A d v a n c e s i n th e

Reconstruction of Orbital
F r a c t u res
Scott E. Bevans, MDa,b, Kris S. Moe, MDc,*

KEYWORDS
 Orbit fracture  Navigation  Mirror image  Computer  Preoperative planning  Endoscopic
 Outcomes

KEY POINTS
 Repair of orbital fractures should be carried out to restore premorbid orbital contours with the great-
est possible precision.
 Reconstruction should be performed after resolution of edema from the injury.
 Exophthalmometry is important in the decision to operate, intraoperative measurements, and post-
operative outcome evaluation.
 Orbital endoscopy improves ability to visualize the entire extent of the fracture with increased illu-
mination and magnification while reducing retraction of orbital contents.
 Surgical navigation with mirror-image overlay guidance provides a template for reconstruction
when normal anatomic landmarks have been damaged and, when used with an endoscopic tech-
nique, leads to significant improvement in multiple surgical outcome metrics.

INTRODUCTION determinant of beauty, failure to restore preopera-

tive appearance in this highly visible and difficult-
Orbital reconstruction is one of the most chal- to-camouflage location often creates significant
lenging tasks of the surgeon who treats craniofa- emotional distress.
cial trauma. Suboptimal outcomes may lead to In addition to the high functional and emotional
debilitating morbidity with significant emotional, impact of these injuries, repair of orbital fractures
functional, and occupational deficits. These defi- is challenging because of the complexity and vari-
cits can include diminished visual acuity, diplopia, ability of the anatomy. Reconstructive landmarks
loss of depth perception, chronic or severe pain, are often obscured by the trauma; the contralateral
as well as depression and impaired mobility. Given structure cannot be exposed for comparison; and
that the orbital region is perceived as the greatest the orbital contents are often markedly displaced

Disclosure Statement: S.E. Bevans is a member of the United States Army. The views expressed here are those of
the authors and do not reflect the official policy or position of the Department of the Army, Department of
Defense, or the U.S. Government. Additionally, reference herein to any specific commercial products, process,
or service by trade name, trademark, manufacturer, or otherwise, does not necessarily constitute or imply its
facialplastic.theclinics.com

endorsement, recommendation, or favoring by the United States Government. K.S. Moe is the Founder of SPI
Surgical, Inc but has no conflicts of interest.
a
Department of Otolaryngology, Medical Corps, US Army, San Antonio Military Medical Center, 3551 Roger
Brooke Drive, San Antonio, TX 78234, USA; b Department of Surgery, Uniformed Services University, 4301
Jones Bridge Road, Bethesda, MD 20814, USA; c Division of Facial Plastic and Reconstructive Surgery, Depart-
ments of Otolaryngology and Neurological Surgery, University of Washington School of Medicine, 325 9th
Avenue, Seattle, WA 98104, USA
* Corresponding author.
E-mail address: [email protected]

Facial Plast Surg Clin N Am 25 (2017) 513–535

http://dx.doi.org/10.1016/j.fsc.2017.06.014
1064-7406/17/Ó 2017 Elsevier Inc. All rights reserved.
514 Bevans & Moe

into adjacent anatomic regions. Furthermore, even approach, material used for reconstruction, intra-
minor inaccuracy in repair of the fracture can operative implant positioning confirmation, and so
cause functional and esthetic disturbances post- forth). In this article, the authors describe the
operatively, as can the edges of a fracture or technique they have developed and currently
entrapment of orbital contents under the implant. use at the University of Washington Harborview
Orbital fractures are frequent injuries, with a Medical Center (a level I trauma service) with a
nationwide incidence exceeding more than summary of recent literature applicable to these
100,000 patients per year in the United States.1 controversial topics.
The cause of orbital injuries is shifting in the United
States and other developed countries; motor ORBITAL ANATOMY
vehicle accidents have overtaken assault as the
most common cause. An increasing rate of falls The orbit is formed by the confluence of 7 bones
make this the third most common cause of orbital (Figs. 1 and 2). Conceptually, these are catego-
fracture, followed by sports and industrial injuries. rized into an orbital exoskeleton and endoskeleton.
In all reports, the most frequently injured subgroup The exoskeleton is created by the external por-
is men between 21 and 35 years of age; however, tions of the maxillary and frontal and zygomatic
injuries to women, adolescents, and the elderly are bones, which form the orbital rims. The endoskel-
also common.2,3 Domestic violence remains an eton, the internal walls of the orbit, are created by
important cause of midface or isolated orbital the intraorbital portions of these bones with the
injury among women. addition of the lacrimal, palatine, and sphenoid
Brain injury occurs in 38% to 61% of patients bones.
with orbital injuries, and the incidence of multiple At the junction of the ethmoid and frontal bones
facial fractures and brain injury increases with are the ethmoid arteries. It is typically taught that
higher-impact injuries.4 The rate of ocular injury there are 2 vessels, the anterior ethmoid artery
ranges from 14% to 40% of patients with facial located 24 mm posterior to the anterior lacrimal
fractures, highlighting the need for a low threshold crest and the posterior branch 12 mm further pos-
for ophthalmologic evaluation.5 Most fractured or- terior, 6 mm from the optic canal. There is actually
bits are minimal, however, and do not require significant variability in the number and location of
repair even if other coincident facial fractures branches of ethmoid arterial system, most often
require surgical intervention.2,3,5,6 with 3 arteries in unpredictable positions.11 At
A recent biomechanical study validated histori- the junction of the lateral orbital wall with the
cal observations regarding the amount of force orbital floor is the zygomaticofacial neurovascular
required to fracture orbital walls, finding only 2 bundle anteriorly and the zygomaticotemporal
N-m of force was required to fracture the orbital neurovascular bundle posteriorly. The superior
floor relative to more than 4 N-m of force required orbital fissure and adjacent bone contain both sen-
to fracture the medial orbital wall.7 Several the- sory and motor nerves as well as the mechanical
ories of force transfer have been proposed. The anchors important to extraocular motion, whereas
hydraulic theory suggests that force is transferred the inferior orbital fissure contains only minor sen-
to the orbital contents, increasing orbital pressure, sory nerves, which can be sacrificed without
and, thus, exerting hydraulic pressure on the notable deficit (see Fig. 1).
orbital walls causing a fracture. Alternatively, the The orbital floor is the shortest wall of the orbit
buckling theory describes transmission of force and comprises the roof of the maxillary sinus. It
from direct contact with the orbital rim, creating is 35 to 40 mm in anterior/posterior length and
a shockwave whereby the weakest area bone suc- variably concave, with a depression just behind
cumbs to forces of deformation. Less commonly, the orbital rim and an upward slope to the orbital
direct contact only with the globe results in retro- apex. The inferior rectus muscle runs in close
pulsion into an orbital wall causing a fracture.8–10 proximity to the orbital floor for most of its
Despite the relative frequency with which sur- length. The muscle belly is normally oval in
geons will be asked to evaluate and manage pa- appearance on coronal imaging but can become
tients with orbital fractures, there remains a rounded when damaged or inflamed (a sign to
great deal of controversy about patient selection evaluate on imaging). Because of the close
for operative management and how to achieve approximation to the orbital floor, small spicules
optimal results. Specifically, debate remains of bone are often in close approximation to the
about how to determine which patients will need inferior rectus on coronal imaging.12 The total
operative intervention, timing of surgery, preoper- orbital volume for an adult is approximately 30
ative and postoperative antibiotic use, and a to 35 mL, approximately 7 mL of which is occu-
myriad of intraoperative techniques (eg, surgical pied by the globe.13
 Advances in Orbital Reconstruction 515

