Orbital floor fractures--should they be explored early?

One hundred consecutive cases of orbital floor fractures from varying causes are reviewed, and the admission symptoms and signs are compared to the late results. We considered the early findings of diplopia, infraorbital rim step-off, and hypesthesia (with an associated clinical diagnosis of malar bone involvement) an indication for exploration of the orbital floor and possible placement of silicone sheeting. When this was done, minimal complications resulted.     

Reconstruction of orbital floor fracture using solvent-preserved bone graft

The orbital floor is one of the most frequently damaged parts of the maxillofacial skeleton during facial trauma. Unfavorable aesthetic and functional outcomes are frequent when it is treated inadequately. The treatment consists of spanning the floor defect with a material that can provide structural support and restore the orbital volume. This material should also be biocompatible with the surrounding tissues and easily reshaped to fit the orbital floor. Although various autografts or synthetic materials have been used, there is still no consensus on the ideal reconstruction method of orbital floor defects. This study evaluated the applicability of solvent-preserved cadaveric cranial bone graft and its preliminary results in the reconstruction of the orbital floor fractures. Twenty-five orbital floor fractures of 21 patients who underwent surgical repair with cadaveric bone graft during a 2-year period were included in this study. Pure blowout fractures were determined in nine patients, whereas 12 patients had other accompanying maxillofacial fractures. Of the 21 patients, 14 had clinically evident diplopia (66.7 percent), 12 of them had enophthalmos (57.1 percent), and two of them had gaze restriction preoperatively. Reconstruction of the floor of the orbit was performed following either the subciliary or the transconjunctival approach. A cranial allograft was placed over the defect after sufficient exposure. The mean follow-up period was 9 months. Postoperative diplopia, enophthalmos, eye motility, cosmetic appearance, and complications were documented. None of the patients had any evidence of diplopia, limited eye movement, inflammatory reactions in soft tissues, infection, or graft extrusion in the postoperative period. Providing sufficient orbital volume, no graft resorption was detected in computed tomography scan controls. None of the implants required removal for any reason. Enophthalmos was seen in one patient, and temporary scleral show lasting up to 3 to 6 weeks was detected in another three patients. Satisfactory cosmetic results were obtained in all patients. This study showed that solvent-preserved bone, which is a nonsynthetic, human-originated, processed bioimplant, can be safely used in orbital floor repair and can be considered as another reliable treatment alternative.     

Reconstruction using a three-dimensional orbitozygomatic skeletal model of titanium mesh plate and soft-tissue free flap transfer following total maxillectomy

The surgical strategy for maxillary reconstruction after maxillectomy has yet to be standardized. The authors developed a technique using a three-dimensional orbitozygomatic skeletal model of a titanium mesh for skeletal reconstruction after maxillectomy. From May of 1996 to September of 2000, 18 patients underwent reconstruction using the titanium mesh model in conjunction with a soft-tissue free flap following total maxillectomy for a maxillary malignancy. The soft-tissue free flap was conventional and consisted of two skin paddles to the maxillary defect. One skin paddle became the lateral nasal wall and the other was used to close the palatal defect. After modeling, the titanium mesh plate was implanted between the orbital contents and the upper edge of the free flap to lie over the front of the flap. The model was fixed to the residual zygoma laterally and to the nasal or frontal bone medially. The palatal skin paddle was anchored by three or four dermal stitches to the bottom edge of the titanium mesh to create a concave neopalate that allowed the patient to wear a denture. Thirteen of 18 patients who underwent implantation had good facial appearance and oral function. This procedure prevented lagophthalmos, facial deformity, and sagging of the palatal skin paddle caused by gravitational force. Five patients (27.8 percent) developed exposure or infection of the implant and lost the benefit of having the prosthesis. However, treatment did not require total removal of the implant. Maintaining adequate tissue volume during soft-tissue transfer on either side of the mesh plate may minimize the complication rate. Titanium mesh implantation for skeletal reconstruction after maxillectomy avoids the need for bone grafting and may be especially beneficial in fragile or aged patients.     

