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Address reprint requests and correspondence: J. David Kriet, MD, Department of Otolaryngology, Eaton Hall, Mail Stop 3010, 3901 Rainbow Boulevard, Kansas City, KS 66160-7380
Orbital injuries can only be treated most effectively, aesthetically, and safely when the surgeon's armamentarium includes all contemporary orbital approaches. The lateral orbit, orbital floor, and medial orbit are useful anatomic divisions that are each exposed best through distinct approaches. Lateral brow, upper blepharoplasty, and coronal approaches provide access to the lateral orbit. The orbital floor is accessible through subciliary, subtarsal, transconjunctival, or transantral approaches. Lynch, transcaruncular, transnasal, and coronal approaches are useful for medial orbital exposure. When the surgeon utilizes these approaches appropriately with meticulous surgical technique and close postoperative observation for rare potential complications, excellent outcomes can be achieved following orbital trauma.
Orbital injuries frequently require surgical treatment. Zygomaticomaxillary, nasoorbitalethmoid, orbital rim, and blow-out fractures are among the injuries requiring intervention. Modern approaches are safe and esthetically acceptable when performed properly. Selecting the most appropriate surgical approach will optimize exposure and increase the likelihood of successful treatment.
Immediate intervention in the treatment of orbital floor fractures is indicated only when orbital soft-tissue entrapment is associated with the oculocardiac reflex. This situation is most commonly observed in younger patients with a closed trap-door fracture. Most orbital fractures can be repaired within 2 weeks when edema has resolved adequately but significant fibrosis has not yet developed.
We obtain ophthalmology consultation after complex orbital trauma and if any ocular injury is suspected before surgical intervention. Evidence of hyphema or ocular rupture should delay internal orbital approaches until these injuries can be addressed by an ophthalmologist and surgically treated if necessary.
The orbital skeleton contains contributions from the lacrimal, maxillary, zygomatic, greater and lesser wings of the sphenoid, frontal, and ethmoid bones. Locations of the optic foramen, ethmoid artery foramina, and orbital fissures are shown in Figure 1. Moving posteriorly, the anterior ethmoid artery, posterior ethmoid artery, and optic nerve are located approximately 24 mm, 36 mm, and 42 mm, respectively, from the anterior lacrimal crest. Upper and lower eyelid layers are detailed in Figure 2.
Figure 1The lacrimal, maxillary, zygomatic, greater and lesser wings of the sphenoid, frontal, and ethmoid contributions to the orbital skeleton are as shown. As measured from the anterior lacrimal crest, the anterior ethmoid artery, posterior ethmoid artery, and optic foramina are located at 24, 36, and 42 mm, respectively.
The medial canthal tendon attaches via a thicker limb to the anterior lacrimal crest and a thinner limb containing Horner's muscle to the posterior lacrimal crest. The lateral canthal tendon also consists of 2 limbs. A thin anterior limb blends with the orbicularis oculi muscle fibers and periosteum of the lateral orbital rim, and a thicker posterior limb attaches to Whitnall's tubercle of the zygoma. Intimately related to the medial canthal tendon is the lacrimal system. Upper and lower puncta begin 5 to 7 mm lateral to the canthus and continue as a common canaliculus into the lacrimal sac located between the anterior and posterior limbs of the medial canthal tendon within the lacrimal fossa. The sac empties into the inferior meatus via the nasolacrimal duct. The lacrimal gland is located within the lateral upper lid and divided into a larger orbital portion and a smaller palpebral portion by the lateral horn of the levator aponeurosis. Anteriorly, the gland's orbital portion is in contact with the orbital septum.
Extraocular muscles include the 2 oblique and 4 rectus muscles. The course of the superior oblique muscle brings it into nearly direct contact with the periorbita of the orbital roof and medial wall at the trochlea. The inferior oblique is in proximity to the orbit at its origin just posterior to the inferomedial orbital rim, lateral to the superior end of the nasolacrimal canal, and occasionally from the fascia over the lacrimal sac. The superior, inferior, lateral, and medial rectus muscles originate from the annulus of Zinn and insert onto the sclera.
