Operative Complications of the Transconjunctival Inferior Fornix Approach CHRISTOPHER T. WESTFALL, MD, Lt Col, USAF MC,t JOHN W. SHORE, MD,t WILLIAM R. NUNERY, MD/ MICHAEL J. HAWES, MD, 3 MICHAEL J. YAREMCHUK, MD4
Abstract: The transconjunctival inferior fornix incision provides access to the floor, rim, lateral, and inferior medial walls of the orbit. Complications of this surgical approach to the orbit are known to be rare but heretofore have not been clearly defined. Over an 8-year period, in an estimated 1200 cases, the authors have encountered cicatricial entropion, lower eyelid retraction, canthal dehiscence, lower eyelid avulsion, canalicular laceration, buttonhole laceration of the lower eyelid, conjunctival chemosis, and lacrimal sac laceration. Attention to anatomic landmarks and sound surgical execution will prevent these com plications in most patients. Ophthalmology 1991; 98: 1525-1528
The transconjunctival fornix incision for orbital access has enjoyed increasing popularity in recent years. Partic ularly when combined with canthotomy and cantholysis, the incision provides wide exposure of the lateral wall, floor, and inferior medial wall of the orbit. Specifically, the procedure has been described for biopsy of orbital tumors, orbital decompression into the maxillary antrum and ethmoid sinuses, repair of the orbital rim and floor fractures, repair of trimalar fractures, and for lower blepharoplasty. A particularly beneficial aspect of the procedure is the hidden nature of the incision, resulting in excellent cosmesis. The inferior fornix approach to the orbit can be asso ciated with complications. During the past 8 years, the Originally received: March 5, 1991. Revision accepted: June 19, 1991. 1
Department of Eye Plastics and Orbital Surgery, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston. 2 Department of Ophthalmology, Midwest Eye Institute and Methodist Hospital of Indiana, Indianapolis. 3 Department of Ophthalmology, University of Colorado, Denver. 4 Department of Plastic Surgery, Massachusetts General Hospital and Har· vard Medical School, Boston. Presented at the 21st Annual Scientific Symposium of the American Society of Ophthalmic Plastic and Reconstructive Surgery, Atlanta, October 1990. Reprint requests to John W. Shore, MD, Director, Eye Plastic and Orbit Service, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114.
authors have used the inferior fornix incision in an esti mated 1200 cases. We have encountered several compli cations related to the procedure. These have tended to be infrequent and of a correctable nature. In this report we discuss the complications previously reported in the lit erature, tabulate the complications we have encountered, and suggest methods for minimizing surgical risk.
HISTORICAL REVIEW Tessier 1 credits Bourquett for describing the inferior fornix conjunctival approach in 1924 as a method for accomplishing lower blepharoplasty. A proliferation of applications for the incision began in the early 1970s. In 1971, Tenzel and Mille~ described the transconjunctival technique for the repair of small to medium sized floor fractures. Of their 23 patients, only one experienced a complication, and that was due to limited exposure. Tessier 1 reported his experience with the conjunctival ap proach to congenital malformations in 1973, and in that year Converse et al 3 advocated the incision as an approach to orbital floor fractures. They suggested that canthotomy would improve exposure and pointed out that the tech nical inconvenience of exposed orbital fat was counter balanced by the invisibility of the scar. Neither Tessier nor Converse et al addressed complications. Lynch et al4 added their acceptance of the incision in 1974. They echoed concerns about limitation of exposure, and cited 1525
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the risk of tearing the lower eyelid. They did not state whether they encountered this complication in their six patients. Articles by Habal and Chaset5 in 1974, Wray et al6 in 1977, and Holtmann et al 7 in 1981 sought to compare the conjunctival incision to other approaches to the in ferior orbit. Habal and Chaset listed complications of the infraciliary approach to be scar and ectropion. In contrast, they noted that the conjunctival approach led to vertical tears in the lower eyelid in 3 of their 11 patients. They pointed out that canthotomies had not been accomplished in these cases. Wray et al gave considerable impetus to the conjunctival approach when they systematically com pared 45 transconjunctival incisions with 45 subciliary incisions. An astounding number of ectropions ( 19 of 45 cases) were noted after the subciliary incision. Fortunately, 15 of these resolved without intervention, but 3 required surgical correction. In contrast, the transconjunctival in cision was associated with one lower eyelid laceration (no canthotomy), and one transient entropion. It is important to note that Wray et al's subciliary approach involved a skin flap and not a skin-muscle flap as reported by Heckler et al. 8 This latter approach has been used successfully by one of our authors (MJY) with a very low complication rate. In a follow-up to Wray et al's initial article, Holtmann et al studied alternative incisions. Thirty cases