Combined intracranial and extracranial approach for reconstruction of widened orbital distance

Treating diseases: brain swelling Indication 1. Moderate or severe interpupillary widening. 2. The sieve plate is lower than the plane of the nose and forehead. 3. Combined with brain bulge. Contraindications 1. A child with mental retardation or dementia. 2. Mild pupil distance is widened. 3. The general condition is poor, and can not tolerate long-term general anesthesia under craniotomy. Preoperative preparation 1. Complete the various preoperative examinations listed below to fully understand the patient's local deformity and extent. (1) Clinical examination: Various measurements are made on the above-mentioned malformations, and other abnormalities of the face are examined and described. (2) Ophthalmic examination: including vision, light reflection, eye movement and fundus. Also pay attention to the presence or absence of strabismus. Visual field and eyeball protrusion should be checked. (3) Nasal examination: pay attention to the situation in the nasal cavity, whether there is a nasal septum deviation, whether there is brain swelling, whether the smell is normal or not. (4) Neurosurgical examination: According to the clinical needs, exercise function examination, EEG or angiography can be performed. (5) Radiation examination: The conventional skull radiography examination of the anterior and posterior position can show that the pupil distance is too wide, and it can also show the vertical asymmetry. The inner side wall and the outer side wall of the crucible can be displayed on the base tomographic X-ray sheet, such as length, thickness, degree of displacement, and angle. If the distance between the inner side walls of the two sides is the same as before and after, even if the front is narrow and wide, the operation is difficult. Generally it is wide before the front and narrow. The distance between the optic nerve holes on both sides can also be displayed on the tomographic radiograph. The anterior and posterior tomographic X-ray films show the condition of the superior and inferior wall of the ankle. Pay attention to the position of the sieve plate from the X-ray film. Patients with widened distances often have a sieve plate prolapse. At the same time, the development and extent of frontal sinus and ethmoid sinus The CT film provides clear images of the brain, ventricles, and sputum and helps to design surgical procedures and postoperative complications. 2. Complete liver, kidney, heart, lung function tests and blood biochemistry, blood gas and other related tests to understand the patient's overall condition. 3. 2 days before surgery, start with antibiotic droplets, nose, mouth, spray the mouth, and cut the nose hair. 4. Start antibiotics and hemostasis drugs 1 day before surgery. 5. Early blood matching 2000 ~ 3000ml spare. 6. Wash your hair and take a shower. Wash the head with 1:1000 chlorin, and shave the head. Surgical procedure 1. Flip the scalp frontal flap to reveal the head and face skeleton A bilateral scalp coronal incision was made on both sides to the upper edge of the zygomatic arch and in front of the tragus, and the superficial temporal artery was retained in the flap. In order to reduce bleeding, the suture can be sutured on both sides of the incision line before the incision, and the physiological saline containing 1:500,000 epinephrine is injected between the two lines of suture, or the scalp is wounded after cutting the epidermis. The scalp clip on the bleeding site. Under the scalp cap-like aponeurosis, the flap was turned upside down on the periosteum, and the periosteum was cut transversely 1 cm above the upper edge of the iliac crest. From then on, the periosteum was attached to the flap. Continue to peel down. When peeling to the upper hole, the lower wall of the hole is cut to relieve the bundle of nerve fibers. Peeling from the periosteum into the upper, inner and outer sidewalls of the ankle. Strip the trochle, medial malleolar ligament and lateral malleolus ligament. The ligament sutures are respectively identified as signs. Peel the lacrimal sac from the tear groove. Peel the sides of the humerus and the lower edge of the zygomatic arch on both sides. From the coronal incision can be revealed to the lower edge of the nasal bone, and the nasal mucosa behind the nasal bone is separated by a curved separator. It can be further separated under the perichondrium of the alar cartilage, and care should be taken to avoid piercing the nasal mucosa. 