**5. Endoscopic repair of facial fracture**

Endoscopy is not a new concept; it is however, relatively new to the field of craniomaxillofacial surgery. Surgeons weigh the risk of an operation and its approach against the benefits of preventing complications, and recommend surgery based on this analysis. In general, if a procedure has a lower risk of complications, it is more widely applied. Endoscopic techniques may provide lower rates of complications and higher acceptance rates in patients, and therefore, they may be more widely employed. Because these techniques are very detailed and have a steep "learning curve," surgeons should be patient in their evaluation and use.

#### **5.1. Frontal sinus fracture repair**

Fractures of the frontal sinus and orbit are relatively common in facial trauma patients (5 to 15% of all maxillofacial traumas).[28]-[31] Although a significant percentage of these fractures can be managed non-operatively, operative intervention is often required to avoid late complications. Frontal sinus fracture is commonly treated via an endoscope. If the fracture is a simple type that places a small depression on the forehead, it is very amenable to endoscopic techniques. Frontal sinus fractures essentially come in four types.

**The first type** is anterior table fracture only, which is perfect for endoscopic technique because these fractures are the easiest to treat and the most conspicuous. The fragments must be evaluated with anatomic precision. The bony fragments may be reduced in situ or, more likely, removed, plated, and replaced either through a scalp or a brow incision.

**The second (most common)** fracture type is fracture of the anterior and posterior tables. Because a large amount of energy is required to cause this type of fracture, patients are often comatose or require c-spine precautions and wound care until open reduction and internal fixation (ORIF) can be done. These fractures are often associated with CSF leakage and need not only facial and sinus surgery, but also dural repairs and brain surgery. Patients often require cranialization of the sinus and cannot be treated with endoscopic techniques.

**The third type of fracture** is fracture of the posterior table itself. These fractures are rare, but when they occur they require a craniotomy for repair.

**The fourth type of fracture** is one that disrupts the ducts. If the duct is damaged, the patient would benefit from some procedure to defunctionalize the sinus. This could be cranialization (if a craniotomy is required) or obliterations with bone or fat.

An illustration detailing the incisions for endoscopic repair of anterior table frontal sinus fractures can be seen in Figure 8.

#### **5.2. Orbital fractures**

Orbital fractures are common and typically occur as blow-out fractures (BOF). BOF fractures are fractures that result in trauma directly over the orbital rim and floor. These fractures are not associated with the typical zygomaticomaxillary complex fractures. Medial orbital fractures are treated similarly to floor fractures except that these require more extensive knowledge of intranasal anatomy. To undertake the endoscopic repair, you must be aware of endoscopic skull base anatomy and be comfortable taking or medializing the middle turbinate and taking the uncinate process and ethmoid bulla down. Medial wall fractures are essentially an extended ethmoidectomy and treated via placement of an alloplastic sheet.

procedure has a lower risk of complications, it is more widely applied. Endoscopic techniques may provide lower rates of complications and higher acceptance rates in patients, and therefore, they may be more widely employed. Because these techniques are very detailed and have a steep "learning curve," surgeons should be patient in their evaluation and use.

Fractures of the frontal sinus and orbit are relatively common in facial trauma patients (5 to 15% of all maxillofacial traumas).[28]-[31] Although a significant percentage of these fractures can be managed non-operatively, operative intervention is often required to avoid late complications. Frontal sinus fracture is commonly treated via an endoscope. If the fracture is a simple type that places a small depression on the forehead, it is very amenable to endoscopic

**The first type** is anterior table fracture only, which is perfect for endoscopic technique because these fractures are the easiest to treat and the most conspicuous. The fragments must be evaluated with anatomic precision. The bony fragments may be reduced in situ or, more likely,

**The second (most common)** fracture type is fracture of the anterior and posterior tables. Because a large amount of energy is required to cause this type of fracture, patients are often comatose or require c-spine precautions and wound care until open reduction and internal fixation (ORIF) can be done. These fractures are often associated with CSF leakage and need not only facial and sinus surgery, but also dural repairs and brain surgery. Patients often

**The third type of fracture** is fracture of the posterior table itself. These fractures are rare, but

**The fourth type of fracture** is one that disrupts the ducts. If the duct is damaged, the patient would benefit from some procedure to defunctionalize the sinus. This could be cranialization

An illustration detailing the incisions for endoscopic repair of anterior table frontal sinus

Orbital fractures are common and typically occur as blow-out fractures (BOF). BOF fractures are fractures that result in trauma directly over the orbital rim and floor. These fractures are not associated with the typical zygomaticomaxillary complex fractures. Medial orbital fractures are treated similarly to floor fractures except that these require more extensive knowledge of intranasal anatomy. To undertake the endoscopic repair, you must be aware of endoscopic skull base anatomy and be comfortable taking or medializing the middle turbinate and taking the uncinate process and ethmoid bulla down. Medial wall fractures are essentially

an extended ethmoidectomy and treated via placement of an alloplastic sheet.

require cranialization of the sinus and cannot be treated with endoscopic techniques.

techniques. Frontal sinus fractures essentially come in four types.

when they occur they require a craniotomy for repair.

fractures can be seen in Figure 8.

