Standardized Reattachment of the Lateral Canthal Tendon in the Swinging Lower Eyelid Approach: A Step-by-Step Technique.

BackgroundVarious techniques have been proposed for treating orbito-zygomaticomaxillary fractures, each with distinct benefits and drawbacks.Aim of this studyTo compare Trans-tarsal Stair-Step Lateral Extension of the Transconjunctival approach with transconjunctival approach combined with lateral eyebrow incision in the management of orbital and zygomaticomaxillary complex fractures with respect to accessibility to fracture site and exposure duration as primary aims.Materials and methodsTwenty patients, aged between 18 and 60 years, who has orbito-zygomaticomaxillary complex fractures were randomly assigned to two equal groups: Group A underwent the trans-tarsal stair-step lateral extension of the transconjunctival approach and Group B received the conventional transconjunctival approach combined with lateral eyebrow incision. Intraoperative parameters which were accessibility to fracture site, exposure duration and total operative time and postoperative parameters which were postoperative edema, postoperative scar and esthetic appearance, postoperative pain and infraorbital sensory nerve function objectively, all were assessed.ResultsGroup A achieved same surgical access to the fracture site as Group B. Group A and group B had same exposure time. Group A had less total operative time than Group B. Group A consistently showed the less postoperative edema at first 48 h, one week, and four weeks. Non noticeable scarring was reported only in Group A patients while group B had a noticeable scar at the lateral eyebrow incision. Within the first 24 h, there was significant difference in pain levels that was noted between the two groups. Group A had faster recovery in sensory nerve function than group B.ConclusionThe trans-tarsal stair-step lateral extension of the transconjunctival approach demonstrated favorable postoperative outcomes regarding pain, edema, and sensory recovery compared to the conventional technique with lateral eyebrow incision with same exposure area and no increase in exposure time and less total operative time.Trial registrationThe trial has been retrospectively registered on clinicaltrials.gov (ID: NCT07044258) on 19-6-2025.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12903-026-08842-1.

To evaluate the therapeutic effect of transconjunctival orbital fat repositioning and orbicularis oculi muscle plication and suspension surgery in patients with lower eyelid aging characterized by lower eyelid bags and tear trough deformities without significant skin laxity. This study enrolled patients with lower eyelid bags and tear trough deformities. All patients underwent orbital fat repositioning and orbicularis oculi muscle plication and suspension using a transconjunctival approach. Surgical outcomes were assessed based on surgery duration, pain scores, Allergan grading, and patient satisfaction. Additionally, soft tissue changes were evaluated using ultrasonographic imaging. A total of 40 patients were included in this study. Surgical duration ranged from 28 to 49 min, with intraoperative pain scores between 2 and 4. Ultrasonographic assessment revealed that soft tissue thickness between the skin and the infraorbital rim reached the maximum at 5 days postoperatively, gradually decreasing over time. At 6 months postoperatively, soft tissue thickness remained significantly greater than preoperative levels (P < 0.05). Age group analysis revealed that the 30-40-year-old group exhibited the greatest difference in Allergan scores between postoperative and preoperative periods (P < 0.05). Patient satisfaction 6 months postoperatively was 96.6%. Transconjunctival lower eyelid blepharoplasty with orbital fat repositioning and orbicularis oculi muscle suspension is an effective surgical approach for correcting lower eyelid bags and tear trough deformities in young and middle-aged patients without significant skin laxity. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A scoping review of modifications of the transconjunctival approach for maxillofacial fracture management and proposal of evidence-based algorithm for incision selection.

Transconjunctival approach for involutional entropion: Impact on the ocular surface.

BackgroundSurgical approaches for zygomaticomaxillary complex (ZMC) fractures have evolved toward minimizing cutaneous incisions while maintaining adequate exposure. Conventional approaches for frontozygomatic fixation, such as lateral brow or transconjunctival incisions with lateral extension, may result in visible scarring or periocular complications. Building on previous transconjunctival techniques, we applied an independent upper eyelid transconjunctival incision as a non-cutaneous approach for frontozygomatic fixation in selected ZMC tripod fractures.MethodsThis retrospective comparative study included 27 patients with unilateral ZMC tripod fractures, of whom 12 underwent non-scar fixation using an upper eyelid transconjunctival approach, and 15 underwent fixation through preexisting periorbital traumatic lacerations. The surgical strategy consisted of initial reduction and fixation via an intraoral approach, followed by selective additional fixation of the frontozygomatic region when residual step deformity or instability was present. Preoperative and 6-month postoperative computed tomography and three-dimensional photogrammetry were used to evaluate bony and soft tissue intermalar height differences.ResultsPreoperative intermalar height differences were comparable between groups. At 6 months postoperatively, both groups showed marked improvement, with bony differences of −0.2 ± 1.2 mm and −0.4 ± 0.4 mm, and soft tissue differences of 0.0 ± 0.6 mm and −0.2 ± 0.7 mm in the non-scar and control groups, respectively, with no clinically meaningful between-group differences. No clinically significant approach-related ophthalmic complications were observed.ConclusionsThe upper eyelid transconjunctival approach is a reliable non-cutaneous option for frontozygomatic fixation in selected ZMC tripod fractures, providing adequate exposure and stable fixation without visible scarring.

