The main objectives in treating naso-orbital-ethmoid (NOE) fractures include management of the medial canthal tendon to restore the intercanthal distance, restoration of collapsed nasal projection and orbital volumes.
NOE fractures involve complex and intricate anatomy of the midface, which makes it extremely difficult to achieve perfect results.
Determining the appropriate treatment of frontal sinus fractures is based on creation of a safe sinus as well as restoration of the contours of the upper third of the face. This process includes management of the nasofrontal duct. The nasofrontal duct should be preserved when possible.
Panfacial fractures may be treated using a top-to-bottom, bottom-to-top, or outside-in approach. The best sequence of reduction and stabilization of panfacial fractures often depends on the clinical scenario, and no single philosophy is necessarily superior to another. The goals of reconstruction are to restore facial height, width, projection, symmetry, and function.
These fractures often involve concomitant ocular, cerebral, and cervical spine injuries that require high-level, coordinated care with other specialists, often including neurosurgery, ophthalmology, orthopedic, and trauma surgery.
Introduction: nature of the problem
Naso-orbital-ethmoid (NOE) fractures are complex fractures that involve the hard and soft tissues of the midface ( Fig. 1 ). Diagnosis of NOE fractures is best performed by a combination of computed tomography (CT) imaging, three-dimensional (3D) CT reconstructions, and clinical examination. The intricate anatomy of this region makes obtaining excellent results extremely difficult. Particularly, management of the soft tissues is critical for obtaining functional and esthetic results. The lacrimal duct, eyelids, and medial canthal tendon are important anatomic structures to inspect during the clinical examination.
Concomitant injuries to the eyes as well as the brain are common and both ophthalmologic and neurosurgical consultation should be obtained when indicated.
Although there have been multiple classification schemes for NOE fractures, the Markowitz classification has been widely adopted. It groups the fractures into 3 types depending on the degree of comminution of the central fragment and the status of the attachment of the medial canthal tendon. Type I fractures have a single central fragment with an attached tendon. Type II fractures have a comminuted central segment with the tendon remaining attached to a solid piece of smaller bone. Type III fractures have a comminuted central segment and a detached tendon. Management of a detached medial canthal tendon is imperative to the success of the operation because of the increase in intercanthal distance created by a detached tendon, or traumatic telecanthus (see Fig. 1 ). Normal intercanthal distances are usually between 30 and 35 mm in adults. Other facial proportions often referenced for the correct intercanthal distance include half of the interpupillary distance and the width of the alar base.
The timing of the repair is also important to consider because the soft tissues may begin to scar down in their widened position, making it extremely difficult to return to the original form, which may result in a pseudotelecanthus even if the canthal tendon is properly reapproximated.
The objectives in treating these injuries include restoration of dorsal nasal height; orbital rim contours; orbital volume; and importantly, the intercanthal distance. Historically, this has been attempted by both open and closed techniques. Adams (1942) described a threaded wire placed through the nose fixed to lead plates to stabilize the fractures and intercanthal distance. Mustarde (1964) recommended exposing the ligament and fixing a transnasal wire. Stranc (1970) recommended routine open exploration and repair. Current treatment strategies include conservative or closed management if there is minimal displacement of the bones involved; however, if there is significant displacement of bones, detachment of the medial canthal tendon, loss of nasal dorsal height, or an increase in orbital volume open exploration with internal fixation is indicated.
Surgical technique (naso-orbital-ethmoid)
CT imaging should be reviewed carefully for preoperative planning ( Fig. 2 ). Clinically, a bowstring test can be used to determine attachment of the medial canthal tendon. In addition, a bimanual intranasal or extranasal mobility test can determine the attachment of the medial canthal tendon and the shape, size, and mobility of the bony segment attached to it. It is wise to review preinjury facial features and photographs when available, especially intercanthal distance and dorsal nasal height. A thorough medical assessment and consultation with other specialists, including neurosurgery, ophthalmology, and anesthesiology, should be performed. Photographs of the patient before the injury are helpful in determining the pretraumatic intercanthal distance and nasal dorsal projection. In addition, arrangement for intraoperative CT scanning or navigation equipment can significantly improve outcomes and reduce need for reoperation.
