Reconstruction of traumatic orbital floor defects using irradiated cartilage homografts

Is there an ideal implant for orbital reconstructions? Prospective 64-case study

The aim of this study was to compare the effectiveness of porous polyethylene, titanium mesh, and castor oil-derived biopolymer randomized in orbital reconstructions of defects larger than 1 cm in length on the inferior and medial walls. A total of 63 patients (64 orbits) were evaluated to determine the presence of diplopia, enophthalmos ocular motility, and infraorbital nerve paraesthesia in both the preoperative and postoperative periods. The surgeons' opinions of the ease in handling the implants were also obtained after each procedure. The patients were divided into 3 groups: 17 received porous polyethylene, 21 received castor oil-derived biopolymer, and 26 received titanium mesh. In the preoperative period, 30 patients experienced enophthalmos, 11 experienced diplopia, and 12 experienced ocular motility. Ninety days after the orbital reconstruction, 6 cases of enophthalmos persisted, as did 2 cases of diplopia and 2 cases of ocular motility. Ten patients developed some type of postoperative complication. Material removal was required in only 1 case. Regardless of the size of the defect, the materials used were found to be effective for reconstructing orbital volume; they were also found to offer ease in handling and stabilization.

A review of materials currently used in orbital floor reconstruction

Orbital fractures are common fractures of the midface. As such, numerous techniques and materials exist for the repair of this region, each with inherent advantages and disadvantages. But does the ideal implant material exist? Should we stop and simply use readily available materials, or should the cycle of need and discovery continue? A comprehensive review of materials used in orbital reconstruction and possible new directions in orbital floor reconstruction are presented.

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.

Biomaterials and implants for orbital floor repair

Treatment of orbital floor fractures and defects is often a complex issue. Repair of these injuries essentially aims to restore the continuity of the orbital floor and to provide an adequate support to the orbital content. Several materials and implants have been proposed over the years for orbital floor reconstruction, in the hope of achieving the best clinical outcome for the patient. Autografts have been traditionally considered as the "gold standard" choice due to the absence of an adverse immunological response, but they are available in limited amounts and carry the need for extra surgery. In order to overcome the drawbacks related to autografts, researchers' and surgeons' attention has been progressively attracted by alloplastic materials, which can be commercially produced and easily tailored to fit a wide range of specific clinical needs. In this review the advantages and limitations of the various biomaterials proposed and tested for orbital floor repair are critically examined and discussed. Criteria and guidelines for optimal material/implant choice, as well as future research directions, are also presented, in an attempt to understand whether an ideal biomaterial already exists or a truly functional implant will eventually materialise in the next few years.

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.

MOC-PSSM CME article: Zygomatic fractures

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the common signs, symptoms, and treatment options for zygomatic fractures. 2. Answer basic questions on therapy for zygomatic fractures.

SUMMARY

This maintenance of certification article on zygomatic fractures attempts to review the current approaches to the treatment of these fractures. Although the article does not deal with extended approaches to treatment, it does in a general sense present the preoperative, intraoperative, and postoperative thinking for the plastic surgeon approaching these patients in general practice. A further in-depth review can be obtained through the references at the end of the article.

