Neuronavigation and Endoscopy as Adjunctive Tools in Orbital Floor Implant Revision: Surgical Management of Infected, Misplaced Orbital Floor Implant with Chronic Eyelid Fistula and Sinusitis

CHAPTER 1

I'm Dr. Thomas Lee. I work at Virginia Commonwealth University in the Department of Otolaryngology. And today I'm gonna be discussing a case, and this case is a good example for those that performs orbital trauma. So this patient had an orbital floor implant that was placed about two years ago, and unfortunately, there are a lot of things that were done at the time where it is one of the commonly seen complications that I see when these implants get infected. So when reviewing this patient's CT scan, we noticed that the patient has a right orbital floor implant that is not placed properly along the medial orbit, where it's actually going into the sinus. And as a result, whenever the patient blows his nose, the air escapes through his eyelid, where it's been draining purulence for the last several years. So it's an interesting case in the sense that it tells you what to avoid when you're doing primary repair so that you could avoid these complications in the future. And for those that do revision surgeries for something like this - hopefully, this would be a good example to know how to address something like this. The key steps to the surgery, the steps we're gonna start is we'll have the patient setup for neuronavigation, which would be critical for the surgical case. So we're gonna start with the neuronavigation setup. We'll look inside the sinus, because looking at the CT scan, I have a feeling that the implant might be visible. So we'll start looking into the sinus and see if we can see any orbital implant coming through. And then, next, proceed with exposure of the implant. So we'll do a transconjunctival approach and approach the implant, and lift any eyelid scar contracture that's present. And once we get onto the orbital floor, then we'll perform subperiosteal dissection to expose the entire implant. And once the implant is fully exposed, we'll then proceed with hardware removal and remove the actual orbital implant. Now, once the orbital implant is removed, the next step is to decide, are we gonna place a new implant? And if we do decide to place a new implant, we'll then proceed with putting a new implant into the correct shape once the entire orbit has been properly exposed for placement. Once everything's exposed properly, we'll bend the orbital implant into proper position and secure it, and position it into the defect, which we'll then later confirm with neuronavigation to ensure that it's sitting in the proper location, which would be critical, especially, in a situation like this when the anatomy is grossly altered. And we'll then proceed with securing the implant, making sure that the implant does not extrude beyond the infraorbital rim. Secure it with a screw. And then, we'll either decide to continue with the sinus surgery, if we're gonna do that, or focus on closing the skin. And in this situation, patient has a eyelid scar. So we will focus on figuring out a way to remove the site where the fistula was present, and figure out a way to restore both skin and the muscular support that sits behind it, orbicularis muscle, and close it in a way that would minimize chance of ectropion to form after the surgery.

CHAPTER 2

So this particular gentleman had a trauma to the right eye, and unfortunately, started having infection involving the implant, where he started noticing drainage in this location. And, when he currently blows his nose, air will start escaping through the floor of the eye area. And this area has been draining. Give me some gauze. Our plan is to remove the old implant that's obviously infected. We'll also possibly replace it if there's no signs of major infection. If there's significant infection and the orbit seems fairly well supported, we might stage reconstruction as... Yeah, if the hardware is currently infected, we don't wanna put a new hardware in there. Yeah, we'll need that in a second. You got some irrigations? That's very congested. Yeah, let's get a pledget. Maybe - yeah, okay, can we get one more. All right, I guess we'll just start with the eye.

So there's a fistula site right there. Still draining. Palpating to feel the infraorbital rim. So normally, this tissue won't be stuck right there, but in this case, it is. Let's inject the lateral canthus area. Do we have a Colorado tip? Yep. Can you put the Bovie down to 15? 15, yep. This is stuck down. Do you want the Bovie? It's really stuck down. So, I'll worry about... It's not gonna dissect properly here. Thank you. All right, here's this back. Giving 1% with lido with epi for the local there. Do you have a Desmarres retractor? The other one? The other one, yep. And do we have the eye shield by any chance? Like a corneal shield? Yeah. Please. Hold that. Yeah. So the problem is, normally, when you pull this down like this, there's not stuff in between. But because there's stuff in between, if I do that, I'm gonna come right through the skin here. So you're gonna have to push this little bit out of the norm. So normally, you would be doing something like this. Yeah, do you have a number 9? Yep. So the way we normally do this is I'll sweep all this stuff back, and when I do this, this part exposes the infraorbital rim. But because it's scarred, I can't do it that way. Come on out like that. I think I see a fistula right there opening up.

CHAPTER 3

Let's do this one. Hold that, please? All right, so I'm gonna do a canthotomy. Go straight back. Then I'm gonna cut down. Start releasing the lower lid here, the inferior lid. Now, with that, we will start swinging this lid out. Can you suction right here?

