CLINICAL STUDY
Application of Three-Dimensional Printing Technology
in the Orbital Blowout Fracture Reconstruction
Xiang Zhang, MM, Wei Chen, MD,y Ting-Yuan Luo, MM,z Juan Ma, MM, Zhen Dong, MM,y
Gang Cao, MD,y Jin-ke Xu, MM,y Bin-Yao Liu, MM,y Qi-Rui Zhang, MM,§ and Sen-Lin Zhang, MDy
Abstract: The aim of this study was to investigate the clinical
outcomes of orbital blowout fracture repair by using the three-
dimensional (3D) printing-assisted fabrication of individual tita-
nium mesh. Clinical and radiologic data were analyzed for 12
patients with orbital floor and/or medial wall fractures. Lower
eyelid incision was used to expose the fractures. Preoperative
computed tomographic data were input into an imaging software
to rebuild a 3D orbit and mirror the unaffected side into the
affected side to replace the demolished orbit. A resin model of the
reshaped orbit was generated and used to develop an individual
titanium mesh for repairing the fractured orbital. The surgical
results were assessed by value of enophthalmos and a comparison
of preoperative and postoperative orbital volume difference. All
patients had a successful treatment outcome without any com-
plications. Clinical significant enophthalmos were not observed
after treatment, and diplopia were solved within 2 weeks postop-
erative. No extraocular muscle limitation was observed. Postop-
erative computed tomography scans demonstrated appropriate
positioning of titanium mesh and there was no implant displace-
ment. The postoperative orbital volume and enophthalmos differ-
ence between the 2 eyes decreased significantly than preoperative
(P < 0.001). Three-dimensional printing-assisted fabrication of
From the The Affiliated Stomatological Hospital of Soochow University,
Suzhou, Jiangsu; yDepartment of Stomatology, Jinling Hospital, School
of Medicine, Nanjing University, Nanjing; zHuizhou Stomatological
Hospital, Jinan University, Huizhou; and §Department of Medical
Imaging, Jinling Hospital, Nanjing College of Clinical Medicine, South-
ern Medical University, Nanjing, China.
Received February 3, 2019.
Accepted for publication March 8, 2019.
Address correspondence and reprint requests to Wei Chen, MD and Sen-
Lin Zhang, MD, Department of Stomatology, Jinling Hospital, School
of Medicine, Nanjing University, 305 East Zhongshan Road, Nanjing
210002, Jiangsu, China; E-mail: rollphy@aliyun.com;
doczhangsl@gmail.com
XZ, WC, and T-YL equally contributed to this work.
This study was supported by grants from the Project of Invigorating Health
Care through Science, Technology and Education of Jiangsu Province
(Grant no. QNRC2016907). This investigation was approved by the
Ethics Committee on Human Study at Jinling Hospital (Approved No.
2014-135). The authors report no conflicts of interest.
Supplemental digital contents are available for this article. Direct URL
citations appear in the printed text and are provided in the HTML and
PDF versions of this article on the journal’s Web site (www.jcraniofa-
cialsurgery.com).
Copyright # 2019 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000005574
The Journal of Craniofacial Surgery  Volume 30, Number 6, September 2019
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
individual titanium mesh is appropriate for use in orbital blowout
fracture.
Key Words: Diplopia, enophthalmos, orbital blowout fracture,
three-dimension printing (3D printing), titanium mesh
(J Craniofac Surg 2019;30: 1825–1828)
D iplopia is one of the common complications of blowout
fractures. Limited ductions occur in the field of the antagonist
muscle due to restriction of the entrapped muscle.1 Ocular motil-
ity disturbances are caused not only by the entrapment of rectus
muscles and soft tissues, but also by hemorrhage, muscle edema,
muscle fibrosis, and motor nerve palsies.2,3 Diplopia and
enophthalmos in the presence of orbital wall fracture are the main
indications for surgical intervention. The orbital floor and medial
wall are common sites of facial bone fracture and may cause
serious functional impairment.4 Numerous cases of reconstruc-
tive implant use have been described in the literature.5 The repair
of orbital floor and medial wall fractures is difficult due to the
complex anatomy involved and the limited intraoperative view.6
Meticulous imaging and clinical examination are indispensable
for treatment planning, to restore orbital volume and shape.
