of the n3 types of fixation: interfragmentary wiring, microplate and screw fixation, and “extensive microplate and screw fixation.” They concluded that osteotomy and fixation in a growing primate skull resulted in visible and measureable changes in skull growth and morphology. In general, they noticed an increased restriction growth with increasing amount of fixation hardware in the frontal region. They also observed compensatory effects (cranial lengthening) supporting the previously published studies by Lin et al18 and Eppley et al. 19 The authors also encouraged the option of removing the rigid fixation hardware soon after the healing process at the osteotomy sites. This concept was also recommended by Manson21 based on tentative conclusions affirming less growth restriction if plate removal was performed. The most significant impact of Yaremchuk et al’s study was the design of an ideal experimental model that resembled clinical surgery in humans. Mooney et al22 were aware of the differences in mammalian facial sutures when compared with calvarial sutures. They designed an animal model to investigate the role of rigid fixation in compensatory midfacial growth changes in 1.5-week-old rabbits. Their results showed that by, 3.5 weeks, the group with bilateral premaxillomaxillary plate fixation had significant shortened premaxillary lengths (P < 0.05), class 3 malocclusion, decreased midfacial height, and abnormal palatocranial base angles compared with sham control animals. Interestingly, by 12 weeks old, “catch up” growth was evident in most dimensions. This study inspired them to develop and investigate the use of biodegradable plates and screws, for short-term rigid internal fixation as a potential compromise in neonatal and infant populations with rapid growth of facial and calvarial sutures. The literature allows us to conclude that the use of rigid fixation in the developing craniofacial skeleton of selected animal models has shown to have a dynamic impact in bone growth characterized by restrictive patterns and compensatory mechanisms. Extrapolation of findings from many of these studies is limited because of the differences between the experimental animal models and the human skeleton. The significant amount of evidence suggesting the potential risk of using rigid fixation on the growing craniofacial skeleton and the accumulated proof of other associated problems (palpability, intracranial migration, shielding and scatter problems with imaging and radiation therapy, sensitization to various
metallic alloys, hypersensitivity to cold, etc.) have triggered the study and development of alternatives such as (1) secondary removal of metallic devices once healing has occurred (10% of lifetime risk of requiring removal due to any of the aforementioned complications) and the use of biodegradable internal fixation devices. 21,23 Synthetic biodegradable polymers have been used in surgery since the 1970s. The most common polymers used today are polylactic acid, polyglycolic acid, and polyparadioxanone. These polymers have also been combined to copolymers such as Vicryl (polylactic and polyglycolic acids) and Maxon (glycolic acid and trimethylcarbonate). The resorption of these polymers is mainly by hydrolysis. 24 Bos et al25 were among the firsts to report the use of biodegradable internal bone fixation devices in craniofacial trauma (zygomatic fractures). They treated 10 patients with zygomatic fractures using polylactic acid plates and screws with reported good bone healing. Unfortunately, after several years, some of the patients developed a foreign body reaction. This persistent swelling around the implantation site led to further scrutiny resulting in the clinical discontinuation of the polymer used in their studies, poly-L-lactic acid. It was thought the large size of the implant might have contributed to the adverse reactions. Gerlach26 also reported on their results treating 15 patients with zygomatic fractures using polylactic acid plates and screws. Good bone stabilization was reported, and no adverse effects were noted in 20-month follow-up. Despite multiple studies showing good results and adequate bone healing, the commercial development and clinical applicability of bioabsorbable internal fixation devices for the craniofacial skeleton was not possible in part because of their inherent properties such as decreased strength, large sizes, and poor malleability. 24,27–30 In 1996, Eppley et al23 published a landmark study reporting on the experimental work that lead to the development of LactoSorb (Biomet, Warsaw, IN), the first completely resorbable plating system to be introduced in the United States. 23,31 He recognized the differences between polymers and metals and worked on overcoming the factors that prevented the successful use of polymers in the human craniofacial skeleton including polymer composition, plate design and flexibility, screw placement, and device delivery. They reported 25 cases of facial fractures using 217 plate and screw devices in the upper and midfacial regions. They excluded mandible fractures because of concerns of increased load forces. They did not include NOE fractures because of the technical difficulty
FIGURE 19. One year postoperative: worm’s eye view. Demonstrates slight deviation of the nasal tip to the left, asymmetry of the left nostril secondary to scar contracture at the nasal sill (previous traumatic laceration), and slight left enophthalmos.
FIGURE 21. One year postoperative: right lateral.
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of applying these devices in smaller comminuted bones. They were able to apply the devices to the curved contours of the facial skeleton without complications as long as there was a good bone stock and minimal comminution. No postoperative complications were reported (follow-up was 3–12 mo). In 7 of the 25 patients who were seen within 9 to 12 months after surgery, the fixation hardware was not palpable, and there was radiographic evidence of bone healing. In a more recent study, Eppley8 published what we think is the largest series of pediatric facial fractures treated with resorbable fixation. Forty-four pediatric facial fractures were treated during a period of 10 years in his institution (29 mandible fractures, 15 midfacial fractures), but no NOE fractures were treated in this series. No longterm implant-related complications were reported. A significant limitation of the study is no report in the duration of follow-up. There is significant data to suggest a detrimental result with the use of rigid fixation in the growing pediatric craniofacial skeleton. Nonetheless, there are no clinical studies documenting differences in craniofacial measurements in children treated with resorbable fixation and those with normal growth and no history of trauma. With the improvements in the biomechanics and the reported minimal complication rates with the use of resorbable plates, we agree with Suuronen et al24 on that bioabsorbable hardware should be considered the standard of care in facial fracture fixation not only in children but also in selected adult facial fractures. We elected to treat our 7-year-old patient with what we think should be the standard of care in the management of facial fractures in children—biodegradable internal fixation devices. This particular fracture, which we classified as a type 1 NOE fracture, showed minimal comminution simplifying the technicality of applying the absorbable devices to fixate the NOE segment to the inferior orbital rim and nasomaxillary buttress. The cephalad portion of the NOE segment did not require fixation. To our advantage, the traumatic facial lacerations gave us good access to the fractures. No intraoperative technical difficulties were encountered with our described approach. We have presented here our 1-year follow-up results with an acceptable outcome. The presence of a slight left enophthalmos was visible only in the worm’s eye view (Fig. 19). As the patient has no evidence of diplopia and the described deformity is minor, we elected to continue to treat the patient conservatively as she has not reached facial skeletal maturity. We would consider further imaging to investigate these findings if the patient becomes symptomatic or if the degree of facial deformity becomes a psychologic burden in the future. We hope the patient continues to have a normal craniofacial development now that we have limited, at least in theory, the chances of having any growth restriction in her midface. In the event of an altered growth pattern, we will never know if it was related to the trauma itself or the surgical intervention.