Some irrigation, please. Good. All right, you have a Colorado tip, there? All right, so a little bit unusual incision. So - there's tarsus here, and what you don't wanna do this cut onto the tarsus. So we wanna leave at least 5 mm there, and then cut down, lower down. All right, this is what we're gonna do. I'm gonna make this incision first. Now again, the other issue is, where is it guys? The puctum is right there, so you don't want go into the punctum. So stay lateral to the punctum, and stay at least 5 mm down to preserve the tarsus. We're gonna connect it to this incision. So normally, it'd be a lot faster than this because this tissue won't be all attached like this. Start releasing it out laterally. Okay, come on out with this for a second. This is very scarred down. And come across. Do you have a double prong skin hooks? I think that's on the implant is what it looks like to me. I think this is the implant we're looking at. Okay, I'm just gonna palpate and see what we got going on. All right, you got the surf board-looking thing? Yep, that's it. All right, I'm gonna start scooping this back. Of course, his orbital fat is right there. Lemme get a... Want me to grab the Bovie? Sure. Can I have the Bovie, please? Suction. Do you have a malleable? Come on out with that for a second. So I'm getting down there. I'll take the Desmarres retractor back. Do you have the wider malleable next? That's all tethered still. I think everything is scarred down. I wanna make sure I don't cut into the orbital fat. You can see there's orbital fat. Yes. Let me see a blue towel, please. A little bit more. What is all this here? I'm just gonna get down to the floor. Normally, there'll be infraorbital rim that we can just cut right down onto. In this case, everything is scarred up. In this case, my goal is to find the bone. Just gonna follow that down. Come on out one second. One second, come on out. You see the lateral canthus completely detached now, but the skin, being tethered, is holding us up. You have a number 9, please? Ideally, preserve the skin, and if I can't preserve it, I have to excises this and then we do all of that. You have a malleable, again, the medium size? Okay, you got a Desmarres retractor again? Yeah, it's getting down there. Do you have a Senn retractor, actually? I don't want to cut down, and then come right through the skin. That would be counterproductive. I think the skin is lifting up where I can start coming down. But I think this is the implant that we're looking at. So I need to at least lift the skin up, so that I can get down to the right plane. Mm-hmm, suction. So I feel something hard. And there's a little bit of pus pocket, or whatever, drainage, granulation tissue right in the middle there. That's probably a sinus-related infection. So our main priority is to at least remove this out of the sinus. That's the implant right there. Interesting here, I feel a gap, which I wouldn't expect. Do you have the Colorado tip, please? And there are two screws holding this. So right now when I do that, I can feel something very firm. So either there's implant or there's bone. I'm gonna start getting down onto the subperiosteal tissue plane. There's something hard there. Do you have a number 9, please? Sharp coming back to you. We're gonna get that outta here. There it is. That's bone. There is some sort of a plate hole. Then my goal is to... When I'm elevating this, you see how there's bare bone? We want to make sure... Sorry, just put that back. Lemme see number 9 back. I wanna make sure I'm elevating the periorbital with this. And normally, in a case like this where orbital floor fracture has happened, the sinus - the orbit will go into the maxillary sinus. And this is like the... Do you have a Bayonet forceps? So this stuff right there does not look normal. This stuff right here. Can you send that as specimen? Call it right orbital floor content. Right orbital floor content. Yeah. There is a fair amount of that down there, I see. Just let's swing over this way. So laterally, we're kinda coming up. Let's get right there. Can I have some irrigation, please? Yeah, where is the implant? I'm just gonna follow this stuff down. Because - I'm hoping to start seeing some Medpore because if it's just straight titanium, it's gonna be very hard to get out. This is why I don't use - for orbital floor reconstruction, I do not use just titanium-only implants. And I'm afraid it is a titanium-only implant. So this is something that I would highly recommend against using. All right, this - that's not good, suboptimal. Hold that, please. Ay ay ay. It's very scarred in here. And the titanium has actually started to... Yeah, that needs to come out. That might be nasal mucosal lining here that I want to take out. Bayonet forceps. I think this is the nasal maxillary sinus. Do we have the neuronavigation suction by any chance? This white stuff. I think that might be it. Yeah, that's good. That little, see that hint of white, gritty stuff? I think that's the Medpor. All right, that makes it a lot easier to remove. All right, retractable suction, you just gotta plug it in. All right, so I think the key is - get these screws out. The other thing I try to do when I screw this implant is to... I try to put it along the orbital floor if I can instead of coming around the bend. All right, let's go back to this. We'll get the screws out in this side to side. Hold that, please. You got the Colorado tip, please? So you start to see a chunk of bone, so that we don't leave the screws in. Number 9. Suction right there. There you go. I thought I saw a screw here. Okay, let's come - slide over this way. Now, good, there is a screw. I think that is a screw. I think there's two screws on this, from what I can tell. Okay. Hold that, please. A little, medially. So the other common mistake that I see here - do you see how the plate is extending beyond the infraorbital rim? Yeah. That is the other common mistake we see. And that will lead to - one, it can be palpable, and two, it can extrude like this in some way. Hold that, please. So that you don't want implants sticking out beyond it because one, it can do this where it scars down and now it might extrude, and two... Suction right there. It's also just palpable. Now cut right on down onto the screw hole of the plate. We wanna go subperiosteal again. A lot of scar tissue in this area. What we're seeing is... The extension from, likely the Medpor implant - with titanium component. This screw is loose. Yeah, that's where the fistula was present earlier. But you can see that's right where the screw is. It is, yeah. That's why I don't wanna... Yeah, so this corresponds to that. The skin's lifting up. It's not lifting up smoothly, but it is coming up. Really minimize... Creating a new fistula defect. Do you have a mosquito? The screw's already out. Can you see that in there? I saw, yeah, the more medial one was already... It's completely loose. It's harder a fail there, obviously. Here's your screw back. There's a screw on there. And then there's