Volume 136, Number 1 • Letters Correspondence to Dr. Persing Yale Plastic Surgery Yale University School of Medicine 330 Cedar Street, 3rd Floor New Haven, Conn. 06520 [email protected]
disclosure The authors have no financial interest to declare in relation to the content of this communication. references 1. Hashim P, Patel A, Yang J, et al. The effects of whole-vault cranioplasty versus strip craniectomy on long-term neuropsychological outcomes in sagittal craniosynostosis. Plast Reconstr Surg. 2014;134:491–501. 2. Patel A, Hashim P, Yang J, et al. The impact of age at surgery on long-term neuropsychological outcomes in sagittal craniosynostosis. Plast Reconstr Surg. 2014;134:608e–617e. 3. Persing JA, Babler WJ, Nagorsky MJ, Edgerton MT, Jane JA. Skull expansion in experimental craniosynostosis. Plast Reconstr Surg. 1986;78:594–603. 4. Tuggle CT, Patel A, Broer N, Clune JE, Sosa JA, Persing JA: Craniosynostosis: Population-level predictors of surgical technique in 1,680 patients. Paper presented at: 14th International Society of Craniofacial Surgery Biennial Congress; August 28–September 1, 2011; Livingstone, Zambia. 5. Leppänen PH, Hämäläinen JA, Guttorm TK, et al. Infant brain responses associated with reading-related skills before school and at school age. Neurophysiol Clin. 2012;42:35–41. 6. Leppänen PH, Hämäläinen JA, Salminen HK, et al. Newborn brain event-related potentials revealing atypical processing of sound frequency and the subsequent association with later literacy skills in children with familial dyslexia. Cortex 2010;46:1362–1376. 7. Hashim PH, Brooks D, Persing JA, et al. Direct brain recordings reveal impaired neural function in infants with singlesuture craniosynostosis: A future modality for guiding management? J Craniofac Surg. 2015;26:60–63.
Modified Transconjunctival Lower Lid Approach for Orbital Fractures in East Asian Patients: The Lateral Paracanthal Incision Revisited Sir:
W
e have read the article “Modified Transconjunctival Lower Lid Approach for Orbital Fractures in East Asian Patients: The Lateral Paracanthal Incision Revisited” by Song et al.1 Because we have published similar results of our own,2 we read the article with great interest and congratulate the authors on their efforts. We share views similar to those of Song et al. but would like to address our method of “modified lateral canthal incision” published in 2009. This modified method provides less conspicuous scars and canthal distortion compared with the classic lateral canthotomy.3,4 Our modified canthal incision starts 2 to 3 mm medial to the canthal angle (Fig. 1). The full-thickness lower eyelid, involving the tarsal plate, is incised with scissors vertically at a right angle to the lateral canthus.
Fig. 1. Modified lateral canthal incision design.
This incision is then extended laterally parallel to the natural skin crease. The difference between our method and the lateral paracanthal incision made by Song et al. is that our incision is made at a right angle to the lateral canthus and an extended skin incision is made parallel to the natural skin crease. This incision does not disrupt the canthal angle and its attachment to the orbit, and results in less morbidity and in better cosmetic outcomes. This L-shaped incision facilitates anatomical repair of the lid because of easy identification of the gray line, which serves as an important landmark. With this method, we were able to avoid significant lid malpositioning, the most concerning complication of lateral canthotomy. The senior author (D.W.K.) of our own series is still performing orbital operations through the transconjunctival approach with or without modified extensions to the lateral canthus, and until now has not experienced any functional or cosmetic complications. DOI: 10.1097/PRS.0000000000001336
Na-Hyun Hwang, M.D. Deok-Woo Kim, M.D., Ph.D. Department of Plastic and Reconstructive Surgery Ansan Hospital Korea University Medical Center Gyeonggi-do, Republic of Korea Correspondence to Dr. Kim Department of Plastic and Reconstructive Surgery Ansan Hospital Korea University Medical Center 123, Jeokgeum-ro, Danwon-gu Ansan-si, Gyeonggi-do 425-707, Republic of Korea [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.
