Plastic & Reconstructive Surgery:
Upper Eyelid Crease Approach to the Medial Orbital Wall
Cruz, Antonio A. V. M.D., Ph.D.; Akaishi, Patricia M. S. M.D.; Baccega, Adriano M.D.
Craniofacial Unit; Department of Ophthalmology, Otorhinolaryngology, and Head and Neck Surgery; School of Medicine of Ribeirão Preto; University of São Paulo; São Paulo, Brazil
Correspondence to Dr. Cruz; Hospital das Clínicas-Campus; Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço; Av. Bandeirantes 3900; 14049-900, Ribeirão Preto, São Paulo, Brasil; email@example.com
Surgical access to the postseptal segment of the medial wall is an essential step in the management of a variety of conditions, such as fractures of the lamina papyracea and Graves’ optic neuropathy. Although there are many different approaches to the medial wall, there is a strong trend among orbital surgeons to favor the transcaruncular approach to access the deep portion of the medial wall.1 This route poses no problems for ophthalmologists who are familiar with operations on the globe. However, for surgeons with surgical training in other specialties, the necessity of performing incisions on the eyeball is a disadvantage of the transconjunctival approach.
We report here our experience in accessing the postseptal portion of the medial wall through the upper eyelid crease. In our opinion, the lid crease offers a natural plane to the posterior part of the medial wall, allowing excellent exposure with virtually no globe manipulation.
A musculocutaneous incision is performed on the medial one-third of the crease. The orbital septum is incised horizontally to expose the aponeurotic fat. The nasal fat pad is then located and gently mobilized laterally, exposing a natural hollow area between this pad and the medial wall (Fig. 1). With malleable retractors, this plane is enlarged inferiorly and medially, providing wide access to the superior aspect of the medial wall (Fig. 2). The periorbita of the medial wall is incised and elevated from the underlying lamina papyracea of the ethmoid bone. A small amount of dissection is performed superiorly and posteriorly to localize the anterior ethmoid neurovascular bundle. The wall is thus entirely exposed from the frontoethmoidal suture to the medial portion of the floor.
We have used this access without any difficulty to correct medial blowout fractures and for decompressing the orbit.
We believe that Katowitz et al.2 were the first to use the lid crease to approach the medial wall in a case report of medial blowout. Their work was completely overlooked, and no other report on this approach is found in the literature. To the best of our knowledge, Pérez Moreiras from Spain is the only surgeon who has described the lid crease incision for orbital decompression.3
The lid crease incision is a natural approach to the medial wall. There is no need to retract the globe laterally and thus the postoperative inflammatory symptoms related to the eye are minimized. The approach allows an easy and complete exposure of the medial wall without any difficulty. The superior oblique muscle, which lies close to the ethmoid-frontal junction, is the most important landmark of the superior limit of the surgical field. Immediately below this muscle, the surgeon finds the anterior ethmoid neurovascular bundle. In orbital decompression, bone removal starts from this level toward the orbital floor and posteriorly toward the apex. During the inferior dissection toward the floor, the surgeon naturally works behind the posterior lacrimal crest. No harm is done to the medial canthal ligament or the anterior insertion of the Horner muscle.
Antonio A. V. Cruz, M.D., Ph.D.
Patricia M. S. Akaishi, M.D.
Adriano Baccega, M.D.
Department of Ophthalmology, Otorhinolaryngology, and Head and Neck Surgery
School of Medicine of Ribeirão Preto
University of São Paulo
São Paulo, Brazil
1. Chang, E., Bernardino, C. R., and Rubin, P. Transcaruncular orbital decompression for management of compressive optic neuropathy in thyroid-related orbitopathy. Plast. Reconstr. Surg.
112: 739, 2003.
2. Katowitz, J. A., Welsh, M. G., and Bersani, T. A. Lid crease approach for medial wall fracture repair. Ophthalmic Surg.
18: 288, 1987.
3. Pérez Moreiras, J. V., Sánchez, M. C. P., Bockos, J. C., et al. Oftalmopatia distiroidea. In J. V. Pérez Moreiras and M. C. Prada Sánchez (Eds.), Patologia Orbitária,
Tomo 2, 1st Ed. Barcelona: Ferre Olsina, 2002.
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David H. Song, M.D., M.B.A. is the President-elect of the American Society of Plastic Surgeons (ASPS). He is a consultant with BioMet, Emmi Solutions, LLC, a consortium-member providing senior debt for Brava, and consultant with and investor in HealthEngine.com. He receives author royalties from Elsevier. Scot Glasberg, M.D. is the President of the American Society of Plastic Surgeons (ASPS). He is a consultant with LifeCell Corp and Mentor Corp and an investor with Strathspey Crown. The authors have no sources of funding to report related to the writing or submission of this discussion.
The location and affiliation information should read as follows: Arlington Heights, Ill. From the American Society of Plastic Surgeons/Plastic Surgery Foundation.
David H. Song, M.D., M.B.A., 444 E. Algonquin Rd. Arlington Heights, IL 60005, firstname.lastname@example.org
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