ORIGINAL ARTICLE
Evolving Trends in the Management of Orbital Floor Fractures Salah Aldekhayel, MD, MEd,* Hattan Aljaaly, MD,* Omar Fouda-Neel, MD, FRCSC,* Abdul-Wahab Shararah, MD, PharmD,* Waleed Suliman Zaid, DDS, MSc,Þ and Mirko Gilardino, MD, MSc* Background: The management of orbital floor fractures is diverse and continues to evolve. The purpose of the current study was to provide an updated summary of the literature, with a focus on interspecialty differences, and contrast that with current treatment strategies of actively practicing plastic surgeons. Methods: A survey was conducted of surgeons who currently manage orbital floor fractures. The results are summarized and compared with a 10-year literature review (2002Y2012) of surgical approaches, indications and timing of surgery, and implant selection in various surgical disciplines. Inclusion criteria included studies in English language with 10 or more patients. Results: The survey response rate was 56%, of which 86 surgeons were identified to currently manage orbit fractures. A third of participants reported they are less likely to operate on these fractures relative to earlier in their career. Six factors were found to have the greatest influence on surgeon’s operative decision: enophthalmos, hypophthalmos, positive forced duction, defect size, motility restriction, and persistent diplopia. The most common preferred approach to the orbit is midlid/infraorbital (45%) followed by transconjunctival (31%) and subciliary (24%). Medpor and titanium are the most preferred implants (83%) compared with autologous bone (5%).
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From the *H. Bruce Williams Craniofacial and Cleft Surgery Unit, Montreal Children’s Hospital, and Division of Plastic & Reconstructive Surgery, McGill University Health Center, Montreal, Quebec, Canada; and †Department of Oral and Maxillofacial Surgery, Louisiana State University, New Orleans, Louisiana Received July 22, 2013. Accepted for publication September 17, 2013. Address correspondence and reprint requests to Mirko Gilardino, MD, MSc, FRCSC, FACS, H. Bruce Williams Craniofacial and Cleft Surgery Unit, Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal Children’s Hospital, 2300 Tupper St, C11.33, Montreal, Quebec, Canada H3H 1P3; E-mail: [email protected] Presented at the 67th Annual Meeting of the Canadian Society of Plastic Surgeons, in Calgary, Alberta, Canada, May 28 to June 1, 2013. The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000441
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Conclusions: Significant interdisciplinary and intradisciplinary differences in the management of orbital fractures exist. The most significant trends are the growing popularity of alloplastic versus autogenous materials for orbital floor reconstruction and the fact that one-third of surgeons are more likely to opt for a nonoperative (conservative) approach compared with earlier in their careers. Key Words: Orbit fractures, facial fractures, Canadian Society of Plastic Surgeons, implants, biomaterials (J Craniofac Surg 2014;25: 258Y261)
T
he treatment of orbital floor fractures continues to evolve. Surgeons must make choices regarding the approach, the material used to reconstruct the orbit floor, and, importantly, the indication and timing of surgical intervention. Adding to the variety of surgical techniques is the fact that orbit fractures are managed by various surgical specialties including plastic surgery, oral and maxillofacial surgery (OMFS), otolaryngology (ENT), and ophthalmology. While the goal of treatment is always the restoration of orbital form and function, the diversity in surgical training, specialty-specific trends, and even surgeons’ personal experience contribute to the variability by which it is achieved. The purpose of the current study was to present an updated literature review of the surgical trends in orbital floor fracture management, with specific focus on the differences between surgical specialties.1Y8 The authors also aimed to provide the most current treatment strategies by way of a focused survey of actively practicing plastic surgeons who perform these repairs and contrast these trends with the literature and historical patterns. Ultimately, such information may provide useful feedback that allows surgeons to compare their current treatment strategies with that of their interdisciplinary and intradisciplinary surgical colleagues.
MATERIALS AND METHODS Literature Review A PubMed MEDLINE literature search was performed to identify clinical studies reporting the management of orbital floor fractures. Studies with 10 or more patients, published in English language between 2002 and 2012, were included. Parameters collected were timing of surgery, indications for operative intervention, types of material used for orbital floor reconstruction, and incision utilized. Results were classified according to specialty: plastic surgery, ENT, ophthalmology, and OMFS.
