Neuronavigation and Endoscopy as Adjunctive Tools in Orbital Floor Implant Revision: Surgical Management of Infected, Misplaced Orbital Floor Implant with Chronic Eyelid Fistula and Sinusitis

Sheen, Derek

doi:https://doi.org/10.24296/jomi/410

Main Text

Orbital floor fractures represent common sequelae of facial trauma that may result in significant functional and aesthetic consequences. This article presents a comprehensive overview of the management of a revision case involving an orbital floor fracture, focusing on complications related to extruded, infected orbital hardware. In addition, common mistakes that involve improper placement of orbital floor implant, poor implant sizing, and lack of adequate implant fixation are discussed.

The featured case involves delayed wound healing and a sino-orbital cutaneous fistula (SOCF) due to infected orbital hardware from a previous orbital floor fracture repair. The discussion centers on preoperative planning, including the choice of surgical approach (transconjunctival with lateral canthotomy) and implant material. Intraoperative neuronavigation was utilized as an adjunctive tool to confirm the position of the newly placed orbital implant. This case provides valuable insight on preventable complications for this procedure, nuances in surgical approach, and uncommon challenges faced by providers who perform operative facial trauma repair.

Orbital fracture; orbital floor; transconjunctival approach; hardware infection; orbital implant; Medpor; polyethylene; titanium; eyelid fistula.

Pneumo-orbit, involving air in the orbital cavity, often stems from sinus-to-orbit connections after orbital trauma. While such cases typically heal spontaneously postfracture repair, persistent fistulas indicate underlying issues. Case reports highlight sino-orbital cutaneous fistula (SOCF) from non-autologous orbital trauma implants.^1–3 In this case, hardware misplacement into the maxillary osteomeatal complex led to ongoing sinus obstruction, creating an anomalous passage to the lower eyelid skin weakened by infected hardware. Addressing this challenging scenario is crucial for restoring normal bony anatomy and preventing similar complications in the future.

A 34-year-old male initially sought care for chronic recurrent drainage under his right eye, stemming from a right orbital blowout fracture seven years ago due to assault. The fracture was initially repaired with open reduction and internal fixation at another institution. Since then, he has experienced intermittent purulent drainage from the right nasal cavity and a lower eyelid fistula. He also noted air movement through the prior incision site when blowing his nose and delayed-onset diplopia with enophthalmos. After initial surgery, the patient underwent multiple courses of antibiotics with waxing and waning symptom improvement.

The physical exam revealed a 3-cm skin dehiscence at the infraorbital rim with crusting and purulent drainage upon palpation. Mild erythema was noted along the skin of the right infraorbital rim at the fistula site. The patient reported mildly decreased right V2 sensation. Diplopia was observed in both primary and directional gazes, and extraocular movements were intact with preserved visual acuity. Nasal endoscopy revealed purulent drainage from the right middle meatus.

Computed tomography (CT) maxillofacial imaging revealed displaced prior hardware along the right orbital floor (Figure 1–3). The right maxillary sinus exhibited complete opacification, indicating presumed chronic maxillary sinusitis and osteomeatal complex obstruction. Persistent bony defects were noted in the medial orbital wall and orbital floor. In sagittal view, the implant was displaced into the maxillary sinus, failing to reconstruct the posterior orbital floor defect. Axial view showed the orbital floor implant extending beyond the infraorbital rim, with an air pocket around a screw, suggesting hardware failure with infection.

Figure 1. Preoperative non-contrast coronal CT scan. CT image demonstrating inferior displacement of the medial aspect of the orbital floor implant and the connection between the paranasal sinuses and orbital cavity.

Figure 2. Preoperative non-contrast sagittal CT scan. CT image demonstrating inferior displacement of the orbital floor implant into the maxillary sinus as well as inadequate posterior seating on the residual orbital floor.

Figure 3. Preoperative non-contrast axial CT scan. CT image demonstrating free air adjacent to the lateral screw in the orbital rim.

Orbital trauma workup necessitates a thorough physical examination focusing on external deformities, along with a comprehensive ophthalmic and neurologic examination. Preoperative imaging with fine-cut non-contrast CT scans aid in intraoperative decision-making. When integrated with neuronavigation, CT assists in differentiating landmarks, particularly in distorted anatomy.

The foremost priority was eliminating the source of ongoing infection by removing compromised hardware. Next, addressing persistent diplopia by restoring premorbid orbital volume was crucial. The third priority focused on resolving the blockage of the maxillary sinus drainage pathway leading to persistent maxillary sinusitis. The final goal encompassed addressing the eyelid scar resulting from the fistula and improving cosmesis.

Patients presenting with hardware infections beyond one month postoperatively, especially those who have failed multiple antibiotic courses, typically benefit from complete hardware removal due to potential biofilm formation.⁴ Surgical intervention is often recommended for patients with persistent diplopia and globe malpositioning lasting more than 1–3 months, as advised by senior authors (TL, DS).

Revision orbital surgery may not be necessary if hardware infection responds to antibiotics within the first month postsurgery, prior to biofilm formation. In cases of severe orbital trauma, such as intraconal hemorrhage or retinal detachment, surgery is contraindicated to minimize the risk of further intraoperative orbital injury from globe retraction.

The patient in this case underwent 1) orbital hardware removal with a postseptal, transconjunctival approach and lateral canthotomy, 2) orbital floor implant replacement using a Medpor-titanium implant with neuronavigation, 3) conservative maxillary antrostomy with tissue removal, and 4) eyelid fistula excision with local tissue advancement closure.

The patient’s facial region was draped with the contralateral orbit exposed to assess for symmetry. Lidocaine and epinephrine were injected for hemostasis and hydrodissection of tissue planes, particularly at the orbital rim where tethering around the fistula had occurred. The senior author (TL), as a matter of preference, operates with a corneal shield. Subsequently, a lateral canthotomy was performed to enhance exposure and mobilize the lower lid.

Orbital floor fractures are generally approached through transconjunctival or transcutaneous approaches. Transcutaneous incisions, such as the subciliary, subtarsal, and orbital rim approaches, pose a higher risk of postoperative ectropion.^5–8 In contrast, the transconjunctival approach is preferred due to its avoidance of external incisions, resulting in lower rates of ectropion or retraction, while preserving the innervation of the orbicularis muscle.^9, 10

The senior authors (TL, DS) favor a transconjunctival incision in a postseptal plane down to the orbital rim. Although this dissection plane is considered simpler, there is no statistically significant difference in rates of entropion, ectropion, foreign body sensation, and scar formation.⁹ In the transconjunctival approach, preserving the tarsal plate is crucial. The incision should be made near the infraorbital rim, with the lower eyelid retracted using a Desmarres retractor. If the incision is medial to the punctum, caution is needed to prevent injury to the canaliculus and lacrimal system. Staying close to the caruncle or transitioning to a transcaruncular incision can help mitigate the risk of damage.

In this case, identifying the subperiosteal tissue plane through the transconjunctival incision was difficult due to fibrosis and adhesions from the previous infection along the infraorbital rim. To address this, the lateral canthotomy site was used to initially identify the subperiosteal tissue plane along the lateral orbital wall, which was then carried centrally to the transconjunctival incision. Deeper in the postseptal plane, the Jaeger lid and malleable retractors facilitated the retraction of orbital fat posteriorly during dissection down to the infraorbital rim. The orbital floor implant was discovered within the maxillary sinus, and a #9 periosteal elevator was used to lift the orbital contents by dissecting immediately superficial to the displaced implant. This maneuver allowed a malleable to sweep the herniated orbital content superiorly while identifying stable peripheral orbital bone. Debridement of bony fragments from the maxillary sinus was performed with care to preserve the infraorbital nerve and extraocular muscles.

Nasal endoscopy revealed hardware extrusion medially beneath the uncinate process, forming an abnormal fistula connecting nasal, maxillary sinus, and orbital cavities. Consideration of ipsilateral maxillary mega-antrostomy was debated but was deferred due to the concerns about increased orbit-nasal communication and implant exposure. Instead, a conservative maxillary sinusotomy was performed by extending the natural maxillary sinus opening inferiorly to prevent recirculation with plans for serial CT imaging for potential future definitive sinus surgery if sinusitis recurs.

Following removal of the previous implant, significant herniation of orbital content into the sinus from the orbital floor and medial orbital wall defect was noted. A new orbital floor implant was placed, stabilized by identifying solid posterior and medial bony ledges with neuronavigation.