This randomized clinical trial aimed to compare patient-specific titanium and zirconia implants for orbital floor reconstruction with respect to reconstruction accuracy, orbital volume restoration, patient satisfaction, and cost-effectiveness. Twenty-four patients presenting with orbital blowout fractures underwent open reduction and internal fixation with orbital floor and/or medial wall reconstruction using patient-specific implants through a transconjunctival approach. Virtual surgical planning was performed by mirroring the contralateral intact orbit combined with digital fracture reduction. Postoperative evaluation included orbital volume measurements and 3-dimensional superimposition analysis to assess reconstruction accuracy. Patient satisfaction and implant manufacturing cost were also recorded. Both zirconia and titanium implants achieved comparable restoration of orbital volume and reconstruction accuracy, with no statistically significant differences between groups. Patient satisfaction scores were better in the zirconia group, although the difference was not statistically significant. Postoperative complications occurred only in the titanium group, including one case of globe restriction requiring partial implant removal and 2 cases suggestive of titanium hypersensitivity managed medically. Zirconia implants demonstrated a significantly lower manufacturing cost. Zirconia patient-specific implants provide anatomic and clinical outcomes similar to titanium implants, with a favorable cost profile, supporting their use as a viable alternative for orbital reconstruction.

Lower eyelid plasty is important for facial rejuvenation. Tear trough deformities and eyebags are among the most common and urgent problems encountered in lower eyelid aesthetic surgery. Compared with fillers such as hyaluronic acid and fat particles, a pedicled orbital septal fat flap for the correction of tear trough deformities has several advantages, including a higher survival rate, biocompatibility, and long-term results. To simultaneously solve the problem of eyebags combined with tear trough deformities, we performed eyebag surgery while releasing the orbital septal fat, trimming it to form 2-3 clusters of pedicled orbital septal fat flaps, and separating the fat flaps vertically at the orbital rim periosteum to reset the cavity and correct the tear trough deformities. This technique meets the needs of today's youthful aesthetics, effectively avoids complications such as lid ectropion caused by the external incision approach, and has reliable safety and efficacy with satisfactory cosmetic results.

Post-traumatic injuries of the maxilla, accompanied by destruction of the walls of the paranasal sinuses, occupy the second place after damage to the nasal bones, which proves the relevance of numerous studies aimed at developing biocompatible plastic materials for bone defects closure. The creation of innovative surfaces of endoprostheses in a reactive medium is based on both the use of alloys of various metals and absence of application of metals, in particular, from zirconium dioxide. Objective. To evaluate the effectiveness of a developed zirconium dioxide implant use in patients with acquired defects in the walls of the maxillary sinuses. Patients and methods. The study included 27 patients with acquired defects in the walls of the maxillary sinuses, which were corrected with zirconium dioxide implants. In the course of surgical intervention aimed at eliminating defects of the anterior wall of the maxillary sinus, intraoral approach was used (13 patients). In defects up to 10 mm in diameter, the implant was fixed with fibrin adhesive along the edges of the bone defect. For defects greater than 10 mm, the implant was fixed with surgical sutures (polysorb, biosyn, vicryl 4.0). Plasty of the superior wall of the maxillary sinus bone defect in 14 patients was performed through subciliary (9 cases) or transconjunctival approaches (5 cases), implants were adapted along the edges of the defect and fixed with sutures or fibrin adhesive. Results. Positive anatomical result has been observed in 26 out of 27 patients in the immediate (1 month) and long-term (1 year) postoperative periods of patients. In one case of prosthesis of the superior wall of the maxillary sinus, partial migration of the implant to the sinus lumen has been observed, which was caused by insufficient covering of the bone defect edges by endoprosthesis and partial lysis of the bone framework. Conclusion. The use of standard and individually manufactured zirconium dioxide implants is a key for the successful restoration of destroyed anatomical structures, allows to fully restore bone structures and achieve a small number (up to 2.9%) of complications.

