Joseph S. Gruss

The importance of the zygomatic arch in complex midfacial fracture repair and correction of posttraumatic orbitozygomatic deformities.

Collapse of the zygomatic arch following trauma results in inadequate anteroposterior projection of the zygomatic body and an increase in facial width. Accurate assessment of the position of the zygomatic arch in relation to the cranial base posteriorly and the midface anteriorly is the key to the acute repair of complex midfacial fractures and the secondary reconstruction of posttraumatic deformities of the orbitozygomaticomaxillary complex. Loss of projection of the zygomatic arch may occur with injuries confined to the orbitozygomaticomaxillary region or in association with complex midfacial fractures. A safe anatomic approach to the zygomatic arch allows exact anatomic restoration of the zygomatic arch using miniplates and screws and results in the reconstruction of an outer facial frame with a correct anteroposterior projection and facial width. The zygomatic arch injury is diagnosed using axial CT scanning. Three-hundred and seventeen arches have been exposed through a coronal incision following acute trauma and 47 arches have been exposed in patients requiring late correction of a posttraumatic orbitozygomaticomaxillary deformity. Permanent palsy to the frontal branch of the facial nerve has occurred in one patient following the exact definition of the anatomy of this region.

Complications of soft tissue expansion

Abstract This paper presents a critical review of the results of tissue expansion in our clinical experience. Seventy-six expansions performed in 66 patients between 1981 and August 1986 are included in the study. Complications necessitating some revision in the original treatment plan were documented in 39% of cases. However, sufficient tissue was usually generated to complete the proposed reconstruction without compromising the final results. The complications of tissue expansion are further analysed in relation to their anatomical distribution, time of onset and ultimate consequences. Causative factors are identified and preventative measures are introduced.

The pattern and incidence of nasolacrimal injury in naso-orbital-ethmoid fractures: the role of delayed assessment and dacryocystorhinostomy

Abstract A detailed review of forty-six patients with severe naso-orbital-ethmoid injury confirms that naso-lacrimal system injury is less common than originally suspected. Post-operative epiphora is more frequently due to eyelid malposition than naso-lacrimal obstruction. Eight patients (17.4%) required eventual dacryocystorhinostomy. Three out of five patients (60%), treated with closed reduction and external splint fixation, needed dacryocystorhinostomy. This treatment predisposes to external compression of the naso-lacrimal system by malpositioned bone fragments and segments. Open reduction and internal fixation of all fractures provides optimal repair and minimises the incidence of post-operative epiphora. During fracture repair, the naso-lacrimal sac should be identified, but not probed or intubated unless obviously lacerated. The upper lacrimal pathway is protected by the medial canthal ligament. Obstruction usually occurs in the bony naso-lacrimal canal. Telecanthus invariably accompanies severe naso-orbital-ethmoid injuries and subsequent nasolacrimal obstruction. Dacryocystography is useful in the investigation of naso-lacrimal function. When dacryocystorhinostomy is necessary, it should be performed at least 3 months after the primary repair.

Complex orbital fractures: a critical analysis of immediate bone graft reconstruction

The present study reviews the long-term results of immediate reconstruction and primary grafting in 49 complex orbital fractures. The clinical features of these injuries are defined, and methods of investigation and surgical correction are outlined. The residual postoperative abnormalities, including enophthalmos, strabismus, and telecanthus, are critically analyzed. Recent modifications in fracture fixation, in orbital cavity reconstruction, and in the use of various types of autogenous grafts are discussed in detail.

