Postoperative Enophthalmos Research Articles

Early Versus Late Repair of Orbital Blowout Fractures

To compare early and late surgical repair of orbital blowout floor fractures. A retrospective, comparative interventional case series reviewed medical records of 50 consecutive patients who underwent unilateral orbital floor fracture repair in a 4-year period. Comparative analysis was performed between patients operated on within 2 weeks of injury and those operated on at a later stage. Assault, motor vehicle accidents, and sports injuries were the most common causes of injury. Surgery was performed due to inferior rectus muscle entrapment and limitations in up gaze in 20 (40%) patients or to prevent enophthalmos in cases with significant bony orbital expansion in 30 (60%) patients. After surgery, enophthalmos improved an average of 0.8 mm. Limitation in ocular motility improved after surgery but was statistically significant only in up gaze. Patients who underwent early repair (within 2 weeks) achieved less improvement in enophthalmos versus patients who underwent late repair (delta enophthalmos of 0.2 +/- 1.1 vs 1.3 +/- 1.9 mm, respectively; P = .02). In these patients, postoperative vertical ductions and postoperative enophthalmos improved after fracture repair. Surgery was associated with a low rate of postoperative complications. No apparent difference in surgical outcome was seen between early (within 2 weeks) and late surgical repair.

Reconstruction of Bony Orbit Using Endoscope and Polyethylene with Embedded Titanium for a Patient with Postoperative Enophthalmos

Enophthalmos means displacement of the globe into the bony orbit backward, and usually downward. In post-traumatic enophthalmos, the mechanisms that determine the globe position can be the enlargement of the orbital cavity, the herniation of orbital fat into the maxillary sinus, fat atrophy, loss of ligament support, and scar contracture. It can be reconstructed through several approaches such as transconjunctival, canthotomy, lower eye lid, coronal approach, and by using bone, cartilage, and alloplastic materials. The authors report a case of postoperative enophthalmos reconstructed through subciliary and transnasal endoscopic approaches using porous polyethylene with embedded titanium.

Complex Midfacial Reconstruction: A Combined Technique of Computer-Assisted Surgery and Microvascular Tissue Transfer

The human midface is a complex anatomic region. The maxilla is the structural support between the skull base and the occlusal plane, resisting the forces of mastication, anchoring the dentition, separating the oral and nasal cavities, supporting the globe, and supporting the face and its mimetic musculature. 1 Futran N.D. Mendez E. Developments in reconstruction of midface and maxilla. Lancet Oncol. 2006; 7: 249 Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar The midface region dominates our outward appearance, which is unique to each individual, and its esthetic restoration after loss of the maxilla is of major importance for quality of life. Destruction of the midface may result from trauma, infectious or malignant disease, as well as from rare disorders of the immune system. The morbidity associated with total maxillectomy potentially includes impairment of deglutition and nutrition, orbital function and vision, speech and communication, self-image and mental health, and maintenance of hygiene and social acceptability. 1 Futran N.D. Mendez E. Developments in reconstruction of midface and maxilla. Lancet Oncol. 2006; 7: 249 Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar Reconstruction of midfacial defects still remains a surgical challenge, especially in cases with total loss of the maxilla including the orbital floor and preservation of orbital contents. 2 Cordeiro P.G. Santamaria E. Kraus D.H. et al. Reconstruction of total maxillectomy defects with preservation of the orbital contents. Plast Reconstr Surg. 1998; 102: 1874 Crossref PubMed Scopus (128) Google Scholar The overall goal is to replace the form and function of native tissue. In addition to separation of oral and nasal cavities, the contours of the bony orbit and the zygomatic prominence should be exactly restored, preserving optical function and facial symmetry. The prevention of diplopia as a result of postoperative enophthalmos should be of major importance, especially when orbital contents are not affected. ErratumJournal of Oral and Maxillofacial SurgeryVol. 72Issue 4PreviewIn “Complex Midfacial Reconstruction: A Combined Technique of Computer-Assisted Surgery and Microvascular Tissue Transfer” (Kokemueller et al., J Oral Maxillofac Surg 66:2398-2406) the author Martin Rücker MD, DMD, PhD should be listed as “Martin Rücker, MD, DMD”. Full-Text PDF

