Tái tạo chấn thương phức hợp mũi – sàng – ổ mắt hai bên ReconstruCTion of complex bilateral nASO-orbito-ethmoid and orbital trauma

Naso-orbito-ethmoid (NOE) fractures are among the more complex injuries of the central midface. Beyond nasal deformity, displacement of the central facial skeleton can alter orbital shape and volume, affect globe position, injure the lacrimal drainage system, and, in severe trauma, occur in association with anterior skull-base injuries.

This case involved a 24-year-old man who sustained extensive craniofacial trauma following a road traffic accident, including an anterior frontal sinus wall fracture, bilateral NOE fractures, and a right zygomaticomaxillary complex fracture.

When central facial displacement affects both orbits differently

Following the injury, the central nasoethmoidal complex was displaced posteriorly and toward the left.

This produced different effects on the two orbits.

On the right side, displacement of the orbital framework resulted in enlargement of the orbit, contributing to posterior displacement of the globe and post-traumatic enophthalmos.

On the left side, the orbital space became relatively narrowed, resulting in relative anterior displacement of the globe.

Together with the right zygomatic injury, these changes produced severe distortion of the central and upper facial skeleton.

The injury was further complicated by comminuted fractures of both orbital roofs communicating with the frontal sinus region.

The reconstructive objective was therefore not simply to fix individual fracture lines, but to restore the three-dimensional architecture of the entire frontal–nasoethmoidal–orbital–zygomatic complex.

Reconstructing the facial framework before reconstructing the orbit

Surgical exposure was obtained through a bilateral coronal approach, providing wide access to the frontal bone, superior orbital rims, nasoethmoidal region, and zygomatic arches.

The displaced skeletal components—including the nasoethmoidal complex, anterior frontal sinus wall, and right zygomatic complex—were repositioned toward their anatomical locations and stabilized with internal fixation.

Accurate restoration of the skeletal framework surrounding the orbit was a critical step.

The orbit is a complex three-dimensional structure. If its surrounding boundaries are not correctly repositioned before orbital wall reconstruction, the final orbital shape and volume may remain inaccurate even when the wall defect itself is adequately covered.

Once the surrounding framework had been restored, the orbital defects were reconstructed with titanium mesh to reproduce the original orbital anatomy and volume as closely as possible.

The overall objective was to simultaneously restore midfacial architecture, orbital symmetry, and globe position.

Why NOE injuries require careful assessment

NOE trauma can produce much more than flattening or displacement of the nasal bridge.

The nasoethmoidal region lies at the anatomical intersection of the nose, orbits, frontal sinus, and anterior skull base. High-energy trauma in this area can therefore involve several functionally important structures.

Displacement of the medial orbital walls can alter orbital volume and globe position. The lacrimal drainage apparatus may be injured. Extension of the fracture toward the skull base may be associated with cerebrospinal fluid leakage and intracranial complications.

In orbital trauma more broadly, acute complications such as retrobulbar hemorrhage with orbital compartment syndrome must also be recognized promptly because delayed treatment can result in permanent visual loss.

Assessment of complex central facial trauma should therefore extend beyond the obvious nasal deformity or individual fracture lines and consider the entire craniofacial injury pattern.

The role of the coronal approach

The coronal approach is a classic craniofacial surgical exposure that provides broad access through an incision concealed within the scalp.

Depending on the extent and plane of dissection, it can provide excellent exposure of the frontal bone, superior and lateral orbital regions, nasoethmoidal complex, zygomatic arches, and adjacent craniofacial skeleton.

In extensive injuries such as this one, wide exposure allows multiple displaced skeletal components to be visualized simultaneously and reconstructed as part of a single anatomical framework rather than treating each fracture independently through multiple limited incisions.

Surgical access to the zygomatic arch and temporal region also requires careful consideration of the anatomy of the frontal branch of the facial nerve. Injury to this branch may result in weakness of forehead movement. Appropriate surgical planes and detailed knowledge of the temporal anatomy are therefore essential when exposing this region.

Craniofacial trauma reconstruction is a three-dimensional problem

This case illustrates a fundamental principle of complex craniofacial trauma reconstruction:

The orbit cannot be accurately reconstructed until the skeletal framework surrounding it has been accurately restored.

Even a few millimeters of residual displacement involving the nasoethmoidal complex, orbital rims, or zygomatic skeleton can alter orbital geometry and volume, potentially affecting globe position and facial symmetry.

For this reason, the objective in complex NOE and orbital trauma extends beyond simply reducing and fixing individual fractures. The ultimate goal is to reconstruct the three-dimensional architecture of the injured craniofacial skeleton as a whole.