Abstract
Reconstruction of the frontal bar following complex craniofacial fractures involving the frontal sinus is a central strategic element, and inaccurate reduction can result in contour defects and non-union. Such defects can be reconstructed using autogenous bone from the inner table of a calvarial graft. Traditionally this is done with rotary instruments and osteotomes. In this article, we describe the use of piezoelectric surgery to harvest the graft. This technique allows for more precise and less destructive harvesting of autogenous bone with the additional benefit of reducing the risk of injury to the surgeon.
Reconstruction of the frontal bar following complex craniofacial fractures involving the frontal sinus is a central strategic element, and inaccurate reduction can result in contour defects and non-union. Reconstruction of continuity defects with bone is an accepted part of this algorithm.
Autogenous bone may be harvested intracranially; this has the advantage over other sites in that it may be harvested simultaneously with the neurosurgical repair of the dura and does not leave a secondary donor site defect. The inner table bone graft can be mobilized using rotary instruments and osteotomes, but the process is destructive and inaccurate, and in addition such instruments can injure the surgeon. Piezoelectric surgery is a relatively new technique for thin precise bone cutting. It is based on ultrasonic microvibrations, and allows precise cutting of mineralized tissue with soft tissue preservation. With the use of this technique, very accurate osteotomies can be performed, with minimal heating of bone, and there is no risk of perforating the surgeon’s glove.
Case report
The authors used piezoelectric surgery to treat a patient who had sustained Markowitz 1 naso-orbito-ethmoid ( Table 1 for classification), anterior and posterior frontal sinus, right zygomatic, and right orbital floor and medial wall fractures in a road traffic accident ( Fig. 1 ).
| Classification | Fracture pattern |
|---|---|
| Type 1 | Single segment central fragment |
| Type 2 | Comminuted central fragment with fractures remaining external to the medial canthal tendon insertion |
| Type 3 | Comminuted central fragment with fractures extending into bone bearing the canthal insertion |
Following craniectomy, the frontal bar was reassembled, and marked comminution of the anterior table was noted. The missing bone was marked via a template formed from a metal suture packet, and this was transferred to the craniectomy. The inner table was then harvested using the piezoelectric surgery technique ( Fig. 2 ) and the grafts used to reconstruct the frontal bar ( Fig. 3 ). The right zygomatic fracture and floor and medial walls were then repaired using a preformed titanium plate, and the frontal bar was lined with a double fold of pericranium, which provided coverage of the plates before being fed into the anterior skull base to seal the defect.
