TECHNICAL STRATEGY
Medpor Implant Fixation Using Fibrin Glue in the Treatment of Medial Orbital Wall Fracture Nakheon Kang, MD, Seung Han Song, MD,y Hyunwoo Kyung, MD,y and Sang-Ha Oh, MDyz Abstract: The optimal treatment modalities are determined based on the symptoms and degree of the bone defects in patients with medial orbital wall blowout fracture. Most of the patients in this series underwent implant surgery. However, there are many patients whose implants were not fixed during surgery. Therefore, some patients who had implant migration occurred had been reported. We have therefore used methods for applying fibrin glue (Tisseel, Baxter Healthcare, Norfolk, United Kingdom) for the fixation of implant. Between 2007 and 2013, a total of 168 patients underwent porous polyethylene orbital implant (Medpor) surgery with the application of Tisseel. All the patients underwent surgical treatments via a transcaruncular approach, for which the Medpor was used. Postoperative complications include 6 cases of the limitation of extraoccular movement, 10 cases of diplopia, and 7 cases of enophthalmos. However, there were no specific complications caused by Tisseel. All the patients were satisfied with the treatment outcomes. In this study, we report the usefulness of Tisseel in the fixation of the medial orbital wall fracture using the Medpor implant with a review of literatures. Key Words: Medpor, implant fixation, fibrin glue (J Craniofac Surg 2015;26: 1361–1364)
O
rbital wall fracture occurs if a physical blow is given to patients. In addition, when there are prolapse of orbital contents to the bone defect areas and the entrapment of soft tissue in patients with orbital wall fracture, such patients are vulnerable to enophthalmos, diplopia, and limitation of extraoccular movement (EOM). It is generally recommended that conservative treatments be performed for patients with medial wall fracture who had small defect areas and presented with mild to moderate symptoms. In patients who had a great difference in the height between 2 orbits, were positive for the forced duction test, and had severe bone From the Department of Plastic and Reconstructive Surgery, School of Medicine; yClinical Anatomy Institution, Chungnam National University Hospital, Jung-gu; and zBiO & J Inc., Daejeon, South Korea. Received April 29, 2014. Accepted for publication January 31, 2015. Address correspondence and reprint requests to Seung Han Song, MD, Department of Plastic and Reconstructive Surgery, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 301-721, Korea; E-mail: [email protected] The authors have certified that the process of the research is in accordance with ethical standards of Helsinki declaration, domestic and foreign committees that preside over human experiment. This work was supported by research fund of Chungnam National University. The authors report no conflict of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001688
The Journal of Craniofacial Surgery
defects on radiologic examinations, surgeons should consider surgical operations.1 On reaching the fracture sites through various approaches, surgeons should remove the prolapsed orbital contents and thereby should restore the orbital volume. To prevent the recurrence of symptoms, surgeons should use inorganic implants or autogenous materials for the reconstruction of the bone defect areas. To date, several methods have been developed to fix the implants in patients with orbital floor fracture. However, there are few appropriate treatment methods for patients with medial orbital wall fracture. The displacement of implant also remains problematic. It has also been reported that the implant is protruded outside of the skin.2 Given the above background, we have successfully performed the Medpor implant fixation using fibrin glue (Tisseel, Baxter Healthcare, Norfolk, United Kingdom). Here, we report our treatment outcomes with a review of literatures.
PATIENTS AND METHODS Study Patients Of the patients who were diagnosed with medial orbital wall fracture at the department of plastic and reconstructive surgery of our medical institution between 2007 and 2013, 168 underwent surgical treatments. Since 2011, Tisseel was used during surgery. The patients who fixed the implant using other methods were excluded from the comparison. Surgical indications include diplopia, decreased visual acuity, abnormal findings on forced duction test, severe enophthalmos with a more than 2 mm difference in the height between the 2 orbits, larger bone defect areas on computed tomography (CT) scans and severe prolapse of the orbital contents.
Surgical Methods All the surgical procedures were performed under general anesthesia. For bleeding control, we performed nasal packing with 1% phenylephrine gauze and then maintained eye opening with a lid speculum. In addition, we also performed traction suture at the sites of medial rectus muscle using a 4-0 black silk. While grasping the conjunctiva using forceps around the caruncle, we made an incision using scissors. Then, we made a blunt dissection to the sites of incision. On reaching the periosteum of medial orbital wall, we made a periosteal incision. With the full elevation of periorbita, we exposed the medial orbital wall. While reducing the prolapsed orbital contents, we performed forced duction test and thereby confirmed the ocular motility. In patients where the medial orbital wall was well maintained solely with the bone reduction, we performed titanium mesh Medpor implant insertion surgery. Then, we performed forced duction test again to confirm the ocular motility. We also used the Tisseel in the fixation of Medor. While cautioning not to mobilize the fibrin glue layer, we repaired the periosteum and conjunctival wounds (Fig. 1).
