Evaluation of Subciliary Incision Used in Blowout Fracture Treatment: Pretarsal Flattening after Lower Eyelid Surgery
Yong Kyu Kim, M.D. Jae Won Kim, M.D.
Background: The skin-muscle flap has been widely used for many years in eyelid surgery. However, lid retraction and pretarsal flattening are considerable cosmetic complications. Furthermore, it has also been reported that damage of the zygomatic branch reduces muscle tone and contributes to the development of various complications. The authors investigated whether denervation of the zygomatic branch affects lid retraction and pretarsal flattening in pure blowout fractures. Methods: The authors studied 286 unilateral pure blowout fracture patients from January of 2005 to December of 2006. Mean patient age was 35.6 years (range, 9 to 72 years), the male-to-female ratio was 1.7:1, and the mean follow-up period was 28 months (range, 19 to 40 months). No patients had undergone eyelid surgery previously. Eyelid tone was evaluated using the snap test and the lid distraction test. Pretarsal shape was evaluated using photographs, which were presented to three plastic surgeons and six medical students unaware of surgical information. Results: Increased laxity was found in only 13 patients (4.5 percent). When viewing photographic comparisons, medical students noticed visible scars in 10 patients (3.5 percent), pretarsal flattening in eight patients (2.8 percent), and eyelid malposition in eight patients (2.8 percent), whereas the plastic surgeons noticed visible scars in 10 cases (3.5 percent), pretarsal flattening in 10 cases (3.5 percent), and eyelid malposition in nine cases (3.1 percent). Conclusions: In this study, it can be inferred that pretarsal flattening may not be a problem associated with the skin-muscle flap itself accompanying denervation of the zygomatic branch. Instead, technical expertise, conservation of the buccal branch, and meticulous hemostasis are essential for the prevention of complications. (Plast. Reconstr. Surg. 125: 1479, 2010.)
egardless of whether plastic surgery is conducted for aesthetic purposes or for treating trauma,1– 4 subciliary or transconjunctival approaches to lower eyelid operations may be considered. Since the skin-muscle flap was first described by Beare5 in 1967, the subciliary approach has been widely used for lower eyelid surgery. However, Tomlinson and Hovey6 and Carraway7 described a transconjunctival approach for lower eyelid operations devised to minimize the various complications associated with lower eyelid surgery. The representative complications of the subciliary approach include scleral show and ectro-
pion caused by lower lid retraction, and, from the cosmetic perspective, lower eyelid flattening (pretarsal muscle roll disappearance) caused by reduced lower eyelid pretarsal muscle volume. In particular, this latter complication appears as evidence of the aging process in the orbital region because pretarsal muscle roll is characteristic of a youthful face. As a result, pretarsal flattening should be avoided, especially in cosmetic lower eyelid surgery. Changes in lower eyelid shape after lower eyelid surgery have been reported to occur at a rate of 5 to 30 percent,8 –12 and many studies have been undertaken to ascertain the reasons for these complications. We questioned whether pretarsal flattening and other complications follow-
From the Department of Plastic and Reconstructive Surgery, Inje University Ilsan Paik Hospital. Received for publication June 28, 2009; accepted November 20, 2009. Copyright ©2010 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3181d5120d
Disclosure: The authors have no financial interest to declare in relation to the content of this article.
and lower eyelid malposition (scleral show or ectropion) between the site that had been operated on and the contralateral side with reference to the postoperative follow-up photographs based on preoperative photographs obtained during the above period. the incision does not reach the medial aspect of the punctum. and the mean follow-up period was 28 months (range.6 years (range. there were no patients in whom the laxity was markedly increased on the normal side.Plastic and Reconstructive Surgery • May 2010
Fig.2) 273 (95.5)* 8 (2. The snap
test and lid distraction test were conducted during follow-up visits.
PATIENTS AND METHODS
From January of 2005 to December of 2006. and postoperative photographs were compared with those from the unaffected.
Fig. This evaluation was performed based on an analysis of the clinical results that were obtained between postoperative months 19 and 28.to 5-mm strip of pretarsal muscle (Fig. we used 286 unilateral blowout fracture patient who had orbital wall reconstruction surgery.
ing cosmetic lower eyelid surgery are associated with a skin-muscle flap approach itself. 9 to 72 years).
