Surgical Approaches to the Orbit
Approaches to the Inferior Orbit
To begin, a traction suture is placed through the lower eyelid margin. Next, an incision is made through the inferior palpebral conjunctiva using either a scalpel or needle-point monopolar cautery 1-2mm below the border of the tarsus. The inferior palpebral conjunctiva is secured using another traction suture and blunt dissection is carried in the preseptal plane towards the orbital rim. At this juncture, the decision can be made whether extraperiosteal dissection or preperiosteal dissection is needed.
If the decision is made to open the septum, the lateral orbital septum can be opened using monopolar cautery or Wescott scissors. As the septum is opened medially, care should be taken to identify the inferior oblique muscle, whose origin is posterior to the inferomedial orbital rim. Protection and movement of the globe can be performed using malleable retractors.
5-0 Vicryl suture can be used for closure of the periosteum. Buried 6-0 gut suture can be used for closure the conjunctiva.
Figure 1: Transconjuctival approach to the orbital floor depicting the (a) the initial incision, (b) dissection of the arcus marginalis, and (c) fracture exposed.
Other indications for this approach include:
- Biopsy or excision of lesions in the inferior orbit
- Accessing the optic nerve
- Drainage of inferior orbital abscesses
- Orbital fat decompression
The transconjunctival approach is preferred in many cases due to favorable cosmetic outcome. This approach can be combined laterally with a lateral canthotomy and inferior cantholysis and medially with a transcaruncular incision if necessary to improve exposure
- Orbital fat prolapse
- Entropion or ectropion
- Canalicular injury
- Conjunctival granuloma
- Intractable chemosis
- Lower eyelid retraction
- Vision loss
When compared to the subciliary approach, an analysis by Bronstein et al found no statistically significant difference in post-operative complications. However, the study indicated that the transconjunctival approach is associated with an increased incidence of entropion, canthal malposition, and complications associated with longer operating times. The subciliary incision is associated with increased incidence of lagophthalmos, ectropion, and lower lid retraction
The subciliary approach is accomplished by performing an incision 2 mm inferior to the eyelashes or within an existing rhytid. It allows for direct access to the inferior orbit. Traction sutures are passed through the eyelid margin followed by careful dissection down to the tarsal plate with separation of the preseptal orbicularis oculi fibers.  The orbital septum can then be opened to gain access to the extraconal space or periosteal elevation can be performed for orbital floor exposure.
Figure 2: Subciliary approach to the orbital floor depicting the (a) initial incision, (b) preseptal dissection, and (c) fracture exposed.
- Exploration of the orbital floor
- Access to preseptal lesions in the inferior orbit
- Increased incidence of lagophthalmos
- Scleral show
- Visible scarring
- Lower lid retraction
For surgeries aimed at orbital volume augmentation with lower lid tightening, the subciliary approach is preferred over the transconjunctival incision due to the risk of fornix shortening.
The transantral approach involves an incision superior to the upper gingivobuccal sulcus (Caldwell-Luc incision). Next, the anterior maxilla and zygoma are exposed via elevation of the periosteum and soft tissue. It is important to avoid injury to the infraorbital neurovascular bundle. A bone flap is created into the maxillary sinus with a chisel or an oscillating saw. At this point, the maxillary roof and orbital floor can be visualized. 
Figure 3: The initial steps to the transantral approach is depicted with (a) upper gingivobuccal incision and (b) exposition of the maxilla to make osseus cuts for a bone flap.
- Indications for the transantral approach include:
- Posteriorly located orbital floor fractures
- Repair of associated mid-face fractures
- Orbital decompression
- Biopsy and resection of posterior lesions 
While orbital floor fractures are typically treated through the transconjunctival and subciliary approaches, the transantral approach is commonly used in cases to reduce herniated orbital contents and to restore orbital volume. The transantral approach also minimizes eyelid complications seen with the classic transorbital approaches. Fractures and lesions that are located anteriorly may require the use of an endoscope or the classical transorbital approach.
