HEAD AND NECK SURGERY
Benefits of the Retrocaruncular Approach to the Medial Orbit A Clinical And Anatomic Study Steve J. Kempton, MD,* David C. Cho, MD,† Brinda Thimmappa, MD, MBA,‡ and Mark C. Martin, MD, DMD§ Background: Current trends in the management of medial orbital wall fractures are toward the development of transconjunctival incisions and the use of endoscopic-assisted methods. Different authors have suggested variations of the medial transconjunctival approach. Methods: (1) In 30 fresh cadaver orbits, the classic transcaruncular approach was compared with the precaruncular and retrocaruncular approach under magnified dissection. (2) A retrospective analysis was conducted on a series of 20 consecutive patients that underwent primary repair of medial orbital wall fractures using a retrocaruncular approach without endoscopic assistance. Postoperative computed tomography scans were obtained for all patients and were evaluated by 3 experienced clinicians. Results: (1) Anatomic dissections showed that all 3 approaches provided excellent exposure of the entire medial orbital wall. The transcaruncular and precaruncular approaches, however, (a) both resulted in exposure of the upper and lower tarsi when incisions greater than 10 mm were used; (b) both required a transition from the preseptal plane to the postseptal plane when combined with inferior fornix incisions. (2) A clinical study of 20 patients showed all reconstructions were possible without endoscopic assistance, resulting in no postoperative complications. Postoperative computed tomography scans showed anatomic orbital reconstruction in all patients judged as excellent by the clinicians. Conclusions: Medial orbital wall fractures can be successfully repaired using transconjunctival incisions without using endoscopes. The retrocaruncular approach surpasses the transcaruncular and precaruncular methods due to its decreased risk of postoperative lid complications and its ability to be directly carried to the inferior conjunctival fornix. Key Words: medial orbital wall, transcaruncular, transconjunctival, retrocaruncular (Ann Plast Surg 2016;76: 295–300)
F
ractures to the medial orbital wall are a prominent finding in orbital trauma and frequently present in combination with fractures to the orbital floor.1–4 Surgical repair of these fractures is often indicated in patients presenting with worsening diplopia, enophthalmos, and/or entrapment of the medial rectus muscle.3 Currently, multiple surgical specialties manage medial orbital wall fractures, which has resulted in the development of a number of surgical approaches.5–9 A modification of the medial transconjunctival incision, as described by Garcia et al10 in 1998, is a frequently utilized approach to access the medial orbital wall for fracture repair. Three variations of this
technique are referenced in current literature and include the transcaruncular, precaruncular, and retrocaruncular approaches (Fig. 1).10–12 Multiple reports outlining clinical outcomes using these techniques have been published; however, authors are inconsistent in the naming and the description of their approaches.4,13–17 An ongoing understanding of complex medial canthal anatomy has demonstrated that the lacrimal caruncle is an embryologic remnant of the lower eyelid with important functional attachments to the lower lid retractors.18–20 As such, preserving these attachments may result in a reduction of lower lid complications. The purpose of this study is to provide an anatomic comparison of the transcaruncular, precaruncular, and retrocaruncular approaches with careful attention paid to the plane of dissection around the caruncle and preservation of the attachments to the lower lid retractors. Additionally, a clinical analysis of the surgical and radiographic outcomes of the retrocaruncular approach in 20 consecutive facial trauma patients is presented.
MATERIALS AND METHODS Anatomic Cadaver Study Thirty orbits from 15 fresh cadaver heads were dissected to demonstrate the transcaruncular, precaruncular, and retrocaruncular approaches to the medial orbital wall. Before dissection, the caruncle was identified and retracted nasally and temporally to determine the presence of fibrous attachments to the upper and lower eyelids. The orbits were divided evenly between the 3 approaches. For the transcaruncular approach, an incision was made directly through the caruncular tissue and carried down to the posterior lacrimal crest in a preseptal plane between Horner’s muscle and the medial orbital septum. The precaruncular approach incision was made anterior and medial to the caruncular tissue with dissection to the posterior lacrimal crest in a similar preseptal plane. For the retrocaruncular approach, an incision was made between the caruncle and the plica semilunaris and extended to the posterior lacrimal crest posterior to the medial orbital septum (retro-septal plane). In all orbits, dissection was carried subperiosteally to the orbital apex, and incisions were extended to the inferior fornix to expose the bony orbital floor. Degree of medial orbital wall exposure, disruption of the medial orbital septum, presence of intraorbital fat herniation, and exposure of the inferior tarsus were recorded for each dissection.
Clinical Study Received January 8, 2015, and accepted for publication, after revision, March 16, 2015. From the *Division of Plastic and Reconstructive Surgery, University of Wisconsin Hospital and Clinics, Madison, WI; †Straub Clinic and Hospital, Plastic Surgery Practice, Honolulu, HI; ‡Department of Plastic Surgery, Wake Forest Medical Center, Winston-Salem, NC; and §Department of Plastic and Reconstructive Surgery, Loma Linda University, Loma Linda, CA. Conflicts of interest and sources of funding: none declared. Reprints: Steve J. Kempton, MD, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Wisconsin Hospital and Clinics, 600 Highland Avenue, G5/361 Clinical Science Center. Mail Code 3236, Madison, WI 53792. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7603–0295 DOI: 10.1097/SAP.0000000000000531
Annals of Plastic Surgery • Volume 76, Number 3, March 2016
From May 2006 to January 2009, all patients that underwent repair of medial orbital fractures by the senior author (M.M.) were retrospectively reviewed. Fractures were diagnosed using computed tomography (CT) maxillofacial imaging, and all patients received a comprehensive ophthalmologic evaluation before and after undergoing surgery. Indications for surgical repair included enophthalmos greater than 2 mm, diplopia within 30 degrees of primary gaze, and radiographic or clinical evidence of medial rectus muscle entrapment. All patients underwent surgery using a retrocaruncular approach, without endoscopic assistance, with placement of a Synthes titanium implant (Synthes, West Chester, PA). Data obtained from patient charts included patient age, sex, trauma history, preoperative diagnosis, and procedures www.annalsplasticsurgery.com
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Surgical Procedures (Retrocaruncular Approach) A 15-mm vertical incision is made in the interval between the plica semilunaris and the caruncle. The incision is carried down to the posterior lacrimal crest in a retroseptal plane, taking care to sweep all periorbital fat posteriorly with an insulated malleable. The subperiosteal dissection is completed, exposing the fractured medial orbital wall superiorly and inferiorly. A freer elevator is placed in the ethmoid sinus and used to indentify the most posterior stable bone using a stair step technique. The medial fornix incision is carried into the inferior fornix in a retroseptal plane in cases of combined orbital floor fractures. A Synthes titanium implant is inserted and fixed using a single 1.5 mm screw secured to the uppermost aspect anteriorly. All implants are custom-formed based on intraoperative measurements taken between the frontoethmoidal suture and the optic strut. In cases combined with orbital floor fractures, angular measurements between the medial wall and floor using the preoperative CT scan of the uninjured side were used.
