Correction of post-traumatic enophthalmos with anatomical absorbable implant and iliac bone graft

BACKGROUND: Trauma is one of the most common causes of enophthalmos, and post-traumatic enophthalmos primarily results from an increased volume of the bony orbit. We achieved good long-term results by simultaneously using an anatomical absorbable implant and iliac bone graft to correct post-traumatic enophthalmos.METHODS: From January 2012 to December 2016, we performed operations on seven patients with post-traumatic enophthalmos. In all seven cases, reduction surgery for the initial trauma was performed at our hospital. Hertel exophthalmometry, clinical photography, three-dimensional computed tomography (3D-CT), and orbital volume measurements using software to calculate the specific volume captured on 3D-CT (ITK-SNAP, Insight Toolkit-SNAP) were performed preoperatively and postoperatively.RESULTS: Patients were evaluated based on exophthalmometry, clinical photographs, 3D-CT, and orbital volume measured by the ITK-SNAP program at 5 days and 1 year postoperatively, and all factors improved significantly compared with the preoperative baseline. Complications such as hematoma or extraocular muscle limitation were absent, and the corrected orbital volume was well maintained at the 1-year follow-up visit.CONCLUSION: We present a method to correct enophthalmos by reconstructing the orbital wall using an anatomical absorbable implant and a simultaneous autologous iliac bone graft. All cases showed satisfactory results for enophthalmos correction. We suggest this method as a good option for the correction of post-traumatic enophthalmos.

Clinical usefulness of fixation of absorbable implants with cyanoacrylate in comminuted fractures of the maxilla

BACKGROUND: The open reduction of craniofacial bone fractures requires internal fixation using metal plates and screws, which have been considered the gold standard. However, metal implants pose a risk of palpation, protrusion, and foreign body reaction, and they may require an additional operation for removal. Recently, good results have been reported for absorbable implants which complement the disadvantages of metal implants. This study presents the results of using absorbable mesh, plates, and screws with cyanoacrylate for more accurate and firmer fixation of comminuted fractures of the maxilla. METHODS: In total, 235 patients underwent operations for comminuted fractures of the maxilla. From January 2012 to December 2014, absorbable mesh and screws were used in 114 patients, while from January 2015 to December 2017, absorbable mesh, plates, and screws with cyanoacrylate were used in 121 patients. Open reduction of the bone fragments was performed, after which absorbable implants were accurately molded and fixed by screws. RESULTS: All patients underwent postoperative computed tomography scans, which showed highly accurate reduction and firm fixation in the patients who underwent procedures using absorbable implants, screws, and cyanoacrylate. There were no postoperative complications or cases of abnormal facial contour. CONCLUSION: When absorbable implants and screws are used for maxillary fractures, no additional surgery to remove the metal plate is required. In addition, the use of cyanoacrylate enables accurate and firm fixation of the tiny bone fragments that cannot be fixed with screws.

Orbital Wall Reconstruction with Osteoconductive Unsintered Hydroxyapatite/Poly L-Lactide

PURPOSE: To evaluate the effect of orbital wall reconstruction with absorbable osteoconductive unsintered hydroxyapatite/poly L-lactide by assessment of the orbital volume via orbital computed tomography. METHODS: 24 patients who followed up at least 6 months after orbital wall reconstruction with unsintered hydroxyapatite/poly L-lactide were included. Retrospective clinical chart reviews for clinical manifestations and complications were performed, and orbital volume measurements were taken using the Eclipse Treatment Planning System (ver.13.0, Varian Medical System Inc., Palo Alto, CA, USA) through orbital computed tomography, which were taken before operation, right after operation, and at last follow up. RESULTS: Fourteen patients (58.3%) showed diplopia and extraocular muscle movement limitation preoperatively. Diplopia was resolved at last follow up and extraocular muscle movement limitation was improved at postoperative 6 months for all cases. The mean volumes of the fractured orbit and the unaffected orbit before operation were 23.62 ± 0.45 cm3 and 21.95 ± 1.01 cm3, respectively (p = 0.003). The mean volumes of the fractured orbit and the unaffected orbit right after operation were 21.65 ± 0.91 cm3 and 21.78 ± 0.83 cm3, respectively (p = 0.542). The mean volumes of the fractured orbit and the unaffected orbit at last follow up were 21.84 ± 0.93 cm3 and 21.81 ± 0.91 cm3, respectively (p = 0.889). CONCLUSIONS: Absorbable osteoconductive unsintered hydroxyapatite/poly L-lactide was effective for clinical improvement and orbital volume assessment in cases of orbital wall reconstruction and it can be used safely without definite implant related complications.

