PEDIATRIC/CRANIOFACIAL

Evaluation of Subciliary Incision Used in

Blowout Fracture Treatment: Pretarsal
Flattening after Lower Eyelid Surgery
Yong Kyu Kim, M.D.
Background: The skin-muscle flap has been widely used for many years in eyelid
Jae Won Kim, M.D. surgery. However, lid retraction and pretarsal flattening are considerable cosmetic
Goyang, Korea complications. Furthermore, it has also been reported that damage of the zygomatic
branch reduces muscle tone and contributes to the development of various com-
plications. The authors investigated whether denervation of the zygomatic branch
affects lid retraction and pretarsal flattening in pure blowout fractures.
Methods: The authors studied 286 unilateral pure blowout fracture patients from
January of 2005 to December of 2006. Mean patient age was 35.6 years (range, 9
to 72 years), the male-to-female ratio was 1.7:1, and the mean follow-up period was
28 months (range, 19 to 40 months). No patients had undergone eyelid surgery
previously. Eyelid tone was evaluated using the snap test and the lid distraction test.
Pretarsal shape was evaluated using photographs, which were presented to three
plastic surgeons and six medical students unaware of surgical information.
Results: Increased laxity was found in only 13 patients (4.5 percent). When viewing
photographic comparisons, medical students noticed visible scars in 10 patients (3.5
percent), pretarsal flattening in eight patients (2.8 percent), and eyelid malposition
in eight patients (2.8 percent), whereas the plastic surgeons noticed visible scars in
10 cases (3.5 percent), pretarsal flattening in 10 cases (3.5 percent), and eyelid
malposition in nine cases (3.1 percent).
Conclusions: In this study, it can be inferred that pretarsal flattening may not be
a problem associated with the skin-muscle flap itself accompanying denervation of
the zygomatic branch. Instead, technical expertise, conservation of the buccal
branch, and meticulous hemostasis are essential for the prevention of
complications. (Plast. Reconstr. Surg. 125: 1479, 2010.)

R
egardless of whether plastic surgery is con-
ducted for aesthetic purposes or for treating
trauma,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 approach
has been widely used for lower eyelid surgery.
However, Tomlinson and Hovey6 and Carraway7
described a transconjunctival approach for lower
eyelid operations devised to minimize the various
complications associated with lower eyelid sur-
gery. The representative complications of the sub-
ciliary approach include scleral show and ectro-
From the Department of Plastic and Reconstructive Surgery,
Inje University Ilsan Paik Hospital.
Received for publication June 28, 2009; accepted November
20, 2009.
Copyright ©2010 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181d5120d
pion caused by lower lid retraction, and, from the
cosmetic perspective, lower eyelid flattening (pre-
tarsal muscle roll disappearance) caused by re-
duced lower eyelid pretarsal muscle volume. In
particular, this latter complication appears as ev-
idence of the aging process in the orbital region
because pretarsal muscle roll is characteristic of a
youthful face. As a result, pretarsal flattening
should be avoided, especially in cosmetic lower
eyelid surgery. Changes in lower eyelid shape after
lower eyelid surgery have been reported to occur
at a rate of 5 to 30 percent,8 –12 and many studies
have been undertaken to ascertain the reasons for
these complications. We questioned whether pre-
tarsal flattening and other complications follow-
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.