Functional reconstruction of maxilla with free latissimus dorsi-scapular osteomusculocutaneous flap

Restoration of oral and nasal function together with facial appearance is still challenging in maxillary reconstruction. Use of a composite flap transfer merely to fill the defect results in unsatisfactory functional and aesthetic outcomes. The authors present a reconstructive procedure for complex maxillary defects using the latissimus dorsi-scapular rib osteomusculocutaneous flap. Some modifications for the reconstruction of the nasal cavity and the hard palate contributed to excellent postoperative functions. Five cases of extended maxillary defect were reconstructed using a novel procedure between February of 1997 and October of 2000. The hard palate was reconstructed with a vascularized scapular angle. The infraorbital rim was reconstructed with a vascularized rib if it was required. A prop bone graft, replacing the zygomatic buttress, was added between the infraorbital rim and the hard palate. The latissimus dorsi muscle flap, which was supported by a skeletal framework and obliterated the remaining cavities around the bone grafts, was left exposed into the nasal cavity, and an 8-French (no. 10) nasal airway tube was placed as a stent in the nasal meatus for 3 weeks after surgery. A skin graft was applied on the scapular angle to reconstruct the oral side of the hard palate. If required, facial skin defect was repaired with a latissimus dorsi musculocutaneous flap or scapular flap. No major complications at the recipient or the donor sites occurred postoperatively in any of the five cases. In cases in which the eyeballs were preserved, almost normal facial appearance was obtained and an orbital extirpation case showed an acceptable postoperative appearance. All five patients returned to an unrestricted diet and their speech was assessed as normal by a speech test. Nasal breathing through the re-epithelialized meatus was possible in all cases. The reconstructed nasal cavity was maintained for more than 6 months in all cases and for more than 2 years in one early case. Rhinometry demonstrated normal function, and histologic findings of the re-epithelialized mucosa over the muscle flap in the nasal cavity revealed a nearly normal architecture. This technique simplifies the reconstructive procedure of massive maxillary defects, including those in the lateral wall of the nasal cavity. It also improves the postoperative oral and nasal functions of the patients.     

The osteocutaneous scapular flap for mandibular and maxillary reconstruction

Microfil injections in 8 cadavers and clinical experience with 26 patients have demonstrated a reliable blood supply to the lateral border of the scapula based on branches of the circumflex scapular artery. This tissue has been used successfully for reconstruction of a variety of defects resulting from maxillectomy and mandibular defects from cancer and benign tumor excisions. Advantages of this tissue over previous reconstructive methods include the ability to design multiple cutaneous panels on a separate vascular pedicle from the bone flap allowing improvement in three-dimensional spatial relationships for complex mandibular and maxillary reconstructions. The lateral border of the scapula provides up to 14 cm of thick, straight corticocancellous bone that can be osteotomized where desired. The thin blade of the scapula provides optimum tissues for palate and orbital floor reconstruction. There have been no flap failures and minimal donor-site complications.     

Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture.

Pure orbital blowout fracture first occurs at the weakest point of the orbital wall. Although the medial orbital wall theoretically should be involved more frequently than the orbital floor, the orbital floor has been reported as the most common site of pure orbital blowout fractures. A total of 82 orbits in 76 patients with pure orbital blowout fracture were evaluated with computed tomographic scans taken on all patients with any suspicious clinical evidence, including nasal fracture. Isolated medial wall fracture was most common (55 percent), followed by medial and inferior wall fracture (27 percent). The most common facial fracture associated with medial wall fracture was nasal fracture (51 percent), not inferior wall fracture (33 percent). This finding suggests that the force causing nasal fracture is an important causative factor of pure medial wall fracture as the buckling force from the medial orbital rim. Of patients with medial wall fractures, 25 percent had diplopia and 40 percent had enophthalmos. On plain radiographs, diagnostic signs were found in 79 percent of medial wall fractures and in 95 percent of inferior wall fractures. On computed tomographic scans, late enophthalmos was expected in 76 percent of medial wall fractures. Therefore, the medial orbital blowout fracture may be an important cause of late enophthalmos, because it has a high incidence of occurrence, a low diagnostic rate, and a high severity of defect. Among the causes of limitation of ocular motility, muscle traction of the connective septa and direct muscle injury were found frequently, but true incarceration of the muscle was extremely rare in all fractures. The medial and inferior orbital walls are clearly demarcated by the bony buttress, which is an important structure supporting these orbital walls. Its buttress was closely correlated with the fracture of these orbital walls. Most orbital blowout fractures without collapse of the bony buttress had a trapdoor fracture with or without small fragments of punched-out fracture.     

