Reconstruction Of Medial Orbital Wall Research Articles

Resection of orbital apex tumours in the medial orbit via four-handed endonasal and transcaruncular approaches.

To report the surgical outcomes of 4-handed endoscopic and transcaruncular approaches for orbital apex tumours located in the medial orbit. This retrospective, observational study included 6 patients (2 males and 4 females; 3 right and 3 left; mean age, 49.5 years; age range, 38-60 years) who underwent excision of an orbital apex tumour in the medial orbit via 4-handed endonasal and transcaruncular approaches. Data on age, sex, affected side, surgical record and complications, and results of pathological examinations, imaging studies, and ophthalmologic examinations were collected. Tumours pathologically corresponded to a cavernous haemangioma in 5 cases and a schwannoma in 1 case. The cavernous haemangioma was completely removed in all cases, while the schwannoma was only debulked because the tumour attached to the surrounding tissues. The medial orbital wall was reconstructed simultaneously in 1 case and 8 days after tumour resection in 1 case. Postoperatively, the visual acuity improved or was maintained in all patients. One patient without medial orbital wall reconstruction showed significant enophthalmos on the affected side after surgery. Another patient without medial orbital wall reconstruction did not obtain binocular single vision field in any direction of gaze after surgery due to severe esotropia. This report indicates that 4-handed endoscopic and transcaruncular approaches are useful for removal of an orbital apex tumour located in the medial orbit. Medial orbital wall reconstruction after tumour resection may be a better option for reducing the risk of postoperative enophthalmos and esotropia.

Reconstruction of Medial Orbital Wall Using Autologous Perpendicular Plate of Ethmoid.

The aim of this study is to investigate the feasibility of perpendicular plate of ethmoid as material for the reconstruction of medial orbital wall. The main outcome measurement was preoperative and postoperative orbital volume. The authors performed a study including 17 patients who have isolated medial orbital wall fracture (blow-out fracture). All the patients were fixed the defect using autologous perpendicular plate of ethmoid under endonasal approach. The authors compared the preoperative and postoperative orbital volume difference (unaffected orbit, affected orbit) of all the patients, and observed the improvement of diplopia or ocular motility disorders after operation. All 17 medial orbital wall reconstruction surgeries were successful with no severe postoperative ophthalmic complications. Statistically significant differences were found between the preoperative and postoperative orbital tissue volumes for the affected orbit. There was no statistically significant difference found between the tissue volume of the contralateral unaffected orbit and the affected orbit after reconstruction. And postoperative computed tomography showed the implant is in place and there is no medial rectus incarceration. Autologous perpendicular plate of ethmoid proved to be safe and effective in the reconstruction of medial orbital wall under endonasal approach with cost-effectivence, low complication rate, high biocompatibility, and minimally invasion.

Comparison of Orbital Reconstructive Effect between Customized Orbital Implants Using Three-Dimensional Printed Templates and Conventional Manual-Bending Implants in Blowout Fracture Surgery

The aim of the present study was to determine the orbital reconstructive effect of customized orbital implants using three-dimensional (3D) printed templates compared with conventional manual-bending implants using computed tomography (CT)-based orbital volume measurements. This retrospective study reviewed the medical records and 3D-CT images of 90 patients who underwent medial, inferior, or inferomedial orbital wall reconstruction. The selected patients were categorized into two groups: (1) the 3D group that underwent surgery using 3D-printed customized orbital implant templates and (2) the manual group that received a conventional manual technique to mold the implant. The volume discrepancy (VD) was obtained by subtracting the volume of the contralateral unaffected eye from that of the injured eye. Of the 90 patients, 33 and 57 were divided into the 3D and manual groups, respectively. The volumes on the contralateral unaffected side and on the pre- and postoperative injured sides were 22.5 ± 2.9, 23.7 ± 3.0, and 22.3 ± 2.8 cm3 (mean ± SD), respectively, in the 3D group, and 21.5 ± 2.5, 22.7 ± 2.8, and 21.2 ± 2.7 cm3 in the manual group. The postoperative VD did not differ between the 3D (–0.2 ± 0.3 cm3) and manual (–0.3 ± 0.9 cm3) groups (p = 0.794). The volume on the postoperative injured side did not differ significantly from that on the contralateral unaffected side in the 3D group, but these did differ significantly in the manual group. Postoperative VD also increased with the preoperative VD in the manual group (Pearson correlation coefficient = 0.548, p = 0.001), whereas there was no such association in the 3D group. The orbital volume restoration effect had superior surgical outcomes for large fractures using the customized orbital implant with 3D-printed templates compared with manual-bending implants.

