Subciliary Approach Research Articles

Use of a dial tension gauge to assess quantitatively the intraoperative improvement of ocular movement after endoscopic transantral repair of fracture of the orbital floor

i l ractures of the orbital floor are common midfacial fractures. lthough conventional approaches such as the subciliary or ransconjunctival approach are usually used for such fracures, the endoscopic transantral approach is safe and reliable n suitably selected patients1 and has recently been used as inimally invasive treatment.1,2 Improvement of ocular movement after the repair of a racture of the orbital floor is generally confirmed by the orced duction test. However, such improvement is more ifficult to assess after the endoscopic transantral approach ithout direct visualisation of soft tissues above the orbital oor, because the assessment depends on the surgeon’s skill nd experience and there are few objective indicators. We eport the use of a dial tension gauge to assess quantitaively the intraoperative improvement of ocular movement fter endoscopic transantral repair of a fracture of the orbital oor. Under general anaesthesia, 5/0 nylon is sutured to the nsertion of the inferior rectus muscle so that the globe is ot injured by the conjunctiva being grasped at the inserion. This procedure is not as traumatic as multiple trials of

Preseptal transconjunctival vs. subciliary approach in treatment of infraorbital rim and floor fractures

Background:Injuries in the orbital region have profound functional as well as aesthetic implications. Treatment of orbital fractures remains one of the most controversial issues in maxillofacial trauma with regard to the classification, diagnosis, surgical approach and treatment.Purpose:This study evaluated and compared the efficacy of two most commonly applied approaches the preseptal transconjunctival with lateral canthotomy and the subciliary approach for the treatment of infraorbital floor and rim fractures.Patients And Methods:Twenty patients reported to G.D.C.R.I. Bangalore who suffered infraorbital floor and rim fractures, were randomly divided into two groups with 10 patients in each group. In one group, anatomic reduction and reconstruction was done with preseptal transconjunctival approach with lateral canthotomy and in the other group with subciliary approach.Results:In transconjunctival group, transient entropion was significant (30%). In subciliary group, transient ectropion was significant (30%).Conclusion:In our study, preseptal transconjunctival approach with lateral canthotomy and subciliary skin-muscle flap approach for the open reduction and rigid fixation of infraorbital floor and rim fractures had showed less morbidity and lesser risk of complications and given satisfactory results.

Validity and accuracy of subciliary endoscopic-aided repair of orbital floor fractures

Several approaches are used to reconstruct orbital floor fractures and restore orbital position and function, but many have the drawback of incomplete visualization, especially of the posterior part of the orbit. The aim is to assess the validity and accuracy of endoscopically aided subciliary approach repair of orbital floor fractures, as regards functional and cosmetic outcomes. Nine patients with orbital floor fractures were treated with iliac crest bone graft under complete endoscopically aided visualization, through a subciliary approach graft that was placed over the defect under complete visual control using endoscopes, through the same incision, to reconstruct the defect and assess the correction of the posterior edge of orbital floor defect. Improvement was assessed 2 weeks postoperatively. All operated cases had satisfactory results, both functionally and cosmetically. No permanent drawbacks from the incision were observed at 6 months follow-up. In case of repair of orbital floor fractures via a transciliary approach, the use of endoscopic aid through the same incision, allows better visualization of the posterior edge of the orbital floor and facilitates confirmation that all orbital soft tissues have been accurately elevated from the fracture site and that the bone grafts are placed in proper position. 1b (individual inception study with >80% F/U).

