J Oral
Maxillofac Surg
48:042-954,1990
Cutaneous Approaches to the Orbital Skeleton and Periorbital Structures BARRY L. EPPLEY, MD, DMD,* PHILIP L. CUSTER, MD,t AND A. MICHAEL SADOVE, MD*
Surgical access to the orbital skeleton and periorbital structures through the eyelids and anterior orbit has been accomplished by an array of cutaneous incisions. Due to the superficial nature of the underlying anatomy, albeit muscle, fat, tendon, or bone, many different incisional approaches will provide reasonable access to the desired structures. There can be significant differences, however, in the resultant esthetic appearance and orbital function between the various choices of incision. Historically, the incisions used for this anatomic area appear to have their origins, at least partly, in the treatment of two separate facial problems: zygomatico-orbital fractures and cosmetic blepharoplasty. These historic trends are still evident today as it is not uncommon to witness the same surgeon use different incisions for each of these procedures. Incision choices are also partially affected by the specialty and the individual, dependent on their training and experience with the eye, as well as their understanding of physiologic orbital function. Surgeons with less experience and knowledge of the eyelid may be inclined to use more peripherally placed incisions. There is a current trend toward more central placement of incisions with respect to the globe in recognition that nearly equal access, but a markedly improved esthetic outcome, results. Successful utilization of these approaches is dependent on an ap-
preciation periorbital
American
Association
of Oral
and
Maxillofacial
eyelid/
Anatomic Considerations A detailed account of the anatomy of the orbital region is beyond this text, and several excellent publications are available for review.lA From an incisional viewpoint, however, one must not only consider the cutaneous anatomy of the orbit but also its unique underlying structures, for they are densely compacted, intricate, and contain many critical elements in close proximity. As with any circular structure in which its enveloping muscle layers serve as a sphincter, skin creases will differ and occasionally change dependent on the extent of muscle tone and contraction. Because the orbicularis oculi muscle functions as the eyelid sphincter, which component contracts will affect the extent of orbital and periorbital skin creasing. The palpebral component of the orbicularis, further subdivided into pretarsal and preseptal portions, functions to close the lids involuntarily as occurs in blinking (Fig 1A). Its only contribution to skin creasing is in the lids where the upper and lower creases are created by the attachment of the eyelid protractors. The superior crease generally follows the contour of the upper eyelid margin, running from 8 to 10 mm above the ciliary margin where the levator aponeurosis inserts into the pretarsal orbicularis muscle. The lower crease runs more obliquely from the lower lid margin, being higher medially (3 to 5 mm) than laterally (5 to 7 mm), and is formed by the attachment of an extension of the inferior rectus muscle, the capsuiopalpebra1 fascia, onto the inferior tarsus’ (Fig 1, B and C). When the orbital portion of the orbicularis functions, the surrounding tissues of the orbit, including the forehead and cheek, are drawn in concentrically and extensive periorbital skin creases are created.’ In youth, this action of the underlying orbicularis muscle on skin creates the well-known relaxed-skin tension lines (Fig 2). These lines are then further demarcated by the aging process.
* Fellow, Craniofacial Program, James Whitcomb Riley Hospital for Children, Indiana University Medical Center, Indianapolis, IN. t Onhthalmic Plastic, Reconstructive, and Orbital Surgery, Barnes Hospital, St Louis, MO. t Director. Craniofacial Prouram. and Chief. Plastic Suraerv Section, James Whitcomb Riley Hospital for Children, Ind&a University Medical Center, Indianapolis, IN. Address correspondence and reprint requests to Dr. Eppley: James Whitcomb Riley Hospital for Children, 702 Barnhill Dr, Suite 2514, Indianapolis, IN 46202-5200. 0 1990 geons
of the relationship between anatomy and lid/ocular function
Sur-
0278-2391190/4808-0013$3.00/O
842
EPPLEY, CUSTER, AND SADOVE
Preseptal Pretarsal
FIGURE 1. A, Divisions of orbicularis oculi muscle layers. B, The lid creases are formed by the attachment of the levator aponeurosis in the pretarsal muscle superiorly and the attachment of the lower lid retractors to the tarsus inferiorly. C, Cross-sectional anatomy of the eyelids and anterior orbit. A, orbital septum; B, levator aponeurosis; c, superior fomix; D, preseptal orbicularis; E, Muller’s muscle; F, superior tarsus; G, meibomian glands of tarsus; H, pretarsal orbicuktrk; 1, conjunctiva; I, pretarsal orbicularis; K, inferior tarsus; L, lower lid retractors (inferior aponeurosis and inferior tarsal muscle); M, orbital septum; N, inferior rectus muscle; 0, inferior oblique muscle.
Skin thickness varies considerably over this region, being thinnest in the eyelids and thicker over the orbital rim areas. This thinness, combined with its immediate attachment to the underlying, richly vascular orbicularis muscle (without intervening subcutaneous tissue), allows eyelid incisions to heal more rapidly and with less scar formation than the surrounding periorbital tissues. This healing capability is evident in all eyelid manipulation, but is particularly illustrated in eyelid lacerations and avulsions, where even necrotic tissue will progress to healing, and in lid skin grafting where nearly 100% graft take can be consistently expected. Although the contributions of the orbicularis oculi muscle may be beneficial in eyelid incisions, it
FIGURE 2.
Relaxed skin tension lines of the periocular region.
844 may have detrimental effects on incisions outside the orbit. In this area, the muscle lies deeper to the skin and, in conjunction with contraction over the prominent orbital rims, places tangential forces on concentrically placed incisions, which may result in depressed or wide scar formation. Another important underlying difference between eyelid and more peripheral orbital incisions is in their potential for affecting orbital function. Incisions around the orbital rim place at risk peripheral sensory branches of the fifth cranial nerve, including the supraorbital, supratrochlear, infraorbital, and the temporal and zygomatic divisions of the seventh cranial nerve. Thus, sensation over the forehead, cheek, or lip, as well as eyelid closure, may be adversely affected. Eyelid incisions, however, more directly affect lid position and contour. The upper eyelid is responsible for the vast majority of eye opening capability. Movement of the lower lid is not essential in this regard as evidenced by the success of a static lower lid reconstruction provided upper eyelid function is intact.5 An important anatomic feature of upper lid anatomy is the insertion of the levator palpebrae superioris aponeurosis (Fig 1B). This structure is attached to the lateral and medial orbital rims and terminates at the anterior surface of the tarsal plate and pretarsal orbicularis muscle (Fig 3). It is this attachment that not only creates the superior lid crease but also affects the position of the lid as it drapes over the anterior globe. While an upper lid incision will not affect its innervation, which is supplied by the third cranial nerve, failure to identify and evaluate the levator
ORBITAL APPROACHES
attachment may result in a postoperative ptosis. In addition, if a suture is passed too deeply during skin closure, the levator may be entrapped in the ligature and a postoperative lid retraction will result. Lastly, a frequently overlooked consideration in orbital incisions is the pathway of lymphatic drainage. As there are no lymph nodes in the orbit, lymphatic drainage from the ocular adnexa travels almost exclusively to the preauricular and intraparotid lymph nodes. A small amount of drainage from the medial canthal and lower eyelid areas also passes into the submental and submandibular nodes.6 Violation of this primary lymphatic pathway by incision or laceration predisposes the patient, particularly the adult and aged, to intractable lymphedema. It is for this reason that incisions placed around the orbit should never follow the circular outline of the bony orbit laterally but should tail off in a skin crease, thus avoiding transection of these lateral orbital lymphatic pathways. Incision Planning Incision placement and design are obviously guided by the goals of good intraoperative visibility and minimal postoperative scar formation. The ability to achieve these goals can best be realized by knowledge of all possible incisional approaches and their limitations. Although the orbit is relatively small, a diverse number of incisions have been described. For the sake of classification, they can be divided into superior and inferior orbital approaches.
FIGURE 3. A, Cadaver dissection, with removal of palpebral skin and orbicularis muscle, lacrimal gland, and orbital septum and fat, to reveal posterior origin of levator muscle and its aponeurotic attachment to the tarsal plate. The proximity of this muscle to the overlying skin should be noted. B, Intentional detachment of the levator muscle from the tarsal plate. Manipulation of this muscle attachment will directly determine lid position over the globe as is done for a ptosis repair.
