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Orbitofacial Masses in Children
An Endoscopic Approach
Matthew H. Steele, MD;
Dana L. Suskind, MD;
Michael Moses, MD;
Evelyn Kluka, MD;
Donald C. Liu, MD, PhD
Arch Otolaryngol Head Neck Surg. 2002;128:409-413.
ABSTRACT
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Objective To describe an endoscopic approach for pediatric orbitofacial masses.
Design A retrospective medical chart review.
Setting Tertiary-care children's hospital.
Participants Patients (4 boys, 7 girls) ranged in age from 6 months to 11 years.
All children underwent endoscopic excision of an orbitofacial mass.
Intervention A single port approach was used in all but the initial case. The scalp
incision was placed approximately 2.0 cm behind the frontal hairline. A subgaleal
dissection was performed to minimize risk of nerve injury. Under endoscopic
visualization, the mass was resected.
Main Outcome Measures Ability to successfully excise the mass endoscopically, and the incidence
of complication.
Results All lesions were successfully resected endoscopically. The surgical
time varied from 30 to 105 minutes (mean, 50.5 minutes). Pathologic examination
revealed 10 dermoid cysts and 1 neurofibroma. Two children had transient frontalis
branch palsies that resolved spontaneously. There was 1 unilateral frontal
hypoesthesia in the patient with the neurofibroma (an expected result). There
were no other complications.
Conclusions An endoscopic approach to pediatric orbitofacial tumors is safe and
effective. Although the risk of nerve injury may be higher, a thorough knowledge
of frontotemporal anatomy and careful dissection will minimize this risk.
The distinct advantage of an endoscopic approach is the absence of any facial
scar in these young patients.
INTRODUCTION
PEDIATRIC ORBITOFACIAL masses represent a diverse group of lesions,
ranging from the uncommon nasal glioma and encephalocele to the relatively
more common periorbital dermoid.1-3
These lesions typically present early in life as a slowly enlarging solitary
mass but in some cases may only manifest themselves after episodes of infection.4-5 After a thorough clinical examination,
most masses are found to be superficial and readily amenable to surgical excision.3, 6 Midline nasoglabellar masses and some
orbital masses, however, require further radiological examination to exclude
intracranial extension.3, 5, 7-9
The typical surgical approach for most orbitofacial masses involves an incision
in the eyelid or eyebrow in a relaxed skin tension line of the forehead or
an incision directly over the mass.3, 6
While the results are typically described as cosmetically acceptable, a scar
is still created.
Since the introduction of the endoscopic forehead lift in the early
1990s, surgical endoscopic procedures have expanded to encompass many applications
within the specialty of plastic surgery. The primary advantage of surgical
endoscopic procedures is their minimally invasive nature, allowing for equivalent
surgical manipulation but without the need for a long incision.9-12
With the recent application of these techniques to the pediatric population,
the advantages of endoscopic plastic surgery are even more appealing.9-10 To further promote the safety and
efficacy of endoscopic surgical techniques in the pediatric population, we
present our experience in the endoscopic approach to the removal of pediatric
orbitofacial masses.
PATIENTS AND METHODS
From September 1, 1997, to February 28, 2001, 11 patients underwent
endoscopic excision of an orbitofacial mass at The Children's Hospital of
New Orleans. There were 7 girls and 4 boys with ages ranging from 6 months
to 11 years at the time of surgery, with a mean age of 24.7 months. The most
common location for these lesions was the eyebrow (n = 7) followed by the
orbit (n = 2) and nasoglabellar area (n = 2). All patients with a midline
nasoglabellar lesion had preoperative computed tomography scans to rule out
possible intracranial extension.
After discussing the risks of the endoscopic approach vs the traditional
open approach, informed consent was obtained from the parent or guardian and
the patient was taken to the operating theatre. Depending on the location
of the lesion, a 1.5- to 2.0-cm incision was created cephalad to the mass,
at least 2 cm behind the hairline (Figure
1). A single port approach was used in all cases but the first one,
in which both midline and temporal incisions were used to remove a mass from
the left superior lateral brow. The scalp incision was carried down to the
subgaleal plane. Spreading dissection in the subgaleal plane continued to
cephalad to the mass, at which time the endoscope was inserted (Figure 2). Care was taken to stay directly on the periosteum or
deep temporalis fascia to minimize the risk of injury to the supratrochlear
and supraorbital nerves medially and the frontal branch of the facial nerve
laterally. The endoscopic setup included a 6-mm 30° endoscope, a xenon
light source, and video camera with monitor. Under endoscopic visualization,
the dissection was completed until the dermoid was well circumscribed. A combination
of sharp and blunt dissection with the microscissors and periosteal elevators
was used to free the periosteum overlying the mass and to remove the intact
lesion. In most cases, there was a scalloped depression in the underlying
bone (Figure 3). After copious irrigation,
the wound was closed primarily, and all patients were discharged on the day
of surgery.
