Dr Mohsin FazalSenior Registrar

Islamic International Dental College

SURGICAL APPROACHES TO THE ORBIT

Inferior rim & floor: Transcutaneous

Subciliary Subtarsal Infraorbital Patterson-Ethmoidectomy

Transconjunctival Preseptal Postseptal

Superolateral Orbit Lateral Eyebrow Supratarsal Fold Coronal

Medial Orbit Lynch Patterson Ethmoidectomy

ORBITAL APPROACHES

Converse in 1944

Incision approx 2mm

Skin undermined

SUBCILIARY INCISION

Orbicularis oculi traversed till orbital septum The dissection superficial to orbital septum

Periosteum incised on anterior surface of maxilla & ZygomaPeriosteum is reflected inward and upward

Contd…

“Skin Only Incision”

Inferior dissection is carried superficially to orbicularis oculi muscle till orbital septum is reached.

“Skin-muscle Incision”Incision is carried through both skin and muscle at the same level till the tarsal plate.

MODIFICATIONS

Incision extended laterally by 1-1.5 cm

Supraperiosteal dissection at entire lateral orbital rim The periosteum is incised in the middle of lat orbital rim.

EXTENDED LOWER EYELID APPROACH

Subperiosteal dissection strips tissues from orbital wall

Contd…

Tessier & Converse in 1973 Lateral Canthotomy Incision:Scissors inserted to the depth of orbital rim and cut in horizontally.The lateral canthal tendon released with a

vertical incisionScissors used to dissect through small

incision in conjunctiva to free the vestibular conjunctiva

TRANSCONJUNCTIVAL APPROACH

Periosteum is incised, avoiding the lacrimal sac laterally

Periosteum over orbital rim and anterior surface of maxilla, zygoma and orbital floor is reflected

Lateral Eyebrow Incision

Upper blepheroplasty Incision

Coronal Incision

Lateral Canthotomy Incision

SUPERIOR & MEDIAL APPROACH

Incision placed at outer aspect of eyebrowSkin of eyebrow is tented over superior

orbital rim1.5cm incision made in a beveled fashion

parallel to hair follicles

Skin incision retracted over ZF suture, orbicularis oculi muscles fibres incised overlying the rim

LATERAL EYEBROW INCISION

Additional undermining and dissection carried out in inferolateral direction

Skin and muscle incisions are stepped for more favorable healing.

Incision is made at upper eyelid crease extending into the subcutaneous tissue

Incision retracted laterally and extended to orbicularis muscleOrbicularis oculi and periosteum exposed by

sharp dissectionApprox 1cm incision is given but can be extended if required

BLAPHEROPLASTY INCISION

Subperiosteal dissection of orbit and orbital rim is performed.

Lacrimal fossa, a deep concavity in the inferolateral orbit

1cm area of hairline at incision is shaved

Incision is carried out through skin, subcutaneous tissue and aponeurosis.

A curvilinear incision given 2 cm behind incision line extending lateraly parallel to hairline and finally in the preauricular region

CORONAL INCISION

The incision is given through skin, subcutaneous tissue and aponeurosis.

The flap may be elevated with finger dissection or blunt periosteal dissection

Periosteal incision given 3-4 cm superior to supraorbital rims extending lateraly till the superior temporal line

Subperiosteal dissection carried out till superior orbital rimThe lateral portion of the flap is dissected above temporalis fascia upto within 2-4cm of Zygoma, the flap is dissected inferiorly to zygomatic archAn incision is made through periosteum along posterior border of zygoma and the orbital rim, to meet the horizontal periosteal incision.

Further reflection of flap accomplished by carrying dissection into the orbit

Dissection of periosteum around medial and superior orbital walls retracts the flap to the junction of nasal bones & lateral nasal cartilage

A vertical curvilinear 1cm incision 5-10mm medial to insertion of medial canthus

Incisoin is placed over lateral nasal structures, the dissection is made medially through skin, subcutaneous tissue and periosteum.

The medial canthal tendon and lacrimal sac lie posterior and superior to the incision.

LATERAL NASAL APPROACH

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