Endoscopic Treatment of Facial Fractures

Reid Mueller, M.D.1

ABSTRACT

The application of endoscopic surgical techniques to the treatment of craniomax- illofacial fractures not only has decreased the morbidity associated with the surgical approaches but has significantly altered the treatment philosophy for many types of fracture. Frontal sinus fractures, orbital floor fractures, zygomatic arch fractures, and subcondylar mandible fractures are the most notable examples where endoscopic techniques have found acceptance.

KEYWORDS: Face, fracture, orbital floor, blowout, frontal sinus, zygomatic arch, subcondylar, mandible, endoscope, endoscopic

The treatment of facial fractures has undergone of a ridged or flexible tube with a light delivery system several revolutions over the last century. The advent of usually composed of fiber optics to route light from an ridged internal fixation has given us the tools to perform external source to the area of interest. There is a system more accurate repairs of facial fractures while at the same of lenses in ridged endoscopes that transmit the image to time reducing much of the morbidity. Modern recon- an eyepiece or video camera for the surgeon. Most structive surgery has focused on accurate, reliable resto- flexible endoscopes rely on a coherent optical fiber ration of the facial bony framework; however, the soft system to transmit the image. Many endoscopes will tissue sequelae of many surgical approaches persist as a also have channels for irrigation, suction, or the intro- lasting reminder of the original injury. The most notable duction of surgical instruments. examples of this are temporal wasting and scalp alopecia The first descriptions of endoscopy were by Hip- associated with the bicoronal approach, ectropian asso- pocrates (460–375 BCE) who used rectal speculums that ciated with lower lid incisions, and facial nerve injury are little different than those used today. The Romans and scar associated with approaches to subcondylar also had a variety of speculums used to peer into orifices fractures. Over the last 10 years, innovative surgeons and body cavities with nothing more than available have applied alternative endoscopic approaches to facial light.1 For over a century, various simple tubes were fracture repair in an effort to achieve results equal to used, but the lack of good illumination hampered their traditional open approaches but with reduced morbidity use. from the surgical approach. Phillip Bozzini (1773–1809), an obstetrician, is credited with the first major endoscopic advancement to improve illumination. His invention consisted of a light HISTORY OF ENDOSCOPY guide (Lichtleiter) that would reflect candlelight via a Endoscopy literally means to look inside (Origin: < Gk, mirror down a funnel-shaped tube.2 The faculty in comb. form of e´ndon within þ skopı´a, watching), typi- Vienna ridiculed him for his ‘‘undue curiosity’’; however, cally referring to looking inside the body for a medical his ideas lived on. Others improved on the basic design purpose with an endoscope. Modern endoscopes consist with brighter lights and better mirrors and lens systems.

1Division of Plastic Surgery, Oregon Health Sciences University, Aesthetic Reconstruction of Head and Neck Defects; Guest Editors, Portland, Oregon. Manoj T. Abraham, M.D., F.A.C.S., Keith E. Blackwell, M.D. Address for correspondence and reprint requests: Reid Mueller, Facial Plast Surg 2008;24:78–91. Copyright # 2008 by Thieme M.D., Associate Professor, Division of Plastic Surgery, Oregon Health Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, Sciences University, 3303 SW Bond Avenue, CH5P, Portland, OR USA. Tel: +1(212) 584-4662. 97239. DOI 10.1055/s-2008-1037452. ISSN 0736-6825. 78 ENDOSCOPIC TREATMENT OF FACIAL FRACTURES/MUELLER 79

