4

SURGICAL REPAIR
OF UPPER CENTRAL FACE
INJURY AND THE ORBITAL
FLOOR
JOHN BOWERMAN, M.B., F.R.C.S., F.D.S.R.C.S
 SURGICAL REPAIR OF UPPER CENTRAL FACE INJURY AND THE ORBITAL FLOOR 39

UPPER CENTRAL FACE INJURY

 Injury to the upper central face results in varying
degrees of fronto-naso-orbital dislocation. It is essential
for competent management that the operator has a
thorough grasp of the surgical anatomy.
The skeletal foundation of the nasoethmoid com-
plex consists of a strong triangular bony frame. The
frontal process of the maxillary bone on each side of
the nose is united above to the frontal bone and below
to the premaxilla (Bowerman, 1985). The nose lies in
front of the frame, and behind the frame is the
interorbital space, described by Dingman and
associates (1969). These structures are relatively fragile,
and a force sufficient to disrupt the frame will result
in severe comminution of these weaker structures.
This type of injury corresponds to the plane 3 injury,
described by Stranc and Robertson (1978). Depressed
fractures of the frontal bones, particularly of the
anterior wall of the frontal sinus, may occur in
isolation, but when combined with upper central
midface injury, the bony dislocations and commi-
nutions are frequently very severe.
Such injuries can be isolated to the fronto-naso-
ethmoid complex and can be unilateral or bilateral
(Bowerman, 1985). They are frequently combined
with other injuries to the midface.
The management of intracranial injury and dis-
placed fractures of the frontal bone and anterior
cranial base, particularly involving the posterior wall
of the frontal sinus and orbital roof, is outside the
scope of this chapter. Suffice to say that cranio-orbital
trauma of this nature requires neurosurgical collab-
oration.
PREOPERATIVE ASSESSMENT
Clinical Assessment
An accurate history of the incident that caused the
injury is essential because it will give an indication
of the type of injury that will be found. For instance, a
penetrating injury from glass fragments or a knife
might well indicate avulsion of a canthal ligament,
whereas high-velocity impact anteriorly on the face is
likely to lead to canthal spread with severe dis-
placement and comminution of the underlying bones.
Likewise, equestrian injuries are usually associated
with severe bony comminution without appreciable
soft tissue injury, particularly when resulting from
direct impact of a horse's hoof on the face.
A careful clinical examination of the upper face
should be done, noting bruising and lacerations.
Swelling is usually severe and may limit the value of
digital palpation of the underlying bones and of
radiographs in the early postinjury period. The prin-
cipal clinical features of injury to the upper central
face are nasal deformity, canthal spread, and frontal
depression. The physical signs of each of these will
be outlined.
40 SURGICAL REPAIR OF UPPER CENTRAL FACE INJURY AND THE ORBITAL FLOOR
Posterior Displacement of the Nose
The essential physical signs of displacement of the
nose into the interorbital space are usually classic
when bilateral (Fig. 4-1). The tip of the nose is.
upturned, and this produces a more obtuse nasola-bial
angle. The base of the nose is displaced under the
glabella, and this may result in rupture of the glabella
skin or the production of marked depression of the skin
at the base of the nose. Severe posterior displacement
of the base of the nose with attached canthal ligaments
into the interorbital space produces an enhanced
nasojugal fold.
When unilateral (Fig. 4-2), resulting from a kick in
the face with the toe or heel of a boot, this type of
injury is frequently misdiagnosed as a simple nasal
fracture and manipulated externally. It is character-
ized by semicircular depression of the side of the
nose, and the nasojugal fold is usually accentuated.
Due to instability of the frontal process of the max-
illary bone and an associated medial orbital wall
"blow-out," relapse inevitably occurs, resulting in
nasal deformity and enophthalmos. The injury results
in displacement of the frontal process of the maxillary
bone into the interorbital space, with associated
comminution of the underlying ethmoid bone. Open
reduction and repair are mandatory.
 SURGICAL REPAIR OF UPPER CENTRAL FACE INJURY AND THE ORBITAL FLOOR 41

Figure 4-1. The tip of the nose is

upturned and the nasolabial angle
is obtuse. There is a deep
depression of the skin where the
base of the nose has been dis-
placed posteriorly into the inter-
orbital space. Note the enhanced
nasojugal fold. (From Bowerman,
J.E.: Fractures of the middle third
of the facial skeleton. In Rowe,
N.L., Williams, J.L.: Maxillofacial
Injuries, vol 1. Edinburgh,
Churchill Livingstone, 1985.)

————————————————————————————_^__M———•••^•^MMB^MM^^MM^H D

Figure 4-2. Unilateral nasoethmoid injury resulting from a kick in the face. Note the semicircular depression of the right side of the nose. (From
Bowerman, J.E.: Fractures of the middle third of the facial skeleton. In Rowe, N.L., Williams, J.LI: Maxillofacial Injuries, vol 1. Edinburgh,
Churchill Livingstone, 1985.)
42 SURGICAL REPAIR OF UPPER CENTRAL FACE INJURY AND THE ORBITAL FLOOR
Canthal Spread
It is essential to have a high index of suspicion that
canthal spread has occurred in all upper face injuries,
particularly with fractures at the Le Fort II and III
levels. The normal intercanthal distance was given
with a mean distance of 32 to 33 mm in women and 33
to 34 mm for Caucasian men by Wardenburg in 1951.
In 1980, Freihofer suggested that an intercanthal
distance between 25 and 35 mm should be considered
a reasonable range for normality, with a mean figure
of 31.2 mm. It is my experience that in Caucasians a
distance of 35 mm or more is usually
indicative of canthal spread. The intercanthal distance
should be measured with dividers, taking special care
to note the midpoint of the nose so that unilateral
displacement is not missed. An increased
measurement of 2 to 3 mm unilaterally may represent
very significant canthal displacement. The palpebral
fissure should be scrutinized because it becomes
almond shaped, with blunting of the medial angle,
and the caruncle is less easily visualized (Fig. 4-3).
The epicanthal fold may become more prominent and
the naso-orbital valley more shallow. The canthal
ligament may be difficult to feel on palpation because
of its increased laxity.
Figure 4-3. Displacement of the right canthal ligament showing
the typical features of canthal spread. (From Bowerman, J.E.:
Fractures of the middle third of the facial skeleton. In Rowe, N.L.,
Williams, J.LI: Maxillofacial Injuries, vol 1. Edinburgh, Churchill
Livingstone, 1985.) , . , . . . , ..„
 SURGICAL REPAIR OF UPPER CENTRAL FACE INJURY AND THE ORBITAL FLOOR 43