Inaccurate surgical techniques and unfitting implants may lead
to visual disturbances and unaesthetic results.7 Computer-assisted
three-dimensional (3D) treatment planning and individual poly-
amide models are routinely used to achieve stable reconstruction
and adequate postoperative results. Then the contemporary stan-
dardized titanium meshes are manually adjusted to fit the indi-
vidual polyamide models of patients.8 These easily manufactured,
ready-made patient-specific implants facilitate a more cost-
and time-effective operating procedure. Here we reported our
surgical strategy for orbital blowout fractures according to the
fracture location.
MATERIALS AND METHODS
Data Collection
From May 2014 to May 2018, at Department of Stomatology,
Jinling Hospital, School of Medicine, Nanjing University, China, a
total of 12 patients with diplopia and (or) enophthalmos due to
orbital blowout fracture were included in this study. This investiga-
tion was approved by the Ethics Committee on Human Study at
Jinling Hospital (Approved No. 2014-135). Follow-up data were
obtained in all patients using the clinical chart notes, correspon-
dence with the referring physician, the patient, or the patient’s
family. Surgery notes were reviewed for technical details of incision
and titanium mesh implantation. Follow-up data including func-
tional results (ocular motility, improvement of diplopia), orbital
volume, and enophthalmus were collected. Functional results were
subjectively assessed by the surgeons. Follow-up time was mea-
sured from the date of the surgery until the date of the last contact.
1825
Zhang et al The Journal of Craniofacial Surgery
Patient Characteristics
All of our patients were adult Chinese. The age of patients at
presentation ranged from 19 to 51 years (mean was 33.7 years) (see
Supplemental Digital Content, Table 1, http://links.lww.com/SCS/
A506). Out of the 12 patients, there were 9 males and 3 female. The
main presenting symptom in all 12 patients were diplopia and
enophthalmus. The cause of fractures were traffic accident, fist
or kick trauma, and fallen. All patients had preoperative and
postoperative computed tomography (CT) images. Eligibility cri-
teria include the following: CT examination showed the orbital wall
fracture, both of the 2 eyeballs are not broken and not with other
maxillofacial fractures. Surgical indications are follows: (1) limited
eye movements, (2) diplopia, (3) CT examination clearly showed
fracture under the orbital wall and/or orbital medial wall. Operation
time after trauma: 9 cases within 1 week of injury, 2 cases within 1
to 4 weeks, and 1 case received surgery at 2 months.
Orbital Volume Measurements
Three-dimensional CT images (Siemens SOMATOM Sensation
64 CT, Munich, Germany) were obtained in continuous 1.0-mm-
thick axial and coronal slices. In these cases, the patients underwent
CT scans within 1 week of injury and at 3 months after surgical
treatment. Boundary of the orbital content including the implant
was traced on each image with the SIEMENS Syngo via VB30. The
volume of orbital cavity was calculated by multiplying the orbital
area by the thickness of each scan slice; the sum of volumes of the
scan slices was used to compute the volume occupied by the
measured structure in each orbit. By this measurement, the bilateral
orbital volumes of preoperative and postoperative patients were
obtained. Left and right sides of the orbital volume of the normal
people are exactly equal.9 Therefore, using destroyed side of orbital
volume to minus the healthy side of orbital volume is the orbital
volume difference.
Eyeball Protrusion Measurements
We measured the 2 sides of eyeball protrusion before surgery.
Three months after operation, we measured the data again. In CT,
axial images displayed the largest diameter of eyeball. If the injured
eyeball had any invagination, then we selected a level in the
maximum diameter between 2 sides of the eyeball to make the
eye section symmetry on both sides. We measured the vertical
distance between the highlight point of corneal and the front side of
bilateral orbital rim, as eyeball protrusion degree values.10 The
difference of the axial globe positions between the affected and
unaffected side was recorded. Therefore, using healthy side of
eyeball protrusion degree values to minus the destroyed side one
is the eyeball protrusion difference.