A polyethylene-coated (Medpor) titanium implant was chosen to avoid periorbital scar contracture associated with bare titanium. The implant was soaked in Betadine, contoured to fit the natural orbit curvature, and trimmed for stability without extending beyond the infraorbital rim. Neuronavigation in the coronal view ensured proper positioning. Screws and the implant were placed behind the infraorbital rim, with one screw typically sufficient, anchored through the orbital floor implant. Due to near total orbital floor defect, a prong extending from the implant was used to secure the implant. In cases of inadequate stable orbital floor, screws should be placed in regions with thicker skin, such as along the nasal sidewall or lateral orbital rim. Nasal endoscopy post-reimplantation confirmed proper positioning, resolving the initial medial displacement blocking the maxillary sinus drainage pathway.

Before closure, the cutaneous eyelid fistula borders were excised, and local tissue advancement lifted the eyelid scar contracture off the infraorbital rim. The lateral canthal tendon was reapproximated onto the Whitnall’s tubercle with 4-0 clear nylon.

To reduce entropion risk, absorbable suture (5-0 fast absorbable gut in this case) was used by the senior author (TL) for transconjunctival incision closure, which is a matter of surgeon preference.

The patient was observed overnight and discharged the next day. Immediate postoperative CT imaging (Figures 4–6) confirmed proper orbital hardware positioning. Sinus precautions (avoiding nose blowing, bearing down, or increasing intrathoracic pressure) were advised to prevent potential vascular and visual compromise due to unintentionally trapped orbital air, and Augmentin was prescribed for 7 days. Due to the pre-existing nasal-orbital fistula, sinus irrigations were deferred.

At the 8-month follow-up, the patient reported significant diplopia improvement, with intact extraocular movements and no recurrence of eyelid fistula or sinusitis. Clinical progress will be monitored with serial CT sinus imaging for potential maxillary sinusitis recurrence.

Figure 4. Immediate postoperative day 1 coronal non-contrast CT scan. CT image demonstrating the presence of early persistent opacification in the right maxillary sinus.

Figure 5. Immediate postoperative day 1 axial non-contrast CT scan. CT image demonstrating the new orbital floor implant, which does not extend beyond the infraorbital rim.

Figure 6. Immediate postoperative day 1 sagittal non-contrast CT scan. CT image demonstrating appropriate orbital floor implant positioning with the posterior portion resting above a stable ledge of posterior orbital bone.

This case presented a delayed SOCF resulting from hardware malpositioning, requiring removal of infected hardware, restoration of native anatomy, and correction of diplopia.

Surgical indications for orbital floor repair include: 1) extraocular muscle entrapment with or without oculocardiac reflex, 2) malpositioned globe with persistent diplopia, 3) diplopia with an orbital defect (larger than 2–3 cm ² with at least 3 mm of displacement) and resulting enophthalmos or a fracture involving over 50% of the orbital floor, 4) extruded or infected orbital hardware, and 5) a persistent SOCF that does not resolve with conservative management.^11–15

Late complications of orbital surgery, arising from delayed wound healing, fibrosis, and scar contracture, encompass a spectrum of issues often requiring revision surgery. These complications include ectropion, entropion, hardware failure, chronic infections, fistula formation, persistent paresthesias, and lagophthalmos. Scar contracture and lamellar shortening from various surgical approaches can lead to ectropion and entropion.¹⁶ The transconjunctival approach, preserving the tarsus, is preferred for patients with a negative vector, reducing the risk of ectropion formation.

Persistent diplopia, occurring in 8–52% of cases for weeks postoperatively, is exacerbated by preoperative edema, intrinsic fibrosis, muscular ischemia, inflammation, and improper implant placement causing extraocular muscle impingement.^5,7,17 Imaging aids in identifying causes of diplopia. If postoperative orbital volume is normal, observation allows for potential central nervous system compensation. In this case, persistent diplopia resulted from improper implant placement, shape, and size, causing inadequate orbital volume. Distinct from globe malpositioning, traumatic injuries to cranial nerves or extraocular muscles can also cause prolonged diplopia with strabismus. After restoring proper orbital volume and globe position, a strabismus specialist is essential for assessing and treating diplopia from these injuries.

Another late complication includes delayed enophthalmos (occurring in 7–27% of cases postoperatively) and hypoglobus, which can gradually emerge due to tissue deficits from prior devascularization and ischemia.^5,12,18 However, a more common cause, as observed in this case, is the aberrant expansion of the orbital cavity with implant displacement or improper sizing. Effectively addressing late enophthalmos poses challenges and may necessitate implant replacement or augmentation to restore proper orbital volume.⁵

Recent studies emphasize the advantages of individualized implants created through selective 3D printing with improved outcomes and lower revision rates comparable to intraoperative neuronavigation.^19,20 Drawbacks include increased cost and manufacturing delays of a few weeks.²⁰ The decision between individualized and non-individualized implants should be tailored. The senior author (TL) typically reserves customized orbital floor implants for patients with complex zygomaticomaxillary fractures and concurrent orbital floor fractures requiring simultaneous correction of malar flattening.

To prevent orbital complications, it's crucial to avoid common mistakes during the initial surgery. We will briefly describe potential factors that may have contributed to the complications seen in this patient. Inadequate exposure may have played a significant role for this patient. The orbital implant should ideally rest on the stable posterior and/or lateral orbital floor and a stable medial orbital wall. Our patient's significant medial orbital wall defect, extending posteriorly, was likely not properly exposed. In cases like this, a transcaruncular incision posterior to the nasolacrimal duct, in addition to a transconjunctival approach, may be necessary for proper medial orbital wall exposure. Cautious subperiosteal dissection minimizes injury during superior dissection along the medial orbital wall, where identifying arteries like the anterior ethmoidal and posterior ethmoidal is crucial. Staying in the subperiosteal plane is also key to preserving structures like the inferior oblique muscle during intraorbital dissection.

Similarly, the fracture extends quite extensively posteriorly along the orbital floor, and this region likely remained inadequately exposed. This is evident from the inferior displacement of the implant into the maxillary sinus. Given the presence of crucial cranial nerves and extraocular muscles at the orbital apex, there is a natural hesitation and anxiety associated with dissecting in this area. The use of neuronavigation, particularly in revision cases, adds an additional layer of reassurance and certainty, especially when dealing with significantly altered anatomy. Insufficient exposure of the fracture leads to incomplete reduction and potential complications, including implants displacing into the sinus, resulting in globe malposition or the entrapment of orbital tissue. This, in turn, can lead to limitations in extraocular motility due to the tethering of the extraocular muscles.

When designing the implant shape, it is important to be mindful of the gentle S-curve of the natural orbital floor when viewed in a sagittal plane. The floor descends immediately posterior to the rim and then gently climbs upwards closer to the orbital apex. Along the medial orbital floor, there is a gentle transition to the medial orbital wall. Unfortunately, it appears that the original orbital floor implant did not follow these contours, resulting in reconstruction of a portion of the orbital floor defect without the medial orbital wall component. This likely further contributed to chronic sinusitis and eyelid fistula formation after the medial component of the orbital implant obstructed the natural osteomeatal complex that allows for proper maxillary sinus drainage. Once chronic sinusitis developed, bacterial colonization developed along the orbital aspect of the implant and further contributed to ongoing periorbital infection.

Regarding implant sizing, it is important to shape it so that the implant sits posterior to the infraorbital rim to prevent erosion of the hardware through the lower eyelid. It is best to avoid excess hardware placement along the anterior surface of the infraorbital rim to prevent implant palpability, undesirable scarring, and/or hardware exposure as seen in this particular patient. In respect to anterior and posterior dimensions of the orbital floor implant, the implant should be sufficiently long enough to reach stable bone located posteriorly while being careful to avoid impinging the orbital apex contents. During the implant sizing and shaping process, neuronavigation can help identify stable medial, posterior, and lateral orbital bone for implantation. After placement of a new orbital floor implant, a neuronavigation probe can be used to trace the outline of the new orbital floor hardware to ensure proper shape, positioning, and stability intraoperatively. The intraoperative usage of neuronavigation may be of particular benefit in a complex orbital revision case such as this or in patients with concurrent sinus or skull base issues.

