|Year : 2012 | Volume
| Issue : 2 | Page : 161-167
The versatility of lower eyelid blepharoplasty incision: In open reduction and fixation of zygomatic complex injuries
V. S. R. Chandran1, R Candamourty2, A Thangavelu3
1 Department of Oral and Maxillofacial Surgery, Best Dental College, Madurai, India
2 Department of Oral and Maxillofacial Surgery, Indira Gandhi Institute of Dental Sciences, Mahatma Gandhi Medical College and Research Institute Campus, Pillaiyarkuppam, Pondicherry, India
3 Department of Oral and Maxillofacial Surgery, Rajah Muthiah Dental College and Hospitals, Annamalai University, Chidambaram, India
|Date of Web Publication||3-Oct-2012|
Professor and Head, Department of Oral and Maxillofacial Surgery, Indira Gandhi Institute of Dental Sciences, Mahatma Gandhi Medical College and Research Institute Campus, Pillaiyarkuppam, Pondicherry - 607 402
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: A zygomatic complex fracture includes disruption of the four articulating sutures: zygomaticofrontal, zygomaticotemporal, zygomaticomaxillary and zygomaticosphenoidal sutures. All zygomatic complex fractures involve the orbital floor and therefore an understanding of orbital anatomic features is essential for those treating these injuries. Aims and Objectives: To analyze the efficacy and shortcomings of this approach. To evaluate the adequacy, role of tarsorrhaphy, difficulties, role of steroid in postoperative edema control in lower lid blepharoplasty approach. Materials and Methods: A total number of six patients were included in this study and all the patients were treated surgically under general anesthesia. All the patients were approached through lower eyelid blepharoplasty incision. The first skin crease in the lower eyelid region is selected for this incision. Results: All patients were administered with steroid injection. Frost sutures were placed in four cases and tarsorrhaphy was done in two patients. Three cases encountered immediate mild edema and immediate scar formation. Late scar was present only in two patients with a follow up of three months. Conclusion: Lower eyelid blepharoplasty incision is an excellent, non complicated, simple procedure in the management of fractures in the infraorbital region, orbital floor, which occurs as a part of zygomatic complex fractures.
Keywords: Lower lid blepharoplasty, lateral middle third fractures, subciliary approach, zygomatic complex fractures
|How to cite this article:|
Chandran V, Candamourty R, Thangavelu A. The versatility of lower eyelid blepharoplasty incision: In open reduction and fixation of zygomatic complex injuries. J Nat Sc Biol Med 2012;3:161-7
|How to cite this URL:|
Chandran V, Candamourty R, Thangavelu A. The versatility of lower eyelid blepharoplasty incision: In open reduction and fixation of zygomatic complex injuries. J Nat Sc Biol Med [serial online] 2012 [cited 2020 Jan 21];3:161-7. Available from: http://www.jnsbm.org/text.asp?2012/3/2/161/101900
| Introduction|| |
Transconjunctival incision with lateral canthotomy is one of the commonly used incisions for access to the infraorbital rim and the floor of the orbit for esthetic, reconstructive and traumatic surgery. The three most commonly used cutaneous lower lid incisions are subtarsal, infraorbital and the lower blepharoplasty incision. Subciliary incision is made approximately 2 mm inferior to free margin of eyelid, subtarsal is made 5 to 7 mm inferior to lower eyelid whereas infraorbital is made at the inferior orbital rim region. 
The infraorbital skin crease incision is still very popular and widely practiced. It is safe, gives rise to relatively few surgical complications and is thus regarded as a relatively sound approach. Nevertheless, the main disadvantage of this approach may be noticeable scarring, which is particularly unacceptable in young people where such a scar usually increases in size with growth. The incision provides limited access to the lower aspect of the lateral orbital rim and wall. In order to improve access it can be extended too far laterally or in an upward direction, when it may cause lower lid lymph edema which subsequently lasts for a variable period.
The transconjunctival incision for exploration of the orbital rim and floor was introduced by Bourquet and has been popularized by Tessier.  This approach produces superior cosmetic results when compared to any other commonly used incision. Its main disadvantage is the limited access to the orbital floor and thus should only be considered as an approach to the fractures of the orbital rim and floor where there is no need for extensive fixation procedures. It is an excellent approach for correction of pure orbital (inferior) blow out fractures. Sailer (1977) advocates the transconjunctival incision to approach fractures of the orbital rim and floor when he inserts staples for the fixation of bone fragments. Where it is necessary to improve access to the fracture site the transconjunctival incision can be extended laterally with the use of lateral canthotomy. In these situations, however, the extended lower blepharoplasty incision is the approach of choice. The lower blepharoplasty incision has been used as an approach to the orbital fractures since 1978. 
