Original Investigation

Evaluation of the Retro-Orbital Fatty Tissue Volume in Delayed Orbital Blow-Out Fractures Ozgur Pilanci, M.D.*, Fatih Ceran, M.D.*, Mehmet Sagir, M.D.*, Abdurezzak Teken, M.D.†, and Samet Vasfi Kuvat, M.D.‡ *Department of Plastic, Reconstructive and Aesthetic Surgery, †Department of Radiology, Bagcilar Training and Research Hospital; and ‡ Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University Faculty of Medicine, Istanbul, Turkey

Purpose: In patients where diplopia and enophthalmia are manifest, surgical intervention is usually necessary. The pathogenesis of these symptoms usually includes the prolapse of orbital tissues into the sinus or compression by the surrounding bone structures. Although the retro-orbital fatty tissue, orbital fascia, and the muscle tissue can be reduced to the original place after being incarcerated into the maxillary space, it is obvious that the procedure can lead to significant fibrosis in these structures. The authors have aimed to carry out a quantitative evaluation of the fatty tissue volumes in patients with repair delayed for more than two weeks. Methods: The preoperative and postoperative fatty tissue volumes and the changes in total orbital volume were evaluated by using CT on the patients (n = 9) who were consulted to the authors’ clinic from other health centers. Results: Although no significant correlation was observed between the prolapsed volume and the postoperative reduction in the fatty tissue, the reduction in the retro-orbital fatty tissue was statistically significant. Conclusion: Evaluating postoperative retro-orbital fatty tissue volumes may have implications for surgical intervention in the future. (Ophthal Plast Reconstr Surg 2016;32:207–210)

F

ractures of the orbital floor generally occur due to blunt traumas to and around the eye, and may present with various findings such as dystopia, enophthalmia, displacement of the eyeball, and double vision. If left untreated, they may cause functional and aesthetic problems.1–3 In patients where diplopia and enophthalmia are manifest, surgical intervention is usually necessary. The pathogenesis of these symptoms usually includes the prolapse of the orbital tissues into the sinus or compression by the surrounding bone structures.4–7 Surgery usually involves the reduction of the prolapsed tissues and closure of the opening in the orbital floor using autogenous or synthetic materials.8–13 Although the retro-orbital fatty tissue, orbital fascia and the muscle tissue can be repositioned to the original place after being

Accepted for publication February 21, 2015. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Fatih Ceran, M.D., Ulubatli Hasan Cad. Mutlu Apt. Nu: 9/10, Bahcelievler, Istanbul, Turkey. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000467

Ophthal Plast Reconstr Surg, Vol. 32, No. 3, 2016

incarcerated into the maxillary space, it is obvious that the procedure and delaying the operation may lead to significant fibrosis in these structures. Especially, the fibrosis and atrophy that occurs in the fatty tissue may also lead to enophthalmia in later periods.14–16 There are very few studies in the literature concerning fatty tissue volume following fractures of the orbital floor.17 Changes in the fatty tissue volume that occur in the later periods may affect the success of the treatment even though an ideal surgical repair is made in the first place. We have aimed to carry out a quantitative evaluation of the fatty tissue volume of patients in whom repair was delayed more than two weeks, and who consulted to the authors’ clinic from other health centers. The preoperative and postoperative fatty tissue volume and the changes in total orbital volume were evaluated using CT. Although no significant correlation was observed between the prolapsed volume and the postoperative reduction in the fatty tissue, the reduction in the retro-orbital fatty tissue was statistically significant.