another screw. You don't need this many screws, you just need one. There's another screw that failed. You could see the bones moving from the bone. Here you go. Flip this extension part. Unfortunately, it's completely scarred into the skin here. There's the fistula that we saw before. And this stuck onto this screw hole. Okay. The main reason I wanted to use it is to use this to figure out where all the screws are. I think there was one here. There's one there. I think there's three screws; one, two, and three. Yeah. So that might be the last one. All right, let me see the flexible suction one more time, the navigation suction. Great. I think there's... There's one. There's one screw, there's two, there's... I think that's the other screw that I got out. And then this one over here, we need to... We'll need a screwdriver for it. Do you have a screwdriver up, please? And this part... You want it? Yeah, one second, please. Hold that, please. And the problem is it's a lot of scar tissue. You can see it's attached to the skin still. You can start over this way, yeah. This is where the tethering is happening. You see that scar band, right there? There we go. Start over, yep. There we go. There it is, okay. So that's the harder portion here. I don't think there's anything more medially. I'm not really sure why it's all twisted. That's not the way it should be. Ideally, it'd be contoured to the bone. All right, can I see a screwdriver? Remove the screw. Screw back. Number 9, please. And I should be able to sweep under. Is there a sinuscope hooked up still? Yep. Yeah, let's take a look in there. I just wanna see if I can actually see it from the nasal side. So that's the sinus down there, I believe. Okay? So I think that actually is the sinus membrane, right there. Can you suction in there? Don't pop into it, but yeah, right there. There's the sinus. There's probably the roof of the maxillary sinus. So normally, you'll see a cavity in there, but because it's... Come on out with this for a second, yeah. Yeah, we're right on top of the roof there. So let me see what the... Let's see with the scope. I bet you, you could see the plate in there if there's enough decongesting that happened since we waited. Now, the skin is almost released, a little bit attached more medially, which we'll work on. Yeah, I wonder if that scar tissue there is coming out. Yeah. Then push the middle turbinate medially. Yeah, snake it in, and then push it out medially. Right, there's your uncinate, right behind it. And I bet you that's what we're... This is the implant. If I wiggle... It's part of the granulation tissue that you see. Does it feel firm to you? Yeah, so you can see it. I think it's actually this part of the implant. Yeah, you can see it moving. So that's the implant on the other side of that, which is not how it's supposed to be. Okay. Can you also get a... Bring in a Medpor titanium, right-sided orbital floor implant. But don't open it yet. Right orbital floor implant, right-sided. But don't open it. Just bring it in the room. There's one that's 1-mm thick, and there's 0.5. Do you have irrigations, please? Do you see the implant there, Kevin? Do you see that? The camera is up there, but I see it. Yeah, so that's the implant. Irrigation, please. Just regular, that's fine. Just squirt it in there, please. Yeah, you could see the implant right there. Right there. See that little hint of plastic? That's why he has what he has. Yeah, that's it right there. All right, great. All right, we'll be right back. Great. Can we send this as a permanent sinus content? I just write sinus right-sided, nasal... Yeah, just write nasal con... Right sinus content. That's your orbital floor implant that shouldn't be doing that. The other issue is... He's more prone to get sinus infection, but this is not his natural opening. Natural opening is gonna be up here. So that being there causes other issues. So you could see his neuronavigation shift is completely opacified because it's blocking where the sinus would normally drain out. So, Kevin, I think we should do maxillary antrostomy. Now whether that's mega or not - is debatable. But definitely take the uncinate down. We gotta at least connect it to here. You wanna do that before taking out the... That's what I'm debating. Because I think this bridge has to be removed for this to not recur. Now, the only other question is, by this being here, would it put orbital content at-risk? In which case it might be better to dissect all that away? Because it's gonna be right on the other side of this. Yeah, let's do the orbital stuff first. Okay, yeah, let's do the orbital stuff first. So normally, you wanna connect all that, but because just everything is displaced inferiorly, if we just come through there with the shaver, there's a potential for orbital stuff, which you don't wanna shave. Normally, it's not that obvious where it sticks out, but in this case, it's very... It's actually visible where the implant has been... You can almost see it on the pre-op. Yeah, you can definitely see it on there. But a lot of time you could see like mucosa kind of covering it, but I think because it's so exposed, it's very visible. Can you hold that? Do you think this was improper placement or migration after? Yeah. It's not migrated because the improper placement from the beginning. And I think what happened, they missed the medial orbit. So then, it's now under the medial orbit, and that's where the problem has happened. This titanium piece is all bent. So navigation, that hole right there is the infraorbital nerve coming out. And again, if the issue is weight medially, and completely, incorrect position. So my first priority is expose this hardware and get this out. Because it's so scarred down that I'm having a very hard time dissecting it. Can I have some irrigations? Normally, this should peel up. Yeah we can go ahead and irrigate. Okay, just have it in the room. Don't open it yet, please. Whoa, big vessel right there. Yeah, no kidding. See that in there, Brooke? That's a really big one. Bleeding prevention is preemptively a bipolar act, the nod. I think it might be traveling with the... It's under the floor. Okay, hold a second, and there's a - I see a bone fragment over the floor. A bone fragment, right there. Dr. Lee, is it sinus? Sinonasal, this one. And this hole in there is going to the sinus... That part got lifted up. There's a lot of scarring going on. So my first question is... Just loosen up where I can just pull this out. Can I get a number... I think it is loose enough. Get this out. So that's the implant. It is Medpor titanium. That looks not good color, probably infection and stuff happening. It's very wide. I would've cut a lot of these. I would have cut a lot of those. And like these random, this wire is in the sinus. I think this part was a part... I think this corner was the part that was sticking out, probably. All right, here's your... Can we take a picture of that, if you don't mind. Just set it aside, like a specimen. All right, let me see the malleable.

