안와골파열골절 정복술 후 지속되는 안구함몰 환자에서 정상측 안구의 안구 감압술의 치험례

이준호,박원용,남현재,김용하 대한두개안면성형외과학회 2008 Archives of Craniofacial Surgery Vol.9 No.2

Purpose: Diplopia and cosmetically unacceptable enophthalmos are the major complications of blow out fracture. Prolapse of orbital tissue into the sinuses, enlarged orbital volume, atrophy of orbital fat and loss of support of orbital walls play a role in the pathogenesis of enophthalmos. To correct post-traumatic enophthalmos, freeing of incarcerated orbital contents combined with reduction of bony orbital volume and reconstruction of suspensory support of globe is necessary. But remained enophthalmos after surgical treatment is difficult to correct completely. In this case, the authors performed implant insertion for affected orbit and endoscopic orbital decompression for unaffected orbit for correction of late enophthalmos. Received August 14, 2008 Revised September 23, 2008 Accepted September 30, 2008 Address Correspondence: Yong-Ha Kim, M.D., Department of Plastic & Reconstructive Surgery, College of Medicine, Yeungnam University Hospital, 317-1 Daemyung 5-dong, Nam-gu, Daegu 705-717, Korea. Tel: 053)620-3482/Fax: 053)626-0705/E-mail: yhkim@med.yu.kr *본 논문은 2008년 대한성형외과학회 제64차 춘계학술대회에서 포스터발표 되었음. Method: We reviewed a girl patient with right inferomedial orbital wall blow out fracture, right zygoma fracture treated at our hospital for correction of enophthalmos. An 18-year-old female had sustained posttraumatic enopthalmos. Two surgical management was performed for correction blow out fracture at the other hospital. But residual diplopia, enophthalmos, cheek drooping were found. And then she transferred to our hospital. She had severe enophthalmos(5mm) also had diplopia and extraocular muscle limitation. We performed operation for correction of enophthalmos. After operation, she showed minimal improvement of diplopia and enophthalmos(3mm). The authors make plan for operation for correction enophthalmos due to cosmetical improvement. Implant insertion was performed for affected orbit. For unaffected orbit, nasoendoscopic medial orbital wall decompression was proceeded. Result: Correction of enophthalmos was found after operation and was maintained for nine years follow-up. Patient expressed satisfaction for the result. Conclusion: To correct persistant enophthalmos, we could have satisfactory result with orbital wall reconstruction on affected eye and decompression on unaffected eye.

외상성 안구함몰에서 안와용적 변화에 관한 연구

황욱배,배용찬,전재용,황소만,이 진,김동헌 大韓成形外科學會 1997 Archives of Plastic Surgery Vol.24 No.5

The CT examinations of 72 consecutive patients attending the department of plastic surgery in Pusan National University Hospital for surgical correction of orbital blow-out fractures were reviewed. Additional 13 patients, post-traumatic enophthalmos had undergone the same evaluation. All scans were performed on a SOMATOM Plus using transaxial scan technique (12OkVp, 210mA, 1 second scan time, 3mm contiguous sections). Each orbital volume and enophthalmos was measured on the CT console. Orbital volume in post-traumatic enophthalmos showed linear correlation with enophthalmos: lcm increase in orbital volume causing 0.97mm of enophthalmos. This confirms the cause of enophthalmos after blow-out fracture to be inereasni in orbital volume rather than fat atrophy or fibrosis. In blow-out fracture, orbital volume correlated well with enophthalmos, with a lcm increase in orbital volume causing 0.68 rnm of enophthalmos. This was probably because of the presence of edema, hemorrhage, or both behind the globe which would prevent immediate development of enophthalmos. CT masurement of orbital volume in blow-out fracture may predict the final degree of enophthalmos and edentify those patientd at risk of late enophthalmos, allowing approriate early surgical intervention.

