Original Investigation
Tear Trough Incision for External Dacryocystorhinostomy Brett W. Davies, M.D., M.S.*, Michael S. McCracken, M.D.†, Michael J. Hawes, M.D., F.A.C.S.‡, Eric M. Hink, M.D.*, Vikram D. Durairaj, M.D., F.A.C.S.*§, and Ron W. Pelton, M.D., Ph.D., F.A.C.S.║ *Oculofacial Plastic and Orbital Surgery, University of Colorado Hospital, Aurora, Colorado; †McCracken Eye and Face Institute, Parker, Colorado; ‡Denver, Colorado; §Texas Oculoplastic Consultants, Austin, Texas; and ║Colorado Springs, Colorado, U.S.A.
Purpose: Scar formation is a frequently cited complication of external dacryocystorhinostomy (exDCR). The purpose of this study is to evaluate scar appearance after exDCR with the skin incision placed in the tear trough. Methods: Multicenter, prospective, noncomparative interventional study was approved by the University of Colorado Institutional Review Board. Patients undergoing exDCR from February 2013 to January 2014 were included in the study, and surgeries were performed by all authors. The incision site for all patients started just under the medial canthal tendon and extended inferolaterally into the tear trough for 10 mm to 15 mm. External dacryocystorhinostomy was performed in the usual manner, and the incision was closed according to the surgeon’s preference. At 3 months postop, all patients were asked to rate their scar on the basis of the following grading scale: 0, invisible incision; 1, minimally visible incision; 2, moderately visible incision; and 3, very visible incision. Functional success of the surgery was also determined by asking the patients if their symptoms resolved, improved, or did not change. External photographs taken at 3 months after surgery were graded by 3 independent oculofacial and facial plastic surgeons using the same grading scale. Results: Seventy-two surgeries were performed in 68 consecutive exDCR patients with nasolacrimal duct obstruction during the study period. Sixty-nine out of 72 patients reported improved or resolved symptoms (95.8%). The average patient scar grade was 0.21, while the average surgeon scar grade was 0.99 (p < 0.001). Sixty out of the 72 patients graded the scar as invisible (83.3%), and only 3 patients graded the scar as moderately visible (4.2%). No patients graded the scar as very visible. Of the 216 surgeon grades, 55 scars were graded as invisible (25.5%), while 8 were graded as very visible (3.7%). Conclusions: Scar appearance after exDCR with the incision placed in the tear trough is minimally visible to surgeons, and more importantly, nearly invisible to patients. (Ophthal Plast Reconstr Surg 2015;31:278–281)
endonasal DCR has gained popularity in recent years. This is in part due to improved techniques and advances in the quality of endoscopes and video monitors.8–10 An often cited advantage of the endonasal approach is the lack of a visible skin incision.11–16 However, several studies have proved that a wellplaced exDCR incision can result in an inconspicuous scar to surgeon and patient alike.17–19 Previously described incision sites include relaxed tension lines of the lower eyelid,20 and subciliary21 and transconjunctival incisions.22 Although mentioned in the literature, incision in the tear trough has not been studied prospectively.20,23,24 The purpose of this study is to evaluate the appearance of exDCR skin incision placed in the tear trough.
METHODS This multicenter, prospective, noncomparative interventional study was approved by the Institutional Review Board at the University of Colorado. Patients undergoing exDCR from February 2013 to February 2014 were included in the study, and surgeries were performed by all authors. The diagnosis of primary acquired nasolacrimal duct obstruction was made after complete ocular and nasal examination as well as lacrimal irrigation. Patients with secondary nasolacrimal duct obstruction or previous eyelid or lacrimal surgery were excluded from the study. Following the procedure (described below), external photographs were taken at 3 months after surgery. Images were taken in a standardized manner with a digital single-lens reflex camera at an angle of 30° and straight on. All the images were uniformly cropped to include eyebrow to nasal ala vertically and tragus to facial midline horizontally. Images were placed onto a PowerPoint (Microsoft Inc., Redmond, WA, U.S.A.) presentation for grading. The presentation was then shown to 3 independent surgeons for grading. These surgeons included 2 oculoplastic surgeons and 1 facial plastic surgeon. They evaluated each incision by using the following scar grading scale described previously19: 0, invisible incision; 1, minimally visible incision; 2, moderately visible incision; and 3, very visible incision (Fig. 1). At 3 months postop, patients were also asked to evaluate both their improvement in symptoms and the visibility of the scar. Scar visibility was graded by the above scale, and functional improvement was described by the patient as resolved, improved, or unchanged.