Total Excision of an Intraosseous Zygomatic Hemangioma via Subciliary Approach

intraosseus hemangiomas of the face and malar regions. 2. To review advantages and disadvantages of surgical approaches for removal of these lesions, including the Weber-Ferguson, hemi/bicoronal, extended transconjunctival, transoral gingivobuccal, and extended subciliary incisions. Study Design: Case report and review of the literature. Surgical, radiographic, and histopathologic findings are shown and discussed. Methods: We describe a case of a 44-year-old woman with a twoyear history of a slowly-enlarging, tender mass over her right zygoma. Magnetic resonance imaging demonstrated a lytic, expansile lesion centered within the cortex of the zygoma at the zygomaticomaxillary suture. Results: Total excision of the mass was achieved through a single extended subciliary incision. The lesion was dissected circumferentially out of the zygoma with a cuff of normal bone. Histopathologic examination revealed an intraosseus hemangioma. Conclusions: Intraosseus hemangioma is a rare lesion of the zygomatic area. En bloc surgical excision is the best treatment for these expansile masses. The cure rate is excellent if complete removal is achieved; however, as these are benign lesions, postoperative cosmetic deformities remain a significant issue when considering the surgical approach. Many reconstructive methods have been described to minimize bony defects following excision but do not address the extensive external skin incisions that are required and scarring that can result. A thorough understanding of the many skin incision options and selection of the least invasive approach that will permit complete resection are paramount. In select cases, an extended subciliary approach can provide the necessary exposure and a cosmetically favorable result. Total Excision of an Intraosseous Zygomatic Hemangioma via Subciliary Approach

Retrospective analysis of orbital floor fractures—complications, outcome, and review of literature

This retrospective study aimed at investigating indications, surgical approaches, and the materials used for orbital floor reconstructions, as well as the clinical follow-up, particularly with regard to postoperative complications. This study comprised 189 patients who underwent surgery for fractures of the orbital floor between 2003 and 2007. Diagnosis and treatment were based on both physical examination and computed tomography scan of the orbit. Patients were retrospectively analyzed for data, such as mechanism of injury, classification of fracture, and complications. The most common cause of injury was physical assault followed by traffic accidents. Surgery was conducted with a mean delay of 2.9days after the incident. Mid lower eyelid incision was the most common surgical approach to the orbital floor. For orbital floor reconstruction, polydioxanone sheets (70.5%) were mainly used, followed by Ethisorb Dura (23.3%) and titanium mesh (6.2%). There were 19.0% of patients who showed postoperative complications: 5.8% suffered from persisting motility impairment, 3.7% from enophthalmos, 3.2% from consistent diplopia, 2.6% from ectropion, and 0.5% from orbital infection. Intraorbital hematoma (3.2%) represented the most severe complications, one patient suffered lasting impairment of sight and another one, complete blindness of the affected eye. If postoperative impairment of vision becomes evident, immediate surgical intervention is mandatory. Retrobulbar hematoma is more likely to occur in heavily traumatized patients with comminuted fractures and also in patients taking anticoagulative medication. The subciliary approach to the orbit and repeated operations by the same approach are associated with a higher risk of developing ectropion.

Treatment of Orbital Fractures

Reconstruction of the fractured orbit serves to prevent functional and aesthetic posttraumatic sequels. In 2004, the surgical protocol at our unit was modified with respect to techniques for surgical access, types, and materials for reconstruction. The modifications were as follows: (a) introduction of medial orbital wall reconstructions through a bicoronal approach, (b) transconjunctival approach instead of the subciliary approach, and (c) porous polyethylene or porous polyethylene-titanium instead of autologous bone grafts. To evaluate the different surgical techniques and materials used, orbital reconstructions performed at our unit from 2000 to 2007 were retrospectively studied. In total, 177 primary or first-time secondary reconstructions were performed in 176 patients. The overall rate of early complications requiring medical or surgical intervention was 6.4%, and the reoperation rate was 3.4%. There were no statistically significant differences in the frequency of cicatricial eyelid complications between the subciliary and the transconjunctival approaches. There was a reduction in operative time with the use of implants compared with the use of bone. The overall rate of infections was 2%; however, there were no infections in the group treated with implants. Seven patients had secondary surgery for persistent enophthalmos, 4 of them due to defects in the medial orbital wall that had not been corrected at the time of primary reconstruction of the orbital floor. In conclusion, porous polyethylene/porous polyethylene-titanium is a safe material for orbital reconstructions. Reconstruction of the medial orbital wall is important to prevent posttraumatic enophthalmos, particularly in combined medial wall-orbital floor fractures.

