Flattening of the orbital lower eyelid fat as a long-term outcome after surgical treatment of orbital floor fractures

Our aim was to report the incidence of asymmetry of the lower eyelid (that manifests itself as flattening of the eyelid fat) as a long-term complication of the surgical approach of unilateral fractures of the orbital floor. We retrospectively reviewed the aesthetic appearance of the lower eyelid in 43 patients after repair of such fractures. Long-term asymmetry seen as asymmetrical flattening of the eyelid fat was evaluated and graded qualitatively as mild, moderate, and severe. We studied its relations to the surgical approach, patient’s age and sex, and postoperative time; 20 of the 43 had flattening of the lower eyelid fat. There were significantly more patients with flattening of the fat after a transconjunctival approach than after transcutaneous ones (p = 0.03). We found a statistical likelihood of the development of flattening of the fat when patients were between 40 and 60 years old at the time of operation (p = 0.006). Increasing age at the time of the study was related to increased severity (p = 0.0019), with the greatest significance over 55 years old (p = 0.006). We found no relation to patients’ sex, or duration of operation. To our knowledge this is the first time that flattening of the eyelid fat has been described as a long-term complication after a particular approach to orbital floor fractures. The transconjunctival incision was more likely to be associated with this long-term outcome. Patients over 40 years old are also at risk of developing flattening, and this is more severe when the patient is over 55. A short follow-up period is not sufficient for the evaluation of the aesthetic outcome of traditional approaches to fractures of the orbital floor in the lower eyelid.     

Efficacy of Transcaruncular approach to reconstruct isolated medial orbital fracture

Background  

Traditional approaches used to repair medial orbital wall fracture include transcutaneous incision such as advocated by Killian and Lynch, or coronal approach. Transcaruncular approach provides an anatomically safe and efficient alternative, allowing generous exposure without the cutaneous scar.     

Laterocaudal approach to the inferior rim of the orbit

Purpose

Fractures of the orbital floor and orbital rim are frequently treated in maxillofacial departments. Various approaches to the orbital floor are described in the literature. We present an investigation of a modified subciliary approach (laterocaudal approach) with respect to its feasibility and clinical outcome.

Aesthetic outcomes of upper eyelid blepharoplasty: a systematic review

Although upper blepharoplasty is a common cosmetic surgical intervention, a better scientific understanding of the aesthetic results and the preferred surgical technique to achieve the best aesthetic results is still needed. A systematic search using four search engines (PubMed, Embase, CINAHL, and Cochrane) was performed to identify any study on the aesthetic outcome of a solitary upper blepharoplasty; these were subjected to quality assessment for possible inclusion. Eligible studies were randomized controlled trials, controlled trials, cohort studies, and case series (n ≥ 10). A total of 4043 studies were assessed, of which 26 were included. Aesthetic outcomes included patient-reported outcome measures, scarring, eyebrow height, tarsal platform show, and panel or expert evaluation. Meta-analysis was not possible. Patients were generally satisfied with the aesthetic result and scar formation after an upper blepharoplasty. The amount of tarsal platform show increases, which positively affects the aesthetics. The eyebrow seems to move down slightly. The surgical technique used (skin only or skin/muscle removal) did not influence patient satisfaction or the physician-assessed aesthetic outcomes. Patients are generally satisfied after an upper blepharoplasty. The optimal design of the skin excision is still a matter of debate, especially when addressing lateral hooding. Further objective research is advised.     

An anomalous case of an indirect orbital floor fracture

Fractures of the orbital floor are common in facial trauma. Those that comprise only the orbital floor are called indirect fractures or pure internal orbital floor fractures.     

