A Surgical Treatment of Severe Late Posttraumatic Enophthalmos Using Sliced Costal Cartilage Chip Grafts

Late reconstruction of post-traumatic enophthalmos and hypoglobus using three-dimensional implants: a case series

Post-traumatic enophthalmos and hypoglobus are common sequelae of facial bone fractures, even after reduction surgery. They are associated with functional and esthetic issues, which may lower the quality of life. These deformities frequently present late, and adequate correction is difficult. We report three cases of late inferior orbital rim reconstructions with three-dimensional printed implants to help resolve these problems. The average duration between the traumatic event and surgery was 3 years and 4 months. One patient was treated with a completely absorbable implant and exhibited satisfactory results until the implant started to biodegrade at 1 year and 9 months after surgery. Two patients were treated with a permanent implant and demonstrated satisfactory results. However, longer follow-up periods were needed. There were no complications such as infection, diplopia, or restriction of ocular motion and the patients were satisfied with the esthetic results.

Investigation of the Orbital Arterial Distribution Using Image Superimposition to Determine Safe Zones for Retrobulbar Injection and to Prevent Filler Complications

BACKGROUND

Retrobulbar filler injection has recently been considered an ideal method for orbital volume enhancement due to its nontoxic, easily reversible, and noninvasive characteristics. This study determined the arterial distribution in the orbit with the aim of defining a safety zone for retrobulbar filler injections used to enhance the orbital volume.

METHODS

Twenty-seven orbits of 24 formalin-embalmed cadavers were dissected. The orbital arteries were identified after removal of the eyeball, extraocular muscles, and connective tissues. The course of each orbital artery was then recorded in each specimen, and all of the courses were then superimposed to determine the arterial distribution in the orbit.

RESULTS

The superimposition of lined images based on the orbital vasculature of each specimen revealed that the arterial density was highest in the superonasal region and lowest in the inferotemporal region. In particular, orbital arteries were scarce at 8 o'clock and 4 o'clock in the right and left orbits, respectively, and an artery-free zone was demonstrated in the outer part of those directions.

CONCLUSIONS

When performing a transcutaneous retrobulbar injection of filler for orbital volume enhancement, the relative safety zone could be considered to be located at 8 o'clock and 4 o'clock in the right and left orbits, respectively. The detailed topographic information about the arterial distribution in the orbit, provided by the present study, may help oculofacial surgeons to avoid injury to major vessels and decrease the risk of retrobulbar hemorrhage and vision-threatening complications.

Enophthalmos: Exploration of Quantitative Treatment With Retro-Orbital Fat Globules Injection

Craniomaxillofacial and plastic surgeons are often confronted with patients who present with enophthalmos caused mainly by trauma. In many patients, one-stage reconstruction repairs only the bony orbit, leaving intact the disfiguring enophthalmos. Thus, some filler is needed to restore the normal volume of the orbit. The authors describe a technique to correct such deformation safely and effectively. Data were collected from 30 enophthalmic patients (average age 36.67 ± 11.66 years) who underwent retro-ocular injections of fat globules between August 2014 and July 2018. CT helped identify a safe injection site, and specific CT measurements quantified the volume of fat globules required. There was a significant difference between the preoperative and postoperative values for lateral orbital protrusion (P < .01), superior orbital protrusion (P < .01), and orbital volume (P < .01). Most patients were satisfied with the outcome. There were no significant complications. Injecting fat globules into the retro-orbital area is an effective technique for correcting enophthalmos deformity.

Autologous Fat Graft for the Treatment of Sighted Posttraumatic Enophthalmos and Sunken Upper Eyelid

PURPOSE

The treatment of enophthalmos and sunken upper eyelid is challenging. Although autologous fat graft has been widely used in breast augmentation, buttock contouring, and facial rejuvenation, its application in enophthalmos and sunken upper eyelid is not yet widely utilized. The clinical safety and value of autologous fat graft in sighted patients with enophthalmos and sunken upper eyelid are unclear. This study retrospectively analyzed the cosmetic results and safety of autologous fat graft in the correction of sighted traumatic enophthalmos and sunken upper eyelid.

