Techniques in orbital repair are mainly dictated by the severity of the fracture and the types of incisions used for gaining access to the fracture site. For example, multiple surgical approaches may be necessary for a four-wall reconstruction, while a single incision may be used for an isolated single wall fracture. Access incisions to the orbital floor and infraorbital rim include subciliary, subtarsal and transconjunctival. A lateral extension of the incision and a lateral canthotomy can be used to gain access to the lateral rim.
The subcilliary approach described by Converse is made a few millimeters below the lash line. The incision is carried down through the orbicularis muscle to the tarsal plate. The plane above the tarsal plate can then be followed to the orbital septum and subsequently the orbital rim periostium which is then divided anteriorly for access to the orbital floor.
In a stair-stepped approach, a plane is dissected anterior to the orbicularis until the inferior tarsal margin. The dissection then proceeds through the muscle to the orbital septum and the orbital periostium. In the "skin only" subcilliary approach, the orbicularis muscle is divided at the level of the infraorbital rim, along with the orbital periostium. This variation of the subciliary approach is prone to skin flap necrosis, hematoma, ecchymosis and ectropion. Therefore, the skin/muscle flap techniques are preferred.
The subcilliary incision extends from the punctum medially to the lateral canthus laterally. A lateral release of approximately 1.5 cm can be added to increase exposure of the lateral orbital wall, frontozygomatic suture and malar eminence. Advantages of the subcilliary approach include a well-camouflaged scar and ease of dissection. An important disadvantage is the higher incidence of scleral show than with a subtarsal approach.
The subtarsal approach, also popularized by Converse, is a version of a skin/ muscle flap technique. The incision is made in the skin of the subtarsal fold, or if obscured by edema, 5-7 mm below the lash line directed inferolaterally, approximating the crease.
The orbicularis muscle is divided a few millimeters below the incision, and then the dissection continues to the orbital septum and orbital rim periostium. The subtarsal approach offers the easiest dissection technically and an acceptable scar although it is the most conspicuous of the techniques described here. Also, there tends to be more lid edema with this approach.
The transconjunctival approach for access to the bony orbit was described by Tessier. The technique involves scleral-corneal protection followed by a conjunctival incision just below the lower tarsal margin. Dissection then proceeds inferiorly between the orbicularis oculi and orbital septum to the infraorbital rim. The infraorbital periostium is incised to gain access to the orbital floor.
A lateral canthal or paracanthal release can be performed to allow for wider exposure of the lateral orbital wall. The advantage of this approach over the others is the absence of a visible scar and enhanced medial exposure. Disadvantages include limited lateral exposure without lateral release and a risk of postoperative ectropion. Regardless of which technique is utilized, an important point to decrease lower lid retraction is to not divide the orbital septum or risk shortening it. Rather, one should incise the orbital periostium inferior and anterior to the rim.
Another technique available for repair of isolated orbital floor fractures is the endoscopic approach. Although this technique requires a specialized skill set with a learning curve, it does not violate the eyelid soft tissues and thus is inherently less morbid. An upper gingivobuccal incision exposes the anterior maxillary wall. The technique proceeds as follows:
Many complications from orbital fracture repair have been reported. The most common include infection, visual disturbances, changes in visual acuity, diplopia, lid and canthal malposition (ectropion and entropion), lacrimal obstruction, resorption or malposition of implants, and infraorbital nerve dysesthesia. The most feared and dangerous acute postoperatve complication is retrobulbar hematoma with elevation of intraocular pressure.
This is a surgical emergency which requires orbital decompression through immediate release of sutures and lateral canthotomy followed by control of hemorrhage. Steroids, diuretics and ice may also be of therapeutic benefit in this situation.
Our website is not responsible for the information contained by this article. Webworldarticles.com is a free articles resource thus practically any visitor can submit an article. However if you notice any copyrighted material, please contact us and we will remove the article(s) in discussion right away.
This article was sent to us by:
Sean Barnes at
02142011
1. Chemoprotective effects of anthocyanin found in berries
All articles in this directory are property of their respective authors. Additionally, read our Privacy Policy
© 2010 WebWorldarticles.com - All Rights Reserved. Partners: Gunblade Saga