PEDIATRIC/CRANIOFACIAL Modified Transconjunctival Lower Lid Approach for Orbital Fractures in East Asian Patients: The Lateral Paracanthal Incision Revisited Jeonghoon Song, Gordon K. Lee, Sung Tack Kwon, Suk Wha Kim, Eui Cheol Jeong,
M.D. M.D. M.D. M.D. M.D.
Seoul and Iksan, Republic of Korea; and Palo Alto, Calif.
Background: Optimal repair of an orbital fracture requires adequate exposure into the orbit. The transconjunctival approach with lateral canthotomy is a valid option in East Asian patients, who are especially sensitive to the appearance of an external skin scar, although one must also recognize the potential complications associated with eyelid aperture mechanics. The authors report the modification of the transconjunctival approach, in which a lateral paracanthal incision is made along with division of the lateral tarsal plate but not at the lateral canthus. This was developed to overcome the complications of traditional lateral cantholysis. Methods: A retrospective chart review was performed for all patients who had received the modified transconjunctival incision. Patient demographics, injury characteristics, and surgical outcomes were evaluated. Results: The baseline demographics of 30 patients in this study was typical of orbital fractures in the Korean population. A take-back operation was required in one case of preseptal hematoma. The mean follow-up period was 6 months, and no long-term functional complications were identified. Of the 30 total patients, 29 showed excellent aesthetic outcome. One patient did present with postoperative notch deformity but did not feel the need for a revision operation. Conclusions: The transconjunctival approach with a lateral paracanthal incision is an alternative approach to the orbital wall. The decoupling of the lower eyelid through the lateral portion of the tarsal plate provides excellent exposure of the orbital floor and provides a reliable and consistent landmark by which the anatomy of the eyelid can be restored. The aesthetic and functional outcomes are excellent. (Plast. R econstr. Surg. 134: 1023, 2014.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
I
n the surgical management of orbital fractures, the foremost determinant of success is the choice of access. Theoretically, the ideal
From the Department of Plastic Surgery, Seoul Metropolitan Government–Seoul National University Boramae Medical Center and Department of Plastic and Reconstructive Surgery, College of Medicine, Seoul National University; the Department of Plastic and Reconstructive Surgery, School of Medicine, Wonkwang University; and the Division of Plastic and Reconstructive Surgery, Stanford University Medical Center. Received for publication October 6, 2013; accepted April 17, 2014. Poster presented at Plastic Surgery The Meeting: 82nd Annual Meeting of the American Society of Plastic Surgeons, in San Diego, California, October 11 through 15, 2013. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000639
approach into the orbit has two main goals: to provide adequate operative exposure and to minimize functional and aesthetic complications.1 In practice, these two goals are often at odds with each other because, all things being considered, larger exposures lead to larger scars. The larger scars, in turn, lead to a higher likelihood of functional and aesthetic complications. This is especially a concern among East Asian patients, who have a higher tendency to develop hypertrophic scars. Among various methods of orbital access, the main advantage of the transconjunctival incision Disclosure: The authors have no financial interest to declare in relation to the content of this article.
www.PRSJournal.com
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Plastic and Reconstructive Surgery • November 2014 is that it leads to minimal scar formation. When compared with transcutaneous approaches such as subciliary and subtarsal access, however, exposure gained by means of transconjunctival incisions is limited and often inadequate.1,2 Previously, the limitation of this exposure was overcome by adding a lateral canthotomy, also referred to as a “swinging lower eyelid flap.”3 Unfortunately, the violation of lateral canthal anatomy defeats the very goal of minimizing morbidities associated with orbital access and, consequently, the original intent behind the design of the transconjunctival incision. To avoid the complications associated with lateral canthotomy, the authors have devised a modification to the swinging lower eyelid flap, in which the main incision is extended with a lateral paracanthal incision. The authors present the experience of refining this procedure previously introduced by de Chalain et al.4
PATIENTS AND METHODS A retrospective chart review was performed. The inclusion criteria were all patients who presented with periorbital fractures between January of 2011 and December of 2012. The operative indications included extensive fracture, muscle impingement, and/or enophthalmos.2,5 Depending on the fracture to be reduced, the orbital wall was reconstructed with alloplastic materials such as polylactide copolymer plates, porous polyethylene sheets, or preformed titanium implants. More complex fractures involving the medial orbital wall, zygoma, and/or maxilla were treated by means of additional incisions such as transcaruncular, lateral eyebrow, and upper gingivobuccal incisions. Patient demographics and injury characteristics were noted and tabulated (Table 1). Aesthetic and functional outcomes, such as lower eyelid malposition or visible scar formation, were assessed from postoperative clinic records at follow-up visits. All clinic visit photographs were taken in a standardized manner with a digital camera (EOS 350D; Canon, Tokyo, Japan) with indirect lighting at a distance of 50 cm. Before processing, the images were cropped to include the eyebrow to the lower eyelid and the lateral canthi bilaterally. The scar, webbing, ectropion, entropion, and scleral show were evaluated objectively and subjectively.6 Photographs taken at the 6-month postoperative visit were offered to two physicians for objective grading of the scar. Because all cases underwent surgery on only one side, some images were processed with a horizontal flip effect so that evaluators would see them
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Table 1. Patient Demographics Characteristic
Value
No. of patients 30 Men 21 Women 9 Age, yr Mean 38.6 Range 18–64 Follow-up period, mo Mean 6 Range 2–13 Cause, no. of patients Altercation 13 (all men) Fall 13 (6 men, 7 women) Traffic accident 3 (2 men, 1 woman) Enophthalmos deformity (zygoma malunion) 1 (1 woman) Repaired site of orbit, no. of patients Right orbit floor 15 Left orbit floor 15 Concomitant fracture, no. of patients Nasal bone fracture 7 Zygomatic fracture (ipsilateral) 7 Medial orbit wall fracture (ipsilateral) 3 Frontal sinus fracture 1
as belonging to the right side. Presenting photographs in this way allows for standardization. Each photograph was evaluated as 0 for an invisible scar, 1 for a minimally visible scar, 2 for a moderately visible scar, and 3 for a very visible scar. Patients were solicited for subjective assessment of scar visibility using the same grading scale. Functional outcomes were also evaluated by these two physicians. The 18 patients were included in this evaluation because the others were not followed up exactly at 6 months postoperatively. The data among evaluators were analyzed using the kappa statistic for measurement of interrater agreement. All statistical operations were calculated using IBM SPSS Version 19.0 for Windows (IBM Corp., Armonk, N.Y.). Surgical Technique The standard surgical preparation includes globe lubrication with topical saline irrigation and use of a corneal shield. The paracanthal incision is designed by marking its origin along the gray line, approximately 3 mm medial from the lateral canthus. From this point, a line is drawn perpendicularly to the tangent of the gray line, past the eyelashes (approximately 3 mm away from gray line). The design is extended obliquely in the inferolateral direction by approximately 5 to 8 mm, along an appropriately chosen minor skin crease (Fig.1, above, left). The handle of an empty scalpel holder can be placed on the tarsal plate next to the paracanthal
Volume 134, Number 5 • Lateral Paracanthal Incision
Fig. 1. (Above, left) Lateral paracanthal incision design in comparison with the traditional canthotomy incision. (Above, right) Paracanthal incision with scalpel. (Below, left) Transconjunctival incision extended from the severed tarsal plate. (Below, right) Closed wounds.
