Operative Technique in Plastic Surgery – Kevin C.Chung

• MCT injuries are often seen with naso-orbital-ethmoid fractures
■ CSF leaks should be suspected in all patients with frontal sinus fractures.
■ The nasal cavity should be cleared of debris and examined using nasal
endoscopy
■ Any rhinorrhea should be examined using the halo test or sent for beta-2-
transferrin analysis.1,3–6
• The halo test consists of capturing fluid from the nasal secretions on a cloth
or gauze and observing whether a clear “halo” is visible around a central
pool of blood within the drainage (CSF migrates faster than does blood).
This test is suggestive of the presence of CSF but is not diagnostic as saline
and mucus can also lead to false-positive results.
• Testing of fluid for beta-2-transferrin is the mainstay of evaluation for CSF.
This protein can be found in CSF, vitreous humor of the eye, and perilymph.
IMAGING
■ Fine-cut, triplanar maxillofacial CT scans are the standard means of radiologic
evaluation for frontal sinus fractures.
■ Coronal views provide excellent visualization of the frontal sinus floor,
anterior ethmoid cells, and medial orbital walls. Injuries to any of these areas
mean there is a high likelihood of damage to the FSDP and an increased risk
of chronic sinusitis and mucocele formation.
■ Axial views are used to evaluate displacement of frontal sinus fractures and
can demonstrate comminution or pneumocephalus (FIG 2).
■ The patency of the FSDP is best assessed on the sagittal views, though it
requires careful assessment in all planes.
• Fractures involving the FSDP typically occur with more severe
maxillofacial trauma, and patients are 3 times more likely to have other
facial fractures when this area is involved.1
■ 3D reconstruction is useful in minimally displaced fractures of the anterior
table and can help determine if expectant management is an acceptable
treatment option.

FIG 2 • An axial CT view of a minimally displaced frontal
sinus fracture. The posterior table appears intact, and
the frontal sinus is completely opacified.
■ If expectant management with delayed endoscopic treatment is a possible
treatment option, the axial views provide the most accurate means of
estimating the size of the fracture, as they are not influenced by volume
averaging.
NONOPERATIVE MANAGEMENT
■ Based on the algorithm in FIG 3, expectant management of a frontal sinus
fracture can be considered if no significant posterior table injury is present.
■ Repeat imaging and physical examination should be conducted regularly at 3,
6, and 12 months on all patients who are observed after this injury.
■ The frontal sinus mucosa normally regains proper mucociliary clearance
spontaneously after a fracture. However, repeat imaging is required to confirm
that the mucociliary clearance is functioning properly.
■ Patients can suffer from chronic frontal sinusitis or possibly mucocele
formation if the mucosa does not function properly.
■ Observation is an appropriate treatment option in patients with no evidence of
FSDP injury who have nondisplaced fractures or fractures limited to either the
anterior or posterior table.
■ Isolated posterior table fractures can be observed once FSDP injury, dural tear,

and CSF leak have been ruled out. Mucocele formation due to ingrowth of
mucosa into the fracture is rare but should be evaluated at regular intervals.
■ Minimally displaced anterior table fractures without FSDP injury can be
observed with close follow-up. Should the patient have aesthetic deformities
after resolution of the soft tissue edema, endoscopic cranioplasty can be a
useful means of correcting this issue.
■ These patients often have minimal cosmetic deformity 3 to 6 months after
their injury, particularly those with thick brows.
SURGICAL MANAGEMENT
■ In the acute setting, endoscopic reduction and internal fixation of anterior table
fractures is a treatment option when there is a minimally displaced, isolated,
noncomminuted anterior table fracture that does not involve the FSDP.
FIG 3 • Algorithm for the management of anterior table
fractures. Endoscopic or expectant management can be
considered in four of the eight clinical scenarios.
Posterior table injury includes displacement of more
than one table width, evidence of intracranial injury, a
comminuted fracture, or a cerebrospinal fluid leak.
FSDP, frontal sinus drainage pathway.
■ Minimally displaced fractures are typically defined as less than 2 mm or 1
width of the anterior table.

■ The patient with a receding hairline may not be an optimal candidate for this
approach, as some endoscopic incisions are highly visible.
■ Delayed endoscopic cranioplasty is indicated in the patient who was initially
observed after sustaining a minimally displaced anterior table fracture without
FSDP injury but has continued cosmetic deformity of the frontal area following
resolution of the soft tissue edema.
■ Discussion of traditional open surgical techniques for correcting frontal sinus
fractures can be found in other chapters.
■ Endoscopic management of these fractures can avoid a large coronal incision
and allow for a quicker recovery.
■ Endoscopic cranioplasty and fixation techniques should be performed by
surgeons who are proficient in endoscopic browplasty procedures.
■ Additional endoscopic endonasal sinus procedures required for the involved
frontal sinus can accompany delayed treatment of the fracture.7
■ Endoscopic frontal sinusotomy can be performed to improve aeration of the
frontal sinus and can also be used to provide access for balloon catheterization
of the frontal sinus.
■ Transnasal endoscopic placement of a frontal sinus instrument or Foley
catheter balloon into the frontal sinus can be used to reduce an anterior table
fracture and provide the support required to place a screw into the fractured
segment of bone.
Preoperative Planning
■ CT imaging should be reviewed prior to the procedure.
■ Proper antibiotic coverage should be started prior to the procedure.
■ Adequate coverage of typical sinus flora is provided by using ampicillin-
sulbactam or clindamycin.
■ Discussion with the patient regarding the possible need for conversion to an
open procedure including the use of a coronal incision should be included in
the consent prior to the procedure.
■ The proper equipment should be present in the operating room, including 4
mm 30- and 70-degree endoscopes (FIG 4), a rigid endosheath, a camera,
standard endoscopic browplasty instruments, endoscopic video tower, and
either a plating system or a porous polyethylene sheet depending on the type of
planned repair.
■ Preoperative measurement of the fracture and trimming of the polyethylene

sheet (0.85 mm thick) or mesh to dimensions 10 mm larger than the fracture
size is recommended. This allows for overlap of the sheet over the defect edges
and an area for screw placement.
■ Hydroxyapatite cement can also be used for endoscopic treatment of frontal
sinus fractures and provides similar cosmetic results.
■ Caution should be exercised when considering hydroxyapatite cement, as it
typically fills a portion of the underlying frontal sinus and can increase the
risk of mucocele formation after this procedure.
FIG 4 • A 4-mm endoscope with an endoscopic sheath
should be used once an optical cavity is created in a
subperichondrial plane.
Positioning
■ The patient should be positioned supine on the operating table, and the head of
the bed should be turned between 90 and 180 degrees for complete access to
the patient’s head and placement of the endoscopic equipment and tower.
■ The surgeon should sit at the head of the bed, facing toward the patient’s feet.
The endoscopic video screen should be placed near the abdomen, facing
toward the head of the bed (FIG 5).
■ The patient’s eyes should be closed and protected to prevent accidental trauma
during the procedure.
■ Sterile prep is applied from the upper nose to an area at least 2 or 3 cm
posterior to the hairline.
Approach
■ The endoscopic approach is the same for both delayed and acute scenarios.

■ The entire anterior table to the level of the superior orbital rims, inferiorly, and
the temporal lines, laterally, can be accessed through two or three small
incisions just behind the hairline.
FIG 5 • The surgeon should be seated at the head of
the bed facing the patient with the screen at the level of
the patient’s abdomen.
T E C H N I Q U E S
■ Endoscopic Approach to the Anterior Table of the
Frontal Sinus
■ Two parallel incisions should be marked on the forehead, approximately 2
cm behind the hairline (TECH FIG 1).
■ The central incision should be made in the midline and is used for the
endoscope.
■ The lateral incision should be made 4 to 6 cm lateral to midline, on the side
corresponding to the larger portion of the fracture.
■ Another vertical incision can be made on the contralateral side, if greater

reach is required in that area.
■ If a large piece of porous polyethylene or mesh is to be used, the scalp
incisions may need to be enlarged, or a temporal incision 2 cm behind the
hairline should be made to introduce this material.
TECH FIG 1 • Incisions for endoscopic repair of frontal
sinus fractures. A midline incision is separated from
two lateral incisions by approximately 2.5 cm and
placed 1 cm posterior to the hairline. The optional
temporal incisions are even further lateral and should
be made just posterior to the temporal hairline.
■ The use of temporal incisions creates greater tissue trauma, introduces the
possibility of injury to the frontal branch of the facial nerve, and does not
increase the size of the optical cavity. This incision should be used with
caution.
■ Incisions should be made with a scalpel through the skin and subcutaneous
tissue.
■ Electrocautery can be used to continue the dissection to the subperiosteal
layer.

