PEDIATRIC/CRANIOFACIAL

Evaluation of Subciliary Incision Used inBlowout Fracture Treatment: PretarsalFlattening after Lower Eyelid Surgery

Yong Kyu Kim, M.D.Jae Won Kim, M.D.

Goyang, Korea

Background: The skin-muscle flap has been widely used for many years in eyelidsurgery. However, lid retraction and pretarsal flattening are considerable cosmeticcomplications. Furthermore, it has also been reported that damage of the zygomaticbranch reduces muscle tone and contributes to the development of various com-plications. The authors investigated whether denervation of the zygomatic branchaffects lid retraction and pretarsal flattening in pure blowout fractures.Methods: The authors studied 286 unilateral pure blowout fracture patients fromJanuary of 2005 to December of 2006. Mean patient age was 35.6 years (range, 9to 72 years), the male-to-female ratio was 1.7:1, and the mean follow-up period was28 months (range, 19 to 40 months). No patients had undergone eyelid surgerypreviously. Eyelid tone was evaluated using the snap test and the lid distraction test.Pretarsal shape was evaluated using photographs, which were presented to threeplastic surgeons and six medical students unaware of surgical information.Results: Increased laxity was found in only 13 patients (4.5 percent). When viewingphotographic comparisons, medical students noticed visible scars in 10 patients (3.5percent), pretarsal flattening in eight patients (2.8 percent), and eyelid malpositionin eight patients (2.8 percent), whereas the plastic surgeons noticed visible scars in10 cases (3.5 percent), pretarsal flattening in 10 cases (3.5 percent), and eyelidmalposition in nine cases (3.1 percent).Conclusions: In this study, it can be inferred that pretarsal flattening may not bea problem associated with the skin-muscle flap itself accompanying denervation ofthe zygomatic branch. Instead, technical expertise, conservation of the buccalbranch, and meticulous hemostasis are essential for the prevention ofcomplications. (Plast. Reconstr. Surg. 125: 1479, 2010.)

Regardless of whether plastic surgery is con-ducted for aesthetic purposes or for treatingtrauma,1–4 subciliary or transconjunctival ap-

proaches to lower eyelid operations may be con-sidered. Since the skin-muscle flap was first de-scribed by Beare5 in 1967, the subciliary approachhas been widely used for lower eyelid surgery.However, Tomlinson and Hovey6 and Carraway7

described a transconjunctival approach for lowereyelid operations devised to minimize the variouscomplications associated with lower eyelid sur-gery. The representative complications of the sub-ciliary approach include scleral show and ectro-

pion caused by lower lid retraction, and, from thecosmetic perspective, lower eyelid flattening (pre-tarsal muscle roll disappearance) caused by re-duced lower eyelid pretarsal muscle volume. Inparticular, this latter complication appears as ev-idence of the aging process in the orbital regionbecause pretarsal muscle roll is characteristic of ayouthful face. As a result, pretarsal flatteningshould be avoided, especially in cosmetic lowereyelid surgery. Changes in lower eyelid shape afterlower eyelid surgery have been reported to occurat a rate of 5 to 30 percent,8–12 and many studieshave been undertaken to ascertain the reasons forthese complications. We questioned whether pre-tarsal flattening and other complications follow-

From the Department of Plastic and Reconstructive Surgery,Inje University Ilsan Paik Hospital.Received for publication June 28, 2009; accepted November20, 2009.Copyright ©2010 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e3181d5120d

Disclosure: The authors have no financial interestto declare in relation to the content of this article.

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ing cosmetic lower eyelid surgery are associatedwith a skin-muscle flap approach itself. To com-pare shape changes of lower eyelid objectively, weused 286 unilateral blowout fracture patient whohad orbital wall reconstruction surgery.

PATIENTS AND METHODSFrom January of 2005 to December of 2006, 286

patients treated at the plastic surgery department ofour hospital with denervation of the zygomaticbranch during subciliary incision using a skin-mus-cle flap for pure unilateral blowout fractures wereenrolled in the present study. The procedure con-sisted of dissection of the orbicularis oculi muscle,leaving a 3- to 5-mm strip of pretarsal muscle (Fig. 1).The subciliary incision line should not pass the punc-tum on the medial side. Furthermore, an intraop-erative dissection of the medial side should be min-imized. The mean patient age was 35.6 years (range,9 to 72 years), the male-to-female ratio was 1.7:1, andthe mean follow-up period was 28 months (range, 19to 40 months). No patient had undergone previouslower eyelid surgery. Furthermore, patients weretreated by the same surgeon, and all patients com-pleted prescribed follow-up procedures. The snap

test and lid distraction test were conducted duringfollow-up visits, and postoperative photographs werecompared with those from the unaffected, contralat-eral side by three plastic surgeons not involved inpatient care and by six medical students unaware ofsurgical information. This evaluation was performedbased on an analysis of the clinical results that wereobtained between postoperative months 19 and 28,when all of the patient data were available. Reviewerswere asked to compare perceptible scar, pretarsalflattening, and lower eyelid malposition (scleralshow or ectropion) between the site that had beenoperated on and the contralateral side with refer-ence to the postoperative follow-up photographsbased on preoperative photographs obtained dur-ing the above period. For the use of recognizablephotographs, patients gave written consent.