Volume 26, Number 4, June 2015
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Kang et al
Volume 26, Number 4, June 2015
TABLE 1. The Incidence of Postoperative Complications
Group 1 (n ¼ 51, 30.4%) Group 2 (n ¼ 117, 69.6%)
Diplopia
Enophthalmos
Limitation of EOM
4 (7.8) 10 (8.5) 14 (8.3)
3 (5.8) 7 (5.9) 10 (5.6)
3 (5.8) 6 (5.1) 9 (5.4)
Values are presented as the number of patients (%). Group 1: Medpor only/group 2: Medpor and Tisseel. FIGURE 1. Schematic representation. Left, medial orbital wall fracture. Center, Medpor implant insertion. Right, Tisseel application.
RESULTS In our series, a total of 168 patients were surgically treated for medial orbital wall fracture; they are composed of 133 men (79.1%) and 35 women (20.9%). In 51 patients (30.4%), the medial orbital wall was reconstructed with the insertion of Medpor implant without using Tisseel (group 1). There were 117 patients (69.6%) for whom we used both Medpor and Tisseel (group 2). Before discharge, CT scan was performed in all patients, there were no patients who had the displacement of Medpor implant in group 2 (Fig. 2). The postoperative complications occurred in patients who did not undergo Tisseel application surgery; these include 4 cases (7.8%) of diplopia, 3 cases (5.8%) of enophthalmos, and 3 cases (5.8%) of the limitation of EOM. In addition, the postoperative complications also occurred in patients who underwent Medpor implant surgery with Tisseel application; these include 10 cases (8.5%) of diplopia, 7 cases (5.9%) of enophthalmos, and 6 cases (5.1%) of the limitation of EOM (Table 1). In group 1, symptoms improved spontaneously in most patients, but revision surgery was performed in 3 cases. Among them, 1 case was observed in the migration of Medpor implant. Despite the occurrence of complications, in group 2, there were no patients who presented with severe symptoms to such an extent that they should undergo revision surgery. Our clinical series of patients gradually achieved improvement of the symptoms and were followed up while receiving conservative treatments, within 2 weeks to 3 months after operation depending patients. Also, foreign body reaction or permanent swelling, expected to be incurred from the use of Tisseel, was not observed.
DISCUSSION It is generally known that the blow out fracture occurs when the 2 fragile parts of the orbital bone, the lamina papyracea or orbital floor, are fractured when they are given physical blows. This may also be accompanied by the occurrence of enophthalmos that is characterized by the prolapse of soft tissue and the orbital displacement.3 Blow out fracture occurs based on the following 2 mechanisms: (1) With the posterior displacement of eyeball, the intraocular
FIGURE 2. The titanium mesh Medpor implant was well maintained on postoperative CT scans. Left, preoperative CT scans. Center, 6 days after reconstruction. Right, 3 months after reconstruction.