Survey A survey was developed to identify eligible candidates who currently manage orbit fractures. Respondents who do not routinely
The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
TABLE 1. Demographics
Evolving Trends in Orbit Fractures
TABLE 3. Preferred Implants in Orbital Floor Reconstruction Among CSPS Members
Demographics
Frequencies, n (%) Implants
Postresidency training Craniofacial fellowship NonYcraniofacial fellowships, courses None Years in practice G5 5Y10 11Y15 16Y20 920 No. cases of orbital fractures per year G5 5Y10 11Y20 920
Frequency
Autologous Calvarium Rib Maxilla Cartilage Orbital floor fragments Alloplastic Medpor Titanium Composite Medpor/titanium Silicone Others*
18 (17.4) 54 (62.7) 17 (19.8) 16 (18.6) 24 (27.9) 10 (11.6) 6 (7) 30 (34.9) 33 (38.4) 30 (34.9) 15 (17.4) 8 (9.3)
1% 1% 1% 1% 1% 45% 29% 9% 4% 8%
*Nylon (Supramid), PDS, Vitallium, polyglycolide, polylactide.
operative decision, operative timing, implant choice, and surgical approach. A W2 test was used for comparisons as appropriate. P G 0.05 was considered statistically significant. Analysis was done using SPSS software, version 20.0 (IBM Corp, Armonk, NY).
manage orbital floor fractures were eliminated. The remainder of the survey was composed of 2 sections: (a) demographics and (b) management of orbit fractures with 5 subsections: preoperative planning, indications for surgery, timing of surgery, operative approach, and implants. The survey was sent electronically to all 353 practicing members of the Canadian Society of Plastic Surgeons (CSPS) through SurveyMonkey (www.surveymonkey.com, Palo Alto, CA).
RESULTS The survey was sent to all 353 practicing members of the Canadian Society of plastic surgeons, of whom 198 responded with a response rate of 56%. Of the respondents, 86 surgeons were identified as currently managing orbit fractures and hence deemed eligible for this study.
Statistical Analysis The following variables were stratified for the analysis process: & the influence of different factors on the decision making to operate was stratified into positive influence (very strong and strong) and zero influence (no effect, weak, and very weak) & operative timing scale was stratified into early (G2 weeks), late (92 weeks), and no intervention & postresidency training: craniofacial and noncraniofacial fellowships & experience of surgeons: 10 years or less and more than 10 years & continuing education: current (attended courses in last 5 years) and none & implants: autologous (bone, cartilage) and alloplastic (all others)
Demographics Table 1 summarizes the demographics data. Only 17% of surgeons have postgraduate craniofacial training. More than half of participants had more than 10 years of experience. With regard to continuing medical education in craniomaxillofacial trauma, 32 surgeons (37%) reported to have attended an AO and/or an American Society of Maxillofacial Surgeons course in the last 5 years.
Management of Orbit Fractures Preoperative Planning
Postgraduate training, surgeon’s experience, and continuing education were examined against each of the following variables to determine if there was any significant impact: factors influencing
Almost a third of participating surgeons reported they were less likely to operate on these fractures compared with earlier in
TABLE 2. Influence of Different Factors on the Decision to Operate on a Patient With Isolated Orbital Floor Fracture and the Timing of Surgical Intervention if Indicated Influence* Factor
Timing of OR*
Very Strong
Strong
No Effect
Weak
Very Weak
G24 h
24Y96 h
96 hY2 wk
92 wk
No OR
40% 72% 66% 7% 48% 64% 5% 30% 12% 0
47% 27% 28% 20% 34% 25% 17% 43% 10% 2%
4% 1% 4% 45% 8% 7% 33% 11% 52% 43%
8% 0 2% 22% 10% 4% 33% 13% 11% 12%
1% 0 0 6% 0 0 12% 3% 15% 43%
1% 1% 2% 1% 25% 36% 1% 0 22% 0
31% 28% 29% 17% 27% 35% 11% 18% 7% 1%
57% 55% 52% 24% 31% 20% 33% 34% 8% 8%
9% 15% 15% 7% 12% 7% 13% 35% 1% 10%
2% 1% 2% 51% 5% 2% 42% 13% 62% 81%
Defect size Enophthalmos Hypophthalmos Change of muscle shape on CT Vertical motility restriction Positive forced-duction test Early diplopia Persistent diplopia (at 2 wk) Oculocardiac reflex Cranial nerve V2 paresthesia *†P = 0.000.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
259
The Journal of Craniofacial Surgery
Aldekhayel et al
& Volume 25, Number 1, January 2014
TABLE 4. Literature Review of Surgical Approaches Used in Orbital Floor Fractures Exploration Among Different Specialties Between 2002 and 2012
Specialty
No. Studies
No. Patients
14 18 10 8
1164 1349 683 496
Plastic surgery OMFS Ophthalmology ENT
Surgical Approach TC 105 370 677 274
(9%) (27%) (99%) (55%)
SC
ST
IO
E
1002 (86%) 760 (56%) 3 (0.5%) 5 (1%)
15 (1%) 144 (11%) 2 (0.3%) 0
42 (4%) 42 (3%) 1 (0.2%) 0
0 33 (3%) 0 217 (44%)
TC indicates transconjunctival; SC, subciliary; ST, subtarsal; IO, infraorbital; E, endoscopic.
their career. However, the majority (55%) stated their operative indications have not changed, whereas 11% reported that they were more likely to operate.
education on each of the following: operative decision making, timing of operative intervention, implant choice, and surgical approach.