CHAPTER 4

There you go, I got it. Thank you. Thank you. So now, the first question is, what is that vessel? We're under the orbit, so there's nothing really dangerous there. The posterior leg is beyond this. So we're actually pretty close. So maybe I could leave it, but it's actually in my way. All right, I'm at the ledge there. Unfortunately, I do think... Let me see that bipolar, please. The orange one. So this is in front of the... The suction is on my - the poster ledge. This is just - vessel is actually blocking where I need to be to reduce this. Buzz it. I'm not near the... Yeah, I think it's near the infraorbital nerve, so it might be a vessel traveling with it. It can be safely sacrificed. All right, buzz it. Okay, let me get Metz in a second. Give me a minute. Can we do it one more time? Buzz it. Okay. Buzz it. Okay, that's good. We see that better now. Can I get your scope in there? I can actually see this probably from this side. What I wanna avoid is leaving nasal mucosa lining in there because then everything will get infected again. So this right here is the sinus. Yeah, I could actually see the other side of that is the sinus. If you got a thing I could just scrape some of this away. You have number 9, please? I'm leaning towards... Hmm. I'm just trying to see if it's worth putting a new harder in there or not. Not near the medial wall. I gotta get down to the medial wall now because obviously, I don't wanna repeat the same mistake that was made. All that granulation tissue here. I think so. Because it's going to be... It doesn't look that bad. The other concern is if this orbit comes down this far down, he is gonna have significant hypoglobus happening. I think, unfortunately... Well, if it was grossly infected, I wouldn't do it, but I think in this case... I'm sorry? Best? Because part of me is kind of wondering... if you just like put the implant in, just be like doing it for the first time and just let him heal. Yeah, because I agree. It may just... One concern is if you do like mega-antrostomy, it might actually... Expose the implant more? Yeah, that, and make the fistula wider. Oh, okay. And I mean like - opening towards the fistula wider. So if you blew it hard enough, it might still do what it did once before. You gonna get us some irrigation, please? I dunno. Just so you know, I don't know if I have enough right primary nasal content for them to actually see anything. It's all right, that's fine. They don't need to see anything really. I'm sweeping all this granulation tissue, or sinus content - it's hard to tell if it's sinus lining or not at this point, inferiorly, so that it doesn't touch the orbit. I feel like I have a good exposure laterally. Okay, far down, you can see a scar here. Can you guys see in there? That's the posterior wall. Going back. Need to come all the way across this part, when I'm going this way is all scarred. Normally, there would be a natural plane there but in this case it's scarred. I'm just kind of gently peeling it away until what feels like a bony ledge. I feel something there. It should be great. Yeah, there's bone. But that's the bone there. Can we look with the endoscopes there? So that, I think is stable posterior ledge. So orientation-wise, this is the... It's the posterior bone here. If you look this way medially, over here is your sinus, and this way - can I get the irrigation once again? I think this is... Yeah, this is beginning of the... Right there, we're beginning of the medial orbit here. So I need to expose this a little bit more so that I can place the hardware properly.

Okay, I can kind of see things a little bit better. You got a skinnier malleable? So basically, release all that scar band from midline all the way over to this way. And I think this is the medial orbit that we should catch. Yeah. Pretty sure that's what it is. All right, let me see this to confirm Start of it, at least. There, yeah, so... I know I'm not in the sinus, but still, it looks like there's something. What is this? So that makes me wonder if I'm really in the sinus or not because this navigation might be off a little bit. Yeah, it's off. See on axial we're off about. Yeah, a couple millimeters. Yeah. So, is that - we're off to the left more. Yeah, we're off to the left about 3 mm. So that tells me this is the right down. Yeah... So let me see number 9 back, please. Remember seeing that? There's a hole right there. That might be the sinus. That might be also like the natural os, I'm not sure. I think there's like a horizontal strip. So we might have to go even higher than that. Yeah, I think that is... Put it in there? I'm pretty sure that is sinus. And it's out of focus. Probably relax on that. That's not doing anything. You good? Irrigation. That's like there's a hole right there. Irrigate. Mm-hmm, that's good. So right there... I think that's... I think there's the sinus. I think I need to go above this, but this is starting at the medial orbit. Question is how high it could be. Can you just come... This is... Could you just make it not as wide, and just have it end right there so it's not sticking out? I want to be above it so that this is below me. That's kind of what I'm thinking in my mind. It ends here, so I wonder if there's like a significant fracture. Come on out for a second. Meaning, the whole medial orbit might be damaged, so that... Let me get a wider malleable. I should be getting close to the anterior ethmoidal artery. It might be okay. I'm not really seeing a good medial orbit to catch. Suction, please. I see a hint of the medial orbit. You can see this fractured bone right there, I'm pretty sure that is a medial orbit I need to catch. But ideally, I should have a bit more firmer bone to anchor to or lean on it at least medially. Do you have a Mosquito? There's your bone. There's just bone that came out. That is garbage. Do you have the navigation again? Where are we here? So that's the medial orbit, okay. Now the problem is, I see a hole above that. So that's actually going into the sinus there. Actually it might not be bad. Let me see - how tall are we navigation-wise? It's actually not bad there. I don't know why the... Okay, so midline is pretty accurate. Irrigation, please. We can irrigate this out. Okay, so that's... I guess what I'm having a hard time with - right above this hole. So I thought that's where I wanted to anchor the medial orbit to start, but right above that there's a defect of the bone. So then I wonder if I need to go even higher than that location. I'm having a hard time. That's not bad, right there is actually not bad. I'm having a hard time finding stable bone. Hmm, there you go. That's good there. Yeah, thats - yeah, and the axial looks like we're not in the sinus, coronal looks good too. So we'll anchor to this point. Can you guys see in there? And it's really hard to see anything, but that's the hole that I was worried about. This is all medial orbit here. Posteriorly. Looking at the coronal, you can see how much the orbital content has dropped. Like right there about, dropped by a centimeter. You can see right next to me at the, at least at that scan is inferior rectus, so I think it has to be corrected. So number 9, please. All right, go ahead and open the implant, the orbital implant, please. And let's dip it in paint. Dr. Lee. Yeah. I have a 41 by 42 by 0.5 and a 41 by 42 by 1.0. Let's do 0.5. That's the right side, right? Right side. Right eye? Okay, great. Yep, right eye is... I think I am posterior enough. Anterior posteriorly. And I think let's do a little bit further out. True, yeah. - [Dr. Lee] Yeah. It seems like this is pretty helpful for us. This is helpful. Now the problem is - it's done preoperatively, right? Yeah, exactly. It could be different. So it's completely off, but I'm just using it like this. I'm using it to mirror the other side. So that's why I use it for that reason. All right, so here, that bone actually looks like the stable bone, meaning this... Yeah, so you can see where that is. You wanna get a scope in there? You can actually see pretty well right now. The tricky part is, all this bone, inferiorly, is displaced, and it's fused that way. But this is right where my suction is right there. Right above me is where I want to be right in this ledge. This is the ledge I want to catch. But inferior to that, all that bone is not in the right place. This bone is not in the right place. Yeah. So if I anchor it, if I use that as a reference, then everything's gonna be off. I need to be up here. This to me looks correct superiorly. Yeah, you could see that on the sagittal scan, that's the correct posterior ledge to catch. And you could see the floor was following - the implant was following the floor being incorrect, and they didn't correct that unfortunately. I need to catch that back ledge, and then come all the way around this way. Let me dissect a little bit more. I feel like we're not quite enough exposed. I'm having a hard time seeing that medial border. Do you have a skinnier malleable? Medially, this... Our goal is to get all this exposed to where we're gonna anchor the bone to. I think he's just missing bone right where I'm looking at. Mm-hmm, this is all missing bone here. That's where I need to be. We'll stop there. Having hard time. This is the medial wall. It just ends. I need to be higher up is the issue. Hold that. I feel like it's not adequately exposed medially. Suction one with malleables. That's a good bone up there. Or this is, where is all this in the middle. There's no bone here. There should be a bone is what I'm confused about. Okay, I think his lacrimal duct is not preserved. Not having a... Let's just kind of see where this is supposed to be.