E
Surgical Procedure. All surgeries were performed by oculofacial plastic surgeons. Surgery was performed under general or local anesthesia
Accepted for publication July 1, 2014. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Brett W. Davies, M.D., M.S., University of Colorado Hospital, Aurora, CO 80909. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000302
FIG. 1. Scar grading system.
xternal dacryocystorhinostomy (exDCR) is the gold standard treatment for acquired nasolacrimal duct obstruction.1 It can be performed safely in elderly patients under local anesthesia, with minimal blood loss, low economic cost, and a high success rate.2–6 While exDCR is still preferred by many surgeons,7
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Ophthal Plast Reconstr Surg, Vol. 31, No. 4, 2015
depending on surgeon’s and patient’s preference. The incision site was first marked with a pen. The incision started just below the medial canthal ligament, and extended inferiorly and laterally in the tear trough for a length of 10 mm to 15 mm (Fig. 2). This incision site is strategically placed to avoid the angular vessels, and also falls parallel to and slightly anterior to the anterior lacrimal crest. When necessary, the incision was extended superiorly over the medial canthal tendon. The inferior aspect of the tendon could then be detached if more exposure was needed. Local anesthetic was injected subcutaneously into the tear trough, and the incision was made with either a scalpel blade 15 (Bard-Parker, Caledonia, MI, U.S.A.) or a microdissection needle electrocautery depending on surgeon’s preference. Blunt or sharp dissection was then directed to the anterior lacrimal crest. When first attempting this approach, it was helpful to angle the dissection anteriorly and superiorly toward the anterior lacrimal crest, or even further anteriorly onto the maxillary bone. Once the periosteum was opened, dissection was carried out posteriorly and inferiorly in the lacrimal fossa. The remainder of the procedure was performed in a standard manner, including creation of a large osteum and placement of bicanalicular stents. Once ready for closure, most patients received a skin only closure with running or interrupted absorbable sutures. One surgeon (MJH) preferred to close the wound in layers, with closure of the periosteum (lacrimal diaphragm) and skin performed separately.
RESULTS Seventy-two surgeries were performed in 68 consecutive patients with nasolacrimal duct obstruction during the study period. The average patient age was 61.2 years (range, 18–89). Forty procedures were performed on the right side and 32 were performed on the left side. Sixty-nine out of 72 patients reported improved or resolved symptoms (95.8%). The average patient scar grade was 0.21, while the average surgeon scar grade was 0.99 (p < 0.001). Sixty out of 72 patients graded the scar as invisible (83.3%), and only 3 patients graded the scar as moderately visible (4.2%). No patient graded the scar as very visible, and all patients were happy with the appearance of the scar (Fig. 3). Of the 216 surgeon grades, 55 scars were graded as invisible (25.5%), while 8 were graded as very visible (3.7%). Figure 4 summarizes the grading results from both patients and surgeons.
DISCUSSION The fact that the endonasal approach to dacryocystorhinostomy has gained popularity in recent years cannot be denied. In one 2014 edition of Ophthalmic Plastic and Reconstructive Surgery, 5 original articles were dedicated to endoscopic DCR.25 The lack of a visible scar is one of the often cited advantages of
FIG. 2. Location of the tear trough incision.