EPPLEY,
CUSTER,
AND SADOVE
SUPERIOR ORBIT
A variety of incisions have been advocated for exposure of the supraorbital rim, frontozygomatic suture, frontonasal junction, and upper eyelid, and the superior, medial, and lateral orbital spaces (Fig 4). These incisions have been used for diverse conditions including skeletal fractures, aging (dermatochalasis), tumors, ptosis (congenital and acquired), and esthetic bone contouring. Essentially, seven incisions have been described: the rim, superolateral, lateral canthotomy, lid crease, Lynch, medial lid crease, and the bicoronal scalp flap. SUPERIOR RIM
Incisions placed over the superior (medial brow) and lateral (lateral brow) orbital rims have a long history of use in fracture repair; they are discussed in any textbook, new or old, that describes the treatment of facial fractures.7-10 They offer the advantages of speed of execution and acceptable exposure of the underlying bony anatomy (frontozygomatic junction) due to their proximity to it. However, they may result in poor scar appearance, as well as eyebrow hair loss, when placed within the brow, due to transection of hair follicles if the incision is not directed completely parallel to the emerging hairs. Furthermore, incisions placed over this area must be limited in length and blunt dissection carried down through the orbicularis and peri-
FIGURE 4. Orbital incisional choices: a, rim (upper); b, Wright; c, lateral canthotomy; d, lid crease (upper); e, Lynch; f. bicoronal flap; g, forehead; h, subciliary; i, lid crease (lower); j, rim (lower); k, conjunctival; 1, vestibular.
845 osteum to reduce the risk of fifth and seventh cranial nerve injury. As a result of their size limitations, they produce only limited access. SUPEROLATERAL
An incision along the orbital rim beneath the lateral brow continued down to the level of the lateral canthus, and extended laterally onto the zygoma if necessary, was originally described by Wright.” It exposes the lacrimal fossa, the lateral half of the superior orbit, and the frontal extension of the zygoma. I2913The curved or gentle S-shape of the incision allows extensive stretching so that wide exposure can be achieved. This approach is not only effective for fractures and the application of internal fixation, but also permits a lateral orbitotomy, in which the lateral orbital rim is outfractured, for diagnostic biopsy and removal of tumors of the lateral orbit. Its major disadvantage is the prominent scar created beneath the brow, which is in a minimally shaded facial area. The lateral canthal extension usually heals less conspicuously because it is in a relaxed skin tension line, particularly in older patients. Smaller variations of the Wright incision can be used, but scarring remains evident (Fig 5). LATERAL CANTHOTOMY
This incisional approach, originally described by Berke,i4 extends several millimeters from the lat-
FIGURE 5. Partial Wright incision places scar between lateral brow and superior lid crease, an unnatural skin line being higher than the superior tarsal fold.
846
ORBITALAPPROACHES
eral canthus, in a skin crease. It is a versatile approach and is commonly incorporated as an extension of other orbital incisions. It offers nearly equal exposure to the lateral orbit as the Wright incision, and direct access is obtained to the frontozygomatic junction and lateral orbital wall and rim (Fig 6). It does not provide good visibility, however, of the lacrimal fossa and anterosuperior orbital space. In addition, even with the wide exposure achieved by lateral wall osteotomies and temporal displacement of the globe, the apical portion of the optic nerve, as well as the posterior nasal quadrant of the orbit, is poorly visualized. This approach, when used alone, is most useful for lateral orbitotomies for the exposure of orbital masses. It may also occasionally be indicated in trauma for zygomatic arch manipulation and fixation of the frontozygomatic suture. However, for medial apical masses and displaced fractures of the floor and rim, its combination with a conjunctival incision or peritomy is necessary for optimal visualization.‘*-” Concern over preservation of the frontal branch of the facial nerve with this approach, although frequently quoted, is rarely of consequence as the incision generally does not extend this far laterally. More pertinently, the lateral canthus must be located and reapproximated, if necessary, to maintain symmetric intercanthal distances with the contralatera1 orbit as well as good lid apposition to the globe. UPPER LID CREASE (BLEPHAROPLASTY) An incision made in the upper lid crease, as a result of its placement in a naturally occurring, ageindependent skin line, offers the best cosmetic result of all superior orbital approaches. Even if the
A, Lateral canthotomy and orbitotomy result, with scar in natural skin crease.
FIGURE 6.
lid crease is not detactable, secondary to congenital anomaly, trauma, or involutional levator dehiscence, it may be easily marked and corelated with the contralateral side based on traditional measurements (Fig 7). A skin-muscle flap may be developed superiorly, medially, and laterally (with an incisional extension following the natural skin fold and curving slightly upward) in a plane deep to the orbicularis muscle and can be raised close to the brow18,19 (Fig 8). The periosteum may then be divided at the desired point over the rim for bony exposure and dissection can proceed through the spetum for access to the deeper superior orbital spaces (Fig 9). A skin flap only, above the orbicularis, intuitively appears easier and minimizes the risk of levator injury and postoperative ptosis. However, it is associated with an increased incidence of bleeding and hematoma formation (due to the muscle separation) and the potential risk of loss of flap viability. Furthermore, it is technically more difficult to develop due to the adherence of the thin layer of orbicularis. Thus, the skin-muscle flap is preferred. The lid approach decreases many of the risks associated with more peripherally placed incisions. Little danger exists for injury to peripheral nerve branches, although transient weakness of the orbicularis may occur in the region where its fibers were divided. Despite extensive undermining and raising of the flap, the vascular&y of its muscle component ensures skin viability and excellent healing. Essentially, any aspect of the superior orbit can be reached from this approach and, if necessary, lateral extensions of this incision onto the zygoma may be made for more peripheral aspects of the orbit or zygoma. The esthetic results are comparatively superior and the scar is usually undetectable.
for removal of a hemangioma
from the lateral intraorbital
space. B, Postoperative
EPPLEY, CUSTER, AND SADOVE
847
FIGURE 7. Lid markings for superior lid crease (8 mm medially, 10 mm centrally, and 9 mm laterally).
MEDIAL CREASE The utilization of the medial half of a standard lid crease incision has been described for both removal of superomedial orbital masses and anterior medial orbital wall fracture repair.20T2’ The distensibility of lid skin and underlying orbicularis permits good access to the medial orbital wall. The trochlea and superior oblique tendons can be temporarily detached from the orbital wall with little secondary disability, as experienced after craniofacial surgery.** This approach, while not as direct as a Lynch incision, produces a less detectable scar. LYNCH A preseptal nearly vertical incision placed in the superomedial orbit is usually referred to as a Lynch incision. 23It provides excellent exposure to the medial orbit and lateral part of the nose (Fig 4). It is useful for access to medial and posteromedial orbital tumors, medial wall fractures, and in the treatment of ethmoidal sinus disease. The inferior portion of the incision may also be used as the approach for a dacrocystorhinostomy. It produces a noticeable scar, however, because of its prominent location in the midface and because it crosses relaxed skin tension lines which normally run superomedially from the medial canthus to the glabella. Webbing of the skin secondary to scar contracture may also develop along the concave surface of the rim.*’ Modifications of the initial incision, including Z- and W-plasty designs, have been suggested to
FIGURE 8. A, Lid crease approach to superolateral orbit for tumor excision. B, Postoperative incision closure. C, Blepharoplasty approach for tumor excision.
848
ORBITAL APPROACHES
decrease the scar, but the use of other more esthetic approaches is preferable. BICORONAL
FLAP
A bicoronal scalp flap carried down to the supraorbital rim, with preservation of the superior neurovascular bundle, can be used for entry into the superior or anterior orbit for tumor remova123,24; for frontal-supraorbital, naso-ethmoidal, zygomaticoorbital, and isolated zygomatic arch fracture repair; for osteoplastic flap exposure of the diseased frontal sinus; and for esthetic contouring of the supraorbital rim to enhance the rim-globe relationship.“‘” It has also been recently described as an alternative approach for the lateral orbitotomy.*s This approach provides wide, direct visualization of underlying skeletal anatomy (Fig 10) and the risk of potential complications, consisting of wide scarring, focal loss of hair along the incision line, skin necrosis, hematoma, or infection, are very low (Fig 11). Its use, however, may be esthetically unacceptable in the patient with partial or complete alopecia. An alternative approach in aged, alopecic patients is to use a mid-forehead, irregular incision placed in a prominent horizontal skin crease.29 Access to areas other than the underlying superior orbit, however, is considerately limited (Fig 4). INFERIOR
FIGURE 10. Bicoronai flap reflected for extensive skeletal exposure in preparation for orbital translocation. The median nasal bone is marked for removal.
ORBIT
Incisions for the lower orbit are necessary for fracture repair, osteotomies, secondary orbital floor reconstructions, and cosmetic and reconstructive
FIGURE 9. Lateral upper lid crease approach for frontozygomatic fracture repair.
FIGURE 11. Initial exuberant scar formation is most likely to occur in the infantile patient as demonstrated in this 9-month-old child 3 months after receiving a bicoronal flap. Over time, however, marked diminuition in scar width occurs.