were ap proached by inferior lower eyelid incisions, entering the lid at the midpoint between the orbital rim and lash line. This technique resulted in one transient ectropion and two transient hypertrophic scars. Orbital rim incisions were associated with no complications. The authors con cluded that both incisions are acceptable approaches to the inferior orbit, but that improved exposure is at the expense of a visible but cosmetically acceptable scar. In his discussion of the article, 7 Converse emphasized the risk of vertical shortening of the lower eyelid with the subciliary approach. Interestingly, he refers to his 1973 article and intimates that the conjunctival approach is unnecessarily complicated and causes a vertical shortening of the eyelid. Application ofcanthotomy and cantholysis to the tran sconjunctival lower eyelid approach was emphasized by McCord and Moses9 in 1979. This addition to the tech nique results in improved exposure and would be expected to minimize the risk of tearing or avulsing the eyelid. Nunery 10 in 1985 carried this one step further when he recommended the severance of upper and lower canthal tendons to allow complete exposure of fractures of the zygoma. In 1987, Shore 11 emphasized the wide exposure and versatility provided by the transconjunctival fornix approach. A technical description ofthe procedure is pro vided in Shore's article. That same year, Manson et al 12 provided further discussion of the eyelid incision as an approach to the zygoma, and suggested complications in cluding ectropion, scleral show, and shortening of the or bital septum. Complications were not addressed in the articles by McCord and Moses, Nunery, or Shore. Baylis et aP 3 in 1989 discussed the transconjunctival approach in the setting originally proposed by Borquett in 1924, that of lower blepharoplasty. Complications en1526
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Table 1. Complications Noted in the Historical Review Author
Limited Eyelid Exposure Laceration Entropion Hemorrhage Granuloma
Tenzel and Miller 2 Habal and Chaset 5 Wray et al 6 Baylis et al 13 Goldberg et al 14
3
2
countered in his 122 cases included inadequate fat excision in 9 patients and postoperative hemorrhage in 1. Com plications listed but not encountered included lower eyelid retraction, ectropion, entropion, inferior oblique palsy, and overexcision of orbital fat. Goldberg et al 14 in 1990 prospectively looked at the complications associated with the incision in a series of 25 patients. They reported tran sient entropion in two patients and one case of suture granuloma. In summary, complications reported to date include limited exposure, tearing of the lower eyelid, transient entropion, laceration of the lower eyelid, suture granu loma, and postoperative hemorrhage. Additional theo retical complications not specifically reported to date in clude ectropion, scleral show, shortening of the orbital septum, and inferior oblique palsy (Table 1).
CASE REPORTS Case 1 (Medial Lower Eyelid Avulsion). A 27-year-old man underwent repair of a left zygomatic fracture through a trans conjunctival approach. No canthotomy was accomplished. Traction on the lower eyelid resulted in lower eyelid avulsion 2 mm nasal to the punctum with laceration of the canaliculus. Primary repair was accomplished. There were no sequelae. Case 2 (Lower Eyelid Avulsion). A 52-year-old woman un derwent orbital decompression for Graves ophthalmopathy. Canthotomy and inferior cantholysis were accomplished. Vig orous traction resulted in a full-thickness laceration of the lower eyelid lateral to the punctum. This was repaired primarily with out sequelae. Case 3 (Full-thickness Skin Laceration (Buttonhole)). A 45 year-old woman with Graves disease underwent bilateral orbital decompressions using the fornix approach in conjunction with a Berke lateral orbitotomy. During the fornix approach on the left side, a full-thickness horizontal laceration over the lateral inferior orbital rim was noted. The 1-cm "buttonhole" incision was repaired primarily and went on to heal with a small scar. Eyelid malposition did not develop. Case 4 (Full-thickness Skin Laceration (Buttonhole)). A 27 year-old man underwent surgery for repair of a right orbital floor fracture. After lateral canthotomy, the lower eyelid was everted with skin hooks. The orbital soft tissue was retracted with a malleable retractor. After conjunctival incision with a #15 Bard Parker blade, a full~thickness 15-mm horizontal eyelid