Frontal Depression (Bowerman, 1984) (Fig. 4-4). A suitable laceration

can be utilized and perhaps modified by incorporating
Frontal depression may be obvious clinically but
the "W" approach described by Bowerman (1975).
can frequently be masked by overlying soft tissue
An approach incorporating incisions limited to the
swelling. This physical sign can usually be elicited by
careful digital palpation. The clinical features of hair borders below both eyebrows but avoiding
cerebrospinal fluid rhinorrhea and diplopia are not extension over the nose has recently been described
specifically diagnostic of upper central face injury but by Raveh and Vuillemin (1988). Their procedure
are frequently present and may be associated with the incorporates radical resection of the ethmoid cells to
physical signs of midface injury, described elsewhere. expose the anterior subcranium. However, the bicor-
Severe hemorrhage from the nose arising from the onal approach has virtually superseded all these
anterior or posterior ethmoidal arteries can be a methods because early repair of soft tissue lacerations is
particular feature of severe nasoethmoidal crush. advocated and these need not be disturbed when
raising the coronal flap during the later repair of the
bony skeleton. It also provides wide exposure of the
frontal bone, and thus a bifrontal craniotomy can be
Radiographic Assessment incorporated when necessary to deal with cranio-
naso-orbital injuries. It furthermore ensures more
The most useful radiograph for diagnosis of upper accurate fracture reduction and an enhanced cosmetic
central face injury is the occipitofrontal taken at a 25° result.
angle. It shows the interorbital space and the frontal
processes of the maxillary bones and thus clearly
delineates lateral displacement of these bones. A
lateral view of the skull and facial bones is also
essential, and soft tissue amplification of the facial
profile is also helpful in relation to nasal deformity.
These plain radiographs can be supplemented by
tomography and computed tomography with three-
dimensional imaging to fully assess preoperatively
the extent of displacement and comminution of the
bone fragments.

Indications for Surgical Treatment

There are a number of absolute indications for
surgical treatment, but the clinician should have
extensive practical experience in the management of
this type of injury so that apparent indications are not
overlooked during assessment. I would err on the side
of exploration if in doubt because to miss and not
correct this type of injury would lead to disastrous
consequences.

Absolute Indications
1. Nasal displacement into the interorbital space
(unilateral or bilateral)
2. Can thai spread (unilateral or bilateral)
3. Depressed fracture of the frontal bone, partic-
ularly the anterior wall of the frontal sinus with or
without nasal injury

SURGICAL APPROACH
In the past 20 years, authors have described dif- Figure 4-4. (From Bowerman, J.E.: Fractures of the middle third of
ferent approaches to the nasoethmoidal complex the facial skeleton. In Rowe, N.L., Williams, J.M.: Maxillofacial
Injuries, vol 1. Edinburgh, Churchill Livingstone, 1985.)
44 SURGICAL REPAIR OF UPPER CENTRAL FACE INJURY AND THE ORBITAL FLOOR
The Coronal Approach
The scalp and face are prepared and draped. The
incision extends from the vertex across the scalp,
joining two preauricular incisions (Fig. 4-5A). Prior
to making the cuts it is helpful to inject normal saline
into the subaponeurotic areolar tissue, which lies just
superficial to the pericranium, thus facilitating sepa-
ration of these two layers. The soft tissues are thus
divided down to the plane superficial to the pericra-
nium and the flap is raised by dissecting forward
along this plane, thus turning the flap downward and
forward. Care should be taken to protect the temporal
branch of the facial nerve as it crosses the midpoint of
the zygoma tic arch. Bleeding is controlled in the
posterior edge of the incision with artery forceps, and
it is helpful to use clips (e.g., Raney clips) on the
mobilized edge of the flap. The periosteum is then
divided some 2 cm above the bridge of the nose and
supraorbital ridges, and the dissection is then
continued subperiosteally. The frontal nerves, if
contained within a foramen, are released by fracturing
the anterior margin with an osteotome as the flap is
turned downward. In this
way the frontal bone is exposed almost in its entirety,
together with the upper part of the nose and canthal
ligaments, and 'access is also provided to the roof
and medial and lateral walls of the orbits, including
the zygoma tic arches (Fig. 4-5B and C).
When the definitive repair of the bony injury has
been completed, the soft tissue flap is returned.
Particular care should be taken to resuture the peri-
osteal incision above the supraorbital ridge to ensure
accurate realignment of the eyebrows. Vacuum drains
may be inserted under the scalp flap in the absence
of dural perforation prior to careful and meticulous
soft tissue closure. A simple plaster of Paris splint
should be applied accurately to the soft tissue anterior
to the medial angles of each palpebral fissure.
Carefully performed, this technique produces an
excellent cosmetic result because the scar lines are
usually within the hairline and the preauricular ex-
tensions lie within the skin folds between the pinna
and the facial skin. The surgical exposure achieved
by this approach facilitates accurate reduction and
thus ultimately a better cosmetic and functional re-
sult.
 Figure 4-5. (A) The line of the skin incision
is marked for the bicoronal flap. The
preauricular extensions lie in the skin
fold in front of the pinna, and the scalp
incision extends up toward the vertex.
(This is particularly important in male
patients with a receding hairline.)