Lower lid blepharoplasty incision was first described by Converse in 1944; the advantage of this approach owes adequate exposure to inferolateral orbital region. Floor reconstruction, infraorbital nerve decompression and plate fixation of the rim can be easily done through this approach. This approach results in minimal scarring, but vertical lower eyelid shortening, as evidenced by scleral show and ectropion may occur occasionally secondary to fibrosis from the dissection. 
Hence a study was undertaken in division of Oral and Maxillofacial Surgery in Rajah Muthiah Dental College and Hospital during the year 2003 to 2006 to analyze the efficacy of lower eyelid blepharoplasty incision in surgical exposure of the lower orbital region and to analyze the shortcomings of this approach in isolated and complex mid-facial injuries involving the orbital skeleton.
| Materials and Methods|| |
This study was conducted in the division of Oral and Maxillofacial Surgery, Rajah Muthiah Dental College and Hospital, from the year 2003 to 2006 after obtaining approval of the institutional ethics committee and informed consent of the participants. Patients selected for this study were between the age group of 20 and 40 years. The clinical examination was performed using standard protocols.
None of the patient was taken up for surgery immediately after the trauma. The time period was 4 to 7 days after the trauma. All of the patients included in this study had displaced fracture zygoma with or without associated facial bone fractures.
- All the patients were generally examined for associated injuries.
- All the patients were subjected to routine invest-igation, which includes routine blood investigation, radiographs (PNS and OPG). Advanced investigation like CT scan and rapid prototype are taken wherever necessary.
A total number of six patients were included in this study and all the patients were treated surgically under general anesthesia. All the patients were approached through lower eyelid blepharoplasty incision with the help of sterile instruments [Figure 1]. The first skin crease in the lower eyelid region is selected for this incision.
Blepharoplasty Approach to Infraorbital and Floor of The Orbit
Before the incision is placed, incision line is marked with sterile ink [Figure 2]a and frost bite is placed in the gray lines of the lower eyelids [Figure 2]b, c. This is to minimize postoperative edema and it also acts as an additional retraction other than the manual retraction of the surgical site.
|Figure 2: (a) Skin marking (b) Frost suture (c) Tarsorrhaphy (d) Exposure of orbicularis oculi muscle|
Click here to view
The tissues were infiltrated with 2% lignocaine solution containing adrenaline (1:2,00,000 units). The skin incision was made 2 to 3 mm inferior to the gray line of the lower eyelid but always superior to the inferior palpebral fold. The incision runs parallel to the lid margin from the punctum medially to the orbital rim laterally. The lateral extent of the incision was tapered inferiorly within skin crease and along the whole length of the margins of the lower eyelid.
Dissection was either anterior or posterior to the orbicularis oculi muscle when the anterior dissection was used and the muscle was not disturbed at the level of incision, but was divided bluntly at the level of the infraorbital rim [Figure 2]d. In the posterior dissection, the muscle was sharply divided immediately beneath the incision line and then separated from the orbital septum until the outline of the inferior orbital rim can be visualized. Care was taken not to penetrate the septum to avoid the problems of the prolapse of the fatty tissue into surgical field. When the orbital rim was exposed, the periosteum was incised 3 mm inferior to it to avoid postoperative tethering of the peri orbita and to facilitate good periorbital closure [Figure 3]a. The displaced infraorbital rim fracture was reduced under direct vision (4 cases) or indirectly by Gillie's temporal approach. The reduced fragment was held in the anatomical position using four hole stainless steel plates (1.5 mm) and screws [Figure 3]b. The surgical area was debrided and cleaned with saline and antiseptic (Betadine). The wound was closed in layers by using 3-0 Vicryl for the closure of the orbicularis oculi muscle and 5-0 silk or nylon was used for skin closure [Figure 3]c, d. Muscle and skin was closed from medial to lateral end without any tension. After recovery of the patients from general anesthesia, immediate ice fermentation was given to avoid postoperative edema formation. Pre- and postoperative radiographs were taken [Figure 4]c, d.
|Figure 3: (a) Fracture site exposed (b) Miniplate fixation (c) Multilayer closure (d) Single layer closure|
Click here to view
|Figure 4: (a) Preoperative appearance (b) Postoperative appearance (c) Preoperative radiograph (d) Postoperative radiograph|
Click here to view
Suture removal was done on the fourth postoperative day. Betadine dressing was given at the operated site and patient was discharged from the ward after five days from the day of surgery. Patient was reviewed every first week, first month and 3 rd month postoperatively and found that the individuals responded well with minimal scar formation [Figure 4]a, b.
- Drugs like amoxicillin, Metrogyl, analgesic and single or tapering dose of steroid was given (depending upon postoperative edema) to control postoperative infections, edema and pain.
- Pressure dressing was given for 24 h to the operated site to control postoperative edema.