MATERIALS AND METHODS The study was approved by the Bagcilar Training and Research Hospital Ethics Committee of Research by the 2015–338 number. Cases The pre- and postsurgical fatty tissue volume and the changes in total orbital volume were evaluated using CT on the nine patients who underwent surgery in the authors’ clinic between 2009 and 2012 due to fractures of the orbital floor with distinct soft tissue prolapse. The patients’ ages varied between 9 and 47 years, with a mean age of 22. All the patients were male with the exception of 2 female. Among the patients, 3 had distinct enophthalmia (>2 mm), 2 had diplopia, and 4 had radiologically proven orbital floor defects >1 cm2 with enophthalmia. The inclusion criterion of the patients was surgical repair performed within 15 days14–16,18,19 following the trauma. Transconjunctival approach was used as described before.2,8,20 The repair of the orbital floor was performed using titanium mesh (Trimed medium and large size) in all patients. The preoperative CT was compared with a repeat CT taken 6–8 months postoperatively (Figs. 1, 2, 3). Tomographic Evaluation A Philips Briliance 64 detector CT was used to obtain axial images with an average thickness of 1 mm. Sagittal and coronal reformatted images were obtained and the fatty tissue between 180-30 HU was accepted as retro-orbital adipose tissue. On each 1 mm cross section passing through the orbit, the volume of the retro-orbital fatty tissue was calculated by subtracting the volume of the globe together with the retro-orbital muscle and neural tissues from the total volume of the soft tissues within the orbit. The volume of the prolapsed fatty tissue into the orbital floor, the total

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FIG. 1.  Coronal section: Right blow out fracture with r­ etro-orbital fatty tissue (in blue) plunged into the maxillary sinus.

FIG. 3.  Sagittal section: Retro-orbital fatty tissue shifted into the maxillary sinus (in blue). The volume of the prolapsed fatty tissue varied between 0.5 and 2.4 cc. The reduction in total orbital fatty tissue during the postoperative period was found between 0.1 and 1.9 cc. The postoperative change in the volume of the fatty tissue varied between 2 and 18%. Although no significant correlation was observed between the prolapsed volume and the postoperative reduction in the fatty tissue, the reduction in the retroorbital fatty tissue was statistically significant (Table 2). The Wilcoxon matched pairs test performed to reveal if the means of the control and postoperative total values show a statistically significant difference pointed out that the difference between the arithmetic means is statistically significant (Z = -2.938; p = 0.003 < 0.05). The mean of control (cc; x = 9.218) was higher than the postoperative total mean (cc; x = 8.127) (Table 2). The Wilcoxon matched pairs test performed to find out if the postoperative/preoperative (surgically corrected/reducted volume) means and the prolapsus values show a statistically significant difference pointed to a statistically insignificant result (p > 0.05; Table 3). During the 18-month clinical follow-up period, diplopia was observed to continue in 1 patient, whereas in all the other patients the diplopia completely disappeared. There were no other complications.

DISCUSSION FIG. 2.  Axial cross section: Right retro-orbital fatty tissue (in blue). preoperative fatty tissue volume, the postoperative volume of the retroorbital fatty tissue on the repaired side, and the total volume of the fatty tissue on the unaffected side were recorded (Table 1). There are no data or measurements in literature to define these values, and orbital volumes are individualized. We used the fat volume of the unaffected side as a control for the presumed pre-injury volume of the fractured side.

RESULTS The data obtained from the study were analyzed using the Statistical Package for Social Sciences (SPSS) for Windows 17.0 software. The data were evaluated with the help of complementary statistical methods. The Wilcoxon matched pairs test has been employed to evaluate the difference between the qualitatively related groups. The obtained results were assessed within a 95% confidence interval and statistical significance was based on a value of p = 0.05.

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Orbital floor fractures were first named by Smith and Regan.18 The condition is usually brought about by blunt trauma on or around the orbit due to car crashes, workplace accidents, or assault. The clinical condition involves a prolapse of the retroorbital fatty tissues and sometimes muscle structures as they are pressed into the maxillary sinus through the fractured delicate bones on the orbital floor. The condition may lead to enophthalmia, diplopia, and limitation of movement due to entrapment of the extraocular muscles or their fascial attachments. In the patients with this condition, the main surgical aim is to release the displaced and compressed orbital soft tissues from the space into which they have prolapsed and to relocate them to correct or minimize the diplopia and/or enophthalmia. Subciliary, transconjunctival, or endoscopic transmaxillary approaches may provide access to the fracture line.19–21 Although in suitable patients the fracture can be reduced after the relocation of the compressed tissues, in many patients, the repair of the orbital floor is only possible with the help of autogenous

© 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.