Orbital Wall Reconstruction with Osteoconductive Unsintered Hydroxyapatite/Poly L-Lactide

PURPOSE: To evaluate the effect of orbital wall reconstruction with absorbable osteoconductive unsintered hydroxyapatite/poly L-lactide by assessment of the orbital volume via orbital computed tomography. METHODS: 24 patients who followed up at least 6 months after orbital wall reconstruction with unsintered hydroxyapatite/poly L-lactide were included. Retrospective clinical chart reviews for clinical manifestations and complications were performed, and orbital volume measurements were taken using the Eclipse Treatment Planning System (ver.13.0, Varian Medical System Inc., Palo Alto, CA, USA) through orbital computed tomography, which were taken before operation, right after operation, and at last follow up. RESULTS: Fourteen patients (58.3%) showed diplopia and extraocular muscle movement limitation preoperatively. Diplopia was resolved at last follow up and extraocular muscle movement limitation was improved at postoperative 6 months for all cases. The mean volumes of the fractured orbit and the unaffected orbit before operation were 23.62 ± 0.45 cm3 and 21.95 ± 1.01 cm3, respectively (p = 0.003). The mean volumes of the fractured orbit and the unaffected orbit right after operation were 21.65 ± 0.91 cm3 and 21.78 ± 0.83 cm3, respectively (p = 0.542). The mean volumes of the fractured orbit and the unaffected orbit at last follow up were 21.84 ± 0.93 cm3 and 21.81 ± 0.91 cm3, respectively (p = 0.889). CONCLUSIONS: Absorbable osteoconductive unsintered hydroxyapatite/poly L-lactide was effective for clinical improvement and orbital volume assessment in cases of orbital wall reconstruction and it can be used safely without definite implant related complications.

A Case of Delayed Orbital Cellulitis after Orbital Wall Fracture Repair Using Absorbable Implant

PURPOSE: To report a case of delayed orbital cellulitis with subperiosteal abscess after orbital floor fracture repair using an absorbable sheet implant (Macropore®, Medtronic Inc., Minneapolis, MN, USA). CASE SUMMARY: A 16-year-old male visited the oculoplastic clinic for left eye pain, lower eyelid swelling and vertical diplopia for 1 day. The patient had a history of inferior orbital wall fracture repair surgery using Macropore® 20 months prior. The orbital computed tomography scan showed a subperiosteal cystic mass with surrounding infiltration at the left orbital floor, and ethmoidal and maxillary sinusitis; however, sheet implant was not clearly observed. Despite systemic antibiotic treatment for 3 days, his clinical findings did not improve, thus we decided to drain the subperiosteal abscess through a transconjunctival approach. Intraoperatively, the Macropore® sheet was almost dissolved, but small pieces remained. The culture of drained contents showed no microorganisms. Systemic antibiotics were continued for 18 days after surgery, and clinical symptoms completely improved. CONCLUSIONS: Delayed orbital cellulitis should be considered in patients with extraocular muscle movement limitation and painful orbital swelling if the patient has a history of orbital wall fracture repair, even if a bioresorbable implant was used. Prompt imaging evaluation should be emphasized for early diagnosis and proper treatment.

Delayed-Onset Methicillin-Resistant Staphylococcus aureus Infection at 18 Months after Absorbable Plate Fixation for Zygomaticomaxillary Complex Fracture