RESULTS FIGURE 1. Cadaveric picture/diagram of the classic transcaruncular, precaruncular, and retrocaruncular incisions in relationship to the anatomic caruncle. LC, lacrimal caruncle.
performed. Outcome data were recorded for incidence of enophthalmos, symblepheron, and lower lid retraction.
Radiographic Analysis Postoperative CT maxillofacial scans were obtained for each patient to assess adequate titanium plate placement. Angular relationships between the medial wall and floor of the orbit were determined on hemicoronal images in a blinded fashion. Injured orbit angular measurements were compared to the uninjured orbit. In addition, 3 experienced facial trauma surgeons evaluated the quality of the reconstruction based on axial and coronal views and assigned ratings (poor to excellent) based on a Likert scale.
FIGURE 2. Caruncle is drawn anteriorly to show the caruncular attachment to the superior and inferior tarsal plates. These attachments consist of fibrous bands and conjunctival folds. 296
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Anatomical Cadaver Study Examination of medial canthal surface anatomy found the caruncle to be firmly attached to the medial aspects of the superior and inferior tarsal plates by way of conjunctival folds and fibrous bands in all 30 orbits (Fig. 2). The transcaruncular, precaruncular, and retrocaruncular approaches were accurately carried out in a manner similar to the surgical setting (Fig. 3 and Fig. 4). All three approaches resulted in exposure of the medial orbital wall to the orbital apex. Under magnified dissection, the transcaruncular and precaruncular incisions resulted in disruption of the medial orbital septum (transseptal plane) when carried to the posterior lacrimal crest. Additionally, when incisions greater than 10 mm were used or when incisions were extended into the inferior fornix, both approaches required cutting the caruncular attachment to the inferior tarsus. This resulted in further medial orbital septum disruption and exposure of the medial portion of the inferior tarsal plate (Fig. 5 and Fig. 6, green/blue). Exposure of the inferior tarsus and violation of the medial orbital septum occurred in all 20 dissected orbits (10 transcaruncular, 10 precaruncular).
FIGURE 3. Normal medial canthal anatomy. Key for subsequent figures. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Annals of Plastic Surgery • Volume 76, Number 3, March 2016
Medial Transconjunctival Approach
FIGURE 4. Axial view diagram of the classic transcaruncular (left), the precaruncular (middle), and the retrocaruncular (right) approaches. Posterior to the lacrimal sac, the layers include the posterior limb of the medial canthal tendon, Horner’s muscle, the medial orbital septum, and the medial check ligament arising from the mrCPF.
In comparison, the retrocaruncular approach was carried to the posterior lacrimal crest in a postseptal plane that did not require violation of the caruncular attachment to the lower lid when transitioned to the inferior fornix (Fig. 6, red). Damage to the medial orbital septum and tarsal exposure was avoided in all 10 dissected orbits. Herniation of orbital fat contents, however, occurred in all 10 dissected orbits and was managed using an insulated malleable.
31.9 years. Trauma history included assault in 10 cases, motor vehicle accidents in 7 cases, auto versus pedestrian in 2 cases, and 1 case involving a weightlifting accident. There were 11 isolated medial orbital wall fractures and 9 combined medial orbital wall and orbital floor fractures.
Clinical Study Twenty patients with medial orbital wall fractures underwent repair using the retrocaruncular approach without the need for endoscopic assistance. There were 17 men and 3 women with average age of
FIGURE 5. Picture of the precaruncular incision extended into the inferior fornix in a cadaver orbit. Exposure of the medial lower lid tarsal plate occurred in all 20 dissections using the precaruncular and transcaruncular approaches. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
FIGURE 6. Axial diagram 3 mm below the eyelid margin of the lower eyelid. Blue and green lines represent the extension of the transcaruncular and precaruncular incisions into the inferior fornix. Note that the medial OS and the mrCPF connecting the caruncle to the lower lid TP are violated. Red line represents the extension of the retrocaruncular approach to the inferior fornix in a natural plane. OS indicates orbital septum; TP, tarsal plate. www.annalsplasticsurgery.com
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TABLE 1. Patient Demographics, Retrospective Clinical Analysis Results, and Radiographic Analysis Clinical Analysis
Patient
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Radiographic Analysis
Age/Sex
Mechanism of Injury
Date of Surgery
Diagnosis
Approach
Complications
Postoperative Midorbital Angle Compared to Contralateral Side, degrees
7/M 39/M 24/F 48/M 35/M 19/M 42/M 35/M 46/F 12/M 38/M 44/M 53/M 24/M 31/M 37/M 28/M 23/M 24/F 30/M
Auto vs Ped Assault MVA Assault Assault Weight Lifting MVA Assault Auto vs Ped Assault MVA Assault MVA Assault MVA Assault Assault Assault MVA MVA
5/28/06 2/2/07 2/3/07 2/9/07 2/23/07 3/5/07 4/1/07 4/26/07 6/15/07 10/20/07 10/25/07 12/23/07 1/10/08 2/22/08 5/9/08 7/20/08 10/17/08 11/23/08 12/12/08 1/30/09
L Medial Wall/Floor R Medial Wall R Medial Wall/Floor R Medial Wall/Floor R Medial Wall/Floor L Medial Wall L Medial Wall/Floor L Medial Wall R Medial Wall L Medial Wall L Medial Wall L Medial Wall L Medial Wall/Floor R Medial Wall/Floor R Medial Wall R Medial Wall L Medial Wall R Medial Wall L Medial Wall/Floor R Medial Wall/Floor
Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular
None None None None None None None None None None None None None None None None None None None None
≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5
Likert CT Evaluation
Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent
MVA indicates motor vehicle accident; M, male; F, female.
Postoperative ophthalmologic examinations reported no enophthalmos, horizontal diplopia, or cosmetic sequelae relating to the conjunctival incision. On follow-up, there were no cases of symblepharon, granuloma, or lid malposition (Table 1).