Rather than shining light down a tube, Maximilian bicoronal approach are more problematic than the Nitze (1848–1906) placed a light source on the end of underlying contour defect from the fracture. The endo- the endoscope saying ‘‘to light up the room one must scopic approach addresses this problem for isolated outer carry the lamp inside.’’3 He accomplished this by placing table fractures but has no application for those fractures a glowing platinum wire on the end of the endoscope. with significant posterior table displacement or naso- A number of internal burns resulted. In further develop- frontal duct disruption. There are two basic endoscopic ments, the glowing wire was replaced with a small light treatment options: endoscopic reduction and miniplate bulb and lenses were placed into the tube to magnifying fixation or camouflage of the contour defect. the image. Despite these improvements, the light and The first reported use of an endoscope for treat- image quality was poor. ment of a frontal sinus fracture was in 1996.26 Since then, To address the limitations of the Nitze optical a number of authors have reported on the reduction and system Harold Hopkins (1918–1995) developed the rod miniplate fixation of isolated outer table fractures using lens system4 that replaced the air spaces between lenses an endoscopic approach.28–30,32,33,92 The basic technique with solid glass rods cemented between the lenses. This involves two or three small incisions placed behind the significantly increased light transmission and allowed for hairline in much the same way as one would approach an wider field of view, better color rendition, and smaller endoscopic brow-lift. A subperiosteal dissection exposes caliber endoscopes. This basic system is the basis for the depressed anterior table fragments (Fig. 1). rigid endoscopes today. The most challenging aspect of this technique is Modern flexible endoscopes are not based on the the elevation of the depressed fragments. In the author’s rod lens but on fiber optics. In 1930, Lamm, a German , the most reliable method to elevate the depressed urologist, showed that a bundle of thin glass fibers would segments is to use a threaded fragment manipulator transmit light despite flexure.5 The idea floundered until (Fig. 2)—basically a long self-drilling, self-tapping 2.0 the 1950s, when Hopkins used fiber optics in a flexible screw (Synthes, Paoli, PA) that is inserted through a gastroscope to transmit light in and image out. Fibers small stab incision and screwed into the depressed frag- that are not aligned in an orderly manner (incoherent) ment or fragments. A rocking and pulling motion is then can be used to transmit light into the body; fibers that are used to reduce the fracture (Fig. 3). Often a surprising arranged identically on both ends (coherent) will trans- amount of force is required to pull the fragment into mit a useful image out. reduction in part because the original compressive forces Endoscopic techniques have revolutionized many that were generated during collapse of the anterior table areas of surgery and have been applied to both aesthetic are re-created when elevating the fragment (Fig. 4). and reconstructive procedures in head, neck, and cranio- After the segments have been reduced, miniplates are maxillofacial surgery. The first applications in craniomax- illofacial surgery were for aesthetic procedures such as brow-lifting,6–8 procerus resection,8 and forehead recon- touring.9,10 In short order, endoscopy was applied to many different areas of the head and neck in craniomax- illofacial surgery, including cranial synostosis,11–19 resec- tion of forehead and scalp soft tissue and bony tumors,20– 25 treatment of frontal sinus fractures,26–35 decompres- sion for Graves opthamalopathy,36–41 treatment of orbital wall fractures,42–71 distraction osteogenesis,72–76 and treatment of zygoma fractures44,47,48,77–83 and subcon- dylar fractures.84–90

FRONTAL SINUS The logical extension of an endoscopic brow-lift ap- proach was to apply the same techniques and tools to the treatment of a variety of forehead pathologies, including lipomas,21,22,24,25 benign bony tumors,91 frontozygo- matic dermoid cysts,23 and osteomas22 as well as endo- scopic reduction and internal fixation of anterior table fractures. Figure 1 An endoscopic view of an isolated anterior table It is important to remember that an isolated outer frontal sinus fracture. The depressed segment is visible; a table frontal sinus fracture is a cosmetic defect. Often the green arrow points toward the supraorbital vessels and scar, alopecia, and temporal wasting associated with a nerve. 80 FACIAL PLASTICS SURGERY/VOLUME 24, NUMBER 1 2008

Figure 2 The threaded fragment manipulator is introduced and secured to the depressed anterior table fragment prior to reduction.

used to secure the fragments (Fig. 5). If more than one fragment has been elevated, it is useful to apply a long plate starting on stable and then proceed sequen- tially across the fragments (stable bone ! fragment ! fragment ! stable bone). Self-drilling screws and screw- driver are introduced via small stab incisions; alterna- tively, a right angle screwdriver may be used. Severely comminuted fractures are not amenable to this technique due to the difficulty of reducing and holding multiple small fragments simultaneously. Figure 4 As the threaded fragment manipulator is pulled outward (blue arrow), the depressed anterior wall segments of the frontal sinus go through a compression (red arrow) before achieving reduction. The force required can be con- siderable.

