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

Probing real-world Central European population midfacial skeleton symmetry for maxillofacial surgery

OBJECTIVES

Symmetry is essential for computer-aided surgical (CAS) procedures in oral and maxillofacial surgery (OMFS). A critical step for successful CAS is mirroring the unaffected side to create a template for the virtual reconstruction of the injured anatomical structure. The aim was to identify specific anatomical landmarks of the midfacial skeleton, to evaluate the symmetry in a group of the real-world Central European population, and to use these landmarks to assess midfacial symmetry in CT scans.

MATERIAL AND METHODS

The retrospective cross-sectional study defined landmarks of the midface's bony contour using viscerocranial CT data. The distances of the skeletal landmarks (e.g., the frontozygomatic suture and temporozygomatic suture) of the left and right sides from the midline were measured and statistically compared. Midfacial symmetry for reference points was defined as a difference within 0 mm and their mean difference plus one standard deviation.

RESULTS

We examined a total of 101 CT scans. 75% of our population shows symmetrical proportions of the midface. The means of the differences for the left and right sides ranged from 0.8 to 1.3 mm, averaging 1.1 ± 0.2 mm for all skeletal landmarks. The standard deviations ranged from 0.6 to 1.4 mm, with a computed mean of 0.9 ± 0.3 mm.

CONCLUSION

We established a methodology to assess the symmetry of the bony midface. If the determined differences were equal to or lower than 2.5 mm in the mentioned midfacial skeletal landmarks, then the symmetry of the bony midface was considered present, and symmetry-based methods for CAS procedures are applicable.

CLINICAL RELEVANCE

Many CAS procedures require facial symmetry. We provide an easy-to-apply method to probe for symmetry of the midface. The method may be used for population-based research, to check for proper reduction of fractures after reposition or to screen for symmetry prior to CAS planning.

Surgical Approaches to Orbital Fractures: A Practical and Systematic Review

Orbital fractures constitute a significant percentage of all midface injuries. Here, we present a contemporary evidence-based review of the major surgical approaches for orbital wall fractures and analyze the literature to compare all major surgical procedures and their complication rates.

Method

A systematic review was conducted to compare surgical approaches (subciliary, transcaruncular, transconjunctival, subtarsal, and endoscopic) and postoperative complications in patients who underwent surgical fixation of orbital wall fractures. A database search in PubMed (PubMed Central, MEDLINE and Bookshelf) was performed for all articles containing the terms "orbital," "wall," "fracture," and "surgery" with different combinations.

Results

A total of 950 articles were obtained and 25 articles were included, representing an analysis of 1137 fractures. The most frequent surgical approach was the endoscopic (33.3%) followed by the external surgical approaches, specifically transconjunctival (32.8%), subciliary (13.5%), subtarsal (11.5%), and transcaruncular (8.9%). The transconjunctival approach had a statistically significantly higher rate of complications (36.19%), followed by the subciliary (21.4%), and endoscopic approach (20.2%, P < 0.0001). The subtarsal approach had a statistically significantly lower rate of complications (8.2%) followed by the transcaruncular approach (14.0%, P < 0.0001).

Conclusion

The subtarsal and transcaruncular approaches were observed to have the lowest rates of complications, whereas the transconjunctival, subciliary, and endoscopic approaches were reported to have higher rates of complications.

Is Surgery Needed for Diplopia after Blowout Fractures? A Clarified Algorithm to Assist Decision-making

Diplopia is a common symptom after blowout fractures, with an incidence of 43.6%–83%. Although there is some consensus toward surgical correction, diplopia is not always resolved by surgery. Thus, there is a clinical dilemma for surgeons with regard to performing surgery at a specific time. This review aimed to create an algorithm to support accurate and effective decision-making.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Transconjunctival Approach Using Lateral Skin Extension for Reconstruction of Orbit Zygomatic Complex Fractures: Technique Description and a Case Series Analysis

Study Design

A descriptive-observational study of a series case report of patients diagnosed with orbito-zygomatic complex (OZMC) fracture with lateral wall involvement, was conducted. All patients were assessed in the Oral and Maxillofacial Surgery Service at Hospital El Carmen, Maipu, Santiago, Chile.

