Complex Revision of the Previously Reconstructed Posttraumatic Orbital Floor: should we be Revisiting the Anterior Orbitotomy in The Digital Age

Abstract

Secondary reconstructive surgery on the traumatized orbit can be challenging, and none more so than revision cases. It is now relatively commonplace in specialist maxillofacial units to consider orbitozygomatic osteotomy, in conjunction with orbital floor reconstruction. Furthermore, with the capacity to digitally plan and manufacture custom implants, it can be done with a high degree of accuracy. In modern practice, implant material for orbital floor reconstruction is predominantly non-autologous, and in significant defects a stock or custom titanium implant is the gold standard. Historically autologous materials such as calvarial bone or rib cartilage were used. Approaches also vary and a transcutaneous approach remains in common practice, despite the potential superiority of transconjunctival access. We present a complex case of a male patient in his 40 s who presented with progressive hyperglobus, vertical diplopia and a mass emanating from his infraorbital rim. The patient was an amateur boxer and had suffered a right orbital floor fracture in the 1990s, as a result of a punch. He had undergone reconstruction of his orbital floor with autologous rib via a transcutaneous approach. Imaging showed the orbital floor reconstruction was now a coalesced soft tissue mass altering the globe position. Using this case and extensive intraoperative photography, we explore the benefits of anterior orbitotomy including digital planning, custom cutting guides, and placement of the custom implants for complex revision cases. Posing the question should we revisit this technique now we have the technology, equipment and skill to utilize it to its full potential?