Lower blepharoplasty using bony anatomical landmarks to identify and avoid injury to the inferior oblique muscle

In the resection of redundant orbital fat during lower blepharoplasty, selective excision is performed from the medial, central, and lateral compartments. During transcutaneous blepharoplasty, the inferior oblique muscle is susceptible to injury because of its intimate association between the medial and central compartments. When performing a transconjunctival approach, the inferior oblique muscle is even more susceptible to injury because it lies in the direct path of dissection for fat pad exposure. Injury to the inferior oblique muscle can result in symptoms ranging from transient diplopia to a more debilitating permanent strabismus. Fresh cadaver heads were used to identify bony anatomical landmarks that would help to more accurately define the origin and body of the inferior oblique muscle. The orbital rim, infraorbital foramen, and supraorbital notch were chosen as guideline landmarks. The origin of the inferior oblique muscle was designated with respect to the above structures, and the muscle course was delineated. The inferior oblique muscle originates on the orbital floor, 5.14 +/- 1.21 mm posterior to the inferior orbital rim, on a line extending from the infraorbital foramen to 10 +/- 0.9 mm inferior to the supraorbital notch along the supramedial orbital rim. The muscle belly extends from this origin to its insertion into the posterolateral globe in an oblique direction toward the lateral canthal area. Identification of the orbital rim, infraorbital foramen, and supraorbital notch more accurately localizes the origin and course of the inferior oblique muscle, which may facilitate fat resection during lower blepharoplasty by preventing morbidity associated with inferior oblique muscle injury.     

Functional reconstruction after a total maxillectomy using a fibula osteocutaneous flap with osseointegrated implants

The fibula osteocutaneous flap with osseointegrated implants was used for reconstruction of a total maxillectomy defect. We have achieved satisfactory reconstruction of three-dimensional facial structure, orbit support, and a functional prosthesis. Our procedure restored the patient's masticatory function of the maxilla and enabled good speech and a natural facial appearance. A very high quality of function was obtained without any complications, but long-term follow-up is necessary for maintenance of the implants.     

A current 10-year retrospective survey of 199 surgically treated orbital floor fractures in a nonurban tertiary care center.

This study characterizes the surgically treated patient population suffering from orbital floor fractures by use of current data from a large series consisting of 199 cases taken from a nonurban setting. Data were gathered through a retrospective chart review of patients surgically treated for orbital floor fractures at the University of Michigan Health System, collected over a 10-year period. Data regarding patient demographics, signs and symptoms of presentation, cause of injury, nature of injury, associated facial fractures, ocular injury, and associated nonfacial skeleton trauma were collected. In total, there were 199 cases of orbital floor fractures among 189 patients. Male patients outnumbered female patients by a 2:1 ratio and were found to engage in a wider range of behaviors that resulted in orbital floor fractures. Motor vehicle accidents were the leading cause of orbital floor fractures, followed by physical assault and sports-related mechanisms. The ratio of impure to pure orbital floor fracture was 3:1. The most common signs and symptoms associated with orbital floor fractures, in descending order, were periorbital ecchymosis, diplopia, subconjunctival hemorrhage, and enophthalmos. Associated facial fractures were found in 77.2 percent of patients, the most prevalent of which was the zygoma-malar fracture. Serious ocular injury occurred in 19.6 percent of patients, with globe rupture being the most prevalent, accounting for 40.5 percent of those injuries. There was a 38.1 percent occurrence of associated nonfacial skeletal trauma; skull fracture and intracranial injury were the most prevalent manifestations. Associated cervical-spine fractures were rare (0.5 percent). Statistical examination, using odds ratios and chi-squared analysis, demonstrated significant associations that have not previously been reported. Impure and pure orbital floor fractures revealed striking differences in several demographic aspects, including mechanism of injury, signs and symptoms of presentation, spectrum of associated trauma, and the severity of concomitant trauma.     