■ Cautery should be used sparingly on the subcutaneous tissue and skin to
avoid damage to the hair follicles and subsequent alopecia.
■ Blunt dissection using a sharp dissecting instrument, such as the endoscopic
periosteal elevator, should be used to create a pocket in the subperiosteal
plane.
■ Bimanual palpation should be used to confirm that the pocket extends from
both temporal lines to approximately 2 to 3 cm anterior to the incisions.
• Blind dissection of this pocket is required before placement of the
endoscope into the incision.
■ Introduce the 30-degree endoscope through the central incision and the
dissecting instrument through the lateral incision and continue the dissection
in the subperiosteal plane to a level just below the inferior edge of the
fracture.
■ Ensure that the fractured segments are not displaced during this portion of
the dissection, as they can be very difficult to move back into the proper
orientation using the endoscope.
• Alternatively, comminuted fracture segments can be removed and plated
together on the back table if they are displaced.
■ Dissection over the fracture segment can also be performed in the
suprapericranial layer by making a small incision in the pericranium and
identifying the proper plane.
• This technique allows the fracture segments to remain attached and
reduces the likelihood of displacement during the dissection.
■ Endoscopic Reduction and Internal Fixation of the
Anterior Table
■ A 25-gauge hypodermic needle is used to identify the proper areas for
percutaneous port placement.
■ All fractured segments should have at least two points of fixation with
larger pieces benefitting from three points.
■ Ideally, one port incision could be used to place screws into multiple plates
in order to decrease the number of incisions.
■ A no. 11 blade scalpel should be used to create a stab incision in this area for
placement of screws and other percutaneous instruments.
■ Once the fracture is dissected free from the overlying periosteum,

instruments including nerve hooks and Steinmann pins should be introduced
through the percutaneous ports to reduce the fracture segments.
■ Miniplates can be introduced through the scalp incisions and moved to
positions overlying the fracture segment.
■ 1.7-mm self-drilling screws (4 to 6 mm in length) can be used
percutaneously to fixate the fracture segments to the stable bone.
■ A drill with a percutaneous drill guide can be used to create starting holes
on the fracture segments if the screws are not taking hold.
■ Acellular dermis or Vicryl mesh can be placed over the surface of the repair
in the subperiosteal plane to provide further camouflage of any remaining
contour abnormalities.
■ The percutaneous port incisions can be closed with absorbable sutures or
tissue adhesives.
■ The access incisions should be closed with absorbable deep sutures and skin
staples.
■ Endoscopic Placement of Mesh or Polyethylene
Plate
■ Complete the endoscopic approach to the anterior table of the frontal sinus
as described above.
■ Ideally, one port incision can be used to place screws into opposing areas
of the plate or mesh to decrease the number of incisions.
■ A no. 11 blade scalpel should be used to create a stab incision in this area for
placement of screws and other percutaneous instruments.
■ The precut polyethylene plate or mesh is introduced into the optical cavity
and moved into the proper position.
■ A mark should be placed on the superior portion of the plate to aid with
orientation after the plate is placed into the optical cavity.
■ The entire fracture should be covered with a portion of the plate
overlapping the surrounding stable bone.
■ 1.7-mm self-drilling screws (4–6 mm in length) should be used through the
percutaneous ports to secure the plate or mesh to the stable bone (TECH FIG
2).
■ All plates and mesh should have at least two points of fixation, with larger

pieces benefitting from three points.
■ Screws should be placed at least 2 mm from the plate edge in order to
avoid tearing.
TECH FIG 2 • Endoscopic view of a percutaneous
screwdriver used to place screws in the reconstructive
plate. The percutaneous incision should be made in
an area that allows for access to the entire plate if
possible to reduce cosmetic deformity.
■ Acellular dermis or Vicryl mesh can be placed over the surface of the repair
in the subperiosteal plane to provide further camouflage of any remaining
contour abnormalities.
■ The percutaneous port incisions can be closed with absorbable sutures or
tissue adhesives.
■ The access incisions should be closed with absorbable deep sutures and skin
staples.
PEARLS AND PITFALLS

Indications
■ Frontal sinus fractures that involve the FSDP, surrounding
maxillofacial bones, or are severely comminuted make poor
endoscopic candidates.
■ Fractures that also involve the posterior table may be endoscopic
candidates if they are observed first to ensure there is no CSF leak.
Consent
■ A discussion should take place with all patients regarding the need
for a possible coronal incision and open reduction with internal
fixation if the fractures are not amenable to the endoscopic
approach.
Preoperative
planning
■ Miniplates can be used for reduction and internal fixation in the
acute setting.
■ Polyethylene plates or mesh should be used in the delayed setting
and should be cut to appropriate size based on the axial cuts of the
CT scan before the case.
Camouflage
■ A thin layer of Vicryl mesh or acellular dermis should be placed
over the fracture after plating or fixation to camouflage further
contour abnormalities.
Postoperative
care
■ Patients should undergo routine physical and radiologic
examinations 1, 3, and 6 mo after endoscopic treatment of their
fracture no matter which type of surgery was used.
■ Osteomyelitis and mucocele formation occur infrequently but have
better treatment outcomes when recognized early.
POSTOPERATIVE CARE
■ A mildly compressive dressing is placed over the forehead immediately after
surgery to prevent hematoma or seroma formation.
■ This can be removed after 48 hours.
■ The patient should be warned to avoid activities that put him or her at risk for
future trauma to the forehead.
■ The patient can resume regular activities after approximately 2 weeks or after
most of the swelling has resolved.
■ The staples are removed 7 to 10 days after the surgery.
■ The patient should still receive routine physical examinations and CT scans 1,
3, and 6 months after the surgery to monitor for osteomyelitis and mucocele
formation.
■ Annual imaging should be obtained after this period.

OUTCOMES
■ Endoscopic treatment of frontal sinus fractures has a similar success rate to
open approaches in regard to cosmetic outcomes, with a lower rate of
complications.1,5
■ A smaller subset of patients with less severe fractures qualify for endoscopic
management that leads to an inherent decrease in complications.
COMPLICATIONS
■ Complications from endoscopic repair of frontal sinus fractures are similar to
those from open repair and include wound infections, osteomyelitis, mucocele,
mucopyocele, aesthetic complications, paresthesias to the frontal area
(secondary to injury of the supraorbital or supratrochlear neurovascular
bundles), diplopia, hematoma or seroma formation, hardware infection, and
bone resorption.1–6,8
■ Mucoceles can form at any point from the immediate postoperative period to
20 years after the surgery.
REFERENCES
1. Gossman DG, Archer SM, Arosarena O. Management of frontal sinus
fractures: a review of 96 cases. Laryngoscope. 2006;116:1357-1362.
2. Fox PM, Garza R, Dusch M, et al. Management of frontal sinus fractures:
treatment modality changes at a level I trauma center. J Craniofac Surg.
2014;25(6):2038-2042.
3. Rice DH. Management of frontal sinus fractures. Curr Opin Otolaryngol
Head Neck Surg. 2004;12(1):46-48.
4. Wallis A, Donald PJ. Frontal sinus fractures: a review of 72 cases.
Laryngoscope. 1988;98:593-598.
5. Strong EB. Endoscopic repair of anterior table frontal sinus fractures. Facial
Plast Surg. 2009;25(1):43-48.
6. Chen KT, Chen CT, Mardini S, et al. Frontal sinus fractures: a treatment
algorithm and assessment of outcomes based on 78 clinical cases. Plast
Reconstr Surg. 2006;118(2):457-468.
7. Smith TL, Han JK, Loehrl TA, Rhee JS. Endoscopic management of the
frontal recess in frontal sinus fractures: a shift in the paradigm? Laryngoscope.
2002;112:784-790.
8. Pham AM, Strong EB. Endoscopic management of facial fractures. Curr Opin
Otolaryngol Head Neck Surg. 2006;14(4):234-241.

52
CHAPTER
Operative Management of a
Late Presentation of Frontal
Sinus Mucocele
Kibwei A. McKinney and Brent A. Senior
DEFINITION
■ A mucocele is a benign, cystic collection of mucus lined with respiratory
epithelium that results from obstruction of the drainage pathway of a paranasal
sinus ostium.
■ The mucus within a mucocele may become infected and is then termed a
pyocele or mucopyocele.1
■ Mucoceles present most frequently in the frontal and ethmoid sinuses,
accounting for between 54% and 73% of lesions occurring within the paranasal
sinuses.2
■ The vast majority of mucoceles occur in the setting of pre-existing sinus
disease (eg, nasal polyps or sinonasal neoplasms), whereas a minority present
as a long-term sequela of prior trauma to the frontal sinus drainage pathway.3
■ Trauma to the frontal drainage pathway is thought to result in post-traumatic
scar formation, inflammation, and obstruction that prevent normal mucociliary
clearance, thus resulting in mucocele formation.4,5
■ Frontal mucoceles can result in significant morbidity, due to their expansile,
erosive nature, and close proximity to the orbit and brain. Complications
include facial asymmetry, orbital proptosis, cellulitis of the orbit and facial
skin, and intracranial extension.6
■ The treatment of mucoceles of the frontal sinus is particularly challenging due
to the limitations of external and endoscopic techniques.
■ External approaches may result in poor appearance, hypesthesia of the facial
skin, and poor access to the frontal sinus drainage pathway.