CONCLUSIONS In conclusion, pediatric facial fractures represent a rare and complicated problem. Although rigid fixation techniques have revolutionized the treatment of craniofacial trauma in adults, extrapolation of data from animal studies suggests a potential detrimental effect in the growth of the pediatric craniofacial skeleton. The use of biodegradable plates and screws in the treatment of pediatric craniofacial trauma is well documented with multiple clinical studies showing adequate bone healing and minimal complications. Bioabsorbable internal fixation devices should be the standard in the surgical treatment of pediatric facial fractures. The benefits of biodegradable plates and screws go far beyond the theoretical avoidance of facial growth disturbances in the growing facial skeleton, and we will not be surprised to see in the near future an increase in popularity for resorbable plates in adult craniomaxillofacial trauma. We
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encourage others to continue to contribute to the literature with their cases and experiences in the management of this and other infrequent pediatric facial fractures.
REFERENCES 1. Imahara SD, Hopper RA, Wang J, et al. Patterns and outcomes of pediatric facial fractures in the United States: a survey of the National Trauma Data Bank. J Am Coll Surg 2008;207:710–716 2. Koltai PJ, Rabkin D. Management of facial trauma in children. Pediatr Clin North Am 1996;43:1253–1275 3. Iizuka T, Thoren H, Annino DJ Jr, et al. Midfacial fractures in pediatric patients. Frequency, characteristics, and causes. Arch Otolaryngol Head Neck Surg 1995;121:1366–1371 4. Liau JY, Woodlief J, van Aalst JA. Pediatric nasoorbitoethmoid fractures. J Craniofac Surg 2011;22:1834–1838 5. Persing JA, Babler WJ, Jane JA, et al. Experimental unilateral coronal synostosis in rabbits. Plast Reconstr Surg 1986;77:369–377 6. Resnick JI, Kinney BM, Kawamoto HK Jr. The effect of rigid internal fixation on cranial growth. Ann Plast Surg 1990;25:372–374 7. Moe KS, Weisman RA. Resorbable fixation in facial plastic and head and neck reconstructive surgery: an initial report on polylactic acid implants. Laryngoscope 2001;111:1697–1701 8. Eppley BL. Use of resorbable plates and screws in pediatric facial fractures. J Oral Maxillofac Surg 2005;63:385–391 9. Bell RB, Kindsfater CS. The use of biodegradable plates and screws to stabilize facial fractures. J Oral Maxillofac Surg 2006; 64:31–39 10. Ahn YS, Kim SG, Baik SM, et al. Comparative study between resorbable and nonresorbable plates in orthognathic surgery. J Oral Maxillofac Surg 2010;68:287–292 11. Ellis E III. Rigid skeletal fixation of fractures. J Oral Maxillofac Surg 1993;51:163–173 12. Erich JB, Austin LT. Traumatic injuries of facial bones. Philadelphia: Saunders 1944 13. Buck G. Fracture of the lower jaw with displacement and interlocking of fragments. Analyst (Lond) 1846–1847;1:245–246 14. Adams WM. Internal wiring fixation of facial fractures. Surgery 1942;12:523 15. Beals SP, Munro IR. The use of miniplates in craniomaxillofacial surgery. Plast Reconstr Surg 1987;79:33–38 16. Jackson IT, Somers PC, Kjar JG. The use of Champy miniplates for osteosynthesis in craniofacial deformities and trauma. Plast Reconstr Surg 1986;77:729–736 17. Posnick J. Discussion: the effect of rigid fixation on craniofacial growth of rhesus monkeys. Plast Reconstr Surg 1994;93:11–15 18. Lin KY, Bartlett SP, Yaremchuk MJ, et al. An experimental study on the effect of rigid fixation on the developing craniofacial skeleton. Plast Reconstr Surg 1991;87:229–235 19. Eppley BL, Platis JM, Sadove AM. Experimental effects of bone plating in infancy on craniomaxillofacial skeletal growth. Cleft Palate Craniofac J 1993;30:164–169 20. Yaremchuk MJ, Fiala TG, Barker F, et al. The effects of rigid fixation on craniofacial growth of rhesus monkeys. Plast Reconstr Surg 1994;93:1–10; discussion 11–15 21. Manson P. Discussion: long-term effects of rigid fixation on the growing craniomaxillofacial skeleton. J Craniofac Surg 1991;2:69–70 22. Mooney MP, Losken HW, Siegel MI, et al. Plate fixation of premaxillomaxillary suture and compensatory midfacial growth changes in the rabbit. J Craniofac Surg 1992;3:197–202 23. Eppley BL, Prevel CD, Sadove AM, et al. Resorbable bone fixation: its potential role in cranio-maxillofacial trauma. J Craniomaxillofac Trauma 1996; 2:56–60 24. Suuronen R, Kallela I, Lindqvist C. Bioabsorbable plates and screws: current state of the art in facial fracture repair. J Craniomaxillofac Trauma 2000;6:19–27 25. Bos RR, Boering G, Rozema FR, et al. Resorbable poly (L-lactide) plates and screws for the fixation of zygomatic fractures. J Oral Maxillofac Surg 1987;45:751–753
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26. Gerlach KL. The treatment of zygomatic fracture with biodegradable poly (L-lactide) plates and screws. Clinical implant materials. In: Heimke G, Soltesz U, Lee ACJ, eds. Advances in Biomaterials Vol 9. Amsterdam, Netherlands: Elsevier Science Publisher, 1990:715–720 27. Kulkarni RK, Moore EG, Hegyeli AF, et al. Biodegradable poly (lactic acid) polymers. J Biomed Mater Res 1971;5:169–181 28. Cutright DE, Hunsuck EE, Beasley JD. Fracture reduction using a biodegradable material, polylactic acid. J Oral Surg 1971;29:393–397 29. Cutright DE, Hunsuck EE. The repair of fractures of the orbital floor using biodegradable polylactic acid. Oral Surg Oral Med Oral Pathol 1972;33:28–34 30. Getter L, Cutright DE, Bhaskar SN, et al. A biodegradable intraosseous appliance in the treatment of mandibular fractures. J Oral Surg 1972;30:344–348 31. Biomet. About Biomet microfixation. Available at: http://biometmicrofixation.com/about_us.php. Accessed April 22, 2013
Hemangioma Mimicking Dorsal Nasal Hump Hakan Demirel, MD,* Gaye Taylan Filinte, MD,* Hakan Şirinoğlu, MD,* Mehmet Bozkurt, MD,* Fuat Karakuş, MD† Abstract: A 24-year-old female patient with a dorsal nasal hemangioma mimicking a prominent dorsal nasal hump, which was noticed during the rhinoplasty operation, is presented. Key Words: Dorsal nasal hump, nasal hemangioma, rhinoplasty, hump reduction, dorsal nasal hemangioma
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valve collapse and a prominent dorsal nasal hump. The appearance of the nasal dorsum was slightly telangiectatic (Fig. 1). The main complaint of the patient was the appearance of the nasal dorsum, and rhinoplasty with open approach was planned. The patient was operated on under general anesthesia. The dissection of the nasal dorsum demonstrated a firm and solid mass attached to the caudal half of the bony dorsum. The lesion was removed with the cartilaginous and bony dorsum in en bloc fashion using a fine osteotome. The dorsal nasal hump was largely formed by the lesion, and the amount of the resected bony and cartilaginous hump was limited. The operation was completed after performing the subsequent steps of the rhinoplasty procedure without any problem. The early postoperative period was uneventful, and the histopathologic evaluation of the lesion was reported as hemangioma (Fig. 2). The postoperative second-year examination of the patient demonstrated a good-looking nose, and no recurrence of the lesion was observed (Fig. 3).
