Authors of section

Authors

Scott Bartlett, Michael Ehrenfeld, Gerson Mast, Adrian Sugar

Executive Editor

Edward Ellis III

General Editor

Daniel Buchbinder

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Orbit malar construction with vascularized bone graft

1. Introduction

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.

orbit malar construction with vascularized bone graft

2. Approaches

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.

It is imperative that the plane of dissection in the area where the bone graft will be harvested is supra periosteal.

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.

orbit malar construction with vascularized bone graft

3. Harvest of bone graft

Bone graft for the zygomatic complex

A template of the proposed zygomatic complex is made and taken to the skull. A T-shape calvarial bone graft serving to reconstruct the body of the zygoma, zygomatic arch, and the inferior orbital rim is outlined with an electrocautery needle through the periosteum.

The vascularity or blood supply of the bone graft is based on the temporalis pedicle and around 2/3 of the bone harvested for the horizontal arm of the T should be attached to the temporalis muscle.

orbit malar construction with vascularized bone graft

Parallel incisions through the temporalis muscle to allow mobilization of the pedicled bone graft are necessary.

orbit malar construction with vascularized bone graft

A small tunnel/portion of the muscle is elevated at the inferior osteotomy line to allow for the osteotomy.

orbit malar construction with vascularized bone graft

One burr hole is made and the desired shaped graft is harvested using a craniotome. Care is taken not to damage the periosteum overlaying the bone flap.

orbit malar construction with vascularized bone graft

The bone flap is carefully lifted making sure that no dural lacerations occur.

orbit malar construction with vascularized bone graft

The periosteum must remain attached to the bone and can be facilitated by drilling small holes at the periphery of the graft and suturing it in place.

orbit malar construction with vascularized bone graft

Bone graft for orbital floor/wall/rim

A split thickness cranial bone graft is harvested from an adjacent area of the skull for the reconstruction of the lateral orbital wall/floor/rim. Harvesting of split thickness cranial bone is described in the coronal approach.

4. Construction

Zygoma

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

orbit malar construction with vascularized bone graft

The bone graft is then rotated into position and attached with plates and screws to the zygoma and lateral orbital rim (resorbable plates and screws in children). The neo-orbital rim is trimmed and smoothened with a contouring burr.

orbit malar construction with vascularized bone graft

Orbital floor

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

orbit malar construction with vascularized bone graft

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.

treacher collins syndrome

Reconstruction of donor defect

Reconstruction of the donor defect is necessary not only to restore the contour but to protect the brain. Reconstructive options include split thickness calvarial bone graft, cranial bone graft shavings in children, and titanium mesh, porous polyethylene or polymethylmethacrylate (PMMA) in adults.

Cranial reconstruction in adults is discussed in the section on postablative reconstruction.

orbit malar construction with vascularized bone graft

5. Aftercare following construction of zygomatico orbital complex

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.