1362
pressure is increased due to the hydraulic transmission. (2) With the direct impact given to the orbital rim, the orbital wall fracture occurs.4 Depending on the sites of bone fracture, the blow out fracture is classified into the orbital floor fracture, medial wall fracture, and compound orbital fracture. Although less prevalent than the orbital floor fracture, the medial orbital wall fracture occurs at a relatively higher incidence, ranging from 18% to 33%, depending on the authors. Moreover, depending on whether it is concurrently present with other types of fracture, it may also be classified into the pure orbital fracture and impure one.5 The symptoms of blow out fracture include subconjunctival hemorrhage, hyphema, enophthalmos, diplopia, ecchymosis, ptosis, nasal bleeding, damaged lacrimal apparatus, and papillary dilatation. Moreover, diplopia, enophthalmos, and disorder of ocular movement are so serious conditions as to leave sequelae.6 Patients with medial orbital wall fracture are vulnerable to diplopia because of the spasm of the extraoccular muscle rather than the prolapse of soft tissue. It is commonly encountered that patients with diplopia achieved a recovery of the symptoms. It remains problematic, however, that patients with enophthalmos cannot achieve a recovery of the symptoms over time.7 Current treatment modalities for the medial orbital wall fracture can be classified into the conservative treatment and surgical one. In association with this, Putterman8,9 and Emery et al8,9 reported that surgeons should consider the conservative treatment as the first line of choice in patients with medial orbital wall fracture. However, they should also consider surgical treatments in patients who were positive for forced duction test and had a degree of enophthalmos greater than 2 mm. With the recent development of CT technology, it has become useful in estimating the accurate size of bone defect areas. Lee et al7 reported that surgical treatments would be effective in reducing the occurrence of late enophthalmos in patients with areas of bone defects greater than 0.55 cm2. This indicates that surgical treatments should be performed for patients with large bone defects confirmed on CT scans. In the treatment of patients with medial orbital wall fracture, various types of conventional approaches have been attempted; these include subpalpebral incision, transconjunctival incision, medial superior palpebral incision, medial epicanthoplasty, and coronal incision. There are recent trends where endoscopy has been increasingly used in the field of plastic and reconstructive surgery. This is also accompanied by the increased use of endoscopic endonasal reduction in the treatment of patients with medial orbital wall fracture.10 The endoscopic endonasal reduction is advantageous in that it causes no herniation because it can be performed under local anesthesia without implant or autogenous materials. On the other hand, it is disadvantageous in that silastic sheet inhibits the nasal secretion and thereby causes sinusitis. Moreover, there are also some case reports about cerebrospinal fluid leakage and concomitant facial fracture occurring in patients who underwent endoscopic endonasal reduction. It is not an easy technique because surgeons should also perform secondary procedures to remove the packing materials. Moreover, it is also #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015Reconstruction of the Medial Orbital Wall Using Fibrin Glue
disadvantageous in that it reduces the supporting force from the lamina papyracea because of the removal of the ethmoidal structure. Furthermore, patients with severe bone defects are contraindicated in the endoscopic endonasal reduction.11 We have therefore used a transcaruncular approach, which leaves no scars for all the patients, thus making it easier to have an access to the bone fracture sites. Then, we could reduce the prolapsed soft tissue and restore the orbital volume. It is known that it would not be effective in maintaining the fracture sites to reduce the bone fragments in patients with medial orbital wall fracture. This explains why many patients with medial orbital wall fracture are indicated in Medpor implant surgery or autogenous bone graft. Autogenous bone graft is advantageous in that the infection occurs at a lower incidence, and it can also be performed for large bone defects. It is also disadvantageous, however, in that the operation time may be prolonged and the appropriate shape cannot be obtained. In addition, it may also be absorbed over time.12 Inorganic material can be designed to a desirable shape. However, the risk of developing infection is relatively higher as compared with autogenous bone graft. Medpor is composed of small pores. Because of the tissue in-growth, it has a lower risk of infection as compared with other materials. It is therefore prevalently used.13 For the reconstruction of orbital bone fracture, the grafted implant should be appropriately fixed. Cuts are made to fit the implant. Thus, it is fixed below the bone fragment of the orbital rim. Otherwise, it may also be fixed using plates and screws.14,15 In cases of medial orbital wall fracture, however, there are many cases for which no specific fixation is attempted. In cases of inferior-medial wall fracture, the defects are reconstructed using titanium mesh plates. This is followed by the fixation of orbital rim using screws.16 It has been reported, however, that it produces complications caused by a mesh plate, such as orbital adherence syndrome.17 Currently, there are no appropriate methods for fixing the implant in patients with medial orbital wall fracture. In cases of the displacement of implant, however, there is a possibility that the symptoms might recur, the implant might be protruded outside of the skin, might compress the optic nerve, or might cause dacryocystitis.18,19 Although rare, it has also been reported to cause an extraorbital migration.2 We have therefore successfully fixed the implant with the application of Tisseel after the placement of Medpor, thus confirming that it was well fixed in the original location on postoperative CT scans. The fibrin glue is composed of fibrinogen, plasmatic protein, factor XIII, thrombin, CaCl2, and aprotinin injections. Once mixed, it forms the fibrin clots and thereby increases the adhesion force between the adjacent tissues. This reduces the shearing force and the bleeding to the final stage of physiologic hemostasis. Over the past several decades, it has been used for gastrointestinal anastomosis surgery, breast surgery, face lift surgery, abdominal surgery, and neurosurgical operations.20 In the early stage, it is obtained by extracting fibrin from the donated blood. It is therefore unavoidable that its quality is relatively poorer and its amount is relatively smaller. There is also a possibility that infections might occur through the blood donation. This limits its availability in a clinical setting.21 Thereafter, fibrin glues, such as Tisseel, have been developed after the thermal treatment to make sure that the risk of infection should be decreased. The scope of their clinical use has been gradually expanded. The structural integrity of fibrin clot is maintained for approximately 3 weeks with the actions of antifibrinolytic component such as aprotinin.22 During that period, the adjacent tissues grow into the small pores of Medpor. This is accompanied by wound healing process. Thus, the stability of reconstruction sites is maintained over time. In our series, on CT scans taken immediately after #
2015 Mutaz B. Habal, MD
surgery and at least 3 months postoperatively, Medpor was well maintained in the original location. During the wound healing process, it causes no fibrosis or foreign body reactions. Over time, it is completely absorbed.23 Therefore, there are no effects caused by Tisseel while increasing the volume. Animal experiments have also shown that it causes no toxicity, mutagenicity, and teratogenicity.24 Our results also showed that there were no complications caused by Tisseel. On a theoretical basis, there is also a risk of viral infections.24 In an actual clinical setting, however, there are no reports about viral infections caused by Tissel. We also did not experience any cases of infection caused by Tisseel. However, Tanemoto and Fujinami25 reported that there is a possibility that bacterial colonization might occur during surgery. In addition, Kyung et al26 also reported that there is a risk of infection. This indicates that surgeons should be careful in the risk of infection when performing implant surgery and applying Tisseel in patients who concurrently had severely contaminated wounds.
