Delayed and secondary repair of posttraumatic enophthalmos and orbital deformities.

Enophthalmos is a cosmetically deforming and often functionally disabling abnormality and should not be ignored. The prominent position of the eyes makes subtle abnormalities noticeable, and dramatic malpositions should be considered unacceptable by the facial plastic surgeon. For many years, it was believed that long-standing enophthalmos was not amenable to surgical repair. Although some investigators have suggested that most patients are not bothered by enophthalmos [1,2], more recent experience has demonstrated that this is not true. A surprisingly rapid evolution of ideas has occurred over the past 2 decades on the etiologies of posttraumatic enophthalmos, the apparent reparability of the problem, and the techniques that should be used to accomplish the repair. When considering repair, one must distinguish between persistent enophthalmos and persistent diplopia, because the likelihood of correcting residual diplopia is much less. In 1982 Kawamoto [3] reported on the use of osteotomies and bone grafts to correct the deformity associated with malpositioned zygomaticomaxillary fractures, concluding that ‘‘long established posttraumatic enophthalmos . . . is a correctable deformity.’’ In a series of subsequent articles, Kawamoto has refined his technique from one of maximal exposure to minimal exposure, still allowing for the use of osteotomies and bone grafts as necessary [4–6]. The most important advances readily available to all surgeons are high-quality imaging studies that allow for more accurate assessment of the anatomic abnormalities that are causing the enophthalmos as well as correct assessment of the results of attempts at surgical repair. Intraoperative imaging may allow for immediate assessment of the correctness of a repair, even before the wounds are closed; however, because this technology is currently less accessible, postoperative assessment should be carried out with the understanding on the part of the patient and surgeon that additional revision surgery may be needed if a satisfactory outcome is to be achieved. Navigational technology currently under development may ultimately increase the likelihood of more accurate repairs that can be performed more precisely and predictably. Etiologies of late (or persistent) enophthalmos (or hypophthalmos) are listed in Box 1. The categories are, for the most part, self-explanatory; however, a few important points should be emphasized. First, one must distinguish between blow-out fractures, that is, fractures involving one or more walls of the orbit without disruption of the orbital rims, and fractures that do indeed disrupt the orbital rims. Failure to address a malpositioned orbital rim will make it difficult, if not impossible, to reconstruct properly the true orbital shape. Furthermore, a displaced lateral orbital rim has a dramatic effect on globe position, because the lateral rim is positioned approximately at the equator of the globe, and medial or lateral displacement of the rim will push the globe forward or backward, respectively [7]. Second, a displaced zygomaticomaxillary fracture, with inferolateral displacement of the lateral orbital rim and wall, will have a more dramatic effect on globe position than a simple blow-out fracture. If the misplaced bone is not osteotomized and repositioned, an excessive amount of graft material would be required to reposition the globe adequately and repair the enophthalmos. The best repair necessitates repo-