Resident Manual of Trauma to the Face, Head and Neck

CHAPTER 3: Upper Facial Trauma

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.

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