B
 SURGICAL REPAIR OF UPPER CENTRAL FACE INJURY AND THE ORBITAL FLOOR 45

Figure 4-5 Continued (B and C) The coronal flap turned down provides wide exposure of the frontal bones, nose, supraorbital ridges, and
zygomas. Note the incision of the periosteum 2 to 3 cm above the supraorbital ridges. The depression of the anterior wall of the frontal sinus
and the fracture of the nasal bones are clearly visualized. (D) Pre-disimpaction position. Note the anterior wall of the frontal sinus is removed
and stored. (Asch's forceps are used for reducing the nasal complex, and a bone hook can be applied for additional traction, as illustrated.) (E)
Postreduction position prior to transosseous wiring. (F) Multiple transosseous wires in situ prior to tightening. Note (white arrow) lateral
displacement of frontal process of the maxillary bone after disimpaction. This will be reduced by a transnasal wire (double arrows, white and
black) secured over "toggles." (G) Final reduction. Note the wire used to provide anterior traction on the nose during tightening. This is
removed subsequently. (From Bowerman, J.E.: Fractures of the middle third of the facial skeleton. In Rowe, N.L, Williams, J.L1.: Maxillofacial
Injuries, vol 1. Edinburgh, Churchill Livingstone, 1985.)
46 SURGICAL REPAIR OF UPPER CENTRAL FACE INJURY AND THE ORBITAL FLOOR
Reduction of Bone Fragments
Because there may be multiple bone fragments that
may be difficult to orientate in the case of a severe
nasoethmoid crush, it is important to have a planned
approach to the reduction of such bone fragments.
Initially, associated fractures at the Le Fort II and
III levels should be disimpacted and reduced. They
should then be stabilized by an appropriate method
(see Chapter 2). After this has been accomplished, the
upper central injury to the face can be dealt with. In
the case of an isolated injury, initial reduction may be
performed by means of Asch's forceps in the nose; a
bone hook or large skin hook may be used for
additional traction to the upper part of the nose by
applying the hook either behind the nasal cap, if this is
still attached, or to the posterior edge of the nasal
septum (Fig. 4-5D). When the gross disimpaction and
reduction have been achieved, the bone fragments
should be orientated (Fig. 4-5E), and this may prove
quite difficult in case of a severe nasoethmoid crush
(Fig. 4-6). The nasal cap is usually intact but may be
fractured vertically, in which case the two fragments
should be sought and wired together. This can then be
united to the base of the frontal bone if it is still intact.
The frontal processes of the maxillary bones should
then be aligned to the frontal bones and inferiorly at
the infraorbital margin (Fig. 4-5F and G). Usually this
requires a separate approach, either by a subciliary
incision or an infraorbital skin incision, described
below. The canthal ligaments, if displaced, should
then be reduced by transnasal wiring, described below.
In summary, the three critical points of bony re-
duction and alignment are:
1. Nasal cap to frontal bone
2. Frontal process of maxillary bone to frontal bone
3. Frontal bone to frontal bone
I still favor, to a large extent, the use of transos-
seous wiring because it facilitates a more controlled
and accurate reduction. Continental and North
American authors advocate the use of small mini bone
plates, but the main disadvantage of these plates is
that they are unyielding in use and on application can
give rise to deformation. Very rigid vertical anterior
stability can be achieved by the application of two
contoured mini bone plates screwed centrally to the
frontal bone above and below on each side to the
frontal process of the maxillary bone (Stoll et al.,
1982). The author has found that a central mini plate
contoured and screwed to the frontal bone above and
to a nasal bone graft below can provide the required
rigidity and a foundation structure in reconstruction in
the severe nasoethmoid crush injury. Selective use of
Figure 4-6. This illustrates the problem of bone orientation in the
severe nasoethmoid crush.
mini plates can provide the required stability, which
cannot be provided by wire fixation, for example,
when hanging the upper face to the base of the skull,
particularly at the frontozygomatic sutures. The ad-
vantage of wire fixation is that sequential tightening
of wires facilitates very accurate reduction, and dis-
placing forces can thus be controlled. Very small
fragments of bone can be united with catgut sutures
or the application of bone glue. It is also helpful
during the tightening of wires and mini plates to
provide anterior traction via a transnasal wire (see
Fig. 4r-5G).
Crcmialization of the Frontal Sinus
Radiologic evidence of displaced fracture of the
posterior wall of the frontal sinus is an indication for a
cranial approach using a bifrontal craniotomy as
described by Poole and Briggs (1989). The posterior
walls of the sinuses are completely removed and the
entire sinus mucosa is curetted away. The inner table
of the craniotomy bone flap can be used as necessary
to repair the anterior wall of the frontal sinus after
appropriate dural repair.
Canthal Repair Medial
Canthal Ligament
The basis of repair demands a knowledge of the
anatomy, and the reader is referred to the excellent
description given by Robinson and Stranc in 1970.
With careful dissection, the adequate exposure pro-
vided by the bicoronal approach facilitates the loca-
tion of the medial canthal ligament. When the liga-
ment is avulsed, the key to location is the inner can
thus. The firm bundle of fibers that makes up the
SURGICAL REPAIR OF UPPER CENTRAL FACE INJURY AND THE ORBITAL FLOOR 47
Figure 4-7, (A) An awl Is passed
transnasally to pick up the wire
threaded twice through the medial
canthal ligament. (B) The awl is with-
drawn and the transnasal wire is
tightened over "toggles." Note the
stump of medial canthal ligament
drawn into the hole drilled in the
bone to a diameter adequate to
allow for adjustment of the ligament.
ligament should be sought and grasped with tissue
forceps; when medial traction is applied, the canthus
will be seen to move (the coronal flap is turned back
so that the medial canthus can be visualized). Final
repositioning and stabilization of the medial canthal
ligament is done by direct transnasal wiring. The
various techniques are described below.
UNILATERAL DISPLACEMENT When the medial
canthal ligament is avulsed or attached to a very small
fragment of bone too fragile for direct wiring, the
stump of the ligament is picked up and threaded twice
using fine 0.35-mm diameter (prestretched 10 per
cent), stainless steel wire. A hole large enough to
accommodate the stump of the canthal ligament is
then drilled posterior to the anterior lacrimal crest
and a further smaller hole is drilled close to the upper
point of the anterior lacri-
mal crest on the unaffected side. A curved awl is then
passed from the unaffected side through the two
holes, and the two wires previously threaded through
the stump of the canthal ligament are then picked up
and drawn across the nose. The stump of the ligament