- Ice fermentation was given immediately after recovery of the patient from general anesthesia for two hours at the interval of every 20 min.
- Check chart was maintained for
- Movement of the globe
- Injury to orbit and contents
- Infraorbital nerve function
- Postoperative scar formation for a period of 8 weeks
| Results|| |
The majority of the participants belonged to the age group of 20 to 32 years. Skin-muscle flap was used in majority of the cases. All patients were administered with steroid injection. Frost sutures were placed in four cases and tarsorrhaphy was done in two patients [Table 1]. In the postoperative phase, three cases encountered immediate mild edema and immediate scar formation. Late scar was present only in two patients with a follow up of three months [Table 2].
| Discussion|| |
The zygoma is the main buttress between the maxilla and the cranium and is also the principle component of the superficial lateral pillar of a buttress system of platforms and pillars that surround and protect the orbit. Strong impact forces directed to the zygoma are usually absorbed by the fragmentation of the weaker bones with which the zygoma articulates. The frontozygomatic sutures suffer from a clean separation whereas the zygomaticomaxillary buttress area and the medial aspect of the inferior orbital rim will be comminuted. The zygomatic arch will suffer either a single telescoped fracture near its mid point or a double fracture that produces a displaced and possibly rotated central fragment. Therefore fracture dislocation of the zygoma may fragment both ends of the horizontal arc of contour and the lower end of the vertical arc. The degree of this disruption and the amount of displacement of the zygoma determine the severity of the injury and thus the complexity of the needed repair. 
Paranasal sinus view is the most important X-ray to diagnose the infraorbital rim fracture. The possibilities that exist and may be confusing are 1) no fracture 2) pseudo fracture line and 3) fracture line not revealing correctly the amount of displacement. Campbell and Trapnell  lines were used for interpretation of paranasal sinus view. Hopper et al.  and Kaufman Y et al.  suggested that the use of conventional radiographs can be supplemented by coronal CT.
Gillie's temporal method is the most frequently used procedure with minimal morbidity and a short duration of general anesthesia.  An additional exposure may be needed for direct fixation with miniplate in certain situations where care is needed to protect infraorbital nerve.  Bradycardia was reported during the elevation of zygomatic arch, which could be due to trigemino-vagal reflex or oculo-cardiac reflex. ,,
Surgical access to the orbital skeleton and periorbital structures through the eyelids and anterior orbit has been accomplished by an array of cutaneous approach. The incisions used for this anatomic area appear to have their origins at least partly in the treatment of zygomatico-orbital and cosmetic blepharoplasty.
Various cutaneous approaches and its indications has been proposed by various authors for approaching orbit, which includes medial brow, lateral brow, lateral canthotomy, upper lid blepharoplasty, bicoronal flap, medial crease, lynch, subciliary, lower lid blepharoplasty and inferior orbital rim incisions. ,
There are a variety of incisions advocated exclusively for exposure of the lower half of the bony orbit:
The lid incisions must be used with proper under-standing and the orbital function must be assessed postoperatively. Meticulous attention should be given for the protection and care of anterior globe. The thinness of the tissues, edema and bruising may require more postoperative time.
- The infraorbital incision made in a natural skin crease which is still commonly used by many surgeons;
- The orbital rim incision made directly over the infraorbital rim;
- The lower lid blepharoplasty incision which can be extended laterally and combined with either pre- or post-orbicularis dissection;
- The transconjunctival incision often combined with lateral canthotomy.
Converse in 1944 introduced the use of subciliary incision for approaching the floor of the orbit and also described about skin-muscle flap technique and skin flap technique. The lower lid blepharoplasty approach allowed a good exposure of the orbital rim and fractures of the orbital floor. Fractures of the lower half of the lateral orbital rim could be reached by a lateral extension of the standard lower blepharoplasty incision. The flexibility of this approach achieved by this extension contrasted favorably with the more conventional infraorbital or orbital rim approach.  The lower lid blepharoplasty post orbicularis approach offers excellent exposure to the lower half of the orbit and is therefore recommended for complicated wiring or plating procedures. 
The skin incision is made 2-3 mm inferior to gray line but it should always be superior to the inferior palpebral fold. The dissection may be anterior or posterior to the orbicularis oculi and care needs to be taken not to penetrate orbital septum and when perforated resorbable sutures should be used to prevent prolapse of fatty tissue. When the rim is exposed, the periosteum is incised 3 mm inferior to it to avoid postoperative tethering of the periorbita and to facilitate good periosteal closure. Pospisil O.A et al.  suggested that edema present on the day of operation is the main contributory factor to the development of ectropion and also recommended that operation be deferred until edema has subsided. Fractures of the zygoma are common maxillofacial injuries secondary to nasal fractures. While many of these are of minimal clinical significance, those that possess esthetic deformities or functional limitations demand surgical reduction. A simple towel clips can be used for reduction of isolated fractured zygoma. It is a simple, quick and effective technique with minimal invasive, carries little risk of infection or neurovascular injury and leaves no visible scarring. , However, combination of transcutaneous reduction of non-comminuted zygoma, which can be stabilized by external pin fixation is more effective method for immobilization of zygoma. 