2. Osteotomy and intracranial osteotomy On both sides of the midline of the frontal bone, two bone flaps are respectively turned up, and each bone flap carries a periosteum pedicle on the temporal side. Or designed as a bone flap, osteotomy and craniotomy. Place cerebrospinal fluid to reduce intracranial pressure. The dura mater on both sides of the anterior cranial fossa was dissected to expose the anterior cranial fossa 3. The lateral wall osteotomy The muscle is cut off in the upper part of the anterior border of the diaphragm, and the leading edge of the muscle is peeled back, and the boundary line between the medial side and the anterior side of the armpit is detected. Use the osteotome to cut along the longitudinal line of the boundary line (up and down) and enter the sputum, which is the posterior chisel seam of the outer wall of the iliac crest. Use a micro-thin saw to cut the outer side wall longitudinally. If the outer side wall of the crucible is too thin to open the outer outer side wall, the outer side edge of the crucible is separately opened, so that the thickness of the entire outer side wall moves inward. 4. Cut off the widened bone between the two iliac crests and remove the ethmoid sinus The intercondylar space is revealed by removing the bone piece of the anterior wall between the medial or two median sides. First remove the inner part of the nose and maxillary frontal projection, which is equivalent to the part below the plane of the sieve plate. The deep side of the bone plate is the nasal mucosa, and the deep side of the midline is connected to the nasal septum. You can use a micro-bone drill to remove the bone boundary, but do not wear deep mucosa. Starting from the lower edge of the nasal bone with a small curved separator, the mucosa is gradually separated, the bone is gradually removed with a rongeur, and the bone can be assisted by a micro-bone drill. Remove the nasal bone that is connected to the nasal septum. Use a curette to scrape off the left and right loose sinus air chambers. When scraping the sinus sinus air chamber, the nasal mucosa of the inner side of the sinus sinus should be avoided. At the same time, the inner wall of the sinus sinus should be prevented from rupturing. Under the condition of protecting the dura mater, the part of the frontal part of the plan is removed. Carefully separate the nasal mucosa below the sieve plate and separate the dura mater above the sieve plate. With the small bone chisel, small rongeur and micro drill, the planned sieve plate is gradually removed from front to back. In order to bring the eyelids on both sides closer together, the ethmoid sinus in front of the cockscomb should also be removed. 5. Removal of nasal septum The nasal septum can appear too thick, bifurcated and curved. In order to allow the eyelid to move to the proper position and keep the nasal passages open, it is sometimes necessary to remove the cartilage of the nasal septum. The method is to separate the nasal septum mucosa from the front and then remove part of the nasal septal cartilage. All or most of the nasal septum should be removed if necessary, including cartilage and nasal septum mucosa. If the nasal septum is removed, a uniform nasal passage is formed on both sides, and the remaining midline nasal mucosa is sutured from the front to the back in the plane of the nasal floor to cover the exposed nasal septal cartilage. Continue suturing upwards, pulling the nasal mucosa toward the midline at the top and suturing it. So the nasal cavity is separated from the anterior cranial fossa. At the top, the mucosa is pulled to the midline suture, and the ineffective cavity outside the mucosa is destroyed by the inner wall of the tendon moving toward the midline. If the septum is bifurcated, the skeleton is removed, leaving the mucosal lining and continuity with the sinus lining. The mucosa on the upper part of the septum and the upper turbinate contains olfactory receptors, which should be removed under the mucosa and the middle turbinate should be removed. The mucosa must be preserved. When the median bone mass is removed, the bone resection continues upwards, entering the cranial fossa on either side of the sieve deck. 6. Incision of the anterior cranial fossa and the medial and lateral iliac crest A transverse bone incision line is made about 8 to 10 mm in front of the optic nerve and crossed the dome. When the line is reached, it can be crossed behind the sieve plate and continuous with the incision line on the other side of the sieve plate. The bone incision line is then passed around the edge of the outer edge of the screen deck. Extend the incision line through the posterior wall of the eyelid and the back of the tear. On the outside, it is connected to the incision line through the lateral wall of the ankle. 