is then drawn into the larger hole and the wires are
twisted over a "toggle" wire; this facilitates
adjustment of the canthus under direct vision as the
wires are tightened. The required inter-canthal
distance can then be measured directly (Fig. 4-7).
Frequently the displaced ligament is attached to an
adequate piece of the fontal process of the maxillary
bone. In such cases, a small hole sufficient to
accommodate the transnasal awl is drilled and a
transnasal wire applied in a similar fashion as de-
scribed above. It is advisable to insert a toggle wire
under the loop because this prevents cut-out or
fracture of the bone fragment (Fig. 4-8).
Figure 4-8. (A) An awl is passed to pick
up the transnasal wire prior to fracture
reduction. Note the lateral
displacement of the canthus on the
fragment of the frontal process of the
maxillary bone. Inadequate reduction
and failure to apply a transnasal wire
will result in post-traumatic tele-
canthus. (B) Reduction achieved.
48 SURGICAL REPAIR OF UPPER CENTRAL FACE INJURY AND THE ORBITAL FLOOR
BILATERAL DISPLACEMENT
When adequate bone fragments are attached to the
medial canthal ligaments, the procedure of reduction
and stabilization is virtually the same as just de-
scribed (Fig. 4-9). It is not sufficient just to wire the
bone fragments to the adjacent bones because the pull
of the orbicularis oculi muscles may result in relapse,
and thus traumatic telecanthus may result.
Bilateral avulsion may be encountered in the na-
soethmoid crush, and adequate bone fragments may
not be present. The two stumps of the canthal
ligaments are picked up and each is threaded twice
through a transnasal wire. In the presence of severe
comminution, suitable bone grafts may need to be
interposed, again with appropriate tightening of the
wires over "toggles." Jackson and associates (1982)
illustrated this procedure using a rib graft, but I prefer
to use harvested cranial bone.
In all these procedures an element of overcorrec-
tion is desirable because there is usually some slight
relapse. It is important to apply a plaster of Paris or
collodion splint to the nose, with pressure applied
over the medial canthi during the postoperative pe-
riod, as described under postoperative care.
Lateral Canthal Ligament
When the lateral canthal ligament has been de-
tached, particularly when exploring the lateral wall of
the orbit, it should be reattached. A small hole is
drilled through the frontal process of the zygomatic
bone, and the lateral canthus is then picked up with a
nylon or prolene suture.
Figure 4-9. Bilateral reduction of medial canthal ligaments.
TIMING OF THE OPERATIVE
PROCEDURES
In the early postinjury phase it may be necessary
for a patient to be taken to the operating theater for
emergency treatment of associated injuries, trache-
ostomy, and repair of severe facial lacerations. Pro-
viding the medical status of the patient is not com-
promised, the simpler facial fractures may be reduced
and immobilized at this time. It is, however, quite
wrong to embark on any complicated maxillofacial
repair, particularly to the upper face, at this stage.
There is no doubt that patients who have sustained
this type of severe injury will benefit from a period of
rest, nursing care, and appropriate medical resus-
citation in the early days post injury. During this
period, swelling and bruising will subside, and this
allows comprehensive clinical and radiologic assess-
ment, which will facilitate more accurate diagnosis
and planning of the operative procedure required.
The optimum time for the reduction of upper face
injury is usually 5 to 10 days post injury. Satisfactory
reduction can be achieved after this time, but with
each succeeding day disimpaction of bone fragments
becomes more difficult, and after 14 days post injury
union of bone fragments will occur. After 2 weeks
definitive reduction becomes more difficult because
refracture of bone fragments prior to disimpaction
complicates the procedure and reduces the possibility
of accurate reduction, thereby increasing the inci-
dence of residual deformity.
SURGICAL REPAIR OF UPPER CENTRAL FACE INJURY AND THE ORBITAL FLOOR 49
INTRAOPERATIVE
COMPLICATIONS
When the nose has been displaced posteriorly, there
may not be clinical evidence of canthal spread, but
lateral movement of the upper part of the frontal
processes of the maxillary bone may be observed with
open reduction (see Fig. 4r-5F). If this feature is
overlooked, particularly with closed manipulation and
reduction, post-traumatic telecanthus will result. In the
severe crush injury with extreme comminution
associated with soft tissue loss, bone fragments may
be missing. It may thus be necessary to reconstitute
the forehead with a cranial bone graft. It is on these
occasions that the use of bone plates may facilitate
more rigid fixation. Small bone fragments, associated
with a detached canthal ligament, may not be large
enough or strong enough to withstand the stress of
transnasal wiring and may thus cut-out. The canthal
ligaments can be wired directly (see Fig. 4-7). Great
care should always be taken to protect the eyes from
the sharp ends of the wires and drill bits during wiring
and plating procedures, and a temporary tarsorrhaphy
is thus recommended.
POSTOPERATIVE MANAGEMENT f!
The plaster of Paris splint should be changed at
frequent intervals during the postoperative period as
the swelling regresses (Fig. 4-10). The purpose of
such a splint is to apply continuous gentle pressure to
the soft tissue overlying the canthal ligaments, thus
reducing the build-up of subcutaneous scar tissue,
which can spoil the ultimate cosmetic result.
Meticulous wound care and toilet are essential, and
facial sutures should be removed early and replaced
with Steri-Strips to improve the eventual scar lines.
Appropriate antibiotics are indicated, particularly
when the fracture is associated with dural puncture.
When the soft tissue swelling has resolved, appro-
priate postoperative radiographs can be taken to check
bone alignment.
Figure 4-10. Nasal plaster accurately applied to provide pressure
to the medial canthal area (arrow). Note temporary tarsorrhaphy
and careful suture of the incision. (From Bowerman, J.E.: Fractures
of the middle third of the facial skeleton. In Rowe, N.L., Williams,
J.L1.: Maxillofacial Injuries, vol 1. Edinburgh, Churchill Livingstone,
1985.)
50 SURGICAL REPAIR OF UPPER CENTRAL FACE INJURY AND THE ORBITAL FLOOR
THE ORBITAL FLOOR
Fractures of the orbital floor occur most commonly
as direct extensions of the infraorbital rim in fractures
of the zygoma tic complex and at the Le Fort II level.
Isolated fractures of the orbital floor without involve-
ment of the orbital rim are of two types: (1) the blowout
fracture and (2) the blow-in fracture. The indirect
blow-out fracture of the floor of the orbit was de-
scribed by Pfeiffer in 1942. The injury occurs from a
direct blow to the front of the eyeball from such
things as a ball or a fist, and transmitted pressure
results in the thin weak bone of the orbital floor
giving way. The much rarer blow-in fracture was
