Purpose: To quantitatively compare the degrees of surgical freedom achieved by a lateral orbitotomy without bone removal versus a lacrimal keyhole-assisted approach, in which the superolateral orbital rim is shaved without full removal. Methods: Preoperative orbital computed tomography scans from consecutive lateral orbitotomy patients (January 2023–April 2025) were retrospectively analyzed. Using Brainlab software, we compared the theoretical volume of surgical freedom and horizontal and vertical attack angles between a simulated orbitotomy without bone removal and the keyhole-assisted technique with incremental rim shaving (25% to 100%). Statistical analysis included paired t tests and linear regression. Results: Twelve patients (mean age: 52.2 years; 58% female) were evaluated. The complete keyhole-assisted approach significantly increased the volume of surgical freedom by 21% (6.2 ± 2.2 mm³ vs. 5.1 ± 2.0 mm³; p = 0.005) and the horizontal and vertical attack angles by 62% (20.4 ± 7.2° vs. 12.6 ± 4.2°; p < 0.001) and 38% (36.4 ± 9.5° vs. 26.4 ± 8.4°; p < 0.001), respectively. Partial rim shaving also yielded significant, progressive gains ( p < 0.05). Linear regression showed that each 1 mm of bone shaved improved the horizontal angle by 16%, the vertical angle by 10%, and the volume of surgical freedom by 6%. The size of the rim prominence strongly correlated with surgical freedom (r = 0.74, p = 0.02). No postoperative cosmetic or functional deficits were observed. Conclusions: The lacrimal keyhole-assisted orbitotomy significantly enhances surgical freedom for orbital lesions. This minimally invasive technique offers a titratable alternative to marginotomy, allowing tailored bone removal for required maneuverability while preserving orbital rim integrity.
Ma et al. (Fri,) studied this question.
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