We read with great interest the article “Treatment of low subcondylar fractures—A 5-year retrospective study”, by Leiser et al. We appreciate the high scientific quality of the study and the ingenious modifications made to the procedure published by our group in 2008. However, as one of us was the main author of the original technique cited in the paper, we would like to discuss some points related to the procedure itself and the position of the high cervical transmasseteric (HCTM) approach among the other techniques of open reduction and internal fixation (ORIF) for mandibular subcondylar fractures.
First, the HCTM approach was originally published by Meyer et al. of the University of Besançon, France, in 2006 ; these authors modified the reference Risdon cervical approach (higher cutaneous incision and stair-step dissection in order to preserve the marginal branch of the facial nerve). The original procedure cited in Leiser’s study is already an evolution of the technique of Meyer et al.: indeed the stair-step dissection was modified in order to increase safety for the facial nerve and to improve the exposure of the fracture line. The HCTM approach has become more popular in recent years, especially in France ; it is now practiced more often in France than the Risdon and the intraoral approaches.
Second, the reduction in the length of the skin incision and the sub- and retroangular incision may minimize the aesthetic sequelae of surgery. In summary, the authors perform a ‘mixture’ of the original HCTM and the classical retromandibular approach. Nevertheless, in our experience, the scars resulting from the original technique (a 5-cm curved incision 1 cm below the lower border of the mandible, in a natural fold of the skin) are almost invisible after 6 months, if they are accurately integrated into Langer’s lines.
Third, the HCTM approach is very safe with regard to the facial nerve (especially the marginal branch). We noted that the authors did not observe any facial palsy in the 10 patients who underwent surgery. Our experience is the same, in more than 100 patients operated on to date. However we believe that deep infiltration of the fracture site and the incision area with adrenalized anaesthetic creates a theoretical risk of facial nerve injury because of a potential perioperative block of the nerve due to the diffusion of the local anaesthetic. Hence monitoring of the facial nerve would not be effective and a nerve injury could occur. For this reason we recommend that the adrenalized anaesthetic approach is avoided. In practice we use only a small quantity of local anaesthetic in the incision area (less than 1 ml).
Fourth, and in contrast to the statement of the authors, we believe that the HCTM approach is an easy and reproducible procedure, feasible when undertaken by an experienced resident in oral and maxillofacial surgery. There is sometimes difficulty in the reduction of the fracture in its anatomical position due to the morphology of the patient (obesity, thick masseter muscle), or to a certain degree of comminution of the fracture line. With this in mind we aim to evaluate the feasibility of the complementary use of endoscopy to facilitate visualization of the fracture and the osteosynthesis in the correct position, or the use of perioperative computed tomography imaging.
We believe that the HCTM approach is a good technique for ORIF of mandibular subcondylar fractures. Leiser’s modifications to our procedure are appreciated and we were very pleased to read how a technique learnt in our department in France has been the subject of further development. Once again, I would like to thank the authors for sharing their valuable experience in the surgery of mandibular condyle fractures.