Effectiveness of a nasoseptal cartilaginous graft for repairing traumatic fractures of the inferior orbital wall

The goals of reconstruction after an orbital fracture are to restore the continuity of the floor, provide support for the orbital contents, and prevent fibrosis of the soft tissues. Nasoseptal cartilage is an easily accessible, abundant, and autogenous source that supports the orbital floor and gives minimal donor site morbidity. We evaluated the effectiveness of nasoseptal cartilage for repairing traumatic defects of the orbital floor. Autogenous nasoseptal cartilage was used in 20 patients. Presence or absence of diplopia, enophthalmos, paraesthesia of the infraorbital nerve, dystopia, range of covering of the defect by nasoseptal cartilage, complications at the recipient and donor sites, resorption of the graft, and ocular mobility disorders were recorded. Entrapment of orbital tissues, a large orbital defect (more than 50% of orbital floor or more than 8mm), or defects of the orbital floor with involvement of other fractures of the zygomaticofrontal complex are indications for exploration of the orbit. In one case after 24 months, the surgical field was explored for direct evaluation of the efficacy of the graft. All patients were treated successfully by restoration of the continuity of the orbital floor. Six months to 2 years follow up showed only one patient with postoperative enophthalmos. There was no donor site morbidity, and no grafts became infected or extruded. The nasoseptal graft was completely covered with underlying tissue. Nasoseptal cartilage is readily accessible autogenous tissue that should be considered when an autogenous graft is needed for reconstruction of a defect of the orbital floor.

Management of bone-invasive, hyperostotic sphenoid wing meningiomas

The hyperostosis frequently associated with sphenoid wing meningiomas is actual invasion of bone by the tumor. The intracranial portion of the tumor is usually thin with en plaque spread, and the tumor tends to invade the orbit through the superior orbital fissure. The authors reviewed the records of 67 patients with sphenoid wing meningiomas who underwent surgery at the University of Arkansas for Medical Sciences between 1994 and 2004. In all 67 cases, the surgery was performed by the senior author. Seventeen of the patients had the distinguishing characteristics of hyperostotic sphenoid wing meningiomas-extensive bone invasion, en plaque dural involvement, and a minimal intracranial mass with minimal orbital involvement. In all patients, hyperostosis was determined on the basis of preoperative neuroimaging. Histopathological evaluation of bone specimens was performed in 14 cases. Estrogen and progesterone receptor expression and Ki 67 labeling were evaluated in all specimens. Chromosome analysis was performed in all tumors resected since 2001 (seven cases). Particular attention was paid to removing all involved bone and dura mater. Total removal was achieved in 14 cases (82.3%), with only one recurrence (7.1%) over a mean follow-up period of 36 months (range 5-72 months). Radical resection was followed by cranioorbital reconstruction to prevent enophthalmos and to obtain good cosmetic results. No deaths or serious complications occurred in association with surgery. Proptosis was corrected in all cases and visual acuity improved in seven (70%) of 10 cases. Revision of the orbital reconstruction was required because of postoperative enophthalmos (two cases) or restricted postoperative ocular movement (one case). Sphenoid wing meningiomas frequently invade bone, although such invasion does not represent malignancy. These lesions are generally histologically benign. Total removal with a prospect for cure and visual preservation should be the goal of treatment. This requires extensive drilling of the invaded bone and extensive excision of the involved dura. When the optic canal is involved, it should be decompressed. Extensive bone resection should be followed by cranioorbital reconstruction for good cosmesis and to prevent enophthalmos.