METHODS

Autologous fat graft was performed in 9 patients with posttraumatic enophthalmos and sunken upper eyelid. The visual acuity, orbital swelling, eye movement, enophthalmos, and sunken upper eyelid were observed.

RESULTS

Eight to 24 months after autologous fat graft, enophthalmos and sunken upper eyelid in 9 patients improved significantly. Although orbital swelling occurred in the early postoperative period, no vision loss, eye movement limitation, or fat embolism had occurred.

CONCLUSION

Autologous fat graft is an effective, predictable, scarless, and minimally invasive surgery for the correction of the sighted posttraumatic enophthalmos and sunken upper eyelid. The possible risk of fat embolization and blindness from the compression of the optic nerve should not be neglected. Further studies and more cases must be performed.

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.

Correction of Late Posttraumatic Enophthalmos Using an Antral Balloon

Enophthalmos is the posterior displacement of the ocular globe within the bony orbit. Correction of late posttraumatic enophthalmos is one of the most challenging surgical procedures. We have performed a corrective procedure for late enophthalmos using an antral balloon, with or without minimal bone grafting. All orbital contents were separated from the bone fragments, infraorbital nerve, and mucosa of the maxillary antrum. The remaining orbital floor was fractured by the surgeon's digital pressure from the maxillary antrum. The antral balloon was placed in the maxillary antrum and inflated under direct vision from inside the orbit. After a consolidation period, the patient underwent antral balloon removal. A total of 5 patients underwent repair of late enophthalmos using this antral balloon technique. The median time from initial injury was 14 months (range, 6-90 months). The median antral balloon placement duration was 76 days (range, 53-106 days). Satisfactory symmetries were achieved in 4 patients. Mild residual enophthalmos remained in 1 patient, who had an orbital framework deformity and was missing the entire orbital bony floor preoperatively and who required simultaneous bone grafting. The ideal indication for our technique was the need for orbital floor reconstruction, without an orbital framework deformity. This technique could avoid autogenous bone grafting or permanent alloplastic implantation, which may cause a foreign body reaction, chronic inflammation, and migration. We believe that our new technique is one of the least invasive corrective procedures for late posttraumatic enophthalmos.

Secondary reconstruction of a mobile eye socket 30 years after enucleation of the eyeball for retinoblastoma: a case report

A mobile eye socket is generally reconstructed by inserting an implant into the scleral pocket immediately after bulbar exenteration, or by attaching the extra-ocular muscles to the implanted artificial eyeball immediately after enucleation. However, exposure of the implanted material and other problems can occur. We achieved satisfactory reconstruction of a mobile eye socket by using an autogenous cartilage graft and a pericranial flap in a patient with long-standing anophthalmia due to enucleation. This case is presented with a review of the relevant literature.

Correction of posttraumatic enophthalmos

Management of posttraumatic enophthalmos can present as a challenge to the reconstructive surgeon, particularly in cases of late presentation. This article reviews the pertinent anatomy of the orbit, diagnostic modalities, indications for surgery, and surgical approaches as they relate to the treatment of posttraumatic enophthalmos. Internal orbital reconstruction has evolved to an elegant procedure incorporating various biologic or alloplastic implants, including anatomical pre-bent implants. Successful repair of late enophthalmos has been demonstrated in multiple recent studies and is likely related to the precision with which orbital anatomy can be restored.

A pitfall of reconstruction for severe enophthalmos: role of the posterior wall of the maxillary sinus-2

This report describes a pitfall of reconstruction for severe enophthalmos after time has passed following traumatic injury. In severe cases, hypoglobus may be refractory to reconstructive surgery. The posterior wall of the maxillary sinus is sometimes implicated in severe enophthalmos. Thus, we considered that reconstruction of this posterior wall is critical for improvement in hypoglobus. In addition, a satisfactory contour and improvement in hypoglobus were maintained postoperatively.

