Re: “Secondary Orbital Reconstruction in Patients With Prior Orbital Fracture Repair”

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We thank Drs. Kashkouli and Sianati for their interest in the recent publication describing the outcomes of revision surgery in patients with prior orbital fracture repair.1 They suggest that unsatisfactory outcomes and the need for revision surgery may be influenced by progressive fat atrophy and tissue fibrosis and that secondary orbit reconstruction may require additional volume with titration of implant size to preoperative enophthalmos.2
While we certainly acknowledge orbital injury and prior surgery may induce fat atrophy and tissue fibrosis, our study demonstrates that secondary surgery, with an anatomically correct, single layer reconstruction, can in many instances correct the orbital volume deficiency3 and motility defects that arise following inadequate primary repair. In our study, patients who had placement of anatomically correct implant did not required additional material to enhance orbital volume.
Malpositioned orbital implants, with intrusion into adjacent sinuses cavities may also incite additional inflammation worsening orbital fibrosis and atrophy. The addition of further material stacked on an initially malpositioned implant may worsen this pre-existing cycle and not address the primary problem.
Decision making in secondary orbital reconstruction should be customized based on severity of clinical findings and adequacy of primary repair. The removal of previously placed implants can be technically challenging but our opinion is that good outcomes are achievable and surgeons should consider revision in patients with significant clinical deficits. Further studies may help us elucidate the relative contribution of fibrosis and atrophy and we thank Drs. Kashkouli and Sianati for their comments.
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