design to provide traction (Fig.1, above, right). The incision is made through the skin and full thickness of the eyelid, including the tarsal plate. The transconjunctival incision is then extended medially toward the punctum along the inferior margin of the tarsal plate. The resulting conjunctival flap is stretched superiorly to cover and protect the cornea for the remainder of the operation. The lower lid can readily be distracted, or “swung,” away from the globe without the need for excessive tension. The inferior orbital rim and floor are accessed by dissecting through the submuscular plane (Fig.1, below, left). With satisfactory reduction of orbital fracture(s), the incision is closed by meticulous apposition of the divided structures. Most notably, the tarsal plate and gray line are used as focal loci of approximation to restore the anatomy of lower eyelid. The tarsal plate is repaired with simple 6-0 Vicryl (Ethicon, Inc., Somerville, N.J.) sutures with the knot buried. The conjunctiva is closed with 7-0 Vicryl and the skin is repaired with 6-0 silk (Fig.1, below, right).
RESULTS A total of 30 patients (21 men and nine women) were identified in the study period. The mean age of the patients was 38.6 years (range, 18 to 64 years). The mean follow-up period was 6 months (range, 2 to 13 months). According to the inclusion criteria, all of the patients had a unilateral orbital floor fracture with proper indications for an operative intervention. Along with floor fractures, there were three patients with associated medial wall fractures, seven patients with zygomaticomaxillary fractures, and a single patient with a delayed presentation of enophthalmic deformity because of zygomatic malunion (Table 1). The modified transconjunctival lower lid approach was used to access the orbital floor. Fractures of the medial orbital wall, zygoma, and maxilla required transcaruncular, lateral eyebrow, and upper gingivobuccal incisions, respectively. All of the operations had been performed by a single surgeon (E.C.J.). In the evaluated group of patients (n = 18), no ectropion, entropion, webbing, or lid malposition
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Plastic and Reconstructive Surgery • November 2014 was observed. The physicians’ average scar grade of both physicians was 0.6 and the patientreported scar grade was lower at 0.2. No physicians or patients reported the scar to be grade 3 (Table 1). In terms of agreement among multiple raters, the kappa statistic showed a significant result (κ = 0.432, p < 0.001). Interestingly, whereas two physicians showed high agreement (κ = 0.708, p < 0.001), the agreement between patient and each of the physicians was low (κ = 0.349, p = 0.060 for physician 1 and patient; and κ = 0.259, p = 0.139 for physician 2 and patient). The physician evaluation yielded a somewhat higher incidence of visible incisions than patient perception. Actually, one patient did have a notch deformity at the site of the paracanthal incision and was given the option for revision surgery. However, the patient was satisfied with the overall outcome of the operation and gave the scar a grade of 1 (minimally visible). The patient elected to forgo further surgery. In the review of follow-up reports, the others also had no long-term functional complications
(e.g., webbing, ectropion, entropion, and scleral show) and were aesthetically pleased with the postoperative outcomes. One of them, with chronic liver cirrhosis, developed a preseptal hematoma and required a secondary operation. The source of bleeding was identified in a small branch of the marginal arcade along the tarsal plate and was easily controlled with electrocautery.
CASE REPORTS Case 1 A 46-year-old man presented with painful right periorbital swelling and epistaxis after an altercation. Clinical examination revealed subcutaneous emphysema and diplopia on upward and neutral gaze (Fig. 2, above, left). The suspicion of blowout fracture was confirmed on computed tomographic imaging, which identified medial wall and floor lesions (Fig. 2, below, left). A prophylactic antibiotic was administered, and the reconstruction was commenced 5 days after injury. The orbital floor was accessed by means of the modified transconjunctival lower lid approach with a transcaruncular extension for access to the medial wall. The orbital wall was reconstructed with a preformed titanium implant (MatrixMIDFACE Orbital Plate; Synthes GMBH, Switzerland).
Fig. 2. Case 1. A 46-year-old man was diagnosed with a blowout fracture of the right orbit floor and medial orbital wall, and nasal bone fractures. (Above, left) Preoperative and (above, right) postoperative photographs. (Below, left) Preoperative axial computed tomographic scan. (Below, right) Postoperative axial computed tomographic scan showing reconstruction with preformed titanium implant.
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Volume 134, Number 5 • Lateral Paracanthal Incision Postoperative computed tomographic imaging demonstrated adequate reduction of soft tissues, with anatomical restoration of the medial wall (Fig. 2, below, right). The diplopia gradually improved and resolved completely by postoperative day 14. The postoperative scar from the paracanthal incision was inconspicuous, and no functional morbidities were observed (Fig. 2, above, right).
