Repair of orbital floor fracture #2
Richard C. Allen, MD, PhD, FACS
Additional Notes: Length 04:21
This video demonstrates repair of a left orbital floor fracture. Forced ductions are checked which are shown to be restricted in supraduction. 4–0 silk sutures are placed through the lower eyelid at the level of the tarsus. A lateral canthotomy is then performed with a 15 blade followed by an inferior cantholysis. A trans-conjunctival incision is then made with the needle tip cautery inferior to the inferior border the tarsus. Dissection is then carried out between the orbicularis muscle and the orbital septum. 4–0 silk sutures are placed through the cut end of the lower lid retractors and conjunctiva. Dissection then proceeds with the needle tip cautery. Sometimes it is useful to bluntly dissect with your fingertip to the inferior orbital rim. Cotton-tipped applicators can also be used for this. The inferior orbital rim is then identified and the periosteum is incised with the needle tip cautery. A Freer periosteal elevator is then used to elevate the periosteum from the orbital floor. The orbital fracture is then encountered and dissection is carried out around the fracture. Usually I perform this anteriorly, followed by medially and laterally. This allows elevation of the tissue from the fracture. The posterior extent of the fracture should be identified. This can be performed with the Freer periosteal elevator as well as the suction tip. Once all sides of the fracture have been identified and the tissue is elevated from the fracture, forced ductions are again checked which are now free. Again one should grasp at the area of the insertion of the inferior rectus. The distance between the posterior shelf and the orbital rim is measured with the suction tip. A Supramid implant is then fashioned to cover the fracture. In this case, it was determined that a Titan implant would be used due to the size the fracture. This implant is placed in the subperiosteal plane. The implant is then fixated to the inferior orbital rim with a 1 by 4 millimeter screw. 2 screws are used in order to ensure fixation. Forced ductions are again checked after placement of the implant to ensure that no tissue was caught in the implant placement. The trans-conjunctival incision is then closed with 7–0 Vicryl sutures. The lateral cantholysis is then closed by suturing the tarsus of the lateral lower eyelid to the tarsus of the lateral superior eyelid. This is performed with 4–0 Vicryl suture. The lateral canthotomy incision is closed with the 7–0 Vicryl sutures.
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