Preseptal transconjunctival approach to the orbital floor fractures. Surgical technique

Abstract

Orbital floor fractures may be reached through 2 types of conjunctival approaches, the preseptal one and the retroseptal one. While the retroseptal approach offers a more direct and easier route to the orbital rim and floor, it is associated with a significantly higher rate of lower lid complications compared to the preseptal approach. We will focus on the preseptal transconjunctival approach. The conjunctival incision is performed with a guarded needle-tip electrocautery or with a long-handled scalpel (blade No. 15) from the inferior extremity of the semilunar fold to the lateral canthal region. The subconjunctival plane is divided with Stevens scissors medially and laterally. This plane, located between the preseptal cranial conjunctival flap covered by the orbital septum and the caudal conjunctival flap covered by the orbicular muscle's fascia, is opened with the scissors toward the inferior orbital rim. The periosteum over the inferior orbital rim is incised and reflected. The subperiosteal dissection is continued toward the orbital floor. The incarcerated periorbital tissues are repositioned to expose the stable bone margins of the fracture before orbital reconstruction. The closure of the periorbita is performed with uninterrupted 5-0 Vicryl sutures. The conjunctiva is closed with a running 6-0 Maxon suture. Although technically more demanding than the retroseptal approach, the preseptal approach enables a large and safe access to the entire orbital floor by passing through an anatomical bloodless plane. This approach can also be combined with a lateral canthotomy/cantholysis and with a medial caruncular transconjunctival incision, thus providing extended exposure of the entire orbit.