External DCR, Tear Trough, Scar Formation
the endonasal approach.11–16 Because many surgeons still prefer the external approach,7 techniques to minimize scar formation abound in the literature. Perioperative antibiotics, careful surgical technique, layered closure, and local anesthetics with epinephrine to maintain a bloodless field have all been cited as important measures to prevent scar formation.20,23,26,27 The classic approach to exDCR involves a nasal sidewall incision 10 mm to 20 mm in length (Fig. 5).1,17–19 While the anatomic success of exDCR has been well validated,1 fewer studies have evaluated the cosmetic outcomes from this incision. Tarbet and Custer1 followed up exDCR patients with telephone interviews, and found that 81% of patients rated their scar as invisible, while 90% rated it as excellent. Devoto et al.19 found that 44% of patients graded their scar as invisible at 6 months and 90% graded them as minimally visible or better. They also had 3 independent observers to grade the incisions (2 ophthalmologists, 1 technician), who all reported average scar grades between invisible and minimally visible at 6 months.19 Caesar et al.17 mailed a questionnaire to patients who underwent exDCR with a lateral nasal sidewall incision. Out of 155 responses, 67% of patients rated the scar as invisible and 97% reported that they were happy with the scar. Sharma et al.18 used the same study design, and out of 296 responses, 80.4% of patients rated the scar as invisible. Only 10.5% of patients rated the scar as minimally visible and 4% rated it as moderately visible or worse. Other studies have modified the nasal sidewall incision to improve cosmetic outcomes. Ciftci et al.27 compared cosmetic results of the lateral nasal sidewall incision with and without closure of the lacrimal diaphragm. Scar grade was evaluated by 2 ophthalmologists at 6 months after surgery, who found that skin only closure resulted in significantly more scar visibility.27 While 8.3% of patients in the skin only closure group developed hypertrophic scarring, only 1.1% developed similar scarring with closure of the lacrimal diaphragm. Patchouli and Jamshidian-Tehrani28 evaluated scar formation after using a 5 mm nasal sidewall incision without suture closure. Using bimanual manipulation of the incision to allow wide osteotomy, they achieved functional success in 81 of 85 procedures (95.3%). Wound elongation to 8 mm occurred in 3 cases, and mean patient satisfaction score for the scar was 99.2 on a visual analog scale of 0 to 100.28 While these results indicate that most patients are content with the appearance of the exDCR scar, a small percentage of patients are not satisfied with the cosmetic outcome. In efforts to improve the cosmetic results of exDCR, several studies have evaluated the effect of placing the incision elsewhere. Even well before endoscopic techniques gained popularity, Harris et al.20 suggested placing the exDCR in the relaxed skin tension lines of the eyelid to minimize scar visibility. Their incision started 10 mm medial to the medial canthus, and extended inferiorly and laterally in the first lower eyelid crease. Similarly, Kim et al.29 studied the eyelid crease incision in Asian patients. Their incision was 15 mm to 18 mm in length, did not go medial to the medial canthal tendon, and was placed in the most prominent wrinkle. While they reported the scar as cosmetically acceptable, scar appearance was not officially graded. Using a similar approach with the incision placed in a relaxed skin tension line of the eyelid, Akaishi et al.30 reported that patients graded their scar on average between invisible and minimally visible at 6 months after surgery. Dave et al.21 studied the subciliary approach in 16 patients. At the final follow up, 88% of patients rated the scar as invisible and 100% rated it as invisible or minimally visible. Objective grading by the physician, who was also one of the authors, showed 47% of scars to be invisible and 88.2% of scars to be invisible or minimally visible.21
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
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FIG. 3. Example of final scar appearance in both a younger patient and an older patient.
FIG. 4. Summary of subjective (patient) and objective (surgeon) scar grades.
FIG. 5. The patient had an exDCR on the right side with standard nasal side wall incision 1 year previously. Note the appearance of the scar compared with the left side, which was approached with a tear trough incision.