The use of Teflon in orbital floor reconstruction following blunt facial trauma: a 20-year experience

A myriad of materials have been used for reestablishing continuity of the orbital floor following blunt facial trauma. Traditionally, autogenous grafts have been the material of choice for orbital floor reconstruction; however, alloplastic materials have gained popularity because of their availability and ease of use. A large clinical experience with long-term treatment results has never been reported for any substance used in orbital floor reconstruction. The purpose of this study was to review our long-term treatment results using Teflon for orbital floor reconstruction following blunt trauma, with emphasis on the incidence of infection, extrusion, and implant displacement. This report presents a 20-year review of 230 Teflon implants for reconstruction of traumatic orbital floor defects. With a mean follow-up period of 30 months, there was only one implant infection and no complications of extrusion or implant displacement. These findings support the use of Teflon as a safe and effective material for the reconstruction of orbital floor defects following blunt facial trauma.     

A classification system and algorithm for reconstruction of maxillectomy and midfacial defects

Maxillectomy defects become more complex when critical structures such as the orbit, globe, and cranial base are resected, and reconstruction with distant tissues becomes essential. This study reviews all maxillectomy defects reconstructed immediately using pedicled and free flaps to establish (1) a classification system and (2) an algorithm for reconstruction of these complex problems. Over a 5-year period, 60 flaps were used to reconstruct defects classified as the following: type I, limited maxillectomy (n = 7); type II, subtotal maxillectomy (n = 10); type IIIa, total maxillectomy with preservation of the orbital contents (n = 13); type IIIb, total maxillectomy with orbital exenteration (n = 18); and type IV, orbitomaxillectomy (n = 10). Free flaps (45 rectus abdominis and 10 radial forearm) were used in 55 patients (91.7 percent), and the temporalis muscle was transposed in five elderly patients who were not free-flap candidates. Vascularized (radial forearm osteocutaneous) bone flaps were used in four of the 60 patients (6.7 percent) and nonvascularized bone grafts in 17 (28.3 percent). Simultaneous reconstruction of the oral commissure using an Estandler procedure was performed in 10 patients with maxillectomy and through-and-through soft-tissue defects. Free-flap survival was 100 percent, with reexploration in five of 55 patients (9.1 percent) and partial-flap necrosis in one patient. Seven of the 60 patients (11.7 percent) had systemic complications, and four died within 30 days of hospitalization. Fifty patients had more than 6 months of follow-up with a mean time of 27.7 (+/- 15.6) months. Postoperative radiotherapy was administered in 32 of these patients (64.0 percent). Chewing and speech functions were assessed in 36 patients with type II, IIIa, and IIIb defects. A prosthetic denture was fixed in 15 of 36 patients (41.7 percent). Return to an unrestricted diet was seen in 16 patients (44.4 percent), a soft diet in 17 (47.2 percent), and a liquid diet in three (8.3 percent). Speech was assessed as normal in 14 of 36 patients (38.9 percent), near normal in 15 (41.7 percent), intelligible in six (16.7 percent), and unintelligible in one patient (2.8 percent). Globe and periorbital soft-tissue position was assessed in 14 patients with type I and IIIa defects. There were no cases of enophthalmos, and one patient had a mild vertical dystopia. Ectropion was observed in 10 of 14 patients (71.4 percent). Oral competence was considered good in all 10 patients with excision/reconstruction of the oral commissure; however, two patients (20 percent) developed microstomia after receiving radiotherapy. Aesthetic results were evaluated at least 6 months after reconstruction in 50 patients. They were good to excellent in 29 patients (58 percent) for whom cheek skin and lip were not resected, and poor to fair (42 percent) when the external skin or orbital contents were excised. Secondary procedures were required in 16 of 50 patients (32.0 percent). Free-tissue transfer provides the most effective and reliable form of immediate reconstruction for complex maxillectomy defects. The rectus abdominis and radial forearm flaps in combination with immediate bone grafting or as osteocutaneous flaps reliably provide the best aesthetic and functional results. An algorithm based on the type of maxillary resection can be followed to determine the best approach to reconstruction.     