Indications for Operative Intervention
DISCUSSION
Six factors were considered by the majority of surgeons to be the most influential on the decision to operate: defect size, enophthalmos, hypophthalmos, motility restriction, positive forced duction, and late diplopia (at 2 weeks). Table 2 summarizes the influence of different key factors (either clinical or radiological) on the surgeon’s decision to surgically intervene on these fractures. It also demonstrates the timing of operative intervention, if indicated, for each factor when considered individually. A defect size of 1 to 2 cm2 was considered an indication for surgery by 52% of surgeons, whereas 43% considered defects of more than 2 cm2 as such. The majority of surgeons (82%) considered enophthalmos of more than 2 mm as a significant indicator for surgical intervention.
The current study summarizes the current management of orbital floor fractures by plastic surgeon members of the CSPS. A literature review across other surgical specialties that manage orbit fractures was also performed to investigate cross-specialty differences or trends. The results of the survey and literature summary demonstrate that the management of orbital floor fractures continues to vary significantly across various specialties and even within specialties themselves. Variability is particularly noted in surgical approaches, implant selection for orbital floor repair, and clinical indications for operative intervention. These differences are explored below.
Implant Materials
Implants
Table 3 summarizes the preferred choice of implants for orbital floor reconstruction among the respondents. Medpor (Stryker, Kalamazoo, MI) and titanium implants were the most commonly utilized (83%), whereas autogenous bone grafts were preferred by less than 5% of surgeons.
Surgical Approach Midlid/infraorbital approaches were used by 45% of surgeons, followed by transconjunctival and subciliary approaches (31% and 24%, respectively). A Frost stitch was ‘‘infrequently’’ used by 72% of surgeons. Our 10-year literature review of preferred surgical approaches across different surgical specialties (Table 4) demonstrated that plastic (and OMFS) surgeons favored subciliary incisions, whereas ophthalmologists and ENT surgeons preferred the transconjunctival approach.
Statistical Analysis Multivariate analysis did not show any statistically significant impact of surgeons’ training, experience, or continuing medical
A variety of implants are routinely used by the survey participants including titanium, porous polyethylene, polydioxanone (PDS; Ethicon, Somerville, NJ), and autogenous bone graft. Contrary to the literature, which states that plastic (and ENT) surgeons historically equally prefer autologous bone to alloplastic implants (Table 5), the results from the survey found that the majority of Canadian plastic surgeons (83%) use alloplastic materials, namely, Medpor, titanium, or Synpor (Synthes, Paoli, PA). This trend toward alloplastic materials is likely the result of ease of use (no donor site harvest) and a rapidly growing body of evidence demonstrating safety and efficacy of synthetic materials for this indication. The latter evolution is supported by the subanalysis of the literature, which demonstrated that the predominant material used in the 1990 to 1999 cohort was autologous bone (45% bone vs 32% Medpor or titanium), whereas in the more recent publications dated 2000 to 2012 the relative frequencies were reversed (30% bone graft vs 46% alloplastic implants). These results are summarized in Table 6. Thus, the trend seen among our Canadian plastic surgeon participants echoes a global trend toward the use of alloplastic implants for orbital floor reconstruction.
TABLE 5. Literature Review of the Use of Implants in Orbital Floor Reconstruction Among Different Specialties Between 2002 and 2012
Specialty Plastic surgery OMFS Ophthalmology ENT
No. Studies
No. Patients
20 26 18 9
1886 1760 1246 601
Implants Medpor 589 89 468 203
(31%) (5%) (38%) (34%)
Titanium 166 299 102 62
(9%) (17%) (8%) (10%)
Synpor
Autogenous Bone
Silicone
PDS
Ethisorb
Supramid
Others*
87 (5%) 42 (2%) 128 (10%) 14 (2%)
582 (31%) 143 (8%) 36 (3%) 233 (39%)
58 (3%) 0 0 14 (2%)
0 466 (26%) 0 0
0 257 (15%) 0 0
0 0 361 (29%) 0
404 (21%) 464 (27%) 151 (12%) 75 (13%)
*Others include PLLA, cartilage, allografts, hydroxyapatite, gel film, resorbable sheets, lyophilized dura, bioactive glass, nylon foil.
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* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
Evolving Trends in Orbit Fractures
TABLE 6. Comparison of the Used Implants in Orbital Floor Reconstruction in Plastic Surgery Literature Over Periods of 1990 to 1999 Versus 2000 to 2012
Years 2000Y2012 1990Y1999
Implants
No. Studies
No. Patients
Medpor
Titanium
Synpor
Autogenous Bone
Silicone
Others*
23 11
1955 599
589 (30%) 100 (17%)
223 (11%) 89 (15%)
87 (5%) 0
582 (30%) 273 (45%)
58 (3%) 0
416 (21%) 137 (23%)
*Others include PLLA, cartilage, allografts, hydroxyapatite, Vitallium, resorbable sheets, lyophilized dura.
