Delayed orbital floor implant complications: Case report and review of the literature

Purpose

Foreign body reaction to non-absorbable alloplastic orbital implants utilized for bony reconstruction are infrequently documented in the literature. We present the workup and surgical management of a giant cystic mass encapsulating a patient's alloplastic orbital implant, which was ultimately deemed to be a result of foreign body reaction.

Observations

A 41-year-old male patient with distant history of a right orbital floor fracture had undergone repair with the placement of a nylon foil implant. The patient presented twenty years later with progressive ipsilateral globe proptosis and was found to have a giant inferior orbital cyst. Surgical exploration and removal of the implant and capsule were performed. Histopathology confirmed a delayed foreign body reaction around the patient's alloplastic implant.

Conclusions

Alloplastic implants may result foreign body reaction and cyst encapsulation as a delayed complication.

Quality of life after reconstruction of traumatic orbital floor defects using titanium mesh and medpore: A randomised controlled trial

AIM AND OBJECTIVES

The aim of this study was to analyse the outcomes of orbital floor reconstruction with two types of orbital implants and assess patients' quality of life.

MATERIAL AND METHODS

39 sequential patients with clinical and radiological evidence of orbital floor fracture, presenting diplopia, enophthalmos, paraesthesia or a post traumatic residual orbital deformity were included in this study and randomised for orbital floor reconstruction using porous polyethylene sheet (Biopore™) or preshaped titanium mesh on a 3D model. Their pre and postoperative quality of life were compared. Success rate was assessed and scored with a minimum of zero (none) and a maximum of ten (excellent) for improvement in the signs of diplopia, enophthalmos, hypoglobus, paraesthesia and aesthetics.

RESULTS

Both QOL scores and Success score was greater in cases which reconstruction of orbital floor was performed with preshaped titanium mesh as compared to those with Biopore™.

CONCLUSION

Preshaped titanium mesh shows better results than reconstruction with Biopore™. However a large sample size and a long term follow up is needed for generating the best evidence. Quality of life extensively improves after orbital floor reconstruction motivating the patients desire to live.

Feasibility of Endoscopically Assisted Repair of Zygomatico-Maxillary Complex Orbital Fractures: Case Series

Aim

To assess the feasibility and the outcome of endoscopically assisted repair of zygomatico-maxillary complex orbital fractures in a tertiary care hospital.

Materials and methods

A descriptive study was carried out over a period of 2 years (01. 11. 2014-31. 10. 2016). 0°-4 mm endoscopes were used for intra-operative endoscopic exploration. Regular armamentarium for management of maxillofacial trauma along with standard plating systems was used. Commercially available medical grade titanium meshes were utilised for orbital floor reconstruction.

Results

Fifty-seven of hundred and twelve surgically managed zygomatico-maxillary complex fractures required orbital exploration. Twenty-one of these had reconstruction of the orbital floor. Endoscopically assisted exploration was performed in 10 of the 21; trans-nasally in three cases, the Caldwell-Luc approach was used in three cases, and in another three, the existing fracture in the anterior wall of the maxilla was utilised. In addition, an endoscopic trans-nasal-sphenoidal approach was opted for to access the orbital apex to manage fractured bone fragments that were impinging on the optic nerve in one of the patients.

Conclusion

Endoscopes serve as the primary tool in minimally invasive procedures. They are yet to evolve as a major role player in the maxillofacial arena. The authors conclude that endoscopes are truly beneficial as an adjunct to existing techniques. They hold much promise for the future.

Application of three-dimensional printing technology in orbital floor fracture reconstruction

Importance

Orbital floor fracture is common among patients suffering from facial trauma. Open reduction and reconstruction of the orbital floor with Medpor is the treatment of choice in our centre to correct diplopia and enophthalmos.

Objective

Application of locally available 3D printing service in perioperative planning of orbital floor reconstruction with porous polyethylene.

Design

We present two patients who suffered from orbital floor fracture complicated by diplopia. Open reduction and orbital floor reconstruction with Medpor was performed with the guidance of a 3D printed customized model of the orbital floor defect.

Participants

Both patients were admitted through the Emergency Department to surgical ward after facial trauma. CT scan of the face showed orbital floor fracture with entrapment of inferior rectus muscle. Clinically patients also suffered from diplopia on extreme gaze.