늑연골 절편이식을 이용한 외상성 안구함몰의 교정

김남복,이택종 大韓成形外科學會 1993 Archives of Plastic Surgery Vol.20 No.2

Enophthalmos is not uncommon squela of orbital fracture. Moreover it is difficult to treat secondarily. Two methods have been employed to correct posttraumatic enophthalmos. one is ostetomy and repositioning of the malunited zygoma and the other is simple filling up the volume defect with some implants. But the latter is preferred because of its simplicity and accuracy of volume correction. When we treat the enophthalmos by volumetric addition, it is essential to estimate the volume defect correctly. We chose simple method only using facial plaster mold and wax as described by Matsuo. With this technique and sliced costal cartilage grafts, we treated six posttraumatic enophthalmos patients and followed-up ranged from 8 months to 30 months. There were two recurrences of enophthalmos lately. It may be due to impossibility of insertion of all measured amount of cartilage. As adding the cartilage of measured amount into the orbit, in severe cases, the intraorbital pressure was increased much because of the newly created additional spaces among the cartilage slices, so it was impossible to insert all the calculated cartilages to avoid the retinal circulatory impairment. Consequently, the spaces among the cartilage slices were decreased and partial cartilage resorption occurred with time, and enophthalmos might recur due to this sequence.

오래 경과된 외상성 안구함몰의 치료

권민상,김정근,배기범,권재환,조중환 대한이비인후과학회 2007 대한이비인후과학회지 두경부외과학 Vol.50 No.2

Background and Objectives:Enophthalmos is a comon sequelae of orbital fracture. Moreover, it is difficult to treat second-arily. We assessed the effect of filling up the orbital volume defect with implants on the correction of late posttraumatic enoph-thalmos. Subjects and Method:because of late postraumatic enophthalmos from July 2001 to December 2005. To corect late posttraumatic enophthalmos, porous polyethylene (Medpor), Medporenophthalmos wedge implant, absorbable mesh, bone graft particulate, rib cartilage, auricle cartilage, and maxilla anterior wall were used. Results:Among 11 patients, 6 patients were men and 5 patients were women. The average age was 33.2 years with the follow-up period of 21.8 months. Five patients had orbital floor fracture, 1 3 patients had zygoma fracture. Excellent results were obtained in all 5 patients with diplopia. The amount of enophthalmos corrected was between 1 and 5 mm (mean 2.5 mm). There was no case of visual loss, infection, migration, or exposure of implant, but we caried out re-operation on 1 case due to over reduction. Conclusion:Filling up the volume defect with proper implants is a relatively simple, safe and efficient technique in corecting late posttraumatic enophthalmos. (Korean J Otolaryngol 2007;50:128-33)

New anthropometric data for preoperative planning in orbital wall fracture treatment: the use of eyelid drooping

이한별,이수향 대한두개안면성형외과학회 2018 Archives of Craniofacial Surgery Vol.19 No.4

Background: The presence of enophthalmos is an important determinant in the decision of orbital wall fracture surgery. We proposed eyelid drooping as a new anthropometric diagnostic measure and analyzed whether eyelid drooping is associated with enophthalmos. Methods: This retrospective study was performed from January 2014 to December 2016. A total of 75 patients with blowout fractures were studied. One experimenter measured the degree of enophthalmos using a Hertel exophthalmometer at 1 week after trauma and at 3 months after surgery. The height change of the upper eyelid was measured using the marginal reflex distance (MRD) on both sides, and the degree of eyelid drooping was calculated by comparing the two lengths. We analyzed statistically the correlation between enophthalmos and eyelid drooping. Results: We found a highly significant correlation between the degree of enophthalmos and the reduction rate of MRD (RRM, as an indicator of eyelid drooping) at 1 week after trauma (r= 0.845). Approximately 2.0 mm of enophthalmos was associated with a 30.8% reduction in MRD on the affected side as compared with the normal side. At 3 months after surgery, patients showed improved eyelid appearance, with a moderate association between enophthalmos and RRM. Conclusion: We demonstrated that the degree of enophthalmos, measured using an exophthalmometer, is associated with a change in the height of the upper eyelid. Thus, upper eyelid drooping can be used as another indicator for orbital wall fracture surgery. Compared with conventional methods, measurements of eyelid drooping are easy to perform, offering a great advantage and understanding to the patient.

