J Oral Maxillofac Surg 49:494503.1991
The Transconjunctival Approach Treating Orbital Trauma
for
PETER D. WAITE, MPH, DDS, MD,* AND DENNIS D. CARR, DMD, MDt Twelve patients with a variety of maxillofacial injuries were treated with a transconjunctival incision and lateral canthotomy for orbital floor, and inferior and lateral rim reconstruction. Mean follow-up was 12 months, during which time no immediate or delayed complications developed. The exposure and access was satisfactory in all cases for reduction and rigid fixation of both inferior and lateral rim through a single incision.
Recent success of miniplates has placed a greater emphasis on open reduction of zygomatic fractures and has obligated surgeons to search for incisions that provide adequate access with esthetic results.’ The same esthetic goals used for a patient seeking elective cosmetic surgery should be used for the facial fracture patient. The transconjunctival incision fulfills this requirement for patients with fractures of the orbital rim and floor. Through a single incision, the lateral rim and floor can be repaired.
shown in Table 1. The results are compared with those of previous techniques to reconstruct the orbital rim through bicoronal flaps, subciliary , brow, and transoral incisions. Anatomy and Technique An understanding of eyelid anatomy is essential for operative procedures in this area (Fig 1). The lower lid is made up of six layers. The most superficial is the skin, which is most adherent to underlying tissue at the tarsal plate and becomes thinner and more loosely adherent to underlying tissue as it extends caudally to the orbital rim. A very thin layer of subcutaneous tissue separates the skin from the orbicularis oculi, which has classically been divided into the pretarsal, preseptal, and orbital portions. The pretarsal portion overlies the tarsal plate
Materials and Methods Possible complications from using the transconjunctival approach to the infraorbital rim, orbital floor, and lateral orbital rim were analyzed in 12 trauma patients (mean age, 25 years; 4 females and 8 males) observed for an average of 12 months (range, 9 to 19 months). Preoperative and postoperative examinations were performed to evaluate the enophthalmus, scarring, ectropion, diplopia, dystopia, and limited ocular function. Such problems occasionally arise in the management of orbital trauma. Follow-up facial radiographs were used to evaluate the position of the zygoma and determine the adequacy of access in reduction of these fractures. The types of fractures treated are
Table 1. Rosults of Using the TransconjunctivrlIncisionfor Treating Orbit81Trauma
Age Patient
Received from the Department of Oral and Maxillofacial Surgery, The University of Alabama School of Dentistry, Birmingham. * Associate Professor. t Chief Resident. Address correspondence and reprint requests to Dr Waite: Department of Oral and Maxillofacial Surgery, The University of Alabama School of Dentistry, Birmingham, AL 35294. 0 1991 American
Association
of Oral and Maxillofacial
Follow-up
(yr)
Diagnosis
Complication
Blowout ZMC FX LF 1,2, ZMC LF 1, 2, 3, ZMC LF 1.2, ZMC LF 1,2, ZMC ZMC , frontal Blowout ZMC FX GSW ZMC FX ZMC FX
None None None None None None None None None None None None
AP SW cs TP JH cc BS CM WH MH JW MK
19 19 9 14 9 11 9 8 8 11 9 14
5 23 44 28 6 25 4.5 67 25 26 11 33
Mean
12
25
Sur-
geons
Abbreviations: GSW, gunshot wound; LF, Le Fort; ZMC FX, zygomaxillary complex fracture.
0278-2391 I91 /4905-0009$3.00/O
499
TRANSCONJUNCTIVAL APPROACH FOR ORBITAL TRAUMA
Fomix Tarsal plate Conjunctiva Orbicularis oculi Orbital septum Orhital fat Skin Subcutaneous tissue Periosteum Infraorbital rim
and inserts into the skin. Laterally, the pretarsal muscles of the upper and lower lids fuse to create the thick posterior limb of the lateral canthus, which blends with a suspensory lateral canthal tendon to insert on Whitnall’s tubercle. The preseptal muscles of the upper and lower lid fuse laterally to form the anterior limb of the lateral canthus, a thin but tough raphe, which inserts into the skin. Coursing between the anterior and posterior limb is the lateral palpebral artery. A submuscular layer separates the orbicularis oculi from the septum. The orbital septum is a fascial structure composed of a thin, fibrous membrane that in the lower lid extends from the tarsal plate to the inner aspect of the infraorbital rim. It also extends medially and laterally to the orbital margins where it is secured to the periorbita, thereby maintaining the integrity of the orbital contents. Deep to the septum is a thin connective tissue layer that separates the septum from the conjunctiva. The conjunctiva is a thin mucous membrane that is divided into two parts: the palpebral conjunctiva lines the back of the eyelids, and the bulbar conjunctiva is transparent and lines the globe. In the lower lid, the palpebral conjunctiva is firmly adherent to the
FIGURE 1. Diagrammatic representation of the basic six tissue layers of the lower eyelid.