I use this kind of as a guide. This is resting on the posterior ledge there. I kind of see this spot where we're gonna anchor it to. So about this long. You got the implant, please?

CHAPTER 5

So, here is your implant. It's almost the full length of it. The other piece just had this, but we're gonna create a medial orbit as well. This is the medial orbit component. So the sinus should be sitting in this area. So you have a heavy scissors? And I might use one or two of these. Definitely don't want to anchor anything here. I'm gonna curve this out, round this out, and then also... Then we're gonna... it's kind of the right shape that we want. to kind of sit like this. Okay. We don't need all these binders. Can I get a Mosquito, please? Make sure it doesn't extend out beyond the infraorbital rim. All right. One of the challenges when you start doing this is the angle of it is something that's kind of hard to figure out. Yeah, so all this bone here essentially is very deceptive. So this is at the right point here. This is the right floor and it could follow up. Yeah, that's pretty decent. Make sure we're good medially. On more malleable. And kind of do like a crisscross. So one's going out Medially one's going out laterally. Okay. So that's good. I think, medially, that's... If I can get to that point, it's good. All right, you wanna take a look at the scope and then let's put the implant in. Now the other question is, is it worth taking out all that bone? Probably not because it's gonna start oozing like crazy, but at least for a postoperative scan, it'll look nicer if this bone, this all displays, it's just not there. So this is a bone that doesn't belong. You need to catch the bone up here. This is the ledge that you're gonna catch posteriorly. Everything below this line is - this is all abnormal bone here. Okay, lemme see the implant, please. Lemme see the implant. Now the perspective you wanna get used to is this angle. Do you have a Ragnell? This is not quite working. The Senn retractor you gave me earlier? So like this slope, you gotta get used to... This angle? Yeah, yeah, because it looks - people just put it in like this. It needs to be like this angle where it slopes up. Pickup, get our pickup. So we lost all that, unfortunately. And do we have the TPS drill up? We got it up, it's all ready. We do? Lovely. Okay, let me see the implant. So put it in like this. Make sure this isn't too long. I think it's too long, is my impression. Way too long. See, we're well beyond - the implant there is just way too big. And I'll revise that, obviously. Do you have the heavy scissors again? Thank you. Thank you. I shortened it because it was sticking out way too far. Anterior to the infraorbital rim, which you always wanna avoid. Now for sutures, can you guys get 4-0 clear nylons, 4-0 Vicryl, and 5-0 fast. 4-0 Vicryl? Yep. Okay, it kind of feels correct to me. Can I get a Desmarres retractor? First question is, is this too long again? There's your infraorbital rim. It doesn't look bad. It's just about just right. Doesn't look bad. So I don't want this rim sticking up beyond that because that always causes problems. And the secondary question is, Is this angled properly? Get the slope up. Let me see a skinnier one. I get rid of those extensions. Lemme see a malleable. Not malleable, number 9, please. I'll just check the angle with the implant.

Make sure it's going to the back. Still high on this side. That's medially what we're doing. That's better. So I'm inside the implant, inside the floor. This is the medial margin of the wall. We want a wall that kind of comes down like that. That looks like it's seated properly. That looks okay. I just like to run it all on the floor to kind of see if it's going in the right plane. Yeah, see that's where it's doing. Okay, so that's good. That's what I would want. All right, following that floor up. It goes up to where we want it to. Can I have the right angle? And we make sure we're not in the... That's just the medial, yeah, that's good. You are on the right side of the orbit there. It's more posterior medial orbital wall reconstructed. That's more posterior along the medial orbit. So it's following where you want to fill in, the bony defect. Yeah and that's where we're on the back ledge. Yeah, I think that's gonna be good. We want that angle there. Cool. Looks okay, Kevin? Yeah, that looks pretty good. Okay.