117e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • July 2015 REFERENCES 1. Song J, Lee GK, Kwon ST, Kim SW, Jeong EC. Modified transconjunctival lower lid approach for orbital fractures in East Asian patients: The lateral paracanthal incision revisited. Plast Reconstr Surg. 2014;134:1023–1030. 2. Kim DW, Choi SR, Park SH, Koo SH. Versatile use of extended transconjunctival approach for orbital reconstruction. Ann Plast Surg. 2009;62:374–380. 3. Suga H, Sugawara Y, Uda H, et al. The transconjunctival approach for orbital bony surgery: In which cases should it be used? J Craniofac Surg. 2004;15:454–457 4. Yoon ES, Koo SH, Park SH, et al. Lateral paracanthal transconjunctival incision for orbital fractures. J Korean Soc Plast Reconstr Surg. 1998;25:411–418.
Reply: Modified Transconjunctival Lower Lid Approach for Orbital Fractures in East Asian Patients: The Lateral Paracanthal Incision Revisited Sir:
We appreciate Dr. Kim’s great interest and thoughtful comments on our article. Regarding his use of a paracanthal incision in orbital surgery, we generally agree with his concept of modified lateral canthal incision, published in 2009.1 Our techniques are further refinements and modifications of transconjuctival approaches, and we believe that they are also sufficient to trigger interest in readers who are searching for information regarding lateral cantholysis, a common procedure used in orbital surgery, including repair of orbital trauma. Sharing the knowledge is fundamental for the improvement of the previous idea. Our modifications were developed from comprehensive knowledge gathered from other articles and our own efforts to minimize adverse effects.2,3 The tarsal plate was a better anatomical landmark for repair rather than the delicate fascial structure of the lateral canthal tendon,4 and the overall results of the transconjuctival paracanthal incision were satisfactory in every case to both patients and surgeons; however, there are some technical pitfalls for those attempting to use this approach for the first time. First, the location of the paracanthal incision is important. The amount of remaining lateral portion of tarsus should be sufficient to be reapproximated later. Observing the tarsus from the conjuctival side with eversion of the lower eyelid is helpful in marking the point of transection of the tarsus.4 Second, the paracanthal incision line should be closed layer by layer and the repaired wound unexposed during wound healing. Postoperatively, ophthalmic solutions are commonly used for approximately 1 week. When applying eyedrops, the patients touch the eyelids to drop the solution into the eye, a maneuver that can expose the repaired paracanthal area. I recently added temporary tarsorrhapy between the lateral limbus of the pupil and lateral canthus for 1 week to keep the repaired wounds safe and at the same time allow space for vision.5 The scar is quite unnoticeable and lid deformity is rare, even on close examination after several months.
Consequently, I believe that the paracanthal incision is very useful, especially in patients who abhor external scars. DOI: 10.1097/PRS.0000000000001340
Euicheol C. Jeong, M.D., Ph.D. Jihyeon Han, M.D. Department of Plastic Surgery SMG-SNU Boramae Medical Center affiliated to Department of Plastic and Reconstructive Surgery Seoul National University College of Medicine Seoul, Republic of Korea Correspondence to Dr. Jeong Department of Plastic Surgery SMG-SNU Boramae Medical Center 20 Boramae-ro 5-gil, Dongjak-gu Seoul 156-707, Republic of Korea [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Kim DW, Choi SR, Park SH, Koo SH. Versatile use of extended transconjunctival approach for orbital reconstruction. Ann Plast Surg. 2009;62:374–380. 2. Ridgway EB, Chen C, Colakoglu S, Gautam S, Lee BT. The incidence of lower eyelid malposition after facial fracture repair: A retrospective study and meta-analysis comparing subtarsal, subciliary, and transconjunctival incisions. Plast Reconstr Surg. 2009;124:1578–1586. 3. de Chalain TM, Cohen SR, Burstein FD. Modification of the transconjunctival lower lid approach to the orbital floor: Lateral paracanthal incision. Plast Reconstr Surg. 1994;94:877–880. 4. Song J, Lee GK, Kwon ST, Kim SW, Jeong EC. Modified transconjunctival lower lid approach for orbital fractures in East Asian patients: The lateral paracanthal incision revisited. Plast Reconstr Surg. 2014;134:1023–1030. 5. Hidalgo DA. An integrated approach to lower blepharoplasty. Plast Reconstr Surg. 2011;127:386–395.
Evidence-Based Medicine: Unilateral Cleft Lip and Nose Repair Sir:
W
e read with great interest the article by Dr. Greives et al.1 entitled “Evidence-Based Medicine: Unilateral Cleft Lip and Nose Repair.” We would like to acknowledge the authors for sharing with us this very comprehensive analysis, performed to provide us with a practice-based assessment of preoperative evaluation, anesthesia, surgical treatment plan, perioperative management, and outcomes. Moreover, the different techniques used for cheiloplasty and nasal repair are critically discussed, giving us a complete overview and providing us with exceptional consultation material for decision-making.
