Lateral eyebrow approach

The lateral eyebrow approach provides a simple and rapid access to the superolateral orbital rim. No functionally important neurovascular structures are at risk in this approach.

Note: Because of the possibility of a prominent scar and damage to the eyebrow, this incision is infrequently utilized and not recommended.

Subcutaneous infiltration of a local anesthetic/vasoconstrictor solution of the soft tissues overlying the superolateral orbital rim is helpful for hemostasis.

The cornea is protected with a temporary tarsorrhaphy or with a corneal shield.

Below, the steps of a temporary tarsorrhaphy are shown.

Temporary tarsorrhaphy using a mattress suture

The needle is passed in the lower eyelid from the Gray line into the skin where it exits.

Needle passing through Gray line of the lower eyelid during temporary tarsorrhaphy – transcutaneous lower-eyelid approach.

The suture is guided back, picking up the same soft-tissue portions in the lower and upper eyelids to complete the mattress loop.

Completing the mattress suture during temporary tarsorrhaphy – transcutaneous lower-eyelid approach.

The tarsorrhaphy is not secured tightly, and some space is left between the knot and the upper-eyelid skin. A hemostatic clamp is used to grasp the suture and apply traction to the lower lid for full eyelid closure during the surgical procedure.

Clinical photograph showing the space is left between the knot and the upper-eyelid skin during temporary tarsorrhaphy – transcutaneous lower-eyelid approach.

Since the suture was not fully tightened, when the hemostatic clamp is released, the lid may be opened for a forced duction test or evaluation of the pupil during the procedure.

Eyelid may be opened for a forced duction test or evaluation of the pupil – transcutaneous lower-eyelid approach.

Note: A less traumatic approach preferred by many involves placing a needle a few millimeters from the edge of the upper and lower lids through skin and muscle only and placing it under traction. This avoids the risk of lacerating the lid margin or the cartilage of the tarsal plate.

Allternative approach for corneal protection – transcutaneous lower-eyelid approach.

Before the incision, the lateral eyebrow hair is moistened and parted to open a line for the planned incision. An approximately 2 cm long horizontal incision is marked within the bounds of the lateral eyebrow parallel to the hair follicles. The incision goes through the skin first and then through the subcutaneous fat and muscular tissue layers.

Care is taken not to injure the hair follicles during the incision.

The orbicularis oculi muscle is undermined at a level below the retro-orbicularis oculi fat to expose the supra-periosteal plane.

The wound edges become freely moveable by the supraperiosteal dissection and are retracted over the zygomaticofrontal suture or the fracture area.

Skin incision – lateral eyebrow approach.

The periosteum is exposed and split sharply with a scalpel along the middle of the superolateral orbital rim.

Access to the periosteum – lateral eyebrow approach.

The underlying bony structures are freed using sharp periosteal elevators.

The medial surface of the superolateral orbital rim is exposed first to gain entrance to the fossa of the lacrimal gland. Starting the subperiosteal dissection from within this bony concavity inside the anterolateral portion of the orbital roof, the periosteal envelope can be stripped off with ease from the superolateral orbital rim and the adjacent intraorbital quadrant.

Exposure to the lower portion of the lateral orbital rim is facilitated by a wide undermining of the skin and periosteum.