- Inflammation of the maxillary sinus
- Worsened extraocular muscle limitation
- Lip anesthesia and V2 hypoesthesia
- Ocular pain 
Due to reports of high rates of diplopia and globe dystopia postoperatively, the transantral approach has been used less frequently and replaced by other decompression techniques.
Approaches to the Medial Orbit
The transcaruncular approach is performed by first retracting the upper and lower eyelids. A 10-12 mm vertical incision is made in the conjunctiva between the caruncle and plica semilunaris using Wescott scissors. The soft tissue surrounding the medial orbital wall is dissected posteromedially to the posterior lacrimal crest until the periosteum overlying the anterior ethmoidal sinus is reached. The periosteum is incised and a subperiosteal dissection plane is formed. Care should be taken to identify and preserve the anterior and posterior ethmoidal arteries using this approach. 
Figure 4: Incision line shown for transcaruncular approach to medial orbit.
The transcaruncular approach has gained popularity due to excellent surgical exposure, no visible scarring, and its increased safety profile.
- Medial orbital decompression
- Medial orbital wall fracture repair
- Drainage of subperiosteal abscesses
- Biopsy or excision of tumors in the medial orbit
The transcaruncular approach can also be used in conjunction with the endoscopic endonasal procedure to provide greater access to the medial orbit. When used in conjunction with an ethmoidectomy, this approach allows for thyroid orbital decompression and medial orbital wall fracture repair.
- Injury to the globe, lacrimal apparatus, inferior and superior oblique muscles, trochlea, medial canthal tendon, and ethmoidal vessels
- Medial canthal scarring
Transcutaneous - Lynch Incision
The Lynch incision is a 2-3 cm curved incision made between the medial canthus and the nasal dorsum. After the initial skin incision, cutting cautery can be used until the periosteum is reached. The periosteum can be reflected with special care to preserve the lacrimal sac. Alternatively, dissection can be carried through the orbital septum depending on the purpose of the surgery. If surgical exposure is inadequate, the anterior crus of the medial canthal tendon can be disinserted from the anterior lacrimal crest. The lacrimal sac can also be dissected away from its fossa to the level of the nasolacrimal duct. The nasolacrimal duct limits exposure inferiorly and the trochlea limits exposure superiorly.
Figure 5: Modified Lynch Incision
The Lynch incision is used predominantly for the treatment of medial orbit pathologies in situations where the transcaruncular approach cannot be performed due to extreme orbital swelling and limited visualization. Before the introduction of the transcaruncular approach, the Lynch incision was the most commonly used method to reach the medial orbit. The approach may also be useful for repairing naso-orbital-ethmoid fractures and transnasal wiring.
- Visible scarring
- Detachment and reconstruction of the medial canthal apparatus
- Potential injury to the lacrimal sac
The Lynch incision is largely associated with facial scarring and webbing of the medial canthal region and is less effective in individuals of Asian descent due to a wider nasal bridge. This incision has fallen out of common use in favor of the transcaruncular approach due to its cosmetic complications. Additionally, due to the subcutaneous tissue dissection, this approach often extends operative time and prolongs recovery.
The endonasal approach begins with a middle meatal antrostomy with in-fracturing and medialization of the middle nasal turbinate. This is followed by an uncinectomy allowing exposure to the ostium of the maxillary sinus. A sphenoethmoidectomy is then performed where the lamina papyracea can be elevated from the periorbita. Care should be taken to maintain its integrity during elevation to prevent orbital fat herniation. Periorbita is then opened in a posterior to anterior fashion parallel to the medial rectus muscle. Depending on the desired surgical endpoint, the dissection corridor can be moved superiorly or inferiorly. Pre-operative CT imaging paired with a surgical navigation system would be indicated to increase the safety of this approach.