Frontal

Ethmoid

Sphenoid
eno
oid
id Lacrimal

Zygoma Palatine

Maxillary

Lat. rectus Sup. rectus

Superior orbital fissure: Levator Sup. oblique
V1-lacrimal Med. rectus

V1-frontal
Optic canal:
Sup. ophth. vein
II-optic
IV-trochlear
Ophth. artery
III-oculomotor (sup. branch)
Annulus of Zinn
V1-nasociliary
VI-abducens Inferior rectus

III-oculomotor (inf. branch)

Inf. ophth. vein
Pterygopalatine ganglion
branches of V2
Inferior orbital fissure:
Infraorbital artery
V2-infraorbital
V2-zygomatic
Emissary vein
Fig. 1. Orbital bone anatomy, fissures, and contents.

INITIAL EVALUATION AND MANAGEMENT hemorrhage), visual acuity, effortful extraocular

motion (for motility status and pain with motion),
Any patient with a history of blunt trauma to the and color vision status. Evidence of hyphema,
orbit should undergo evaluation for orbital fracture. decreased visual acuity, loss of color vision, or
Because of the high frequency of coincident facial an afferent pupillary defect can represent damage
or intracranial injury, this should include a full to the globe or neural pathways, which warrants
craniofacial trauma evaluation at the time of pre- further specific neuro-ophthalmologic evaluation.
sentation. After ruling out significant intracranial These types of injuries will influence both the
injury and assuring hemodynamic stability, tar- need for and timing of surgical intervention.
geted examinations must rule out damage to the An orbital fracture may be present in up to 7% of
globe, with ophthalmology consultation as indi- patients with a history of periorbital trauma who
cated. This evaluation should include palpation have no findings on examination.3 Therefore, a
of the orbit rim and adjacent soft tissue to assess low threshold for obtaining cross-sectional imag-
for discontinuity, mobility, or emphysema. Ocular ing should be maintained. The authors re-
examination should include pupil shape and size, commend obtaining a maxillofacial computed
surface examination (for conjunctival edema or tomography (CT) scan with 0.625-mm axial slices
516 Bevans & Moe

Superior rectus Acute treatment in the absence of muscle

Levator palpebrae entrapment is directed toward decreasing edema.
superioris Skin In cases of significant edema, a steroid taper for 4
Frontalis to 7 days may be considered. The authors counsel
patients to ice with saline-soaked gauze or a thinly
covered bag of frozen peas for 10 to 20 minutes
Orbital fat
Superior oblique per hour while awake for the first 72 hours and
Orbicularis occuli (preseptal) elevate the head of the bed while sleeping. The au-
thors recommend oxymetazoline nasal spray for a
Orbital septum
short period after injury as needed for epistaxis
Müller’s muscle and saline nasal spray but no nasal irrigations. Pa-
Levator aponeurosis fibers tients should be educated on sinus precautions:
most importantly sneezing with an open mouth
Orbicularis occuli (pretarsal)
and avoiding nose blowing. These practices speed
Tarsus
the resolution of edema, which improves the ability
Conjunctiva to assess functional and esthetic deficits, im-
Capsulopalpebral fascia
proves intraoperative visualization, and reduces
the need for retraction of orbital contents. The
Lockwood’s ligament
use of prophylactic antibiotics does not seem to
Inferior oblique
be indicated.14,15
Orbital septum

Orbicularis occuli
PREOPERATIVE CLINIC MANAGEMENT
Orbital fat
Unless there are urgent issues related to the globe,
Inferior rectus
the authors typically delay the first clinic visit
Fig. 2. Sagittal view of the orbit soft tissues relevant until at least 5 days (typically 7–10 days) after
to surgical approach. injury. This delay allows the edema to resolve,
making physical examination more effective and
improving the ability to predict what the untreated
from the vertex through the mandible, with naviga- globe position will be. Furthermore, as the edema
tion protocol. The authors request 3-dimensional decreases, early onset diplopia may resolve.
(3D) reconstructions be performed on all scans Conversely, diplopia that was not present or iden-
with significant fractures to improve understand- tifiable at the initial examination because of edema
ing of the fracture geometry. of the orbital contents may become apparent in a
Actual extraocular muscle entrapment within a delayed fashion.
fracture is relatively rare, though gaze restriction At the initial clinic visit, patients are questioned
is common in the setting of orbital fractures. regarding diplopia or other visual disturbances and
Entrapment is thought to occur when a fracture whether they notice a difference in the position of
separates allowing soft tissue herniation, then re- the eye. A detailed physical examination of the face
duces in green-stick fashion. This entrapment is and eyes is performed. This examination includes vi-
more likely to occur in the softer bone of the pedi- sual acuity, a pupil examination, and assessment of
atric orbit. True entrapment should be suspected if extraocular muscle function. The presence of any
there is a hard stop during extraocular motion diplopia (monocular or binocular) is noted, including
accompanied by nausea, vomiting, and/or brady- the approximate location of binocular diplopia
cardia, even if there is little external evidence of measured by degree of deviation from the horizon
fracture (white eye fracture). Typical CT findings or midline (eg, 15 , 30 , or 45 ). Complete absence
include herniation of an extraocular muscle within of muscle function, such as adduction, suggests
a relatively small orbital defect. When actual injury to a cranial nerve; neuro-ophthalmologic eval-
entrapment occurs in the pediatric population, uation should be considered.
the fracture should be repaired urgently to prevent Function of sensory nerves in the periorbital re-
permanent muscle damage. A more common pre- gion is also checked both to determine the extent
sentation is patients with reduced extraocular mo- of injury and to counsel patients before surgery.
tion in at least one direction, often with a CT The globe position is measured and noted. Her-
showing an edge of bone near a slightly rounded tel exophthalmometry is performed to measure the
extraocular muscle without true entrapment. position of the globe (exophthalmometry value
When there is uncertainty regarding entrapment, [EV]) relative to the lateral orbital rim (Fig. 3).
forced ductions should be considered. Rather than using this measurement as an
 Advances in Orbital Reconstruction 517

Fig. 3. Hertel exophthalmometry. (A) The instrument rests on the lateral orbital rims. (B) The farthest projection
of the cornea is measured on the grid visible in the prism.