Approaches to the lateral orbit and orbital roof
Lateral brow
The lateral brow and upper blepharoplasty approaches are useful for accessing the zygomaticofrontal and zygomaticosphenoid sutures. The lateral portion of the superior orbital rim can be exposed as well. Incision placement for each of these approaches is shown in Figure 3.
Figure 3The brow incision is placed within or just below the hair follicles of the lateral 2 to 3 cm of the eyebrow. An upper blepharoplasty incision is placed in the lateral one third to one half of the supratarsal fold and can be extended as necessary, following a horizontal crease above the lateral canthus. (Reprinted with permission.
For the lateral brow approach, local anesthetic with epinephrine is infiltrated just inferior and parallel to the hair follicles of the lateral 2 to 3 cm of the inferior brow. Some clinicians advocate making this incision within the brow, but this may result in undesirable alopecia. The incision is carried through both the skin and orbicularis oculi with a #15 blade. The periosteum over the lateral orbital rim is sharply incised and raised with a Freer elevator to obtain the desired exposure. Closure is performed in layers, with the surgeon reapproximating the periosteum and then orbicularis oculi with 5-0 polydioxanone suture in an interrupted fashion. The skin is closed with either a 6-0 polypropylene or fast-absorbing gut in a running fashion.
The primary advantage of this approach is the simplicity of the technique. Disadvantages include the possibility of visible scarring and brow alopecia. It is because of this scarring that this approach has largely been replaced by the upper blepharoplasty approach.
Upper blepharoplasty
For the upper blepharoplasty approach, the supratarsal fold is marked (typically 7-9 mm above the ciliary line). The incision is extended within the fold and horizontally beyond the lateral canthus in a skin crease as needed for exposure (Figure 3). Local anesthetic with epinephrine is injected subcutaneously and down to the lateral orbital rim at the zygomaticofrontal suture. The skin is incised and scissors or a Colorado dissector can then be used to traverse the orbicularis oculi, dividing the muscle parallel to the fibers. Dissection then proceeds to the lateral orbital rim and zygomaticofrontal suture in a plane superficial to the orbital septum and lacrimal gland. The periosteum is elevated over the rim and zygomaticofrontal suture as needed. If necessary, the superolateral orbital wall can be dissected to assess zygomaticosphenoid suture alignment (Figure 4). Closure is performed in layers, with the surgeon reapproximating the periosteum by using a 5-0 polydioxanone suture followed by skin closure with a 6-0 polypropylene or fast absorbing gut suture in a running fashion. The advantage of the upper blepharoplasty approach is a cosmetically favorable scar that is barely discernable once healed.
The coronal approach is a workhorse for craniomaxillofacial surgery and can be used for broad access to the medial, superior, and lateral orbit as well as the zygomatic arch. Access to the lateral aspect of the infraorbital rims is also possible by extending the incision along the preauricular creases. The coronal approach has been well-described in the literature. For further reading, Frodel and Marantette
provide an excellent discussion of anatomical considerations and surgical technique for this approach.
The primary advantage of the coronal flap is broad exposure and access to both orbits and the nasal skeleton that is unparalleled by any other approach. Disadvantages include incision length, extensive dissection, and potential morbidity including alopecia, forehead numbness, and injury to the temporal branch of the facial nerve.
originally described the subciliary approach to the orbit in 1944. He and others have also advocated a subtarsal variation of this approach. Both are transcutaneous approaches that provide access to most of the orbital floor. The orbital rim incision is an alternative transcutaneous approach, which we do not use or recommend because of the potential for visible scarring.