Effect of porous polyethylene channel implants on volume reconstruction of large orbital wall fractures evaluated by computed tomography measurement

To assess the clinical effectiveness of porous polyethylene medpor channel implants (MCI) to restore orbital volume in repairing orbital wall fractures, evaluated by computed tomography (CT) and volume measurement program. Sixteen patients with unilateral large orbital fractures were included in this study. Computed tomography (CT) scans were used to obtain computer-based orbital volume measurement to assess the change in orbital volume pre- and post-operatively. Pre- and post-operative enophthalmos were measured using a Hertel exophthalmometer. The average time interval between injury and surgery was (17.4+/-10.0) days, and the mean follow-up period was 9 months. Postoperative CT scan showed that most of the MCI to be well positioned. The orbital volume of the injured orbit was significantly increased [mean: (28.16+/-4.32) cm3] as compared with unaffected orbit preoperatively (t=3.044, P<0.01). There was no statistical difference in orbital volume between the injured and normal orbits after orbital reconstruction (t=0.069, P>0.05). The orbital volume change after reconstructive surgery was significantly positively correlated with the decrease of enophthalmos (r=0.715, P<0.01). In order to resolve 2 mm enophthalmos, more than 2.86 cm3 orbital volume augmentation is recommended. Orbital volume measurement by CT scan is useful in the post-traumatic evaluation of severity of orbital fractures, and it can help predict the degree of late enophthalmos. Orbital reconstruction with the MCI, when indicated, is recommended.

Isolated Medial Orbital Wall Fractures With Medial Rectus Muscle Incarceration

To retrospectively review and analyze cases of isolated medial orbital wall fractures with medial rectus muscle incarceration presenting to a tertiary ophthalmic plastic surgery practice from 1997 to 2005. Retrospective chart review and literature review. Nine cases of isolated medial wall fracture with medial rectus muscle incarceration are presented. The most frequently encountered clinical feature was adduction deficit on the affected side. Extraocular motility improved in all patients who underwent surgery, and mean postoperative enophthalmos was minimal. Isolated medial orbital wall fractures with medial rectus muscle incarceration are rare. Ocular motility abnormalities were the only indication of underlying fracture in the majority of our cases. Clinicians should be alerted to the anticipated presentation of medial wall fractures with incarceration of the medial rectus muscle, including the possibility of a "white eye" and normal abduction of the traumatized eye.

Repair of traumatic inferior orbital wall defects with nasoseptal cartilage

This study evaluated the effectiveness of nasoseptal cartilage for repairing traumatic orbital floor defects. Autogenous septal cartilage was used in 20 patients. They were evaluated for the presence or absence of diplopia, enophthalmus, infraorbital nerve paresthesia, and ocular motility disorders. Surgical indications for orbital exploration included entrapment of orbital tissues, large orbital defect (greater than 50% of the orbital floor or more than 8 mm), or orbital floor defects with involvement of other zygomaticofrontal complex fractures. All patients were successfully treated by restoration of the orbital wall continuity. Follow-up at 1 week to 6 months showed 1 patient with postoperative enophthalmos and 1 patient with lower lid edema. There were no donor site and graft infections or graft extrusion. Nasal septal cartilage is a readily accessible autogenous tissue that should be considered when an autogenous graft is needed for orbital floor defect reconstruction.

Selection of Materials for Orbital Floor Reconstruction

A clinically significant orbital floor defect will be defined as a gap remaining after reduction or elevation of orbital floor fracture fragments that requires a semirigid implant to avoid postoperative enophthalmos or orbital dystopia. Therefore, this definition excludes small defects (,5 mm in width) where Gelfilm (Pharmacia and Upjohn Inc, Kalamazoo, Mich) or fascia could be used without the need for rigid or semirigid support of the orbital contents. Fractures involving the orbit are relatively common in individuals with facial trauma because of the prominence of the globe and periorbital region. Inadequate reduction and reconstruction can result in substantial disturbances in function and appearance if the preinjury eye position has not been restored. Treatment of orbital floor fractures aims to prevent longterm sequelae, especially enopthalmos, persistent diplopia, and orbital dystopia, by reconstructing large floor defects and preventing herniation of orbital contents into the maxillary sinus. No consensus exists on the choice of implant materials for orbital reconstruction, and a plethora of materials is currently available and used depending on individual surgeons’ preferences. The materials currently used can be broadly categorized as autologous, allogenic, and alloplastic. A list of some of these materials appears below:

Selection of materials for orbital floor reconstruction.