tarsal plate, and is more loosely bound as it proceeds caudally toward the infraorbital rim in the fomix. In traumatized patients, it is often difficult to determine if the dissection is preseptal or postseptal. The preseptal dissection is preferable because it will avoid the orbital fat. However, the septum and periorbita may already be tom, and it may be impossible to avoid orbital fat hemiation. The postseptal approach used in blepharoplasty also can be used when necessary (Fig 2). The transconjunctival approach begins with a lateral canthotomy (Fig 3A). Blunt scissors are used to cut horizontally through the lateral canthus down to the lateral rim for about 1 cm. A Desmarres retractor is then used to retract the lower lid away from the globe. The lateral aspect of the lower lid, however, is still tethered to the inferior limb of the lateral canthal tendon. This is isolated and cut with blunt scissors, thereby completing the cantholysis (Fig 3B) and allowing better lower lid retraction and eversion. With a guarded needle tip, electrosurgery is used to make a conjunctival incision midway between the tarsal plate and the inferior fomix, extending medially from the lateral canthotomy and
FIGURE 2. Either the preseptal or postseptal approach can be combined with cantholysis. The preseptal avoids the orbital fat.
Retro-septal transconjunctival
disection
Pre-septal trsnsconjunctival
dlsection
WAITE AND CARR
FIGURE 3. Diagram demonstrating the transconjunctival approach to the orbital rim and floor. A, Lateral canthotomy; B, cantholysis completion; C, transconjunctival incision; D, periosteal incision; E, elevation of periosteum and periorbita; F, conjunctival closure and canthal tendon repair.
terminating lateral to the lacrimal punctum (Fig 3C). Alternatively, tenotomy scissors can be used to extend the cantholysis medially through the conjunctiva. A plastic cornea1 shield can be used to protect
FIGURE 4. Rigid fixation of zygomaticofrontal region with a miniplate.
501 the globe. However, injury to the globe can be avoided without a comeal shield if careful technique and attention to detail are used. Blunt postseptal or preseptal dissection is used to expose the infraorbital rim (Fig 2). A malleable retractor is then placed posterior to the orbital rim to protect the globe. When the infraorbital rim is identified, the periosteum is incised with a no. 15 scalpel blade (Fig 3D). Elevation of the periosteum and orbital floor exploration are accomplished in the routine fashion (Fig 3E). The zygoma can be elevated and reduced by passing an elevator through the canthotomy incision. Orbital floor reconstruction with lyophilized dura, bone grafts, or orbital floor plates is then performed. The infraorbital rim and frontozygomatic region can be exposed adequately for fractures to be fixed with mini- or microplating techniques (Figs 4 and 5). Closure of the periosteum is not done. Wound closure is accomplished by using a 6-Ochromic gut suture to reapproximate the conjunctiva. Often only two interrupted sutures are needed. This is done before repair of the cantholysis (Fig 3F). The inferior limb of the lateral canthal tendon is then reattached by suturing the lateral tarsus to the remaining superior canthal tendon with a 4-O polyglactin suture. This fixation suture is placed as deep and as high as possible in the firm connective tissue along the lateral canthal tendon. The skin is then closed with an interrupted 6-Ochromic suture. Postoperatively, an eye patch is used for the first 24 to 36 hours. An ophthalmic antibiotic solution and a systemic antibiotic are routinely used for 5 postoperative days. Skin sutures are removed on
502
TRANSCONJUNCTIVAL
APPROACH FOR ORBITAL TRAUMA
FIGURE 6. One week postoperative result of transconjunctival approach (Fig 5 is radiograph of the same patient).
