## 4 Discussion
The search was conducted on Pubmed, with a retrospective limit of 10 years. Only papers regarding isolated medial orbital wall fractures were included in the evaluation. Several authors have described the importance of endoscopic surgery, either alone or combined with an external approach, as shown in Table 2.  
For each paper, we analyzed the endoscopic surgical steps and the implanted material. The analysis of the literature showed that the endoscopic endonasal approach has become the gold standard for this kind of fracture. All authors reported the opposition of alloplastic material, such as fine sheets of Medpor (Stryker, Kalamazoo, MI, USA), Synpor (Depuy Synthes; Johnson and Johnson, New Brunswick, NJ, USA), dura mater substitutes, or a combination of a titanium mesh with a layer of porous Medpor [4; 12; 14; 17]. Four papers described anteroposterior ethmodectomy, performed for most posterior fractures as a necessary step to dominate the fracture field [18; 19]. The authors of all the selected papers adopted the exposition of alloplastic sheets on the fractured lamina [10; 14; 20; 21; 22]. In one of these four papers, it reported the use of intraoperative navigational assistance to obtain a more precise reduction by uploading a mirroring of the healthy orbit. Navigation was also used to compare orbital volumes before and after treatment, to assess the stability of the outcome [8]. The surgical procedure we performed was in agreement with the data obtained from the literature regarding surgical approaches: in our procedure, not considering if the fracture was anterior or posterior, the medial orbital wall was accessed by removing the uncinate process, the ethmoid bulla, and passing through the lamina basalis of the middle turbinate, facing the sphenoid sinus as the posterior limit. This corridor allowed us to increase the visibility of the surgical field and to completely dominate the fracture. This passage must be carefully performed, to respect the locoregional buttressing. When the MT buttress is preserved, the postsurgical anatomy remains intact in the long term, resulting in an excellent outcome. In our cases, no implantation of absorbable material was performed. Despite the fact that the width of the fracture could represent an indication, we preferred a more conservative approach; in the larger fracture, we did not remove bony fragments. We just gently laterally pushed them back. Once the fractured wall was reduced, a small gloved nylon-anchored Merocel was used as a temporary endonasal splint to maintain the position of the fragments. Keeping the small Merocel gloved preserves it from fluid imbibition that could decrease its rigidity. This technique has been successful in terms of both clinical results in the immediate postoperative period and after 6 months. Compared to the literature, the adoption of the endoscopic approach cancels the incidence of complications, such as scarring, lagophthalmos, and epiphora, risks associated with the transcutaneous approach. The decision to not insert alloplastic material reduces the incidence of complications such as implant infection, residual diplopia, and material migration [13]. In our population, cases of residual diplopia (four patients; two per group) were evaluated by immediate postoperative clinical imaging in order to assess eventual reduction of misplacement. Incidence was attributed to postoperative edema and did not undergo further treatments other than corticosteroid therapy. On the basis of our experience, clinical outcome improved compared to patients treated with the previous transcutaneous approach. We recorded the resolution of preoperative symptoms in almost all cases and the stability of the anatomical reduction of the fracture after 6 months. The goal of personalized patient care has led to the growing use of new technologies and dedicated software [23, 24].