CONCLUSIONS We have successfully performed the Medpor implant surgery with the application of Tisseel in the treatment of patients with medial orbital wall fracture. Our results also showed that Tisseel did not appear to increase the complication rate between the conventional methods and ours and did not cause complication because of Tisseel itself compared to other materials.
REFERENCES 1. Converse JM, Smith B. Blowout fracture of the floor of the orbit. Trans Am Acad Ophthalmol Otolaryngol 1960;64:676–688 2. Massaro-Giordano M, Kirschner RA, Wulc AE. Orbital floor implant migration across the ethmoidal sinuses and nasal septum. Am J Ophthalmol 1999;128:122–123 3. Smith B, Regan WF Jr. Blowout fracture of the orbit: mechanism and correction of internal orbital fracture. Am J Ophthalmol 1957;44:733– 739 4. Pfeiffer RL. Traumatic enophthalmos. Arch Ophthalmol 1943;30:718 5. Kim YS, Lee KN, Ahn HC, et al. Clinical importance of medial wall fracture of orbit. J Korean Soc Plast Reconstr Surg 1995;22:99–106 6. Mucci B. A new perspective on blow-out fracture of the orbit. Injury 1997;28:555–556 7. Lee WT, Kim HK, Chung SM. Relationship between small-size medial orbital wall fracture and late enophthalmos. J Craniofac Surg 2009;20:75–80 8. Putterman AM. Management of blow out fractures of the orbital floor.III. The conservative approach. Surv Ophthalmol 1991;35:292– 298 9. Emery JM, Noorden GK, Sclernitzauer DA. Orbital floor fractures: long-term follow-up of cases with and without surgical repair. Trans Am Acad Ophthalmol Otolaryngol 1971;75:802–812 10. Park DH, Lee JW, Han DG, et al. The endoscopic treatment of orbital fracture. J Korean Soc Plast Reconstr Surg 1997;24:61 11. Chung WC, Lee MJ, Kang YS, et al. Transnasal Endoscopic Reduction of medial orbital blowout fracture. J Korean Soc Plast Reconstr Surg 1999;109:1101–1106 12. Kim YJ, Kim IJ, Lim P. A clinical analysis of the pure blowout fracture. J Korean Soc Plast Reconstr Surg 1994;21:736–744 13. Kim HS, Ryu YA, Woo JS, et al. Comparative observation of barrier sheet and non-barrier sheet Medpor inserted on orbital floor in rabbits J Korean Soc Plast Reconstr Surg 2004;31:682 14. Tse DT. Cyanoacrylate tissue adhesive in securing orbital implants. Ophthalmic Surg 1986;17:577–580 15. Manson PN. Facial Fractures. In: Mathes SJ, ed. Plastic Surgery. 2nd ed. Philadelphia: Saunders Elsevier; 2006:77 16. Garibaldi DC, Iliff NT, Grant MP, et al. Merbs use of porous polyethylene with embedded titanium in orbital reconstruction: a review of 106 patients. Ophthal Plast Reconstr Surg 2007;23:439–444
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17. Lee HBH, Nunery WR. Orbital adherence syndrome secondary to titanium implant material. Ophthal Plast Reconstr Surg 2009;25:33–36 18. Jordan DR, Onge PS, Anderson RL, et al. Complications associated with alloplastic implants used in orbital fracture repair. Ophthalmology 1992;89:1600–1608 19. Mauriello JA, Fiore PM, Kotch M. Dacryocystitis: late complication of orbital floor fracture repair with silicone implant. Ophthalmology 1987;94:248–250 20. Grossman JA, Capraro PA. Long term experience with the use of fibrin sealant in aesthetic surgery. Aesthet Surg J 2007;27:558–562 21. Gibble JW, Ness PM. Fibrin glue: the perfect operative sealant? Transfusion 1990;30:741–747
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22. Radosevich M, Goubran HI, Burnouf T. Fibrin sealant: scientific rationale, production methods, properties, and current clinical use. Vox Sang 1997;72:133–143 23. Brennan M. Fibrin glue. Blood Rev 1991;5:240–244 24. Ali SN, Gill P, Oikonomou D, et al. The combination of fibrin glue and quilting reduces drainage in the extended latissimus dorsi flapdonor site. Plast Reconstr Surg 2010;125:1615–1619 25. Tanemoto K, Fujinami H. Experimental study on bacterial colonization of fibrin glue and its prevention. Clin Ther 1994;16:1016–1027 26. Kyung H, Song SH, Kang N, et al. Medpor implant fixation using fibrin glue in blowout fracture surgery. J Craniofac Surg 2013;24:1781–1784