Data Analysis, 3D Printing Model, and Titanium
Mesh Fabricating
Preoperative CT data were processed to generate a 3D recon-
struction of both affected and unaffected orbit, using the non-
affected orbit as a template. Geomagic Studio12.0 software was
used along the midline skull vector to resect the lateral half of the
eye socket. The mirror tool on a shaft centerline was used to copy
and replace the contra lateral eye socket resulting in normal
bilateral vision. The 3D model used a methodical system based
on imaging data before and after, using a rapid prototyping
machine (Makerbot Replicator 2X, the United States) to accumu-
late resin. According to the preoperative CT scan, we measured
the size of the bone defect. The size of the titanium mesh was a
little larger than the defect. Reference and orbital fracture models
of CT images reflected the orbital wall model calibration,
1826
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 30, Number 6, September 2019
position, and size as well as scope of the defect, according to
the shape bending titanium mesh (thickness of 0.4 mm; Matrix-
MIDFACE, 04.503.801, Swiss Synthes Company). Preoperative
titanium meshes were clean with ultrasonic oscillation, regular
disinfection, and ready for use. Overextended titanium meshes
were easily reduced in size with pincers and manual adjustment,
although, to a lesser degree, compared with standardized titanium
meshes. Comparing with the resin model, we shape the titanium
mesh to make its size 1 to 2 mm beyond the fracture zone. The need
for manual adjustment should be avoided by meticulous preoper-
ative titanium mesh planning.
Surgical Procedure
The procedure was performed with the patient under general
anesthesia in all cases. We used the lower eyelid incision. The skin
incision was placed 2 mm below the lash line, starting medially
below the level of the lacrimal punctum and following the limbus
palpebralis to the level of the lateral canthus. First, after the skin
and the orbicularis oculi muscle were incised, the orbital septum
was incised horizontally to expose aponeurotic fat. The aponeuro-
sis and lower eyelid retractor were dissected to expose the orbital
fat. The globe was pressed gently, enabling the excessively herni-
ated orbital soft tissues to protrude. The periorbital floor was
incised. The bone fragments and the periorbita were stripped
out from the front to the deep orbita carefully. Thus, the entire
floor wall was exposed from the low edge of orbita to the neuro-
vascular bundle. Next, the lower lid and inner canthus were
retracted with saddle retractor. With a malleable retractor and a
thin periosteal elevator, we separated the herniated orbital soft
tissues of the medial orbita from the medial wall, enlarging the
access inferiorly and medially. Thus, both the floor wall and the
medial wall were exposed. After exposing all the margins of bony
defect, the herniated orbital soft tissues were reduced carefully
from the maxillary and ethmoid sinus using 2 thin periosteal
elevators. The reduction was maintained with a wider malleable
retractor, and the periosteal elevators were removed. Finally, we
inserted the individual titanium mesh. The malleable retractor was
then removed. A forced duction test was performed and compared
with the test performed before the implant was inserted ensuring
there was no resistance. One-point fixation at the anterior edge of
the implant using 1 to 4 screws may be necessary. Hemostasis was
achieved with careful electrocautery. The muscle and the skin were
closed carefully.
Statistical Analysis
Data were analyzed using SPSS 17.0 statistical software (SPSS
Inc., Chicago, IL). Data were tested for statistical significance using
linear regression. All P values were two-sided, and significance was
defined as P < 0.05.
RESULTS
All patients underwent reconstruction of the medial wall fractures alone
or together with floor fractures, via individual titanium mesh using a 3D
printer, using a lower eyelid incision. Computed tomography scans
were performed preoperatively and postoperatively to show accurate fit
of the titanium mesh after surgical treatment. All individually manu-
factured titanium meshes were inserted without difficulty obviating the
need for manual adjustment. Follow-up periods ranged from 6 to
54 months (median, 25 months). The preoperative orbital volume
(2.57  0.43 mL) was significantly higher than the postoperative value
(0.09  0.60 mL) (P < 0.001) (see Supplemental Digital Content,
Table 2, http://links.lww.com/SCS/A506). The postoperative eyeball
protrusion (2.21  0.90 mm) was also significantly higher than the
preoperative value (0.12  0.50 mm) (P < 0.001) (see Supplemental
# 2019 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery  Volume 30, Number 6, September 2019 3D Printing Helps Reconstruction of Orbital Wall
FIGURE 1. Schematic diagram of a typical clinical case. A resin model was
created, based on the data mirrored from the nonaffected orbit, and the
individual titanium mesh was developed (A). Individual titanium mesh was used
in the operation to reconstruct the orbital wall (B). Open-eye views of
preoperative (C) and postoperative at 3 months (D). The scar of the left-side
lower eyelid incision was almost invisible.