None of the reports of delayed infection mentioned a latent period exceeding 13 months. we report an infection that developed 18 months after implantation of an absorbable plate. A 16-year-old adolescent girl had undergone reduction and fixation with an absorbable plate for Lefort I and zygomaticomaxillary complex fractures 18 months prior at our hospital. In her most recent hospital visit as an outpatient, abscess was observed in periocular area. Computed tomography revealed sinusitis with an abscess above the infraorbital rim. Wound culture yielded methicillin-resistant Staphylococcus aureus . Despite conservative treatments, wound state did not improve. Therefore, our department decided to perform surgery. Absorbable plate had been mostly absorbed but remained a bit. Bony depression of infraorbital rim and mucosal exposure of maxillary sinus anterior wall were observed. After the surgery, the patient recovered. We believe that the reason the wound infection and sinusitis manifested at the same time is because of several factor such as alcohol abuse, smoking, and mucosal exposure of maxillary sinus anterior wall. Absorbable plate takes 9 months to 3 years to be completely absorbed, thus we suggest studies with a follow-up of at least 3 years be undertaken to determine the outcomes of patients with many risk factors.

Delayed Foreign Body Reaction around the Absorbable Implants in Facial Bone Fracture: A Case Report

PURPOSE: Absorbable implants are frequently used to fix facial bone fractures, because they are radiolucent and compatible with magnetic resonance imaging(MRI). Despite their increasing usage, however, there have been few reports about their long-term side-effects. In this paper, a case in which absorbable implants led to a foreign body reaction 17 months after their insertion is presented. METHODS: A previously healthy 19-year-old male fell from a flight of stairs and visited the authors' hospital with right periorbital pain. Zygomaticomaxillary fracture involving right orbital floor was detected via a facial bone computed tomography(CT). Internal fixation with absorbable implants was followed by open reduction. 17 months after the surgery, the patient complained of localized periorbital swelling. Removal of the granulomatous lesion including the absorbable implants along with their biopsy and culture was performed. RESULTS: The granulomatous lesion around the implants was firm and extended into the maxillary sinus. The histologic finding showed a microabscess with a foreign body reaction. Methicillin-sensitive Staphylococcus aureus growth was confirmed in the culture. No definite abnormal symptoms ensued after the complete removal. CONCLUSION: A microabscess-forming granulomatous lesion around the absorbable implant can cause delayed symptomatic foreign body reaction despite its rare occurrence. Complete removal of the lesion including implants is expected to have a successful outcome if it is encountered.

Rigid Fixation using Bioabsorbable Mesh and Screws in Facial Bone Fracture

PURPOSE: Absorbable plate and screw fixation is widely used technique for internal rigid fixation in craniomaxillofacial surgery. However, there are some potential problems associated with the use of plate. The purpose of this study is to evaluate the feasibility of bone fixation in facial fracture using absorbable mesh in place of absorbable plate. METHODS: The records of 55 patients with zygomaticomaxilla fractures treated by open reduction, performed by the author from February 2008 to May 2009, were retrospectively reviewed. Patients were selected to receive absorbable mesh fixation. The incidence of all complications including infection, hypoesthesia, and deformity was examined. Analysis with postoperative computed tomography follow-up demonstrates degree of reduction. RESULTS: Forty-six patients met criteria for inclusion in the study. All patients went on to satisfactory healing without complication. Postoperative computed tomography revealed good bony alignment similarly non affected side. CONCLUSION: This study demonstrates that the rigid internal fixation of fractured bone fragments using absorbable mesh is more effective than absorbable plate, especially in comminuted fracture of maxilla.

Rigid Fixation using Bioabsorbable Mesh and Screws in Facial Bone Fracture

PURPOSE: Absorbable plate and screw fixation is widely used technique for internal rigid fixation in craniomaxillofacial surgery. However, there are some potential problems associated with the use of plate. The purpose of this study is to evaluate the feasibility of bone fixation in facial fracture using absorbable mesh in place of absorbable plate. METHODS: The records of 55 patients with zygomaticomaxilla fractures treated by open reduction, performed by the author from February 2008 to May 2009, were retrospectively reviewed. Patients were selected to receive absorbable mesh fixation. The incidence of all complications including infection, hypoesthesia, and deformity was examined. Analysis with postoperative computed tomography follow-up demonstrates degree of reduction. RESULTS: Forty-six patients met criteria for inclusion in the study. All patients went on to satisfactory healing without complication. Postoperative computed tomography revealed good bony alignment similarly non affected side. CONCLUSION: This study demonstrates that the rigid internal fixation of fractured bone fragments using absorbable mesh is more effective than absorbable plate, especially in comminuted fracture of maxilla.