Blow-in Fractures of the Orbit

A blow-in fracture is an inwardly displaced fracture of the orbital rim or wall resulting in decreased orbital volume. The purpose of this study is to classify orbital blow-in fractures, describe the distinguishing clinical and radiologic features, and review the result of treatment. The series consists of 41 patients with blow-in fractures (34 males and 7 females). The mean age of the patients was 36 years. All were treated between 1979 and December of 1986 at Sunnybrook Medical Centre in Toronto. Clinical features of blow-in fractures were primarily related to the decrease in volume of the orbital cavity. Proptosis was a consistent finding, and in 27 percent of patients, the globe was further displaced in a coronal plane. Restricted ocular motility and diplopia were documented in 24 and 32 percent of patients, respectively. Fracture fragments displaced into the orbit resulted in globe rupture in 12 percent of patients, superior orbital fissure syndrome in 10 percent, and optic nerve injury in 1 patient. Blow-in orbital injuries were classified as pure fractures, consisting of an isolated blow-in of a segment of the roof, floor, or walls, or impure fractures, where the orbital rim itself was disrupted. In all cases, early decompression of the orbit and open reduction of fractures was necessary. Late sequelae of blow-in fractures were primarily related to injuries of intraorbital contents. Twelve percent of patients underwent enucleation and 8 percent reported persistent diplopia. Despite the presence of superiororbital fissure syndrome and complete ophthalmoplegia in 10 percent of patients, early orbital decompression resulted in resolution of nerve palsies in all but one patient.

Facial sensibility testing in the normal and posttraumatic population.

A reliable, reproducible, simple examination of facial sensibility is described. Evaluation of 60 healthy subjects established normal values, trends, and variations of facial sensibility. Comparison of these normal values with 20 posttraumatic patients revealed that postfacial fracture sensibility testing was abnormal. Abnormalities in pressure threshold testing was most consistently associated with functional sensory complaints. Twelve of the 20 patients had significant sensory complaints at one year following the trauma.

Complex nasoethmoid-orbital and midfacial fractures: role of craniofacial surgical techniques and immediate bone grafting.

A detailed review of 104 patients with severe nasoethmoid-orbital injuries has facilitated the classification of these injuries into five types. The recognition and diagnosis of each specific injury pattern will define the correct treatment choice in each instance. Special attention should be focused on injuries with comminution and bone loss in the medial wall and floor of the orbit, loss of cartilaginous nasal support, and orbital displacement and dystopia. An open, direct approach to these fractures with meticulous reduction, internal fixation, and repair of the medial canthal ligaments provides optimal repair. The use of craniofacial surgical techniques and immediate bone graft replacement of missing or severely damaged bone will allow reconstruction of even the most difficult injuries in one stage. Three hundred and nine primary bone grafts have been used in 66 patients. No significant complications of their use have occurred.

The biomechanical effects of deep tissue support as related to brow and facelift procedures

The adverse effects of increased tension across a healing wound are well known. However, the effect of closing a wound in layers in order to decrease tension on the epidermis has been a source of controversy. It is hypothesized that deep tissue support decreases skin tension upon wound closure. In order to clarify this issue, a two-part study was designed to address the immediate effects of deep tissue support in vitro using fresh-frozen cadavers and in vivo on patients undergoing scheduled surgery. Closing skin tension was measured at standard reference points in coronal brow lift and rhytidectomy procedures performed with and without galeal closure and superficial musculoaponeurotic system (SMAS) procedures, respectively. Deep tissue support was found to significantly (p< 0.05) decrease skin tension at the time of skin closure at standard reference points in coronal brow lift and rhytidectomy procedures performed on fresh-frozen cadavers. Similar significant (p<0.05) decreases in closing skin tension also were found in vivo in patients undergoing similar surgical procedures. Stress relaxation was not found to play a significant role in contributing to this immediate decrease in closing skin tension. It would appear, therefore, that deep tissue support, in the form of galeal closure and an SMAS procedure in coronal brow lift and rhytidectomy procedures, respectively, provides increased viscoelastic support, producing immediate significant decreases in closing skin tension in these procedures. The beneficial effects on wound healing, scar formation, tension-related trophic skin changes, and possible improved long-term results are discussed.

Soft tissue expanders in upper limb surgery

Five cases in which soft tissue expanders have been used as an aid to reconstruction in the upper limb are reported. The cases involved the reconstruction of the shoulder mound after forequarter amputation, excision of a large tattoo of the forearm, excision of a malignant melanoma of the elbow, excision of a giant hairy nevus of the forearm, and the creation of large advancement flaps to release an axillary burn scar contracture. No complications were noted with the use of these expanders. Patient tolerance was excellent, and the final result was significantly enhanced by the use of this technique.

Cantilever nasal bone grafting with miniscrew fixation.

A technique of rigid miniscrew fixation of cantilever nasal bone grafts is described. This produces stable, predictable nasal contour and tip projection without significant bone graft resorption.