Digital Content, Table 3, http://links.lww.com/SCS/A506). No com-
plications including blindness, infection of implanted material, implant
migration, postoperative mydriasis, epiphora, or worsening of diplopia
were seen. None of the patients reported sensations indicative of
foreign bodies or visual impairment. No visual impairments were
reported after 2 weeks. After 3 months, the patient showed an excellent
cosmetic result with an inconspicuous scar.
Typical Clinical Case
This case concerns a 42-year-old woman sustained a left facial
injury from a traffic accident. Two months later, she complained of
discomfort and diplopia. Clinical symptoms demonstrated a little
enophthalmos and a 1.5 cm scar in the left upper eyelid (Fig. 1C).
The CT findings showed a blowout fracture associated with the
floor and medial wall of the left orbit (Fig. 2A–C). There was lateral
limitation of ocular motion. The value of the affected orbital volume
is 27.06 mL, whereas the unaffected side is 24.01 mL preoperative.
The value of the affected eyeball protrusion is 15.54 mm, whereas
the unaffected side is 17.78 mm preoperative. Open reduction and
FIGURE 2. Computed tomography scan images of orbital wall restoring surgery
of a typical clinical case. The fractured orbital walls were restored with the
combined 3D-dimension printing-assisted fabrication of individual titanium
mesh with lower eyelid incision. Preoperative (A–C) and postoperative (D–F)
CT scan of inferomedial orbital wall fracture in transection, coronal, and 3D
reconstruction.
# 2019 Mutaz B. Habal, MD
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
orbital wall reconstruction with a titanium mesh were performed
3 days after admission to hospital. Postoperative CT demonstrated
signal reduction of the soft tissues and reconstruction of the medial
orbital wall in the anatomical position without muscle injury or intra
orbital hematoma (Fig. 2D–F). Postoperative diplopia and
enophthalmos were resolved completely after 2 weeks. The value
of the affected orbital volume is 23.81 mL and its eyeball protrusion
is 17.74 mm postoperative. Three months later, the postoperative
scar on the lower eyelid was inconspicuous (Fig. 1D).
DISSCUSION
Diplopia, ocular motility disorders, and enophthalmos are common
complications of blowout fractures. Limited ductions occur in the
field of antagonist muscle due to restriction of the entrapped
muscle. Ocular motility disturbances are caused not only by the
entrapment of rectus muscles and soft tissues, but also by muscle
edema, muscle fibrosis, hemorrhage, and motor nerve palsies.
Diplopia and enophthalmos in the presence of orbital floor and
medial wall fractures are the main indications for surgical inter-
vention.11 Strong indications for operative intervention include
diplopia in the primary field of gaze that fails to resolve after 2
weeks, enophthalmos >2 mm during the first week, or severe
hypoglobus, all of above often indicated that there were a enlarged
orbital volume than 2 to 3 mL. In 2007, early intervention has
become preferable because late repairs were found to be associated
with the adhesion and fibrosis of injured orbital tissues.12 The
primary goal of orbital wall fracture reconstruction is the restoration
of the bony orbit shape and volume, the latter is a more significant
factor for late enophthalmos deformity.13,14
Several surgical approaches have been reported for the medial
orbital wall including medial canthal incision (Lynch incision),
medial conjunctival incision, inferior conjunctival incision, sub-
ciliary incision, intranasal approach, lid crease incision, and bicor-
onal incision. Generally, repairing orbital medial wall factures
includes subciliary and medial canthus, transnasal–transethmoidal,
and transcaruncular approaches with medial brow and conjunctival
incisions.
The medial canthal incision, which was first reported as a Lynch
incision, provides extensive exposure to the medial wall for com-
plete reconstruction.15 However, it requires detachment of the
medial canthal tendon for wide exposure, with a possible disloca-
tion of the tendon or telecanthus. Furthermore, the direction of the
incision runs vertical to the relaxed skin tension lines on the medial
orbital area. Therefore, the possibility of scar widening, hypertro-
phy, or webbing deformity is not low. Several modifications were
reported to solve these challenges, but without any photographic
evidence to support postoperative cosmetic outcomes. To circum-
vent the scar, the medial brow incision is recommended. However,
it results in the risk of permanent numbness of the medial forehead
caused by supratrochlear nerve injury. Also, exposure of the entire
medial wall and insertion of a large implant through a small incision
are difficult.