Copyright © 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.

Ophthal Plast Reconstr Surg, Vol. 32, No. 3, 2016

Retro-Orbital Fatty Tissue Volume

TABLE 1.  Evaluation of retro-orbital fat Mean reduction (%)

Postoperative– preoperative (cc)

Prolapsed volume (cc)

Control (cc)

Postoperative total (cc)

-1.9 -1.3 -0.5 -0.6 -0.8 -0.8 -0.6 -1.5 -1

2.4 1 0.5 0.8 0.6 0.8 0.5 0.8 0.5

11.3 10.4 8 7.3 13.2 9.1 5.7 8.7 6.6

9.4 9.1 7.5 6.7 12.4 8.3 5.1 7.2 5.6

17 13 2 9 6 9 11 18 16

Mean reduction (%), postoperative–preoperative volume (cc), prolapsed volume (cc), control volume (cc), and postoperative total volume (cc) measurements are defined. There is a significant reduction in postoperative volumes. This situation might be attributed to surgical trauma and delayed procedure.

CONCLUSION

TABLE 2.  Statistical analysis of the data Control (cc)

Postoperative total (cc)

Mean

SD

Mean

SD

N

Z

p

9.218

2.245

8.127

2.035

11

-2.938

0.003

These data compare control volume and postoperative total volume. The reduction in the retro-orbital fatty tissue is statistically significant.

TABLE 3.   Statistical analysis of the data Postoperative/ Preoperative (cc)

In patients with orbital blow-out fractures and fat prolapse into the maxillary sinus, the authors believe that delayed surgical intervention and possibly surgical trauma are the main factors in determining retro-orbital fatty tissue volume. Although the prolapsed tissue can be surgically repositioned, volume losses in the retro-orbital fatty tissue may be observed during the postoperative period and this situation might be attributed to both the initial injury and subsequent surgical trauma. The authors are of the opinion that quantitatively describing the reduction in the volume of the fatty tissue, as shown here, may contribute to the planning of secondary procedures.

Prolapsus (cc)

REFERENCES

Mean

SD

Mean

SD

N

Z

P

-1.046

0.535

1.082

0.707

11

-0.307

0.759

This statistical analysis shows that there is no statistically significant difference between postoperative/preoperative (surgically corrected/reducted volume) volume and prolapsed volume.

tissues, such as bones or cartilage or using synthetic materials such as Medpor or titanium mesh.8–13 In the literature, there are authors who underline the importance of early surgical intervention to prevent enophthalmia due to fibrosis and atrophy in the soft tissues, especially after the relocation of the tissues and the repair of the orbital floor performed within the first 4 weeks following the trauma.22,23 For the purposes of this study, the authors performed surgery longer than 2 weeks after the trauma because of delayed consultations. We observed a significant reduction in the retro-orbital fatty tissue during the sixth to eighth postoperative months. The authors think that delayed reconstruction as well as possible surgical trauma may be determinants of postoperative retro-orbital fatty tissue volume. Fat graft injection to restore the retrobulbar volume in enophthalmic patients has been advocated the literature due to its minimal complication rates and clinical success.24 Although attempts have been made to increase the orbital volume through the injection of cross-linked collagen (Zyplast) in enophthalmic patients, the method has limited use in healthy eyes.25 In patients where enophthalmia is expected, considering the successful results obtained through the injection of fat grafts, a treatment algorithm may be established based on the tomographically assessed quantitative loss of volume and the volume to be required for the fat graft injection, which should be the subject of another study.

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© 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.

Copyright © 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.

Evaluation of the Retro-Orbital Fatty Tissue Volume in Delayed Orbital Blow-Out Fractures.

In patients where diplopia and enophthalmia are manifest, surgical intervention is usually necessary. The pathogenesis of these symptoms usually inclu...
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