A costlier option is intraoperative CT scanning, where the orbital floor implant is placed and scanned to confirm implant positioning. This allows for immediate adjustments without the need for additional trips to the operating room. It's important to note that despite many studies comparing surgical outcomes to the contralateral eye, there may not always be an exact 3D symmetry in both orbits.²¹

To prevent delayed hardware migration, fixation of the orbital floor implant is crucial. Ideally, the fixation screw should pass through the implant, securing it to a stable segment of the orbital floor. In cases with a near-total orbital floor defect, hardware can be secured to stable bone along the infraorbital rim. Optimal screw placement is along the medial or lateral extremes of the orbit, where the overlying skin is thicker (nasal skin or lateral canthal regions). In this case, the original hardware's excess titanium was placed along the central segment of the infraorbital rim that underlies thin lower eyelid skin, contributing to the hardware failure issue.

The senior authors (TL, DS) recommend porous polyethylene (Medpor) or Medpor-titanium hybrid implants to minimize abnormal scarring, soft tissue ingrowth, and scar contracture. Medpor-titanium implants have radiopacity for easy identification on CT scans, unlike radiolucent Medpor alone. Studies consistently show lower rates of orbital adherence syndrome with Medpor implants compared to bare titanium plates.^22–25 The polyethylene coating promotes fibrovascular ingrowth without cicatricial tethering, crucial in revision cases for diplopia.^17,23

After removing the original hardware in the case of persistent infection, the decision to place another orbital floor implant depends on the ability to maintain globe position. In this patient, severe hypoglobus and enophthalmos were anticipated due to increased orbital volume and lack of support along the orbital floor and medial wall. Given there was no gross purulent infection and there was healthy surrounding tissue, an immediate alloplastic orbital floor reconstruction was performed. In cases of active infection, debridement and the use of vascularized autogenous grafting material may be considered. One option that has been successfully employed by the senior author (TL) is an iliac bone graft wrapped in a vascularized pericranial flap from the cranial vault (Figure 7). If there is any potential of sinonasal contamination or lingering infection, wrapping the entire bone graft with a pericranial flap is essential to avoid total bone graft failure.

Figure 7. Iliac bone graft used to reconstruct medial and orbital floor defect. This is an intraoperative photograph of an iliac bone graft (left and central) wrapped in a vascularized pericranial flap from the cranial vault; it can be used to reconstruct the orbital floor (right). This particular patient had an infected orbital floor implant with a previous history of radiation. Due to concerns of radiated skin not tolerating Medpor orbital implant, the patient’s orbit was reconstructed with iliac bone graft. This type of non-vascularized bone reconstruction should be wrapped in vascularized pericranial flap if there is any potential for sinonasal communication or infection.

In conclusion, revision orbital floor fracture cases can present with a unique set of complications that require multiple factors to be considered for successful treatment. Using a combination of adjunctive tools such as intraoperative neuronavigation and nasal endoscopy may be helpful in managing a complex orbital fracture case with concurrent sinusitis. Careful consideration for surgical approach and orbital hardware material may also contribute to the long-term success of the surgery.

Medtronic StealthStation Neuronavigation.
Stryker Medpor-Titanium Orbital implant.

Nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Citations

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Cite this article

Sheen D, Yu C, Debs S, Yu KM, Calder AN, Quinn KJ, Sismanis D, Lee T. Neuronavigation and endoscopy as adjunctive tools in orbital floor implant revision: surgical management of infected, misplaced orbital floor implant with chronic eyelid fistula and sinusitis. J Med Insight. 2024;2024(410). doi:10.24296/jomi/410.

Procedure Outline

1. Introduction
2. Surgical Approach
3. Transconjunctival Approach to the Orbital Floor and Removal of Infected Implant
4. Exposure of Entire Orbital Floor Defect and Preparation for New Implant
5. Placement of New Orbital Floor Implant
6. Examine and Consider Opening Up Maxillary Sinus
7. Closure
8. Post-op Remarks

Inject 1% Lidocaine with 1:100,000 Epinephrine

Start with Lateral Canthotomy
Create Transconjunctival Incision While Preserving Tarsus

Expose Stable Remaining Medial Orbital Wall
Estimate Length and Shape of Implant

Use Malleables to Retract Orbital Content Superiorly; Prepare for Implant Placement
For Complex Revision Cases, Use Neuronavigation to Check for Implant Positioning
Secure Implant with Screws

Address Eyelid Fistula Site
Close Transconjunctival Incision
Close Lateral Canthotomy
Resuspend Lateral Canthus

Transcription

CHAPTER 1

I'm Dr. Thomas Lee.I work at Virginia Commonwealth Universityin the Department of Otolaryngology.And today I'm gonna be discussing a case,and this case is a good examplefor those that performs orbital trauma.So this patient had an orbital floor implantthat was placed about two years ago,and unfortunately, there are a lot of thingsthat were done at the timewhere it is one of the commonly seen complicationsthat I see when these implants get infected.So when reviewing this patient's CT scan,we noticed that the patient has a right orbital floor implantthat is not placed properly along the medial orbit,where it's actually going into the sinus.And as a result, whenever the patient blows his nose,the air escapes through his eyelid,where it's been draining purulencefor the last several years.So it's an interesting case in the sense thatit tells you what to avoid when you're doing primary repairso that you could avoid these complications in the future.And for those that do revision surgeriesfor something like this -hopefully, this would be a good exampleto know how to address something like this.The key steps to the surgery,the steps we're gonna start iswe'll have the patient setup for neuronavigation,which would be critical for the surgical case.So we're gonna start with the neuronavigation setup.We'll look inside the sinus,because looking at the CT scan,I have a feeling that the implant might be visible.So we'll start looking into the sinusand see if we can see any orbital implant coming through.And then, next, proceed with exposure of the implant.So we'll do a transconjunctival approachand approach the implant,and lift any eyelid scar contracture that's present.And once we get onto the orbital floor,then we'll perform subperiosteal dissectionto expose the entire implant.And once the implant is fully exposed,we'll then proceed with hardware removaland remove the actual orbital implant.Now, once the orbital implant is removed,the next step is to decide,are we gonna place a new implant?And if we do decide to place a new implant,we'll then proceed with putting a new implantinto the correct shapeonce the entire orbit has been properly exposedfor placement.Once everything's exposed properly,we'll bend the orbital implant into proper positionand secure it, and position it into the defect,which we'll then later confirm with neuronavigationto ensure that it's sitting in the proper location,which would be critical,especially, in a situation like thiswhen the anatomy is grossly altered.And we'll then proceed with securing the implant,making sure that the implant does not extrudebeyond the infraorbital rim.Secure it with a screw.And then, we'll either decideto continue with the sinus surgery, if we're gonna do that,or focus on closing the skin.And in this situation, patient has a eyelid scar.So we will focus on figuring out a wayto remove the site where the fistula was present,and figure out a way to restore both skinand the muscular support that sits behind it,orbicularis muscle,and close it in a way that would minimizechance of ectropion to form after the surgery.

CHAPTER 2

So this particular gentlemanhad a trauma to the right eye,and unfortunately, started having infectioninvolving the implant,where he started noticing drainage in this location.And, when he currently blows his nose,air will start escapingthrough the floor of the eye area.And this area has been draining.Give me some gauze.Our plan is to remove the old implantthat's obviously infected.We'll also possibly replace itif there's no signs of major infection.If there's significant infectionand the orbit seems fairly well supported,we might stage reconstruction as...Yeah, if the hardware is currently infected,we don't wanna put a new hardware in there.Yeah, we'll need that in a second.You got some irrigations?That's very congested.Yeah, let's get a pledget.Maybe - yeah, okay, can we get one more.All right, I guess we'll just start with the eye.

So there's a fistula site right there.Still draining.Palpating to feel the infraorbital rim.So normally, this tissue won't be stuck right there,but in this case, it is.Let's inject the lateral canthus area.Do we have a Colorado tip? Yep.Can you put the Bovie down to 15?15, yep.This is stuck down.Do you want the Bovie?It's really stuck down.So, I'll worry about...It's not gonna dissect properly here.Thank you.All right, here's this back.Giving 1% with lido with epi for the local there.Do you have a Desmarres retractor?The other one? The other one, yep.And do we have the eye shield by any chance?Like a corneal shield? Yeah.Please. Hold that.Yeah.So the problem is,normally, when you pull this down like this,there's not stuff in between.But because there's stuff in between, if I do that,I'm gonna come right through the skin here.So you're gonna have to push this little bitout of the norm.So normally, you would be doing something like this.Yeah, do you have a number 9?Yep.So the way we normally do this isI'll sweep all this stuff back,and when I do this, this part exposes the infraorbital rim.But because it's scarred, I can't do it that way.Come on out like that.I think I see a fistula right there opening up.

