Orbital reconstruction

Goal of orbital reconstruction
• To return the patient to form and function by
restoring the external and internal orbital
anatomy to its premorbid form
• To repair or reposition entrapped or injured
tissues.
Reference :Current therapies in omfs

AIMS OF ORBITAL SURGERY
• TO RESTORE THE ANATOMICAL STRUCTURE TO
ITS NATURAL AND AESTHETIC FORM
• TO PRESERVE VISION
• IMPROVE EYE MOVEMENT & LACRIMATION
• TO RESTORE FACIAL AESTHETICS
• (WARDBOOTH P.217)

AIM OF ORBITAL RECONSTRUCTION
• TO ACHIEVE THE CORRECT PREINJURY
ANATOMY OF SKELETON (P 861 LARS
ANDERSON)

GOAL OF RECONSTRUCTION
• TO RESTORE THE SHAPE OF THE ORBIT AND
ORBITAL VOLUME WITH A RECONSTRUCTIVE
MATERIAL.

Indications for Repair
• Diplopia that persists beyond 7 to 10 days
• Obvious signs of entrapment
• Relative enophthalmos greater than 2mm
• Fracture that involves greater than 50% of the orbital
floor (most of these will lead to significant
enophthalmos when the edema resolves)
• Entrapment that causes an oculocardiac reflex with
resultant bradycardia and cardiovascular instability
• Progressive V2 numbness

Immediate repair
• Nonresolving oculocardiac
reflex with entrapment
– Bradycardia, heart block,
nausea, vomiting, syncope
• Early enophthalos or
hypoglobus causing facial
asymmetry
• “White-eyed” floor fracture
with entrapment
Clinical Recommendations for Repair of Isolated Orbital Floor
Fractures, An Evidence-based Analysis, Michael A Burnstine, MD,
Ophthalmology 2002; 109: 1207-1210.

Repair Within Two Weeks
• Symptomatic diplopia with positive forced
duction test
• Large floor fracture causing latent
enophthalmos
• Significant hypoglobus
• Progressive infraorbital hypesthesia
Clinical Recommendations for Repair of Isolated Orbital Floor Fractures,
An Evidence-based Analysis, Michael A Burnstine, MD, Ophthalmology
2002; 109: 1207-1210.

Observation
• Minimal diplopia
– Not in primary or downgaze
• Good ocular motility
• No significant enophthalmos
• No significant hypoglobus
Clinical Recommendations for Repair of Isolated Orbital Floor
Fractures, An Evidence-based Analysis, Michael A Burnstine, MD,
Ophthalmology 2002; 109: 1207-1210.

ABSOLUTE INDICATIONS OF ORBITAL
FLOOR FRACTURE EXPLRATION
1) Acute enophthalmos (> 2 to 3 mm) and/or
hypoopthalmos (>2 TO 3 mm)
2) Mechanical restriction of gaze associated with
diplopia
Reference: atlas of craniomaxillofacial surgery

Relative indications
• conditions that can later cause
enophthalmous and/or
hypoophthalmous, theoretically
2-3 mm of a 1.5 cm to 2 cm2area
of displaced wall or soft tissue can cause these
deformities .these changes can be recognised ON
CORONAL AND HORIZONTAL CT SCANS.

Trapdoor Fractures
• Trapdoor fractures with entrapment differ in children and
adults
– Children repaired within 5 days of injury do better that
those repaired within 6-14 days or those repaired > 14
days
– There is no difference in early timing of adults (1-5
days or 6-14 days)
– Adults repaired less than 14 days from injury have less
long term sequela than those repaired greater than 14
days from injury
The Differences of Blowout Fracture of the Inferior Orbital
Wall Between Children and Adults, Kwon et al. Archives
Oto head & Neck.

Orbital floor fracture
WHEN TO OBSERVE
• indicated in slightly or non-dislocated orbital
floor fractures without disturbance of eye
mobility, or in cases where patient condition
does not allow surgical intervention.
The decision to observe or to perform surgery
is based on thorough evaluation; correction of
a potential secondary deformity is challenging.
Observation may also be considered in a
significant orbital fracture of the only seeing
eye.