So now, I want to secure this. The question is how. We have a lot of options here. Let's put one screw right there. You have a self drilling screws? Yep. Let me see that, please. Five? Yes. Those... Sure. Self drilling. We can put one in here - yeah, I don't think I like that. I just don't want this moving. It's kind of the whole concept. It's not good bone there. Mosquito back. All right, one more screw. Self drilling? Sure. You want to reuse this one? I'm sorry? Yeah, that's fine. You can use that again. Do you have a drill? Mm-hmm. I don't like how that's pushing on everything. I saw the implant move. Number 9 for a second. Mosquito for a second. So the other thing I need to worry about is the skin incision. Drill. I want to make sure wherever I put it... You wanna use the same? You want to do a non-self drilling? Yeah, mm-hmm. Okay. You have some irrigations? Squirt in there a little bit just to cool it down, yeah. Good. That's better. Okay, all right, let me get a Mosquito. And let me get a... Do we have an in situ plate cutter, if not heavy scissors? I got this little nippy nipper. Yes, that's perfect. Okay, number 9. And a malleable, please. So this, obviously, like you don't want to stick it out like that, so... The other thing that makes the plate look really good on the scan is just kind of make sure you mold it to the surrounding bone. That's usually what we want. Lemme just confirm - I just saw it shift, so I want to make sure it didn't knock it outta place. That's good, where it starts. That's good there. That's good. That's pretty good. Yeah. That's good. Okay, all righty, I think that's good. Number 9 again.

CHAPTER 6

All right, and then let's look at the sinus, and then we need to decide if we need to fix that or not. Let's come on out for a second. Lemme get a... Do you have bell prong skin hooks? Just one, just one's good. Do you have a Metz, baby Metz? So again, the hardware is not sitting directly over - it's way over here. I want to release all this. It's still tethered. Still tethered. I think his infraorbital nerve here is not working preoperatively, but infraorbital nerve is right there, so you gotta be mindful of that. There we go. That was the release I was looking for. There's still a fair amount of scar bands. So my goal is if we can save the skin it'd be nice, but I'm prepared to excise. Do you have a Ragnell or Senn retractors? Hook back. Irrigation. Send me bipolar. Bipolar. So let's look in the sinus before we close this. So at this point we shouldn't be able to see the implant that we were seeing before. Okay, and I'll take irrigations. So that part looks better. There's less stuff in the way. What am I looking at? Is that the... Yeah, this is where the implant was before. That looks a lot more open like how it should. Should we mess with it? Should we do? Question is do we open this up or not? The downside of opening it will be higher chance for air stuff to go in there. Gimme a quick look. Debating if it's worth opening or not. It would be better for implant to be not be infected again. Can I get a - oh yeah, much better. Yeah, see that's where it was before. Feels soft. There is... Ideally, this and this should be opened up for this to drain properly. Do you have a curved suction? You know, like the one with the little 90-degree bend on it? Let's see if I can use this. If this is full of puss - I'm gonna... You see I'm in there, and the navigation tells you that we're inside the sinus. I don't really see a lot of pus in there though. It's good. Yeah, so it's open. It's definitely not filled with stuff today. I don't see pus coming out. It's not the right location. If I open this and I see hardware, then that's bad. We don't want to see hardware because then I'm just exposing more of that. I feel like - you get up in there and flush the sinus out? Incase there's any badness in there? Yeah. I guess what I'm worried about is will there be delayed sinus obstruction? Then, now it'll be filled with mucus in there, which will then hit the orbital implant that we put in and might get infected again. So then another option is to create an unnatural opening from here to here. What we call like mega-antrostomy, so that it cannot get exposed - or it cannot accumulate anything in there. Another option is to let it be. Let it mucosalize, hopefully. We want that to seal up there. Lemme just rock it up so that hopefully that can stick down. Once it seals up, then I can do a lot more with what I should be able to do. Yeah, this navigation doesn't work. Yeah, I'm afraid if you do a full maxillary, we're gonna start seeing the implant, which I prefer I don't see it. I don't want it exposed to the nasal content. Do you guys have any thoughts? Should we open it, not open it? Just let it be. Yeah, that's what I'm thinking. If he has to have a maxillary antrostomy in the future, that's like a small scale thing, but if he has to have his floor implant replaced again, that sucks. Yeah, that would be worse. I feel like just trying to optimize it for the implant. Yeah, I think... That would be less trouble. Yeah, maybe you can do a CT scan like in a month or so, a post-op scan. If it's still obstructed then come back and open it up. I feel like you're not really burning any bridges that way. No, because the real issue is just, it was just coming in here was the real problem and obstructing everything, and there's nothing inside it that I can see. So yeah, let's just not do the sinus part today. We will consider doing it as a staged fashion depending on postoperative scans, maybe two, three months down the road. If it's still opacified then, two, three months out, it will perform sinus surgery to open it up.