849
EPPLEY. CUSTER.AND SADOVE lower lid surgery. Based on the increased incidence of orbital rim/floor fractures, as compared with superior orbital fractures, inferior orbital approaches are probably used more frequently. As a result, the types of incisions for the lower orbit have been more critically assessed and compared.30-32 Six types of incisions have been described: subciliary, lid crease, rim, conjunctival, lateral canthotomy, and vestibular. SUBCILIARY The subciliary incision, which is placed approximately 2 mm below and parallel to the lower lid margin beginning medially at the punctum and continuing laterally beyond the lateral canthus in a skin crease (Fig. 4), has been used for over 40 years since first being described by Converse in 1944.33734 Wide exposure of the inferolateral orbit is achieved and floor reconstruction, infraorbital nerve decompression, and plate fixation of the rim can easily be done. It results in a minimal scar (Fig 12), but vertical lid shortening, as evidenced by increased scleral show and ectropion, may occasionally occur secondary to fibrosis from the dissection. Vertical dissection over the pretarsal fibers of the orbicularis is necessary after the skin incision to avoid disrupting the lower tarsus. Reports are variable concerning this complication, ranging from a low percentage of temporary ectropion to significant permanent occurrence in separate series.30,32 This most likely represents a diversity of experience with the technique among surgeons. LOWER LID CREASE (Blepharoplasty) The lower lid crease incision, which has also been called subtarsal or lower eyelid incision, is made
FIGURE 12.
A,
FIGURE 13. Lid markings for inferior lid crease (4 mm medially, 5 mm centrally, and 7 mm laterally). along the lower border of the tarsus of the lower lid in the skin crease in an oblique fashion mediolaterally. When the skin crease cannot be visualized, as may occur with edema from trauma, traditional skin markings are used (Fig 13). After skin incision, the underlying bony orbit can be approached either by undermining a skin flap or developing a combined skin-muscle flap, as with the upper lid crease. The skin flap was initially popular, but an unacceptable number of complications were reported, including ectropion, lash eversion, and skin necrosis.30*35 While the skin flap is still used by some surgeons for blepharoplasty,36 it has largely been replaced by the skin-muscle flap which not only is easier to dissect but has also reduced the complications of hematoma, ectropion, and other lid abnormalities.31*32*36 This incisional technique not only results in a very acceptable scar, but also is easy and rapid to perform and produces exposure comparable to all other inferior orbital approaches.
Subciliary incision for release of cicatricial ectropion. B, Minimal appearance of scar.
850
ORBITAL APPROACHES
INFERIORRIM
The rim incision undoubtedly evolved in an effort to avoid any lid complications, as well as to provide the shortest route between skin and bone. It is placed several millimeters lower than the blepharoplasty incision, at the inferior orbital margin, which produces a minor fold with the cheek (Fig 14). This really represents the junction of the orbital and palpebral portions of the orbicularis as well as the region where the orbital septum extends upward from the periosteum of the rim. Although this intuitively appears to be a good incisional choice, scarring and depression are frequent (Fig 15). In acknowledgment of this complication, stepping of the incision has been advocated to lengthen and alter the line of healing to produce a scar level more compatible with adjacent skin areas3’ Although this does offer some improvement, the prominence of this facial area and the presence of an unnatural, unmatched line below the lower lid crease is esthetically compromising. The incision does, however, offer the advantages of easy execution and negligible risk of postoperative lid dysfunction. In addition, the medial half of the rim incision may be used for dacrocystorhinostomies due to its proximity to the lacrimal sac (Fig 16). This not only results in improved postoperative scars compared with the more traditional Lynch or lateral nasal incisions, but also avoids transection of the angular artery which is common with the other approaches .
FIGURE 15. A poorly placed lower rim incision combined with a Wright (superolateral) incision for zygomatico-orbital fracture repair results in prominent periocular scarring.
CONJUNCTIVAL
Access through the fomix was advocated in the early 1970s by Tenzel, Tessier and Converse.38-40 An incision placed in the fomix results in equal exposure of the floor and rim when compared with the other inferior orbital approaches. When combined with a lateral canthotomy incision, wide exposure of both the inferior orbit and zygoma can be
FIGURE 14. A, Rim incision for exposure of inferior orbit. B, Wide exposure, as is necessary for extensive orbital floor reconstruction, is easily obtained with the lower rim incision.
EPPLEY,
CUSTER,
AND SADOVE
FIGURE 16. Medial lower rim approach for dacrocystorhinotomy.
achieved. Despite its early popularity, many complications were subsequently reported with its use, including ectropion, entropion, and tearing of the lid margin. 3034’These complications, combined with unfamiliarity in manipulation of inner lid tissues and the lateral canthus, probably led to its abandonment by many surgeons. The emergence of both craniofacial and oculoplastic experiences, where orbital intervention and manipulation is frequent, has spurred a new wave of enthusiasm for its use.15V36*41 It has been used not only for fractures and osteotomies but also for tumor removal, orbital decompression, and cosmetic lid surgery.‘5,42,43 It must be acknowledged that an incision limited
851
to the conjunctiva offers the advantage of the absence of a facial scar but may produce less than the desired access. This lack of access should not detract from its use, but does necessitate forethought as to the planned operation. Exploration of isolated floor fractures with minimal rim involvement and lack of a zygomatic component, as well as removal of infraorbital fat, can be done nicely from this approach. Manipulation of the zygoma or lateral orbit, or the placement of bone plates, requires a lateral canthotomy extension. Once this extension is necessary, which introduces facial scarring, the esthetic advantage of the conjunctival approach is partially lost. Many suggestions have been made to decrease the potential complications from this approach.3’*37,41 The most critical are the level of incision in the fornix and a preseptal versus retroseptal approach. The conjunctival incision should be placed between the lower border of the tarsus and the lowest point in the fornix. If the incision is placed higher, vertical dissection within the lid will be necessary and the risk of fibrosis and ectropion is increased. If placed too low in the fornix, the potential for injury to the inferior oblique muscle is more likely (Fig 10, and dissection must proceed through orbital fat. Furthermore, identifying the anterior fat capsule, which almost always protrudes into the wound after transection of the inferior lid retractors, and dissecting anterior to it (preseptal) down to the level of the rim, will aid in preventing
FIGURE 17. A, Periosteum and inferior orbital rim exposed through a conjunctival incision. Dissection has proceeded anterior to the fat capsule. B, While the exposure obtained with the conjunctival incision is less generous than with other approaches, orbital floor reconstruction (with alloplastic material in this case) is still readily accomplished. The addition of a lateral canthotomy incision enables access to other orbital and periorbital skeletal structures.
ORBITAL APPROACHES
annoying fat prolapse, as well as increase visualization (Fig 17). Fat, once displaced into the wound and not excluded from contact with the conjunctiva by meticulous closure of the inferior lid retractors, can form adhesions with the mucosal lining of the lid, and the risk of vertical lid shortening by secondary contracture may be increased. A reverse Frost suture, placed through the lower lid and taped to the forehead after the conjunctiva is closed (Fig 18) and allowed to remain for the first postoperative day, is a good adjunctive technique that, if consistently used, will nearly eliminate the potential for ectropion and poor lid position in all lower lid approaches.
Effective use of the lateral canthotomy requires appreciation of its tendinous form. The lateral canthal tendon is one component of the lateral retinaculum, which is a collection of all the supporting adnexal structures of the orbit at the lateral region.3 It is composed of both anterior and posterior limbs (Figs 1B and 19). The anterior limb is thin and is derived from orbicularis fascia which attaches and blends into temporal fascia and galea aponeurotica (Fig 19A). The posterior limb is much thicker and combined with the lateral horn of the levator aponeurosis and Lockwood’s ligament insert at a bony tubercle (Whitnall’s tubercle) at the lateral orbital rim3,36*44(Fig 19B). Both of these limbs contribute to the shape and position of the lateral palpebral fissure which usually is positioned slightly higher than the medial fissure. This palpebral relationship, combined with a slight bowing at the lateral third of the lower eyelid, creates the desirable almond shape to the eye.45 After the skin incision and subcutaneous dissec-
FIGURE 18. A reverse Frost suture technique to aid in reduction of the risk of ectropion in lower lid-fomix approaches.