鼻内镜手术在眼眶骨折中的应用

传统的眼眶骨折手术是经皮肤或结膜的直接途径,能提供良好的手术视野,但手术创伤大,皮肤遗留瘢痕。鼻内镜手术照明好、多角度、视野清晰、入路简捷、可以微创的手术处理达到最佳的手术效果。鼻内镜下经筛窦/上颌窦入路适于复位单纯的眶壁骨折,直视眶壁后份骨折的骨质缺损以及突入到窦腔的眼眶内容物,并辅助眼眶骨折的临床诊断。鼻内镜手术联合其他经鼻外皮肤或结膜的入路,在修复鼻眶筛复合体骨折时优势明显。本文就鼻内镜在眼眶骨折中的诊断价值、鼻内镜手术治疗眼眶骨折的优缺点和临床指征、操作要点、植入材料以及骨折固定材料等方面作一综述。     

Neurosensory recovery after trauma to the orbital floor: a prospective trial with dexamethasone

Our aims were to document the occurrence of neurosensory disturbances of the infraorbital nerve six months after operation for an orbital blow-out fracture, and to find out whether dexamethasone facilitates neurosensory regeneration. Patients were randomly assigned to one of two groups: the study group was given a total of dexamethasone 30 mg, whereas the control group were given neither glucocorticoid nor placebo. Each patient’s infraorbital neurosensory state was recorded preoperatively, immediately postoperatively, and six months later. A total of 18 patients were included, eight of whom had neurosensory disturbances six months after the initial trauma that was not affected by dexamethasone. Six of the seven patients who had a delay of seven days or more between trauma and operation had significantly prolonged disturbance at the 180-day clinical follow up compared with those in whom it was less than seven days (p = 0.005). Other possible predictors made no significant difference. Although dexamethasone did not facilitate sensory recovery, its benefits in the management of pain and reduction of swelling may justify its use in the management of facial trauma in selected patients.     

Tarsal strip technique for correction of malposition of the lower eyelid after treatment of orbital trauma

Purpose

The transconjunctival, subciliary, subtarsal, and subpalpebral approaches for accessing the infraorbital rim and orbital floor have both advantages and disadvantages. The most common complications include rounding of the lateral canthal angle, lower eyelid retraction with inferior scleral show, and frank ectropion.

Materials and patients

From 2000 to 2007, we treated 29 patients with lower eyelid malposition after surgery to manage the floor and infraorbital trauma (22 subciliary approaches, five transconjunctival approaches and lateral canthotomies, and two transconjunctival approaches). To correct lower eyelid malposition, we applied the tarsal strip technique in all patients.

Results

Twenty-five patients had scleral show and four patients had ectropion: three were previous treated using transconjunctival access and one using subciliary access. Twenty-six patients obtained satisfactory correction of eyelid malposition in a single-step surgical procedure, while three patients required a second surgical step to correct the remaining scleral show. Good aesthetic and functional results were achieved in all cases.

Conclusions

All approaches to the infraorbital rim or orbital floor have the potential for postoperative sequelae. The tarsal strip technique is a relatively simple technique that oral and maxillofacial surgeons can use to manage lower lid malposition, such as scleral show and ectropion.     

双重睑切口在颧额缝骨折内固定入路的临床应用

目的　探讨双重睑切口在颧额缝骨折内固定入路的临床应用效果。方法　选取12例颧骨复合体骨折、骨折段移位明显、伴有面部塌陷或张口受限等功能障碍患者,行局部小切口切开复位内固定术,其中颧额缝采用双重睑切口入路,术后评价骨折复位固定、功能和畸形改善、术后瘢痕等情况。结果　所有骨折复位固定方便,患者颧面部外形满意,功能改善明显,术后瘢痕隐蔽。结论　双重睑切口作为颧骨复合体骨折复位内固定其中的手术入路,既能达到骨折复位,又能减少创伤,具有一定的临床使用价值。     

Blending of the eyelid–cheek junction and removal of protruding fat: an intraoral approach to blepharoplasty of the lower eyelid

Blepharoplasty is one of the most common aesthetic procedures done today. The protruding fat and lid–cheek junction are the most conspicuous signs of aging that need attention. During zygomatic reduction by an intraoral approach we found occasionally that the orbital fat can be exposed through the perforated periosteum at the inferior obital rim. We therefore developed a new blepharoplasty procedure using an oral approach.Seventeen patients aged from 26 to 38 years, of whom six had had a previous unsuccessful blepharoplasty and one had a history of injury to the lower lid, were studied. The operation was done under an infraorbital nerve block and local anaesthesia through an intraoral incision at the upper vestibular groove. The periosteum was raised on the surface of the maxilla to the infraorbital rim, and the infraorbital nerve preserved. The periosteum and the orbital septum were incised along the whole length of the infraorbital rim. The fat that was exposed through the incision was either removed or preserved and fixed to the outer soft tissue with sutures.Cosmetic results were good and the oral incision healed without infection. Six patients developed numbness in the infraorbital region, five of whom recovered within 3 months; the other recovered by 6 months postoperatively.     