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laceration was noted 14 mm inferior Jo the lower eyelid margin. The cause of injury was believed to be an incision through a fold of eyelid trapped by instruments as the lower eyelid was everted. The eyelid defect was repaired with a layered closure in standard fashion after completing repair of the orbital floor fracture. At the 6-month follow-up visit, a fine horizontal lower eyelid scar was evident but eyelid function was normal. Eyelid malposition did not develop. Case 5 (Canthal Dehiscence). One week after the repair of a left orbital blowout fracture a 27-year-old man rubbed his lower eyelid in his sleep. The next day an ectropion was noted. The wound was explored under local anesthesia. The 4-0 Polydek suture was found to be loose deep in the wound at the lateral canthus. It appeared that the knot had become untied. The eyelid was reattached with another 4-0 Polydek suture. The patient was instructed not to rub his eyelid and was given a Fox shield to use at night. The eyelid healed in a normal position with no further complications. Case 6 (Cicatricial Entropion). A young man suffered a pan facial fracture that was repaired through transconjunctival, buc cal-gingival, and bicoronal incisions. Six months after surgery, the patient presented with a red, irritated eye and a cicatricial lower eyelid entropion. Extensive scarification of the lower eyelid necessitated release ofthe cicatrix with resurfacing ofthe bulbar surface and eyelid margins with a conjunctival autograft from the opposite eye and reconstruction ofthe posterior lamella with palatal mucosa. Postoperative recovery was uneventful. Case 7 (Lower Eyelid Retraction and Ectropion with Scleral Show). A 28-year-old woman sustained a right orbital floor and tripod fracture. She underwent primary repair through the lateral canthal inferior fornix approach. Postoperatively, she developed right lower eyelid retraction and mild marginal ectropion. The stiffened lower eyelid was retracted approximately 5 mm with resultant scleral show. The retraction was repaired by recessing the inferior eyelid retractors, elevating the lateral canthal tendon, and adding full thickness skin to the anterior lamella. Case 8 (Hematoma followed by Abscess). A man sustained a right orbital floor fracture, which was repaired through the fornix. Postoperatively, the patient developed a lower eyelid hematoma with progression to a secondary abscess. The abscess drained spontaneously 9 days later. The patient subsequently developed a slight foreign body sensation. Case 9 (Conjunctival Chemosis after Tripod Fracture Repair). A 21-year-old man suffered a tripod fracture approached through the fornix and a concurrent brow incision. Three days after sur gery, a significant inferior chemosis developed, necessitating the placement of a suture tarsorrhaphy for 5 days. The chemosis resolved. Case 10 (Lacrimal Sac Laceration). During the repair of an orbital floor fracture, exposure of the medial orbital floor was maintained with a Senn retractor. After placement of a silicone floor implant, a 4-mm rent was noted in the lateral aspect of lacrimal sac. The defect was oversewn with 7-0 Vicryl suture and the wound closed in a standard fashion. The nasolacrimal collecting system was not intubated. At the 6-month follow-up visit, the patient was free of epiphora. The nasolacrimal system irrigated freely into the nose. The eyelid was in normal anatomic position and the extraocular motility also was normal. A summary of our experience may be found in Table 2.
DISCUSSION The first two cases describe lower eyelid laceration sec ondary to vigorous retraction on the part of an assistant
Table 2. Tabulation of Complications Encountered by the Authors (8-year Cumulative Experience, Estimated 1200 Cases) Vertical eyelid laceration or avulsion Horizontal eyelid laceration (buttonhole) Canthal dehiscence Entropion Ectropion or lower lid retraction Hematoma (followed by abscess) Conjunctival chemosis Lacrimal sac laceration
2 2 1 1 1 1 1 1
attempting to improve intraoperative exposure. This complication is the most commonly reported in our his torical review. Preventive efforts should be directed toward the lysis of the lateral canthal tendon. This will improve exposure and at the same time relieve tension on the lower eyelid. In one of our cases, a generous canthotomy and cantholysis had been accomplished, and so this procedure will not completely prevent the complication. An aware ness of the potential for avulsion coupled with careful instruction for the assistant would seem to be appropriate. In those cases in which the fornix approach might not provide the required exposure, alternatives may be con sidered such as an orbital rim incision or sibciliary incision with a skin-muscle flap. Buttonhole lacerations of the lower eyelid occurred in cases 3 and 4 in our series. This problem has been pre viously noted in the literature. An awareness of the po tential is the surgeon's best defense. Eversion of the lower eyelid over an instrument such as a Desmarres retractor particularly predisposes to a full-thickness horizontal eye lid laceration. Attention to the details of placement of the tarsal fix ation suture at the internal aspect of the lateral orbital rim will often prevent dehiscence ofthe lower eyelid. We use a permanent suture, which must be placed into the periosteum. In those cases in which the periosteum is not intact or will not provide adequate support, small holes may be drilled at the lateral orbital rim to provide the necessary support for the suture. We recommend the use of a permanent suture such as Polydek or Prolene, with the appropriate number of knots to secure the chosen suture. Those cases (6 and 7) involving entropion, ectropion, and lower eyelid retraction probably relate to shortening of the middle or posterior lamella. Fortunately these complications are rare, particularly when compared with the incidence associated with the subciliary incision re ported by Holtmann et al. 7 Special care must be taken not to suture the orbital septum. We close only the con junctiva at the termination of the procedure. Separate sutures are not placed in the periosteum, septum, or lower eyelid retractors. We use a very fine absorbable suture for this layer, but a monofilament pull-out suture would be expected to have the same effect. In the event of early postoperative entropion, the fornix sutures may be re moved and eyelid massage employed to hasten resolution. The presence of conjunctival chemosis after repair of 1527