Radiographic Analysis
preseptal dissection plane carried down to the posterior lacrimal crest between Horner’s muscle and the medial orbital septum. Since that time, the medial transconjunctival approach has gone by a variety of names; with precaruncular, transcaruncular, and retrocaruncular approaches described.10–17,21–29 In this study, we define the transcaruncular approach as an incision through the caruncular tissue, and the precaruncular and
All preoperative CT scans demonstrated fractures to the medial orbital wall, with orbital floor involvement in 9 of the 20 cases. Radiographic evidence of medial rectus muscle entrapment occurred in 1 patient. Postoperative CT scans demonstrated anatomic orbital reconstruction in all patients (Fig. 7). All patients had a midorbital inferiormedial wall angulation within 5 degrees of the uninjured orbit (Fig. 8). Subjective assessment by three expert facial trauma surgeons judged on a Likert scale determined excellent restoration of orbital contours (Table 1).
DISCUSSION Among the variations of the medial transconjunctival approach, our anatomic dissections demonstrated that the precaruncular, transcaruncular, and retrocaruncular approaches provided excellent exposure of the medial orbital wall to the orbital apex. When compared to the transcaruncular and precaruncular approaches, the retrocaruncular approach did not violate the medial orbital septum or the attachment of the caruncle to the lower lid tarsal plate when incisions larger than 10 mm were used or when the incision was carried into the inferior fornix. In 20 consecutive patients, use of the retrocaruncular approach resulted in adequate visualization of the medial orbital wall without use of an endoscope and no complications related to lower lid malposition, symblepheron, or prolonged conjunctival edema were identified. In 1998, Garcia and colleagues10 described a medial transconjunctival incision through the lateral third of the caruncle with a 298
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FIGURE 7. 3-D CT Scan showing adequate placement of a titanium implant to an isolated medial orbital wall fracture. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Annals of Plastic Surgery • Volume 76, Number 3, March 2016
FIGURE 8. Postoperative coronal CT scan demonstrating retrocaruncular medial orbital wall repair. Synthes titanium mesh implants were used and formed by hand based on mid-orbital angular measurements between the orbital wall and floor. All reconstructions were within 5 degrees of the uninjured side and judged as excellent by clinicians.
retrocaruncular approaches as incisions medial or posterior/lateral to the caruncle, respectively. In the literature, some authors are inconsistent in the naming and the description or diagramming of their approaches with most authors reporting use of a transcaruncular approach when their incision is actually placed between the plica semilunaris and the caruncle (retrocaruncular).4,13–16 Clarification of these small differences is important for the proceeding discussion and for surgeons adopting these techniques into clinical practice. The transcaruncular and precaruncular approaches are defined by vertical incisions directly through or anterior to the caruncle, respectively.10,11,21–26 In both approaches, the incision is carried to the posterior lacrimal crest in a preseptal plane with the advantage of being relatively avascular and avoiding herniation of intraorbital fat into the surgical field.11,21 In our anatomic dissections using these 2 approaches, we found it difficult to consistently separate the medial orbital septum from Horner’s muscle, resulting in frequent septal disruption (transseptal plane). Although this may have been due to postmortem desiccation of these thin tissues, a recent study by Goldberg and coworkers26 commented that it is impossible to avoid disruption and damage to the diaphanous medial orbital septum when using the transcaruncular approach and that fat herniation into the surgical field is inevitable. As the precaruncular incision uses the same plane, similar septal violation is likely; however, this has not been reported. A potential advantage of the precaruncular approach to the transcaruncular approach is the avoidance of an incision directly through the caruncle, which may result in a decreased risk of postoperative edema and erythema due to the complex histology of this tissue.27,30 Additional problems with the transcaruncular and precaruncular approaches arise when incisions greater than 10 mm are required and when transitioning the incision into the inferior fornix for repair of a combined orbital floor fracture. Our anatomic dissections found that a fibrous attachment was present between the caruncle and the medial aspect of the lower lid tarsal plate in all 30-cadaver orbits. When performing the transcaruncular and precaruncular approaches, incisions © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Medial Transconjunctival Approach
greater than 10 mm or extension of the incision into the inferior fornix resulted in violation of this fibrous attachment and exposure of the tarsal plate in all 20 dissections. Additionally, carrying this incision inferior laterally resulted in further medial septal violation as the plane of dissection went from preseptal to retroseptal. These findings are clinically pertinent as an incision length of 15 mm was used in our clinical approach, and lengths greater than 10 mm are commonly used in the literature.4,13,22–25 Additionally, with 6.8% to 12.2% of orbital fracture trauma involving the medial wall and floor, incisions will often need to be carried into the inferior fornix.3,4 Both tarsal exposure and septal violation theoretically increase the risk of developing postoperative lid complications, including mid lamellar ectropion, entropion, prolonged chemosis, and simblepharon. The dense fibrous fascia of the caruncle serves as an important insertion site for the anterior medial orbital septum, the medial extension of the pretarsal orbicularis oculi (Horner’s muscle), and the medial rectus capsulopalprebral fascia (mrCPF).26,31 Recently, Kakizaki et al18–20 demonstrated important relationships between the caruncle and the lower lid. They observed that medial canthal anatomy became dynamic with eye movement, suggesting that the medial aspect of the upper and lower tarsus were supported by Horner’s muscle and the mrCPF.18 Subsequent histologic study found the caruncle to have a direct connection to the mrCPF and the lower retractors at the medial horn in 12 cadaveric orbits. The author additionally showed that in 17 patients undergoing the transcaruncular approach, the caruncle falls laterally in a similar fashion to lower lid involutional changes.19 As such, severing the attachment of the caruncle to the lower lid could result in medial lower lid ectropion.18 These findings are consistent with our anatomic dissections for the transcaruncular and precaruncular approaches. This study identified the retrocaruncular approach as a favorable approach due to its posterior relationship to the orbital septum and its preservation of the caruncular attachment to the medial aspect of the inferior tarsal plate. In addition, the incision can be easily carried to the inferior fornix in a retroseptal surgical plane when indicated, without violation of the orbital septum. Orbital fat and periosteal herniation are expected consequences of orbital floor and medial orbital wall disruption and can be easily managed using a malleable retractor.32 Clinical use of the retrocaruncular approach is described more frequently in the literature, despite often being labeled as transcaruncular.4,12–17,28 Two large series demonstrate use of this approach with no reported lid malposition and an ease of carrying the incision in the inferior fornix.4,16 In our clinical series, 20 patients with medial orbital wall fractures (9 combined with floor fractures) were evaluated. Alloplastic titanium mesh implants were effectively formed based on preoperative CT scans without the need for complex manufacturing.33 Although use of endoscopy has shown to improve visualization of the posterior medial orbit,4,12,28,29 it was not needed for the exposure or reduction in our series. Postoperative CT scans confirmed accurate placement of the implants and complete reduction of the fracture sites as evidenced by less than a 5-degree difference between mid-orbital inferior-medial wall angulation when compared to the uninjured side. Lastly, there were no compilations related to lid malposition, midlamellar ectropian, symblepheron, or prolonged conjunctival edema.