■ Endoscopic approaches have decreased morbidity but are limited in their
ability to access lesions localized to the superior and lateral aspects of the
sinus.
ANATOMY
Frontal Sinus
■ The frontal sinuses are paired structures of the forehead that are present in
90% of the population and exhibit different patterns of pneumatization among
individuals.7
■ The frontal sinus arises embryologically from an anterior ethmoid furrow that
evaginates into the frontal bone, forming an inverted, pyramidal-shaped, air-
filled structure, along the roof of the orbit.7,8
■ The anterior table of the frontal sinus varies between 4 and 12 mm and
thickens at its inferior extent to form the frontal “beak,” where it forms an
articulation with the frontal process of the maxilla.
■ The anterior table is covered by skin, subcutaneous fat, frontalis muscle, and
pericranium.
■ The posterior table is much thinner and forms the boundary between the sinus
cavity and the intracranial space.
■ The intersinus septum is a bony partition that divides the right and left frontal
sinuses into two sinus cavities with independent drainage pathways.
■ These cavities may be asymmetric in size and can potentially communicate
via an intersinus septal cell.
Frontal Recess
■ This is an hourglass-shaped space through which the frontal sinus drains.
■ The internal frontal ostium is the narrowest segment of this space.
■ It is bordered anteriorly by the frontal beak and posteriorly by the skull base.
■ The ostium drains inferiorly into the frontal recess (previously referred to as
the nasofrontal duct), a space that is defined by the following limits:
■ Anterior—frontal beak and posterior wall of the agger nasi cell
■ Posterior—anterior face of the ethmoid bulla
■ Lateral—lamina papyracea and lacrimal apparatus
■ Medial—lateral lamella of the cribriform plate, middle turbinate, and
uncinate process 7,8

Frontal Pneumatization Patterns
■ The anterior ethmoid cells may pneumatize in various patterns, thus resulting
in a multitude of different orientations of the frontal sinus outflow tract.
■ The development of these cells may lead to displacement of the frontal recess,
thus resulting in a circuitous pattern of drainage.
■ Agger nasi cell: the most anterior and most anatomically consistent anterior
ethmoid cell, located between the lateral nasal wall and the uncinate process,
directly anterior to the vertical attachment of the middle turbinate to the skull
base (FIG 1)
■ Type 1 frontal cell: a single cell located superior to the agger nasi cell. Its
posterior border displaces the frontal recess posteriorly.
■ Type 2 frontal cell: two or more stacked cells located superior to the agger
nasi cell. These cells result in posterior displacement of the frontal recess.
■ Type 3 frontal cell: a single, large anterior ethmoid cell superior to the agger
nasi cell that extends superiorly beyond the internal frontal ostium, into the
frontal sinus. It posteriorly displaces the frontal recess.
■ Type 4 frontal cell: a single anterior ethmoid cell located entirely within the
frontal sinus. Its anterior wall is either the anterior table of the frontal sinus or
the floor of the frontal sinus.
FIG 1 • Illustration of the named ethmoid cells, on
parasagittal view. Demonstrated is the frontal recess

(FR), which is bordered anteriorly by the agger nasi cell
(AN) and posteriorly by the frontal bullar cell (FB). The
agger nasi cell is a reliable landmark, present in virtually
all sinonasal cavities. Also shown are the uncinate
process (U, dashed line), suprabullar cell (SB), ethmoid
bulla (B), posterior ethmoid cells (P), basal lamella of
the middle turbinate (M), and the sphenoid sinus (S).
■ Supraorbital ethmoid cell: one or more anterior ethmoid cells that pneumatize
superiorly into the frontal sinus. This is typically posterior and lateral to the
frontal recess, resulting in anteromedial displacement of the drainage
pathway. It may result in a septate appearance of the frontal sinus on coronal
imaging.
■ Frontal bullar cell: an anterior ethmoid cell located above the ethmoid bulla
that extends into the frontal sinus. It borders the skull base and posterior table
of the frontal sinus, causing anterior displacement of the frontal recess. It is
thought to arise from pneumatization of the lamella of the anterior ethmoid
bulla (see FIG 1).
■ Suprabullar cell: an anterior ethmoid cell located above the ethmoid bulla
that borders the skull base. Similar to the frontal bullar cell, it forms from
pneumatization of the bulla lamella and displaces the frontal recess anteriorly.
It does not, however, extend into the frontal sinus (see FIG 1).
■ Intersinus septal cell: a pneumatized partition of the frontal sinus septum that
drains inferiorly into one of the paired outflow tracts.7,8
Soft Tissue Anatomy
■ The afferent innervation of the frontal region is supplied by distal
ramifications of the ophthalmic branch of the trigeminal nerve, the
supratrochlear and supraorbital nerves.
■ The supratrochlear nerve is the medial branch of the frontal nerve.
■ It courses superior to the trochlea (within the orbit) and penetrates the orbital
septum at the medial aspect of the orbit.
■ The nerve then traverses the corrugator muscle to provide sensory
innervation to the soft tissues of the inferomedial aspect of the forehead.
■ The supraorbital nerve is the lateral division of the frontal nerve.
■ It exits the orbit through the supraorbital foramen, at the junction between the

medial one-third and lateral two-thirds of the orbital rim.
■ It courses superiorly deep to the corrugator muscle and penetrates the
frontalis muscle to provide sensory innervation to the upper and lateral
forehead.
■ Its distal branches enter retrograde through the anterior table of the frontal
sinus (along with the diploic veins) to provide afferent innervation to the sinus
cavity.
PATHOGENESIS
■ The function of the frontal sinus is not known, but is thought to increase the
surface area of respiratory mucosa for air humidification and serves as a
protective barrier to forces directed toward the anterior cranium.
■ The frontal sinus is lined by pseudostratified, ciliated, columnar epithelium.
■ Mucoceles are lined by the same respiratory-type epithelium, but their exact
pathogenesis remains unknown.
■ They are believed to arise from mucosal inflammation causing obstruction of
the natural drainage pathway of the sinus in which they originate. This leads to
retained secretions and osteolysis of the surrounding bone, thus resulting in the
expansion that is often noted radiographically.2,6,9
■ Insults that lead to ostial obstruction vary considerably and include9
■ Trauma
■ Chronic sinusitis
■ Nasal polyposis
■ Iatrogenic (postsurgical)
■ Neoplasm
NATURAL HISTORY
■ Due to their pathogenesis, frontoethmoidal mucoceles tend to be slow-
growing, with clinical manifestations occurring late in the disease process.2
■ Alternatively, some mucoceles remain completely asymptomatic and are only
discovered incidentally through radiographic imaging for unrelated issues.
■ Various series that have looked at postoperative complications from sinus
surgery support the indolent nature of frontal mucocele formation. They have
found a mean duration to symptom onset of 5 years following the initial
surgery.10
■ Because of this, many of these lesions go unrecognized and may present
dramatically with serious complications, due to intraorbital or intracranial

extension.
■ Mucoceles occurring secondary to antecedent trauma to the frontal sinus have
been reported up to 50 years following the initial injury.1,11,12
■ The peak incidence of these lesions remains unknown. Therefore, all patients
who have had any history of frontal sinus trauma are at risk for this late stage
complication.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Because of indolent growth patterns, frontal mucoceles tend to be
asymptomatic for many years prior to their clinical presentation.
■ They typically become clinically evident only after extensive expansion and
erosion, due to compression of surrounding structures.
■ Symptomatically, patients most often present with proptosis (61.5%), frontal
pain/pressure (38.5%), and nasal drainage (38.5%).6
■ Less commonly, patients may also experience headaches, nasal obstruction,
diplopia, lid swelling, loss of visual acuity, and orbital cellulitis.4,6
IMAGING
■ Imaging is typically obtained in the axial, coronal, and sagittal planes, in order
to demonstrate the location of the lesion and its relationship to the surrounding
anatomical structures.
■ CT scan of the maxillofacial skeleton with fine cuts through the paranasal
sinuses is the standard imaging modality used in the diagnosis of frontal
mucoceles.
■ Contrast enhancement may be utilized to better delineate the degree of
intracranial or intraorbital extent and to differentiate these lesions from other
pathologic entities.
■ CT provides excellent bony definition and typically demonstrates a cystic,
homogenous, fluid-filled structure with thinning of the surrounding bone (FIG
2A,B).
■ MRI may be used in tandem with computed tomography, particularly if the
diagnosis remains in question.
■ The T2 sequence will reveal a hyperintense signal, consistent with a
mucocele’s high fluid content.4,11
■ Alternatively, in lesions that have higher protein content, the T2 sequence
images may demonstrate an isointense or hypointense signal.