Several studies have avoided external scar formation altogether by placing the incision through the conjunctiva or the caruncle.22,31 Kaynak-Hekimhan and Yilmaz22 evaluated a transconjunctival approach to exDCR in 25 eyes. While the incision was well concealed, 34% of cases had to be converted to an external approach due to technical difficulties and access issues. Adenis and Robert published a series of 10 patients (11 procedures) who underwent a retrocaruncular approach to exDCR. They did not report any intraoperative complications, but their success rate of 82% was a little lower than previous published exDCR results.31 The authors’ results are consistent with the abovereported studies in terms of cosmetic outcomes. The average
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subjective scar grade as rated by the patients was 0.21. In all, 83.3% of patients rated the scar as invisible and 96% reported it as invisible or minimally visible. Only 3 patients (4.2%) rated the scar as moderately visible, but none of these patients were unhappy with the scar. These results compare favorably to the cosmetic results of the nasal sidewall incision, in which 44% to 80% of patients grade the incision as invisible.1–17 Also consistent with previous studies, surgeons in this study graded the scars more severely than patients.19,21 The average surgeon grade across 3 independent surgeons was 0.99. While this was significantly higher than the average patient grade, it still falls under the score for minimally visible (1). Besides its acceptable
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 4, 2015
cosmetic appearance, the advantage of the tear trough incision includes avoidance of the angular vessels, easy access to the lacrimal sac fossa, and ability of patients to wear glasses immediately postop. Strengths of this study include its prospective nature, number of patients studied, and the enrollment of 3 independent oculofacial and facial plastic surgeons for objective grading of scars. Weaknesses include nonstandardized skin closure, length of follow up, and the use of different cameras for photo acquisition. In conclusion, the tear trough incision for exDCR provides good surgical access while minimizing scar appearance. The scar formed at 3 months after surgery is minimally visible to surgeons, and more importantly, nearly invisible to patients.
REFERENCES 1. Tarbet KJ, Custer PL. External dacryocystorhinostomy. Surgical success, patient satisfaction, and economic cost. Ophthalmology 1995;102:1065–70. 2. Benger R. Day-surgery external dacryocystorhinostomy. Aust N Z J Ophthalmol 1992;20:243–5. 3. Hurwitz JJ, Merkur S, DeAngelis D. Outcome of lacrimal surgery in older patients. Can J Ophthalmol 2000;35:18–22. 4. Jordan DR. Avoiding blood loss in outpatient dacryocystorhinostomy. Ophthal Plast Reconstr Surg 1991;7:261–6. 5. Kratky V, Hurwitz JJ, Ananthanarayan C, et al. Dacryocystorhinostomy in elderly patients: regional anesthesia without cocaine. Can J Ophthalmol 1994;29:13–6. 6. McNab AA, Simmie RJ. Effectiveness of local anaesthesia for external dacryocystorhinostomy. Clin Experiment Ophthalmol 2002;30:270–2. 7. Mirza S, Al-Barmani A, Douglas SA, et al. A retrospective comparison of endonasal KTP laser dacryocystorhinostomy versus external dacryocystorhinostomy. Clin Otolaryngol Allied Sci 2002;27:347–51. 8. Woog JJ, Kennedy RH, Custer PL, et al. Endonasal dacryocystorhinostomy: a report by the American Academy of Ophthalmology. Ophthalmology 2001;108:2369–77. 9. Duffy MT. Advances in lacrimal surgery. Curr Opin Ophthalmol 2000;11:352–6. 10. Ramakrishnan VR, Hink EM, Durairaj VD, et al. Outcomes after endoscopic dacryocystorhinostomy without mucosal flap preservation. Am J Rhinol 2007;21:753–7. 11. Boush GA, Lemke BN, Dortzbach RK. Results of endonasal laserassisted dacryocystorhinostomy. Ophthalmology 1994;101:955–9. 12. Cokkeser Y, Evereklioglu C, Er H. Comparative external versus endoscopic dacryocystorhinostomy: results in 115 patients (130 eyes). Otolaryngol Head Neck Surg 2000;123:488–91.