described by Dingman and Natvig in 1964. A bone
fragment or fragments will be seen projecting upward
into the orbit on radiographic examination. The
mechanism of this type of bony displacement is, at the
present time, speculative.
This section deals essentially with the isolated
fractures of the orbital floor, and the reader is referred
to Chapters 1 and 2 for the clinical assessment and
management of fractures of the orbital rim that extend
into the orbital floor.
PREOPERATIVE ASSESSMENT
Clinical Assessment
Indirect or isolated fractures of the orbital floor are
frequently missed at the time of injury owing to
difficulties in diagnosis and the absence of physical
signs. A history of a direct blow to the front of the eye
should alert the clinician that an indirect fracture of the
orbital floor may have occurred.
Both eyes should be carefully inspected and com-
pared. Visual acuity should be checked and ophthal-
moscopic examination performed. The shape and
angulation of the palpebral fissures should be re-
corded and the intercanthal distance measured. The
position of the globe in both vertical and horizontal
axes should be checked together with the range of eye
movements. A Hess chart should then be obtained.
Clinical features that should arouse suspicion are as
follows:
1. Traumatic mydriasis
2. Limited elevation and/or depression of vertical
eye movement
3. Diplopia, particularly in relation to restricted
vertical gaze
4. Enophthalmos * floor is minimal when compared with the difficulties
5. Slight narrowing of the palpebral fissue
6. Deepening of the superior palpebral fold
7. Alteration in ocular level. Initial swelling may
result in slight elevation of the ocular level, but if
there has been considerable herniation of the orbital
contents into the maxillary sinus below, then the
ocular level may be depressed.
Radiographic Assessment
The standard occipitomental projections at 0° and
30°, if taken after the initial swelling and bleeding
resulting from soft tissue injury have resolved, will, if
of good quality, show on the 0° projection the typical
"hanging drop" appearance. This herniation of the
orbital fat into the maxillary sinus, depending on its
volume, may or may not give rise to abnormal
physical signs, such as restricted eye movement in
the vertical gaze, diplopia, and enophthalmos. An-
other useful projection is the occipitofrontal 25° pro-
jection, providing the petrous bone is thrown clear of
the orbital floor.
Orbital tomography 25° (to the baseline) using a
posteroanterior (PA) projection should be used to
assess the degree of herniation of orbital contents
into the adjacent paranasal sinuses, but it is essential
for air to be present to provide contrast with orbital
soft tissues. Thus, it is a waste of time to attempt
tomography until the standard occipitomental or
occipitofrontal views show the presence of air in the
maxillary sinus. The examination is frequently de-
layed until 8 to 10 days after injury to allow the
resolution of hematoma.
Computed tomography (CT) scanning with coronal
sections of the face provides a valuable diagnostic
view in the examination of the orbits and paranasal
sinuses and should be obtained, if technically possible.
CT is not the investigation of first choice in all cases
of orbital trauma, particularly when simpler
conventional methods give a satisfactory diagnosis.
CT has, however, become accepted as the best form
of orbital radiography, and good axial and coronal
positioning will give slice images clearly showing
major orbital structures in relationship to the walls of
the orbit.
Indications for Surgical
Treatment
The morbidity of careful exploration of the orbital
encountered in treating established enophthalmos and
diplopia resulting from a missed diagnosis or
 SURGICAL REPAIR OF UPPER CENTRAL FACE INJURY AND THE ORBITAL FLOOR 51
conservative management. There is no substitute for
clinical experience, but careful clinical and radio-
graphic assessment will reveal most of the absolute
indications for surgical exploration. The main prob-
lem arises when there are no abnormal clinical signs,
such as restricted eye movement and diplopia with
radiographic evidence of orbital floor fracture. I
would advise exploration for bony spicules protruding
upward into the orbit, bone fragments hinged down
into the antrum, and the presence of herniated soft
tissues into the maxillary sinus depicted radio-
logically. I have never had cause to regret an explo-
ration of the orbital floor under these circumstances
in the absence of physical signs, because prevention is
better than cure.
Absolute Indications
1. Restricted vertical gaze, upward or downward
2. Concomitant diplopia
3. Clinical evidence of enophthalmos, even if only
of minor degree
4. Radiologic evidence of a blow-in or blow-out
fracture of the orbital floor ,. --. - -. ,
Absolute Contraindication
In all patients sustaining orbital injuries, visual
acuity of both eyes should be carefully assessed pre-
operatively. Severe impairment or absence of sight in
the unaffected eye is an absolute contraindication to
surgical intervention.
Timing of Surgical Intervention
There is virtually no indication for early exploration
of the orbital floor. Swelling and bruising should be
allowed to resolve, which will improve the quality of
clinical and radiographic assessment. The indication
for surgical treatment will then become more appar-
ent. When there are absolute indications, exploration
can be carried out within 10 to 14 days post injury.
However, in the absence of physical signs, explora-
tion can be delayed for 2 to 4 weeks post injury to
facilitate further assessment, such as additional Hess
charting and radiographic examination. In my opinion,
there is nothing to be gained by conservative
management beyond this period and at this stage a
definite decision regarding whether or not to explore
should be made.
SURGICAL APPROACH
Excluding the use of an appropriate laceration, four
main approaches have been described: (1) the
conjunctival approach, (2) the subciliary approach, (3)
the lower eyelid incision, and (4) the low infraor-bital
incision, also variously described as the subtar-sal or
orbital rim incision. It is of interest that the consensus
of opinion among experienced surgeons (Converse,
1981) is that the subtarsal or orbital rim incision is the
approach of choice. This is also my view; it provides
rapid access and adequate exposure with minimal or
no intra- or postoperative complications (Holtmann et
al., 1981).
The low infraorbital incision is described here in
detail, because it is the most versatile approach to the
orbital floor and because it can be used at any time
after injury, even in the presence of swelling and
bruising. It is also particularly applicable for the
approach to the orbital rim for direct transosseous
wiring or bone plating after reduction of fractures of
the zygoma tic complex and at the Le Fort II level.
Any direct extension of the fractures into the orbital
floor can then be readily explored and repaired as
necessary.
52 SURGICAL REPAIR OF UPPER CENTRAL FACE INJURY AND THE ORBITAL FLOOR