Open treatment OF ORBITAL FLOOR #
• The decision to perform open treatment or to observe
is based on thorough clinical and radiographic (CT)
evaluation.
• Open treatment is indicated in the presence of:
• Significant internal orbital defects proven by imaging
• Disturbances of eye mobility that are the result of
incarceration of ocular muscles
• Enophthalmos
• Exophthalmos secondary to blow-in fractures
• Hypophthalmos

orbital floor fracture, Reduction with
or without fixation
• In some cases the orbital floor may be
reduced and the fracture segment may be
stable. Fixation may not be necessary. In other
cases, a small plate can be used to maintain
the position of the reduced trap door. In these
cases, the patient should have close clinical
follow-up.

orbital floor fracture, Reduction with
or without fixation

Contraindications
• Severe ocular trauma such as a rupture of the
globe, hyphema, retinal detachment,
traumatic optic nerve lesions, or other severe
globe injury may necessitate delay of orbital
wall repair.
• General patient condition not allowing surgery
• Orbital fracture in the only seeing eye (relative
contraindication)

Orbital floor fracture, Reconstruction
• The majority of cases require reconstruction of the orbital floor to support the globe
position and restore the shape of the orbit as the bony walls are comminuted and/or
bone fragments are missing. Reconstructing of the missing bone rather than
reducing bone fragments can be achieved with different materials.
• There is hardly any anatomic region in the human body that is so controversial in
terms of appropriate material used for fracture repair:
• Nonresorbable versus resorbable
• Autogenous/allogenous/xenogenous versus alloplastic material
• Non-prebent versus prebent (anatomical) plates
• Standard versus custom-made plates
• Nonporous versus porous material
• Noncoated versus coated plates

ORBITAL FLOOR # RECONSTRUCTION

ORBITAL FLOOR # RECONSTRUCTION
• Many surgeons recommend materials that allow bending to an
anatomical shape, that are radiopaque (to allow for intra- or
postoperative radiologic confirmation of placement) and stable
over time.
• Recontouring of the dislocated orbital walls is demanding.
Secondary changes to this contour are undesirable. This is why one
must be critical in considering the use of resorbable materials
• There are different preferences of implant material depending on
regional differences, variations in schools of teaching, and socio-
economic factors. There is a paucity of evidence to support the
ideal choice for an orbital implant. Modern imaging analysis offers a
unique chance to quantitatively assess the surgical result and
stability over the time. This can provide valuable information for
future recommendations.

Titanium meshes
Advantages:
• Availability
• Stability
• Contouring (eased by the artificial sterile skull)
• Adequate in large three-wall fractures (the prebent plate is
limited to medial wall and orbital wall fractures only).
• Radiopacity
• Spaces within the mesh to allow dissipation of fluids
• No donor site needed
• Tissue incorporation may occur

TITANIUM
• strong, inert metal. It does not integrate but
can be easily fixated to the surrounding bones
and can provide excellent support for orbital
structures. If bone resorption occurs, it may
infrequently require removal. Overall,
titanium mesh can be an excellent choice for
orbital fracture repair and has a significant
track record of safety

DISADVANTAGES
• reoperations following implantation of
titanium mesh are more difficult as fibrous
scar tissue insinuates itself into the holes of
the mesh .
• COST
• Possible sharp edges if not properly trimmed

Porous polyethylene sheets (PPE)
Advantages:
• Availability
• Smooth edges
• Allows tissue ingrowth
• Disadvantages:
• Not radiopaque (not visible on postoperative images)
• Lack of rigidity when a very thin wafer of PPE is used. When
a thicker rigid wafer is used there is a risk of causing a
dystopia.
• Less drainage from the orbit than with titanium mesh

Porous polyethylene sheets (PPE)

Composite of porous polyethylene
and titanium mesh
• By combining titanium mesh with porous
polyethylene the material becomes
radiopaque, and more rigid than porous
polyethylene of a similar thickness. Some
surgeons also believe that there is less risk of
retention from sharp barbs, which can lead to
an entrapment of soft tissues during
placement.

Composite of porous polyethylene
and titanium mesh

Advantages Of composite of PPE
WITH TITANIUM
• Availability
• Stability
• Adequate in large three-wall fractures (the
prebent plate is limited to medial wall and orbital
wall fractures only).
• Radiopacity
• No donor site needed
• Tissue incorporation may occur

Disadvantages Of composite of PPE
WITH TITANIUM
• Less drainage from the orbit than with
titanium mesh

Resorbable materials
• Advantages:
• Availability
• Handling/contourability (only for
thermoplastics)
• Smooth surface and smooth edge

Resorbable materials
• Disadvantages:
• No radiopacity
• Degradation of material with possible contour
loss
• Sterile infection / inflammatory response
• Difficult to shape according to patients anatomy
(only for non-thermoplastics)
• Less drainage from the orbit than with uncovered
titanium mesh (when nonperforated material is
used)

Preformed orbital implant
Advantages:
• Radiopacity
• Smooth surface
• Minimal or no contouring necessary
Disadvantages:
• Cost