Objective

The purpose of this study was to evaluate a single-institution experience with the transconjunctival approach to the orbit, utilizing a lateral skin extension as unique approach to access to fronto-zygomatic suture, infraorbital rim and/or orbital floor.

Method

The authors identified 41 patients with OZMC fractures who underwent to surgical treatment over a 45 months period. Among this group, 21 patients needed fixation with osteosynthesis of the frontozygomatic suture, and 16 of whom were treated with the approach being studied. The authors assessed scleral exposure, eyelid position changes, ectropion, and entropion as outcome measures, and reported satisfactory outcomes at a minimum of 9 months follow-up.

Conclusions

This study concludes that in our experience, the transconjunctival approach utilizing a lateral skin extension allows a direct, easy, and quick access to the entire infra orbital rim, orbital floor, fronto-zygomatic suture and lateral wall of the orbit, up to spheno-zygomatic suture, with low associated morbidity and complications.

Repair of unilateral combined orbital floor and medial wall fracture using two titanium mesh plates: a modified technique

Background

Compared to isolated orbital wall fracture, combined orbital floor and medial wall fractures are more likely to be required surgical correction due to a higher possibility of complications. However, it remains a challenge to repair concomitant orbital fracture using a one-piece implant due to the complex anatomic structures of the orbit. Aiming to reduce surgical difficulties and enhance therapeutic effects, we repaired unilateral combined orbital floor and medial wall fractures using two separated modified titanium mesh plates in this study.

Methods

A retrospective study was conducted on 21 consecutive patients who presented with unilateral combined orbital floor and medial wall fractures in Tianjin Medical University General Hospital between November 2010 and January 2016. The orbital fractures were repaired with two separated titanium mesh plates. The corner at the transition zone area between the orbital floor and the medial wall was reconstructed simultaneously through a combined transcaruncular and inferior subciliary approach with lateral canthotomy. The pre- and post-operative functions and aesthetic results were evaluated.

Results

Preoperatively, all patients presented with 3.5-6.5 mm enophthalmos, five patients presented with diplopia with ocular motility limitation in injured eyes, and six patients presented with hypoglobus ranging from 1.5 to 3.5 mm. Orbital floor and medial wall fractures of all patients were successfully repaired with two separated titanium mesh plates. Postoperatively, enophthalmos was improved in all patients, which was less than 2 mm on the last follow-up day. Hypoglobus was disappeared in all six patients postoperatively. Diplopia was resolved in five patients within 3 months post operation, and was reduced in one patient.

Conclusions

In cases of unilateral concomitant orbital floor and medial wall fractures, two titanium mesh plates implantation is a safe and effective procedure. It is worthwhile to take the technique into account when the key points to consider when applying this method include reconstruction of the special orbital shape and the complete return reposition of prolapsed intraorbital soft tissues were intended.

Reconstruction of the orbital floor using supercritical CO2 decellularized porcine bone graft

Orbital floor fractures subsequently lead to consequences such as diplopia and enophthalmos. The graft materials used in orbital floor fractures varied from autografts to alloplastic grafts, which possess certain limitations. In the present study, a novel porcine bone matrix decellularized by supercritical CO2 (scCO2), ABCcolla® Collagen Bone Graft, was used for the reconstruction of the orbital framework. The study was approved by the institutional review board (IRB) of Kaohsiung Medical University Chung-Ho Memorial Hospital (KMUH). Ten cases underwent orbital floor reconstruction in KMUH in 2019. The orbital defects were fixed by the implantation of the ABCcolla® Collagen Bone Graft. Nine out of ten cases used 1 piece of customized ABCcolla® Collagen Bone Graft in each defect. The other case used 2 pieces of customized ABCcolla® Collagen Bone Graft in one defect area due to the curved outline of the defect. In the outpatient clinic, all 10 cases showed improvement of enophthalmos on CT (computerized tomography) at week 8 follow-up. No replacement of implants was needed during follow-ups. To conclude, ABCcolla® Collagen Bone Graft proved to be safe and effective in the reconstruction of the orbital floor with high accessibility, high stability, good biocompatibility, low infection rate and low complication rate.

