Repair of Traumatic Orbital Wall Defects Using Conchal Cartilage

A systematic literature review and narrative synthesis on the use of autologous cartilage in the repair of orbital fractures

Introduction

Fractures of the orbit are common injuries within the maxillofacial skeleton, and can often result in restrictions to ocular movement, diplopia, and enophthalmous if herniation of globe content occurs. Various studies have demonstrated the use of autologous cartilage grafts in the reconstruction of orbital fractures.

Methods

A systematic review protocol was registered with PROSPERO, and reported in accordance with the Preferred Reporting for Items for Systematic Reviews and Meta-Analyses. Comprehensive electronic search strategies of four databases were developed. Studies were screened according to the inclusion and exclusion criteria by two independent reviewers.

Results

Seven thousand one hundred seventy-one articles were identified following a comprehensive literature search. These articles were filtered for relevance and duplication, which reduced the number of articles to 16. A total of 259 patients underwent orbital reconstruction with the use of autologous cartilage. Conchal cartilage was harvested in 148 patients, auricular cartilage in 22 patients, nasoseptal cartilage in 72 patients, and costal cartilage in 17 patients. Thirty, seven, twelve, and four complications were observed in patients where cartilage was harvested from the concha, auricle, nasoseptum and rib, respectively. Most common complications included diplopia (n=23), infra-orbital para/anaesthesia (n=27), and enophthalmos (n=7). No failure of graft or donor site morbidity were observed in the studies.

Conclusion

Autogenous materials such as cartilage can be used as an alternative for orbital reconstruction. Cartilage was considered by the authors to provide adequate structural support to the orbital contents, and that it was easy to harvest, shape, and position.

The Conchal Vascular Foramen of the Posterior Auricular Artery: Application to Conchal Cartilage Grafting

The posterior auricular artery (PAA), a branch of the external carotid artery, gives rise to a conchal network formed by PAA perforators through the conchal floor of the auricle. However, this branch and its entrance (foramen) to the anterior concha, is rarely illustrated in the literature and has not been studied in detail. Therefore, we aimed to investigate the morphology of the perforating artery (PA) and its vascular foramen (VF). Ten sides from five formalin-fixed frozen Caucasian cadaveric heads were used. The number, diameter of the VF, diameter of the perforating artery (PA), shape of the VF (circular or oval), distance from the middle of the tragus and origin of the artery were documented. The number of VF ranged from 1 to 2; one was seen on 90% of the sides and two were seen on 10% of the sides. The VF was oval in 36% of the sides and circular in the remaining 64%. The mean diameter of the long and short axes of the VF, and PA was 2.0±1.4 mm, 1.3±0.9 mm, and 0.7±0.4 mm, respectively. Diameter of the PA was 1.0 mm or greater in 18% of the sides. The mean distance from the middle of the tragus to the VF was 10.7±2.6 mm. The perforating artery of the concha originated from the posterior auricular artery on all 11 sides.

Reconstruction of Orbital Floor With Auricular Concha

Orbital floor fractures of varying sizes commonly occur after orbital injuries and remain a serious challenge. Serious complications of such fractures include enopthalmos, restriction of extraocular movement, and diplopia. There is a dearth of literature that can be applied widely, easily, and successfully in all such situations, and therefore there is no consensus on the treatment protocol of this pathology yet. Autogenous grafts and alloplastic and allogenic materials with a wide variety of advantages and disadvantages have been discussed. The value of preoperative and postoperative ophthalmological examination should be standard of care in all orbital fracture patients. An ideal reconstructed orbital floor fracture should accelerate the restoration of orbital function with acceptable cosmetic results. Management parameters of orbital fractures such as timing of surgery, incision type, and implant materials, though widely discussed, remain controversial. In this study, 55 patients with orbital floor fractures surgically reconstructed with conchal cartilage grafts between 2008 and 2014 were retrospectively evaluated. Complications and long-time follow-up visit results have been reported with clinical and radiographic findings. The aim of this study was to present the authors' clinical experiences of reconstruction of blow-out fractures with auricular conchal graft and to evaluate the other materials available for use.

