For years, the medial wall of the orbit has been neglected by most surgeons. Specifically, since the transcutaneous approaches (as the Lynch incision) led to poor esthetic outcomes, it was felt that most isolated fractures of the medial wall (medial wall fracture, MWF) were best managed by leaving them untreated. Consequently even the presence of the fracture itself might have been overlooked and the sequelae derived by not treating them were disregarded.
However, thing started to change recently. Pubmed registered nine papers regarding MWF in 2001 compared to 31 in 2012. Since then, a number of new techniques have appeared to treat these fractures.
We do know now that MWF are frequent, and according to some research, even more frequent than fractures of the orbital floor [Citation1].
The Authors of the present paper [Citation2] address MWF by means of a transcaruncular approach and restore the fractured wall by means of a resorbable mesh with the aid of navigation. This makes perfect sense and we congratulate with the Authors for their results.
In our Institution, we used to manage MWF through a retrocaruncular approach and to reconstruct the bone with either titanium or polyethylene meshes.
In our opinion, the real weakness of this approach is a very limited (to none) vision of the posterior and the uppermost part of the medial wall. This can result in suboptimal reconstruction of the most important site of the fracture in terms of globe projection.
Since few years we introduced a new method to treat MWF using a pure transnasal approach, through which we were able to properly reconstruct the fractured medial wall with a polyethylene mesh, appropriately shaped [Citation3]. Since then we have used this technique to treat all isolated MWF [Citation4]. We believe that this approach is superior as compared to conventional external approaches because it allows to clearly visualize and control the whole wall, included its posterior and upper part, that are, as said, poorly managed with external approaches.
We also noticed that the immediate postoperative comfort for the patient is extremely good, with very low to no symptoms at all. We did not do a prospective comparative study because the difference was so obvious since the first cases that we felt ethically debatable doing so.
We have then applied the same philosophical concept when dealing with intraorbital masses, located medially either intra or extraconally. For instance, we do remove venous malformations of the orbit (improperly called cavernous hemangiomas), medially located, through a pure transnasal approach. This is not a new concept as many other Authors have described this before we did. However, after we have removed the mass, we proceed with the same kind of reconstruction of the medial wall [Citation5]. The need to reconstruct the medial wall after the removal of an orbital mass through a transnasal approach is constantly a debated issue at the meetings. Most surgeons declare that there is no need to do any reconstruction. However this is highly controversial. If we do need to reconstruct MWF, and if we do a radical ethmoidectomy to decompress Grave’s orbitopathy (because this will reduce the exophthalmos), why should these concepts not be applicable to tumor or tumor-like lesions removal? In our opinion, since reconstructing the medial wall at the end of an endoscopic procedure is easy in experienced hands, and since in our experience we had zero complications, this should be the way to go.
Declaration of interest
The author has no competing interests to declare.
REFERENCES
- Choi K-E, Lee J, Lee H, Chang M, Park M, Baek S. The paradoxical predominance of medial wall injuries in blowout fracture. J Craniofac Surg. 2015;26(8):e752–e755.
- Dong Q, Karino M, Koike T, et al. Navigation-assisted isolated medial orbital wall fracture reconstruction using an u-HA/PLLA sheet via a transcaruncular approach. J Invest Surg. 2019;33(7):644–652.
- Colletti G, Pipolo C, Lozza P, et al. Orbital medial wall fractures: purely endoscopic endonasal repair with polyethylene implants. Clin Otolaryngol. 2016;43(1):396–398.
- Colletti G, Saibene AM, Giannini L, et al. Endoscopic endonasal repair with polyethylene implants in medial orbital wall fractures: a prospective study on 25 cases. J Cranio-Maxillo-Fac Surg. 2018;46(2):274–282.
- Colletti G, Saibene AM, Pessina F, et al. A shift in the orbit: immediate endoscopic reconstruction after transnasal orbital tumors resection. J Craniofac Surg. 2017;28(8):2027–2029.