Case 2 A 47-year-old woman with a history of a right facial injury presented to the outpatient clinic with the complaint of “small right eye” (Fig. 3, above, left). The injury had occurred several years previously while the patient had been abroad, and at that time, she had been informed of a bony fracture but did not elect to undergo reconstruction. On examination, no limitations were found in ocular motion. Hertel exophthalmometry showed an anterior corneocanthal displacement of 14 mm on the right and 16 mm on the left, with an interlateral canthal base of 93 mm. Computed tomographic imaging revealed a zygomatic malunion with an old blowout fracture involving the medial wall and floor of the right orbit (Fig. 3, below, left). The patient readily consented to an elective operation to correct the asymmetry. The modified transconjunctival lower lid approach was used, along with transcaruncular extension for medial wall exposure. The orbital wall was reconstructed with porous polyethylene sheets (SYNPOR; Synthes GMBH, Switzerland). Postoperatively, computed tomographic imaging revealed anatomical repositioning of orbital soft tissue (Fig. 3, below, right).
At the postoperative clinic visit at 1 month, Hertel exophthalmometry revealed corneocanthal displacement of 14 and 13.5 mm in the right and left eyes, respectively, with an interlateral canthal base of 91 mm. There was no functional complication from the operation, and the postoperative scar was inconspicuous (Fig. 3, above, right).
DISCUSSION The orbital floor is commonly accessed through transcutaneous incisions. Among these, the subciliary approach, also called the lower blepharoplasty incision, is often quite popular. The incision provides a decent exposure to the inferior rim and floor, with less postoperative edema and scar formation compared with other forms of the transcutaneous approach. However, this approach suffers from notable rates of lid retraction (9.7 to 19.1 percent).1,7 The transconjunctival incision is made through the conjunctiva of the inferior fornix, from the caruncle medially to the lateral fornix. It was first described in 1924 by Bourquet for aesthetic blepharoplasty.8 Tessier introduced the transconjunctival approach for orbital bone
Fig. 3. Case 2. A 47-year-old woman was diagnosed with a malunion of the zygoma with unrepaired right medial orbital wall and floor. (Above, left) Preoperative and postoperative (above, right) photographs. (Below, left) Preoperative axial computed tomographic scan. (Below, right) Postoperative axial computed tomographic scan showing reconstruction with porous polyethylene sheets.
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Plastic and Reconstructive Surgery • November 2014 Table 2. Self-Reported Scar Grading from Patients during 6-Month Follow-Up Visit*† No. of Patients (n = 18) Grade 0 1 2 3 Average grading score
First Physician Grading
Second Physician Grading
Subjective Patient Grading
9 8 1 0 0.6
9 7 2 0 0.6
14 4 0 0 0.2
*0 = invisible scar, 1 = minimally visible scar, 2 = moderately visible scar, and 3 = very visible scar. †p = 0.289, Fisher’s exact test.
surgery in trauma and congenital cases.9 This approach subsequently became popular in the mid to late 1980s, when the repair of orbitozygomatic fractures by means of a combined transconjunctival–lateral canthotomy approach was first reported.10,11 However, long-term experience with the technique revealed a high incidence of wound complication, scleral show, and/or ectropion, which is likely associated with the initial violation of the canthal tendon and improper repair.12,13 In a retrospective review of 274 orbital wall fractures by Salgarelli et al.,1 subciliary, transconjunctival-only, and transconjunctival with lateral canthotomy approaches were evaluated with respect to aesthetic outcomes and postoperative functional complications. The study demonstrated that the transconjunctival-only approach was associated with the best outcomes, with the subciliary approach perhaps best reserved for those fractures requiring extensive exposure. Lateral canthotomy was associated with the highest rates of functional and aesthetic complications, which nullified the advantages that the transconjunctival approach conferred over the subciliary approach. However, the transconjunctival approach has the benefit of avoiding an external lower eyelid scar. In the East Asian population, postoperative scars are perceived negatively, and this is a significant problem for this patient population, who often develop hypertrophic scars. It is in this context that the transconjunctival approach to lower blepharoplasty has become popular in certain Asian countries in spite of the transcutaneous approaches available. In addition to the issue of postoperative scarring, transconjunctival approaches do not violate the orbicularis oculi muscle, and this is important in preserving the pretarsal fullness of the lower eyelid, which is often considered a physical sign of youth in East Asian aesthetics.14
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In the setting of an orbital fracture, complications of lateral canthotomy arise from improper repair of the lateral canthus. This improper repair, in turn, arises from a combination of two factors. The first factor is the consequence of the injury itself—edema, hematoma, tissue disruption, and presence of a foreign body—which tends to obfuscate recognition of normal anatomy. The second factor is the delicate anatomy of the lateral canthus itself. The fine fascial and retinacular structures of the canthus are intermingled and delicate such that, after a prolonged period of eyelid retraction during operative manipulation, precise repair of the canthus is virtually impossible.15 The main idea of lateral canthotomy in transconjunctival incision is to uncouple the fascial structure between the tarsal plate and the canthi. Lateral canthotomy accomplishes this goal of uncoupling and allows for the resulting lower eyelid flap to swing out of the way. However, severing this fascial connection is associated with the problems mentioned above. Keeping this principle in mind, the authors realized that the mechanical link between the lower eyelid and canthus did not necessarily need to be severed through the delicate fibers. On further contemplation, a paracanthal incision appeared to offer the possibility of a swinging eyelid flap without the complications associated with the improper repair of lateral canthotomy. The paracanthal incision would uncouple the lower eyelid through the tarsus, which would be easier to reapproximate compared with divided canthal fibers. Although there is no removal of tarsus in this modification, the direct approximation of the tarsal plate does not weaken the lower eyelid support, conceptually similar to the modern modified Kuhnt-Szymanowski procedure used for senile ectropion.16 Therefore, this modified canthotomy was conceived with the idea that the uncoupling of the lower eyelid would occur at a paracanthal location and was used in the management of orbital floor fractures at the institution. On further review of the literature, the authors came across an antecedent report by de Chalain et al. that describes a “lateral paracanthal incision” as a modified transconjunctival approach.4 In their article, the eyelid is decoupled by severing the inferior limb of the lateral canthus; however, we had been decoupling the eyelid by the lateralmost division of the tarsal plate, leaving the canthal structures intact. The exposure to the inferior orbital floor was reported to be excellent, but the authors did note two cases of eyelid notching deformities, which were corrected with secondary operations. We believe that the operation we