Lid laxity or ectropion were never experienced. There were no abnormal scars. Postreduction complications, such as enophthalmus, diplopia, and dystopia were not noted. These complications are not related to the method of access; regardless of which approach is used, these postoperative problems can occur. Discussion FIGURE 5. Postreduction Waters’ radiograph demonstrates microplate fixation at lateral and infraorbital rim.
the 5th day, but the conjunctival sutures are left in place until resorbed. Results
Experience with more than 12 trauma patients showed that the transconjunctival approach yields very satisfactory results. The esthetic results were consistently excellent. The conjunctival incision healed well without scar formation. Within 1 to 2 months, the transconjunctival incision and lateral canthotomy are undetectable (Figs 6 and 7). This is not true for subciliary incisions. Access to the infraorbital rim, orbital floor, and lateral orbital rim for plating the zygomaticofrontal region were always satisfactory when a lateral canthotomy and cantholysis was performed (Table 1). No case required alternative means of access for reconstructing the orbital floor or placing infraorbital or zygomaticofrontal rigid fixation. Fracture reduction and plate placement was no more difficult than when previous approaches, such as a subciliary or brow incision, were used. No comeal abrasions were noted. Subconjunctival ecchymosis and periorbital edema were frequently experienced and persisted for 1 to 2 weeks.
The transconjunctival approach without cantholysis was first described by Bourquet in 1923.2Tessier advocated this approach for removal of periorbital fat as early as 1955, but later abandoned it because of limited exposure.3 In 1971, Tanzel and Miller emphasized the retroseptal transconjunctival approach for orbital floor blowout fractures but reported limited exposure.4 Also in 1971, Paul Tessier
FIGURE 7. One month postoperative junctival approach.
result of the transcon-
503
CLINTON D. McCORD JR
presented work on craniofacial surgery in which the preseptal approach was used for access for orbital floor osteotomies for midface advancement. In 1973, Converse suggested a lateral canthotomy incision, which provided much more exposure.5 Moses and McCord, in 1979, demonstrated that the inferior fomix incision and lateral canthotomy provided good exposure of the nasal, inferior, and lateral orbit, while still preserving the integrity of the lower lid.6 It has also been demonstrated that adequate access is possible to reduce both frontozygomatic and infraorbital rim fractures through this single incision.7 The literature reveals that this approach is used in ophthalmology, otolaryngology, and plastic surgery .6,8-10 Comparison of complications with the subciliary and transconjunctival incisions does indicate a statistically significant difference. The incidence of ectropion is greater following subciliary incisions.” Because of the successful clinical experience with this approach, it is now recommended as the primary approach to the orbital floor, and infraorbital and lateral rim. It is not used, however, if an existing laceration can be used. The indications are similar to those for the traditional approaches, such as the infraciliary or subciliary incisions. Access is essentially the same as with other surgical techniques and the complications of facial scars, ectropion, and alterations in the tarsal plate are diminJ Oral Maxillofac 49:503.
ished. It appears that there are no disadvantages to this technique. However, it is obvious that meticulous care to protect the globe is necessary to prevent cornea1 abrasions or other ocular damage. References 1. Rinehart GC, Marsh JL, Hemmer KM: Internal fixation of malar fractures: An experimental biophysical study. Plast Reconstr Surg 84:21, 1989 2. Bourget J: Notre traitment chirforgical de “poches” sons less san cicatrice. Arch Graefes Belg Chir 31:133, 1928 3. Tessier P: The conjunctival approach to the orbital floor and maxilla in congenital malformation and trauma. J Maxillofac Surg 1:3, 1973 4. Tenzel RR, Miller GR: Orbital blow-out fracture repair, conjunctival approach. Am J OphthaImol71:1141, 1971 5. Converse JM, Firman F, Wood-Smith D, et al: The conjunctival approach in orbital fracture. Plast Reconstr Surg 52:656, 1973 6. McCord CD Jr, Moses JL: Exposure of the inferior orbit with fomix incision and lateral canthotomy. Ophthalmic surg 10:53, 1979 7. Manson PN, Ruas E, Ilift N, et al: Single eyelid incision for exposure of the zygomatic bone and orbital reconstruction. Plast Reconstr Surg 79:120, 1987 8. Lynch DJ, Lamp JC, Royster HP: The conjunctival approach for exploration of the orbital floor. Plast Reconstr Surg 54:153, 1974 9. Shemen LJ, Neltzer M: Inferior fomix incision for orbital rim and floor fractures. Laryngoscope %: 1164, 1986 10. McCord CD: Orbital decompression for Graves disease explore through lateral canthal: Inferior fomix incision. Ophthalmology 88:533, 1981 11. Wray RC Jr, Holtmann B, Ribardo JM, et al: A comparison of conjunctival and subciliary incisions for orbital fractures. Br J Plast Surg 30:142. 1977
Surg
1991