#
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Medpor Implant Fixation Using Fibrin Glue in the Treatment of Medial Orbital Wall Fracture Nakheon Kang, MD, Seung Han Song, MD,y Hyunwoo Kyung, MD,y and Sang-Ha Oh, MDyz Abstract: The optimal treatment modalities are determined based on the symptoms and degree of the bone defects in patients with medial orbital wall blowout fracture. Most of the patients in this series underwent implant surgery. However, there are many patients whose implants were not fixed during surgery. Therefore, some patients who had implant migration occurred had been reported. We have therefore used methods for applying fibrin glue (Tisseel, Baxter Healthcare, Norfolk, United Kingdom) for the fixation of implant. Between 2007 and 2013, a total of 168 patients underwent porous polyethylene orbital implant (Medpor) surgery with the application of Tisseel. All the patients underwent surgical treatments via a transcaruncular approach, for which the Medpor was used. Postoperative complications include 6 cases of the limitation of extraoccular movement, 10 cases of diplopia, and 7 cases of enophthalmos. However, there were no specific complications caused by Tisseel. All the patients were satisfied with the treatment outcomes. In this study, we report the usefulness of Tisseel in the fixation of the medial orbital wall fracture using the Medpor implant with a review of literatures. Key Words: Medpor, implant fixation, fibrin glue (J Craniofac Surg 2015;26: 1361–1364)
O
rbital wall fracture occurs if a physical blow is given to patients. In addition, when there are prolapse of orbital contents to the bone defect areas and the entrapment of soft tissue in patients with orbital wall fracture, such patients are vulnerable to enophthalmos, diplopia, and limitation of extraoccular movement (EOM). It is generally recommended that conservative treatments be performed for patients with medial wall fracture who had small defect areas and presented with mild to moderate symptoms. In patients who had a great difference in the height between 2 orbits, were positive for the forced duction test, and had severe bone From the Department of Plastic and Reconstructive Surgery, School of Medicine; yClinical Anatomy Institution, Chungnam National University Hospital, Jung-gu; and zBiO & J Inc., Daejeon, South Korea. Received April 29, 2014. Accepted for publication January 31, 2015. Address correspondence and reprint requests to Seung Han Song, MD, Department of Plastic and Reconstructive Surgery, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 301-721, Korea; E-mail: [email protected] The authors have certified that the process of the research is in accordance with ethical standards of Helsinki declaration, domestic and foreign committees that preside over human experiment. This work was supported by research fund of Chungnam National University. The authors report no conflict of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001688
The Journal of Craniofacial Surgery
defects on radiologic examinations, surgeons should consider surgical operations.1 On reaching the fracture sites through various approaches, surgeons should remove the prolapsed orbital contents and thereby should restore the orbital volume. To prevent the recurrence of symptoms, surgeons should use inorganic implants or autogenous materials for the reconstruction of the bone defect areas. To date, several methods have been developed to fix the implants in patients with orbital floor fracture. However, there are few appropriate treatment methods for patients with medial orbital wall fracture. The displacement of implant also remains problematic. It has also been reported that the implant is protruded outside of the skin.2 Given the above background, we have successfully performed the Medpor implant fixation using fibrin glue (Tisseel, Baxter Healthcare, Norfolk, United Kingdom). Here, we report our treatment outcomes with a review of literatures.