Orbitalization of Ethmoidal Sinus With Stacked Cross-linked Acellular Dermal Matrix: A New Strategy to Reconstruct Medial Orbital Wall Fracture.

The use of an acellular dermal matrix (ADM) has not been reported in medial orbital wall fracture reconstruction previously. This study aimed to share our early experience with the cross-linked ADM as an allograft material for medial orbital wall reconstruction. In this study, the author evaluated the medical records and serial facial computed tomography scans of 27 patients with pure medial orbital wall fractures reconstructed by a single surgeon between May 2021 and March 2023. The author routinely approached the medial orbital wall with a retrocaruncular incision. Five out of 27 patients were reconstructed with trimmed, multiple folded, 1.0-mm-thick cross-linked ADM (MegaDerm; L&C Bio, South Korea). All cases reconstructed with cross-linked ADM improved clinically and radiologically without complications. The serial computed tomography findings revealed that implanted cross-linked ADM successfully covered the defect while providing a significant volumizing effect. This is the first study to show the efficacy of cross-linked ADM for orbital medial wall fracture reconstruction. Our strategy of orbitalization of ethmoidal sinus with stacked cross-linked ADM would be an excellent surgical option.

A comparative study of porous polyethylene versus absorbable polydextro- and polylevolactic-lactide plate in reconstruction of isolated medial orbital wall fracture

Several materials for medial orbital wall reconstruction have been mentioned in the literature. Our main purpose was to investigate postoperative enophthalmos and diplopia after medial orbital wall reconstruction with polydextro- and polylevolactic (poly-L/DL) acid (P[L/DL]LA) mesh plates and porous polyethylene plates. Using a retrospective study design, we enrolled a cohort of isolated medial blowout fracture patients treated during a 58-month interval. The predictor variable was medial orbital wall reconstruction materials (P(L/DL)LA mesh plate and porous polyethylene plate. The main outcome variables included the occurrence of postoperative enophthalmos and diplopia at 1 week, 1, 3, 6, and 12 months post-surgery. Appropriate descriptive, uni- and bivariate statistics were computed, and P < 0.05 was considered significant. Three hundred-two isolated medial blowout fracture patients were included (24.5% females, 67% treated with P(L/DL)LA mesh plate). Exophthalmos measured highest in both groups 1 week after surgery and decreased steadily for 6 months postoperatively. Statistically significant differences were observed between both groups at 1 week, 1 month, and 3 months after surgery, with a higher incidence of exophthalmos observed in the P(L/DL)LA mesh plate group (P < 0.001). No significant differences were observed at 6 and 12 months after surgery. The occurrence of enophthalmos after medial blowout fracture reconstruction with P(L/DL)LA mesh plate is comparable with the use of porous polyethylene plate. Both P(L/DL)LA mesh and porous polyethylene plates are, therefore, reliable implants for medial orbital wall reconstruction.

Accuracy of free-hand positioned patient specific implants (PSI) in primary reconstruction after inferior and/or medial orbital wall fractures

BackgroundTo assess the accuracy with which CAD/CAM-fabricated patient-specific titanium implants (PSI) are positioned for inferior and/or medial orbital wall reconstruction without the use of intraoperative navigation. MethodsPatients who underwent a primary reconstruction of the orbital walls with PSI due to fractures were enrolled in this retrospective cohort analysis. The primary outcome variables were the mean surface distances (MSD) between virtually planned and postoperative PSI position and single linear deviations in the x-, y- and z-axis at corresponding reference points. Secondary outcome variables included demographic data, classification of orbital wall defects and clinical outcomes. ResultsA total of 33 PSI (orbital floor n = 22; medial wall, n = 11) were examined in 27 patients. MSD was on a comparable level for the orbital floor and medial wall (median 0.39 mm, range 0.22–1.53 mm vs. median 0.42 mm, range 0.21–0.98 mm; p = 0.56). Single linear deviations were lower for reconstructions of the orbital floor compared to the medial wall (median 0.45 vs. 0.79 mm; p < 0.05). There was no association between the occurrence of diplopia and the accuracy level (p = 0.418). ConclusionsFree-hand positioning of PSI reaches a clinically appropriate level of accuracy, limiting the necessity of navigational systems to selected cases.

