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Repair of traumatic inferior orbital wall defects with nasoseptal cartilage
J Oral Maxillofac Surg 59:1397-1400, 2001
Repair of Traumatic Inferior Orbital Wall Defects With Nasoseptal Cartilage Mordechai Kraus, MD,* Albert Gatot, MD, DMD,† and Dan M. Fliss, MD‡ Purpose:
This study evaluated the effectiveness of nasoseptal cartilage for repairing traumatic orbital floor defects. Patients and Methods: Autogenous septal cartilage was used in 20 patients. They were evaluated for the presence or absence of diplopia, enophthalmus, infraorbital nerve paresthesia, and ocular motility disorders. Surgical indications for orbital exploration included entrapment of orbital tissues, large orbital defect (greater than 50% of the orbital floor or more than 8 mm), or orbital floor defects with involvement of other zygomaticofrontal complex fractures. Results: All patients were successfully treated by restoration of the orbital wall continuity. Follow-up at 1 week to 6 months showed 1 patient with postoperative enophthalmos and 1 patient with lower lid edema. There were no donor site and graft infections or graft extrusion. Conclusions: Nasal septal cartilage is a readily accessible autogenous tissue that should be considered when an autogenous graft is needed for orbital floor defect reconstruction. © 2001 American Association of Oral and Maxillofacial Surgeons The goal of surgical repair of orbital fractures is to restore the traumatized walls to prevent herniation of the globe content into the maxillary sinus or ethmoid air cells, because the latter will be followed by undesirable atrophy of orbital tissue, ocular motility disturbances, and enophtalmus.1,2 Simple repositioning of orbital floor fragments into their anatomic position is generally not possible, and an implant is then needed to reconstruct the floor. The materials used for this purpose are both autogenous and alloplastic. The selection depends on the characteristics of the material and the surgeon’s preference and experience.3 Recently, there has been a trend toward using autogenous grafts in reconstructive orbital surgery. These autogenous grafts include cranial bone, iliac bone, split rib, and cartilage. The nasoseptal cartilage
*Lecturer, Department of Otolaryngology, Head and Neck Surgery, Soroka University Hospital, Ben Gurion University, Beer Sheva, Israel. †Senior Lecturer, Department of Otolaryngology, Head and Neck Surgery, Soroka University Hospital, Ben-Gurion University, Beer Sheeva, Israel. ‡Professor, The Skull Base Unit, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel. Address correspondence and reprint requests to Dr Fliss: The Skull Base Unit, Otolaryngology Department, Sorasky Medical Center, 6 Weitzman St, Tel-Aviv, Israel; e-mail: [email protected] © 2001 American Association of Oral and Maxillofacial Surgeons
0278-2391/01/5912-0003$35.00/0 doi:10.1053/joms.2001.28265
is an autogenous graft that is readily available and can be harvested with minimal morbidity. It is a durable material and has been shown in animal studies to be incorporated into the periorbital tissues.4 This study reviewed our experience with 20 patients using nasoseptal cartilage for orbital floor fracture repair.