External DCR, Tear Trough, Scar Formation
13. Massaro BM, Gonnering RS, Harris GJ. Endonasal laser dacryocystorhinostomy. A new approach to nasolacrimal duct obstruction. Arch Ophthalmol 1990;108:1172–6. 14. Watkins LM, Janfaza P, Rubin PA. The evolution of endonasal dacryocystorhinostomy. Surv Ophthalmol 2003;48:73–84. 15. Woog JJ, Metson R, Puliafito CA. Holmium:YAG endonasal laser dacryocystorhinostomy. Am J Ophthalmol 1993;116:1–10. 16. Zílelíoğlu G, Tekeli O, Uğurba SH, et al. Results of endoscopic endonasal non-laser dacryocystorhinostomy. Doc Ophthalmol 2002;105:57–62. 17. Caesar RH, Fernando G, Scott K, et al. Scarring in external dacryocystorhinostomy: fact or fiction? Orbit 2005;24:83–6. 18. Sharma V, Martin PA, Benger R, et al. Evaluation of the cos metic significance of external dacryocystorhinostomy scars. Am J Ophthalmol 2005;140:359–62. 19. Devoto MH, Zaffaroni MC, Bernardini FP, et al. Postoperative evaluation of skin incision in external dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2004;20:358–61. 20. Harris GJ, Sakol PJ, Beatty RL. Relaxed skin tension line incision for dacryocystorhinostomy. Am J Ophthalmol 1989;108:742–3. 21. Dave TV, Javed Ali M, Sravani P, et al. Subciliary incision for external dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2012;28:341–5. 22. Kaynak-Hekimhan P, Yilmaz OF. Transconjunctival dacryocystorhinostomy: scarless surgery without endoscope and laser assistance. Ophthal Plast Reconstr Surg 2011;27:206–10. 23. Olver JM. Tips on how to avoid the DCR scar. Orbit 2005;24:63–6. 24. Ali MJ, Naik MN, Honavar SG. External dacryocystorhinostomy: tips and tricks. Oman J Ophthalmol 2012;5:191–5. 25. Hodgson N, Bratton E, Whipple K, Priel A, et al. Outcomes of endonasal dacryocystorhinostomy without mucosal flap preservation. Ophthal Plast Reconstr Surg 2014;30:24-7. 26. Yazici B, Meyer DR. Selective antibiotic use to prevent postoperative wound infection after external dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2002;18:331–5; discussion 335. 27. Ciftci F, Dinc UA, Ozturk V. The importance of lacrimal diaphragm and periosteum suturation in external dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2010;26:254–8. 28. Kashkouli MB, Jamshidian-Tehrani M. Minimum incision no skin suture external dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2014;30:405–9. 29. Kim JH, Woo KI, Chang HR. Eyelid incision for dacryocystorhinostomy in Asians. Korean J Ophthalmol 2005;19:243–6. 30. Akaishi PM, Mano JB, Pereira IC, et al. Functional and cosmetic results of a lower eyelid crease approach for external dacryocystorhinostomy. Arq Bras Oftalmol 2011;74:283–5. 31. Adenis JP, Robert PY. Retrocaruncular approach to the medial orbit for dacryocystorhinostomy. Graefes Arch Clin Exp Ophthalmol 2003;241:725–9.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Tear Trough Incision for External Dacryocystorhinostomy Brett W. Davies, M.D., M.S.*, Michael S. McCracken, M.D.†, Michael J. Hawes, M.D., F.A.C.S.‡, Eric M. Hink, M.D.*, Vikram D. Durairaj, M.D., F.A.C.S.*§, and Ron W. Pelton, M.D., Ph.D., F.A.C.S.║ *Oculofacial Plastic and Orbital Surgery, University of Colorado Hospital, Aurora, Colorado; †McCracken Eye and Face Institute, Parker, Colorado; ‡Denver, Colorado; §Texas Oculoplastic Consultants, Austin, Texas; and ║Colorado Springs, Colorado, U.S.A.