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tripod fracture through an inferior fornix incision has not been previously reported, although the pathophysiology is such that it might be a common occurrence. In fact, chemosis and subconjunctival hemorrhage are known to occur frequently with orbital fractures and blunt orbital trauma. In our series, only one such case was identified. Aside from the degree ofinjury, no other identifiable con tributory factors are evident. Resolution followed the placement of a marginal suture tarsorrhaphy for a few days. Consideration should be given to prophylactic placement of such sutures in patients predisposed to de veloping postoperative chemosis and in any patient in whom chemosis is present preoperatively or at the con clusion of surgery. The location ofthe lacrimal sac puts it at risk for injury during any approach to the orbital floor and inferior rim. Attention to anatomic detail and care during the medial dissection will probably prevent most injuries to this structure. Such an injury is easily identified by the excel lent exposure provided by the inferior fornix incision and may be less readily seen during other surgical approaches to the same area. We do not recommend intubating the collecting system during repair unless the laceration is extensive or associated with nasolacrimal duct fractures. 15 We identified no injuries to the inferior oblique muscle, and although Baylis lists this as a theoretical concern, no such occurrences have been reported. Nevertheless, it would behoove surgeons operating through the conjunc tival approach to be aware of the location ofthe origin of the muscle and to protect it during dissection.
SUMMARY Complications associated with the recently popularized inferior fornix approach to the orbit have been sporadi cally addressed in the literature. Our historical review pinpoints limited exposure, tearing (avulsion) of the lower eyelid, transient entropion, laceration (buttonhole) of the lower eyelid, suture granuloma, and postoperative hem orrhage as previously reported complications. A review ofour experience with approximately 1200 cases over the past 8 years has identified canthal dehiscence, ectropion, conjunctival chemosis, canalicular avulsion, lacrimal sac laceration, and abscess as additional complications. We have discussed contributory factors and methods for min
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imizing risk. Most complications will be prevented by at tention to anatomic landmarks and sound surgical exe cution.
ACKNOWLEDGMENT The authors thank Gary E. Borodic, MD, for contributing case material for this article.
REFERENCES 1. Tessier P. The conjunctival approach to the orbital floor and maxilla in congenital malformation and trauma. J Maxillofac Surg 1973; 1:3
8.
2. Tenzel RR, Miller GR. Orbital blow-out fracture repair, a conjunctival approach. Am J Ophthalmol1971; 71:1141-2. 3. Converse JM, Firmin F, Wood-Smith OJ, Friedland JA. The conjunctival approach in orbital fractures. Plast Reconstr Surg 1973; 52:656-7 . 4. Lynch OJ, Lamp JC, Royster HP. The conjunctival approach for ex· ploration of the orbital floor. Plast Reconstr Surg 1974; 54:153-6. 5. Habal MB, Chaset RB. lnfraciliary transconjunctival approach to the orbital floor for correction of traumatic lesions. Surg Gynecol Obstet 1974; 139:420-2. 6. Wray RC, Holtmann B, Ribaudo JM, et al. A comparison of conjunctival and subciliary incisions for orbital fractures. Br J Plast Surg 1977; 30: 142-5. 7. Holtmann B, Wray RC, Little AG. A randomized comparison of four incisions for orbital fractures. Plast Reconstr Surg 1981; 67:731-7. 8. Heckler FR, Songcharoen S, Sultani FA. Subciliary incision and skin· muscle eyelid flap for orbital fractures. Ann Plast Surg 1983; 10:309 13. 9. McCord CO Jr, Moses JL. Exposure of the inferior orbit with fornix incision and lateral canthotorny. Ophthalmic Surg 1979; 10(6):53-63. 10. Nunery WR. Lateral canthal approach to repair of trimalar fractures of the zygoma. Ophthalmic Plast Reconstr Surg 1985; 1:175-83. 11. Shore JW. The fornix approach to the inferior orbit. Adv Ophthalmic Plast Reconstr Surg 1987; 6:377-85. 12. Manson PN, Ruas E, Iliff N, Yaremchuk M. Single eyelid incision for exposure of the zygomatic bone and orbital reconstruction. Plast Re· constr Surg 1987; 79:120-6. 13. Baylis HI, Long JA, Groth MJ. Transconjunctivallower eyelid bleph· aroplasty: technique and complications. Ophthalmology 1989; 96: 1027-32. 14. Goldberg RA, Lessner AM, Shorr N, Baylis HI. The transconjunctival approach to the orbital floor and orbital fat. A prospective study. Ophthalmic Plast Reconstr Surg 1990; 6:241-6. 15. Harris GJ, Fuerste FH. Lacrimal intubation in the primary repair of midfacial fractures. Ophthalmology 1987; 94:242-7.