Discussion The Transconjunctival Approach for Treating Orbital Trauma Clinton D. McCord Jr, MD Atlanta, GA In years past, one of the main complicationsof surgical techniques dealing with orbital fractures has been postoperative lower lid malposition. The malposition can either take place as an ectropion from a contracture of the external skin-muscle layer, or a vertical retraction, with scarring in the orbital septal area binding the lid down to the infraorbital rim. In many cases, the lid is uninvolved by the trauma and the secondary problems associated with the surgical intervention are very disconcerting to the surgeon and to the patient. Adequate surgical exposure for repair of orbital floor rim and zygomatic fractures is greatly enhanced with the fomix incision and extended canthotomy and cantholysis as adequately referenced in this article. As the authors mention, this does give quite adequate surgical exposure for reduction of fractures and application of miniplates. Because the lower eyelid is completely bypassed, without an incision, there remains very little to cause the lid to contract or retract following this type of exposure. Possibly the one disadvantage of the fornix incision is the
uncovering of the eyelid and orbital fat, which can tend to billow out and obscure the bony orbital rim. However, this is easily remedied with the placement of small malleable retractors. The authors quite adequately describe the anatomic layers of the lid and include a series of standard patients who have had uncomplicated results from application of this procedure. The only objection I have to their presentation is the so-called preseptal approach using the fomix incision. The concept of the fomix incision with canthotomy and cantholysis is that the integrity of the eyelid is not violated by an incision so as to avoid any fibrous contractive forces. The second illustration shows an incision through the inferior edge of the tarsal plate, which in most cases involves a marginal artery of the lid. In addition, with this technique, the orbital septum may be stimulated by the incision to perhaps produce fibrosis, and my personal thought would be that it is too big a price to pay to avoid seeing orbital fat with the so-called preseptal approach, because in some cases it may still produce some septal scarring and downward retraction of the eyelid. Other than this specific objection, I think the authors have demonstrated well that the fomix approach has been used successfully by them and I’m sure will be used similarly by many others for repair of orbital fractures.
The Transconjunctival Approach Treating Orbital Trauma
for
PETER D. WAITE, MPH, DDS, MD,* AND DENNIS D. CARR, DMD, MDt Twelve patients with a variety of maxillofacial injuries were treated with a transconjunctival incision and lateral canthotomy for orbital floor, and inferior and lateral rim reconstruction. Mean follow-up was 12 months, during which time no immediate or delayed complications developed. The exposure and access was satisfactory in all cases for reduction and rigid fixation of both inferior and lateral rim through a single incision.
Recent success of miniplates has placed a greater emphasis on open reduction of zygomatic fractures and has obligated surgeons to search for incisions that provide adequate access with esthetic results.’ The same esthetic goals used for a patient seeking elective cosmetic surgery should be used for the facial fracture patient. The transconjunctival incision fulfills this requirement for patients with fractures of the orbital rim and floor. Through a single incision, the lateral rim and floor can be repaired.
shown in Table 1. The results are compared with those of previous techniques to reconstruct the orbital rim through bicoronal flaps, subciliary , brow, and transoral incisions. Anatomy and Technique An understanding of eyelid anatomy is essential for operative procedures in this area (Fig 1). The lower lid is made up of six layers. The most superficial is the skin, which is most adherent to underlying tissue at the tarsal plate and becomes thinner and more loosely adherent to underlying tissue as it extends caudally to the orbital rim. A very thin layer of subcutaneous tissue separates the skin from the orbicularis oculi, which has classically been divided into the pretarsal, preseptal, and orbital portions. The pretarsal portion overlies the tarsal plate
Materials and Methods Possible complications from using the transconjunctival approach to the infraorbital rim, orbital floor, and lateral orbital rim were analyzed in 12 trauma patients (mean age, 25 years; 4 females and 8 males) observed for an average of 12 months (range, 9 to 19 months). Preoperative and postoperative examinations were performed to evaluate the enophthalmus, scarring, ectropion, diplopia, dystopia, and limited ocular function. Such problems occasionally arise in the management of orbital trauma. Follow-up facial radiographs were used to evaluate the position of the zygoma and determine the adequacy of access in reduction of these fractures. The types of fractures treated are
Table 1. Rosults of Using the TransconjunctivrlIncisionfor Treating Orbit81Trauma
Age Patient
Received from the Department of Oral and Maxillofacial Surgery, The University of Alabama School of Dentistry, Birmingham. * Associate Professor. t Chief Resident. Address correspondence and reprint requests to Dr Waite: Department of Oral and Maxillofacial Surgery, The University of Alabama School of Dentistry, Birmingham, AL 35294. 0 1991 American
Association
of Oral and Maxillofacial
Follow-up
(yr)
Diagnosis
Complication
Blowout ZMC FX LF 1,2, ZMC LF 1, 2, 3, ZMC LF 1.2, ZMC LF 1,2, ZMC ZMC , frontal Blowout ZMC FX GSW ZMC FX ZMC FX
None None None None None None None None None None None None
AP SW cs TP JH cc BS CM WH MH JW MK
19 19 9 14 9 11 9 8 8 11 9 14
5 23 44 28 6 25 4.5 67 25 26 11 33
Mean
12
25
Sur-
geons
Abbreviations: GSW, gunshot wound; LF, Le Fort; ZMC FX, zygomaxillary complex fracture.
