13.1 Introduction
Orbital lesions, depending on their location and relationship with the intra-orbital structures, can be approached through different surgical routes (transcranial or trans-orbital).
The lateral orbitotomy, also known as Krönlein approach, and its further modifications allow for an easy reach of intra-orbital lesions located in the superior, lateral, and inferior intraconal compartments as well as pathologies of the lateral aspect of the orbital apex.
Lateral orbitotomy takes advantage of a direct approach to orbital content, avoiding potential complication of a transcranial or direct transorbital route.
13.2 Indications
• Orbital intra-conal and extra-conal lesions.
• Lesions of the lateral aspect of the orbital apex.
13.3 Patient Positioning
• Position: The patient is positioned supine with the head fixed with a horseshoe head holder.
• Body: The head is slightly elevated, to facilitate the venous backflow.
• Head: The head is turned 45° to the contralateral side.
• Neck: The neck is slightly extended (about 20°).
• The zygoma must be the highest point in the surgical field.
13.4 Skin Incision
• Italic “S” skin incision (Fig. 13.1)
◦ Starting point: Incision starts at the lateral third of the eyebrow, just above the orbital rim.
◦ Course: Incision line runs posteriorly and inferiorly toward the postero-superior (temporal) border of the zygomatic bone.
◦ Ending point: It ends at the zygomatic-temporal suture.
13.4.1 Critical Structures
• Frontal branch of the facial nerve.
• Orbicularis oculi muscle.
• Supraorbital nerve and vessels.
• Lateral canthal ligament.
13.5 Soft Tissue Dissection (Figs. 13.2, 13.3)
• Temporal fascia and periorbit
◦ Superficial temporal muscle fascia is incised, avoiding transecting underlying muscle fibers.
◦ Periorbit is dissected from the inner surface of the lateral wall of the orbit.
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