Abstract: The transconjunctival inferior fornix incision provides access to the floor, rim, lateral, and inferior medial walls of the orbit. Complications of this surgical approach to the orbit are known to be rare but heretofore have not been clearly defined. Over an 8-year period, in an estimated 1200 cases, the authors have encountered cicatricial entropion, lower eyelid retraction, canthal dehiscence, lower eyelid avulsion, canalicular laceration, buttonhole laceration of the lower eyelid, conjunctival chemosis, and lacrimal sac laceration. Attention to anatomic landmarks and sound surgical execution will prevent these com plications in most patients. Ophthalmology 1991; 98: 1525-1528
The transconjunctival fornix incision for orbital access has enjoyed increasing popularity in recent years. Partic ularly when combined with canthotomy and cantholysis, the incision provides wide exposure of the lateral wall, floor, and inferior medial wall of the orbit. Specifically, the procedure has been described for biopsy of orbital tumors, orbital decompression into the maxillary antrum and ethmoid sinuses, repair of the orbital rim and floor fractures, repair of trimalar fractures, and for lower blepharoplasty. A particularly beneficial aspect of the procedure is the hidden nature of the incision, resulting in excellent cosmesis. The inferior fornix approach to the orbit can be asso ciated with complications. During the past 8 years, the Originally received: March 5, 1991. Revision accepted: June 19, 1991. 1
Department of Eye Plastics and Orbital Surgery, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston. 2 Department of Ophthalmology, Midwest Eye Institute and Methodist Hospital of Indiana, Indianapolis. 3 Department of Ophthalmology, University of Colorado, Denver. 4 Department of Plastic Surgery, Massachusetts General Hospital and Har· vard Medical School, Boston. Presented at the 21st Annual Scientific Symposium of the American Society of Ophthalmic Plastic and Reconstructive Surgery, Atlanta, October 1990. Reprint requests to John W. Shore, MD, Director, Eye Plastic and Orbit Service, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114.
authors have used the inferior fornix incision in an esti mated 1200 cases. We have encountered several compli cations related to the procedure. These have tended to be infrequent and of a correctable nature. In this report we discuss the complications previously reported in the lit erature, tabulate the complications we have encountered, and suggest methods for minimizing surgical risk.
HISTORICAL REVIEW Tessier 1 credits Bourquett for describing the inferior fornix conjunctival approach in 1924 as a method for accomplishing lower blepharoplasty. A proliferation of applications for the incision began in the early 1970s. In 1971, Tenzel and Mille~ described the transconjunctival technique for the repair of small to medium sized floor fractures. Of their 23 patients, only one experienced a complication, and that was due to limited exposure. Tessier 1 reported his experience with the conjunctival ap proach to congenital malformations in 1973, and in that year Converse et al 3 advocated the incision as an approach to orbital floor fractures. They suggested that canthotomy would improve exposure and pointed out that the tech nical inconvenience of exposed orbital fat was counter balanced by the invisibility of the scar. Neither Tessier nor Converse et al addressed complications. Lynch et al4 added their acceptance of the incision in 1974. They echoed concerns about limitation of exposure, and cited 1525
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the risk of tearing the lower eyelid. They did not state whether they encountered this complication in their six patients. Articles by Habal and Chaset5 in 1974, Wray et al6 in 1977, and Holtmann et al 7 in 1981 sought to compare the conjunctival incision to other approaches to the in ferior orbit. Habal and Chaset listed complications of the infraciliary approach to be scar and ectropion. In contrast, they noted that the conjunctival approach led to vertical tears in the lower eyelid in 3 of their 11 patients. They pointed out that canthotomies had not been accomplished in these cases. Wray et al gave considerable impetus to the conjunctival approach when they systematically com pared 45 transconjunctival incisions with 45 subciliary incisions. An astounding number of ectropions ( 19 of 45 cases) were noted after the subciliary incision. Fortunately, 15 of these resolved without intervention, but 3 required surgical correction. In contrast, the transconjunctival in cision was associated with one lower eyelid laceration (no canthotomy), and one transient entropion. It is important to note that Wray et al's subciliary approach involved a skin flap and not a skin-muscle flap as reported by Heckler et al. 8 This latter approach has been used successfully by one of our authors (MJY) with a very low complication rate. In a follow-up to Wray et al's initial article, Holtmann et al studied alternative incisions. Thirty cases were ap proached by inferior lower eyelid incisions, entering the lid at the midpoint between the orbital rim and lash line. This technique