We sincerely appreciate the insightful points raised by Dr. Cotrufo. They provide us with the opportunity to further clarify key concepts regarding the relationship between the technique described in our article, “Temporal Modified Orbicularis Repositioning: Going beyond the Limits of Temporal Lifting,”1 and the anatomical structures of the periorbital region. Regarding the concern that a complete denervation of the orbicularis oculi muscle could occur during temporal modified orbicularis repositioning (MORE), we would like to offer some reassurances. While some interruption of the lateral motor components of the orbicularis muscle is possible, our clinical experience in a large number of cases has shown no cases of permanent functional impairment of the orbicularis. This observation is in accordance with the literature. Specifically, Innocenti et al.,2 during the Reidy–Adamson flap-harvesting procedure, noted that even when “most of the orbicularis oculi muscle’s extracanthal innervation source is transected,” there is no clinical evidence of denervation sequelae. This electroneurography study confirmed that extracanthal motor innervation is not the muscle’s primary nerve supply, which is concentrated at the medial palpebral corner.2 This conclusion is reinforced by an important anatomical study by Choi and Kim,3 who demonstrated that orbicularis motility also derives from other nerve fibers reaching its medial portion. This interesting research identified several motor nerve branches originating not only from the zygomatic branch but also from the buccal branch of the facial nerve, which is generally preserved during our procedure (Fig. 1). The same authors classified 3 terminal motor systems composed of these nerve branches: the lower palpebral, upper medial palpebral, and glabellar. All 3 run obliquely along what they called the “medial orbicularis motor line.”Fig. 1.: Photograph from a dissection course showing some of the branches of the facial nerve, with emphasis on the zygomatic branches, which run deep to the zygomaticus major muscle. Note the safety margin between the frontal branch and the incision in the orbicularis oculi muscle.In the context of the temporal MORE, the concept of denervation goes beyond these issues, configuring a new concept that we call “orbicularis oculi selective denervation. In our experience, this selective denervation can even improve crow’s feet, which are primarily caused by orbicularis muscle hyperactivity. We believe that these improvements may derive from the combination of the selective denervation, the subcutaneous dissection, and the subsequent fibrosis between planes. As mentioned in our original article, the temporal MORE technique can also be combined with lower blepharoplasty. Both conjunctival and subciliary approaches may be used and gradually tailored to the patient’s needs. The transconjunctival approach, with direct access to the fat pads, preserves the anterior lamella and is a valid option in cases where excess skin removal is not mandatory. The pinch lower blepharoplasty may be considered a valid ally when limited skin removal (3 to 4 mm) is sufficient, while the transcutaneous approach, with skin flap elevation and fat remodeling, is mandatory for greater skin excision. This gradual approach culminates in a more articulated technique in selected cases, the “extended lower blepharoplasty.” In cases of significant medial midface ptosis, the subperiosteal or supraperiosteal midface lift is recommended to achieve a “direct management” of soft tissues following a more vertical vectorial repositioning, which can outperform the traditional superolateral vector in select patients, as previously described in 2015.4 An additional consideration is the “passive septal tightening” described by Hester et al. in 2006.5 When the orbicularis muscle is stretched and suspended (orbiculopexy), excess fat pads are repositioned into their natural anatomical location. So, we obtain a restoration of the muscle’s supportive role while also reducing the need for fat excision. In our experience, fat preservation does not compromise cosmetic long-term results or increase the recurrence of herniation. For these considerations, we recommend performing lower blepharoplasty only after deep supraperiosteal dissection along the lateral and inferior orbital rim and orbiculopexy. Furthermore, we would like to highlight that excessive orbicularis stretching should be avoided, as it may cause ocular irritation, chemosis, and epiphora. Intraoperative lateral tarsorrhaphy can help prevent these complications in selected cases. Even postoperative tobramycin- and dexamethasone-based eye drops can be useful if these complications occur. In addition, the powerful soft-tissue lift achieved with the temporal MORE technique lends itself to reconstructive purposes. This is the case of anterior lamella retraction/deficit after cosmetic lower blepharoplasty. Temporal MORE may be the key for more middle-third soft-tissue recruitment, which is essential for correcting this kind of complication. This expands the potential indications of the technique, demonstrating that it is not only an effective cosmetic procedure but also a valuable reconstructive tool. We remain available for any further clarifications. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. No funding or other support was received from a sponsor, commercial entity, or third party.