A clinically significant orbital floor defect will be defined as a gap remaining after reduction or elevation of orbital floor fracture fragments that requires a semirigid implant to avoid postoperative enophthalmos or orbital dystopia. Therefore, this definition excludes small defects (,5 mm in width) where Gelfilm (Pharmacia and Upjohn Inc, Kalamazoo, Mich) or fascia could be used without the need for rigid or semirigid support of the orbital contents. Fractures involving the orbit are relatively common in individuals with facial trauma because of the prominence of the globe and periorbital region. Inadequate reduction and reconstruction can result in substantial disturbances in function and appearance if the preinjury eye position has not been restored. Treatment of orbital floor fractures aims to prevent longterm sequelae, especially enopthalmos, persistent diplopia, and orbital dystopia, by reconstructing large floor defects and preventing herniation of orbital contents into the maxillary sinus. No consensus exists on the choice of implant materials for orbital reconstruction, and a plethora of materials is currently available and used depending on individual surgeons’ preferences. The materials currently used can be broadly categorized as autologous, allogenic, and alloplastic. A list of some of these materials appears below:

Criteria for selective management of the orbital rim and floor in zygomatic complex and midface fractures.

To develop objective criteria with which to identify patients with zygomatic complex (ZMC) or midface fractures who require a surgical exploration and treatment of the orbital component of their fracture to prevent postoperative enophthalmos, diplopia, or malar depression. Nonrandomized, prospective management of facial trauma patients. Urban, university referral center. Ninety-seven patients with facial fractures (72 with ZMC fractures and 25 with midface fractures) who presented to the maxillofacial and oculoplastics trauma teams at the University of Cincinnati, Cincinnati, Ohio, for management. The decision whether to include an orbital exploration as part of the management plan was made based on a specific set of physical and radiological criteria that are detailed in the text. Patients were evaluated postoperatively for possible complications related to the orbital and periorbital portions of their fractures. Thirty-four percent of the study patients (30% of the patients with ZMC fractures and 44% of the patients with midface fractures) underwent orbital rim exposure and orbital floor exploration as part of their fracture management. Sixt-six percent of these patients (70% of the patients with ZMC fractures and 56% of the patients with midface fractures) were managed without orbital exploration. Postoperatively, none of the patients who did not undergo exploration experienced diplopia or enophthalmos and only 1 patient had a residual malar depression. The criteria reported herein allow surgeons to identify the minority of patients with midfacial and ZMC fractures who require an orbital exploration for optimal fracture management. Orbital exploration, and its potential complications, can be avoided in the majority of patients with ZMC and midface fractures without significantly increasing the risk of morbidity related to the orbital component of their fractures.

A surgical technique to avoid postoperative enophthalmos in the cranioorbital approach. Technical note.

The authors describe a surgical technique to avoid postoperative enophthalmos when using the cranioorbital approach. To perform osteotomies with a less demanding technique, two separate bone flaps were created: 1) a free frontotemporal bone flap and 2) en bloc removal of the superior and lateral orbital rims: Because the latter bone flap includes both the orbital roof and the posterolateral wall of the orbit with the greater wing of the sphenoid bone, unnecessary bone defects in the lateral orbital wall are avoided. The technique has been performed in seven patients treated for medially located skull base neoplasms or complex anterior circulation aneurysms without postoperative enophthalmos or other cosmetic problems. The authors believe this cranioorbital approach, with its simpler, less invasive surgical technique, offers a definite advantage by avoiding postoperative enophthalmos.

