Discussion
fracture, postoperative edema, ectropion, pain, postoperative ocular complications, entropion, cutaneous Y-modification, fractures, periorbital edema, ocular complications, trauma
SCAR, ECTROPION, COMPLICATION, ENTROPION, SCARRING, REGRESSION, PERIORBITAL EDEMA, COMPLICATIONS
Several incisions have been used by maxillofacial surgeons to approach the orbital rim in ZMC fractures and have been investigated to reach the most accessible approach with the least complication rate. The aim of our study was comparing three surgical approaches: the subtarsal approach, the conventional transconjunctival approach and the transconjunctival approach with Y modification.Twenty-four patients were included in our study; 79.2% of them were males and 20.8% were females with a ratio of 3.8:1. This agrees with several previous studies showing male predominance in maxillofacial trauma [Our results have shown a significant difference concerning the operative time starting from the incision till exposure of the fracture site. The group of transconjunctival approach with Y modification had the longest duration (23.38 ± 1.41 min), followed by the subtarsal approach group (13.50 ± 1.77 min) then the conventional transconjunctival approach group having the shortest duration (8.75 ± 1.28 min). This disagrees with Novelli et al. who assumed that both the transconjunctival and palpebral approaches take nearly the same operative time [Exposure duration with comparable results to the Y cutaneous modification approach is the transconjuctival approach with lateral canthotomy. Subramanian et al. recorded a familiar duration (22 min) as well as Holtmann et al. (20 min) when performing the transconjuctival approach with lateral canthotomy [Differences in exposure time between studies may be partially related to the learning curve, expertise and technical skills of the operator managing each surgical approach. Specifically, the longer duration of the transconjunctival approach with Y modification may be attributed to the extended cutaneous Y incision that necessitated more time for the added tissue dissection. Moreover, the transconjuctival approach necessitates the meticulous reconstruction of the lateral canthal tendon to avoid mal-positioning of the lid caused by any canthal asymmetry [Concerning accessibility to the surgical site, easy access to infraorbital rim, orbital floor and medial orbital wall was achieved in all groups of our study with no statistically significant difference. This is in accordance with Novelli et al. who have proved through their research on 56 cases that the transconjunctival approach provides very good visualization to the orbital floor and does not interfere with the lacrimal drainage system and they claimed that it is the best surgical approach in terms of function and esthetics. Moreover, they revealed the absence of any long term complications [In our study, for all of the 8 cases in group C, the cutaneous Y-modification offered the surgeon a profound accessibility to both; the inferior and lateral orbital rims omitting the necessity for a supplementary lateral eyebrow incision. The resultant box shaped window created by the retraction of Y incision of the transconjunctival approach provided a wide and easy visibility to both fracture sites. This coincided with Ilankovan et al. who conducted the Y modification technique declaring that simultaneous exposure to both the inferior orbital and the lateral orbital rims was the most practical compared to other approaches [Earlier reports on the Y modifications come in agreement with the findings of our study, where sufficient exposure was obtained Martinez et al. (2012), in the 24 subjects, and by Rajkumar et al. (2016), in 10 cases [After the first week, pain was significantly higher in groups, A (subtarsal approach) and C (transconjunctival approach with Y modification), with respect to group B (conventional transconjunctival approach). This contrasts with the findings of El-Anwar et al. who have reported a non-significant difference in the mean pain score between the subciliary and transconjunctival approaches [For the 3 groups in this study, there was a statistically significant decrease in pain after 1 week compared to 24 h postoperatively. This was in accordance with Dickinson and Gausas and another research by Shoukath et al. in which pain regression was linked to the decline in the value of the postoperative edema [The least postoperative edema was observed in group B after 24 h, one week and four weeks compared to groups A and C. These values were statistically significant. Nevertheless, El-Anwar et al. have found periorbital edema in all patients of the subciliary and transconjunctival approaches during the first postoperative week being more severe in the transconjunctival group (with lateral canthotomy) [With respect to scarring, groups B and C showed no scar in all cases while Group A showed scars in all cases. The Y modification of the transconjunctival approach yielded the most inconspicuous and well-masked scar, since having the advantage of being hidden in the crow’s feet skin crease which is a natural feature. Our findings are consistent with those of Rajkumar et al. where a good cosmetic result was obtained through the Y modification of the transconjunctival approach due to hiding the small cutaneous scar within a natural skin crease [Regarding ocular complications, wound healing and sensory nerve function, there was no statistically significant difference between any of our study groups. This goes hand in hand with the study by Oztel et al. where the difference in overall complication rate was not statistically significant between the subtarsal approach group and the transconjunctival approach group, however; their need for reoperation was higher in the transconjunctival group [Only two cases of the subtarsal group and one case of the Y-modification group of the present study reported affection of the infraorbital sensory nerve function. However, all patients have completely recovered and regained normal sensation by the end of the follow up period. A similar finding was reported by Yassin et al. [Our study has shown ocular complications in 37.5% of cases with subtarsal approach, in 25% of cases with conventional transconjunctival approach and in 12.5% of cases with modified transconjunctival approach. All the ocular complications were minimal and transient, causing no significant disturbance to the patients. Using a corneal shield for globe protection throughout the operation and application of a suspensory frost suture at the end of the surgical procedure helped greatly in minimizing postoperative ocular complications. Ridgway et al. performed transconjunctival approach and recorded entropion in 2 of the cases along a period of 10 years and contributed these results to the lack of exposure of the field that compelled extensive retraction [Wray et al. have reported an incidence of ectropion in 42% of cases with subciliary approach in comparison to no ectropion in patients with transconjunctival approach [However, the present study had few limitations including the inability to apply blinding to the patients or operators due to the obvious nature of the incision, in addition to the relatively short follow up period.