Purpose: Scar formation is a frequently cited complication of external dacryocystorhinostomy (exDCR). The purpose of this study is to evaluate scar appearance after exDCR with the skin incision placed in the tear trough. Methods: Multicenter, prospective, noncomparative interventional study was approved by the University of Colorado Institutional Review Board. Patients undergoing exDCR from February 2013 to January 2014 were included in the study, and surgeries were performed by all authors. The incision site for all patients started just under the medial canthal tendon and extended inferolaterally into the tear trough for 10 mm to 15 mm. External dacryocystorhinostomy was performed in the usual manner, and the incision was closed according to the surgeon’s preference. At 3 months postop, all patients were asked to rate their scar on the basis of the following grading scale: 0, invisible incision; 1, minimally visible incision; 2, moderately visible incision; and 3, very visible incision. Functional success of the surgery was also determined by asking the patients if their symptoms resolved, improved, or did not change. External photographs taken at 3 months after surgery were graded by 3 independent oculofacial and facial plastic surgeons using the same grading scale. Results: Seventy-two surgeries were performed in 68 consecutive exDCR patients with nasolacrimal duct obstruction during the study period. Sixty-nine out of 72 patients reported improved or resolved symptoms (95.8%). The average patient scar grade was 0.21, while the average surgeon scar grade was 0.99 (p < 0.001). Sixty out of the 72 patients graded the scar as invisible (83.3%), and only 3 patients graded the scar as moderately visible (4.2%). No patients graded the scar as very visible. Of the 216 surgeon grades, 55 scars were graded as invisible (25.5%), while 8 were graded as very visible (3.7%). Conclusions: Scar appearance after exDCR with the incision placed in the tear trough is minimally visible to surgeons, and more importantly, nearly invisible to patients. (Ophthal Plast Reconstr Surg 2015;31:278–281)
endonasal DCR has gained popularity in recent years. This is in part due to improved techniques and advances in the quality of endoscopes and video monitors.8–10 An often cited advantage of the endonasal approach is the lack of a visible skin incision.11–16 However, several studies have proved that a wellplaced exDCR incision can result in an inconspicuous scar to surgeon and patient alike.17–19 Previously described incision sites include relaxed tension lines of the lower eyelid,20 and subciliary21 and transconjunctival incisions.22 Although mentioned in the literature, incision in the tear trough has not been studied prospectively.20,23,24 The purpose of this study is to evaluate the appearance of exDCR skin incision placed in the tear trough.
METHODS This multicenter, prospective, noncomparative interventional study was approved by the Institutional Review Board at the University of Colorado. Patients undergoing exDCR from February 2013 to February 2014 were included in the study, and surgeries were performed by all authors. The diagnosis of primary acquired nasolacrimal duct obstruction was made after complete ocular and nasal examination as well as lacrimal irrigation. Patients with secondary nasolacrimal duct obstruction or previous eyelid or lacrimal surgery were excluded from the study. Following the procedure (described below), external photographs were taken at 3 months after surgery. Images were taken in a standardized manner with a digital single-lens reflex camera at an angle of 30° and straight on. All the images were uniformly cropped to include eyebrow to nasal ala vertically and tragus to facial midline horizontally. Images were placed onto a PowerPoint (Microsoft Inc., Redmond, WA, U.S.A.) presentation for grading. The presentation was then shown to 3 independent surgeons for grading. These surgeons included 2 oculoplastic surgeons and 1 facial plastic surgeon. They evaluated each incision by using the following scar grading scale described previously19: 0, invisible incision; 1, minimally visible incision; 2, moderately visible incision; and 3, very visible incision (Fig. 1). At 3 months postop, patients were also asked to evaluate both their improvement in symptoms and the visibility of the scar. Scar visibility was graded by the above scale, and functional improvement was described by the patient as resolved, improved, or unchanged.
E
Surgical Procedure. All surgeries were performed by oculofacial plastic surgeons. Surgery was performed under general or local anesthesia
Accepted for publication July 1, 2014. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Brett W. Davies, M.D., M.S., University of Colorado Hospital, Aurora, CO 80909. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000302
FIG. 1. Scar grading system.
