Orbital blow-out fractures: surgical timing and technique

Purpose To recommend a tailored approach to surgical timing in the repair of orbital blow-out fractures, and to offer suggestions for improved functional and aesthetic surgical outcomes. Methods Traditional guidelines for surgical timing are reviewed. An evidence-based approach that considers soft-tissue disruption relative to bone-fragment separation is presented. The author's techniques for repair of isolated orbital floor, isolated medial wall, and combined floor–medial wall fractures are presented. Results As demonstrated previously, greater degrees of soft-tissue incarceration or displacement, with presumably greater intrinsic damage and subsequent fibrosis, result in poorer motility outcomes despite complete release of soft tissues. There is a suggestion that earlier intervention for such injuries might improve outcomes. Lower fornix and transcaruncular incisions, careful extrication of incarcerated tissue, and thin alloplastic implants have proven successful in the author's hands. Conclusions The degree of soft-tissue displacement relative to bone fragment distraction, as depicted in preoperative computed tomography (CT) scans, should be considered in the timing of surgery. Incisions, soft-tissue handling, and implant material, thickness, and positioning can all affect the functional and aesthetic outcomes.