For the subciliary and subtarsal approaches, local anesthetic with epinephrine is infiltrated subcutaneously in the lower eyelid and along the inferior orbital rim. A lateral temporary tarsorrhaphy is performed on the operative eye for protection and retraction. The subciliary cutaneous incision is made 2 mm below and parallel to the lash line with the use of a #15 blade (Figure 5). The incision should be carried no further medially than the lower lid punctum. Laterally, the incision can be extended up to 15 mm beyond the lateral canthus. If this lateral extension is performed, it should be directed horizontally and not inferiorly to promote an esthetically acceptable scar. A subcutaneous dissection superficial to the orbicularis oculi is followed inferiorly by the surgeon using either sharp dissection or the Colorado dissector until just inferior to the tarsal plate where the orbicularis is divided parallel to its fibers. It is crucial to preserve this rim of orbicularis over the tarsal plate to maintain lower lid structure and support. A preseptal plane is then followed down to the orbital rim. The periosteum is incised on the anterior aspect of the inferior orbital rim and elevation proceeds posteriorly onto the orbital floor using a Freer elevator. For the subtarsal variation of this approach, the skin incision is made in the subtarsal fold or 5 to 7 mm below the lash line when the fold is obscured by edema (Figure 5). The orbicularis oculi is divided a few millimeters below the level of the skin incision to discourage scar inversion. For either approach, closure is performed by the surgeon reapproximating the skin with a running 6-0 polypropylene or fast absorbing gut suture. A Frost suture is sometimes used to support the lid in the early postoperative period.
Figure 5Paths traversed by the subciliary and subtarsal approaches through the lower eyelid are shown. It is important to step the incisions as shown to preserve lid integrity and avoid scar inversion.
Advantages to the subciliary and subtarsal approaches are that they are easy to learn and offer broad access to the orbital floor. Disadvantages are greater rates of postoperative lower lid malposition and visible scarring when compared with the transconjunctival approach.
argue that the subtarsal variation of this approach produces less risk of vertical lid shortening, scleral show, and ectropion but slightly greater risk of visible scarring. Innervation to the pretarsal and much of the preseptal orbicularis is better preserved through the subtarsal variant which may help maintain the preoperative lower lid position.
Transconjunctival approach
Bourquett first described the inferior fornix conjunctival or transconjunctival approach for blepharoplasty in 1924.
Exposure of most of the orbital floor can be achieved through the transconjunctival approach.
Local anesthetic with epinephrine is infiltrated at the lateral canthus, just under the conjunctiva of the lower lid, and transcutaneously down to the orbital rim. Lateral canthotomy and cantholysis using a curved iris scissor is optional for greater retraction and exposure. If the canthal release is not performed, great care must be taken to avoid excessive retraction or abrasion of the tarsal plate mucosa as these conditions are associated with a higher incidence of lower eyelid malposition. With a Jaeger lid plate placed over the globe and one finger on the skin inferior to the tarsal plate to evert the lid, an incision is made through the conjunctiva of the lower lid 2 mm inferior to the tarsal plate using a Colorado dissector. The incision is continued through the lower lid retractors taking care to violate neither the thin lower lid skin nor the orbital septum. Blunt dissection between the orbicularis oculi and orbital septum—a preseptal approach—then proceeds using a cotton tipped applicator. A 5-0 silk suture is placed through the orbital septum and pulled superiorly to further protect the globe. Alternatively, the orbital septum can be incised to reveal a dissection plane between the orbital septum and periorbital fat—a postseptal approach (Figure 6). Blunt dissection with a malleable retractor over the septum or orbital fat and a Ragnel retractor on the lower lid and orbicularis oculi will reveal the periosteum of the inferior orbital rim. The Colorado dissector is used to incise the periosteum on the anterior surface of the rim. Elevation of the periosteum is performed with a Freer elevator, and the malleable retractor can be used to continually retract the orbital contents and expose the desired portion of the orbital floor (Figure 7). No closure of the conjunctiva is needed so long as it is properly repositioned at the conclusion of the procedure. If canthotomy and cantholysis are performed, the tarsal plate is resuspended to the orbital periosteum near Whitnall's tubercle with a single 5-0 polydioxanone suture. The canthus is reapproximated by the surgeon using a single 6-0 fast absorbing gut suture placed through the gray line of the lateral upper and lower lids. Interrupted sutures are used as needed to close any remaining canthotomy defect laterally.
