DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left old orbital floor blowout fracture.
POSTOPERATIVE DIAGNOSIS: Left old orbital floor blowout fracture.
OPERATION PERFORMED: Exploration and reconstruction of left orbital floor blowout fracture with split calvarial bone graft.
SURGEON: John Doe, MD
ANESTHESIA: General.
FLUIDS: About 2 liters of crystalloids.
ESTIMATED BLOOD LOSS: About 150 mL.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old male who was apparently assaulted and sustained a blow to the eye region. The patient sustained a fracture in that area. The patient came in complaining of pain to his eye, in addition some diplopia on upward and lateral gaze. He did not have any straight forward gaze diplopia. He also complained of some numbness in the left infraorbital nerve distribution. The patient was told of the options, and the patient agreed to go forward with surgery. The patient was explained the risks, complications, benefits, alternatives, including the risks of bleeding, infection, scarring, injury to nerve. The patient understood and wanted to proceed with exploration and reconstruction of left orbital floor blowout fracture with split calvarial bone graft.
OPERATIVE FINDINGS: Clinically showed the patient with enophthalmos; it was significant. The patient did have some numbness in the left infraorbital nerve distribution. Again, his diplopia was in an upward and lateral gaze and not on straight gaze. During surgery, there was a lot of scarring, adhesions of the fatty tissue in the maxillary sinus.
DESCRIPTION OF OPERATION: The patient was brought into the operating suite and given general endotracheal anesthesia for exploration and reconstruction of left orbital floor blowout fracture with split calvarial bone graft. The patient was then repositioned appropriate, prepped and draped in usual sterile manner. We infiltrated into the lower eyelid on the left side as well as the left temporoparietal region, where the bone graft would be harvested from. The patient had been prepped and draped in usual sterile manner.
What we did first was to make the subciliary incision. A subciliary incision was made going lateral to medial. The skin flap was elevated exposing the muscle. The muscle was then divided. Dissection was then carried down to the septum orbitale. This was a deep plane of dissection. Dissection was carried down to the inferior orbital rim. Electrocautery was used to incise the periosteum and the inferior orbital rim.
We then took the Joseph periosteal elevator and dissected into the eye. As we dissected into the eye, the fracture was noted with the herniated orbital contents into the maxillary sinus. We very carefully then teased the scar tissue around the fat into the orbit proper. The inferior orbital nerve was identified and kept intact at all times going along the orbital floor.
We then dissected all the way back posteriorly following the posterior ledge. Medial, lateral, anterior ledges were well defined, and as we dissected further back, posterior ledge was then defined. The defect was obvious; although, orbital contents were now taken out of the defect into the orbit proper.
We then went ahead and went to the left temporoparietal region and made an incision to the scalp. This was done using 10 blade. Dissection was then carried through the subcutaneous tissue, galea down to the underlying periosteum of bone in this area.
We then exposed the area and drew out the bone graft that we wanted to harvest. It was 3 cm in length and the anterior widest portion of it was about 2.5 cm and it tapered down to the apex as it went anterior to posterior. The bur was used to harvest the split calvarial graft.
We burred down to the diploic space first. We did this completely circumferentially around this marked out area. Once we got to the diploic space, we then harvested the split calvarial bone graft with the osteotome; it came out nicely. The periosteum was kept intact. We then went back to the orbital floor and the contour of the bone graft to fit nicely in the orbital floor.
We shortened it somewhat and we put a groove in it in the apical area to accommodate the infraorbital nerve, which would be impinged upon had we not made this groove. At any rate, we contoured the bone graft, fit in nicely. It sat in nicely and orbital contents were then allowed to rest upon it.
We then went back to the skull area and obtained hemostasis, irrigated and placed a 7 mm Jackson-Pratt drain. The wound closure was performed in 2-layer fashion approximating the galea with 2-0 Vicryl and the skin with staples. We then closed the subciliary incision with 6-0 fast-absorbing gut.
Clinically, the patient had good correction of the enophthalmos; although, there was some swelling and this made it rather difficult to tell. The patient was then awakened, extubated and taken to the recovery room in satisfactory condition having tolerated the procedure well.