Endoscopic slide-in orbital wall reconstruction for isolated medial blowout fractures.

BackgroundThis study evaluated the efficacy of the endoscopic medial orbital wall repair by comparing it with the conventional transcaruncular method. This surgical approach differs from the established endoscopic technique in that we push the mesh inside the orbit rather than placing it over the defect.MethodsWe retrospectively reviewed 40 patients with isolated medial orbital blowout fractures who underwent medial orbital wall reconstruction. Twenty-six patients underwent endoscopic repair, and 14 patients underwent external repair. All patients had preoperative computed tomography scans taken to determine the defect size. Pre- and postoperative exophthalmometry, operation time, the existence of diplopia, and pain were evaluated and compared between the two methods. We present a case showing our procedure.ResultsThe operation time was significantly shorter in the endoscopic group (44.7 minutes vs. 73.9 minutes, <i>p</i>= 0.035). The preoperative defect size, enophthalmos correction rate, and pain did not significantly differ between the two groups. All patients with preoperative diplopia, eyeball movement limitation, or enophthalmos had their symptoms resolved, except for one patient who had preexisting strabismus.ConclusionThis study demonstrates that endoscopic medial orbital wall repair is not inferior to the transcaruncular method. The endoscopic approach seems to reduce the operation time, probably because the dissection process is shorter, and no wound repair is needed. Compared to the previous endoscopic method, our method is not complicated, and is more physiological. Larger scale studies should be performed for validation.

Neurogenic Blepharoptosis After Medial Orbital Wall Reconstruction.

Neurogenic blepharoptosis after orbital wall reconstruction is a rare complication. It can either present as an isolated blepharoptosis, or accompany with other ocular symptoms. The authors introduce 4 cases of post-operative neurogenic blepharoptosis after reconstruction of medial orbital wall via transcaruncular approach.Immediately after the surgery, 2 adolescent patients experienced unilateral islolated complete blepharoptosis with no other ocular symptoms. The other 2 adult patients presented unilateral complete blepharoptosis accompanied by lateral displacement of the globe and evident extraocular movement limitations. The 2 adolescent patients were observed with no particular treatment, whereas the other 2 adult patients were treated with intravenous systemic steroids. The blepharoptosis symptom began to improve at 2 weeks post-operatively and completely recovered within 3 to 4 months in all patients, while the globe displacement and extraocular movement limitation started to improve at 4 weeks after the surgery and fully recovered within 6 months.Although neurogenic blepharoptosis after medial orbital wall reconstruction is a very rare complication, it can be critical once it occurs. According to the author's experience, it fortunately shows a favorable clinical course of spontaneous recovery. Post-operative neurogenic blepharoptosis usually recovers between 2 weeks and 4 months and other ocular symptoms related to oculomotor nerve injury recovers within 6 months after the surgery.

Medial Orbital Wall Reconstruction With Porous Polyethylene by Using a Transconjunctival Approach With a Caruncular Extension.

The reported rate of isolated medial orbital wall fractures varies widely but has been found to be as high as 55% of all orbital fractures. Identifying and repairing medial orbital wall defects by using appropriate materials improves patient outcome considerably; however, most related research has focused on orbital floor defect management rather than medial orbital wall treatment, and no consensus on repairing medial orbital wall fractures exists. Furthermore, medial orbital wall fracture is a main cause of posttraumatic enophthalmos. In this study, we introduce a modified surgical technique for repairing large medial wall fractures stably, also reviewed relevant literature and established an algorithm for managing medial orbital wall fractures. We reviewed the outcomes of facial trauma patients who underwent facial bone reduction and internal fixation surgery in our hospital between October 1, 2010, and October 1, 2013. The patients were all treated medial orbital wall reconstruction with porous polyethylene by using a transconjunctival approach with a caruncular extension for large medial orbital wall fractures. Medical records and radiologic images of the patients were reviewed retrospectively. The outcomes evaluated were trauma mechanism, clinical findings of ocular injury, preoperative and postoperative ocular symptoms, degree of enophthalmos, and orbital volume restoration after surgery. Transconjunctival approach with a caruncular extension was performed without any complications. The incidence of diplopia was 47.4% and enophthalmos (>2 mm) was 31.6%, with no significant diplopia and enophthalmos after surgery. Patients were symptom-free on follow-up. The average enophthalmos was successfully corrected from 0.88 mm preoperatively to 0.26 mm and orbital volume was corrected from 26.22 to 22.99 cm after surgery; these results also showed P less than 0.001. The current results suggest that the proposed method of medial orbital wall reconstruction, in which porous polyethylene is implanted by using a transconjunctival approach with a caruncular extension, yields favorable outcomes. The approach facilitates a wide visualization of the operative field, which provides sufficient working space for implant insertion and is consequently free from iatrogenic trauma or surgery-related complications.