www.PRSJournal.com 1479

Fig. 1. Intraoperative view of the zygomatic branch of the facial
nerve. Vertical nerve branches are seen; the incision does not
reach the medial aspect of the punctum.
ing cosmetic lower eyelid surgery are associated
with a skin-muscle flap approach itself. To com-
pare shape changes of lower eyelid objectively, we
used 286 unilateral blowout fracture patient who
had orbital wall reconstruction surgery.
PATIENTS AND METHODS
From January of 2005 to December of 2006, 286
patients treated at the plastic surgery department of
our hospital with denervation of the zygomatic
branch during subciliary incision using a skin-mus-
cle flap for pure unilateral blowout fractures were
enrolled 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, and
the mean follow-up period was 28 months (range, 19
to 40 months). No patient had undergone previous
lower eyelid surgery. Furthermore, patients were
treated by the same surgeon, and all patients com-
pleted prescribed follow-up procedures. The snap
Table 1. Comparisons of the Results Obtained Using Normal Sides as Controls (n ⴝ 286)
Perceptible scar
Pretarsal flattening
Lower eyelid malpositions (scleral show or ectropion)
Laxity alteration
*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.
1480
Plastic and Reconstructive Surgery • May 2010
Fig. 2. The distribution of complication cases (n ⫽ 21).
test and lid distraction test were conducted during
follow-up visits, and postoperative photographs were
compared with those from the unaffected, contralat-
eral side by three plastic surgeons not involved in
patient care and by six medical students unaware of
surgical information. This evaluation was performed
based on an analysis of the clinical results that were
obtained between postoperative months 19 and 28,
when all of the patient data were available. Reviewers
were asked to compare perceptible scar, pretarsal
flattening, and lower eyelid malposition (scleral
show or ectropion) between the site that had been
operated on and the contralateral side with refer-
ence to the postoperative follow-up photographs
based on preoperative photographs obtained dur-
ing the above period. For the use of recognizable
photographs, patients gave written consent.
RESULTS
Preoperatively, an accurate assessment of the
laxity on the fractured side was difficult. On preop-
erative evaluation, however, there were no patients
in whom the laxity was markedly increased on the
normal side. In the present study, normal and op-
erated sides were compared after surgery. Increased
Medical Students (%) Plastic Surgeons (%)
ⴙ – ⴙ –
10 (3.5)* 276 (96.5) 10 (3.5)* 276 (96.5)
8 (2.8)† 278 (97.2) 10 (3.5) 276 (96.5)
8 (2.8)† 278 (97.2) 9 (3.1) 277 (97.2)
— — 13 (4.5) 273 (95.5)
Volume 125, Number 5 • Complications after Lower Eyelid Surgery

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

laxity was found in 13 cases (4.5 percent). Compar- following: perceptible scar, flattening of the lower
isons of photographs were performed by three plas- eyelid pretarsal area, and lower eyelid malposition.
tic surgeons (who were unaware of surgical infor- Data on scars were collected by medical students,
mation) and six medical students, who assessed the who determined that 10 patients were unsatisfied