DISCUSSION A prominent dorsal nasal hump is one of the major complaints requiring esthetic rhinoplasty. A bad-looking nose and a very enthusiastic patient may lead the surgeon to perform a rhinoplasty procedure without doing a detailed physical examination or radiologic evaluation. In the presented patient, the telangiectatic appearance could possibly be a warning sign for the mass lesion, but it should be noted that the nasal dorsum is a very infrequent location for hemangiomas.4
CONCLUSIONS In conclusion, esthetic expectations may cause misdiagnoses of the underlying pathology, and the surgeon may overlook the exact problem preoperatively. The esthetic surgeon has to perform a throughout physical examination and expose the whole pathology before performing any esthetic intervention.
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sthetic rhinoplasty is one of the most commonly performed operations in routine plastic and reconstructive surgery practice.1 Although the success of the operation depends on many factors, dorsal hump reduction is an essential part for a good-looking nose.2 Hemangiomas are the most common encountered tumor in childhood and may also be present in adulthood in any portion of the head and neck including the nose.3 In this article, a patient with a dorsal nasal hemangioma mimicking a dorsal nasal hump, which was noticed during the operation, is presented.
FIGURE 1. The preoperative appearance of the patient showing a prominent dorsal nasal hump. The telangiectasic area may be noticed at the cranial half of the nasal dorsum.
CLINICAL REPORT A 24-year-old female patient with a history of septoplasty was referred to our clinic with difficulty in breathing and obvious nasal deformity. Detailed physical examination revealed an internal nasal From the *Department of Plastic, Reconstructive and Aesthetic Surgery, Lütfi Kirdar Kartal Training and Research Hospital, Istanbul; and †Kilis State Hospital, Gaziantep, Turkey. Received January 4, 2014. Accepted for publication February 17, 2014. Address correspondence and reprint requests to Hakan Şirinoğlu, MD, Gümüşpinar Mahallesi Filiz Sokak Demirlipark Sitesi B/19 Yakacik, Kartal, İstanbul; 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.0000000000000947
FIGURE 2. The histopathologic appearance of the dorsal nasal mass showing characteristic microscopic features of hemangioma.
FIGURE 3. The postoperative second-year appearance of the patient showing a good-looking nose without any sign of recurrence.
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14. Lang B, Pohl Y, Filippi A. Knowledge and prevention of dental trauma in team handball in Switzerland and Germany. Dent Traumatol 2002;18:329–334 15. Persic R, Pohl Y, Filippi A. Dental squash injuries—a survey among players and coaches in Switzerland, Germany and France. Dent Traumatol 2006;22:231–236 16. Avila MM. A case study of the community health agents program in Uruburetama, Ceará (Brazil). Cien Saude Colet 2011;16:349–360 17. Sousa MF, Parreira CM. Green, healthy environments: training of community health agents in the city of São Paulo, Brazil. Rev Panam Salud Publica 2010;28:399–404 18. Shi L. Health care in China: a rural–urban comparison after the socioeconomic reforms. Bull World Health Organ 1993;71:723–736 19. Walker A, Brenchley J. It’s knockout: survey of the management of avulsed teeth. Accid Emerg Nurs 2000;8:66–70 20. Lin S, Levin L, Emodi O, et al. Physician and emergency medical technicians' knowledge and experience regarding dental trauma. Dent Traumatol 2006;22:124–126 21. Hamilton FA, Hill FJ, Mackie IC. Investigation of lay knowledge of management of avulsed permanent incisors. Endod Dent Traumatol 1997;13:19–23 22. Andreasen JO, Andreasen FM. Textbook and colour atlas of traumatic injuries to the teeth. 3rd ed. Copenhagen: Munksgaard, 1994 23. Pacheco LF, Garcia Filho PF, Letra A, et al. Evaluation of the knowledge of the treatment of avulsions in elementary school teachers in Rio de Janeiro, Brazil. Dent Traumatol 2003;19:76–78 24. Mori GG, Turcio KLH, Borro VPB, et al. Evaluation of knowledge of the tooth avulsion of schools professionals from Adamantina, São Paulo, Brazil. Dent Traumatol 2007;23:2–5 25. Sterenborg EM, van Hooft MJ, Frankenmolen FW, et al. What does the non-dentistry-trained person know about avulsion? Ned Tijdschr Tandheelkd 1999;106:42–45 26. Kinoshita S, Kojima R, Taguchi Y, et al. Tooth replantation after traumatic avulsion: a report of ten cases. Dent Traumatol 2002;18:153–156 27. Stokes AN, Anderson HK, Cowan TM. Lay and professional knowledge of methods for emergency management of avulsed teeth. Endod Dent Traumatol 1992;8:160–162 28. Cohenca N, Forrest JL, Rotstein I. Knowledge of oral health professionals of treatment of avulsed teeth. Dent Traumatol 2006;22:296–301 29. Flores MT, Andersson L, Andreasen JO, et al. International Association of Dental Traumatology. Guidelines for the management of traumatic dental injuries: II. Avulsion of permanent teeth. Dent Traumatol 2007;23:130–136 30. Andreasen JO, Ravn JJ. Epidemiology of traumatic dental injuries to primary and permanent teeth in a Danish population sample. Int J Oral Surg 1972;1:235–239
The Management of Pediatric Type 1 Nasoorbitoethmoidal Fractures With Resorbable Fixation Jose Rodriguez-Feliz, MD, Karan Mehta, BS, Ash Patel, MD From the Division of Plastic Surgery, Albany Medical College, ALbany, NY. Received October 17, 2013. Accepted for publication February 16, 2014. Address correspondence and reprint requests to Ash Patel, MD, Division of Plastic Surgery, Albany Medical College, 50 New Scotland Avenue, MC-190, 1st Floor, Albany, NY 12208; 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.0000000000000937
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Abstract: Nasoorbitoethmoid (NOE) fractures are rare in the pediatric population. A recent study reported that NOE fractures account for 1% to 8% of all pediatric craniofacial fractures based on the National Trauma Data Bank. Although infrequent, NOE fractures must be appropriately identified and treated because of potential severe esthetic and functional complications. In this report, we discuss our experience treating the uncommon case of a 9-year-old girl who was involved in a motor vehicle accident and had traumatic injuries to the midface, including a type 1 NOE fracture. We elected to use biodegradable plates to treat her left type 1 NOE fracture because of concerns of facial growth disturbances with the use of conventional rigid fixation techniques at her young age. At 1-year follow-up, the patient demonstrated an acceptable outcome with no functional problems reported. We have also incorporated in this article a thorough review of the literature relating the evolution of biodegradable plates for the treatment of pediatric facial fractures. Key Words: NOE fractures, nasoorbitoethmoid fractures, pediatric facial fractures, resorbable fixation, biodegradable fixation, bioabsorbable fixation, facial growth restriction, facial growth disturbances, telecanthus, midface fractures, craniofacial fractures, facial fractures