CHAPTER 7

So then let's just focus on closing the eye. Some irrigation, please. And let me see Adson pickups. We're like wrapping up, probably 20 minutes-ish I think, maybe less. So one thought I have is, Do you have a - yeah, that one. Let me get suction, please. It would be ideal if I can put something there. Do you have iodine? You can see the implant is not extending beyond the infraorbital rim. That was a part of the first issue. Now I want to, if there's a way to drape this with something, I would like to do that. Yeah, I was thinking about that earlier. - [Dr. Lee] Yeah, like maybe this tissue, I feel like this doesn't have much to give. It does not, yeah. I thought about like, oh would you ever consider doing like fat, but you don't want something that's gonna get infected? Fat injection you mean? Yeah. Yeah, not today. What I - there's this little bit of muscle or I'm not really sure, scar tissue here. Can you lift the head up, please? Yes. You wanna hold this up, please? I'm gonna see - all right, there's a little bit of... A little bit more, please. That's good, thank you. What is this material here? I think that's where all this stuff happened. All the scar tissue. I'm trying to see if there's a way to... It would be beneficial to drape this. I mean, thankfully, there's no hardware sitting under this skin breakdown. We'll just let it be. That's right. Don't want to tug too much, and then have it not be able to close. Close, yeah. Could be an ectropion issue. Very good. Can you hold this? I think I need a bipolar. Bipolar, please. Hold on. Yeah, sure. Bipolar. Buzz, yep. Okay, good. All righty. All right, let's just focus on this first. I think I should excise some of it. You have 15 blade, please? It actually doesn't look that terrible. Yeah, it doesn't, yeah. Not as bad as I thought it was going to. Me too, I thought it would look a lot worse. It's gonna freshen up the edges. Yeah, it actually is not that bad. But I would excise some so that at least the edges are clean. What's that? Like internal ear stuff? No, it's just external. Okay, okay. Everything external. I'm just going to sew. Releasing some of the scar bands here. Skin is... Okay, do you have a 4-0 Vicryl? So if I had hardware I would drape something on top. But in this case, everything is intraorbital, so thankfully I don't have to worry about that. Is that needle okay? Yeah, that's fine. I'm gonna put this back together. This is probably orbicularis that has scarred down to the hardware. It's restoring the anterior and the middle structure. Okay. So I do want him to get a post-op CT scan. Maybe just get CT sinus without contrast. Okay. With neuronavigation. Just do neck space or have them get the whole face? Does it catch sinus though? Yeah, it should. We can just tell them that it should go all the way back. Okay, yeah, we can do that. Do you have a fast? And antibiotic? Yeah. Do you want him to do any nasal irrigation stuff, or nasal sprays, or just let it be? Just let it be. We didn't really do anything to the nose, so I would just let it be. I feel like if he blow hard enough, it will... Yeah, sinus percautions... Come up this way. Yeah. That looks better. It's not scarred down to the rim like it was before. It should revise. I'm debating if I should revise that scar. Yeah, I thought about that because like we don't want to - we don't want to injure it, but also it doesn't look great. Yeah, it looks weird. I might just mobilize just the skin. You have a 15 blade? Here's your... I'm gonna take this back - needle in a second. It's not going in there. Can I have suction. Skin growing in there. Skin growing inside. That's not where it should - skin shouldn't be under the skin. Hmm, the under surface of the skin looks weird. Like this area makes me wonder if there's skin there. Yeah, there might be some skin there still. I'm just gonna remove - the abnormal skin. Hmm, there's skin there. Yeah, see there's skin. Good thing that we found it. Was this their approach? I'm sorry? Is this their approach? No, I think this is where the hardware came through, and then the skin started growing around it, and then it actually ended up rolling under and healing that way. Do you have a 4-0 Vicryl for us? And then I'll take that next. What's that? Let's check real quick. Yeah, I think we're done with the sinuscope. Let me see the 4-0 Vicryl. That looks better. And more importantly, that skin that was buried is now gone. Okay, suction there. Reestablish the muscle. Here you go. Can I see a 15 blade back, then I'll take the 5-0. And we'll need a 5-0, or not 5-0, we need a Dermabond at the end of the case. Let me see a 5-0 fast. Knife back. Okay. A little redundant. I'm just gonna keep it so that I'll - I can always revise that. I don't want to cause an ectropion. It's gonna contract down regardless. It's nice to have a little bit of extra. Can I have that 4-0 clear nylon next, please. Actually, you know what? Before that, let me just... Yeah, just have that one ready. I'm gonna use this 5-0 fast one more time. Do you have the - could I get the hook - the hook again. Do you have a skin hooks?

Just a little bit of space. So hold that, please. Okay, irrigation. You got some irrigations? So I know not everybody closes, but here we go. Here's this back for a second. I had a patient who had conj that didn't heal properly, and caused entropion, so I just will place a couple sutures to line things up. You got the 5-0 fast? I might need one more fast if that is all of it that we have left. Yeah, just one more would be nice. And suction. Mm-hmm, just right there. Okay, now come out with that. Come on out with that. Okay, let me get one more 5-0 fast, and then I'll also take the 4-0 clear nylon next. Okay, which one do you want next? 5-0 fast.

So, I am going to place this first. So that this triangle shape along the lateral canthus is present still once we secure it. Sure. What is that? Is that hair? We just do the skin portion of the lateral canthus and leave it attached for now. Okay.

Let me know when you have it. Ready. Nice, perfect. This is perfect. Do you get credit for the campus work, or is it just part of the approach? I think it's part of the approach. If we did like stripping and stuff, then maybe you could repair, they could call it ectropion repair, but I think it's just part of the approach is my understanding. Do you have a Senn retractor? It's all swollen from all that being released. Did he get steroids? I'm gonna check for - while we do that, we'll check for... It doesn't look entrapped. Suction. See the whole head's kind of moving. This is a confusing little bit. Okay, so let's just see this. Good. Secure. And before we cut it, I'll do one more suture. I'm gonna be medial to the lateral orbital rim. Catch the Whitnall's tubercle. Let me get a empty needle driver. Thank you. So again, just by doing this, this should be this reattached. I'm gonna cut this shorter. So that stitch, basically, recreated the triangle there, and then this is the crow's feet area, just gonna line it up. They're gonna just continue to close here. Should hide nicely the crow's feet area. Let me get a - you guys have a Dermabond ready? Yep. Great. Can we get a NG tube from you guys? Or OG tube, rather. Can I have some irrigations? You wanna do any more local? No, but thanks. I think this is - he came in with that I think. Suction out his stomach. Do it one more time. Okay. Do it one more time. I think I'm not really in the esophagus. Okay, it's going down the right way. Okay, one more time. Okay. Let me get a Dermabond, please. You see this was already - this was stuck down before, so I think this - hopelly, there is a higher chance of this healing now that it's not infected at the infraorbital rim.

