Orbital fractures commonly occur in the midface region, thus accounting for 13.3% of all facial bone fractures, with reported rates of isolated medial orbital wall fractures ranging from 0% to 55% [1]. Orbital medial wall fracture is difficult to correct and dissect because of its adjacent location to the globe, nerves and vessels, and the limited visual fields.

To date, a variety of surgical approaches have been used to reconstruct the medial orbital wall fracture. These include medial canthal incision (Lynch incision), transconjunctival incision, subciliary incision, intranasal approach, lid crease incision, and bicoronal incision. Of these, the transconjunctival approach leaves no visible scar and has a brief course but provides narrow operative exposure, possible postoperative conjunctival irritation and the potential for conjunctival granuloma [2]. Subciliary incision is a familiar method of accessing the lower half or lower two-thirds of the medial wall, but it is not easy to obtain full exposure of the operative field [3]. There is still a controversy as to their applicability because of postoperative scars, injury of anatomical structures and limited visual fields. Sufficient dissection of the fracture site is difficult with any incision method [4].

To date, a replacement has been performed rather than restoration to reconstruct orbital medial wall fracture, for which subperiosteal dissection is mandatory. When placing a large implant, even a small misstep in alignment will result in significant deviation of the plate from an anatomic reduction of the orbital size. Sufficient exposure and visualization of the medial wall are necessary to avoid this problem [5].

Given the above background, we have devised a useful additional procedure for dissecting the medial orbital wall fracture considering the anatomical characteristics of the orbit as there might be no clear method for periosteal dissection. The purpose of this study was to introduce a useful additional medial subbrow approach for better reduction and securement more accurate implant pocket of medial orbital wall fracture with the subciliary technique.

Due to the difficulty of dissection, postoperative scar, limited visual fields, complications such as maxillary sinusitis, physiologic problems, packing, long learning curve and inconvenience of manipulation, the medial orbital wall fracture poses a surgical dilemma for surgeons [7,8].

The difficulty of dissection is closely associated with the adjacent presence of the globe, nerves, vessels, lacrimal apparatus and medial canthal tendon. The supratrochlear nerve and vessels are present in the superior part of the orbital medial wall. In addition, the anterior and posterior ethmoidal arteries are distributed in the lamina papyracea of the medial orbital wall. Therefore, a periosteal dissection should be cautioned [9].

To date, subciliary incision has been used to reconstruct the medial orbital wall fracture. But this approach causes postoperative complications such as the formation of scars around the eyelid and ectropion. It is well known that complete dissection of the fracture site could be rarely achieved irrespective of types of incision in patients with medial orbital wall fracture. Patients with bursting fracture of the inferior or medial orbital wall are vulnerable to worsening of the severity of bony displacement. It is therefore difficult to reposition bone fragments to the original location in these patients [10,11].

A transcaruncular approach is a useful modality in that it does not cause visible scars. Due to relatively smaller visual fields, non-experienced surgeons encounter difficulty in placing the implant as well as performing dissection and reduction of fracture fragments. Furthermore, a longer learning curve is another disadvantage [12,13].

An endoscopic approach is used to reduce the orbital fracture via a nasal cavity and ethmoidal or maxillary sinus under the endoscopic guidance [14-17]. This ensures access to the medial and inferior orbital wall even without making an incision. An endoscopic approach is advantageous in not only preventing the separation between the fracture site and the periosteum but also minimizing the occurrence of bone defects. But its disadvantages include a restriction of visual fields and a difficulty in intraoperatively evaluating the degree of replacement. This lowers the accuracy of an anatomical reduction of the fracture. Moreover, it also requires a complete understanding of the anatomical structure and the skilled use of an endoscope. The applicability of an endoscopic approach is limited in patients with deviated nasal septum; these patients should receive additional surgeries such as septoplasty [7,18]. Its complications may include the entrapment of orbital contents between the orbital wall and a balloon or silastic sheet, orbital compression due to over-reduction, leakage of cerebrospinal fluid, the obstruction of sinus drainage pathways in the dependent sinus and infection [19]. Additionally, it also remains problematic that use of nasal packing materials, such as Nasopore (Polyganics, Groningen, the Netherlands) or Merocel (Medtronic Inc., Minneapolis, MN, USA) may also cause patient discomfort [16].

We have therefore devised a useful additional procedure considering the anatomical characteristics that the orbit and its lateral wall, roof, and floor have a sharply concave arcus marginalis. But the transitional zone between the orbital roof and medial wall showed a round-to-flat arcus marginalis [20]. Therefore, we have speculated that it would be easier to dissect the medial wall if we have access to the superomedial portion of the orbit.

For stability, a fan-shaped dissection was performed (Fig. 4), but with the spatula of the subciliary dissection, the subperiosteal space was maintained while the resistance was detected with direct visual confirmation. Dissection and orbital soft tissue reduction were performed in a stepwise manner while detecting resistance. Since the orbital medial wall is flat and the lateral wall is conical, there is little concern about injury to the medial rectus muscle.

For convenience, the learning curve is relatively shorter because slit incision was performed and the procedure is relatively simpler.

For efficacy, while floor dissection was also performed with a subciliary approach, at least some degree of orbital medial wall area was secured. In this regard, a fan-shaped dissection was performed in posterosuperior direction to expose sufficient fracture sites. This is essential for ensuring that there is sufficient and secure space to insert the implant. Because the implant is inserted in the medial part of the tip while looking directly at the tip of the Louisville elevator, the implant can be positioned properly.

Advantages of our additional procedure are as follows. First, herniated orbital soft tissue reduction is easier and definite. Second, almost no visible scars are left except for subciliary incision. An only puncture wound is needed during surgery. Third, the extent of dissection is relatively larger. With an ability to perform a fan-shaped dissection, a sufficient extent of dissection of the medial orbital wall could be achieved. Fourth, a more stable implant setting is achieved. A sufficient dissection of the fracture site makes it easier to place and fix an implant to the desired location more easily. Fifth, surgery can be performed simultaneously with an accurate replacement.

Based on the above advantages, we propose that our technique be used to achieve a sufficient dissection of the medial orbital wall. A single use of conventional approaches for the medial orbital wall fracture often achieves an insufficient dissection of the medial orbital wall. Therefore, we have shown that concomitant use of our procedure was useful in resolving the above problem. Our procedure is a valuable option in that it is reproducible and convenient, and causes almost no complications. The globe is surrounded by the condensation of fascia with a sufficient degree of strength and thickness, and it is composed of Tenon’s capsule [21]. A sufficient dissection of the fracture site without hemorrhage was possible. Bone fragments can also be successfully dissected without breakage through a piece-by-piece dissection of them.

An accurate reconstruction of the medial orbital fracture poses a surgical dilemma for plastic surgeons because of disadvantages of conventional methods of dissection, limited visual fields and the presence of vital structures such as the globe and orbital nerve. If sufficient removal and reconstruction of the defected area is the goal of the current operation, it is not easy to cover the affected area as much as possible. Our procedure was useful in achieving a sufficient dissection of the fracture site. A learning curve is relatively short.

Our procedure was useful in dissecting the medial wall, and it was also such a safe method as to cause little complications in our clinical series of the patients. Moreover, it leaves nonvisible ancillary subbrow puncture wound. Therefore, it is a recommendable surgical modality.

A complete dissection of the medial orbital wall is always a difficult procedure. However, we assume that our procedure is an efficient approach option to a sufficient dissection of the medial orbital wall through a minimal incision.