Patients and Methods A prospective evaluation was performed on 20 patients (age range, 8 to 65 years) presenting to the Soroka University Medical Center from 1992 through 1999. Only patients with pure and impure blowout fractures were included in this study. They had undergone surgical exploration and reconstruction of orbital floor fractures with nasoseptal cartilage. The medical records were analyzed for age, sex, type of fracture, mechanism of injury, length of time between injury and surgery, and length of follow-up. All patients underwent preoperative and postoperative otolaryngologic, maxillofacial, and ophthalmologic evaluation. The preoperative radiographic evaluation included craniofacial axial and coronal tomographic scans. Each patient was evaluated for the presence or absence of the following preoperative clinical findings: diplopia, enophthalmos, infraorbital nerve paresthesia, and limitation of ocular motility. The results were recorded in the patient’s chart. Diplopia was evaluated to document primary and extreme gaze symptoms. Globe malposition was assessed with respect to
1397
1398 axial and vertical dystopia and vertical differences between the pupils, respectively. A forced duction test was performed in all cases. The criteria for orbital surgery consisted of one or more of the following findings: extraocular muscle entrapment, large orbital defects (defined as more than 8 mm or greater than 50% of the orbital floor), or orbital floor involvement along with other midface fractures. SURGICAL TECHNIQUE
The orbit was approached through a transconjunctival approach or through pre-existing skin lacerations in the orbital region. The transconjunctival incision was carried out with the lower lid everted and retracted away from the globe by a Desmarres retractor to the level of the inferior orbital rim. The periosteum overlying the orbital rim was incised, and elevation of the periosteum and orbital floor exploration was accomplished in a routine fashion until the fracture was exposed. The degree of orbital tissue herniation and the size of the orbital floor defect were then measured. The size of the nasoseptal cartilage graft was estimated according to the size of the orbital floor defect. A hemitransfiction incision at the caudal rim was used to expose the nasoseptal cartilage. Once the mucoperichondrium covering the septal cartilage was infiltrated with 1% lidocaine with 1:100,000 epinephrine, a sharp dissection was carefully carried through the mucoperichondrium. The mucoperichondrium was then elevated from the most dorsal aspect of the septum to the maxillary crest bilaterally. A single piece of the quadrilateral cartilage was harvested to cover the orbital floor defect (Fig 1). The incision was closed with interrupted 4-0 Vicryl sutures (Ethicon, Somerville, NJ), and nasal packing was performed at the end of the procedure. Reduction of the orbital contents herniated into the maxillary sinus was performed, and the septal carti-
FIGURE 1. Specimen of harvested septal cartilage. The graft is carved before being placed in the orbital floor.
REPAIR OF TRAUMATIC INFERIOR ORBITAL WALL DEFECTS
lage was placed over the orbital floor to completely cover the margins of the defect. Although no fixation of the cartilage was used, care was taken to ensure that it extended well behind the inferior orbital margin. The conjunctival incision was closed with absorbable 6-0 Vicryl sutures. A forced duction test was performed at the end of the procedure to evaluate postoperative ocular motility. The success of the surgical repair and the postoperative status were evaluated at 1 week, 3 months, and 6 months.
Results During the study period of 1992 to 1999, 25 patients with facial fractures associated with orbital floor defects were surgically treated at our medical center. Twenty patients underwent surgical reconstruction of the orbital floor with nasoseptal cartilage. The 5 patients in whom the orbital floor repair was performed with other autogenous and alloplastic materials were excluded from the study. The patient population consisted of 15 males and 5 females, aged 8 to 65 years (mean, 29 years). The mechanism of injury in all patients was blunt trauma. Of the 20 patients included in this study, 9 had pure inferior blowout fractures and 11 had impure orbital floor fractures. The average length of time between injury and surgery was 3 days, with a range of 12 hours to 12 days. In 8 patients, the surgical reconstruction was performed on the same day of admission to the hospital. Although our policy is early surgical intervention in facial fractures, in 11 patients, surgery was delayed because of severe systemic conditions. The most common preoperative clinical findings in this series was limited ocular motility in 19 patients (95%), paresthesia or hypoesthesia in 7 (35%), and diplopia in 5 (25%). The indication for surgery in the patients was a large orbital wall defect (more than 8 mm or greater than 50% of the orbital floor) with herniation of orbital tissue or orbital floor defects associated with other midface fractures. A transconjunctival approach without lateral canthotomy was used for orbital floor exploration. No complications related to the performance of the submucosal resection of the nasal septum, such as hemorrhage, infection, perforation, or anterior displacement of the cartilage, occurred. In addition, no complications, such as ectropion, entropion, paranasal sinus infection, or complications in the harvested cartilage site, occurred in the postoperative period. No patient in this series underwent revision surgery (Fig 2). Two patients with preoperative diplopia and 1 patient with preoperative paresthesia of the check continued to experience these inconveniences during the
1399
KRAUS, GATOT, AND FLISS
FIGURE 2. Pre- and postoperative views of patient treated with nasoseptal cartilage. A, Oblique axial scan (30°) reveals depressed left inferior wall fracture associated with a tripod fracture of the zygomaticomalar complex. B, Postoperative coronal computed tomography scan showing satisfactorily repaired left orbital floor.
postoperative follow-up period. The postoperative complications included enophthalmos and lower lid edema in 2 different patients (Table 1). The mean length of follow-up was 12.3 weeks with a range of 1 week to 6 months.
