SURGICAL CORRECTION OF COMMUNITED FRONTONASAL FRACTURE USING BIORESORBABLE MESH NOAH A. SANDLER, DMD, MD, MARK W. OCHS, DMD, MD, MICHAEL J. BUCKLEY, DMD, MS
High velocity trauma to the frontonasal region often results in severe aesthetic and functional derangements. Disruption of the frontonasal-orbital rim frame, inward telescoping of the nasal buttress, and telecanthus may result. Often there is concomitant involvement of the skull base, ethmoid, and frontal sinuses. Associated intracranial injuries including brain contusion or cerebrospinal fluid leaks secondary to dural tears are not uncommon and can lead to long-term pathology. Direct compression of the optic nerve in the canal by bone fragments or secondary to pressure may also occur. 1,2 Although there has been a great deal written regarding the management of nasal-orbital-ethmoid fractures as well as frontal sinus fractures, few authors have addressed the finding of combined injuries. The presence of a communited anterior frontal sinus fracture requiring surgical intervention and a depressed nasal-orbital ethmoid fracture offers a unique opportunity to improve anteroposterior projection of the nasal complex through the frontal sinus. Conventional treatment methods for these types of injuries typically is achieved through a combination of rigid and skeletal fixation. These techniques often result in adequate bone positioning for healing; however, it is often difficult to achieve adequate anteroposterior positioning of the bony segments using these techniques. In addition, the ability to retrieve metallic plates and screws in the frontonasal-orbital region is often difficult once soft-tissue healing has occurred. Recently, a resorbable rigid fixation device system has been approved by the Food and Drug Administration for clinical use. These devices are made of a specific polylacticpolyglycolic acid copolymer (Lactosorb, Biomet, Warsaw, IN) that shows adequate initial strength with complete resorption of all polymer via the process of hydrolysis, between 9 and 15 months after implantation.3 In clinical studies, this system has been used for fixation of midface fractures, in craniosynostosis surgery, and in pediatric craniofacial surgery with favorable results. 4-6 The use of a bioresorbable mesh within the frontal sinus to maintain
From the Department of Oral and Maxillofacial Surgery, University of Pittsburgh, PA. Address reprint requests to Noah A. Sandier, DMD, MD, University of Pittsburgh, Department of Oral and Maxillofacial Surgery, 1112 Kaufmann Bldg, 3471 Fifth Ave, Pittsburgh, PA 15213. Copyright © 1997 by W.B. Saunders Company 1043-1810/97/0802-0013505.00/0
anteroposterior projection in a communited frontonasal fracture is described.
CASE REPORT D.D. is a 23-year-old white male who was an unrestrained driver in a head-on motor vehicle accident. He was ambulatory at the scene and noted to be under the influence of alcohol. He was amnestic to the event. The patient's past medical history was significant for previous head trauma with a left frontal craniotomy. On physical examination, a large, diffuse, frontal hematoma was evident. No obvious cranial fractures were palpable. No otorrhea or evidence of cranial base injury was evident. Pupils were 3 m m bilaterally and briskly reactive. There was a 3-cm right supraorbital laceration. He was noted to have epistaxis, and a 2-cm laceration of the nasal dorsum and a 1-cm laceration of the left alar base. There was obvious crepitance of the nasal dorsum and depression at the nasal radix (Fig 1). Additional injuries included left radial and ulnar fractures, which were treated in the emergency department via a closed reduction. Computerized tomographic (CT) scan of the head showed a significantly communited and depressed anterior frontal sinus fracture with a depressed nasal-orbitalethmoid fracture (Fig 2). No evidence of posterior wall involvement of the sinus or intracranial injury was evident. After clearance of the patient for spinal or intraabdominal injuries, the patient was taken to surgery for repair of his facial injuries. A bicoronal approach was used to access the frontal sinus and radix region. As noted from the CT scans, a communited frontal sinus with depressed nasal-orbital-ethmoid fracture was evident. Attempts at reduction of the nasal component of the fracture proved difficult, and stabilization of the segment in proper anteroposterior projection was not possible intranasally. It was noted that the nasal complex could be manipulated within the frontal sinus and adequate projection achieved. Traditional bone plate fixation from inside the frontal sinus was ill-advised secondary to the possible need for retrieval. A 1.5-mm bioresorbable mesh (Lactosorb, Biomet, Warsaw, IN) bent in a 90 ° angle was used to maintain anteroposterior projection. The mesh was secured using four 5-mm screws within the frontal bone superior to the orbital roof (Figs 3 through 12). Before fixation, the mucosa of the frontal sinus mucosa was removed and the sinus was obliterated with a pedicled pericranial flap 7 (Figs 13, 14). The communited sinus fracture was plated using multiple 1.5-mm plates (Walter Lorenz, Jacksonville, FL) before closing (Fig 14).
