ADVANCES IN SURGICAL RECONSTRUCTION OF ISOLATED MEDIAL ORBITAL WALL FRACTURES

Abstract

Isolated medial orbital wall fractures remain a small but technically demanding subset of orbital trauma. The deep location of the defect, the thin lamina papyracea, the risk of medial rectus entrapment, and the challenge of securing posterior support have kept reconstruction strategy under debate even as imaging, implants, and navigation have improved. A focused narrative review was prepared with emphasis on studies from the last decade that directly addressed isolated medial orbital wall fractures or offered closely transferable data on orbital reconstruction technology, implant positioning, and revision. Priority was given to systematic reviews, comparative studies, large case series, and technique papers reporting indications, access route, reconstruction method, implant choice, orbital volume restoration, diplopia, enophthalmos, motility, complications, and reintervention. Recent literature shows a clear shift from simple defect coverage toward anatomy-driven reconstruction. Transcaruncular and retrocaruncular exposure remain the main direct routes because they combine scar avoidance with reliable access to the medial wall. Endoscopic endonasal repair has matured from a niche alternative into a reproducible minimally invasive option with strong functional results in selected cases. A 2025 systematic review of 204 patients reported improvement or resolution of diplopia in 98.1 percent, enophthalmos in 88.2 percent, and motility restriction in 100 percent, with no reported revision surgery. Comparative and technical series also support newer repositioning methods, endoscopic slide-in reconstruction, and hybrid transcaruncular plus transethmoidal approaches. Material selection has become more tailored than dogmatic. Porous polyethylene, absorbable meshes, titanium devices, and u-HA and PLLA composites each have a defensible role when matched to defect geometry and the need for structural support. Digital tools are increasingly important in the deep posterior orbit, where free-hand reconstruction is most vulnerable to error. Navigation improves volumetric accuracy and lowers revision in broader orbital reconstruction, and medial-wall-specific data now show better orbital volume correction with navigation than without it. The major advances in medial wall reconstruction are not simply new implants. They are better control of the posterior boundary of the defect, safer minimally invasive access, and more accurate restoration of orbital volume. The field is moving toward selective endoscopic repair, navigation-guided reconstruction, and defect-matched biomaterials, but the evidence base remains dominated by retrospective series rather than high-level comparative trials.