Professional Documents
Culture Documents
Sta te of t he Art
Jason Liss, MDa,e, S. Tonya Stefko, MD, FACSb,c,e,
William L. Chung, DDS, MDd,*
KEYWORDS
Orbital Fracture Floor Roof Medial wall
Surgery Management
The floor of the orbit is commonly fractured in children and adults. The floor fracture may be isolated
or occur as a component of a panfacial injury. The
most frequently encountered combination of fractures is the orbital floor and medial orbital wall, but
floor fractures also occur as part of zygomaticomaxillary complex fractures, naso-orbital-ethmoid
fractures, LeFort fractures, and frontal sinus and
orbital roof fractures. Detailed imaging using multiplanar computed tomography (CT) is essential for
understanding the injury completely. Advances in
imaging have revolutionized the thought
processes and treatment planning; reconstructed
sagittal views and three-dimensional rendering
with mirror imaging techniques are new areas
that provide the surgeon with new insight heretofore unavailable. The reader is referred to the
articles by Branstetter and Bell elsewhere in this
issue for a more detailed discussion of these
new technologies and their use for orbital surgery.
Timing of Repair
The theoretic advantage of delaying surgical repair
for several weeks or months is to give symptoms
of diplopia or disturbances in extraocular motility
an opportunity to improve. However, many studies
have reported suboptimal results regarding the
correction of enophthalmos or diplopia with delayed repair. Almost all of the reports mentioned
are retrospective in design and use self-reported
data, with the inherent biases that are unavoidable
in such circumstances. Level II and III evidence is
important and helps guide treatment planning
when higher-level evidence is lacking, but critical
analysis is necessary when applying these data
to particular clinical situations. Dogmatic statements about particular techniques being superior
to others are not academically sound (ie, lacking
superior evidence, although surgeons make
decisions based on the best available data).
Oculoplastic Surgery, University of Pittsburgh Medical Center, 203 Lothrop Street, Pittsburgh, PA 15213, USA
Department of Ophthalmology, University of Pittsburgh Medical Center, 203 Lothrop Street, Pittsburgh, PA
15213, USA
c
Oculoplastic, Esthetic, and Reconstructive Surgery, University of Pittsburgh Medical Center, 203 Lothrop
Street, Pittsburgh, PA 15213, USA
d
Department of Oral & Maxillofacial Surgery, University of Pittsburgh Medical Center, 3459 5th Avenue, Suite
202 South, Pittsburgh, PA 15213, USA
e
UPMC Eye Center, 203 Lothrop Street, Pittsburgh, PA 15213, USA
* Corresponding author.
E-mail address: chungwl@upmc.edu
b
oralmaxsurgery.theclinics.com
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Liss et al
Hawes and Dortzbach3 found residual diplopia
in 38% of patients who had surgery 2 months after
injury and in 7% of those operated on within 2
months. Yilmaz and colleagues4 found that in the
9 fractures they repaired more than 4 weeks after
injury, they had 3 results with diplopia and 4 with
enophthalmos, compared with just 1 diplopia in
17 early repairs. Some believe that it is more difficult to achieve an anatomic repair with delayed
surgery because of early orbital fibrosis and scarring.5 Others believe that ongoing damage to
orbital tissue leads to orbital fat atrophy and extraocular muscle dysfunction.4,610 Harris6 suggests
that if soft-tissue displacement is disproportionate
to the bony defect on radiographic imaging, there
is a high risk for soft-tissue ischemia and surgery
should be undertaken as soon as possible. Thus,
if a fracture is determined to require surgery, the
surgeon may consider performing the repair within
the first 2 to 3 weeks, if not within the first several
days, after injury.
Surgical Incisions
Initially, orbital floor fractures were accessed by
an intraoral transantral approach, and then later
by a lower eyelid subciliary incision. Nam and
colleagues10 performed 405 subciliary incisions
with Frost suture removal on postoperative day 3
and subsequent vigorous lower lid massage and
reported no cases of lid retraction or ectropion.
However, some report a high incidence of eyelid
retraction and ectropion with the subciliary incision.