Discussion The question of whether to use alloplastic or autogenous implants for reconstructive orbital surgery is still a matter of controversy. The decision to use a specific orbital implant depends on the surgeon’s
preference and on the availability and cost of the implant.3,5 Three types of alloplastic implants can be used for orbital reconstruction: nonporous, porous, and absorbable. The group of the nonporous implants includes silicone, Teflon (DuPont, Wilmington, DE), and metallic implants. Hydroxyapatite and porous polyethylene are the two most popular porous implants. The most important advantage of these implants is the ability of fibromuscular ingrowth into the alloplast, which offers better positional stabilization and fixation of the implant to the bony orbit and resistance to infection once it is vascularized.2,3 Furthermore, the ability to use alloplastic implants without an additional operation (usually obligatory for autogenous grafts) is another advantage. However, the alloplastic materials can cause complications, such as extrusion, migration, and infection, as well as dental or maxillary sinus infection.6,7 Homografts, such as lyophilized dura, can be used in moderately displaced orbital fractures. Because of the acquired immunodeficiency syndrome epidemic and a reported case of Creutzfeldt-Jacob disease, the use of these grafts is decreasing nowadays.4 Autogenous materials have been used since the beginning of the century. The commonly used implants in clinical reconstructive surgery include the outer table of the calvarium, iliac bone, split rib, mandibular bone, and cartilage. These grafts undergo resorption after placement, with reduction in bone volume, which complicates the correction of enophthalmos. Despite this relative disadvantage of autogenous graft and the concomitant additional operation required to harvest them, autogenous tissue has greater biocompatibility and minimal morbidity, with a lower infection rate, when compared with alloplastic materials. Complications, such as graft extrusion, migration, and displacement, which occur with alloplastic implants, are rare with autografts.6-10 Among the autogenous grafts, cartilage has the lowest vascu-
Table 1. COMPLICATIONS IN 20 PATIENTS TREATED WITH NASOSEPTAL CARTILAGE FOR POST-TRAUMATIC ORBITAL FLOOR DEFECTS
Complication
No. Patients (%)
Infraorbital paresthesia Diplopia Entropion Enophthalmos Lower lid edema Graft displacement Graft extrusion Sinus infection Orbital infection Total
0 (%) 0 (%) 0 (0%) 1 (5%) 1 (5%) 0 (%) 0 (%) 0 (%) 0 (%) 2 (10%)
1400 larity and hence an increased survival rate and lower resorption as compared with bone grafts. The nasoseptal cartilage is a durable material for orbital floor defects that is located close to the operative field and can be harvested with insignificant increased operative time and noncosmetic morbidity. Despite these advantages, only a few authors have reported on the use of this graft in orbital floor fractures.6,11 To the best of our knowledge, our study is the largest reported series of patients in whom septal cartilage was used to repair orbital floor fractures. In this series, no complications in the donor site were observed. Thus, the preliminary results with the use of this autogenous material are encouraging. Although the time of viability of the septal cartilage is not clear, an experiment in dogs with the use of septal cartilage showed that it remains viable in the orbital floor for more than 10 weeks after surgery.11 The transconjunctival approach was used in all cases in this study. Comparison between transconjunctival and subciliary approaches indicates better aesthetic results and a lower incidence of ectropion with the transconjunctival approach.12,13 Although we did not perform a lateral canthotomy, access to the orbital floor was satisfactory. The complication rate in this series was comparable to the complication rate reported in other series.6 Although Lai et al6 showed that the nasocartilage graft is a superior material in the repair of pure blowout fractures, our report shows that it also can be safety used
in more severe traumatic injuries of the facial skeleton with minimal recipient and donor site morbidity.