xternal dacryocystorhinostomy (exDCR) is the gold standard treatment for acquired nasolacrimal duct obstruction.1 It can be performed safely in elderly patients under local anesthesia, with minimal blood loss, low economic cost, and a high success rate.2–6 While exDCR is still preferred by many surgeons,7
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Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 4, 2015
depending on surgeon’s and patient’s preference. The incision site was first marked with a pen. The incision started just below the medial canthal ligament, and extended inferiorly and laterally in the tear trough for a length of 10 mm to 15 mm (Fig. 2). This incision site is strategically placed to avoid the angular vessels, and also falls parallel to and slightly anterior to the anterior lacrimal crest. When necessary, the incision was extended superiorly over the medial canthal tendon. The inferior aspect of the tendon could then be detached if more exposure was needed. Local anesthetic was injected subcutaneously into the tear trough, and the incision was made with either a scalpel blade 15 (Bard-Parker, Caledonia, MI, U.S.A.) or a microdissection needle electrocautery depending on surgeon’s preference. Blunt or sharp dissection was then directed to the anterior lacrimal crest. When first attempting this approach, it was helpful to angle the dissection anteriorly and superiorly toward the anterior lacrimal crest, or even further anteriorly onto the maxillary bone. Once the periosteum was opened, dissection was carried out posteriorly and inferiorly in the lacrimal fossa. The remainder of the procedure was performed in a standard manner, including creation of a large osteum and placement of bicanalicular stents. Once ready for closure, most patients received a skin only closure with running or interrupted absorbable sutures. One surgeon (MJH) preferred to close the wound in layers, with closure of the periosteum (lacrimal diaphragm) and skin performed separately.
RESULTS Seventy-two surgeries were performed in 68 consecutive patients with nasolacrimal duct obstruction during the study period. The average patient age was 61.2 years (range, 18–89). Forty procedures were performed on the right side and 32 were performed on the left side. Sixty-nine out of 72 patients reported improved or resolved symptoms (95.8%). The average patient scar grade was 0.21, while the average surgeon scar grade was 0.99 (p < 0.001). Sixty out of 72 patients graded the scar as invisible (83.3%), and only 3 patients graded the scar as moderately visible (4.2%). No patient graded the scar as very visible, and all patients were happy with the appearance of the scar (Fig. 3). Of the 216 surgeon grades, 55 scars were graded as invisible (25.5%), while 8 were graded as very visible (3.7%). Figure 4 summarizes the grading results from both patients and surgeons.
DISCUSSION The fact that the endonasal approach to dacryocystorhinostomy has gained popularity in recent years cannot be denied. In one 2014 edition of Ophthalmic Plastic and Reconstructive Surgery, 5 original articles were dedicated to endoscopic DCR.25 The lack of a visible scar is one of the often cited advantages of
FIG. 2. Location of the tear trough incision.
External DCR, Tear Trough, Scar Formation
the endonasal approach.11–16 Because many surgeons still prefer the external approach,7 techniques to minimize scar formation abound in the literature. Perioperative antibiotics, careful surgical technique, layered closure, and local anesthetics with epinephrine to maintain a bloodless field have all been cited as important measures to prevent scar formation.20,23,26,27 The classic approach to exDCR involves a nasal sidewall incision 10 mm to 20 mm in length (Fig. 5).1,17–19 While the anatomic success of exDCR has been well validated,1 fewer studies have evaluated the cosmetic outcomes from this incision. Tarbet and Custer1 followed up exDCR patients with telephone interviews, and found that 81% of patients rated their scar as invisible, while 90% rated it as excellent. Devoto et al.19 found that 44% of patients graded their scar as invisible at 6 months and 90% graded them as minimally visible or better. They also had 3 independent observers to grade the incisions (2 ophthalmologists, 1 technician), who all reported average scar grades between invisible and minimally visible at 6 months.19 Caesar et al.17 mailed a questionnaire to patients who underwent exDCR with a lateral nasal sidewall incision. Out of 155 responses, 67% of patients rated the scar as invisible and 97% reported that they were happy with the scar. Sharma et al.18 used the same study design, and out of 296 responses, 80.4% of patients rated the scar as invisible. Only 10.5% of patients rated the scar as minimally visible and 4% rated it as moderately visible or worse. Other studies have modified the nasal sidewall incision to improve cosmetic outcomes. Ciftci et al.27 compared cosmetic results of the lateral nasal sidewall incision with and without closure of the lacrimal diaphragm. Scar grade was evaluated by 