CHAPTER 8

In this situation we couldn't see the orbital hardware right away because it was very congested. So then we started with the nasal congestion using a nasal decongestion to decongest the nose. And while that's going on, we did proceed with starting with the right orbital approach using transconjunctival approach. We performed lateral canthotomy to swing the lower eyelid down. The difficulty is because the eyelid has scarred down onto the infraorbital rim, we couldn't do the traditional postseptal approach to the bone because then we would come through the eyelid, which should be not what we wanna do. In this case, we wanted to save all the eyelid skin and orbicularis muscle. So we had to, instead of cutting right down onto the infraorbital rim, which was typically done in the primary case, I had to make incision through the transconjunctiva while preserving parcel height, so at least 5 mm away from the posterior lid margin, and come through the conjunctiva and go through until we could find some sort of bony structure. And I started this by starting along the right lateral orbital wall because that area had minimal scar contracture occurred compared to other areas. Once I found the bone, I connected it through the eyelid incision, and once we did that, we were able to get down to the orbital floor implant. It had titanium extension where the screws are secured. It was a lot more than what I would typically leave behind, because there was so much titanium and screw holes exposed. A lot of the scar contractures was actually happening right over the screws where the hardware was located. And at this point, we proceeded to expose the orbital floor implant going into the orbit. At this point we were able to identify the area where there's a sinus connection. We proceeded to also at this point, remove the nasal pledget to see what's going on inside the sinus. And we could actually see, once everything decongested, the orbital floor implant coming through the lateral nasal wall inferior to the uncinate. So at an unnatural, non-anatomic location, and this was likely contributing to the issue of purulence, nasal content, and air escaping through from the nose to the eyelid. So at this point we decided to remove the hardware. Once the hardware was removed, the focus was then to expose the entire orbital floor defect where the bone had given away support. And we exposed it fairly relatively easily posteriorly. Medially, there was a lot of bone missing, so we had some difficulty identifying where the stable bone starts along the medial orbit. We use navigation to confirm that we are within the medial orbital wall. And once that was completed in terms of exposing all the orbital bone defect that needs to be reconstructed, we then proceeded to shape the Medpor titanium implant into include both the medial orbit as well as a floor component. Bend it to proper shape. We then measure the distance from the posterior aspect to the infraorbital rim, and cut the implant to the proper size. And we then inserted the implant into the orbit and confirmed proper positioning and also correct angle of insertion using neuronavigation. And this was critical just because the existing anatomy was grossly distorted because the orbital floor actually healed in a way that was more inferiorly displaced than what it should be. So once that was complete with the implant in place, and we confirmed proper position with the neuronavigation, we used a screw to secure it in place. And once that was all done, we then look inside the sinus, and we were contemplating if we should open up the maxillary sinus further or leave it behind. The upside of opening it would minimized risk of future maxillary sinus. The downside being we can now have loss of mucosal coverage, which would then lead to the orbital implant being exposed again from the nasal side. So as a result, we decided not to proceed with the sinus surgery, which is different than what we had initially thought of going in. Instead, we decided to obtain postoperative CT scans in the future to see if the sinuses do opacify, in which case we'll consider early sinus surgery to make sure that maxillary sinus healed. But hopefully by then, the orbital floor implant will be covered and not be exposed again. And once we decided not to proceed with the sinus surgery, we focused on closing. In this case, we excised the eyelid scar that had healed onto the infraorbital rim and the hardware. We did notice that the skin didn't heal properly from the fistula, and the skin was actually buried under the skin, which obviously would cause issue with infection down the road. And at this point, we excised the scar along the eyelid. We also released scar contracture along the orbicularis. Orbicularis muscle was suture together. The skin, eyelid, lower eyelid skin was sutured together, Then we resuspended the lateral canthus using 4-0 clear nylons to resuspend the lateral canthus, and we closed the skin with 5-0 fast absorbing gut sutures. And that was the procedure. Here's a postoperative CT scan in a coronal view. Here, you can see the beginning of the orbital floor implant that was placed, medial wall component and the floor component showing the symmetry with the opposite side. And most importantly, this medial wall component is not sitting down here, which the previous one was, and it was causing maxillary sinus opacification from inability for the sinus to drain properly. So you could see it more posteriorly. You could see the entire implant is sitting below the muscle and the orbital content. Now this bone is sitting here because of the previous implant caused it to fuse in that location. We didn't decide to fracture this, and potentially make the infraorbital nerve irritation worse in the process. So we left it where it is and secured it to a stable location, and recontoured it so that the medial orbital wall is now sitting in a better position. And even though this is only about a 1-week out postoperative T scan, you can see the maxillary sinus already beginning to aerate properly. Here we're looking at the postoperative CT scan in the axial view. Here's your orbital floor implant that was placed. And you can see there's no hardware that's extending beyond the infraorbital rim. And this particular screw is actually placed from the orbital floor side so that there's minimal hardware extruding beyond the infraorbital rim. Here again, coming back up, seeing the orbital floor implant and the medial wall is relatively well preserved in this newly placed orbital floor implant. And lastly, the maxillary sinus is already beginning to aerate, which is a significant improvement from the previous preoperative condition.