Reconstructive Interventions in Posttraumatic Deformities and Defects of a Cranioorbital Area

S.A. Eolchiyan, A.A. Potapov, M.G. Kataev, N.K. Serova, A.S. Karayan, V.V. Roginsky, I.N. Pronin,
V.O. Zakharov, A.V. Evseev

(Burdenko Research Institute of Neurosurgery of the Russian Academy of Medical Science, Moscow)

Cranioorbital injuries are one of the most complicated and frequent types of craniofacial trauma in neurosurgical practice. Trauma of a cranioorbital area is accompanied by simultaneous craniocerebral injury and results in damage of an orbit and its structures, a middle facial zone and accessory nasal sinuses. This circumstance conditions use of a definite algorithm of treatment. Its absence leads either to unjustified delay or unintentional refuse from surgical interventions on the visceral skull and orbit, which should be performed in an acute period, or aggressive debridement with removal of free-lying bone fragments and formation of extensive defects and deformities in a cranioorbital area. In its turn, it causes dystopia of an eyeball, oculomotor disorders and diplopia, cosmetic defects, being a cause of additional invalidism and lower quality of life.

There were 134 patients (5-76 years old) with craniofacial trauma and its sequelae, operated in the Burdenko Institute of Neurosurgery in 1998-2001. All of them were subject to craniography, CT examination in axial and frontal planes. Planning of operations in complicated cases was carried out with application of three-dimensional CT and stereolithographic models. We performed 157 operations in 134 patients. There were 97 (62%) reconstructive operations on the skull and visceral skeleton. Other intra- (37) and extracranial (23) operations were performed in 60 patients.

We elaborated different types of reconstructive operations in traumatic deformities and defects of a cranioorbital area, based on application of an autobone and fixation with mini- and microplates and screws. Depending on a character and spread of injuries, as well as temporal parameters, we performed one- or multi-stage operations. Their goal was restoration of a forehead shape, contours and size of an orbit; elimination of hernial protrusion of brain substance into an orbit and separation of orbital structures from the skull cavity and/or accessory sinuses; reposition of eyeballs, restoration of their movements, elimination diplopia and preparation of an orbit for subsequent ophthalmoplasty.

A total number of reconstructive operations for deformities and defects of a cranioorbital area was equal to 87; 55 of them (63.2%) were interventions for bone defects and deformities of a frontoorbital area. Isolated deformities and defects of zygomaticoorbital and nasoorbital areas, walls of an orbit were eliminated during performing 32 (36.8%) out of 87 operations. Bone autografts, in particular splitted skull bones (28 cases), were used 34 patients during reconstructive interventions on a cranioorbital area. In case of absence of any communication between bone defect and accessory sinuses methyl methacrylate was used (17 cases). We managed to achieve satisfactory functional and cosmetic results in the majority of patients.

Optimum results can be attained in two cases: when primary reconstructive operations and neurosurgical interventions are performed simultaneously in an acute period or when the former are the second-stage operations, made in an early period of trauma after stabilization of a patient's general condition. Elimination of defects and deformities of a cranioorbital area in a remote period often requires repeated interventions for obtaining a satisfactory cosmetic and functional effect.