Larry A. Sargent

Management of the medial canthal tendon in nasoethmoid orbital fractures : the importance of the central fragment in classification and treatment

The medial canthal tendon and the fragment of bone on which it inserts (“central” fragment) are the critical factors in the diagnosis and treatment of nasoethmoid orbital fractures. The status of the tendon, the tendonbearing bone segment, and the fracture pattern define a clinically useful classification system. Three patterns of fracture are appreciated: type I—single-segment central fragment; type II—comminuted central fragment with fractures remaining external to the medial canthal tendon insertion; and type III—comminuted central fragment with fractures extending into bone bearing the canthal insertion. Injuries are further classified as unilateral and bilateral and by their extension into other anatomic areas. The fracture pattern determines exposure and fixation. Inferior approaches alone are advised for unilateral single-segment injuries that are nondisplaced superiorly. Superior and inferior approaches are required for displaced unilateral single-segment injuries, for bilateral single-segment injuries, and for all comminuted fractures. Complete interfragment wiring of all segments is stabilized by junctional rigid fixation. All comminuted fractures require transnasal wiring of the bones of the medial orbital rim (medial canthal tendon-bearing or “central” bone fragment). If the fracture does not extend through the canthal insertion, the canthus should not be detached to accomplish the reduction.

Reconstruction of internal orbital fractures with vitallium mesh

Trauma to the face frequently results in internal orbital fractures that may produce large orbital defects involving multiple walls. Accurate anatomic reconstruction of the bony orbit is essential to maintain normal appearance and function of the eye following such injuries. Autogenous bone grafts do not always produce predictable long-term support of the globe. Displacement and varying amounts of bone-graft resorption can lead to enophthalmos. This study examines the use of Vitallium mesh in the acute reconstruction of internal orbital defects. Fifty-four patients with 66 orbits underwent reconstruction of internal orbital defects with Vitallium mesh. Associated fractures were anatomically reduced and rigidly fixed. Forty-six patients and 57 orbits had adequate follow-up for analysis of results. The average follow-up was 9 months, with 85 percent of the patients followed 6 months or longer. There were no postoperative orbital infections, and none of the Vitallium mesh required removal. Large internal orbital defects can be reconstructed using Vitallium mesh with good results and little risk of infection. Vitallium mesh appears to be well tolerated in spite of free communication with the sinuses. Stable reconstruction of the internal orbit can be achieved and predictable eye position maintained without donor-site morbidity.Trauma to the face frequently results in internal orbital fractures that may produce large orbital defects involving multiple walls. Accurate anatomic reconstruction of the bony orbit is essential to maintain normal appearance and function of the eye following such injuries. Autogenous bone grafts d

Nasoethmoid Orbital Fractures: Diagnosis and Treatment

Summary: Blunt trauma to the midface frequently results in fractures of the nasoethmoid orbital skeleton. These complex injuries are often misdiagnosed or inadequately treated and are perhaps the most difficult of all facial fractures to treat. The purpose of this article is to describe the authors technique for the diagnosis and treatment of these complex fractures. Presented is an organized approach to the diagnosis and surgical management of nasoethmoid orbital fractures that has evolved in the authors treatment of over 450 nasoethmoid fractures. Early diagnosis is confirmed by computed tomographic scan using the simple classification system described. Fractures that demonstrate displacement or movement on examination require open reduction and stabilization. Identifying the extent and type of fracture pattern and associated injuries determines the exposure and method of fixation needed. Wide exposure with meticulous reduction is necessary, with stabilization of the medial orbital rim fragment using a transnasal wire technique. Plate-and-screw fixation of the superior and inferior rim is performed with bone graft reconstruction of the nose as needed. Attention to redraping of soft tissue in the naso-orbital valley with the use of nasal compression bolsters is a crucial step in the repair. Multiple clinical cases are used to illustrate the different fracture patterns, soft-tissue injuries, and surgical technique recommended. This organized approach has proven effective in restoring preinjury appearance. Early diagnosis combined with the aggressive surgical techniques described will optimize results and minimize the late posttraumatic deformity.

Modified towel-clamp technique to effect reduction of displaced mandible fractures.

We report a technique that uses a modified standard towel clamp, allowing a single surgeon to perform and maintain an anatomic reduction of displaced mandible fractures simultaneous with the application of internal fixation. The reduced convergent angle of the modified towel clamp allows bicortical engagement of the clamp, which prevents comminution of the fracture or the outer cortex of the mandible. Additionally, the modification allows the clamp to engage the bone with less exposure than conventional towel clamps. In our clinical experience of treating more than 100 mandible fractures a year, this technique proves superior to others described in the literature.

Surgical management of Gorlin syndrome: a 4-decade experience using local excision technique.

AbstractBasal cell nevus syndrome (aka Gorlin syndrome, Gorlin-Goltz syndrome, nevoid basal cell carcinoma syndrome, and fifth phacomatosis) is a rare but well-described autosomal dominant condition with variable penetrance. We present a female patient who has been successfully treated using local surgical excision and diligent skin surveillance for more than 4 decades, demonstrating that simple local incision is an efficacious and reasonable surgical alternative that may circumvent the specialization and expense of Mohs technique.

Midfacial and total nasal reconstruction with bilateral pectoralis major myocutaneous flaps

A previously undescribed technique for total nasal reconstruction is presented. The primary advantage of the method is the distant donor site that avoids additional facial scarring.

Paramedian forehead flap to treat chronically infected base of skull defect in a posttraumatic patient.

AbstractFrontal sinus cranialization with obliteration of the frontal sinus outflow tracts is rarely needed but may be required with extensive comminution of the anterior and posterior walls of the frontal sinus. There is little in the literature about treatment of chronic larger defects of the anterior cranial fossa that communicate with the nose and drain externally after cranialization. We present a 49-year-old man who experienced extensive facial trauma requiring cranialization of the frontal sinus. Three years later, the patient presented with a chronic draining forehead wound that extended into the previously cranialized frontal sinus space with communication of the anterior cranial fossa and the internal nose. After thorough irrigation and debridement, the remaining dead space was found to be large and communicated with the nose, making autologous grafts a poor choice. A pericranial flap was not an option due to the previous soft tissue trauma. A paramedian forehead flap was deepithelialized and rotated into the space, obliterating the dead space and closing the communication between the nose and the anterior cranial fossa. Six months postoperatively, there are no signs of recurrence. The deepithelialized paramedian forehead flap should be considered for obliterating large dead spaces and closing off the communication between the cranial base and the nose.