1 Principles topenlarge
Because NOE type I injuries represent a noncomminuted fracture, the goal should be to achieve a perfect reduction of the frontal process of the maxilla.
The fracture then requires internal fixation to maintain its proper position. This could include 1-, 2-, or 3-point fixation.
The proper repositioning of the fragment and thus the medial canthal tendon is crucial to the final result.
Great care should be taken when considering placing plates anterior to the medial canthal ligament as these may be visible through the thin overlying skin.
Nasal bone involvement
If the nasal bones are also fractured, they should be reduced.
Selection of approach
The most common access for reduction of NOE type I fractures includes the extended glabellar and the maxillary vestibular approaches. Existing lacerations can also be used. The lower eyelid approach may be used in case of associated zygomatic fractures. For isolated unilateral NOE type I fractures a coronal approach is usually not necessary.
2 Reduction topenlarge
NOE type I fractures are usually not difficult to reduce because they are not comminuted.
While visualizing the reduction of the bone fragment through one surgical approach, the surgeon must continually recheck the reduction through the other surgical incisions.
3 Fixation topenlarge
Displaced NOE type I fractures require internal fixation to maintain proper position. This could include 1-, 2-, or 3-point fixation.
NOE type I fractures that are hinged at the frontomaxillary suture, repositioning of the frontal process of the maxilla by rotating the infraorbital segment nasally may only require one point exposure and fixation at the piriform aperture via a maxillary vestibular incision.
NOE type I fractures that require fixation at the frontomaxillary/frontonasal junction may require an extended glabellar approach or a transconjunctival approach with medial extension for fixation at this fracture site. For isolated unilateral NOE type I fractures a coronal approach is usually not necessary.
Placement of first plate
The first plate is generally placed inferiorly, from the fractured fragment to the solid maxillary bone of the piriform aperture. This is performed through a vestibular incision.
In some cases the bone fragment may be hinged superiorly so that inferior fixation may be sufficient.
Placement of a second plate
If two-point fixation is needed, the second plate is placed at the frontonasal suture.
Placement of third plate (if necessary)
A third plate may be necessary in case of associated fractures.
Pearl: preliminary fixation of first plate if more than one plate is needed
A recommendation would be to place and loosely tighten just one screw on each side of the fracture allowing for minimal movement of the segment. This allows some 3-dimensional movement and correction for a further reduction during the other 2-point fixation. After the other point or points have been fixated, the final screws will then be placed in the first plate.
4 Fixation topenlarge
A problem with NOE fractures is that even with a perfect bony reduction there may be a lack of definition in the medial canthal area (Epicanthal fold). Many surgeons advocate placing some sort of external nasal splints at the end of the procedure. If one chooses to use this technique, extreme caution is recommended. Patients will commonly have significant postoperative edema in this area, surgical incisions and lacerations can be present. If the splints are placed too tight, the patient is at risk of having
skin necrosis in the medial canthal area.
This technique may be more relevant with the increased complexity of the NOE fracture. It may not be as applicable with a simple type I fracture where there has been minimal degloving of the soft tissues from the bone in the medial canthal area. It may be more beneficial in type II and type III fractures where there has been more comminution associated with a greater need for degloving of the soft tissues to achieve adequate reduction and fixation.
However, NOE type I fractures usually give good result as far the definition in the medial canthal area.