RESULTSPreoperatively, an accurate assessment of the

laxity on the fractured side was difficult. On preop-erative evaluation, however, there were no patientsin whom the laxity was markedly increased on thenormal side. In the present study, normal and op-erated sides were compared after surgery. Increased

Fig. 1. Intraoperative view of the zygomatic branch of the facialnerve. Vertical nerve branches are seen; the incision does notreach the medial aspect of the punctum. Fig. 2. The distribution of complication cases (n � 21).

Table 1. Comparisons of the Results Obtained Using Normal Sides as Controls (n � 286)

Medical Students (%) Plastic Surgeons (%)

� – � –

Perceptible scar 10 (3.5)* 276 (96.5) 10 (3.5)* 276 (96.5)Pretarsal flattening 8 (2.8)† 278 (97.2) 10 (3.5) 276 (96.5)Lower eyelid malpositions (scleral show or ectropion) 8 (2.8)† 278 (97.2) 9 (3.1) 277 (97.2)Laxity alteration — — 13 (4.5) 273 (95.5)*They were found to be the same patients from evaluations performed by medical students and plastic surgeons.†All of the results of medical students were included in those of plastic surgeons.

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laxity was found in 13 cases (4.5 percent). Compar-isons of photographs were performed by three plas-tic surgeons (who were unaware of surgical infor-mation) and six medical students, who assessed the

following: perceptible scar, flattening of the lowereyelid pretarsal area, and lower eyelid malposition.Data on scars were collected by medical students,who determined that 10 patients were unsatisfied

Fig. 3. (Above, left) Postoperative image at 38 months of a 30-year-old man who underwent left orbital wall reconstruction bymeans of a skin-muscle flap. The pretarsal muscle roll is preserved and no scar is visible. (Above, right) Postoperative image at 33months of a 36-year-old man who underwent left orbital wall reconstruction by means of a skin-muscle flap. A slight crease is notedon the left lower eyelid but pretarsal muscle roll is preserved. (Center, left) Postoperative image at 37 months of a 45-year-old manwho underwent left orbital wall reconstruction by means of a skin-muscle flap. Mild ectropion is noted on the left lower eyelid, butpretarsal muscle roll is preserved. (Center, right) Postoperative image at 35 months of a 70-year-old man who underwent left orbitalwall reconstruction by means of a skin-muscle flap. There is no ectropion or visible scar. (Below) Postoperative image at 35 monthsof a 25-year-old man who underwent right orbital wall reconstruction by skin-muscle flap. The contour change is noted slightly,but no ectropion or pretarsal muscle roll change is seen.

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(3.5 percent); and by three plastic surgeons (blindedto the surgery type), who reported perceptible scarsin the same 10 cases (3.5 percent) as well. Lowereyelid pretarsal flattening was reported in eight cases(2.8 percent) by medical students and in 10 cases(3.5 percent) by the plastic surgeons on operatedsides compared with normal sides. Lower eyelid mal-position (scleral show or ectropion) was also ob-served in eight cases (2.8 percent) by medical stu-dents and nine cases (3.1 percent) by plasticsurgeons (Table 1 and Figs. 2 and 3).

DISCUSSIONTranscutaneous blepharoplasty using a skin

flap was first described by Castanares13 in 1951,and Beare,5 in 1967, described the skin-muscleflap and the subciliary approach, which continuesto be widely used for lower eyelid surgery. How-ever, the skin-muscle flap by means of the subcili-ary approach has been shown to have several at-tendant problems, which has encouraged othersto try alternative approaches. The zygomatic branchof the facial nerve is a motor branch that innervatesthe orbicularis oculi muscle, and damage to thisnerve has been associated with lower eyelid surgicalapproaches used to manage trauma or in aestheticsurgery. A transconjunctival approach is useful foravoiding orbital septum injury (which is a causativefactor of lid retraction) and also for avoiding zygo-matic branch injury. As a result, the transconjunc-tival approach is now considered an acceptable al-ternative to the subciliary approach and has been thesubject of several studies.11,14–16

In 1990, Carraway and Mellow7,17 recom-mended that a deep dissection be made to muscleson the lateral side of the lower eyelid area toprevent denervation of the orbicularis oculi mus-cle during skin-muscle flap surgical management.This method was based on the belief that the path-way of the zygomatic branch initiates from thelateral side and that it then runs to the orbicularisoculi. However, since then, the pathway of thezygomatic branch has been clarified, and deepdissection from the lateral side is known to beunnecessary. Nevertheless, it remains to be deter-mined whether the zygomatic branch of the facialnerve is involved in lower eyelid changes.

