Advances in the Reconstruction of Orbital Fractures

Long-term enophthalmos after complex orbital bone loss successfully treated with patient-specific porous titanium implants: A case series

INTRODUCTION

Long-term enophthalmos and diplopia resulting from orbital bone loss pose significant challenges in reconstructive surgery. This study evaluated the effectiveness of patient-specific porous titanium implants (PSIs) for addressing these conditions.

MATERIALS AND METHODS

This retrospective study involved 12 patients treated at Croix-Rousse Hospital, Lyon, from April 2015 to April 2022 who underwent late reconstruction via PSI for unilateral complex orbital bone loss. These implants were customized via 3D mirroring techniques on the basis of high-resolution computed tomography (CT) scans of the patients' unaffected orbits.

RESULTS

All 12 patients presented with significant preoperative enophthalmos, with an average displacement of 3.24 mm, which was effectively corrected postoperatively to an average of 0.17 mm (p < 0.001). Orbital volume notably improved from a preoperative average of 3.38 mL to 0.37 mL postsurgery (p < 0.001). Functional improvements were evident as both enophthalmos and diplopia resolved completely. The Lancaster test revealed an improvement in the visual field, with 83.3 % of patients achieving normal results postoperatively.

DISCUSSION

By ensuring anatomical accuracy, patient-specific porous titanium implants, tailored from patient-specific imaging and fabricated via advanced 3D printing technology, provide a precise, effective, and reliable solution for reconstructing complex orbital defects and performing complicated revision surgeries.

Changes in Facial Symmetry Following Computer-Assisted Secondary Correction of Craniofacial Fractures

OBJECTIVE

For patients without dysfunctions, the main purpose of secondary correction for craniofacial fractures is restoring facial symmetry. Computer-assisted surgery techniques including virtual surgical planning and intraoperative navigation provide the help to restore the bony symmetry as much as possible. The authors retrospectively quantitatively analyzed patients who received computer-assisted secondary correction for craniofacial fractures on facial symmetry pre and postoperation.

METHODS

This observational study reviewed the medical records of 17 patients requiring secondary correction for craniofacial fractures. Pre and postoperative computed tomography data were used to quantitatively analyze the changes in facial symmetry and enophthalmos.

RESULT

All patients enrolled in this study showed mid-facial asymmetry but without dysfunctions except for enophthalmos, and 5 patients had bone defects in the frontal-temporal area. The corrective surgical techniques were different for each patient according to their specific condition. Virtual surgical planning with or without intraoperative navigation was performed for all patients. Compared with the preoperative condition, their facial symmetry was significantly improved. The maximum discrepancy value between the affected side and the mirrored unaffected side decreased from 8.10 ± 2.69 to 3.74 ± 2.02 mm postoperatively, and the mean discrepancy value decreased from 3.58 ± 1.29 to 1.57 ± 0.68 mm. In addition, the Enophthalmos Index decreased from 2.65 to 0.35 mm.

CONCLUSION

This observational study objectively demonstrated that computer-assisted secondary correction for craniofacial fractures can significantly improve facial symmetry. And the authors recommend that virtual surgical planning and intraoperative navigation should be a must step in craniofacial fracture correction.

Current Trends in Head and Neck Trauma

The practicing otolaryngologist frequently encounters consultation for injuries in the head and neck. Restoration of form and function is essential to normal activities of daily living and quality of life. This discussion intends to provide the reader with an up-to-date discussion of various evidence-based practice trends related to head and neck trauma. The discussion focuses on the acute management of trauma with minor emphasis on secondary management of injuries. Specific injuries related to the craniomaxillofacial skeleton, laryngotracheal complex, vascularity, and soft tissues are explored.