Volume 134, Number 5 • Lateral Paracanthal Incision devised is an improvement over the one previously described. The outcomes from our review support the merit of our modified transconjunctival lower lid approach for orbital fracture repair. With experience and familiarity with the approach, we have come to understand the advantages of this technique and to execute the operation more precisely. In the report by de Chalain et al.,4 the mechanical component of the lower lid was transected approximately 2 mm from the canthus, and an eyelash or two was kept on the lateral side of the incision to simplify reapproximation at the time of closure. In the paracanthal incision we presented, the lateralmost portion of the tarsus was used as the landmark. The tarsus is easily observed from the conjunctival side with eversion of the lower eyelid. The tarsal transection was designed to create a lateral remnant of tarsus that was as small as possible. Along the remnant tarsus, the lower eyelid margin was marked for cutaneous incision, and this point was often identical to the location described in the publication by de Chalain et al.4 For patients in whom the lateral eyelashes were missing as a result of trauma or aging, using the lateral tarsal margin provided a more reliable landmark in a few cases in our series. Considering the similarities in method and outcomes, it is hard to argue that the technique presented here is a vast improvement over the procedure described by de Chalain et al.4 However, we believe that our technique is a further refinement in the continuum of transconjunctival approaches and that it is a particularly useful approach in the East Asian population for the reasons discussed above. Among the 30 patients in this study, one patient did have a notch deformity at the site of the paracanthal incision. As the deformity was covered by the upper eyelashes and caused no aesthetic issues, the patient did not feel that the secondary operation offered was necessary. In addition, there was the single case of preseptal hematoma in a patient with chronic liver cirrhosis. At the take-back operation, the source of bleeding was identified as a small branch of the marginal arcade along the tarsal plate, which was easily controlled with cauterization. In the antecedent report, the plane of dissection had not been described. In our patients, the dissection was carried out in the preseptal submuscular plane. Our rationale was that a preseptal dissection was likely to be safer than a retroseptal dissection plane of most transconjunctival exposures, as the orbital septum impedes the development of a retrobulbar hematoma, one of the more feared complications
in the management of blowout fractures. Because of this, we were able to easily identify and control the bleeding in the preseptal plane in the single case of postoperative hematoma. This study does support previous findings that the modified transconjunctival approach with lateral paracanthal incision allows adequate exposure of the orbital wall floor. The outcomes are excellent, with no apparent long-term complications, and the postoperative scar is inconspicuous, as the cutaneous portion of the incision amounts to less than 0.5 cm.
SUMMARY The choice of access to the orbit is dictated by the nature of the fracture to be addressed and the anatomy of the eyelid aperture. The access provided by the lateral paracanthal incision avoids the complication of lid malposition associated with cantholysis and provides wide exposure of the orbital floor. Because the lower eyelid is decoupled through the tarsal plate as opposed to through those delicate structures of the lateral canthus, the restoration of eyelid anatomy is simplified. Overall, aesthetic outcomes are excellent, with minimal external scars in East Asian patients. Eui Cheol Jeong, M.D. Department of Plastic Surgery SMG-SNU Boramae Medical Center 5 Gil 20 Boramae-Road Dongjak-Gu, Seoul 156-707, Republic of Korea [email protected]
PATIENT CONSENT
Patients provided written consent for the use of their images. acknowledgments
The authors thank Dr. Aram Harijan for assistance with the English language in this article, Dr. Sohee Oh for the statistical data analysis, and Dr. Jong Ho Kim for the clinical photography. references 1. Salgarelli AC, Bellini P, Landini B, Multinu A, Consolo U. A comparative study of different approaches in the treatment of orbital trauma: An experience based on 274 cases. Oral Maxillofac Surg. 2010;14:23–27. 2. Chen CT, Chen YR. Update on orbital reconstruction. Curr Opin Otolaryngol Head Neck Surg. 2010;18:311–316. 3. McCord CD Jr, Moses JL. Exposure of the inferior orbit with fornix incision and lateral canthotomy. Ophthalmic Surg. 1979;10:53–63.
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Plastic and Reconstructive Surgery • November 2014 4. 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. 5. Hazani R, Yaremchuk MJ. Correction of posttraumatic enophthalmos. Arch Plast Surg. 2012;39:11–17. 6. Raschke GF, Rieger UM, Bader RD, Schaefer O, Guentsch A, Schultze-Mosgau S. Transconjunctival versus subciliary approach for orbital fracture repair: An anthropometric evaluation of 221 cases. Clin Oral Investig. 2013;17:933–942. 7. 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. 8. Bourquet J. Les hernies graisseuses de l’orbite: Notre traitement chirurgical. Bull Acad Med (Paris) 1924;92:1270. 9. Tessier P. The conjunctival approach to the orbital floor and maxilla in congenital malformation and trauma. J Maxillofac Surg. 1973;1:3–8.
10. Converse JM, Firmin F, Wood-Smith D, Friedland JA. The conjunctival approach in orbital fractures. Plast Reconstr Surg. 1973;52:656–657. 11. Nunery WR. Lateral canthal approach to repair of trimalar fractures of the zygoma. Ophthal Plast Reconstr Surg. 1985;1:175–183. 12. Ridgway EB, Chen C, Lee BT. Acquired entropion associated with the transconjunctival incision for facial fracture management. J Craniofac Surg. 2009;20:1412–1415. 13. Westfall CT, Shore JW, Nunery WR, Hawes MJ, Yaremchuk MJ. Operative complications of the transconjunctival inferior fornix approach. Ophthalmology 1991;98:1525–1528. 14. Kim SW, Kim WS, Cho MK, Whang KU. Transconjunctival laser blepharoplasty of lower eyelids: Asian experience with 1,340 cases. Dermatol Surg. 2003;29:74–79. 15. Kakizaki H, Zako M, Nakano T, Asamoto K, Miyaishi O, Iwaki M. Microscopic findings of lateral tarsal fixation in Asians. Ophthal Plast Reconstr Surg. 2008;24:131–135. 16. Ben Ayed H, Hidalgo C, Hamédani M, Morax S. Ectropions. In: Encyclopédie Médico-Chirurgicale. Paris: Elsevier; 2005:1–14.
