2017-18 HSC Section 3 Green Book

The Journal of Craniofacial Surgery & Volume 25, Number 1, January 2014

Aldekhayel et al

TABLE 4. Literature Review of Surgical Approaches Used in Orbital Floor Fractures Exploration Among Different Specialties Between 2002 and 2012

Surgical Approach

No. Studies

No. Patients

Specialty

TC

SC

ST

IO

E

Plastic surgery

14 18 10

1164 1349

105 (9%) 370 (27%) 677 (99%) 274 (55%)

1002 (86%) 760 (56%)

15 (1%)

42 (4%) 42 (3%)

0

OMFS

144 (11%)

33 (3%)

Ophthalmology

683 496

3 (0.5%)

2 (0.3%)

1 (0.2%)

0

ENT

8

5 (1%)

0

0

217 (44%)

TC indicates transconjunctival; SC, subciliary; ST, subtarsal; IO, infraorbital; E, endoscopic.

their career. However, the majority (55%) stated their operative in- dications have not changed, whereas 11% reported that they were more likely to operate.

education on each of the following: operative decision making, timing of operative intervention, implant choice, and surgical approach.

Indications for Operative Intervention

DISCUSSION The current study summarizes the current management of orbital floor fractures by plastic surgeon members of the CSPS. A literature review across other surgical specialties that manage orbit fractures was also performed to investigate cross-specialty differ- ences or trends. The results of the survey and literature summary demonstrate that the management of orbital floor fractures con- tinues to vary significantly across various specialties and even within specialties themselves. Variability is particularly noted in surgical approaches, implant selection for orbital floor repair, and clinical indications for operative intervention. These differences are ex- plored below. A variety of implants are routinely used by the survey par- ticipants including titanium, porous polyethylene, polydioxanone (PDS; Ethicon, Somerville, NJ), and autogenous bone graft. Con- trary to the literature, which states that plastic (and ENT) surgeons historically equally prefer autologous bone to alloplastic implants (Table 5), the results from the survey found that the majority of Canadian plastic surgeons (83%) use alloplastic materials, namely, Medpor, titanium, or Synpor (Synthes, Paoli, PA). This trend toward alloplastic materials is likely the result of ease of use (no donor site harvest) and a rapidly growing body of evidence demonstrating safety and efficacy of synthetic materials for this indication. The latter evolution is supported by the subanalysis of the literature, which demonstrated that the predominant material used in the 1990 to 1999 cohort was autologous bone (45% bone vs 32% Medpor or titanium), whereas in the more recent publications dated 2000 to 2012 the relative frequencies were reversed (30% bone graft vs 46% alloplastic im- plants). These results are summarized in Table 6. Thus, the trend seen among our Canadian plastic surgeon participants echoes a global trend toward the use of alloplastic implants for orbital floor reconstruction. Implants

Six factors were considered by the majority of surgeons to be the most influential on the decision to operate: defect size, enophthalmos, hypophthalmos, motility restriction, positive forced duction, and late diplopia (at 2 weeks). Table 2 summarizes the influence of different key factors (either clinical or radiological) on the surgeon’s decision to surgically intervene on these fractures. It also demonstrates the timing of operative intervention, if indi- cated, for each factor when considered individually. A defect size of 1 to 2 cm 2 was considered an indication for surgery by 52% of surgeons, whereas 43% considered defects of more than 2 cm 2 as such. The majority of surgeons (82%) considered enophthalmos of more than 2 mm as a significant indicator for surgical intervention.

Implant Materials

Table 3 summarizes the preferred choice of implants for or- bital floor reconstruction among the respondents. Medpor (Stryker, Kalamazoo, MI) and titanium implants were the most commonly utilized (83%), whereas autogenous bone grafts were preferred by

less than 5% of surgeons. Surgical Approach

Midlid/infraorbital approaches were used by 45% of sur- geons, followed by transconjunctival and subciliary approaches (31% and 24%, respectively). A Frost stitch was ‘‘infrequently’’ used by 72% of surgeons. Our 10-year literature review of pre- ferred surgical approaches across different surgical specialties (Table 4) demonstrated that plastic (and OMFS) surgeons favored subciliary incisions, whereas ophthalmologists and ENT surgeons preferred the transconjunctival approach. Statistical Analysis Multivariate analysis did not show any statistically signifi- cant impact of surgeons’ training, experience, or continuing medical

TABLE 5. Literature Review of the Use of Implants in Orbital Floor Reconstruction Among Different Specialties Between 2002 and 2012

Implants

No. Studies

No. Patients

Ethisorb Supramid Others *

Specialty

Medpor

Titanium Synpor

Autogenous Bone Silicone

PDS

Plastic surgery

20 26 18

1886 589 (31%)

166 (9%) 299 (17%) 102 (8%) 62 (10%)

87 (5%) 42 (2%)

582 (31%) 143 (8%)

58 (3%)

0

0

0 0

404 (21%) 464 (27%) 151 (12%) 75 (13%)

OMFS

1760

89 (5%)

0 0

466 (26%)

257 (15%)

Ophthalmology

1246 468 (38%) 601 203 (34%)

128 (10%)

36 (3%)

0 0

0 0

361 (29%)

ENT

9

14 (2%)

233 (39%)

14 (2%)

0

*Others include PLLA, cartilage, allografts, hydroxyapatite, gel film, resorbable sheets, lyophilized dura, bioactive glass, nylon foil.

* 2014 Mutaz B. Habal, MD

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