Evidence-Based Medicine for Midface/Orbit/Upper Facial Fracture Repair

The face is one of the most common areas of traumatic injury, making up approximately 25% of all injuries in 2016. Assault, motor vehicle collision (MVC), fall, sports, occupational, and gunshot wounds (GSW) are all common causes of facial fractures, with MVC and GSW leading to significantly higher severity of injuries. Most facial fractures occur in the upper two-thirds of the face. Most facial fractures require timely assessment, diagnosis, and treatment for optimal restoration of facial structures and functions. Without proper initial management, significant complications including immediate complications such as airway compromise, massive bleeding, infection, intracranial hemorrhages, or even death, and long-term complications such as poor functional outcomes and aesthetic setbacks can occur. The goal of this review is to summarize the management of fractures of the upper face, orbit, and midface and provide an update about complications and their management.

Orbital Soft Tissue Displacement After Blow-Out Fracture Repair Using Poly (L-Lactide-Co-Glycolide) Polymer Plates Based on Image Fusion Technique

PURPOSE

To analyze the displacement of orbital soft tissue after blow-out fracture (BOF) repair with poly (L-lactide-co-glycolide) plates.

MATERIALS AND METHODS

In this retrospective study, all patients who had undergone repair operations for orbital BOF from 2017 to 2021 were evaluated. Poly (L-lactide-co-glycolide) plates were used as repair materials. Preoperative and postoperative computed tomography images were integrated into the same coordinate system applying image fusion technique and were compared to determine the maximum displacement of orbital tissue after surgical repair.

RESULTS

A total of 15 patients were included. Five were male, and 10 were female. Mean age was 33±16 years. Median waiting period was 18 (12-23) days. Six cases were medial wall fractures, 5 were floor fractures, and 4 were combined fractures. Maxillo-ethmoidal strut was involved in 4. Mean defect area was 176.52±108.48 mm 2 . Median interval between postoperative imaging examinations was 292 (223-600) days. Mean orbital tissue displacement was 2.6±1.8 mm. Using simple and multivariable linear regression analysis, the fracture defect area ( P =0.001) and maxillo-ethmoidal strut involvement ( P =0.013) were found to be significantly associated with orbital tissue displacement. Median orbital volume change was 0.804 (0.647-1.010) cm 3 . Average proptosis variation was 1.2±0.8 mm.

CONCLUSIONS

Poly (L-lactide-co-glycolide) plates were more suitable for orbital BOF with small defect size. Those with large defect or maxillo-ethmoidal strut involved might have greater tissue displacements due to decline of supporting strength of poly (L-lactide-co-glycolide) plates.

Prospective Evaluation of Two Wall Orbital Fractures Involving the Medial Orbital Wall: PSI Reconstruction versus PDS Repair—Worth the Effort?

Proper treatment of the two-wall fractured orbit is still controversial. Specifically, there is no consensus on the issue of the necessity of medial orbital wall repair. With anatomically critical structures at risk during the surgical approach, surgeons’ view on the necessity of medial orbital wall repair often is restricted and an aesthetically disturbing enophthalmos is more likely to be accepted. Therefore, treatment options range from leaving the medial wall without repair to reconstruction with autogenous tissue or alloplastic materials, which can lead to moderate to severe side effects. However, emerging technologies such as patient-specific implants (PSI) offer a reliable and anatomically correct reconstruction of the bony orbit. This study aimed to evaluate the outcome of full orbital reconstruction using PSIs compared to only orbital floor repair using PDS (bioresorbable polydioxanone) foils leaving the medial orbital wall untouched in traumatic two-wall orbital fractures. Of all patients treated at the University Hospital of Düsseldorf between 2017 and 2019 who suffered from traumatic orbital fracture, only patients with a two-wall orbital fracture involving both the orbital floor and the medial wall (n = 68) were included. Patients were treated either with a PSI (n = 35) or a PDS foil (n = 33). Primary outcome parameters were ophthalmological disturbances analyzed via clinical investigation and intra-orbital angles, volumes and implant position analyzed with radiological 3D-datasets. While a two-wall reconstruction using PSIs led to a significant improvement of the enophthalmos, the rate of postoperative enophthalmos was significantly increased in cases of only orbital floor repair with PDS foils. Radiologically, a significant reconstruction of the three-dimensional bony orbit succeeded with the simple use of PSIs leading to a significant reduction in the traumatically enlarged orbital volume. PSI also led to a significant reduction in the traumatically enlarged medial angle of the orbit. This was not the case for single-floor repair with PDS foil. The results of this study suggest that complex orbital fractures can be reconstructed at an even higher degree of accuracy with selective laser-melted PSIs than PDS foils. In order to achieve a true to original reconstruction of the bony orbit, surgical treatment of the medial orbital wall can be advocated for in the long term depending on the indication.