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M.D. M.D. M.D. M.D. M.D.
Seoul and Iksan, Republic of Korea; and Palo Alto, Calif.
Background: Optimal repair of an orbital fracture requires adequate exposure into the orbit. The transconjunctival approach with lateral canthotomy is a valid option in East Asian patients, who are especially sensitive to the appearance of an external skin scar, although one must also recognize the potential complications associated with eyelid aperture mechanics. The authors report the modification of the transconjunctival approach, in which a lateral paracanthal incision is made along with division of the lateral tarsal plate but not at the lateral canthus. This was developed to overcome the complications of traditional lateral cantholysis. Methods: A retrospective chart review was performed for all patients who had received the modified transconjunctival incision. Patient demographics, injury characteristics, and surgical outcomes were evaluated. Results: The baseline demographics of 30 patients in this study was typical of orbital fractures in the Korean population. A take-back operation was required in one case of preseptal hematoma. The mean follow-up period was 6 months, and no long-term functional complications were identified. Of the 30 total patients, 29 showed excellent aesthetic outcome. One patient did present with postoperative notch deformity but did not feel the need for a revision operation. Conclusions: The transconjunctival approach with a lateral paracanthal incision is an alternative approach to the orbital wall. The decoupling of the lower eyelid through the lateral portion of the tarsal plate provides excellent exposure of the orbital floor and provides a reliable and consistent landmark by which the anatomy of the eyelid can be restored. The aesthetic and functional outcomes are excellent. (Plast. R econstr. Surg. 134: 1023, 2014.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
I
n the surgical management of orbital fractures, the foremost determinant of success is the choice of access. Theoretically, the ideal
From the Department of Plastic Surgery, Seoul Metropolitan Government–Seoul National University Boramae Medical Center and Department of Plastic and Reconstructive Surgery, College of Medicine, Seoul National University; the Department of Plastic and Reconstructive Surgery, School of Medicine, Wonkwang University; and the Division of Plastic and Reconstructive Surgery, Stanford University Medical Center. Received for publication October 6, 2013; accepted April 17, 2014. Poster presented at Plastic Surgery The Meeting: 82nd Annual Meeting of the American Society of Plastic Surgeons, in San Diego, California, October 11 through 15, 2013. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000639
approach into the orbit has two main goals: to provide adequate operative exposure and to minimize functional and aesthetic complications.1 In practice, these two goals are often at odds with each other because, all things being considered, larger exposures lead to larger scars. The larger scars, in turn, lead to a higher likelihood of functional and aesthetic complications. This is especially a concern among East Asian patients, who have a higher tendency to develop hypertrophic scars. Among various methods of orbital access, the main advantage of the transconjunctival incision Disclosure: The authors have no financial interest to declare in relation to the content of this article.
www.PRSJournal.com
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Plastic and Reconstructive Surgery • November 2014 is that it leads to minimal scar formation. When compared with transcutaneous approaches such as subciliary and subtarsal access, however, exposure gained by means of transconjunctival incisions is limited and often inadequate.1,2 Previously, the limitation of this exposure was overcome by adding a lateral canthotomy, also referred to as a “swinging lower eyelid flap.”3 Unfortunately, the violation of lateral canthal anatomy defeats the very goal of minimizing morbidities associated with orbital access and, consequently, the original intent behind the design of the transconjunctival incision. To avoid the complications associated with lateral canthotomy, the authors have devised a modification to the swinging lower eyelid flap, in which the main incision is extended with a lateral paracanthal incision. The authors present the experience of refining this procedure previously introduced by de Chalain et al.4
PATIENTS AND METHODS A retrospective chart review was performed. The inclusion criteria were all patients who presented with periorbital fractures between January of 2011 and December of 2012. The operative indications included extensive fracture, muscle impingement, and/or enophthalmos.2,5 Depending on the fracture to be reduced, the orbital wall was reconstructed with alloplastic materials such as polylactide copolymer plates, porous polyethylene sheets, or preformed titanium implants. More complex fractures involving the medial orbital wall, zygoma, and/or maxilla were treated by means of additional incisions such as transcaruncular, lateral eyebrow, and upper gingivobuccal incisions. Patient demographics and injury characteristics were noted and tabulated (Table 1). Aesthetic and functional outcomes, such as lower eyelid malposition or visible scar formation, were assessed from postoperative clinic records at follow-up visits. All clinic visit photographs were taken in a standardized manner with a digital camera (EOS 350D; Canon, Tokyo, Japan) with indirect lighting at a distance of 50 cm. Before processing, the images were cropped to include the eyebrow to the lower eyelid and the lateral canthi bilaterally. The scar, webbing, ectropion, entropion, and scleral show were evaluated objectively and subjectively.6 Photographs taken at the 6-month postoperative visit were offered to two physicians for objective grading of the scar. Because all cases underwent surgery on only one side, some images were processed with a horizontal flip effect so that evaluators would see them
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Table 1. Patient Demographics Characteristic
Value
No. of patients 30 Men 21 Women 9 Age, yr Mean 38.6 Range 18–64 Follow-up period, mo Mean 6 Range 2–13 Cause, no. of patients Altercation 13 (all men) Fall 13 (6 men, 7 women) Traffic accident 3 (2 men, 1 woman) Enophthalmos deformity (zygoma malunion) 1 (1 woman) Repaired site of orbit, no. of patients Right orbit floor 15 Left orbit floor 15 Concomitant fracture, no. of patients Nasal bone fracture 7 Zygomatic fracture (ipsilateral) 7 Medial orbit wall fracture (ipsilateral) 3 Frontal sinus fracture 1
as belonging to the right side. Presenting photographs in this way allows for standardization. Each photograph was evaluated as 0 for an invisible scar, 1 for a minimally visible scar, 2 for a moderately visible scar, and 3 for a very visible scar. Patients were solicited for subjective assessment of scar visibility using the same grading scale. Functional outcomes were also evaluated by these two physicians. The 18 patients were included in this evaluation because the others were not followed up exactly at 6 months postoperatively. The data among evaluators were analyzed using the kappa statistic for measurement of interrater agreement. All statistical operations were calculated using IBM SPSS Version 19.0 for Windows (IBM Corp., Armonk, N.Y.). Surgical Technique The standard surgical preparation includes globe lubrication with topical saline irrigation and use of a corneal shield. The paracanthal incision is designed by marking its origin along the gray line, approximately 3 mm medial from the lateral canthus. From this point, a line is drawn perpendicularly to the tangent of the gray line, past the eyelashes (approximately 3 mm away from gray line). The design is extended obliquely in the inferolateral direction by approximately 5 to 8 mm, along an appropriately chosen minor skin crease (Fig.1, above, left). The handle of an empty scalpel holder can be placed on the tarsal plate next to the paracanthal
Volume 134, Number 5 • Lateral Paracanthal Incision
Fig. 1. (Above, left) Lateral paracanthal incision design in comparison with the traditional canthotomy incision. (Above, right) Paracanthal incision with scalpel. (Below, left) Transconjunctival incision extended from the severed tarsal plate. (Below, right) Closed wounds.
