Orbit malar construction with free bone graft

The typical deformity of TCS is a lateral cleft through the orbit and zygoma, with loss of ocular support. This is corrected utilizing bone grafts.

Note: Due to the poor soft tissue environment, bone graft resorbtion frequently occurs. In patients whom this occurs, and in patients with more mild deformities, this may be addressed by placement of an alloplastic malar implant once basal bone continuity is established.

The zygomatico-orbital complex is best approached through a coronal approach. When choosing the location of the incision, an eventual ear construction should be considered.

Access to the orbital floor is gained through a lower eyelid transconjunctival approach.

A complete circumferential subperiosteal dissection of the orbit and periorbital skeleton is performed.

The following pages provide general information regarding orbital anatomy and dissection

• Preoperative considerations
• Anatomy of the bony orbit
• Correlation of surface and cross sectional anatomy
• Introduction to periorbital dissection
• Orbital floor dissection
• Medial orbital wall dissection
• Lateral orbital wall dissection
• Orbital roof dissection
• Adjunctive access procedures (orbitotomies)
• Retrobulbar hemmorage

A 1 cm wide split thickness calvarial bone graft is harvested with a sufficient length to span from the residual zygoma to the native zygomatic arch.

The harvest of calvarial bone graft is performed as described in the coronal approach.

An additional split thickness calvarial bone graft is harvest for the reconstruction of the lateral orbital wall and rim.

The lateral and infraorbital rims may need to be adjusted to accept the corresponding regions of the bone graft. This can be done by the use of saws and burrs.

The bone grafts are secured with plates and/or screws to the host bone. The neo-orbital rim is trimmed and smoothened with a contouring burr.

The prolapsed contents of the orbit are separated and retrieved from the inferior orbital fissure or cleft.

A split thickness cranial bone graft is adapted to cover the internal orbital defects and may be secured either with screw fixation only or with plate and screw fixation (as illustrated). Resorbable plate and screw fixation is recommended in children.

Apply ice packs (may be effective in a short term to minimize edema).

Eye lid incisions should be kept well lubricated with ophthalmic antibiotic ointment. A temporary tarsorrhaphy may be useful to help protect the globe.

The sterile dressing placed over the incisions is maintained for a minimum of 48 hours. Thereafter routine wound care should be instituted.

Antibiotic prophylaxis is continued for 1-5 days depending on the nature, complexity, and duration of the surgical procedure.

Remove sutures from skin after approximately 7-10 days if nonresorbable sutures have been used.

Regular follow up examinations to monitor healing are required.

Avoid sun exposure and tanning to skin incisions for several months.