Vertical Plication of Attenuated Orbital Septum

Aesthetic surgery for correction of the lower lid bulge can be classified into 3 groups of subtractive surgery, redraping, and repositioning. The authors present a new repositioning technique with vertical plication of the orbital septum for correction of lower lid bulge. This procedure was performed on 30 individuals during a 3-year period between March 2003 and March 2006. The length of follow-up varied from 3 months to 1 year, with an average of 6 months. There was no lower lid retraction or ectropion. Contour was smooth without any visible deformation or palpable suture line along the vertical plication. In the follow-up visits of minimum of 3 months, no recurrence of bulge was present and the scar was inconspicuous. Vertical plication of the orbital septum is an effective way to reposition the orbital fat inside the orbit. It anatomically corrects lower lid bulge, preserves the orbital fat pad and the vertical dimension of the lower lid, and provides a smooth contour in the periorbital area without the need to penetrate the orbital septum or manipulate the fat pad. Morbidity is minimal and transient, and the results are satisfactory. We suggest this technique for correction of lower lid bulge when there is excess lower lid skin and a subciliary approach is selected.

An Examination of Posttraumatic, Postsurgical Orbital Deformities: Conclusions Drawn for Improvement of Primary Treatment

Sir: The article entitled “An Examination of Posttraumatic, Postsurgical Orbital Deformities: Conclusions Drawn for Improvement of Primary Treatment” by Wolfe et al. (Plast Reconstr Surg. 2008;122:1870–1881) was at once informative, interesting, and a pleasure to read. It was stated that the application of the basic principles of craniofacial reconstruction set forth by Paul Tessier would improve the management of orbital injuries and prevent postsurgical orbital deformities. We also think that the methods set by Tessier constitute the mainstay of the management of craniofacial fractures and deformities. We have offered mild criticism regarding some of the topics. At first, according to us, routine usage of a coronal incision might cause some problems such as visible scars and partial alopecia at the frontotemporal region. We often use subtarsal or subciliary incisions for orbital fractures. While we are using a subciliary approach, we deepithelialize the lateral part of the flap and fix it to the bone periosteum to prevent ectropion to establish the tight structural support. As a result, the frequency of eyelid retraction would be diminished. In addition, we do not use the transconjunctival approach, because it would easily interfere with the inferior retractor mechanism of the lower eyelid. In case of reconstruction of the orbital floor with autogenous grafts and alloplastic materials, the authors should make a contribution about the infection and resorption rate of bone grafts. We agree that alloplastic materials provide us no benefit, as their complications would be more hazardous. Recently, we have used resorbable mesh plates and acellular dermal matrix grafts, and our results have been satisfactory so far. We would like to express our thanks to the authors for this valuable article reporting a greater than 30-year experience in the management of orbital fractures. Serdar Altun, M.D. Burak Alhan, M.D. Emre İnözü, M.D. Enver Arpacı, M.D. Ramazan E. Ünlü, M.D. Second Department Plastic and Reconstructive Surgery Ankara Numune Training and Research Hospital Ankara, Turkey

A comparative study of different approaches in the treatment of orbital trauma: an experience based on 274 cases

The aim of the study was to compare the aesthetic results, complications and surgical indications in patients treated for orbital trauma by one of three different approaches: subciliary, transconjunctival or transconjunctival with lateral canthotomy. In this retrospective study, 274 patients (169 men and 105 women aged 16-78 years) who had been treated for orbital trauma without soft tissue lacerations of orbital region and then returned for long-term follow-up (6-48 months) between 2000 and 2007 were evaluated in terms of aesthetics and function for the presence of a visible scar and lower-eyelid malposition (scleral show or ectropion). Of the 274 patients, 50 (18.2%) experienced complications. In the group of 219 patients treated with the subciliary approach, 41 experienced complications, whereas amongst the 32 patients treated with the transconjunctival approach, there was one complication (0.3%) and amongst the 23 patients treated with the transconjunctival approach and canthotomy, there were eight complications (34.8%). Patients treated for orbital trauma with the transconjunctival approach with canthotomy had a higher rate of lower eyelid malposition. Transconjunctival incision without canthotomy was the most successful surgical approach for the treatment of isolated fracture of the orbital floor; however, when major surgical exposure is necessary, subciliary incision is recommended.