Bone graft
• Advantages
• Low material costs
• Smooth surface
• Variability in thickness
• Radiopacity
• Maximal biocompatibility
• Periorbita readily dissects off of the bone in
secondary reconstructions
• Avoid risk of infected implant

Disadvantages
• Additional donor site required (harvest time,
pain, scar, and possible surgical complications)
• Possible contour and dimensional changes
due to remodeling
• Difficult to shape to patients anatomy
• Less drainage from the orbit than with
titanium mesh

Medial orbital wall fracture
Observation
• Observation may be indicated in non- or slightly
dislocated medial orbital wall fractures where
increase in orbital volume is minimal and there is
no disturbance of eye motility. Observation may
also be necessary in cases where patient
condition does not allow for surgical intervention.
• The decision to observe or to perform surgery is
based on thorough clinical and radiographic (CT)
evaluation because correction of a potential
secondary deformity is challengin

Orbital medial wall fracture, Open
treatment
• The decision to perform orbital reconstruction or
to observe is based on thorough clinical and
radiographic (CT) evaluation.
• Orbital reconstruction is indicated when there
is/are:
• Significant internal orbital defects proven by
imaging
• Disturbance of eye mobility as a result of
• Enophthalmos

Contraindications for opening
• Contraindications:
globe injury may require delay of orbital wall
repair.
contraindication)

Combined orbital fracture (medial wall
and orbital floor), Observation
• Observation may be indicated in slightly or non-
dislocated orbital wall fractures without
disturbance of eye mobility, or in cases where
patient condition does not allow surgical
intervention.
The decision to observe or to perform surgery is
based on thorough evaluation; correction of a
potential secondary deformity is challenging.
Observation may also be considered in a
significant orbital fracture of the only seeing eye.

Combined orbital fracture (medial
wall and orbital floor), Observation

Combined orbital fracture (medial wall and
orbital floor), Open treatment
• The decision to perform orbital reconstruction or to
observe is based on thorough clinical and radiographic
(CT) evaluation.
• Orbital reconstruction is indicated in the presence of:
• Significant internal orbital defects proven by imaging
• Disturbances of eye mobility that are the result of
• Enophthalmos
• Hypophthalmos

Combined orbital fracture (medial wall and
orbital floor), Open treatment

Contraindications:
globe injury may necessitate delay of orbital
wall repair.
contraindication)

• The majority of cases require reconstruction of
the orbital walls to support the globe position
and restore the shape of the orbit as the bony
walls are comminuted and/or bone fragments are
missing (see CT scan). It is therefore impossible to
reduce the bony fragments. The orbital walls
must be reconstructed.
• Reconstruction of missing bone rather than
reducing bone fragments can be achieved using
various materials

Orbital roof fracture, Observation
• Observation is often indicated, especially if there
is no effect on the orbital shape and volume, or
displacement of the globe. Depending on
accompanying lesions (eg, CSF leak, injury to the
dura) of the adjacent tissues, specific treatment
of these accompanying lesions may be necessary
and should be addressed.
The decision to observe or to perform surgery is
based on thorough evaluation because correction
of a potential secondary deformity is challenging.

Orbital roof fracture, Open treatment
• The decision to perform open treatment or to
observe is based on thorough clinical and
radiographic (CT) evaluation.
• Open treatment is indicated when there is/are:
• Significant internal orbital defects proven by
imaging
• Disturbance of eye or upper eyelid mobility
• Hypophthalmos

Contraindications
• Severe ocular trauma such as rupture of the
globe injury may require delay of orbital wall
repair
contraindication)

Surgical approaches
• For access to orbital floor
• Subciliary
• Infraorbital
• Transconjunctival

Subciliary lower-eyelid
• The skin incision is made just below the
eyelashes. Subsequent to the skin incision
there are three optional pathways for the
dissection down to the orbital rim:
• Subcutaneous
• Deep to the orbicularis oculi muscle
• Step dissection or layered Converse technique

Subcutaneous DISSECTION
• Subcutaneous dissection produces an
extremely thin skin flap predisposed to scar
contracture and hence a high incidence of
ectropion. For access to the infraorbital rim
the orbicularis muscle and the periorbita must
be split below the infraorbital rim.

• In options 2(Deep to the orbicularis oculi
muscle) and 3(Step dissection or layered
Converse technique)
the integrity of the orbital septum has to be
meticulously preserved, otherwise there is a
risk of vertical lid shortening. The incision
through the periosteum for entry into the
floor of the orbit is made beneath the
infraorbital rim.