resulted in one transient ectropion and two transient hypertrophic scars. Orbital rim incisions were associated with no complications. The authors con cluded that both incisions are acceptable approaches to the inferior orbit, but that improved exposure is at the expense of a visible but cosmetically acceptable scar. In his discussion of the article, 7 Converse emphasized the risk of vertical shortening of the lower eyelid with the subciliary approach. Interestingly, he refers to his 1973 article and intimates that the conjunctival approach is unnecessarily complicated and causes a vertical shortening of the eyelid. Application ofcanthotomy and cantholysis to the tran sconjunctival lower eyelid approach was emphasized by McCord and Moses9 in 1979. This addition to the tech nique results in improved exposure and would be expected to minimize the risk of tearing or avulsing the eyelid. Nunery 10 in 1985 carried this one step further when he recommended the severance of upper and lower canthal tendons to allow complete exposure of fractures of the zygoma. In 1987, Shore 11 emphasized the wide exposure and versatility provided by the transconjunctival fornix approach. A technical description ofthe procedure is pro vided in Shore's article. That same year, Manson et al 12 provided further discussion of the eyelid incision as an approach to the zygoma, and suggested complications in cluding ectropion, scleral show, and shortening of the or bital septum. Complications were not addressed in the articles by McCord and Moses, Nunery, or Shore. Baylis et aP 3 in 1989 discussed the transconjunctival approach in the setting originally proposed by Borquett in 1924, that of lower blepharoplasty. Complications en1526
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Table 1. Complications Noted in the Historical Review Author
Limited Eyelid Exposure Laceration Entropion Hemorrhage Granuloma
Tenzel and Miller 2 Habal and Chaset 5 Wray et al 6 Baylis et al 13 Goldberg et al 14
3
2
countered in his 122 cases included inadequate fat excision in 9 patients and postoperative hemorrhage in 1. Com plications listed but not encountered included lower eyelid retraction, ectropion, entropion, inferior oblique palsy, and overexcision of orbital fat. Goldberg et al 14 in 1990 prospectively looked at the complications associated with the incision in a series of 25 patients. They reported tran sient entropion in two patients and one case of suture granuloma. In summary, complications reported to date include limited exposure, tearing of the lower eyelid, transient entropion, laceration of the lower eyelid, suture granu loma, and postoperative hemorrhage. Additional theo retical complications not specifically reported to date in clude ectropion, scleral show, shortening of the orbital septum, and inferior oblique palsy (Table 1).
CASE REPORTS Case 1 (Medial Lower Eyelid Avulsion). A 27-year-old man underwent repair of a left zygomatic fracture through a trans conjunctival approach. No canthotomy was accomplished. Traction on the lower eyelid resulted in lower eyelid avulsion 2 mm nasal to the punctum with laceration of the canaliculus. Primary repair was accomplished. There were no sequelae. Case 2 (Lower Eyelid Avulsion). A 52-year-old woman un derwent orbital decompression for Graves ophthalmopathy. Canthotomy and inferior cantholysis were accomplished. Vig orous traction resulted in a full-thickness laceration of the lower eyelid lateral to the punctum. This was repaired primarily with out sequelae. Case 3 (Full-thickness Skin Laceration (Buttonhole)). A 45 year-old woman with Graves disease underwent bilateral orbital decompressions using the fornix approach in conjunction with a Berke lateral orbitotomy. During the fornix approach on the left side, a full-thickness horizontal laceration over the lateral inferior orbital rim was noted. The 1-cm "buttonhole" incision was repaired primarily and went on to heal with a small scar. Eyelid malposition did not develop. Case 4 (Full-thickness Skin Laceration (Buttonhole)). A 27 year-old man underwent surgery for repair of a right orbital floor fracture. After lateral canthotomy, the lower eyelid was everted with skin hooks. The orbital soft tissue was retracted with a malleable retractor. After conjunctival incision with a #15 Bard Parker blade, a full~thickness 15-mm horizontal eyelid
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laceration was noted 14 mm inferior Jo the lower eyelid margin. The cause of injury was believed to be an incision through a fold of eyelid trapped by instruments as the lower eyelid was everted. The eyelid defect was repaired with a layered closure in standard fashion after completing repair of the orbital floor fracture. At the 6-month follow-up visit, a fine horizontal lower eyelid scar was evident but eyelid function was normal. Eyelid malposition did not develop. Case 5 (Canthal Dehiscence). One week after the repair of a left orbital blowout fracture a 27-year-old man rubbed his lower eyelid in his sleep. The next day an ectropion was noted. The wound was explored under local anesthesia. The 4-0 Polydek suture was found to be loose deep in the wound at the lateral canthus. It