Sliced Costochondral Chip Grafts in Posttraumatic Enophthalmos Correction

BACKGROUND

Posttraumatic enophthalmos is a relatively common problem following orbitozygomatic fractures. However, inadequate long-term results are frequently observed due to the difficulty of performing intraoperative fine adjustments to soft-tissue volume and orbital size and gradual absorption of some grafted materials. Here, the authors describe an efficient method of enophthalmos correction using sliced costochondral bone and cartilage combination grafts.

METHODS

From 2005 to 2011, the authors corrected enophthalmos in 12 patients using sliced costochondral grafts. The mean follow-up period was 13 months. For costochondral graft harvest, an approximately 5-cm skin incision was made directly above the seventh costal cartilage, the perichondrium was peeled back, and a small piece of rib bone and costal cartilage was harvested from the anterior part of the seventh rib bone and cartilage and cut into 2-mm-thick slices. A subciliary and/or transcaruncular incision was made in the affected side eyelid to expose the operating field, subperiosteal dissection was performed in the orbit and orbital floor. The cartilage chips were gradually grafted onto the dissected areas from the posterior orbit.

RESULTS

Aesthetically satisfactory results were obtained in all patients. No complications in the donor area were observed. Furthermore, no patients experienced a recurrence or deterioration of diplopia over the follow-up period. One patient experienced temporary high intraocular pressure, which spontaneously resolved with medication and eye drops.

CONCLUSION

The costochondral graft is adequate for the reconstruction of the fracture, easy to obtain, easily adaptable to the orbital walls, and has minimal morbidity at the donor site.

A Surprise in the Lacrimal Sac

To present a case with recurrent dacryocystitis as an unusual complication of medial orbital wall fracture repair with cartilage tissue graft. A 20-year-old male had facial trauma and underwent surgery to reconstruct right medial orbital wall fracture. During follow-up, he presented with continuous epiphora, mucopurulent discharge from the right eye. A thorough history taking indicated that medial orbital fracture was reconstructed with postauricular cartilage. We planned a standard external dacryocystorhinostomy (DCR). During the creation of lacrimal sac flaps, hard tissue was noted in the lacrimal sac. This tissue was excised and sent for pathological examination. The pathological examination revealed cartilage tissue. There were no further ipsilateral symptoms or complications after DCR. In patients with lacrimal system injury related to orbital wall fracture, iatrogenic foreign bodies in the lacrimal sac should be considered in patients with recurrent dacryocystitis who had reconstructive surgery for facial and orbital trauma.

Novel reconstructive methods of the conchal central strut using an absorbable plate after total harvesting of the conchal cartilage

PURPOSE

Conchal cartilage is widely used in the field of plastic surgery, but donor-site morbidity is inevitable when all of the conchal cartilage is harvested. To maintain ear shape, the authors introduce a new method using an absorbable plate to reconstruct the conchal central strut after total harvesting of the conchal cartilage.

METHODS

In total, 18 subjects underwent surgery, and 14 subjects who were followed up for more than 12 months were included in this article. Before the total harvesting of the conchae, an absorbable plate was adjusted to the proper curvature and length. After harvesting, the central strut was reconstructed by the precrafted absorbable plate. When the harvested cartilage was too large or one implant was not sufficient to reconstruct the central strut, an additional implant was added to the cymba conchae.Outcomes were evaluated by photogrammetry and questionnaires. Seven items were selected to evaluate the shape of the ear and conchal cavity. The authors compared preoperative and postoperative photographs, looking at proportion indices of 7 items using Photoshop. Ten assessors who did not participate in the operation were also shown preoperative and postoperative photographs and answered questionnaires about the shapes of the ear, conchal cavity, and conchal central strut.

RESULTS

Except for the effective conchal cavity height index, no statistically significant differences were observed between preoperative and postoperative ear shapes. Additionally, the questionnaire showed excellent assessments for all items.

CONCLUSIONS

Reconstruction of the central strut using an absorbable plate after total harvest of the conchal cartilage was a simple and effective method to prevent ear collapse.

Biomaterials for repair of orbital floor blowout fractures: a systematic review

PURPOSE

To evaluate the reported use and outcomes of implant materials used for the restoration of post-traumatic orbital floor defects in adults.

