Advantages of the Retroseptal Transconjunctival Approach With Lateral Canthotomy for the Treatment of Orbital Fractures. A Series of 22 Cases

Advantages of the Retroseptal Transconjunctival Approach With Lateral Canthotomy for the Treatment of Orbital Fractures. A Series of 22 Cases | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Advantages of the Retroseptal Transconjunctival Approach With Lateral Canthotomy for the Treatment of Orbital Fractures. A Series of 22 Cases Pedro Tapia, Jessica Zeballos, Fernanda Díaz, Tomás Chesta, María Guerrero, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8389853/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Orbital fractures account for a significant proportion of midfacial trauma, with reported incidences between 10% and 25%. Timely surgical intervention is essential to prevent aesthetic and functional complications. The retroseptal transconjunctival approach with lateral canthotomy has gained popularity due to its minimally invasive nature and enhanced surgical access Material and Methods This retrospective case series analyzed 22 patients treated for orbital floor or orbito-malar fractures at Dr. Franco Ravera Zunino Hospital between 2020 and 2022. All patients underwent surgery using the aforementioned approach under general anesthesia. Data on demographics, fracture type, and complications were collected. Results The most common fractures included isolated orbital floor (8), orbital floor with medial wall (7), and orbito-malar fractures (5). Only two patients experienced minor complications—one case of diplopia and one of ectropion—both of which resolved within three weeks. No infections or significant ophthalmologic sequelae occurred. Conclusions This technique provides wide exposure, favorable aesthetic results, and a low complication rate, supporting its effectiveness in orbital fracture management. Orbital fractures transconjunctival approach lateral canthotomy orbital surgery maxillofacial trauma Figures Figure 1 Figure 2 Figure 3 1. INTRODUCTION Orbital fractures represent up to 40% of all traumatic injuries of the middle third of the face and 10–25% of facial injuries [ 1 , 2 ]. These types of fractures can lead to herniation of the soft contents of the orbit and entrapment of extraocular muscles, clinically manifesting as ocular mobility disorders and diplopia, severely impacting patients' quality of life [ 3 ]. The primary treatment for these fractures involves reconstructive surgery, aimed at releasing trapped extraocular muscles, reincorporating the soft tissue herniations and repairing the continuity defects of the orbital frame and walls [ 3 ]. However, this type of intervention poses significant challenges for maxillofacial surgeons due to the complex anatomy of the orbit and its relationship with noble structures [ 4 ]. In addition, the clinical, functional, and esthetic sequelae are not always immediately evident [ 2 ]. Several factors influence surgical outcomes, including the timing of the intervention, the repair materials, and the surgical approach [ 3 ]. Several surgical approaches have been described for orbital fractures, including subciliary, subtarsal, endoscopic, transcaruncular and transconjunctival [ 1 ]. The latter, first described by Bourguet in 1928 [ 5 ], can be performed retroseptally or preseptally depending on the access route to the infraorbital rim [ 1 ]. This approach allows the floor of the orbit to be exposed; however, to access the medial wall and extraorbital sites, extensions may be required [ 1 ]. Converse et al. reported in their study a modification of the technique, adding a lateral incision to this approach (lateral canthotomy), thus improving access to adjacent anatomical areas. However, this technique is not free of complications such as eyelid malposition if there is not adequate soft tissue management [ 6 ]. This study evaluates the outcomes and benefits of the retroseptal transconjunctival approach with lateral canthotomy in 22 cases treated at the Regional Hospital Dr Franco Ravera Zunino, Rancagua City. 2. MATERIALS AND METHODS We reviewed the medical records of 22 patients (2020–2022) who underwent orbital fracture repair via transconjunctival approach with lateral canthotomy. Inclusion criteria include pure orbital floor fractures and orbit malar fractures. The diagnoses were confirmed by clinical examination and imaging (computerized axial tomography) (Fig. 1 A- 1 B- 1 C). Authorization was obtained for the use of complementary examinations, photographs, and informed consents for the research. To perform this access, all patients underwent surgery under general anesthesia. Patients were previously infiltrated with 