Acceso retrocaruncular para la reconstrucción de la pared medial de la órbita

ObjectiveTo present a retrospective analysis of the use of retrocaruncular approach to access medial orbital wall reconstruction. Additionally, the technique for performing this access is described. Material and methodThe sample for this study was chosen from the population of patients referred to the Maxillofacial Surgery Service at the Hospital Clínico Mutual de Seguridad C.Ch.C (Santiago, Chile) for the treatment of orbital fractures between 1st of January 2011 and 31st of December 2014. Subjects eligible for study inclusion had age ≥18, either isolated medial orbital wall fractures or combined with floor fractures, uni or bilateral, with surgical indication, accessed with retrocaruncular approach and 6 month of follow up at least. Exclusion criteria: roof and/or lateral orbital wall fractures. ResultsBetween January 2011 and December 2014, a total of 168 orbits were treat. 27 orbits with medial wall fractures were accessed with retrocaruncular approach with transconjunctival extension and lateral canthotomy and were included in this study. Of them, 6 were pure medial wall fractures and 21 combined with floor fractures. Except for one case that required delayed reconstruction with customized orbital implant, all orbital reconstructions were successful in the first surgery. Except for a patient who developed a conjunctival granuloma in relation to the caruncle, no patients had complications related to retrocaruncular access. ConclusionesThe retrocaruncular approach presented allows asafe, wide and direct access for repairing medial orbital wall fractures with optimal aesthetics results and minimal functional complications.

Endoscopic transnasal approach and intraoperative navigation for the treatment of isolated blowout fractures of the medial orbital wall.

The aim of this study is to describe the reduction of medial orbital wall fractures using a combination of two different techniques: the endoscopic reduction and the navigation aided reconstruction. The endoscopic approach avoids an external incision and allows the observation of the fracture site clearly. Navigation-aided reconstruction is essential to achieve precise and predictable results in orbital reconstruction. It consists in an ideal virtual reconstruction of the target area created using a mirroring tool, and superimposing and comparing the unaffected and the affected sides. This technique opens a broad spectrum of possible surgical approaches, especially in situations in which anatomical landmarks for precise positioning of bone fragments, or bone grafts, are missing. This study is the first to combine these two techniques. The study was carried out in seven patients who underwent endoscopic reduction of isolated blowout fractures of the medial orbital wall and navigation-aided reconstruction at the authors' institution. This pilot study clearly shows that a combination of the endoscopic reduction and the navigation-aided reconstruction provides functional results and great advantages in terms of anatomical preservation and postoperative morbidity.

Endoscopic Endonasal Approach of Orbital Medial Wall Reconstruction using Septal Cartilage: A Rare Surgical Case Report

ABSTRACT Orbital fractures can cause facial disfigurement and disturbs vision. Medial orbital wall fractures are diagnosed with frequent use of computed tomography (CT) scans in the diagnosis of orbital trauma. Orbital reconstruction plays a challenging role for the surgeons as it comes in a multitude of different forms. We report a case of 45-year male with a history of assault presented with diminution of vision, restricted abduction and diplopia of the left eye. Computed tomography scan showed fracture of the left medial orbital wall fracture and the patient was treated by endoscopic endonasal approach of medial orbital wall reconstruction using septal cartilage. How to cite this article Rajasekar MK, Vivek M, Narendrakumar V. Endoscopic Endonasal Approach of Orbital Medial Wall Reconstruction using Septal Cartilage: A Rare Surgical Case Report. Clin Rhinol An Int J 2015;8(1):30-33.

