Operative Technique in Plastic Surgery – Kevin C.Chung

maxillofacial computed tomographic scans in trauma patients. Plast Reconstr
Surg. 2011;127:1270-1278.
5. Soparkar CNS, Patrinely JR. The eye examination in facial trauma for the
plastic surgeon. Plast Reconstr Surg. 2007;120(7):49S-56S.
6. De Chalain TM, Cohen SR, Burstein FD. Modification of the
transconjunctival lower lid approach to the orbital floor: lateral paracanthal
incision. Plast Reconstr Surg. 1994;94(6):877-880.
7. Song J, Lee GK, Kwon ST, et al. Modified transconjunctival lower lid
approach for orbital fractures in east asian patients: the lateral paracanthal
incision revisited. Plast Reconstr Surg. 2014;134(5):1023-1030.
8. Ridgway EB, Chen C, Lee BT. Acquired entropion associated with the
transconjunctival incision for facial fracture management. J Craniofac Surg.
2009;20(5):1412-1415.

54
CHAPTER
Correction of Orbital Floor
Blow-out Fractures:
Variation 2
Henry C. Vasconez
DEFINITION
■ The orbit is a paired structure of the upper craniofacial skeleton.
■ It houses the globe, nerves, vessels, and surrounding soft tissue structures.
■ The orbital floor consists of very thin bone and ligamentous structures and
therefore is easily fractured when sustaining a significant force.
■ Orbital floor fractures can be defined as pure blow-out fractures or impure
blow-out fractures (FIG 1).1
ANATOMY
■ The orbit is a paired structure that has a conical shape and is separated in the
midline by the interorbital structures consisting primarily of the ethmoid and
frontal sinuses and the underlying nasal structures.
■ The cone or bony pyramid of the orbit is made up of a roof, floor, and medial
and lateral walls.
■ At the apex of the cone posteriorly lie the optic nerve and other important
nerves and vessels.
■ The orbital floor forms the roof of the maxillary sinus, slopes upward and
medially toward the apex of the cone, and has an AP distance of approximately
45 mm.
■ The bony orbit volume is approximately 30 cc and the globe is approximately
7 cc.
■ The anterior portion of the floor is concave; the posterior portion is convex
and is the thinnest part of the floor and sustains most of the fractures.

PATHOGENESIS
■ Orbital floor fractures are categorized as pure or impure blow-out fractures.2
FIG 1 • Pure globe-to-wall blow-out fracture (A) vs
buckling or impure blow-out fracture (B).
■ There are also linear or cracked and trapdoor fractures as well as comminuted
fractures of the floor.
■ The type of fracture depends, in large measure, on the vector and amount of
force applied to the orbit or surrounding skeletal structures.
■ A pure blow-out fracture involves the thin floor and medial and/or lateral walls
of the orbit.
■ An impure blow-out fracture involves the disruption of the thick orbital rim
and, many times, adjacent facial skeletal structures.
■ A trapdoor orbital fracture is a pure orbital blow-out fracture, whereby a bony
fragment is displaced inferiorly, into the maxillary sinus, while still being
hinged. Orbital structures herniate through this defect and become entrapped.
■ Orbital contents that can become entrapped include the periocular muscles,
commonly the inferior rectus and inferior oblique. Muscle entrapment causes
restriction of upward gaze and consequent diplopia.
NATURAL HISTORY
■ Significant controversy remains regarding the indications for operative repair

of orbital floor fractures.
■ Nondisplaced or mildly displaced orbital floor fractures will tend to do well
after edema subsides and the brain adapts to the small visual field discrepancy.
■ Diplopia secondary to enophthalmos, significant defects in ocular motility, and
significant radiographic findings are all important indications for operative
intervention.
■ Entrapment of orbital contents, especially in the pediatric age group, can lead
to significant, early symptoms, both visual and systemic (including nausea and
vomiting), and should be addressed urgently.
■ Significant orbital floor fractures that remain untreated can later present
problems to the patient and can be very challenging to correct properly.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Most orbital floor fractures result from blunt injuries, primarily from motor
vehicle crashes or assaults.3
■ Signs and symptoms of these fractures include edema and bruising, pain,
diplopia, subconjunctival hemorrhage, sensory deficits mostly in the
infraorbital region, and, at times, visual deficits.
■ Ophthalmology should be consulted with any visual field deficits.
■ The position of the globe, including cornea and pupil, is important to asses and
compare with the contralateral, uninjured side.
■ Extraocular muscle movements are then tested for any pain or deficits.
■ In the unconscious patient, extraocular muscle movements can be assessed by
performing a forced duction exam, testing for any restriction of muscles or
associated structures (FIG 2). If possible, this result is compared with the
contralateral side.
■ Gentle yet thorough palpation of the orbit and its periorbital structures, is
performed to identify obvious fractures or step-offs.
■ Examination of the pupils is important to identify an optic nerve injury or
other afferent pupillary defects. Consensual and accommodation reflexes are
also evaluated.
■ The oculocardiac reflex is particularly important in children with entrapment
of orbital structures in the floor. An increase in vagal tone can lead to nausea
and vomiting and ultimately cardiac disorders, including asystole. These cases
should be managed emergently.
■ Volume discrepancies of the orbit can lead to enophthalmos or dystopia of the

globe. Early evaluation can be difficult because of edema and should be
carefully monitored over a 2-week period as the edema subsides and the
displacement becomes more obvious.
FIG 2 • The forced duction test.
■ Delayed enophthalmos repair may be necessary even weeks after the injury if
it is noted to be greater than 2 mm in an AP direction or is contributing to
visual disturbances.
IMAGING
■ CT scanning has revolutionized the diagnosis and treatment of orbital
fractures.
■ Coronal and sagittal reconstructions are most helpful for orbital floor fractures
(FIG 3). They define the extent, size, and location of the injury, as well as
associated injuries.
■ 3D reconstructions can be helpful, especially in extensive injuries to outline

any other affected structures. This is very usual in nasoethmoidal orbital
fractures, as well as associated zygomatic maxillary fractures.
■ CT scan imaging distinguishes between a pure and an impure orbital floor
blow-out fracture.
DIFFERENTIAL DIAGNOSIS
■ Orbital roof fractures
■ Medial orbit fractures
■ Lateral orbital wall fractures
■ Endocrine or systemic abnormalities affecting the orbit
NONOPERATIVE MANAGEMENT
■ Significant controversy still remains regarding the operative vs nonoperative
management of orbital floor fractures.
■ As CT imaging technology has become more refined, a better evaluation and
understanding of the injuries involved to the orbital floor permit better
assessment and better selection of nonoperative candidates.
■ Conservative management has become increasingly popular in recent years.
■ Some practitioners use a 1-cm defect in the floor as a cutoff for exploration
as long as there is no evidence of herniation or clinical symptoms.
■ After swelling and ecchymosis have resolved, if the patient is functionally
intact, surgical correction may not be warranted. Delayed operative
intervention after 2 or more weeks is also increasingly common among certain
practitioners, especially ophthalmologists.
■ Definite operative indications include significant enophthalmos, diplopia,
ocular motility disturbances, and visual disturbances.
SURGICAL MANAGEMENT
Preoperative Planning
■ A complete clinical assessment of the patient in particular of the orbit and
periorbital structures.
■ A good understanding of the mechanism of injury, of which structures are
thought to be affected, and of the status of previous injuries to the area is vital.
■ If any visual abnormalities are found or suspected, an ophthalmology
consultation and a written assessment are crucial. If vision is normal, this
should also be documented.