Correction of post-traumatic enophthalmos with anatomical absorbable implant and iliac bone graft

Choi, Ji Seon,Oh, Se Young,Shim, Hyung-Sup Korean Cleft Palate-Craniofacial Association 2019 Archives of Craniofacial Surgery Vol.20 No.6

Background: Trauma is one of the most common causes of enophthalmos, and post-traumatic enophthalmos primarily results from an increased volume of the bony orbit. We achieved good long-term results by simultaneously using an anatomical absorbable implant and iliac bone graft to correct post-traumatic enophthalmos. Methods: From January 2012 to December 2016, we performed operations on seven patients with post-traumatic enophthalmos. In all seven cases, reduction surgery for the initial trauma was performed at our hospital. Hertel exophthalmometry, clinical photography, three-dimensional computed tomography (3D-CT), and orbital volume measurements using software to calculate the specific volume captured on 3D-CT (ITK-SNAP, Insight Toolkit-SNAP) were performed preoperatively and postoperatively. Results: Patients were evaluated based on exophthalmometry, clinical photographs, 3D-CT, and orbital volume measured by the ITK-SNAP program at 5 days and 1 year postoperatively, and all factors improved significantly compared with the preoperative baseline. Complications such as hematoma or extraocular muscle limitation were absent, and the corrected orbital volume was well maintained at the 1-year follow-up visit. Conclusion: We present a method to correct enophthalmos by reconstructing the orbital wall using an anatomical absorbable implant and a simultaneous autologous iliac bone graft. All cases showed satisfactory results for enophthalmos correction. We suggest this method as a good option for the correction of post-traumatic enophthalmos.

Surgical indication analysis according to bony defect size in pediatric orbital wall fractures

Kim, Seung Hyun,Choi, Jun Ho,Hwang, Jae Ha,Kim, Kwang Seog,Lee, Sam Yong Korean Cleft Palate-Craniofacial Association 2020 Archives of Craniofacial Surgery Vol.21 No.5

Background: Orbital fractures are the most common pediatric facial fractures. Treatment is conservative due to the anatomical differences that make children more resilient to severe displacement or orbital volume change than adults. Although rarely, extensive fractures may result in enophthalmos, causing cosmetic problems. We aimed to establish criteria for extensive fractures that may result in enophthalmos. Methods: We retrospectively reviewed the charts of patients aged 0-15 years diagnosed with orbital fractures in our hospital from January 2010 to February 2019. Computed tomography images were used to classify the fractures into linear, trapdoor, and open-door types, and to estimate the defect size. Data on enophthalmos severity (Hertel exophthalmometry results) and fracture pattern and size at the time of injury were obtained from patients who did not undergo surgery during the follow-up and were used to identify the surgical indications for pediatric orbital fractures. Results: A total of 305 pediatric patients with pure orbital fractures were included-257 males (84.3%), 48 females (15.7%); mean age, 12.01±2.99 years. The defect size (p=0.002) and fracture type (p=0.017) were identified as the variables affecting the enophthalmometric difference between the eyes of non-operated patients. In the linear regression analysis, the variable affecting the fracture size was open-door type fracture (p<0.001). Pearson's correlation analysis demonstrated a positive correlation between the enophthalmometric difference and the bony defect size (p=0.003). Using receiver operating characteristic curve analysis, a cutoff value of 1.81 ㎠ was obtained (sensitivity, 0.543; specificity, 0.724; p=0.002). Conclusion: The incidence of enophthalmos in pediatric pure orbital fractures was found to increase with fracture size, with an even higher incidence when open-door type fracture was a cofactor. In clinical settings, pediatric orbital fractures larger than 1.81 ㎠ may be considered as extensive fractures that can result in enophthalmos and consequent cosmetic problems.

안와주위에 두개골이식을 통한 안구함몰의 이차적 성형재건 치험례

김성길,Kim, Sung-Gil 대한악안면성형재건외과학회 1998 Maxillofacial Plastic Reconstructive Surgery Vol.20 No.4