. Intraoperative view of the zygomatic branch of the facial nerve.2) —
*They were found to be the same patients from evaluations performed by medical students and plastic surgeons. Furthermore. For the use of recognizable photographs. The mean patient age was 35. The procedure consisted of dissection of the orbicularis oculi muscle. The distribution of complication cases (n
21).5) 277 (97. patients were treated by the same surgeon. however.
Preoperatively. 19 to 40 months). No patient had undergone previous lower eyelid surgery.8)† — 276 (96. an intraoperative dissection of the medial side should be minimized. leaving a 3. 1).5) 276 (96.5)
Table 1. 2. pretarsal flattening. 1.5) 276 (96.8)† 8 (2. †All of the results of medical students were included in those of plastic surgeons.5)* 10 (3. To compare shape changes of lower eyelid objectively. Increased
Plastic Surgeons (%) – 10 (3. On preoperative evaluation.1) 13 (4.7:1. Vertical nerve branches are seen. the male-to-female ratio was 1. contralateral side by three plastic surgeons not involved in patient care and by six medical students unaware of surgical information.5) 9 (3. 286 patients treated at the plastic surgery department of our hospital with denervation of the zygomatic branch during subciliary incision using a skin-muscle flap for pure unilateral blowout fractures were enrolled in the present study. Furthermore.5) 278 (97.2) 278 (97. patients gave written consent. normal and operated sides were compared after surgery. and all patients completed prescribed follow-up procedures. Comparisons of the Results Obtained Using Normal Sides as Controls (n
Medical Students (%) – Perceptible scar Pretarsal flattening Lower eyelid malpositions (scleral show or ectropion) Laxity alteration 10 (3. The subciliary incision line should not pass the punctum on the medial side. In the present study. when all of the patient data were available. an accurate assessment of the laxity on the fractured side was difficult. Reviewers were asked to compare perceptible scar.
right) Postoperative image at 35 months of a 70-year-old man who underwent left orbital wall reconstruction by means of a skin-muscle flap. Comparisons of photographs were performed by three plastic surgeons (who were unaware of surgical information) and six medical students. who determined that 10 patients were unsatisfied
. left) Postoperative image at 37 months of a 45-year-old man who underwent left orbital wall reconstruction by means of a skin-muscle flap. right) Postoperative image at 33 months of a 36-year-old man who underwent left orbital wall reconstruction by means of a skin-muscle flap. (Center. 3. flattening of the lower eyelid pretarsal area. (Above. (Below) Postoperative image at 35 months of a 25-year-old man who underwent right orbital wall reconstruction by skin-muscle flap. but pretarsal muscle roll is preserved.
laxity was found in 13 cases (4. Mild ectropion is noted on the left lower eyelid. The pretarsal muscle roll is preserved and no scar is visible. The contour change is noted slightly. Data on scars were collected by medical students. left) Postoperative image at 38 months of a 30-year-old man who underwent left orbital wall reconstruction by means of a skin-muscle flap. Number 5 • Complications after Lower Eyelid Surgery
Fig. A slight crease is noted on the left lower eyelid but pretarsal muscle roll is preserved. (Above. who assessed the
following: perceptible scar.5 percent). and lower eyelid malposition. but no ectropion or pretarsal muscle roll change is seen.Volume 125. There is no ectropion or visible scar. (Center.