0278-2391 I91 /4905-0009$3.00/O
499
TRANSCONJUNCTIVAL APPROACH FOR ORBITAL TRAUMA
Fomix Tarsal plate Conjunctiva Orbicularis oculi Orbital septum Orhital fat Skin Subcutaneous tissue Periosteum Infraorbital rim
and inserts into the skin. Laterally, the pretarsal muscles of the upper and lower lids fuse to create the thick posterior limb of the lateral canthus, which blends with a suspensory lateral canthal tendon to insert on Whitnall’s tubercle. The preseptal muscles of the upper and lower lid fuse laterally to form the anterior limb of the lateral canthus, a thin but tough raphe, which inserts into the skin. Coursing between the anterior and posterior limb is the lateral palpebral artery. A submuscular layer separates the orbicularis oculi from the septum. The orbital septum is a fascial structure composed of a thin, fibrous membrane that in the lower lid extends from the tarsal plate to the inner aspect of the infraorbital rim. It also extends medially and laterally to the orbital margins where it is secured to the periorbita, thereby maintaining the integrity of the orbital contents. Deep to the septum is a thin connective tissue layer that separates the septum from the conjunctiva. The conjunctiva is a thin mucous membrane that is divided into two parts: the palpebral conjunctiva lines the back of the eyelids, and the bulbar conjunctiva is transparent and lines the globe. In the lower lid, the palpebral conjunctiva is firmly adherent to the
FIGURE 1. Diagrammatic representation of the basic six tissue layers of the lower eyelid.
tarsal plate, and is more loosely bound as it proceeds caudally toward the infraorbital rim in the fomix. In traumatized patients, it is often difficult to determine if the dissection is preseptal or postseptal. The preseptal dissection is preferable because it will avoid the orbital fat. However, the septum and periorbita may already be tom, and it may be impossible to avoid orbital fat hemiation. The postseptal approach used in blepharoplasty also can be used when necessary (Fig 2). The transconjunctival approach begins with a lateral canthotomy (Fig 3A). Blunt scissors are used to cut horizontally through the lateral canthus down to the lateral rim for about 1 cm. A Desmarres retractor is then used to retract the lower lid away from the globe. The lateral aspect of the lower lid, however, is still tethered to the inferior limb of the lateral canthal tendon. This is isolated and cut with blunt scissors, thereby completing the cantholysis (Fig 3B) and allowing better lower lid retraction and eversion. With a guarded needle tip, electrosurgery is used to make a conjunctival incision midway between the tarsal plate and the inferior fomix, extending medially from the lateral canthotomy and
FIGURE 2. Either the preseptal or postseptal approach can be combined with cantholysis. The preseptal avoids the orbital fat.
Retro-septal transconjunctival
disection
Pre-septal trsnsconjunctival
dlsection
WAITE AND CARR
FIGURE 3. Diagram demonstrating the transconjunctival approach to the orbital rim and floor. A, Lateral canthotomy; B, cantholysis completion; C, transconjunctival incision; D, periosteal incision; E, elevation of periosteum and periorbita; F, conjunctival closure and canthal tendon repair.
terminating lateral to the lacrimal punctum (Fig 3C). Alternatively, tenotomy scissors can be used to extend the cantholysis medially through the conjunctiva. A plastic cornea1 shield can be used to protect
FIGURE 4. Rigid fixation of zygomaticofrontal region with a miniplate.