Results

With the aid of 3D printed model, it shortened operative time and duration of anaesthesia. Defect-specific Medpor could be trimmed and molded easily from the model and thus reduced fatigue of the material. Furthermore, the model was helpful in patient education and explanation of the surgical procedure.

Conclusions and relevance

Application of 3D printing in medical specialties is rapidly developing in the past few years. In orbital floor fracture reconstruction, 3D printed model provides a customized solution, decreases operative time and duration of anaesthesia.

Study of anatomical variations of the zygomaticofacial foramen and calculation of reliable reference points for operation

Dissection on to the facial aspect of the zygoma is common in procedures of the midface for trauma, craniofacial deformity, and cosmesis. These procedures carry the risk of injury to the neurovascular structures that exit from the zygomaticofacial foramen (ZFF). The purpose of this study was to map the ZFF, and to establish reliable reference points from which to identify it before and during operation. We also aimed to compare the anatomy of the ZFF between sexes and among geographical populations. A total of 429 adult skulls from nine geographical sites were used. A cross-line laser was superimposed on to each zygoma to generate consistent landmarks (lines 1 and 2) from which to measure the ZFF, and the number of ZFF on each zygoma was recorded. The site and incidence of ZFF differed significantly among geographical populations, but not between sexes. Of all 858 sides, no foramina were found in 16.3%, one foramen in 49.8%, two foramina in 29%, three in 3.4% and four in 1.4%. A total of 93% of foramina were within a 25mm diameter zone (ZFF zone) centred 5mm anterior to the intersection of lines 1 and 2 on the right zygoma, and 94% were within equivalent measurements on the left. Using these landmarks, we propose a new method of identifying a ZFF zone that is irrespective of sex or geographical population. This technique may be useful in the prevention of iatrogenic damage to the ZFF neurovascular bundle during procedures on the midface and in local nerve blocks.

Use of human nail for reconstruction of the orbital floor: an experimental study in rabbits

The orbital floor is the thinnest part of the orbital wall, and in 20% of all maxillofacial injuries it is fractured. Autografts, allografts, and alloplastic materials are used in reconstruction, but there is no consensus about which material is the most appropriate. Nail is a semirigid material that is easy to reshape and is not antigenic. Alloplastic materials, which are used in reconstructions of the orbital floor, have various complications and are expensive. Autografts have donor-site problems, high rates of resorption, and take a long time to do. We created bilateral 10mm defects in the orbital floors in 18 New Zealand rabbits. We reconstructed the left orbital floors with double-ground human nail while the right orbital floors were left open as controls. The orbital floors were examined macroscopically and microscopically at 4, 8, and 12 weeks postoperatively, and there were no macroscopic signs of infection, inflammation, or extrusion. Forced duction tests showed that it was possible to induce movement of the eyeball for all 18 of the reconstructed sides throughout the observation period, and in 14 of the 18 rabbits on the control sides. Positive forced duction test shows us that orbital muscles are trapped in orbital floor defect and due to this movement of eyeball is restricted. Acute and chronic inflammation, fibrosis, vascularisation, and the presence of foreign body giant cells were evaluated microscopically. Acute inflammation and the presence of foreign body giant cells were recorded as mild, whereas fibrosis, chronic inflammation, and vascularisation were severe, as were epithelialisation on the maxillary sinus side of the nails, calcification, and progression of collagen. We found no signs of resorption of the nails.

Mechanical properties of collagen membranes modified with pores--are they still sufficient for orbital floor reconstruction?

Adequate mechanical strength is essential for materials used to reconstruct the orbital floor, and collagen membranes have recently been suggested for the repair of isolated fractures of the orbital floor. However, their mechanical properties after modification with pores for increased drainage of blood into the sinus have not been sufficiently investigated. We have tested the mechanical resistance of polydioxanone foils (PDS) to distortion and compared it with that of 3 resorbable collagen membranes (Smartbrane(®), Bio-Gide(®), and Creos(®)) in mint condition and when artificially aged (3 weeks, 6 weeks, and 8 weeks) after modification with pores (diameter 2mm) in a standard configuration (n=12 in each group). PDS and Creos(®) had comparable initial values for mechanical resistance of about 2.3N/mm(2), and Bio-Gide(®) and Smartbrane(®) had about 20% and 80% lower initial mechanical resistance, respectively. All materials tested had lower values after artificial ageing. After eight weeks of ageing, PDS lost about 99% of its initial mechanical resistance, Creos(®) about 66%, Bio-Gide(®) about 30%, and Smartbrane(®) about 95%. After 3 weeks the mechanical resistance in all groups was significantly less than the initial values (p=0.05), but there was no difference between samples aged artificially for 6 compared with 8 weeks. The mechanical resistance of the tested materials was not influenced by the presence of pores in a standard configuration and was in the appropriate range for moderate fractures of the orbital floor. We recommend further clinical investigations of collagen membranes modified with pores.