Enophthalmos Following Orbital Transposition for Craniofacial Malformations

This is a retrospective study of the frequency and factors that portend enophthalmos following orbital osteotomies and transposition for craniofacial malformations. Clinically obvious postoperative enophthalmos (POE) was noted in 23 (37.7 percent) of 61 patients undergoing such procedures. Postoperative enophthalmos was observed in 86 percent of Apert patients who had combined anteromedial orbital transposition and in 48 percent of patients with hypertelorbitism who had standard 360-degree osteotomies. In contrast, the incidence of postoperative enophthalmos was 21 percent following frontofacial (monobloc) or subcranial (Le Fort III) advancement. Postoperative enophthalmos also correlated with the occurrence of orbital fracture/fragmentation and with disruption of the periorbita. This study underscores the importance of establishing the correct relationship of the globe to the orbital rim (euophthalmos) while maintaining the spatial position of the eye, especially its anterior projection. Postoperative enophthalmos can be prevented by inserting bone grafts into orbital osteotomy gaps, correcting orbital volume/morphology following floor or wall outfracture/fragmentation, and preserving the periorbital supporting system.

Optimizing The Management Of Orbitozygomatic Fractures

Our understanding of the biomechanics and current management of orbitozygomatic fractures has evolved with the development of craniomaxillofacial surgery. Early management was minimal, with reduction alone as the uniform treatment, and the only variation was the approach used. However, a critical review of the literature using these methods revealed that many of these fractures were unstable after simple reduction alone. Using the principles of craniofacial surgery, our clinical experience, and the data presented in this article, a pragmatic algorithm for optimizing the management of orbitozygomatic fractures is presented. Our approach to this problem has been graduated, with orbitozygomatic fractures being divided into two general categories: nondisplaced and displaced. The nondisplaced orbitozygomatic fracture is treated nonoperatively, with close patient follow-up to detect signs of malunion. Displaced fractures are openly reduced and rigidly fixed internally with mini- and/or microplates. The orbit is routinely explored, especially in high-velocity injuries. The orbit is anatomically as well as volumetrically reconstructed with bone grafts, if needed, to prevent postoperative enophthalmos.

Midfacial Movements A Reappraisal

The statement of six years ago14 that the possibilities of midfacial movements are found in the principle while being restricted by the details can still be sustained. Planning has basically remained unchanged. We consider our indications for osteotomies on higher levels to be well founded. Predicting a defined result, on the other hand, remains notably hindered by a number of factors. Of these, the absence of knowledge about soft-hard tissue ratios of movements in the lateral parts of the midface should be emphasized. But even if one day we will have such knowledge, a reliable prediction will still not be possible. The general rules of timing have been confirmed. A limiting factor has been added by the study of the topography of the tooth buds and anlage. Various maxillary and midfacial osteotomies are possible to match individual patient needs. Several suggestions have been put forward to cope with the difficult advancement on the Le Fort I level. Segmentation of the upper jaw, which has become routine, increases the latitude. The use of miniplates clearly facilitates stabilization on the high levels. On the Le Fort I level, they can make intermaxillary fixation superfluous. In our center, however, this technique is not used routinely. In addition to being time-consuming, it is more difficult to achieve as good an occlusion as with intermaxillary fixation. Follow-up studies have confirmed the problems arising on the occlusal level when performing high osteotomies on children. However, in the adult as well, less satisfactory results are seen on that level than in the periorbital region. One should carefully watch to avoid postoperative enophthalmos, which seems to be a greater problem than is currently assumed. For an exact evaluation of the orbital area, the tools were not available until recently. It may be that in this region, we will be surprised by certain negative findings. Nevertheless, clinical evaluation suggests that their impact on the overall result is of minor importance. The use of autologous transplants is not diminished, but the choice of other donor sites has reduced the problems for the patient significantly. In conclusion, there have not been any spectacular changes in this surgery since our earlier paper, and the progress that has been achieved to date has been accomplished by small steps. Still, it certainly can be stated that the versatility of midface osteotomies has been confirmed, and they may be applied on all levels with increasing success and satisfaction to both patient and surgeon alike.

Repair of orbital floor fractures with marlex® mesh

The best method for reconstructing the acutely fractured orbital floor is controversial. In this review, the outcome of 81 patients with an operatively confirmed pure orbital blow-out fracture is evaluated with respect to postoperative enophthalmos, diplopia, infection, and extrusion. A Marlex mesh implant was used to repair 58 of the fractures, with minimal resultant complications. We believe that Marlex mesh is an ideal implant for use in repairing the early blow-out fracture.