tion in a lateral canthotomy approach, the tendon should be identified and severed from its lateral rim attachment with ligature identification of the residual stump. Mobilization of the periosteum along the lateral wall of the orbit, the frontal process of the zygoma, the zygomatic process of the frontal bone, and the lateral supraorbital rim will provide wide exposure extending from the zygomaticofrontal suture to the inferior orbit. 36Reattachment of the tendon should be concentrated solely on the posterior limb and its surrounding tissue mass (which will contain periosteum and orbicularis) with firm fixation to the residual stump of tendon by nonresorbable suture. Positioning and tightening of the lateral fissure and eyelids is then done by tension adjustment on the sutures and by comparison to the contralateral uninvolved side. Wire fixation to the lateral orbit has been advocated,45 but is usually unnecessary when reattachment, and not entire tendon repositioning, is being done. VESTIBULAR
The intraoral approach, while obviating any facial scar, produces severely restricted access. Only the inferior aspect of the orbital rim and zygoma can be reached, which allows minimal manipulation of bone segments and no inspection of intraorbital contents. Such an approach has historically been used for antral access to floor fractures and infraorbital nerve procedures, but is of limited use in extensive zygomatico-orbital fracture repair or intraorbital surgery. Summary Multiple cutaneous approaches to both the superior and inferior orbit have been reviewed. Incisional choices are optimally based on both facial esthetics and orbital function, which are achieved by an understanding of the unique anatomy of this region. The superior orbit is best approached by a blepharoplasty (lid crease) incision in conjunction with a lateral extension if additional exposure is necessary. Almost all aspects of the bony orbit can be reached with the exception of the frontal bone superior to the supraorbital rim. When wide exposure of the orbital skeleton is necessary, a bicoronal scalp flap is most effective in a nonalopecic patient. The inferior orbit can be approached by a ciliary, blepharoplasty, or conjunctival incision with a lateral canthotomy. None has proven esthetic advantages over the others, with the exception of the conjunctival incision when used alone. The lid incisions must be used with the understanding that orbital function must be assessed both
EPPLEY, CUSTER, AND SADOVE
853
FIGURE 19. Thin, supertical anterior limb of lateral canthal tendon (open arrow) composed of orbicularis fascia blending into the surrounding temporalis fascia. a, lacrimal gland; b, orbital fat. B, Thick posterior limb of lateral canthal tendon with contributions of the lateral horn of the levator (open arrow) and Lockwood’s ligament (dark arrow) which produces the primary lateral support for lid position
pre- and postoperatively and meticulous attention paid to protection and care of the anterior globe. In addition, because of the thinness of the tissues being manipulated, edema, bruising, and final settling of lid form may require more postoperative time than is typical of more peripheral approaches. References I. Zide BM: Anatomy of the eyelids. Clin Plast Surg 8:623, 1981 2. Wessberg GA, Wolford LM, Zerdecki JW, et al: Ophthalmologic considerations in maxillofacial trauma. Anatomy and diagnostic evaluation. Int J Oral Surg 10:236, 1981 3. Zide BM. Jelks GW: Surgical anatomy of the orbit. Plast Reconstr Surg 74:301, 1983 4. Weisman RA: Surgical anatomy of the orbit. Otolaryngol Clin North Am 21:1, 1988 5. Byrd HS: Eyelid reconstruction. Select Readings Plast Surg 4:1, 1987 6. Koziol JK: Anatomy of the orbit, in Peyman GA, Sanders DR, Goldberg MF (eds): Principles and Practice of Ophthalmology. Philadelphia, PA, Saunders, 1980, p 86 7. Dingman RO, Natvig P: Surgery of Facial Fractures. Philadelphia, PA, Saunders, 1964, p 239 8. Hotte HHA: Orbital Fractures. Springfield, IL, Thomas, 1970, p 227 9. Converse JM. Smith B, Wood-Smith D: Malunited fractures of the orbit. in Converse JM (ed): Plastic and Reconstructive Surgery. vol 2. Philadelphia, PA, Saunders, 1977, p 1027 10. Rowe NL, Williams JL: Maxillofacial Injuries, vol 1. London, England, Churchill Livingstone, 1985, p 482 Il. Wright JE: Clinical presentation and management of lacrimal gland tumors. Br J Ophthalmol63:6OO, 1979 12. Osguthorpe JD, Weisman R, Tapert MJ: Management of lacrimal fossa masses. Arch Otolaryngol Head Surg 112: 166, 1986
13. Nowinski T, Anderson RL: Advances in orbital surgery. Ophthalmol Plast Surg 1:211, 1985 14. Berke RN: A modified Kronlein operation. Arch Ophthalmol51;609, 1954 15. McCord CD Jr, Moses JL: Exposure of the inferior orbit with fomix incision and lateral canthotomy. Ophthalmic Surg 10:53, 1979 16. Smith JL: Antero-lateral approach to the orbit. Trans Am Acad Ophthalmol Otolaryngol 75: 1059, 1971 17. McCord CD Jr: A combined lateral and medial orbitotomy for exposure of the optic nerve and orbital apex. Ophthalmic Surg 958, 1978 18. Baker TJ, Gordon HL, Posrenko P: Upper lid blepharonlastv. Plast Reconstr Sura 60:692. 1977: 3:225. 1980 19. Gradinger GP: Cosmetic upper blepharopiasty. Clin Plast Surg 15:289, 1988 20. Wolfley DE: The lid crease approach to the superomedial orbit. Ophthalmic Surg 16:652, 1985 21. Katowitz JA, Welsh MG, Bersani TA: Lid crease approach for medial wall fracture repair. Ophthalmic Surg 18:288, 1987 22. Diamond GR, Katowitz JA, Whitaker LA, et al: Ocular alignment with craniofacial reconstruction. Am J Ophthalmol 90:248, 1980 23. Kennerdell JS, Maroon JC, Malton ML: Surgical approaches to orbital tumors. Clin Plast Surg 15:273. 1988 24. Maroon JC, Kennerdell JS: Surgical approaches to the orbit. Indications and techniques. J Neurosurg 60: 1226, 1984 25. Lassus C: Osteotomy of superior orbital rim in cosmetic blepharoplasty. Plast Recdnstr Surg 63:481, 1979 26. Marchac D: Radical forehead remodeline. Plast Reconstr Surg 61:823, 1978 27. Marchac D: Relationship of the orbits to the upper eyelids. Clin Plast Sum 8:717, 1981 28. Stewart WB, LeGin PS, Toth BA: The technique of coronal scalp flap approach to the lateral orbitotomy. Arch Ophthalmol 106: 1724, 1988 29. Brennan HG, Rafaty FM: Midforehead incisions in treatment of the aging face. Arch Otolaryngol 108:732, 1982 30. Wray RC, Holtmann B, Ribaudo JM, et al: A comparison of conjunctival and subciliary incisions for orbital fractures. Br J Plast Surg 30:142, 1977
854
31. Holtmann B, Wray RC, Little AG: A randomized comparison of four incisions for orbital fractures. Plast Reconstr Surg 67:731, 1981 32. Heckler FR, Songcharoen S, Sultani FA: Subciliary incisions and skin-muscle eyelid flap for orbital fractures. Ann Plast Surg 10:309, 1983
ORBITAL APPROACHES
38. 39.
33. Converse JM: Two plastic operations for repair of orbit following severe trauma and extensive comminuted fracture. Arch Ophthalmol 31:323, 1944
40.
34. Converse JM, Smith B, Obear MF, et al: Orbital blow-out fractures: A ten-year survey. Plast Reconstr Surg 39:20, 1967 35. Pospisil OA, Fernando TD: Review of the lower blepharoplasty incision as a surgical approach to zygomaticoorbital fractures. Br J Oral Maxillofac Surg 22:261, 1984
41.
36. Manson PN, Ruas E, Iliff N, et al: Single eyelid incision for exposure of the zygomatic bone and orbital reconstruction. Plast Reconstr Surg 79:120, 1987
44.
37. Rowe NL: Fractures of the zygomatic complex and orbit, in
42. 43.
45.