CONCLUSIONS With a variety of surgical options, the medial transconjunctival approach leads to adequate exposure and effective repair of fractures to the medial orbital wall. The use of endoscopy, which help with visualization, however, is unnecessary for implant placement on stable bone ledges. The retrocaruncular approach was found to have distinct anatomical advantages when compared to the transcaruncular and precaruncular approaches and should be the preferred approach when incisions greater than 10 mm are planned or if the incision needs to be carried to the inferior fornix in the setting of combined medial wall www.annalsplasticsurgery.com
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and floor fractures. Our clinical study demonstrates the utility of the retrocaruncular approach to the medial orbital wall in 20 successful orbital repairs. REFERENCES 1. Burm J-S, Chung C-H, Oh S-J. Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture. Plast Reconstr Surg. 1999;103: 1839–1849. 2. Tse R, Allen L, Matic D. The white-eyed medial blowout fracture. Plast Reconstr Surg. 2007;119:277–286. 3. Jank S, Schuchter B, Emshoff R, et al. Clinical signs of orbital wall fractures as a function of anatomic location. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;96:149–153. 4. Wu W, Jing W, Selva D, et al. Endoscopic transcaruncular repair of large medial orbital wall fractures near the orbital apex. Ophthalmology. 2013;120:404–409. 5. Lynch R-C. The technique of a radical frontal sinus operation which has given me the best results. Laryngoscope. 1921;31:1–5. 6. Katowitz J-A, Welsh M-G, Bersani T-A. Lid crease approach for medial wall fractures repair. Ophthalmic Surg. 1987;18:288–290. 7. McCord C-D Jr, Tanenbaum M, Nunery W-R. Medial Wall Fractures. Oculoplastic surgery. 3rd ed. New York: Raven Press; 1995:537–538. 8. Lee H-M, Han S-K, Chae S-W, et al. Endoscopic endonasal reconstruction of blowout fractures of the medial orbital walls. Plast Reconstr Surg. 2002;109: 872–876. 9. Magnus W-W, Castner D-V, Schonder A-A, et al. A conjunctival approach to repair of fracture of medial wall of orbit: report a case. J Oral Surg. 1971;29: 664–667. 10. Garcia G-H, Goldberg R-A, Shorr N. The transcaruncular approach in repair of orbital fracture: a retrospective study. J Craniomaxillofac Trauma. 1998;4:7–12. 11. Moe K-S. The precaruncular approach to the medial orbit. Arch Facial Plast Surg. 2003;5:483–487. 12. Meningaud J-P, Arnnop P-P, Bertrand J-C. Endoscopic-assisted repair of medial orbital wall fractures using a retrocaruncular approach. J Oral Maxillofac Surg. 2007;65:1039–1043. 13. Kim S, Lew H-M, Chung S-H, et al. Repair of medial orbital wall fracture: transcaruncular approach. Orbit. 2005;24:1–9. 14. 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 Surg. 2011;69:1415–1420. 15. Rodriquez J, Galan R, Forteza G, et al. Extended transcaruncular approach using detachment and repositioning of the inferior oblique muscle for the traumatic repair of the medial orbital wall. Craniomaxillofac Trauma Reconstr. 2009;2:35–40.
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16. Lee C-S, Yoon J-S, Lee S-Y. Combined transcaruncular and transcaruncular approach for repair of large medial orbital wall fractures. Arch Ophthalmol. 2009; 127:291–296. 17. Morris D-E, Liliav B, Cohen M. Transcaruncular approach to the isolated medial orbital wall fracture: technical perspective and cadaveric dissection. J Craniofac Surg. 2014;25:1047–1049. 18. Kakizaki H, Zako M, Nakano T, et al. Direct insertion of the medial rectus capsulopalpebral fascia to the tarsus. Ophthal Plast Reconstr Surg. 2008;24: 126–130. 19. Kakizaki H, Takahashi Y, Nakano T, et al. The anatomical relationships between the lower eyelid retractors and the lacrimal caruncle: a microscopic study. Am J Ophthalmol. 2010;150:905–908. 20. Kakizaki H, Valenzuela A-A. Lacrimal caruncle: continuation to the lower eyelid retractors. Ophthal Plast Reconstr Surg. 2011;27:198–200. 21. You H-J, Kim D-W, Dhong E-S, et al. Precaruncular approach for the reconstruction of medial orbital wall fractures. Ann Plast Surg. 2014;72:652–656. 22. Shorr N, Baylis H-I, Goldberg R-A, et al. Transcaruncular approach to the medial orbit and orbital apex. Ophthamology. 2000;107:1459–1463. 23. Baumann A, Ewers R. Transcaruncular approach for reconstruction of medial orbital wall fracture. Int J Oral Maxillofac Surg. 2000;29:264–267. 24. Edgin W, Morgan-Marshall A, Fitzsimmons T-D. Transcaruncular approach to medial orbital wall fractures. J Oral Maxillofac Surg. 2007;65:2345–2349. 25. Malhotra R, Saleh G-M, Sousa J-L, et al. The transcaruncular approach to orbital fracture repair: ophthalmic sequelae. J Craniofac Surg. 2007;18:420–426. 26. Goldberg R, Mancini R, Demer J. The transcaruncular approach: Surgical anatomy and technique. Arch Facial Plast Surg. 2007;9:443–447. 27. Lee K, Snape L. Efficacy of transcaruncular approach to reconstruct isolated medial orbital fracture. J Maxillofac Oral Surg. 2010;9:142–145. 28. Chen C, Chen Y, Tung T, et al. Endoscopically assisted reconstruction of orbital medial wall fractures. Plast Reconstr Surg. 1999;103:714–720. 29. Mun G-H, Song Y-H, Bang S-I. Endoscopically assisted transconjunctival approach in orbital medial wall fractures. Ann Plast Surg. 2002;49:337–343. 30. Zide B-M, McCarthy J-G. The medial canthus revisited—an anatomical basis for canthopexy. Ann Plast Surg. 1983;11:1–9. 31. Zide B-M, Jelks G-W. Surgical anatomy of the orbit. New York: Raven Press; c1985. 32. Shemen L-J, Meltzer M. Inferior fornix incision for orbital rim and floor fractures. Laryngoscope. 1986;96:1164–1167. 33. Metzger M-C, Schon R, Zizelmann C, et al. Semiautomatic procedure for individual performing of titanium meshes for orbital fractures. Plast Reconstr Surg. 2007;119:969–976.