The versatile temporoparietal fascial flap: adaptability to a variety of composite defects

The unique properties of the temporoparietal fascial flap (TPFF) offer adaptability in reconstruction of a variety of composite defects. The broad, thin sheet of vascularized tissue may be transferred alone or as a carrier of subjacent bone or overlying skin and scalp. As a pedicled flap, it is ideal for defects of the orbital, malar, mandibular, and mastoid regions. As a free-tissue transfer, the large vessels and lack of bulk find broad utility in reconstruction of the extremities. This flap is our choice for reconstruction of the dorsal hand and non-weight-bearing surfaces of the foot. A viscous gliding surface decreases friction for tendon excursion. The thin contour is aesthetically superior to thicker flaps, allowing unmodified footwear or gloves. The pliable fascia convolutes into surface defects (e.g., bone craters) or drapes over skeletal frameworks (e.g., ear cartilage). The rich capillary network offers nutrition to saucerized bone, cartilage or tendon grafts, and overlying skin grafts. The geometry of the skull lends to fabrication of membranous bone for complex facial puzzles. The donor site is well disguised by hair growth. Twelve cases performed over a 2-year period demonstrate the versatility of this flap. These include complex foot reconstruction, ear and scalp avulsion, shotgun wound of the cheek and orbit, posttraumatic jaw recontouring, chronic osteomyelitis of the hand and foot, and acute resurfacing of dorsal hand with tendon reconstruction.     

高密度聚乙烯多孔材料在创伤性眶底缺损整复的临床观察

目的：观察高密度聚乙烯多孔材料Medpor在眶底缺损修复中的临床应用效果,分析相关并发症的术后改善情况。方法：2001年1月起选取20例创伤性眶底缺损患者采用高密度聚乙烯多孔材料作为眶底填充材料实施眼眶重建术,同期选取16例常规钛金属修复作为对照。术后6m嘱患者进行复查评价两者的治疗效果;评价内容包括息者外貌、眼球功能和创伤性眶底缺损常见并发症的改善情况等;术前履术后6m头颅三维螺旋CT检查观察眶底缺损修复后眼眶结构的连续性。结果：36例患者术后面中部对称性都逐渐恢复,眼球的运动功能明显好转。创伤性眶底缺损常见并发症如眼球内陷、复视及眶下神经感觉迟钝术后明显改善,采用Medpor材料修复和常规钛金属修复的患者无明显差异。同期螺旋三维CT显示与钛金属修复相比,采用生物材料保持了眶结构的连续性,维持了正常眶容积。有利于缺损修复,骨缺损面积明显缩小。结论：研究表明高密度聚乙烯多孔材料操作容易,可塑性高,材料在体内可促进自体骨组织长入,具有较好的修复效果,时临床眼眶修复重建的手术治疗具有一定的指导意义。     

The dorsalis pedis free flap: technique of elevation, foot closure, and flap application

The dorsalis pedis free flap is an excellent reconstructive tool for thin remote mucosal defects, for heel and hand defects where innervation is critical, and as an osteocutaneous flap with unique application to mandibular and floor of mouth reconstruction. The major criticism with this flap is related to its uncertain vascularity and the donor defect. We have found in our series of 45 cases that the vascular anatomy is exceedingly reliable. Problems with the donor defects are all related to technique. With care in flap elevation and foot closure, which we describe in detail, an acceptable donor site with minimal complications can be achieved. The clinical applications of this flap are illustrated by three case reports. Our experience with the donor site has not been problem-free. However, we do believe that with meticulous technique primary healing will occur without functional disability and with minimal cosmetic deformity.     

