Alternative Technique Extended Lower Eyelid Approach

The extended lower eyelid approach provides access to the entire lateral orbital rim to a point approximately 10 to 12 mm superior to the frontozygomatic suture. For this added exposure, however, amore generous incision and wide undermining are necessary. Additionally, the lateral canthal tendon must be stripped from its insertions and carefully repositioned. In spite of these concerns, the approach is useful when one requires access to the entire lateral orbit, lateral orbital rim, orbital floor, and inferior orbital rim.

The incision for the "extended" subciliary approach is exactly as described for the standard subciliary incision, but the incision must be extended laterally approximately 1 to 1,5 cm in a natural crease (see Fig. 2-13). If no natural skin crease extends laterally from the lateral palpebral fissure, the extension can usually be made straight laterally, or slightly inferolaterally.

Supraperiosteal dissection of the entire lateral orbital rim is performed with scissor dissection to a point above the frontozygomatic suture (Fig. 2-29). The orbicularis oculi musculature and superficial portion of the lateral canthal tendon are retracted as the dissection proceeds._

Figure 2-29 Technique used to obtain increased exposure of the lateral orbital rim. The initial incision is extended laterally 1 to 1,5 cm, and supraperiosteal dissection along the lateral orbital rim proceeds

With retraction, an incision through the periosteum 2 to 3 mm lateral to the lateral orbital rim is made from the highest point obtained with supraperiosteal dissection (Fig. 2-30). The periosteal incision is connected to the one described from the standard approach to the orbital floor and infraorbital rim (see previous text). Subperiosteal dissection must strip all of the tissue from the orbital floor and lateral orbital wall. This includes stripping the insertions of the deep portion of the lateral canthal tendon, Lockwood's suspensory ligament, and the lateral check ligament, from the orbital (Whitnall's) tubercle of the zygoma. Generous subperiosteal dissection deep into the lateral orbit allows retraction of these tissues to expose the frontozygomatic suture.

Figure 2 30 Dissection to the level of the frontozygomatic suture. The tissues superficial to the periosteum are retracted superiorly with a small retractor and an incision through periosteum is made 3 to 4 mm lateral to the lateral orbital rim. Subperiosteal dissection exposes the entire lateral orbital rim. Dissection into the lateral orbit frees the tissues and allows retraction superiorly.

Figure 2 30 Dissection to the level of the frontozygomatic suture. The tissues superficial to the periosteum are retracted superiorly with a small retractor and an incision through periosteum is made 3 to 4 mm lateral to the lateral orbital rim. Subperiosteal dissection exposes the entire lateral orbital rim. Dissection into the lateral orbit frees the tissues and allows retraction superiorly.

No lateral canthopexy is necessary if careful repositioning and suturing of periosteum along the lateral orbital rim are performed. This maneuver brings the superficial portion of the lateral canthal tendon into proper position, giving the lateral palpebral fissure satisfactory appearance.

references

1. Zide BM, Jelks Gw : Surgical Anatomy of the Orbit. New York, Raven Press, 1985

2. Anderson RC: The medial canthal tendon branches out, Arch Ophthalmol 95:2051, 1977

3. Zide BM, McCarthy JG : The medial canthus revised. An anatomical basis for canthopexy, Ann Plast Surg 11:1, 1983

4. Rodriguez RL, Zide BM : Reconstruction of the medial canthus. Clin Plast Surg 15:255, 1988.

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