In the midfacial fracture, the orbital region presents many additional complication unique to the orbit. Among them are ectropion, entropion, lid ptosis, injury to the lacrimal apparatus, diplopia or the late development of enophthalmos. The residual problem confronting the surgen is usually enophthalmos or diplopia. Enophthalmos becomes cosmetically obvious at 3mm and if more severe it can interfere with vision from obstruction by the orbital rim. In this clinical situation, many patients prefer the simpler intraorbital volume expansion to the more complex orbital osteotomy. In general, except in mild cases of enophthalmos, the procedure of choice is osteotomy and repositioning for zygoma fracture and volume augmentation for blow-out fracture. Late treatment is performed by volume augmentation based on the CT findings behind the axis of the globe. Inferiorly placed grafts elevate the globe, posterior superior grafts move the globe anterior and medially positioned grafts push the globe laterally. In this two cases, the patients who has stable orbitozygomatic rim, the use of calvarial bone grafts more than 3 areas around intraorbital content, we corrected late enophthalmos combined with diplopia. As result, the first patient had 2mm advance in exophthalmometric check with improvement of the diplopia gradually. The second patient had 1.5mm advance with correction of vertical ocular dystopia and cosmetically good results respectively.

결막 절개를 통한 중증의 외상 후 안구함몰의 교정

임영국,김효헌,김용하 대한성형외과학회 2003 Archives of Plastic Surgery Vol.30 No.5

Surgical treatment of post-traumatic enophthalmos is one of the most challenging procedures following facial injury. The purpose of this study is to evaluate the advantage of transconjunctival approach and/or medial and lateral extension in reconstruction of orbit in patient with severe post-traumatic enophthalmos. This study includes 7 patients. All operative procedures were performed through preseptal transconjunctival approach and/or medial and lateral extension. After release of scar tissues around orbital contents, reconstruction of orbit was performed using titanium dynamic mesh and silastic sheet. In 5 patients, repositioning of the malunited zygoma was done as concomitant surgery. The aesthetic and functional results were satisfactory. The results were good in 5 patients(72%) and fair in 2 patients(28%). Postoperative improvement of enophthalmos and ocular dystopia were statistically significant by paired t-test(p-value<0.05). No patients complained of postoperative lower lid ectropion. Finally, this approach is much advantageous in patient with severe post-traumatic enophthalmos as wide exposure of lesion and no visible scar on lower lid.

Medpor를 이용한 안와 파열 골절 치료의 임상적 고찰(100명 분석)

변준희 大韓成形外科學會 1998 Archives of Plastic Surgery Vol.25 No.3

The treatment and the operation timing for blowout fracture have been controversial, but recently most surgeons advocate early operative treatment for better postoperative results and decreased incidences of diplopia and enophthalmos. This is a retrospective study on early surgical reconstruction of the blowout fracture with ?? (porous polyethlene) implant. From Dec. 1993 to Aug. 1998, 100 patients (83 males and 17 frmales) with blowout fracture were operated using Medpor. The indications for operation were positive symptoms and signs (diplopia, enophthalmos, limitation in forced duction test, and Hess test)or, although without these, fractures larger than 1 cm in diameter proven with orbital CT. The open reduction was done by subciliary or transconjunctival approach and the bony defect was covered with Medpor (thickness 0.85 mm, pore size-over 100 m). The results were evaluated from the 100 patients who have been followed up over 3 months. The average follow-up time was 22 months, with a range of 3 to 47 months. Diplopia, restricted ocular motility and enophthalmos were preoperatively documented in 67, 34 and 14 percent of patients, respectively. Among these 67 patients of diplopia, 63 patients recovered completely and 4 patients, who were operated after 3 weeks after injury, complained minimal diplopia even in postoperative 6 months. Six of 34 patients who were noted of preoperative extraocular muscle limitation showed some residual limitation of inferior rectus or inferior oblique muscle over postoperative 6 months. Two of 14 patients who were noted of enophthalmos were kept mild enophthalmos over postoperative 6 months. With the use of ?? implant, the operation time was shortened compared with the use of the autogenous bone graft and there were no early and late complications due to the Medpor as a synthetic material. Untreated blowout fracture frequently results in delayed diplopia, enophthalmos, or strabismus although preoperative symptoms and signs are absent or minimal. Therefore the operation should be done as soon as possible. Medpor, porous polyethlene implant, is one of the most suitble material for reconstruction of the fractured orbital wall because of its long-term stability, high tensile strength, easy contouring, a virtual lack of surrounding soft-tissue reaction, and low infection rate, and that porous structure is permitted ingrowth of vascular and osseous tissue.