Patients Comfort Evaluation
Results from the survey showed an average pain and discomfort score of 12.98 and 11.89, respectively, in the immediate postoperative. The day after surgery, the score was 4.81 and 5.34, respectively, while 1 week after surgery, the score was 0.50 and 2.43, respectively (Table 5). We did not record a VAS score > 50 in any case. The highest VAS score was 50 and 45 for pain and discomfort, respectively, in the immediate postoperative; VAS score 20, both for pain and discomfort, the day following reconstructive surgery; VAS score was 0 for pain and 20 for discomfort 1 week after surgery (Table 5). The results from the patient’s general preference and overall satisfaction with the surgical experience were as follow: in the 3-point preference scale, 126 of 135 (93.3%) questions the patient reported: “I was comfortable going home the day after surgery. There was no reason for me to stay longer in the hospital.” In 9 instances (6.6%), the response was “I was concerned about leaving the hospital the day after surgery. I would have felt more comfortable if I had stayed one night more, but it worked out fine.” None of the patients selected: “I should have stayed one night more in the hospital, I was in considerable pain and discomfort at home.” All patients reported that they were “satisfied with the overall experience.” According to previous studies, satisfaction is driven by the difference or discordance between expectation and experience and patients who were extremely anxious and not bothered with surgery would be more satisfied than those who were not concerned and extremely bothered.18
In 1957, Smith and Converse suggested the term “blowout” to refer to an isolated fracture of the orbital floor.1 Blowout fractures are further classified as pure (orbital rim not involved) and impure (orbital rim involved), and pure blowout fractures are categorized as trapdoor (the bone fragment is partially attached to intact bone with frequent incarceration of the periorbita) or punched-out (the fractured bone segment is detached on all sides with infrequent incarceration of the periorbita).2–4 Typically, orbital floor fractures do not occur in isolation but are associated with other facial fractures.3 Their management is shared by different specialties, such as ophthalmology, plastic surgery, and otolaryngology. The management of these fractures has been debated for many years, and recommendations for treatment have been addressed in part by Burnstine.14,15 Nonetheless, no one has described the appropriate anesthesia for surgically repairing these fractures. Rather, most articles focus on the surgical outcome.18–22 Diplopia, enophthalmos, and limited extraocular movements are indications for surgical treatment. Although diplopia is present in most cases, it can resolve within a few days with the resolution of traumatic edema, muscle contusions, and neuropraxia, with the exception of an actual entrapment of the inferior rectus muscle or of the periorbital tissue.14 This issue can be resolved by combining clinical examination and coronal CT scanning, which provide information on herniation, muscle entrapment, dislocation, and details concerning the rim of the fracture.15 The goal of treatment is the restoration of orthoscopic vision and visual acuity. Early fracture repair is associated with improved outcomes compared with a delayed repair approach within 3 weeks.14,15,23–25 Several autologous, alloplastic, and allogenic materials are available for orbital floor fracture repair.25,26 The choice depends as much on surgeon preference as on implant characteristics.5,19 Here, we reviewed the personal case records of patient who underwent orbital floor fractures repair with Medpor to collect a uniform cohort to draw robust conclusions. Usually, we repair orbital floor fractures using biomaterials for defects involving the anterior and/or posterior floor till subtotal reconstruction supposing a remaining bone support; on the contrary, we harvest bone grafts from the calvaria, and in these cases, surgery was performed under general anesthesia. Until now, no one has described repairing an orbital floor fracture under regional anesthesia with an infraorbital nerve block. From the present retrospective review, the complication rate following orbital floor fracture repair under regional anesthesia with conscious sedation when necessary is comparable to the result obtained under general anesthesia in our Level I Trauma Center and in the literature.1,3,5,7,17,18,20,23 However, the decreased reoperative rate for surgical repair under local anesthesia compared to that under general anesthesia was not statically significant (P > 0.05). Topical injections and nerve blocks render insensitivity to pain in the affected area only.11,13 The patient is relaxed, comfortable, and virtually unaware of the procedure due to light medication, but the whole body is not paralyzed.8,9 Complication rates are greater under general anesthesia, and patients often have a sore throat, are fatigued, and are more likely to feel nauseated or to vomit. Furthermore, the recovery period is considerably longer.10,12 A nerve block is a much safer alternative to general anesthesia because it does not put the body under stress.11 Most importantly, fewer drugs are needed, hence recovery is faster, and more procedures can be performed in a single day.12 Systemic toxicity is rare with regional anesthesia and can be prevented using the smallest dose possible and aspirating before injection into the extraneural or paraneural spaces. Anesthesia from a nerve block lasts longer than local infiltration and does not cause swelling or alter the surgical field.13 Overall patients’ endurance and satisfaction of the procedure represent a further point of discussion. In particular, the highest VAS score for pain at any time was 50 (range, 0–50) and the highest VAS score for discomfort 45 (range, 20–45). Presumably, the average VAS score for discomfort was higher than the average VAS score for pain because an almost constant involvement of the infraorbital nerve in the dynamic of the trauma experienced and nervous traumatism can take several months to achieve complete recovery. Nonetheless, the data collected are slightly lower than other previously published data regarding general orbital surgery performed under general anesthesia.18 Somehow this last point gives further support to the present work in addition to the lower rate of surgical revision deriving from the management of orbital floor fractures repair under local anesthesia.