■ Postcontrast T1 sequence images may be used to identify dural enhancement,
if there is evidence of skull base erosion (FIG 2C,D).
DIFFERENTIAL DIAGNOSIS
■ Epidermoid cyst
■ Dermoid cyst
■ Cholesterol granuloma
■ Fibrous dysplasia
■ Encephalocele
■ Meningoencephalocele
■ Allergic fungal rhinosinusitis
■ Inverted papilloma
■ Nasal polyps
SURGICAL MANAGEMENT
■ Three approaches will be discussed:
■ Endoscopic, endonasal marsupialization
■ Frontal sinus trephination
■ Combined open and endoscopic decompression
Preoperative Planning
■ Sinonasal endoscopy plays a critical role in the evaluation of these patients.
■ Purulent secretions may be seen emanating from the middle meatus and
draining posteriorly into the nasopharynx.
■ In the case of very large lesions, the uncinate process may be expanded
medially, with obliteration of the middle meatus.
■ Alternatively, if lesions are well-encapsulated or localized to the superior
aspect of the sinus, the sinonasal endoscopy may appear completely normal.
■ Ophthalmologic evaluation should be requested in any patient with ocular
symptoms or radiographic evidence of orbital extension.
■ Include a baseline assessment of visual acuity, extraocular movements, and
visual field testing.
■ Radiographic review
■ The axial, coronal, and sagittal imaging should be evaluated to determine the
extent of the lesion and involvement of surrounding structures.
■ Of particular importance is the anteroposterior (AP) diameter of the frontal

sinus outflow tract, best depicted on the sagittal series.
■ This dimension determines the ease with which frontal dissection may occur
via the endonasal route.
■ A narrow AP diameter is associated with an increased risk for damage to the
skull base as well as mucosal stripping during the surgery that can lead to
restenosis of the frontal sinus outflow tract.
■ Other considerations include
■ Height of the olfactory cleft
■ Dehiscent bone of the posterior table
■ Dehiscent bone of the lamina papyracea
■ Presence of polyps
■ Location of the anterior ethmoid arteries
■ Slope of the skull base
■ Preoperative antibiotics: In the acutely infected mucopyocele, preoperative
antibiotics are indicated.
FIG 2 • Noncontrast CT scans of the paranasal sinuses
in the coronal (A) and axial (B) planes. There is an
expansile mucocele of the right agger nasi cell and
frontal sinus, with thinning of the bone constituting the
lamina papyracea and anterior skull base. There is
extension of the lesion across the midline, into the left
frontal recess. T1-weighted post–gadolinium enhanced
images in the coronal (C) and axial (D) planes
demonstrate a heterogeneously enhancing cystic lesion
of the right frontal recess, with erosion of the right
lamina papyracea and skull base. The heterogeneity of
the lesion is likely due to proteinaceous elements within
the lesion.

Positioning
■ Following induction, the head of bed is rotated 90 to 180 degrees away from
anesthesia to permit access to the right side of the patient. The display tower is
typically positioned on the contralateral side, opposite the surgeon, to provide
an unobstructed view of the monitor.
■ The patient should be placed in the supine position with the head of bed in a
slightly elevated position relative to the heart. This minimizes blood loss, thus
improving visualization.
■ Pledgets are soaked in a topical anesthetic/decongestant solution and placed
intranasally, to dilate the nasal airway.
■ If an external approach or trephination is expected with a combined approach,
local anesthetic is instilled into the planned incision sites. 1% lidocaine with
epinephrine 1:100 000 is generally used.
■ Any of the commercially available image guidance systems is acceptable and
appropriate for use. The preoperative imaging should be formatted
appropriately for use with the chosen guidance system.
■ The use of an electromagnetic-based system requires fixation of a patient
tracker that may limit access to the forehead, if an external approach is
planned.13
■ In this case, an infrared navigation system with line-of-sight registration may
be preferred.13
Approach
■ The surgical approach should be tailored to the extent of the mucocele and its
involvement with surrounding structures.
■ The goals of surgery are to marsupialize the mucocele cavity and restore the
patency and function of the frontal sinus outflow tract.
■ In most cases, this is achieved through an endoscopic approach, with or
without removal of the floor of the frontal sinus (Draf IIb or III), depending
on the amount of access that is required.12
■ In the case of a Draf IIb, the floor of the sinus is removed from the
supraorbital ridge to the septum, in the midline. This includes excision of the
anterior attachment of the middle turbinate to the floor of the frontal sinus.12
■ In a Draf III, a common cavity defect is created by removing the floor of the
bilateral frontal sinuses. This includes the excision of both middle turbinates
and the superior aspect of the nasal septum.12

■ In the case of a superiorly or laterally situated mucocele, a frontal sinus
trephination may be performed.
T E C H N I Q U E S
■ Endoscopic Endonasal Marsupialization
■ Following induction and positioning, the topical decongestant-soaked
pledgets are removed.
■ Dissection begins using the zero-degree endoscope.
Uncinectomy
■ To access the frontal recess, an uncinectomy is first performed, using
backbiting forceps to divide its horizontal and vertical segments (TECH FIG
1).
■ The vertical segment is bluntly reflected forward and separated from its
attachment to the lacrimal crest using the 90-degree Blakesley forceps.
■ The horizontal segment is then sharply removed, with through-cutting
instruments or a microdebrider. Preserve the basal lamella of the middle
turbinate.
■ For large lesions, wide exposure is warranted for panoramic exposure of the
frontal recess.
■ This requires a maxillary antrostomy and anterior ethmoidectomy.
■ If there is more extensive involvement or erosion of the orbit, posterior
ethmoid dissection may be required as well.
Maxillary Antrostomy and Anterior Ethmoidectomy
■ The anterior fontanelle is identified and dilated, using the maxillary ostium
seeker.
■ The membranous medial wall of the maxillary sinus is taken down with
straight through-cutting forceps, thus connecting the anterior and posterior
fontanelles.
■ A 45-degree angled endoscope should be used for greater visualization of the
surgical antrostomy. This ensures that the surgical antrostomy is in continuity
with the natural ostium of the maxillary sinus, thus avoiding postoperative

recirculation.
■ The ethmoid bulla is a reliable landmark that is easily identified after the
uncinectomy has been performed. It forms the posterior aspect of the frontal
sinus outflow tract.
■ It is removed via a retrobullar approach.
■ A J-curette is placed into the sinus lateralis or retrobullar space and the bulla
is dissected anteriorly and removed (TECH FIG 2).
TECH FIG 1 • Uncinectomy. The backbiter (BB) is
placed within the hiatus semilunaris and used to
transect the horizontal from the vertical portion of the
uncinate process, thus opening the maxillary antrum.
NS, nasal septum; MT, middle turbinate; LC, lacrimal
crest; EB, ethmoid bulla.
TECH FIG 2 • Anterior bullectomy. The J-curette (JC)
is placed within the sinus lateralis (SL), the space
immediately posterior to the ethmoid bulla (EB). The
bulla is disarticulated from the lamina papyracea (LP)

and skull base, thus opening the anterior ethmoid
cavity. MA, maxillary antrum; IT, inferior turbinate.
Frontal Dissection
■ With the anterior ethmoidectomy and maxillary antrostomy completed,
frontal dissection is performed using the 45-degree endoscope.
■ The anterior ethmoid artery is identified along the skull base, coursing from
posterolateral to anteromedial.
■ It is critical to identify this structure, as it marks the posterior limit of the
frontal sinus outflow tract, approximately 2 to 5 mm posterior to the opening.
Inadvertent injury to this structure may result in retraction of the lateral
stump of the artery into the orbit, causing an orbital hematoma.
■ The frontal sinus outflow tract is identified and widened using frontal sinus
(Bolger-Kuhn) probes or curettes, which are specifically angled for this
purpose (TECH FIG 3A).
■ The tract is typically located posterior and medial to the agger nasi cell. In
two-thirds of patients, it drains lateral to the uncinate process and into the
ethmoid infundibulum.
■ The agger nasi cell is removed in a posterior-to-anterior direction. Avoid
inadvertent entry into the intracranial space through the posterior table of the
frontal sinus.
■ The horizontal table of bone along the anterior and medial aspect of the
frontal drainage pathway is safe for resection. The posterolateral mucosa is
left intact to permit re-epithelization of the frontal outflow tract.
■ Removal of the floor of the frontal sinus is best performed using a
combination of grasping and through-cutting giraffe forceps (TECH FIG
3B), curved rongeurs (eg, angled Kerrison 45 or 90 degrees), and Hosemann
through-cutting punch forceps (TECH FIG 3C) or with angulated, powered
drills to widely marsupialize the mucocele cavity.
■ 90-degree giraffe forceps are used to remove all free-floating fragments.
■ Culture and Gram stain are obtained once the mucocele cavity is drained, to
direct the choice of postoperative antibiotics.
■ In general, if there is significant lateral or superior extension of the
mucocele, the entire floor of the frontal sinus is removed, from orbit to the
midline and posteriorly to the location of the first olfactory filament (Draf
IIb).12