Maxillofacial Injuries, vol 1. London, England, Churchill Livingstone, 1985, p 512 Tenzel RR, Miller GR: Orbital blow-out fracture repair, conjunctival approach. Am J Ophthalmol71: 1141, 1971 Tesser P. The conjunctival approach to the orbital floor and maxilla in congenital malformation and trauma. J Maxillofac Surg 1:3, 1973 Converse JM, Firman F, Wood-Smith D, et al: The conjunctival approach in orbital fractures. Plast Reconstr Surg 52:656, 1973 Jackson IT: The conjunctival approach to the orbital floor and maxilla-Advantages and disadvantages. Ann Plast Surg 1946, 1987 Maniglia AJ: Conjunctival approach for lower lid blepharoplasty. Laryngoscope 89:1869, 1979 Schwarz F, Randall P: Conjunctival incision for herniated orbital fat. Ophthalmic Surg 11:276, 1980 Couly G, Hureau J, Tessier P: The anatomy of the external palpebral ligament in man. J Maxillofac Surg 4: 195, 1976 Whitaker LA: Selective alteration of palpebral fissure form by lateral canthopexy. Plast Reconstr Surg 74:611, 1984
Maxillofac Surg
48:042-954,1990
Cutaneous Approaches to the Orbital Skeleton and Periorbital Structures BARRY L. EPPLEY, MD, DMD,* PHILIP L. CUSTER, MD,t AND A. MICHAEL SADOVE, MD*
Surgical access to the orbital skeleton and periorbital structures through the eyelids and anterior orbit has been accomplished by an array of cutaneous incisions. Due to the superficial nature of the underlying anatomy, albeit muscle, fat, tendon, or bone, many different incisional approaches will provide reasonable access to the desired structures. There can be significant differences, however, in the resultant esthetic appearance and orbital function between the various choices of incision. Historically, the incisions used for this anatomic area appear to have their origins, at least partly, in the treatment of two separate facial problems: zygomatico-orbital fractures and cosmetic blepharoplasty. These historic trends are still evident today as it is not uncommon to witness the same surgeon use different incisions for each of these procedures. Incision choices are also partially affected by the specialty and the individual, dependent on their training and experience with the eye, as well as their understanding of physiologic orbital function. Surgeons with less experience and knowledge of the eyelid may be inclined to use more peripherally placed incisions. There is a current trend toward more central placement of incisions with respect to the globe in recognition that nearly equal access, but a markedly improved esthetic outcome, results. Successful utilization of these approaches is dependent on an ap-
preciation periorbital
American
Association
of Oral
and
Maxillofacial
eyelid/
Anatomic Considerations A detailed account of the anatomy of the orbital region is beyond this text, and several excellent publications are available for review.lA From an incisional viewpoint, however, one must not only consider the cutaneous anatomy of the orbit but also its unique underlying structures, for they are densely compacted, intricate, and contain many critical elements in close proximity. As with any circular structure in which its enveloping muscle layers serve as a sphincter, skin creases will differ and occasionally change dependent on the extent of muscle tone and contraction. Because the orbicularis oculi muscle functions as the eyelid sphincter, which component contracts will affect the extent of orbital and periorbital skin creasing. The palpebral component of the orbicularis, further subdivided into pretarsal and preseptal portions, functions to close the lids involuntarily as occurs in blinking (Fig 1A). Its only contribution to skin creasing is in the lids where the upper and lower creases are created by the attachment of the eyelid protractors. The superior crease generally follows the contour of the upper eyelid margin, running from 8 to 10 mm above the ciliary margin where the levator aponeurosis inserts into the pretarsal orbicularis muscle. The lower crease runs more obliquely from the lower lid margin, being higher medially (3 to 5 mm) than laterally (5 to 7 mm), and is formed by the attachment of an extension of the inferior rectus muscle, the capsuiopalpebra1 fascia, onto the inferior tarsus’ (Fig 1, B and C). When the orbital portion of the orbicularis functions, the surrounding tissues of the orbit, including the forehead and cheek, are drawn in concentrically and extensive periorbital skin creases are created.’ In youth, this action of the underlying orbicularis muscle on skin creates the well-known relaxed-skin tension lines (Fig 2). These lines are then further demarcated by the aging process.
* Fellow, Craniofacial Program, James Whitcomb Riley Hospital for Children, Indiana University Medical Center, Indianapolis, IN. t Onhthalmic Plastic, Reconstructive, and Orbital Surgery, Barnes Hospital, St Louis, MO. t Director. Craniofacial Prouram. and Chief. Plastic Suraerv Section, James Whitcomb Riley Hospital for Children, Ind&a University Medical Center, Indianapolis, IN. Address correspondence and reprint requests to Dr. Eppley: James Whitcomb Riley Hospital for Children, 702 Barnhill Dr, Suite 2514, Indianapolis, IN 46202-5200. 0 1990 geons
of the relationship between anatomy and lid/ocular function
Sur-
0278-2391190/4808-0013$3.00/O
842
EPPLEY, CUSTER, AND SADOVE
Preseptal Pretarsal
FIGURE 1. A, Divisions of orbicularis oculi muscle layers. B, The lid creases are formed by the attachment of the levator aponeurosis in the pretarsal muscle superiorly and the attachment of the lower lid retractors to the tarsus inferiorly. C, Cross-sectional anatomy of the eyelids and anterior orbit. A, orbital septum; B, levator aponeurosis; c, superior fomix; D, preseptal orbicularis; E, Muller’s muscle; F, superior tarsus; G, meibomian glands of tarsus; H, pretarsal orbicuktrk; 1, conjunctiva; I, pretarsal orbicularis; K, inferior tarsus; L, lower lid retractors (inferior aponeurosis and inferior tarsal muscle); M, orbital septum; N, inferior rectus muscle; 0, inferior oblique muscle.
Skin thickness varies considerably over this region, being thinnest in the eyelids and thicker over the orbital rim areas. This thinness, combined with its immediate attachment to the underlying, richly vascular orbicularis muscle (without intervening subcutaneous tissue), allows eyelid incisions to heal more rapidly and with less scar formation than the surrounding periorbital tissues. This healing capability is evident in all eyelid manipulation, but is particularly illustrated in eyelid lacerations and avulsions, where even necrotic tissue will progress to healing, and in lid skin grafting where nearly 100% graft take can be consistently expected. Although the contributions of the orbicularis oculi muscle may be beneficial in eyelid incisions, it
FIGURE 2.
Relaxed skin tension lines of the periocular region.
844 may have detrimental effects on incisions outside the orbit. In this area, the muscle lies deeper to the skin and, in conjunction with contraction over the prominent orbital rims, places tangential forces on concentrically placed incisions, which may result in depressed or wide scar formation. Another important underlying difference between eyelid and more peripheral orbital incisions is in their potential for affecting orbital function. Incisions around the orbital rim place at risk peripheral sensory branches of the fifth cranial nerve, including the supraorbital, supratrochlear, infraorbital, and the temporal and zygomatic divisions of the seventh cranial nerve. Thus, sensation over the forehead, cheek, or lip, as well as eyelid closure, may be adversely affected. Eyelid incisions, however, more directly affect lid position and contour. The upper eyelid is responsible for the vast majority of eye opening capability. Movement of the lower lid is not essential in this regard as evidenced by the success of a static lower lid reconstruction provided upper eyelid function is intact.5 An important anatomic feature of upper lid anatomy is the insertion of the levator palpebrae superioris aponeurosis (Fig 1B). This structure is attached to the lateral and medial orbital rims and terminates at the anterior surface of the tarsal plate and pretarsal orbicularis muscle (Fig 3). It is this attachment that not only creates the superior lid crease but also affects the position of the lid as it drapes over the anterior globe. While an upper lid incision will not affect its innervation, which is supplied by the third cranial nerve, failure to identify and evaluate the levator
ORBITAL APPROACHES
attachment may result in a postoperative ptosis. In addition, if a suture is passed too deeply during skin closure, the levator may be entrapped in the ligature and a postoperative lid retraction will result. Lastly, a frequently overlooked consideration in orbital incisions is the pathway of lymphatic drainage. As there are no lymph nodes in the orbit, lymphatic drainage from the ocular adnexa travels almost exclusively to the preauricular and intraparotid lymph nodes. A small amount of drainage from the medial canthal and lower eyelid areas also passes into the submental and submandibular nodes.6 Violation of this primary lymphatic pathway by incision or laceration predisposes the patient, particularly the adult and aged, to intractable lymphedema. It is for this reason that incisions placed around the orbit should never follow the circular outline of the bony orbit laterally but should tail off in a skin crease, thus avoiding transection of these lateral orbital lymphatic pathways. Incision Planning Incision placement and design are obviously guided by the goals of good intraoperative visibility and minimal postoperative scar formation. The ability to achieve these goals can best be realized by knowledge of all possible incisional approaches and their limitations. Although the orbit is relatively small, a diverse number of incisions have been described. For the sake of classification, they can be divided into superior and inferior orbital approaches.
FIGURE 3. A, Cadaver dissection, with removal of palpebral skin and orbicularis muscle, lacrimal gland, and orbital septum and fat, to reveal posterior origin of levator muscle and its aponeurotic attachment to the tarsal plate. The proximity of this muscle to the overlying skin should be noted. B, Intentional detachment of the levator muscle from the tarsal plate. Manipulation of this muscle attachment will directly determine lid position over the globe as is done for a ptosis repair.
