2017-18 HSC Section 3 Green Book

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

Evolving Trends in Orbit Fractures

TABLE 6. Comparison of the Used Implants in Orbital Floor Reconstruction in Plastic Surgery Literature Over Periods of 1990 to 1999 Versus 2000 to 2012

Implants

No. Studies

No. Patients

Others *

Years

Medpor

Titanium

Synpor

Autogenous Bone

Silicone

2000 Y 2012 1990 Y 1999

23 11

1955

589 (30%) 100 (17%)

223 (11%) 89 (15%)

87 (5%)

582 (30%) 273 (45%)

58 (3%)

416 (21%) 137 (23%)

599

0

0

*Others include PLLA, cartilage, allografts, hydroxyapatite, Vitallium, resorbable sheets, lyophilized dura.

Surgical Approach

Although the survey was not set up to answer this question, the authors wonder whether surgeon experience itself may not also be a key point in the decision to operate. The results of the survey imply that, with experience, plastic surgeons become more conservative in their indications to operate on orbital floor fractures, based likely on a better knowledge of potential operative morbidity and the acceptable outcomes of nonoperative management for select cases. CONCLUSIONS An evolving trend toward the use of alloplastic materials over bone grafts in orbital floor traumatic reconstruction is demonstrated by the current practices of Canadian plastic surgeons and confirmed by the chronological shift in the plastic surgery literature. Further- more, the finding of a more conservative approach toward the management of these injuries among CSPS members relative to earlier in their career warrants further investigation. Interspecialty and intraspecialty differences continue to exist with respect to im- plant choice, incision selection, and exact indication for operative intervention. At present, midlid/infraorbital incisions are the pre- ferred choice along with alloplastic materials for orbital floor re- construction by CSPS members. ACKNOWLEDGMENT The authors thank EliseMok, PDt, PhD, for her statistical advice. REFERENCES 1. Courtney DJ, Thomas S, Whitfield PH. Isolated orbital blowout fractures: survey and review. Br J Oral Maxillofac Surg 2000;38:496 Y 504 2. Lynham AJ, Chapman PJ, Monsour FN, et al. Management of isolated orbital floor blow-out fractures: a survey of Australian and New Zealand oral and maxillofacial surgeons. Clin Exp Ophthalmol 2004;32:42 Y 45 3. Ridgway EB, Chen C, Colakoglu S, et al. The incidence of lower eyelid malposition after facial fracture repair: a retrospective study and meta-analysis comparing subtarsal, subciliary, and transconjunctival incisions. Plast Reconstr Surg 2009;124:1578 Y 1586 4. Ellis E 3rd. Orbital trauma. Oral Maxillofac Surg Clin North Am 2012;24:629 Y 648 5. Burnstine MA. Clinical recommendations for repair of isolated orbital floor fractures: an evidence-based analysis. Ophthalmology 2002;109:1207 Y 1210 6. Manson PN, Clifford CM, Su CT, et al. Mechanisms of global support and posttraumatic enophthalmos: I. The anatomy of the ligament sling and its relation to intramuscular cone orbital fat. Plast Reconstr Surg 1986;77:193 Y 202 7. Matic DB, Tse R, Banerjee A, et al. Rounding of the inferior rectus muscle as a predictor of enophthalmos in orbital floor fractures. J Craniofac Surg 2007;18:127 Y 132 8. Grant JH 3rd, Patrinely JR, Weiss AH, et al. Trapdoor fracture of the orbit in a pediatric population. Plast Reconstr Surg 2002;109:482 Y 489

Whereas midlid/infraorbital incisions were the most commonly used incisions among Canadian plastic surgeons in this survey (45%), they were the least used across all other specialties (Table 4). On the contrary, whereas a subciliary incision was the least frequent ap- proach noted in this survey, it was the most commonly reported inci- sion in the plastic surgery literature (24% vs 86%, respectively). Although plastic surgeons are generally comfortable with a subciliary approach because of experience with aesthetic eyelid surgery, the data have steadily demonstrated that this approach for repair of orbit fractures has the highest rate of ectropion (14%) when compared with the other approaches. 3 Although this shift likely reflects an evolution based on literature evidence, the current study cannot confirm the etiology of this change in practice. Operative Indications and Timing Six factors were identified by the survey to have the greatest influence on the decision to operate (Table 2) with globe malposition, defect size, evidence of muscle entrapment, and/or persistent dip- lopia having the strongest impacts. This finding is consistent with cur- rent trends in the OMFS and ophthalmology literature. 4,5 Burnstine, 5 in his evidence-based analysis of the literature, found strong support- ing evidence (level I) for immediate surgical intervention in cases in- volving diplopia with a nonresolving oculocardiac reflex, white-eyed blow-out fractures, or early enophthalmos or hypophthalmos. Level II evidence for delayed intervention within 2 weeks was identified in cases involving minimally improving diplopia, positive forced- duction test, large defect size with late enophthalmos, or signifi- cant hypophthalmos. 5 Contrary to the literature, surveyed surgeons did not feel that a change inmuscle shape on computed tomography (CT) scan and/or an oculocardiac reflex significantly influenced the decision to op- erate. Rounding of the inferior rectus muscle on CT scan has been reported to potentially indicate a disruption in orbital floor soft tissue and bony support sufficient to cause enophthalmos, 6 and hence early surgical repair might be warranted in those cases to prevent the development of late enophthalmos. 7 Similarly, other studies have advocated an urgent surgical intervention for frac- tures associated with oculocardiac reflex to treat a theoretical ‘‘acute compartment syndrome’’ of the inferior rectus muscle and prevent its potential consequences including Volkmann contracture. 4,5,8 From the perspective of timing for surgical repair, the major- ity of surgeons in the current survey ( 9 50%) considered diplopia with positive forced-duction test or vertical motility restrictions as indications for acute repair (within the first 96 hours), whereas sig- nificant defect size, enophthalmos, and hypophthalmos being in- dications for subacute repair (4 Y 14 days). An important final finding of the survey was the fact that a third of Canadian plastic surgeons reported being less likely to repair orbital floor fractures relative to earlier in their career.

* 2014 Mutaz B. Habal, MD

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