Wray et al.1 reported that the subciliary ap-proach causes a higher incidence of adverse ef-fects than other surgical approaches. Further-more, other studies have concluded that damageof the zygomatic branch of the facial nerve is acrucial etiologic factor for sclera show, ectropion,and pretarsal flattening caused by loss of muscletone of the lower eyelid.4,11,14,17–24

In contrast, in 1995, Netscher et al.12 undertooka study on the effect of denervation of the orbicularisoculi muscle on lower eyelid shape using the sub-ciliary approach and a skin-muscle flap, and foundno significant difference between the two when thetransconjunctival and subciliary approaches wereused on right and left sides, respectively. In 2005,DiFrancesco et al.25 compared preoperative andpostoperative pretarsal electromyographic findingsafter lower blepharoplasty using a conventional sub-ciliary incision. Meanwhile, these authors cited thereports by McCord et al.26 (that a myoneurectomy oforbicularis oculi muscle was performed for the treat-ment of benign essential blepharospasm) and byLowry et al.27 They concluded that complicationsafter lower blepharoplasty cannot be explained bydenervation of the zygomatic branch.

Moreover, recently published authoritative ana-tomical studies have revealed that the zygomaticbranches form fascicles by means of positioning un-derneath the subciliary orbicularis oculi muscle andsegmentally innervating nearly vertical to muscle,and revealed no existence of functionally dominantbranches24,28,29 (Fig. 4). Because the medial side ofthe nerve fascicle is composed mainly of zygomaticbranches and buccal branches, and the lateral side

Fig. 4. Schematic image of periorbital nerve innervations. Zygo-matic branches form fascicles by means of positioning under-neath the orbicularis oculi muscle and are segmentally inner-vated nearly vertical to muscle. The medial side nerve fasciclesare composed mainly of zygomatic branches and buccalbranches.

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nerve fascicle is innervated mainly from the zygo-matic branches, preservation of the medial segmentbranch is important for innervation of the orbicu-laris oculi muscle. This can also be confirmed byfunctional impairment of the lower eyelid seen incases in which the medial side fascicle was damagedduring Mohs’ surgery or dacryocystorhinostomy be-cause it was medially restricted. Accordingly, whensurgery was performed using a skin-muscle flap witha subciliary approach, conservation of the buccalbranch forming the plexus on the medial sideshould be given more priority.

In the present study, skin-muscle flaps were per-formed using a subciliary approach to treat unilat-eral blowout fractures. Lower eyelid shape changesin patients with zygomatic branch denervation wereconfirmed by comparing lower eyelids on operatedand normal sides, as described above. In those casesin which a follow-up observation was available afterpostoperative month 28, there were no changes inthe lower eyelid shape (Fig. 3). The degree of asym-metry or malposition of the pretarsal area that canbe present before the onset of injury (unilateralblowout fracture) was used for comparison of the

Fig. 5. (Left) Preoperative images at 5 to 7 days after trauma. (Right) Postoperative long-term follow-up images.

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results with reference to a preoperative photograph(surgery was performed between 5 and 14 days afterthe onset of injury, and a preoperative photographwas taken on the date of surgery) (Fig. 5). Normalsides are probably most suitable for assessing lowereyelid changes in the pretarsal area postoperatively.Furthermore, in the present study, we recruited theassistance of blinded medical students and plasticsurgeons to ensure objectivity.30,31

CONCLUSIONSIn the current article, the number of patients

who presented with postoperative complications was21 (7.3 percent). Based on the results, it could notbe determined whether the incidence of complica-tions that are worrisome in cosmetic lower eyelidsurgery would be increased following the use of asubciliary approach with a skin-muscle flap. In par-ticular, the approach itself bears little relation to thepostoperative pretarsal flattening. Instead, technicalexpertise, delicate tissue management, and meticu-lous hemostasis are essential for the prevention ofcomplications. We recommend that conservation ofthe buccal branch be given greater priority.25–29

Yong Kyu Kim, M.D.Department of Plastic and Reconstructive Surgery

Inje University Ilsan Paik HospitalGoyang, 411-706, Koreapsinbrain@hotmail.com

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