EPPLEY,
CUSTER,
AND SADOVE
SUPERIOR ORBIT
A variety of incisions have been advocated for exposure of the supraorbital rim, frontozygomatic suture, frontonasal junction, and upper eyelid, and the superior, medial, and lateral orbital spaces (Fig 4). These incisions have been used for diverse conditions including skeletal fractures, aging (dermatochalasis), tumors, ptosis (congenital and acquired), and esthetic bone contouring. Essentially, seven incisions have been described: the rim, superolateral, lateral canthotomy, lid crease, Lynch, medial lid crease, and the bicoronal scalp flap. SUPERIOR RIM
Incisions placed over the superior (medial brow) and lateral (lateral brow) orbital rims have a long history of use in fracture repair; they are discussed in any textbook, new or old, that describes the treatment of facial fractures.7-10 They offer the advantages of speed of execution and acceptable exposure of the underlying bony anatomy (frontozygomatic junction) due to their proximity to it. However, they may result in poor scar appearance, as well as eyebrow hair loss, when placed within the brow, due to transection of hair follicles if the incision is not directed completely parallel to the emerging hairs. Furthermore, incisions placed over this area must be limited in length and blunt dissection carried down through the orbicularis and peri-
FIGURE 4. Orbital incisional choices: a, rim (upper); b, Wright; c, lateral canthotomy; d, lid crease (upper); e, Lynch; f. bicoronal flap; g, forehead; h, subciliary; i, lid crease (lower); j, rim (lower); k, conjunctival; 1, vestibular.
845 osteum to reduce the risk of fifth and seventh cranial nerve injury. As a result of their size limitations, they produce only limited access. SUPEROLATERAL
An incision along the orbital rim beneath the lateral brow continued down to the level of the lateral canthus, and extended laterally onto the zygoma if necessary, was originally described by Wright.” It exposes the lacrimal fossa, the lateral half of the superior orbit, and the frontal extension of the zygoma. I2913The curved or gentle S-shape of the incision allows extensive stretching so that wide exposure can be achieved. This approach is not only effective for fractures and the application of internal fixation, but also permits a lateral orbitotomy, in which the lateral orbital rim is outfractured, for diagnostic biopsy and removal of tumors of the lateral orbit. Its major disadvantage is the prominent scar created beneath the brow, which is in a minimally shaded facial area. The lateral canthal extension usually heals less conspicuously because it is in a relaxed skin tension line, particularly in older patients. Smaller variations of the Wright incision can be used, but scarring remains evident (Fig 5). LATERAL CANTHOTOMY
This incisional approach, originally described by Berke,i4 extends several millimeters from the lat-
FIGURE 5. Partial Wright incision places scar between lateral brow and superior lid crease, an unnatural skin line being higher than the superior tarsal fold.
846
ORBITALAPPROACHES
eral canthus, in a skin crease. It is a versatile approach and is commonly incorporated as an extension of other orbital incisions. It offers nearly equal exposure to the lateral orbit as the Wright incision, and direct access is obtained to the frontozygomatic junction and lateral orbital wall and rim (Fig 6). It does not provide good visibility, however, of the lacrimal fossa and anterosuperior orbital space. In addition, even with the wide exposure achieved by lateral wall osteotomies and temporal displacement of the globe, the apical portion of the optic nerve, as well as the posterior nasal quadrant of the orbit, is poorly visualized. This approach, when used alone, is most useful for lateral orbitotomies for the exposure of orbital masses. It may also occasionally be indicated in trauma for zygomatic arch manipulation and fixation of the frontozygomatic suture. However, for medial apical masses and displaced fractures of the floor and rim, its combination with a conjunctival incision or peritomy is necessary for optimal visualization.‘*-” Concern over preservation of the frontal branch of the facial nerve with this approach, although frequently quoted, is rarely of consequence as the incision generally does not extend this far laterally. More pertinently, the lateral canthus must be located and reapproximated, if necessary, to maintain symmetric intercanthal distances with the contralatera1 orbit as well as good lid apposition to the globe. UPPER LID CREASE (BLEPHAROPLASTY) An incision made in the upper lid crease, as a result of its placement in a naturally occurring, ageindependent skin line, offers the best cosmetic result of all superior orbital approaches. Even if the
A, Lateral canthotomy and orbitotomy result, with scar in natural skin crease.
FIGURE 6.
lid crease is not detactable, secondary to congenital anomaly, trauma, or involutional levator dehiscence, it may be easily marked and corelated with the contralateral side based on traditional measurements (Fig 7). A skin-muscle flap may be developed superiorly, medially, and laterally (with an incisional extension following the natural skin fold and curving slightly upward) in a plane deep to the orbicularis muscle and can be raised close to the brow18,19 (Fig 8). The periosteum may then be divided at the desired point over the rim for bony exposure and dissection can proceed through the spetum for access to the deeper superior orbital spaces (Fig 9). A skin flap only, above the orbicularis, intuitively appears easier and minimizes the risk of levator injury and postoperative ptosis. However, it is associated with an increased incidence of bleeding and hematoma formation (due to the muscle separation) and the potential risk of loss of flap viability. Furthermore, it is technically more difficult to develop due to the adherence of the thin layer of orbicularis. Thus, the skin-muscle flap is preferred. The lid approach decreases many of the risks associated with more peripherally placed incisions. Little danger exists for injury to peripheral nerve branches, although transient weakness of the orbicularis may occur in the region where its fibers were divided. Despite extensive undermining and raising of the flap, the vascular&y of its muscle component ensures skin viability and excellent healing. Essentially, any aspect of the superior orbit can be reached from this approach and, if necessary, lateral extensions of this incision onto the zygoma may be made for more peripheral aspects of the orbit or zygoma. The esthetic results are comparatively superior and the scar is usually undetectable.
for removal of a hemangioma
from the lateral intraorbital
space. B, Postoperative
EPPLEY, CUSTER, AND SADOVE
847
FIGURE 7. Lid markings for superior lid crease (8 mm medially, 10 mm centrally, and 9 mm laterally).
MEDIAL CREASE The utilization of the medial half of a standard lid crease incision has been described for both removal of superomedial orbital masses and anterior medial orbital wall fracture repair.20T2’ The distensibility of lid skin and underlying orbicularis permits good access to the medial orbital wall. The trochlea and superior oblique tendons can be temporarily detached from the orbital wall with little secondary disability, as experienced after craniofacial surgery.** This approach, while not as direct as a Lynch incision, produces a less detectable scar. LYNCH A preseptal nearly vertical incision placed in the superomedial orbit is usually referred to as a Lynch incision. 23It provides excellent exposure to the medial orbit and lateral part of the nose (Fig 4). It is useful for access to medial and posteromedial orbital tumors, medial wall fractures, and in the treatment of ethmoidal sinus disease. The inferior portion of the incision may also be used as the approach for a dacrocystorhinostomy. It produces a noticeable scar, however, because of its prominent location in the midface and because it crosses relaxed skin tension lines which normally run superomedially from the medial canthus to the glabella. Webbing of the skin secondary to scar contracture may also develop along the concave surface of the rim.*’ Modifications of the initial incision, including Z- and W-plasty designs, have been suggested to
FIGURE 8. A, Lid crease approach to superolateral orbit for tumor excision. B, Postoperative incision closure. C, Blepharoplasty approach for tumor excision.
848
ORBITAL APPROACHES
decrease the scar, but the use of other more esthetic approaches is preferable. BICORONAL
FLAP
A bicoronal scalp flap carried down to the supraorbital rim, with preservation of the superior neurovascular bundle, can be used for entry into the superior or anterior orbit for tumor remova123,24; for frontal-supraorbital, naso-ethmoidal, zygomaticoorbital, and isolated zygomatic arch fracture repair; for osteoplastic flap exposure of the diseased frontal sinus; and for esthetic contouring of the supraorbital rim to enhance the rim-globe relationship.“‘” It has also been recently described as an alternative approach for the lateral orbitotomy.*s This approach provides wide, direct visualization of underlying skeletal anatomy (Fig 10) and the risk of potential complications, consisting of wide scarring, focal loss of hair along the incision line, skin necrosis, hematoma, or infection, are very low (Fig 11). Its use, however, may be esthetically unacceptable in the patient with partial or complete alopecia. An alternative approach in aged, alopecic patients is to use a mid-forehead, irregular incision placed in a prominent horizontal skin crease.29 Access to areas other than the underlying superior orbit, however, is considerately limited (Fig 4). INFERIOR
FIGURE 10. Bicoronai flap reflected for extensive skeletal exposure in preparation for orbital translocation. The median nasal bone is marked for removal.
ORBIT
Incisions for the lower orbit are necessary for fracture repair, osteotomies, secondary orbital floor reconstructions, and cosmetic and reconstructive
FIGURE 9. Lateral upper lid crease approach for frontozygomatic fracture repair.
FIGURE 11. Initial exuberant scar formation is most likely to occur in the infantile patient as demonstrated in this 9-month-old child 3 months after receiving a bicoronal flap. Over time, however, marked diminuition in scar width occurs.