Simultaneous reconstruction of the secondary bilateral cleft lip and nasal deformity: Abbé flap revisited

The purpose of this retrospective study was to review the method of using the Abbé flap for correction of secondary bilateral cleft lip deformity in selected patients with tight upper lip, short prolabium, lack of acceptable philtral column and Cupid's bow definition, central vermilion deficiency, irregular lip scars, and associated nasal deformity. A total of 39 patients with the bilateral cleft lip nasal deformity received Abbé flap and simultaneous nasal reconstruction during a period of 6 years. Mean patient age at the time of the operation was 19.1 years, and ranged from 6.6 to 38.5 years. The average follow-up period was 1.8 years. Fourteen patients had prior orthognathic operations. The Abbé flap was designed 13 to 14 mm in length and 8 to 9 mm in width and contained full-thickness tissue from the central lower lip, with a slightly narrow reverse-V caudal end. The prolabium, including the scars and central vermilion, was excised. Lengthening procedures of the upper lip segments were performed if vertical deficiency existed. Part of the prolabial skin was preserved and mobilized for columellar elongation, if indicated. Open rhinoplasty was carried out with or without cartilage graft for columella and nasal tip reconstruction. Reduction of the alar width and nostrils was achieved by a Z-plasty or excision of scar tissue at the nostril floor. The Abbé flap was then transposed cephalad, insetting into the median defect and sutured in layers. The results demonstrated no flap problems or perioperative complications. Seven patients needed further minor revisions on the nose and/or lip. Laser treatment was used to improve the lip scars in three patients. The patients were satisfied with the final outcome and found the lower lip scars acceptable. In conclusion, the described technique of Abbé flap and simultaneous rhinoplasty is an effective reconstructive method for select patients with bilateral cleft lip and nasal deformity.     

Infraorbital nerve injury associated with zygoma fractures: documentation with neurosensory testing

Persistent sensibility abnormalities after correction of zygoma fractures indicate injury to the infraorbital nerve and may produce pain. To investigate this, a retrospective study of 25 patients who had undergone surgical correction of a zygoma fracture was performed. Bilateral neurosensory measurements were obtained with the Pressure-Specified Sensory Device (Sensory Management Services, Baltimore, Md.). Seven of the 25 patients had required orbital floor reconstruction. Each patient had undergone fracture correction at least 6 months earlier and was interviewed, at the time of sensibility testing, regarding symptoms related to the fracture. The data were evaluated by a blinded examiner, from a separate clinical facility, who attempted to predict the side of the fracture and the degree of zygoma displacement on the basis of measurements of sensibility of the paranasal, upper lip, and zygomaticotemporal areas. Seventy-six percent of patients demonstrated abnormal sensibility on the side of the zygoma fracture, compared with the contralateral side. Sensibility was abnormal for 100 percent of the patients who required orbital floor reconstruction. Seventy-four percent of patients with abnormal sensibility reported symptoms related to the fracture. Eighty percent of the zygoma fractures were correctly identified, with respect to the side of the fracture, by the blinded examiner on the basis of the neurosensory measurements alone (p < 0.005). Predictions proved correct for 91 percent of the patients with widely displaced fractures and none of the patients with nondisplaced fractures. The results of this study suggest that neurosensory testing is an important clinical adjunct for the evaluation of patients with facial pain or dysesthesia after facial fracture reconstruction. The results suggest the need to develop algorithms for the diagnosis and treatment of trigeminal nerve injuries after craniofacial trauma. This approach could also be applicable to dysesthesia or pain after aesthetic facial surgical procedures.     

Orbitozygomatic fracture management

Orbitozygomatic fractures are frequently encountered in plastic surgery. Management depends on a thorough preoperative physical examination, with attention to the ophthalmologic assessment. Coronal and axial computed tomography is essential for identifying fracture extent and orbital involvement. Adequate exposure and mobilization of fracture segments is essential for successful anatomical reduction. Failure to perform effective fixation may lead to subsequent complications, such as enophthalmos and diplopia. The authors illustrate the appropriate management of orbitozygomatic fractures in an effort to reduce complications and attain aesthetically satisfying results.     