**5.2. Orbital fractures**

(if a craniotomy is required) or obliterations with bone or fat.

removed, plated, and replaced either through a scalp or a brow incision.

**5.1. Frontal sinus fracture repair**

500 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Figure 8.** Illustration of incisions used for endoscopic repair of anterior table frontal sinus fractures. The working inci‐ sion is in line with the fracture. The endoscope incision is just medial to the working incision.

The instrumentation is virtually identical. These techniques were first used for endoscopic subcondylar repair [28]-[30] and are now also used for transantral orbital floor reconstruction, zygomatic arch and frontal sinus repair. Subcondylar fractures are difficult to treat openly in even the best of circumstances and seeing and treating the condyle in its native position has numerous advantages. Once this use became more common, other facial fractures began to be examined from an endoscopic perspective.

Some of the more typical complications of orbital fractures are diplopia from muscle entrap‐ ment, visual loss, and exophthalmoses from volume expansion into the surrounding sinus leading to pseudoptosis. The typical complications from frontal sinus injuries are much less common but much more significant when encountered. These include frontal contour irregularities, spinal fluid leak (predisposing to meningitis), ocular complications including vision loss and blindness and late complications i.e. mucoceles (Figure 9).

Traditionally, external transorbital approaches have been used in the repair of blowout fracture (BOF) of the orbit. External approaches generally require either a medial canthal incision, a subciliary incision, or a transconjunctival incision, depending on the location, extent and complexity of the fracture. External repairs with transorbital incisions have known complica‐ tions that include external scars, ectropion and a frequent need for alloplastic materials to support the fractured wall.[32]

loss and blindness and late complications i.e. mucoceles (**Figure 9**).

examined from an endoscopic perspective.

zygomatic arch and frontal sinus repair. Subcondylar fractures are difficult to treat openly in even the best of circumstances and seeing and treating the condyle in its native position has numerous advantages. Once this use became more common, other facial fractures began to be

Some of the more typical complications of orbital fractures are diplopia from muscle entrapment, visual loss, and exophthalmoses from volume expansion into the surrounding sinus leading to pseudoptosis. The typical complications from frontal sinus injuries are much less common but much more significant when encountered. These include frontal contour

**Figure 9.** Coronal CT views of left orbital blow-out fracture

Endoscopic repair of BOF of the orbit has been reported to provide surgeons with several advantages over conventional external repair. [32]-[42] **Figure 9: Coronal CT views of left orbital blow‐out fracture** Traditionally, external transorbital approaches have been used in the repair of blowout fracture

First, it provides excellent visualization of the medial and inferior walls of the orbit, which enables safe removal of bony fragments and clear anatomic reduction of fractures. Second, the use of intraocular alloplastic implants, commonly used with external repairs, can be avoided or minimized. (BOF) of the orbit. External approaches generally require either a medial canthal incision, a subciliary incision, or a transconjunctival incision, depending on the location, extent and complexity of the fracture. External repairs with transorbital incisions have known complications that include

Third, endoscopy virtually eliminates the risk of significantly visible facial scarring and eyelid complications, reported with transorbital incisions. Fourth, endoscopic surgery can be performed under local anesthesia, which makes intra-operative evaluation of ocular move‐ ments and diplopia possible. external scars, ectropion and a frequent need for alloplastic materials to support the fractured wall.32 Endoscopic repair of BOF of the orbit has been reported to provide surgeons with several

When the anterior maxillary wall is fractured, Medpor is used to support the orbital floor; an endoscope enables clear identification of the bony shelves so that the implant can be placed safely and with adequate support (Figures 10 and 11). advantages over conventional external repair. 32‐42

No specific major disadvantages have been reported for endoscopic repair of BOF.[42], [43] One potential difficulty with transantral repair of inferior BOF is in the fabrication and maintenance of a balloon that conforms to the shape of the orbital floor to support the reduced orbital tissue. Under usual circumstances, the balloon is removed three to four weeks after surgery. 19

In medial BOF, the balloon can be removed early if the fracture is small or if only those bony fragments that might interfere with ocular muscle function are removed. In inferior BOF, the balloon can be removed early when a trapdoor type fracture is reduced with the bony fragment intact or when the fracture site is supported by a large bony fragment or implant. Usually, the balloon packing that supports the medial wall can be removed earlier than a balloon catheter that supports the inferior wall because the inferior wall must be rigid enough to support the orbit against gravity. Failure of diplopia to improve after adequate repositioning of orbital tissue is not an infrequent outcome after surgery for BOF. [42], [45] There are a few explanations for residual diplopia even after adequate surgery.

First, it provides excellent visualization of the medial and inferior walls of the orbit, which enables

safe removal of bony fragments and clear anatomic reduction of fractures. Second, the use of

intraocular alloplastic implants, commonly used with external repairs, can be avoided or minimized.