118e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
disclosure The authors have no financial interest to declare in relation to the content of this communication. references 1. Hashim P, Patel A, Yang J, et al. The effects of whole-vault cranioplasty versus strip craniectomy on long-term neuropsychological outcomes in sagittal craniosynostosis. Plast Reconstr Surg. 2014;134:491–501. 2. Patel A, Hashim P, Yang J, et al. The impact of age at surgery on long-term neuropsychological outcomes in sagittal craniosynostosis. Plast Reconstr Surg. 2014;134:608e–617e. 3. Persing JA, Babler WJ, Nagorsky MJ, Edgerton MT, Jane JA. Skull expansion in experimental craniosynostosis. Plast Reconstr Surg. 1986;78:594–603. 4. Tuggle CT, Patel A, Broer N, Clune JE, Sosa JA, Persing JA: Craniosynostosis: Population-level predictors of surgical technique in 1,680 patients. Paper presented at: 14th International Society of Craniofacial Surgery Biennial Congress; August 28–September 1, 2011; Livingstone, Zambia. 5. Leppänen PH, Hämäläinen JA, Guttorm TK, et al. Infant brain responses associated with reading-related skills before school and at school age. Neurophysiol Clin. 2012;42:35–41. 6. Leppänen PH, Hämäläinen JA, Salminen HK, et al. Newborn brain event-related potentials revealing atypical processing of sound frequency and the subsequent association with later literacy skills in children with familial dyslexia. Cortex 2010;46:1362–1376. 7. Hashim PH, Brooks D, Persing JA, et al. Direct brain recordings reveal impaired neural function in infants with singlesuture craniosynostosis: A future modality for guiding management? J Craniofac Surg. 2015;26:60–63.
Modified Transconjunctival Lower Lid Approach for Orbital Fractures in East Asian Patients: The Lateral Paracanthal Incision Revisited Sir:
W
e have read the article “Modified Transconjunctival Lower Lid Approach for Orbital Fractures in East Asian Patients: The Lateral Paracanthal Incision Revisited” by Song et al.1 Because we have published similar results of our own,2 we read the article with great interest and congratulate the authors on their efforts. We share views similar to those of Song et al. but would like to address our method of “modified lateral canthal incision” published in 2009. This modified method provides less conspicuous scars and canthal distortion compared with the classic lateral canthotomy.3,4 Our modified canthal incision starts 2 to 3 mm medial to the canthal angle (Fig. 1). The full-thickness lower eyelid, involving the tarsal plate, is incised with scissors vertically at a right angle to the lateral canthus.
Fig. 1. Modified lateral canthal incision design.
This incision is then extended laterally parallel to the natural skin crease. The difference between our method and the lateral paracanthal incision made by Song et al. is that our incision is made at a right angle to the lateral canthus and an extended skin incision is made parallel to the natural skin crease. This incision does not disrupt the canthal angle and its attachment to the orbit, and results in less morbidity and in better cosmetic outcomes. This L-shaped incision facilitates anatomical repair of the lid because of easy identification of the gray line, which serves as an important landmark. With this method, we were able to avoid significant lid malpositioning, the most concerning complication of lateral canthotomy. The senior author (D.W.K.) of our own series is still performing orbital operations through the transconjunctival approach with or without modified extensions to the lateral canthus, and until now has not experienced any functional or cosmetic complications. DOI: 10.1097/PRS.0000000000001336
Na-Hyun Hwang, M.D. Deok-Woo Kim, M.D., Ph.D. Department of Plastic and Reconstructive Surgery Ansan Hospital Korea University Medical Center Gyeonggi-do, Republic of Korea Correspondence to Dr. Kim Department of Plastic and Reconstructive Surgery Ansan Hospital Korea University Medical Center 123, Jeokgeum-ro, Danwon-gu Ansan-si, Gyeonggi-do 425-707, Republic of Korea [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.
117e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • July 2015 REFERENCES 1. Song J, Lee GK, Kwon ST, Kim SW, Jeong EC. Modified transconjunctival lower lid approach for orbital fractures in East Asian patients: The lateral paracanthal incision revisited. Plast Reconstr Surg. 2014;134:1023–1030. 2. Kim DW, Choi SR, Park SH, Koo SH. Versatile use of extended transconjunctival approach for orbital reconstruction. Ann Plast Surg. 2009;62:374–380. 3. Suga H, Sugawara Y, Uda H, et al. The transconjunctival approach for orbital bony surgery: In which cases should it be used? J Craniofac Surg. 2004;15:454–457 4. Yoon ES, Koo SH, Park SH, et al. Lateral paracanthal transconjunctival incision for orbital fractures. J Korean Soc Plast Reconstr Surg. 1998;25:411–418.