References 1. Nguyen PN, Sullivan P: Advances in the management of orbital fractures. Clin Plastic Surg 19:87, 1992 2. Hes J, de Man K: Use of blocks of hydroxyapatite for secondary reconstruction of the orbital floor. Int J Oral Maxillofac Surg 19:275, 1990 3. Rubin PAD, Bilyk JR, Shore JW: Orbital reconstruction using porous polyethylene sheets. Ophthalmology 101:1697, 1994 4. Prichard J, Thadani V, Kalb R, et al: Rapidly progressive dementia in a patient who received cadaveric dura mater graft. JAMA 257:1036, 1987 5. Bevivino JR, Nguyen PN, Yen LI : Reconstruction of traumatic orbital floor defects using irradiated cartilage homograft. Ann Plast Surg 33:32, 1994 6. Lai A, Glicklick RE, Rubin PAD: Repair of orbital blow out fractures with nasoseptal cartilage. Laryngoscope 108:645, 1998 7. Palley JW, Ringer SL: The use of Teflon in orbital floor reconstruction following blunt facial trauma: A 20-year experience. Plast Reconstr Surg 79:39, 1987 8. Chen JM, Zingg M, Laedrach K, et al: Early surgical intervention for orbital floor fractures: A clinical evaluation of lyophilized dura and cartilage reconstruction. J Oral Maxillofac Surg 50: 935, 1992 9. Webster K: Orbital floor repair with lyophilized porcine dermis. Oral Surg 65:161, 1998 10. Rozema FR, Bos PRM, Pennings AJ, et al: Poly(L-Lactide) implants in repair of defects of the orbital floor. An animal study. J Oral Maxillofac Surg 49:1305, 1990 11. Wiesenbaugh JM Jr, Beil MC: Orbital floor repair with nasal septal cartilage. Trans Int Conf Oral Surg 4:308, 1973 12. Wray RC Jr, Holtman B, Ribardo JM, et al: A comparison of conjunctival and subciliary incisions for orbital fractures. Br J Plast Surg 30:142, 1977 13. Waite PD, Carr DD: The transconjuctival approach for treating orbital trauma. J Oral Maxillofac Surg 49:499, 1991
Repair of Traumatic Inferior Orbital Wall Defects With Nasoseptal Cartilage Mordechai Kraus, MD,* Albert Gatot, MD, DMD,† and Dan M. Fliss, MD‡ Purpose:
This study evaluated the effectiveness of nasoseptal cartilage for repairing traumatic orbital floor defects. Patients and Methods: Autogenous septal cartilage was used in 20 patients. They were evaluated for the presence or absence of diplopia, enophthalmus, infraorbital nerve paresthesia, and ocular motility disorders. Surgical indications for orbital exploration included entrapment of orbital tissues, large orbital defect (greater than 50% of the orbital floor or more than 8 mm), or orbital floor defects with involvement of other zygomaticofrontal complex fractures. Results: All patients were successfully treated by restoration of the orbital wall continuity. Follow-up at 1 week to 6 months showed 1 patient with postoperative enophthalmos and 1 patient with lower lid edema. There were no donor site and graft infections or graft extrusion. Conclusions: Nasal septal cartilage is a readily accessible autogenous tissue that should be considered when an autogenous graft is needed for orbital floor defect reconstruction. © 2001 American Association of Oral and Maxillofacial Surgeons The goal of surgical repair of orbital fractures is to restore the traumatized walls to prevent herniation of the globe content into the maxillary sinus or ethmoid air cells, because the latter will be followed by undesirable atrophy of orbital tissue, ocular motility disturbances, and enophtalmus.1,2 Simple repositioning of orbital floor fragments into their anatomic position is generally not possible, and an implant is then needed to reconstruct the floor. The materials used for this purpose are both autogenous and alloplastic. The selection depends on the characteristics of the material and the surgeon’s preference and experience.3 Recently, there has been a trend toward using autogenous grafts in reconstructive orbital surgery. These autogenous grafts include cranial bone, iliac bone, split rib, and cartilage. The nasoseptal cartilage
*Lecturer, Department of Otolaryngology, Head and Neck Surgery, Soroka University Hospital, Ben Gurion University, Beer Sheva, Israel. †Senior Lecturer, Department of Otolaryngology, Head and Neck Surgery, Soroka University Hospital, Ben-Gurion University, Beer Sheeva, Israel. ‡Professor, The Skull Base Unit, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel. Address correspondence and reprint requests to Dr Fliss: The Skull Base Unit, Otolaryngology Department, Sorasky Medical Center, 6 Weitzman St, Tel-Aviv, Israel; e-mail: [email protected] © 2001 American Association of Oral and Maxillofacial Surgeons
0278-2391/01/5912-0003$35.00/0 doi:10.1053/joms.2001.28265
is an autogenous graft that is readily available and can be harvested with minimal morbidity. It is a durable material and has been shown in animal studies to be incorporated into the periorbital tissues.4 This study reviewed our experience with 20 patients using nasoseptal cartilage for orbital floor fracture repair.