■ In lesions that cross the midline, a superior septectomy with resection of the
floor of the contralateral frontal sinus and partial septectomy is performed
(Draf III) (TECH FIG 3D).
TECH FIG 3 • A. Frontal curettes used to enter into
and widen the frontal recess to allow the use of other
curved instruments. B. Kuhn frontal sinus forceps,
designed to sharply cut or grasp ledges of bone for
removal from the frontal sinus outflow tract. C. Frontal
rongeurs, used to amputate dense or osteitic bone
from the frontal recess, when delicate instrumentation
is insufficient. D. Endoscopic view of a Draf III frontal
sinusotomy defect. The dashed line indicates
confluence of the right (F) and left (f) frontal sinus
outflow tracts after removal of the superior aspect of
the nasal septum and the leading edge of the bilateral
middle turbinates.
Completion
■ If the skull base and orbit are not dehiscent, the sinus cavity is irrigated with
buffered saline solution to remove all debris and infectious contents.
■ Visualization is achieved using the 70-degree endoscope to confirm the

patency of the frontal sinus outflow tract and to ensure that no residual
septations exist that may result in postoperative obstruction or scar formation.
■ The decision of whether to stent the frontal outflow tract depends on a
number of factors that portend a poor prognosis, such as:
■ A-P diameter of the frontal outflow tract less than 8 mm
■ History or presence of nasal polyps
■ Prior recurrence of mucocele
■ Prior history of sinonasal surgery
■ Previous frontal sinus trauma14–16
■ A variety of stents are available, including steroid-eluting products that
slowly resorb over time.
■ Alternatively, a T-shaped stent may be fashioned from a piece of 1/100-in.-
thick Silastic sheeting that is rolled and cut to the appropriate length to
adequately traverse the frontal sinus outflow tract.
■ Hemostasis is then achieved. Packing may be placed but is generally not
necessary unless there is a substantial risk of postoperative epistaxis (ie, pre-
existing coagulopathy, extensive intraoperative blood loss) or if there is
significant destabilization of the middle turbinate that may lead to scar
formation.
■ Frontal Sinus Trephination
■ In mucoceles that are located laterally and superiorly within the frontal
sinus, or those that have caused marked osteoneogenesis of the frontal sinus
outflow tract, frontal sinus trephination may be required for extirpation of the
infection.
Exposure
■ Various incisions have been described, including the suprabrow, intrabrow,
and infrabrow.
■ The infrabrow is classically described, because it allows for safe entry into
the frontal sinus medially and inferiorly, at the broadest and most dependent
region of the sinus.
■ 1% lidocaine with epinephrine 1:100 000 is injected into the planned
surgical site (TECH FIG 4).
■ The incision extends 1.5 to 2.0 cm horizontally along the inferior margin of
the eyebrow beginning at the medial brow tuft.

■ Medial extension beyond this point may result in noticeable scarring of the
skin.
TECH FIG 4 • Incision sites for trephination. Infrabrow
—immediately inferior to the brow, along the orbital
rim. Intrabrow—directly through the midportion of the
brow. Suprabrow—superior edge of brow.
■ Placement of the incision too far inferior may result in trephination of the
frontal sinus outflow tract, resulting in postoperative scarring and
obstruction.
■ The skin is then sterilely prepped and draped.
■ The incision is made using a no. 15 blade. It is extended through the skin,
subcutaneous tissue, orbicularis oculi and corrugator muscles, and
periosteum.
■ Hemostasis is achieved with bipolar (rather than monopolar cautery) in order
to avoid thermal damage to the skin and periosteum.
■ The periosteum is elevated from the frontal bone using a periosteal elevator,
thus exposing a 1 × 1 cm area where the osteotomy may be performed.
Osteotomy

■ The osteotomy is ideally made at the level of the floor of the frontal sinus
(TECH FIG 5).
■ This avoids the frontal sinus outflow tract, which is located inferiorly;
injury to the tact results in postoperative neo-osteogenesis and obstruction.
TECH FIG 5 • The osteotomy is ideally made at the
level of the floor of the frontal sinus. Using a 4-mm
rough cutting round diamond bur, an approximately 8
to 10 mm of bone of the anterior table is saucerized.
■ It also avoids entry into the anterior table of the sinus through which
diploic veins course. Exposure of these vessels can cause seeding of the
infection from the mucocele cavity, resulting in osteomyelitis of the frontal
bone or intracranial extension of the infection.
■ The osteotomy is made using a 4-mm rough cutting bur. An area measuring
8 to 10 mm is saucerized on the anterior table, without entry into the sinus
cavity.
■ The bone is drilled until close proximity to the underlying mucosa is
reached.

■ A curette is used to enter through the mucosa.
■ The osteotomy is widened with the Kerrison rongeur to a diameter of 1 to
1.5 cm, depending on the size required for access to the mucocele and
introduction of endoscopic instruments.
■ The mucocele is then drained under direct visualization. Cultures are
obtained to guide the postoperative antibiotic regimen.
■ If the trephination is combined with an endoscopic, endonasal approach,
instruments may be introduced transnasally, while visualization is provided
from above through the trephination site.
■ All bony septations of the mucocele and their associated mucosa are
removed with powered drills and/or the Kerrison rongeur.
Completion
■ The sinus cavity is then irrigated with buffered saline solution, except in the
case of a dehiscence into the orbit or posterior table.
■ One-to-two red rubber catheters can be placed through the trephination site
to provide a conduit for postoperative irrigation.
■ These are secured with a 4-0 nylon suture to the skin.
■ The periosteum and surrounding soft tissues are closed with 4-0 Vicryl
suture.
■ The skin around the drain is closed with interrupted nonresorbable suture.
■ Combined Endonasal-External Approach
■ The above-mentioned approaches may be used in tandem for cases in which
there is more extensive disease that does not lend itself to a single approach.
■ Trephination is rarely performed as a stand-alone procedure, as the
likelihood of recurrence of the mucocele is high.
■ Marsupialization via trephination combined with the creation of a
permanent drainage pathway via an endoscopic frontal sinusotomy
provides a more permanent solution for frontal sinus mucoceles.
■ Other approaches to the frontal sinus, including osteoplastic flap and
bicoronal approach, are covered elsewhere in this text.

PEARLS AND PITFALLS
Visualization
■ Endoscopic visualization of the frontal recess is difficult, even in
the trained surgeon’s hands.
■ Use of the 70-degree endoscope may improve visualization, by
providing a more panoramic view of the frontal sinus outflow tract.
■ This will help to avoid mistaking a supraorbital ethmoid cell for the
frontal sinus, thus ensuring proper dissection.
Mucosal
stripping
■ Use through-cutting instrumentation, in order to avoid damage to
the posterior and lateral mucosa of the frontal sinus outflow tract.
■ Failure to do so may result in extensive postoperative scar
formation and disruption of mucociliary clearance of the sinus
cavity.
Hemostasis
■ Obtain hemostasis prior to the reversal of anesthetic because of the
fluctuations in blood pressure that may occur during this process.
■ Multiple hemostatic agents are commercially available that are
effective in controlling mild oozing.
■ Brisk, arterial bleeding must be controlled with monopolar or
bipolar cautery.
■ Avoid injury to the sphenopalatine and anterior ethmoid arteries.
■ Prior to reversal, a Valsalva maneuver should be performed to
confirm that there is no persistent bleeding.
■ Resorbable or nonresorbable packing may be placed within the
middle meatus for hemostasis.
■ Avoid vasoconstrictive agents toward the end of the case. This may
conceal areas of active bleeding that will rebleed following reversal.
POSTOPERATIVE CARE
■ Endoscopic, endonasal marsupialization
■ In cases approached endoscopically, postoperative care includes systemic
antibiotics, and possibly steroids, depending on the amount of mucosal
inflammation and polyposis noted at surgery.17
■ Patients are uniformly placed on 2 to 3 times daily sinonasal irrigation with a
buffered saline solution to remove debris and promote mucosal healing.17
• This may be impregnated with steroid and/or antibiotics, depending on the
degree of polyposis and the culture result and sensitivity profile.17