2% lidocaine solution containing epinephrine 1:100,000, with 1cc administrated in the palpebral conjunctiva and another 1cc in the lateral canthal region. The conjunctival incision was meticulously made using a cold scalpel to preserve the integrity of the lacrimal punctum and lacrimal duct. The conjunctival extension was performed up to the external palpebral canthus where it communicates with a skin incision of approximately 5 to 7 mm. Retroseptal dissection through the orbital fat was performed up to the bony plane and laterally dissection was continued up to the external canthus without cantholysis (without rupture of the canthal ligament). Separation of this area was only carried out after achieving access to the bony plane through traction. It should be noted that during the surgical access the conjunctiva was tarsorrhaphied to protect the eyeball (Fig. 2 ). Patient data were tabulated according to sex, mean age, type of fracture and complications (Table 1 : Characteristics of patients treated for orbital fractures). Postoperative follow-up was performed in all cases, with regular monitoring for signs or symptoms of functional impairment and/or ocular mobility. Serial assessments were performed at 7, 14 and 21 days post-surgery, as well as at 1, 3, and 6 months following the procedure. Table 1 Characteristics of patients treated Characteristics Patients Nº 22 Sex Female 8 Male 14 Mean Age 39 Type of Fracture Orbital floor fracture 8 Le fort II - Orbital Floor 3 Orbital floor and medial wall 7 Malar orbit with orbital floor 5 Lefort I and II orbital wall 6 Panfacial with orbital floor and medial orbital wall 1 Complications Diplopia 1 Ectropion 1 3. RESULTS Among the 22 patients (mean age: 39 years), 14 were male and 8 female. The types of fractures presented included: 8 pure orbital floor fractures, 7 combined orbital floor and medial wall fractures, 5 orbito-malar fractures, 3 Le Fort II-type fractures involving the orbital floor, and 1 panfacial fracture involving both the floor and medial wall. Orbital reconstruction was performed using the described approach (Fig. 3 A– 3 B). Only two patients developed minor postoperative complications: one case of diplopia and one case of ectropion, both of which resolved within three weeks. There were no cases of postoperative infection, ophthalmologic complications, or impairments in ocular motility, visual field, or visual acuity (Table 1 ). 4. DISCUSSION Pure orbital fractures can result in clinical manifestations that significantly reduce patients’ quality of life. If left untreated, they may lead to sequelae such as herniation of orbital soft tissues, enophthalmos, hypophthalmos, diplopia, and extraocular muscle entrapment, among others [ 3 , 7 ]. When surgical intervention is indicated, a variety of approaches are available [ 3 , 8 ]. Achieving restoration of the facial structure with minimal aesthetic compromise remains a challenge for the surgical team, highlighting the importance of choosing an appropriate and minimally invasive approach [ 9 ]. According to most authors, the transconjunctival incision offers a scarless resolution and reduces the risk of postoperative lower eyelid retraction, ectropion, and scleral exposure [ 8 , 10 , 11 ]. Retroseptal access provides a more direct route compared to the preseptal approach; however, careful dissection of the periorbital fat is required. Its main disadvantage lies in the technical sensitivity of the procedure and the limited surgical exposure it provides [ 10 ]. This limitation is often addressed by combining the approach with medial access or lateral canthotomy, which enhances exposure and reduces traction on the eyelid [ 10 , 12 ]. Sharma et al. further concluded that the transconjunctival approach with lateral canthotomy is a safe, aesthetically favorable, and effective technique for the management of zygomaticomaxillary complex fractures [13]. It is important to note that lateral canthotomy increases surgical complexity and may result in additional tissue trauma. However, with experience and progression along the learning curve, operative times tend to decrease, and access to the periorbital region improves significantly [ 3 , 8 , 10 , 11 ]. In this case series, the modified transconjunctival approach with lateral canthotomy for the treatment of orbital fractures demonstrated favorable outcomes. This technique provided rapid and aesthetically satisfactory access, with broad exposure of the malar bone and extended orbital fractures, ultimately contributing to reduced operative time. Regarding complications, only 2 out of the 22 patients experienced minor postoperative issues, both of which resolved by the third postoperative week without lasting consequences. A thorough review of the literature concerning the benefits and potential complications of the retroseptal transconjunctival approach with lateral canthotomy remains essential. Such analysis enhances surgeons’ confidence in selecting this technique and supports improved postoperative recovery for patients. 