Surgical Approach Whereas midlid/infraorbital incisions were the most commonly used incisions among Canadian plastic surgeons in this survey (45%), they were the least used across all other specialties (Table 4). On the contrary, whereas a subciliary incision was the least frequent approach noted in this survey, it was the most commonly reported incision in the plastic surgery literature (24% vs 86%, respectively). Although plastic surgeons are generally comfortable with a subciliary approach because of experience with aesthetic eyelid surgery, the data have steadily demonstrated that this approach for repair of orbit fractures has the highest rate of ectropion (14%) when compared with the other approaches.3 Although this shift likely reflects an evolution based on literature evidence, the current study cannot confirm the etiology of this change in practice.
Operative Indications and Timing Six factors were identified by the survey to have the greatest influence on the decision to operate (Table 2) with globe malposition, defect size, evidence of muscle entrapment, and/or persistent diplopia having the strongest impacts. This finding is consistent with current trends in the OMFS and ophthalmology literature.4,5 Burnstine,5 in his evidence-based analysis of the literature, found strong supporting evidence (level I) for immediate surgical intervention in cases involving diplopia with a nonresolving oculocardiac reflex, white-eyed blow-out fractures, or early enophthalmos or hypophthalmos. Level II evidence for delayed intervention within 2 weeks was identified in cases involving minimally improving diplopia, positive forcedduction test, large defect size with late enophthalmos, or significant hypophthalmos.5 Contrary to the literature, surveyed surgeons did not feel that a change in muscle shape on computed tomography (CT) scan and/or an oculocardiac reflex significantly influenced the decision to operate. Rounding of the inferior rectus muscle on CT scan has been reported to potentially indicate a disruption in orbital floor soft tissue and bony support sufficient to cause enophthalmos,6 and hence early surgical repair might be warranted in those cases to prevent the development of late enophthalmos.7 Similarly, other studies have advocated an urgent surgical intervention for fractures associated with oculocardiac reflex to treat a theoretical ‘‘acute compartment syndrome’’ of the inferior rectus muscle and prevent its potential consequences including Volkmann contracture.4,5,8 From the perspective of timing for surgical repair, the majority of surgeons in the current survey (950%) considered diplopia with positive forced-duction test or vertical motility restrictions as indications for acute repair (within the first 96 hours), whereas significant defect size, enophthalmos, and hypophthalmos being indications for subacute repair (4Y14 days). An important final finding of the survey was the fact that a third of Canadian plastic surgeons reported being less likely to repair orbital floor fractures relative to earlier in their career.
Although the survey was not set up to answer this question, the authors wonder whether surgeon experience itself may not also be a key point in the decision to operate. The results of the survey imply that, with experience, plastic surgeons become more conservative in their indications to operate on orbital floor fractures, based likely on a better knowledge of potential operative morbidity and the acceptable outcomes of nonoperative management for select cases.
CONCLUSIONS An evolving trend toward the use of alloplastic materials over bone grafts in orbital floor traumatic reconstruction is demonstrated by the current practices of Canadian plastic surgeons and confirmed by the chronological shift in the plastic surgery literature. Furthermore, the finding of a more conservative approach toward the management of these injuries among CSPS members relative to earlier in their career warrants further investigation. Interspecialty and intraspecialty differences continue to exist with respect to implant choice, incision selection, and exact indication for operative intervention. At present, midlid/infraorbital incisions are the preferred choice along with alloplastic materials for orbital floor reconstruction by CSPS members.
ACKNOWLEDGMENT The authors thank Elise Mok, PDt, PhD, for her statistical advice.
REFERENCES 1. Courtney DJ, Thomas S, Whitfield PH. Isolated orbital blowout fractures: survey and review. Br J Oral Maxillofac Surg 2000;38:496Y504 2. Lynham AJ, Chapman PJ, Monsour FN, et al. Management of isolated orbital floor blow-out fractures: a survey of Australian and New Zealand oral and maxillofacial surgeons. Clin Exp Ophthalmol 2004;32:42Y45 3. Ridgway EB, Chen C, Colakoglu S, et al. The incidence of lower eyelid malposition after facial fracture repair: a retrospective study and meta-analysis comparing subtarsal, subciliary, and transconjunctival incisions. Plast Reconstr Surg 2009;124:1578Y1586 4. Ellis E 3rd. Orbital trauma. Oral Maxillofac Surg Clin North Am 2012;24:629Y648 5. Burnstine MA. Clinical recommendations for repair of isolated orbital floor fractures: an evidence-based analysis. Ophthalmology 2002;109:1207Y1210 6. Manson PN, Clifford CM, Su CT, et al. Mechanisms of global support and posttraumatic enophthalmos: I. The anatomy of the ligament sling and its relation to intramuscular cone orbital fat. Plast Reconstr Surg 1986;77:193Y202 7. Matic DB, Tse R, Banerjee A, et al. Rounding of the inferior rectus muscle as a predictor of enophthalmos in orbital floor fractures. J Craniofac Surg 2007;18:127Y132 8. Grant JH 3rd, Patrinely JR, Weiss AH, et al. Trapdoor fracture of the orbit in a pediatric population. Plast Reconstr Surg 2002;109:482Y489
* 2014 Mutaz B. Habal, MD
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Evolving Trends in the Management of Orbital Floor Fractures Salah Aldekhayel, MD, MEd,* Hattan Aljaaly, MD,* Omar Fouda-Neel, MD, FRCSC,* Abdul-Wahab Shararah, MD, PharmD,* Waleed Suliman Zaid, DDS, MSc,Þ and Mirko Gilardino, MD, MSc* Background: The management of orbital floor fractures is diverse and continues to evolve. The purpose of the current study was to provide an updated summary of the literature, with a focus on interspecialty differences, and contrast that with current treatment strategies of actively practicing plastic surgeons. Methods: A survey was conducted of surgeons who currently manage orbital floor fractures. The results are summarized and compared with a 10-year literature review (2002Y2012) of surgical approaches, indications and timing of surgery, and implant selection in various surgical disciplines. Inclusion criteria included studies in English language with 10 or more patients. Results: The survey response rate was 56%, of which 86 surgeons were identified to currently manage orbit fractures. A third of participants reported they are less likely to operate on these fractures relative to earlier in their career. Six factors were found to have the greatest influence on surgeon’s operative decision: enophthalmos, hypophthalmos, positive forced duction, defect size, motility restriction, and persistent diplopia. The most common preferred approach to the orbit is midlid/infraorbital (45%) followed by transconjunctival (31%) and subciliary (24%). Medpor and titanium are the most preferred implants (83%) compared with autologous bone (5%).