COMPLICATIONS ASSOCIATED WITH
SUBCUTANEOUS AND DEEP TO ORBICULARIS OCULI
MUSCLE
Common complications Are:
• skin buttonholes,
• darkening of the skin,
• ectropion, and
• occasionally entropion

WHAT IS ECTROPION
• Ectropion is an abnormal eversion (outward
turning) of the lid margin away from the
globe. Without normal lid globe apposition,
corneal exposure, tearing, keratinization of
the palpebral conjunctiva, and visual loss may
result.

DEEP TO THE ORBICULARIS
DISSECTION
• The path of dissection deep to the orbicularis
oculi muscle includes the pretarsal orbicularis
muscle in the elevated skin muscle flap if the
skin incision is placed across the tarsus. Motor
denervation can critically reduce lower lid
tone and diminish vertical lid support.

Step dissection
• The step dissection is technically easier than
the other two methods. It preserves pretarsal
fibers of the orbicularis oculi, thereby limiting
scarring at the eyelid margin.

The advantages of the step dissection
• imperceptible scar and
• the ease of extending laterally for additional
exposure of the entire lateral orbital rim.

Evaluation of skin creases
• The skin creases around the orbit are
evaluated carefully. If a lateral extension of
the subciliary incision line is anticipated, it is
useful to mark the lateral tail of the skin
crease that passes inferiorly. The lateral
extension of the subciliary incision always
follows the natural crease. If edema obscures
the direction of skin creases, one may look at
the contralateral eyelid to determine the
direction and position of the creases.

Marking of skin incision
• Marking of the incision line is planned just
below the eyelashes paralleling the lid margin.
The lateral extension runs out into a natural
skin crease. It can reach approximately 2 cm
past the lateral canthus.
Next, the lower eyelid may be infiltrated using
a local anesthetic containing a vasoconstrictor.

Subcutaneous dissection
• A skin flap over the pretarsal portion of the
orbicularis oculi muscle is developed along the
entire extent of the incision.

Sc dissection
• This skin flap goes inferiorly over an approximate
distance of 4-6 mm. This is performed by sharp
dissection with scalpel or scissors. Clinical
example shows the separation of the pretarsal
skin flap. The intact muscular portion of the
orbicularis oculi is revealed.
•

Undermining of orbicularis
• The approach is continued in stepwise
fashion. The orbicularis oculi layer is
undermined and a dissection plane between
the muscle and the septum orbitale is created.
• The suborbicular undermining begins with a
slit-like lateral incision of the muscle over the
bony infraorbital rim.

OPENING OF PLANE
• Next, the suborbicular dissection plane is
opened by spreading the introduced scissors.
This leaves the orbital septum intact. The
suborbicular pocket is extended downwards
over the anterior edge of the infraorbital rim.

OPENING OF SUBORBICULARIS PLANE

Extending and Opening of pocket
• The pocket is extended over the whole lower
palpebral region. Finally, the upper portion of
the pocket below the tarsus is opened with
the spreading scissors. This allows for the step
incision of the muscle.

Extending and Opening of pocket

Incision between pretarsal and preseptal
portions of orbicularis oculi muscle
• The remaining orbicularis oculi muscle layer is
then separated at the level just below the lower
border of the tarsus to complete the step
incision. This enables retraction of the lower lid
as a skin muscle flap.
•

Periosteal incision over the
infraorbital rim
• The skin muscle flap is retracted inferiorly over
the anterior edge of the infraorbital rim along
its whole horizontal extent.
• An incision through the periosteum at this
level should avoid the orbital septum and is
inclined to the lateral side.
•

Periosteal incision over the
infraorbital rim

Subperiosteal dissection of anterior
maxilla and/or orbit
• Periosteal elevators are then used to strip the
periosteum from the underlying osseous skeleton.
The infraorbital nerve is located below the medial
portion of the infraorbital rim and can be approached
after the periosteal incision is made. After identifying
the infraorbital foramen and the nerve exit zone, the
upper facial surface of the anterior maxilla can be
dissected in the subperiosteal plane.
• The infraorbital rim is exposed superiorly for the
subsequent periorbital dissection.
•

Subperiosteal dissection of anterior
maxilla and/or orbit

Schematic view of the subperiosteal dissection of the
anterior maxilla and the dissection of the periorbita (=
periosteum of the orbital cavity).

Closure
• Closure can be performed in two or three layers:
• Periosteum
• Muscle (optional)
• Skin
• The periosteum is redraped over the bony surfaces and
closed with resorbable interrupted sutures.

Suturing of orbicularis
• Suturing of the orbicularis oculi muscle is
optional in a limited approach. It is
recommended if the approach is extended
with vertical cuts through the muscle and/or
excessive stripping over the zygomatic body.
• Resorbable interrupted sutures are placed
laterally, in particular when the orbicularis
oculi muscle has been cut at this position.