5. CONCLUSION The retroseptal transconjunctival incision with lateral canthotomy offers rapid and extensive access while resulting in an almost imperceptible skin scar and minimizing the risk of postoperative complications. Its use may significantly reduce surgical time in a minimally invasive manner, particularly when compared to conventional cutaneous approaches, which are often associated with less favorable aesthetic outcomes. Declarations Funding Declaration No funding to declare. Clinical Trial Number Not applicable Compliance with ethical standards The authors declare no conflict of interest, financial or otherwise. Data availability No datasets were generated or analysed during the current study. Declarations of Competing interests The authors declare no competing interests. Ethics approval This study was performed in line with the principles of the Declaration of Helsinki, the identity of the patients remained anonymous according to the ethical principles. For this study, all signed informed consents were obtained from the patients; that said, approval by an ethics committee was not justified or required. Consent to participate The use of the clinical cases with their respective images is supported by the informed consent obtained and signed by all legally responsible adults of the individual participants included in this study. Consent to publish The authors affirm that the legal guardians of the human research participants gave their informed consent for the publication of the images in Fig. 2 and 3 CRediT authorship contribution statement Conceptualization; PTC, FZC, Data curation; PTC, FZC, TCO, MGG, BOZ Formal analysis;PTC, FZC, TCO, MGG, BOZ Investigation; PTC, JZC, FZC, Methodology; PTC, JZC, FZC, BOZ Project administration; PTC FZC, BOZ Resources; PTC, JZC Supervision; PTC Validation; JZC Visualization; PTC, FZC Roles/Writing - original draft; PTC, FZC, BOZ and Writing - review & editing. PTC, FZC, TCO, MGG, BOZ References Palavalli MH, Huayllani MT, Gokun Y, Lu Y, Janis JE. Surgical approaches to orbital fractures: a practical and systematic review. Plast Reconstr Surg Glob Open 2023;11(5):e4967. Kotecha S, Ferro A, Harrison P, Fan K. Orbital reconstruction: a systematic review and meta-analysis evaluating the role of patient-specific implants. Oral Maxillofac Surg 2022. https://doi.org/10.1007/s10006-022-01074-x. Zhang J, He X, Qi Y, Zhou P. The better surgical timing and approach for orbital fracture: a systematic review and meta-analysis. Ann Transl Med 2022;10(10):564. Al-Moraissi EA, Thaller SR, Ellis E. Subciliary vs. transconjunctival approach for the management of orbital floor and periorbital fractures: a systematic review and meta-analysis. J Craniomaxillofac Surg 2017;45(10):1647–54. Emam HA, Stevens MR, Larsen PE, Jatana CA. Lateral tarsotomy: a practical alternative to lateral canthotomy to increase orbital access. Oral Surg Oral Med Oral Pathol Oral Radiol 2016;122(1):e1–4. Contreras PT, Enríquez MS, Cucurella SM, Dueñas BR, Castro FR. Uso del polietileno poroso de alta densidad como alternativa en reconstrucción de fracturas orbitarias. Serie de 22 casos: use of high-density porous polyethylene as an alternative in orbital fracture reconstruction. 22 case series. Ars Med 2022;47(1):5–8. Kothari NA, Avashia YJ, Lemelman BT, Mir HS, Thaller SR. Incisions for orbital floor exploration. J Craniofac Surg 2012;23(7 Suppl 1):1985–9. Ha YI, Kim SH, Park ES, Kim YB. Approach for naso-orbito-ethmoidal fracture. Arch Craniofac Surg 2019;20(4):219–22. Sanjaya IGPH, Hamid ARRH, Adnyana IMS, Purwanthi IGAP, Magdalena P, Mardhika PE. Risk of lower eyelid malposition in subciliary compared to transconjunctival approach in maxillofacial fractures management: a systematic review and meta-analysis. Open Access Maced J Med Sci 2019;7(17):2953–7. Oztel M, Goh R, Hsu E. Subtarsal versus transconjunctival approach: a long-term follow-up of esthetic outcomes and complications. J Oral Maxillofac Surg 2021;79(6):1327.e1–1327.e6. Bernardini FP, Nerad J, Fay A, Zambelli A, Cruz AAV. The revised direct transconjunctival approach to the orbital floor. Ophthal Plast Reconstr Surg 2017;33(2):93–100. Sharma R, Singh S, Patrikar S. Retroseptal transconjunctival approach for fractures of the zygomaticomaxillary complex: a retrospective study. Br J Oral Maxillofac Surg 2018;56(1):29–33. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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2","display":"","copyAsset":false,"role":"figure","size":434495,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative showing approach.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8389853/v1/b940b5e4c37cadf55dbd3690.jpeg"},{"id":100437088,"identity":"548cbffe-4415-4886-bb1e-5e84af2c814d","added_by":"auto","created_at":"2026-01-16 15:50:24","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":268398,"visible":true,"origin":"","legend":"\u003cp\u003ePhotographs 3 weeks postoperatively\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8389853/v1/b95b56cd60ce18ef32a96c94.jpeg"},{"id":105670414,"identity":"10ce641d-4fd4-45b5-af72-9987bcaf1bc1","added_by":"auto","created_at":"2026-03-29 13:24:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1399010,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8389853/v1/f3aec8c8-a215-4546-aa88-a8817d0237d4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eAdvantages of the Retroseptal Transconjunctival Approach With Lateral Canthotomy for the Treatment of Orbital Fractures. A Series of 22 Cases\u003c/p\u003e","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eOrbital fractures represent up to 40% of all traumatic injuries of the middle third of the face and 10\u0026ndash;25% of facial injuries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These types of fractures can lead to herniation of the soft contents of the orbit and entrapment of extraocular muscles, clinically manifesting as ocular mobility disorders and diplopia, severely impacting patients' quality of life [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe primary treatment for these fractures involves reconstructive surgery, aimed at releasing trapped extraocular muscles, reincorporating the soft tissue herniations and repairing the continuity defects of the orbital frame and walls [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, this type of intervention poses significant challenges for maxillofacial surgeons due to the complex anatomy of the orbit and its relationship with noble structures [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In addition, the clinical, functional, and esthetic sequelae are not always immediately evident [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral factors influence surgical outcomes, including the timing of the intervention, the repair materials, and the surgical approach [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral surgical approaches have been described for orbital fractures, including subciliary, subtarsal, endoscopic, transcaruncular and transconjunctival [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The latter, first described by Bourguet in 1928 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], can be performed retroseptally or preseptally depending on the access route to the infraorbital rim [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This approach allows the floor of the orbit to be exposed; however, to access the medial wall and extraorbital sites, extensions may be required [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConverse et al. reported in their study a modification of the technique, adding a lateral incision to this approach (lateral canthotomy), thus improving access to adjacent anatomical areas. However, this technique is not free of complications such as eyelid malposition if there is not adequate soft tissue management [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e This study evaluates the outcomes and benefits of the retroseptal transconjunctival approach with lateral canthotomy in 22 cases treated at the Regional Hospital Dr Franco Ravera Zunino, Rancagua City.\u003c/p\u003e"},{"header":"2. MATERIALS AND METHODS","content":"\u003cp\u003eWe reviewed the medical records of 22 patients (2020\u0026ndash;2022) who underwent orbital fracture repair via transconjunctival approach with lateral canthotomy. Inclusion criteria include pure orbital floor fractures and orbit malar fractures. The diagnoses were confirmed by clinical examination and imaging (computerized axial tomography) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA-\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB-\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). Authorization was obtained for the use of complementary examinations, photographs, and informed consents for the research. To perform this access, all patients underwent surgery under general anesthesia. Patients were previously infiltrated with 2% lidocaine solution containing epinephrine 1:100,000, with 1cc administrated in