However. Furthermore. Schematic image of periorbital nerve innervations.5 in 1967. In 2005. Meanwhile. and Beare. which continues to be widely used for lower eyelid surgery.26 (that a myoneurectomy of orbicularis oculi muscle was performed for the treatment of benign essential blepharospasm) and by Lowry et al. which has encouraged others to try alternative approaches. and by three plastic surgeons (blinded to the surgery type). A transconjunctival approach is useful for avoiding orbital septum injury (which is a causative factor of lid retraction) and also for avoiding zygomatic branch injury.1 percent) by plastic surgeons (Table 1 and Figs. Carraway and Mellow7. the skin-muscle flap by means of the subciliary approach has been shown to have several attendant problems. and damage to this nerve has been associated with lower eyelid surgical approaches used to manage trauma or in aesthetic surgery.Plastic and Reconstructive Surgery • May 2010
(3.11.4. This method was based on the belief that the pathway of the zygomatic branch initiates from the lateral side and that it then runs to the orbicularis oculi. 4. DiFrancesco et al.29 (Fig.12 undertook a study on the effect of denervation of the orbicularis oculi muscle on lower eyelid shape using the subciliary approach and a skin-muscle flap. in 1995. Zygomatic branches form fascicles by means of positioning underneath the orbicularis oculi muscle and are segmentally innervated nearly vertical to muscle. other studies have concluded that damage of the zygomatic branch of the facial nerve is a crucial etiologic factor for sclera show. Nevertheless. In contrast.25 compared preoperative and postoperative pretarsal electromyographic findings after lower blepharoplasty using a conventional subciliary incision. Netscher et al.14 –16 In 1990.27 They concluded that complications after lower blepharoplasty cannot be explained by denervation of the zygomatic branch. The zygomatic branch of the facial nerve is a motor branch that innervates the orbicularis oculi muscle. recently published authoritative anatomical studies have revealed that the zygomatic branches form fascicles by means of positioning underneath the subciliary orbicularis oculi muscle and segmentally innervating nearly vertical to muscle. As a result. Lower eyelid malposition (scleral show or ectropion) was also observed in eight cases (2. and deep dissection from the lateral side is known to be unnecessary. Because the medial side of the nerve fascicle is composed mainly of zygomatic branches and buccal branches. Moreover.5 percent) as well. ectropion.17 recommended that a deep dissection be made to muscles on the lateral side of the lower eyelid area to prevent denervation of the orbicularis oculi muscle during skin-muscle flap surgical management. and found no significant difference between the two when the transconjunctival and subciliary approaches were used on right and left sides. described the skin-muscle flap and the subciliary approach. the pathway of the zygomatic branch has been clarified. and pretarsal flattening caused by loss of muscle tone of the lower eyelid. Wray et al.8 percent) by medical students and nine cases (3.
.5 percent).11. However. 2 and 3). who reported perceptible scars in the same 10 cases (3. and the lateral side
Transcutaneous blepharoplasty using a skin flap was first described by Castanares13 in 1951.1 reported that the subciliary approach causes a higher incidence of adverse effects than other surgical approaches.5 percent) by the plastic surgeons on operated sides compared with normal sides. Lower eyelid pretarsal flattening was reported in eight cases (2. 4). since then. these authors cited the reports by McCord et al.28. and revealed no existence of functionally dominant branches24. it remains to be determined whether the zygomatic branch of the facial nerve is involved in lower eyelid changes.8 percent) by medical students and in 10 cases (3. The medial side nerve fascicles are composed mainly of zygomatic branches and buccal branches. the transconjunctival approach is now considered an acceptable alternative to the subciliary approach and has been the subject of several studies.14. respectively.17–24
conservation of the buccal branch forming the plexus on the medial side should be given more priority. there were no changes in the lower eyelid shape (Fig. skin-muscle flaps were performed using a subciliary approach to treat unilateral blowout fractures.Volume 125. Lower eyelid shape changes in patients with zygomatic branch denervation were confirmed by comparing lower eyelids on operated and normal sides.
nerve fascicle is innervated mainly from the zygomatic branches. Accordingly. when surgery was performed using a skin-muscle flap with a subciliary approach. Number 5 • Complications after Lower Eyelid Surgery
Fig. The degree of asymmetry or malposition of the pretarsal area that can be present before the onset of injury (unilateral blowout fracture) was used for comparison of the
. preservation of the medial segment branch is important for innervation of the orbicularis oculi muscle. In those cases in which a follow-up observation was available after postoperative month 28. This can also be confirmed by functional impairment of the lower eyelid seen in cases in which the medial side fascicle was damaged during Mohs’ surgery or dacryocystorhinostomy because it was medially restricted. (Right) Postoperative long-term follow-up images. (Left) Preoperative images at 5 to 7 days after trauma. 5.
In the present study. 3). as described above.
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