Closure of skin wound
• The skin wound is closed with a 6-0
nonresorbable or fast-resorbing suture. Either
running or interrupted sutures can be used.

Subciliary more clear concept
• The subciliary, or blepharoplasty incision, is made
approximately 2 mm inferior to, and parallel with,
the superior free margin of the lower lid. It
extends from the medial canthal region into or
parallel to one of the resting skin tension lines
located along the lateral aspect of the orbit,
which usually turn slightly inferiorly. Once the
incision has been made, the dissection can be
made 1 of 2 ways depending on the path of
dissection through the orbicularis oculi muscle.

Skin only techinique
• With the skin-only technique the dissection is
entirely between the skin and orbicularis
muscle to the level of the infraorbital rim.

Skin muscle flap
• The skin-muscle technique differs in that the flap is
made by dissecting through the orbicularis muscle
either initially, or in a stepped manner, first dissecting
the skin for several millimeters before penetrating the
orbicularis oculi muscle. Both of these approaches
preserve the position of the pretarsal orbicularis oculi
muscle. However, when the skin and orbicularis muscle
are incised coincidently, no orbicularis oculi muscle is
left attached to the inferior tarsus. With either method,
once the orbital rim is reached, an incision through the
periosteum is made and subperiosteal dissection
exposes the orbital region of interest.

Infraorbital incision,
• the skin, orbicularis oculi muscle, and
periosteum are incised coincidently. This
approach, relative to the other
transcutaneous approaches, provides the
quickest and most direct route to the orbital
rim and floor.
• Disadvantages: visible scar

Subtarsal lower-eyelid approach
• Evaluation of skin creases

Marking of skin incision
• Marking of the incision line is planned in a
natural crease at a level below the inferior
margin of the lower tarsus. If edema obscures
the direction of skin creases, the contralateral
eyelid determines the direction and position
of the creases.
The incision is diagonally oriented and starts
medially about 2–3 mm below the lid margin
and courses in a laterocaudal direction.

LA
• Next, the lower eye lid may be infiltrated using
a local anesthetic containing a vasoconstrictor.

Skin incision
• The initial incision can be made through skin
and orbicularis musculature. However, it can
also be performed only through the skin as
demonstrated here.

• The orbicularis muscle is exposed.

Dissection of the orbicularis muscle
layer
• The muscle is elevated laterally from the
orbital septum and a small slit is opened using
scissors.

ORBICULARIS DISSECTION
• Through this opening, the orbicularis muscle is
undermined in the preseptal space.

ORBICULARIS DISSECTION
• Then the muscle layer is separated from
laterally to medially along the course of the
muscle fibers leaving the orbital septum
intact.

Orbital dissection
• The dissection proceeds inferiorly in a
preseptal suborbicular plane until the
infraorbital bony margin is reached.

suborbicular dissection
• The suborbicular dissection can be carried out
sharply using a scalpel, always adhering to the
muscle plane

suborbicular dissection
• Alternatively, a pair of scissors can be used for
suborbicular blunt dissection with spreading
motions.

Exposure of infraorbital rim
• The infraorbital rim is dissected in a
supraperiosteal plane.

Subperiosteal dissection
• To gain access to the orbit, the periosteum
over the infraorbital rim is incised starting
laterally at a level below the rim.

• The infraorbital rim is exposed superiorly for
the subsequent periorbital dissection.

Periorbital dissection
• The periorbital dissection is continued to
expose any fractures of the orbital walls in the
infero-mediolateral circumference of the bony
cavity.

• Wound closure
• After repair of the orbital walls, the subtarsal
approach is closed in layers starting with the
periosteum. Next, the orbicular muscle layer is
reapproximated as shown.

• Intraoperative appearance after closure of the
orbicularis muscle.

• Skin closure with running or interrupted
sutures. The latter is shown here.

Suspensory suture for lower eyelid
• Transcutaneous lower-eyelid approaches may be
complicated by vertical scar contraction during the
healing period with an ectropion. Skin and septal
scaring may be counteracted by so called Frost sutures.
• This is a mattress suture through the Gray line of the
lower lid and is applied at the end of the operation. It
lengthens the lower eyelid when it is taped to the
forehead. This creates traction for several days until
the wound healing has passed its first critical phase.

Suspensory suture for lower eyelid

• The taping to the forehead is done in several
layers in order to suspend the suture firmly and
prevent downward slippage.
• The suture is positioned over a first layer of tape
which is applied directly to the skin. It is then
secured with a second tape over it.
• Next, the suture is folded over this second layer
and another strip of tape secures it finally.
•

• Postoperative examination of vision is possible
by either removing the two uppermost layers
of tape and opening both eyelids or by
reflecting the upper eyelid only.

