Combined Transcutaneous Transethmoidal/Transorbital Approach for the Treatment of Medial Orbital Blowout Fractures

Abstract

The transcutaneous transorbital approach to medial orbital wall fractures facilitates placing a large implant or autogenous graft. However, its major disadvantage is the difficulty of accurately reducing the fractured medial orbital wall and herniated soft tissues with minimal morbidity. To resolve this problem, a combined transcutaneous transethmoidal/transorbital approach through the same skin incision was developed at the Chonnam National University Medical School. Between 1997 and 2003, this approach was used in 54 patients with pure medial orbital blowout fractures. All fractures were larger than 2 cm in defect size and had 3 mm or more of bone displacement. Postoperative computed tomographic scans showed complete release of entrapped soft tissues and accurate reconstruction of bone defects in all cases. Complications related to the operation such as intraorbital and intramuscular hemorrhage, infection, and eyeball and optic nerve injuries were not observed, except in two cases with slight implant displacement. Follow-up ranged from 2 to 22 months, with an average of 9 months. Forty-one patients were evaluated 6 months or more after their reconstructive procedure. At the time of surgery, diplopia was present in 39 patients, eyeball movement limitation in 35 orbits, and enophthalmos of more than 2 mm in 16 orbits. Postoperatively, diplopia and eyeball movement limitation were resolved in most cases. Two patients had persistent diplopia for more than 1 year after surgery, and one of these needed extraocular muscle surgery. Enophthalmos of more than 2 mm developed in three orbits, but enophthalmos of more than 3 mm was not observed in any orbit. Cosmetic results at the incision site were acceptable in all patients. The combined transcutaneous transethmoidal/transorbital approach is a safe procedure that can be performed with minimal morbidity; it offers the advantages of both the transcutaneous approach and the trans-nasal approach. Therefore, the authors suggest that this method be considered as a surgical alternative for the treatment of medial orbital blowout fractures, especially large and combined fractures of the medial wall and other parts of the orbit.