■ Patients are seen at 1 to 2 weeks postoperatively for the first debridement,
which is performed endoscopically in the outpatient setting, with a topical
anesthetic.
• If packing was placed intraoperatively, it is removed at this time with a
straight Blakesley forceps.
• If a nonabsorbable stent was placed in the frontal recess, it is typically
removed at the first postoperative visit but may be left longer if there is a
significant concern for scarring of the frontal outflow tract.14–16
■ Patients are seen in the office every 2 to 3 weeks and examined using the
endoscope for the first three months. Follow-up is then performed every 3
months for the first year and every 6 to 12 months thereafter.4–6
■ Frontal sinus trephination
■ Antibiotic ointment is placed on the drain twice daily until the first
postoperative visit.
■ The external drains are irrigated 1 to 2 times daily with buffered saline
solution for 3 to 5 days.
■ The drains are then removed and the surrounding skin defect is left to heal by
secondary intention. Nonresorbable skin sutures are removed at 5 to 7 days
postoperatively.
OUTCOMES
■ Endoscopic drainage of sinonasal mucoceles has a high success rate, with a
low rate of recurrence.18
■ Studies evaluating lesions that are amenable to endoscopic drainage have
reported long-term recurrence rates of 0% to 11%.4,9
■ In these cases, repeat endoscopic evaluation is critical in the surveillance of
these patients for disease recurrence.
■ External approaches are associated with a higher risk of recurrence, likely
owing to the severity of the lesion or its location (making endoscopic detection
difficult).
■ Reported rates of recurrence for external approaches may be as high as 6.8%
to 23.5%.2
COMPLICATIONS
■ Complications associated with endoscopic, endonasal marsupialization of
frontal mucoceles are similar to those associated with endoscopic sinus surgery.
■ These risks include both major and minor complications.

■ Major complications:
■ Orbital injury
■ CSF leak
■ Severe hemorrhage
■ Nasolacrimal duct injury
■ Meningitis
■ Minor complications:
■ Minor hemorrhage
■ Violation of the lamina papyracea
■ Overall, the incidence of complications is between 0.9% and 23%.19,20
■ The risk of complications is increased with revision surgery, as compared to
primary surgery.
■ External trephination is subject to the same complications as the endoscopic
approach, but also has additional associated risks, including:
■ Hypesthesia of the forehead
■ Refractory pain
■ Poor cosmesis due to scarring and contour deformity
ACKNOWLEDGMENTS
We thank Patrick M. Colley, MD, for his assistance in the preparation of this
chapter.
REFERENCES
1. Kamoshima Y, Terasaka S, Nakamaru Y, et al. Giant frontal mucocele
occurring 32 years after frontal bone fracture: a case report. Case Rep Neurol.
2012;4:34-37.
2. Du Mayne MD, Moya-Plana A, Malinvaud D, et al. Sinus mucocele: natural
history and long-term recurrence rate. Eur Ann Otorhinolaryngol Head Neck
Dis. 2012;129:125-130.
3. Lee TJ, Li SP, Fu CH, et al. Extensive paranasal sinus mucoceles: a 15-year
review of 82 cases. Am J Otalaryngol. 2009;30:234-238.
4. Topdag M, Iseri M, Sari F, et al. Paranasal sinus mucoceles: our clinical
experiments. Int J Clin Exp Med. 2015;8(10):18518-18522.
5. Koudstaal MJ, Van der Wal KGH, Bijvoet HWC, et al. Post-trauma mucocele
formation in the frontal sinus; a rationale of follow-up. Int J Oral Maxillofac
Surg. 2004;33:751-754.
6. Herndon M, McMains KC, Kountakis SE. Presentation and management of

extensive fronto-orbital-ethmoid mucoceles. Am J Otolaryngol. 2007;28:145-
147.
7. Wormald PJ. The Agger Nasi cell: the key to understanding the anatomy of
the frontal recess. Otolaryngol Head Neck Surg. 2003;129:497-507.
8. Lee WT, Kuhn FA, Citardi MJ. 3D computed tomographic analysis of frontal
recess anatomy in patients without frontal sinusitis. Otolaryngol Head Neck
Surg. 2004;131:164-173.
9. Serrano E, Klossek JM, Percodani J, et al. Surgical management of paranasal
sinus mucoceles: a long-term study of 60 cases. Otolaryngol Head Neck Surg
2004;131:133-140.
10. Meetze K, Palmer JN, Schlosser RJ. Frontal sinus complications after frontal
craniotomy. Laryngoscope. 2004;114(5):945-948.
11. Mourouzis C, Evans B, Shenouda E. Late presentation of a mucocele of the
frontal sinus: 50 years postinjury. J Oral Maxillofac Surg. 2008;66:1510-1513.
12. Turner JH, Vaezeafshar R, Hwang PH. Indications and outcomes for Draf IIB
frontal sinus surgery. Am J Rhinol. 2016;30:70-73.
13. Metson R, Gliklich R, Cosenza M. A comparison of image guidance systems
for sinus surgery. Laryngoscope. 1998:108:1164-1170.
14. Har-El G. Endoscopic management of 108 sinus mucoceles. Laryngoscope.
2001;111:2131-2134.
15. Har-El G, Balwally A, Lucente F. Mucoceles: is marsupialization enough?
Otolaryngol Head Neck Surg. 1997;117(6):633-640.
16. Lawson W, Ho Y. Open frontal sinus surgery: a lost art? Otolaryngol Clin N
Am. 2016;49:1067-1089.
17. Govindaraj S, Cohen N, Chiu A. Surgical treatment of the lateral frontal sinus
lesion. Operative techniques in Otolaryngol. 2006;17:24-27.
18. Kazuhiro N, Hidaka H, Arakawa K, et al. Outcomes of frontal mucoceles
treated with conventional endoscopic surgery. Acta Oto Laryngologica.
2015;135(8):819-823.
19. Stankiewicz JA, Lal D, Welch K. Complications in endoscopic sinus surgery
for chronic rhinosinusitis: a 25 year experience. Laryngoscope.
2011;121(12):2684-2701.
20. Asaka D, Nakayama T, Hama T. Risk factors for complications of endoscopic
sinus surgery for chronic rhinosinusitis. Am J Rhinol Allergy. 2012;26(1):61-
64.

53
CHAPTER
Section VII: Orbital Trauma
Correction of Orbital Floor
Blow-out Fractures:
Variation 1
Jean-Francois Lefaivre and David Charles A. Fisher
DEFINITION
■ Orbital blow-out fractures commonly result from force directly applied to the
globe with subsequent energy transmission through the thin surrounding bones.
The affected bones are typically the orbital floor and medial wall. It may be
accompanied by entrapment of the inferior rectus muscle and inferior oblique
muscle. True entrapment is a rare clinical finding. It is often mentioned on
radiology reports and must be differentiated from herniation.
■ Orbital floor fractures are often associated with additional facial fractures and
soft tissue injury.
ANATOMY1
■ The orbital floor is composed of thin maxillary and zygomatic bone.
Anteriorly, just behind the orbital rim, the floor is concave and becomes
convex, posterior to the axis of the globe. It is bordered laterally by the lateral
orbital wall, which is relatively thick, and consists of the frontal process of the
zygoma, and greater and lesser wings of the sphenoid. Medially, the floor
slopes upward toward the medial orbital wall, which is also a thin bony
structure, made of the frontal bone superiorly, lacrimal bone anteriorly, and
lamina papyracea of the ethmoid and lesser wing of the sphenoid posteriorly.
The lamina papyracea, as its name implies, is thin and fragile.
■ The inferior orbital fissure is located between the orbital floor and lateral

orbital wall. Structures present in the fissure include the maxillary division of
the trigeminal nerve, infraorbital artery, zygomatic nerve, branches of the
sphenopalatine ganglion, and branches of the ophthalmic vein. The inferior
orbital fissure is also known as the sphenomaxillary fissure (FIG 1).
■ The orbital plate of the maxilla and a portion of the zygoma represent the
orbital floor. The zygoma makes up the anterior portion of the orbital floor,
anterior to the inferior orbital fissure. The infraorbital nerve runs through the
orbital floor in the infraorbital groove posteriorly and in the infraorbital canal
anteriorly. The nerve often provides a landmark and a good plane of dissection.
■ The infraorbital rim is made of zygomatic bone and maxilla. The frontal
zygomatic suture is exposed during dissection. Just inferior to the inferior
orbital rim, the infraorbital foramen is located about 1 cm below the rim,
generally in line with the midaxis of the pupil.
■ Both the orbital floor and medial orbital wall are vulnerable to injury because
they are relatively thin compared to the surrounding structures.
■ Knowledge of anatomy is essential to perform safe dissection and optimal
exposure of the orbital floor defect.
PATHOGENESIS
■ Orbital blow-out fracture is often the result of blunt injury to the globe and/or
orbital rim, sustained during altercations, falls, sports-related injury, or motor
vehicle accidents. These injuries transmit an external force to the orbital
contents and orbital bones. The weakest portion of the orbit then fractures,
resulting in herniation of orbital contents through the bony defect. The anterior
and posterior portions of the orbital floor are thicker. The middle portion of the
orbital floor is thinner, which accounts for the majority of fractures into the
maxillary sinus. The medial orbital wall also commonly fractures into the
ethmoid sinus air cells.
■ The globe typically moves posteriorly, inferiorly, and medially if there is
significant prolapse or herniation of the orbital content into the orbital floor
defect.