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Benefits of the Retrocaruncular Approach to the Medial Orbit A Clinical And Anatomic Study Steve J. Kempton, MD,* David C. Cho, MD,† Brinda Thimmappa, MD, MBA,‡ and Mark C. Martin, MD, DMD§ Background: Current trends in the management of medial orbital wall fractures are toward the development of transconjunctival incisions and the use of endoscopic-assisted methods. Different authors have suggested variations of the medial transconjunctival approach. Methods: (1) In 30 fresh cadaver orbits, the classic transcaruncular approach was compared with the precaruncular and retrocaruncular approach under magnified dissection. (2) A retrospective analysis was conducted on a series of 20 consecutive patients that underwent primary repair of medial orbital wall fractures using a retrocaruncular approach without endoscopic assistance. Postoperative computed tomography scans were obtained for all patients and were evaluated by 3 experienced clinicians. Results: (1) Anatomic dissections showed that all 3 approaches provided excellent exposure of the entire medial orbital wall. The transcaruncular and precaruncular approaches, however, (a) both resulted in exposure of the upper and lower tarsi when incisions greater than 10 mm were used; (b) both required a transition from the preseptal plane to the postseptal plane when combined with inferior fornix incisions. (2) A clinical study of 20 patients showed all reconstructions were possible without endoscopic assistance, resulting in no postoperative complications. Postoperative computed tomography scans showed anatomic orbital reconstruction in all patients judged as excellent by the clinicians. Conclusions: Medial orbital wall fractures can be successfully repaired using transconjunctival incisions without using endoscopes. The retrocaruncular approach surpasses the transcaruncular and precaruncular methods due to its decreased risk of postoperative lid complications and its ability to be directly carried to the inferior conjunctival fornix. Key Words: medial orbital wall, transcaruncular, transconjunctival, retrocaruncular (Ann Plast Surg 2016;76: 295–300)
F
ractures to the medial orbital wall are a prominent finding in orbital trauma and frequently present in combination with fractures to the orbital floor.1–4 Surgical repair of these fractures is often indicated in patients presenting with worsening diplopia, enophthalmos, and/or entrapment of the medial rectus muscle.3 Currently, multiple surgical specialties manage medial orbital wall fractures, which has resulted in the development of a number of surgical approaches.5–9 A modification of the medial transconjunctival incision, as described by Garcia et al10 in 1998, is a frequently utilized approach to access the medial orbital wall for fracture repair. Three variations of this
technique are referenced in current literature and include the transcaruncular, precaruncular, and retrocaruncular approaches (Fig. 1).10–12 Multiple reports outlining clinical outcomes using these techniques have been published; however, authors are inconsistent in the naming and the description of their approaches.4,13–17 An ongoing understanding of complex medial canthal anatomy has demonstrated that the lacrimal caruncle is an embryologic remnant of the lower eyelid with important functional attachments to the lower lid retractors.18–20 As such, preserving these attachments may result in a reduction of lower lid complications. The purpose of this study is to provide an anatomic comparison of the transcaruncular, precaruncular, and retrocaruncular approaches with careful attention paid to the plane of dissection around the caruncle and preservation of the attachments to the lower lid retractors. Additionally, a clinical analysis of the surgical and radiographic outcomes of the retrocaruncular approach in 20 consecutive facial trauma patients is presented.
MATERIALS AND METHODS Anatomic Cadaver Study Thirty orbits from 15 fresh cadaver heads were dissected to demonstrate the transcaruncular, precaruncular, and retrocaruncular approaches to the medial orbital wall. Before dissection, the caruncle was identified and retracted nasally and temporally to determine the presence of fibrous attachments to the upper and lower eyelids. The orbits were divided evenly between the 3 approaches. For the transcaruncular approach, an incision was made directly through the caruncular tissue and carried down to the posterior lacrimal crest in a preseptal plane between Horner’s muscle and the medial orbital septum. The precaruncular approach incision was made anterior and medial to the caruncular tissue with dissection to the posterior lacrimal crest in a similar preseptal plane. For the retrocaruncular approach, an incision was made between the caruncle and the plica semilunaris and extended to the posterior lacrimal crest posterior to the medial orbital septum (retro-septal plane). In all orbits, dissection was carried subperiosteally to the orbital apex, and incisions were extended to the inferior fornix to expose the bony orbital floor. Degree of medial orbital wall exposure, disruption of the medial orbital septum, presence of intraorbital fat herniation, and exposure of the inferior tarsus were recorded for each dissection.
Clinical Study Received January 8, 2015, and accepted for publication, after revision, March 16, 2015. From the *Division of Plastic and Reconstructive Surgery, University of Wisconsin Hospital and Clinics, Madison, WI; †Straub Clinic and Hospital, Plastic Surgery Practice, Honolulu, HI; ‡Department of Plastic Surgery, Wake Forest Medical Center, Winston-Salem, NC; and §Department of Plastic and Reconstructive Surgery, Loma Linda University, Loma Linda, CA. Conflicts of interest and sources of funding: none declared. Reprints: Steve J. Kempton, MD, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Wisconsin Hospital and Clinics, 600 Highland Avenue, G5/361 Clinical Science Center. Mail Code 3236, Madison, WI 53792. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7603–0295 DOI: 10.1097/SAP.0000000000000531
Annals of Plastic Surgery • Volume 76, Number 3, March 2016
From May 2006 to January 2009, all patients that underwent repair of medial orbital fractures by the senior author (M.M.) were retrospectively reviewed. Fractures were diagnosed using computed tomography (CT) maxillofacial imaging, and all patients received a comprehensive ophthalmologic evaluation before and after undergoing surgery. Indications for surgical repair included enophthalmos greater than 2 mm, diplopia within 30 degrees of primary gaze, and radiographic or clinical evidence of medial rectus muscle entrapment. All patients underwent surgery using a retrocaruncular approach, without endoscopic assistance, with placement of a Synthes titanium implant (Synthes, West Chester, PA). Data obtained from patient charts included patient age, sex, trauma history, preoperative diagnosis, and procedures www.annalsplasticsurgery.com
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Surgical Procedures (Retrocaruncular Approach) A 15-mm vertical incision is made in the interval between the plica semilunaris and the caruncle. The incision is carried down to the posterior lacrimal crest in a retroseptal plane, taking care to sweep all periorbital fat posteriorly with an insulated malleable. The subperiosteal dissection is completed, exposing the fractured medial orbital wall superiorly and inferiorly. A freer elevator is placed in the ethmoid sinus and used to indentify the most posterior stable bone using a stair step technique. The medial fornix incision is carried into the inferior fornix in a retroseptal plane in cases of combined orbital floor fractures. A Synthes titanium implant is inserted and fixed using a single 1.5 mm screw secured to the uppermost aspect anteriorly. All implants are custom-formed based on intraoperative measurements taken between the frontoethmoidal suture and the optic strut. In cases combined with orbital floor fractures, angular measurements between the medial wall and floor using the preoperative CT scan of the uninjured side were used.
