Title: Transpalpebral and Extended Transconjunctival Approach in Fractures of the Upper Orbit
Authors: Sang-Hwan Koo, MD, Eul-Sik Yoon, MD,
Dong-Hee Kang, MD, Seung-Ha Park, MD
In line with increase of facial trauma by assaults, fall-down, or high-energy impact, the frequency of orbital fracture has been increased gradually. The most frequent sites of orbital fracture are orbital floor and medial wall.
To reduce orbital fracture involving floor or inferomedial wall, the fracture site can be accessed by several approaches such as subcilliary approach, mid-lower lid approach, infraorbital rim approach, and transconjunctival approach. Meanwhile, in case of orbital fracture of the upper orbit involving superomedial wall or roof, these approaches have marked limitation to expose the fracture site enough, so that the bicoronal incision was required.
The bicoronal approach provides the best exposure without interference of the medial canthal tendon, but conspicuous incision scar can be shown easily in bald patients, and even in non-bald patients the bicoronal incision can be accompanied by possible risk factors such as alopecia, loss of scalp sensation, and damage of frontal branch of the facial nerve.
Method: To avoid these problems, we authors performed transpalpebral approach1, instead of bicoronal approach, to expose fracture site in case of orbital roof fracture.
In case of superomedial wall fracture of the orbit, we used extended transconjunctival approach, which is composed of transcaruncular incision2, transconjunctival incision3, and lateral canthotomy4, with or without transpalpebral approach.
Result: We executed transpalpebral and extended transconjunctival approach on 21 orbits of 19 patients who consulted plastic surgeons to reduce or reconstruct fracture of the upper orbit including enophthalmos. The cases, which necessarily required bicoronal incision because of accompanying malar complex or skull fracture, were excluded.
We got enough exposure of fracture site and satisfactory reduction or reconstruction in all cases. There are no significant complications except hypesthesia on ipsilateral forehead in transpalpebral approach cases. But these sensory changes were temporary and persist for 9 months in maximum. No permanent sensory loss in the forehead noted. The external scar on the supratarsal fold of the upper lid was invisible with no scar deformities or contractures in any patients.
Conclusion: We propose that the transpalpebral approach can be substitution for bicoronal approach especially in the fractures of the supero-medial wall and roof of the orbit.
References
1. Knize, DM: Transpalpebral Approach to the Corrugator Supercilii and Procerus Muscles. Plast Reconstr Surg 95:52, 1995
2. Shorr N, Baylis HI, Goldberg RA, Perry JD: Transcaruncular Approach to the Medial Orbit and Orbital Apex. Ophthalmology 107: 1459, 2000
3. Peter DW, Dennis DC: The Transconjunctival Approach for Treating Orbital Trauma. J Oral Maxillofac Surg 49: 499, 1991
4. McCord CD Jr, Moses JL: Exposure of the Inferior Orbit with Fornix Incision and Lateral Canthotomy. Ophthalmic Surg 10(6): 53, 1979