FIG 1 • Anatomy of the left orbit.
NATURAL HISTORY
■ Untreated fractures generally result in enophthalmos. Depending on the
volume increase associated with orbital fracture, it will range from minimally
to significantly noticeable. Enophthalmos can be identified clinically with 2
mm of posterior displacement of the globe.2 A 5% increase in orbital volume is
sufficient for a clinical diagnosis of enophthalmos.2 An important part of
informed surgical consent is to discuss the anticipated natural history of
untreated defects. Hypoesthesia in the distribution of a second branch of the
trigeminal nerve generally resolves over several months. Diplopia may
improve if it is secondary to muscle contusion.
■ If an entrapped muscle is not treated promptly, permanent ischemic injury to
the extraocular muscle will result in diplopia. It is the only emergency
associated with orbital floor fractures. Our experience, as previously reported,
is that it is more common in children than in adults.
■ Retrobulbar hematoma that results in optic nerve compression is an
emergency; however, in a blow-out fracture, there is typically an expanded
volume that alleviates the pressure on the orbital apex.

■ Patients with large orbital floor defects are generally treated acutely secondary
to obvious enophthalmos. Patients with more subtle findings may be observed
initially and surgically treated when/if they develop enophthalmos. These are
generally patients with smaller defects on computed tomography (CT) scans.3
■ The decision of whether or not to operate can generally be made within the
first 6 weeks following injury. Longer follow-up may be recommended in
patients managed nonoperatively.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Specific trauma-related history helps elucidate the amount of force transmitted
to the globe and orbit.
■ Previous eye surgery, eye injury, or pathology should be documented as well
as the use of prescription glasses or contact lenses.
■ Physical examination often reveals
■ Periorbital ecchymosis and swelling
■ Subconjunctival hemorrhage
■ Enophthalmos, most easily identified by both a worm’s eye and a bird’s eye
view; may be masked by edema early after injury
■ Diplopia, often in upward gaze
■ Hypoesthesia in the distribution of the second branch of the trigeminal nerve,
involving the cheek, nose, upper lip, gingiva, and upper teeth in various
distributions
■ Visual acuity, extraocular movements, and pupil examination need to be
assessed
■ Preoperative consultation with ophthalmology may be beneficial, especially in
patients with decreased visual acuity or retrobulbar hemorrhage.
IMAGING
■ Orbital or maxillofacial CT scan with 1 to 2 mm axial cuts and coronal and
sagittal cuts will help understand the size and location of the defect, as well as
soft tissue herniation. It will help determine the length and width of the bone
graft or implant required for adequate repair4 (Video 1).

Video p2-c053_01
■ A three-dimensional (3D) reconstruction is often beneficial in patients with
multiple associated facial fractures. It is not essential for isolated orbital floor
fractures.
DIFFERENTIAL DIAGNOSIS
■ Medial orbital wall fractures may result in similar findings.
■ Medial orbital wall defects should be identified preoperatively.
■ Surgical treatment of orbital floor fractures that do not address associated
medial floor fractures will result in only partial correction of enophthalmos.
NONOPERATIVE MANAGEMENT
■ Small defects without herniation of orbital contents and without entrapment
may be managed conservatively with close follow-up.
SURGICAL MANAGEMENT
■ The primary objective of surgical intervention is to recreate normal anatomy
with restoration of the orbital floor integrity and reduction of herniated soft
tissue into normal position. Restoration of orbital shape and volume should
help rebalance extraocular muscles and correct diplopia.
■ Indications to correct orbital floor fractures include the following:
■ Enophthalmos
■ Large orbital floor defects with herniation on CT scan. Some authors mention
that a 1 to 2 cm2 defect or 50% of the orbital floor surface will result in
enough orbital volume increase to result in clinically significant
00:00 / 00:00

enophthalmos.2,3
■ Diplopia associated with entrapment
■ Entrapment with positive forced duction test. Extraocular muscles recover
better if surgically released within 48 hours.
■ Persistent oculocardiac reflex may be associated with soft tissue entrapment.
Patients who benefit from early surgical intervention are those presenting with
nausea, vomiting, and bradycardia, exacerbated with upward gaze.2
Preoperative Planning
■ Complete review of the chart including medications is important, particularly
anticoagulants.
■ If long-acting dilating eye drops are used by ophthalmology, it is generally
recommended to wait before taking the patient to the operating room. Pupil
diameter is assessed preoperatively. If a pupil dilates intraoperatively, it is often
secondary to excess retraction. This phenomenon cannot be observed in
patients with pupils pharmacologically dilated.
■ If the patient has a retrobulbar hematoma, clearance from ophthalmology prior
to surgery is recommended.
■ A thorough eye examination should be performed by the plastic surgeon and
documented in the chart preoperatively.5
■ Clearance from trauma team, neurosurgery, and other consultants is obtained
prior to surgery.
■ Timing of surgery depends on associated injuries. It may be beneficial to wait
a few days and operate after periorbital swelling improves.
■ CT scans are reviewed. The decision to proceed with bone grafts and titanium
or resorbable implant is often made preoperatively. Other types of implants
have been associated with complications such as extrusion3 (Video 1).
■ Informed consent is obtained. Risks, goals, and benefits are explained to the
patient or family members. Risks include bleeding, infection, scar, ectropion,
diplopia, residual enophthalmos, hypoesthesia, need for additional surgery, and
blindness.
Positioning
■ Patient is in supine position, operating room table rotated 90 or 180 degrees.
■ Vertex should be aligned with the head of the bed. This will help decrease
surgeon fatigue and discomfort.

■ In patients without cervical injury, the head of the bed could be slightly
extended to better visualize the orbital floor.
■ In patients with cervical injury, the cervical collar is left in place and the whole
table can be placed in Trendelenburg to help visualize the orbital contents.
■ A headlight is essential. Battery-powered headlights provide more freedom,
allowing the surgeon to review the CT scan if necessary and to evaluate the
patient in worm’s eye and bird’s eye views alternatively.
■ Loupe magnification is based on preference.
■ Operating room monitor with ability to project CT scan is also helpful.
■ Sequential compression devices and body warmers are applied to all patients
unless contraindicated.
Approach
■ Subtarsal incision or transconjunctival incision provides adequate exposure.
■ The subciliary incision carries a higher risk of ectropion and should be
avoided.3
■ The subtarsal incision is rapid, reliable, and easy to learn. It is also easier if
one has to reoperate in a complex panfacial fracture patient. The key step is to
preserve a strip of pretarsal orbicularis muscle to decrease the likelihood of
postoperative ectropion.
■ When using a transconjunctival incision, a modified lateral canthotomy6,7 is
helpful. This gives better exposure than does a regular transconjunctival
approach and avoids a lateral canthotomy. Entropion is a rare complication
associated with the transconjunctival approach.8
■ With either incision, the surgeon must visualize all edges of the floor defect.
T E C H N I Q U E S
■ Markings and Preparation
■ Marking is made in the preoperative holding area in a natural eyelid skin
crease for subtarsal approach (TECH FIG 1A–C).
■ General anesthesia with an oral RAE tube improves surgical access
compared to a regular orotracheal tube. If a regular tube is used, it is taped to
the chin. For patients with multiple facial fractures, the orotracheal tube is

often wired to a permanent bicuspid or molar. If the patient has maxillary
and/or mandibular fractures requiring intraoperative assessment of occlusion,
a nasal RAE tube is used and secured to the nasal septum with a 0-silk suture.
■ Infiltration of lidocaine 1% with epinephrine 1:100 000 on the lower lid and
over the infraorbital rim prior to prepping and draping allows enough time for
effective vasoconstriction.
■ After prepping and draping, the eyes are thoroughly irrigated with balanced
salt solution. Normal saline solution is generally avoided because the pH may
not be balanced.
■ Forced duction test is performed as a baseline.
■ Corneal protector and ocular lubricant are applied.
■ Tension is applied on the lower lid through either traction sutures or a
double-pronged skin hook pulling superiorly and away from the globe
(TECH FIG 1D).
TECH FIG 1 • A. Planned incision in a natural skin

crease, below the level of the tarsal plate and below
the pretarsal orbicularis muscle. It can be extended
laterally in the crow’s feet to provide better exposure.
B. The incision is drawn in a natural skin crease and
extends laterally and downward in the crow’s feet. C.
By pulling downward on the eyelid, it is easy to see
that the pretarsal portion of the orbicularis oculi
muscle will be preserved. D. The surgeon is standing
at the head of the bed. This will allow better access to
the orbital floor. Once a corneal protector is in place,
the double hook is used to apply tension upward on
the lower lid while the assistant pulls downward to
apply countertraction while the incision is made
through skin only. The blade is then placed tangential
to elevate skin from the orbicularis muscle. An incision
through the orbicularis muscle is made lower than the
skin incision with the tenotomy scissors.
■ Exposure
■ Subtarsal skin incision with no. 15 blade
■ The blade is turned tangential to the skin to elevate skin over the underlying
orbicularis oculi muscle for a few millimeters.
■ Curved iris scissors are used to split the orbicularis muscle parallel to fibers,
exposing the underlying preseptal plane. This is a stepped approach with
orbicularis oculi incision slightly below the level of the skin incision.
■ Meticulous hemostasis is provided with electrocautery through an insulated
needle tip at a low setting or with bipolar cautery.
■ Blunt dissection is performed with a finger down to the infraorbital rim in an
avascular plane. Good exposure of the infraorbital rim is provided (TECH
FIG 2A–C).