design to provide traction (Fig.1, above, right). The incision is made through the skin and full thickness of the eyelid, including the tarsal plate. The transconjunctival incision is then extended medially toward the punctum along the inferior margin of the tarsal plate. The resulting conjunctival flap is stretched superiorly to cover and protect the cornea for the remainder of the operation. The lower lid can readily be distracted, or “swung,” away from the globe without the need for excessive tension. The inferior orbital rim and floor are accessed by dissecting through the submuscular plane (Fig.1, below, left). With satisfactory reduction of orbital fracture(s), the incision is closed by meticulous apposition of the divided structures. Most notably, the tarsal plate and gray line are used as focal loci of approximation to restore the anatomy of lower eyelid. The tarsal plate is repaired with simple 6-0 Vicryl (Ethicon, Inc., Somerville, N.J.) sutures with the knot buried. The conjunctiva is closed with 7-0 Vicryl and the skin is repaired with 6-0 silk (Fig.1, below, right).
RESULTS A total of 30 patients (21 men and nine women) were identified in the study period. The mean age of the patients was 38.6 years (range, 18 to 64 years). The mean follow-up period was 6 months (range, 2 to 13 months). According to the inclusion criteria, all of the patients had a unilateral orbital floor fracture with proper indications for an operative intervention. Along with floor fractures, there were three patients with associated medial wall fractures, seven patients with zygomaticomaxillary fractures, and a single patient with a delayed presentation of enophthalmic deformity because of zygomatic malunion (Table 1). The modified transconjunctival lower lid approach was used to access the orbital floor. Fractures of the medial orbital wall, zygoma, and maxilla required transcaruncular, lateral eyebrow, and upper gingivobuccal incisions, respectively. All of the operations had been performed by a single surgeon (E.C.J.). In the evaluated group of patients (n = 18), no ectropion, entropion, webbing, or lid malposition
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Plastic and Reconstructive Surgery • November 2014 was observed. The physicians’ average scar grade of both physicians was 0.6 and the patientreported scar grade was lower at 0.2. No physicians or patients reported the scar to be grade 3 (Table 1). In terms of agreement among multiple raters, the kappa statistic showed a significant result (κ = 0.432, p < 0.001). Interestingly, whereas two physicians showed high agreement (κ = 0.708, p < 0.001), the agreement between patient and each of the physicians was low (κ = 0.349, p = 0.060 for physician 1 and patient; and κ = 0.259, p = 0.139 for physician 2 and patient). The physician evaluation yielded a somewhat higher incidence of visible incisions than patient perception. Actually, one patient did have a notch deformity at the site of the paracanthal incision and was given the option for revision surgery. However, the patient was satisfied with the overall outcome of the operation and gave the scar a grade of 1 (minimally visible). The patient elected to forgo further surgery. In the review of follow-up reports, the others also had no long-term functional complications
(e.g., webbing, ectropion, entropion, and scleral show) and were aesthetically pleased with the postoperative outcomes. One of them, with chronic liver cirrhosis, developed a preseptal hematoma and required a secondary operation. The source of bleeding was identified in a small branch of the marginal arcade along the tarsal plate and was easily controlled with electrocautery.
CASE REPORTS Case 1 A 46-year-old man presented with painful right periorbital swelling and epistaxis after an altercation. Clinical examination revealed subcutaneous emphysema and diplopia on upward and neutral gaze (Fig. 2, above, left). The suspicion of blowout fracture was confirmed on computed tomographic imaging, which identified medial wall and floor lesions (Fig. 2, below, left). A prophylactic antibiotic was administered, and the reconstruction was commenced 5 days after injury. The orbital floor was accessed by means of the modified transconjunctival lower lid approach with a transcaruncular extension for access to the medial wall. The orbital wall was reconstructed with a preformed titanium implant (MatrixMIDFACE Orbital Plate; Synthes GMBH, Switzerland).
Fig. 2. Case 1. A 46-year-old man was diagnosed with a blowout fracture of the right orbit floor and medial orbital wall, and nasal bone fractures. (Above, left) Preoperative and (above, right) postoperative photographs. (Below, left) Preoperative axial computed tomographic scan. (Below, right) Postoperative axial computed tomographic scan showing reconstruction with preformed titanium implant.
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Volume 134, Number 5 • Lateral Paracanthal Incision Postoperative computed tomographic imaging demonstrated adequate reduction of soft tissues, with anatomical restoration of the medial wall (Fig. 2, below, right). The diplopia gradually improved and resolved completely by postoperative day 14. The postoperative scar from the paracanthal incision was inconspicuous, and no functional morbidities were observed (Fig. 2, above, right).