The technical difficulties achieving endoscopic reduction and fixation of comminuted frontal sinus fractures have spawned recommendations for camou- flage rather than reduction and fixation. These camou- flage procedures are best done after the wound has healed and the frontal sinus is no longer in continuity with the subperiosteal space. After a few months of healing, a subperiosteal endoscopic dissection is used to expose the fracture. The defect is then camouflaged with hydroxyapatite cement,29 porous polyethylene cus- tom implants, or 0.85-mm porous polyethylene sheets35 inserted endoscopically. If hydroxyapatite cement is used, it is injected Figure 3 The threaded fragment manipulator has pulled through a small tube into the defect and contoured to the fragment into reduction. A plate is being secured with appropriate shape (Fig. 6). Some have found that placing a self-drilling screw. thin plastic membrane over the cement as it is hardening ENDOSCOPIC TREATMENT OF FACIAL FRACTURES/MUELLER 81

tures,68,71 and assistance in locating the posterior edge in open orbital floor repair.66 Endoscopic approaches for repair of orbital fractures include transnasal approach with balloon catheter stabilization,46 transconjunctival medial approach for medial blowout fractures,42,43,55,59 transnasal approach for medial blowout fractures,54,60,65 and transantral repair of orbital floor fractures with bone,63,70 titanium mesh,64 and porous polyethylene sheets49,50,56,64,69; endoscopic approaches can also be used for balloon stabilization52,58 and placement of resorbable plates.61 The most accepted endoscopic approach is the transantral approach via an upper sulcus incision and maxillary antrostomy. Most authors agree that the best candidates for this procedure are those with trapdoor fractures or blowout fractures located between the infraorbital nerve and the medial wall of the . Large orbit fractures require careful restoration of orbit shape and volume that is simply not possible with this Figure 5 The frontal sinus fracture is reduced then fixed technique. with a miniplate. The approach involves an upper buccal sulcus incision and subperiosteal dissection to expose the maxilla makes it easier to contour the cement without fragmen- and inferior orbital nerve. A maxillary antrostomy meas- tation. uring about 2 1 cm is made just below the nerve and Porous polyethylene implants may be inserted above the canine tooth root. A small cutout on the endoscopically to camouflage the defect. Experimental inferior aspect of the antrostomy forms a stable resting work in cadavers has shown that if the defect is not too spot for the endoscope (Fig. 7). The endoscope is inserted large, using a porous (0.85 mm) polyethylene sheet into the sinus and directed up toward the orbital floor secured with several screws is just as effective as a custom (Fig. 8). Oxymetolazine-soaked pledgets will decrease implant in resorting forehead contour.35 In addition, the bleeding and improve visualization. A Freerer-type sheet is readily available, inexpensive, and easy to insert elevator is used to strip the mucosa from the margins of through a small incision. the defect and free the orbital contents from the fracture margins. Loose, unstable bone should be removed. Once the entire defect is visualized and stable bone is identified, ORBIT the implant can be cut to size. In the author’s opinion, the Endoscopy has been used for orbital decompression in best material for repair of the defect is 0.85-mm-thick Graves disease,36–41 transantral diagnosis of orbital frac- porous polyethylene. It is possible to use titanium mesh,

Figure 6 Hydroxyapatite cement is placed into an anterior Figure 7 A2 1-cm antrostomy is made below the inferior table fracture and contoured. The cement was introduced alveolar nerve, avoiding the canine tooth root and pyriform through a separate stab incision; however, it may also be aperture. A notch is cut in the inferior aspect to accommo- applied via the other access incisions. date the endoscope. 82 FACIAL PLASTICS SURGERY/VOLUME 24, NUMBER 1 2008

Figure 8 The endoscope is inserted into the to view the roof of the sinus and the floor of the orbit. A porous polyethylene sheet is inserted from the sinus to repair the orbital floor.

bone, or bioresporbable sheets; however, the flexibility of size just right. The implant is placed into the defect in the polyethylene sheets makes the placement of the much the same way an acoustic ceiling tile is placed by implant much easier. sliding one edge into the defect, sliding the implant to The implant is cut just slightly large than the one side to allow the opposite side to lift over the edge, defect. This is often a trial and error process to get the and then sliding the implant back to the middle (Fig. 9).