Transient and Isolated Neurogenic Blepharoptosis After Medial Orbital Wall Reconstruction

Neurogenic blepharoptosis related to orbital surgery is very rare and only 1 report was published in the literature. This report presents 1 case of transient and isolated neurogenic blepharoptosis after medial orbital wall reconstruction. A 12-year-old male patient who suffered from periorbital trauma visited our hospital with right periorbital pain. During the physical examination, mild ecchymosis and eyelid edema were reported; however, there were no signs of either limitation of ocular motion or anisocoria. On the orbital CT images, a 17 mm × 20 mm-sized medial orbital bony defect was observed and the medial rectus muscle and orbital fat were herniated. The operation was performed 12 days after injury and the transcaruncular approach was used to reach the medial orbital wall. After the operation, he had right side blepharoptosis with mild eyelid edema and ecchymosis. However, ocular movement was normal and there were no signs of anisocoria. He did not receive any additional medication for blepharoptosis and was discharged 3 days postoperation. By the ninth day of postoperative recovery, the patient still suffered from right blepharoptosis with no levator palpebrae superioris muscle function. We prescribed a low dose of oral corticosteroid and the patient was monitored on a weekly basis. Finally, he recovered completely with normal symmetric eyelid position and levator function.

Two-Year Follow-up on the Use of Absorbable Mesh Plates in the Treatment of Medial Orbital Wall Fractures

BackgroundAbsorbable materials offer many advantages in the reconstruction of orbital walls; however, the possibility of postoperative enophthalmos after complete absorption cannot be excluded. We evaluated the postoperative results of absorbable mesh plates used as onlay implanting on the medial orbital wall to determine whether they are suitable for medial orbital wall reconstruction.MethodsThe study included 20 patients with medial orbital wall fractures who were followed up for more than 2 years postoperatively. We used absorbable mesh plates in all of the patients. We measured the following: the changes in the expanded orbital volume by comparing the preoperative and postoperative computed tomography (CT) scans and the degree of clinical enophthalmos.ResultsThere were no major complications associated with the use of absorbable materials such as infection, migration, or extrusion of mesh plates during the long-term follow-up. The orbital volumetric changes between the preoperative and postoperative CT scans were not statistically significant. However, the expanded orbital volume was not related to the degree of clinical enophthalmos.ConclusionsThe reconstructed orbital wall may provide supportive scar tissue to the orbital contents even after the absorbable materials have dissolved completely. Absorbable mesh plates could be another option for the reconstruction of the medial orbital wall.

Management of Pure Medial Orbital Wall Fracture With Autogenous Bone Graft

The orbit is an irregular conical cavity formed from 7 bones including the frontal, sphenoid, zygomatic, maxillary, ethmoid, lacrimal, and palatine bones. Fractures of the internal orbit can cause a number of problems, including diplopia, ocular muscle entrapment, and enophthalmos. Although muscle entrapment is relatively rare, diplopia and enophthalmos are relatively common sequelae of internal orbital fractures. Medial orbital wall fracture is relatively uncommon and represents a challenge for its anatomical reconstruction. In this context, autogenous bone graft has been the criterion standard to provide framework for facial skeleton and orbital walls. Therefore, it is possible to harvest grafts of varying size and contour, and the operation is performed through the bicoronal incision, which is the usual approach to major orbital reconstruction. Thus, this article aimed to describe a patient with a pure medial orbital wall fracture, and it was causing diplopia and enophthalmos. The orbital fracture was treated using autogenous bone graft from calvarial bone. The authors show a follow-up of 12 months, with facial symmetry and without diplopia and enophthalmos. In addition, a computed tomography scan shows excellent bone healing at the anterior and posterior parts of the medial orbital wall reconstruction.

Reconstruction par greffons de Hübner et conque après exérèse étendue palpébro-cantho-orbitaire médiale – Présentation de deux cas

Post-ablative medial canthus and medial orbital wall reconstruction may involve various materials. Few articles present such reconstructions using cartilage homografts, and very few opt for conchal cartilage. In some cases of medial orbital wall excision, at least half of the eyelid must also be removed. We present two cases where we decided to use conchal cartilage to reconstruct the medial orbital wall and tarsomarginal Hübner grafts to reconstruct the eyelid. This combination offers several advantages: a very limited resorption, only one operative field and a reduced infection risk.