The transconjunctival incision provides the obvious
advantage of a lack of an external scar. Appling and
colleagues11 found 12% transient ectropion and
28% permanent increased scleral show in subciliary incisions compared with no ectropion and 3%
increased scleral show with transconjunctival incisions. Villareal and colleagues12 and Patel and
colleagues13 also report highly favorable results
using a transconjunctival incision. Lane and
colleagues14 documented 1 case of lid retraction
in 85 transconjunctival incisions. Schmal and
colleagues15 performed 209 transconjunctival incisions for floor repairs, and found no cases of ectropion or lid retraction, and 2 unsatisfactory scars
from his 181 lateral canthotomies. These reports
represent lower-level evidence, but are the best
available literature for use in careful decision
making. Based on these reports, the transconjunctival incision, with or without a lateral canthotomy,
has become favored over the subciliary incision.
Orbital Implants
The subject of greatest debate regarding the repair
of orbital fractures surrounds the choice of
Fig. 1. (A) Axial CT scan of comminuted frontal sinus and orbital roof fractures secondary to gunshot wound. (B)
Exposed, unroofed orbits (arrows) by frontal craniotomy. (C) Split-thickness frontal (sinus) bone graft in sagittal
plane. (D) Inner table frontal sinus used to recreate orbital roofs (arrows). (E, F) Anterior table and frontal bone
reconstruction. (G, H) Postoperative axial CT scans of reconstructed orbital roofs and frontal sinus.
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Table 1
Characteristics of common alloplastic orbital implants
Implant
Silicon (Silastic)
Nylon (Supramid, SupraFoil)
Titanium
Vitallium
Porous Polyethylene (Medpor)
PTFE (Teflon)
PGLA
Porous
Nonporous
Rigid
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Soft
Absorbable
Osteoconductive
X
X
X
1/
X
differences in outcome. As with all evidencedbased decision making, the surgeon must not
blindly follow prospective evidence only, but integrate the best available knowledge with individual
experience and patient factors to make the best
choices possible.
After the surgeon decides the best implant
material for reconstruction, placing it precisely
becomes the primary objective. Before inserting
the implant over the floor fracture, it is ideal to
expose and directly visualize the stable posterior
shelf of the orbital floor. The surgeon should
conceptually understand that the orbital floor
slopes superiorly toward the most posterior
portion of the orbit, so that the posterior shelf is
superior to the orbital rim (Fig. 5). Keeping this in
mind prevents placement of the implant directly
into the posterior maxillary sinus. A useful technique for locating the stable posterior shelf is to
run a periosteal elevator along the posterior wall
of the maxillary sinus until it curves anteriorly to
join the undersurface of the posterior orbital floor.1
Alternatively, endoscopic approaches, image
guidance, and active navigation techniques may
be used to assist in placement of a material and
Fig. 3. (A) Titanium orbital floor implant. (B) Orbital rim and floor fractures exposed. (C) Titanium orbital rim and
floor implants fixated through lower eyelid crease incision.
Fig. 4. (A) Titan Mesh orbital floor implant. (B) Titan Mesh orbital implant with medial and lateral wings and
titanium extensions for fixation onto the orbital rim.
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Liss et al
Fig. 5. The posterior ledge of bone must be identified and is used as a guide to the inclination of the orbital walls
in reconstruction and as a support for the orbital implant or graft. (From Holck DEE, Ng JD. Evaluation and
treatment of orbital fractures. Philadelphia: WB Saunders; 2006. p. 146; with permission.)
Surgical Approaches
Several approaches to the medial orbital wall have
been described. The approach that offers the
greatest exposure and access is the coronal incision, and this approach is optimal in cases of
extensive facial trauma. However, concerns such
as scarring in male pattern baldness, alopecia,
frontalis palsy, scalp numbness, and increased
surgical time make other more direct approaches
desirable in certain situations.
In 1921 Lynch38 described a semilunar incision
between the medial canthal tendon and the nasal
dorsum (Fig. 6). This incision provides good access
but carries the risk of scarring or webbing, and
injury to the lacrimal system or canthal tendon.39
Variations of the Lynch incision are commonly
used for approach to the medial wall. Nunery and
colleagues7 repaired 102 combined medial wall
and floor fractures using a 1-cm vertical skin incision just anterior to the medial canthal tendon,
and found 1 patient with resultant enophthalmos
Fig. 6. Lynch incision. (From Holck DEE, Ng JD. Evaluation and treatment of orbital fractures. Philadelphia: WB
Saunders; 2006. p. 293.)