PATIENTS AND METHODS Study Patients Of the patients who were diagnosed with medial orbital wall fracture at the department of plastic and reconstructive surgery of our medical institution between 2007 and 2013, 168 underwent surgical treatments. Since 2011, Tisseel was used during surgery. The patients who fixed the implant using other methods were excluded from the comparison. Surgical indications include diplopia, decreased visual acuity, abnormal findings on forced duction test, severe enophthalmos with a more than 2 mm difference in the height between the 2 orbits, larger bone defect areas on computed tomography (CT) scans and severe prolapse of the orbital contents.
Surgical Methods All the surgical procedures were performed under general anesthesia. For bleeding control, we performed nasal packing with 1% phenylephrine gauze and then maintained eye opening with a lid speculum. In addition, we also performed traction suture at the sites of medial rectus muscle using a 4-0 black silk. While grasping the conjunctiva using forceps around the caruncle, we made an incision using scissors. Then, we made a blunt dissection to the sites of incision. On reaching the periosteum of medial orbital wall, we made a periosteal incision. With the full elevation of periorbita, we exposed the medial orbital wall. While reducing the prolapsed orbital contents, we performed forced duction test and thereby confirmed the ocular motility. In patients where the medial orbital wall was well maintained solely with the bone reduction, we performed titanium mesh Medpor implant insertion surgery. Then, we performed forced duction test again to confirm the ocular motility. We also used the Tisseel in the fixation of Medor. While cautioning not to mobilize the fibrin glue layer, we repaired the periosteum and conjunctival wounds (Fig. 1).
Volume 26, Number 4, June 2015
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Kang et al
Volume 26, Number 4, June 2015
TABLE 1. The Incidence of Postoperative Complications
Group 1 (n ¼ 51, 30.4%) Group 2 (n ¼ 117, 69.6%)
Diplopia
Enophthalmos
Limitation of EOM
4 (7.8) 10 (8.5) 14 (8.3)
3 (5.8) 7 (5.9) 10 (5.6)
3 (5.8) 6 (5.1) 9 (5.4)
Values are presented as the number of patients (%). Group 1: Medpor only/group 2: Medpor and Tisseel. FIGURE 1. Schematic representation. Left, medial orbital wall fracture. Center, Medpor implant insertion. Right, Tisseel application.
RESULTS In our series, a total of 168 patients were surgically treated for medial orbital wall fracture; they are composed of 133 men (79.1%) and 35 women (20.9%). In 51 patients (30.4%), the medial orbital wall was reconstructed with the insertion of Medpor implant without using Tisseel (group 1). There were 117 patients (69.6%) for whom we used both Medpor and Tisseel (group 2). Before discharge, CT scan was performed in all patients, there were no patients who had the displacement of Medpor implant in group 2 (Fig. 2). The postoperative complications occurred in patients who did not undergo Tisseel application surgery; these include 4 cases (7.8%) of diplopia, 3 cases (5.8%) of enophthalmos, and 3 cases (5.8%) of the limitation of EOM. In addition, the postoperative complications also occurred in patients who underwent Medpor implant surgery with Tisseel application; these include 10 cases (8.5%) of diplopia, 7 cases (5.9%) of enophthalmos, and 6 cases (5.1%) of the limitation of EOM (Table 1). In group 1, symptoms improved spontaneously in most patients, but revision surgery was performed in 3 cases. Among them, 1 case was observed in the migration of Medpor implant. Despite the occurrence of complications, in group 2, there were no patients who presented with severe symptoms to such an extent that they should undergo revision surgery. Our clinical series of patients gradually achieved improvement of the symptoms and were followed up while receiving conservative treatments, within 2 weeks to 3 months after operation depending patients. Also, foreign body reaction or permanent swelling, expected to be incurred from the use of Tisseel, was not observed.
DISCUSSION It is generally known that the blow out fracture occurs when the 2 fragile parts of the orbital bone, the lamina papyracea or orbital floor, are fractured when they are given physical blows. This may also be accompanied by the occurrence of enophthalmos that is characterized by the prolapse of soft tissue and the orbital displacement.3 Blow out fracture occurs based on the following 2 mechanisms: (1) With the posterior displacement of eyeball, the intraocular
FIGURE 2. The titanium mesh Medpor implant was well maintained on postoperative CT scans. Left, preoperative CT scans. Center, 6 days after reconstruction. Right, 3 months after reconstruction.