RESULTS FIGURE 1. Cadaveric picture/diagram of the classic transcaruncular, precaruncular, and retrocaruncular incisions in relationship to the anatomic caruncle. LC, lacrimal caruncle.
performed. Outcome data were recorded for incidence of enophthalmos, symblepheron, and lower lid retraction.
Radiographic Analysis Postoperative CT maxillofacial scans were obtained for each patient to assess adequate titanium plate placement. Angular relationships between the medial wall and floor of the orbit were determined on hemicoronal images in a blinded fashion. Injured orbit angular measurements were compared to the uninjured orbit. In addition, 3 experienced facial trauma surgeons evaluated the quality of the reconstruction based on axial and coronal views and assigned ratings (poor to excellent) based on a Likert scale.
FIGURE 2. Caruncle is drawn anteriorly to show the caruncular attachment to the superior and inferior tarsal plates. These attachments consist of fibrous bands and conjunctival folds. 296
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Anatomical Cadaver Study Examination of medial canthal surface anatomy found the caruncle to be firmly attached to the medial aspects of the superior and inferior tarsal plates by way of conjunctival folds and fibrous bands in all 30 orbits (Fig. 2). The transcaruncular, precaruncular, and retrocaruncular approaches were accurately carried out in a manner similar to the surgical setting (Fig. 3 and Fig. 4). All three approaches resulted in exposure of the medial orbital wall to the orbital apex. Under magnified dissection, the transcaruncular and precaruncular incisions resulted in disruption of the medial orbital septum (transseptal plane) when carried to the posterior lacrimal crest. Additionally, when incisions greater than 10 mm were used or when incisions were extended into the inferior fornix, both approaches required cutting the caruncular attachment to the inferior tarsus. This resulted in further medial orbital septum disruption and exposure of the medial portion of the inferior tarsal plate (Fig. 5 and Fig. 6, green/blue). Exposure of the inferior tarsus and violation of the medial orbital septum occurred in all 20 dissected orbits (10 transcaruncular, 10 precaruncular).
FIGURE 3. Normal medial canthal anatomy. Key for subsequent figures. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Annals of Plastic Surgery • Volume 76, Number 3, March 2016
Medial Transconjunctival Approach
FIGURE 4. Axial view diagram of the classic transcaruncular (left), the precaruncular (middle), and the retrocaruncular (right) approaches. Posterior to the lacrimal sac, the layers include the posterior limb of the medial canthal tendon, Horner’s muscle, the medial orbital septum, and the medial check ligament arising from the mrCPF.
In comparison, the retrocaruncular approach was carried to the posterior lacrimal crest in a postseptal plane that did not require violation of the caruncular attachment to the lower lid when transitioned to the inferior fornix (Fig. 6, red). Damage to the medial orbital septum and tarsal exposure was avoided in all 10 dissected orbits. Herniation of orbital fat contents, however, occurred in all 10 dissected orbits and was managed using an insulated malleable.
31.9 years. Trauma history included assault in 10 cases, motor vehicle accidents in 7 cases, auto versus pedestrian in 2 cases, and 1 case involving a weightlifting accident. There were 11 isolated medial orbital wall fractures and 9 combined medial orbital wall and orbital floor fractures.
Clinical Study Twenty patients with medial orbital wall fractures underwent repair using the retrocaruncular approach without the need for endoscopic assistance. There were 17 men and 3 women with average age of
FIGURE 5. Picture of the precaruncular incision extended into the inferior fornix in a cadaver orbit. Exposure of the medial lower lid tarsal plate occurred in all 20 dissections using the precaruncular and transcaruncular approaches. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
FIGURE 6. Axial diagram 3 mm below the eyelid margin of the lower eyelid. Blue and green lines represent the extension of the transcaruncular and precaruncular incisions into the inferior fornix. Note that the medial OS and the mrCPF connecting the caruncle to the lower lid TP are violated. Red line represents the extension of the retrocaruncular approach to the inferior fornix in a natural plane. OS indicates orbital septum; TP, tarsal plate. www.annalsplasticsurgery.com
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TABLE 1. Patient Demographics, Retrospective Clinical Analysis Results, and Radiographic Analysis Clinical Analysis
Patient
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Radiographic Analysis
Age/Sex
Mechanism of Injury
Date of Surgery
Diagnosis
Approach
Complications
Postoperative Midorbital Angle Compared to Contralateral Side, degrees
7/M 39/M 24/F 48/M 35/M 19/M 42/M 35/M 46/F 12/M 38/M 44/M 53/M 24/M 31/M 37/M 28/M 23/M 24/F 30/M
Auto vs Ped Assault MVA Assault Assault Weight Lifting MVA Assault Auto vs Ped Assault MVA Assault MVA Assault MVA Assault Assault Assault MVA MVA
5/28/06 2/2/07 2/3/07 2/9/07 2/23/07 3/5/07 4/1/07 4/26/07 6/15/07 10/20/07 10/25/07 12/23/07 1/10/08 2/22/08 5/9/08 7/20/08 10/17/08 11/23/08 12/12/08 1/30/09
L Medial Wall/Floor R Medial Wall R Medial Wall/Floor R Medial Wall/Floor R Medial Wall/Floor L Medial Wall L Medial Wall/Floor L Medial Wall R Medial Wall L Medial Wall L Medial Wall L Medial Wall L Medial Wall/Floor R Medial Wall/Floor R Medial Wall R Medial Wall L Medial Wall R Medial Wall L Medial Wall/Floor R Medial Wall/Floor
Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular Retrocaruncular
None None None None None None None None None None None None None None None None None None None None
≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5
Likert CT Evaluation
Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent
MVA indicates motor vehicle accident; M, male; F, female.
Postoperative ophthalmologic examinations reported no enophthalmos, horizontal diplopia, or cosmetic sequelae relating to the conjunctival incision. On follow-up, there were no cases of symblepharon, granuloma, or lid malposition (Table 1).