Patients and Methods A prospective evaluation was performed on 20 patients (age range, 8 to 65 years) presenting to the Soroka University Medical Center from 1992 through 1999. Only patients with pure and impure blowout fractures were included in this study. They had undergone surgical exploration and reconstruction of orbital floor fractures with nasoseptal cartilage. The medical records were analyzed for age, sex, type of fracture, mechanism of injury, length of time between injury and surgery, and length of follow-up. All patients underwent preoperative and postoperative otolaryngologic, maxillofacial, and ophthalmologic evaluation. The preoperative radiographic evaluation included craniofacial axial and coronal tomographic scans. Each patient was evaluated for the presence or absence of the following preoperative clinical findings: diplopia, enophthalmos, infraorbital nerve paresthesia, and limitation of ocular motility. The results were recorded in the patient’s chart. Diplopia was evaluated to document primary and extreme gaze symptoms. Globe malposition was assessed with respect to
1397
1398 axial and vertical dystopia and vertical differences between the pupils, respectively. A forced duction test was performed in all cases. The criteria for orbital surgery consisted of one or more of the following findings: extraocular muscle entrapment, large orbital defects (defined as more than 8 mm or greater than 50% of the orbital floor), or orbital floor involvement along with other midface fractures. SURGICAL TECHNIQUE
The orbit was approached through a transconjunctival approach or through pre-existing skin lacerations in the orbital region. The transconjunctival incision was carried out with the lower lid everted and retracted away from the globe by a Desmarres retractor to the level of the inferior orbital rim. The periosteum overlying the orbital rim was incised, and elevation of the periosteum and orbital floor exploration was accomplished in a routine fashion until the fracture was exposed. The degree of orbital tissue herniation and the size of the orbital floor defect were then measured. The size of the nasoseptal cartilage graft was estimated according to the size of the orbital floor defect. A hemitransfiction incision at the caudal rim was used to expose the nasoseptal cartilage. Once the mucoperichondrium covering the septal cartilage was infiltrated with 1% lidocaine with 1:100,000 epinephrine, a sharp dissection was carefully carried through the mucoperichondrium. The mucoperichondrium was then elevated from the most dorsal aspect of the septum to the maxillary crest bilaterally. A single piece of the quadrilateral cartilage was harvested to cover the orbital floor defect (Fig 1). The incision was closed with interrupted 4-0 Vicryl sutures (Ethicon, Somerville, NJ), and nasal packing was performed at the end of the procedure. Reduction of the orbital contents herniated into the maxillary sinus was performed, and the septal carti-
FIGURE 1. Specimen of harvested septal cartilage. The graft is carved before being placed in the orbital floor.
REPAIR OF TRAUMATIC INFERIOR ORBITAL WALL DEFECTS
lage was placed over the orbital floor to completely cover the margins of the defect. Although no fixation of the cartilage was used, care was taken to ensure that it extended well behind the inferior orbital margin. The conjunctival incision was closed with absorbable 6-0 Vicryl sutures. A forced duction test was performed at the end of the procedure to evaluate postoperative ocular motility. The success of the surgical repair and the postoperative status were evaluated at 1 week, 3 months, and 6 months.