849
EPPLEY. CUSTER.AND SADOVE lower lid surgery. Based on the increased incidence of orbital rim/floor fractures, as compared with superior orbital fractures, inferior orbital approaches are probably used more frequently. As a result, the types of incisions for the lower orbit have been more critically assessed and compared.30-32 Six types of incisions have been described: subciliary, lid crease, rim, conjunctival, lateral canthotomy, and vestibular. SUBCILIARY The subciliary incision, which is placed approximately 2 mm below and parallel to the lower lid margin beginning medially at the punctum and continuing laterally beyond the lateral canthus in a skin crease (Fig. 4), has been used for over 40 years since first being described by Converse in 1944.33734 Wide exposure of the inferolateral orbit is achieved and floor reconstruction, infraorbital nerve decompression, and plate fixation of the rim can easily be done. It results in a minimal scar (Fig 12), but vertical lid shortening, as evidenced by increased scleral show and ectropion, may occasionally occur secondary to fibrosis from the dissection. Vertical dissection over the pretarsal fibers of the orbicularis is necessary after the skin incision to avoid disrupting the lower tarsus. Reports are variable concerning this complication, ranging from a low percentage of temporary ectropion to significant permanent occurrence in separate series.30,32 This most likely represents a diversity of experience with the technique among surgeons. LOWER LID CREASE (Blepharoplasty) The lower lid crease incision, which has also been called subtarsal or lower eyelid incision, is made
FIGURE 12.
A,
FIGURE 13. Lid markings for inferior lid crease (4 mm medially, 5 mm centrally, and 7 mm laterally). along the lower border of the tarsus of the lower lid in the skin crease in an oblique fashion mediolaterally. When the skin crease cannot be visualized, as may occur with edema from trauma, traditional skin markings are used (Fig 13). After skin incision, the underlying bony orbit can be approached either by undermining a skin flap or developing a combined skin-muscle flap, as with the upper lid crease. The skin flap was initially popular, but an unacceptable number of complications were reported, including ectropion, lash eversion, and skin necrosis.30*35 While the skin flap is still used by some surgeons for blepharoplasty,36 it has largely been replaced by the skin-muscle flap which not only is easier to dissect but has also reduced the complications of hematoma, ectropion, and other lid abnormalities.31*32*36 This incisional technique not only results in a very acceptable scar, but also is easy and rapid to perform and produces exposure comparable to all other inferior orbital approaches.
Subciliary incision for release of cicatricial ectropion. B, Minimal appearance of scar.
850
ORBITAL APPROACHES
INFERIORRIM
The rim incision undoubtedly evolved in an effort to avoid any lid complications, as well as to provide the shortest route between skin and bone. It is placed several millimeters lower than the blepharoplasty incision, at the inferior orbital margin, which produces a minor fold with the cheek (Fig 14). This really represents the junction of the orbital and palpebral portions of the orbicularis as well as the region where the orbital septum extends upward from the periosteum of the rim. Although this intuitively appears to be a good incisional choice, scarring and depression are frequent (Fig 15). In acknowledgment of this complication, stepping of the incision has been advocated to lengthen and alter the line of healing to produce a scar level more compatible with adjacent skin areas3’ Although this does offer some improvement, the prominence of this facial area and the presence of an unnatural, unmatched line below the lower lid crease is esthetically compromising. The incision does, however, offer the advantages of easy execution and negligible risk of postoperative lid dysfunction. In addition, the medial half of the rim incision may be used for dacrocystorhinostomies due to its proximity to the lacrimal sac (Fig 16). This not only results in improved postoperative scars compared with the more traditional Lynch or lateral nasal incisions, but also avoids transection of the angular artery which is common with the other approaches .
FIGURE 15. A poorly placed lower rim incision combined with a Wright (superolateral) incision for zygomatico-orbital fracture repair results in prominent periocular scarring.
CONJUNCTIVAL
Access through the fomix was advocated in the early 1970s by Tenzel, Tessier and Converse.38-40 An incision placed in the fomix results in equal exposure of the floor and rim when compared with the other inferior orbital approaches. When combined with a lateral canthotomy incision, wide exposure of both the inferior orbit and zygoma can be
FIGURE 14. A, Rim incision for exposure of inferior orbit. B, Wide exposure, as is necessary for extensive orbital floor reconstruction, is easily obtained with the lower rim incision.
EPPLEY,
CUSTER,
AND SADOVE
FIGURE 16. Medial lower rim approach for dacrocystorhinotomy.
achieved. Despite its early popularity, many complications were subsequently reported with its use, including ectropion, entropion, and tearing of the lid margin. 3034’These complications, combined with unfamiliarity in manipulation of inner lid tissues and the lateral canthus, probably led to its abandonment by many surgeons. The emergence of both craniofacial and oculoplastic experiences, where orbital intervention and manipulation is frequent, has spurred a new wave of enthusiasm for its use.15V36*41 It has been used not only for fractures and osteotomies but also for tumor removal, orbital decompression, and cosmetic lid surgery.‘5,42,43 It must be acknowledged that an incision limited
851
to the conjunctiva offers the advantage of the absence of a facial scar but may produce less than the desired access. This lack of access should not detract from its use, but does necessitate forethought as to the planned operation. Exploration of isolated floor fractures with minimal rim involvement and lack of a zygomatic component, as well as removal of infraorbital fat, can be done nicely from this approach. Manipulation of the zygoma or lateral orbit, or the placement of bone plates, requires a lateral canthotomy extension. Once this extension is necessary, which introduces facial scarring, the esthetic advantage of the conjunctival approach is partially lost. Many suggestions have been made to decrease the potential complications from this approach.3’*37,41 The most critical are the level of incision in the fornix and a preseptal versus retroseptal approach. The conjunctival incision should be placed between the lower border of the tarsus and the lowest point in the fornix. If the incision is placed higher, vertical dissection within the lid will be necessary and the risk of fibrosis and ectropion is increased. If placed too low in the fornix, the potential for injury to the inferior oblique muscle is more likely (Fig 10, and dissection must proceed through orbital fat. Furthermore, identifying the anterior fat capsule, which almost always protrudes into the wound after transection of the inferior lid retractors, and dissecting anterior to it (preseptal) down to the level of the rim, will aid in preventing
FIGURE 17. A, Periosteum and inferior orbital rim exposed through a conjunctival incision. Dissection has proceeded anterior to the fat capsule. B, While the exposure obtained with the conjunctival incision is less generous than with other approaches, orbital floor reconstruction (with alloplastic material in this case) is still readily accomplished. The addition of a lateral canthotomy incision enables access to other orbital and periorbital skeletal structures.
ORBITAL APPROACHES
annoying fat prolapse, as well as increase visualization (Fig 17). Fat, once displaced into the wound and not excluded from contact with the conjunctiva by meticulous closure of the inferior lid retractors, can form adhesions with the mucosal lining of the lid, and the risk of vertical lid shortening by secondary contracture may be increased. A reverse Frost suture, placed through the lower lid and taped to the forehead after the conjunctiva is closed (Fig 18) and allowed to remain for the first postoperative day, is a good adjunctive technique that, if consistently used, will nearly eliminate the potential for ectropion and poor lid position in all lower lid approaches.
Effective use of the lateral canthotomy requires appreciation of its tendinous form. The lateral canthal tendon is one component of the lateral retinaculum, which is a collection of all the supporting adnexal structures of the orbit at the lateral region.3 It is composed of both anterior and posterior limbs (Figs 1B and 19). The anterior limb is thin and is derived from orbicularis fascia which attaches and blends into temporal fascia and galea aponeurotica (Fig 19A). The posterior limb is much thicker and combined with the lateral horn of the levator aponeurosis and Lockwood’s ligament insert at a bony tubercle (Whitnall’s tubercle) at the lateral orbital rim3,36*44(Fig 19B). Both of these limbs contribute to the shape and position of the lateral palpebral fissure which usually is positioned slightly higher than the medial fissure. This palpebral relationship, combined with a slight bowing at the lateral third of the lower eyelid, creates the desirable almond shape to the eye.45 After the skin incision and subcutaneous dissec-
FIGURE 18. A reverse Frost suture technique to aid in reduction of the risk of ectropion in lower lid-fomix approaches.
