The Dilemma of Reconstructive Material Choice for Orbital Floor Fracture: A Narrative Review

The aim of this study is to present a narrative review of the properties of materials currently used for orbital floor reconstruction. Orbital floor fractures, due to their complex anatomy, physiology, and aesthetic concerns, pose complexities regarding management. Since the 1950s, a myriad of materials has been used to reconstruct orbital floor fractures. This narrative review synthesises the findings of literature retrieved from search of PubMed, Web of Science, and Google Scholar databases. This narrative review was conducted of 66 studies on reconstructive materials. Ideal material properties are that they are resorbable, osteoconductive, resistant to infection, minimally reactive, do not induce capsule formation, allow for bony ingrowth, are cheap, and readily available. Autologous implants provide reliable, lifelong, and biocompatible material choices. Allogenic materials pose a threat of catastrophic disease transmission. Newer alloplastic materials have gained popularity. Consideration must be made when deliberating the use of permanent alloplastic materials that are a foreign body with potential body interactions, or the use of resorbable alloplastic materials failing to provide adequate support for orbital contents. It is vital that surgeons have an appropriate knowledge of materials so that they are used appropriately and reduce the risks of complications.

Autogenous mucochondral-osteal nasoseptal graft for reconstruction of orbital floor: a preliminary study

<p class="abstract">Resection of malignant sinonasal/skull base tumors that erode the orbital floor often result in large defects. We describe a technique for orbital floor reconstruction using a structural pedicled mucochondral-osteal nasoseptal flap (PMCONSF) that includes both soft tissue and bony-cartilaginous components with a continuous pedicled vascular supply. Case presentation was 11 patients having tumors associated with midface requiring maxillectomy and removal of inferior wall of orbit were included. Reconstruction of floor of orbit was done using PMCONSF. Post-operative outcomes of the techniques were studied. In all 11 cases reconstruction of floor of orbit was done using pedicled nasoseptal cartilage and in none of the cases communication of the orbital content with maxillary sinus was encountered. Complete ophthalmic examination revealed no significant diplopia, no entrapment of ocular structures with good ocular motility. Adequate reconstruction of the orbital floor is crucial to maintaining long-term ocular function. The PMCONSF offers great flexibility in flap design as well as a high rate of success. The bony-cartilaginous component offers a rigid structural part to the orbital floor, eliminating the functional defects that can occur from anatomical changes. The pedicled vascular supply helps assist in graft integration, limiting the potential for graft rejection or necrosis following postoperative radiotherapy. We believe that this graft offers a viable alternative to existing methods for orbital reconstruction in patients with large orbital floor defects, especially for cases in which adjuvant postoperative radiotherapy is anticipated.</p>

Pediatric Orbital Floor Reconstruction with Split Corticocancellous Rib Graft

Background: Orbital floor fractures constitute roughly 20% of all pediatric facial fractures. Reconstructive techniques are broadly subdivided into alloplastic and autologous. While pediatric literature exists for alloplastic orbital reconstruction, autologous orbital reconstruction studies are limited. Here we present several cases of posttraumatic pediatric orbital reconstruction utilizing autologous split rib graft. Methods: After IRB approval, a retrospective chart review was conducted at Monroe Carell Jr. Children’s Hospital at Vanderbilt from 2003 to 2019. A review of relevant published literature was also performed. Results: From 2003 to 2019, 5 pediatric patients underwent orbital reconstruction with split rib graft. Of the 5 patients, 3 were female and 2 were male with an age range of 4 to 8 years old (mean 4.8). Two patients had isolated orbital blow-out fractures while 3 presented with concurrent midfacial fractures. In each patient, the orbit was reconstructed by contoured split rib corticocancellous graft. Average length of stay was 5.2 days. There were no postoperative pneumothoraces. Mean follow-up length was 18.7 months, with no rib donor site complications. Each patient had adequate orbital volume restoration with no postoperative globe malposition or persistent diplopia. Conclusion: Pediatric orbital fractures are complex and challenging injuries. While alloplastic reconstruction is common and reliable, the risks of foreign body implantation and fixation must be carefully considered in patients who have not yet reached skeletal maturity. This is especially pertinent in younger patients as orbital growth continues until approximately 9 years of age. Rib graft use for adult orbital reconstruction has been explored. Data in the pediatric literature has not been identified. Corticocancellous rib graft harvest mandates a second surgical site; however, it is relatively inconspicuous with low postoperative morbidity. Corticocancellous rib grafting is a safe and durable option for orbital reconstruction and should be considered for use in the pediatric patient with a growing facial skeleton.