TECH FIG 2 • A. Suborbicularis dissection proceeds
to the infraorbital rim. Gentle traction with skin hooks
provides excellent exposure. B. This plane is relatively
bloodless, following areolar tissue. C. The inferior
orbital rim is exposed. Corneal protectors are always
used when skin hooks are used to retract tissue
around the eye. D. Once the inferior orbital rim is
exposed, the malleable retractor is placed over the
orbital contents and a Desmarres eyelid retractor is
used to retract the lower lid. Electrocautery is used to
incise the periosteum. E. An assistant holds the
Desmarres retractor while the surgeon holds the
malleable and periosteal elevator to expose the
defect.

■ Infraorbital rim periosteum at the anterior edge is incised with electrocautery
(TECH FIG 2D).
■ Subperiosteal dissection is initiated over the anterior edge of the infraorbital
rim, from medial to lateral, followed by intraorbital subperiosteal dissection.
Wide subperiosteal dissection, often well beyond the fracture site,3 is
required to provide adequate exposure of the defect.
■ An orbital retractor or malleable retractor is used to gently retract the
orbital contents away from the floor (TECH FIG 2E).
■ A graduated orbital retractor helps determine how far into the orbit the
dissection extends. The orbital apex is typically 45 mm from the
infraorbital rim. This distance should be kept in mind as one dissects from
anterior to posterior. Most orbital floor fractures will be within 30 to 35
mm from the infraorbital rim. This should have been measured
preoperatively on the CT scan.
■ Bradycardia may be encountered if too much pressure is applied to the
globe. If this occurs, retractors are removed until the heart rate normalizes.
Ongoing communication with the anesthesia team is essential.
■ The corneal protector is removed to assess whether the pupil has dilated
secondary to retraction/pressure on the globe. If this is the case and there are
no medical contraindications, intravenous dexamethasone may be used
intraoperatively and postoperatively for 24 to 48 hours.
■ Dissection also includes reduction of all herniated soft tissue. There is
generally an areolar plane over the infraorbital nerve. Avoid grasping the
nerve while reducing orbital contents.
■ Hematoma inside the maxillary sinus is aspirated. Irrigation of saline or
bacitracin solution is also helpful in draining maxillary sinus hematoma.
■ Use of 1 × 3-in. neuropledgets can help hold intraorbital fat and assist with
exposure. They can be soaked in epinephrine solution to aid in hemostasis.
■ Implant Placement and Completion
■ The orbital floor defect is measured. It should correlate with preoperative
measurements based on CT scan. An implant slightly longer and wider than
the defect is chosen. It may have to be cut to the desired size.
■ The bone graft or implant is carefully applied (TECH FIG 3A; Video 2),
making sure that it rests over the posterior ledge of the defect and does not

prolapse into the maxillary sinus. It should extend 1 or 2 mm beyond the
posterior ledge. A longer implant or graft may impinge on the posterior
aspect of the inferior rectus muscle or orbital apex structures.
Video p2-c053_02
■ The graft or implant must be properly positioned (TECH FIG 3B,C). This is
the most critical portion of the procedure.
■ Enophthalmos should be corrected. The globe position will appear slightly
overcorrected because of intraoperative swelling.
■ A forced duction test is repeated to be certain there is no entrapment (TECH
FIG 3D; Video 3). The globe is rotated upward to make sure that there is no
inferior rectus muscle entrapment. The globe is also moved laterally to make
sure that there is no medial rectus muscle entrapment in the case of
associated medial orbital wall fractures. The corneal protector is removed to
perform this test and reapplied afterward.
00:00 / 00:00

Video p2-c053_03
00:00 / 00:00

TECH FIG 3 • A. Once the defect is completely
exposed, a bone graft or titanium implant is placed to
bridge the defect. B. Titanium orbital floor implant
similar to the one used in surgery. The medial
extension “M” and the anterior four extensions are cut
prior to insetting. C. Titanium orbital floor implant in
place; left orbit with suction tip in medial position and
malleable retractor holding the orbital content. The
anterior edge of the implant is behind the inferior
orbital rim. Note that the plate has been trimmed to
cover the defect. D. A forced duction test is performed
after the implant or bone graft is placed on the orbital
floor. It is better to perform a forced duction test before
surgery, as a baseline, to be able to better appreciate
changes following the procedure.
■ Irrigation with bacitracin solution
■ Closure of the periosteum with resorbable suture such as 3-0 or 4-0 Vicryl
suture
■ Hemostasis is re-evaluated.

■ The orbicularis muscle is redraped.
■ Orbicularis muscle may be resuspended laterally to the periosteum of the
lateral orbital rim to provide support.
■ Skin can be closed with a running 5-0 Prolene suture or with 6-0 interrupted
fast-absorbing gut suture.
■ Corneal protector is removed. Eyes are irrigated again with balanced salt
solution.
■ Temporary tarsorrhaphy may be applied through the gray line, lateral to the
lateral limbus with 6-0 Vicryl or 5-0 plain gut suture in patients on whom
postoperative chemosis could be a concern.
■ Eyes are thoroughly irrigated with balanced salt solution.
■ Lacri-Lube or ophthalmic ointment is applied in the eye and over the suture
line.
■ Frost suture is applied to provide gentle traction to the lower lid. It is
removed 48 to 72 hours after surgery, after swelling improves.
■ At the completion of procedure, communication with the anesthesia team is
essential in order to avoid Valsalva, traumatic emergence from anesthesia and
perioperative hypertension.
PEARLS AND PITFALLS
Physical
findings
■ Enophthalmos may not be obvious initially because of swelling.
Decreased range of motion of extraocular muscles does not mean
entrapment. Entrapment is rare. Oculocardiac reflex should raise
the suspicion for entrapment. A forced duction test can be used in
selective cases to rule out entrapment. Visual acuity should be
assessed preoperatively.
Technique
■ It is important to dissect the orbital floor to expose the entire
defect to make sure that anatomic repair is achieved. Placement of
plate or bone graft should be done under direct vision to make sure
that it covers the posterior ledge of the defect without going too far
posteriorly. An intraoperative forced duction test helps ensure that
there is no entrapment after the plate or bone graft is applied.
Postoperative
care
■ Failure to recognize and address a retrobulbar hematoma may
result in decreased visual acuity.

POSTOPERATIVE CARE
■ Patients are generally observed overnight, with the head of the bed elevated 30
degrees. Most patients without concomitant injuries are discharged the morning
after surgery.
■ Extraocular movements and visual acuity need to be evaluated soon after
surgery.
■ If a Frost suture or a tarsorrhaphy suture is placed, it is generally removed
after 48 to 72 hours, when swelling starts to resolve.
■ Periorbital edema is expected as well as blurred vision secondary to ocular
edema. If there is any significant decrease in visual acuity, the patient may
have a retrobulbar hematoma. This is a surgical emergency, requiring
decompression of the orbit in order to prevent blindness.
■ Patients should avoid nose blowing early after surgery because there is a risk
of pneumo-orbit with air extending to the soft tissue envelope. Over-the-
counter nasal spray is recommended postoperatively.
■ Lacri-Lube is recommended for patients who cannot completely close their
eyelids.
■ A postoperative CT scan may be indicated if there is any question about
residual enophthalmos (Video 4). Diplopia is often seen early postoperatively
and usually gets better over a few weeks, sometimes a few months. Patients
should do range-of-motion exercises. If diplopia persists, ophthalmology
consultation is indicated.
Video p2-c053_04
00:00 / 00:00