Operative technique for a combined transcaruncular-transconjunctival approach to double-walled orbital fractures

Abstract

Double-walled orbital fractures involving the floor and medial wall are commonly encountered in instances of significant midface trauma. Operative intervention is indicated in the presence of persistent diplopia, significant enophthalmos, or muscle entrapment. Surgical repair of these injuries may be challenging due to large fracture sizes or loss of bony supports. The transconjunctival and transcaruncular approaches have been popularized to reconstruct isolated floor and medial wall fractures, respectively. However, surgical approaches for fractures involving both these walls have not been well described in the literature. In this technical note, we detail a combined transcaruncular-transconjunctival approach that is safe, effective, and aesthetically sensitive.

Keywords

Orbital fracture / trauma / transconjunctival / transcaruncular

References

[1] Roth FS,Goldberg JS.Pearls of orbital trauma management.Semin Plast Surg2010;24:398-410 PMCID:PMC3324224

[2] Shokri T,Hammons M,Sokoya M.Management of orbital floor fractures.Facial Plast Surg2019;35:633-9

[3] Cruz AA.Epidemiology and management of orbital fractures.Curr Opin Ophthalmol2004;15:416-21

[4] Thiagarajah C.Medial wall fracture: an update.Craniomaxillofac Trauma Reconstr2009;2:135-9 PMCID:PMC3052654

[5] Jank S,Emshoff R.Clinical signs of orbital wall fractures as a function of anatomic location.Oral Surg Oral Med Oral Pathol Oral Radiol Endod2003;96:149-53

[6] Kesselring AG,Strabbing EM,Koudstaal MJ.Lower eyelid malposition following orbital fracture surgery: a retrospective analysis based on 198 surgeries.Craniomaxillofac Trauma Reconstr2016;9:109-12 PMCID:PMC4858425

[7] Oztel M,Hsu E.Subtarsal versus transconjunctival approach: a long-term follow-up of esthetic outcomes and complications.J Oral Maxillofac Surg2021;79:1327.e1-6

[8] Nguyen DC,Snyder-Warwick A,Woo AS.Transcaruncular approach for treatment of medial wall and large orbital blowout fractures.Craniomaxillofac Trauma Reconstr2016;9:46-54 PMCID:PMC4755730

[9] Kunz C,Cornelius CP,Rudderman R.The comprehensive AOCMF classification system: orbital fractures - level 3 tutorial.Craniomaxillofac Trauma Reconstr2014;7:S092-102 PMCID:PMC4251722

[10] Dreizin D,Diaconu SC,Bodanapally UK.Multidetector CT of midfacial fractures: classification systems, principles of reduction, and common complications.Radiographics2018;38:248-74

[11] Borad V,Hamlar DD,Yadava GK.Intraoperative imaging changes management in orbital fracture repair.J Oral Maxillofac Surg2017;75:1932-40

[12] Wolkow N.Transconjunctival and transcaruncular approaches to the orbit.J Neurol Surg B Skull Base2020;81:422-34 PMCID:PMC7561462

[13] Shahzad F,Snider-warwick A.The transcaruncular approach for treatment of medial wall and giant orbital blowout fractures.Plast Reconstr Surg2011;128:31

[14] Lee CS,Lee SY.Combined transconjunctival and transcaruncular approach for repair of large medial orbital wall fractures.Arch Ophthalmol2009;127:291-6

[15] Scolozzi P.Reconstruction of severe medial orbital wall fractures using titanium mesh plates placed using transcaruncular-transconjunctival approach: a successful combination of 2 techniques.J Oral Maxillofac Surg2011;69:1415-20

[16] Alinasab B,Rudström R.New algorithm for the management of orbital blowout fracture based on prospective study.Craniomaxillofac Trauma Reconstr2018;11:285-95 PMCID:PMC6224287