ediatric facial fractures are uncommon. Imahara et al1 described the epidemiology of pediatric facial injuries using data from the American College of Surgeons National Trauma Data Bank. Of the 277,008 pediatric trauma admissions, only 4.6% (12,739) were associated with facial fractures.1 The most commonly reported pediatric facial fractures occurred in the mandible and nasal bones. 1,2 Midfacial fractures are exceedingly rare in children3; moreover, nasoorbitoethmoid (NOE) fractures are responsible for only 1% to 8% of all pediatric facial fractures.1 This can be explained by the difference between a child's facial anatomy and an adult's facial anatomy. The volume occupied by the skull in comparison with that by the face shifts from 8:1 to 2:1 between infancy and adulthood.2 As a result, in infants, the cranium is much more vulnerable to injury than the face. As a child develops and the face enlarges, the incidence of midfacial fractures also increases eventually reaching adult levels.4 The presence of immature cancellous bone and greater elasticity of the pediatric skeleton also protects children against facial fractures by incorporating an additional degree of flexibility to bone.4 The lack of complete development of the sinuses and, therefore, decreased pneumatization of facial bones could also explain the lower incidence of pediatric NOE fractures. 3 The NOE area lies at the intersection of the forehead, nose, orbits, and upper portion of the midface. This area is near the chondrocranial sphenoethmoidonasal growth center. Its appearance is dictated by the active interaction and development of all these surrounding structures. Therefore, injury to this area and operative intervention make subsequent growth of the region difficult to predict and an important concern in the management of these fractures in the pediatric patient. The NOE fractures yield a typical facie characterized by a shortened width of the palpebral fissures, telecanthus from lateral migration of the medial canthus, and a saddle nose deformity. 4 Although pediatric NOE fractures occur rarely, they must be appropriately identified and treated because of a potential for severe esthetic and functional complications.2 The NOE fractures in adults are treated according to wellestablished protocols that call for rigid fixation using miniplates and screws. The use of rigid fixation in the treatment of pediatric facial fractures poses a unique problem due to the active growth of
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the craniomaxillofacial skeleton during childhood. Persing et al5. reported that immobilization of the coronal suture in 9-day-old rabbits with methylcyanoacrylate adhesive resulted in significantly decreased growth across the suture. A later study by Resnick and colleagues6 showed a reduction in growth across plated coronal sutures in 6-week-old rabbits. Similar findings were later reported by a number of other animal studies. We believe that treating a pediatric NOE fracture with rigid titanium fixation has the potential for a higher chance of growth disturbances in the midface considering the multiple growth centers in the vicinity. In light of the limitations posed by rigid titanium fixation, the use of resorbable fixation seems promising for the treatment of NOE fractures in pediatric patients that have not reached facial growth plateau. Moe and Weisman7 (2001) reported on their experience in 30 patients and 35 procedures (cosmetic and reconstructive) using polylactic acid resorbable fixation plates. They reported good outcomes in different clinical scenarios including craniofacial fractures, craniomaxillofacial osteotomies (Le Fort 1/Le Fort 2), and soft tissue suspension for endoscopic brown lift. There were no reported cases of wound infections, malunion, delayed fracture healing, or plate extrusion. Eppley8 reported on 44 pediatric facial fractures effectively treated using resorbable plates and screws with no long-term complications. Bell and Kindsfater9 also reported effective healing in 59 patients who received resorbable fixation for a variety of pediatric facial fractures. In 2010, Ahn et al10 found resorbable fixation to be so effective that they recommended that resorbable fixation be the standard of care for the fixation of pediatric facial fractures. Although the use of biodegradable internal fixation techniques has been increasing in popularity in the management of pediatric facial fractures, we did not find any reported cases in the literature for its use in the treatment of pediatric NOE fractures. This clinical report aims to describe our experience using resorbable plates and screws for the treatment of a pediatric patient with a type 1 NOE fracture after a motor vehicle accident. We will discuss the scientific data that suggested the potential for growth disturbances in the pediatric craniofacial skeleton with the use of rigid titanium fixation and those studies that led to an era of research, development, and application of biodegradable plates and screws for the treatment of not only pediatric facial fractures but also adult craniomaxillofacial trauma.
CASE PRESENTATION The patient is a 9-year-old girl who was a restrained back-seat passenger in a multivehicle car accident. She presented to our institution as hemodynamically stable, with a reported temporary loss of consciousness. As part of her trauma assessment, she underwent imaging including computed tomography scans of the head and face. She was found to have facial bone fractures, including a right minimally displaced frontal bone fracture extending caudally toward the nasal bones, bilateral nasal bone fractures, a left type 1 NOE fracture with comminution at the left nasomaxillary buttress, left inferior
FIGURE 1. Axial CT scan image demonstrating the left nasomaxillary buttress fractured and significantly displaced, with associated bilateral nasal bone fractures and deviation of the nasal bones to the left.