Figure 6Paths traversed by the pre- and postseptal variations of the transconjunctival approach are shown. (Reprinted with permission.
Figure 7A Davida malleable neurosurgical retractor (Flexbar Machine Corporation, Islandia, NY) is positioned to retract the ipsilateral cheek (A). A 10- by 20-mm defect is then created in the anterior wall of the maxillary sinus for access to the orbital floor. As shown, the medial buttress, lateral buttress, and inferior orbital rim remain intact (B). (Color version of figure is available online.)
Although the continually protruding periorbital fat can be an annoyance, a theoretical advantage of the postseptal technique is decreased incidence of postoperative lower lid malposition since the plane between the orbicularis oculi and orbital septum is not violated.
Transantral approach
Farwell and Strong have described the endoscopically assisted transantral approach to orbital floor fractures.
The approach may be used as an isolated technique or combined with a more traditional approach to assist in fracture visualization and reduction.
Local anesthetic with epinephrine is injected in the maxillary gingivolabial sulcus. An incision is made in the sulcus using cautery while preserving a 4- to 5-mm cuff of mucosa on the gingival side for closure. The periosteum is incised on the maxilla. A Longenbeck retractor should be used to retract the lip, and a Freer elevator is used to expose the anterior wall of the maxillary sinus up to the level of the infraorbital nerve. An osteotome and Kerrison rongeur are used to make a 10 by 20 mm defect in the anterior wall of the sinus (Figure 7). Zero- and 30-degree 4-mm telescopes are then inserted through the antrostomy to visualize the orbital floor (Figure 8). The floor defect is usually obvious and mucosa can be elevated adjacent to the defect for visualization and reduction of the orbital contents. Trap door or greenstick type fractures can occasionally be reduced using this approach alone without need for fixation if the bony shelf once reduced is stable. An implant can also be inserted if necessary by placing it first onto the posterior shelf and then sliding it up onto the anterior shelf (Figure 9). Closure proceeds by the surgeon reapproximating the gingivolabial sulcus mucosa using interrupted 3-0 polyglactin suture.
Figure 8A right orbital blow-out fracture as identified with computed tomography (A) and as visualized endocopically via a transantral endoscopic approach with herniation of bone fragments, periorbita, and orbital fat into the maxillary sinus (B). (Color version of figure is available online.)
Figure 9Orbital blow-out fracture shown in Figure 8 following reduction of herniated orbital fat and placement of a Medpor® linear high density polyethylene implant (Porex Surgical Inc, Newnan, GA) supported by the anterior and posterior shelves of the floor defect. (Color version of figure is available online.)
Advantages to this approach include improved visibility of the posterior orbit and especially the posterior shelf of a floor defect. Disadvantages include difficulty in reconstructing the orbital floor lateral to the infraorbital nerve, the need to violate the anterior maxillary face, and the need for specialized endoscopic instrumentation.
described his transcutaneous approach to the medial orbit and frontal sinus for sinusitis in 1921. Access to most of the medial orbital wall is achievable through this approach. Local anesthetic with epinephrine is injected down to the ipsilateral nasal bone and the medial orbital rim. An incision is made with a #15 blade over the superomedial orbital rim from a point inferior to the medial brow to the superior aspect of the nasofacial junction. This incision is carried down through periosteum using the Colorado dissector. A Freer elevator is used to expose the medial orbital wall, staying superior to the canthal tendons and lacrimal apparatus until posterior to these structures. If exposing the superomedial orbit, care should be taken to identify and cauterize or ligate the ethmoid arteries. Closure is performed by reapproximating the skin using running 6-0 polypropylene or fast absorbing gut suture. Simplicity and exposure are the primary advantages to this approach. A significant disadvantage is the risk of medial canthal web formation and visible scarring which can be decreased by incorporating a z-plasty at the time of closure.