■ CT scan images of the orbital floor fracture, including coronal and sagittal
reconstruction from the axial images. The location and extent of the orbital
floor fractures should be documented preoperatively.
■ A forced duction test comparing the injured eye with the contralateral side.
FIG 3 • A. Coronal CT scan image showing left orbital
floor blow-out including opacification of maxillary sinus.
B. Sagittal CT image of orbital blow-out fracture. C.
Axial CT image showing fracture of left orbital floor.

Orbital rim is intact. D. Bone image CT showing left
orbital blow-out fracture.
■ Tetracaine 0.5% drops may be required for local anesthesia.
■ There are many types of materials that have been used that include, but are not
limited to, autogenous bone graft, titanium mesh, porous polyethylene, porous
polyethylene incorporated into a titanium mesh, gel foam, supramid cartilage,
dermal fat grafts, etc.
■ Our choice, at present, in a noncomplicated orbital blowout fracture, is to use
porous polyethylene-coated titanium mesh.
■ The thickness of the orbital implant is also important to keep in mind. There
are thinner and thicker orbital implants, depending on the amount of the
disruption of the floor and the need to elevate the globe to a certain level.
■ The implant should be curved and fashioned to conform to the shape of the
orbital floor. If the fracture extends to the medial or lateral walls, the implant
can be curved to fit those extensions.
Positioning
■ The patient is placed in a supine position.
■ A shoulder roll is placed under both shoulders for gentle hyperextension of the
neck. Both eyes and midfacial structures are exposed for evaluation and
comparison.
■ A corneal protective lens is placed on the affected side and usually on the
contralateral side. The lens can be removed to check globe position and to
perform ocular motility exams.
Approach
■ A subconjunctival approach provides good exposure for the orbital floor.
■ A subciliary incision is preferred for more extensive fractures of the floor.
■ A canthotomy can be used with a subconjunctival incision for improved
exposure.
T E C H N I Q U E S

Video p2-c054
■ Dissection of the Orbital Floor
■ Inject the lower eyelid, extending to the orbital rim, with lidocaine 1% with
epinephrine 100 000.
■ Perform a forced duction test and tactically evaluate globe pressure for
future reference.
■ The subconjunctival incision—at least 4 mm below the internal subciliary
margin—is made with a Colorado Bovie tip set at 12 (TECH FIG 1A,B).
■ A preseptal dissection is used to reach the orbital rim without penetrating the
orbital septum or the fat pockets (TECH FIG 1C,D).
■ The orbital rim periosteum is incised with cautery (TECH FIG 1E).
00:00 / 00:00

TECH FIG 1 • A. Incision is made in the conjunctiva
with Bovie tip. B. Lateral view of cauterization of the
conjunctiva. C. The septum is exposed. D. Lateral
view of preseptal dissection. E. The septum is

dissected and the periosteum is incised with cautery.
F. The fracture is exposed and the periosteum
elevated.
■ The orbital periosteum is dissected with a periosteal elevator.
■ Avoid further disruption of the delicate orbital floor.
■ Visualize the infraorbital nerve and keep it out of harm’s way.
■ Expose the fracture and tease out the herniated contents and retrieve them
back into the orbit (TECH FIG 1F).
■ Continue the dissection posteriorly, measuring the distance from the orbital
rim every so often, in order to note how close to the orbital apex the
dissection has proceeded.
■ Dissect posteriorly until the hard, bony ledge of the posterior orbit.
■ The synthetic or bone implant must rest on this area to avoid prolapse into
the maxillary antrum.
■ Implant Placement and Completion
■ When dissection of the floor is complete, with visualization of the fracture, a
decision is made about the reconstruction material.
■ The defect is measured and the implant is tailored to fit the defect.
■ The implant must sit on the posterior orbital ledge with extension to the
orbital rim for fixation (TECH FIG 2).
■ Once the implant is positioned, another forced duction exam is conducted to
determine any restrictions in globe mobility.
■ Both globes are then compared for symmetry.

TECH FIG 2 • A. Implant is positioned on the posterior
orbital ridge and fixated to the orbital rim. B. Lateral
view of implant in place.
■ The reconstructed globe may be higher than the normal globe due to
swelling.
■ The surgical site is irrigated with normal saline and hemostasis obtained.
■ Closure consists of approximating periosteal layers over the implant.
■ The conjunctiva is sutured with interrupted, buried 5-0 catgut sutures.
■ Some surgeons do not repair the conjunctiva; however, closure may avoid
the risk of entropion.
■ Ophthalmic antibiotic ointment is applied to the conjunctiva and eyelid.
PEARLS AND PITFALLS
Implant
placement
■ Check the position of the implant to be certain it has not been
displaced prior to closure.
■ Conduct a forced duction test after placement of the implant.
■ Fixation of the implant at the orbital rim will prevent implant
dislodging.

■ Close the periosteum over the implant to minimize palpability and
decrease exposure or infection.
Side-to-side
comparison
■ Compare the final position of the operated globe with the
contralateral side. The operative site will have a more elevated
globe position due to swelling.
■ Digital palpation of both globes before and after completion of
surgery will determine that both globes are soft and within normal
limits.
Postoperative
care
■ Check vision, globe pressure, and degree of pain control in the
early postoperative period in the recovery room.
FIG 4 • A. Postoperative CT scan showing repair of
orbital floor fracture (arrow). B. Sagittal CT image
showing floor reconstruction with titanium plate in
position. C. 3D CT image showing left orbital floor
repair. D. Axial CT image showing repair of orbital floor
with titanium plate.
POSTOPERATIVE CARE

■ Preoperative IV antibiotics are given and maintained for 24 hours
postoperatively.4,5
■ The position of the implant needs to be verified by CT in the postoperative
period (FIG 4).
OUTCOMES
■ The use and incorporation of alloplastic materials in the orbit have been shown
to be of great benefit (FIG 5).
■ These implant materials have better results than autogenous bone grafting.
■ They maintain their shape, thickness, and size.
■ Their porous nature helps vascular integration and decreases the chance of
infection.3
COMPLICATIONS
■ Acute complications include retrobulbar hematoma, sudden blindness,
increased pain, and pressure in the globe.
■ These all require immediate attention with release of sutures and a return to
the operating room for further evaluation.6

FIG 5 • Six-month postoperative views. A. Patient
looking forward. Note symmetry of globes without
dystopia. B. Patient looking up, showing good
extraocular muscle function. C. Patient looking down.
He describes no diplopia. D. Patient from below
showing no evidence of enophthalmos.
■ Long-term complications include infection, migration or displacement of the
implant, exposure and palpability of the implant, residual enophthalmos,
diplopia, dystopia, and ocular motility problems.3
■ With any of these complications, a CT scan should be conducted in the early
postoperative period.
REFERENCES
1. Smith B, Regan WF Jr. Blowout fracture of the orbit: mechanism and
correction of internal orbital fracture. Am J Ophthalmol. 1957;44:733-739.
2. Converse JM, Smith B. On the treatment of blow-out fractures of the orbit.
Plast Reconstr Surg. 1978;62:100-104.
3. Kirby EJ, Turner JB, Vasconez HC. Orbital floor fractures: outcomes of
reconstruction. Ann Plast Surg. 2011;66:5018-5512.
4. Classen DC. The timing of prophylactic administration of antibiotics and the
risk of surgical-wound infection. N Engl J Med. 1992;326:281-286.
5. Courtney DJ, Thomas S, Whitfield PH. Isolated orbital blowout fractures:
survey and review. Br J Oral Maxillofac Surg. 2000;38:496-503.
6. Gart MS, Gosain AK. Evidence-based medicine: orbital floor fractures. Plast

Reconstr Surg. 2014;134:1345-1355.