What Is This Box? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code links to the online version of the article.
From the *H. Bruce Williams Craniofacial and Cleft Surgery Unit, Montreal Children’s Hospital, and Division of Plastic & Reconstructive Surgery, McGill University Health Center, Montreal, Quebec, Canada; and †Department of Oral and Maxillofacial Surgery, Louisiana State University, New Orleans, Louisiana Received July 22, 2013. Accepted for publication September 17, 2013. Address correspondence and reprint requests to Mirko Gilardino, MD, MSc, FRCSC, FACS, H. Bruce Williams Craniofacial and Cleft Surgery Unit, Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal Children’s Hospital, 2300 Tupper St, C11.33, Montreal, Quebec, Canada H3H 1P3; E-mail: [email protected] Presented at the 67th Annual Meeting of the Canadian Society of Plastic Surgeons, in Calgary, Alberta, Canada, May 28 to June 1, 2013. The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000441
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Conclusions: Significant interdisciplinary and intradisciplinary differences in the management of orbital fractures exist. The most significant trends are the growing popularity of alloplastic versus autogenous materials for orbital floor reconstruction and the fact that one-third of surgeons are more likely to opt for a nonoperative (conservative) approach compared with earlier in their careers. Key Words: Orbit fractures, facial fractures, Canadian Society of Plastic Surgeons, implants, biomaterials (J Craniofac Surg 2014;25: 258Y261)
T
he treatment of orbital floor fractures continues to evolve. Surgeons must make choices regarding the approach, the material used to reconstruct the orbit floor, and, importantly, the indication and timing of surgical intervention. Adding to the variety of surgical techniques is the fact that orbit fractures are managed by various surgical specialties including plastic surgery, oral and maxillofacial surgery (OMFS), otolaryngology (ENT), and ophthalmology. While the goal of treatment is always the restoration of orbital form and function, the diversity in surgical training, specialty-specific trends, and even surgeons’ personal experience contribute to the variability by which it is achieved. The purpose of the current study was to present an updated literature review of the surgical trends in orbital floor fracture management, with specific focus on the differences between surgical specialties.1Y8 The authors also aimed to provide the most current treatment strategies by way of a focused survey of actively practicing plastic surgeons who perform these repairs and contrast these trends with the literature and historical patterns. Ultimately, such information may provide useful feedback that allows surgeons to compare their current treatment strategies with that of their interdisciplinary and intradisciplinary surgical colleagues.
MATERIALS AND METHODS Literature Review A PubMed MEDLINE literature search was performed to identify clinical studies reporting the management of orbital floor fractures. Studies with 10 or more patients, published in English language between 2002 and 2012, were included. Parameters collected were timing of surgery, indications for operative intervention, types of material used for orbital floor reconstruction, and incision utilized. Results were classified according to specialty: plastic surgery, ENT, ophthalmology, and OMFS.