absolute value, the authors compare it with It is often suggested that the percentage of the
the normal side. The measurement can be orbital floor that is involved with the fracture should
confounded by abnormalities in bone or soft tissue be noted with the recommendation that if it is
overlying the lateral orbit, but it is nevertheless greater than 50%, patients should undergo repair.
useful as a guide. As noted later, the authors do not follow this prac-
The difference in EV should be 2 mm or less be- tice: it is not possible to conveniently measure the
tween the eyes. If an exophthalmometer is not percentage of the floor that is fractured, as it is not
available, the projection of the eyes can be esti- visualized on a single CT image, and many patients
mated by viewing from above and below. Any ab- with even larger fractures will have no functional
normality in eyelid position is documented. The compromise. More important than the percentage
function of the levator muscle and aponeurosis is of the structure that is involved is whether the orbital
measured from extreme down gaze to extreme support structure, particularly the periosteum, is left
upward gaze, while holding the brow stationary intact to prevent herniation of the orbital contents.
(there should be at least 5 mm of lid excursion). Photographic documentation is then performed
If not already available, a fine-cut CT scan of the when indicated, including views demonstrating
face protocoled for intraoperative navigation is ob- globe projection (basal or superior views).
tained. The scans are reviewed for the location of
the fracture, number of walls involved, and degree DECISION TO OPERATE
of herniation of orbital contents into the adjacent
ethmoid and maxillary sinuses. Adjacent struc- The decision to recommend surgery is based on
tures are evaluated for injury with special attention the presence of an alteration in form and/or func-
to the skull base and brain; the presence of pneu- tion manifesting as globe malposition or diplopia,
mocephalus is a strong indicator of cerebrospinal respectively. There is no absolute indication for
fluid (CSF) leak, which would be addressed at surgery, and the judgment is not made based on
the time of orbital surgery if indicated. CT findings alone. Fig. 4 demonstrates the CT

Fig. 4. Severe bilateral 4 wall orbital fractures. (A) Coronal CT. (B) Photograph demonstrating only mild asymme-
try in globe position. The patient declined surgical intervention.
518 Bevans & Moe

images and photograph of a man who sustained from the initial injury has resolved, which can often
severe bilateral orbital fractures when he was take 2 or 3 weeks. This delay increases the ability
ejected from a vehicle in a high-speed collision. to displace the mobile orbital contents within the
Despite the CT findings of fractures of all the finite volume of unfractured orbital bones. This
orbital bones and skull base, after resolution of displacement creates a larger optical cavity, mak-
the initial edema, he had only slight asymmetry ing it is easier to see the entire fracture site,
of globe position with mild enophthalmos and retrieve the orbital contents from the paranasal si-
hypoglobus on the right side. His initial diplopia nuses, and accurately place and shape the
resolved. Because the orbital asymmetry did not implant. Restoration of the final orbital shape and
bother him, he elected not to undergo surgical volume is, thus, more accurate.
reconstruction. Five months after the injury, he The presence of bilateral orbital fractures pre-
remained symptom free. sents a unique challenge. In this situation, the
This example illustrates that increase in orbital authors’ preferred technique of creating a mirror-
volume associated with orbital fractures is image overlay (MIO) template (see later discus-
variable. sion) is ineffective for initial repair, given the lack
In fact, there have been several attempts to of a normal contralateral bone structure to super-
use objective measurements and formulas to impose over the fracture site. When this is the
calculate the change in orbital volume without case, the authors first repair the side with the least
success.16 Several studies have attempted to damage to critical reconstructive landmarks, such
correlate size of fracture, location of fracture as the apex of the orbital floor and the orbital rims.
(naso-ethmoidal strut, posterior floor fractures), They use navigation to aid in implant positioning
degree of orbital content displacement, and and shaping and occasionally intraoperative CT
rounding of inferior rectus to predict the degree scan if needed (mobile 3D radiographs can also
of enophthalmos or restriction with varying suc- be used). The authors then let the edema subside
cess.16–19 Subsequent publications attempted and obtain a new CT scan. With the new reference
to use computer modeling to calculate increase CT, a MIO can be created for reconstruction of the
in orbital volume to predict the degree of enoph- second orbit. In this manner, they are able to
thalmos. Correlations of volumetric increase rela- achieve postoperative bone symmetry, which,
tive to enophthalmos varied widely, from 0.4 mm even if the bone position is not in the exact pre-
to 0.8 mm of enophthalmos per 1-cm3 increase in morbid state, seems to achieve good outcomes
orbital volume.20–22 Substratisfying the fracture in both globe position and resolution of diplopia
based on location and calculating a ratio of (Fig. 5).
native to increased orbital volume may be more Another critical issue is the presence of other
predictive of patients requiring operative inter- adjacent fractures. As noted earlier, the authors
vention but still has an imperfect correlation.23 consider the orbital bones as consisting of the in-
Orbital volume estimation becomes dramatically ternal endoskeleton formed by the walls, floor,
more complex in patients with multi-wall frac- and roof and the exoskeleton formed by the
tures. Despite the significant amount of research orbital rims and nasal bone. It is essential to accu-
in this area, a clear-cut reproducible formula for rately reconstruct the exoskeleton before repair-
predicting the degree of enophthalmos has not ing the endoskeleton. If the orbital rims and
been accepted. zygomaticomaxillary complex are not in the cor-
There are other factors as well to consider in the rect position, the error will be propagated to the
decision to operate, not the least of which is the orbital bones when they are reconstructed.
occupational impact. For the professional athlete Because of this, they often elect to repair signifi-
who depends on perfect binocular vision, the au- cant injuries of the exoskeleton first, let the surgi-
thors do not operate to correct globe malposition cal edema resolve, then return to the operating
unless there is also diplopia that is not improving. room at a later date to perform the endoskeletal
For a lumberjack who works overhead, a small reconstruction when it can be performed more
amount of diplopia in superior gaze might mandate accurately as described earlier. This staged
surgical correction that would not be required for reconstruction avoids issues with navigation error
an undertaker. cause by edema or significant movement of
Timing of surgery is important. Several publica- the navigation reference points (which decreases
tions have evaluated operating within 14 or the navigation utility during orbital repair).
21 days of injury, concerned that rate of complica- Although this can be overcome by obtaining an
tion is higher in patients who have more delayed intraoperative CT scan and reregistering the nav-
intervention. Conversely, when possible, the au- igation, this adds significantly to the time and
thors delay surgical correction until the edema complexity of the procedure.
 Advances in Orbital Reconstruction 519

injury), there can be drawbacks to a long delay in

the reconstruction. If there is significant hernia-
tion of orbital contents into the adjacent sinus,
the orbital fat and periosteum may scar down
and adhere to those structures. Repositioning
of the orbital contents is more challenging in
this situation, and there can be damage and sub-
sequent atrophy of the orbital fat leading to
enophthalmos.
Given the complexity of the reconstruction,
before proceeding with surgery it is critical to
obtain informed consent through a detailed dis-
cussion with patients about the details of the pro-
cedure as well as its risks. The most common risks
of the procedure are persistent temporary or per-
manent diplopia, persistent globe malposition,
eyelid malposition, corneal abrasion, and postop-
erative retrobulbar hemorrhage that could require
revision surgery. Although extremely rare, there
is a risk of globe rupture and blindness.

