Supratarsal fold incision for approach to the superior lateral

orbit
David S. Kung, DDS, MD, a and Leonard B. Kaban, DMD, MD, b Boston, Mass.
DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY, MASSACHUSETTS GENERAL HOSPITAL

Objective. To report and evaluate the use of the supratarsal fold incision for access to the lateral and superior orbit.
Design. This is a retrospective evaluation of seven patients with zygomatic and orbital fractures who underwent repair
with the supratarsal fold incision used to expose the frontozygomatic region or supraorbital rim: Data were obtained by
review of hospital charts, radiographs, and by clinical examination.
Results. Excellent exposure and access were obtained because of the proximity of the incision to the lateral and superior
orbit. Mobility of the eyelid tissue allowed for atraumatic manipulation and retraction. All fractures were adequately
reduced by clinical and radiographic examination without complication.
Conclusion. The supratarsal fold incision is a versatile incision for access to the zygomaticofrontal suture and supraorbital
rim. In addition to providing excellent exposure, it produces a superb cosmetic result with a scar well-hidden in the skin
folds of the upper eyelid.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81;522-5)

Satisfactory repair of zygomatic-orbital fractures re- METHODS

quires anatomic reduction of the walls and floor of the
orbit. Facial symmetry and globe position are depen-
dent on anatomic reduction of the lateral and inferior
orbital rims as well as reestablishment of the orbital
floor and contour of the zygomatic prominence. Re-
duction of the zygomatic arch usually improves man-
dibular hypomobility that may result from mech-
anical impingement on the mandibular ramus in the
infratemporal fossa. Successful surgical repair is de-
pendent on adequate exposure of any combination of
the zygomaticofrontal suture, infraorbital rim, zygo-
matic buttress, and orbital floor depending on the
anatomy of the fracture.
For direct access to the zygomaticofrontal suture as
well as the supraorbital rim, we recommend the su-
pratarsal fold (upper blepharoplasty or upper eyelid)
incision. Recently noted as an approach to the facial
skeleton by Ellis and Zide, 1 it was reported for repair
of zygomatic complex fractures in 1986 by Chuong
and Kabanfl The incision has also been used to expose
the supraorbital rim. In this article, we review the
technique of the supratarsal fold incision and present
selected cases of open reduction and fixation of zy-
gomatic-orbital fractures.
aFormer chief Resident.
bWalter C. Guralnick Professor mad Chairman.
Received for publication July, 25, 1995; returned for revision
Aug.21, 1995; accepted for publication Jan 2, 1996.
Copyright 9 1996 by Mosby-Year Book, Inc.
1079-2104/96/$5.00 + 0 7/12/71651
Patients with isolated zygomatic complex or su-
praorbital rim fractures treated at the Massachusetts
General Hospital over a 7-month period were in-
cluded for evaluation. The indications for surgical
repair included facial asymmetry, diplopia, limitation
of mandibular opening, pain, and paresthesia. The
clinical diagnosis was confirmed by plain radio-
graphs (including Waters' view) and by axial and
coronal computerized tomographic (CT) studies
when indicated. The supratarsal fold incision was
used for access to the zygomaticofrontal suture and
the supraorbital rim. Internal fixation with titanium
miniplates was used to stabilize the zygomatic com-
plex (Table I). The supratarsal fold incision was
supplemented by a subciliary incision for access to
the infraorbital rim and orbital floor, as well as a buc-
cal sulcus incision for access to the zygomatic
buttress. A successful outcome was defined as stable
reduction of fractures with return to function and
symmetry and a resultant eyelid scar unnoticeable at
6 months.
SURGICAL ANATOMY AND TECHNIQUE
The eyelids serve to protect and lubricate the ante-
rior surface of the globe. Each eyelid consists of skin,
subcutaneous tissue, striated muscle fibers (of the or-
bicularis oculi), orbital septum (confluent with the
tarsal plates), smooth muscle (composing superior
and inferior tarsal muscles), and conjunctiva. The
upper eyelid also receives fibers from the levator
palpebrae superioris (a striated muscle that raises the
upper lid). The aponeurotic fibers of the levator insert

522
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Kung and Kaban ;523
Volume 81, Number 5

A B
Fig. 1. A, Illustration of supratarsal fold incision (solid line) with medial and lateral extensions (dotted and
dashed lines) placed in supratarsal fold of left upper eyelid above tarsal plate (shaded). B, Exposure of zy-
gomaticofrontal suture (with diastasis) and supraorbital rim (with fracture through supraorbital foramen).

Table I. Patient diagnosis and treatment data

Age~Sex Diagnosis* Incision Fixation site

38/M Medially rotated right ZMC Supratarsal fold, subciliary ZF suture, infraorbital rim
fracture
37/17 Laterally rotated left ZMC Supratarsal fold None
fracture
36/M Left supraorbital rim fracture Supratarsal fold Supraorbital rim
32/M Medially rotated left ZMC Supratarsal fold, subciliary ZF suture, infraorbital rim
fracture
19/M Medially rotated right ZMC Supratarsal fold, subciliary ZF suture, infraorbital rim
fi'acture
34/M Laterally rotated left ZMC Supratarsal fold, buccal sulcus ZF suture, zygomatic buttress
fracture
18/M Medially rotated right ZMC Supratarsal fold, subciliary, ZF suture, infraorbital rim,
fracture buccal sulcus zygomatic buttress
*Based on Knight and North's7 classification according to the type of displacement. ZMC, zygomatic complex; ZF, zygomaticofrontal.