There are several advantages to surgically repairing isolated orbital floor fractures under regional and local anesthesia that include the following: surgeons can check the surgical outcome intraoperatively, thereby reducing the reoperation rate; patient discomfort due to general anesthesia is eliminated; and the hospital stay is reduced, thus decreasing overall healthcare costs. Most patients tolerate orbital reconstructive surgery comfortably, safely, and with minimal pain suggesting that reconstruction of the orbital floor performed under local anesthesia is safe and well tolerated.
Patients provided written consent for the use of their images.
1. Kirby EJ, Turner JB, Davenport DL, et al. Orbital floor fractures: outcomes of reconstruction. Ann Plast Surg. 2011;66:508–512
2. Kempster R, Beigi B, Galloway GD. Use of enophthalmic implants in the repair of orbital floor fractures. Orbit. 2005;24:219–225
3. Yano H, Nakano M, Anraku K, et al. A consecutive case review of orbital blowout fractures and recommendations for comprehensive management. Plast Reconstr Surg. 2009;124:602–611
4. Ng SG, Madill SA, Inkster CF, et al. Medpor porous polyethylene implants in orbital blowout fracture repair. Eye (Lond). 2001;15(Part 5):578–582
5. Bae YC, Choi SJ, Moon JS, et al. Comparison of the postoperative outcome in pure medial orbital fracture among three groups: using porous polyethylene or hydroxyapatite through subciliary approach and transnasal endoscopic correction. Ann Plast Surg. 2007;59:287–290
6. Kozakiewicz M, Elgalal M, Piotr L, et al. Treatment with individual orbital wall implants in humans—1-year ophthalmologic evaluation. J Craniomaxillofac Surg. 2011;39:30–36
7. Rhim CH, Scholz T, Salibian A, et al. Orbital floor fractures: a retrospective review of 45 cases at a tertiary health care center. Craniomaxillofac Trauma Reconstr. 2010;3:41–47
8. Friedberg BL. What is general anesthesia? Plast Reconstr Surg. 2010;125:222e–223e
9. Friedberg BL. Cosmetic surgery: postoperative pain and postoperative nausea and vomiting—dissociative anesthesia reconsidered. Plast Reconstr Surg. 2010;125:184e–185e
10. Friedberg BL. Safety and efficacy of sedation anesthesia for breast augmentation. Aesthet Surg J. 2005;25:385
11. Friedberg BL. Anesthesia for cosmetic facial surgery. Int Anesthesiol Clin. 2003;41:13–28
12. Friedberg BL. A role for the anesthesiologist in elective cosmetic surgery. Plast Reconstr Surg. 2003;111:1365–1366
13. Salam GA. Regional anesthesia for office procedures: part I. Head and neck surgeries. Am Fam Physician. 2004;69:585–590
14. Burnstine MA. Clinical recommendations for repair of orbital facial fractures. Curr Opin Ophthalmol. 2003;14:236–240
15. Burnstine MA. Clinical recommendations for repair of isolated orbital floor fractures: an evidence-based analysis. Ophthalmology. 2002;109:1207–1210 discussion 1210–1211; quiz 1212–1213.
16. Dutton JJ. Management of blow-out fractures of the orbital floor. Surv Ophthalmol. 1991;35:279–280
17. Putterman AM. Management of blow out fractures of the orbital floor. III. The conservative approach. Surv Ophthalmol. 1991;35:292–298
18. Korn BS, Kikkawa DO, Vasani SN, et al. Evaluation of patient comfort with outpatient orbital surgery. Orbit. 2007;26:19–22
19. Ridgway EB, Chen C, Colakoglu S, et al. The incidence of lower eyelid malposition after facial fracture repair: a retrospective study and meta-analysis comparing subtarsal, subciliary, and transconjunctival incisions. Plast Reconstr Surg. 2009;124:1578–1586
20. Kozakiewicz M, Elgalal M, Loba P, et al. Clinical application of 3D pre-bent titanium implants for orbital floor fractures. J Craniomaxillofac Surg. 2009;37:229–234
21. Gilliland GD, Gilliland G, Fincher T, et al. Timing of return to normal activities after orbital floor fracture repair. Plast Reconstr Surg. 2007;120:245–251
22. Patel PC, Sobota BT, Patel NM, et al. Comparison of transconjunctival versus subciliary approaches for orbital fractures: a review of 60 cases. J Craniomaxillofac Trauma. 1998;4:17–21
23. Pearl RM. Treatment of enophthalmos. Clin Plast Surg. 1992;19:99–111
24. Chen CT, Chen YR. Endoscopically assisted repair of orbital floor fractures. Plast Reconstr Surg. 2001;108:2011–2018 discussion 2019.
25. Egbert JE, May K, Kersten RC, et al. Pediatric orbital floor fracture: direct extraocular muscle involvement. Ophthalmology. 2000;107:1875–1879
© 2014 American Society of Plastic Surgeons
26. Harris GJ. Orbital blow-out fractures: surgical timing and technique. Eye (Lond). 2006;20:1207–1212