Here is the very long op report (after prep & anesthesia) Attention was given to the left iliac crest, whereby a 30x12 mm dermal fat graft was harvested with a #15 Beaver blade and Stevens tenotomy scissors. The epidermis was removed and the dermal graft with conjoined fat graft was harvested en bloc. Meticulous hemostatsis was acheived with fine-tipped electrocautery. The wound was then closed in a layered fashion with 4-0 Vicryl and a 5-0 running Prolene. OpSite dressing was applied to the wound. Attention was given to the patient's orbit where lateral canthal skin incision was performed and a lateral canthal skin incision was then performed. A lower lid cantholysis was performed and a transconjuntival dissection was performed to the inferior orbital wall. Note is taken patient is status post previous open reduction, internal fixation for which a 1/4 compression plate was identified to the infraorbital rim. A Leibinger mesh orbital implant was appreciated to the floor of the orbit. The Leibinger mesh was noted to be free floating and suspended in cicatrix involving the periorbita and posterior tenons. The periosteum was opened along the infraorbital floor and the aforementioned Leibinger mesh plate was dissected. This was noted to be performed and with a considerable amount of cicatrization, the plate was removed medially using plate scissors laterally that the plate appeared to be secure and well confined within a very vascular adhesive cicatrix.
Inspection medially was then performed in a subperiosteal fashion, whereby large amounts of herniated fat were retrieved from the ethmoid sinus, as there was noted to be a significant fractional lamina papyracea with orbital contents extruding medially. This dissection performed is for superiorly as the anterior and posterior ethmoid arteries which were identified and ligated. The medial orbital wall fracture was then confined and was consequently defined and a Leibinger plated was selected and trimmed to meet the deficit of the medial wall. Consequently, the plate was trimmed , placed into the medial wall and secured to the infraorbital rim with two-point fixation of one 2x3 mm self drilling screws. The plate was noted to be intact and consequently dissection performed anteriorly, demonstrating a moderate amount of volume atrophy for which conjoined fat grafts were placed between the plate and the contents of the orbit. Inspection of the orbital wall demonstrated an early extruding silicone ball for which the capsule was opened and an 18mm silicone ball was identified and easily removed. The capsule was dissected from the orbital contents. An attempt to isolate the rectus muscles was performed; however, the orbit was noted to be markedly distorted as a result of the gunshot injury and the cicastrization. a 20-mm hydroxyapatitie implant was produced. This was impregnated with Garamycin and Marcaine solution. This was overwrapped with eye bank sclera which the sclera was sewn closed using a running 6-0 Vicryl. Insertion sites were performed in the sclera. The deep orbital tissue was then meticulously dissected using fine-tipped electrocautery and the 20-mm hydroxyapatite scleral overwrap matrix was placed into the orbit and this was secured to cicatrization of posterior tenons using the preplaced scleral fixation holes. Consequently, the decision to proceed with dermal graft was made over the surface of the implant. Dermal graft was then trimmed from the conjoined fat grafts and the dermal fat graft was then secured to inferior conjunctiva as there was noted to be significant fornix shortening to the lower lid prior to surgery. the dermal fat graft was then fixated to anterior tenons using multiple interrupted 5-0 vicryl sutures. the conjunctiva was oversewn onto the surface of the dermal fat graft using a running 6-0 Vicryl. The canthus was then closed using 5-0 Vicryl and 6-0 Chromic. Conforma was placed. The orbit was injected with approximately 5 ml of 0.5% Marcaine plain. The orbit was dressed. Anesthesia was reversed and patient left the operating room in stable condition and without any obvious complications.
thank you for your help!