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Surgical Technique |

The Transcaruncular Approach Surgical Anatomy and Technique

Robert A. Goldberg, MD; Ronald Mancini, MD; Joseph L. Demer, MD, PhD
Arch Facial Plast Surg. 2007;9(6):443-447. doi:10.1001/archfaci.9.6.443.
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With a detailed understanding of the pertinent surgical anatomy, the transcaruncular approach provides safe access and excellent exposure of the medial orbit and orbital apex. We herein describe our technique of the transcaruncular approach and delineate the pertinent associated surgical anatomy via dissection, magnetic resonance imaging, and histologic examination. The isolated transcaruncular approach provides exposure of the medial orbital floor from the region of the maxilloethmoidal strut to the orbital roof area superior to the frontoethmoidal suture. When combined with an inferior fornix incision, the transcaruncular approach allows for continuous exposure from the frontozygomatic suture laterally to the frontoethmoidal suture medially. Attention to anatomical details promotes creation of an effective and safe caruncular incision. The conjunctival incision should be ample. The orbital septum should be carefully dissected from the posterior surface of the Horner muscle to minimize fat spillage, and the periosteum should be opened widely at the beginning of surgery.

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Figure 1.

Cadaver transcaruncular dissection of the fan-shaped medial attachment of the Lockwood ligament. The ligament arises midway between the lacrimal duct opening and the medial canthal tendon, starting near the inferior portion of the Horner muscle. Copyright 2006 Regents of the University of California.

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Figure 2.

Intraoperative view of right transcaruncular approach to the orbit. The lacrimal rake holds the cut edge of conjunctiva. The medial orbital fat has been dissected off the Horner muscle (H); residual fibrous tissue on the muscle surface represents part of the medial orbital septum (arrow). Copyright 2006 Regents of the University of California.

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Figure 3.

Axial T1-weighted magnetic resonance imaging studies of a healthy 23-year-old woman. The white arrow (C) points to the Lockwood ligament, visualized on the patient's left side only. The lacrimal sacs are colored green (A and D); the medial orbital septa, yellow (C and D); and fibers of the medial rectus suspensory ligaments and pulley, pink (D). Copyright 2006 Regents of the University of California.

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Figure 4.

Seventeen-month-old specimen. Fibrous tissue originates from the posterior lacrimal crest in the area corresponding to the attachment of the Lockwood ligament (L), midway between the medial canthal tendon and the lacrimal duct opening. The lacrimal sac is indicated in green. IO indicates inferior oblique; OO, orbicularis oculi (the Horner muscle). (Masson trichrome, original magnification ×4). Copyright 2006 Regents of the University of California.

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Figure 5.

Design of the conjunctival incision. The caruncle marks the approximate location of the Horner muscle and the medial orbital septum. The conjunctival incision should be of adequate length to allow unencumbered dissection of the surgical plane. The incision (marked in black dots) extends at least to the level of the upper and lower puncta and transects the lateral quarter of the junction of the caruncle. Copyright 2006 Regents of the University of California.

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Figure 6.

Surgical dissection. A, The dissection between the posterior surface of the Horner muscle and the orbital septum is performed by bluntly feeling the posterior lacrimal crest with Stevens tenotomy scissors and then spreading the scissor tips while they rest on the posterior lacrimal crest. B, As the tips of the scissor are spread apart and rest on the posterior lacrimal crest, the inferior blade touches the insertion of the Lockwood ligament (purple). The Horner muscle (red) is shown on the lateral surface of the lacrimal sac (blue). Copyright 2006 Regents of the University of California.

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Figure 7.

The periosteal incision is made before any dissection into the orbit is performed. The periosteal incision must be long enough to allow unimpeded visualization of the surgical space; a long, clean incision will provide some protection against orbital fat spillage. The Lockwood ligament (purple) is lifted from its bony insertion (enthesis). Copyright 2006 Regents of the University of California.

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Figure 8.

Combined medial and inferior conjunctival incision for access to the medial wall and floor; the Lockwood ligament and inferior oblique muscle must be transected. Copyright 2006 Regents of the University of California.

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