tion in a lateral canthotomy approach, the tendon should be identified and severed from its lateral rim attachment with ligature identification of the residual stump. Mobilization of the periosteum along the lateral wall of the orbit, the frontal process of the zygoma, the zygomatic process of the frontal bone, and the lateral supraorbital rim will provide wide exposure extending from the zygomaticofrontal suture to the inferior orbit. 36Reattachment of the tendon should be concentrated solely on the posterior limb and its surrounding tissue mass (which will contain periosteum and orbicularis) with firm fixation to the residual stump of tendon by nonresorbable suture. Positioning and tightening of the lateral fissure and eyelids is then done by tension adjustment on the sutures and by comparison to the contralateral uninvolved side. Wire fixation to the lateral orbit has been advocated,45 but is usually unnecessary when reattachment, and not entire tendon repositioning, is being done. VESTIBULAR
The intraoral approach, while obviating any facial scar, produces severely restricted access. Only the inferior aspect of the orbital rim and zygoma can be reached, which allows minimal manipulation of bone segments and no inspection of intraorbital contents. Such an approach has historically been used for antral access to floor fractures and infraorbital nerve procedures, but is of limited use in extensive zygomatico-orbital fracture repair or intraorbital surgery. Summary Multiple cutaneous approaches to both the superior and inferior orbit have been reviewed. Incisional choices are optimally based on both facial esthetics and orbital function, which are achieved by an understanding of the unique anatomy of this region. The superior orbit is best approached by a blepharoplasty (lid crease) incision in conjunction with a lateral extension if additional exposure is necessary. Almost all aspects of the bony orbit can be reached with the exception of the frontal bone superior to the supraorbital rim. When wide exposure of the orbital skeleton is necessary, a bicoronal scalp flap is most effective in a nonalopecic patient. The inferior orbit can be approached by a ciliary, blepharoplasty, or conjunctival incision with a lateral canthotomy. None has proven esthetic advantages over the others, with the exception of the conjunctival incision when used alone. The lid incisions must be used with the understanding that orbital function must be assessed both
EPPLEY, CUSTER, AND SADOVE
853
FIGURE 19. Thin, supertical anterior limb of lateral canthal tendon (open arrow) composed of orbicularis fascia blending into the surrounding temporalis fascia. a, lacrimal gland; b, orbital fat. B, Thick posterior limb of lateral canthal tendon with contributions of the lateral horn of the levator (open arrow) and Lockwood’s ligament (dark arrow) which produces the primary lateral support for lid position
pre- and postoperatively and meticulous attention paid to protection and care of the anterior globe. In addition, because of the thinness of the tissues being manipulated, edema, bruising, and final settling of lid form may require more postoperative time than is typical of more peripheral approaches. References I. Zide BM: Anatomy of the eyelids. Clin Plast Surg 8:623, 1981 2. Wessberg GA, Wolford LM, Zerdecki JW, et al: Ophthalmologic considerations in maxillofacial trauma. Anatomy and diagnostic evaluation. Int J Oral Surg 10:236, 1981 3. Zide BM. Jelks GW: Surgical anatomy of the orbit. Plast Reconstr Surg 74:301, 1983 4. Weisman RA: Surgical anatomy of the orbit. Otolaryngol Clin North Am 21:1, 1988 5. Byrd HS: Eyelid reconstruction. Select Readings Plast Surg 4:1, 1987 6. Koziol JK: Anatomy of the orbit, in Peyman GA, Sanders DR, Goldberg MF (eds): Principles and Practice of Ophthalmology. Philadelphia, PA, Saunders, 1980, p 86 7. Dingman RO, Natvig P: Surgery of Facial Fractures. Philadelphia, PA, Saunders, 1964, p 239 8. Hotte HHA: Orbital Fractures. Springfield, IL, Thomas, 1970, p 227 9. Converse JM. Smith B, Wood-Smith D: Malunited fractures of the orbit. in Converse JM (ed): Plastic and Reconstructive Surgery. vol 2. Philadelphia, PA, Saunders, 1977, p 1027 10. Rowe NL, Williams JL: Maxillofacial Injuries, vol 1. London, England, Churchill Livingstone, 1985, p 482 Il. Wright JE: Clinical presentation and management of lacrimal gland tumors. Br J Ophthalmol63:6OO, 1979 12. Osguthorpe JD, Weisman R, Tapert MJ: Management of lacrimal fossa masses. Arch Otolaryngol Head Surg 112: 166, 1986
13. Nowinski T, Anderson RL: Advances in orbital surgery. Ophthalmol Plast Surg 1:211, 1985 14. Berke RN: A modified Kronlein operation. Arch Ophthalmol51;609, 1954 15. McCord CD Jr, Moses JL: Exposure of the inferior orbit with fomix incision and lateral canthotomy. Ophthalmic Surg 10:53, 1979 16. Smith JL: Antero-lateral approach to the orbit. Trans Am Acad Ophthalmol Otolaryngol 75: 1059, 1971 17. McCord CD Jr: A combined lateral and medial orbitotomy for exposure of the optic nerve and orbital apex. Ophthalmic Surg 958, 1978 18. Baker TJ, Gordon HL, Posrenko P: Upper lid blepharonlastv. Plast Reconstr Sura 60:692. 1977: 3:225. 1980 19. Gradinger GP: Cosmetic upper blepharopiasty. Clin Plast Surg 15:289, 1988 20. Wolfley DE: The lid crease approach to the superomedial orbit. Ophthalmic Surg 16:652, 1985 21. Katowitz JA, Welsh MG, Bersani TA: Lid crease approach for medial wall fracture repair. Ophthalmic Surg 18:288, 1987 22. Diamond GR, Katowitz JA, Whitaker LA, et al: Ocular alignment with craniofacial reconstruction. Am J Ophthalmol 90:248, 1980 23. Kennerdell JS, Maroon JC, Malton ML: Surgical approaches to orbital tumors. Clin Plast Surg 15:273. 1988 24. Maroon JC, Kennerdell JS: Surgical approaches to the orbit. Indications and techniques. J Neurosurg 60: 1226, 1984 25. Lassus C: Osteotomy of superior orbital rim in cosmetic blepharoplasty. Plast Recdnstr Surg 63:481, 1979 26. Marchac D: Radical forehead remodeline. Plast Reconstr Surg 61:823, 1978 27. Marchac D: Relationship of the orbits to the upper eyelids. Clin Plast Sum 8:717, 1981 28. Stewart WB, LeGin PS, Toth BA: The technique of coronal scalp flap approach to the lateral orbitotomy. Arch Ophthalmol 106: 1724, 1988 29. Brennan HG, Rafaty FM: Midforehead incisions in treatment of the aging face. Arch Otolaryngol 108:732, 1982 30. Wray RC, Holtmann B, Ribaudo JM, et al: A comparison of conjunctival and subciliary incisions for orbital fractures. Br J Plast Surg 30:142, 1977
854
31. Holtmann B, Wray RC, Little AG: A randomized comparison of four incisions for orbital fractures. Plast Reconstr Surg 67:731, 1981 32. Heckler FR, Songcharoen S, Sultani FA: Subciliary incisions and skin-muscle eyelid flap for orbital fractures. Ann Plast Surg 10:309, 1983
ORBITAL APPROACHES
38. 39.
33. Converse JM: Two plastic operations for repair of orbit following severe trauma and extensive comminuted fracture. Arch Ophthalmol 31:323, 1944
40.
34. Converse JM, Smith B, Obear MF, et al: Orbital blow-out fractures: A ten-year survey. Plast Reconstr Surg 39:20, 1967 35. Pospisil OA, Fernando TD: Review of the lower blepharoplasty incision as a surgical approach to zygomaticoorbital fractures. Br J Oral Maxillofac Surg 22:261, 1984
41.
36. Manson PN, Ruas E, Iliff N, et al: Single eyelid incision for exposure of the zygomatic bone and orbital reconstruction. Plast Reconstr Surg 79:120, 1987
44.
37. Rowe NL: Fractures of the zygomatic complex and orbit, in
42. 43.
45.
Maxillofacial Injuries, vol 1. London, England, Churchill Livingstone, 1985, p 512 Tenzel RR, Miller GR: Orbital blow-out fracture repair, conjunctival approach. Am J Ophthalmol71: 1141, 1971 Tesser P. The conjunctival approach to the orbital floor and maxilla in congenital malformation and trauma. J Maxillofac Surg 1:3, 1973 Converse JM, Firman F, Wood-Smith D, et al: The conjunctival approach in orbital fractures. Plast Reconstr Surg 52:656, 1973 Jackson IT: The conjunctival approach to the orbital floor and maxilla-Advantages and disadvantages. Ann Plast Surg 1946, 1987 Maniglia AJ: Conjunctival approach for lower lid blepharoplasty. Laryngoscope 89:1869, 1979 Schwarz F, Randall P: Conjunctival incision for herniated orbital fat. Ophthalmic Surg 11:276, 1980 Couly G, Hureau J, Tessier P: The anatomy of the external palpebral ligament in man. J Maxillofac Surg 4: 195, 1976 Whitaker LA: Selective alteration of palpebral fissure form by lateral canthopexy. Plast Reconstr Surg 74:611, 1984