7. upper bone incision A transverse osteotomy was made 1 cm above the dome, extending through the upper iliac crest above the lateral wall of the iliac crest. On the inside, it is connected to the longitudinal osteotomy line of the intercondylar area. This osteotomy line also penetrates the wall before the anterior cranial fossa. 8. Underarm bone incision The skin and orbicularis oculi muscle were cut transversely at 0.25 cm below the iliac crest and separated down the septum to the inferior temporal margin. The periosteum of the infraorbital margin was cut transversely, and separated along the periosteum, to the posterior plane of the inferior tibiofibular fissure, and the inferior wall of the inferior iliac crest was traversed. The inner end of the osteotomy line was wound around the posterior tibial groove. The front side of the maxilla is cut transversely below the underarm hole, and the inner side is plucked into the plow hole. The mucosa of the nasal side wall was peeled back from the plow hole, and the lateral nasal wall was cut back from the edge of the plow hole. 9. The posterior wall of the humerus is incision From the armpit, extend into the osteotome, and explore the lateral part of the inferior tibiofibular fissure, and cut the posterior bone of the tibia from the inferior tibiofibular sulcus and meet the lower end of the longitudinal tibial line. Here is the blind operation. 10. Two eyes move inward At this point in the operation, the portion of the cut eyelid has been easily moved. Move the two turns to the inside. In the case of internal eyelid movement, in the case of resistance, it is usually that the maxillary frontal process is not sufficiently cut at the proximal base, and can be cut with a bone knife. 11. Internal fixation and bone transplantation An inter-segmental small steel plate or wire is placed between the frontal bone skeleton and the inwardly moving truss. The humerus or rib graft is wedged into the space between the lateral wall of the ankle and the humerus to maintain the inward position of the eyelid. 12. Stitching fixation of the medial malleolar ligament Re-find the inner end of the medial malleolar ligament, and use a soft wire to wrap the two to prevent the ligament from being cut. One ligament is used for each ligament. A bone hole is made in the inner side wall of the crucible so that the ligament can be attached to the bone. This hole is later in the tears, after the tears are placed, in the plane of the forehead. The most important thing is to get the ligaments completely into the bone hole. In this way, the postoperative ligament can be prevented from dissociating. Each wire traverses through the nasal root and contralateral bone holes, and passes out of the skin from the contralateral inner iliac crest, and then passes through the prepared iodoform gauze pad and resin buckle, respectively, and tightens and kinks. When the wire is used, the skin of the inner palate can be adhered to the bone surface to minimize the interpupillary distance. If the intrinsic ligament is not separated during surgery, this step is omitted. 13. Nasal deformity and bone graft It is often necessary to remove too much soft tissue along the nares. When the nose is split, the bone graft is placed on the back of the bone when the tip of the nose removes excess skin and repeated cartilage. The bone graft extending to the tip of the nose is fastened with a wire that passes through the nasal bone. The nose can be lengthened by a VY propulsion flap or a Z-shaped remodeling formed at the nasal forehead. The outer cymbal can also be secured to the bore of the outer edge of the cymbal with a wire. 14. Closure and dressing of the wound Check for meningeal tears and cerebrospinal fluid leakage, and the sutures are repaired with sutures. The meninges are sutured in small holes in the edge of the defect to prevent ineffective cavities and submucosal hematoma. Put back the skull, usually without wire ligation in place to accommodate short-term cerebral edema. The scalp coronal incision and the incisional incision were sutured. For temporary sutures. Negative pressure drainage is placed on both sides of the frontal flap. Make a medium pressure bandage on the head. complication Death Surgery mortality has been reported as high as 3% to 7.1%. Common causes of surgical death are cerebral edema, excessive blood loss, and postoperative intracranial infection. Precautionary measures are to make a careful surgical plan before surgery, careful operation during surgery, reduce surgical bleeding, pay attention to hemostasis and timely blood transfusion, maintain effective blood volume and maintain blood pressure at normal levels, timely prevent and treat brain edema, use high-efficiency, broad-spectrum antibiotics to prevent infection . 