501 the globe. However, injury to the globe can be avoided without a comeal shield if careful technique and attention to detail are used. Blunt postseptal or preseptal dissection is used to expose the infraorbital rim (Fig 2). A malleable retractor is then placed posterior to the orbital rim to protect the globe. When the infraorbital rim is identified, the periosteum is incised with a no. 15 scalpel blade (Fig 3D). Elevation of the periosteum and orbital floor exploration are accomplished in the routine fashion (Fig 3E). The zygoma can be elevated and reduced by passing an elevator through the canthotomy incision. Orbital floor reconstruction with lyophilized dura, bone grafts, or orbital floor plates is then performed. The infraorbital rim and frontozygomatic region can be exposed adequately for fractures to be fixed with mini- or microplating techniques (Figs 4 and 5). Closure of the periosteum is not done. Wound closure is accomplished by using a 6-Ochromic gut suture to reapproximate the conjunctiva. Often only two interrupted sutures are needed. This is done before repair of the cantholysis (Fig 3F). The inferior limb of the lateral canthal tendon is then reattached by suturing the lateral tarsus to the remaining superior canthal tendon with a 4-O polyglactin suture. This fixation suture is placed as deep and as high as possible in the firm connective tissue along the lateral canthal tendon. The skin is then closed with an interrupted 6-Ochromic suture. Postoperatively, an eye patch is used for the first 24 to 36 hours. An ophthalmic antibiotic solution and a systemic antibiotic are routinely used for 5 postoperative days. Skin sutures are removed on
502
TRANSCONJUNCTIVAL
APPROACH FOR ORBITAL TRAUMA
FIGURE 6. One week postoperative result of transconjunctival approach (Fig 5 is radiograph of the same patient).
Lid laxity or ectropion were never experienced. There were no abnormal scars. Postreduction complications, such as enophthalmus, diplopia, and dystopia were not noted. These complications are not related to the method of access; regardless of which approach is used, these postoperative problems can occur. Discussion FIGURE 5. Postreduction Waters’ radiograph demonstrates microplate fixation at lateral and infraorbital rim.
the 5th day, but the conjunctival sutures are left in place until resorbed. Results
Experience with more than 12 trauma patients showed that the transconjunctival approach yields very satisfactory results. The esthetic results were consistently excellent. The conjunctival incision healed well without scar formation. Within 1 to 2 months, the transconjunctival incision and lateral canthotomy are undetectable (Figs 6 and 7). This is not true for subciliary incisions. Access to the infraorbital rim, orbital floor, and lateral orbital rim for plating the zygomaticofrontal region were always satisfactory when a lateral canthotomy and cantholysis was performed (Table 1). No case required alternative means of access for reconstructing the orbital floor or placing infraorbital or zygomaticofrontal rigid fixation. Fracture reduction and plate placement was no more difficult than when previous approaches, such as a subciliary or brow incision, were used. No comeal abrasions were noted. Subconjunctival ecchymosis and periorbital edema were frequently experienced and persisted for 1 to 2 weeks.
The transconjunctival approach without cantholysis was first described by Bourquet in 1923.2Tessier advocated this approach for removal of periorbital fat as early as 1955, but later abandoned it because of limited exposure.3 In 1971, Tanzel and Miller emphasized the retroseptal transconjunctival approach for orbital floor blowout fractures but reported limited exposure.4 Also in 1971, Paul Tessier
FIGURE 7. One month postoperative junctival approach.
result of the transcon-
503
CLINTON D. McCORD JR
presented work on craniofacial surgery in which the preseptal approach was used for access for orbital floor osteotomies for midface advancement. In 1973, Converse suggested a lateral canthotomy incision, which provided much more exposure.5 Moses and McCord, in 1979, demonstrated that the inferior fomix incision and lateral canthotomy provided good exposure of the nasal, inferior, and lateral orbit, while still preserving the integrity of the lower lid.6 It has also been demonstrated that adequate access is possible to reduce both frontozygomatic and infraorbital rim fractures through this single incision.7 The literature reveals that this approach is used in ophthalmology, otolaryngology, and plastic surgery .6,8-10 Comparison of complications with the subciliary and transconjunctival incisions does indicate a statistically significant difference. The incidence of ectropion is greater following subciliary incisions.” Because of the successful clinical experience with this approach, it is now recommended as the primary approach to the orbital floor, and infraorbital and lateral rim. It is not used, however, if an existing laceration can be used. The indications are similar to those for the traditional approaches, such as the infraciliary or subciliary incisions. Access is essentially the same as with other surgical techniques and the complications of facial scars, ectropion, and alterations in the tarsal plate are diminJ Oral Maxillofac 49:503.