1362
pressure is increased due to the hydraulic transmission. (2) With the direct impact given to the orbital rim, the orbital wall fracture occurs.4 Depending on the sites of bone fracture, the blow out fracture is classified into the orbital floor fracture, medial wall fracture, and compound orbital fracture. Although less prevalent than the orbital floor fracture, the medial orbital wall fracture occurs at a relatively higher incidence, ranging from 18% to 33%, depending on the authors. Moreover, depending on whether it is concurrently present with other types of fracture, it may also be classified into the pure orbital fracture and impure one.5 The symptoms of blow out fracture include subconjunctival hemorrhage, hyphema, enophthalmos, diplopia, ecchymosis, ptosis, nasal bleeding, damaged lacrimal apparatus, and papillary dilatation. Moreover, diplopia, enophthalmos, and disorder of ocular movement are so serious conditions as to leave sequelae.6 Patients with medial orbital wall fracture are vulnerable to diplopia because of the spasm of the extraoccular muscle rather than the prolapse of soft tissue. It is commonly encountered that patients with diplopia achieved a recovery of the symptoms. It remains problematic, however, that patients with enophthalmos cannot achieve a recovery of the symptoms over time.7 Current treatment modalities for the medial orbital wall fracture can be classified into the conservative treatment and surgical one. In association with this, Putterman8,9 and Emery et al8,9 reported that surgeons should consider the conservative treatment as the first line of choice in patients with medial orbital wall fracture. However, they should also consider surgical treatments in patients who were positive for forced duction test and had a degree of enophthalmos greater than 2 mm. With the recent development of CT technology, it has become useful in estimating the accurate size of bone defect areas. Lee et al7 reported that surgical treatments would be effective in reducing the occurrence of late enophthalmos in patients with areas of bone defects greater than 0.55 cm2. This indicates that surgical treatments should be performed for patients with large bone defects confirmed on CT scans. In the treatment of patients with medial orbital wall fracture, various types of conventional approaches have been attempted; these include subpalpebral incision, transconjunctival incision, medial superior palpebral incision, medial epicanthoplasty, and coronal incision. There are recent trends where endoscopy has been increasingly used in the field of plastic and reconstructive surgery. This is also accompanied by the increased use of endoscopic endonasal reduction in the treatment of patients with medial orbital wall fracture.10 The endoscopic endonasal reduction is advantageous in that it causes no herniation because it can be performed under local anesthesia without implant or autogenous materials. On the other hand, it is disadvantageous in that silastic sheet inhibits the nasal secretion and thereby causes sinusitis. Moreover, there are also some case reports about cerebrospinal fluid leakage and concomitant facial fracture occurring in patients who underwent endoscopic endonasal reduction. It is not an easy technique because surgeons should also perform secondary procedures to remove the packing materials. Moreover, it is also #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015Reconstruction of the Medial Orbital Wall Using Fibrin Glue
disadvantageous in that it reduces the supporting force from the lamina papyracea because of the removal of the ethmoidal structure. Furthermore, patients with severe bone defects are contraindicated in the endoscopic endonasal reduction.11 We have therefore used a transcaruncular approach, which leaves no scars for all the patients, thus making it easier to have an access to the bone fracture sites. Then, we could reduce the prolapsed soft tissue and restore the orbital volume. It is known that it would not be effective in maintaining the fracture sites to reduce the bone fragments in patients with medial orbital wall fracture. This explains why many patients with medial orbital wall fracture are indicated in Medpor implant surgery or autogenous bone graft. Autogenous bone graft is advantageous in that the infection occurs at a lower incidence, and it can also be performed for large bone defects. It is also disadvantageous, however, in that the operation time may be prolonged and the appropriate shape cannot be obtained. In addition, it may also be absorbed over time.12 Inorganic material can be designed to a desirable shape. However, the risk of developing infection is relatively higher as compared with autogenous bone graft. Medpor is composed of small pores. Because of the tissue in-growth, it has a lower risk of infection as compared with other materials. It is therefore prevalently used.13 For the reconstruction of orbital bone fracture, the grafted implant should be appropriately fixed. Cuts are made to fit the implant. Thus, it is fixed below the bone fragment of the orbital rim. Otherwise, it may also be fixed using plates and screws.14,15 In cases of medial orbital wall fracture, however, there are many cases for which no specific fixation is attempted. In cases of inferior-medial