Trans-tarsal Stair-Step Technique for Lateral Extension of the Transconjunctival Incision: A Technical Note and Case Series

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An optimal surgical approach in the treatment of orbitomalar fractures is one that provides adequate exposure for the surgeon while minimizing postoperative complications and maximizing aesthetic outcomes for the patient. Multiple surgical approaches to the orbital floor have been described and are broadly categorized as transcutaneous or transconjunctival (Figure 1A and 1B).^1-4 While transcutaneous approaches (subciliary, subtarsal, and orbital rim) provide sufficient intraoperative access, there is a higher risk of scarring and eyelid malposition.^1,5-12 This is particularly the case for the subciliary and orbital rim incisions, and for that reason, it is not routinely recommended.^{1,5, 9}

Figure 1. Lower eyelid cross sections of a transcutaneous incision (A) and transconjunctival incision (B).

The transconjunctival approach, first described in 1928 by Bourquet et al for blepharoplasty and later in 1971 by Tenzel and Miller for orbital floor trauma, offers improved aesthetic outcomes as it avoids a transcutaneous incision.^3,5-13 However, a commonly cited disadvantage to this approach is limited intraoperative visibility, especially when wider access to the orbital rim is needed for fracture fixation or when access to the lateral buttress is needed for reduction of a Le Fort or orbitomalar fracture.^6,7 Traditionally, this limitation has been overcome by extending the incision laterally with lateral canthotomy and cantholysis.¹⁴ Nevertheless, disruption of the lateral canthus has been associated with higher rates of complications including scleral show, ectropion, visible scarring, and asymmetry.^11,15,16

In 1994, Chalain et al proposed to modify the transconjunctival approach with a lateral paracanthal incision whereby only the inferior limb of the lateral canthus was transected.^17,18 This technique has more recently been revisited in East Asia by Kim et al in 2009 and Song et al in 2014, who instead incised the tarsal plate 2 to 3 mm medially thereby avoiding the lateral canthus.^19-24 While their initial results in the East Asian population have been promising, this technique has not yet been commonly practiced or formally studied in Western patients.^19,21,25,26 We describe our modified technique for a trans-tarsal stair-step incision for lateral extension of the transconjunctival incision in a Western population. In our experience, this novel technique compares favorably with more commonly used transcutaneous and transconjunctival approaches and has the potential to circumvent the aesthetic complications commonly associated with lateral canthotomy and cantholysis.

Surgical Technique

The operation begins with a standard transconjunctival approach (Figure 2A). The senior author prefers the preseptal plane, which provides ample exposure of the floor without the herniation of postseptal fat limiting visibility (Figure 1B). The arcus marginalis and periosteum along the orbital rim are incised in order to obtain a subperiosteal dissection along the inferior orbital rim and orbital floor. Next, a 1 to 2-cm transverse transcutaneous incision is made in a predetermined rhytid over the lateral orbital rim (Figures 2B and 3A). Dissection is carried down to the lateral orbital rim, and subperiosteally the dissection is carried medially to meet the dissection plane of the transconjunctival approach. We then make a trans-tarsal incision, perpendicular to the eyelid margin, roughly 2 to 3 mm medial to the lateral canthus that connects to the transconjunctival incision (Figure 2C). To complete the “stair step,” this is then connected at a right angle to the lateral transcutaneous incision using either a subciliary or subtarsal incision technique (Figure 3B). To facilitate these incisions, tension can be provided by placing a freer elevator or Senn retractor in the subperiosteal space, connecting the lateral transcutaneous incision to the transconjunctival dissection plane (Figures 2D and 3C). This completes the incisional exposure component of the operation, with the remaining steps similar to the standard exposure, reduction, and fixation of the orbito-malar fracture.

Figure 2. Intraoperative photographs of the lateral extension of a transconjunctival incision with a trans-tarsal stair-step incision. 

Figure 3. Illustration of the lateral extension of a transconjunctival incision with a trans-tarsal stair-step incision: A predetermined lateral rhytide is selected for optimal cosmesis (A). A trans-tarsal incision is made 2 to 3 mm medial to the lateral canthus and connected at a right angle to the transcutaneous lateral rhytid incision at the subciliary or subtarsal level (B). The lateral transcutaneous incision is connected to the transconjunctival incision (C). The tarsal plate is repaired using a 4-0 PDS suture (D).

At the time of closure, we begin by resuspending the midface using a 4-0 PDS suture, followed by closure of the periosteal layer at the lateral aspect of the incision. Next the tarsal plate is meticulously repaired using a 4-0 PDS buried simple suture in the tarsal plane, taking great care to align the lid margin. Next, the posterior lamella is addressed using a buried 6-0 or 7-0 vicryl suture at the conjunctival corner of the stair-step incision (Figures 2E and 3D). A 6-0 or 7-0 vicryl suture is used at the lid margin to ensure perfect alignment. The orbicularis oculi is reapproximated using buried 5-0 monocryl sutures, and superficial 5-0 fast gut or 6-0 prolene simple sutures are used to close the skin (Figure 2F). A lateral tarsorrhaphy is then performed with a 6-0 prolene suture and xeroform pledgets. In our experience, this helps offload the lower lid, and prevents conjunctival irritation from repetitive eyelid movement, while the transconjunctival incision is healing.

Results

The demographic characteristics of our pilot population are detailed in Table 1. The most common primary fracture type was a zygomaticomaxillary complex (ZMC) fracture. The trans-tarsal stair-step incision was used in 10 patients, while the transconjunctival with lateral canthotomy and subtarsal incisions were used in 4 and 20 patients, respectively. The subciliary and orbital rim approaches were not used. There were no incision-related complications in the patients who underwent the trans-tarsal stair-step incision. Six patients who underwent the transconjunctival with lateral canthotomy or subtarsal incisions experienced complications, the most common of which was ectropion. Two patients required eyelid taping, and 4 patients required incision-related revision. Detailed outcomes are further described in Table 1.

We present a concise description of our technique for a transtarsal stair-step incision for lateral extension of the transconjunctival incision and our preliminary experience with its use in the repair of complex orbitomalar fractures. In our cohort, our technique demonstrated lower rates of incision-related complications with no cases of ectropion or incision-related revision when compared with traditionally practiced techniques (Figure 4). We found this approach to provide sufficient surgical exposure for even complex orbito-malar fractures requiring a Carroll-Girard screw in the malar prominence for reduction. Our initial findings are in line with previously published experiences in East Asian patients and are the first to report on the use of this technique on Western patients.^19,21,25,26 In a series of 113 patients, Kim et al reported no cases of noticeable scaring, scleral show, or ectropion.¹⁹ Similarly, Song et al had no cases of ectropion, entropion, or lid malposition with low scar grading by both patient and physician.²¹ Additionally, when compared with traditional techniques, Suh et al noted a significant increase in the area of the surgical field.²⁶ Finally, Chung et al reported scars to be inconspicuous without patient dissatisfaction with scarring.²⁵ In light of our experiences and the published literature, we advocate for more widespread adoption of this technique in the Western population. We believe our simplified technique would be easy to adopt for any type of orbito-malar fracture patterns in which a standard transconjunctival approach alone provides inadequate surgical exposure to the orbital rim or lateral buttress of the zygoma.

Figure 4 Postoperative photographs of patients who underwent the trans-tarsal stair-step incision on the right (A and B) and left (C and D).