The precaruncular approach to the medial orbit

Most approaches to the medial orbit and lower provide suboptimal access and leave visible scars. The transcaruncular approach is an improvement over previous procedures, but disadvantages remain: there is no defined surgical plane through the caruncle; the caruncular tissue is highly vascular; and the approach may cause considerable postoperative morbidity. For these reasons, cadavers were studied to develop a surgical approach that would avoid the caruncle. A prospective outcome evaluation was then performed.

Two male and 2 female cadavers were studied to ascertain whether the plane medial or lateral to the caruncle provided optimal access to the medial orbit. Fifteen consecutive procedures were then prospectively evaluated using the medial approach.

The "precaruncular" approach medial to the caruncle provided the most direct route to the medial orbit, with a clear, avascular path of dissection and improved exposure. In 15 consecutive procedures, there were no complications. The patients healed rapidly, with minimal postoperative morbidity.

The precaruncular approach was demonstrated on cadavers to be more efficacious than approaches directly through or lateral to the caruncle. This finding was confirmed in a prospective evaluation of 15 procedures, in which no complications occurred. More rapid healing was noted than with prior experience using the transcaruncular route. The precaruncular approach provides a preseptal plane to the medial orbit that can be extended to the orbital floor or roof as needed, and offers a direct connection between the posterior lacrimal crest and the tarsal plate for medial canthopexy.