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FIGURE 2. Axial CT scan image demonstrating the fractured left frontal process of the maxilla (NOE segment) with involvement of the left inferior orbital rim.
orbital rim fracture, left medial orbital wall fracture, and left orbital floor fracture (Figs. 1–4). She had a full-thickness laceration of the right forehead extending across the glabella that was repaired at the bedside (Fig. 5). The patient also had pneumocephalus and a subdural hematoma in the left fronto-orbital region. She was evaluated and cleared by neurosurgery and ophthalmology and scheduled for surgical management of her facial fractures. The patient was taken to the operating room 6 days after her initial injury. The most significant injury was a left type 1 NOE fracture with comminution of the left nasomaxillary buttress and telecanthus on the left (Figs. 5–8). She also had bilateral nasal bone fractures with an associated fracture/deviation of the nasal septum, a left medial orbital wall fracture, and a left orbital floor fracture involving the inferior orbital rim. The right frontal bone fracture was minimally displaced, and repair was not required. The procedure was performed under general anesthesia. The traumatic laceration was used for direct access to the NOE region (Fig. 9). A subperiosteal dissection was performed on the left NOE region preserving the left canthal tendon and the lacrimal apparatus (Fig. 10). The left canthal tendon was found to be attached to the fractured NOE segment confirming a type 1 NOE fracture. We then performed a left transconjunctival incision to expose the left orbital rim and orbital floor (Fig. 11). Via the left nostril, the intranasal laceration gave us direct access to the fractured nasomaxillary buttress (Fig. 12). After reducing the fractures, a resorbable plate was placed on the orbital rim as our first point of fixation. A second point of fixation was achieved by placing a resorbable box plate at the left nasomaxillary buttress through the traumatic intranasal laceration (Fig. 13). The medial orbital wall and orbital floor were repaired with a resorbable mesh implant.
RESULTS The patient was discharged on the second postoperative day without signs of early complication. She was seen as an outpatient 2 weeks postoperative (Figs. 14, 15). A slight deviation of the nasal tip to the left was noted. There was also edema of the left periorbital region and the left cheek. Healing of the forehead scar was appropriate. There was no evidence of telecanthus. In Figures 16 and 17, there is markedly improvement of the periorbital edema with a satisfactory result at 5 weeks postoperative. At 1-year follow-up, there is persistence of nasal tip deviation to the left and fullness of the left
FIGURE 3. Coronal CT scan image demonstrating a significant fracture of the entire medial left orbit and left nasomaxillary buttress.
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FIGURE 4. Three-dimensional reconstruction. Despite artifact from an oxygen mask, fractures of the nasal bones and left type 1 NOE fracture are demonstrated.
FIGURE 5. Preoperative frontal view illustrating the traumatic laceration in the right forehead/glabella region that was used to access the fractured NOE segment. Left-sided telecanthus is visible.
cheek. The patient also shows some rounding of the left medial canthus along with a slight degree of enophthalmos visible only on the worm’s eye view (Figs. 18–21). There is no evidence of telecanthus. The forehead scar has matured appropriately. There is asymmetry of the nares (Fig. 19) secondary to scar contracture on the left nasal sill at the site of traumatic laceration. Her visual acuity was normal, and she did not complain of diplopia. The patient has returned to her baseline activities. There have not been any psychologic disturbances reported secondary to her appearance. Despite the results at her 1-year follow-up, the mother was counseled regarding the importance of close follow-up until the patient becomes adolescent to identify any growth disturbances that may occur as the patient’s craniofacial skeleton continues to develop.
DISCUSSION The Evolution of Biodegradable Fixation Plates and Screws The case of a pediatric patient in the midst of her facial growth and development with a type 1 NOE fracture requiring operative management is presented here. The challenges of this particular case included not only the complex nature of the fracture itself but also the fact that we were confronted with an uncommon problem in which plastic surgeons have had limited clinical experience. Here, we discuss the literature that supports our management of this patient. Internal fixation of facial fractures was not popular until after the antibiotic era. Before the advent of antibiotics, it was thought
FIGURE 6. Worm’s eye view demonstrating deviation of the tip of the nose to the left. The nasal sill and intranasal lacerations were used for access to the fractured nasomaxillary buttress.
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FIGURE 7. Lateral view from the right.
that an open operation for the reduction or fixation of fractures of the jaws too often resulted in osteomyelitis and that, as a result, intraoral and external appliances should be used to adequately immobilize the fragments of the jaw.11,12 In the United States, the treatment of facial fractures continued to evolve since the first reported use of intraosseous wire for the fixation of a mandibular fracture in 1846 to 1847. 11,13 In 1942, Adams14 described the use of internal fixation for midface fractures using wires after his dissatisfaction with the outcomes of nonoperative treatment of midface fractures. 11 This landmark study revolutionized the treatment of facial fractures and opened the path for further studies and the development of better fixation techniques that evolved from wires to rigid fixation devices. Rigid fixation has become the standard of care in the treatment of craniomaxillofacial trauma. Because of its success in the adult population, craniofacial surgeons have extended its application to treat craniomaxillofacial deformities and trauma in children. 15,16 Many immediate postoperative advantages were attributed to the use of rigid fixation techniques in pediatric craniofacial reconstruction such as (1) the ability to create stable three-dimensional shapes, (2) prevention of osteotomy and/or bone graft collapse, (3) facilitation of primary bone healing, (4) reduced bone graft mobility decreasing the rate of infection and graft resorption, and (5) elimination of problems caused by wires under the skin.17 Despite these advantages, the long-term effects of rigid fixation on the growth of the craniofacial skeleton led to a number of experimental animal studies in the late 1980s and early 1990s. Lin and colleagues18 evaluated the effect of compression miniplates in craniofacial growth in 12-week-old kittens. In this study, the surgical group with osteotomy (fronto-orbital craniectomy) and either wire or rigid fixation revealed a statistically significant growth restriction on the operated side when compared with the control group. They also found compensatory growth disturbances on adjacent craniometric measurements in the surgical group with rigid
FIGURE 8. Lateral view from the left.
FIGURE 9. The traumatic laceration in the forehead/glabella region was used for direct exposure of the fracture.
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FIGURE 10. View of the medial left orbit.
FIGURE 11. Transconjunctival exposure of the left orbital rim.
