RU2637622C1 - Method for access to frontal bone during treatment of isolated damage of orbit roof, upper orbit border, forehead - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: skin is cut through the palpebral fold, the circular eye muscle in the perceptual portion, and the soft tissue dissection is performed maintaining the septum and the supraorbital vascular-neural bundle along the upper edge of the orbit and the superciliary region. The periosteum is dissected along the upper edge of the orbit. The upper margin of the orbit, the upper wall of the orbit, and the frontal bone are separated subperiosteally. Reposition of the bone structures of the orbit upper wall, the frontal bone with bone structures fixation in the anatomical and physiological position by the nodal titanium plates and titanium screws. The circular muscle of the eye is sutured with nodal matching sutures. A continuous intradermal matching suture is applied to the skin, which is removed in 3-4 days.

EFFECT: method allows direct access to the bone structures of the orbit roof of the, the upper edge of the orbit and forehead, while excluding the damage to anatomical formations vital for the quality of life.

10 dwg, 1 ex

Description

The present invention relates to medicine, namely to surgery, and can be used for damage to the upper wall of the orbit.

Fractures of the upper edge and orbit roof are characteristic of pediatric practice. Most of them do not need surgical treatment (53-93%) (R.H. Haug, J.E. VanSickels, 2002). In adults, the above injury is the result of a highly kinetic craniofacial injury aged 20 to 40 years with a predominance in men (89-93%). Traumatic injuries, as well as ballistic and catatrauma, prevail.

Injury associated with a fracture of the upper edge and the roof of the orbit (1-9%) is rarely isolated. It is combined with neurotrauma (57-90%), damage to the eyeball (14-38%), damage to the contents of the orbit, the apparatus of the eye (76%) and fractures of the facial skull (33%) (FS Roth, JC Koshy, JS Goldbergetal, 2010) . Isolated injuries of the upper wall of the orbit, forehead, which do not have emergency indications, can be treated in a delayed period of 7-10 days. In the later stages of surgical treatment, reposition difficulties are possible due to the consolidation of fragments.

Indications for surgical intervention are deformation of the eyebrow, forehead, displacement of fragments of the roof of the orbit into the cavity of the orbit itself, which can lead to exophthalmos, diplopia, lagophthalmos, which is a consequence of damage to the cranial nerves, as well as damage to the rectus and oblique muscles of the eye, damage to the elevator upper eyelid.

In routine surgical practice, to access the upper wall of the orbit, the forehead, use coronary access (according to Zueter). Access involves dissection of the skin, soft tissues, periosteum along a line drawn from the tragus of one ear, rising along the temporal region, crossing the parietal region, then similarly to the tragus of the other ear.

The complications and disadvantages of which are:

the need for massive tissue dissection, a high level of blood loss, the comparative duration of the operation, a long period of hospital stay, an extended scar, allopecia, and the visibility of scar localization mainly in male patients due to coronary access (RH Haug, JE VanSickels, 2002; M.R. Markiewicz, RB Bell, 2012).

The choice of optimal surgical approach depends on the location and extent of the lesions. For the closest analogue, direct access through an eyebrow is adopted (Patent of the Russian Federation RU 2302834), in which an incision of the skin, soft tissues and periosteum is made through the eyebrow.

The disadvantages of this method are:

loss of sensitivity, loss of the function of the forehead, one of the abdomen of the frontal muscle, malposition of the eyebrow, the presence of a visible scar in connection with direct access through the eyebrow.

Tasks: to minimize trauma to the soft tissues of the upper zone of the face, to avoid lengthy incisions on the scalp, to avoid visible scars in the socially significant zone, to reduce the duration of surgery, to speed up the healing process and thereby reduce the length of the patient’s hospital stay.

The essence of the invention is access during surgical treatment of isolated fractures of the roof and upper edge of the orbit, forehead, offering the exclusion of skin incisions visible in a socially significant area, or extended incisions on the skin of the scalp. Instead of the incisions described above, a skin incision is made in the palpebral fold of the upper eyelid of the affected side. Dissect the skin, the circular muscle of the eye in a preseptal portion. Then, soft tissues are dissected without damaging the septum to the upper edge of the orbit and the superciliary region. The periosteum is dissected along the upper edge of the orbit with a length corresponding to the size of the defect, with the release of the supraorbital neurovascular bundle without damage. Subperiosteal skeletonize the frontal bone, the upper edge of the orbit, the upper wall of the orbit.

The fragments are reponited, free fragments are removed in the orbit cavity and osteosynthesis with titanium plates is performed according to the classical technique in the anatomical and physiological position.

Technical result: the method allows direct access to the bone structures of the roof of the orbit, the upper edge of the orbit and forehead, comparable in width to the classical accesses to this area with good visualization of traumatic injuries through a blepharoplastic incision on the skin of the upper eyelid with dissection of the circular muscle of the eye and dissection to the upper edge of the orbit without damage to the septum and supraorbital neurovascular bundle.