ished. It appears that there are no disadvantages to this technique. However, it is obvious that meticulous care to protect the globe is necessary to prevent cornea1 abrasions or other ocular damage. References 1. Rinehart GC, Marsh JL, Hemmer KM: Internal fixation of malar fractures: An experimental biophysical study. Plast Reconstr Surg 84:21, 1989 2. Bourget J: Notre traitment chirforgical de “poches” sons less san cicatrice. Arch Graefes Belg Chir 31:133, 1928 3. Tessier P: The conjunctival approach to the orbital floor and maxilla in congenital malformation and trauma. J Maxillofac Surg 1:3, 1973 4. Tenzel RR, Miller GR: Orbital blow-out fracture repair, conjunctival approach. Am J OphthaImol71:1141, 1971 5. Converse JM, Firman F, Wood-Smith D, et al: The conjunctival approach in orbital fracture. Plast Reconstr Surg 52:656, 1973 6. McCord CD Jr, Moses JL: Exposure of the inferior orbit with fomix incision and lateral canthotomy. Ophthalmic surg 10:53, 1979 7. Manson PN, Ruas E, Ilift N, et al: Single eyelid incision for exposure of the zygomatic bone and orbital reconstruction. Plast Reconstr Surg 79:120, 1987 8. Lynch DJ, Lamp JC, Royster HP: The conjunctival approach for exploration of the orbital floor. Plast Reconstr Surg 54:153, 1974 9. Shemen LJ, Neltzer M: Inferior fomix incision for orbital rim and floor fractures. Laryngoscope %: 1164, 1986 10. McCord CD: Orbital decompression for Graves disease explore through lateral canthal: Inferior fomix incision. Ophthalmology 88:533, 1981 11. Wray RC Jr, Holtmann B, Ribardo JM, et al: A comparison of conjunctival and subciliary incisions for orbital fractures. Br J Plast Surg 30:142. 1977
Surg
1991
Discussion The Transconjunctival Approach for Treating Orbital Trauma Clinton D. McCord Jr, MD Atlanta, GA In years past, one of the main complicationsof surgical techniques dealing with orbital fractures has been postoperative lower lid malposition. The malposition can either take place as an ectropion from a contracture of the external skin-muscle layer, or a vertical retraction, with scarring in the orbital septal area binding the lid down to the infraorbital rim. In many cases, the lid is uninvolved by the trauma and the secondary problems associated with the surgical intervention are very disconcerting to the surgeon and to the patient. Adequate surgical exposure for repair of orbital floor rim and zygomatic fractures is greatly enhanced with the fomix incision and extended canthotomy and cantholysis as adequately referenced in this article. As the authors mention, this does give quite adequate surgical exposure for reduction of fractures and application of miniplates. Because the lower eyelid is completely bypassed, without an incision, there remains very little to cause the lid to contract or retract following this type of exposure. Possibly the one disadvantage of the fornix incision is the
uncovering of the eyelid and orbital fat, which can tend to billow out and obscure the bony orbital rim. However, this is easily remedied with the placement of small malleable retractors. The authors quite adequately describe the anatomic layers of the lid and include a series of standard patients who have had uncomplicated results from application of this procedure. The only objection I have to their presentation is the so-called preseptal approach using the fomix incision. The concept of the fomix incision with canthotomy and cantholysis is that the integrity of the eyelid is not violated by an incision so as to avoid any fibrous contractive forces. The second illustration shows an incision through the inferior edge of the tarsal plate, which in most cases involves a marginal artery of the lid. In addition, with this technique, the orbital septum may be stimulated by the incision to perhaps produce fibrosis, and my personal thought would be that it is too big a price to pay to avoid seeing orbital fat with the so-called preseptal approach, because in some cases it may still produce some septal scarring and downward retraction of the eyelid. Other than this specific objection, I think the authors have demonstrated well that the fomix approach has been used successfully by them and I’m sure will be used similarly by many others for repair of orbital fractures.