Survey A survey was developed to identify eligible candidates who currently manage orbit fractures. Respondents who do not routinely
The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
TABLE 1. Demographics
Evolving Trends in Orbit Fractures
TABLE 3. Preferred Implants in Orbital Floor Reconstruction Among CSPS Members
Demographics
Frequencies, n (%) Implants
Postresidency training Craniofacial fellowship NonYcraniofacial fellowships, courses None Years in practice G5 5Y10 11Y15 16Y20 920 No. cases of orbital fractures per year G5 5Y10 11Y20 920
Frequency
Autologous Calvarium Rib Maxilla Cartilage Orbital floor fragments Alloplastic Medpor Titanium Composite Medpor/titanium Silicone Others*
18 (17.4) 54 (62.7) 17 (19.8) 16 (18.6) 24 (27.9) 10 (11.6) 6 (7) 30 (34.9) 33 (38.4) 30 (34.9) 15 (17.4) 8 (9.3)
1% 1% 1% 1% 1% 45% 29% 9% 4% 8%
*Nylon (Supramid), PDS, Vitallium, polyglycolide, polylactide.
operative decision, operative timing, implant choice, and surgical approach. A W2 test was used for comparisons as appropriate. P G 0.05 was considered statistically significant. Analysis was done using SPSS software, version 20.0 (IBM Corp, Armonk, NY).
manage orbital floor fractures were eliminated. The remainder of the survey was composed of 2 sections: (a) demographics and (b) management of orbit fractures with 5 subsections: preoperative planning, indications for surgery, timing of surgery, operative approach, and implants. The survey was sent electronically to all 353 practicing members of the Canadian Society of Plastic Surgeons (CSPS) through SurveyMonkey (www.surveymonkey.com, Palo Alto, CA).
RESULTS The survey was sent to all 353 practicing members of the Canadian Society of plastic surgeons, of whom 198 responded with a response rate of 56%. Of the respondents, 86 surgeons were identified as currently managing orbit fractures and hence deemed eligible for this study.
Statistical Analysis The following variables were stratified for the analysis process: & the influence of different factors on the decision making to operate was stratified into positive influence (very strong and strong) and zero influence (no effect, weak, and very weak) & operative timing scale was stratified into early (G2 weeks), late (92 weeks), and no intervention & postresidency training: craniofacial and noncraniofacial fellowships & experience of surgeons: 10 years or less and more than 10 years & continuing education: current (attended courses in last 5 years) and none & implants: autologous (bone, cartilage) and alloplastic (all others)
Demographics Table 1 summarizes the demographics data. Only 17% of surgeons have postgraduate craniofacial training. More than half of participants had more than 10 years of experience. With regard to continuing medical education in craniomaxillofacial trauma, 32 surgeons (37%) reported to have attended an AO and/or an American Society of Maxillofacial Surgeons course in the last 5 years.
Management of Orbit Fractures Preoperative Planning
Postgraduate training, surgeon’s experience, and continuing education were examined against each of the following variables to determine if there was any significant impact: factors influencing
Almost a third of participating surgeons reported they were less likely to operate on these fractures compared with earlier in
TABLE 2. Influence of Different Factors on the Decision to Operate on a Patient With Isolated Orbital Floor Fracture and the Timing of Surgical Intervention if Indicated Influence* Factor
Timing of OR*
Very Strong
Strong
No Effect
Weak
Very Weak
G24 h
24Y96 h
96 hY2 wk
92 wk
No OR
40% 72% 66% 7% 48% 64% 5% 30% 12% 0
47% 27% 28% 20% 34% 25% 17% 43% 10% 2%
4% 1% 4% 45% 8% 7% 33% 11% 52% 43%
8% 0 2% 22% 10% 4% 33% 13% 11% 12%
1% 0 0 6% 0 0 12% 3% 15% 43%
1% 1% 2% 1% 25% 36% 1% 0 22% 0
31% 28% 29% 17% 27% 35% 11% 18% 7% 1%
57% 55% 52% 24% 31% 20% 33% 34% 8% 8%
9% 15% 15% 7% 12% 7% 13% 35% 1% 10%
2% 1% 2% 51% 5% 2% 42% 13% 62% 81%
Defect size Enophthalmos Hypophthalmos Change of muscle shape on CT Vertical motility restriction Positive forced-duction test Early diplopia Persistent diplopia (at 2 wk) Oculocardiac reflex Cranial nerve V2 paresthesia *†P = 0.000.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
259
The Journal of Craniofacial Surgery
Aldekhayel et al
& Volume 25, Number 1, January 2014
TABLE 4. Literature Review of Surgical Approaches Used in Orbital Floor Fractures Exploration Among Different Specialties Between 2002 and 2012
Specialty
No. Studies
No. Patients
14 18 10 8
1164 1349 683 496
Plastic surgery OMFS Ophthalmology ENT
Surgical Approach TC 105 370 677 274
(9%) (27%) (99%) (55%)
SC
ST
IO
E
1002 (86%) 760 (56%) 3 (0.5%) 5 (1%)
15 (1%) 144 (11%) 2 (0.3%) 0
42 (4%) 42 (3%) 1 (0.2%) 0
0 33 (3%) 0 217 (44%)
TC indicates transconjunctival; SC, subciliary; ST, subtarsal; IO, infraorbital; E, endoscopic.
their career. However, the majority (55%) stated their operative indications have not changed, whereas 11% reported that they were more likely to operate.
education on each of the following: operative decision making, timing of operative intervention, implant choice, and surgical approach.