A simple method to estimate the linear length of the orbital floor in complex orbital surgery

Background

The orbital floor (OrF) and infraorbital rim (IOR) repair in cases of complete destruction is challenging mainly due to the fact that the defect length cannot be measured. The aim of the current study is to develop a method of calculating the Orf length by using the gender and the lengths of the medial, superior and lateral orbital walls (OrW) of the same orbit.

Ageing increases risk of lower eyelid malposition after primary orbital fracture reconstruction

Lower eyelid malposition (LEM) is a common sequela after orbital fracture reconstruction. This study aimed to analyse the development of LEM, specifically ectropion and entropion, following primary orbital fracture reconstruction, to identify predictive factors for LEM, and to assess the effect of the eyelid complication on patients’ daily lives. The retrospective cohort comprised patients who had undergone orbital floor and/or medial wall fracture reconstruction for recent trauma. Demographics, fracture type and site, surgery and implant-related variables, follow-up time and number of visits, type and severity of LEM, subsequent surgical correction, and patient satisfaction, were analysed. The overall occurrence of LEM was 8%, with ectropion in 6% and entropion in 2% of patients. Older age, complex fractures, transcutaneous approaches, preoperative traumatic lower lid wounds, and implant material were associated with the development of LEM. Of all patients, 3% needed surgical correction of LEM. Six of the 13 patients (46%) who developed LEM required surgical correction. The transconjunctival approach and patient-specific implants should be preferred, especially in elderly patients and those with more complex fractures. LEM often requires subsequent surgical correction, and the treatment period is substantially prolonged, with multiple extra visits to the clinic.     

Influence of age on the management of blow-out fractures of the orbital floor

This study concerns 50 patients with blow-out fractures of the orbital floor, including 15 children, and was designed to evaluate the influence of age on clinical presentation and postoperative results. Fourteen of the 15 children were found to have a trap-door fracture. This type of fracture was not found in adults, who usually present with a large "open-door" fracture. In trap-door fractures, orbital tissues are liable to become trapped and even strangulated. It is therefore suggested that young patients with severely restricted eyeball motility, an unequivocal positive forced duction test, and findings indicating blow-out fracture of the orbital floor on CT, should undergo operative treatment as soon as possible after injury. A "wait and see" policy, keeping the patient under observation, seems to be appropriate for blow-out fractures in adults. Surgical treatment is recommended only in those adult patients who demonstrate impairment of vertical eyeball motility within the mainfield of view after the haemorrhage and oedema have resolved and in whom change in motility is no longer seen and Hertel measurements have stabilized.     

The influence of concomitant medial wall fracture on the results of orbital floor reconstruction

Introduction

Up to 35% of orbital floor fractures extend to the medial wall. This results in restriction of both abduction and adduction, leading to horizontal diplopia. The greater the defect, the more pronounced the enophthalmos.

Anthropometric changes in the morphology of the lower eyelid after using three different approaches in patients with orbital fractures