This allows you to: eliminate damage to anatomical formations that are important for the quality of life, which is caused by the anatomical and topographic structure of the upper eyelid, which embryologically corresponds to the derivatives of SMAS, a derivative of the surface fascia of the body; to exclude a long traumatic incision along the scalp with the formation of scars and the risk of alopecia in the delayed period; to avoid scars on the skin in a socially significant area with direct percutaneous access; allows you to speed up the rehabilitation period.

Excludes loss of sensitivity of the forehead skin, disruption of the corrugator, malposition of the eyebrow.

The method was tested on 23 patients with isolated damage to the roof and upper edge of the orbit. At the same time, a reduction of rehabilitation periods by 3-4 beds was obtained due to earlier terms for removing stitches, a high aesthetic result was achieved in the deferred period due to a hidden scar in the fold of the upper eyelid without extensive scars in a socially significant zone.

The method is as follows: the intervention is carried out in the operating room under general anesthesia with mechanical ventilation through orotracheal intubation.

The first step is the intraoperative marking. Surgical access is via the palpebral fold of the upper eyelid of the affected side. The skin, the circular muscle of the eye in its preseptal portion are dissected. If necessary, a resection of excess skin is determined, determined preoperatively, in the vertical position of the patient, with symmetrization on the healthy side; by a known method, a resection of a strip of circular muscle of the eye with a width of up to 2 mm is performed. The purpose of the last two manipulations is to minimize the manifestations of lymphostasis of the upper eyelid over the forming scar, and to accelerate the repair time.

In the preseptal layer, tissue is dissected to the superciliary region. The supraorbital neurovascular bundle is visualized, excreted without damage. The periosteum is dissected along the upper edge of the orbit. The upper edge of the orbit, the upper wall of the orbit, and the frontal bone are separated subperiostally.

The bone structures of the upper wall of the orbit and the frontal bone are repositioned with the fixation of the bone structures in the anatomical and physiological position by the bone titanium plates and titanium screws. The circular muscle of the eye is sutured with Vicryl 6.0 nodal matching sutures. A continuous intradermal matching suture, Prolene 6.0, is removed on the skin, removed for 3-4 days.

For a better understanding of the method, a clinical case is given and photographs 1-10 are shown, where:

Photo 1 - 3D reconstruction before surgery;

photo 2 - preoperative marking;

photo 3 - dissection of the skin along the palpebral fold;

photo 4 - preseptal dissection;

Photo. 5 - subperiosteal skeletonization of the surface of the defect;

photo 6 - reposition of bone fragments, fixation with titanium plates;

photo 7 - suturing the wound with an intradermal matching suture;

Photo 8 - 3D reconstruction after surgery;

photo 9 - the patient a week after surgery;

photo 10 - the patient 3 months after surgery.

Example. Patient Z., 29 years old, was admitted to the Department of Maxillofacial Surgery 05/17/2016 with isolated traumatic damage to the roof, upper edge of the orbit, forehead. Injury received in a brawl with the unknown 05/16/16.

Examined clinically and radiologically (photo 1).

05/18/16 in a planned manner, surgical treatment was performed in the amount of open reposition of fragments and osteosynthesis in the anatomical and physiological position through the palpebral incision of the upper eyelid of the damaged side. Access is carried out by the proposed method. Preoperative marking was performed (photo 2).

The intervention was carried out in the operating room through orotracheal intubation. After standard antiseptic treatment, the skin was dissected along the palpebral fold of the upper eyelid of the affected side according to the preoperative marking (photo 3), the circular muscle of the eye in a preseptic portion. Dissection of the soft tissues of the upper eyelid in the preseptal layer to the superciliary region was performed (photo 4).

The supraorbital neurovascular bundle was visualized and isolated without damage. The periosteum was cut along the edge of the orbit, followed by subperiosteal skeletonization of the upper edge of the orbit, the frontal bone, and the upper wall of the orbit (photo 5).

Fracture visualized. The fragments of the frontal bone, the upper wall of the orbit and the upper edge of the orbit were repositioned in the anatomical and physiological position (photo 6). Fragments are fixed with cutaneous titanium low-profile mini-plates and 1.5 mm Conmet mini-screws. The wound was sutured in layers: the circular muscle of the eye was sutured with Safil 6.0 matching matching sutures, the upper eyelid skin was sutured with the continuous intradermal suture Promelene 6.0 (photo 7).

The postoperative period was uneventful (photo 8). The sutures were removed on the 4th day, the patient was discharged with the condition of subsequent observation.

Control examinations were performed one week later (photo 9) and 3 months later (photo 10) after surgery.

Results: minimized trauma to the soft tissues of the upper zone of the face, the absence of extended incisions on the scalp, the avoidance of visible scars in the socially significant zone, the time of surgical intervention was reduced, and the regeneration processes were accelerated and, thereby, the length of the patient’s stay in the hospital was reduced.

Claims (1)

A method of providing access to the frontal bone in the treatment of isolated injuries of the roof of the orbit, upper edge of the orbit, forehead, including dissection of the skin, periosteum, skeletonation of the frontal bone, restoration of the integrity of the damaged area, characterized in that the skin is dissected along the palpebral fold, the circular muscle of the eye in a preseptal portion and soft tissue desection is performed with the condition of preservation of the septa and supraorbital neurovascular bundle along the upper edge of the orbit and the superciliary region.

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