SURGICAL TECHNIQUE
Meticulous surgical technique plays a critical role
Fig. 5. Bilateral orbit fractures. (A) Right orbit has in the outcome of orbital reconstruction. This point
been repaired. Note hyperglobus from residual is true in the placement of incisions to gain access
edema. (B) Edema has resolved from right orbit; pa-
to the orbit, in isolating the region of the fracture
tient is now ready for repair of left side, which is
and reduction of orbital contents back into the
enophthalmic. (C) Left side has been repaired, enoph-
thalmos resolved. orbit, and in the shaping and placement of the
implant. Suboptimal performance of any of these
tasks may lead to a poor functional and/or esthetic
Although there are benefits to waiting to recon- outcome, with a major impact on quality of life
struct the orbital endoskeleton, and there is no (Figs. 6–9).
set point that is too long to wait (the authors Three technologic advances have had a pro-
have reconstructed orbits 10 years or more after found influence on the authors’ surgical outcomes:

Fig. 6. (A) Coronal CT scan showing implant with improper position and shape in the central right orbit. (B) MRI
demonstrating location of the implant between the inferior rectus muscle and the globe, with damage to the
medial rectus muscle. The patient did not regain normal motion after correction of the implant surgery.
520 Bevans & Moe

Fig. 7. (A) CT of implant that perforated skull base during placement causing CSF rhinorrhea; implant was under-
sized and placed in a nonanatomic medial position that obstructed frontal outflow tract causing sinusitis. Note
pneumocephalus. (B) CSF leak repaired; new double implant anatomically placed, spanning the large defect
while allowing normal frontal outflow function with clearance of frontal opacification.

A. Orbital endoscopy lighting is improved, with reduced shadowing

B. Virtual surgical planning with mirror-image CT and blind spots; the image is significantly magni-
overlay fied; display of the image on video monitors allows
C. Navigation-guided implant placement and the entire surgical team to assist more effectively
shaping and learn from the case; and less retraction of
the orbital contents and eyelids is required (Figs.
10 and 11).
Orbital Endoscopy
Orbital endoscopy is performed with standard
Orbital endoscopy provides several major advan- sinus endoscopes or with smaller 3-mm diameter
tages over standard open approaches.24 The endoscopes. The latter allow increased space
for instrumentation within the optical cavity.
The orbital contents are gently retracted with
malleable brain retractors, taking care not to

Fig. 8. CT demonstrating an undersized implant Fig. 9. CT scan showing porous polyethylene implant
placed in an excessively lateral position, with the placed to repair a left medial wall fracture more
medial component protruding between the globe than a decade earlier. The patient developed multiple
and the medial rectus. The implant failed to span episodes of sinusitis and orbital cellulitis with persis-
the full defect in the medial wall, allowing herniation tent diplopia. Medial arrow: medial orbital wall dis-
of orbital contents into the maxillary sinus. This herni- placed into the ethmoid sinus causing obstruction;
ation will result in recurrent sinusitis and orbital center arrow: lucency indicating position of implant;
cellulitis. lateral arrow: mucocele within the medial orbit.
 Advances in Orbital Reconstruction 521

hand. (It is helpful to attach the Freer with a length

of silicon rubber (Silastic) tubing, which is more
compliant and easier to maneuver than standard
suction tubing.) In this fashion, the periorbita is
lifted off the orbital bone over the complete
anatomic structure that is involved. Once this is
achieved, the orbital contents are meticulously
dissected out of the fracture site, taking care to
preserve as much of the involved periorbita as
possible, avoiding damage to the orbital fat and
muscles. The excellent lighting and magnification
provided by endoscopy are highly beneficial for
this (Fig. 12).

Fig. 10. Open versus endoscopic orbital surgery. Endo- Virtual Surgical Planning with Mirror-Image
scopic approach moves light source from surgeon to Overlay
orbit, allows reduced optical cavity with improved ge-
ometry, improves ability to visualize entire fracture MIO is another aid that plays a critical role in the
site, and decreases the displacement of orbital authors’ method of posttraumatic and oncologic
content. orbital reconstruction25 that helps by providing vir-
tual anatomic landmarks. With this technique, the
CT scan is uploaded in typical fashion into the nav-
place excessive pressure on the globe. The igation system. The same scan is then uploaded
cornea is protected with lubricating ointment, again but this time in mirror image (left over right).
and the pupil is monitored throughout the proced- This image is then reduced to the anatomic area of
ure for enlargement or change in shape that sug- interest, colored to distinguish it from the original,
gests excessive pressure on the globe or ciliary and then superimposed over the original CT (Figs.
ganglion. If this occurs, the pressure is taken off 13 and 14). In the authors’ initial report of this tech-
the globe until normal contours return. Typically, nique, they studied 113 consecutive cases and
the assistant retracts the eyelid margin with a found a significant decrease in postoperative
Ragnell retractor in one hand and the orbital con- diplopia using this method. This finding was partic-
tents with a conformed malleable retractor in the ularly true with more severe fractures. By using this
other hand (which is bent to allow decreased technique for severe 3- and 4-wall fractures, they
fulcrum and holding the retractor further from reduced the need for revision surgery from 20%
the incision). Without withdrawing the retractor, to 4%. As their experience with this technology
pressure on the retractors should be minimized has increased, their outcomes have continued to
at every opportunity. The surgeon holds the endo- improve. An example of the symmetry that can
scope in one hand and dissects in a subperiosteal be obtained with this technique is demonstrated
plane using a suction Freer elevator in the other in Fig. 15. An additional use of this advanced

Fig. 11. Open versus endoscopic fracture visualization. (A) Open approach. (B) Endoscopic approach demon-
strating internal lighting, magnification, and panoramic view improving ability to visualize the entire fracture
as well as orbital contents entrapped within the floor fracture.
522 Bevans & Moe

Fig. 12. Lighting, magnification, and exposure achievable with orbital endoscopy. Note fracture of left medial
wall and floor. (A) Medial wall and floor, suction Freer elevator raising orbital contents. (B) Visualization of
apex of orbital floor for placement of implant; this region is challenging to view with open approach but critical
to repair for an optimal outcome.

