Changing concepts in the management of secondary orbital deformities.

Techniques borrowed for the correction of congenital craniofacial deformities and acute traumatic reconstruction have improved the quality of secondary post-traumatic orbital reconstruction. These techniques include precise pre- and postoperative assessment made possible by thin section axial and coronal CT imaging. Wide exposure through remote incisions borrowed from aesthetic surgery allows access for repositioning or recontouring of malaligned structures without additional morbidity to the soft tissues. The use of osteotomy and camouflage techniques will depend on the severity of comminution and displacement. Most often, a combination of techniques is employed. Rigid fixation techniques, particularly the use of micro systems, allows the potential for complex configurational reconstruction with little morbidity. The lag microscrew technique allows in-place contouring of onlay grafts and increases volume persistence, thus decreasing the amount of relapse. These techniques taken together provide the potential for unparalleled sophistication in our secondary orbital reconstructions. The factor limiting the quality of the result is most often a function of the damage imparted to the soft tissues at the time of initial injury. The soft tissues are known to absorb more energy at the time of impact than the underlying bones. The resultant contraction of the soft-tissue envelope over the malaligned and compacted skeletal infrastructure can never be restored to its preinjury appearance. For this reason, reconstruction in the acute phase remains the ideal time to prevent or limit post-traumatic orbital deformity.