Reconstruction of Traumatic Orbital Floor Fractures With Resorbable Mesh Plate

Various materials such as autogenous bone, cartilage and alloplastic implants have been used to reconstruct orbital floor fractures. A new material is needed because of disadvantages of nonresorbable alloplastic materials and difficulties in harvesting autogenous tissues. In this study safety and value of the use of resorbable mesh plate in the treatment of orbital floor fractures are discussed. Between 2002 and 2004 a total of 17 maxillofacial trauma patients complicated with orbital floor fractures were treated with resorbable mesh plate through subciliary or transconjunctival incisions. Pure blow-out fractures were determined in 6 patients and 11 patients had accompanying maxillofacial fractures. Resorbable plate was easily shaped to fit to the orbital floor by cutting with scissors. Patients were evaluated clinically and with computed tomography scans preoperatively and at 3-, 6- and 12-month intervals postoperatively. Twelve patients had preoperative enophthalmos. Two patients had diplopia that was corrected postoperatively. In all 17 cases there was no evidence of infection, diplopia and gaze restriction postoperatively. Scleral show appeared in three patients by the second postoperative week but resolved totally within 3 to 6 weeks except one patient. In this patient anterior displacement of mesh was evident which caused ectropion and enophthalmos and required re-operation. No any other mesh related problems were seen at 15 months mean follow-up time. The advantage of the resorbable mesh system in orbital floor fracture is the maintenance of orbital contents against herniation forces during the initial phase of healing and then complete resorption through natural processes after its support is no longer needed. Our experience represents that resorbable mesh is a safe and effective material for reconstruction of the selected, non-extensive orbital floor fractures.

Reconstruction of Orbital Floor Fracture Using Solvent-Preserved Bone Graft

The orbital floor is one of the most frequently damaged parts of the maxillofacial skeleton during facial trauma. Unfavorable aesthetic and functional outcomes are frequent when it is treated inadequately. The treatment consists of spanning the floor defect with a material that can provide structural support and restore the orbital volume. This material should also be biocompatible with the surrounding tissues and easily reshaped to fit the orbital floor. Although various autografts or synthetic materials have been used, there is still no consensus on the ideal reconstruction method of orbital floor defects. This study evaluated the applicability of solvent-preserved cadaveric cranial bone graft and its preliminary results in the reconstruction of the orbital floor fractures. Twenty-five orbital floor fractures of 21 patients who underwent surgical repair with cadaveric bone graft during a 2-year period were included in this study. Pure blowout fractures were determined in nine patients, whereas 12 patients had other accompanying maxillofacial fractures. Of the 21 patients, 14 had clinically evident diplopia (66.7 percent), 12 of them had enophthalmos (57.1 percent), and two of them had gaze restriction preoperatively. Reconstruction of the floor of the orbit was performed following either the subciliary or the transconjunctival approach. A cranial allograft was placed over the defect after sufficient exposure. The mean follow-up period was 9 months. Postoperative diplopia, enophthalmos, eye motility, cosmetic appearance, and complications were documented. None of the patients had any evidence of diplopia, limited eye movement, inflammatory reactions in soft tissues, infection, or graft extrusion in the postoperative period. Providing sufficient orbital volume, no graft resorption was detected in computed tomography scan controls. None of the implants required removal for any reason. Enophthalmos was seen in one patient, and temporary scleral show lasting up to 3 to 6 weeks was detected in another three patients. Satisfactory cosmetic results were obtained in all patients. This study showed that solvent-preserved bone, which is a nonsynthetic, human-originated, processed bioimplant, can be safely used in orbital floor repair and can be considered as another reliable treatment alternative.

A comparison of parietal and iliac crest bone grafts for orbital reconstruction

PURPOSE

This study evaluated the results of cranial (membranous) versus iliac crest (endochondral) bone grafts as implants to correct post-traumatic globe malposition and/or diplopia.

PATIENTS AND METHODS

Twenty-two patients underwent 25 orbital reconstructions with bone for enophthalmos, hypophthalmos, and diplopia after trauma to the orbit. Inclusion criteria consisted of at least 4 months postsurgical follow-up, pre- and postsurgical quantitative orbital measurements, photographic documentation, and complete medical records regarding inpatient and outpatient data.

RESULTS

Nine cranial bone grafts and 16 iliac crest grafts were placed. Ages were similar in both groups. The average follow-up was 24 months for the cranial graft group (range, 4 to 54 months) and 18 months for the iliac crest graft group (range, 4 to 51 months). Preoperative enophthalmos averaged 4.11 and 5.06 mm in the cranial and iliac crest groups, respectively, and postoperatively the measurements were 1.78 and 1.37 mm, respectively. Changes in hypophthalmos generally reflected changes in the enophthalmos correction. In 10 patients diplopia was corrected by the procedure. There was a statistically significant change in the enophthalmos of patients when comparing pre- and postoperative status, but no statistically significant difference between the results of the cranial and iliac crest graft groups.

