Jin Sik Burm

Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture.

Pure orbital blowout fracture first occurs at the weakest point of the orbital wall. Although the medial orbital wall theoretically should be involved more frequently than the orbital floor, the orbital floor has been reported as the most common site of pure orbital blowout fractures. A total of 82 orbits in 76 patients with pure orbital blowout fracture were evaluated with computed tomographic scans taken on all patients with any suspicious clinical evidence, including nasal fracture. Isolated medial wall fracture was most common (55 percent), followed by medial and inferior wall fracture (27 percent). The most common facial fracture associated with medial wall fracture was nasal fracture (51 percent), not inferior wall fracture (33 percent). This finding suggests that the force causing nasal fracture is an important causative factor of pure medial wall fracture as the buckling force from the medial orbital rim. Of patients with medial wall fractures, 25 percent had diplopia and 40 percent had enophthalmos. On plain radiographs, diagnostic signs were found in 79 percent of medial wall fractures and in 95 percent of inferior wall fractures. On computed tomographic scans, late enophthalmos was expected in 76 percent of medial wall fractures. Therefore, the medial orbital blowout fracture may be an important cause of late enophthalmos, because it has a high incidence of occurrence, a low diagnostic rate, and a high severity of defect. Among the causes of limitation of ocular motility, muscle traction of the connective septa and direct muscle injury were found frequently, but true incarceration of the muscle was extremely rare in all fractures. The medial and inferior orbital walls are clearly demarcated by the bony buttress, which is an important structure supporting these orbital walls. Its buttress was closely correlated with the fracture of these orbital walls. Most orbital blowout fractures without collapse of the bony buttress had a trapdoor fracture with or without small fragments of punched-out fracture.

Correction of inverted nipples by strong suspension with areola-based dermal flaps

The goal of inverted nipple correction is both aesthetically satisfactory projection of the nipple and functional preservation of the lactiferous ducts. To achieve this outcome, many surgeons1–7 have used areolar dermal flap techniques that add bulk or struts underneath the nipple and tighten the nipple neck. However, the base of these flaps is placed at the nipple neck, which cannot provide a rigid, immobile fulcrum. If the nipple neck is not reconstructed tightly, these flaps can be pulled down simultaneously with the nipple because of scarring or retraction forces. Consequently, these techniques have a risk of nipple inversion or flattening recurrence, especially in severely inverted nipples (Fig. 1, above), indicating the need for a stronger supporting system. If the bases of the dermal flaps are placed on the areola and thereby supported by the compact subcutaneous tissue and the mammary gland, these flaps may strongly resist scarring and retraction forces and may support the nipple more effectively (Fig. 1, below). In this article, we present a strong nipple suspension technique using areola-based dermal flaps for correcting moderately and severely inverted nipples.

Internal Fixation in Trapdoor-type Orbital Blowout Fracture

Background: The most common orbital blowout fracture is a trapdoor type. In many cases of trapdoor fracture, the bony segment has a stable hinge consisting of a greenstick fracture and the sinus mucoperiosteum that is attached to the intact orbital wall. If the displaced bony segment opposite the hinge is reduced into the original position and fixed on the unaffected bone, the orbital fracture may be reconstructed by internal fixation of the bony segment itself rather than requiring substitution with alloplastic implants or a bone graft. Methods: In 20 cases of orbital blowout fracture of a trapdoor type, internal fixation was performed using a cantilever fixation technique (with a piece of titanium micromesh or a titanium microplate plus a microscrew) or a ledge fixation technique (with a piece of micromesh). Results: In all cases, the orbital wall was accurately reconstructed in its normal anatomical position. The associated ocular problems disappeared except for mild diplopia in one patient and there were no surgical complications associated with the internal fixation. Conclusions: The advantages of internal fixation include anatomical reconstruction of the orbital wall; preservation of the original orbital bone and the mucoperiosteum of the sinus as an osteomucoperiosteal flap resulting in rapid wound healing and normal mucus drainage function of the sinus; the simplicity of the procedure; and con-sequently, the absence of surgery-related complications. This technique is presented as one of the preferred treatments for trapdoor-type orbital blowout fractures.

Prevention and treatment of wide scar and alopecia in the scalp: wedge excision and double relaxation suture.

The visible linear scar of the scalp is a cosmetically serious complication of a scalp incision in scalp surgery, forehead lift, and craniofacial surgery, especially on the temporal scalp. Its causes are cicatrical alopecia and scar widening. To solve this problem, we performed the wedge excision of the scalp and the double relaxation suture of the galea in 2 patients undergoing facial surgery through the coronal approach and in 15 patients with scalp alopecia ranging from 0.5 to 3.0 cm in width. The wedge excision using the beveling incision at an angle of 30 degrees to the hair follicles preserves the deep hair follicles of the flap margins and allows the hair to grow into the scar, eventually preventing cicatricial alopecia and camouflaging the linear scar. The double relaxation suture of the trimmed galea with nonabsorbable suture with or without the relaxation incision minimizes skin tension for a long time, eventually preventing scar widening. This procedure was followed by the superficial skin suture for maintaining the skin sutures for a long time and avoiding the injury of the superficial hair follicles. In all patients, we observed an excellent cosmetic result of unnoticed scar line without complications during the follow-up period of 10 weeks to 6 months.