Radiographic Analysis
preseptal dissection plane carried down to the posterior lacrimal crest between Horner’s muscle and the medial orbital septum. Since that time, the medial transconjunctival approach has gone by a variety of names; with precaruncular, transcaruncular, and retrocaruncular approaches described.10–17,21–29 In this study, we define the transcaruncular approach as an incision through the caruncular tissue, and the precaruncular and
All preoperative CT scans demonstrated fractures to the medial orbital wall, with orbital floor involvement in 9 of the 20 cases. Radiographic evidence of medial rectus muscle entrapment occurred in 1 patient. Postoperative CT scans demonstrated anatomic orbital reconstruction in all patients (Fig. 7). All patients had a midorbital inferiormedial wall angulation within 5 degrees of the uninjured orbit (Fig. 8). Subjective assessment by three expert facial trauma surgeons judged on a Likert scale determined excellent restoration of orbital contours (Table 1).
DISCUSSION Among the variations of the medial transconjunctival approach, our anatomic dissections demonstrated that the precaruncular, transcaruncular, and retrocaruncular approaches provided excellent exposure of the medial orbital wall to the orbital apex. When compared to the transcaruncular and precaruncular approaches, the retrocaruncular approach did not violate the medial orbital septum or the attachment of the caruncle to the lower lid tarsal plate when incisions larger than 10 mm were used or when the incision was carried into the inferior fornix. In 20 consecutive patients, use of the retrocaruncular approach resulted in adequate visualization of the medial orbital wall without use of an endoscope and no complications related to lower lid malposition, symblepheron, or prolonged conjunctival edema were identified. In 1998, Garcia and colleagues10 described a medial transconjunctival incision through the lateral third of the caruncle with a 298
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FIGURE 7. 3-D CT Scan showing adequate placement of a titanium implant to an isolated medial orbital wall fracture. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Annals of Plastic Surgery • Volume 76, Number 3, March 2016
FIGURE 8. Postoperative coronal CT scan demonstrating retrocaruncular medial orbital wall repair. Synthes titanium mesh implants were used and formed by hand based on mid-orbital angular measurements between the orbital wall and floor. All reconstructions were within 5 degrees of the uninjured side and judged as excellent by clinicians.
retrocaruncular approaches as incisions medial or posterior/lateral to the caruncle, respectively. In the literature, some authors are inconsistent in the naming and the description or diagramming of their approaches with most authors reporting use of a transcaruncular approach when their incision is actually placed between the plica semilunaris and the caruncle (retrocaruncular).4,13–16 Clarification of these small differences is important for the proceeding discussion and for surgeons adopting these techniques into clinical practice. The transcaruncular and precaruncular approaches are defined by vertical incisions directly through or anterior to the caruncle, respectively.10,11,21–26 In both approaches, the incision is carried to the posterior lacrimal crest in a preseptal plane with the advantage of being relatively avascular and avoiding herniation of intraorbital fat into the surgical field.11,21 In our anatomic dissections using these 2 approaches, we found it difficult to consistently separate the medial orbital septum from Horner’s muscle, resulting in frequent septal disruption (transseptal plane). Although this may have been due to postmortem desiccation of these thin tissues, a recent study by Goldberg and coworkers26 commented that it is impossible to avoid disruption and damage to the diaphanous medial orbital septum when using the transcaruncular approach and that fat herniation into the surgical field is inevitable. As the precaruncular incision uses the same plane, similar septal violation is likely; however, this has not been reported. A potential advantage of the precaruncular approach to the transcaruncular approach is the avoidance of an incision directly through the caruncle, which may result in a decreased risk of postoperative edema and erythema due to the complex histology of this tissue.27,30 Additional problems with the transcaruncular and precaruncular approaches arise when incisions greater than 10 mm are required and when transitioning the incision into the inferior fornix for repair of a combined orbital floor fracture. Our anatomic dissections found that a fibrous attachment was present between the caruncle and the medial aspect of the lower lid tarsal plate in all 30-cadaver orbits. When performing the transcaruncular and precaruncular approaches, incisions © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Medial Transconjunctival Approach
greater than 10 mm or extension of the incision into the inferior fornix resulted in violation of this fibrous attachment and exposure of the tarsal plate in all 20 dissections. Additionally, carrying this incision inferior laterally resulted in further medial septal violation as the plane of dissection went from preseptal to retroseptal. These findings are clinically pertinent as an incision length of 15 mm was used in our clinical approach, and lengths greater than 10 mm are commonly used in the literature.4,13,22–25 Additionally, with 6.8% to 12.2% of orbital fracture trauma involving the medial wall and floor, incisions will often need to be carried into the inferior fornix.3,4 Both tarsal exposure and septal violation theoretically increase the risk of developing postoperative lid complications, including mid lamellar ectropion, entropion, prolonged chemosis, and simblepharon. The dense fibrous fascia of the caruncle serves as an important insertion site for the anterior medial orbital septum, the medial extension of the pretarsal orbicularis oculi (Horner’s muscle), and the medial rectus capsulopalprebral fascia (mrCPF).26,31 Recently, Kakizaki et al18–20 demonstrated important relationships between the caruncle and the lower lid. They observed that medial canthal anatomy became dynamic with eye movement, suggesting that the medial aspect of the upper and lower tarsus were supported by Horner’s muscle and the mrCPF.18 Subsequent histologic study found the caruncle to have a direct connection to the mrCPF and the lower retractors at the medial horn in 12 cadaveric orbits. The author additionally showed that in 17 patients undergoing the transcaruncular approach, the caruncle falls laterally in a similar fashion to lower lid involutional changes.19 As such, severing the attachment of the caruncle to the lower lid could result in medial lower lid ectropion.18 These findings are consistent with our anatomic dissections for the transcaruncular and precaruncular approaches. This study identified the retrocaruncular approach as a favorable approach due to its posterior relationship to the orbital septum and its preservation of the caruncular attachment to the medial aspect of the inferior tarsal plate. In addition, the incision can be easily carried to the inferior fornix in a retroseptal surgical plane when indicated, without violation of the orbital septum. Orbital fat and periosteal herniation are expected consequences of orbital floor and medial orbital wall disruption and can be easily managed using a malleable retractor.32 Clinical use of the retrocaruncular approach is described more frequently in the literature, despite often being labeled as transcaruncular.4,12–17,28 Two large series demonstrate use of this approach with no reported lid malposition and an ease of carrying the incision in the inferior fornix.4,16 In our clinical series, 20 patients with medial orbital wall fractures (9 combined with floor fractures) were evaluated. Alloplastic titanium mesh implants were effectively formed based on preoperative CT scans without the need for complex manufacturing.33 Although use of endoscopy has shown to improve visualization of the posterior medial orbit,4,12,28,29 it was not needed for the exposure or reduction in our series. Postoperative CT scans confirmed accurate placement of the implants and complete reduction of the fracture sites as evidenced by less than a 5-degree difference between mid-orbital inferior-medial wall angulation when compared to the uninjured side. Lastly, there were no compilations related to lid malposition, midlamellar ectropian, symblepheron, or prolonged conjunctival edema.