Transcaruncular approach
The transcaruncular approach was first described by Shorr et al.
It allows access to the entire medial orbital wall posterior to the lacrimal fossa. Local anesthetic with epinephrine is injected transcutaneously down to the medial orbital rim. The injection to the caruncle should be minimized to avoid distortion of the tissue planes. A Colorado dissector to is used to make a 12- to 15-mm incision either through or just posterior to the caruncle and anterior to the semilunar fold (Figure 10). The upper and lower lids are retracted with Demares retractors and the orbital contents protected using a small or medium malleable retractor. A plane posterior to Horner's muscle is developed with iris scissors until the posterior lacrimal crest is palpable or clearly anterior to plane of dissection. The orbital contents are retracted with a malleable retractor to expose the periosteum posterior to the crest. The Colorado dissector is used to incise the periosteum posterior to all medial canthal attachments and the lacrimal apparatus (Figure 11). A Freer elevator is used to gain the desired exposure of the medial orbital wall, and the anterior and posterior ethmoid arteries are ligated as necessary. Figure 11 shows the typical access obtained with this technique. If exposure of both the medial wall and floor of the orbit is desired, one can sharply free the attachment of the inferior oblique, allowing broad unobstructed access to the floor and medial wall. Care must be taken to identify the inferior oblique at its bony attachment if it is to be released as injury to the belly of the muscle may result in a functional deficit.
Figure 10The transcaruncular incision is placed either over or just posterior to the caruncle in the sulcus between the caruncle and the semilunar fold. (Reprinted with permission.
Figure 11The transcaruncular approach follows a plane immediately posterior to Horner's muscle down to the periosteum of the medial orbital wall posterior to both the canthal attachments and lacrimal apparatus (A). Periosteal elevation can then proceed without disturbing these structures (B). (Reprinted with permission.
This approach has replaced Lynch's technique as the standard for access to the medial orbital wall because it eliminates the potential for visible scarring and webbing associated with the transcutaneous Lynch incision. One disadvantage to this approach is that it can be difficult to insert and manipulate an implant through the relatively small incision. Combining the transcaruncular approach with either a transconjunctival or transnasal approach can be helpful in this situation. Care must be used to avoid injury to lacrimal apparatus by following the proper dissection plane to the posterior lacrimal crest.
have described using a transnasal approach to either place stenting material between the middle turbinate and a medial orbital defect or in conjunction with a transcaruncular or transconjunctival approach to facilitate precise placement of an implant for medial orbital wall reconstruction.
The nose is decongested using oxymetazoline on cottonoid pledgets. A 4-mm 0-degree endoscope is advanced into the nasal cavity. The middle turbinate is gently medialized with a Frazier suction or blunt tipped right angle probe to visualize the uncinate process. Local anesthetic with epinephrine is injected along the uncinate process. A Kerrison rongeur is then used by the surgeon to remove the uncinate, leaving 3 to 4 mm superiorly to prevent formation of nasofrontal recess synechiae. The ethmoid bulla and maxillary os are identified. The majority of medial orbital injuries are associated with nasal trauma and there may be significant intranasal damage in addition to the prolapsing orbital contents. Care must be taken to bluntly dissect the tissues and definitively identify landmarks as one proceeds to avoid creating or enlarging an orbital or skull base defect. The bulla ethmoidalis is entered using a small Frazier suction and the ethmoid cells are opened back to the ground lamella, exposing the lamina papyracea and medial orbital defect. Orbital contents can be carefully reduced using both the transorbital and transnasal approaches at this point. An implant can be better visualized and manipulated using the combined approaches as well.
Advantages to this approach include the excellent visualization it provides of the extent of the bony defect and the limited risk it poses to intraorbital structures when the surgeon is experienced with intranasal endoscopic surgical techniques. Easier identification of the orbital defect and skull base can be facilitated with the use of a computed tomography image guidance system when available. A disadvantage to the transnasal approach is the potential increased risk of skull base injury and cerebral spinal fluid leak. This approach also lacks utility as a single approach because of both limited space for implant introduction and the need to insert an implant toward rather than away from orbital structures in an area that can potentially place pressure on the optic nerve. No increased morbidity from sinus disease postoperatively has been described in the literature.
