Correction of Medial Blowout Fractures According to the Fracture Types.

BACKGROUND: Regarding the issue of blowout fracture, a variety of approaches and surgical techniques have been reported to improve postoperative results. However, there are no extant guidelines for the selection of these various methods. The current authors classified the medial blowout fracture into 3 different types and adapted to suitable surgical techniques. METHODS: Between October 2010 and March 2013, 89 patients who had medial blowout fracture were included in this study. We classified the study patients into 3 different categories: greenstick, simple, and complex. The greenstick type used the transnasal endoscopic approach and was reduced with packing after applying a silastic sheet. The simple type used an onlay covering technique. The complex type was treated using the transcaruncular approach and inlay implanting technique. After surgery, the continuity of orbital wall was checked by computed tomography. Patients were then examined for the following conditions: diplopia, eyeball movement, and enophthalmos. RESULTS: The greenstick category consisted of 12 cases, most cases were satisfied. One case relapsed after removal of the packing. In the simple category, a total of 9 cases were treated by onlay covering technique. In all 68 cases of the complex type, we could obtain suitable anatomical reconstruction with inlay implanting technique. Only 2 cases complained of transient diplopia and moderate enophthalmos. CONCLUSIONS: Appropriate clinical classification, depending on the type of fracture and selection of optimal treatment methods, could obtain the satisfactory result and improve the treatment outcomes in the correction of medial orbital wall fracture.

Medial canthopexy using Y-V epicanthoplasty incision in the correction of telecanthus.

BACKGROUND: Telecanthus occurs because of the disruption of the medial canthal tendon (MCT). The deformity of medial canthus can result from nasoorbitoethmoid fractures, tumor resection, craniofacial exposure, congenital malposition, or aging. Repair of the MCT using transnasal wiring is regarded as a method of choice to treat telecanthus. We have introduced an oblique transnasal wiring using Y-V epicanthoplasty incision rather than the well-known classical bicoronal approach. METHODS: Eight patients with telecanthus were treated with this method. Through the medial canthal horizontal and periciliary incision, we could have an access to the medial orbital wall and the MCT. An oblique transnasal wiring was performed with the following steps: (1) after slit skin incision on the nasal recession of the contralateral frontoglabella area, 2 drill holes were made from this point to the superior and posterior region of the lacrimal fossa of the affected orbit; (2) a 2-0 wire was passed through the MCT and the holes; (3) the wire was pulled and tightened until the MCT was ensured and was twisted in the contralateral side. After the repositioning of the MCT, the skin was simply sutured. The excess skin was trimmed, and then the skin was sutured with nylon 7-0. The remaining "dog ear" in the lateral portion can be removed by additional periciliary skin incision and excision. RESULTS: All the patients achieved an improvement and a prompt recovery. The interepicanthal distance was decreased by 6.3 mm on average compared with that in the preoperative condition. All patients had no complication associated with surgeries. Of posttraumatic telecanthus, 5 patients were much satisfied with the outcomes, and 1 patient had recurrence on postoperative month 3. In cases of congenital anomaly or neoplasm, the telecanthus was also improved. CONCLUSIONS: An oblique transnasal wiring using Y-V epicanthoplasty incision could be a simple, safe method to correct the telecanthus with the following advantages: first, we could fix the MCT to the appropriate position with oblique transnasal wiring; second, a horizontal incision and a periciliary incision could be acquired with enough operative fields; third, Y-V epicanthoplasty incision is an effective method for minimizing unsightly scar formation.

Treatment of complex facial fractures: clinical experience of different timing and order.

Given the variability of the timing and order of surgeries, it is difficult to choose the best treatment for patients with complex facial fractures. Based on the clinical experiences, the authors have reviewed their experience with the timing and order of operations depending on the sites of complex facial fractures and their concurrent injuries. The current study was based on a total of 105 patients with complex facial fractures from the year 2002 to 2011. After assessing the patients' clinical records, radiological data, and clinical photographs, the following data were analyzed: patients' age and sex, causes of injury, concurrent injuries, sites of fractures, the interval between trauma and the operations, the presence of additional surgeries, and the aesthetic and functional outcomes.For most of the patients, early operation was performed (within 2 weeks in 95.2%). Additional surgeries within 1 month after injuries were performed in 22 patients. Usually, a top-to-bottom direction repair was applied when head injuries were involved, and bottom-to-top direction repair was applied when occlusal problems were involved. Of 105 patients whom we were able to follow up, 49 patients showed complications or were dissatisfied with the outcomes. However, except them, most of the patients were satisfied with the outcomes of surgical treatments. There were 14 cases of cheek asymmetry, 9 enophthalmos, 30 paresthesia, 4 malocclusion, and a single case of persistent trismus.In the current study, satisfactory results could be achievable under the following principles: a repair should be done in the early stage after the onset of the injury; supportive surgeries should be done, if necessary, within 2 weeks (no later than 4 weeks); and the order of surgical treatment should be determined by the severity of bone fracture and the systemic status.

Inlay implanting technique for the correction of medial orbital wall fracture.

BACKGROUND: For blowout fractures of the medial orbital wall, the goals of treatment are complete reduction of the herniated soft tissue and anatomical restoration of the orbital wall without surgical complications. Surgeons frequently worry about damage to the optic nerve caused by dissection when the part over the posterior ethmoidal foramen is fractured. The authors performed small incision and inlay implantation of porous polyethylene for reconstruction of medial orbital wall fractures. METHODS: Between January of 2007 and December of 2009, 55 patients were included in an analysis of the outcome of corrected medial orbital wall fractures. For 55 patients with posterior comminuted fractures of the medial orbital wall, insertion of porous polyethylene into the ethmoid sinus was performed in multiple layers, through the transconjunctival approach. RESULTS: In all cases, the orbital cavity was restored to its normal anatomical shape. The associated ocular problems disappeared except for mild enophthalmos in three patients and diplopia in one patient. There were no serious surgical complications associated with inlay implantation. CONCLUSIONS: The advantages of the inlay technique include the anatomical reconstruction of the orbital wall, the avoidance of optic nerve injury, the simplicity of the procedure, and consequently the absence of surgery-related complications. This technique is presented as one of the preferred treatments for posterior comminuted fractures of the medial orbital wall.