Fig. 13. MIO. (A) Navigation-guidance CT for revision surgery, area to be mirrored. (B) Mirror area colored and (C)
reversed in mirror image. (D) Mirrored area fused with original scan provides template for reconstruction of the
orbital and adjacent bone.
 Advances in Orbital Reconstruction 523

Fig. 14. MIO navigation. Panfacial fractures, with bilateral orbital floor and medial wall fractures. (A) The right
orbit was repaired earlier and will be used as a template. (B) MIO template colored green, superimposed over
fractures. Implant is then placed, and navigation is performed on all aspects of its surface to compare it with
the contralateral side for shape and position. Crossed lines indicate position of navigation instrument tip. After
adjustment, navigation confirms conformity with surgical plan.

technology is for planning approaches. For necessary. To adjust the shape, they use a small
example, when approaching a fracture in the re- right-angle instrument similar to a nerve hook
gion adjoining the orbital floor and medial wall, (the Browne Hook) to make corrections in situ,
either a medial or inferior approach could be without removing the implant, under endoscopic
used. The choice of approaches in this case can visualization. They then renavigate the implant to
actually be aided by navigation vector analysis at confirm that the desired contouring has been
the beginning of the procedure by using the vector achieved.
propagation feature built into the manufacturer’s Although there have been multiple reports that
software. This feature is particularly useful when advocate the use of intraoperative imaging to
treating fractures of the medial wall that approach confirm that the orbital implant is in appropriate po-
the optic nerve or for orbital apex or/optic nerve sition, the use of MIO has nearly eliminated the need
decompression. Fractures of the orbital roof that for intraoperative imaging in the authors’ practice.
include injury to the frontal lobe of the brain are
another indication for this type of planning and SURGICAL APPROACH AND REPAIR
intraoperative navigation, particularly if there is a
component of subdural hemorrhage. The basic steps of orbital reconstruction are
similar for each anatomic region of the orbit. The
pupils are checked at the beginning of surgery to
Navigation-Guided Implant Placement and
note their size, shape, and symmetry to allow
Shaping
monitoring for change during the procedure.
In addition to the aforementioned benefits of using Asymmetric change in the pupil during surgery
virtual surgical planning, navigation-guided sur- suggests increased intraocular pressure or exces-
gery can also be of significant benefit in improving sive retraction of the orbital contents and man-
the accuracy of implant placement and shaping. dates temporary removal of instrumentation from
With moderate to severe fractures, particularly the orbit until normalization occurs. A tarsorrhaphy
those involving multiple regions, it can be difficult placed at the lateral limbus on the nonoperated
to determine whether the orbital contents have eye allows for frequent visual reference of the
been fully repositioned with the construct, whether normal pupil while still keeping the cornea pro-
the posterior edge of the fracture has been tected. Ophthalmic lubricant is placed and main-
bridged, and whether the implant is a safe dis- tained over both corneas. Extraocular motion is
tance from the optic nerve. Once an orbital implant checked using forced ductions at the beginning
is in place, the authors, therefore, navigate along and end of the surgical case.
its entire surface to confirm its position. They The authors perform Hertel exophthalmometry
also note any changes in shape that are with patients under anesthetic at the beginning of
524 Bevans & Moe

Fig. 15. Outcomes with MIO. (A) Bilat-

eral severe orbital fractures involving
the medial and lateral walls and floor.
(B) Right orbit has been repaired with
navigation guidance. (C) Left orbit has
been repaired using MIO (see Fig. 14)
of right side over left for reconstruction
guide. Note the symmetry between the
right and left reconstructions.
 Advances in Orbital Reconstruction 525

the operation to note the degree of asymmetry in visualize the adjacent bone. The fragments are
globe position and again at the end of the proced- then repositioned or removed depending on the
ure to determine how much the globe has advance degree of fragmentation and ability to maintain
and its position relative to the contralateral side. the bone in its repositioned site without fixation.
Because of intraoperative (or unresolved preoper- If removed, care must be taken to dissect the
ative) edema, if the globe is not at least 2 mm prop- dura from the superior surface of the bone. If the
totic when the reconstruction is complete, there is bone is removed, the dura is repositioned and
a significant likelihood that the restoration is not devitalized brain is gently debrided as needed.
anatomic and postoperative enophthalmos and The area is then resurfaced with allogenic dermis
hypoglobus may result. or dura substitute as desired (Fig. 17). Rigid recon-
The incision and surgical approaches are cho- struction of this region is not required, and the
sen based on the quadrant of the orbit that is authors typically avoid its use to prevent pressure
affected. The approaches to the medial and lateral on the levator muscle. The authors occasionally
walls and floor are transconjunctival; the approach resurface the orbital roof with resorbable
to the roof is transcutaneous as noted later. 0.25-mm polydioxanone (PDS) foil to avoid soft tis-
sue catching on the overlying bone, particularly if
Orbital Roof Fractures there is a large defect into the floor of the frontal si-
nus (Fig. 18). The wound is then closed in 2 layers,
To access the orbital roof, the authors use a bleph- with 6-0 resorbable sutures to reapproximate the
aroplasty approach through an incision in the upper orbicularis muscle and then the skin. If a CSF
lid crease.26,27 A preseptal dissection is performed, leak was repaired, the authors use a water-tight
raising a skin-orbicularis muscle flap to the orbital closure with running permanent suture.28
rim. Care is taken to preserve the supraorbital and
supratrochlear neurovascular pedicles as they
course inferior to or through the rim (Fig. 16).
Medial Wall Fractures
At the superior orbital rim, the periosteum is Fractures of the medial wall are approached
incised and the dissection continues onto the through a precaruncular incision29 (Fig. 19). A pre-
orbital roof, elevating the plane between the caruncular incision is preferred over a transcarun-
bone and periorbita. Once the dissection has pro- cular incision for improved healing and an optimal
ceeded several millimeters into the orbit, endo- dissection plane on the deep surface of the poste-
scopic visualization is begun and dissection is rior limb of the medial canthal tendon. Until the
performed with a suction Freer elevator. Dissec- surgeon is experienced with the approach,
tion proceeds around the bone fragments to lacrimal probes are placed into the canaliculi for
protection and a corneal protector is placed on
the lubricated cornea. The caruncle is grasped
with forceps and gently lateralized, and a Westcott
scissor is used to make an incision through the
conjunctiva at the medial aspect of the caruncle.
The scissor is then spread, entering the plane on
the deep surface of the posterior limb of the medial
canthal tendon. The incision is lengthened inferi-
orly into the inferior fornix (see the discussion on
orbital floor approach later) to increase the surgical
access. The incision can be extended superiorly
for only a few millimeters because of the risk of
damage to the superior fornix. Following this blunt
dissection, the lamina papyracea is reached where
a subperiosteal plane is entered under endoscopic
visualization. The periosteum is then elevated from
the medial wall, and the ethmoid arteries are
cauterized with bipolar forceps and divided as
needed. After visualization of the entire wall and
Fig. 16. Upper eyelid, skin, and orbicularis muscle optic nerve as indicated, the orbital contents are
removed. Dotted line demonstrates dissection plane reduced out of the ethmoid sinuses, the fractured
to orbital rim, where the periosteum is incised and bone is repositioned or removed in order to pre-
the plane between the orbital roof and periorbita is vent delayed sinus complications (Figs. 20 and
dissected. 21), and an implant is placed. For very small
526 Bevans & Moe

