Authors of section

Authors

Nicolas Homsi, Paulo Rodrigues, Gregorio Sánchez Aniceto, Beat Hammer, Scott Bartlett

Executive Editors

Edward Ellis III, Eduardo Rodriguez

General Editor

Daniel Buchbinder

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Intraorbital volume augmentation

1. Introduction

Insertion of augmentation material inside the orbit and posterior to the globe equator will produce an axial anterior projection of the globe with a near 1ml/1mm ratio.

Autogenous or alloplastic materials may be used. Autogenous costal cartilage is the preferred material of this author, porous polyethylene is also a good option.

intraorbital volume augmentation

3. Volume augmentation

Dissections

Deep orbital anteroposterior subperiosteal dissection is performed in three locations. The aim is to create three pockets (not wider than 1cm) in the deep orbit where the implants will be placed.

First pocket: Superolaterally over the great sphenoid wing, between the superior and lateral rectus muscles.

intraorbital volume augmentation

Second pocket: Inferomedially back to the palatine bone, between the inferior and medial rectus muscles.

intraorbital volume augmentation

Third pocket: Inferolaterally just above the inferior fissure, between the inferior and lateral rectus muscles.

intraorbital volume augmentation

Cartilage harvest

Costal cartilage is harvested following standard procedures. Cartilage blocks are carved with a scalpel and contoured to a bean shape.

intraorbital volume augmentation

Augmentation

The total volume (ml) to be inserted should be approximately equal to the desired axial enophthalmic correction (mm). More than one implant may be inserted in each "pocket".

intraorbital volume augmentation

4. Aftercare following correction of orbital deformities

Evaluation of the patient's vision and pupillary response are performed as soon as awakened from anesthesia and then at regular intervals until they are discharged from the hospital.

Postoperative positioning

Head of bed elevation may significantly reduce edema and pain.
A cooling mask may be used to further reduce edema.

orbital reconstruction

Nose-blowing

To prevent orbital emphysema, nose-blowing should be avoided for at least 14 days following surgery.

Medication

The use of the following perioperative medication is controversial.

  • Analgesia as necessary
  • Antibiotics (many surgeons use perioperative antibiotics. There is no clear advantage of any one antibiotic, and the recommended duration of treatment is debatable.)
  • Steroids may diminish postoperative edema. Some surgeons have noted increased complications with perioperative steroids.
  • Ophthalmic ointment should follow local and approved protocol. This is not generally required in case of periorbital edema. Some surgeons prefer it. Some ointments have been found to cause significant conjunctival irritation.

Ophthalmological examination

The following signs and symptoms are usually evaluated:

  • Visual acuity
  • Extraocular motion (motility)
  • Diplopia
  • Globe position
  • Lid position

Postoperative imaging

Postoperative imaging has to be performed within the first days after surgery. 3-D imaging (CT, cone beam) is recommended.

Wound care

Remove sutures from skin after approximately 5 days if non resorbable sutures have been used.
Avoid sun exposure and tanning to skin incisions for several months.

Clinical follow-up

Clinical follow-up depends on the complexity of the surgery, and whether the patient has any postoperative problems. In most patients one week, four weeks, six months and one year follow up is recommended.
Additionally, ophthalmological, ENT, and neurological/neurosurgical examination may be necessary. A regular follow-up CT scan is recommended 3-6 months after surgery.
Travel in commercial airlines is permitted following orbital surgery. Commercial airlines pressurize their cabins. Mild pain on descent may be noticed. However, flying in non-pressurized aircrafts should be avoided for a minimum of six weeks.
No scuba diving should be permitted for at least six weeks.