Figure 9 An is repaired via a transantral approach. (A) The blowout fracture with orbital fat bulging into the maxillary sinus. (B) The sinus after limited mucosal stripping from the periphery of the fracture, removal of loose bone, and insertion of a piece of porous polyethylene. (C) The prosthetic material partially inserted into the defect. (D) The implant is fully in place and the defect repaired. Note the limited mucosal stripping. The asterisk shows the location of the maxillary sinus ostia. ENDOSCOPIC TREATMENT OF FACIAL FRACTURES/MUELLER 83

One must pay particular attention to the infraorbital much of the morbidity that concerns critics of open nerve and make sure the implant is not impinging upon treatment. When applied to favorable fractures, endo- it. A forced duction test is done to make sure there is no scopic-assisted treatment combines the best of open and entrapment of orbital contents. closed treatments. In the final analysis, it seems clear that we should not ask ourselves ‘‘Should condylar process fractures be treated open or closed?’’ but rather ‘‘What is ZYGOMA the best treatment for this particular fracture?’’ basing Endoscopic approaches for zygomatic arch fractures our decision on the patient’s age, fracture geometry, and have received the least acceptance from the craniomax- our patient’s informed preference. illofacial community and will only be mentioned briefly. In 1997, Honda et al reported on the use of Kobayashi et al first described the endoscopic approach an endoscope to improve visualization for resection of for a fractured zygoma and reported success but difficulty the mandibular angle in cases of masseteric hypertro- with the fixation.77 Lee and colleagues advocated re- phy.108 The following year, Lee and colleagues pio- moving the comminuted segment of zygoma and attach- neered the use of endoscopy to assist in the reduction ing a miniplate ex vivo with subsequent reinsertion and and fixation of subcondylar fractures.84,109 Over the fixation proximally and distally.47,48,78 Subsequently, last decade, a number of authors have used pure other authors found that 25% of patients who had ex transoral, transoral with cheek trochar, or submandib- vivo plating had resorption of the arch on long-term ular incisions for endoscopic reduction and internal follow-up.81 The author has had some success with fixation.85,86,88–90,110–117 In addition to fracture treat- precontouring a plate and lagging the fractured arch ment, orthognathic applications for condylectomy, segments up to the plate, thereby reducing the risk of costochondral graft reconstruction, and mandibular absorption of the comminuted segment. The technique vertical ramus osteotomy have been successfully per- involves an incision superior to the ear and endoscopic formed.74,87,118 In addition, foreign bodies have also dissection on top of the deep temporal fascia down to the been successfully removed from the condylar process119 arch. At this point, a precontoured plate may be intro- and temporomandibular joint.120 duced and the fractured arch segments lagged up to the Open approaches to condylar neck fractures have plate. This can be accomplished with a right angle not found broader application outside the traditional screwdriver or a small stab incision for screw application. indications set forth by Zide and Kent94 in 1983 because There are several reports of transient frontal nerve of technical demands of the open approach, external scar, palsy with endoscopic zygomatic arch approaches.80 fear of facial nerve injury, and the belief that a closed approach was adequate. Most surgeons accept, on an intellectual level, that fracture reduction and rigid fix- SUBCONDYLAR MANDIBLE FRACTURES ation with restoration of anatomy is a laudable goal if it Few aspects of mandible fracture management generate can be achieved without undue morbidity. For most more controversy than the management of condylar surgeons, the risk and demands of an external approach process fractures. Traditionally, the majority of these have not warranted its use for routine condylar neck fractures have been managed with closed techniques. fractures. The endoscopic approach described here has Proponents of closed treatment point to a large body of the potential to reduce morbidity by limiting scar, literature that suggests that most patients do well after a reducing the risk to the facial nerve, and eliminating period of maxillomandibular fixation (MMF) followed the need for MMF, all the while embracing the accepted by physiotherapy and training elastics. Although accept- advantages of anatomic reduction and rigid fixation. The able outcomes have usually been achieved with closed reduced morbidity associated with endoscopic reduction treatment, clinicians advocating open reduction argue may well expand the indications for reduction and rigid that the failure of MMF to restore anatomy leads to fixation in the future. condylar deformity, mandibular dysfunction, and facial Patients with condylar process fractures are se- asymmetry. Open approaches have been reserved for lected for endoscopic-assisted reduction and fixation certain specific circumstances,93,94 which many regard based on age, location of fracture, degree of comminution, as too restrictive given modern techniques. Eager for direction of proximal fragment displacement, dislocation better and more predictable outcomes, some have turned of condylar head, concomitant medical or surgical illness, to open reduction with ridged fixation, and recent work and—importantly—patient choice. Contraindications are reveals comparable if not superior results with the open listed in Table 1. The guidelines put forth by Zide and approach.95–107 Kent in 198394 for open treatment of condylar fractures Proponents of endoscopic-assisted approaches to form a starting point for surgical decision making; how- condylar process fractures have strived to accomplish ever, their relative indications should be broadened in the equivalent anatomic reduction and ridged fixation seen context of current surgical technique and decreased mor- with traditional open approaches while eliminating bidity when using an endoscopic approach. 84 FACIAL PLASTICS SURGERY/VOLUME 24, NUMBER 1 2008