Transconjunctival lower-eyelid
approaches
•
Transconjunctival lower-eyelid approaches are
performed in several ways.
• A) Transconjunctival (inferior fornix transconjunctival
using a retroseptal or preseptal route)
B) Transcaruncular (=medial transconjunctival)
C) Transconjunctival with lateral skin extension(lateral
canthotomy/”swinging eyelid”)
D) Combination of inferior (A) and medial (B)
transconjunctival
E) C-shaped incision (ie, Combination of inferior (A)
and medial transconjunctival (B) plus lateral skin
extension (C))

Access areas
• The typical (lower fornix) transconjunctival
approach in the lower eyelid exposes the floor of
the orbit and infraorbital rim as well as the upper
edge of the anterior maxilla (A).
Via a pre- or transcaruncular incision, the medial
wall of the orbit behind the posterior lacrimal
crest can be exposed (B).
The combination of the lower fornix and the
medial transconjunctival approach provides
access to both previously mentioned areas at a
time.

ACCESS
• Extensions:
• • Lateral Skin / Lateral Canthotomy (“Swinging
Eyelid”)
• If a canthotomy is performed in conjunction
with the lower fornix transconjunctival
approach, the lateral orbital rim and wall can
additionally be accessed (C).

C-shaped Incision
• The C-shaped incision combines the medial
and inferior transconjunctival approach with
the lateral canthotomy and provides the
maximal exposure of the medio-inferolateral
orbit and the zygomatic body.

Complications
• Transconjunctival approaches demand surgical
precision in execution because several
complications can occur:
• Damage and abrasion to the cornea
• Damage to extraocular muscles
• Eyelid malposition
• A thorough evaluation is essential to choose the
appropriate lower eyelid approach (eg, a snap-
back test to assess the laxity of the eyelid).

Surgical routes
• The typical inferior fornix transconjunctival approach
can use two different routes to access the infraorbital
rim:
• Retroseptal
• Preseptal
• These two approaches vary in relation to the orbital
septum on the pathway to the infraorbital rim.
Controversy exists on the advantages and
disadvantages of these two surgical routes. We explain
the retroseptal approach in more detail.

Retroseptal - route
• The retroseptal route enters directly into the
fat compartments of the lower eyelids.

RETROSEPTAL ROUTE
• After vasoconstriction and insertion of a corneal shield
two or three traction sutures are place through the
lower eyelid.
• After eversion of the lower eyelid, the position of the
lower border of the tarsal plate is identified.
• The incision is placed in the depth of the fornix. For the
incision, scissors, scalpels, or electrocautery can be
used.
• When using scissors, the conjunctiva is elevated
laterally with a fine forceps and incised over a distance
of about 8 mm including the lower-eyelid retractors.

Retroseptal – Incision and dissection
• Starting from the initial transconjunctival
incision, the conjunctiva and the lower-eyelid
retractors are undermined towards the inner
angle of the lids.

Medial extension and fat exposure
• Then the incision line is extended from
laterally to medially to expose the fat
compartment behind the orbital septum.

Alternative: scalpel or electrocautery
incision
• Instead of using scissors, the transsection of
the conjunctiva and the lower-eyelid
retractors can be carried out using a scalpel.
Prior to this, the conjunctival tissues of the
lower fornix are spanned over the infraorbital
rim using a spatula and to small retractors.

scalpel or electrocautery incision

Retroseptal – Incision of the
periorbita
• The lower lid is retracted downwards to expose
the periorbita just behind the edge of the
infraorbital rim.
• (If it was decided to suture the posterior edge of
the conjunctival flap as corneal protection, this is
done now).
• Next, the periorbita is incised parallel but just
posterior to the infraorbital rim.
• Once the infraorbital rim is exposed the
periorbital dissection can be performed in the
usual fashion

Retroseptal – Incision of the
periorbita

Retroseptal - Closure
• Closure of the periosteum or the periorbita
respectively is not possible. The conjunctival
incision is closed with a running 6-0 fast-
absorbing suture. The suture ends may be
buried or guided transcutaneously to bury the
knots.

Preseptal - Route
• Principle
The preseptal route requires entering the
suborbicularis oculi/preseptal space above the
fusion of the lower lid retractors and the
orbital septum. This allows direct visualization
of the septum.