CONCLUSIONS With a variety of surgical options, the medial transconjunctival approach leads to adequate exposure and effective repair of fractures to the medial orbital wall. The use of endoscopy, which help with visualization, however, is unnecessary for implant placement on stable bone ledges. The retrocaruncular approach was found to have distinct anatomical advantages when compared to the transcaruncular and precaruncular approaches and should be the preferred approach when incisions greater than 10 mm are planned or if the incision needs to be carried to the inferior fornix in the setting of combined medial wall www.annalsplasticsurgery.com
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and floor fractures. Our clinical study demonstrates the utility of the retrocaruncular approach to the medial orbital wall in 20 successful orbital repairs. REFERENCES 1. Burm J-S, Chung C-H, Oh S-J. Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture. Plast Reconstr Surg. 1999;103: 1839–1849. 2. Tse R, Allen L, Matic D. The white-eyed medial blowout fracture. Plast Reconstr Surg. 2007;119:277–286. 3. Jank S, Schuchter B, Emshoff R, et al. Clinical signs of orbital wall fractures as a function of anatomic location. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;96:149–153. 4. Wu W, Jing W, Selva D, et al. Endoscopic transcaruncular repair of large medial orbital wall fractures near the orbital apex. Ophthalmology. 2013;120:404–409. 5. Lynch R-C. The technique of a radical frontal sinus operation which has given me the best results. Laryngoscope. 1921;31:1–5. 6. Katowitz J-A, Welsh M-G, Bersani T-A. Lid crease approach for medial wall fractures repair. Ophthalmic Surg. 1987;18:288–290. 7. McCord C-D Jr, Tanenbaum M, Nunery W-R. Medial Wall Fractures. Oculoplastic surgery. 3rd ed. New York: Raven Press; 1995:537–538. 8. Lee H-M, Han S-K, Chae S-W, et al. Endoscopic endonasal reconstruction of blowout fractures of the medial orbital walls. Plast Reconstr Surg. 2002;109: 872–876. 9. Magnus W-W, Castner D-V, Schonder A-A, et al. A conjunctival approach to repair of fracture of medial wall of orbit: report a case. J Oral Surg. 1971;29: 664–667. 10. Garcia G-H, Goldberg R-A, Shorr N. The transcaruncular approach in repair of orbital fracture: a retrospective study. J Craniomaxillofac Trauma. 1998;4:7–12. 11. Moe K-S. The precaruncular approach to the medial orbit. Arch Facial Plast Surg. 2003;5:483–487. 12. Meningaud J-P, Arnnop P-P, Bertrand J-C. Endoscopic-assisted repair of medial orbital wall fractures using a retrocaruncular approach. J Oral Maxillofac Surg. 2007;65:1039–1043. 13. Kim S, Lew H-M, Chung S-H, et al. Repair of medial orbital wall fracture: transcaruncular approach. Orbit. 2005;24:1–9. 14. 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 Surg. 2011;69:1415–1420. 15. Rodriquez J, Galan R, Forteza G, et al. Extended transcaruncular approach using detachment and repositioning of the inferior oblique muscle for the traumatic repair of the medial orbital wall. Craniomaxillofac Trauma Reconstr. 2009;2:35–40.
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16. Lee C-S, Yoon J-S, Lee S-Y. Combined transcaruncular and transcaruncular approach for repair of large medial orbital wall fractures. Arch Ophthalmol. 2009; 127:291–296. 17. Morris D-E, Liliav B, Cohen M. Transcaruncular approach to the isolated medial orbital wall fracture: technical perspective and cadaveric dissection. J Craniofac Surg. 2014;25:1047–1049. 18. Kakizaki H, Zako M, Nakano T, et al. Direct insertion of the medial rectus capsulopalpebral fascia to the tarsus. Ophthal Plast Reconstr Surg. 2008;24: 126–130. 19. Kakizaki H, Takahashi Y, Nakano T, et al. The anatomical relationships between the lower eyelid retractors and the lacrimal caruncle: a microscopic study. Am J Ophthalmol. 2010;150:905–908. 20. Kakizaki H, Valenzuela A-A. Lacrimal caruncle: continuation to the lower eyelid retractors. Ophthal Plast Reconstr Surg. 2011;27:198–200. 21. You H-J, Kim D-W, Dhong E-S, et al. Precaruncular approach for the reconstruction of medial orbital wall fractures. Ann Plast Surg. 2014;72:652–656. 22. Shorr N, Baylis H-I, Goldberg R-A, et al. Transcaruncular approach to the medial orbit and orbital apex. Ophthamology. 2000;107:1459–1463. 23. Baumann A, Ewers R. Transcaruncular approach for reconstruction of medial orbital wall fracture. Int J Oral Maxillofac Surg. 2000;29:264–267. 24. Edgin W, Morgan-Marshall A, Fitzsimmons T-D. Transcaruncular approach to medial orbital wall fractures. J Oral Maxillofac Surg. 2007;65:2345–2349. 25. Malhotra R, Saleh G-M, Sousa J-L, et al. The transcaruncular approach to orbital fracture repair: ophthalmic sequelae. J Craniofac Surg. 2007;18:420–426. 26. Goldberg R, Mancini R, Demer J. The transcaruncular approach: Surgical anatomy and technique. Arch Facial Plast Surg. 2007;9:443–447. 27. Lee K, Snape L. Efficacy of transcaruncular approach to reconstruct isolated medial orbital fracture. J Maxillofac Oral Surg. 2010;9:142–145. 28. Chen C, Chen Y, Tung T, et al. Endoscopically assisted reconstruction of orbital medial wall fractures. Plast Reconstr Surg. 1999;103:714–720. 29. Mun G-H, Song Y-H, Bang S-I. Endoscopically assisted transconjunctival approach in orbital medial wall fractures. Ann Plast Surg. 2002;49:337–343. 30. Zide B-M, McCarthy J-G. The medial canthus revisited—an anatomical basis for canthopexy. Ann Plast Surg. 1983;11:1–9. 31. Zide B-M, Jelks G-W. Surgical anatomy of the orbit. New York: Raven Press; c1985. 32. Shemen L-J, Meltzer M. Inferior fornix incision for orbital rim and floor fractures. Laryngoscope. 1986;96:1164–1167. 33. Metzger M-C, Schon R, Zizelmann C, et al. Semiautomatic procedure for individual performing of titanium meshes for orbital fractures. Plast Reconstr Surg. 2007;119:969–976.
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