Reply: Modified Transconjunctival Lower Lid Approach for Orbital Fractures in East Asian Patients: The Lateral Paracanthal Incision Revisited Sir:
We appreciate Dr. Kim’s great interest and thoughtful comments on our article. Regarding his use of a paracanthal incision in orbital surgery, we generally agree with his concept of modified lateral canthal incision, published in 2009.1 Our techniques are further refinements and modifications of transconjuctival approaches, and we believe that they are also sufficient to trigger interest in readers who are searching for information regarding lateral cantholysis, a common procedure used in orbital surgery, including repair of orbital trauma. Sharing the knowledge is fundamental for the improvement of the previous idea. Our modifications were developed from comprehensive knowledge gathered from other articles and our own efforts to minimize adverse effects.2,3 The tarsal plate was a better anatomical landmark for repair rather than the delicate fascial structure of the lateral canthal tendon,4 and the overall results of the transconjuctival paracanthal incision were satisfactory in every case to both patients and surgeons; however, there are some technical pitfalls for those attempting to use this approach for the first time. First, the location of the paracanthal incision is important. The amount of remaining lateral portion of tarsus should be sufficient to be reapproximated later. Observing the tarsus from the conjuctival side with eversion of the lower eyelid is helpful in marking the point of transection of the tarsus.4 Second, the paracanthal incision line should be closed layer by layer and the repaired wound unexposed during wound healing. Postoperatively, ophthalmic solutions are commonly used for approximately 1 week. When applying eyedrops, the patients touch the eyelids to drop the solution into the eye, a maneuver that can expose the repaired paracanthal area. I recently added temporary tarsorrhapy between the lateral limbus of the pupil and lateral canthus for 1 week to keep the repaired wounds safe and at the same time allow space for vision.5 The scar is quite unnoticeable and lid deformity is rare, even on close examination after several months.
Consequently, I believe that the paracanthal incision is very useful, especially in patients who abhor external scars. DOI: 10.1097/PRS.0000000000001340
Euicheol C. Jeong, M.D., Ph.D. Jihyeon Han, M.D. Department of Plastic Surgery SMG-SNU Boramae Medical Center affiliated to Department of Plastic and Reconstructive Surgery Seoul National University College of Medicine Seoul, Republic of Korea Correspondence to Dr. Jeong Department of Plastic Surgery SMG-SNU Boramae Medical Center 20 Boramae-ro 5-gil, Dongjak-gu Seoul 156-707, Republic of Korea [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Kim DW, Choi SR, Park SH, Koo SH. Versatile use of extended transconjunctival approach for orbital reconstruction. Ann Plast Surg. 2009;62:374–380. 2. Ridgway EB, Chen C, Colakoglu S, Gautam S, Lee BT. The incidence of lower eyelid malposition after facial fracture repair: A retrospective study and meta-analysis comparing subtarsal, subciliary, and transconjunctival incisions. Plast Reconstr Surg. 2009;124:1578–1586. 3. de Chalain TM, Cohen SR, Burstein FD. Modification of the transconjunctival lower lid approach to the orbital floor: Lateral paracanthal incision. Plast Reconstr Surg. 1994;94:877–880. 4. Song J, Lee GK, Kwon ST, Kim SW, Jeong EC. Modified transconjunctival lower lid approach for orbital fractures in East Asian patients: The lateral paracanthal incision revisited. Plast Reconstr Surg. 2014;134:1023–1030. 5. Hidalgo DA. An integrated approach to lower blepharoplasty. Plast Reconstr Surg. 2011;127:386–395.
Evidence-Based Medicine: Unilateral Cleft Lip and Nose Repair Sir:
W
e read with great interest the article by Dr. Greives et al.1 entitled “Evidence-Based Medicine: Unilateral Cleft Lip and Nose Repair.” We would like to acknowledge the authors for sharing with us this very comprehensive analysis, performed to provide us with a practice-based assessment of preoperative evaluation, anesthesia, surgical treatment plan, perioperative management, and outcomes. Moreover, the different techniques used for cheiloplasty and nasal repair are critically discussed, giving us a complete overview and providing us with exceptional consultation material for decision-making.
118e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