SummaryObjective:This study aimed to investigate and analyse the complications and outcomes of orbital fracture repair in Oman.Methods:This multicentre retrospective study included all patients with orbital floor and/or medial wall fractures who underwent orbital reconstruction at four tertiary hospitals in Oman between January 2014 and December 2021. The data collected included demographics, fracture aetiology, surgical approach, reconstruction material, complications and repair outcomes.Results:A total of 41 patients were included in this study. Motor vehicle collisions (MVCs) were the most common cause of orbital fractures, accounting for (53.7%) of the patients. Isolated orbital fractures were encountered in 25 patients, 12 patients had orbital fractures associated with the zygomaticomaxillary complex and 4 had fractures associated with naso-orbital ethmoidal fractures. The transconjunctival approach was the most common surgical method (36.6%), followed by the infraorbital approach (24.4%). Titanium mesh was the primary implant material used in (63.4%) of the cases. The most common complications at 2-weeks to 3-months postoperatively were enophthalmos (17.1%) and residual diplopia (13%). Beyond 3 months postoperatively, complications occurred in 10 patients, resulting in an overall complication rate of (24.4%). Analysis of 24 postoperative computed tomography scans revealed that the ideal implant positioning in the anterior, middle and posterior zones was achieved in (87.5%), (45.8%) and (12.5%) of the cases, respectively.Conclusion:The study findings showed that MVCs were the primary cause of orbital fractures in Oman. The complication rate of orbital reconstruction was low and comparable to that reported in the published literature.

Background/Objectives: This network meta-analysis aimed to evaluate and compare the risks of lower eyelid complications-ectropion, entropion, scleral show, and postoperative scarring-associated with four surgical approaches (subciliary, subtarsal, infraorbital, and transconjunctival) for orbital and zygomaticomaxillary fracture repair. Methods: A systematic search of PubMed, Embase, and Cochrane databases identified relevant studies published between 1 January 1990 and 10 January 2026. Twenty-seven eligible studies involving 2790 patients were included. Direct pairwise meta-analyses and network meta-analyses were conducted to compare complication risks among the approaches. Sensitivity analyses were performed to assess the influence of individual studies, and inconsistency tests were applied to evaluate model robustness. Results: The subciliary approach was associated with the highest risk of ectropion and scleral show. The transconjunctival approach had the lowest risk of ectropion and scarring but the highest risk of entropion. The subtarsal approach had the lowest risk of scleral show, while the infraorbital approach had the highest risk of postoperative scarring. Sensitivity analyses confirmed consistent rankings, and no significant inconsistency was detected. Conclusions: This study provides updated, comprehensive evidence to guide the choice of surgical approach for orbital and zygomaticomaxillary fracture repair. Surgeons should balance operative exposure, cosmetic outcomes, and complication risk, and communicate these trade-offs clearly with patients to optimize decision-making.

Background: Pediatric orbital floor fractures differ from adult injuries due to bone elasticity and a higher incidence of trapdoor-type defects with extraocular muscle entrapment, often presenting with limited external signs but carrying a high risk of functional impairment. Early recognition and prompt surgical release are essential to prevent irreversible neuromuscular damage and persistent binocular vision disturbances. Case Presentation: A 13-year-old patient sustained an orbital floor blow-out fracture with inferior rectus muscle incarceration following blunt trauma. The child presented with vertical diplopia, ocular motility restriction, and infraorbital hypoesthesia. Computed tomography demonstrated a posteriorly located linear orbital floor defect with soft-tissue entrapment, supporting the indication for urgent surgical intervention to avoid ischemic injury. Management and Outcome: Through a transconjunctival retroseptal approach, the entrapped muscle was promptly released, and orbital floor continuity was restored using an autologous bone graft harvested from the anterior maxillary wall with piezosurgery. This technique allowed controlled and precise bone harvesting while preserving adjacent anatomical and developing dental structures. Postoperative recovery was uneventful, with complete resolution of diplopia and full restoration of binocular ocular motility during follow-up. Conclusion: Early surgical intervention plays a pivotal role in achieving functional recovery in pediatric orbital floor fractures with muscle entrapment. Autologous reconstruction supported by piezosurgical bone harvesting represents a safe and effective approach in growing patients, providing reliable functional and anatomical outcomes. This case reinforces the clinical relevance of timely intervention and highlights practical considerations in pediatric orbital trauma management.