The transconjunctival approach has become increasingly popu-
lar since its original description in 1924. It provides excellent
cosmetic results without external scar formation. It offers a good
approach to the inferior orbital wall due to a markedly lower risk of
lower eyelid retraction compared with the transcutaneous
approach.16 It offers superior visualization when a lateral canthot-
omy is performed but only limited exposure to the medial orbital
wall. The medial canthal tendon hinders the surgical approach.
Therefore, insertion of a large implant is difficult. Furthermore,
patients might complain of a foreign body sensation or exudate
caused by postoperative conjunctival irritation, with possible con-
junctival granuloma, entropion, or conjunctival inclusion cyst.
1827
Zhang et al The Journal of Craniofacial Surgery
The upper eyelid crease approach enables reconstruction of
moderate-to-severe blowout fractures of the medial orbital wall
by creating a 2- to 3-mm superomedial extension incision. The
advantages of this approach include invisible incision line and
extension of the thin upper eyelid skin along with an inconspicuous
postoperative scar. This approach provides a wide surgical field and
a large implant insertion with a relatively small incision. Dissection
is simple and easy, so beginners can perform dissection without
difficulty. However, for surgeons with surgical training in other
specialties, it may be unfamiliar of performing incision on the globe
and may present disadvantages.
Intranasal endoscopy provides the best cosmetic result without
external scar formation and with minimal possibility of implant
extrusion. It eradicates the concomitant abnormalities in the eth-
moid.17 The primary surgical approach is to support the medial side
of affected orbital with a nasopore. However, there is a learning
curve, with the possibility of serious complications such as leakage
of cerebrospinal fluid, infection from packing the ethmoidal sinus,
and injury to the extraocular muscle. Disadvantages include the
need for removal of the implant in a secondary operation and the
difficulty in reconstructing a large defect of the medial orbital wall.
Endoscopic transnasal approaches provide a clear view of the
orbital wall from the paranasal sinuses, resulting in accurate
reduction. However, placing a large implant on the orbital side
is difficult via endoscopy. Therefore, a combination of the 2
approaches might be better than a single approach alone. However,
endoscopy-assisted orbital fracture repair is associated with the
following limitations: larger orbital defect repair implants cannot be
inserted via nasal cavity, and therefore, require an additional
incision; exposure of the orbital implant to the full range of the
orbital and nasal cavities may increase the risk of infection; and the
procedure may injure nasal turbinates and other nasal structures.
In this study, we used the lower eyelid incision for reconstruc-
tion of media orbital wall fracture. The medial orbital wall and
orbital floor was entirely exposed from the low edge of orbital to the
neurovascular bundle through this incision. As we exposed the
medial orbital wall and orbital floor completely, the bone fragments
and the periorbita can be stripped without difficulty, and then the
large individual titanium mesh can also be easily implanted. The
scar of the lower eyelid incision can also be aesthetic and accept-
able. Patients showed little postoperative responses, slight scar,
meeting the requirements of both minimally invasive surgery and
cosmetic surgery.
In the literature, Lee et al have reported the 3D prebent titanium
implants to treat the orbital floor and medial wall fractures in a
South Korean population in 2014. In this study, the fractures were
exposed with a combined transcaruncular and inferior fornix
approach with lateral canthotomy.18
We used 3D printing creating a resin model that copied the full
eye wall forms. We could analysis the size of the fracture area and
the degree of damage intuitively. Then according to the model form,
we bent titanium mesh which perfectly copied the shape of the
orbital wall, and implanted it into affected orbit, restoring shape of
the orbital wall and orbital volume. What is more, our surgical
procedure was simply easy. We just exposed fracture zone and
stripped the bone fragments and orbital contents, and then
implanted titanium mesh. There was no need to bend titanium
mesh during the surgery procedure, which enormously saved our
time. Finally, we improved the problem of diplopia and enophthal-
mos without any additional complications successfully.