Results During the study period of 1992 to 1999, 25 patients with facial fractures associated with orbital floor defects were surgically treated at our medical center. Twenty patients underwent surgical reconstruction of the orbital floor with nasoseptal cartilage. The 5 patients in whom the orbital floor repair was performed with other autogenous and alloplastic materials were excluded from the study. The patient population consisted of 15 males and 5 females, aged 8 to 65 years (mean, 29 years). The mechanism of injury in all patients was blunt trauma. Of the 20 patients included in this study, 9 had pure inferior blowout fractures and 11 had impure orbital floor fractures. The average length of time between injury and surgery was 3 days, with a range of 12 hours to 12 days. In 8 patients, the surgical reconstruction was performed on the same day of admission to the hospital. Although our policy is early surgical intervention in facial fractures, in 11 patients, surgery was delayed because of severe systemic conditions. The most common preoperative clinical findings in this series was limited ocular motility in 19 patients (95%), paresthesia or hypoesthesia in 7 (35%), and diplopia in 5 (25%). The indication for surgery in the patients was a large orbital wall defect (more than 8 mm or greater than 50% of the orbital floor) with herniation of orbital tissue or orbital floor defects associated with other midface fractures. A transconjunctival approach without lateral canthotomy was used for orbital floor exploration. No complications related to the performance of the submucosal resection of the nasal septum, such as hemorrhage, infection, perforation, or anterior displacement of the cartilage, occurred. In addition, no complications, such as ectropion, entropion, paranasal sinus infection, or complications in the harvested cartilage site, occurred in the postoperative period. No patient in this series underwent revision surgery (Fig 2). Two patients with preoperative diplopia and 1 patient with preoperative paresthesia of the check continued to experience these inconveniences during the
1399
KRAUS, GATOT, AND FLISS
FIGURE 2. Pre- and postoperative views of patient treated with nasoseptal cartilage. A, Oblique axial scan (30°) reveals depressed left inferior wall fracture associated with a tripod fracture of the zygomaticomalar complex. B, Postoperative coronal computed tomography scan showing satisfactorily repaired left orbital floor.
postoperative follow-up period. The postoperative complications included enophthalmos and lower lid edema in 2 different patients (Table 1). The mean length of follow-up was 12.3 weeks with a range of 1 week to 6 months.
Discussion The question of whether to use alloplastic or autogenous implants for reconstructive orbital surgery is still a matter of controversy. The decision to use a specific orbital implant depends on the surgeon’s
preference and on the availability and cost of the implant.3,5 Three types of alloplastic implants can be used for orbital reconstruction: nonporous, porous, and absorbable. The group of the nonporous implants includes silicone, Teflon (DuPont, Wilmington, DE), and metallic implants. Hydroxyapatite and porous polyethylene are the two most popular porous implants. The most important advantage of these implants is the ability of fibromuscular ingrowth into the alloplast, which offers better positional stabilization and fixation of the implant to the bony orbit and resistance to infection once it is vascularized.2,3 Furthermore, the ability to use alloplastic implants without an additional operation (usually obligatory for autogenous grafts) is another advantage. However, the alloplastic materials can cause complications, such as extrusion, migration, and infection, as well as dental or maxillary sinus infection.6,7 Homografts, such as lyophilized dura, can be used in moderately displaced orbital fractures. Because of the acquired immunodeficiency syndrome epidemic and a reported case of Creutzfeldt-Jacob disease, the use of these grafts is decreasing nowadays.4 Autogenous materials have been used since the beginning of the century. The commonly used implants in clinical reconstructive surgery include the outer table of the calvarium, iliac bone, split rib, mandibular bone, and cartilage. These grafts undergo resorption after placement, with reduction in bone volume, which complicates the correction of enophthalmos. Despite this relative disadvantage of autogenous graft and the concomitant additional operation required to harvest them, autogenous tissue has greater biocompatibility and minimal morbidity, with a lower infection rate, when compared with alloplastic materials. Complications, such as graft extrusion, migration, and displacement, which occur with alloplastic implants, are rare with autografts.6-10 Among the autogenous grafts, cartilage has the lowest vascu-
