1. Clinical Experience of the Modified Transconjunctival Lower Lid Approach for Orbital Fractures with Lateral Peri-canthal Incision Eui Cheol Jeong M.D., 1 Jeonghoon Song M.D., 2 Gordon K. Lee M.D., Ji Ung Park M.D., Suk Wha Kim M.D., Sung Tack Kwon M.D. Department of Plastic surgery, SMG-SNU Boramae Medical Center and Department of Plastic and Reconstructive surgery, College of Medicine, Seoul National University, Seoul, Korea 1 Department of Plastic and Reconstructive surgery, College of Medicine, Wonkwang University, Iksan, Korea 2 Division of Plastic and Reconstructive surgery, Stanford University Medical Center, Stanford, CA, USA. (Method) Upon the usual surgical preparation, the globe is protected. The peri-canthal incision is designed by marking its origin along the gray line, approximately 3-mm medial from the lateral canthus. From this point, a line is drawn perpendicularly to the tangent of the gray line, past the eyelashes (approximately 3 mm away from gray line). The design is extended obliquely in the inferolateral direction, along an appropriately chosen minor skin crease, for 5 to 8 mm. (Fig.1 A) The handle of empty scalpel holder can be placed on the tarsal plate next to the peri-canthal design to provide traction (Fig.1 B). The incision is made through the skin and full thickness of the eyelid, including the tarsal plate (Fig 1 C). The additional transconjuctival incision is then extended medially towards the punctum along the inferior margin of the tarsal plate. The resulting conjunctival flap is stretched superiorly to cover and protect the cornea for the remainder of the operation. The lower lid can readily be distracted, or "swung", away from the globe without the need for excessive tension. The inferior orbital rim and floor are accessed by dissecting through the usual submuscular plane.(Fig.1 D) With satisfactory reduction of orbital fracture(s), the incision is closed by the meticulous apposition of the divided structures. Most notably, the tarsal plate and gray line are used as focal loci of approximation to restore the anatomy of the lower eyelid. The tarsal plate is repaired with an inverted 6-0 vicryl suture with the knot buried. The conjunctiva is closed with 7-0 vicryl, and skin with 6-0 silk.(Fig.1 E,F,G) (Materials) Between January 2011 and December 2012, the authors used this technique in 26 patients with orbital fractures. Methods and Materials Purpose Reference In the modified transconjunctival incision with lateral peri-canthal incision, the decoupling of lower eyelid through the lateral portion of tarsal plate provides excellent exposure of the orbital floor, while providing a reliable and consistent landmark by which the anatomy of eyelid could again be restored. The aesthetic and functional outcomes of the eyelid aperture were excellent Conclusion Fig. 2. A 46-year-old man was diagnosed with blow out fracture of right orbit floor and medial orbital wall and nasal bone fractures. Preoperative photo (Left) and Postoperative 1-year follow-up photo (Right) The demographic of 30 patient in this study was typical of the orbital fracture population. A take-back operation was required in a case of preseptal hematoma. Through the mean follow-up period of 6 months, no long-term functional complications were identified. Of the total, twenty-nine patients were satisfied with the aesthetic outcome. One patient did present with postoperative notch deformity but did not feel the need for a revisional operation. Fig.1 (A) Design of pericanthal incisoon. (B) Supported by scalpel handle during skin incision. (C) Division of skin and tarsal plate. (D) Swinging lower lid skin-muscle flap (E,F,G) Closure of wounds Editorial correspondence : Eui Cheol Jeong M.D., Department of Plastic Surgery, SMG-SNU Boramae Medical Center (ejeong.md@gmail.com) Optimal repair of orbital fractures requires adequate exposure of the fracture area. The transconjunctival approach with lateral canthotomy has gained increasing popularity. This technique offers arguably improved visualization with lower risk of lid retraction. However, if the lateral canthotomy area is improperly repaired because of anatomical obscurity of lateral canthal tendon, it may also cause lower lid malposition and deformity. 1 The authors report the use of a modified transconjunctival incision method with a lateral peri-canthal incision to overcome this problem in the cantholysis (A) (B) (C) (D) (E) (F) (G) Results 1. Ridgway EB, Chen C, Lee BT. Acquired entropion associated with the transconjunctival incision for facial fracture management. J Craniofac Surg. 2009 Sep;20(5):1412-5.