However, this approach also has its limitations. First, when
patients with double fracture of orbital walls, we cannot make a
model by using 3D printing technology. Second, even we have used
1828
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 30, Number 6, September 2019
the lower eyelid incision, the skin scar still exists. Third, the lower
eyelid incision showed a little limitation of the surgical field, so we
must place the titanium mesh in the operative site by rotating.
Fourth, the case numbers are still a little. We hypothesized that there
shall be a significant linear dependence between the decreased
orbital volume and the changed axial globe position when the
patient numbers are large enough. This method still needs larger
clinical practice to prove its reliability.
CONCLUSIONS
A 3D printing-assisted design of individual titanium mesh com-
bined with lower eyelid incision was used to reconstruct blowout
fracture of the medial orbital wall. This approach provided fast,
easy, and adequate exposure of the medial orbital wall with virtually
no globe manipulation. It brought precise anatomical reconstruction
of the medial wall with proper insertion of a large implant. It also
gives an excellent cosmetic result with an inconspicuous scar. In
combination with lower eyelid incision, the technique facilitates
precise reconstruction of medial orbital fractures using a complete
digital workflow and may be considered as a reliable, primary
treatment for blowout fractures of the medial orbital wall.
REFERENCES
1. Kushner BJ. Paresis and restriction of the inferior rectus muscle after
orbital floor fracture. Am J Ophthalmol 1982;94:81–86
2. Ceylan OM, Uysal Y, Mutlu FM, et al. Management of diplopia in
patients with blowout fractures. Indian J Ophthalmol 2011;59:461–464
3. Rieger UM. Treatment of blowout fracture: optimal treatment modality
yet to be found? J Plast Reconstr Aesthet Surg 2012;65:883–884
4. Shin JW, Lim JS, Yoo G, et al. An analysis of pure blowout fractures and
associated ocular symptoms. J Craniofac Surg 2013;24:703–707
5. Strong EB. Orbital fractures: pathophysiology and implant materials for
orbital reconstruction. Facial Plast Surg 2014;30:509–517
6. Kim HS, Kim SE, Evans GR, et al. The usability of the upper eyelid
crease approach for correction of medial orbital wall blowout fracture.
Plast Reconstr Surg 2012;130:898–905
7. Ewers R, Schicho K, Undt G, et al. Int J Oral Maxillofac Surg
2005;34:1–8
8. Kozakiewicz M, Szymor P. Comparison of pre-bent titanium mesh
versus polyethylene implants in patient specific orbital reconstructions.
Head Face Med 2013;9:32
9. Chen Z, Zheng XH, Xie BJ, et al. Study on the growth of orbital volume
in individuals at different ages by computed tomography. Chin J
Ophthalmol 2006;42:222–225
10. A.N. J.G., Zhang ZY, Zhang Y. A preliminary study on CT and
computer-based method for unilateral post-traumatic enophthalmos
associated with impure orbital fractures. J Mordern Somotal
2006;20:561–563
11. Han DH, Chi M. Comparison of the outcomes of blowout fracture repair
according to the orbital implant. J Craniofac Surg 2011;22:1422–1425
12. Cole P, Boyd V, Banerji S, et al. Comprehensive management of orbital
fractures. Plast Reconstr Surg 2007;120(7 Suppl. 2):57S–63S
13. Chen CT, Chen YR. Update on orbital reconstruction. Curr Opin
Otolaryngol Head Neck Surg 2010;18:311–316
14. He Y, Zhang Y, An JG. Correlation of types of orbital fracture and
occurrence of enophthalmos. J Craniofac Surg 2012;23:1050–1053
15. Burm JS, Oh SJ. Direct local approach through a W-shaped incision in
moderate or severe blowout fractures of the medial orbital wall. Plast
Reconstr Surg 2001;107:920–928
16. Weinberg DA, Baylis HI. Transconjunctival lower eyelid
blepharoplasty. Dermatol Surg 1995;21:407–410
17. Zhang S, Li Y, Fan X. Application of endoscopic techniques in orbital
blowout fractures. Front Med 2013;7:328–332
18. Lee KM, Park JU, Kwon ST, et al. Three-dimensional pre-bent titanium
implant for concomitant orbital floorand medial wall fractures in an East
asian population. Arch Plast Surg 2014;41:480–485
# 2019 Mutaz B. Habal, MD