Orbital Implants
Implant selection for a medial wall fracture
involves the same issues as for a floor fracture,
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Liss et al
Fig. 8. Upper eyelid crease incision for lateral and superior orbital rim exposure. (A) Incision placed in lateral half
of upper eyelid crease and extended either direction for exposure as needed. (B) Subcutaneous dissection in
suborbital fascial plane. (C) The periosteum is incised and elevated off the lateral orbital rim, and periorbita is
elevated off medial surface. (From Holck DEE, Ng JD. Evaluation and treatment of orbital fractures. Philadelphia:
WB Saunders; 2006. p. 302; with permission.)
Surgical Incision
For combined medial wall and orbital floor fractures, the transconjunctival and transcaruncular
(or other medial wall approach) may be used
together. Su and Harris27 fixed 19 patients with
combined fractures through a transcaruncular
and transconjunctival approach, using primarily
0.3-mm nylon implants. In 12 patients an implant
was inserted for each wall fractured, whereas in
7 patients in whom the inferomedial strut was
displaced, a third bridging implant was inserted.
No infection, implant extrusion, enophthalmos
greater than 2 mm, diplopia, vision loss, globe
dystopia, or eyelid malposition was reported. As
with the previously reported studies, the level of
evidence presented in these studies does not
allow dogmatic statements about which technique
is definitively superior, but it represents the best
available literature to guide clinical decisions.
Complications can occur with the transcaruncular incision. One such complication is incision-site
edema caused by lack of a surgical plane,
a problem that may be improved with the precaruncular incision, described by Moe.43 Other
complications include conjunctival scarring and
damage to the inferior oblique muscle, canthal
Surgical Incision
The most direct and cosmetic surgical approach
to an isolated orbital roof fracture is the blepharoplasty incision. Subperiosteal dissection along the
orbital roof exposes all stable bone around the
fracture. Care should be taken when elevating
the periosteum beneath the trochlea of the superior oblique muscle, and the lacrimal gland, to
avoid damage to these structures. If elevated
properly, neither structure needs to be reattached
Lateral Eyebrow
Medial Eyebrow
Temporal (Gillies)
Medial Canthus
Crows Foot
Subcillary
(Biopharoptasty)
Low Infraorbital
Percutaneous
Hook
Not Shown
Bitemporal Flap
Transtonjunctival
Buccal Sulcus
Caldwell-Luc
Trans Nasal/Antral
Fig. 9. Skin incisions for orbital fractures (From Rowe NL, Williams JL. Maxillofacial injuries. Edinburgh (UK):
Churchill Livingstone; 1994. p. 524; with permission.)
Fig. 10. (A, B, C) Axial, coronal, and sagittal CT scans of orbital blow-in fracture. Note displacement of bony roof
into the orbit (arrows).
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Liss et al
Fig. 11. (A, B, C). Axial, coronal, and sagittal CT scans of orbital blow-up fracture. Note large segment of orbital
roof displaced superiorly (arrows).
Computer software and modern image-guidance technology can be used to create a template
of the desired orbital floor implant, based on the
patients contralateral, unfractured orbit. Metzger
and colleagues55 have reported a small series
using computer-assisted design of orbital implants
and have shown an excellent degree of similarity
between the repaired orbit and the uninvolved
orbit postoperatively. This technology can be
particularly useful with repairing more extensive
orbitozygomatic fractures.
SUMMARY
Orbital fractures occur in isolation or as a component of other facial fractures. As with any other
operation, the surgeon has a multitude of decisions and options in the overall management of
these fractures. These complex decisions include
the timing of repair, methods of incision (and
closure), surgical approaches, and specific
implant material. A substantial amount of effort
and time has been devoted in the scientific literature to these topics. Comparative studies with
strong data and a high level of evidence are lacking, but the available literature allows the astute
surgeon to incorporate the available experience
into his or her practice with careful decision
making. The ultimate treatment of any orbital fracture must take into account the specific circumstances surrounding the patients fracture, and
more importantly, the surgeons experience and
comfort level regarding the management of these
injuries.
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