We sincerely appreciate your thoughtful comments regarding our recent paper, “Transnasal balloon-assisted posterior ridge restoration for inferior orbital wall fractures” [1]. We are particularly grateful for your recognition of the clinical significance of our attempt to achieve three-dimensional anatomical reconstruction of the posterior orbital ridge. Below, we address the methodological concerns you raised and provide further explanations regarding points that could not be discussed in detail within the published article.

First, regarding the retrospective study design and the unequal distribution of patients between the two groups (25 vs. 60), we fully acknowledge that prospective randomized controlled trials (RCTs) represent the highest level of clinical evidence and can minimize the risk of selection bias. However, conducting an RCT in this setting was challenging because of strong patient preferences regarding the surgical method. As reflected by the unequal group sizes, when both treatment options were explained, the majority of patients preferred autologous orbital wall reconstruction using absorbable implants rather than reconstruction with permanent orbital implants. Although the clinical outcomes were comparable between the two groups, randomizing patients while disregarding their clearly expressed treatment preferences raises ethical concerns and would present practical challenges in obtaining Institutional Review Board approval. Furthermore, given the close anatomical relationship of the orbit to the maxillary sinus and nasal cavity, concerns regarding long-term infection, chronic inflammation, and foreign body reactions remain relevant considerations. Many patients favored a reconstructive approach utilizing their own bone and absorbable fixation materials because it avoids the permanent placement of alloplastic implants in their orbit [2,3]. Therefore, the unequal distribution of patients between the two groups largely reflects patient preferences and clinical decision-making rather than investigator-driven selection. We recognize that this limitation is inherent to the retrospective design and should be considered when interpreting the study findings.

Second, although the balloon-assisted group demonstrated superior restoration of the native orbital floor curvature on radiological analysis, no statistically significant differences were observed in clinical parameters, including Hertel measurements and orbital volume ratios. As you correctly pointed out, quantitative clinical outcomes were comparable between the two groups, and no major functional complications, such as persistent diplopia or clinically significant enophthalmos, were observed during the follow-up period. Several factors may explain these findings. Primarily, postoperative Hertel measurements often show limited variability because the normal physiological range is relatively narrow, making it difficult to detect statistically significant differences between treatment groups. Additionally, the present study mainly included patients with relatively small and localized orbital floor fractures rather than extensive inferomedial orbital wall defects. As a result, the degree of postoperative orbital volume change was modest in both groups, limiting the likelihood of demonstrating significant differences in volumetric outcomes. Although we introduced a novel curvature analysis method and identified a statistically significant difference in the restoration of orbital floor anatomy, we agree that radiological superiority alone does not necessarily translate into measurable clinical advantages in this patient population. Nevertheless, we believe the key clinical implication of our findings is that the balloon-assisted technique achieved functional and volumetric outcomes comparable to those of conventional reconstruction methods while avoiding the implantation of permanent alloplastic materials within the orbit. From this perspective, the technique may represent an alternative capable of providing comparable clinical results without the potential long-term concerns associated with permanent orbital implants. We also agree that three-dimensional volumetric and surface-mapping analyses could provide additional insights into the relationship between anatomical restoration and clinical outcomes. These advanced imaging assessments will be incorporated into our future investigations to validate the clinical value of this technique [3,4].

Finally, we agree with your comment regarding the limitation of the 6-month follow-up period. Bone remodeling is a dynamic process that continues well beyond the early postoperative phase, and careful long-term observation is necessary to evaluate delayed changes. Long-term clinical follow-up is particularly important when comparing these two surgical approaches with respect to implant-related complications, maintenance of orbital volume, and long-term structural stability. To address this limitation, we are currently collecting follow-up data extending beyond 1 year to assess delayed orbital floor depression and other late postoperative changes.

The fundamental concept of our technique is to minimize the biological burden associated with permanent foreign materials by reducing the reliance on non-absorbable implants during orbital fracture reconstruction. Restoration of the patient’s original orbital wall using temporary balloon support through the nasal cavity can reduce the size of the residual bony defect. As a result, reconstruction can often be achieved using smaller absorbable implants, and in cases where near-complete anatomical reduction of the native orbital wall is obtained, orbital reconstruction may even be possible without the use of any orbital implant [4,5]. We believe that preservation and restoration of the native orbital wall, combined with minimization of permanent implant use, may reduce the risk of long-term implant-related complications while promoting more physiological healing. Although both surgical techniques demonstrated comparable clinical outcomes in the present study, the balloon-assisted approach offers the potential advantage of reducing the need for permanent artificial implants while maintaining satisfactory anatomical and functional results. Therefore, we believe that this technique may represent a safe and biologically favorable alternative for orbital floor reconstruction, although further long-term studies are required to confirm these potential benefits [6].

We sincerely thank you again for your constructive and insightful comments. Your feedback has provided valuable perspectives for refining our surgical strategy and for guiding future research aimed at optimizing orbital fracture reconstruction.