FIGURE 12. Intranasal exposure of the fractured nasomaxillary buttress.
fixation, leading to the idea that rigid fixation techniques might affect the dynamic growth of adjacent bones that could also result in deformities of the craniofacial skeleton. In addition, the group that had a plate placed across the coronal suture without an osteotomy did not show any significant evidence of growth restriction. This may have been related to having rigid fixation across an area that had minimal growth at that time or that the osteotomy was what caused growth restriction as opposed to the type of fixation. The study was limited by an animal model in which kittens had reached 70% of their adult craniofacial size, making it more difficult to compare the effect that similar techniques would have had in humans. To our knowledge, we consider this study to be the first one to provide evidence on the potential long-term effects of rigid fixation on the restriction and dynamic compensatory mechanisms in craniofacial growth, as well as the implications of early surgical interventions during times of faster growth rates in the craniofacial skeleton. They provided the basis for others to improve the design of experimental animal models that would isolate the effect of rigid fixation and resemble the growth of the human craniofacial skeleton. Resnick et al6 were the first ones to document in the American literature a reduction in growth across the plated coronal suture group of New Zealand white male rabbits. They created an experimental model consisting of twelve 6-week-old rabbits (brain was 75% of
FIGURE 13. Reduction and fixation of the left nasomaxillary buttress with a biodegradable plate.
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FIGURE 14. Two weeks postoperative: frontal view. Persistent left periorbital and left cheek swelling.
its adult size by weight) in an attempt to approximate conditions similar to early childhood in humans. They reported a 9% reduction in growth across the coronal suture in the plated group, but in contrast to previous studies, they did not observe an increased growth in the contralateral frontonasal area. Their findings supported the concept presented earlier by Lin et al, suggesting that the age of the rabbit at the time of the operation does influence the degree of subsequent growth disturbance. Eppley et al19 were interested in knowing if the type of rigid fixation had a difference in the growth restriction. They investigated the effect of noncompressive miniplate and microplate fixation techniques in an animal model consisting of 28-day-old New Zealand white rabbits. Their results showed regional alteration of the skeletal growth pattern in association with the fixation plate but did not show any change in the overall symmetry or craniomaxillofacial morphology due to more distant (frontonasal) growth compensation. Yaremchuk et al20 were able to create an animal model consisting of infant rhesus monkeys (Macaca mulatta), which has a facial skeletal anatomy as well as growth and development similar to those of humans. They compared growth effect on the craniofacial skeleton caused by left frontal osteotomy (not involving the coronal
FIGURE 15. Two weeks postoperative: worm's eye view. Slight nasal tip deviation to the left.
FIGURE 16. Five weeks postoperative: frontal view. Correction of the telecanthus.
FIGURE 17. Five weeks postoperative: worm's eye view.
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FIGURE 18. One year postoperative: frontal view.
FIGURE 20. One year postoperative: left lateral.
suture) and repair with 1 of the n3 types of fixation: interfragmentary wiring, microplate and screw fixation, and “extensive microplate and screw fixation.” They concluded that osteotomy and fixation in a growing primate skull resulted in visible and measureable changes in skull growth and morphology. In general, they noticed an increased restriction growth with increasing amount of fixation hardware in the frontal region. They also observed compensatory effects (cranial lengthening) supporting the previously published studies by Lin et al18 and Eppley et al. 19 The authors also encouraged the option of removing the rigid fixation hardware soon after the healing process at the osteotomy sites. This concept was also recommended by Manson21 based on tentative conclusions affirming less growth restriction if plate removal was performed. The most significant impact of Yaremchuk et al’s study was the design of an ideal experimental model that resembled clinical surgery in humans. Mooney et al22 were aware of the differences in mammalian facial sutures when compared with calvarial sutures. They designed an animal model to investigate the role of rigid fixation in compensatory midfacial growth changes in 1.5-week-old rabbits. Their results showed that by, 3.5 weeks, the group with bilateral premaxillomaxillary plate fixation had significant shortened premaxillary lengths (P < 0.05), class 3 malocclusion, decreased midfacial height, and abnormal palatocranial base angles compared with sham control animals. Interestingly, by 12 weeks old, “catch up” growth was evident in most dimensions. This study inspired them to develop and investigate the use of biodegradable plates and screws, for short-term rigid internal fixation as a potential compromise in neonatal and infant populations with rapid growth of facial and calvarial sutures. The literature allows us to conclude that the use of rigid fixation in the developing craniofacial skeleton of selected animal models has shown to have a dynamic impact in bone growth characterized by restrictive patterns and compensatory mechanisms. Extrapolation of findings from many of these studies is limited because of the differences between the experimental animal models and the human skeleton. The significant amount of evidence suggesting the potential risk of using rigid fixation on the growing craniofacial skeleton and the accumulated proof of other associated problems (palpability, intracranial migration, shielding and scatter problems with imaging and radiation therapy, sensitization to various
metallic alloys, hypersensitivity to cold, etc.) have triggered the study and development of alternatives such as (1) secondary removal of metallic devices once healing has occurred (10% of lifetime risk of requiring removal due to any of the aforementioned complications) and the use of biodegradable internal fixation devices. 21,23 Synthetic biodegradable polymers have been used in surgery since the 1970s. The most common polymers used today are polylactic acid, polyglycolic acid, and polyparadioxanone. These polymers have also been combined to copolymers such as Vicryl (polylactic and polyglycolic acids) and Maxon (glycolic acid and trimethylcarbonate). The resorption of these polymers is mainly by hydrolysis. 24 Bos et al25 were among the firsts to report the use of biodegradable internal bone fixation devices in craniofacial trauma (zygomatic fractures). They treated 10 patients with zygomatic fractures using polylactic acid plates and screws with reported good bone healing. Unfortunately, after several years, some of the patients developed a foreign body reaction. This persistent swelling around the implantation site led to further scrutiny resulting in the clinical discontinuation of the polymer used in their studies, poly-L-lactic acid. It was thought the large size of the implant might have contributed to the adverse reactions. Gerlach26 also reported on their results treating 15 patients with zygomatic fractures using polylactic acid plates and screws. Good bone stabilization was reported, and no adverse effects were noted in 20-month follow-up. Despite multiple studies showing good results and adequate bone healing, the commercial development and clinical applicability of bioabsorbable internal fixation devices for the craniofacial skeleton was not possible in part because of their inherent properties such as decreased strength, large sizes, and poor malleability. 24,27–30 In 1996, Eppley et al23 published a landmark study reporting on the experimental work that lead to the development of LactoSorb (Biomet, Warsaw, IN), the first completely resorbable plating system to be introduced in the United States. 23,31 He recognized the differences between polymers and metals and worked on overcoming the factors that prevented the successful use of polymers in the human craniofacial skeleton including polymer composition, plate design and flexibility, screw placement, and device delivery. They reported 25 cases of facial fractures using 217 plate and screw devices in the upper and midfacial regions. They excluded mandible fractures because of concerns of increased load forces. They did not include NOE fractures because of the technical difficulty
FIGURE 19. One year postoperative: worm’s eye view. Demonstrates slight deviation of the nasal tip to the left, asymmetry of the left nostril secondary to scar contracture at the nasal sill (previous traumatic laceration), and slight left enophthalmos.