Case 2 A 47-year-old woman with a history of a right facial injury presented to the outpatient clinic with the complaint of “small right eye” (Fig. 3, above, left). The injury had occurred several years previously while the patient had been abroad, and at that time, she had been informed of a bony fracture but did not elect to undergo reconstruction. On examination, no limitations were found in ocular motion. Hertel exophthalmometry showed an anterior corneocanthal displacement of 14 mm on the right and 16 mm on the left, with an interlateral canthal base of 93 mm. Computed tomographic imaging revealed a zygomatic malunion with an old blowout fracture involving the medial wall and floor of the right orbit (Fig. 3, below, left). The patient readily consented to an elective operation to correct the asymmetry. The modified transconjunctival lower lid approach was used, along with transcaruncular extension for medial wall exposure. The orbital wall was reconstructed with porous polyethylene sheets (SYNPOR; Synthes GMBH, Switzerland). Postoperatively, computed tomographic imaging revealed anatomical repositioning of orbital soft tissue (Fig. 3, below, right).
At the postoperative clinic visit at 1 month, Hertel exophthalmometry revealed corneocanthal displacement of 14 and 13.5 mm in the right and left eyes, respectively, with an interlateral canthal base of 91 mm. There was no functional complication from the operation, and the postoperative scar was inconspicuous (Fig. 3, above, right).
DISCUSSION The orbital floor is commonly accessed through transcutaneous incisions. Among these, the subciliary approach, also called the lower blepharoplasty incision, is often quite popular. The incision provides a decent exposure to the inferior rim and floor, with less postoperative edema and scar formation compared with other forms of the transcutaneous approach. However, this approach suffers from notable rates of lid retraction (9.7 to 19.1 percent).1,7 The transconjunctival incision is made through the conjunctiva of the inferior fornix, from the caruncle medially to the lateral fornix. It was first described in 1924 by Bourquet for aesthetic blepharoplasty.8 Tessier introduced the transconjunctival approach for orbital bone
Fig. 3. Case 2. A 47-year-old woman was diagnosed with a malunion of the zygoma with unrepaired right medial orbital wall and floor. (Above, left) Preoperative and postoperative (above, right) photographs. (Below, left) Preoperative axial computed tomographic scan. (Below, right) Postoperative axial computed tomographic scan showing reconstruction with porous polyethylene sheets.
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Plastic and Reconstructive Surgery • November 2014 Table 2. Self-Reported Scar Grading from Patients during 6-Month Follow-Up Visit*† No. of Patients (n = 18) Grade 0 1 2 3 Average grading score
First Physician Grading
Second Physician Grading
Subjective Patient Grading
9 8 1 0 0.6
9 7 2 0 0.6
14 4 0 0 0.2
*0 = invisible scar, 1 = minimally visible scar, 2 = moderately visible scar, and 3 = very visible scar. †p = 0.289, Fisher’s exact test.
surgery in trauma and congenital cases.9 This approach subsequently became popular in the mid to late 1980s, when the repair of orbitozygomatic fractures by means of a combined transconjunctival–lateral canthotomy approach was first reported.10,11 However, long-term experience with the technique revealed a high incidence of wound complication, scleral show, and/or ectropion, which is likely associated with the initial violation of the canthal tendon and improper repair.12,13 In a retrospective review of 274 orbital wall fractures by Salgarelli et al.,1 subciliary, transconjunctival-only, and transconjunctival with lateral canthotomy approaches were evaluated with respect to aesthetic outcomes and postoperative functional complications. The study demonstrated that the transconjunctival-only approach was associated with the best outcomes, with the subciliary approach perhaps best reserved for those fractures requiring extensive exposure. Lateral canthotomy was associated with the highest rates of functional and aesthetic complications, which nullified the advantages that the transconjunctival approach conferred over the subciliary approach. However, the transconjunctival approach has the benefit of avoiding an external lower eyelid scar. In the East Asian population, postoperative scars are perceived negatively, and this is a significant problem for this patient population, who often develop hypertrophic scars. It is in this context that the transconjunctival approach to lower blepharoplasty has become popular in certain Asian countries in spite of the transcutaneous approaches available. In addition to the issue of postoperative scarring, transconjunctival approaches do not violate the orbicularis oculi muscle, and this is important in preserving the pretarsal fullness of the lower eyelid, which is often considered a physical sign of youth in East Asian aesthetics.14
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In the setting of an orbital fracture, complications of lateral canthotomy arise from improper repair of the lateral canthus. This improper repair, in turn, arises from a combination of two factors. The first factor is the consequence of the injury itself—edema, hematoma, tissue disruption, and presence of a foreign body—which tends to obfuscate recognition of normal anatomy. The second factor is the delicate anatomy of the lateral canthus itself. The fine fascial and retinacular structures of the canthus are intermingled and delicate such that, after a prolonged period of eyelid retraction during operative manipulation, precise repair of the canthus is virtually impossible.15 The main idea of lateral canthotomy in transconjunctival incision is to uncouple the fascial structure between the tarsal plate and the canthi. Lateral canthotomy accomplishes this goal of uncoupling and allows for the resulting lower eyelid flap to swing out of the way. However, severing this fascial connection is associated with the problems mentioned above. Keeping this principle in mind, the authors realized that the mechanical link between the lower eyelid and canthus did not necessarily need to be severed through the delicate fibers. On further contemplation, a paracanthal incision appeared to offer the possibility of a swinging eyelid flap without the complications associated with the improper repair of lateral canthotomy. The paracanthal incision would uncouple the lower eyelid through the tarsus, which would be easier to reapproximate compared with divided canthal fibers. Although there is no removal of tarsus in this modification, the direct approximation of the tarsal plate does not weaken the lower eyelid support, conceptually similar to the modern modified Kuhnt-Szymanowski procedure used for senile ectropion.16 Therefore, this modified canthotomy was conceived with the idea that the uncoupling of the lower eyelid would occur at a paracanthal location and was used in the management of orbital floor fractures at the institution. On further review of the literature, the authors came across an antecedent report by de Chalain et al. that describes a “lateral paracanthal incision” as a modified transconjunctival approach.4 In their article, the eyelid is decoupled by severing the inferior limb of the lateral canthus; however, we had been decoupling the eyelid by the lateralmost division of the tarsal plate, leaving the canthal structures intact. The exposure to the inferior orbital floor was reported to be excellent, but the authors did note two cases of eyelid notching deformities, which were corrected with secondary operations. We believe that the operation we