CHAPTER 3

Let's do this one.Hold that, please?All right, so I'm gonna do a canthotomy.Go straight back.Then I'm gonna cut down.Start releasing the lower lid here, the inferior lid.Now, with that, we will start swinging this lid out.Can you suction right here?

Some irrigation, please.Good.All right, you have a Colorado tip, there?All right, so a little bit unusual incision.So - there's tarsus here,and what you don't wanna do this cut onto the tarsus.So we wanna leave at least 5 mm there,and then cut down, lower down.All right, this is what we're gonna do.I'm gonna make this incision first.Now again, the other issue is,where is it guys?The puctum is right there,so you don't want go into the punctum.So stay lateral to the punctum,and stay at least 5 mm downto preserve the tarsus.We're gonna connect it to this incision.So normally, it'd be a lot faster than thisbecause this tissue won't be all attached like this.Start releasing it out laterally.Okay, come on out with this for a second.This is very scarred down.And come across.Do you have a double prong skin hooks?I think that's on the implantis what it looks like to me.I think this is the implant we're looking at.Okay, I'm just gonna palpateand see what we got going on.All right, you got the surf board-looking thing?Yep, that's it.All right, I'm gonna start scooping this back.Of course, his orbital fat is right there.Lemme get a...Want me to grab the Bovie?Sure.Can I have the Bovie, please?Suction.Do you have a malleable?Come on out with that for a second.So I'm getting down there.I'll take the Desmarres retractor back.Do you have the wider malleable next?That's all tethered still.I think everything is scarred down.I wanna make sure I don't cut into the orbital fat.You can see there's orbital fat.Yes.Let me see a blue towel, please.A little bit more.What is all this here?I'm just gonna get down to the floor.Normally, there'll be infraorbital rimthat we can just cut right down onto.In this case, everything is scarred up.In this case, my goal is to find the bone.Just gonna follow that down.Come on out one second.One second, come on out.You see the lateral canthus completely detached now,but the skin,being tethered, is holding us up.You have a number 9, please?Ideally, preserve the skin,and if I can't preserve it,I have to excises this and then we do all of that.You have a malleable, again, the medium size?Okay, you got a Desmarres retractor again?Yeah, it's getting down there.Do you have a Senn retractor, actually?I don't want to cut down,and then come right through the skin.That would be counterproductive.I think the skin is lifting upwhere I can start coming down.But I think this is the implant that we're looking at.So I need to at least lift the skin up,so that I can get down to the right plane.Mm-hmm, suction.So I feel something hard.And there's a little bit of pus pocket, or whatever,drainage, granulation tissue right in the middle there.That's probably a sinus-related infection.So our main priority is toat least remove this out of the sinus.That's the implant right there.Interesting here, I feel a gap, which I wouldn't expect.Do you have the Colorado tip, please?And there are two screws holding this.So right now when I do that, I can feel something very firm.So either there's implant or there's bone.I'm gonna start getting downonto the subperiosteal tissue plane.There's something hard there.Do you have a number 9, please?Sharp coming back to you.We're gonna get that outta here.There it is.That's bone.There is some sort of a plate hole.Then my goal is to...When I'm elevating this,you see how there's bare bone?We want to make sure...Sorry, just put that back.Lemme see number 9 back.I wanna make sure I'm elevating the periorbital with this.And normally, in a case like thiswhere orbital floor fracture has happened, the sinus -the orbit will go into the maxillary sinus.And this is like the...Do you have a Bayonet forceps?So this stuff right there does not look normal.This stuff right here.Can you send that as specimen?Call it right orbital floor content.Right orbital floor content.Yeah.There is a fair amount of that down there, I see.Just let's swing over this way.So laterally, we're kinda coming up.Let's get right there.Can I have some irrigation, please?Yeah, where is the implant?I'm just gonna follow this stuff down.Because -I'm hoping to start seeing some Medporebecause if it's just straight titanium,it's gonna be very hard to get out.This is why I don't use -for orbital floor reconstruction,I do not use just titanium-only implants.And I'm afraid it is a titanium-only implant.So this is something that I wouldhighly recommend against using.All right, this -that's not good, suboptimal.Hold that, please.Ay ay ay. It's very scarred in here.And the titanium has actually started to...Yeah, that needs to come out.That might be nasal mucosal lining herethat I want to take out.Bayonet forceps.I think this is the nasal maxillary sinus.Do we have the neuronavigation suction by any chance?This white stuff.I think that might be it.Yeah, that's good.That little, see that hint of white, gritty stuff?I think that's the Medpor. All right, thatmakes it a lot easier to remove.All right, retractable suction,you just gotta plug it in.All right, so I think the key is -get these screws out.The other thing I try to dowhen I screw this implant is to...I try to put it along the orbital floor if I caninstead of coming around the bend.All right, let's go back to this.We'll get the screws out in this side to side.Hold that, please.You got the Colorado tip, please?So you start to see a chunk of bone, so that we don't leave the screws in. Number 9.Suction right there.There you go.I thought I saw a screw here.Okay, let's come - slide over this way.Now, good, there is a screw.I think that is a screw.I think there's two screws on this, from what I can tell.Okay. Hold that, please. A little, medially.So the other common mistake that I see here -do you see how the plate isextending beyond the infraorbital rim? Yeah.That is the other common mistake we see.And that will lead to - one, it can be palpable,and two, it can extrude like this in some way.Hold that, please.So that you don't want implants sticking out beyond itbecause one, it can do thiswhere it scars down and now it might extrude,and two...Suction right there.It's also just palpable.Now cut right on down onto the screw hole of the plate.We wanna go subperiosteal again.A lot of scar tissue in this area.What we're seeing is...The extension from, likely the Medpor implant -with titanium component.This screw is loose.Yeah, that's where the fistula was present earlier.But you can see that's right where the screw is.It is, yeah.That's why I don't wanna...Yeah, so this corresponds to that.The skin's lifting up.It's not lifting up smoothly, but it is coming up.Really minimize...Creating a new fistula defect.Do you have a mosquito?The screw's already out.Can you see that in there?I saw, yeah,the more medial one was already...It's completely loose.It's harder a fail there, obviously.Here's your screw back.There's a screw on there.And then there's another screw.You don't need this many screws, you just need one.There's another screw that failed.You could see the bones moving from the bone.Here you go.Flip this extension part.Unfortunately, it's completely scarred into the skin here.There's the fistula that we saw before.And this stuck onto this screw hole.Okay.The main reason I wanted to use itis to use this to figure out where all the screws are.I think there was one here.There's one there.I think there's three screws; one, two, and three.Yeah.So that might be the last one.All right, let me see the flexible suction one more time,the navigation suction.Great.I think there's...There's one. There's one screw, there's two, there's...I think that's the other screw that I got out.And then this one over here, we need to...We'll need a screwdriver for it.Do you have a screwdriver up, please?And this part...You want it?Yeah, one second, please.Hold that, please.And the problem is it's a lot of scar tissue.You can see it's attached to the skin still.You can start over this way, yeah.This is where the tethering is happening.You see that scar band, right there?There we go.Start over, yep.There we go.There it is, okay.So that's the harder portion here.I don't think there's anything more medially.I'm not really sure why it's all twisted.That's not the way it should be.Ideally, it'd be contoured to the bone.All right, can I see a screwdriver?Remove the screw.Screw back.Number 9, please.And I should be able to sweep under.Is there a sinuscope hooked up still?Yep.Yeah, let's take a look in there.I just wanna see if I can actuallysee it from the nasal side.So that's the sinus down there, I believe. Okay?So I think that actually is the sinus membrane, right there.Can you suction in there?Don't pop into it, but yeah, right there.There's the sinus.There's probably the roof of the maxillary sinus.So normally, you'll see a cavity in there,but because it's...Come on out with this for a second, yeah.Yeah, we're right on top of the roof there.So let me see what the...Let's see with the scope.I bet you, you could see the plate in thereif there's enough decongesting that happenedsince we waited.Now, the skin is almost released,a little bit attached more medially,which we'll work on.Yeah, I wonder if that scar tissue there is coming out.Yeah. Then push the middle turbinate medially.Yeah, snake it in, and then push it out medially.Right, there's your uncinate, right behind it.And I bet you that's what we're...This is the implant.If I wiggle...It's part of the granulation tissue that you see.Does it feel firm to you?Yeah, so you can see it.I think it's actually this part of the implant.Yeah, you can see it moving.So that's the implant on the other side of that,which is not how it's supposed to be.Okay.Can you also get a...Bring in a Medpor titanium,right-sided orbital floor implant.But don't open it yet.Right orbital floor implant, right-sided.But don't open it.Just bring it in the room.There's one that's 1-mm thick, and there's 0.5.Do you have irrigations, please?Do you see the implant there, Kevin?Do you see that? The camera is up there, but I see it.Yeah, so that's the implant.Irrigation, please.Just regular, that's fine.Just squirt it in there, please.Yeah, you could see the implant right there.Right there.See that little hint of plastic?That's why he has what he has.Yeah, that's it right there.All right, great.All right, we'll be right back. Great.Can we send this as a permanent sinus content?I just write sinus right-sided, nasal...Yeah, just write nasal con...Right sinus content.That's your orbital floor implantthat shouldn't be doing that.The other issue is...He's more prone to get sinus infection,but this is not his natural opening.Natural opening is gonna be up here.So that being there causes other issues.So you could see his neuronavigation shiftis completely opacifiedbecause it's blockingwhere the sinus would normally drain out.So, Kevin, I think we should do maxillary antrostomy.Now whether that's mega or not -is debatable.But definitely take the uncinate down.We gotta at least connect it to here.You wanna do that before taking out the...That's what I'm debating.Because I think this bridge has to be removedfor this to not recur.Now, the only other question is,by this being here, would it put orbital content at-risk?In which case it might be better to dissect all that away?Because it's gonna be right on the other side of this.Yeah, let's do the orbital stuff first.Okay, yeah, let's do the orbital stuff first.So normally, you wanna connect all that,but because just everything is displaced inferiorly,if we just come through there with the shaver,there's a potential for orbital stuff,which you don't wanna shave.Normally, it's not that obvious where it sticks out,but in this case, it's very...It's actually visible where the implant has been...You can almost see it on the pre-op.Yeah, you can definitely see it on there.But a lot of time you could see like mucosa kind of covering it,but I think because it's so exposed, it's very visible.Can you hold that?Do you think this was improper placementor migration after? Yeah.It's not migratedbecause the improper placement from the beginning.And I think what happened, they missed the medial orbit.So then, it's now under the medial orbit,and that's where the problem has happened.This titanium piece is all bent.So navigation,that hole right there is the infraorbital nerve coming out.And again, if the issue is weight medially,and completely,incorrect position.So my first priority is expose this hardwareand get this out.Because it's so scarred down thatI'm having a very hard time dissecting it.Can I have some irrigations?Normally, this should peel up.Yeah we can go ahead and irrigate.Okay, just have it in the room.Don't open it yet, please.Whoa, big vessel right there.Yeah, no kidding.See that in there, Brooke?That's a really big one.Bleeding prevention is preemptively a bipolar act, the nod.I think it might be traveling with the...It's under the floor.Okay, hold a second, and there's a -I see a bone fragment over the floor.A bone fragment, right there.Dr. Lee, is it sinus?Sinonasal, this one.And this hole in there is going to the sinus...That part got lifted up. There's a lot of scarring going on.So my first question is...Just loosen up where I can just pull this out.Can I get a number...I think it is loose enough.Get this out.So that's the implant.It is Medpor titanium.That looks not good color,probably infection and stuff happening.It's very wide.I would've cut a lot of these.I would have cut a lot of those.And like these random, this wire is in the sinus.I think this part was a part...I think this corner was the part that was sticking out,probably.All right, here's your...Can we take a picture of that, if you don't mind.Just set it aside, like a specimen.All right, let me see the malleable.