55
CHAPTER
Correction of Lateral Orbital
Wall Fractures
Parit A. Patel
DEFINITION
■ Of the seven bones that make up the orbit, the lateral orbit is composed mainly
of the zygomatic bone.
■ Fractures of the lateral orbit can result in expansion of the orbital volume
with subsequent enophthalmos and orbital dystopia.
■ Open reduction and internal fixation of the orbit restore the anatomy of the
orbit and orbital volume. To restore the orbital volume successfully, the
surgeon must have comprehensive understanding of the intricate anatomy of
the orbit and surgical approaches to the orbit.
ANATOMY
■ The orbit is a cone-shaped structure with a fixed volume.
■ The seven bones that compromise the orbit include the sphenoid, maxilla,
zygoma, frontal, ethmoid, lacrimal, and palatine.
■ The contents of the orbit include the globe, extraocular muscles, cranial nerves
II to VI, ophthalmic artery and other minor vessels, orbital fat, orbital septum,
medial and lateral canthal tendons, check and suspensory ligaments, ciliary
ganglion, lacrimal gland and sac, and nasolacrimal duct.
■ The optic canal contains the optic nerve and ophthalmic artery. The superior
orbital fissure contains cranial nerves III, IV, and VI. The inferior orbital
fissure contains the infraorbital artery and vein and branches of the maxillary
nerve.
■ Orbital volume in the adult patient has been demonstrated to be 21.31 ± 2.50
cm3.1
■ Fractures of the lateral orbital wall can cause orbital volume expansion.

Fractures greater than 2.0 cm2 can result in orbital expansion and clinically
relevant enophthalmos.
■ Fractures of the lateral orbital wall occur at the zygomatic sphenoid (ZS)
suture, the greater wing of the sphenoid or the zygoma. The zygomatic portion
of the orbit is the thickest bone of the orbit.
■ Indications for treatment include clinically relevant expansion of the orbital
volume with resulting enophthalmos and diplopia. Patients can also have blow-
in fractures of the lateral orbit with associated proptosis.
■ The lacrimal apparatus is important for tear production and drainage.
■ The lacrimal apparatus consists of the lacrimal gland, which is located in the
superolateral aspect of the orbit and produces tears.
■ The lacrimal canaliculi, lacrimal sac, and nasolacrimal duct are important
structures for draining tears into the nose (FIG 1).
PATHOGENESIS
■ Lateral orbital fractures occur from significant force to the craniofacial
skeleton due to trauma.
■ Impure fractures involve a fracture within both the orbit and the orbital rim.
■ Pure orbital fractures involve isolated fractures within the orbit.
• The incidence of pure lateral orbital fractures is low, approximately 1% of
all orbital fractures.2
■ Lateral orbital fractures most commonly occur at the ZS suture and can be
associated with zygomatic maxillary complex (ZMC) fractures.
■ Fractures of the orbit can result in expansion of the orbital volume resulting in
enophthalmos.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The patient usually presents with a history of significant facial trauma.
■ Associated signs and symptoms include periorbital pain, swelling,
ecchymosis, dysesthesia, diplopia, and/or enophthalmos.

FIG 1 • Lacrimal apparatus.
■ The patient can also have associated facial fractures that can be identified on
physical examination with bony step-offs, gross facial asymmetries, and
malocclusion.
■ Enophthalmos can be identified using a Hertel exophthalmometer.
■ For every 1-cm3 volumetric increase in the orbital volume, enophthalmos
increases by an increment of 0.89 mm.3
■ It can be difficult to assess enophthalmos in the acute setting because of
periorbital swelling.
■ The treating surgeon should be aware of surgical emergencies related to
trauma to the orbit such as globe rupture, hyphema, entrapment, or a
retrobulbar hematoma. In the setting of entrapment, there is restriction of
movement of the globe.
■ The clinical findings of a retrobulbar hematoma include severe ocular pain,
visual acuity disturbance, and proptosis.

■ There should be a low threshold for involving ophthalmology in situations of
significant trauma to the periorbital region.
■ Traumatic superior orbital fissure syndrome, although rare, can occur with
lateral orbital wall fractures and is associated with ophthalmoplegia, proptosis,
eyelid ptosis, a fixed and dilated pupil, and anesthesia in the ipsilateral
ophthalmic branch of the trigeminal nerve. Orbital apex syndrome has a similar
presentation; however, the patient additionally has visual loss from optic nerve
injury.
IMAGING
■ A CT scan of the face confirms clinical findings associated with facial
fractures.
■ The axial images will demonstrate the fracture of the lateral orbital wall and
other related fractures, such as a ZMC fracture.
■ The coronal images will demonstrate the size of the defect, which can be
measured to assist in determining the indications for surgery.
■ Sagittal images can help determine the posterior extent of the fracture and
assist in sizing the implant or graft.
NONOPERATIVE MANAGEMENT
■ If the fracture is less than 2.0 cm2 and there are no signs of acute
enophthalmos, the patient can be managed nonoperatively and monitored
closely for development of enophthalmos and/or diplopia. There is
approximately a 4- to 6-week window to treat the patient before the diplopia
may require surgical correction.
■ If the orbital fracture defect is marginal, the patient can be monitored until the
swelling subsides to evaluate for enophthalmos.
■ After resolution of swelling, if the patient has no signs or symptoms of
enophthalmos or diplopia, surgery is not required.
■ If there is a nondisplaced fracture of the zygomatic portion of the lateral
orbital wall or at the ZS suture, the patient can be managed nonoperatively.
■ Isolated fractures of the greater wing of the sphenoid, even with mild
displacement, can be managed nonoperatively.
SURGICAL MANAGEMENT
■ If the patient is stable, it is ideal to repair the orbital fracture in the first 24 to
48 hours.

■ Beyond that time, there is maximal swelling that makes the operation and
surgical approach more difficult.
■ If the fracture is of marginal size and the patient does not have evidence of
clinically relevant enophthalmos, the surgeon can wait 2 weeks to monitor
and determine if surgery is indicated.
■ Beyond 4 to 6 weeks, symptoms such as diplopia can be permanent and
require strabismus surgery for correction.4,5
■ The objective of surgical intervention is to restore the anatomy of the orbit and
the premorbid orbital volume. This prevents development of facial
asymmetries related to enophthalmos or orbital dystopia. Furthermore,
operative repair reduces the risk of developing strabismus and diplopia in the
subacute phase or long term.
■ Operative repair involves a surgical approach to the orbit through either a
transconjunctival approach or a transcutaneous approach (ie, subciliary or
midlid incision). Once in a subperiosteal plane, the periorbita is dissected free
from the underlying bony orbit.
■ Fractures of the lateral orbital wall occur most commonly at the ZS suture.
The fracture can be comminuted and have an associated defect or be a linear
fracture at the ZS suture or through the zygomatic bone.
■ Depending on the extent of the fracture, the fracture can be repaired without
bony fixation or with a titanium plate. If a sizeable defect is present, the
lateral orbit can be reconstructed with an alloplastic orbital implant, mesh
plate, or bone graft. If the fracture of the lateral orbit is associated with a
ZMC fracture, the fracture at the ZS suture can be used to verify the reduction
of the ZMC segment, with or without plate fixation.
■ After open reduction and internal fixation, the lower lid is reconstructed
appropriately to minimize the risk of ectropion, entropion, or lower lid
malposition.
■ All orbital fractures, including the lateral orbit, can be accessed through a
transconjunctival approach to the orbit. A lateral cantholysis incision can be
performed for additional access to the lateral orbital rim.
Preoperative Planning
■ Risks and complications must be discussed with the patient and family. Risks
include injury to the globe, postoperative enophthalmos, proptosis, orbital
dystopia, persistent diplopia, visual acuity changes, postoperative entrapment,
implant migration/infection, ectropion, entropion, and lower lid malposition.