Table 1 Contraindications for Endoscopic Reduction room to accommodate at least two screws of a 2.0 plate. and Ridged Fixation of Mandibular Condyle Fractures Most subcondylar fractures will have enough length on Absolute Relative the proximal fragment distal to the joint capsule to accommodate two or three screws (Fig. 10). Intercondylar fractures Child < 12 y old Condylar neck fractures Comminuted fracture without sufficient room Medial override of the DEGREE OF COMMINUTION for two fixation screws proximal fragment High-energy comminuted fractures are a relative contra- Any patient with medical When a simpler indication for endoscopic repair and should not be illness or other serious method is equally attempted by the inexperienced endoscopic surgeon. injury who may be harmed effective During reduction, the anterior and posterior border of by a longer surgical procedure the fracture line is used as an anatomic landmark to or extended general anesthesia assess accurate reduction. Comminuted fractures will often have fracture fragments that involve the border and thereby obscure the landmarks. Microcomminution AGE will obscure the interdigitation of small irregularities There is a consensus of opinion that most fractures in along the fracture line, which ordinarily assist in precise children are best treated with MMF. This belief is not reduction. Unfortunately, the visual limitations of en- entirely founded on solid science, and some endoscopic doscopy make reliable assessment of reduction decep- enthusiasts have successfully used endoscopy to assist in tively challenging in the face of comminution. fracture reduction for severely displaced fractures with or without ridged fixation. Endoscopy can be used in selected cases if conditions would otherwise favor tradi- DIRECTION OF PROXIMAL FRAGMENT tional open approach. DISPLACEMENT Fractures with lateral displacement of the proximal fragment are the most favorable for endoscopic repair. LOCATION OF FRACTURE The proximal fragment is much easier to control when Fractures within the joint capsule and those of the abutting the lateral surface of the distal fragment, and condylar neck are not amenable to endoscopic repair reduction is achieved with medially directed pressure via because the proximal fragment will not afford sufficient a cheek trochar. When the proximal fragment is located

Figure 10 Three broad groups of condylar fractures are: intracapsular, involving the condylar head proximal to the insertion of the joint capsule; neck just distal to the joint capsule at the thin and slightly constricted portion of the bone; and subcondylar, which typically extends from the lowest point of the sigmoid notch obliquely toward the posterior border of the ascending ramus. Those fracture within the shaded area may be approached with endoscopic assistance. ENDOSCOPIC TREATMENT OF FACIAL FRACTURES/MUELLER 85