Orbital Fractures

Orbital fractures are common in facial trauma and can be a challenge to treat. Understanding anatomy of the orbit, the clinical evaluation, indications for surgery, surgical approaches, complications, and postoperative are essential in providing appropriate treatment for patients who have sustained orbital fractures. In this article, the authors review the diagnostic evaluation, acute management, treatment options, and common complications of orbital fractures, as well as recent advancements in orbital fracture repairs.

Endoscopic repair of combined orbital floor and medial wall fractures involving the inferomedial strut

OBJECTIVES

To evaluate the safety, efficacy, and feasibility of an endoscopic transconjunctival inferior fornix and precaruncular approach for repair of combined orbital medial wall and floor fractures involving the inferomedial strut.

METHODS

A retrospective study was performed in 84 patients with combined orbital medial wall and floor fractures involving the inferomedial strut. All patients underwent surgery by endoscopic transconjunctival inferior fornix and precaruncular approach. A large polyester mesh plate was implanted to cover the fracture defect. The enophthalmos, diplopia, and surgical complications were evaluated pre- and postoperatively. Patients were followed for at least 6 months.

RESULTS

A total of 84 patients (55 men and 29 women) with a mean age of 36.88 ± 12.95 years were included in this study. Preoperatively, all 84 patients had an enophthalmos >2 mm, and the mean exophthalmometry measurement was 11.6 ± 2.14 mm. Diplopia was presented in 33 patients. Postoperatively, good symmetry was acquired in 81 of 84 patients, with a mean improvement of 3.02 ± 0.99 mm in the enophthalmos (P < 0.05). Recovery from diplopia occurred in 32 of 33 patients. A new onset of diplopia occurred postoperatively in 13 of the remaining 51 patients, only to recover spontaneously after 1 month. One patient suffered retrobulbar hemorrhage after surgery and was cured by conservative therapy. No other serious complications occurred.

CONCLUSIONS

The endoscopic transconjunctival inferior fornix and precaruncular approach is a promising management technique for combined orbital medial wall and floor fractures involving the inferomedial strut.

Three-dimensional analysis of facial asymmetry after zygomaticomaxillary complex fracture reduction: a retrospective analysis of 101 East Asian patients

BACKGROUND

The zygomaticomaxillary complex (ZMC) has a protruded, convex shape and plays a vital role in determining the contour by affecting the width of the middle face. This study aimed to evaluate the efficiency of ZMC fracture reduction and explore detailed directions for outcome improvement.

METHODS

We conducted a retrospective study of patients diagnosed with unilateral ZMC fracture who underwent ZMC reduction surgery at a single hospital between January 2015 and May 2020. The primary outcome variable was facial asymmetry using the difference in the bilateral malar eminence (ME) position measured by computed tomography scan. The 3-dimensional distance (IA, asymmetry index) and the distance in each dimension, Dx (anteroposterior distance), Dy (mediolateral distance), and Dz (superoinferior distance) were compared.

RESULTS

A total of 101 patients with ZMC fractures and 54 non-fracture patients were enrolled in the study. The mean age of the study sample was 43.49 years (control sample, 43.35 years), and the male-to-female ratio was 66.3:33.7 (control sample, 64.8:35.2). There were 53 and 48 patients with right and left ZMC fractures, respectively. The IA was not statistically different between the two groups. In terms of position in each dimension, only Dx was significantly different between the two groups.

CONCLUSION

The results show that overall facial asymmetry was recovered after ZMC reduction, but in certain dimension significant difference in ME position has still remained. For further improvement, treatment should be performed to relieve malar depression in the anteroposterior dimension.