2 ophthalmologists at 6 months after surgery, who found that skin only closure resulted in significantly more scar visibility.27 While 8.3% of patients in the skin only closure group developed hypertrophic scarring, only 1.1% developed similar scarring with closure of the lacrimal diaphragm. Patchouli and Jamshidian-Tehrani28 evaluated scar formation after using a 5 mm nasal sidewall incision without suture closure. Using bimanual manipulation of the incision to allow wide osteotomy, they achieved functional success in 81 of 85 procedures (95.3%). Wound elongation to 8 mm occurred in 3 cases, and mean patient satisfaction score for the scar was 99.2 on a visual analog scale of 0 to 100.28 While these results indicate that most patients are content with the appearance of the exDCR scar, a small percentage of patients are not satisfied with the cosmetic outcome. In efforts to improve the cosmetic results of exDCR, several studies have evaluated the effect of placing the incision elsewhere. Even well before endoscopic techniques gained popularity, Harris et al.20 suggested placing the exDCR in the relaxed skin tension lines of the eyelid to minimize scar visibility. Their incision started 10 mm medial to the medial canthus, and extended inferiorly and laterally in the first lower eyelid crease. Similarly, Kim et al.29 studied the eyelid crease incision in Asian patients. Their incision was 15 mm to 18 mm in length, did not go medial to the medial canthal tendon, and was placed in the most prominent wrinkle. While they reported the scar as cosmetically acceptable, scar appearance was not officially graded. Using a similar approach with the incision placed in a relaxed skin tension line of the eyelid, Akaishi et al.30 reported that patients graded their scar on average between invisible and minimally visible at 6 months after surgery. Dave et al.21 studied the subciliary approach in 16 patients. At the final follow up, 88% of patients rated the scar as invisible and 100% rated it as invisible or minimally visible. Objective grading by the physician, who was also one of the authors, showed 47% of scars to be invisible and 88.2% of scars to be invisible or minimally visible.21
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 4, 2015
B. W. Davies et al.
FIG. 3. Example of final scar appearance in both a younger patient and an older patient.
FIG. 4. Summary of subjective (patient) and objective (surgeon) scar grades.
FIG. 5. The patient had an exDCR on the right side with standard nasal side wall incision 1 year previously. Note the appearance of the scar compared with the left side, which was approached with a tear trough incision.
Several studies have avoided external scar formation altogether by placing the incision through the conjunctiva or the caruncle.22,31 Kaynak-Hekimhan and Yilmaz22 evaluated a transconjunctival approach to exDCR in 25 eyes. While the incision was well concealed, 34% of cases had to be converted to an external approach due to technical difficulties and access issues. Adenis and Robert published a series of 10 patients (11 procedures) who underwent a retrocaruncular approach to exDCR. They did not report any intraoperative complications, but their success rate of 82% was a little lower than previous published exDCR results.31 The authors’ results are consistent with the abovereported studies in terms of cosmetic outcomes. The average
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subjective scar grade as rated by the patients was 0.21. In all, 83.3% of patients rated the scar as invisible and 96% reported it as invisible or minimally visible. Only 3 patients (4.2%) rated the scar as moderately visible, but none of these patients were unhappy with the scar. These results compare favorably to the cosmetic results of the nasal sidewall incision, in which 44% to 80% of patients grade the incision as invisible.1–17 Also consistent with previous studies, surgeons in this study graded the scars more severely than patients.19,21 The average surgeon grade across 3 independent surgeons was 0.99. While this was significantly higher than the average patient grade, it still falls under the score for minimally visible (1). Besides its acceptable
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 4, 2015
cosmetic appearance, the advantage of the tear trough incision includes avoidance of the angular vessels, easy access to the lacrimal sac fossa, and ability of patients to wear glasses immediately postop. Strengths of this study include its prospective nature, number of patients studied, and the enrollment of 3 independent oculofacial and facial plastic surgeons for objective grading of scars. Weaknesses include nonstandardized skin closure, length of follow up, and the use of different cameras for photo acquisition. In conclusion, the tear trough incision for exDCR provides good surgical access while minimizing scar appearance. The scar formed at 3 months after surgery is minimally visible to surgeons, and more importantly, nearly invisible to patients.
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