■ Orbital implants and an orbital/midface plating system should be available.
■ Radiographic imaging should be available in the operating room for reference.
Positioning
■ The patient is positioned supine with a shoulder roll in place.
■ The operating table is positioned in Trendelenburg to maximize visualization
of the orbit.
Approach
■ The author recommends a transconjunctival approach to the orbit due to the
ability to avoid external scars on the skin, ease of additional access to the
lateral orbital rim with a lateral cantholysis from the same surgical field, and
reduced rates of ectropion compared to other approaches.6
T E C H N I Q U E S
■ Markings
■ Needle-tip electrocautery is used to mark the conjunctiva 2 to 3 mm below
the caudal aspect of the tarsal plate with a dotted line.
■ The medial aspect of the marking should be lateral to the punctum.
■ If a lateral cantholysis is needed, a marking is made at the lateral aspect of
the palpebral fissure.
■ Corneal shields are placed to protect the globe, and retraction sutures are
placed in the lower eyelid at the gray line.
■ With gentle traction, the lower lid is everted and pulled away from the globe.
■ Local anesthetic, 50:50 mix of 1% lidocaine with epinephrine 1:200 000 and
0.5% Marcaine plain, is infiltrated into the lower lid conjunctiva and
advanced deep to the orbital rim.
■ Exposure
■ The conjunctiva and lower lid retractors are incised with needle-tip
electrocautery on the pure-cut setting.

TECH FIG 1 • Surgical markings for the
transconjunctival approach.
■ With countertraction, the conjunctiva and lower lid retractors are pulled
away from the lower lid (TECH FIG 1).
■ The dissection continues caudally in the areolar plane between the lower
lid retractors and the orbicularis oculi muscle (TECH FIG 2A).
■ The dissection continues sharply in the preseptal plane to the arcus
marginalis (TECH FIG 2B).
■ The arcus marginalis is incised; in a subperiosteal plane, the periorbita is
elevated from the orbital rim and orbital floor.
■ A periosteal elevator is used to continue the dissection posterior into the
orbit. The periorbita is dissected free from the fracture (TECH FIG 2C).
■ Orbital retractors, including a Desmarres retractor (shown in TECH FIG
2D) and malleables are used for continued exposure of the orbital floor and
lateral orbital wall.

■ The dissection needs to continue into the orbit to identify the posterior
ledge of the lateral orbital wall fracture (TECH FIG 2D).
TECH FIG 2 • A. Dissection between the lower lid
conjunctiva and lower lid retractors. B. Anatomy of the
arcus marginalis of the orbital rim and needle-tip Bovie
incising the arcus marginalis. C. A periosteal elevator
is used to dissect the periorbita free from the fracture

in a subperiosteal plane. D. Desmarres retractor is
used in combination with malleables to retract the
periorbital contents to visualize the lateral oribtal wall
fracture and posterior fracture edge at the level of the
zygomatic sphenoid suture.
■ Fracture Repair
■ If there is a comminuted fracture and a defect of the lateral orbital wall, a
template is made of the defect, which is used to contour the orbital implant or
mesh plate.
■ The implant can be fixated to the lateral orbital rim with a plate and or
screw (TECH FIG 3).
■ If the lateral orbital wall fracture is associated with a ZMC fracture, the
fracture at the ZS suture can be used as a reference point for adequate
reduction of the ZMC fracture.
■ A mini-titanium plate can be placed at the ZS suture.
■ Ensure hemostasis and irrigate with saline.
■ The globes should be assessed for symmetry and to rule out enophthalmos,
proptosis, hyperglobus, or hypoglobus.
■ Perform a forced duction test to verify that the implant is not entrapping
tissue and restricting eye movement.
■ The pupils should be evaluated throughout the case to verify that there is no
compression on the optic nerve.

TECH FIG 3 • Orbital implant contoured and placed
over the bony defect and secured in place with two
screws at the orbital rim.
■ Lateral Cantholysis and Completion
■ If the lateral orbital rim is involved, a lateral cantholysis can be performed
for additional access.
■ The lateral palpebral fissure is incised sharply down to the lateral canthal
tendon.
■ The inferior limb of the tendon is incised sharply until the lower lid is
dissected free and mobile (TECH FIG 4A).
■ The periosteum is incised sharply, and with a periosteal elevator, the soft
tissue is elevated from the lateral orbital rim (TECH FIG 4B).
■ If there is a fracture of the lateral orbital rim and displacement, the fracture
fragments require reduction and fixation with plates and screws.
■ If a lateral cantholysis is performed, the lateral canthal tendon will require
reconstruction.

TECH FIG 4 • A. Lateral cantholysis incision at the
lateral palpebral fissure and through the inferior limb
of the lateral canthal tendon. B. Needle-tip
electrocautery incising the periosteum of the lateral
orbital rim. C. Reconstruction of the lateral canthal
tendon with plating.
■ A 4-0 Polydek suture is used to suture the lower lid to the superior limb of
the lateral canthal tendon and periosteum on the inside of the lateral orbital
rim (TECH FIG 4C).
■ The conjunctival incision is closed with buried simple interrupted 6-0 fast
gut suture.
■ The corneal shields are removed and the globes irrigated with balanced salt
solution.
■ A Frost stitch is placed in the lower lid and secured to the forehead to
support the lower lid postoperatively.
■ In the postanesthesia care unit, visual acuity and the extraocular muscles are
evaluated.
PEARLS AND PITFALLS
Physical
findings
■ It can be challenging to determine when to operate on marginal
orbital wall defects.
■ For defects larger than 2.0 cm2, operative repair is indicated.

■ For defects less than 2.0 cm2, the patient can be monitored for
signs of enophthalmos, and operative repair can be delayed for up
to 4–6 weeks after injury.
Technique
■ The transconjunctival approach is the author’s preferred technique
due to the ability to avoid a scar on the face and the lower
incidence of ectropion or lower lid malposition.6
■ During the lower lid dissection, avoid entering the septum to
minimize herniation of orbital fat into the operative field. The
inferior oblique muscle can be injured if the septum is violated.
■ Perform a forced duction test after placement of the implant and
examine the pupils periodically throughout the operation.
Postoperative
care
■ Evaluate visual acuity and the extraocular muscles.
■ Support the lower lid with a Frost stitch or temporary tarsorrhaphy
stitch to avoid lower lid malposition.
POSTOPERATIVE CARE
■ Remove the Frost stitch on postoperative day 5.
■ Ophthalmic bacitracin to the lateral cantholysis incision if performed.
■ Lower lid and scar massage can be started at 4 weeks as needed.
OUTCOMES
■ The incidence of postoperative enophthalmos has been reported to be as high
as 27.5% and the incidence of postoperative diplopia, 42.5%. Operative repair
before 2 weeks reduces the incidence of postoperative diplopia.7
■ The incidence of infraorbital nerve dysfunction or hyperesthesia has been
noted in 55% of patients postoperatively.7
■ The highest rates of lower lid ectropion and revision surgery are associated
with the subciliary approach (19.9%). Moreover, the lower lid scar was
noticeable and found to have an unacceptable result in 43% of patients.6
■ Of the three surgical approaches to the orbit, the subtarsal incision has the
second highest complication rate and the transconjunctival approach has the
lowest.6,8
■ Hardware extrusion, malposition, or infections related to orbital fractures are
exceedingly rare.7
COMPLICATIONS
■ Persistent diplopia after surgical repair can occur and may require further