Coronal approach
The coronal approach has already been discussed and is useful when broad access to both the nasal bones and bilateral medial orbital walls is needed for repair of nasoorbitalethmoid fractures.
Postoperative care
Forced duction testing should be performed in the operating room after any orbital approach with bony manipulation or implant placement. There should be unrestricted ocular mobility. After surgery, it is our belief that all patients undergoing orbital approaches for traumatic injury should be observed in an inpatient facility overnight. The prompt recognition and attention that orbital complications deserve can best be offered when the patients are observed in this setting. Vision checks for light perception are performed every 2 to 4 hours. Color discrimination is a very sensitive indicator of optic nerve injury, and the ability of the patient to perceive the color red is a useful bedside test as well. Patients that have impaired color perception will see a brownish hue rather than bright red. Pain should also be monitored closely. Corneal abrasion is the most common cause of pain in the early postoperative period, but patients with increasing pain should be immediately assessed for light and color perception. If light or color perception changes with increasing pain or proptosis, the patient should be examined by a physician for evidence of increased intraocular pressure. A determination can then be made whether intervention or further observation is warranted.
Gauze pads soaked in an ice water bath should be applied to the operative eye for 36 to 48 hours after surgery to decrease swelling and promote vasoconstriction. Tobramycin and dexamethasone ointment is applied to the eye twice daily for one week to maintain lubrication and decrease inflammation.
Complications
Diplopia
Diplopia may be the most common complication after surgical approaches for orbital trauma. In many cases, it is preexisting and will persist because of unilateral posttraumatic and postoperative swelling. Forced duction testing with good ocular mobility in the operating suite at the conclusion of the procedure can give the surgeon confidence that there is no persistent entrapment or adherence of orbital contents to the implant. In cases of entrapped rectus muscles which have been released, recovery of function can take many months and may not be complete. If the diplopia is persistent and bothersome to the patient, referral to ophthalmology is indicated for evaluation and treatment.
Vision loss
Vision loss can occur with direct injury to the optic nerve or its vascular supply. Intraoperative mydriasis is a sign of pressure on the ciliary ganglion located 1 cm anterior to the annulus of Zinn between the lateral rectus and optic nerve. When mydriasis develops, it should serve as a warning that excess pressure is being applied to the intraorbital contents but is not a direct indication that the optic nerve has been damaged. Postoperative hemorrhage can result in blindness if not treated immediately. If the patient develops visual changes, such as decreased color discrimination or loss of acuity associated with increased intraocular pressure and proptosis, retroorbital hematoma must be suspected. Canthotomy and cantholysis should be performed immediately at the bedside to decrease intraocular pressure. Wound exploration, removal of the implant, and hematoma evacuation in the operating room are also indicated. Immediate ophthalmology consultation should be obtained in any case of decreasing visual acuity but should not delay initial treatment.
Lid malposition
Lower lid malposition in the form of shortening or ectropion is a complication that develops at least temporarily in 28% to 42% of transcutaneous approaches to the orbital floor.
Misplaced conjunctival incisions or thermal cautery injury may damage the tarsal plate and increase the risk of entropion and scleral show. There is also potential for symblepharon, or scar formation between the tarsal and bulbar conjunctival surfaces. A theoretical and controversial increased risk of lower lid malposition exists using a preseptal rather than a postseptal approach because of scar which may form between the orbital septum and orbicularis oculi following a preseptal dissection. Some cases of postoperative ectropion and entropion are transient and will resolve with massage and observation over a few weeks. If persistent, surgery including lower lid tightening in conjunction with other procedures may be required for correction.
References
Burnstine M.A.
Clinical recommendations for repair of orbital facial fractures.
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