Acquired Entropion Associated With the Transconjunctival Incision for Facial Fracture Management

Transconjunctival incisions are used in cases of orbitozygomatic trauma and elective lower eyelid blepharoplasty. Although this approach has reduced the rates of ectropion, there is a rare but reported incidence of entropion. We review our experience with craniofacial trauma between 1998 and 2008 and our use of the transconjunctival, subtarsal, and subciliary approaches. We describe 2 patients where entropion occurred after a transconjunctival approach for repair of orbital and zygomatic fractures and review the literature. With the increasing popularity of this incision in reconstructive and cosmetic plastic surgery, a complete understanding of orbital anatomy and associated treatment options for entropion is necessary.

Medial Orbital Wall Reconstruction Through Subciliary Approach

The aim of this study is to determine the safety and complication of subciliary approach through the retrospective review of our experiences. From 2005 through 2008, the subciliary skin-muscle flap methods were used in 30 patients undergoing medial orbital wall reconstruction. Preoperative and postoperative ophthalmic findings including diplopia, Hertel exophthalmometry, and occurrence of complications were checked. Resorbable polylactic acid sheet or porous polyethylene sheet was trimmed and molded in L shape, vertical portion to cover the medial wall defect and horizontal portion for stability in orbital floor.In the follow-up of diplopia, half of the patients (3 cases) presenting with diplopia improved during the first month of follow-up, and all of them improved by 6 month. For hypesthesia, all patients improved by 3 months. Enophthalmos of 1 patient improved after operation and did not recur. No patients complained of visible scar 6 months postoperatively, and no ectropion was observed.We think that medial orbital wall could be reconstructed safely through skin-muscle flap subciliary approach without resulting in ectropion or lacrimal canaliculus injury.

Tarsal strip technique for correction of malposition of the lower eyelid after treatment of orbital trauma

Purpose The transconjunctival, subciliary, subtarsal, and subpalpebral approaches for accessing the infraorbital rim and orbital floor have both advantages and disadvantages. The most common complications include rounding of the lateral canthal angle, lower eyelid retraction with inferior scleral show, and frank ectropion. Materials and patients From 2000 to 2007, we treated 29 patients with lower eyelid malposition after surgery to manage the floor and infraorbital trauma (22 subciliary approaches, five transconjunctival approaches and lateral canthotomies, and two transconjunctival approaches). To correct lower eyelid malposition, we applied the tarsal strip technique in all patients. Results Twenty-five patients had scleral show and four patients had ectropion: three were previous treated using transconjunctival access and one using subciliary access. Twenty-six patients obtained satisfactory correction of eyelid malposition in a single-step surgical procedure, while three patients required a second surgical step to correct the remaining scleral show. Good aesthetic and functional results were achieved in all cases. Conclusions All approaches to the infraorbital rim or orbital floor have the potential for postoperative sequelae. The tarsal strip technique is a relatively simple technique that oral and maxillofacial surgeons can use to manage lower lid malposition, such as scleral show and ectropion.

Reconstruction of Bony Orbit Using Endoscope and Polyethylene with Embedded Titanium for a Patient with Postoperative Enophthalmos

Enophthalmos means displacement of the globe into the bony orbit backward, and usually downward. In post-traumatic enophthalmos, the mechanisms that determine the globe position can be the enlargement of the orbital cavity, the herniation of orbital fat into the maxillary sinus, fat atrophy, loss of ligament support, and scar contracture. It can be reconstructed through several approaches such as transconjunctival, canthotomy, lower eye lid, coronal approach, and by using bone, cartilage, and alloplastic materials. The authors report a case of postoperative enophthalmos reconstructed through subciliary and transnasal endoscopic approaches using porous polyethylene with embedded titanium.