Prep and patient positioning
The patient should be in a supine position on the operation table. Standard surgical preparation of the patient is used, ensuring that the upper and middle face is kept exposed. Care must be taken to protect patients with cervical spine (c-spine) injuries, and the head and neck should be stabilized with sandbags or other padding. For isolated midface injuries, a cervical collar may not be in the surgical field and may be left on the patient for the operation.
The most widely used approach for complex NOE fractures is the coronal flap combined with lower lid or transconjunctival and maxillary vestibular incisions ( Fig. 3 ). This approach provides the best access to the fractures. The coronal approach also gives access for cranial bone grafting for use in restoration of the nasal dorsum. Type I fractures may be accessed via a maxillary vestibular incision alone. However, type II and III fractures must be accessed via a coronal flap or through existing lacerations. The coronal flap may be elevated in the subgaleal plane until about 2.5 cm superior to the orbital rims. At this point, the periosteum should be incised and elevated to expose the frontal bone, nasal bones, and medial orbits.
Occasionally, a Weber Ferguson approach may be used (see Fig. 3 C). The author does not advocate use of the gull wing or open sky incisions because they leave large visible scars, except in limited circumstances, such as male pattern baldness.
Identify the medial canthal bearing bone and medial canthal tendon
Careful, blunt dissection on the interior aspect of the flap may be used to dissect the medial canthal tendon. Care must be taken to avoid accidently tearing this attachment. It may also be grasped through the caruncle external to the coronal flap.
Reconstruction of the medial orbital rim and then the internal orbit as needed
A general rule to follow is fixating bony fragments to the most solid bone or areas of stable fixation and moving to less stable smaller fragments. Additional incisions around the orbit may be used as necessitated by the location of orbital fractures.
Resuspending the medial canthal tendon
The main focus in resuspending the tendon is ensuring a posterior and superior vector to replicate the vector of pull provided by the posterior band of the medial canthal tendon. This vector has historically been accomplished with a transnasal canthopexy, in which a hole is drilled transnasally, entering and exiting through the medial orbital walls on each side, and a suture or wire is passed through the tendon and fixated to the opposite side ( Fig. 4 ). A newer technique, described by Engelstad and colleagues, uses a miniplate to suspend a canthal barb that resuspends the tendon in the proper vector. The barb pierces through the caruncle and engages the tendon as it is passed through the soft tissue.
Reducing the nasal septum
This stage is accomplished by traditional nasal septum reduction techniques with the goal of reducing the septum to the pretraumatic position.
Reconstruction of the nasal dorsum and bone grafting
Severe injury to the nasal bones and supporting nasal septum can lead to severe loss of dorsal nasal height and so-called saddle-nose deformity. Restoration of the nasal dorsum is best accomplished using calvarial bone grafts, which are easily accessible through the coronal or through a paracranial incision ( Fig. 5 A). Once the bone has been harvested, the soft tissue is dissected to create a pocket for the graft and it is fixated into place at the tip below the cartilages ( Fig. 5 B, C).
Managing soft tissue
It is critical to ensure reapproximation of the important soft tissues that have been either traumatically severed or dissected during the operation. Careful attention must be paid to the position of the medial canthal tendon and dorsal nasal soft tissue. In addition, the coronal soft tissues should be resuspended near the frontozygomatic suture to avoid sagging of the skin in this area, which would create an aged appearance.
Soft tissue blunting/rounding, inappropriate intercanthal distance/position, residual nasal asymmetry, scarring, orbital dystopia, enophthalmos, and nasolacrimal duct injury are all possible complications. Great care must be taken when managing these structures and expert consultation is often indicated for ophthalmologic injuries.
Pearls and pitfalls
NOE fractures are inherently difficult to treat, and perfect results are not often achieved. One pitfall that can be avoided is pseudotelecanthus. This condition occurs when the traumatic telecanthus is left untreated long enough for the skin and soft tissues to scar in the new, widened position. Even with good bony reduction and reapproximation of the medial canthal tendon, the bulk of the soft tissues may remain widened. Although reoperation is possible, there is no good solution to this complication, and it may be avoidable if treatment occurs in a timely manner. The surgeon may consider exaggerating the reduction of the soft tissues, because there may be relapse postoperatively. Likewise, the soft tissues of the dorsal nose may scar and contract, making reestablishment of nasal projection impossible with late repair.