2. Brain edema The main causes are intraoperative breathing, cardiac arrest and ventilatory disorders (causing hypoxia and carbon dioxide accumulation), excessive craniotomy and intraoperative compression or overstretching of brain tissue. In order to prevent cerebral edema, surgical trauma should be reduced, operation time should be shortened, intraoperative airway should be kept unobstructed, and ventilatory dysfunction should be prevented or released in time. Oxygen should be given to avoid cerebral hypoxia. 20% mannitol 250-500 ml should be given before craniotomy. , lateral ventricle puncture, or directly cut the dura mater, appropriate release of cerebrospinal fluid, suture the dural incision after surgery, do not make a solid fixation when the frontal bone flap is placed back, only a few needles periosteal suture, and can be placed on the temporal side of the bone plate The edge bite off some bones, so that there is room for buffering postoperative cerebral edema. It is not advisable to over-tighten the head wound dressing to prevent the frontal bone plate from being sunken. If necessary, the head bandage should be removed, and the fluid input should be controlled after surgery. Intravenous infusion of 20% mannitol 250ml, 2 ~ 3 / d, for 3d. 3. Insufficient ventilation of the respiratory tract The main reason is that the two sides of the nose are close together in the operation, resulting in poor ventilation of the nasal cavity, or due to swelling of the nasal mucosa after surgery. During surgery, the hypertrophy of the turbinate should be removed or the thickened, curved septal cartilage should be removed, or even the entire septum. It is also possible to bite off the edge of the plow hole that moves inside on both sides. After the operation, the two nostrils were built into the appropriate size of the snorkel for 5 to 7 days. If necessary, make a tracheostomy, and extubate the tube after the swelling subsides after surgery. 4. tilt The movement of the two jaws after the osteotomy is based on the extent of displacement of the medial aspect of the ankle. If the walls of the jaws move at the same distance, the simple rotation of the eyelids around the longitudinal axis will cause the outer sidewall of the jaw to protrude forward. The main cause of squatting is the lateral and lateral pull of the lateral wall when the eyelid is displaced inward (the latter comes from the residual tension in different structures), the postoperative scar contraction, and the role of the orbicularis muscle. Prevention: When separating the iliac crest, it is necessary to avoid the separation of the medial malleolar ligament. The inner wall of the iliac crest should be removed, that is, a small wedge-shaped bone wall should be cut off from the dome to the inner wall of the iliac crest, so that the anterior wall of the iliac crest is the smallest, thus reducing the two Awkward pull. 5. Internal displacement The reason was that the iliac ligament was removed during the operation and no internal fixation was performed. Prevention: Try to keep the normal iliac crest of the medial malleolus ligament during surgery to avoid stripping the medial malleolus ligament. If it has been stripped, it should be used for internal fixation. 6. The ptosis The reason is that the anterior protrusion of the levator levator or the truss during the operation causes the upper eyelid to lose the support of the eyeball, or the outer iliac crest is displaced downward, so that the outer side wall portion of the upper jaw is moved downward to form a sag. Be careful not to damage the upper levator musculature during surgery. When the wall is peeled off along the aponeurosis, it can prevent damage to the levator levator. Be careful not to make the protrusion when moving the truss inside. 7. Eyeball invagination The reason is that the outer side wall of the ankle protrudes forward, causing the eyeball to retreat. It can also be caused by the release of fat from the sputum into the ineffective cavity outside the sputum. The removal of a small wall of the crucible on the inner side wall of the crucible improves the extent of the protrusion of the outer side wall of the crucible. Close the bone defect of the eyelid to prevent fat from coming out.

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