Comparison of transconjunctival and lower lid subciliary approaches for orbital blowout fractures Medpor reconstruction

目的 对比两种不同切口进行眼眶爆裂性骨折多孔聚乙烯板Medpor修复的疗效.方法回顾性分析96例眼眶爆裂性骨折Medpor修复的手术效果,其中52例采用经结膜切口,44例采用经下睑缘下皮肤切口,术中均在分离还纳眶内容后植入修剪塑形的Medpor板.结果 术后眼球突出度较术前均有不同程度的提高,经下睑缘下皮肤切口组提高更为明显.术前存在复视者术后均有改善.经结膜切口组18例术后早期结膜水肿,经治疗后17例消失1例残余小肉芽肿;经下睑缘切口组2例局部瘢痕明显,2例轻度下睑收缩巩膜暴露.结论 两种切口行眼眶爆裂性骨折Medpor修复均可有效矫正眼球内陷及复视,但各有其优缺点,经结膜切口无可见瘢痕但术野小术后早期可出现结膜水肿及异物感;经下睑缘下皮肤切口术野暴露充分但术后可形成瘢痕,部分病例可形成下睑收缩或外翻.应根据具体情况选择最佳术式。

Subciliary versus swinging eyelid approach to the orbital floor

In this retrospective study, the authors compare the outcomes of two different approaches to the orbital floor: the classic subciliary versus the transconjunctival plus lateral canthotomy (swinging eyelid). Forty-five patients who underwent orbital surgery (47 approaches) for different indications (orbital fractures, correction of Grave's exophthalmos, tumours of the internal orbit and correction of enophthalmos in secondary trauma) were placed in two groups, depending on the approach. The long-term effects of the incisions, the outcome of the approach and the complications were recorded and compared. The minimum follow-up for inclusion in the study was 1 year. Twenty-three orbits underwent subciliary incision, and 24 underwent swinging eyelid. No ectropion or entropion was seen in any patient. For the swinging eyelid approach, complications included three cases (12.5%) of canthal malposition; for the subciliary approach, five cases (21.14%) of lagophthalmos and 10 visible scars were observed. Our findings show the advantages of the swinging eyelid: better aesthetic results, the same or greater exposure of the orbital floor and the caudal part of the lateral and medial walls, shorter surgical time (sutureless) and a less extended scar. Although in our experience this approach is preferable in orbital surgery, some indications for the subciliary still remain.

Arcus Marginalis Release in Blepharoplasty I: Technical Facilitation

Resection of intraorbital fat compartments in lower-lid blepharoplasty has been widely replaced by their realignment over the orbital rim. For older patients this usually includes an open subciliary approach with skin resection and orbicularis muscle modification. In younger patients this may be done transconjunctivally. Fixation of the adipose tissue is controversial. Whereas reliance of realignment on spontaneous prolapse may be unpredictable, suture fixations may be tedious and even cause scleral show or ectropion. A monofilament, double-armed, polypropylene suture on bent straight needles can be used safely to transfix the three compartments across maxilla and zygoma. These transcutaneous pullout sutures are simply fixed with steri-strips. After only 2 days the orbital fat will be sufficiently adherent to its new bed.

Surgical Treatment of Posttraumatic Enophthalmos With Diced Medpor Implants Through Mini-Lateral Canthoplasty Incision

High-density porous polyethylene (Medpor Surgical Implants, College Park, GA) enophthalmic implants are used in patients with sunken socket syndrome to augment the orbital volume. A transconjunctival or subciliary approach is used to access the orbital floor. We present a new approach for accessing the orbital floor using diced Medpor implants through a mini-lateral canthoplasty incision. Medpor particles diced about 1 x 1-cm diameter were inserted through alateral canthal incision to orbital floor. The advantages of this technique are limited incision, decreased postoperative edema, volumetric adjustability, and applicability under local anesthesia. Three cases with blow-out and neglected zygomaticomaxillary fractures underwent primary or secondary diced Medpor orbital implantation. No cases showed any implantial infection. Our preliminary results showed no complication, and this novel method seems to have no severe disadvantage in the surgical treatment of posttraumatic enophthalmos.