MATERIALS AND METHODS

A systematic search of the English literature was performed in the databases of PubMed, Cochrane Library, and EMBASE. The study selection process was adapted from the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement, and 55 articles complied with the study inclusion criteria. The primary outcome measures were diplopia, enophthalmos, graft extrusion/displacement, and infection related to the graft material. The secondary outcome measures were infraorbital paresthesia, orbital dystopia, orbital soft tissue entrapment, and donor-site complications.

RESULTS

Of 55 articles, 41 (74.5%) evaluated were retrospective case series, 9 (16.4%) were retrospective case-control studies, 3 (5.5%) were controlled trials, and 2 (3.6%) were prospective case series. Autogenous graft materials were predominantly used in 19 studies, alloplastic materials were used in 33 studies, and the remaining 3 articles reported on allogeneic materials. Overall, 19 different types of implant materials were used in 2,483 patients. Of 827 patients with diplopia before surgery, 151 (18.3%) had diplopia postoperatively. Of 449 patients with enophthalmos before surgery, 134 (29.8%) had enophthalmos postoperatively. Only 2 patients (0.1%) and 14 patients (0.6%) had graft extrusion/displacement and infection related to the graft material, respectively; alloplastic biomaterials were used in all of these cases.

CONCLUSIONS

All graft materials used were successful to variable degrees because all studies reported improvement in terms of the recorded outcome measures. A guideline for choice of implant material based on defect size was developed.

[Eyelid, medial canthus and medial orbital wall reconstruction using a combination of Hübner and conchal grafts with two illustrative cases]

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.

High-density porous polyethylene wedge implant in correction of enophthalmos and hypoglobus in seeing eyes

INTRODUCTION

To report the results of post-traumatic enophthalmos/hypophthalmos correction with high-density porous polyethylene wedge implants in seeing eyes.

METHODS

This is an interventional case series of 25 patients (25 eyes) with post-traumatic enophthalmos and hypophthalmos, who underwent orbital reconstruction to correct the enophthalmos and hypophthalmos using Medpor® wedge implant. The aim was an overcorrection of 1 mm in comparison to the other eye, intra-operatively. If needed, trimming of the wedge implant or adding Medpor® sheets were used to achieve the goal. Success was defined as achieving the globe position within 1 mm of the other eye in the last follow-up. Improvement and failure were considered as correction outside the success range of 1 mm and no change in the amount of enophthalmos/hypophthalmos, respectively.

RESULTS

Patients were followed for at least 6 months (mean= 12.66, SD= 12.32). Success, improvement and failure of enophthalmos correction were: 58.3% (14/24), 37.5% (9/24) and 1 (1/24, 4.1%), respectively. Success, improvement and failure of hypophthalmos correction were 73.68% (14/19), 15.78% (3/19) and 5.26% (1/19), respectively. There was no significant difference between the success rate of enophthalmos versus hypophthalmos correction (P= 0.8). Results of 1-month follow up change in enophthalmos and hypophthalmos significantly correlated (r= 0.92, P= 0.000) with the change recorded at last follow up.

CONCLUSIONS

Porous polyethylene wedge implants are useful and safe in correction of enophthalmos and hypoglobus in seeing eyes. Appropriately positioned implant yields no significant difference in correction of enophthalmos versus hypophthalmos.

Reconstruction of acquired orbital deformity characterized by volume change

Acquired orbital deformity is a common disease in the practice of craniofacial surgery. Defective orbital volume and abnormality of eyeball position are the most important characteristics of pathologic changes. This study includes 87 cases of acquired orbital deformity, which received surgery for volume aberration from 2002 to present. Among them, 73 cases received orbital volume expansion surgery and 14 cases received reduction surgery. Coronal scalp, lower eyelid, or intraoral gingival-buccal incisions were carried out for the approach. In some patients, the original scar around the orbit was chosen for the incision. Operation aims were reduction of orbit and reconstruction of the orbital wall integrity. Operative methods were osteotomy for reduction and implantation of autologous bone or artificial materials. Orbital volume and eyeball position were restored to normal in all patients after the operation, and no serious complications occurred. Treatment of acquired orbital deformity should make restoration of orbital volume as the most important target of therapy. Autologous bone should be the material of first choice, and the selection and amount of implanted material should be decided by the specialty and experience of the physician.