Contemporary Management of Zygomaticomaxillary Complex Fractures

Zygomaticomaxillary complex fracture is one of the most commonly treated facial fractures. Accurate reduction and stable fixation of the zygoma are required to restore facial symmetry and projection and avoid functional sequalae from changes in orbital volume. Achieving optimal outcome is challenging due to the complex three-dimensional anatomy and limited visualization of all affected articulations of the zygoma. This article provides an updated overview of the evaluation and management of zygomaticomaxillary complex fractures based on available evidence and clinical experience at our center. The importance of soft tissue management is emphasized, and approaches to internal orbital reconstruction are discussed. While evidence remain limited, intraoperative imaging and navigation may prove to be useful adjuncts in the treatment of zygomaticomaxillary fractures.

Three-dimensional study of the orbit-related structures according to sex, age and skeletal deformities

Objective: This study aimed to evaluate the relations between orbit-related structures and sex, age and skeletal deformities using cone-beam computed tomography (CBCT). Methods: This retrospective study evaluated 216 consecutive CBCT scans of patients, who were divided according to: sex (male, n=105; female, n=111), age (A1: 18-32 years, n=71; A2: 33-47 years, n=78; A3: 48-62 years, n=67), and skeletal deformities (Class I, n=70; Class II, n=75; Class III, n=71). The supraorbital foramen (SOF) location, volume of orbit, optic canal (OC) and infraorbital canal (IOC) were evaluated. Results were analyzed using the Gamma model test. The Tukey-Kramer post-hoc test was used to compare the variables with three factors (p<0.05). Results: The IOC volume showed higher values for male, A3 and class I patients. The SOF location and the orbital volume also showed higher values for male patients. Regarding the volume of CO, it showed higher values ​​for male and class I patients. Conclusions: According to our results, sex has been shown to have a significant influence on orbit-related structures. Age and skeletal deformities also influenced the volume of IOC and OC. These results eventually help the clinical practice, being useful for orbital reconstruction surgeries, anthropological studies, gender identification and identification of susceptibility to pathological conditions related to sexual dimorphism.

The Versatility of the Free Vastus Lateralis Muscle Flap: Orbital Reconstruction After Removal of Complex Vascular Malformation in a Pediatric Patient

Introduction: Vascular orbital lesions in pediatric population represent a demanding therapeutic challenge which requires a multidisciplinary team. In severe cases, orbital enucleation can be considered. Surgical management of enucleated orbital region in children, differently from the adults, represents a challenging procedure owing to the intrinsic relation between volume replacement and normal orbital growth. Many reconstructive options have been proposed, and many donor sites have been utilized for this purpose but each one have demonstrated potential disadvantages. Despite its well-known versatility, no report of the vastus lateralis free flap in children requiring orbital reconstruction exists in literature. Herein, we propose this surgical strategy as a valid option for the reconstruction of an extended orbital defect in a pediatric patient suffering from a mixed type of vascular malformation.Material and Methods: A patient was referred from a foreign country with an unclear medical history, presenting exorbitism and exophthalmos, proptosis of the eyeball, visus 4/10, and limited ocular motility. We made clinical-instrumental investigations with a diagnosis of complex vascular malformation. It expanded in intraorbital and retrorbital space with bulb anterior dislocation and optic nerve involvement. We performed an emptying of the orbital content via transconjunctival and via coronal incision with eyelid preservation. A free vastus lateralis muscle flap was used for reconstruction, filling the orbital cavity. We anastomosed the flap on the superficial temporal artery. An ocular conformator was then positioned.Results: We report the result at 12 months, showing a good orbital rehabilitation with an adequate prosthetic cavity, a good recovery of volume and facial symmetry, guaranteeing balanced orbital and periorbital growth. There were no major or minor complications associated with the procedure.Discussion: The reconstruction of the orbit remains a “surgical challenge” both in adults, whose goal is the restoration of volume, adequate symmetry and facial esthetics, and children, in which correcting the asymmetry has the additional objective to balance orbital growth. Many reconstructive techniques have been proposed, including the use of free flaps. The versatility of the free vastus lateralis muscle flap is well-known. It offers adequate amount of tissue with minimal morbidity to the donor site, provides a long pedicle, gives the possibility of simultaneous work in a double team, and has a constant anatomy and a safe and rapid dissection. There are no descriptions of its use for pediatric orbital reconstructions.Conclusions: In our opinion, the free vastus lateralis flap should be included as one of the best option for orbital pediatric reconstruction after enucleation.

Case Report: High-Definition 4K-3D Exoscope for Removal of an Orbital Cavernous Hemangioma Using a Transpalpebral Approach

Background: Cavernous hemangioma, also known as cavernous vascular malformation (CVM), is the most common primary lesion of the orbit in adults. The management of these lesions is challenging and is strongly dependent on their location, as well as the patient's symptoms and expectations. The trans-palpebral approach is currently used in surgery for orbital tumors, anterior skull base tumors, and even more, orbital reconstruction, because of its well-demonstrated esthetic advantages. Similarly, the use of magnification can be provided by surgical loupes, microscope, or more recently, endoscope, which is well-documented for its advantages in terms of minimal invasiveness and safety. In the last years, the use of exoscopes in microsurgery has been proposed due to their greater and sharper intraoperative magnification, but never for the removal of orbital tumors.Clinical Presentation: We describe a case of a 38-year-old woman with a right orbital intraconic CVM removed using an inferior transpalpebral approach performed under 4K-3-dimensional (4K-3D) exoscopic vision. Navigation and ultrasound were also used, with the former allowing better identification of the lesion within the orbit and the second overcoming the limitations of navigation, in terms of the retraction on the ocular globe before or just after periorbital incision.Conclusion: The use of a 4K-3D exoscope allowed us to perform the surgery safely, thanks to the high magnification and definition of anatomical details, with the surgeon operating in an upright, comfortable position. The CVM was completely removed with excellent results from both functional and esthetic points of view.