revision surgery.9
■ Postoperative enophthalmos can occur due to expansion of orbital volume,
prolapse of tissue into the orbital defect, and fat atrophy. This situation requires
revision surgery if clinically evident. Orbital dystopia can also occur
postoperatively if there is inadequate reduction of the lateral orbital wall
fracture when associated with a ZMC fracture.7
■ Infraorbital nerve dysesthesia can occur from traumatic injury secondary to the
fracture or by iatrogenic means.7
REFERENCES
1. Wi JM, Sung KH, Chi M. Orbital volume restoration rate after orbital fracture,
a CT-based orbital volume measurement for evaluation of orbital wall
reconstructive effect. Eye. 2017;13:1-7.
2. Boffano P, Roccia F, et al. Diplopia and orbital wall fractures. J Craniofac
Surg. 2014;25:183-185.
3. Fan X, Li J, Zhu J, et al. Computer-assisted orbital volume measurement in
the surgical correction of late enophthalmos caused by blowout fractures.
Ophthal Plast Reconstr Surg. 2003;19:207-211.
4. Harris GJ. Orbital blow-our fractures: surgical timing and technique. Eye.
2006;20:1207-1212.
5. Dal Canto AJ, Linberg JV. Comparison of orbital fracture repair performed
within 14 days versus 15 to 29 days after trauma. Ophthal Plast Reconstr Surg.
2008;24:437-443.
6. Kothari NA, Avashia YJ, Lemelman BT, et al. Incisions for orbital floor
exploration. J Craniofac Surg. 2012;23:1985-1989.
7. Brucoli M, Arcuri F, Cavenaghi R, et al. Analysis of complications after
surgical repair of orbital fractures. J Craniofac Surg. 2011;22:1387-1390.
8. Ridgway EB, Chen C, Colakoglu S, et al. The incidence of lower eyelid
malposition after facial fracture repair: a retrospective study and meta-analysis
comparing subtarsal, subciliary, and transconjunctival incisions. Plast Reconstr
Surg. 2009;124:1578-1586.
9. Kim JS, Lee BW, Korn BS, et al. Secondary orbital reconstruction in patients
with prior orbital fracture repair. Ophthal Plast Reconstr Surg. 2016;32:447-
451.

56
CHAPTER
Medial Orbital Wall
Fractures
Brad M. Gandolfi, Reena Bakshi, and Reza Jarrahy
DEFINITION
■ Medial orbital wall fractures are traumatic injuries of the orbit that
compromise the integrity of the medial orbital wall.
■ These typically occur at the lamina papyracea, the thin central portion of the
medial orbital wall, and may involve herniation of periorbital soft tissues into
the adjacent ethmoid sinuses.
ANATOMY
■ The anatomy of the orbit represents a complex interplay between bony
structures and their associated soft tissues.1–5
Bony Anatomy
■ The overall configuration of the bony orbit is pyramidal, with walls that are
curvilinear.
■ The height of the orbit averages 35 mm, with an average width of 40 mm.
■ The distance from the midpoint of the inferior orbital rim to the orbital apex
measures approximately 45 mm.
■ The medial orbital wall is the thinnest wall of the orbit. It is primarily
composed of the lacrimal bone anteriorly and the orbital plate of the ethmoid
bone posteriorly.
■ These structures are closely related to the orbital processes of the frontal,
sphenoid, maxillary, and palatine bones.
■ Ethmoid bone:
■ The orbital plate of the ethmoid bone accounts for the largest portion of the
medial orbit wall. It is also the thinnest portion of bony orbit.

■ The thin curved central area of this bone is referred to as the lamina
papyracea. Due to its thin nature, most medial orbital wall fractures occur
through the lamina papyracea, as opposed to the thicker anterior and posterior
portions of the medial orbit.
■ An extensive labyrinthine network of honeycomblike pneumatized air cells
forms the ethmoid sinus medial to the lamina (FIG 1A).
■ Frontal bone:
■ The orbital process of the frontal bone articulates with the ethmoid bone in
the superior and posterior portion of the bony orbit.
■ The frontal bone is thicker than the lamina papyracea, providing protection to
adjacent intracranial structures.
■ The roof and medial wall of the orbit meet at the frontoethmoidal suture. The
anterior and posterior ethmoidal arteries, branches of the ophthalmic artery,
enter the orbit through their respective foramina in the frontoethmoidal suture
(FIG 1B).
■ The anterior ethmoid foramen is located approximately 15 mm posterior to
the medial orbital rim and the posterior foramen is located approximately 10
mm further posteriorly.
■ Disruption of the anterior and/or posterior ethmoid arteries contributes to
hemorrhage in the setting of medial orbital wall fractures.
■ Lacrimal bone:
■ The lacrimal bone is related to the anterior and inferior aspects of the
ethmoid bone.
FIG 1 • A. Skull model demonstrating the thin nature of
the lamina papyracea and the network of ethmoid air

cells lying medial to the orbit. B. The anterior and
posterior ethmoid foramen are located on the
frontoethmoidal suture.
■ The central portion of the lacrimal bone is characterized by a depression—the
lacrimal fossa—that contains the lacrimal sac. This central recessed portion of
the lacrimal bone is surrounded by the anterior and posterior lacrimal crests.
■ The medial canthal tendon inserts onto the anterior and posterior lacrimal
crests.
■ Sphenoid bone:
■ The sphenoid bone abuts the posterior edge of the orbital plate of the ethmoid
bone.
■ It delineates the most posterior portion of the medial orbital wall and defines
the optic foramen in the orbital apex.
Soft Tissue Anatomy
■ Knowledge of the soft tissue anatomy of the medial orbit is necessary to safely
and effectively manage medial orbital wall fractures without inadvertently
injuring surrounding critical structures.
■ Lacrimal caruncle and plica semilunaris (semilunar fold):
■ The lacrimal caruncle sits at the medial corner of the eye between the upper
and lower eyelids, in close proximity to the medial canthal tendon. It is a
fleshy nodule that contains sebaceous and sweat glands that help maintain
normal ocular physiology.
■ It serves as a useful anatomical landmark for surgical approaches to the bony
orbit.
■ The plica semilunaris is a fold of conjunctiva that sits between the caruncle
and medial sclera. The plica assists in normal tear function and facilitates
movement of the globe (FIG 2A).
■ Medial canthal tendon:
■ The medial canthal tendon is associated with the orbicularis oculi muscle and
defines the shape and position of the medial poles of the upper and lower
eyelids.

FIG 2 • A. The caruncle (blue arrow) and plica
semilunaris (red arrow) help regulate normal ocular
physiology and globe movement. The puncta on the
upper and lower lids (circled) drain the eye. B. Sagittal
section at the level of the attachment of the medial
canthal tendon to the lacrimal crest. The medial canthal
tendon splits into anterior and posterior components,
enveloping the lacrimal sac and canaliculi. C.
Relationship between the caruncle (C), puncta (P), the
lacrimal apparatus, and the plica semilunaris. The
medial canthal tendon has been removed to show the

anatomy. The lacrimal fossa (outlined in D) houses the
lacrimal sac, which drains through the nasolacrimal duct
(E).
■ The tendon originates from fascial extensions of the upper and lower tarsal
plates and divides into three limbs that insert in a fanlike fashion onto the
medial orbital wall.
■ Disruption of the medial canthal tendon from its bony insertions can have a
significant deleterious effect on ocular function and aesthetics (FIG 2B).
■ Anterior limb:
■ The anterior limb of the medial canthal tendon inserts onto the anterior
lacrimal crest and forms the bulk of the tendon.
■ The pretarsal, preseptal, and orbital orbicularis fibers insert onto the anterior
limb.
■ Superior limb: The superior limb of the medial canthus extends over the
lacrimal sac and covers its anterior and superior portions.
■ Posterior limb:
■ The posterior limb of the medial canthal tendon inserts onto the posterior
lacrimal crest.
■ Although not as robust as the anterior limb, its posterior vector is integral in
maintaining apposition of the upper and lower lids to the globe.
■ It is closely related to the Horner muscle, a slip of the lacrimal portion of the