Computer-Aided Rhinoplasty Using a Novel "navigated" Nasal Osteotomy Technique: A Pilot Study

OBJECTIVE

To describe the surgical technique of navigation-guided nasal osteotomies and assess feasibility of this technique for treating complex nasal bone deformities in reconstructive rhinoplasty.

METHODS

A retrospective chart review was performed in order to identify patients who underwent computer-aided rhinoplasty from August 2014 to February 2017. Inclusion criteria were nasal bone deformities on computed-tomography (CT) that correlated with specific nasal complaints. All patients underwent computer-aided rhinoplasty with navigation-guided nasal osteotomies using a standard navigation system. Osteotomies were performed using real-time visualization on the navigation screen. Additional soft tissue procedures were performed as needed. Medical records were reviewed for presenting symptoms, radiologic and operative findings, and postoperative course. Cosmetic outcomes were subjectively based on patients' standard 6-view photo-documentation from pre- and post-operative timepoints.

RESULTS

Twenty-one patients were included in the study; 8 were revision cases and 3 had mild-to-moderate hemifacial microsomia. Fifteen were completely closed procedures. No cases were opened because of inadequate visualization or difficulty accessing bony pathology. Mean (range) follow up was 98.6 (6-559) days. There were no intra-operative complications, unplanned admissions or re-admissions, or iatrogenic cosmetic complications (ie, "inverted V" or "saddle nose" deformities). Two patients required revision. One was after suffering nasal trauma within 4 weeks of initial rhinoplasty. The second underwent further correction of a deformity that required a costochondral graft. Both experienced good final results.

CONCLUSIONS

Computer-aided rhinoplasty is safe and feasible for treating complex nasal deformities using standard navigation systems.

Clinical outcome following intraoperative computed tomography-assisted secondary orbital reconstruction

BACKGROUND

Secondary post-traumatic orbital reconstructions are challenging. Portable computed tomography (CT) provides the option to acquire real-time, intraoperative images that help to detect the insufficient reconstruction of the orbit immediately. We retrospectively analyzed patients who received intraoperative CT imaging and analyzed the effect of intraoperative CT scans on revision rates and orbital volume changes before, during, and after surgery.

METHODS

From August 2014 to September 2016, eleven patients received intraoperative cone-beam CT scans to evaluate the results of secondary orbit reconstruction using Medpor + titanium implants. Patient demographics, surgical details, CT scanning protocol, and follow-up results were analyzed. 3D CT volumetry was used to analyze the orbital volume based on OsiriX MD software.

RESULTS

Based on intraoperative CT findings, seven cases required intraoperative revision to further augment the orbital cavity or adjust implants. The mean preoperative measured enophthalmos was 3.41±1.4 mm (range: 2-6 mm), which decreased to 0.73±0.4 mm (range: 0-1 mm) at postop assessment (p<0.0001). On the fracture side, there was a significant difference between preoperative vs. intraoperative and preoperative vs. postoperative volume measurements (p<0.01 for both subsets), but no significant difference between intraoperative vs. postoperative measurements.

CONCLUSION

Intraoperative CT is a valuable tool in secondary orbital reconstruction cases based on clinical enophthalmos evaluation and 3D CT volumetry. For these patients, the avoidance of another revision surgery may outweigh the disadvantage of increased operation time and additional radiation exposure.

Efficacy of transconjunctival approach for the treatment of orbital fractures: A protocol for systematic review and meta-analysis

BACKGROUND

This study aims to assess the efficacy of transconjunctival approach (TCA) for the treatment of orbital fractures (OF) comprehensively and systematically.

METHODS

In this study, we plan to search electronic databases of Cochrane Library, MEDLINE, EMBASE, Web of Science, Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, China National Knowledge Infrastructure and for relevant randomized controlled trials. All these databases will be searched from inception to the March 1, 2020 without limitations of language and publication status. Two independent authors will carry out study selection, data collection, and study quality assessment. Any disagreements will be resolved by discussion with another author if necessary. The study quality will be assessed using Cochrane risk of bias tool. Statistical analysis will be conducted using RevMan 5.3 software.