Volume 134, Number 5 • Lateral Paracanthal Incision devised is an improvement over the one previously described. The outcomes from our review support the merit of our modified transconjunctival lower lid approach for orbital fracture repair. With experience and familiarity with the approach, we have come to understand the advantages of this technique and to execute the operation more precisely. In the report by de Chalain et al.,4 the mechanical component of the lower lid was transected approximately 2 mm from the canthus, and an eyelash or two was kept on the lateral side of the incision to simplify reapproximation at the time of closure. In the paracanthal incision we presented, the lateralmost portion of the tarsus was used as the landmark. The tarsus is easily observed from the conjunctival side with eversion of the lower eyelid. The tarsal transection was designed to create a lateral remnant of tarsus that was as small as possible. Along the remnant tarsus, the lower eyelid margin was marked for cutaneous incision, and this point was often identical to the location described in the publication by de Chalain et al.4 For patients in whom the lateral eyelashes were missing as a result of trauma or aging, using the lateral tarsal margin provided a more reliable landmark in a few cases in our series. Considering the similarities in method and outcomes, it is hard to argue that the technique presented here is a vast improvement over the procedure described by de Chalain et al.4 However, we believe that our technique is a further refinement in the continuum of transconjunctival approaches and that it is a particularly useful approach in the East Asian population for the reasons discussed above. Among the 30 patients in this study, one patient did have a notch deformity at the site of the paracanthal incision. As the deformity was covered by the upper eyelashes and caused no aesthetic issues, the patient did not feel that the secondary operation offered was necessary. In addition, there was the single case of preseptal hematoma in a patient with chronic liver cirrhosis. At the take-back operation, the source of bleeding was identified as a small branch of the marginal arcade along the tarsal plate, which was easily controlled with cauterization. In the antecedent report, the plane of dissection had not been described. In our patients, the dissection was carried out in the preseptal submuscular plane. Our rationale was that a preseptal dissection was likely to be safer than a retroseptal dissection plane of most transconjunctival exposures, as the orbital septum impedes the development of a retrobulbar hematoma, one of the more feared complications
in the management of blowout fractures. Because of this, we were able to easily identify and control the bleeding in the preseptal plane in the single case of postoperative hematoma. This study does support previous findings that the modified transconjunctival approach with lateral paracanthal incision allows adequate exposure of the orbital wall floor. The outcomes are excellent, with no apparent long-term complications, and the postoperative scar is inconspicuous, as the cutaneous portion of the incision amounts to less than 0.5 cm.
SUMMARY The choice of access to the orbit is dictated by the nature of the fracture to be addressed and the anatomy of the eyelid aperture. The access provided by the lateral paracanthal incision avoids the complication of lid malposition associated with cantholysis and provides wide exposure of the orbital floor. Because the lower eyelid is decoupled through the tarsal plate as opposed to through those delicate structures of the lateral canthus, the restoration of eyelid anatomy is simplified. Overall, aesthetic outcomes are excellent, with minimal external scars in East Asian patients. Eui Cheol Jeong, M.D. Department of Plastic Surgery SMG-SNU Boramae Medical Center 5 Gil 20 Boramae-Road Dongjak-Gu, Seoul 156-707, Republic of Korea [email protected]
PATIENT CONSENT
Patients provided written consent for the use of their images. acknowledgments
The authors thank Dr. Aram Harijan for assistance with the English language in this article, Dr. Sohee Oh for the statistical data analysis, and Dr. Jong Ho Kim for the clinical photography. references 1. Salgarelli AC, Bellini P, Landini B, Multinu A, Consolo U. A comparative study of different approaches in the treatment of orbital trauma: An experience based on 274 cases. Oral Maxillofac Surg. 2010;14:23–27. 2. Chen CT, Chen YR. Update on orbital reconstruction. Curr Opin Otolaryngol Head Neck Surg. 2010;18:311–316. 3. McCord CD Jr, Moses JL. Exposure of the inferior orbit with fornix incision and lateral canthotomy. Ophthalmic Surg. 1979;10:53–63.
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Plastic and Reconstructive Surgery • November 2014 4. 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. 5. Hazani R, Yaremchuk MJ. Correction of posttraumatic enophthalmos. Arch Plast Surg. 2012;39:11–17. 6. Raschke GF, Rieger UM, Bader RD, Schaefer O, Guentsch A, Schultze-Mosgau S. Transconjunctival versus subciliary approach for orbital fracture repair: An anthropometric evaluation of 221 cases. Clin Oral Investig. 2013;17:933–942. 7. 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. 8. Bourquet J. Les hernies graisseuses de l’orbite: Notre traitement chirurgical. Bull Acad Med (Paris) 1924;92:1270. 9. Tessier P. The conjunctival approach to the orbital floor and maxilla in congenital malformation and trauma. J Maxillofac Surg. 1973;1:3–8.
10. Converse JM, Firmin F, Wood-Smith D, Friedland JA. The conjunctival approach in orbital fractures. Plast Reconstr Surg. 1973;52:656–657. 11. Nunery WR. Lateral canthal approach to repair of trimalar fractures of the zygoma. Ophthal Plast Reconstr Surg. 1985;1:175–183. 12. Ridgway EB, Chen C, Lee BT. Acquired entropion associated with the transconjunctival incision for facial fracture management. J Craniofac Surg. 2009;20:1412–1415. 13. Westfall CT, Shore JW, Nunery WR, Hawes MJ, Yaremchuk MJ. Operative complications of the transconjunctival inferior fornix approach. Ophthalmology 1991;98:1525–1528. 14. Kim SW, Kim WS, Cho MK, Whang KU. Transconjunctival laser blepharoplasty of lower eyelids: Asian experience with 1,340 cases. Dermatol Surg. 2003;29:74–79. 15. Kakizaki H, Zako M, Nakano T, Asamoto K, Miyaishi O, Iwaki M. Microscopic findings of lateral tarsal fixation in Asians. Ophthal Plast Reconstr Surg. 2008;24:131–135. 16. Ben Ayed H, Hidalgo C, Hamédani M, Morax S. Ectropions. In: Encyclopédie Médico-Chirurgicale. Paris: Elsevier; 2005:1–14.
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