The Low Infra orbital Incision

I prefer to make the incision in the skin just below
the well-defined skin crease (subtarsal fold), which
lies along the level of the inferior orbital margin (Fig. 4-
11). The orbicularis muscle is divided parallel with its
fibers by blunt dissection at a slightly lower level than
the skin incision to expose the infraorbital margin
(Fig. 4-12A). The soft tissues are retracted upward to
facilitate division of the periosteum along the anterior
curvature of the infraorbital rim. The dissection is then
continued subperiosteally to expose the orbital floor,
and the orbital contents are retracted upward carefully
by the operator with a soft malleable copper strip
Figure 4-11. Low infraorbital and subciliary incisions. The lateral
(Fig. 4-12B). The origin of the inferior oblique extension increases exposure and particularly reduces tension and
muscle must be identified and preserved. The stretching of the skin in the subciliary approach.
infraorbital foramen and the nerve should be located,
and when the extent of the bony defect of the orbital
floor has been delineated the nerve in the orbital floor
should be identified to avoid inadvertent damage. This
also facilitates a plane of dissection when there has
been severe bone loss and comminution. Once the
extent of the bony injury has been ascertained, the
appropriate means of reconstruction can then be
decided. (Materials and methods of repair will be
described later.) The posterior margins of the defect
are frequently difficult to ascertain, particularly when
extension occurs into the inferior orbital fissure.
Careful dissection posteriorly will reveal the posterior
edge of the infraorbital fissure, which occasionally
can be used with care to provide support for a graft.
It must be ascertained that all orbital fat has been
lifted up out of the maxillary sinus before the graft is
positioned. The forced duction test should be
performed to check globe mobility. The tension and
position of the globe of the eye should be checked to
exclude developing exophthalmos due to hemorrhage,
and hemostasis should be achieved. It is my
experience that the periosteal layer cannot be satis-
factorily repaired, and it is sufficient to insert one or
two absorbable sutures without tension to close the
orbicularis oculi muscle layer. At the same time it is
prudent to incorporate a nylon twist drain or mini-
suction drain, which is brought out through the skin
lateral to the skin incision. If the repair has been
accomplished correctly, the skin margins lie well
opposed and can be repaired with a single 4-0 prolene

Figure 4-12. (A) Low infraorbital incision. Note the stepped ap-
proach. (B) Orbital floor and defect exposed. Note the soft malleable
copper retractor elevating tissues of the lower eyelid.
SURGICAL REPAIR OF UPPER CENTRAL FACE INJURY AND THE ORBITAL FLOOR 53
or nylon subcuticular suture; it is advisable to sup-
plement this with Steri-Strips. The conjunctiva should
be flushed with saline and chloramphenicol ointment
applied.
This incision is simple and expedient and provides
adequate access to the orbital floor, the lateral orbital
floor, and part of the medial floor of the orbit.
Additional exposure can be achieved by extending
this curved incision downward and laterally, and the
lower placement of the incision reduces the amount
of postoperative lymphedema. The residual scars are
usually barely noticeable.

The Conjunctiva! Approach

This approach was originally described by Bour-
quet (1928) for the treatment of fat herniation in the
lower eyelids and was subsequently applied to the
surgical correction of congenital malformations and
fractures of the orbital rim and floor by Tessier (1973)
and Converse and associates (1973). The latter au-
thors concisely described the technique and illus-
trated a choice between a retro- and a preseptal
approach.
The method has the disadvantage of providing very
limited access, and this can only be improved
laterally by carrying out a lateral canthotomy incision.
This, in my opinion, defeats the object of providing
an invisible scar. The technique also requires a
greater degree of manual dexterity by the operator.
The lower eyelid is everted by two traction stay
sutures (Fig. 4-13A), the conjunctiva is incised just
above the lower border of the tarsal plate, and the
dissection is carried down to the orbital rim with fine
scissors (I prefer the preseptal approach although it is
technically more difficult). Thus, the tissues are
separated superficial to the orbital septum but deep to
the orbicularis oculi muscle by blunt dissection; the
use of small gauze swabs facilitates this part of the
dissection. The orbital rim is identified and the
periosteum incised along the anterior border. The
periosteal layer is then raised and retraction facili-
tated by the use of a malleable copper strip (Fig. 4-
13B). Once the repair has been achieved, the con-
junctiva is repaired with a fine, continuous resorbable
suture.
Figure 4-13. (A) Conjunctival approach. Further exposure can be
achieved by lateral canthotomy (dotted line). (B) Preseptal
approach. (C) Exposed infraorbital rim and orbital floor showing
defect.
54 SURGICAL REPAIR OF UPPER CENTRAL FACE INJURY AND THE ORBITAL FLOOR