Indications for Operative Intervention
DISCUSSION
Six factors were considered by the majority of surgeons to be the most influential on the decision to operate: defect size, enophthalmos, hypophthalmos, motility restriction, positive forced duction, and late diplopia (at 2 weeks). Table 2 summarizes the influence of different key factors (either clinical or radiological) on the surgeon’s decision to surgically intervene on these fractures. It also demonstrates the timing of operative intervention, if indicated, for each factor when considered individually. A defect size of 1 to 2 cm2 was considered an indication for surgery by 52% of surgeons, whereas 43% considered defects of more than 2 cm2 as such. The majority of surgeons (82%) considered enophthalmos of more than 2 mm as a significant indicator for surgical intervention.
The current study summarizes the current management of orbital floor fractures by plastic surgeon members of the CSPS. A literature review across other surgical specialties that manage orbit fractures was also performed to investigate cross-specialty differences or trends. The results of the survey and literature summary demonstrate that the management of orbital floor fractures continues to vary significantly across various specialties and even within specialties themselves. Variability is particularly noted in surgical approaches, implant selection for orbital floor repair, and clinical indications for operative intervention. These differences are explored below.
Implant Materials
Implants
Table 3 summarizes the preferred choice of implants for orbital floor reconstruction among the respondents. Medpor (Stryker, Kalamazoo, MI) and titanium implants were the most commonly utilized (83%), whereas autogenous bone grafts were preferred by less than 5% of surgeons.
Surgical Approach Midlid/infraorbital approaches were used by 45% of surgeons, followed by transconjunctival and subciliary approaches (31% and 24%, respectively). A Frost stitch was ‘‘infrequently’’ used by 72% of surgeons. Our 10-year literature review of preferred surgical approaches across different surgical specialties (Table 4) demonstrated that plastic (and OMFS) surgeons favored subciliary incisions, whereas ophthalmologists and ENT surgeons preferred the transconjunctival approach.
Statistical Analysis Multivariate analysis did not show any statistically significant impact of surgeons’ training, experience, or continuing medical
A variety of implants are routinely used by the survey participants including titanium, porous polyethylene, polydioxanone (PDS; Ethicon, Somerville, NJ), and autogenous bone graft. Contrary to the literature, which states that plastic (and ENT) surgeons historically equally prefer autologous bone to alloplastic implants (Table 5), the results from the survey found that the majority of Canadian plastic surgeons (83%) use alloplastic materials, namely, Medpor, titanium, or Synpor (Synthes, Paoli, PA). This trend toward alloplastic materials is likely the result of ease of use (no donor site harvest) and a rapidly growing body of evidence demonstrating safety and efficacy of synthetic materials for this indication. The latter evolution is supported by the subanalysis of the literature, which demonstrated that the predominant material used in the 1990 to 1999 cohort was autologous bone (45% bone vs 32% Medpor or titanium), whereas in the more recent publications dated 2000 to 2012 the relative frequencies were reversed (30% bone graft vs 46% alloplastic implants). These results are summarized in Table 6. Thus, the trend seen among our Canadian plastic surgeon participants echoes a global trend toward the use of alloplastic implants for orbital floor reconstruction.
TABLE 5. Literature Review of the Use of Implants in Orbital Floor Reconstruction Among Different Specialties Between 2002 and 2012
Specialty Plastic surgery OMFS Ophthalmology ENT
No. Studies
No. Patients
20 26 18 9
1886 1760 1246 601
Implants Medpor 589 89 468 203
(31%) (5%) (38%) (34%)
Titanium 166 299 102 62
(9%) (17%) (8%) (10%)
Synpor
Autogenous Bone
Silicone
PDS
Ethisorb
Supramid
Others*
87 (5%) 42 (2%) 128 (10%) 14 (2%)
582 (31%) 143 (8%) 36 (3%) 233 (39%)
58 (3%) 0 0 14 (2%)
0 466 (26%) 0 0
0 257 (15%) 0 0
0 0 361 (29%) 0
404 (21%) 464 (27%) 151 (12%) 75 (13%)
*Others include PLLA, cartilage, allografts, hydroxyapatite, gel film, resorbable sheets, lyophilized dura, bioactive glass, nylon foil.
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* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
Evolving Trends in Orbit Fractures
TABLE 6. Comparison of the Used Implants in Orbital Floor Reconstruction in Plastic Surgery Literature Over Periods of 1990 to 1999 Versus 2000 to 2012
Years 2000Y2012 1990Y1999
Implants
No. Studies
No. Patients
Medpor
Titanium
Synpor
Autogenous Bone
Silicone
Others*
23 11
1955 599
589 (30%) 100 (17%)
223 (11%) 89 (15%)
87 (5%) 0
582 (30%) 273 (45%)
58 (3%) 0
416 (21%) 137 (23%)
*Others include PLLA, cartilage, allografts, hydroxyapatite, Vitallium, resorbable sheets, lyophilized dura.