1481
 Plastic and Reconstructive Surgery • May 2010

(3.5 percent); and by three plastic surgeons (blinded In contrast, in 1995, Netscher et al.12 undertook
to the surgery type), who reported perceptible scars a study on the effect of denervation of the orbicularis
in the same 10 cases (3.5 percent) as well. Lower oculi muscle on lower eyelid shape using the sub-
eyelid pretarsal flattening was reported in eight cases ciliary approach and a skin-muscle flap, and found
(2.8 percent) by medical students and in 10 cases no significant difference between the two when the
(3.5 percent) by the plastic surgeons on operated transconjunctival and subciliary approaches were
sides compared with normal sides. Lower eyelid mal- used on right and left sides, respectively. In 2005,
position (scleral show or ectropion) was also ob- DiFrancesco et al.25 compared preoperative and
served in eight cases (2.8 percent) by medical stu- postoperative pretarsal electromyographic findings
dents and nine cases (3.1 percent) by plastic after lower blepharoplasty using a conventional sub-
surgeons (Table 1 and Figs. 2 and 3). ciliary incision. Meanwhile, these authors cited the
reports by McCord et al.26 (that a myoneurectomy of
DISCUSSION orbicularis oculi muscle was performed for the treat-
Transcutaneous blepharoplasty using a skin ment of benign essential blepharospasm) and by
flap was first described by Castanares13 in 1951, Lowry et al.27 They concluded that complications
and Beare,5 in 1967, described the skin-muscle after lower blepharoplasty cannot be explained by
flap and the subciliary approach, which continues denervation of the zygomatic branch.
to be widely used for lower eyelid surgery. How- Moreover, recently published authoritative ana-
ever, the skin-muscle flap by means of the subcili- tomical studies have revealed that the zygomatic
ary approach has been shown to have several at- branches form fascicles by means of positioning un-
tendant problems, which has encouraged others derneath the subciliary orbicularis oculi muscle and
to try alternative approaches. The zygomatic branch segmentally innervating nearly vertical to muscle,
of the facial nerve is a motor branch that innervates and revealed no existence of functionally dominant
the orbicularis oculi muscle, and damage to this branches24,28,29 (Fig. 4). Because the medial side of
nerve has been associated with lower eyelid surgical the nerve fascicle is composed mainly of zygomatic
approaches used to manage trauma or in aesthetic branches and buccal branches, and the lateral side
surgery. A transconjunctival approach is useful for
avoiding orbital septum injury (which is a causative
factor 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 the
subject of several studies.11,14 –16
In 1990, Carraway and Mellow7,17 recom-
mended that a deep dissection be made to muscles
on the lateral side of the lower eyelid area to
prevent 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 the
lateral side and that it then runs to the orbicularis
oculi. However, since then, the pathway of the
zygomatic branch has been clarified, and deep
dissection from the lateral side is known to be
unnecessary. Nevertheless, it remains to be deter-
mined whether the zygomatic branch of the facial
nerve 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- Fig. 4. Schematic image of periorbital nerve innervations. Zygo-
more, other studies have concluded that damage matic branches form fascicles by means of positioning under-
of the zygomatic branch of the facial nerve is a neath the orbicularis oculi muscle and are segmentally inner-
crucial etiologic factor for sclera show, ectropion, vated nearly vertical to muscle. The medial side nerve fascicles
and pretarsal flattening caused by loss of muscle are composed mainly of zygomatic branches and buccal
tone of the lower eyelid.4,11,14,17–24 branches.

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Volume 125, Number 5 • Complications after Lower Eyelid Surgery
Fig. 5. (Left) Preoperative images at 5 to 7 days after trauma. (Right) Postoperative long-term follow-up images.
nerve fascicle is innervated mainly from the zygo-
matic branches, preservation of the medial segment
branch is important for innervation of the orbicu-
laris oculi muscle. This can also be confirmed by
functional impairment of the lower eyelid seen in
cases in which the medial side fascicle was damaged
during Mohs’ surgery or dacryocystorhinostomy be-
cause it was medially restricted. Accordingly, when
surgery was performed using a skin-muscle flap with
a subciliary approach, conservation of the buccal
branch forming the plexus on the medial side
should 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 changes
in patients with zygomatic branch denervation were
confirmed by comparing lower eyelids on operated
and normal sides, as described above. In those cases
in which a follow-up observation was available after
postoperative month 28, there were no changes in
the lower eyelid shape (Fig. 3). The degree of asym-
metry or malposition of the pretarsal area that can
be present before the onset of injury (unilateral
blowout fracture) was used for comparison of the
1483

results with reference to a preoperative photograph
(surgery was performed between 5 and 14 days after
the onset of injury, and a preoperative photograph
was taken on the date of surgery) (Fig. 5). Normal
sides are probably most suitable for assessing lower
eyelid changes in the pretarsal area postoperatively.
Furthermore, in the present study, we recruited the
assistance of blinded medical students and plastic
surgeons to ensure objectivity.30,31
CONCLUSIONS
In the current article, the number of patients
who presented with postoperative complications was
21 (7.3 percent). Based on the results, it could not
be determined whether the incidence of complica-
tions that are worrisome in cosmetic lower eyelid
surgery would be increased following the use of a
subciliary approach with a skin-muscle flap. In par-
ticular, the approach itself bears little relation to the
postoperative pretarsal flattening. Instead, technical
expertise, delicate tissue management, and meticu-
lous hemostasis are essential for the prevention of
complications. We recommend that conservation of
the buccal branch be given greater priority.25–29
Yong Kyu Kim, M.D.
Department of Plastic and Reconstructive Surgery
Inje University Ilsan Paik Hospital
Goyang, 411-706, Korea
psinbrain@hotmail.com
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