orbicularis oculi muscle, which contributes to regulation of normal lacrimal
flow.
■ Lacrimal system:
■ Puncti: The superior and inferior puncti serve as the primary site of drainage
for the eye. They are located approximately 5 to 7 mm lateral to the medial
canthal angle (circled in FIG 2A). The upper lid punctum is usually
positioned 1 to 2 mm more medial than the lower lid punctum. The majority
of tear volume is drained through the lower lid.
■ Canaliculi: The canaliculi connect the puncti to the lacrimal sac. The
ampullae are the vertical components of the canaliculi and are located directly
beneath the puncti. The ampullae measure 2 mm in length on average. The
canaliculi then turn sharply and extend medially along the border of the
eyelid. They merge into a single duct before entering the lacrimal sac (FIG
2C).
■ Lacrimal sac: The lacrimal sac is located within the lacrimal canal of the
lacrimal bone between the anterior and posterior lacrimal crests and the
anterior and posterior limbs of the medial canthal tendon (FIG 2C–E). It is
partially covered by the superior limb of the medial canthal tendon and
extends 5 mm superior to this structure. The sac continues into the
nasolacrimal duct at the base of the lacrimal fossa, which continues through
an intraosseous tunnel to drain into the nose lateral to the inferior nasal
turbinate through the inferior meatus.
■ Medial rectus muscle: The medial rectus muscle originates at the annular
tendon, a fibrous ring surrounding the optic canal at the orbital apex. It inserts
onto the medial surface of the globe and is innervated by the inferior division
of the oculomotor nerve. Its primary function is to medially adduct the
eyeball. Due to its location in the medial orbit, the medical rectus muscle is
vulnerable to entrapment in a blow-out fracture through the medial orbital
wall.
PATHOGENESIS
■ Medial orbital fractures typically result from direct blunt trauma to the orbit.
Mechanical energy transmitted to the medial orbital wall and/or hydraulic
retropulsion of the globe into the orbit can cause structural damage to the
medial orbital wall, particularly at the thin lamina papyracea.6
■ Fractures of the medial orbital wall can play a protective role: absorption of
energy by bone limits energy transfer to the orbital soft tissues, decreasing the

likelihood of traumatic globe rupture.
NATURAL HISTORY AND PHYSICAL FINDINGS
■ Symptoms of medial orbital wall fractures include pain with extraocular
muscle movement, ecchymoses, and periorbital edema. Physical examination
findings include diplopia, enophthalmos, crepitus, visible or palpable medial
orbital rim irregularities, and telecanthus.
■ Cerebrospinal fluid leakage and epistaxis can also be seen in severe orbital
injuries that involve adjacent intracranial or nasal structures.
■ A formal ophthalmological evaluation should be performed to assess baseline
ocular function. The ophthalmologist should document a complete
examination, including assessment of visual acuity, pupillary reactivity,
anterior and posterior ocular chambers, and extraocular muscle function. In the
setting of medial rectus muscle entrapment, restriction of extraocular
movements may be observed.
IMAGING
■ Plain film radiography is of limited value in the assessment of medial wall
fractures, although disruption of the medial orbit and opacification of the
ethmoid sinus can sometimes be detected on x-ray.
■ Fine-cut axial CT scan with mutiplanar reconstruction has great sensitivity and
specificity for identifying medial orbital wall fractures. Two-dimensional axial
and coronal views can accurately image the disruption of the medial orbital
wall and demonstrate herniation of periorbital soft tissues into the ethmoid
sinuses (FIG 3A,B).
■ Three-dimensional (3D) reconstructions of orbital CT scans are generally not
helpful in diagnosing medial orbital wall fractures. The algorithms used by
most 3D imaging software programs currently do not provide adequately
detailed renderings of the surface anatomy of the thin curved medial orbital
wall7 (FIG 3C,D).

FIG 3 • Axial (A) and coronal (B) computed tomography
(CT) imaging of the orbit demonstrating fracture of the
(right) medial orbital wall with herniation of periorbital
soft tissues into the ethmoid sinus (circled). C,D. 3D
rendering of the same injury does not provide a detailed
anatomic picture.
DIFFERENTIAL DIAGNOSIS
■ Direct trauma to the eye resulting in medial orbital wall fractures can also
cause injury to other parts of the orbit. Orbital floor fractures and, more rarely,
orbital roof fractures can present with edema, ecchymosis, enophthalmos, and
diplopia.
■ Injuries to surrounding structures may also present in similar fashion,
including fractures of the nasal bones, anterior cranial base, frontal sinus, and
naso-orbitoethmoidal (NOE) complex.
■ The pain and ophthalmoplegia of superior orbital fissure syndrome can mimic
the discomfort and restriction of gaze associated with medial rectus
entrapment.

NONOPERATIVE MANAGEMENT
■ In some circumstances, medial orbital wall fractures can be managed
nonoperatively. In the setting of a small defect without diplopia, significant
enophthalmos, or medial rectus entrapment, observation is a reasonable option.
■ Principles of nonoperative management include head elevation, application of
ice cold compresses, and minimizing increased intraorbital pressure by
avoiding nose blowing and other Valsalva maneuvers for 4 to 6 weeks
following the injury.
SURGICAL MANAGEMENT
■ Open repair of medial orbital wall fractures is indicated in the setting of large
bony defects, early or persistent enophthalmos with associated diplopia, or
medical rectus muscle entrapment.
■ The goals of surgical management are release of any entrapped orbital soft
tissues, replacement of periorbita into the bony orbit, restoration of orbital
domain, and correction of enophthalmos and diplopia.
■ A variety of approaches to the medial orbit have been described, each with its
specific advantages and disadvantages6,8 (Table 1). Similarly, there are a
variety of materials that may be used to repair the medial wall defect9 (Table
2). These are discussed in detail elsewhere in this text. The authors’ preferred
technique is a transcaruncular approach to the medial orbit with autologous
split calvarial bone graft repair. Autologous bone harvest adds little additional
time, cost, or morbidity to the operation. In skilled hands, harvesting
autologous bone should be quick, straightforward, safe, and cost efficient.10
■ Split calvarial bone grafts are taken from the parietal region. Here, the diploic
space is well formed and the calvarial bone is consistently thick, particularly in
the central 8 × 10 cm of the parietal bone.
Preoperative Planning
■ The patient should be thoroughly informed of risks, benefits, and expected
outcomes of the procedure, including the possibility of persistent diplopia,
postoperative enophthalmos, or loss of vision.
■ Preoperative CT scans should be used to plan the surgical intervention and
should be available for review during the procedure.
■ Surgery should be performed after resolution of acute postinjury inflammation
and edema. Early intervention has been previously recommended, but recent