Direct local approach through a W-shaped incision in moderate or severe blowout fractures of the medial orbital wall

For moderate or severe blowout fractures of the medial orbital wall, the goals of treatment are complete reduction of the herniated soft tissue and anatomic reconstruction of the wall without surgical complications. Various surgical approaches have been used, depending on the anatomic location and the extent of medial wall fracture. However, there is no consistent method to achieve the treatment goals with minimal morbidity because of one or more problems of limitation of entire medial wall exposure, limitation of large implant or bone graft insertion, surgical damage of important periorbital or intraorbital structures, or postoperative scar deformities. In this study, a direct local approach through a 3‐cm, W‐shaped incision on the superior medial orbital area was used as a consistent method to reconstruct medial orbital blowout fractures. The angle of the W‐limbs is 110 to 120 degrees. Four limbs of the W were placed parallel or oblique to the relaxed skin tension lines. This technique was applied to 39 orbits of 37 patients with moderate or severe blowout fractures of the medial orbital wall. This approach provided exposure of the entire medial orbital wall, adequate placement of a large implant, short operation time within 2 hours, and no damage of important internal structures. Postoperative computed tomographic scans showed complete reduction of the herniated orbital tissues and anatomic reconstruction of the medial orbital wall without complication related to the surgical approach in all cases. During the follow‐up period of 6 to 14 months, excellent functional and cosmetic results were observed with an inconspicuous scar without secondary scar deformities. Therefore, a direct local approach through a W‐shaped incision on the superior medial orbit may be a consistent method to gain the surgical goal in treatment of moderate or severe blowout fractures of the medial orbital wall. (Plast. Reconstr. Surg. 107: 920, 2001.)

indirect Open Reduction through Intercartilaginous Incision and Intranasal Kirschner Wire Splinting of Comminuted Nasal Fractures

&NA; The majority of nasal fractures have been managed by using closed reduction and intranasal packing. In comminuted nasal fractures, open reduction and internal fixation may be indicated for accurate reduction and rigid fixation, but it is a very aggressive procedure. We developed a new technique for comminuted nasal fractures: indirect open reduction and intranasal Kirschner wire splinting. A periosteal elevator is used to elevate the mucoperiosteum posterior to the nasal bone through intercartilaginous incision and to reduce accurately the nasal bone, at the same time detecting the fracture lines. The Kirschner wire is used to insert between the nasal bone and the mucoperiosteum and to splint rigidly the nasal bone. During the follow‐up period of 5 weeks to 4 months, 23 of 27 patients (85 percent) had successful cosmetic results. Four patients had slight cosmetic deformity but did not request a late rhinoplasty. Nineteen patients had accurate reduction on a computed tomography scan. Ten patients had undercorrection of the nasal septum on a computed tomography scan, and three patients had significant septal deviation with airway obstruction. Indirect open reduction through intercartilaginous incision and intranasal Kirschner wire splinting is a reliable and useful method for the treatment of comminuted nasal fractures because it achieves accurate reduction and rigid, long intranasal support, can be done comfortably under local anesthesia, permits early nasal breathing postoperatively, has no external scar, and minimizes complications such as nasal bleeding, soft‐tissue injury, infection, and recurrent displacement. (Plast. Reconstr. Surg. 102: 342, 1998.)

Fist position for skin grafting on the dorsal hand : I. Analysis of length of the dorsal hand surface in hand positions

In skin grafting for reconstruction of burns and contracture deformities of the dorsal hand, the hand is kept in a proper position to provide the greatest amount of skin and to avoid the secondary functional deformity. The safe position has been commonly used for immobilizing the hand, but this is to protect the hand function rather than to provide maximal surface for skin grafting. Split-thickness skin graft contracts up to 30 to 50 percent of the original size owing to secondary contraction. If insufficient skin is grafted, contracture deformity of the dorsal hand may occur. To graft the greatest amount of skin on the dorsal hand, the hand should be kept preoperatively in a position flexing all joints of the wrist, metacarpophalangeal joints, and interphalangeal joints and maximally stretching the dorsal hand (a fist position). We studied the surface length of the dorsal hand between the wrist, the metacarpophalangeal joint, and the eponychium in the anatomic, safe, and fist positions of the right hand in 60 adults. Difference of total length between the anatomic and safe positions was not statistically significant (p > 0.05). The total length in a fist position was significantly increased in comparison with the other two positions (p < 0.05). In a fist position compared with the safe position, the increase in length of the dorsal surface of the proximal hand was 11 to 20 percent except in the thumb, and the increase in length of the dorsal surface of the finger was 12 to 17 percent. The increase in total length of a fist position was about 9 mm (7 to 8 percent) in the thumb and 20 to 32 mm (14 to 18 percent) in the index to little fingers. It suggests that the safe position fails to provide an increased dorsal hand surface area for skin grafting compared with the anatomic position. The greatest amount of skin can be grafted in a fist position. Hand immobilization in a fist position for 7 to 9 days after skin grafting has not resulted in irrevocable joint stiffness in our experience. If injury of the deep structures is not present, the hand should be immobilized in a fist position before skin grafting on the dorsal hand.