The use of miniplates in unstable fractures of the malar complex will result in stable fixation and significantly increases the greater chance of regeneration of the infraorbital nerve than stabilization of the zygoma with wire sutures.  Incase of comminuted zygomatic complex fracture, two-point rigid fixation should be done one at the frontozygomatic suture and another at the infraorbital rim.  Cranial cavity penetration can occur while drilling in the frontozygomatic suture region. In order to avoid the risk of penetration, drilling can be done at an angle of 45 degrees, and 7 mm screws should be used at the frontozygomatic suture area and 5 mm screws should be used above the suture region. 
Miniplates osteosynthesis showed a higher incidence of recovery of infraorbital nerve.  Following reduction of the fractures, the wound is closed in three layers (periosteum, muscle and the skin). Periosteum and muscle are closed with resorbable material whereas skin should be with a fine monofilament suture. The frost suture helps in easier inspection and the insertion of antibiotic ointment to the affected eye. , The frost and pressure pack helps to reduce postoperative edema formation. 
A minor complication has been reported by Pospisil like hematoma, partial wound dehiscence, transient lymphedema and a transient or permanent ectropion. Park et al.  reported foreign body reaction after placement of resorbable plates and screws.
Although exclusively elaborated to abstain the use of this incision in literature owing to time factor, despite its superior postoperative results, we in our study over a series of six patients (7 incisions) have found no such limitations associated with the use of this incision. The incision allowed for easy dissection, exposure of the infraorbital rim, adequate access to manipulate, reduce and stabilize the fractured segments. Postoperative sequelae was eventful in majority of cases, except for case (3) in which the patient had mild ectropion and epiphora. Scarring was noted in cases 2 and 4.
| Summary and Conclusion|| |
This study was undertaken in Rajah Muthiah Dental College and Hospitals between the years 2003 and 2006 to analyze the versatility of "lower eyelid blepharoplasty incision" as an approach in the open reduction and fixation in zygomatic complex injuries. The following conclusions were made:
So from the above-mentioned interferences, there is no doubt that lower eyelid blepharoplasty incision is an excellent, non-complicated, simple procedure in the management of fractures in the infraorbital region, orbital floor, which occurs as a part of zygomatic complex fractures.
- It is always indicated to perform a two-point fixation for unstable displaced zygoma fractures
- Lateral frontal and infraorbital fixation is advanta-geous as it can be performed under direct vision.
- Lower eyelid blepharoplasty incision and approach is an excellent and adequate approach for exposure of infraorbital rim and floor of the orbit.
- Lower eyelid blepharoplasty incision is technically simple when compared to the other infraorbital approach like transconjunctival and subciliary incisions.
- The correct placement of incision, the stepwise dissection and a proper retraction plays a major role in the outcome of this approach.
- Placement of "frost suture" and "tarsorrhaphy" is a mandatory procedure that has to be followed prior to the incision of the lower eyelid.
- The "frost suture" helps in correct placement of lower eyelid blepharoplasty incision and dissection.
- Injection of steroid do not play a definitive role in postoperative edema control, but anyway a single dose of pre-operative or intraoperative injection of steroids definitively minimizes the postoperative edema.
- Lower eyelid blepharoplasty incision is advantageous in complete reconstruction of the orbital floor.
- The minimal entrapment of the extraocular muscle in the zygomatic complex fractures can be relieved and further prevented by approximate reduction and rigid fixation in the infraorbital region.
- Single layer or multilayer sutures do not really play a role in postoperative esthetic and functional outcome of this approach.
- When plate fixation is done in the infraorbital region, a multilayer suture provides an adequate cover and minimizes the chances of plate exposure.
- Postoperative pressure strips and immediate cold fermentation do minimize the postoperative edema and hematoma.
- Correct placement of incision, step dissection, multilayer closure and postoperative pressure strips minimizes the chances of "ectropion" and "epiphora" and immediate postoperative hematoma.
- Skin-muscle flap is comparatively easy to raise and also minimizes the postoperative edema and ectropion. It also maintains the viability of the flaps and reduces wound dehiscence.
This approach is adequate for inspection, reduction under direct vision and rigid fixation. The very few complications associated with this procedure can be easily prevented by adapting simple techniques like frost suturing, raising a skin muscle flap etc., when it comes to the principle of two-point fixation in zygomatic complex fractures. This approach can be adapted, which helps in an appropriate surgical treatment in a minimal time and minimal complications with good esthetic and functional outcome.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]