Porous polyethylene implants in orbital floor reconstruction

The purpose of this article is to present the authors' experience with the use of porous polyethylene ultrathin sheets for orbital floor reconstruction. Thirty-two patients with orbital floor fractures were treated with porous polyethylene ultrathin sheets. Sixteen cases corresponded to orbitozygomatic fractures, 11 cases corresponded to pure orbital floor fractures, and five corresponded to panfacial fractures. The subciliary approach was used in 15 patients and the transconjunctival approach in nine; another three patients were operated on through a preexisting eyebrow wound, two were operated on with a subtarsal approach, two were operated on through an eyebrow extension of a facial wound, and one patient was operated on through the facial wound. Intraoperatively, all patients received a prophylactic dose of intravenous antibiotics. Postoperatively, 24 patients received amoxicillin clavulanate for 5 to 7 days, two patients received clindamycin, and six patients received no antibiotics. Enophthalmos was corrected in 15 of 24 patients (62.5 percent), and hypoglobus in nine of 11 (82 percent). Diplopia was resolved in 25 of 28 patients (89.3 percent) with preoperative impairment. Extrinsic eye movement impairment was resolved in 25 of 27 patients (92.6 percent). A preoperative visual acuity deficit was present in four patients (12.5 percent) and was resolved in one (from 20/100 to 20/20). Visual acuity improved in one patient (from 20/60 to 20/30). In the other two patients, visual acuity remained altered (from 20/30 to 20/30). One patient (3.1 percent) suffered blindness induced by surgery. Nine of 26 patients (34.6 percent) had residual infraorbital nerve hypesthesia and five (19.2 percent) had residual paresthesias. Postoperatively, epiphora was present in six patients (18.8 percent) and ectropion in five (15.6 percent). Although there was no statistical significance between the surgical approach and the presence of epiphora (p = 0.211) and ectropion (p = 0.422), patients who were treated using the transconjunctival approach suffered reduced ectropion (0 percent) compared with patients treated using the subciliary approach (20 percent). However, patients treated using the transconjunctival approach suffered increased epiphora (22.2 percent) compared with those treated with the subciliary approach (13.3 percent). There were four cases (12.5 percent) of postoperative facial infections. Two of these cases were resolved with systemic antibiotics, one was resolved with bone sequestrum resection, and one patient needed removal of the implant. Orbital infections were related in all cases to titanium osteosynthesis miniplates or skull bone graft. When comparing patients who were treated with and without antibiotics, no statistical differences (p = 0.958) were found relative to the presence of infections. Correction of hypoglobus is technically easier than enophthalmos, because enophthalmic correction requires a wide, deep subperiosteal dissection and implant positioning, posterior to the equator of the globe, with the inherent risk of orbital apex injury.     

Correction of lower eyelid ptosis in the anophthalmic orbit: a long-term follow-up

We describe a 10-year review of 53 patients having had correction of lower eyelid ptosis using fascia lata sling suspension by the operation first described in 1973. The overall conclusion is that this continues to be a reliable procedure with a low complication rate. Four major changes relating to operative technique that create a better result are as follows: (1) the surgical correction must begin with a prosthesis that is ideal for the socket; (2) the fascial strip is narrower at 2 mm; (3) the lateral orbital rim burr hole is placed higher; and (4) the passage of the fascial strip is facilitated by the use of Wright's needle. The optimal sequence of operative procedures in the anophthalmic orbit syndrome is (1) correction of enophthalmos and superior sulcus depression, (2) correction of lower eyelid ptosis, and (3) correction of upper eyelid ptosis.     

Transcoronal blepharoplasty.

Some of the patients requesting blepharoplasty have a combination of excessive eyelid fat and brow ptosis but little or no dermatochalasis. Coronal brow lift, combined with transcoronal fat removal, serves these patients well. The prelevator fat pocket is easily entered from above by incising the periosteum of the anterior orbital roof just inside the orbital rim. Since the orbital septum and anterior lamella of the eyelid rim remain undisturbed, the result appears natural. Contraindications to the procedure include significant medical pocket fat and hair patterns that would exclude a coronal or hairline incision. Two complications, unilateral ptosis and unilateral chemosis, were temporary and totally reversible. Minor changes in the procedure have prevented the recurrence of these problems.