Figure 11 A three-dimensional and coronal computed tomography scans of a patient with bilateral subcondylar fractures. The green arrow points to the right fracture, which has a medial override of the condylar fragment. The arrow also depicts the direction of visualization and surgical approach highlighting the inherent difficulties in controlling the condylar fragment with medial override. To simplify the approach to these fractures, the medial override fragment should be converted to a lateral override by distracting the fracture and displacing the fragment laterally. medially, it is difficult to control and is partially hidden (especially in dark-skinned individuals) and facial nerve behind the distal fragment (Fig. 11). The mechanics injury. They should also understand that endoscopy can required for control and reduction of these fractures offer reduced morbidity and good outcomes but that no require some experience with the technique and should long-term data are yet available. be reserved for those with some endoscopic experience.

SURGICAL TECHNIQUE DISLOCATED CONDYLAR HEAD The operation begins with the application of arch bars Fractures associated with nondislocated condylar heads and treatment of other associated mandible fractures. are the most favorable for endoscopic repair. A dis- Precise reduction and fixation of the other fractures will placed condylar head without true dislocation can restore the dental arch and make reduction of the usually be relocated easily into anatomic position; condylar segment more straightforward. After the other however, those fractures with dislocation of the con- fractures have been addressed, MMF is released and dylar head are more challenging. replaced with elastic MMF. Elastic MMF should be tight enough to maintaining proper occlusal relation- ships but not so tight as to prevent distraction of the CONCOMITANT MEDICAL OR SURGICAL fracture when downward traction is applied to the angle ILLNESS of the mandible. Any patient with medical illness or other serious injury The intraoral incision site and the lateral aspect of that may be harmed by a longer surgical procedure or the mandible and condylar region are injected with a extended general anesthetic should not undergo endo- 1:200,000 epinephrine solution 10 minutes prior to scopic repair. Patients with even mild coagulopathies making the incision. The surgeon stands on the ipsi- present difficulties from persistent bleeding that may lateral side, and the assistant stands on the contralateral obscure the limited visual field. side (Fig. 12). The endoscope video monitor is located at the head of the bed slightly toward the contralateral . A 2-cm intraoral incision along the anterior PATIENT PREFERENCE border of the ascending ramus is carried down to When no absolute of relative contraindication exists for periosteum with electrocautery (Fig. 13). The approach endoscopic repair, every patient has the right to choose is much like that used for transoral vertical ramus their treatment after a discussion as to the risks, benefits, osteotomy. A subperiosteal dissection is used to elevate and alternatives. They need to understand that the data the masseteric attachments and liberate the pterygomas- regarding open versus closed treatment of condylar seteric sling from the posterior and inferior ramus. Wide fractures are imperfect, but that in general functional subperiosteal dissection allows for increased mobility of outcomes are at least as good if not better with open the soft tissue envelope and improved visualization by approaches. They should clearly understand the risks of virtue of a larger optical cavity. It is very important that traditional open approaches including significant scar the dissection be strictly subperiosteal to avoid bleeding 86 FACIAL PLASTICS SURGERY/VOLUME 24, NUMBER 1 2008

Figure 12 Arrangement of the surgeon, assistant, and endoscopic video monitor in relation to a fracture.