Medial orbital wall reconstruction with flexible Ethisorb® patches

The aim of this study was to analyse the long-term result after reconstruction of the medial orbital wall with a flexible, biodegradable material (Ethisorb). During a period of almost 8 years, 31 patients with a medial orbital wall fracture were analysed retrospectively. Inclusion criteria were patients with a maximum size fracture of the orbital medial wall measuring 1.5-2 cm(2). Exophthalmos, enophthalmos, bulbus motility, diplopia and skin sensation were investigated over a period of 6 months. In all patients, the medial orbital wall was reconstructed with Ethisorb patches. No significant intraoperative complications were detected. No postoperative infection, abscess or seroma was found in any of the patients receiving an Ethisorb patch. The advantage of the semiflexibility of the Ethisorb patch is that it supplies an anatomically correct fit to the orbital medial wall but does not require fixation by screws or the use of sutures. The low rate of reported bulbus motility disturbance, diplopia, exophthalmos and enophthalmos demonstrates acceptable results after medial orbital wall reconstruction using the Ethisorb patch.

Medial Orbital Wall Reconstruction Through Subciliary Approach

The aim of this study is to determine the safety and complication of subciliary approach through the retrospective review of our experiences. From 2005 through 2008, the subciliary skin-muscle flap methods were used in 30 patients undergoing medial orbital wall reconstruction. Preoperative and postoperative ophthalmic findings including diplopia, Hertel exophthalmometry, and occurrence of complications were checked. Resorbable polylactic acid sheet or porous polyethylene sheet was trimmed and molded in L shape, vertical portion to cover the medial wall defect and horizontal portion for stability in orbital floor.In the follow-up of diplopia, half of the patients (3 cases) presenting with diplopia improved during the first month of follow-up, and all of them improved by 6 month. For hypesthesia, all patients improved by 3 months. Enophthalmos of 1 patient improved after operation and did not recur. No patients complained of visible scar 6 months postoperatively, and no ectropion was observed.We think that medial orbital wall could be reconstructed safely through skin-muscle flap subciliary approach without resulting in ectropion or lacrimal canaliculus injury.

Versatile Use of Extended Transconjunctival Approach for Orbital Reconstruction

When exposing the orbit, the transconjunctival approach is regarded to have limited surgical exposure. The aim of this study is to demonstrate the versatile usability of extended transconjunctival approach, which can be extended medially and laterally, in reconstruction of medial orbital wall, floor, and even the lateral rim in maxillo-malar complex fracture.We reviewed 122 cases of orbital fractures treated with extended transconjunctival approach. The operative results were assessed by postoperative CT scan and reviewing postoperative complications. The extended transconjunctival approach provided sufficient surgical exposures in all cases. There was no ectropion or scleral show during follow-up period. The cutaneous scars were almost invisible in most cases.The extensile character of this approach makes continuous exposure of the orbit from frontozygomatic suture laterally to the frontonasal suture medially, while minimizing scar and eyelid complications.

Navigation-aided reconstruction of medial orbital wall and floor contour in cranio-maxillofacial reconstruction

The reconstruction of the anterio-posterior inclination of the medial aspect of the orbital floor, despite a wide 360 degrees exposure, including coronal and conjunctival incisions, is a challenging task in severe injuries of the orbit with massive comminution and complete displacement of the medial orbital wall and orbital floor. Out of a total of 20 patients with orbital fractures, five underwent a surgical intervention of repositioning the medial aspect of the orbital floor and especially the transition area between the orbital floor and medial orbital wall, using navigation-aided procedures. Using the mirroring tool of the Stryker-Leibinger STN-system, post-operative CTs indicated an average difference of the globe position of -4.9% between the operated side and the unaffected side, depending on the position of the medial aspect of the orbital floor. Navigation-aided procedures proved to be an essential precondition for achieving precise and predictable results in orbital reconstruction. In such cases, unlike those with an intact medial orbital wall remnant as a surgical target, bone grafts for reconstruction of the orbital floor cannot be implanted as onlay grafts.