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Figure 1. Illustration of scalp incisions
for various approaches to orbitofacial masses.
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Figure 2. Endoscopic view of lateral brow
dermoid.
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Figure 3. Endoscopic view of scalloped depression
of frontal bone.
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RESULTS
All patients underwent successful endoscopic resection of orbitofacial
masses.
The average surgical time was 50.5 minutes (range, 30-105 minutes).
A trend toward decreased operative time was noted as the number of prior endoscopic
procedures performed by the surgeon increased. Pathologic examination revealed
10 dermoid cysts and 1 neurofibroma. The neurofibroma was removed from the
left superior medial brow of an 11-year-old girl. Further workup for von Recklinghausen
disease was negative. The remaining patients ranged in age from 6 to 30 months
(average, 13.1 months) with the eyebrow dermoid being the most common presentation.
While some pathologists have classified epidermoid and dermoid cysts together,
we considered only those lesions that contained skin appendages in addition
to cutaneous epithelium as true dermoids.2
All patients healed well with an aesthetically pleasing, hidden scar (Figure 4). There were no perioperative infections
or fluid collections, however, 2 important complications must be noted. A
transient frontalis branch paresis was noted in 2 patients. The first patient
was a 6-month-old girl who had a dermoid cyst removed from the right superior
lateral orbit. A lateral approach was used on this patient, which probably
induced a stretch injury of the frontalis branch of the facial nerve. Complete
recovery was evident 2 months postoperatively. A temporary frontalis paresis
was also noted in an 11-month-old girl after dermoid removal from the left
superior lateral brow. Forehead hypoesthesia was noted postoperatively in
the 11-year-old patient who presented with the neurofibroma. This neurofibroma
involved either the supratrochlear nerve or the superficial branch of the
supraorbital nerve, and given the nature of this tumor, hypoesthesia was probably
an unavoidable, if not expected, result of tumor excision.
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Figure 4. Before (A and B) and after (C
and D) photographs of child with lateral brow dermoid.
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COMMENT
Dermoid cysts in children are commonly found in the head and neck region,
accounting for up to 84% of the total body dermoids in 1 study.2
The orbital and periorbital location is the most frequent site of involvement,
with the neck, scalp, and ear being the next most frequent locations. Nasoglabellar
cysts are much less common, accounting for 1.1% to 2.6% of all dermoid cysts
throughout the body.2, 13 We found
a similar pattern of distribution with 8 of 10 dermoids located in the orbital-periorbital
region.
Complete surgical excision is necessary to avoid recurrence of the cyst
or mass.6, 14 Various surgical
approaches have been advocated to excise these lesions, depending on the location.
Examples include a direct incision over the mass; an incision above, below,
or in the eyebrow; an incision in an adjacent relaxed skin tension line; and
an incision through the natural crease of the upper eyelid.3, 6-7,9, 15
Most brow and orbital dermoids can be approached through the upper eyelid
crease incision with reportedly good exposure and aesthetic results.3, 6, 9 Possible complications
of this approach include damage to the levator aponeurosis, lacrimal gland,
and reflected tendon of the superior oblique muscle.6
If a lesion in the forehead cannot be reached by an incision near the eyebrow,
a camouflaged mid forehead or coronal incision is indicated. The former, while
providing adequate exposure, will leave a conspicuous scar; the latter approach
requires a long scar in the scalp with frequent scar line alopecia and paresthesias.11-12,16 Various approaches
to midline nasal dermoids have been described, usually resulting in a midline
nasal scar.7, 15 Midline lesions
with intracranial extension do not obviate the use of endoscopic techniques
and have been described using an endoscopic transnasal approach.7
Since the introduction of the endoscopic forehead lift in 1991, this
technology has expanded to involve many areas of aesthetic surgery, including
brow and facelifts, breast augmentation, abdominoplasty, and pediatric plastic
surgery.9-10,17-18
Endoscopic forehead-brow lifts are performed routinely with excellent results,
while minimizing operating and recovery time, blood loss, alopecia, paresthesias,
and scar length compared with the traditional coronal approach.11
The minimally invasive nature of endoscopic surgery makes it an excellent
choice for use in pediatric patients. Several reports have been published
in the past few years documenting the use of endoscopic surgery for a variety
of pediatric procedures, including tissue expander placement, torticollis
release, excision of cranial suture release, and excision of facial dermoids.9-10 To further stimulate and encourage
interest in this area, we present our experience with the endoscopic excision
of pediatric orbitofacial masses.