Table 1. COMPLICATIONS IN 20 PATIENTS TREATED WITH NASOSEPTAL CARTILAGE FOR POST-TRAUMATIC ORBITAL FLOOR DEFECTS
Complication
No. Patients (%)
Infraorbital paresthesia Diplopia Entropion Enophthalmos Lower lid edema Graft displacement Graft extrusion Sinus infection Orbital infection Total
0 (%) 0 (%) 0 (0%) 1 (5%) 1 (5%) 0 (%) 0 (%) 0 (%) 0 (%) 2 (10%)
1400 larity and hence an increased survival rate and lower resorption as compared with bone grafts. The nasoseptal cartilage is a durable material for orbital floor defects that is located close to the operative field and can be harvested with insignificant increased operative time and noncosmetic morbidity. Despite these advantages, only a few authors have reported on the use of this graft in orbital floor fractures.6,11 To the best of our knowledge, our study is the largest reported series of patients in whom septal cartilage was used to repair orbital floor fractures. In this series, no complications in the donor site were observed. Thus, the preliminary results with the use of this autogenous material are encouraging. Although the time of viability of the septal cartilage is not clear, an experiment in dogs with the use of septal cartilage showed that it remains viable in the orbital floor for more than 10 weeks after surgery.11 The transconjunctival approach was used in all cases in this study. Comparison between transconjunctival and subciliary approaches indicates better aesthetic results and a lower incidence of ectropion with the transconjunctival approach.12,13 Although we did not perform a lateral canthotomy, access to the orbital floor was satisfactory. The complication rate in this series was comparable to the complication rate reported in other series.6 Although Lai et al6 showed that the nasocartilage graft is a superior material in the repair of pure blowout fractures, our report shows that it also can be safety used
in more severe traumatic injuries of the facial skeleton with minimal recipient and donor site morbidity.
References 1. Nguyen PN, Sullivan P: Advances in the management of orbital fractures. Clin Plastic Surg 19:87, 1992 2. Hes J, de Man K: Use of blocks of hydroxyapatite for secondary reconstruction of the orbital floor. Int J Oral Maxillofac Surg 19:275, 1990 3. Rubin PAD, Bilyk JR, Shore JW: Orbital reconstruction using porous polyethylene sheets. Ophthalmology 101:1697, 1994 4. Prichard J, Thadani V, Kalb R, et al: Rapidly progressive dementia in a patient who received cadaveric dura mater graft. JAMA 257:1036, 1987 5. Bevivino JR, Nguyen PN, Yen LI : Reconstruction of traumatic orbital floor defects using irradiated cartilage homograft. Ann Plast Surg 33:32, 1994 6. Lai A, Glicklick RE, Rubin PAD: Repair of orbital blow out fractures with nasoseptal cartilage. Laryngoscope 108:645, 1998 7. Palley JW, Ringer SL: The use of Teflon in orbital floor reconstruction following blunt facial trauma: A 20-year experience. Plast Reconstr Surg 79:39, 1987 8. Chen JM, Zingg M, Laedrach K, et al: Early surgical intervention for orbital floor fractures: A clinical evaluation of lyophilized dura and cartilage reconstruction. J Oral Maxillofac Surg 50: 935, 1992 9. Webster K: Orbital floor repair with lyophilized porcine dermis. Oral Surg 65:161, 1998 10. Rozema FR, Bos PRM, Pennings AJ, et al: Poly(L-Lactide) implants in repair of defects of the orbital floor. An animal study. J Oral Maxillofac Surg 49:1305, 1990 11. Wiesenbaugh JM Jr, Beil MC: Orbital floor repair with nasal septal cartilage. Trans Int Conf Oral Surg 4:308, 1973 12. Wray RC Jr, Holtman B, Ribardo JM, et al: A comparison of conjunctival and subciliary incisions for orbital fractures. Br J Plast Surg 30:142, 1977 13. Waite PD, Carr DD: The transconjuctival approach for treating orbital trauma. J Oral Maxillofac Surg 49:499, 1991