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Special Communication |

Avoiding Complications in the Repair of Orbital Floor Fractures

Gerald J. Harris, MD1
[+] Author Affiliations
1Section of Orbital and Ophthalmic Plastic Surgery, Department of Ophthalmology, Medical College of Wisconsin, Milwaukee, Wisconsin
JAMA Facial Plast Surg. 2014;16(4):290-295. doi:10.1001/jamafacial.2014.56.
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Fractures of the orbital floor are commonly repaired by all specialists who manage facial trauma. Potential complications include incomplete correction of preoperative enophthalmos or diplopia, as well as induction of hypoglobus or hyperglobus, eyelid malposition, or optic nerve injury. To optimize functional and aesthetic results, a stepwise analysis of the surgical procedure is presented—from the election and timing of repair, through the incision and dissection path, release of herniated orbital tissue, implant material and placement, wound closure, and postoperative care. Key elements include the distinction of floor fracture subtypes, avoiding cicatricial contraction of the lower eyelid, complete release of herniated soft tissue, direct observation of all fracture margins, and proper contouring and positioning of the implant.

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Figures

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Figure 1.
Schematic Representation of Blowout Fracture Subtypes (Coronal Projection)

A, Normal intact floor and inferior fibro-adipose-muscular complex. B, Trapdoor fracture with tightly entrapped soft tissue. C, Displaced fracture with herniated soft tissue proportionate to bone-fragment separation. D, Displaced fracture with herniated soft tissue that exceeds bone-fragment separation—suggesting ongoing tissue damage. Modified with permission from Harris et al.3

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Figure 2.
Orbital Floor Contour and Implications for Repair

Preoperative sagittal cuts through the normal (A) and fractured (B) orbits of the same patient. Ideally, the implant will reproduce the anterior concavity and posterior convexity of the normal floor. C and D, A custom-trimmed 0.3-mm nylon foil should rest behind the orbital rim, bridge the infraorbital canal and fracture defect, and be supported on an intact posterior ledge. Modified with permission from Harris.5

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Figure 3.
Inadequate Correction of Enophthalmos

A and B, Patient referred for residual enophthalmos following right enucleation and attempted blowout fracture repair. C, Intact left orbit with convex posterior floor. D, Right orbit. In the absence of adequate posterior support, the orbital floor implant rests directly on the depressed floor fragment.

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Figure 4.
Poorly Positioned Rim-Fixed Implant

A rim-fixed titanium implant projects above the level of the normal orbital floor, causing hyperglobus, limited motility, and orbital pain.

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Figure 5.
Poorly Positioned Rim-Fixed Implant

A and B, Patient referred for residual enophthalmos, hypoglobus, diplopia, and eyelid malposition following attempted right zygomaticomaxillary complex fracture repair. C, Rim-fixed metal floor implant projects downward into the maxillary antrum. D, Following multiple-stage fracture and soft-tissue revision surgery.

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