The Subciliary Approach Definitive Repair of Orbital

Floor Defect
The line of the incision is shown (see Fig. 4-11)
and follows some 2 mm below the line of the lower A review of the literature reveals that a wide range
eyelashes. At the lateral end the incision can be of materials are available for repair, but I now find
extended downward and laterally within a skin crease. that two materials in particular give satisfactory re-
The incision line is marked, and the injection of local sults in most instances, having tried and tested most
anesthetic with Adrenalin facilitates dissection and of those described.
reduces bleeding. It is important to incise the skin at
Small defects can be adequately repaired, provided
right angles because a shelving incision makes repair
more difficult. The skin is raised carefully by they have an almost complete bony margin for sup-
dissection along the subcutaneous plane (Fig. 4-144) port, by using Dacron-reinforced Silastic sheet, which
and elevated with the aid of skin hooks. The fibers of is cut to shape to cover the defect and must lie
the orbicularis muscle are separated just below the without tension within the inner edge of the infraor-
infraorbital margin. The periosteum is then divided bital margin. A recess must be cut for the origin of
along the anterior border of the orbital margin, after
which it is raised and retracted in the usual manner
(Fig. 4-14B). Pospisil and Fernando in 1984 described
a postorbicularis approach. Once the bony repair has
been completed, absolute hemostasis of the soft
tissues must be achieved. The orbicularis muscle is
repaired with two or three resorbable sutures. In my
opinion, it is mandatory to insert either a nylon twist
drain subcutaneously or a very small vacuum drain if
there is likely to be any bleeding associated with the
bony repair. The skin incision is repaired with a
continuous 5/0 prolene or nylon suture, supported by
the application of Steri-Strips.
The disadvantage of this approach is that there is a
definite risk of postoperative vertical shortening of the
lid. An incidence of transient ectropion of 42 per cent
was reported by Wray and colleagues (1977) and of 37
per cent by Pospisil and Fernando (1984). The latter
authors claimed that transient ectropion did not occur
using the postorbicularis approach, but only seven
patients were included in their study. Wray and
associates also reported that four eyelids in three
patients reviewed required further surgical correction.
The incidence of ectropion following the subciliary
approach increases with the age of the patient and the
presence of edema and bruising at the time of surgical
intervention. This approach is thus contrain-dicated in
the elderly and, if surgical intervention is required, in
the early postinjury period. In my opinion, meticulous
surgical technique, absolute hemostasis prior to skin
closure, and particularly the insertion of a nylon twist
drain reduce the incidence of postoperative transient
ectropion. Use of this approach should be considered
in children and young patients.

Figure 4-14. />y Subciliary incision. Note the line of approach. (B)
Arrow indicates the path of exposure. Note the graft wired in situ.
 SURGICAL REPAIR OF UPPER CENTRAL FACE INJURY AND THE ORBITAL FLOOR 55