appeared that the knot had become untied. The eyelid was reattached with another 4-0 Polydek suture. The patient was instructed not to rub his eyelid and was given a Fox shield to use at night. The eyelid healed in a normal position with no further complications. Case 6 (Cicatricial Entropion). A young man suffered a pan facial fracture that was repaired through transconjunctival, buc cal-gingival, and bicoronal incisions. Six months after surgery, the patient presented with a red, irritated eye and a cicatricial lower eyelid entropion. Extensive scarification of the lower eyelid necessitated release ofthe cicatrix with resurfacing ofthe bulbar surface and eyelid margins with a conjunctival autograft from the opposite eye and reconstruction ofthe posterior lamella with palatal mucosa. Postoperative recovery was uneventful. Case 7 (Lower Eyelid Retraction and Ectropion with Scleral Show). A 28-year-old woman sustained a right orbital floor and tripod fracture. She underwent primary repair through the lateral canthal inferior fornix approach. Postoperatively, she developed right lower eyelid retraction and mild marginal ectropion. The stiffened lower eyelid was retracted approximately 5 mm with resultant scleral show. The retraction was repaired by recessing the inferior eyelid retractors, elevating the lateral canthal tendon, and adding full thickness skin to the anterior lamella. Case 8 (Hematoma followed by Abscess). A man sustained a right orbital floor fracture, which was repaired through the fornix. Postoperatively, the patient developed a lower eyelid hematoma with progression to a secondary abscess. The abscess drained spontaneously 9 days later. The patient subsequently developed a slight foreign body sensation. Case 9 (Conjunctival Chemosis after Tripod Fracture Repair). A 21-year-old man suffered a tripod fracture approached through the fornix and a concurrent brow incision. Three days after sur gery, a significant inferior chemosis developed, necessitating the placement of a suture tarsorrhaphy for 5 days. The chemosis resolved. Case 10 (Lacrimal Sac Laceration). During the repair of an orbital floor fracture, exposure of the medial orbital floor was maintained with a Senn retractor. After placement of a silicone floor implant, a 4-mm rent was noted in the lateral aspect of lacrimal sac. The defect was oversewn with 7-0 Vicryl suture and the wound closed in a standard fashion. The nasolacrimal collecting system was not intubated. At the 6-month follow-up visit, the patient was free of epiphora. The nasolacrimal system irrigated freely into the nose. The eyelid was in normal anatomic position and the extraocular motility also was normal. A summary of our experience may be found in Table 2.
DISCUSSION The first two cases describe lower eyelid laceration sec ondary to vigorous retraction on the part of an assistant
Table 2. Tabulation of Complications Encountered by the Authors (8-year Cumulative Experience, Estimated 1200 Cases) Vertical eyelid laceration or avulsion Horizontal eyelid laceration (buttonhole) Canthal dehiscence Entropion Ectropion or lower lid retraction Hematoma (followed by abscess) Conjunctival chemosis Lacrimal sac laceration
2 2 1 1 1 1 1 1
attempting to improve intraoperative exposure. This complication is the most commonly reported in our his torical review. Preventive efforts should be directed toward the lysis of the lateral canthal tendon. This will improve exposure and at the same time relieve tension on the lower eyelid. In one of our cases, a generous canthotomy and cantholysis had been accomplished, and so this procedure will not completely prevent the complication. An aware ness of the potential for avulsion coupled with careful instruction for the assistant would seem to be appropriate. In those cases in which the fornix approach might not provide the required exposure, alternatives may be con sidered such as an orbital rim incision or sibciliary incision with a skin-muscle flap. Buttonhole lacerations of the lower eyelid occurred in cases 3 and 4 in our series. This problem has been pre viously noted in the literature. An awareness of the po tential is the surgeon's best defense. Eversion of the lower eyelid over an instrument such as a Desmarres retractor particularly predisposes to a full-thickness horizontal eye lid laceration. Attention to the details of placement of the tarsal fix ation suture at the internal aspect of the lateral orbital rim will often prevent dehiscence ofthe lower eyelid. We use a permanent suture, which must be placed into the periosteum. In those cases in which the periosteum is not intact or will not provide adequate support, small holes may be drilled at the lateral orbital rim to provide the necessary support for the suture. We recommend the use of a permanent suture such as Polydek or Prolene, with the appropriate number of knots to secure the chosen suture. Those cases (6 and 7) involving entropion, ectropion, and lower eyelid retraction probably relate to shortening of the middle or posterior lamella. Fortunately these complications are rare, particularly when compared with the incidence associated with the subciliary incision re ported by Holtmann et al. 7 Special care must be taken not to suture the orbital septum. We close only the con junctiva at the termination of the procedure. Separate sutures are not placed in the periosteum, septum, or lower eyelid retractors. We use a very fine absorbable suture for this layer, but a monofilament pull-out suture would be expected to have the same effect. In the event of early postoperative entropion, the fornix sutures may be re moved and eyelid massage employed to hasten resolution. The presence of conjunctival chemosis after repair of 1527
