Figure 5.2a shows a 22-year-old male who presented 4 weeks after the initial injury . The patient was already on oral antibiotics for an infected huge orbital cyst that shows under the sutured skin. After a few days of intravenous antibiotics, the patient underwent a horizontal skin incision (Fig. 5.2b). The cyst was identified and opened. No eye globe tissues were identified. The cyst has probably originated from remnants of conjunctival epithelial cells. Figure 5.2c shows the inside of the cyst. Again, a small amount of skin and cyst lining was excised. The rest of the cyst was kept and used as new socket lining. No orbital implant was inserted. A temporary conformer was placed inside the new socket . A suture was placed to tighten the lower lid laterally (Fig. 5.2d). However, 3 weeks after the surgery, he presented with sagging of the lower lid. He then underwent a myocutaneous cheek rotation flap with a hard palate graft to support it (Fig. 5.2e). Figure 5.2f shows a well-supported lower lid [4].

A 26-year-old male who presented after 3 weeks from his injury (Fig. 5.3a): The lower lid was sutured superiorly to just below the eyebrow. Upon exploration, the wound was reopened and the lower lid margin was found to be sutured directly to the tissues below the eyebrow. Most of the upper lid skin was missing. The cornea was also open with uveal tissue prolapse. The uveal tissue was then cleaned and alcohol was applied (Fig. 5.3b). A 20 mm sphere was inserted and the sclera was sutured on top. A myocutaneous flap was fashioned from the cheek and rotated to reconstruct the missing upper lid tissues (Fig. 5.3c, d). Such rotation flaps are rarely done since they give an unacceptable cheek scar. However, in this case, and because of the extensive facial wounds, this was not of major concern. Three months later, the patient presented for medial canthal reconstruction using the technique that is described for Case 4 (Fig. 5.3e). Figure 5.3f shows the patient after fitting a prosthesis.

A 31-year-old who presented 1 year after his initial injury with severe medial canthal dystopia and an anophthalmic socket with inadequate lower fornix (Fig. 5.4a): Intraoperatively, the medial canthus was totally freed and mobilized superiorly. Trans-nasal wiring was an option in this patient but it carries the risk of working on the opposite normal area. A T-shaped plate for fixation of the medial canthus was another option. Again, we tried to use simple techniques with least expensive material possible. The technique we used is shown in Fig. 5.4b. The bone was opened behind the posterior lacrimal crest using a clamp and two holes were made in the lacrimal fossa using an 18-gauge needle. A double-armed 4-0 prolene suture is then passed the way shown in Fig. 5.4b and then used to fix the medial canthal tissues. An upper to lower lid myocutaneous flap was rotated (Fig. 5.4c) to support and prevent downward traction on the lower lid. Figure 5.4d, e shows the last photos taken before and after the ocular prosthesis was fit. He had an acceptable aesthetic result except for some upper lid retraction [5–7].