Figure 4-15. Dacron-reinforced

Silastic sheet implant wired to the
infraorbital margin via the
subciliary approach. (Inset) Note
the recess cut in the implant to
accommodate the origin of the
interior oblique muscle.
the inferior oblique muscle, more particularly when
the defect lies to the medial side of the orbital floor
(Fig. 4-15).
Larger defects (Fig. 4-16A), more particularly those
that extend to involve the infraorbital fissure, should
be repaired with a contoured bone graft taken from
the inner aspect of the iliac crest (Fig. 4-16B). In
repairs that also require reconstruction of defects in
the infraorbital margin, an adequate graft can be
fashioned to reconstruct the rim and floor in conti-
nuity by extending the graft taken from the inner table
to include part of the inner aspect of the iliac
crest. It is important to secure both a bone graft and a
Silastic sheet implant by sutures to the infraorbital
margin. I prefer to use fine braided stainless steel wire
sutures, but nonresorbable prolene or nylon sutures
can also be used. If this is omitted, prolapse into the
lower lid occurs, particularly in the case of Silastic
sheet.
A moderate degree of enophthalmos can be cor-
rected, provided the globe can be mobilized, by
inserting a contoured bone graft using the inner lip
and table of the iliac crest to reconstruct the orbital
floor. The thicker cortical lip is placed posteriorly.
Figure 4-16. (A) Large orbital floor defect
exposed via a low infraorbital incision. (B)
Bone graft from inner table of iliac crest wired
in situ via the low infraorbital approach. (Inset)
Shape of contoured graft.
56 SURGICAL REPAIR OF UPPER CENTRAL FACE INJURY AND THE ORBITAL FLOOR
INTRAOPERATIVE
COMPLICATIONS
The cornea is particularly at risk during all these
procedures, and corneal abrasion can be prevented
during the subciliary and low infraorbital approaches
by performing a temporary tarsorrhaphy. With the
conjunctival approach the risk can be minimized by
suturing the cut edge of the conjunctiva to the upper
eyelid. Should an abrasion occur, then chloramphen-
icol ointment should be instilled into the conjunctival
sac several times a day and the eye kept closed and
covered with an eye pad for 24 to 36 hours.
The periorbita may be inadvertently torn during
dissection, leading to herniation of fat; these tears
should be sutured.
The infraorbital nerve is particularly vulnerable
when there has been extensive bone loss in the orbital
floor. It should always be carefully identified as it
leaves the infraorbital foramen and then sought in
the orbital floor. Failure to do this may result in its
division. Bleeding, particularly from the infraorbital
vessels in the floor of the orbit, must be controlled
before any graft is inserted.
POSTOPERATIVE MANAGEMENT
A meticulous regimen of toilet to the operated eye
should be instituted. In the early postoperative phase
when there is periorbital swelling and chemosis, the
eye is protected by instilling chloramphenicol oint-
ment into the conjunctival sac and keeping the eye
closed with an eye pad. However, if there has been
manipulation of the orbital walls for associated frac-
tures or if a large graft has been inserted to correct a
degree of enophthalmos, then it is best to avoid the
use of chloramphenicol ointment because this ham-
pers ophthalmoscopic examination.
Retrobulbar hemorrhage, i.e., bleeding into the
orbital muscle cone space, may occur at any stage
during or after manipulation of the orbital floor and its
contents. Thus postoperatively it is important to
regularly examine the eye for dilatation of the pupil
and, using an ophthalmoscope, examine the fundus to
detect constriction of retinal arterioles and pallor of
the optic disc. Severe bleeding will result in proptosis
of the eye, and the globe will feel very hard on
palpation compared with the opposite side. Urgent
treatment is required, i.e., decompression of the orbital
muscle cone space either by opening the incision or
making a new incision in the skin just below and
lateral to the lateral canthus. A pair of curved
mosquito forceps should be inserted into the orbital
muscle cone space between the inferior and lateral
rectus muscles. Suction should be applied and an
appropriate drain inserted. Adjuvant medical
treatment should include the administration of acet-
azolamide, 500 mg IV q4h, and 200 ml 10% mannitol
IV to reduce intraocular pressure; papaverine, 40 mg
IV q4-6h, to overcome vascular spasm, and dexa-
methasone, 60 mg IV q4h, to reduce edema. Subse-
quent dosage is then monitored against the response.
Vision will be lost unless the pressure is reduced and
the vascular spasm is overcome.
\
KEY REFERENCES
Bourguet, ].: Notre traitement chirurgical de "poches sous les yeux"
sans cicatrie. Arch Franco-Beiges Chir 31:133, 1928.
Bowerman, J.E.: The surgical approach to the naso-ethmoid com-
plex. A paper presented at the British Associations of Oral
Surgeons, Autumn Meeting, London, 1975.
Bowerman, J.E.: Late reconstruction of the orbit. Fortschr Kiefer
Gesichteschir XXII:72, 1978.
Bowerman, J.E.: Fractures of the middle third of the facial skeleton. In
Rowe, N.L., Williams, J.L.: Maxillofacial Injuries. New York,
Churchill Livingstone, 1985, pp 363-433.
Converse, J.M.: Discussion to a randomised comparison of four
incisions for orbital fractures. Plast Reconstr Surg 67:736, 1981.
Converse, J.M., Firmin, F., Wood-Smith, D., et al.: The conjunctival
approach in orbital fractures. Plast Reconstr Surg 52:656, 1973.
Dingman, R.O., Natvig, P.: Surgery of Facial Fractures. Philadel-
phia, W.B. Saunders Co., 1964.
Dingman, R.O., Grabb, W.C., O'Neal, R.M.: Management of
injuries of the naso-orbital complex. Arch Surg 98:566, 1969.
Freihofer, H.P.M.: Inner intercanthal and interorbital distances. J
Maxillofac Surg 8(4):324-326, 1980.
Holtmann, B., Wray, R.C., Little, A.G.: A randomised comparison
of four incisions for orbital fractures. Plast Reconstr Surg 67:731,
1981.
Jackson, I.T., Munro, I.R., Sayer, K.E., Whitaker, L.A.: Atlas of
Cranio-maxillo-facial Surgery. St. Louis, C.V. Mosby, 1982, p 425.
Pfeiffer, R.L.: Traumatic enophthalmos. Arch Ophthalmol 30:718,
1943.
Pospisil, O.A., Fernando, T.D.: Review of the lower blepharo-plasty
incisions and surgical approach to zygomatic-orbital fractures. Br J
Oral Maxillofac Surg 22:261-268, 1984.
Raveh, J., Vuillemin, T.: The one-stage surgical management of
combined cranio-maxillo-facial and frontonasal fractures. J Cran-
iomaxillofac Surg 16:160-172, 1988.
Robinson, T.J., Stranc, M.F.: The anatomy of the medial canthal
ligament. Br J Plast Surg 23:1, 1970.
Stoll, P., Schilli, W., Joos, U.: Vertical stabilisation of fractures of
the mid-face. Abstracts of the Sixth Congress of the European
Association for Maxillofacial Surgery, 1982, p 165.
Stranc, M.F., Robertson, G.A.: A classification of injuries of the
nasal skeleton. Ann Plast Surg 2(6):468, 1978.
Tessier, P.: The conjunctival approach to the orbital and maxilla in
congenital malformation and trauma. J Maxillofac Surg 1:3, 1973.
Waardenburg, P.J.: A new syndrome combining developmental
anomalies of eyelids, eyebrows and nose root with pigmentary
defects of iris and head hair and with congenital deafness. Am J
Hum Genet 3:195, 1951.
Wray, R.C., Jr., Holtman, B., Ribaudo, J.M., et al.: A comparison of
conjunctival and subciliary incisions for orbital fractures. Br. J.
Plast. Surg. 30:142, 1977.
REFERENCES
Bowerman, J.E.: The evaluation and management of naso-ethmoid
injuries. Proceedings of the Eighth International Congress of
Oral and Maxillofacial Surgery, Berlin, 1985, pp 212-220.
Poole, M.D., Briggs, M.: Cranio-orbital trauma: a team approach to
management. Ann R Coll Surg Engl 71:187-194, 1989.