into the skin of the upper eyelid to form the superior
p a l p e b r a l s u l c u s . 4 Ttie supratarsal incision is placed
in a skin fold parallel t o t h e superior palpebral sulcus
above the tarsal plate (Fig. 1, A). It is placed approx-
imately 10 to 14 m m above the anterior margin of the
upper eyelid. Although a 2 c m incision is usually ad-
equate, it can be extended medially or laterally into
the " c r o w ' s f o o t " skin crease to add exposure. An
upper tarsal suture can be placed for traction as
well as for protection of the anterior globe. (Scleral
shields should be used as well.) With a modest skin
flap developed, the orbicularis oculi muscle is sepa-
rated along its long axis by blunt dissection. Care is
taken not to perforate the underlying orbital septum
keeping the orbital fat and lacrimal gland out of
the surgical field. The dissection continues superiorly
and laterally to the periosteum of the orbital rim.
This is incised sharply and elevated to expose the
supraorbital rim and zygomaticofrontal suture (Fig. 1,
B). The dissection is carried into the temporal fossa
posterior to the frontal process of the zygoma to
provide access for elevation of the zygomatic com-
plex. The supraorbital foramen can also be identified
from this approach, allowing decompression of its
neural contents as necessary. The incision is closed
with one to three periosteal sutures (often unnec-
essary) and a running subcuticular pull-out nylon
suture.
524 Kung and Kaban
Fig. 2. Intraoperative view of exposure and fixation at, A, right zygomaticofrontal suture, and, B, left su-
praorbital rim with supraorbital nerve (arrow) decompressed.
Fig. 3. Postoperative appearance of right supratarsal fold
incision at 8 months (arrow).
RESULTS
Seven patients underwent repair of zygomatic-or-
bital fractures (Table I). The supratarsal fold incision
provided very satisfactory exposure of not only the
lateral orbital wall and zygomaticofrontal suture but
also the supraorbital rim and foramen (Fig. 2). This
allowed direct reduction of fractures in these areas
with enough exposure for placement of fixation hard-
ware. In five patients, exposure of the infraorbital rim,
orbital floor, and zygomatic buttress regions was re-
quired.
The patients have all been followed for a minimum
of 6 months and have had marked improvement in
facial symmetry. In all cases, the incision is virtually
invisible and masked in the upper eyelid (Fig. 3): Two
patients had dense paresthesia of the second division
of the trigeminal nerve preoperatively and recovered
full normal sensation by 3 months postoperatively.
The others had mild paresthesia that resolved by 6
months. Postoperative radiographic Studies were ob-
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
May 1996
tained that showed excellent reduction of fractures in
all cases. In addition, each patient was pleased with
the esthetic result of the supratarsal fold incision.
There have been no complications to date.
DISCUSSION
Techniques for repair of zygomatic-orbital injuries
have undergone a significant evolution over the past
century. Closed reduction without adequate fixation
resulted in many reports of postoperative instabili-
ty. 5-8 These results and observations eventually led to
an emphasis on open reduction and internal fixation
of zygomaticomaxillary fractures. 9, 10
A variety of surgical approaches have been report-
ed. 11-17 In 1909, Keen 11 described reduction of the
zygoma with an instrument passed through the buc-
cal sulcus. Other intraoral methods include the Cald-
well-Luc approach that allows access to the orbital
floor and zygomatic body through the maxillary
sinus. This approach permits placement of an antral
pack for stability. In 1927, Gillies et al. 12 described
the temporal approach for reduction of zygomatic
arch fractures. Other extraoral approaches include the
coronal, lateral eyebrow, lower eyelid (subciliary or
infraorbital), and upper eyelid incisions. The coronal
incision is well described for access to the zygomatic
complex as well as the entire midface and nasoeth-
moidal region. 13-15 With excellent exposure of the
temporal and infratemporal spaces as well as the su-
perior, lateral, and medial orbital walls, it has become
the approach of choice for the late correction of ma-
jor zygomatic deformities that require osteotomies or
bone grafting. 14
The lateral eyebrow incision provides access to the
infratemporal fossa and to the zygomaticofrontal su-
ture for reduction and fixation of the zygoma. At one
time, it was the most commonly used approach to this
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 81, Number 5
area of the zygomatic complex. The lateral eyebrow
incision was seen as an advance in the treatment of
these fractures because it allowed simple direct access
to the zygomaticofrontal suture. However, recent re-
ports 1, 3 have commented on the limited access and
undesirable cosmetic results achieved with this inci-
sion. The resultant scar is often perceptible in poorly
planned incisions, in patients with eyebrow hair loss,
and in those who do not have eyebrows extending
laterally and inferiorly along the orbital margin. 1
The supratarsal fold incision, as recommended in
this article, offers excellent access to the zygomati-
cofrontal region because of the mobility of the eyelid
tissues and the ability to vary incision length without
impacting on the esthetic result. 2 It also allows for
reduction of the body of the zygoma via the infratem-
p0ral fossa. Another advantage of this incision in-
cludes excellent access to the supraorbital rim. In ad-
dition, the vasculature of the orbicularis oculi muscle
maintains the viability of the skin that is elevated with
it leading to superb healing. Technically, the incision
is not complicated to perform. Potential complica-
tions of this incision include damage to the lacrimal
gland and tarsal plate or levator muscle injury result-
ing in a cosmetic change of the upper eyelid. These
can be avoided by careful dissection and proper sur-
gical planning.
CONCLUSION
The supratarsal fold incision provides excellent
access to the supraorbital rim and zygomaticofrontal
suture. It is our approach of choice for this area given
its relatively safe and uncomplicated design as well
as its excellent cosmetic result.
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Kung and Kaban 525
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Reprint requests:
David S. Kung; DDS, MD
Massachusetts General Hospital
Department of Oral and Maxillofacial Surgery
Warren 1201
Boston, MA 02114