• After vasoconstriction and insertion of a corneal
shield, two or three traction sutures are place
through the lower eyelid.
• After eversion of the lower eyelid, the position of
the lower border of the tarsal plate is identified.
• The posterior edge of the conjunctiva is tented
and secured with a stay suture and traction is
applied to lift the conjunctiva while the lid margin
is everted. The lower border of the tarsal plate is
raised upward in this manner.

stay suture to secure conjunctiva

Preseptal – Incision and blunt
dissection
• The incision is made directly below the lower
tarsal border and the suborbicularis
oculi/preseptal space is entered.
• The incision is made using fine scissors
starting laterally or a scalpel/electrocautery.
Hemostasis is achieved with bipolar
coagulation.

Preseptal – Incision and blunt
dissection

• Blunt preseptal dissection is performed until
the infraorbital rim is reached in the
supraperiosteal plane.
• At this point, the corneal shields are removed
and the cephalic edge of the conjunctival flap
is pulled up to be sutured to the upper lid for
corneal protection.
•

• Once the infraorbital rim is exposed, the
periorbital dissection can be performed in the
usual fashion.
•

Preseptal - Closure
• In the preseptal approach, the periosteum
over the periorbital rim can be closed. The
transconjunctival incision is closed using a 6-0
resorbable running suture with the suture
ends either buried or guided through the skin
externally to bury the knots.
• An accurate alignment of the conjunctival
flaps must be guaranteed.

The caruncula lacrimalis, or lacrimal
caruncle
• small, pink, globular nodule at the inner corner (the medial
angle) of the eye. It is made of skin covering sebaceous
(oil) and sudoriferous (sweat) glands.
• With ocular allergies, the lacrimal caruncle and plica
semilunaris may be inflamed and pruritic (itchy) due to
histamine release in the tissue and tear film.
• When healthcare providers instill ophthalmic medications
into the eye, they apply gentle pressure to the Inner
Canthus with the eyes closed, over the lacrimal caruncle, to
delay drainage of the drug down the punctum, or tear duct
opening, thus preventing systemic absorption of the drug

Transconjunctival lower-eyelid
approaches - transcaruncular
• Principles
• The medial orbital wall can be exposed using a
medial conjunctival incision posterior to the
lacrimal drainage system along the semilunar
fold. The incision is either precaruncular or
transcaruncular.

TRANSCARUNCULAR
• The dissection pathway is continued inside the
periorbital soft tissues until the posterior
lacrimal crest is reached. The posterior limb of
the medial canthus as well as the lacrimal
system is left intact. Along the posterior
lacrimal crest, the periorbita is incised and the
medial orbital wall is dissected directly on the
bony surface.

TRANSCARUNCULAR
• Anatomic specimen showing the
precaruncular incision (caruncula grasped with
forceps) and the dissection pocket inside the
periorbita medially to Horner’s muscle. For
better visualization the lower lid has been
incised and reflected.

HORNERS MUSCLE
• Additional parts of the orbicularis have been
given separate names—namely, Horner’s
muscle and the muscle of Riolan; they come
into close relation with the lacrimal apparatus
and assist in drainage of the tears. The muscle
of Riolan, lying close to the lid margins,..

HORNERS MUSCLE
• Retraction of the lateral conjunctival edge to
fully show Horner’s muscle.

TRANSCARUNCULAR
• After vertical incision of the periorbita
posterior of the insertion of Horner’s muscle,
the medial orbital wall is exposed. The
retractor is located just in front of the anterior
ethmoidal artery.

Vasoconstriction
• The conjunctiva in the area of the semilunar
fold and the caruncle may be infiltrated with a
vasoconstrictor. This is done about 7-10 min
prior to the incision so that any distortion of
the structures can settle by diffusion of the
agent.

Incision
• The upper and lower eyelids next to the medial angle
are retracted with traction sutures. Damage to the
lacrimal puncta and canaliculi should be avoided.
Alternatively, Desmarres or Green retractors can be
used.
Additionally, the globe can be moved laterally with
malleable Jaeger lid plate retractor or broad spatula.
• These maneuvers flatten the caruncle and improve
visibility of the incision area.
• The initial incision with scissors is placed pre- or
transcaruncular while the caruncle is grasped with a
delicate forceps and pulled laterally.

Subconjunctival dissection
• Gradually, the incision is extended vertically
over a distance of 12-15 mm through the
conjunctiva.

DISSECTION TRANSCARUNCULAR
• The soft-tissue space deep to the caruncle is
spread in a posteromedial direction on top of
Horner’s muscle. Following the surface of the
muscle the dissection will proceed directly to
the posterior lacrimal crest where the muscle
inserts. The tip of the scissors may be used to
palpate the underlying bone.