that will quickly obscure the endoscopic view. Hypo- Figure 13 Endoscopic view of the initial incision and the tensive anesthesia will help to minimize bleeding; how- subsequent dissection of the optical cavity in a subperiosteal ever, if bleeding should occur from the retromandibular plane to reveal the proximal condylar fragment. Note the angulation of the proximal fragment. vein, it is best to pack a gauze into the wound, apply external pressure, and wait 5 to 10 minutes—the bleed- ing will usually stop. At this point in the operation, pharmacological muscle A 4-mm 30-degree endoscope fitted with an relaxation will assist in the reduction by paralyzing endoscopic brow sheath (Stortz, Carver City, CA) is the lateral pterygoid and masseter muscles. The initial inserted into the optical cavity. With the endoscope in maneuver to reduce the fracture should be distraction one and a periosteal elevator in the other, the of the mandibular angle downward and medial subperiosteal dissection is carried proximally. The pressure on the condyle with the cheek (Fig. 14). The assistant may hold the endoscope while the surgeon downward traction on the angle can then be released. uses the periosteal elevator and suction to continue the Frequently, interfragmentary friction will hold the dissection proximally to reveal the condylar fragment. fracture in reduction without pressure from the cheek A common mistake is to inadvertently dissect under trochar. (or medial) to the proximal fragment. This occurs Fractures are stabilized with standard five- or six- because of a failure to appreciate the degree of lateral hole 2.0 craniofacial zygoma dynamic compression plates override and coronal plane angulation of the proximal (Synthes, Paoli, PA). This particular plate is thin and fragment. Once the proximal fragment is identified, malleable enough that in situ self-contouring is possible, the subperiosteal dissection continues on the lateral yet it is strong enough that plate failures are rare. The surface up to the joint capsule, or a sufficient distance plate is affixed with at least two 6-mm screws on either to place the fixation hardware. Once the fracture is side of the fracture. The plate is temporarily mounted on exposed, a cheek trochar is passed through the cheek a plate delivery device with a hinge mechanism that directly opposite the fracture at the posterior border of allows for precise positioning of the plate (Fig. 15). the mandible. Others have simply delivered the plate into the wound Appreciation of the position of the condylar on a long clamp or dangling from a suture. The plate fragment will shed light on maneuvers needed to reduce should be positioned with at least two holes on either the fracture. Typically, the proximal fragment is side of the fracture along the posterior border of the situated with a lateral override and in a flexed posture. mandible. ENDOSCOPIC TREATMENT OF FACIAL FRACTURES/MUELLER 87

Figure 14 The maneuvers needed for reduction are shown. (A) Initial configuration; (B) distraction of the fracture by a downward pull on the mandibular angle and rotation of the proximal fragment out of a flexed posture; (C) final reduction after release of downward pull on the angle. Often the fracture will be stable in this configuration by virtue of interfragmentary friction.

Before completing fixation, a check of the reduc- Careful inspection of the anterior and posterior tion should be done. The anterior and posterior border border of the fracture will confirm proper reduction of the fracture should be inspected for anatomic align- (Fig. 16). Any comminution will make assessment of ment. In noncomminuted fractures, this is usually the reduction more difficult. If the condyle was dislo- straightforward; however, a fracture with even slight cated preoperatively and there is any uncertainty about comminution will be difficult to assess. If reduction is the reduction, a cross-table intraoperative lateral ceph- not acceptable, then one screw may be removed and the alogram should be obtained. The elastic MMF is fragments repositioned. Once reduction has been con- released and the fixation is inspected while opening firmed, the remaining screws are placed via the cheek and closing the mouth to confirm stable fixation. trochar. If possible, a second plate should be placed. MMF is not needed postoperatively. The intraoral in- cision is closed with absorbable suture. Lee et al84 published their initial series of 22 fractures in 20 patients and reported 43-mm interincisal jaw opening after 8 weeks, with restoration of premorbid occlusion and radiographic evidence of anatomic reduc- tion in 21 of 22 fractures. Patients were pleased with the aesthetic restoration of their chin projection, jaw line, and the symmetric midline movement of the chin point on jaw opening. Late radiographs showed stable fixation, good bone healing, and no condylar resorption. Other reports have shown encouraging results with minimal morbidity85,87,110,112,121,122; however, good prospective data are not yet available. The author has collected data on 80 fractures in Figure 15 Plate delivery device. A five- or six-hole 2.0 plate 72 patients: 78 of 80 fractures had anatomic reduction, is attached with a locking screw to this delivery device, which and two high-energy severely comminuted fractures is hinged to allow for positioning of the plate. After the plate is where inadequately reduced and required a second endo- affixed to the mandible, the plate is released from the device scopic procedure for reduction. Interincisal opening has with a quarter turn of the locking screw. averaged 42 mm after 8 weeks. The operative time has 88 FACIAL PLASTICS SURGERY/VOLUME 24, NUMBER 1 2008

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