Polypropylene Darning: A New Alternative for Reconstruction of Orbital Floor after Total Maxillectomy

Removal of orbital floor is an integral part of total (radical) maxillectomy (type IIIa), which if not managed properly, may lead to some eye related distressing complications like diplopia, eyelid malposition, epiphora, dacryocystitis, enopthalmos and ectoprion. Among all, diplopia is the most distressing complication which hampers daily activity. Various options for orbital floor reconstruction are available like titanium sheet, polypropylene mesh, non-vascularized or vascularized bone graft, pedicled flaps, micro-vascular free flaps, prosthesis placement, and split skin graft followed by obturator placement. Till date no-body has tried stabilization of eye ball by 'darning' the orbital floor using non-absorbable suture. 'Polypropylene suture darning' is an easy to learn, novel method with equally good results. Five patients with potentially resectable tumors underwent total maxillectomy. I used polypropylene 3-0 round body suture and 'darning' was done at orbital floor, incorporating periosteum (if remaining) and peri-orbital fat into the sutures. Muscle flaps were done to provide bulk and palatal reconstruction. Assessment of patients was done post-operatively at day-5 i.e., before discharge and at 1 month after surgery, and also in further follow up visits. The results were very good in terms of clear vision & eye movements (directly related to 'darning'), and the aesthetic look of patients and bilateral symmetry were satisfactory (not related to darning). Darning of orbital floor by polypropylene after total maxillectomy is an easy to learn and cost-effective method of reconstruction with good results.

Autogenous mandibular symphysis graft for orbital floor reconstruction: a preliminary study

OBJECTIVE

The present study aimed to evaluate and analyze postoperative results of Autogenous Mandibular Symphysis graft material for orbital floor reconstruction.

MATERIAL AND METHODS

A retrospective study was conducted on 11 patients, having an isolated blow out fracture (n=4) or orbital floor defects associated with other fractures (n=7). These fractures were reconstructed with Mandibular symphysis bone grafts. The Grafts were used where the defects were more than 1.5 centimeter [1]in diameter. Follow up as long as 1.5 year was kept. Patients were evaluated at recall visits by checking various extraoccular movements. Evidence of any complications like diplopia or enopthalmos, or rejection of graft or any symptoms of infection, or of paresthesia was recorded.

RESULTS

During a 1.5 year period of follow up, most of the patients had no postoperative complaints. There was good restoration of the orbital floor, with no clinical evidence of enopthalmos or diplopia. Extraoccular movements were intact in all patients. Only one patient presented with the symptoms of infection at a follow up period of 9 months. The infection subsided after removal of titanium plates, used for the stabilization of graft.

CONCLUSION

Autogenous Mandibular Symphysis graft is a good alternative with minimal morbidity for orbital floor reconstruction. The contour as well as the size of the graft available from symphysis region best suits for orbital floor reconstruction.

Medpor in maxillofacial deformities: report of three cases

OBJECTIVE

This paper deals with the usefulness and versatility of the porous high-density polyethylene implants for correction of various facial deformities as an augmentation and an onlay graft material with its advantages.

MATERIALS AND METHODS

Prefabricated porous high-density polyethylene implants were used in three patients (post-trauma facial deformity, Goldenhar syndrome, nasal deformity in cleft patient) for secondary reconstruction of orbital floor, depressed nose and supra-orbital ridge, augmentation of hypoplastic mandible and depressed nasal dorsum under general anaesthesia.

RESULTS

Good esthetic results were achieved in all the three patients treated with porous high-density polyethylene implants with no complications.

CONCLUSION

Porous high-density polyethylene alloplastic implant is an excellent biomaterial for reconstruction of various facial deformities with many advantages over autogenous and other alloplastic materials.