the palpebral conjunctiva and another 1cc in the lateral canthal region. The conjunctival incision was meticulously made using a cold scalpel to preserve the integrity of the lacrimal punctum and lacrimal duct. The conjunctival extension was performed up to the external palpebral canthus where it communicates with a skin incision of approximately 5 to 7 mm. Retroseptal dissection through the orbital fat was performed up to the bony plane and laterally dissection was continued up to the external canthus without cantholysis (without rupture of the canthal ligament). Separation of this area was only carried out after achieving access to the bony plane through traction. It should be noted that during the surgical access the conjunctiva was tarsorrhaphied to protect the eyeball (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePatient data were tabulated according to sex, mean age, type of fracture and complications (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: Characteristics of patients treated for orbital fractures). Postoperative follow-up was performed in all cases, with regular monitoring for signs or symptoms of functional impairment and/or ocular mobility. Serial assessments were performed at 7, 14 and 21 days post-surgery, as well as at 1, 3, and 6 months following the procedure.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of patients treated\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN\u0026ordm;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean Age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of Fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOrbital floor fracture\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLe fort II - Orbital Floor\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOrbital floor and medial wall\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMalar orbit with orbital floor\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLefort I and II orbital wall\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePanfacial with orbital floor and medial orbital wall\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDiplopia\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEctropion\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"3. RESULTS","content":"\u003cp\u003eAmong the 22 patients (mean age: 39 years), 14 were male and 8 female. The types of fractures presented included: 8 pure orbital floor fractures, 7 combined orbital floor and medial wall fractures, 5 orbito-malar fractures, 3 Le Fort II-type fractures involving the orbital floor, and 1 panfacial fracture involving both the floor and medial wall. Orbital reconstruction was performed using the described approach (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA\u0026ndash;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB). Only two patients developed minor postoperative complications: one case of diplopia and one case of ectropion, both of which resolved within three weeks. There were no cases of postoperative infection, ophthalmologic complications, or impairments in ocular motility, visual field, or visual acuity (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003ePure orbital fractures can result in clinical manifestations that significantly reduce patients\u0026rsquo; quality of life. If left untreated, they may lead to sequelae such as herniation of orbital soft tissues, enophthalmos, hypophthalmos, diplopia, and extraocular muscle entrapment, among others [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. When surgical intervention is indicated, a variety of approaches are available [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Achieving restoration of the facial structure with minimal aesthetic compromise remains a challenge for the surgical team, highlighting the importance of choosing an appropriate and minimally invasive approach [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to most authors, the transconjunctival incision offers a scarless resolution and reduces the risk of postoperative lower eyelid retraction, ectropion, and scleral exposure [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Retroseptal access provides a more direct route compared to the preseptal approach; however, careful dissection of the periorbital fat is required. Its main disadvantage lies in the technical sensitivity of the procedure and the limited surgical exposure it provides [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This limitation is often addressed by combining the approach with medial access or lateral canthotomy, which enhances exposure and reduces traction on the eyelid [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Sharma et al. further concluded that the transconjunctival approach with lateral canthotomy is a safe, aesthetically favorable, and effective technique for the management of zygomaticomaxillary complex fractures [13].