Third, endoscopy virtually eliminates the risk of significantly visible facial scarring and eyelid

complications, reported with transorbital incisions. Fourth, endoscopic surgery can be performed

under local anesthesia, which makes intra‐operative evaluation of ocular movements and diplopia

When the anterior maxillary wall is fractured, Medpor is used to support the orbital floor; an

endoscope enables clear identification of the bony shelves so that the implant can be placed safely

**Figure 10: endoscopic repair of orbital floor fracture via alloplastic material Figure 10.** endoscopic repair of orbital floor fracture via alloplastic material

Endoscopic repair of BOF of the orbit has been reported to provide surgeons with several

zygomatic arch and frontal sinus repair. Subcondylar fractures are difficult to treat openly in even the best of circumstances and seeing and treating the condyle in its native position has numerous advantages. Once this use became more common, other facial fractures began to be

Some of the more typical complications of orbital fractures are diplopia from muscle entrapment, visual loss, and exophthalmoses from volume expansion into the surrounding sinus leading to pseudoptosis. The typical complications from frontal sinus injuries are much less common but much more significant when encountered. These include frontal contour irregularities, spinal fluid leak (predisposing to meningitis), ocular complications including vision

First, it provides excellent visualization of the medial and inferior walls of the orbit, which enables safe removal of bony fragments and clear anatomic reduction of fractures. Second, the use of intraocular alloplastic implants, commonly used with external repairs, can be avoided

Traditionally, external transorbital approaches have been used in the repair of blowout fracture (BOF) of the orbit. External approaches generally require either a medial canthal incision, a subciliary incision, or a transconjunctival incision, depending on the location, extent and complexity of the fracture. External repairs with transorbital incisions have known complications that include external scars, ectropion and a frequent need for alloplastic materials to support the fractured

Third, endoscopy virtually eliminates the risk of significantly visible facial scarring and eyelid complications, reported with transorbital incisions. Fourth, endoscopic surgery can be performed under local anesthesia, which makes intra-operative evaluation of ocular move‐

When the anterior maxillary wall is fractured, Medpor is used to support the orbital floor; an endoscope enables clear identification of the bony shelves so that the implant can be placed

Endoscopic repair of BOF of the orbit has been reported to provide surgeons with several

No specific major disadvantages have been reported for endoscopic repair of BOF.[42], [43] One potential difficulty with transantral repair of inferior BOF is in the fabrication and maintenance of a balloon that conforms to the shape of the orbital floor to support the reduced orbital tissue. Under usual circumstances, the balloon is removed three to four weeks after

In medial BOF, the balloon can be removed early if the fracture is small or if only those bony fragments that might interfere with ocular muscle function are removed. In inferior BOF, the balloon can be removed early when a trapdoor type fracture is reduced with the bony fragment intact or when the fracture site is supported by a large bony fragment or implant. Usually, the balloon packing that supports the medial wall can be removed earlier than a balloon catheter that supports the inferior wall because the inferior wall must be rigid enough to support the orbit against gravity. Failure of diplopia to improve after adequate repositioning of orbital

42], [45] There are a few explanations

20

possible.

and with adequate support **(Figures 10 and 11).**

advantages over conventional external repair. [32]-[42]

**Figure 9: Coronal CT views of left orbital blow‐out fracture**

**Figure 9.** Coronal CT views of left orbital blow-out fracture

loss and blindness and late complications i.e. mucoceles (**Figure 9**).

examined from an endoscopic perspective.

502 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

safely and with adequate support (Figures 10 and 11).

tissue is not an infrequent outcome after surgery for BOF. [

for residual diplopia even after adequate surgery.

or minimized.

surgery.

19

wall.32

ments and diplopia possible.

advantages over conventional external repair. 32‐42

**Figure 11.** Medpor with the screw placed as a handle (arrow). Medpor in place to hold periorbital fat above the floor defect.


**•** Third, altered globe position may occur.

Exophthalmos of greater than 2 mm is another indication for surgery, mostly for cosmetic reasons.

Endoscopic repair of orbital blowout fractures represents an innovative and highly successful and safe alternative to external repairs.

Early applications for endoscopic treatment of facial trauma include subcondylar fractures of the mandible, [47]-[50] orbital blow-out fractures, [51]-[56] frontal sinus fractures, [57]-[58] and zygomatic fractures. [57]-[58]

**Advantages** of endoscopic repair include the following: More accurate fracture visualization, small external incisions, reduced soft tissue dissection, potential for visualization around corners and reduced duration of hospital stay.

**Disadvantages** of endoscopic repair include the following: Need for delicate instrumentation, moderate learning curve for the techniques, narrow field of view and limited ability for bimanual instrumentation without an assistant.

**Indications** for endoscopic repair are generally related to fracture location, size, degree of comminution, and the surgeon's ability. Some of the techniques described herein are still under development, and surgeons contemplating the use of these techniques must determine if institutional review board approval is necessary.