Fig. 17. Fracture of orbital roof. (A) Malleable retractor displacing orbital contents inferiorly; bone fragments
have been removed revealing dura and defect in frontal lobe. (B) Dural matrix placed over bone defect.

fractures, the authors use a resorbable PDS foil, in excursion and meticulous hemostasis is assured.
0.25-mm thickness. For larger defects, they use a The incision does not need to be closed. If the
thin titanium orbital implant mesh. This mesh is caruncle does not sit in the correct position, a sin-
implanted and positioned and navigated with gle 6-0 fast-absorbing suture can be placed be-
MIO to confirm that the position and shape are tween the caruncle and medial skin to maintain it
anatomic. The implant is then surfaced on its until the edema resolves.
orbital side with 0.25-mm PDS sheet to prevent
herniation of orbital fat through the titanium and Orbital Floor Fractures
provide a glide surface in case of contact with
Fractures of the orbital floor are approached
the orbital musculature. All aspects of the implant
through a transconjunctival inferior fornix incision.
are inspected to confirm that the optic nerve is
Although there are several alternative approaches,
not compressed and there is no entrapment of
we prefer this approach as it protects the orbital
orbital contents deep to the implant. Forced duc-
septum and avoids postoperative lid retraction30
tions are performed to confirm normal muscle
(Fig. 22). This incision can be connected with the
medial and lateral approaches as needed.
The cornea is protected with a lubricated clear
corneal protector, and the lower lid is retracted
anteriorly with Ragnell retractors. The incision is
made at least 3 mm inferior to the tarsus, through
orbital fat directly to the inferior orbital rim. Medially,
the incision can be carried into a precaruncular inci-
sion as described earlier. Laterally, it can be con-
nected with a lateral retro-canthal approach (see
later discussion) or canthotomy/cantholysis inci-
sion. The periosteum of the orbital rim is incised,
the periorbita is raised, and the dissection con-
tinues over the orbital floor with endoscopic visual-
ization. Care is made to protect the infraorbital
nerve may run inferior, within or above the orbital
floor and is often involved with the fracture. If the
fracture is large, the ligamentous attachments of
Fig. 18. Orbital roof reconstruction. Appearance look- the lateral portion of the inferior orbital fissure can
ing from above downward through frontal sinus on be divided. Similarly, dissection can continue up
PDS foil placed transorbital in the left orbital roof. the medial wall depending on the site and extent
View through endoscope placed into left frontal sinus of the fracture. Dissection is performed circumfer-
through contralateral (right) orbital approach. entially around the fracture before dissecting the
 Advances in Orbital Reconstruction 527

A B

Orbital fat
erior lac
Superior lacrimal
cu
punctum

a ca
Medial canthal
o
tendon
e a orbital
Medial or wall

or lacrimal
Inferior
unctu
punctum

Edge of conjunctiva

Fig. 19. (A) Anatomy of right precaruncular approach demonstrating posterior limb of medial canthal tendon,
which is followed to the bone of the medial orbital wall. (B) Right precaruncular approach. Arrow indicates
caruncle; dotted lines demonstrate incision.

orbital contents out of the maxillary sinus. Similar to positioned, and shaped. Once the implant is placed
medial wall fractures, the position of the bone frag- as desired, navigation is performed against the MIO
ments should be considered with regard to risk of template. The position and shape are then adjusted
future sinus complications and removed or reposi- in situ until the implant is correct, matching the
tioned as indicated. The orbital contents can be anatomy of the contralateral orbit. The implant is
temporarily held in position using a variety of mate- then lined with PDS foil as described earlier. For
rials, including malleable retractors, PDS foil, most fractures, when the implant is contoured to
Silastic sheeting, or saline-soaked cotton pledgets.
The implant is then placed (thin titanium mesh),

Fig. 21. Right medial wall implant viewed transorbital

before placement of PDS foil. Note the proximity of
Fig. 20. Appearance from endoscopic transnasal view the optic nerve (star) entering the optic canal at the
of left medial wall fracture after placement of implant tip of the suction Freer, just beyond the implant. It is
through precaruncular approach. PDS foil (blue) is essential to visualize all regions of the implant to be
placed between the orbital contents and the implant. certain that it is not contacting critical structures or
The PDS can bridge small gaps between the adjacent entrapping orbital contents before completing the
bone and the implant. procedure.
528 Bevans & Moe

fixation of the orbital reconstruction plate can often

cantilever the posterior aspect if it is not conformed
exactly to the small inferior ledge on the back of the
rim. This inadvertently elevates the back of the plate
directly towards the optic nerve, and may not be
well appreciated on direct visual examination.
The orbital floor is the region of the orbit with the
highest anatomic variability. Although many pa-
tients have a spoon-shaped floor with a rise poste-
riorly in the apex, others are flatter in this region. It
is critical to examine the contralateral (atraumatic)
orbit to ascertain patients’ individual contouring
and match that on the reconstructed side. MIO is
extremely helpful in this region and can provide
individualized, highly accurate reconstruction.
The authors do not typically close the conjunc-
Inferior orbital rim
tival incision after repair of orbital floor fractures.
They do place gentle superior traction on the lower
Fig. 22. Inferior deep fornix approach. The lid is re- eyelid to prevent vertical overlap of the lamellae and
tracted anteriorly, and the incision is made through check forced ductions to ensure normal muscular
orbital fat directly onto the inferior orbital rim. function. As described earlier, the authors complete
the case by checking the globe position with
fit the premorbid shape, it will sit within the orbit well exophthalmometry, expecting 2 to 3 mm of prop-
supported by the adjacent bone. For large frac- tosis relative to the opposite globe. This typically re-
tures, however, when significant bone gaps are solves gradually over several weeks, depending on
spanned by the implant, it will require fixation to sta- the size of the fracture (Fig. 23).
ble bone with 1 or 2 screws. The authors prefer self-
Lateral Wall Fractures
drilling 3- or 4-mm screws for this, placed in the
inferior orbital rim if possible. Endoscopy is used Fractures of the lateral orbital wall are very com-
to examine the entire construct to eliminate the mon as a component of zygomaticomaxillary com-
possibility of entrapment of the orbital contents un- plex fractures. In this case, the fracture proceeds
der the implant. It is worth noting that anterior from the frontozygomatic suture inferiorly to join

