Page 17 - Advanced concepts in orbital wall fractures

Surgical principles C1 The shape of the bony orbit and the intricate architecture of the soft tissue
pose surgical challenges. Orbital reconstruction is performed in a confined
space with a limited overview close to vital and delicate structures. This
presents a risk of iatrogenic damage and surgical complications. Detailed planning and adequate exposure of the orbital floor and medial wall is necessary to avoid this as much as possible.
Widely used approaches to restore the orbital boundaries after an orbital wall fracture are transconjunctival, subtarsal, and subciliary16,17. The ideal approach is safe, easy, and quick to perform, facilitates a perfect exposure of the fracture, and has minimal risk of complications. The subtarsal and subciliary approach are both transcutaneous approaches. The subtarsal approach is allegedly the easiest approach, it creates direct exposure to the orbital floor and the scar can be concealed in a skin crease. There is a moderate risk of complications such as lid shortening and ectropion. The subciliary approach is more demanding and allows the best exposure of the orbital rim and floor. The disadvantage is a higher incidence of complications, such as scar formation, lid oedema, ectropion, and scleral show. The transconjunctival approach has no visible scarring as it hides behind the lower eyelid. The initial exposure could be moderately inferior to the other approaches, but the risk of complications, such as entropion, is low. A major advantage of this approach is that the medial wall can be exposed with a transcaruncular extension and exposure of the floor can be improved with a lateral canthotomy16,17. A good overview is required to see the fracture and the landmarks.
Surgical guidance with the use of anatomical landmarks is important for the orientation of the surgeon during orbital reconstruction. The orientation is improved by identifying and measuring the distance between each landmark in relation to the fracture18. The surface area of a fracture is usually overestimated by the surgeon and computed tomography (CT) measurements are the most consistent and accurate19. An excellent overview is particularly important in complex fractures with altered anatomy and protruding adipose tissue. The most anterior landmark that can be identified during the approach is the inferior
General introduction and outline
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