wall fracture, the defects are reconstructed using titanium mesh plates. This is followed by the fixation of orbital rim using screws.16 It has been reported, however, that it produces complications caused by a mesh plate, such as orbital adherence syndrome.17 Currently, there are no appropriate methods for fixing the implant in patients with medial orbital wall fracture. In cases of the displacement of implant, however, there is a possibility that the symptoms might recur, the implant might be protruded outside of the skin, might compress the optic nerve, or might cause dacryocystitis.18,19 Although rare, it has also been reported to cause an extraorbital migration.2 We have therefore successfully fixed the implant with the application of Tisseel after the placement of Medpor, thus confirming that it was well fixed in the original location on postoperative CT scans. The fibrin glue is composed of fibrinogen, plasmatic protein, factor XIII, thrombin, CaCl2, and aprotinin injections. Once mixed, it forms the fibrin clots and thereby increases the adhesion force between the adjacent tissues. This reduces the shearing force and the bleeding to the final stage of physiologic hemostasis. Over the past several decades, it has been used for gastrointestinal anastomosis surgery, breast surgery, face lift surgery, abdominal surgery, and neurosurgical operations.20 In the early stage, it is obtained by extracting fibrin from the donated blood. It is therefore unavoidable that its quality is relatively poorer and its amount is relatively smaller. There is also a possibility that infections might occur through the blood donation. This limits its availability in a clinical setting.21 Thereafter, fibrin glues, such as Tisseel, have been developed after the thermal treatment to make sure that the risk of infection should be decreased. The scope of their clinical use has been gradually expanded. The structural integrity of fibrin clot is maintained for approximately 3 weeks with the actions of antifibrinolytic component such as aprotinin.22 During that period, the adjacent tissues grow into the small pores of Medpor. This is accompanied by wound healing process. Thus, the stability of reconstruction sites is maintained over time. In our series, on CT scans taken immediately after #
2015 Mutaz B. Habal, MD
surgery and at least 3 months postoperatively, Medpor was well maintained in the original location. During the wound healing process, it causes no fibrosis or foreign body reactions. Over time, it is completely absorbed.23 Therefore, there are no effects caused by Tisseel while increasing the volume. Animal experiments have also shown that it causes no toxicity, mutagenicity, and teratogenicity.24 Our results also showed that there were no complications caused by Tisseel. On a theoretical basis, there is also a risk of viral infections.24 In an actual clinical setting, however, there are no reports about viral infections caused by Tissel. We also did not experience any cases of infection caused by Tisseel. However, Tanemoto and Fujinami25 reported that there is a possibility that bacterial colonization might occur during surgery. In addition, Kyung et al26 also reported that there is a risk of infection. This indicates that surgeons should be careful in the risk of infection when performing implant surgery and applying Tisseel in patients who concurrently had severely contaminated wounds.
CONCLUSIONS We have successfully performed the Medpor implant surgery with the application of Tisseel in the treatment of patients with medial orbital wall fracture. Our results also showed that Tisseel did not appear to increase the complication rate between the conventional methods and ours and did not cause complication because of Tisseel itself compared to other materials.
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17. Lee HBH, Nunery WR. Orbital adherence syndrome secondary to titanium implant material. Ophthal Plast Reconstr Surg 2009;25:33–36 18. Jordan DR, Onge PS, Anderson RL, et al. Complications associated with alloplastic implants used in orbital fracture repair. Ophthalmology 1992;89:1600–1608 19. Mauriello JA, Fiore PM, Kotch M. Dacryocystitis: late complication of orbital floor fracture repair with silicone implant. Ophthalmology 1987;94:248–250 20. Grossman JA, Capraro PA. Long term experience with the use of fibrin sealant in aesthetic surgery. Aesthet Surg J 2007;27:558–562 21. Gibble JW, Ness PM. Fibrin glue: the perfect operative sealant? Transfusion 1990;30:741–747
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22. Radosevich M, Goubran HI, Burnouf T. Fibrin sealant: scientific rationale, production methods, properties, and current clinical use. Vox Sang 1997;72:133–143 23. Brennan M. Fibrin glue. Blood Rev 1991;5:240–244 24. Ali SN, Gill P, Oikonomou D, et al. The combination of fibrin glue and quilting reduces drainage in the extended latissimus dorsi flapdonor site. Plast Reconstr Surg 2010;125:1615–1619 25. Tanemoto K, Fujinami H. Experimental study on bacterial colonization of fibrin glue and its prevention. Clin Ther 1994;16:1016–1027 26. Kyung H, Song SH, Kang N, et al. Medpor implant fixation using fibrin glue in blowout fracture surgery. J Craniofac Surg 2013;24:1781–1784
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