evidence has shown that delayed repair of orbital fractures can be equally
effective.11
■ Fine ophthalmological instruments are helpful in manipulating the soft tissues
of the eyelids and medial orbit.
Positioning
■ The patient is placed on the operating room table in the supine position. A
shoulder roll is placed to obtain slight neck extension. This is deferred if the
patient is under cervical spine precautions.
Table 1 Approaches to the Medial Orbital Wal
Approach
Advantage
Disadvantage
Major Indication
Coronal
Full exposure of
the superior and
medial orbit
Higher level of
invasiveness;
extensive external
scar; risk to
temporal nerve;
significant
postoperative
edema
Complex
fractures
involving orbit
and surrounding
structures; NOE
fractures
Medial
transcutaneous
(Lynch incision)
Direct and wide
exposure of
entire medial
orbital wall
Risk of injury to
medial canthal
tendon and
lacrimal structures
Resection of
large lesions
involving the
nose and ethmoid
sinus
Transcaruncular
No skin incision
Limited access to
larger defects
involving the
orbital floor
Isolated medial
orbital injuries
Transconjunctival
with
transcaruncular
extension
Wide exposure of
the orbital floor
and medial orbital
wall
Larger incision
with greater risk of
conjunctival
scarring and
ectropion/ectropion
Orbital wall
injuries involving
both the floor and
the medial orbital
wall
Transnasal
endoscopic
No incisions
Requires
endoscopic
equipment and
Small to medium-
sized isolated
medial orbital

expertise;
potentially difficult
reduction of soft
tissues; limited
reconstructive
options; no direct
access to orbit
fractures
Table 2 Comparison of Commonly Used Reconstructive Materials for
Orbital Wall Repair
Implant Type
Advantages
Disadvantages
Split autologous bone
graft (calvarium, rib,
iliac)
Readily available;
osteoconductive; minimal
scarring in revision
setting; radiopaque; most
cost-effective
Unpredictable resorption;
added donor site
morbidity; not advisable
with intracranial injury or
thin bones (eg, elderly
patients)
Porous polyethylene
Moldable; soft tissue
ingrowth stabilizes
position
Difficult to remove (dense
adhesions to orbital soft
tissues); possible higher
infection rate; high cost
Titanium
Moldable; easy to use;
low infection rate
Difficult to remove (dense
adhesions to orbital soft
tissues); high cost;
unclear safety profile in
children
Absorbable plates
Easily moldable; minimal
infection rate; low
adhesion profile in
revision setting
Cost; less applicable to
large defects
Custom 3D-printed
implant
Custom design for most
accurate fit over defect
Cost; requires presurgical
virtual surgical planning
session; infection risk
unclear; long-term
outcomes unclear
T E C H N I Q U E S

■ Medial Orbit Exposure
■ The procedure is performed under general endotracheal anesthesia via an
oral RAE tube secured in the facial midline.
■ A dose of intravenous cephalosporin antibiotic (cefazolin) is given following
the induction of anesthesia and prior to incision.
■ In anticipation of cranial bone graft harvest, a planned zigzag incision is
marked with ink behind the temporal hairline between the midline of the
skull and the temporal crest. This location avoids the sagittal sinus in the
midline and the temporalis muscle laterally during bone graft acquisition.
The hair overlying this area is clipped (TECH FIG 1A).
■ The scalp and face are prepped in standard fashion, and the head is wrapped
with sterile surgical drapes. A corneal protector may be placed for protection
of the surface of the globe.
■ 0.25% bupivacaine with 1:200 000 dilute epinephrine is used to infiltrate the
conjunctiva, plica semilunaris, and caruncle.
■ The upper and lower eyelids are gently retracted and a needlepoint cautery
tip is used to incise the conjunctiva and bisect the caruncle (TECH FIG 1B).
The initial incision is 15 mm in length. It can be extended in crescentic
fashion either superiorly or inferiorly for increased exposure.
■ Retractors are repositioned under the medial and lateral cut edges of the
caruncle to expose the medial orbital septum. Using cautery, sharp scissor
dissection, Freer elevator, or a cotton-tipped applicator, dissection proceeds
in a preseptal plane toward the medial orbital wall (TECH FIG 1C).

TECH FIG 1 • A. Positioning the incision for cranial
bone graft harvest between the midline and temporal
crest provides direct access to the thick parietal bone
while avoiding the midline sagittal sinus and the
temporalis muscle. B. The caruncle is bisected and
conjunctiva incised and retracted. Cautery and sharp
or blunt dissection are used to perform preseptal
dissection to the medial orbital wall as seen here. C.
The dissection continues posterior to the posterior
lacrimal crest along the bone or whatever remnants of
bone exist. D. The dissection extends through the
caruncle in a subperiosteal plane if available. The

dissection is lateral to the lacrimal apparatus and
medial to the orbital fat pads. E. The entire defect is
exposed in a subperiosteal plane, and stable
surrounding bone is identified for anticipated bone
graft placement.
■ Once the medial orbital wall is exposed, the posterior lacrimal crest must be
identified, and dissection must proceed posteriorly to avoid injury to the
medial canthal tendon (TECH FIG 1D).
■ Needlepoint cautery is used to incise the periosteum posterior to the lacrimal
crest. A Freer elevator is used to obtain wide subperiosteal elevation around
the entire circumference of the bony defect (TECH FIG 1E).
■ During the dissection, all orbital contents should be reduced back into the
orbit, including any entrapped tissues such as the medial rectus muscle.
Malleable retractors are effective in retaining the periorbita within the bony
orbit while periosteal elevators are used to elevate the periosteum.
■ If the anterior or posterior ethmoid arteries are identified during the
dissection and found to be intact, they should be carefully cauterized using a
bipolar cautery device.
■ Dissection should proceed until stable bone to support a bone graft is
identified around the entire periphery of the defect.
■ After the medial wall defect is completely exposed, a template can be made
to guide sizing of the bone graft or implant to be used in the repair. A 1- × 3-
cm cotton sponge is placed over the medial wall defect and used to keep the
orbital contents within the orbit while the bone graft is procured.
■ Graft Harvest
■ 0.25% bupivacaine with 1:200 000 dilute epinephrine is infiltrated into the
zigzag scalp incision site.
■ The scalp is incised with a beveled blade so that the plane of dissection lies
parallel to the hair follicles. The size of the incision varies according to the
size of bone graft needed.
■ Once the dermis and subcutaneous tissues are sharply incised, electrocautery
is used to open the galea. Care is taken to avoid cauterizing the dermis and

hair follicles.
■ Blunt subgaleal dissection with a subperiosteal elevator is performed to
mobilize the overlying scalp. The loose areolar subgaleal plane can be
dissected rapidly and the scalp retracted to expose the underlying parietal
bone with its adherent periosteum.
■ Based on the size of the medial wall defect and template, the margins of the
desired bone graft are marked by incising the periosteum with needle tip
cautery. A graft measuring 2 × 3 cm to 3 × 4 cm is usually adequate. The
graft should be designed to allow for circumferential overlap with the intact
medial orbital wall surrounding the fracture site.
■ A sharp curved osteotome and heavy mallet are used to harvest the graft. The
bone graft is harvested in a superficial plane above the level of the deep
diploe.
■ The depth of the osteotome must be precisely controlled at all times. Avoid
driving the osteotome through the inner table and injuring the intracranial
structures.
■ The graft is harvested from an anterior to posterior direction. The osteotome
is used to shave the bone graft from the outer table of the cranium by
continuously moving between the anterior and lateral edges of the graft and
staying superficial. The graft is elevated with its overlying pericranium,
which serves to the keep the graft intact.
■ If the bone graft begins to flake or fracture due to excessively superficial
positioning of the osteotome, it should be reoriented to engage a deeper layer
of the outer table. Similarly, if there is excessive bleeding from trauma to the
deep diploic space, the osteotome should be redirected to a more superficial
plane.
■ When an adequate length of bone graft has been raised, the osteotome is
directed superficially to release the graft from the skull. Sharp scissors are
used to cut the adherent posterior periosteum, and the graft is delivered from
under the scalp flaps.
■ Hemostasis of the skull donor site and scalp is obtained using bone wax and
cautery as needed.
■ The galea is closed with interrupted buried 3-0 Monocryl suture. The
superficial layer of the scalp is closed with a running locking 4-0 plain catgut
suture.
■ (Note: An alternative technique that yields a full-thickness outer table bone