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 8, NO 2 (JUN), 1997: PP 109-113
Posterior frontal sinus walI (intact)
FIGURE 1. Preoperative view of patient described. Note degree of depression present at the nasal radix.
FIGURE 4. Diagram of Fig 2.
FIGURE 5. Oblique view of bioresorbable mesh used for fixation within the frontal sinus.
FIGURE 2. Axial CT scan of frontal sinus shows communited anterior sinus wall fracture.
FIGURE 6. View of bioresorbable screw on special designed hexagonal screwdriver.
Postoperatively, the patient showed no evidence of a cerebrospinal fluid leak and was discharged on postoperative day one. He was examined every 2 weeks after discharge and continues to maintain adequate nasal and frontal sinus projection 8 weeks post-trauma (Fig 15).
DISCUSSION FIGURE 3. Intraoperative view of bioresorbable mesh in place maintaining nasal projection. Compare with Fig 4. 110
The proposed benefits of using biodegradable materials include decreased restriction of craniofacial growth, infection, extrusion, and palpability compared with traditional BIORESORBABLE MESH FOR FRONTONASAL FRACTURE
FIGURE 7. Five and seven millimeter bioresorbable screws. FIGURE 10. Calcium chloride heating pad used to soften the bioresorbable plates to allow for contouring.
FIGURE 8. Break-away hexagonal portion of screw. FIGURE 11. Bioresorbable plate before heating.
FIGURE 9. Plates, screws, and mesh available in the system. SANDLER ET AL
FIGURE 12. Bioresorbable plate after heating; note malleable state of plate.
FIGURE 13. Pericranial flap harvested to obliterate the frontal sinus.
FIGURE 14. Pericranial flap within the frontal sinus and fixation of the communited anterior sinus wall.
place fixation devices in areas never before possible. Because the devices slowly resorb, e n o u g h time is allowed for bone healing; however, the risk for long-term foreign b o d y reaction or need for plate retrieval is eliminated. This fixation system has been used at our institution for the past 3 years for selected cases of midface fractures, transnasal wiring, and Lefort I osteotomies w i t h o u t evidence of infection, loss of fixation, or extrusion. The current system is not r e c o m m e n d e d in areas u n d e r high stresses such as m a n d i b u l a r fractures or in c o m m i n u t e d fractures.
CONCLUSION Recently, a resorbable fixation system has been a p p r o v e d b y the FDA for clinical use. A m o n g other advantages, this system allows fixation in areas w h i c h have been p r e v i o u s l y inaccessible w h e n retrieval is necessary. A n example of the use of this system is the ability to stabilize bones within sinus cavities. Further follow-up and additional cases will be necessary to evaluate the ability of bioresorbable fixation devices to maintain b o n y projection.
FIGURE 15. Eight weeks postoperative. Note adequate maintenance of frontonasal projection.
metallic fixation. 6 Other benefits of bioresorbable fixation devices include decreased temperature sensitivity, shielding, scattering on imaging and radiation treatment, and sensitization of metallic alloys in certain patients. 3 The use of bioresorbable mesh offers the unique o p p o r t u n i t y to
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1. Raveh J, Laedrach K, Vuillemin T, Zingg M: Management of combined frontonaso-orbital/skull base fractures and telecanthus in 355 cases. Arch Ototarngol Head Neck Surg 118:605-614,1992 2. Raveh J, Vuillemin T, Sutter F: Subcranial management of 395 combined frontobasal-midface fractures. Arch Otolaryngol Head Neck Surg 114:1114-1122,1988 3. EppleyBL, Prevel CD, Sadove AM, Sarver D: Resorbable bone fixation: Its potential role in cranio-maxillofacial trauma. J Cranio-Maxillofac Trauma 2:56-60, 1996 4. Eppley BL, SadoveAM: Resorbable coupling fixation in craniosynostosis surgery: Experimental and clinical results. J Craniofacial Surg 6:455-477,1995 5. Eppley BL, Sadove AM, Havlik RJ: Resorbable plate fixation in pediatric craniofacial surgery: A two year clinical experience. Plastic Reconstruct Surg (in press) 6. Thaller SR, Lee T, Tesluk H: Polyglyconate fixation successfully stabilizes zygomatic osteotomies in a nonhuman primate. J Craniofacial Surg 6:459-464,1995 7. Thaller SR, Donald P: The use of pericranial flaps in frontal sinus fractures. Ann Plastic Surg 32:284-287,1994