FIGURE 21. One year postoperative: right lateral.
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of applying these devices in smaller comminuted bones. They were able to apply the devices to the curved contours of the facial skeleton without complications as long as there was a good bone stock and minimal comminution. No postoperative complications were reported (follow-up was 3–12 mo). In 7 of the 25 patients who were seen within 9 to 12 months after surgery, the fixation hardware was not palpable, and there was radiographic evidence of bone healing. In a more recent study, Eppley8 published what we think is the largest series of pediatric facial fractures treated with resorbable fixation. Forty-four pediatric facial fractures were treated during a period of 10 years in his institution (29 mandible fractures, 15 midfacial fractures), but no NOE fractures were treated in this series. No longterm implant-related complications were reported. A significant limitation of the study is no report in the duration of follow-up. There is significant data to suggest a detrimental result with the use of rigid fixation in the growing pediatric craniofacial skeleton. Nonetheless, there are no clinical studies documenting differences in craniofacial measurements in children treated with resorbable fixation and those with normal growth and no history of trauma. With the improvements in the biomechanics and the reported minimal complication rates with the use of resorbable plates, we agree with Suuronen et al24 on that bioabsorbable hardware should be considered the standard of care in facial fracture fixation not only in children but also in selected adult facial fractures. We elected to treat our 7-year-old patient with what we think should be the standard of care in the management of facial fractures in children—biodegradable internal fixation devices. This particular fracture, which we classified as a type 1 NOE fracture, showed minimal comminution simplifying the technicality of applying the absorbable devices to fixate the NOE segment to the inferior orbital rim and nasomaxillary buttress. The cephalad portion of the NOE segment did not require fixation. To our advantage, the traumatic facial lacerations gave us good access to the fractures. No intraoperative technical difficulties were encountered with our described approach. We have presented here our 1-year follow-up results with an acceptable outcome. The presence of a slight left enophthalmos was visible only in the worm’s eye view (Fig. 19). As the patient has no evidence of diplopia and the described deformity is minor, we elected to continue to treat the patient conservatively as she has not reached facial skeletal maturity. We would consider further imaging to investigate these findings if the patient becomes symptomatic or if the degree of facial deformity becomes a psychologic burden in the future. We hope the patient continues to have a normal craniofacial development now that we have limited, at least in theory, the chances of having any growth restriction in her midface. In the event of an altered growth pattern, we will never know if it was related to the trauma itself or the surgical intervention.
CONCLUSIONS In conclusion, pediatric facial fractures represent a rare and complicated problem. Although rigid fixation techniques have revolutionized the treatment of craniofacial trauma in adults, extrapolation of data from animal studies suggests a potential detrimental effect in the growth of the pediatric craniofacial skeleton. The use of biodegradable plates and screws in the treatment of pediatric craniofacial trauma is well documented with multiple clinical studies showing adequate bone healing and minimal complications. Bioabsorbable internal fixation devices should be the standard in the surgical treatment of pediatric facial fractures. The benefits of biodegradable plates and screws go far beyond the theoretical avoidance of facial growth disturbances in the growing facial skeleton, and we will not be surprised to see in the near future an increase in popularity for resorbable plates in adult craniomaxillofacial trauma. We
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encourage others to continue to contribute to the literature with their cases and experiences in the management of this and other infrequent pediatric facial fractures.
REFERENCES 1. Imahara SD, Hopper RA, Wang J, et al. Patterns and outcomes of pediatric facial fractures in the United States: a survey of the National Trauma Data Bank. J Am Coll Surg 2008;207:710–716 2. Koltai PJ, Rabkin D. Management of facial trauma in children. Pediatr Clin North Am 1996;43:1253–1275 3. Iizuka T, Thoren H, Annino DJ Jr, et al. Midfacial fractures in pediatric patients. Frequency, characteristics, and causes. Arch Otolaryngol Head Neck Surg 1995;121:1366–1371 4. Liau JY, Woodlief J, van Aalst JA. Pediatric nasoorbitoethmoid fractures. J Craniofac Surg 2011;22:1834–1838 5. Persing JA, Babler WJ, Jane JA, et al. Experimental unilateral coronal synostosis in rabbits. Plast Reconstr Surg 1986;77:369–377 6. Resnick JI, Kinney BM, Kawamoto HK Jr. The effect of rigid internal fixation on cranial growth. Ann Plast Surg 1990;25:372–374 7. Moe KS, Weisman RA. Resorbable fixation in facial plastic and head and neck reconstructive surgery: an initial report on polylactic acid implants. Laryngoscope 2001;111:1697–1701 8. Eppley BL. Use of resorbable plates and screws in pediatric facial fractures. J Oral Maxillofac Surg 2005;63:385–391 9. Bell RB, Kindsfater CS. The use of biodegradable plates and screws to stabilize facial fractures. J Oral Maxillofac Surg 2006; 64:31–39 10. Ahn YS, Kim SG, Baik SM, et al. Comparative study between resorbable and nonresorbable plates in orthognathic surgery. J Oral Maxillofac Surg 2010;68:287–292 11. Ellis E III. Rigid skeletal fixation of fractures. J Oral Maxillofac Surg 1993;51:163–173 12. Erich JB, Austin LT. Traumatic injuries of facial bones. Philadelphia: Saunders 1944 13. Buck G. Fracture of the lower jaw with displacement and interlocking of fragments. Analyst (Lond) 1846–1847;1:245–246 14. Adams WM. Internal wiring fixation of facial fractures. Surgery 1942;12:523 15. Beals SP, Munro IR. The use of miniplates in craniomaxillofacial surgery. Plast Reconstr Surg 1987;79:33–38 16. Jackson IT, Somers PC, Kjar JG. The use of Champy miniplates for osteosynthesis in craniofacial deformities and trauma. Plast Reconstr Surg 1986;77:729–736 17. Posnick J. Discussion: the effect of