[A combined transcaruncular transconjunctival approach to orbital medial wall fractures. Surgical technique]

The ideal approach to orbital medial wall fractures remains controversial. Only the coronal approach exposes the medial wall completely. The transcaruncular approach enables a clear and wide view of the medial wall without any visible scar compared to usual transcutaneous techniques. This approach can be combined with a transconjunctival approach, thus providing an extended exposure of the whole medial wall and the orbital floor.

The conjunctival incision is performed with a needle electrocautery in the groove between the plica semilunaris and the caruncle. It is extended laterally within the inferior conjunctival fornix for 20mm to the lateral palpebral commissure. The sub-conjunctival dissection to the posterior lacrimal crest is performed with Stevens scissors through an avascular plane along the medial wall behind Horner's muscle. The periosteum is incised behind the posterior lacrimal crest. The sub-periosteal periorbital dissection is continued medially thus exposing the insertion of the inferior oblique muscle which is coagulated and cut over the inferior orbital rim. Reconstruction is performed after exposing the complete fracture after freeing the periorbital tissue. The periorbita is sutured with interrupted 5-0 Vicryl stitches. The inferior conjunctiva and the caruncle are closed with a continuous 6-0 Maxon suture.