\u003c/p\u003e \u003cp\u003eIt is important to note that lateral canthotomy increases surgical complexity and may result in additional tissue trauma. However, with experience and progression along the learning curve, operative times tend to decrease, and access to the periorbital region improves significantly [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this case series, the modified transconjunctival approach with lateral canthotomy for the treatment of orbital fractures demonstrated favorable outcomes. This technique provided rapid and aesthetically satisfactory access, with broad exposure of the malar bone and extended orbital fractures, ultimately contributing to reduced operative time.\u003c/p\u003e \u003cp\u003eRegarding complications, only 2 out of the 22 patients experienced minor postoperative issues, both of which resolved by the third postoperative week without lasting consequences.\u003c/p\u003e \u003cp\u003eA thorough review of the literature concerning the benefits and potential complications of the retroseptal transconjunctival approach with lateral canthotomy remains essential. Such analysis enhances surgeons\u0026rsquo; confidence in selecting this technique and supports improved postoperative recovery for patients.\u003c/p\u003e"},{"header":"5. CONCLUSION","content":"\u003cp\u003eThe retroseptal transconjunctival incision with lateral canthotomy offers rapid and extensive access while resulting in an almost imperceptible skin scar and minimizing the risk of postoperative complications. Its use may significantly reduce surgical time in a minimally invasive manner, particularly when compared to conventional cutaneous approaches, which are often associated with less favorable aesthetic outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Declaration\u003cbr\u003e\u003c/strong\u003e No funding to declare.\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eClinical Trial Number\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with ethical standards\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare no conflict of interest, financial or otherwise.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;No datasets were generated or analysed during the current study.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eDeclarations of Competing interests\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare no competing interests.\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This study was performed in line with the principles of the Declaration of Helsinki, the identity of the patients remained anonymous according to the ethical principles. For this study, all signed informed consents were obtained from the patients; that said, approval by an ethics committee was not justified or required.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003cbr\u003e\u003c/strong\u003eThe use of the clinical cases with their respective images is supported by the informed consent obtained and signed by all legally responsible adults of the individual participants included in this study.\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eConsent to publish\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors affirm that the legal guardians of the human research participants gave their informed consent for the publication of the images in Fig. 2 and 3\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCRediT authorship contribution statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization; PTC, FZC, Data curation; PTC, FZC, TCO, MGG, BOZ Formal analysis;PTC, FZC, TCO, MGG, BOZ Investigation; PTC, JZC, FZC, Methodology; PTC, JZC, FZC, BOZ Project administration; PTC FZC, BOZ Resources; PTC, JZC Supervision; PTC Validation; JZC Visualization; PTC, FZC Roles/Writing - original draft; PTC, FZC, BOZ and Writing - review \u0026amp; editing. PTC, FZC, TCO, MGG, BOZ\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003ePalavalli MH, Huayllani MT, Gokun Y, Lu Y, Janis JE. Surgical approaches to orbital fractures: a practical and systematic review. Plast Reconstr Surg Glob Open 2023;11(5):e4967.\u003c/li\u003e\n \u003cli\u003eKotecha S, Ferro A, Harrison P, Fan K. Orbital reconstruction: a systematic review and meta-analysis evaluating the role of patient-specific implants. Oral Maxillofac Surg 2022. https://doi.org/10.1007/s10006-022-01074-x.\u003c/li\u003e\n \u003cli\u003eZhang J, He X, Qi Y, Zhou P. The better surgical timing and approach for orbital fracture: a systematic review and meta-analysis. Ann Transl Med 2022;10(10):564.