CHAPTER 4

There you go, I got it.Thank you. Thank you.So now, the first question is, what is that vessel?We're under the orbit,so there's nothing really dangerous there.The posterior leg is beyond this.So we're actually pretty close.So maybe I could leave it, but it's actually in my way.All right, I'm at the ledge there.Unfortunately, I do think...Let me see that bipolar, please.The orange one.So this is in front of the...The suction is on my - the poster ledge.This is just - vessel is actually blockingwhere I need to be to reduce this.Buzz it.I'm not near the...Yeah, I think it's near the infraorbital nerve,so it might be a vessel traveling with it.It can be safely sacrificed.All right, buzz it.Okay, let me get Metz in a second.Give me a minute.Can we do it one more time?Buzz it.Okay.Buzz it.Okay, that's good.We see that better now.Can I get your scope in there?I can actually see this probably from this side.What I wanna avoid isleaving nasal mucosa lining in therebecause then everything will get infected again.So this right hereis the sinus.Yeah, I could actually see the other side of that is the sinus.If you got a thing I could just scrape some of this away.You have number 9, please?I'm leaning towards...Hmm.I'm just trying to see if it's worthputting a new harder in there or not.Not near the medial wall.I gotta get down to the medial wall nowbecause obviously,I don't wanna repeat the same mistake that was made.All that granulation tissue here.I think so.Because it's going to be...It doesn't look that bad.The other concern is if this orbit comes down this far down,he is gonna have significant hypoglobus happening.I think, unfortunately...Well, if it was grossly infected, I wouldn't do it,but I think in this case...I'm sorry? Best?Because part of me is kind of wondering...if you just like put the implant in,just be like doing it for the first timeand just let him heal.Yeah, because I agree.It may just...One concern is if you do like mega-antrostomy,it might actually...Expose the implant more?Yeah, that, and make the fistula wider.Oh, okay.And I mean like -opening towards the fistula wider.So if you blew it hard enough,it might still do what it did once before.You gonna get us some irrigation, please?I dunno.Just so you know, I don't know if I have enough right primary nasal contentfor them to actually see anything.It's all right, that's fine.They don't need to see anything really.I'm sweeping all this granulation tissue, or sinus content -it's hard to tell if it's sinus lining or not at this point,inferiorly, so that it doesn't touch the orbit.I feel like I have a good exposure laterally.Okay, far down, you can see a scar here.Can you guys see in there?That's the posterior wall.Going back.Need to come all the way across this part,when I'm going this way is all scarred.Normally, there would be a natural plane therebut in this case it's scarred.I'm just kind of gently peeling it awayuntil what feels like a bony ledge.I feel something there.It should be great.Yeah, there's bone.But that's the bone there.Can we look with the endoscopes there?So that, I think is stable posterior ledge.So orientation-wise, this is the...It's the posterior bone here.If you look this way medially, over here is your sinus,and this way -can I get the irrigation once again?I think this is...Yeah, this is beginning of the...Right there, we're beginning of the medial orbit here.So I need to expose this a little bit moreso that I can place the hardware properly.