- Decompression of the orbit and optic canal
- Resection of tumors in the medial orbit or apex
- Subperiosteal abscess drainage
- Orbital fractures 
The endoscopic endonasal approach is most suitable for access to the posterior inferomedial orbit and orbital apex without external scarring or injury of the eyelid and associated structures.
- Incomplete resection
- Optic nerve injury
- Cranial neuropathies
- Cerebrospinal fluid leak
- Retrobulbar hematoma
In a study by Han et al, it was shown that an endonasal approach for the treatment of pure medial wall orbit fractures is associated with increased surgery duration, longer hospital stays, and greater cost. Additionally, they showed no statistically significant difference between the transcaruncular and endonasal approaches in terms of extraocular movement limitation, diplopia correction, complications, reduction rate, and enophthalmos. 
Approaches to the Lateral Orbit and Superior Orbit
Upper Eyelid Crease Incision
An incision is made over the upper eyelid crease through the skin and orbicularis. The incision can be extended both medially and laterally. Lateral extension of the upper eye lid crease is most useful for a lateral orbitotomy. An inferiorly directed traction suture is placed through the upper eyelid margin to optimize exposure. Dissection is directed towards the superior orbital rim with care taken to avoid inadvertent damage to the supraorbital neurovascular bundle. The orbital septum can then be opened inferior to the arcus marginalis and adjacent to the lacrimal gland. The levator aponeurosis and preaponeurotic fat pad serve as landmarks. Alternatively, subperiosteal dissection can be performed, as with the 1.1 and 1.2. This can be extended laterally for proper surgical exposure.  
Figure 6: (a) Upper eyelid crease incision line, (b) Sub-brow incision line
- Removal of lesions superior and anterior to the equator of the globe
- Removal of superficial dermoid cysts
- Access to the lateral frontal sinus
- Repair of orbital roof fractures
- Drainage of subperiosteal hemorrhage or abscesses 
- Suture granuloma
- Eyelid hematoma
- Eyelid retraction
- Upper eyelid ptosis
- Lacrimal gland injury 
The general approach to a lateral orbitotomy begins with an incision originating in the lateral eyebrow, curving downward and ending posterolaterally. This incision should not be extended more than 2.4 cm lateral to the lateral canthus to avoid damage to the frontal branch of the facial nerve. The lateral canthal tendon can be released if needed and dissection is carried to the lateral orbital rim. Subperiosteal dissection is performed on the inner wall of the orbit to expose the lateral orbital wall. Additionally, dissection along the outer aspect of the lateral orbital wall can be done to release the temporalis muscle.
The lateral orbital wall can be removed if the view is limited. This is accomplished by making two axial cuts in the lateral orbital bone with a saw. One cut will be superior to the zygomaticofrontal suture while the other cut is right above the zygomatic arch. Once these two cuts are made, the bone is out-fractured and removed. If needed, the periorbita is opened with an incision parallel to the lateral rectus muscle. Intraorbital dissection begins once the surgeon gains adequate exposure. Upon completion of the procedure, the lateral orbital rim can be reconstructed with the use of a craniofacial plating system. However, a thick allograft over the lateral periorbita can be used in cases of severe bony deformity to aid in providing structural support.
Figure 7: Line for initial incision of lateral orbitotomy is shown in red.
- Lateral orbital decompression
- Repair of zygomaticomaxillary fractures
- Biopsy or excision of orbital tumors including lacrimal gland tumors
Transcranial approaches have improved exposure but may carry a higher approach morbidity. With modern technique and endoscopy, the lateral orbitotomy approach has become increasingly popular to reach more difficult areas, including the deep orbital apex, with improved cosmetic outcomes for patients.
- Lateral rectus weakness and diplopia (usually self-resolving)
- Facial nerve damage
- Optic nerve damage with loss of vision
- Cerebrospinal fluid leak
- Orbital hemorrhage
- Persistent dilated pupil from damage to the ciliary ganglion and parasympathetic nerves
- Lateral ptosis
- Lacrimal gland damage
- Bone flap necrosis
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