This document describes various surgical approaches for accessing the orbital rim and floor. It outlines several incision types including transcutaneous, subciliary, subtarsal, infraorbital, and lateral eyebrow incisions. For each incision, it provides details on placement, depth, and the steps of dissection and tissue retraction to access the periosteum and allow for subperiosteal dissection of the orbital wall. Key approaches discussed are the lateral eyebrow incision, upper blepharoplasty incision, coronal incision, and lateral canthotomy incision.

2. Dr Mohsin Fazal
Senior Registrar
Islamic International Dental College

3.  Inferior rim & floor:
 Transcutaneous
 Subciliary
 Subtarsal
 Infraorbital
 Patterson-Ethmoidectomy
 Transconjunctival
 Preseptal
 Postseptal
 Superolateral Orbit
 Lateral Eyebrow
 Supratarsal Fold
 Coronal
 Medial Orbit
 Lynch
 Patterson Ethmoidectomy

4.  Converse in 1944
 Incision approx 2mm
 Skin undermined

5.  Orbicularis oculi traversed till
orbital septum
 The dissection superficial to
orbital septum
 Periosteum incised on anterior
surface of maxilla & Zygoma
 Periosteum is reflected inward
and upward

6. “Skin Only Incision”
 Inferior dissection is carried superficially to
orbicularis oculi muscle till orbital septum is reached.
“Skin-muscle Incision”
 Incision is carried through both skin
and muscle at the same level till the
tarsal plate.

7.  Incision extended laterally by 1-1.5 cm
 Supraperiosteal dissection at
entire lateral orbital rim
 The periosteum is incised in the
middle of lat orbital rim.

8.  Subperiosteal dissection strips tissues from orbital wall

9.  Tessier & Converse in 1973
Lateral Canthotomy Incision:
 Scissors inserted to the depth of
orbital rim and cut in horizontally.
 The lateral canthal tendon released with a vertical
incision
 Scissors used to dissect through small incision in
conjunctiva to free the vestibular conjunctiva

10.  Periosteum is incised, avoiding the lacrimal sac
laterally
 Periosteum over orbital rim and anterior surface of
maxilla, zygoma and orbital floor is reflected

11.  Lateral Eyebrow Incision
 Upper blepheroplasty Incision
 Coronal Incision
 Lateral Canthotomy Incision

12.  Incision placed at outer aspect of eyebrow
 Skin of eyebrow is tented over superior orbital rim
 1.5cm incision made in a beveled fashion parallel to
hair follicles
 Skin incision retracted over ZF suture, orbicularis oculi
muscles fibres incised overlying the rim

13.  Additional undermining and dissection carried out in
inferolateral direction
 Skin and muscle incisions are stepped for more
favorable healing.

14.  Incision is made at upper eyelid crease extending into
the subcutaneous tissue
 Incision retracted laterally and
extended to orbicularis muscle
 Orbicularis oculi and periosteum exposed by sharp
dissection
 Approx 1cm incision is given but
can be extended if required

15.  Subperiosteal dissection of orbit and orbital rim is
performed.
 Lacrimal fossa, a deep concavity in the inferolateral
orbit

16.  1cm area of hairline at incision is shaved
 Incision is carried out through
skin, subcutaneous tissue and
aponeurosis.
 A curvilinear incision given 2 cm behind incision line
extending lateraly parallel to hairline and finally in the
preauricular region

17.  The incision is given through skin, subcutaneous
tissue and aponeurosis.
 The flap may be elevated with finger dissection or
blunt periosteal dissection
 Periosteal incision given 3-4
cm superior to supraorbital
rims extending lateraly till the
superior temporal line

18.  Subperiosteal dissection carried
out till superior orbital rim
 The lateral portion of the flap is dissected
above temporalis fascia upto within 2-4cm
of Zygoma, the flap is dissected inferiorly
to zygomatic arch
 An incision is made through periosteum
along posterior border of zygoma and the
orbital rim, to meet the horizontal periosteal
incision.

19.  Further reflection of flap accomplished by carrying
dissection into the orbit
 Dissection of periosteum around medial and superior
orbital walls retracts the flap to the junction of nasal
bones & lateral nasal cartilage

20.  A vertical curvilinear 1cm incision 5-10mm medial to
insertion of medial canthus
 Incisoin is placed over lateral nasal structures, the
dissection is made medially through skin,
subcutaneous tissue and periosteum.
 The medial canthal tendon and lacrimal sac lie
posterior and superior to the incision.

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