Akademik Veri Yönetim Sistemi
ESPRAS Quadrennial Congress 2022, Porto, Portekiz, 5 - 07 Ekim 2022
WHY SHOULD WE NOT BE AFRAİD OF SUBCİLİARY İNCİSİONS İN MAXİLLOFACİAL
TRAUMAS?
Dokuz Eylul University Faculty of Medicine, Department of Plastic, Reconstructive and
Aesthetic Surgery, Izmir
Introduction: The lower eyelid is a complex structure consisting of anterior to posterior skin,
orbicularis oculi muscle, tars and conjunctiva, and containing mucous and sebaceous glands
in the subconjunctival region. The lower eyelid gains a different feature with the eyelash on
its free edge. With the opening and closing of the eyelids, a tear film is formed on the
conjunctiva and cornea, protecting the eye from drying out and allowing foreign bodies to be
thrown out. In addition, the orbicularis oculi muscle allows the tear ducts to open and close
during lid movements.
In addition to its anatomical importance, it is an important entrance gate for reaching
fracture lines in fractures of the bones around the eyes.Different incision techniques have
been described in the literature. The subciliary incision was first described by Converse in
1944. It is generally used in facial fractures such as traumatic blow-out injuries, infraorbital
rim and orbitozygomatic fractures. It has also been used in aesthetic surgeries of the lower
eyelid. Historically, only two subtypes, skin flap and skin-muscle flap were used. First of all,
only skin flap was used and the risk of skin necrosis and ectropion was found to be high in
this type. The skin-muscle flap contains the skin orbicularis oculi muscle and the dissection
continues deep into the orbicularis oculi muscle to the infraorbital rim. Modification of the
skin-muscle flap is a stepwise approach. This approach includes subciliary incision, removal
of a few millimeters of skin flap, leaving the orbicularis oculi muscle in the tar, and
separation of the muscle after advancing in the caudal direction. İn this study, we aimed to
share the results of the patients we treated with subsiliary incision for fracture reduction
and fixation in maxillofacial traumas.
Material-Method: This study was performed on patients treated with subciliary incision due
to maxillofacial fractures in the plastic surgery clinic of Dokuz Eylul University Hospital
between January 2015 and January 2022. Patients were retrospectively screened through
system records. All patients; age, gender, the eyelid of the subciliary incision, etiology,
comorbidities were recorded. The cases were followed up in the postoperative period and
the mean follow-up period was 11 months (range 6-54 months). The patients were
evaluated in terms of complications (ectropion, entropion, bad-looking scar, lagophthalmos).
All operations were performed under general anesthesia combined with local anesthesia
infiltration with epinephrine on the lower eyelid. Subciliary incisions were made 2 mm below
the ciliary line, the skin flap was elevated. After the tarsal part was passed, the submuscular
plane was entered and advanced as a skin-muscle flap, and the infraorbital rim was reached
by preseptal dissection. After fracture repair, the orbicular muscle was sutured with
absorbable monoflaman suture (Glycomer 631) and the skin was sutured subcutically with
the same suture.
Patients with a follow-up period of less than 6 months were excluded from evaluation for
ectropion and scleral show because these symptoms usually subsided or disappeared after
this period.
Results: A total of 182 patients, 113 men and 69 women, were operated using subciliary
incision due to fractures within the specified date range. 58 patients who delayed their
follow-up in less than 6 months were excluded from the study. 75 men, 49 with an age range
of 16-61. A total of 124 female patients were included in the study. The mean age was 32.4
years.
Considering the etiologies of fractures, motor vehicle accidents were 72 (58%), falls from
height 21 (17%), assault 17 (13.7%), other causes (sports accidents, work accidents, etc.)
were 14 (11.3%). According to the direction of the subciliary incision made due to the
fracture, the left lower eyelid was 50 (40%), the right lower eyelid was 43 (35%), and the
bilateral lower eyelid was 31 (25%). The cases were followed up in the postoperative period
and the mean follow-up period was 11 months ( The range was 6 months to 54 months).
Massage was recommended for mild ectropion and scleral show in the first 6 months, while
tapes were applied to support the lower eyelid at night in addition to more advanced cases.
At the end of 6 months, 2 (1.6%) patients were found to have persistent ectropion. These
patients were repaired with cantopexy and FTSG. Ectropion was not observed in these
patients in the postoperative period. These two patients who developed ectropion also had
additional lacerations around the eyes due to trauma. Entropion and lagophthalmos were
not observed in any of the patients. Additional operation was not considered. Incision scars
healed moderately in all patients, and scar revision was not required in any of the patients.
Discussion: Subciliary approach can be used in blepharoplasty, maxillofacial fracture repair,
extranal dacriocystorhinostomy, maxillectomy, nasal bone reduction. Transient/permanent
ectropion is the most common complication after subciliary approach. Usually, temporary
ectropion occurs and resolves within 6 months without the need for surgery with
conventional wound tracing and massage. In particular, the subciliary approach, where only
the skin flap is removed, was associated with a high ectropion rate of 42%. However, both
temporary and permanent ectropion rates were found to be significantly lower in the skin-
muscle flap approach. Ozakpinar et al. in 2015, he published that while ectropion occurred in
20% of the patients who were operated with the skin flap technique, no ectropion was
observed at the end of 1 year in the patients who were operated with the skin-muscle flap
technique. Pausch et al. In 2016, they reported transient ectropion in 12 (5.3%) and
permanent ectropion in 8 (3.6%) of 225 patients after six months of follow-up in 225
patients with a subciliary approach with a skin-muscle flap. Salgarelli et al. reported no
ectropion after subciliary incisions and only 1.3% scleral show in their study involving 274
patients.
Although the complication rates are so variable, alternative approaches have been described
in the literature instead of subciliary incision. The subtarsal approach has a low risk of
ectropion or scleral show, but often results in a visible and rarely hypertrophic scar. While
the subciliary approach heals with a less visible scar, it comes with an increased risk of
ectropion and scleral show. Finally, postoperative entropion and canthal malposition have
been described, although the transconjunctival approach has been found to have a lower
risk of ectropion in some publications. In addition, repeated surgery with the
transconjunctival approach increases the risk of permanent eyelid complications.
Ectropion is caused by loss of muscle tone or scar tissue between the orbicularis oculi muscle
and surrounding soft tissue. Permanent ectropion rates were found to be lower in our study
compared to the literature. We found that the presence of additional lacerations due to
trauma other than subciliary incision in patients with ectropion increased the risk of
ectropion. We believe that retractions that cause folding and severe retraction of the
muscle-skin flap during fracture fixation will increase the risks of ectropion and bad-looking
scars in the postoperative period.
Key words: maxillofacial, subciliary, tarsoconjunctival, ectropion