Okay, I can kind of see things a little bit better.You got a skinnier malleable?So basically, release all that scar bandfrom midline all the way over to this way.And I think this is the medial orbit that we should catch.Yeah. Pretty sure that's what it is.All right, let me see this to confirmStart of it, at least.There, yeah, so...I know I'm not in the sinus, but still,it looks like there's something.What is this? So that makes me wonderif I'm really in the sinus or notbecause this navigation might be off a little bit.Yeah, it's off.See on axial we're off about.Yeah, a couple millimeters. Yeah.So, is that - we're off to the left more.Yeah, we're off to the left about 3 mm.So that tells me this is the right down.Yeah...So let me see number 9 back, please.Remember seeing that?There's a hole right there.That might be the sinus.That might be also like the natural os, I'm not sure.I think there's like a horizontal strip.So we might have to go even higher than that.Yeah, I think that is...Put it in there?I'm pretty sure that is sinus.And it's out of focus.Probably relax on that.That's not doing anything.You good?Irrigation.That's like there's a hole right there. Irrigate.Mm-hmm, that's good.So right there... I think that's...I think there's the sinus.I think I need to go above this,but this is starting at the medial orbit.Question is how high it could be.Can you just come... This is...Could you just make it not as wide,and just have it end right thereso it's not sticking out?I want to be above it so that this is below me.That's kind of what I'm thinking in my mind.It ends here,so I wonder if there's like a significant fracture.Come on out for a second.Meaning, the whole medial orbit might be damaged, so that...Let me get a wider malleable.I should be getting close to the anterior ethmoidal artery.It might be okay.I'm not really seeing a good medial orbit to catch.Suction, please.I see a hint of the medial orbit.You can see this fractured bone right there,I'm pretty sure that is a medial orbit I need to catch.But ideally, I should have a bit more firmer boneto anchor to or lean on it at least medially.Do you have a Mosquito?There's your bone.There's just bone that came out.That is garbage.Do you have the navigation again?Where are we here?So that's the medial orbit, okay.Now the problem is, I see a hole above that.So that's actually going into the sinus there.Actually it might not be bad.Let me see - how tall are we navigation-wise?It's actually not bad there.I don't know why the...Okay, so midline is pretty accurate.Irrigation, please.We can irrigate this out.Okay, so that's... I guess what I'm having a hard time with -right above this hole.So I thoughtthat's where I wanted to anchor the medial orbit to start,but right above that there's a defect of the bone.So then I wonder if I need to goeven higher than that location.I'm having a hard time.That's not bad, right there is actually not bad.I'm having a hard time finding stable bone.Hmm, there you go.That's good there.Yeah, thats - yeah, and the axial looks like we're not in the sinus,coronal looks good too.So we'll anchor to this point.Can you guys see in there?And it's really hard to see anything,but that's the hole that I was worried about.This is all medial orbit here. Posteriorly.Looking at the coronal,you can see how much the orbital content has dropped.Like right there about, dropped by a centimeter.You can see right next to me at the,at least at that scan is inferior rectus, soI think it has to be corrected.So number 9, please.All right, go ahead and open the implant,the orbital implant, please.And let's dip it in paint.Dr. Lee. Yeah.I have a 41 by 42 by 0.5and a 41 by 42 by 1.0.Let's do 0.5.That's the right side, right?Right side. Right eye? Okay, great.Yep, right eye is...I think I am posterior enough.Anterior posteriorly.And I think let's do a little bit further out.True, yeah.- [Dr. Lee] Yeah.It seems like this is pretty helpful for us.This is helpful.Now the problem is - it's done preoperatively, right?Yeah, exactly.It could be different.So it's completely off,but I'm just using it like this.I'm using it to mirror the other side.So that's why I use it for that reason.All right, so here,that bone actually looks like the stable bone,meaning this...Yeah, so you can see where that is.You wanna get a scope in there?You can actually see pretty well right now.The tricky part is, all this bone, inferiorly, is displaced,and it's fused that way.But this is right where my suction is right there.Right above me is where I want to be right in this ledge.This is the ledge I want to catch.But inferior to that,all that bone is not in the right place.This bone is not in the right place.Yeah.So if I anchor it,if I use that as a reference,then everything's gonna be off.I need to be up here.This to me looks correct superiorly.Yeah, you could see that on the sagittal scan,that's the correct posterior ledge to catch.And you could seethe floor was following - the implant was following the floor being incorrect, andthey didn't correct that unfortunately.I need to catch that back ledge,and then come all the way around this way.Let me dissect a little bit more. I feel like we'renot quite enough exposed.I'm having a hard time seeing that medial border.Do you have a skinnier malleable?Medially, this...Our goal is to get all this exposedto where we're gonna anchor the bone to.I think he's just missing bone right where I'm looking at.Mm-hmm, this is all missing bone here.That's where I need to be.We'll stop there.Having hard time.This is the medial wall. It just ends.I need to be higher up is the issue.Hold that.I feel like it's not adequately exposed medially.Suction one with malleables.That's a good bone up there.Or this is, where is all this in the middle.There's no bone here.There should be a bone is what I'm confused about.Okay, I think his lacrimal duct is not preserved.Not having a...Let's just kind of see where this is supposed to be.

I use this kind of as a guide.This is resting on the posterior ledge there.I kind of see this spot where we're gonna anchor it to.So about this long.You got the implant, please?

CHAPTER 5

So, here is your implant.It's almost the full length of it.The other piece just had this,but we're gonna create a medial orbit as well.This is the medial orbit component.So the sinus should be sitting in this area.So you have a heavy scissors?And I might use one or two of these.Definitely don't want to anchor anything here.I'm gonna curve this out, round this out,and then also...Then we're gonna...it's kind of the right shapethat we want.to kind of sit like this.Okay.We don't need all these binders.Can I get a Mosquito, please?Make sure it doesn't extend outbeyond the infraorbital rim.All right.One of the challenges when you start doing this is theangle of it is something that's kind of hard to figure out.Yeah, so all this bone here essentially is very deceptive.So this is at the right point here.This is the right floor and it could follow up.Yeah, that's pretty decent.Make sure we're good medially.On more malleable. And kind of do like a crisscross.So one's going out Medially one's going out laterally.Okay.So that's good.I think, medially, that's...If I can get to that point, it's good.All right, you wanna take a look at the scopeand then let's put the implant in.Now the other question is,is it worth taking out all that bone?Probably not because it's gonna start oozing like crazy,but at least for a postoperative scan,it'll look nicer if this bone,this all displays, it's just not there.So this is a bone that doesn't belong.You need to catch the bone up here.This is the ledge that you're gonna catch posteriorly.Everything below this line is -this is all abnormal bone here.Okay, lemme see the implant, please.Lemme see the implant.Now the perspective you wanna get used to is this angle.Do you have a Ragnell?This is not quite working.The Senn retractor you gave me earlier?So like this slope, you gotta get used to...This angle?Yeah, yeah, because it looks -people just put it in like this.It needs to be like this angle where it slopes up.Pickup, get our pickup.So we lost all that, unfortunately.And do we have the TPS drill up?We got it up, it's all ready.We do? Lovely.Okay, let me see the implant.So put it in like this.Make sure this isn't too long.I think it's too long, is my impression.Way too long.See, we're well beyond -the implant there is just way too big.And I'll revise that, obviously.Do you have the heavy scissors again?Thank you. Thank you.I shortened itbecause it was sticking out way too far.Anterior to the infraorbital rim,which you always wanna avoid.Now for sutures, can you guys get 4-0 clear nylons,4-0 Vicryl, and 5-0 fast.4-0 Vicryl? Yep.Okay, it kind of feels correct to me.Can I get a Desmarres retractor?First question is, is this too long again?There's your infraorbital rim.It doesn't look bad.It's just about just right.Doesn't look bad.So I don't want this rim sticking up beyond thatbecause that always causes problems.And the secondary question is,Is this angled properly?Get the slope up.Let me see a skinnier one.I get rid of those extensions.Lemme see a malleable.Not malleable, number 9, please.I'll just check the angle with the implant.

Make sure it's going to the back.Still high on this side.That's medially what we're doing.That's better.So I'm inside the implant, inside the floor.This is the medial margin of the wall.We want a wall that kind of comes down like that.That looks like it's seated properly.That looks okay.I just like to run it all on the floorto kind of see if it's going in the right plane.Yeah, see that's where it's doing.Okay, so that's good.That's what I would want.All right, following that floor up.It goes up to where we want it to.Can I have the right angle?And we make sure we're not in the...That's just the medial,yeah, that's good.You are on the right side of the orbit there.It's more posterior medial orbital wall reconstructed.That's more posterior along the medial orbit.So it's following where you want to fill in,the bony defect.Yeah and that's where we're on the back ledge.Yeah, I think that's gonna be good.We want that angle there.Cool. Looks okay, Kevin?Yeah, that looks pretty good. Okay.

So now, I want to secure this.The question is how.We have a lot of options here.Let's put one screw right there.You have a self drilling screws?Yep.Let me see that, please.Five? Yes.Those...Sure. Self drilling.We can put one in here -yeah, I don't think I like that.I just don't want this moving.It's kind of the whole concept.It's not good bone there.Mosquito back.All right, one more screw.Self drilling?Sure.You want to reuse this one?I'm sorry?Yeah, that's fine. You can use that again.Do you have a drill?Mm-hmm.I don't like how that's pushing on everything.I saw the implant move.Number 9 for a second.Mosquito for a second.So the other thing I need to worry aboutis the skin incision. Drill.I want to make sure wherever I put it...You wanna use the same? You want to do a non-self drilling?Yeah, mm-hmm.Okay.You have some irrigations?Squirt in there a little bit just to cool it down, yeah.Good.That's better.Okay, all right, let me get a Mosquito.And let me get a...Do we have an in situ plate cutter, if not heavy scissors?I got this little nippy nipper.Yes, that's perfect.Okay, number 9.And a malleable, please.So this, obviously,like you don't want to stick it out like that, so...The other thing that makes the plate look really good on the scanis just kind of make sure you mold itto the surrounding bone.That's usually what we want.Lemme just confirm - I just saw it shift,so I want to make sure it didn't knock it outta place.That's good, where it starts.That's good there.That's good.That's pretty good.Yeah.That's good.Okay, all righty, I think that's good.Number 9 again.