\u003c/li\u003e\n \u003cli\u003eAl-Moraissi EA, Thaller SR, Ellis E. Subciliary vs. transconjunctival approach for the management of orbital floor and periorbital fractures: a systematic review and meta-analysis. J Craniomaxillofac Surg 2017;45(10):1647\u0026ndash;54.\u003c/li\u003e\n \u003cli\u003eEmam HA, Stevens MR, Larsen PE, Jatana CA. Lateral tarsotomy: a practical alternative to lateral canthotomy to increase orbital access. Oral Surg Oral Med Oral Pathol Oral Radiol 2016;122(1):e1\u0026ndash;4.\u003c/li\u003e\n \u003cli\u003eContreras PT, Enr\u0026iacute;quez MS, Cucurella SM, Due\u0026ntilde;as BR, Castro FR. Uso del polietileno poroso de alta densidad como alternativa en reconstrucci\u0026oacute;n de fracturas orbitarias. Serie de 22 casos: use of high-density porous polyethylene as an alternative in orbital fracture reconstruction. 22 case series. Ars Med 2022;47(1):5\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eKothari NA, Avashia YJ, Lemelman BT, Mir HS, Thaller SR. Incisions for orbital floor exploration. J Craniofac Surg 2012;23(7 Suppl 1):1985\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eHa YI, Kim SH, Park ES, Kim YB. Approach for naso-orbito-ethmoidal fracture. Arch Craniofac Surg 2019;20(4):219\u0026ndash;22.\u003c/li\u003e\n \u003cli\u003eSanjaya IGPH, Hamid ARRH, Adnyana IMS, Purwanthi IGAP, Magdalena P, Mardhika PE. Risk of lower eyelid malposition in subciliary compared to transconjunctival approach in maxillofacial fractures management: a systematic review and meta-analysis. Open Access Maced J Med Sci 2019;7(17):2953\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eOztel M, Goh R, Hsu E. Subtarsal versus transconjunctival approach: a long-term follow-up of esthetic outcomes and complications. J Oral Maxillofac Surg 2021;79(6):1327.e1\u0026ndash;1327.e6.\u003c/li\u003e\n \u003cli\u003eBernardini FP, Nerad J, Fay A, Zambelli A, Cruz AAV. The revised direct transconjunctival approach to the orbital floor. Ophthal Plast Reconstr Surg 2017;33(2):93\u0026ndash;100.\u003c/li\u003e\n \u003cli\u003eSharma R, Singh S, Patrikar S. Retroseptal transconjunctival approach for fractures of the zygomaticomaxillary complex: a retrospective study. Br J Oral Maxillofac Surg 2018;56(1):29\u0026ndash;33.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Orbital fractures, transconjunctival approach, lateral canthotomy, orbital surgery, maxillofacial trauma","lastPublishedDoi":"10.21203/rs.3.rs-8389853/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8389853/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eOrbital fractures account for a significant proportion of midfacial trauma, with reported incidences between 10% and 25%. Timely surgical intervention is essential to prevent aesthetic and functional complications. The retroseptal transconjunctival approach with lateral canthotomy has gained popularity due to its minimally invasive nature and enhanced surgical access\u003c/p\u003e\u003ch2\u003eMaterial and Methods\u003c/h2\u003e \u003cp\u003eThis retrospective case series analyzed 22 patients treated for orbital floor or orbito-malar fractures at Dr. Franco Ravera Zunino Hospital between 2020 and 2022. All patients underwent surgery using the aforementioned approach under general anesthesia. Data on demographics, fracture type, and complications were collected.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe most common fractures included isolated orbital floor (8), orbital floor with medial wall (7), and orbito-malar fractures (5). Only two patients experienced minor complications\u0026mdash;one case of diplopia and one of ectropion\u0026mdash;both of which resolved within three weeks. No infections or significant ophthalmologic sequelae occurred.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis technique provides wide exposure, favorable aesthetic results, and a low complication rate, supporting its effectiveness in orbital fracture management.\u003c/p\u003e","manuscriptTitle":"Advantages of the Retroseptal Transconjunctival Approach With Lateral Canthotomy for the Treatment of Orbital Fractures. A Series of 22 Cases","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 15:50:19","doi":"10.21203/rs.3.rs-8389853/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e0b5100f-337d-4f53-9370-98384c72b1a8","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-29T13:24:28+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 15:50:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8389853","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8389853","identity":"rs-8389853","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}