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tripod fracture through an inferior fornix incision has not been previously reported, although the pathophysiology is such that it might be a common occurrence. In fact, chemosis and subconjunctival hemorrhage are known to occur frequently with orbital fractures and blunt orbital trauma. In our series, only one such case was identified. Aside from the degree ofinjury, no other identifiable con tributory factors are evident. Resolution followed the placement of a marginal suture tarsorrhaphy for a few days. Consideration should be given to prophylactic placement of such sutures in patients predisposed to de veloping postoperative chemosis and in any patient in whom chemosis is present preoperatively or at the con clusion of surgery. The location ofthe lacrimal sac puts it at risk for injury during any approach to the orbital floor and inferior rim. Attention to anatomic detail and care during the medial dissection will probably prevent most injuries to this structure. Such an injury is easily identified by the excel lent exposure provided by the inferior fornix incision and may be less readily seen during other surgical approaches to the same area. We do not recommend intubating the collecting system during repair unless the laceration is extensive or associated with nasolacrimal duct fractures. 15 We identified no injuries to the inferior oblique muscle, and although Baylis lists this as a theoretical concern, no such occurrences have been reported. Nevertheless, it would behoove surgeons operating through the conjunc tival approach to be aware of the location ofthe origin of the muscle and to protect it during dissection.
SUMMARY Complications associated with the recently popularized inferior fornix approach to the orbit have been sporadi cally addressed in the literature. Our historical review pinpoints limited exposure, tearing (avulsion) of the lower eyelid, transient entropion, laceration (buttonhole) of the lower eyelid, suture granuloma, and postoperative hem orrhage as previously reported complications. A review ofour experience with approximately 1200 cases over the past 8 years has identified canthal dehiscence, ectropion, conjunctival chemosis, canalicular avulsion, lacrimal sac laceration, and abscess as additional complications. We have discussed contributory factors and methods for min
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imizing risk. Most complications will be prevented by at tention to anatomic landmarks and sound surgical exe cution.
ACKNOWLEDGMENT The authors thank Gary E. Borodic, MD, for contributing case material for this article.
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2. Tenzel RR, Miller GR. Orbital blow-out fracture repair, a conjunctival approach. Am J Ophthalmol1971; 71:1141-2. 3. Converse JM, Firmin F, Wood-Smith OJ, Friedland JA. The conjunctival approach in orbital fractures. Plast Reconstr Surg 1973; 52:656-7 . 4. Lynch OJ, Lamp JC, Royster HP. The conjunctival approach for ex· ploration of the orbital floor. Plast Reconstr Surg 1974; 54:153-6. 5. Habal MB, Chaset RB. lnfraciliary transconjunctival approach to the orbital floor for correction of traumatic lesions. Surg Gynecol Obstet 1974; 139:420-2. 6. Wray RC, Holtmann B, Ribaudo JM, et al. A comparison of conjunctival and subciliary incisions for orbital fractures. Br J Plast Surg 1977; 30: 142-5. 7. Holtmann B, Wray RC, Little AG. A randomized comparison of four incisions for orbital fractures. Plast Reconstr Surg 1981; 67:731-7. 8. Heckler FR, Songcharoen S, Sultani FA. Subciliary incision and skin· muscle eyelid flap for orbital fractures. Ann Plast Surg 1983; 10:309 13. 9. McCord CO Jr, Moses JL. Exposure of the inferior orbit with fornix incision and lateral canthotorny. Ophthalmic Surg 1979; 10(6):53-63. 10. Nunery WR. Lateral canthal approach to repair of trimalar fractures of the zygoma. Ophthalmic Plast Reconstr Surg 1985; 1:175-83. 11. Shore JW. The fornix approach to the inferior orbit. Adv Ophthalmic Plast Reconstr Surg 1987; 6:377-85. 12. Manson PN, Ruas E, Iliff N, Yaremchuk M. Single eyelid incision for exposure of the zygomatic bone and orbital reconstruction. Plast Re· constr Surg 1987; 79:120-6. 13. Baylis HI, Long JA, Groth MJ. Transconjunctivallower eyelid bleph· aroplasty: technique and complications. Ophthalmology 1989; 96: 1027-32. 14. Goldberg RA, Lessner AM, Shorr N, Baylis HI. The transconjunctival approach to the orbital floor and orbital fat. A prospective study. Ophthalmic Plast Reconstr Surg 1990; 6:241-6. 15. Harris GJ, Fuerste FH. Lacrimal intubation in the primary repair of midfacial fractures. Ophthalmology 1987; 94:242-7.
