Fronto-Orbito Nasal Dislocations: Initial Total Reconstruction

Abstract

The craniofacial trauma can produce compound fractures with bone displacement in the central part of the upper face, i.e. the bones constituting the forehead, orbit, and nose. such dislocations are called fronto-orbito-nasal dislocations. A total and definite surgical reconstruction in one stage offers advantages such as good aesthetic and functional results. An injured person can enter professional and social life without further delay. A major advantage is also the minimizing of the risk of meningeal fistula with infectious mortal risk. A prerequisite for this surgery is accurate clinical and radiological examination to permit a preoperative three-dimensional visualization of the lesions as a basis for careful planning of the operation. The surgical team should include neurosurgeons and plastic surgeons with experience in the maxillofacial area. The operative procedure should start with repair of the orbital frame, beginning at the upper and lateral side, followed by exploration of the four walls of the orbital chamber and of the lacrimal system. The reconstruction then proceeds with the eyelid ligaments and the nervous and vascular pedicles, especially the infra-orbital one, followed by reconstruction of the sinus maxillaris. Afterwards transnasal internal canthopexy wires are placed, the nose reconstructed and bone grafts are used to restore the orbital chamber behind the frame. The lacrimal system is repaired before the tightening of the canthopexies. In cases where neurosurgical intervention is necessary, such as suturing of dura sores or reconstruction of the anterior cranial fossa by bone grafting, this will precede the facial reconstruction. Without a strong frontal cornice it is impossible to restore the nose and orbit. Ocular injuries are treated by ophthalmic surgeons when the orbit is repaired. The last phase of the reconstruction is suturing of the muscular, mucosal and cutaneous lacerations.

Update on the management of orbitozygomatic fractures

“…Postoperation, two elements must be kept in mind [1,3,5,7,15,16]: the protection of the cornea and, avoiding optic nerve compression. Several management possibilities make it possible to protect the cornea: lubricating, ophthalmic ointments, Vaseline, clear adhesive dressings, and the use of Frost or blepharorraphic sutures of short duration, because closing the eyelids contributes to decreased visual acuity and no longer allows the orbit to decompress because of ptosis that is aggravated by orbital edema, thus resulting in orbital syndrome.…”

“…Several complications have been described [15,16]: -Optic neuropathy secondary to contact with implants or reconstruction materials; -Orbital hemorrhaging or edem, which is the most severe complication; -Muscular damage, which cannot be easily managed secondarily, even with strabismus surgery; -The most common complications are enophthalmia and ectropion.…”

Aesthetic Management of the Nasal Component of Naso-Orbital Ethmoid Fractures

“…15,19,[23][24][25] Cruse et al 15 recognized that if severe comminution of the bony septum resulted in a depression of the nasal dorsum, correction with primary fracture reduction was often incomplete. Stranc 31 noted that restoration of the nasal airway and nasal profile during primary surgery is difficult in the presence of severe septal damage.…”

“…The combination of physical examination and images obtained through computed tomography scans allows for the establishment of an operative treatment plan. Optimal results are achieved through open reduction, wide exposure of fractures, rigid internal fixation, 5,6,9,12,14,[17][18][19][20] and correction of orbital volume with immediate bone grafts. 21,22 Existing classification systems are based on the status of the medial canthal ligament and the extent of the fracture pattern.…”

Complications of Frontal Sinus Fractures

“…Reported complications include enophthalmos, exophthalmos, diplopia, macular hole, commotion retinae, retinal detachment, lens displacement, orbital mucopyocele, traumatic encephalocele, proptosis (þ/Àpulsatile), blurred vision, decreased visual acuity, blindness, orbital abscess, cellulitis, and ophthalmoplegia. 40,43,44 Most of these complications are seen early in the disease process. Mucocele, encephalocele, volume loss, and cicatrix related problems are usually late complications.…”