rigid fixation on craniofacial growth of rhesus monkeys. Plast Reconstr Surg 1994;93:11–15 18. Lin KY, Bartlett SP, Yaremchuk MJ, et al. An experimental study on the effect of rigid fixation on the developing craniofacial skeleton. Plast Reconstr Surg 1991;87:229–235 19. Eppley BL, Platis JM, Sadove AM. Experimental effects of bone plating in infancy on craniomaxillofacial skeletal growth. Cleft Palate Craniofac J 1993;30:164–169 20. Yaremchuk MJ, Fiala TG, Barker F, et al. The effects of rigid fixation on craniofacial growth of rhesus monkeys. Plast Reconstr Surg 1994;93:1–10; discussion 11–15 21. Manson P. Discussion: long-term effects of rigid fixation on the growing craniomaxillofacial skeleton. J Craniofac Surg 1991;2:69–70 22. Mooney MP, Losken HW, Siegel MI, et al. Plate fixation of premaxillomaxillary suture and compensatory midfacial growth changes in the rabbit. J Craniofac Surg 1992;3:197–202 23. Eppley BL, Prevel CD, Sadove AM, et al. Resorbable bone fixation: its potential role in cranio-maxillofacial trauma. J Craniomaxillofac Trauma 1996; 2:56–60 24. Suuronen R, Kallela I, Lindqvist C. Bioabsorbable plates and screws: current state of the art in facial fracture repair. J Craniomaxillofac Trauma 2000;6:19–27 25. Bos RR, Boering G, Rozema FR, et al. Resorbable poly (L-lactide) plates and screws for the fixation of zygomatic fractures. J Oral Maxillofac Surg 1987;45:751–753
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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26. Gerlach KL. The treatment of zygomatic fracture with biodegradable poly (L-lactide) plates and screws. Clinical implant materials. In: Heimke G, Soltesz U, Lee ACJ, eds. Advances in Biomaterials Vol 9. Amsterdam, Netherlands: Elsevier Science Publisher, 1990:715–720 27. Kulkarni RK, Moore EG, Hegyeli AF, et al. Biodegradable poly (lactic acid) polymers. J Biomed Mater Res 1971;5:169–181 28. Cutright DE, Hunsuck EE, Beasley JD. Fracture reduction using a biodegradable material, polylactic acid. J Oral Surg 1971;29:393–397 29. Cutright DE, Hunsuck EE. The repair of fractures of the orbital floor using biodegradable polylactic acid. Oral Surg Oral Med Oral Pathol 1972;33:28–34 30. Getter L, Cutright DE, Bhaskar SN, et al. A biodegradable intraosseous appliance in the treatment of mandibular fractures. J Oral Surg 1972;30:344–348 31. Biomet. About Biomet microfixation. Available at: http://biometmicrofixation.com/about_us.php. Accessed April 22, 2013
Hemangioma Mimicking Dorsal Nasal Hump Hakan Demirel, MD,* Gaye Taylan Filinte, MD,* Hakan Şirinoğlu, MD,* Mehmet Bozkurt, MD,* Fuat Karakuş, MD† Abstract: A 24-year-old female patient with a dorsal nasal hemangioma mimicking a prominent dorsal nasal hump, which was noticed during the rhinoplasty operation, is presented. Key Words: Dorsal nasal hump, nasal hemangioma, rhinoplasty, hump reduction, dorsal nasal hemangioma
Brief Clinical Studies
valve collapse and a prominent dorsal nasal hump. The appearance of the nasal dorsum was slightly telangiectatic (Fig. 1). The main complaint of the patient was the appearance of the nasal dorsum, and rhinoplasty with open approach was planned. The patient was operated on under general anesthesia. The dissection of the nasal dorsum demonstrated a firm and solid mass attached to the caudal half of the bony dorsum. The lesion was removed with the cartilaginous and bony dorsum in en bloc fashion using a fine osteotome. The dorsal nasal hump was largely formed by the lesion, and the amount of the resected bony and cartilaginous hump was limited. The operation was completed after performing the subsequent steps of the rhinoplasty procedure without any problem. The early postoperative period was uneventful, and the histopathologic evaluation of the lesion was reported as hemangioma (Fig. 2). The postoperative second-year examination of the patient demonstrated a good-looking nose, and no recurrence of the lesion was observed (Fig. 3).
DISCUSSION A prominent dorsal nasal hump is one of the major complaints requiring esthetic rhinoplasty. A bad-looking nose and a very enthusiastic patient may lead the surgeon to perform a rhinoplasty procedure without doing a detailed physical examination or radiologic evaluation. In the presented patient, the telangiectatic appearance could possibly be a warning sign for the mass lesion, but it should be noted that the nasal dorsum is a very infrequent location for hemangiomas.4
CONCLUSIONS In conclusion, esthetic expectations may cause misdiagnoses of the underlying pathology, and the surgeon may overlook the exact problem preoperatively. The esthetic surgeon has to perform a throughout physical examination and expose the whole pathology before performing any esthetic intervention.
E
sthetic rhinoplasty is one of the most commonly performed operations in routine plastic and reconstructive surgery practice.1 Although the success of the operation depends on many factors, dorsal hump reduction is an essential part for a good-looking nose.2 Hemangiomas are the most common encountered tumor in childhood and may also be present in adulthood in any portion of the head and neck including the nose.3 In this article, a patient with a dorsal nasal hemangioma mimicking a dorsal nasal hump, which was noticed during the operation, is presented.
FIGURE 1. The preoperative appearance of the patient showing a prominent dorsal nasal hump. The telangiectasic area may be noticed at the cranial half of the nasal dorsum.
CLINICAL REPORT A 24-year-old female patient with a history of septoplasty was referred to our clinic with difficulty in breathing and obvious nasal deformity. Detailed physical examination revealed an internal nasal From the *Department of Plastic, Reconstructive and Aesthetic Surgery, Lütfi Kirdar Kartal Training and Research Hospital, Istanbul; and †Kilis State Hospital, Gaziantep, Turkey. Received January 4, 2014. Accepted for publication February 17, 2014. Address correspondence and reprint requests to Hakan Şirinoğlu, MD, Gümüşpinar Mahallesi Filiz Sokak Demirlipark Sitesi B/19 Yakacik, Kartal, İstanbul; 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.0000000000000947
FIGURE 2. The histopathologic appearance of the dorsal nasal mass showing characteristic microscopic features of hemangioma.
FIGURE 3. The postoperative second-year appearance of the patient showing a good-looking nose without any sign of recurrence.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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