• A malleable retractor or periosteal elevator is
inserted and directed against the medial
orbital wall behind the posterior lacrimal
crest.

Periosteal incision and exposure
• The periorbita along the posterior lacrimal
crest is incised in a superoinferior direction
with a spreading motion of sharp, pointed
scissors.

Periosteal incision and exposure

PERIOSTEAL INCISION AND EXPOSURE

Subperiosteal dissection and
exposure of medial orbital wall
• Subperiosteal dissection begins with
periosteal elevation. The retractor or
periosteal elevator is gradually inserted into
the pocket along the bony surface. The medial
orbital wall is exposed with sweeping motions
from superior to inferior in order to obtain a
wide entrance. The ethmoidal arteries
indicate the superior extent of the surgical
cavity while the inferior extension is limited
only by the retractability of the globe

Subperiosteal dissection and
exposure of medial orbital wall

Closure
• The periorbita is usually not closed. The
conjunctiva and the caruncular area are
sutured using 6-0 resorbable sutures, either
interrupted or partially uninterrupted. The
suture ends may be buried.
•

fornix
• The fornix of the conjunctivae refers to loose
arching folds connecting the conjunctival
membrane lining the inside of the eyelid with
the conjunctival membrane covering the
eyeball.
• In anatomy, a vault like or arched structure.
"Fornix" is the Latin word for "vault or arch."

transconjunctival with lateral skin
extension
• General consideration
• The lower transfornix transconjunctival incision
can be extended with a lateral skin incision which
is then enhanced by a lateral canthotomy. The
lateral extension can be combined with a
transconjunctival incision via either the preseptal
or retroseptal route. The approach can be started
with the lateral canthotomy and continued
medially into the transconjunctival approach or
reversely. We describe the former option.

transconjunctival with lateral skin
extension

Vasoconstriction
• The conjunctiva in the area of the lower fornix
and the area of the lateral canthotomy may be
infiltrated with small amount of local
anesthetic containing a vasoconstrictive agent.

Arcus marginalis
• The Arcus Marginalis(AM) is the bone attachment
of the orbital septum. Think of the orbital septum
as a "dam" holding back the lower eyelid fat and
the AM is at the bottom of the dam. As we age,
the orbital septum loses its elasticity and begins
to bulge out forming a "bag". The rate at which
we lose this elasticity is different from person to
person and depends on many factors. This
bulging is also enhanced by the deflation and
dropping of the cheek and sub-obicularis oculi fat
pads - just like the outgoing tide reveals the rocks
on the beach.

Orbital septum
• The orbital septum is a thin sheet of fibrous
tissue that originates in the orbital periosteum
and inserts in the palpebral tissues along the
tarsal plates. The orbital septum provides a
barrier against the spread of periorbital
infections into the orbit proper

Tarsas (eyelids)
• The tarsi (tarsal plates) are two comparatively
thick, elongated plates of dense connective
tissue, about 2.5 cm (1.0 in) in length; one is
found in each eyelid, and contributes to its
form and support. They directly abut the lid
margins.[1] The tarsus has a lower and upper
part making up the palpebrae.
•

What are transcutaneous approaches?
• The subciliary, subtarsal, and infraorbital
incisions are collectively considered the
transcutaneous approaches to the orbital floor
and infraorbital rim

Enophthalmous
• Enophthalmos is the recession of the ocular
globe within the bony orbit.

Enophthalmos
• Two to three millimeters of enophthalmos is
clinically detectable, and more than 5 mm is
disfiguring.

Cornea position
• In the uninjured state, the cornea extends
approximately 16-17 mm anterior to the
lateral orbital rim. Immediately after injury,
however, globe position may appear normal
or proptotic owing to soft tissue swellin

Traumatic enophthalmos
• Traumatic enophthalmos is the most common
residual deformity in complex orbital injuries.
The underlying cause is a discrepancy
between the volume of the bony cavity and its
contents. The intraorbital soft tissue envelope
may diminish in volume, as a result of atrophy
or displacement of fat from within the
intramuscular cone, cicatricial retraction of
the ocular muscles, or entrapment of the
supporting ligament system.

• in posttraumatic enophthalmos, the
mechanisms that determine globe position
are: 1) the enlargement of the orbital cavity;
2) the herniation of orbital fat into the
maxillary sinus; and 3) fat atrophy, loss of
ligament support, and scar contracture.

• the most well accepted concept is the
enlargement of the orbital cavity after
displacement due to orbital fractures.
Generally, a 1 cm3 increase in orbital volume
causes 0.8 mm of enophthalmos
• Chang Gung Med J 2006 May-Jun;29(3):251-61.
Management of posttraumatic enophthalmos.

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