CHAPTER 6

All right, and then let's look at the sinus,and then we need to decide if we need to fix that or not.Let's come on out for a second.Lemme get a...Do you have bell prong skin hooks?Just one, just one's good.Do you have a Metz, baby Metz?So again, the hardware is not sitting directly over -it's way over here.I want to release all this.It's still tethered.Still tethered.I think his infraorbital nerve hereis not working preoperatively,but infraorbital nerve is right there,so you gotta be mindful of that.There we go.That was the release I was looking for.There's still a fair amount of scar bands.So my goal is if we can save the skin it'd be nice,but I'm prepared to excise.Do you have a Ragnell or Senn retractors?Hook back. Irrigation.Send me bipolar.Bipolar.So let's look in the sinus before we close this.So at this point we shouldn't be able to see the implantthat we were seeing before.Okay, and I'll take irrigations.So that part looks better. There's less stuff in the way.What am I looking at?Is that the...Yeah, this is where the implant was before.That looks a lot more open like how it should.Should we mess with it?Should we do?Question is do we open this up or not?The downside of opening it will behigher chance for air stuff to go in there.Gimme a quick look.Debating if it's worth opening or not.It would be better for implant to be not be infected again.Can I get a - oh yeah, much better.Yeah, see that's where it was before.Feels soft.There is... Ideally, this and this should be opened upfor this to drain properly.Do you have a curved suction?You know, like the one with the little 90-degree bend on it?Let's see if I can use this.If this is full of puss -I'm gonna...You see I'm in there,and the navigation tells you that we're inside the sinus.I don't really see a lot of pus in there though.It's good.Yeah, so it's open.It's definitely not filled with stuff today.I don't see pus coming out.It's not the right location.If I open this and I see hardware, then that's bad.We don't want to see hardwarebecause then I'm just exposing more of that.I feel like - you get up in there and flush the sinus out?Incase there's any badness in there?Yeah. I guess what I'm worried about iswill there be delayed sinus obstruction?Then, now it'll be filled with mucus in there,which will then hit the orbital implant that we put inand might get infected again.So then another option is tocreate an unnatural opening from here to here.What we call like mega-antrostomy,so that it cannot get exposed -or it cannot accumulate anything in there.Another option is to let it be.Let it mucosalize, hopefully.We want that to seal up there.Lemme just rock it up so that hopefully that can stick down.Once it seals up, then I can do a lot morewith what I should be able to do.Yeah, this navigation doesn't work.Yeah, I'm afraid if you do a full maxillary,we're gonna start seeing the implant,which I prefer I don't see it.I don't want it exposed to the nasal content.Do you guys have any thoughts?Should we open it, not open it?Just let it be.Yeah, that's what I'm thinking.If he has to have a maxillary antrostomy in the future,that's like a small scale thing,but if he has to have his floor implant replaced again, that sucks.Yeah, that would be worse.I feel like just trying to optimize it for the implant.Yeah, I think...That would be less trouble.Yeah, maybe you can do a CT scanlike in a month or so, a post-op scan.If it's still obstructed then come back and open it up.I feel like you're not really burningany bridges that way.No, because the real issue is just,it was just coming in here was the real problemand obstructing everything,and there's nothing inside it that I can see.So yeah, let's just not do the sinus part today.We will consider doing it as a staged fashiondepending on postoperative scans,maybe two, three months down the road.If it's still opacifiedthen, two, three months out,it will perform sinus surgery to open it up.

CHAPTER 7

So then let's just focus on closing the eye.Some irrigation, please.And let me see Adson pickups.We're like wrapping up, probably 20 minutes-ish I think,maybe less.So one thought I have is,Do you have a -yeah, that one.Let me get suction, please.It would be ideal if I can put something there.Do you have iodine?You can see the implant is not extendingbeyond the infraorbital rim.That was a part of the first issue.Now I want to,if there's a way to drape this with something,I would like to do that.Yeah, I was thinking about that earlier.- [Dr. Lee] Yeah, like maybe this tissue,I feel like this doesn't have much to give.It does not, yeah.I thought about like,oh would you ever consider doing like fat,but you don't want something that's gonna get infected?Fat injection you mean?Yeah.Yeah, not today.What I - there's this little bit of muscle or I'm not really sure,scar tissue here.Can you lift the head up, please? Yes.You wanna hold this up, please?I'm gonna see - all right,there's a little bit of...A little bit more, please.That's good,thank you.What is this material here?I think that's where all this stuff happened.All the scar tissue.I'm trying to see if there's a way to...It would be beneficial to drape this.I mean, thankfully, there's no hardwaresitting under this skin breakdown.We'll just let it be.That's right.Don't want to tug too much, and then have itnot be able to close. Close, yeah.Could be an ectropion issue.Very good.Can you hold this?I think I need a bipolar.Bipolar, please.Hold on.Yeah, sure. Bipolar.Buzz, yep.Okay, good.All righty.All right, let's just focus on this first.I think I should excise some of it.You have 15 blade, please?It actually doesn't look that terrible.Yeah, it doesn't, yeah. Not as bad as I thought it was going to.Me too, I thought it would look a lot worse.It's gonna freshen up the edges.Yeah, it actually is not that bad.But I would excise someso that at least the edges are clean.What's that?Like internal ear stuff?No, it's just external. Okay, okay.Everything external.I'm just going to sew.Releasing some of the scar bands here.Skin is...Okay, do you have a 4-0 Vicryl?So if I had hardware I would drape something on top.But in this case, everything is intraorbital,so thankfully I don't have to worry about that.Is that needle okay?Yeah, that's fine.I'm gonna put this back together.This is probably orbicularisthat has scarred down to the hardware.It's restoring the anterior and the middle structure.Okay.So I do want him to get a post-op CT scan.Maybe just get CT sinus without contrast.Okay.With neuronavigation.Just do neck space or have them get the whole face?Does it catch sinus though?Yeah, it should.We can just tell them that it should go all the way back.Okay, yeah, we can do that.Do you have a fast?And antibiotic?Yeah.Do you want him to do any nasal irrigation stuff,or nasal sprays, or just let it be?Just let it be.We didn't really do anything to the nose,so I would just let it be.I feel like if he blow hard enough, it will...Yeah, sinus percautions...Come up this way.Yeah.That looks better.It's not scarred down to the rim like it was before.It should revise.I'm debating if I should revise that scar.Yeah, I thought about that because like we don't want to -we don't want to injure it, but alsoit doesn't look great.Yeah, it looks weird.I might just mobilize just the skin.You have a 15 blade?Here's your...I'm gonna take this back - needle in a second.It's not going in there.Can I have suction.Skin growing in there.Skin growing inside.That's not where it should -skin shouldn't be under the skin.Hmm, the under surface of the skin looks weird.Like this area makes me wonder if there's skin there.Yeah, there might be some skin there still.I'm just gonna remove -the abnormal skin.Hmm, there's skin there.Yeah, see there's skin.Good thing that we found it.Was this their approach?I'm sorry?Is this their approach?No, I think this is where the hardware came through,and then the skin started growing around it,and then it actually ended up rolling under and healing that way.Do you have a 4-0 Vicryl for us?And then I'll take that next.What's that? Let's check real quick.Yeah, I think we're done with the sinuscope.Let me see the 4-0 Vicryl.That looks better.And more importantly, that skin that was buried is now gone.Okay, suction there.Reestablish the muscle.Here you go.Can I see a 15 blade back, then I'll take the 5-0.And we'll need a 5-0, or not 5-0,we need a Dermabond at the end of the case.Let me see a 5-0 fast. Knife back.Okay.A little redundant.I'm just gonna keep it so that I'll -I can always revise that. I don't want to cause an ectropion.It's gonna contract down regardless.It's nice to have a little bit of extra.Can I have that 4-0 clear nylon next, please.Actually, you know what?Before that, let me just...Yeah, just have that one ready.I'm gonna use this 5-0 fast one more time.Do you have the - could I get the hook -the hook again.Do you have a skin hooks?