Comparison of the Postoperative Outcome in Pure Medial Orbital Fracture Among Three Groups

Many methods of surgical repair of pure medial orbital fractures have been reported. In this study, we discuss the outcome from the surgical corrections of hydroxyapatite (Biocoral) or porous polyethylene (Medpor) through subciliary approach, and the transnasal endoscopic corrections. Between March 1993 and July 2003, 63 patients were treated with porous polyethylene and 48 patients were treated with hydroxyapatite. Between August 2003 and December 2005, 50 patients were treated with transnasal endoscopic approach. Patients had at least 6 months' follow-up, and the records for diplopia, enophthalmos, and other postoperative complications were reviewed retrospectively. As a result, 1 patient from the group using porous polyethylene, 2 patients from the group using hydroxyapatite, and 1 patient from the endoscopic correction group had enophthalmos. Besides enophthalmos, no other complications were observed. There was no significant statistical correlation among 3 groups. In conclusion, a transnasal endoscopic correction may be considered a useful method for surgical repair of pure medial orbital fractures, with no external facial scar and excellent visualization and accuracy comparable to that of the subciliary approach.

Transconjunctival Septal Suture Repair for Lower Lid Blepharoplasty

The need for a safer lower-lid blepharoplasty procedure than the classic subciliary approach has long been recognized. In 1996, de la Plaza and de la Cruz first theorized septal suturing via a transconjunctival approach that preserves both muscle and infraorbital fat. This is the first report of a series of patients treated with this technique. The transconjunctival approach can avoid the complications of "scleral show" and changes in the shape of the aperture that are associated with the subciliary/muscle cutting approach to the fat pads. Transconjunctival septal suturing of the middle and medial fat bags was used to treat 78 consecutive patients (72 women and six men) with visible bulging fat of the lower eyelids. Some patients underwent simultaneous resection of fat from the lateral pad. Bulging fat in the middle and medial compartments was eliminated without overtreatment or undertreatment. Substantial but not total improvement in tear trough deformity was often observed. Aperture shape and lid level were preserved. The results achieved with this series of patients indicate that transconjunctival suture repair of the orbital septum is a safe, predictable, and effective treatment for bulging fat of the medial and middle fat pads of the lower eyelid. Changes in aperture shape and lid level can be avoided without the need for simultaneous lid-tightening procedures.

Contour Restoration of the Secondary Deformities of Zygomaticoorbital Fractures With Porous Polyethylene Implant

Inappropriate treatment or untreated fractures of the zygomaticoorbital area results in secondary deformities such as loss of malar projection, enophthalmos, and dystopia. Secondary deformities can be corrected with osteotomies, contour restoration, or a combination of both. Contour restoration can be performed with using onlay grafting with autogenous material or alloplastic implants. In this study, mild to moderate secondary deformities of zygomaticoorbital fractures were corrected with porous a polyethylene implant, which is a highly biocompatible, durable, and stable material. The number of patients who have no surgical treatment at the time of their initial injury was 15, whereas the number of patients who have an initial treatment that resulted in secondary deformities was seven. Twelve of 15 patients had only loss of cheek projection and three of the 15 patients had dystopia and loss of cheek projection. The remaining seven patients had secondary deformities resulting from skeletal surface contour abnormality as a result of comminuted fractures. In 17 of the patients, we used a subciliary approach while using the old incision scar for access in the remainder. In 22 patients, 24 implants were used. Porous polyethylene implant was carved outside in according to the existing contour deficit and was placed in the subperiosteal plane and fixed with titanium screws. The mean follow-up period was 13 months (range, 6-24 months). In this follow-up period, there was no implant extrusion, exposition, infection, or any complication resulting from subciliary incision. Patients were satisfied with the results. The best result can be achieved with porous polyethylene implant in contour restoration of mild to moderate secondary deformities of zygomaticoorbital fractures. The use of this implant in the zygomaticoorbital area is safe and has minimal morbidity.