RESULTS

This study will be the first 1 to exert direct evidence to evaluate the efficacy of TCA for the treatment of OF.

CONCLUSIONS

The findings of this study will provide an exhaustive view of TCA for the treatment of OF.

STUDY REGISTRATION NUMBER

INPLASY202040154.

Endoscopic Support and Virtual Surgical Planning as an Alternative to Repair Orbital Wall Fractures

The reconstruction of the orbit has been carried out throughout history using different techniques. However, the persistence of high rates of complications mainly associated with the position of the eyeball and the migration of reconstruction implants have generated the need and importance of continuing to study new techniques, including with the help of technology. Virtual planning combined with endoscopic access and 3D models could decrease the number of complications associated with the aforementioned problems. For this, the aim of this observational retrospective study is to show the authors' experience of 19 cases in different orbital fractures using endoscopic support and virtual planning as great alternative in orbital reconstruction.

Computer-assisted navigation in orbitofacial surgery

The purpose of this systematic review is to investigate the most common indications, treatment, and outcomes of computer-assisted surgery (CAS) in ophthalmological practice. CAS has evolved over the years from a neurosurgical tool to maxillofacial as well as an instrument to orbitofacial surgeries. A detailed and organized scrutiny in relevant electronic databases, journals, and bibliographies of the cited articles was carried out. Clinical studies with a minimum of two study cases were included. Navigation surgery, posttraumatic orbital reconstruction, computer-assisted orbital surgery, image-guided orbital decompression, and optic canal decompression (OCD) were the areas of interest. The search generated 42 articles describing the use of navigation in facial surgery: 22 on orbital reconstructions, 5 related to lacrimal sac surgery, 4 on orbital decompression, 2 articles each on intraorbital foreign body and intraorbital tumors, 2 on faciomaxillary surgeries, 3 on cranial surgery, and 2 articles on navigation-guided OCD in traumatic optic neuropathy. In general, CAS is reported to be a useful tool for surgical planning, execution, evaluation, and research. The largest numbers of studies and patients were related to trauma. Treatment of complex orbital fractures was greatly improved by the use of CAS compared with empirically treated control groups. CAS seems to add a favourable potential to the surgical armamentarium. Planning details of the surgical approach in a three-dimensional virtual environment and execution with real-time guidance can help in considerable enhancement of precision. Financial investments and steep learning curve are the main hindrances to its popularity.

Navigation-Assisted Orbital Trauma Reconstruction Using a Bioactive Osteoconductive/Bioresorbable u-HA/PLLA System

Orbital fractures with orbital wall defects are common facial fractures encountered by oral-maxillofacial surgeons, because of the exposed position and thin bony walls of the midface. The primary goal of surgery is to restore the pre-injury anatomy and volume of hard tissue, and to free incarcerated or prolapsed orbital tissue from the fracture by bridging the bony defects with reconstructive implant material and restoring the maxillofacial-orbital skeleton. Numerous studies have reported orbital fracture repair with a wide variety of implant materials that offer various advantages and disadvantages. The ideal orbital implant material will allow conformation to individual patients' anatomical characteristics, remain stable over time, and are radiopaque, especially for the reconstruction of relatively large and/or complex bony walls. Based on these requirements, novel uncalcined and unsintered hydroxyapatite (u-HA) particles and poly-L-lactide (PLLA; u-HA/PLLA) composite sheets could be used as innovative, bioactive, and osteoconductive/bioresorbable implant materials for orbital reconstruction. In addition, intraoperative navigation is a powerful tool. Navigation- and computer-assisted surgeries have improved execution and predictability, allowing for greater precision, accuracy, and minimal invasiveness during orbital trauma reconstructive surgery of relatively complex and large orbital wall defects with ophthalmological malfunctions and deformities. This review presents an overview of navigation-assisted orbital trauma reconstruction using a bioactive, osteoconductive/bioresorbable u-HA/PLLA system.