Swinging upper eyelid incision for a lacrimal gland tumor

Approaches to the superior lateral quadrant include lateral orbitotomy incisions and sometimes even transcranial incisions. I currently prefer a swinging upper eyelid incision especially for large extraconal tumors of the superior lateral quadrant which are usually lacrimal gland tumors. This approach gives wide exposure to this quadrant with a small external lateral canthotomy incision. This is an analogous incision to a lower swinging eyelid incision.

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This is Richard Allen in Houston, TX. This video demonstrates the use of a swinging upper eyelid approach for a lacrimal gland tumor. Imaging shows a lacrimal gland tumor with some bone erosion on the right which enhances with contrast and appears to be encapusulated. This was suspicious for a pleomorphic adenoma or benign mixed tumor. Similar to a lower swinging eyelid approach, a lateral canthotomy is performed followed by an upper cantholysis. 4-0 silk sutures are placed through the upper eyelid at the level of the tarsus for traction. A tranconjunctival incision is the made superior to the superior border of the tarsus extending to the lateral canthotomy incision laterally. This approach will allow wide access to the superior lateral quadrant. Dissection is then carried out through the Muller muscle, levator aponeurosis, and orbital septum to the orbicularis muscle. Dissection then continues superiorly between the orbital septum and the orbicularis muscle to the superior orbital rim. Additional 4-0 silk traction sutures are placed. The superior orbital rim is palpated and the periosteum of the superior and lateral orbital rim are incised with the needle tip cautery. A freer periosteal elevator is used to elevate the periosteum from the orbital roof and lateral orbital wall. This subperiosteal dissection is important to avoid rupture of the capsule of the tumor. Laterally, the area of the boney defect is identified and the periosteum is dissected from the underlying temporalis fascia. This can be performed with the end of the suction. After periosteal dissection is completed, the orbital septum is opened anteriorly and the preaponeurotic fat is dissected from the anterior surface of the tumor. A cotton-tip applicator is used to define the anterior extent of the tumor. Blunt and sharp dissection is the carried out with blunt-tipped Steven’s scissors along the surface of the tumor. The blunt tip of the freer periosteal elevator is then used to palpate around the tumor and release it gently from any deeper adhesions. The tumor can then be gently prolapsed forward and scissors are used to transect any residual attachment. Inspection of the tumor shows the capsule to be intact. The pathologist confirmed the suspected diagnosis of a pleomorphic adenoma with an intact capsule. Palpation of the orbit is performed to determine if any residual tumor is present. The transconjunctival incision is then repaired with interrupted, buried 7-0 Vicryl sutures which engage the cut end of the Muller muscle and levator aponeurosis to the superior border of the tarsus. I tend toward a ptosis after this procedure which I think is protective, as many of the patients will have dry eye after removal of or damage to the lacrimal gland. The lateral cantholysis is repaired by engaging loosely the periorbita laterally followed by the lateral upper and lower eyelid with a 4-0 Vicryl suture. The lateral canthotomy is then repaired with a deep 4-0 Vicryl suture followed by interrupted superficial 5-0 fast absorbing sutures. Antibiotic ointment is placed and the patient follows up in approximately one week.

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• Category

  Eyelid Cancer