A Hole in the Wall

There is a mystical hole in the wall – of the orbit. An ancient myth among oculoplastic and maxillofacial surgeons alike-that once an Orbito- zygomatico-maxillary complex (OZM) fracture or commonly known as ZMC fracture is reduced, the orbital floor fracture automatically gets reduced and there is no need to repair the floor of the orbit. This was classic textbook teaching. However, this is true of only a small percentage of ZMC fractures.

But with modern roads, high speed traffic- high impact injuries are getting quite frequent, more complex fractures are presenting to hospitals. The myth has been busted by experienced surgeons over the years. However, the myth still persists.

Pic 1

We see in Pic 1 that there is a medium sized orbital floor defect extending all the way to the inferior orbital fissure despite excellent reduction of the OZM fracture with the help of our maxillofacial team lead by @prashanth.rajaram . The orbital floor then was repaired with a porous polyethylene sheet to prevent both post operative entrapment and late enophthalmos.

Pic 2

Surgery- We see in Pic 2 intra-operatively that there were additional fractures to fix that were not visible on the Pre-op scans. We can achieve complete exposure of the fractures using a Trans-conjunctival as well as a trans-oral incisions thus avoiding a skin incision altogether. If we need fix the fronto-zygomatic part of the fracture an eyelid crease incision would be used (we didn’t need it in this case). Eyelid crease incision is well hidden in the fold of the upper eyelid crease. Fracture repairs do not require ugly skin scars and can be achieved with hidden incisions.

Pic 3

The Pre and post surgery CT 3D reconstructions shows the excellent reduction of the OZM fracture. In this case a 2 point fixation was enough to reduce the fracture.

Pic 4

In Pic 4 we see the coronal, axial and saggital cuts showing good open reduction and internal fixation (ORIF). The “empty” space seen in the sagittal section in the post op image is occupied by the radio-lucent porous polyethylene sheet (Omnipore) but is holding the orbital contents from prolapsing into the maxilla.

I hope that this busted myth becomes a thing of the past and there is more collaborative work among Oculoplastic, cranio-maxillo-facial, Oto-rhino-laryngologists, Plastic Surgeons and Neurosurgeons in the multi-disciplinary field of facial trauma.

©All patient photos are being used with the express consent of the patient. The copyright for all images belongs to Dr. Raghuraj Hegde. These cannot be shared or reproduced elsewhere.

Published by Dr. Raghuraj Hegde

Free thinker| Poet| Writer| Traveller| Doctor| Ophthalmic Plastic Surgeon

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