Surgical Approach Whereas midlid/infraorbital incisions were the most commonly used incisions among Canadian plastic surgeons in this survey (45%), they were the least used across all other specialties (Table 4). On the contrary, whereas a subciliary incision was the least frequent approach noted in this survey, it was the most commonly reported incision in the plastic surgery literature (24% vs 86%, respectively). Although plastic surgeons are generally comfortable with a subciliary approach because of experience with aesthetic eyelid surgery, the data have steadily demonstrated that this approach for repair of orbit fractures has the highest rate of ectropion (14%) when compared with the other approaches.3 Although this shift likely reflects an evolution based on literature evidence, the current study cannot confirm the etiology of this change in practice.
Operative Indications and Timing Six factors were identified by the survey to have the greatest influence on the decision to operate (Table 2) with globe malposition, defect size, evidence of muscle entrapment, and/or persistent diplopia having the strongest impacts. This finding is consistent with current trends in the OMFS and ophthalmology literature.4,5 Burnstine,5 in his evidence-based analysis of the literature, found strong supporting evidence (level I) for immediate surgical intervention in cases involving diplopia with a nonresolving oculocardiac reflex, white-eyed blow-out fractures, or early enophthalmos or hypophthalmos. Level II evidence for delayed intervention within 2 weeks was identified in cases involving minimally improving diplopia, positive forcedduction test, large defect size with late enophthalmos, or significant hypophthalmos.5 Contrary to the literature, surveyed surgeons did not feel that a change in muscle shape on computed tomography (CT) scan and/or an oculocardiac reflex significantly influenced the decision to operate. Rounding of the inferior rectus muscle on CT scan has been reported to potentially indicate a disruption in orbital floor soft tissue and bony support sufficient to cause enophthalmos,6 and hence early surgical repair might be warranted in those cases to prevent the development of late enophthalmos.7 Similarly, other studies have advocated an urgent surgical intervention for fractures associated with oculocardiac reflex to treat a theoretical ‘‘acute compartment syndrome’’ of the inferior rectus muscle and prevent its potential consequences including Volkmann contracture.4,5,8 From the perspective of timing for surgical repair, the majority of surgeons in the current survey (950%) considered diplopia with positive forced-duction test or vertical motility restrictions as indications for acute repair (within the first 96 hours), whereas significant defect size, enophthalmos, and hypophthalmos being indications for subacute repair (4Y14 days). An important final finding of the survey was the fact that a third of Canadian plastic surgeons reported being less likely to repair orbital floor fractures relative to earlier in their career.
Although the survey was not set up to answer this question, the authors wonder whether surgeon experience itself may not also be a key point in the decision to operate. The results of the survey imply that, with experience, plastic surgeons become more conservative in their indications to operate on orbital floor fractures, based likely on a better knowledge of potential operative morbidity and the acceptable outcomes of nonoperative management for select cases.
CONCLUSIONS An evolving trend toward the use of alloplastic materials over bone grafts in orbital floor traumatic reconstruction is demonstrated by the current practices of Canadian plastic surgeons and confirmed by the chronological shift in the plastic surgery literature. Furthermore, the finding of a more conservative approach toward the management of these injuries among CSPS members relative to earlier in their career warrants further investigation. Interspecialty and intraspecialty differences continue to exist with respect to implant choice, incision selection, and exact indication for operative intervention. At present, midlid/infraorbital incisions are the preferred choice along with alloplastic materials for orbital floor reconstruction by CSPS members.
ACKNOWLEDGMENT The authors thank Elise Mok, PDt, PhD, for her statistical advice.
REFERENCES 1. Courtney DJ, Thomas S, Whitfield PH. Isolated orbital blowout fractures: survey and review. Br J Oral Maxillofac Surg 2000;38:496Y504 2. Lynham AJ, Chapman PJ, Monsour FN, et al. Management of isolated orbital floor blow-out fractures: a survey of Australian and New Zealand oral and maxillofacial surgeons. Clin Exp Ophthalmol 2004;32:42Y45 3. Ridgway EB, Chen C, Colakoglu S, et al. The incidence of lower eyelid malposition after facial fracture repair: a retrospective study and meta-analysis comparing subtarsal, subciliary, and transconjunctival incisions. Plast Reconstr Surg 2009;124:1578Y1586 4. Ellis E 3rd. Orbital trauma. Oral Maxillofac Surg Clin North Am 2012;24:629Y648 5. Burnstine MA. Clinical recommendations for repair of isolated orbital floor fractures: an evidence-based analysis. Ophthalmology 2002;109:1207Y1210 6. Manson PN, Clifford CM, Su CT, et al. Mechanisms of global support and posttraumatic enophthalmos: I. The anatomy of the ligament sling and its relation to intramuscular cone orbital fat. Plast Reconstr Surg 1986;77:193Y202 7. Matic DB, Tse R, Banerjee A, et al. Rounding of the inferior rectus muscle as a predictor of enophthalmos in orbital floor fractures. J Craniofac Surg 2007;18:127Y132 8. Grant JH 3rd, Patrinely JR, Weiss AH, et al. Trapdoor fracture of the orbit in a pediatric population. Plast Reconstr Surg 2002;109:482Y489
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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