IntroductionThe coexistence of heterogeneous tumors, spindle cell hemangioma (SCH) and cavernous hemangioma, is a rare clinical presentation. SCH is an uncommon vascular disease that most often presents as cutaneous or subcutaneous nodules in the distal extremities and only rarely in deep soft tissues.Case presentationA 57-year-old woman developed secondary orbital involvement with two tumors 40 years after removal of a cavernous hemangioma in the same orbit. CT and MRI images showed two tumors in the left orbit. Both were removed entirely via a transconjunctival anterior orbital approach combined with a nasal endoscopic transethmoidal approach. Pathology showed SCH and cavernous hemangioma.ConclusionCoexistence of SCH and cavernous hemangioma in the same area suggests a continuum and a shared origin. Although SCH is rare and its preoperative diagnosis is challenging, it should be included in the differential diagnosis of cavernous hemangioma.

To describe a new approach to the ethmoidal nerve in cats. Prospective, non-blinded, descriptive, cadaveric study. A total of 13 adult feline cadavers. The course of the ethmoidal nerve through the ethmoidal foramen was initially studied by computed tomography (CT) and dissection in two cat cadavers. The ethmoidal foramen was defined as the target, and an injection technique was proposed using an arc-bent 4.2 mm needle obtained from a 24 gauge venous catheter. A 0.2 mL injection of either methylene blue or radiologic contrast was randomly administered to each peribulbar area of the cat cadaver. Enucleation of the eye that had received methylene blue was performed 5 minutes after injection, followed by a CT scan of the cranium. Primary outcomes measured were staining of at least 6 mm of the ethmoidal nerve and contrast distribution around the ethmoidal foramen. Secondary outcomes assessed potential risks associated with the technique, including presence of contrast within the optic canal, optic nerve staining, ocular globe damage, and evidence of intraconal and intracranial migration. Qualitative data were summarised using frequencies and percentages, and quantitative data as mean ± standard deviation. The technique reached its target in 91% (10/11) of the eyes in both the methylene blue and the contrast groups, with a similar spread pattern observed between them. Optic nerve staining occurred in 55% (6/11) of the methylene blue group and intraconal migration in 36% (4/11) of the eyes injected with contrast. No intracranial extension or ocular damage was observed. The transconjunctival approach could effectively reach the ethmoidal nerve in cat cadavers.

Transconjunctival Lower Blepharoplasty.

Transcutaneous Lower Eyelid Blepharoplasty with Skin-Muscle Flap and Orbicularis Muscle Suspension.

Lower eyelid blepharoplasty is performed via transconjunctival and subciliary approaches. In the subciliary approach, we have compared 2 methods: biplanar flaps versus a composite flap, with the goal of improved short-term recovery. Preoperative and 6-day postoperative 2-dimensional patient photographs were reviewed from each patient assigned to 1 of the 2 groups. Two blinded surgeons who neither performed the procedure nor were aware of the technique used reviewed the postoperative pictures from each patient and scored the results based on the Modified Surgeon Periorbital Rating of Edema and Ecchymosis (SPREE) Questionnaire. Forty-one patients (82 eyes) underwent subciliary lower blepharoplasty in the stated time frame. The primary outcome of the modified SPREE survey showed that patients who underwent the composite technique had an average edema score of 1.06 (from a 1-4 increasing severity scale) compared to 1.52 scored on patients with the biplanar technique ( P < 0.00228). For ecchymosis, patients who underwent the composite technique had an average score of 0.25 (from a 0-3 increasing severity scale) compared to 0.60 scored on patients with the biplanar technique ( P < 0.04444). Composite flaps were shown to have a statistically significant decreased Modified SPREE score compared to biplanar flaps.

Improving Periorbital Aesthetics with Volume Augmentation.

Transorbital neuroendoscopic surgery (TONES) has adopted an increasingly prominent role as a minimally invasive technique for the management of orbitocranial pathology. It can be applied to a range of conditions, from intraorbital lesions to complex tumors that cross the boundaries between the orbit and cranial fossa. The primary approaches include the superior lid crease incision and lateral retrocanthal incisions, with other alternatives including the precaruncular and inferior transconjunctival approaches. This review will examine the role of the oculoplastic surgeon in multidisciplinary TONES procedures. Cadaveric and clinical studies have defined anatomical corridors and demonstrated the technical feasibility and functional outcomes of providing access to the anterior and middle cranial fossae. Adjunctive maneuvers, such as a lateral orbitotomy or creation of extra-orbital portals, can be performed to improve surgical freedom and access. The choice of technique can be tailored to the type and location of pathology and surgical objectives regarding diagnosis and resection.