Endoscopic transmaxillary repair of orbital floor fracture

Introduction: Orbital floor fracture repair is common practical clinic and challenging for most surgeons. Open reduction and internal fixation is conventional treatment for a long time. Recently, endocopy has been using as assisted method with many advantages. Materials and Methods: Cross-sectional study. The author reports first five cases in Vietnam which were reconstructed the orbital floor via maxillary sinus intra-oral approach with endoscopic-assisted at Viet Duc University Hospital from 2016 to 2019. Results: 5 cases (2 emergency surgeries and 3 selective surgeries) were treated with transmaxillar-sinus intra oral endoscopy for orbital floor reconstruction (2 titanium mesh, 1 absorable mesh, 2 porous polyethylenne mesh). All patients were evaluated with good results both in function and aesthetic aspect. No complication was recorded. One patient has facial numbness (innervated by inferior orbital nerve) but temporary and resolve after 3 months. Conclusion: The prelimenary results confirmed that transmaxillary-sinus intra-oral endoscopy for orbital floor reconstruction is reliable and safe method. Key word: Orbital fracture, facial trauma, enophthalmos, orbital floor reconstruction, endoscopic surgery. Tóm tắt Đặt vấn đề: Chấn thương sàn ổ mắt khá thường gặp trong thực hành lâm sàng. Điều trị các tổn thương này vẫn luôn là một thách thức với các bác sĩ phẫu thuật. Phương pháp kinh điển là mổ mở vào nếp má mi, dưới viền mi hoặc đường kết mạc. Việc sử dụng nội soi hỗ trợ hay toàn bộ giúp tăng cường khả năng quan sát chính xác của phẫu thuật viên, đặc biệt là với các thương tổn nằm sâu trong ổ mắt, từ đó giúp phục hồi tốt nhất về giải phẫu và thể tích ổ mắt. Phương pháp nghiên cứu: Nghiên cứu cắt ngang 05 người bệnh được chẩn đoán vỡ sàn ổ mắt được phẫu thuật tạo hình sàn ổ mắt với nội soi hỗ trợ từ năm 2016 đến năm 2019. Kết quả: Có 2 trường hợp được phẫu thuật cấp cứu vì kẹt cơ vận nhãn, 3 trường hợp phẫu thuật theo kế hoạch phục hồi sàn ổ mắt với vật liệu nhân tạo (2 Mesh Titanium, 1 Mesh tự tiêu, 2 Mesh Porous Polyethylene) mở xuyên xoang hàm qua đường miệng với nội soi hỗ trợ. Tất cả các trường hợp đều liền sẹo niêm mạc thì đầu, không có biến chứng nào được ghi nhận. Có một trường hợp bị tê bì vùng má (vị trí chi phối của thần kinh dưới ổ mắt) tạm thời, phục hồi hoàn toàn sau 3 tháng. Kết luận: Kết quả bước đầu cho thấy phẫu thuật tạo hình sàn ổ mắt qua đường miệng với nội soi hỗ trợ có những ưu điểm vượt trội cả về chức năng và thẩm mỹ. Từ khóa: Vỡ xương ổ mắt, chấn thương hàm mặt, lõm ổ mắt, tạo hình ổ mắt, phẫu thuật nội soi.