PurposeThe aim of this prospective study was to address the anthropometric changes in the morphology of the lower eyelid and esthetic outcomes after performing subciliary, subtarsal, and transconjunctival approaches in patients with orbital and periorbital fractures.Patients and methodsA prospective randomized controlled clinical study was undertaken on patients with orbital floor and infraorbital rim fractures. These were equally divided into three groups: in group 1, the fractures were approached via a stepped subciliary approach; in group 2, they were approached via a subtarsal approach; in group 3, a retroseptal transconjunctival approach was performed. The patients were assessed for anthropometric changes in the morphology of the lower eyelid, esthetic outcomes, and postoperative lower eyelid complications (LLCs). A one-way ANOVA test was used to analyze differences between the operated and non-operated sides and the effect of the surgical approach on anthropometric measurements.ResultsA total of 45 patients were included in the study. All the surgical approaches provided adequate surgical exposure of the infraorbital rim and orbital floor. The subtarsal approach allowed rapid access to the field (10.5 ± 1.9 min). All incisions resulted in adequate postoperative esthetic outcomes. Anthropometric analysis revealed that there were no significant differences between the three approaches, except for measurements of the eye fissure index (EFI) and lower iris coverage (LIC). Mean EFI measurements increased on all operated sides. The subciliary approach showed the highest percentage of increased measurements of this variable (34.5 ± 4.6), followed by the subtarsal approach (32 ± 2.1), and then the transconjunctival approach (31.1 ± 3.7), with p = 0.046. Furthermore, the subciliary approach significantly decreased the measurements of LIC. This change was also bigger with the subciliary approach (1.09 ± 2.3) than with the subtarsal approach (2.1 ± 2.4) or transconjunctival approach (3.4 ± 2.6), with p = 0.048.ConclusionBased on the results of this study, the subtarsal approach is a minimally invasive incision that provides an adequate and direct approach to orbital floor and infraorbital rim fractures, with a favorable periorbital architecture and the lowest incidence of LLCs. Therefore, the subtarsal technique should be preferred over subciliary and transconjunctival approaches.     

眶底缺损重建材料的研究进展

眼眶底板骨质菲薄,当眶内容物受到钝力作用使眶内压突然升高时易发生骨折。眶底骨折因其所在位置特殊,一旦骨折则无法复位,只能采用材料修补眶底。目前许多材料被用于重建眶底缺损,包括一直被大家认为是“金标准”的自体骨。但自体骨也有一定局限性．如来源少及额外的手术负担,越来越多的异体材料被开发并运用到临床。本文对目前常使用的眶底重建材料作一综述。     

Forehead reduction and orbital contouring in facial feminisation surgery for transgender females

Forehead reduction and orbital contouring form a considerable component of the procedures available to feminise the face in transgender females. In this paper I shall discuss the history and development of techniques to reduce bossing of the forehead and contour the orbits, and describe their classification, assessment, surgical approach, and complications.     

钛网支架修复眶底缺损

目的：探讨经头皮冠状切口或睑结膜切口入路,应用钛网支架重建眶底缺损的临床疗效。方法根据CT扫描和三维成像诊断,对18例眶底缺损患者进行微型钛网内固定术重建眶底缺损,其中10例为眶底伴邻近颅面骨折,采用头皮发际内冠状切口;8例为陈旧性眶底骨折,采用睑结膜切口。结果18例患者的眼球内陷和部分合并颧骨骨折的状况得到纠正,切口均愈合良好,切口位置较隐秘或未遗留瘢痕,颜面畸形得到明显改善。术后随访3～24个月,钛网支架无1例松动或移位或者其他并发症,疗效满意。结论头皮冠状切口入路以及睑结膜入路都能为术者提供足够视野与操作空间,应用微型钛网内固定术可重建眶底缺损,防止复视,术后美观效果佳。     

Clinical anatomy of the superior orbital fissure and the orbital apex

BACKGROUND: There are discrepancies between authors as far as topography of superior ophthalmic vein in the orbital apex is concerned. OBJECTIVES: The aim was to determine the location of the structures within the posterior part of the orbit and in the superior orbital fissure. MATERIAL: One hundred preparations of orbits were derived from the corpses sectioned in Forensic Medicine Department, University Medical School in Warsaw, Poland. STUDY DESIGN: Anatomical preparation was performed with use of standard set of microsurgical equipment and operating microscope. RESULTS: Nine various morphological types of the superior orbital fissure were distinguished. Among those were two main categories: type "a" characterised by a clear narrowing within the fissure and type "b" which lacked such narrowing. The type "a" and "b" fissures were also different in length whereby type "b" fissure was significantly shorter. A diversity of positioning of the soft structures within those types was successfully noted. In type "a" the superior ophthalmic vein was located typically, however in type "b" fissures it was significantly more often the lowest structure in the posterior part of the orbital apex (except for muscles and orbital fat). A short case report of patient with superior orbital syndrome was added. CONCLUSION: Position of soft tissue structures in superior orbital fissure depended on its morphological type.