Fig. 23. A 28-year-old man presented with diplopia, enophthalmos, and hypoglobus after 2 repairs of extensive left
orbital floor and medial wall fracture. Top row: (A) Coronal CT demonstrating appearance before correction, with
Silastic implant in place. (B) Medial aspect of orbital floor fracture, Silastic removed, viewing into maxillary sinus. (C)
Titanium mesh implant in place, in situ adjustment being performed with right angle hook to match with MIO vir-
tual template. Bottom row: (D) Prerevision view. (E) Postoperative view: diplopia, enophthalmos, and hypoglobus
resolved. Note the mild relative ptosis of the left upper eyelid creating visible asymmetry. (F) Preinjury driver’s li-
cense photograph demonstrating that the ptosis in postoperative photograph existed before the original injury.
 Advances in Orbital Reconstruction 529

the orbital floor fracture (Fig. 24). In these cases,

the lateral orbit is repositioned en bloc with the
zygoma. They typically perform a lateral orbitot-
omy to check the alignment of these bones, but
an implant is rarely needed in this region. Occa-
sionally, with high-impact trauma, a fracture of
the greater wing of the sphenoid bone may occur
with compression of the orbital contents or impac-
tion of bone fragments into the lateral rectus mus-
cle. In these cases, decompression with removal
of bone may be required. When bone is removed
in this region, the authors place a layer of thin
PDS foil across the bone defect to prevent adhe-
Fig. 25. Postoperative dehiscence of the lateral can-
sion between the orbital contents and the tempo- tholysis leading to rounding of the canthus, canthal
ralis muscle in the infratemporal fossa. dystopia, and ectropion.
There are 2 types of incisions to access
the lateral orbital wall: a canthotomy with canthol-
encountered at its confluence with the inferior
ysis or a canthal-sparing lateral retro-canthal
fissure. The contents of the superior fissure, as
approach.31 Although a canthotomy and cantholy-
noted earlier, include cranial nerves and should
sis approach provides excellent access, careful
not be disturbed. After adequate exposure, the frac-
canthal reconstruction is required to prevent post-
ture fragments are then repositioned or removed,
operative dehiscence and eyelid malposition or
and the defect resurfaced with PDS foil as needed.
lateral canthal blunting as seen in Fig. 25. The
The incision does not require closure unless a can-
lateral retro-canthal approach places the incision
thotomy and cantholysis were performed, in which
behind (or internal) to the lateral canthus and
case the authors reapproximate the inferior limb of
avoids this complication by preserving the lateral
the lateral canthal tendon to the superior limb using
retinaculum, but exposure to the orbital floor is
5-0 monofilament resorbable suture.
somewhat more limited (Fig. 26).
As described earlier, the authors use an endo-
Choice of Reconstruction Material
scopic technique to lift the periorbita off the lateral
orbital wall. The wall is exposed from the orbital The authors choice of reconstructive materials
roof to the inferior orbital fissure. For fractures varies based on the location and severity of frac-
extending to the orbital floor, the contents of the ture. There are several different types of mate-
lateral aspect of the inferior fissure are ligated with rials suitable for reconstruction, including
bipolar forceps and divided, allowing extended absorbable, nonabsorbable, porous and nonpo-
exposure onto the orbital floor. Dissecting deeper rous, bare titanium, and coated titanium. In gen-
toward the orbital apex, the superior fissure will be eral, they prefer thin titanium 3D orbital implants

Superior tarsus

Inferior tarsus

Conjunctival incision

Fig. 26. The lateral retro-canthal approach in a right

orbit. This conjunctival incision provides access to
Fig. 24. Endoscopic view of left lateral orbital wall the lateral orbit without damage to lateral canthal
fracture after repositioning of bone fragments. tendon or lower eyelid support.
530 Bevans & Moe

lined by PDS foil to provide a glide surface. A POSTOPERATIVE CARE

nonadherent surface is important in case of mus-
cle contact, and use of a layer superficial to the Patients are asked to use iced saline sponges or
titanium prevents herniation of fat through the covered ice packs 20 minutes per hour for 48 hours
mesh (which may also be a cause of muscle after surgery. For patients with significant prop-
dysfunction) (Fig. 27). When the PDS resorbs, a tosis, the authors often prescribe a short course
thin nonadherent layer is left behind. Titanium of oral steroids. If there is significant risk for signif-
implants have been particularly effective in icant postoperative chemosis, such as after repair
reconstruction of more than 1 orbital surface of the orbital floor and both walls, the authors often
(eg, orbital floor and medial wall or 3 wall frac- place a temporary tarsorrhaphy suture at the
tures) to preserve orbital contour shape the lateral limbus until most of the chemosis resolves.
orbital volume long-term. The authors avoid the The pupil can still be examined with this suture in
use of porous polyethylene (PPE) implants place. Patients are seen in the clinic 7 and
when the implant is exposed to sinus cavity 14 days after surgery, then 6 weeks, 3 months,
because of a lifelong risk of infection. and 6 months after surgery.

Fig. 27. A 14-year-old bull rider: left orbit impaled through the upper eyelid by a bull’s horn causing severe frac-
tures of the medial wall, floor, and lateral wall. (A) Preoperative appearance, 9 days after injury after significant
resolution of edema. Note severe enophthalmos and levator injury preventing raising of the upper eyelid. Sur-
gery was 17 days after injury, requiring double orbital implants to span the defect, using MIO guidance. (B) CT
appearance 2 weeks after surgery. Arrow demonstrates PDS foil lining the implant before resorption. (C) appear-
ance 1 year later, ptosis nearly resolved, Hertel exophthalmometry demonstrating symmetric globe position,
diplopia resolved within 45 of central gaze.
 Advances in Orbital Reconstruction 531

