Repair of large orbital floor and medial wall fractures with a combined trans-conjunctival and trans-caruncular incision
Richard C. Allen, MD, PhD, FACS
Length: 07:01
This is Richard Allen at the University of Iowa. This video demonstrates a series of repairs of large medial wall and orbital floor fractures. A lateral canthotomy and inferior cantholysis are performed. A trans-conjunctival incision is then made with the needle tip cautery extending from the punctum medially to lateral canthotomy incision laterally. Dissection is then carried out between the orbital septum and the orbicularis muscle to the inferior orbital rim. The inferior orbital rim is identified and incised with the needle tip cautery. A Freer periosteal elevator is then used to elevate the periosteum from the orbital floor. The fracture is identified along the orbital floor and tissue is gently freed from the fracture. A transcaruncular incision is then made with Westcott scissors. This incision will be connected to the trans-conjunctival incision. Stevens scissors are then used to bluntly dissect to the posterior lacrimal crest. A malleable retractor is placed to expose the periosteum and the Freer periosteal elevator is used to elevate the periosteum from medial wall. The inferior oblique is disinserted with the Freer periosteal elevator so that a 180° view is obtained of the orbit. A Supramid implant is then fashioned as a template of the fracture. A Titan implant is then fashioned and placed to cover the fracture. This implant is fixated to the inferior orbital rim with 1 millimeter titanium screws. The transcaruncular and transconjunctival incisions can then be closed with 7–0 Vicryl sutures.
In the second case, a lateral canthotomy and inferior cantholysis are performed. A trans-conjunctival incision is then made extending from the lateral canthotomy incision laterally to the punctum medially. Dissection is then carried out between the orbicularis muscle and the orbital septum to the inferior orbital rim. A 4-0 silk suture is placed for traction. The inferior orbital rim is identified and incised with the periosteal elevator. Periosteum is then elevated from the orbital floor. Attention is then directed medially where a transcaruncular incision is made with Westcott scissors. Stevens scissors are then used to bluntly dissect to the posterior lacrimal crest. A malleable retractor is then placed and the periosteum is elevated from the medial orbital wall. The two incisions are connected and the inferior oblique is identified and disinserted from the inferior orbital rim. A Supramid orbital implant is then used to make a template of the orbital fracture. A Titan implant is then fashioned in order to cover both the medial and inferior orbital fractures. The implant can be somewhat difficult to place and malleable retractors are used to retract the orbital tissue as the implant is placed into position. The implant is then fixated in position with two 1 millimeter screws to the inferior orbital rim. The trans-conjunctival incision is then closed with interrupted 7–0 Vicryl sutures. The transcaruncular incision is closed with the 7–0 Vicryl suture. At the conclusion of case, the cantholysis and canthotomy are repaired and the globe appears be in good position.
In the third case, a lateral canthotomy and inferior cantholysis are performed with the needle tip cautery. A trans-conjunctival incision is then made with the needle tip cautery. Dissection is then carried out between the orbicularis muscle and the orbital septum to the inferior orbital rim. A 4-0 silk suture is placed for traction. The inferior orbital rim is palpated and the needle tip cautery is used to make an incision through the periosteum of the inferior orbital rim. The Freer periosteal elevator is then used to elevate the periosteum from the orbital floor. The orbital floor is visualized and the orbital fracture is noted medially. A trans-caruncular incision is then made with Westcott scissors. This incision is connected to the trans-conjunctival incision. A malleable retractor is used to identify the medial orbital wall. The inferior oblique is exposed along the medial portion of the inferior orbital rim. The oblique is then disinserted with the Freer periosteal elevator. This results is in a 180° view of the orbit. A Titan implant will be used to cover the fracture. This implant is placed into position with the aid of a large malleable retractor. The globe appears be in good position and the implant is fixated to the inferior orbital rim with titanium screws. The trans-conjunctival and trans-caruncular incisions are then closed with interrupted 7–0 Vicryl sutures.
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