Extended Transcaruncular Approach Using Detachment and Repositioning of the Inferior Oblique Muscle for the Traumatic Repair of the Medial Orbital Wall

Abstract

The fracture of the medial orbital wall is relatively common in orbital trauma. Titanium mesh is possibly the actual standard material for orbital wall reconstruction. When the floor of the orbit and the medial wall are simultaneously affected, one larger mesh gives better results than two independent meshes that need to be fixated independently. However, large meshes need a wider surgical field. To gain sufficient exposure to the medial and inferior orbital walls simultaneously, we present an approach that combines the transconjunctival and transcaruncular incisions, detaching if needed the inferior oblique muscle and, placing our mesh, repositioning it beside the lacrimal duct. This technique should not entirely displace traditional approaches, but it widens the surgical exposure for middle-and upper-third facial trauma. This alternative has minimum morbidity and can save a great deal of surgery time.

Combined Orbital Floor and Medial Wall Fractures Involving the Inferomedial Strut: Repair Technique and Case Series Using Preshaped Porous Polyethylene/Titanium Implants

“…7,17 The combination of these approaches has proven indispensable to us in the management of these challenging cases. Although some authors have advocated dividing the inferior oblique near its origin and reapproximating the muscle with sutures at the end of the case, 26 we have found that direct disinsertion obviates the need for sutures. Mild vertical and/or torsional diplopia can occasionally occur in the early postoperative period, but in our experience has always resolved within a week or two.…”

“…When the two approaches are combined and the inferior oblique muscle disinserted, the entire surgical field becomes beautifully exposed. Combined transconjunctival and transcaruncular orbitotomy has been previously described by several authors, [26][27][28] along with disinsertion of the inferior oblique by others. 7,17 The combination of these approaches has proven indispensable to us in the management of these challenging cases.…”

Clinical Results According to Inferior Oblique Manipulation in Patients with Inferomedial Blowout Fracture Involving the Orbital Strut

“…Seventeen and 23 patients had right and left orbital wall fractures, respectively. The mean follow-up visit was 9 ± 3.47 months (range, [6][7][8][9][10][11][12][13][14][15][16][17]. Patients showed enophthalmos of -1.46 ± 0.25 (range, -5 to 3) mm compared with the normal side.…”

Usefulness of Subciliary Approach by Using Lacrimal Sac Stripping for Large Isolated Medial Orbital Fracture Reconstruction

“…8 The main disadvantage of the pure transcaruncular approach is, however, that the field for working in the medial wall is very limitedVonly small grafts (15 Â 20 mm maximum) can be inserted. 9 It provides only limited exposure, making it difficult to put in the reconstructive materials. 10,11 Also, inserting titanium mesh via transcaruncular approach is technically difficult in some cases, due to the sharp cut edges of the material, especially for larger defects, where herniation of the periorbita makes retraction difficult.…”