Supraorbital Rim Contour Restoration with Porous Polyethylene Implant via Preexisting Scar

Isolated anterior wall fractures with displaced fragments require surgical correction to restore normal forehead contour. The anterior wall is returned to its anatomic position and stabilized with either suture, wire, or metal or resorbable plates, according to the surgeon’s desire and the patient’s age. [1] Treatment principles are emerging from published studies. [2] Many cases with solitary depressed anterior wall fractures require anterior wall restoration to obtain aesthetically acceptable contours. [3]

We present a 40-year-old man who had left supraorbital rim depression caused by blunt trauma 1 year previously. Anterior wall fracture of the left frontal sinus was evaluated with computed tomography (CT; Figure 1). He was treated by porous polyethylene Medpor (Porex Surgical, Inc., College Park, GA) sheet implant (1.5 mm thick; 50 mm wide × 76 mm long) via supraorbital preexisting scar to avoid coronal incision (Figure 1). In the standard treatment modality of frontal sinus fractures, repair is best performed by way of a coronal approach, which offers excellent access. [3] The patient did not want a coronal incision for the contour restoration surgery with implant. The patient did not want to autolog bone graft for restoration of the supraorbital rim contour due to the graft donor site morbidity. He was treated by porous polyethylene implant. The porous polyethylene implants have biomaterial properties favorable for facial skeletal contour restoration. [4,5] The frontal bar depression was accessed by way of preexisting scar (Figure 1). First, the scar was removed and the subperiosteal space was entered along the supraorbital rim after incision of the periosteum medially (Figure 1). Supraorbital soft tissues and neurovascular pedicles were carefully lifted out of the depression area. The porous polyethylene sheet implant overlapped the defect of depression edges. The implant was shaped to bridge the defect and was inserted below the periosteum without any fixation with screws or sutures (Figure 1). Before implantation, the implant was soaked in antibiotic solution containing 1 g ceftriaxone. Oral first-generation cephalosporin was given every 12 hours for 5 days postoperatively. A compressive garment was used to stabilize the polyethylene implant for 1 week postoperatively. No infection was seen in the early or late postoperative period. At 12-month follow-up, the patient did not complain of any disturbance (Figure 2). We have experienced these rules in our case:

• Preexisting scar on the supraorbital area should not be exposed to protect the neurovascular bundle, which is important.
• If access via the preexisting scar is used for contour restoration, preoperative CT evaluation must be precise to calculate the contour of the defect for the alloplastic material.
• A compressive garment must be used to stabilize the polyethylene implant for 1 week if rigid fixation material is not used to stabilize the alloplastic material.

If the surgeon follows these rules, the surgical approach is less invasive and the operation can be performed without problems in selected cases.