Postoperative CT scans are not obtained unless amount, however; patients are seldom aware of
there is concern of a possible complication. Hertel their premorbid status. Various reporting methods
exophthalmometry is obtained at every clinic visit have evaluated outcomes based on the presence
and compared with the measurements taken at of diplopia in primary gaze, 30 or 45 , or whether
the beginning and conclusion of surgery unless prism correction was required. The authors eval-
there are adjacent bone abnormalities that prevent uate their outcomes based on the presence of
accurate measurement. diplopia within 45 . When patients complain of
When most of the surgical edema has resolved, diplopia within this range 6 or more months
patients are asked to begin mild physical therapy. after surgery, the authors obtain a CT scan to
This therapy includes gentle massage of the lower confirm proper implant position and contour and
eyelid and exaggerated tight eye closure and consider referral to a neuro-ophthalmologist
opening (to keep the orbicularis oculi from retract- for further evaluation. Monocular diplopia suggests
ing and/or tethering). If range-of-motion exercises injury to the globe and is an indication for referral to
are indicated, the authors ask patients to perform an ophthalmologist whenever it is discovered.
a full range of extraocular motions tracking their in- Although postoperative globe position is influ-
dex finger (arm fully extended, head still) both verti- enced primarily by bone and implant position, fat
cally and horizontally to the extremes of gaze. This atrophy may occur after the injury and may also
exercise should be done several times daily. contribute to asymmetry. The degree of fat atro-
phy probably increases with the severity of injury,
SURGICAL OUTCOMES but this is challenging to quantify on imaging.
The question may arise regarding intentional over-
Outcome analysis in orbital reconstruction is chal- correction of bone defect repair at the time of sur-
lenging to perform and interpret because of the gery, and some degree of this occurs when thicker
number of structures involved in the injury and PPE-coated implants are used. Given that the de-
disparity in reporting. The structures that may be gree of fat atrophy cannot be measured or antici-
involved in the injury include the eyelids and their pated, the authors strive for exact restoration of
support structures, the lacrimal system, the globe, premorbid bone anatomy and do not overcorrect.
the extraocular muscles and their corresponding For patients with apparent postoperative orbital
motor nerves, the optic nerve, the orbital bones, volume asymmetry despite appropriate anatomic
and potentially the brain. Injury to most of these correction, eyelid position should be carefully
structures can have significant impact on postoper- checked as ptosis or lid retraction can create an
ative outcomes. Yet the surgery that the authors illusion of abnormal globe position. Patients
perform in the initial setting (aside from repair of should also be asked for a preoperative photo-
globe injuries by the ophthalmologist) is largely graph (a driver’s license may be sufficient) to eval-
limited to the closure of lacerations and repair of uate for preexisting asymmetry unnoticed by
fractures. Thus, a significant orbit fracture may result patients, as seen in Fig. 23.
in damage to the adjacent fat, muscle, and nerves; In the authors’ experience, the surgical out-
but the surgery will restore only the bone alignment comes depend on the mechanism, severity, and
and orbital volume. Therefore, when evaluating extent of injury, as expected.25 It is not reasonable
postoperative results, it can be difficult to determine to expect that all patients will be corrected to their
whether, and to what extent, a deficit is due to the premorbid state with normal vision and no diplopia
initial injury versus suboptimal surgical technique. because of the frequent presence of at least mini-
In the postoperative setting, globe position, vi- mal neuromuscular damage. A reasonable goal,
sual acuity, and degree of diplopia should be however, should be restoration of symmetric
measured. Analysis of globe position and visual orbital contours and volume, using an implant
acuity are relatively straightforward; but diplopia, that allows normal extraocular muscle function
for the reasons discussed earlier, can be chal- and has the lowest possible chance of future
lenging to measure. Ophthalmologists often quan- infection.
tify diplopia with the use of prisms, but this is In a study of 113 consecutive patients with severe
complex and less practical for other specialists. orbital fractures, the authors found that by using the
The authors’ practice is to examine muscle function techniques presented in this article (including orbital
to rule out entrapment and note the degree at which endoscopy, MIO, and intraoperative navigation),
diplopia occurs in each direction (15 , 30 , or 45 off they achieved a statistically significant reduction in
neutral gaze). Some degree of binocular diplopia postoperative diplopia and a 4-fold reduction in their
may be normal in the uninjured state, particularly revision rate relative to historical controls. The out-
at extremes of gaze, and is to be expected after comes in globe position were also markedly
fracture repair. There is disagreement on the improved.25
532 Bevans & Moe

Fig. 28. Navigation-guided surgery and MIO in zygomatic and maxillary fractures. (A) right zygomaticomaxillary
complex fracture, yellow square outlining normal anatomy for templating. (B) Oblique view, MIO in yellow. Note
the deviation of the zygomatic arch. (C) after closed repositioning of the bone fragments, navigation is per-
formed along the reconstruction to confirm accurate anatomic reduction. (Blue line represents navigation instru-
ment on bone.)

COMPLICATIONS infraorbital nerve (numbness or worsening pain).

Other complications include upper eyelid ptosis,
The most common complications after orbital frac- lower eyelid malposition (entropion, ectropion, or
ture repair are persistent globe malposition, cicatricial retraction), implant infection requiring
diplopia, and sensory disturbance of the removal and replacement, sinusitis, orbital

Fig. 29. (A) Fracture anterior table left frontal sinus, endoscopic transorbital repair. Green areas represent MIO
plan over area of fracture. Blue line represents navigation instrument demonstrating surgical approach. The frac-
ture is repaired endoscopically through a blepharoplasty approach through the floor of the frontal sinus. The
fracture is reduced, and the bone is then navigated to confirm accurate reduction. (B) Endoscopic view using
trans-orbital approach into the frontal sinus showing dissolvable packing supporting the reduced anterior table
fragment. (C) Inferior view showing total resolution of bony indentation with a small amount of residual post-
operative edema (7 days after injury).
 Advances in Orbital Reconstruction 533

Fig. 30. Cranioplasty. Patient presented after cranioplasty with titanium mesh, dissatisfied with appearance. (A)
Preoperative 3D CT scan. (B) Preoperative MIO surgical analysis; green areas represent overlay of contralateral
normal structures. Note the areas of asymmetry, with overcorrection of the temporal region and undercorrection
of the frontal bone. Patient underwent correction according to the plan, augmenting the construct with hydroxy-
apatite cement.

cellulitis or abscess, CSF leak, diminished visual APPLICATION OF ENDOSCOPY, MIRROR-

acuity, retrobulbar hemorrhage, and blindness. IMAGE OVERLAY, AND NAVIGATION TO
All of these issues, with the exception of implant OTHER TYPES OF CRANIOFACIAL
infection, may be caused by the original injury as RECONSTRUCTION
well.
Retrobulbar hemorrhage, in which patients The techniques of endoscopic visualization,
present with worsening pain, proptosis, and MIO planning, and navigation-guided recon-
decreasing visual acuity, is a surgical emer- struction are applicable to related deformities
gency. In this setting, lateral canthotomy and that often occur in conjunction with orbital frac-
cantholysis should be performed immediately to tures. These applications include repair of zygo-
relieve the intraocular pressure, while obtaining maticomaxillary fractures (Fig. 28), correction of
an ophthalmology consultation. Postoperative frontal sinus and frontal bone fractures (Fig. 29),
blindness is an extremely rare complication and cranioplasty (Fig. 30), and navigation-guided rhi-
demands an emergent ophthalmology evaluation noplasty (Fig. 31). The authors have found that
with orbital exploration or radiographic imaging the use of these minimally disruptive techniques
as indicated. has decreased the extent and number of

Fig. 31. Navigation-guide rhinoplasty: complex nasal fracture with esthetic and functional deformity. (A) 3D CT
scan. (B) Navigation-guided osteotomies to mobilize fracture bone, allowing anatomic reconstruction of nasal
bones. Navigation is used to mark the course of the osteotomies on the skin; the osteotomy is then created
with a navigated osteotome with real-time monitoring similar to a global positioning system. Blue crosshairs indi-
cate position of the tip of the osteotome as the right lateral osteotomy is begun.
534 Bevans & Moe

incisions and amount of dissection that are 14. Doerr TD. Evidence based facial fracture manage-
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function. following nonoperative orbital fractures. Clin Oph-
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16. Hawes MJ, Dortzbach RK. Surgery on orbital floor
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