Implant placement for combined medial wall and orbital floor fractures
This is Richard Allen at the University of Iowa. This video demonstrates repair of a large medial orbital wall and inferior orbital floor fracture. The patient had a previous surgery and the needle tip cautery is used to make a trans-conjunctival incision along the scar of the previous surgery. Dissection is then carried out between the orbital septum the orbicularis muscle to the inferior orbital rim. A trans-caruncular incision is then made with Westcott scissors which connects to the trans-conjunctival incision. Stevens scissors are used to expose the periosteum of the posterior lacrimal crest. A malleable retractor is then placed and the periosteum is elevated from the medial orbital wall with the Freer periosteal elevator. Malleables are then used to expose both orbital walls and the Freer periosteal elevator is then use to disinsert the inferior oblique. A Supramid implant is then used as a template of the fracture and a Titan implant is fashioned and placed into position.
Fashioning the implant is very important. This portion of the video shows a series of implant placements and implant shapes for repair of large medial and inferior orbital wall fractures. In general I will use a Supramid implant to make a template of the fracture. A Titan implant is then usually used to cover the fracture as these implants are quite sturdy. A combination transcaruncular/transconjunctival incision is used to expose the inferior-medial 180 degrees of the orbit. As noted, a clover-shape design is used as the implant needs to be cut out in the back since the orbit is conical in shape. The implant can then be placed into position. In general a relatively large malleable is used for retraction and the inferior oblique has been disinserted.
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