The Use of Microplates for Internal Fixation of Mandibular Fractures

BACKGROUND The use of microplates in mandible fractures is not widely accepted, although microplate systems are commonly used for treatment of maxillofacial fractures. This study evaluated the use of microplates for internal fixation of mandibular fractures with no comminution or bony defects. METHODS Thirty-five patients with mandibular fractures (26 double and nine single) were treated. Of the 61 fractures, 54 were stabilized using 0.55-mm-thick microplates and 1.2-mm monocortical microscrews. The fractures were exposed through either an intraoral or a percutaneous approach. In general, two-point fixation with two microplates or one microplate and wires was performed. Interdental wiring was added for symphyseal or body fractures to confer further stability onto the dental arch. No intermaxillary fixation was used. RESULTS During a follow-up period ranging from 3 to 29 months, all fractures showed complete bone healing. There were eight complications in seven patients with a double fracture, including mild malocclusion (n = 3), paresthesia (n = 3), asymptomatic delayed union (n = 1), and asymptomatic plate fracture (n = 1). No further orthodontic or surgical treatment was performed as a result of these complications. No other complications requiring further treatment occurred. There were three residual complications of mild malocclusion, paresthesia, and asymptomatic plate fracture at final follow-up. CONCLUSIONS These results indicate that two-point fixation with microplates is appropriate for the internal fixation of simple, isolated mandibular fractures. Its advantages include a high adaptability to the fracture site, occlusal self-adjustment, a minimal mass effect, and a relatively strong holding power of two-point fixation.

Fist position for skin grafting on the dorsal hand : II. Clinical use in deep burns and burn scar contractures

The fundamental problem in all types of hand burns is a loss of skin and subsequent deformities. The goal of skin grafting on the dorsal hand is to graft a sufficient amount of skin, as much as the original amount, and to restore normal hand function without secondary deformities. The safe, or Michigan, position commonly has been used for immobilizing the hand. However, this position is to protect hand function rather than to provide for adequate skin grafting. This institution has developed a new hand position (the fist position) for grafting the greatest amount of skin on the dorsal side of the hand. In the fist position, the hand is positioned flexing all joints of the wrist and the fingers and maximally stretching the dorsal surface of the hand before skin grafting. Ten hands with deep second- or third-degree burn (n = 6) and burn scar contracture (n = 4) of the dorsal hand in eight patients were treated with split-thickness skin grafting after immobilizing in the fist position. The burns and contractures involved nearly the total area of the dorsal hand. The hand was kept in the fist position for 7 to 9 days after skin grafting. Excellent functional and cosmetic results were observed in all cases during the follow-up period of 6 months to 2 years. Complications resulting from hand immobilization for a short period did not occur. The fist position may be a proper hand position for skin grafting to reconstruct the dorsal hand.

Rice cooker steam hand burn in the pediatric patient.

&NA; Burn injuries often lead to significant cosmetic and functional deformity. In the Orient, household electric rice cookers have caused a significant number of steam burns to infant hands. The clinical course and treatment outcome of these burns have been studied retrospectively in a review of the medical records of 79 pediatric patients treated for acute hand steam burns and of 38 other patients who underwent correction for postburn contracture. Electric rice cookers caused all of the acute pediatric steam burns treated at our institute. Of the 81 hands treated between 1995 and 1998, 38.3 percent healed with conservative treatment and 61.7 percent required skin grafting. The volar aspects of the index and middle fingers were those most frequently involved. Eighteen of 36 hands (50 percent) grafted with split‐thickness skin developed late contractures requiring additional procedures. Among the 38 patients who underwent correction for postburn deformity, initial treatment was split‐thickness grafting for 60.5 percent, full‐thickness skin grafting for 7.9 percent, and spontaneous healing for 31.6 percent. Awareness among medical personnel and continued public education should be promoted to help prevent this unique type of pediatric steam burn from occurring. (Plast. Reconstr. Surg. 106: 76, 2000.)