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CHAPTER 3: Upper Facial Trauma

Resident Manual of Trauma to the Face, Head, and Neck

lacerations to the end of the operation, to prevent inadvertent dehis-

cence during repair of the bony fractures.

ii. Transconjunctival Approach

The transconjunctival approach can be utilized for isolated medial wall

orbital blowout fractures with entrapment of a small amount of orbital

fat or medial rectus muscle. The incision usually is placed posterior to

the caruncle, and has very limited exposure to other sites of the NOE

complex. However, if a medial orbital fracture is found to extend to the

inferior orbital wall, this incision may be extended to expose that area.

iii. Transcaruncular Approach

A transcaruncular approach is similar to the transconjunctival approach,

except that the incision is placed anterior to the caruncle, which is

elevated with the soft tissue flap. The medial orbital periosteum is

incised just posterior to the posterior lacrimal crest, and the dissection

carefully proceeds back to the posterior ethmoid artery. It provides a

slightly better visualization of the medial orbit, but is insufficient to

provide exposure for repair of more extensive fractures of the complex.

iv. Extended Medial Canthal/Lateral Nasal Approach

An extended medial canthal/lateral nasal approach is often utilized to

reduce and fixate the NOE complex fractures and to reconform the

medial canthal tendons to their proper position. The incision is usually

gull-wing shaped, placed approximately 8–10 mm from the inner

palpebral angle, extending superiorly and inferiorly for approximately

15–20 mm (Figure 3.22). The periosteum can be elevated laterally,

exposing the lacrimal fossa, medial orbit (lamina papyracea), and

Figure 3.22

(right)

Gull-wing medial canthus

incision in patient. Silk

suture is around the body of

the medial rectus muscle for

traction in reducing

entrapment.