CONCLUSION

There is no difference in the ability of cranial and iliac crest bone grafts to correct post-traumatic enophthalmos.

Repair of traumatic inferior orbital wall defects with nasoseptal cartilage

PURPOSE

This study evaluated the effectiveness of nasoseptal cartilage for repairing traumatic orbital floor defects.

PATIENTS AND METHODS

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.

RESULTS

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.

CONCLUSIONS

Nasal septal cartilage is a readily accessible autogenous tissue that should be considered when an autogenous graft is needed for orbital floor defect reconstruction.

Use of membrane and bone grafts in the reconstruction of orbital fractures

OBJECTIVE

To present and analyze the clinical results derived from the use of different grafts for the reconstruction of orbital defects during a 10-year period.

STUDY DESIGN

Fifty-five fracture cases with orbital bony defect, requiring a graft, are presented. The surgical treatment includes the reconstruction of the fracture (osteosynthesis) and the repair of the remaining bone defect by graft, with the type of graft dependent on the size of the defect. For minor defects membranes were used (lyophilized dura or alloplastic dura mater), whereas major defects were repaired with bone grafts (autografts, heterografts, or bone substitute material). All patients have been regularly evaluated for at least one year postoperatively.

RESULTS

All grafts were well tolerated by the patients. Diplopia subsided in all but 5 cases, motility disturbance was fully repaired in all but 3 cases. Esthetics were improved in cases with severe bone defect.

CONCLUSION

The wide variety of grafts available allows successful reconstruction of all types of orbital bony defects. The clinician should be able to use different types of grafts depending on the type and size of the defect.

An evaluation of the support provided by common internal orbital reconstruction materials

PURPOSE

The objectives of this investigation were to assess the weight of the combined internal orbital contents, to evaluate the ability of common internal orbital reconstruction materials to resist loads, and to determine whether these materials provide enough load resistance to support the orbital contents.

MATERIALS AND METHODS

The combined exonerated internal orbital contents (globe, fat, extraocular musculature, neurovascular structures, lacrimal apparatus, and musculocutaneous lids) from 16 human orbits were weighed. Five each of 13 different internal orbital reconstruction materials (titanium mesh, bioresorbables, Marlex [CR Bard, Cranston, RI], Medpore [Porex Medical, College Park, GA], Silastic [Dow Coming, Midland, MI], dried calvarium) were evaluated for their ability to resist loads applied by Instron 85.11 mechanical testing device (Canton, MA) when used to reconstruct uniform orbital floor defects in synthetic skulls (Sawbones, Vashon Island, WA). Yield load, yield displacement, maximum load, and displacement at maximum load were measured. A comparison was then made between orbital content weight and the load-resisting capabilities of the various materials.

RESULTS

The weight of the combined internal orbital contents was 42.97+/-4.05 g (range, 37.80 to 51.03 g). All of the materials tested except Marlex mesh met or exceeded the requirements for support of the combined internal orbital contents.

CONCLUSION

Except in the instance of complete loss of the orbital floor, all of the materials tested should provide adequate orbital support.

Reconstruction of the orbital floor with lyophilized tensor fascia lata

PURPOSE

This article describes the results of using lyophilized tensor fascia lata for the repair of orbital floor defects.

PATIENTS AND METHODS

During a 2-year period, orbital floor reconstruction was performed in 12 patients using lyophilized tensor fascia lata. A Foley catheter was placed into maxillary sinus and left in place for 10 days to provide temporary support for the fascia.

RESULTS

Patients were followed for 12 months to 2 years. No cases of infection, exposure, extrusion, or graft removal were encountered, and enophthalmus, symmetry changes, or restricted movement were not observed during the follow-up period.

CONCLUSION

Lyophilized fascia lata is easy to shape and place in the defect. It provides an excellent material for repair of small to moderate-sized orbital floor defects.