A useful additional medial subbrow approach for the treatment of medial orbital wall fracture with subciliary technique

BACKGROUND

To date, a variety of surgical approaches have been used to reconstruct the medial orbital wall fracture. Still however, there is still a controversy as to their applicability because of postoperative scars, injury of anatomical structures and limited visual fields. The purpose of this study was to introduce a useful additional medial subbrow approach for better reduction and securement more accurate implant pocket of medial orbital wall fracture with the subciliary technique.

METHODS

We had performed our technique for a total of 14 patients with medial orbital wall fracture at our medical institution between January 2016 and July 2017. All fractures were operated through subciliary technique combined with the additional medial subbrow approach. They underwent subciliary approach accompanied by medial wall dissection using a Louisville elevator through the slit incision of the medial subbrow procedure. This facilitated visualization of the medial wall fracture site and helped to ensure a more accurate pocket for implant insertion.

RESULTS

Postoperative outcomes showed sufficient coverage without displacement. Twelve cases of preoperative diplopia improved to two cases of postoperative diplopia. More than 2 mm enophthalmos was 14 cases preoperatively, improving to 0 case postoperatively. Without damage such as major vessels or extraocular muscles, enophthalmos was corrected and there was no restriction of eyeball motion.

CONCLUSION

Our ancillary procedure was useful in dissecting the medial wall, and it was a safe method as to cause no significant complications in our clinical series. Also, there is an only nonvisible postoperative scar. Therefore, it is a recommendable surgical modality for medial orbital wall fracture.

Navigation-Assisted Isolated Medial Orbital Wall Fracture Reconstruction Using an U-HA/PLLA Sheet via a Transcaruncular Approach

Purpose: We investigated the feasibility of isolated medial orbital wall fracture reconstruction using an unsintered hydroxyapatite particles/poly L-lactide (u-HA/PLLA) sheet implant with the assistance of intraoperative navigation via the transcaruncular approach. Patients and methods: Ten consecutive patients (5 males and 5 females; mean age, 57.5 years) were included based on the clinical and imaging criteria. All patients underwent surgical treatment of the isolated medial orbital wall fracture using transcaruncular incision and the u-HA/PLLA implant under navigation. The follow-up time was greater than 6 months. Preoperative and postoperative clinical data regarding the presence of diplopia, eye motility restriction, and enophthalmos were assessed. The orbital volumes of the injured and uninjured orbit were also evaluated using computed tomography images. Results: All patients had improved ophthalmologic functional and esthetic outcomes and were successfully treated without any long-term complications arising during follow-up. There was a significant difference between the preoperative and postoperative injured orbits due to herniation of the orbital contents. Moreover, the orbital volume of the postoperative injured side following surgery was the same as that of the unaffected side, indicating that anatomically good reconstruction had been obtained. Conclusions: Surgical treatment using the transcaruncular approach and u-HA/PLLA materials with intraoperative navigation is a safe, promising, and effective technique for isolated medial orbital wall fracture reconstruction.

Reconstruction of medial orbital wall using a retrocaruncular approach

The purpose of the study was to analyze and describe the retrocaruncular approach to access medial orbital wall. A retrospective analysis was performed in patients referred for the treatment of orbital fractures between January 1st 2011 and July 31st 2017. The study included patients over 18 years old with isolated fractures of the medial orbital wall or combined with the orbital floor who underwent a transconjunctival approach with retrocaruncular extension and lateral canthotomy, and with a minimum follow-up of 6 months. Patients with fractures to the roof and/or lateral orbital wall were excluded. From a total of 319 orbits, 30 medial wall fractures were treated using a retrocaruncular approach, transconjunctival extension and lateral canthotomy. 7 of them were pure medial wall fractures and 23 were combined with orbital floor. Except for one case that required delayed reconstruction with customized orbital implant, all orbital reconstructions were successful in the first surgery. Only one patient developed a conjunctival granuloma in relation to the caruncle. No others patients had complications. This study concluded that this approach is a successful access for surgical treatment of medial orbital wall fractures because of their broad visibility without damaging structures, allowing adequate orbital reconstruction and excellent aesthetic results.