Just a little bit of space.So hold that, please.Okay, irrigation.You got some irrigations?So I know not everybody closes,but here we go.Here's this back for a second.I had a patient who had conj that didn't heal properly,and caused entropion, so I justwill place a couple sutures to line things up.You got the 5-0 fast?I might need one more fastif that is all of it that we have left.Yeah, just one more would be nice.And suction.Mm-hmm, just right there.Okay, now come out with that.Come on out with that.Okay, let me get one more 5-0 fast,and then I'll also take the 4-0 clear nylon next.Okay, which one do you want next?5-0 fast.

So, I am going to place this first.So that this triangle shapealong the lateral canthus is presentstill once we secure it. Sure.What is that? Is that hair?We just do the skin portion of the lateral canthusand leave it attached for now.Okay.

Let me know when you have it.Ready.Nice, perfect.This is perfect.Do you get credit for the campus work,or is it just part of the approach?I think it's part of the approach.If we did like stripping and stuff, then maybe you could repair,they could call it ectropion repair,but I think it's just part of the approachis my understanding.Do you have a Senn retractor?It's all swollen from all that being released.Did he get steroids?I'm gonna check for - while we do that, we'll check for...It doesn't look entrapped.Suction.See the whole head's kind of moving.This is a confusing little bit.Okay, so let's just see this.Good.Secure.And before we cut it, I'll do one more suture.I'm gonna be medial to the lateral orbital rim.Catch the Whitnall's tubercle.Let me get a empty needle driver.Thank you.So again, just by doing this, this should be this reattached.I'm gonna cut this shorter.So that stitch, basically, recreated the triangle there,and then this is the crow's feet area, just gonna line it up.They're gonna just continue to close here.Should hide nicely the crow's feet area.Let me get a - you guys have a Dermabond ready?Yep. Great.Can we get a NG tube from you guys? Or OG tube, rather.Can I have some irrigations?You wanna do any more local?No, but thanks.I think this is - he came in with that I think.Suction out his stomach.Do it one more time.Okay.Do it one more time.I think I'm not really in the esophagus.Okay, it's going down the right way.Okay, one more time.Okay.Let me get a Dermabond, please.You see this was already - this was stuck down before, so I think this -hopelly, there is a higher chance of this healingnow that it's not infected at the infraorbital rim.

CHAPTER 8

In this situationwe couldn't see the orbital hardware right awaybecause it was very congested.So then we started with the nasal congestionusing a nasal decongestion to decongest the nose.And while that's going on,we did proceed with starting with the right orbital approachusing transconjunctival approach.We performed lateral canthotomyto swing the lower eyelid down.The difficulty isbecause the eyelid has scarred downonto the infraorbital rim,we couldn't do the traditionalpostseptal approach to the bonebecause then we would come through the eyelid,which should be not what we wanna do.In this case, we wanted to save all the eyelid skinand orbicularis muscle.So we had to,instead of cutting right down onto the infraorbital rim,which was typically done in the primary case,I had to make incision through the transconjunctivawhile preserving parcel height,so at least 5 mmaway from the posterior lid margin,and come through the conjunctivaand go through until we could findsome sort of bony structure.And I started thisby starting along the right lateral orbital wallbecause that area had minimal scar contracture occurredcompared to other areas.Once I found the bone,I connected it through the eyelid incision,and once we did that,we were able to get down to the orbital floor implant.It had titanium extension where the screws are secured.It was a lot more than what I would typically leave behind,because there was so much titanium and screw holes exposed.A lot of the scar contractureswas actually happening right over the screwswhere the hardware was located.And at this point,we proceeded to expose the orbital floor implantgoing into the orbit.At this point we were able to identify the areawhere there's a sinus connection.We proceeded to also at this point, remove the nasal pledgetto see what's going on inside the sinus.And we could actually see, once everything decongested,the orbital floor implantcoming through the lateral nasal wallinferior to the uncinate.So at an unnatural, non-anatomic location,and this was likely contributingto the issue of purulence, nasal content,and air escaping through from the nose to the eyelid.So at this point we decided to remove the hardware.Once the hardware was removed,the focus was then to expose the entire orbital floor defectwhere the bone had given away support.And we exposed it fairly relatively easily posteriorly.Medially, there was a lot of bone missing,so we had some difficulty identifyingwhere the stable bone starts along the medial orbit.We use navigationto confirm that we are within the medial orbital wall.And once that was completedin terms of exposing all the orbital bone defectthat needs to be reconstructed,we then proceeded to shape the Medpor titanium implantinto include both the medial orbitas well as a floor component.Bend it to proper shape.We then measure the distance from the posterior aspectto the infraorbital rim,and cut the implant to the proper size.And we then inserted the implant into the orbitand confirmed proper positioningand also correct angle of insertion using neuronavigation.And this was criticaljust because the existing anatomy was grossly distortedbecause the orbital floor actually healedin a way that was more inferiorly displacedthan what it should be.So once that was complete with the implant in place,and we confirmed proper position with the neuronavigation,we used a screw to secure it in place.And once that was all done, we then look inside the sinus,and we were contemplatingif we should open up the maxillary sinus furtheror leave it behind. The upside of opening itwould minimized risk of future maxillary sinus.The downside being we can now have loss of mucosal coverage,which would then lead tothe orbital implant being exposed again from the nasal side.So as a result,we decided not to proceed with the sinus surgery,which is different than what we had initially thought of going in.Instead, we decided to obtainpostoperative CT scans in the futureto see if the sinuses do opacify,in which case we'll consider early sinus surgeryto make sure that maxillary sinus healed.But hopefully by then,the orbital floor implant will be coveredand not be exposed again.And once we decided not to proceed with the sinus surgery,we focused on closing.In this case, we excised the eyelid scarthat had healed onto the infraorbital rim and the hardware.We did notice that the skin didn't heal properlyfrom the fistula,and the skin was actually buried under the skin,which obviously would cause issue with infectiondown the road.And at this point, we excised the scar along the eyelid.We also released scar contracture along the orbicularis.Orbicularis muscle was suture together.The skin, eyelid, lower eyelid skin was sutured together,Then we resuspended the lateral canthususing 4-0 clear nylons to resuspend the lateral canthus,and we closed the skin with 5-0 fast absorbing gut sutures.And that was the procedure.Here's a postoperative CT scanin a coronal view.Here, you can see the beginning of the orbital floor implantthat was placed,medial wall component and the floor componentshowing the symmetry with the opposite side.And most importantly,this medial wall component is not sitting down here,which the previous one was,and it was causing maxillary sinus opacificationfrom inability for the sinus to drain properly.So you could see it more posteriorly.You could see the entireimplant is sitting below the muscle and the orbital content.Now this bone is sitting herebecause of the previous implantcaused it to fuse in that location.We didn't decide to fracture this,and potentially make the infraorbital nerve irritationworse in the process.So we left it where it isand secured it to a stable location,and recontoured it so that the medial orbital wallis now sitting in a better position.And even though this is onlyabout a 1-week out postoperative T scan,you can see the maxillary sinusalready beginning to aerate properly.Here we're looking at the postoperative CT scanin the axial view.Here's your orbital floor implant that was placed.And you can see there's no hardwarethat's extending beyond the infraorbital rim.And this particular screwis actually placed from the orbital floor sideso that there's minimal hardwareextruding beyond the infraorbital rim.Here again, coming back up,seeing the orbital floor implant and the medial wallis relatively well preservedin this newly placed orbital floor implant.And lastly, the maxillary sinus is already beginning to aerate,which is a significant improvementfrom the previous preoperative condition.

DOI
Publication Date	2024/01/11
Article ID	410
Production ID	0410
Volume	2024
Issue	410
https://doi.org/10.24296/jomi/410

Neuronavigation and Endoscopy as Adjunctive Tools in Orbital Floor Implant Revision: Surgical Management of Infected, Misplaced Orbital Floor Implant with Chronic Eyelid Fistula and Sinusitis

Main Text

Table of Contents

Abstract

Keywords

Case Overview

Background

History of the Patient

Physical Exam

Imaging

Workup

Rationale for Treatment

Special Considerations

Surgical Details

Postoperative Care

Discussion

Equipment

Disclosures

Citations

Cite this article

Procedure Outline

Table of Contents

1. Introduction

2. Surgical Approach

3. Transconjunctival Approach to the Orbital Floor and Removal of Infected Implant

4. Exposure of Entire Orbital Floor Defect and Preparation for New Implant

5. Placement of New Orbital Floor Implant

6. Examine and Consider Opening Up Maxillary Sinus

7. Closure

8. Post-op Remarks