Evaluation of the application of computer-aided shape-adapted fabricated titanium mesh for mirroring-reconstructing orbital walls in cases of late post-traumatic enophthalmos

PURPOSE

Computer-aided individually shape-adapted fabricated titanium mesh for the mirroring-reconstruction of the orbit is a promising method for the correction of post-traumatic enophthalmos. The purpose of this study was to evaluate the application of this technique and assess the treatment outcomes.

PATIENTS AND METHODS

Twenty-one patients with delayed treatment of unilateral impure orbital fracture and post-traumatic enophthalmos were included in this study. Computed tomography-based mirroring-reconstruction images of the orbit were obtained for each individual to fabricate anatomically adaptive titanium mesh by computer-aided design and computer-aided manufacturing techniques. After exposing the areas of orbital defect and reducing the herniated soft tissue, the titanium mesh was inserted to reconstruct the internal orbit with a mean deep extension of 29.33 mm. Measurements were performed to assess the change in the degree of enophthalmos and orbital volume before and after surgery. Paired samples t test and Pearson correlation coefficient were employed for statistical analysis.

RESULTS

Follow-up examinations revealed that the degree of enophthalmos decreased to less than 2 mm in 11 patients, 2 to 4 mm in 9 patients, and remained greater than 7 mm in 1 patient. Statistical analysis revealed that post-traumatic enophthalmos in this series was 4.05 +/- 2.02 mm, which was associated with an orbital volume increment of 6.61 +/- 3.63 cm(3), with a regression formula of enophthalmos = 0.446 x orbital volume increment + 2.406. Orbital reconstruction effected a orbital volume decrease of 4.24 +/- 2.41 cm(3) and enophthalmos correction of 2.01 +/- 1.46 mm, the regression formula being enophthalmos = 0.586 x orbital volume decrease + 0.508. After surgery, the degree of unresolved enophthalmos was 2.03 +/- 1.52 mm, and the retained orbital volume expansion was 2.23 +/- 2.86 cm(3), and the regression formula was enophthalmos = 0.494 x orbital volume expansion + 1.415.

CONCLUSION

Application of the individual fabricated titanium mesh for orbital reconstruction reduced the trauma-induced orbital volume increment by 65% and corrected 50% of severe late enophthalmos. Additional augmentation of orbital contents was required for further correction. The related treatment parameters were suggested.

Treatment of enophthalmos using corrective osteotomy with concomitant cartilage-graft implantation

Post-traumatic enophthalmos is a relatively common problem following orbitozygomatic fractures. Bony-volume expansion and soft-tissue atrophication are considered the main aetiological causes of this condition. Although most surgeons are familiar with the treatment principles in this field, inadequate long-term results are frequently observed. The cardinal reason is due to overt volume deficits, owing to suboptimal reduction and the ever-existing problem of soft-tissue atrophy. As such, it seemed logical that some treatment steps should be incorporated to increase the volume of orbital tissue. However, making fine adjustments to soft-tissue volume and orbital size during the same actual surgery is extremely difficult, if not impossible, which constitutes the biggest challenge in the treatment of enophthalmos. Based on the experiences from the management of seven patients with chronic enophthalmos (Group II), we could ascertain the average amount of the volume supplement required and were motivated to exploit a novel protocol of one-stage treatment for correction of disfiguring enophthalmos. In addition to the standard fracture-reduction methods, we use autologous, diced-cartilage graft to augment the orbital-tissue volume concomitantly for six consecutive patients (Group I) from 2004 to 2008. The actual quantities of inserted cartilage measured from 3.0 to 5.5ml in total. An aesthetically and functionally satisfactory result is attained in every case thus treated, with only one patient exhibiting a minor degree of overcorrection (1mm exorbitism). We thus advocate that this strategy is a viable option for preventing or rectifying late enophthalmos following severe orbitozygomatic fractures.

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.