graft can be employed as well. Using a high-speed cutting bur, the margins of
the bone graft can be drilled down to the level of the diploic space. The graft
can then be removed from the underlying diploe using the osteotome or a
reciprocating saw, again with great attention to the depth of these
instruments. This full-thickness graft is more stiff and brittle than the partial-
thickness outer table shave and may be less amenable to shaping and
contouring for precise coverage of the medial wall defect.)
■ Fracture Repair
■ Once the graft is harvested, attention is turned to the orbit to complete the
repair of the medial wall fracture. Prior to placement in the orbit, the bone
graft can be cut and contoured as needed ex vivo using bone-cutting
instruments and Tessier bone-bending forceps.
■ The cotton patty that was previously placed in the orbit is removed as a
malleable retractor is again placed to retract the orbital contents laterally and
expose the medial wall fracture.
■ The bone graft is placed over the defect. If appropriately sized and designed,
the graft should rest on the surrounding intact bone with stability, and there
should be no need for fixation (TECH FIG 2).
■ (Note: If the medial wall is severely comminuted and there is a paucity of
stable bone on which the graft can rest, it can be rigidly fixed to stable
anterior bone using 1.3-mm titanium miniplates and screws. In such cases,
the fixation plate can be screwed to the bone graft ex vivo and the graft can
then be placed into the orbit in the desired position. It can then be secured
to the anterior orbit. Great care must be taken to avoid injury to the medial
canthal tendon and the lacrimal apparatus if rigid fixation is implemented.)
■ Once the graft is in place, the retractors are removed and the soft tissues are
released.
■ A forced duction of the eye is performed by gently grasping the medial and
lateral sclera with toothed ophthalmic forceps and moving the globe in all
directions. Free motion of the globe confirms that no entrapment of the
orbital soft tissues has taken place during positioning of the bone graft.
■ The caruncular incision is closed with buried interrupted 6-0 plain catgut
sutures, using the bisected caruncle as a landmark for accurate wound
alignment.

■ If there is significant soft tissue edema of the orbital tissues causing
exophthalmos, and postoperative corneal exposure is a concern, a temporary
lateral tarsorrhaphy suture is placed using 5-0 silk suture.
TECH FIG 2 • The bone graft is placed over the
defect. The surrounding intact bone supports the graft.
PEARLS AND PITFALLS
Corneal
protection
■ Once the patient is anesthetized, communicate with the
anesthesiologist regarding corneal protection. Many
anesthesiologists like to place lubricating ointment on the surface
of the globe to prevent intraoperative corneal desiccation and may
do so without informing the surgeon. However, the presence of
this thick gelatinous ointment can complicate the initial
caruncular incision and dissection. A corneal protector avoids this
issue.
Incision
placement
■ Care must be taken to identify the puncta before incision and to
preserve them throughout the dissection. Careless manipulation of
the eyelid can result in inadvertent injury to the puncta requiring
additional reconstruction.
Enophthalmos
■ Perform a physical examination immediately prior to beginning

surgery with the patient in the supine position. Note the degree of
enophthalmos by examining the patient from superior and inferior
perspectives, and use these observations as indices to judge your
correction once the bone graft is placed.
Anesthesia
■ Local anesthesia may be used to infiltrate the periorbital soft
tissues prior to surgery. Epinephrine injected into the conjunctiva
may cause dilation of the pupil and lower intraocular pressure.
Cautery
■ When using cautery within the orbit, be attentive to the current
settings. Thermal energy from the cautery device can dissipate
throughout the orbit and damage the periorbital soft tissues.
Within the orbit, use bipolar cautery to limit inadvertent heat
transfer.
Soft tissue
dissection
■ Once in the preseptal plane, a back-and-forth sweeping motion
with a cotton-tipped applicator is very safe and effective in
rapidly dissecting the soft tissues down to the level of the orbital
wall.
Anatomic
landmarks
■ The vertical level of the anterior and posterior ethmoidal arteries
within the orbit approximates the level of the cranial base. Be
aware of the location of these anatomic landmarks to identify any
potential involvement of intracranial structures in the medial
orbital injury.
Orbital safe
zone
■ A medial orbital safe zone of dissection exists up to 30 mm
posterior to the orbital rim. Dissection in this zone can be
performed without fear of injury to structures that occupy the
orbital apex.
Pressure on
the globe
■ Pressure on the globe may elicit an oculocardiac reflex with
resultant bradycardia and hypotension. Alert the anesthesiologist
during the surgery if you need to place pressure on the globe and
be prepared to release your retraction if there are any
physiological consequences to your manipulation.
Bone grafts
■ In complex fractures that involve extensive injury to the ethmoid
air cells, multiple bone grafts may be stacked to restore integrity
to the medial orbital wall.
Intraoperative
navigation
■ Intraoperative navigation may assist in defining the medial orbital
defect, confirming accurate placement of the bone graft, and
avoiding injury to critical structures in the orbital apex (FIG 4).

FIG 4 • Intraoperative navigation systems may help
avoid injury to critical structures and confirm accurate
graft placement.
POSTOPERATIVE CARE
■ Cold compresses are placed on the eye continuously for the first 3 to 5 days
following surgery; the first compresses are applied before the patient leaves the
operating room. The patient’s head is elevated during this time as well.
■ Postoperative visual acuity examinations should be performed every 1 to 2
hours for the first 24 hours postoperatively. Even if the eyelids are swollen shut
following surgery, light perception adequately confirms afferent optic nerve
function.
■ If a temporary tarsorrhaphy stitch is placed at the end of the operation, it is
removed on the first postoperative day if there is no evidence of actual or
threatened corneal exposure.

■ The patient is counseled to not blow his/her nose for 6 weeks and to sneeze
with an open mouth during that time to minimize elevation of intraocular
pressure.
OUTCOMES
■ If the medial orbital wall defect is well visualized and the bone graft is
appropriately positioned, success rates are high, as defined by correction of
enophthalmos, resolution of diplopia, release of any entrapped soft tissues, and
preservation of the function and aesthetics of the medial canthal tendon and
upper and lower eyelids.
COMPLICATIONS
■ When using this technique in the treatment of medial orbital wall fractures,
complications are rare. When they do occur, however, they can be severe.
■ Blindness is the most severe and devastating complication that can result from
any intraorbital surgery. Patients must be counseled that this is a possible
outcome of surgery, albeit extremely rare. Knowledge of the surgical anatomy
of the orbit and avoidance of aggressive surgical dissection in the orbital apex
mitigate the chances of vision loss.
■ Persistent or new-onset diplopia may be seen in the postoperative period. This
can be due to iatrogenic injury to the rectus muscles, postoperative muscle
fibrosis, or undiagnosed muscle injury sustained at the time of original trauma.
True medial rectus entrapment warrants urgent intervention and release to
prevent ischemia of the muscle and permanent muscle damage.
■ Corneal injury, either due to iatrogenic abrasion or perioperative exposure, can
lead to visual deficits.
■ Conjunctival scarring can lead to cicatricial entropion or ectropion, both of
which can be very difficult to correct.
■ Injury to the medial canthal tendon during fracture repair may result in
telecanthus that may require medial canthopexy repair.
■ With any orbital surgery, and particularly with procedures that involve
exposure of nonvascularized bone graft to sinus flora, the risk of infection is
not insignificant.
REFERENCES
1. Kim YH, Park Y, Chung KJ. Considerations for the management of medial
orbital wall blowout fracture. Arch Plast Surg. 2016;43(3):229-236.