The primary advantage of an endoscopic approach to orbitofacial mass
excision is the avoidance of a conspicuous facial scar.9-10
The greater tendency toward hypertrophic scarring in the pediatric population
provides further incentive to use a minimally invasive approach. In addition,
this technique is advantageous in ethnic populations prone to keloid formation.
While the upper eyelid crease incision typically results in an aesthetically
pleasing result, the absence of any facial scar is a cosmetic advantage. This
cosmetic advantage is especially evident when a forehead or midline nasal
incision can be avoided by the use of endoscopic surgical techniques. The
minimally invasive nature of the endoscopic approach results in less tissue
trauma with potentially less postoperative edema, blood loss, and recovery
time.11, 16 This is particularly
evident when compared with the coronal approach for a forehead lesion. In
their original description of endoscopically assisted dermoid excision, Huang
et al9 used a 2-port approach, with 1 temporal
incision and 1 incision cephalad to the lesion behind the hairline. We used
a single-port approach in all cases but the first one to minimize the number
of scars.
The primary disadvantage of an endoscopically assisted surgical approach
is the increased risk of sensory and facial nerve injury. When the lesion
is located laterally, the temporalis branch of the facial nerve is at increased
risk for injury. In our series, 2 of 7 patients with laterally based lesions
had a transient postoperative temporalis branch paresis. This was most likely
secondary to stretching of the nerve by the endoscope, while elevating the
overlying flap. Another disadvantage is the potentially higher cost of the
procedure secondary to use of the endoscopic equipment and longer operative
times early in the learning process. However, we noted a trend toward decreased
operative time as the number of procedures performed increased. Some authors
may argue that the use of this procedure is not necessary for small lesions
around the eyebrow or orbit, but we believe that the absence of an appreciable
facial scar is a significant advantage and outweighs the risks of nerve injury.
A thorough knowledge of the anatomy of this region is necessary to minimize
the risk of nerve damage. The frontalis branch of the facial nerve courses
diagonally upward across the zygomatic arch in the temporal region to enter
the frontalis muscle above the superior orbital rim. It courses within the
superficial temporal fascia, which is continuous with the superficial musculoaponeurotic
system inferiorly, the galea superiorly, and the frontalis muscle anteriorly.19 Dissection directly on top of the deep temporal fascia
laterally, and the periosteum medially will avoid injury to the frontalis
branch. The supratrochlear nerve and superficial branch of the supraorbital
nerve can be avoided with safe subgaleal dissection to within 2 cm of the
supraorbital rim. The location of the supraorbital foramen is variable and
may occur up to 1.9 cm above the supraorbital rim.20
Therefore any dissection within 2 cm of the supraorbital rim should be done
carefully under direct visualization.17 The
deep branch of the supraorbital nerve, however, is prone to injury with subgaleal
dissection. Damage to this nerve accounts for the paresthesias noted in the
frontoparietal scalp after traditional coronal forehead-brow lift. This branch
runs in the subgaleal plane parallel and medial to the superior temporal line.21 To avoid damaging this branch, dissection in the
subperiosteal plane is advised during forehead or brow lifting. It is difficult
to know if this branch was damaged during our dissection secondary to the
young age of our patients.
In conclusion, we have successfully resected orbitofacial masses using
an endoscopically assisted approach in a small series of pediatric patients.
Our results correlate well with those published previously.9
This technique is both safe and effective, while providing a superior cosmetic
result compared with the traditional approach. Although the potential risk
of nerve injury is increased, a thorough knowledge of frontotemporal anatomy
will minimize this risk. We believe that the absence of a conspicuous facial
scar provides a cosmetic advantage that outweighs the potential risk of this
approach.
AUTHOR INFORMATION
Accepted for publication September 14, 2001.
This study was presented at the American Society of Pediatric Otolaryngology
Meeting, Scottsdale, Ariz, May 11, 2001.
Corresponding author and reprints: Dana L. Suskind, MD, Division
of Otolaryngology, University of Chicago, 5841 S Maryland Ave, MC1035, Chicago,
IL 60637 (e-mail: dsuskind{at}surgery.bsd.uchicago.edu).
From the Departments of Otolaryngology (Drs Steele, Suskind, and Kluka)
and Surgery (Dr Liu) and the Division of Plastic Surgery (Dr Moses), Louisiana
State University Health Science Center, and The Children's Hospital of New
Orleans (Drs Suskind, Moses, Kluka, and Liu), New Orleans. Dr Suskind is now
with the Division of Otolaryngology, University of Chicago, Chicago, Ill.
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