Med Oral Patol Oral Cir Bucal. 2016 Jan 1;21 (1):e111-7.

Evaluation of transconjunctival and subciliary approaches

Journal section: Oral Surgery doi:10.4317/medoral.20818

Publication Types: Research http://dx.doi.org/doi:10.4317/medoral.20818

The isolated orbital floor fracture from a transconjunctival or subciliary

perspective-A standardized anthropometric evaluation

Gregor Raschke 1, Gabriel Djedovic 2, Andre Peisker 1, Rene Wohlrath 1, Ulrich Rieger 3, Arndt Guentsch 4,
Marta Gomez-Dammeier 1, Stefan Schultze-Mosgau 1

1
MD, DDS, PhD. MD, DDS. DMD. Department of Plastic Surgery & Cranio-Maxillofacial Surgery, Friedrich Schiller Univer-
sity Jena, Erlanger Allee 101, Jena, Germany
2
MD. Department of Plastic, Reconstructive & Hand Surgery, Innsbruck Medical University, Anichstrasse 35, Innsbruck, Aus-
tria
3
MD, PhD. Department of Plastic & Aesthetic, Reconstructive & Hand Surgery, St. Markus Hospital, Johann Wolfgang von
Goethe University, Frankfurt/Main, Germany
4
DMD, PhD. Marquette University School of Dentistry, 250 W Wisconsin Ave., Milwaukee, WI 53233, United States of Amer-
ica

Correspondence:
Department of Cranio-Maxillofacial, Plastic Surgery Raschke G, Djedovic G, Peisker A, Wohlrath R, Rieger U, Guentsch A,
Friedrich Schiller University Jena Gomez-Dammeier M, Schultze-Mosgau S. The isolated orbital floor frac-
Universitätsklinikum Jena ture from a transconjunctival or subciliary perspective-A standardized
D-07747 Jena ,Germany anthropometric evaluation. Med Oral Patol Oral Cir Bucal. 2016 Jan 1;21
raschke.gregor@googlemail.com (1):e111-7.
http://www.medicinaoral.com/medoralfree01/v21i1/medoralv21i1p111.pdf

Article Number: 20818 http://www.medicinaoral.com/

© Medicina Oral S. L. C.I.F. B 96689336 - pISSN 1698-4447 - eISSN: 1698-6946
Received: 09/05/2015 eMail: medicina@medicinaoral.com
Accepted: 17/09/2015 Indexed in:
Science Citation Index Expanded
Journal Citation Reports
Index Medicus, MEDLINE, PubMed
Scopus, Embase and Emcare
Indice Médico Español

Abstract
Background: The influence of orbital fractures and their repair on the rate of deformities of the lower eyelid is
an ongoing source of discussion in the literature. Most of the present studies include isolated blow-out as well as
combined orbital fractures.
Material and Methods: We present a retrospective evaluation of a series of 100 patients after isolated blow-out
fracture repair using reference anthropometric data on standardized photographs. Analysis included eye fissure
width and height, lid sulcus height, upper lid height, upper and lower iris coverage, position of cornea to palpebra
inferior, canthal tilt, scleral show, ectropion and entropion. It was clearly distinguished between operated and con-
tralateral eyelid, whether a transconjunctival or a subciliary approach was performed and amount of fracture. Our
main interests were changes of the aforementioned parameters with regards to eyelid deformities.
Results: Surgery per se did not significantly influence eyelid deformities. However, the surgical approach selected
significantly affected eye fissure index, lower iris coverage and rate of scleral show, indicating retraction of the
lower eyelid.
Conclusions: The standardized measurements described here are accurate and objective to evaluate postoperative
results. The subciliary approach included the highest risk of lower lid retraction as compared to transconjunctival
approaches.

Key words: Transconjunctical approach, subciliary approach, orbital floor fracture.

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Introduction of their routinely recorded documentation including x-

According to our experience, before undergoing surgi- rays and photographies.
cal repair of a blow out fracture, most patients worry All patients were operated at the Department of Plastic
about the risk of distortion of the face and especially the Surgery & Cranio-Maxillofacial Surgery at the Uni-
eyelids. Even minimally displaced blow-out fractures versity Hospital Jena, Germany, between January 2006
may result in aesthetic and functional deformities of the and December 2011. The inferior orbital rim and orbit-
periorbital region (1). al floor were exposed either through a subciliary or a
There is an ongoing discussion in the literature about the transconjunctival approach, which were performed in a
optimal treatment of orbital floor fractures. Especially standardized manner.
the discussion about how to approach the orbital floor is The subciliary approach was performed in the manner
ongoing. To date most studies comparing transconjunc- of a step dissection, the transconjunctival approach in
tival and transcutaneous approaches include patients a retroseptal technique. A photo- and radiographic de-
with isolated orbital floor fractures, zygomaticomaxil- scription of three patients is shown in figure 1.
lary fractures and combined orbitomaxillary fractures
altogether (2,3) without giving results clearly distin-
guishing between these different entities of fractures.
It seems reasonable, as reported earlier, that different
severity and type of trauma have significant impact on
the risk of developing an en-or ectropion (3). Thus the
inclusion of different types of fractures of the orbita in
studies referrring and/or comparing transcutaneous and
transconjunctival approaches limits their validity.
Only few articles referring to a single type of fracture
are available. These articles mostly report on the out-
come of isolated blow-out fractures (4-7). They report
the clinical management (7), functional outcome (5,6)
and clinical outcome of the surgical method (4,6). There
is a lack of elaborated and objective assessments of the
effect of blow out fractures and its surgical treatment on
the eyelid architecture in the current literature.
However, such an assessment is highly desirable, as it
may help to quantify the influence of trauma and partic-
ular surgical procedure selected on the eyelid morphol-
ogy. Normative anthropometric measurements of the
face are available (8-13). Their benefit in planning, per-
formance and evaluation of facial surgery is widely rec-
ognized (11,12,14). In a group of 100 patients suffering
from isolated blow-out fractures, anthropometric meas-
urements were performed on standardized photographs.
We investigated differences between the affected and
the contralateral side and either a transconjunctival or
a subciliary approach was performed. Furthermore we
evaluated the influence of the type of orbital floor frac-
ture.

Material and Methods

Before the study was initiated, the local Ethics Commit-
tee of the University Hospital Jena was asked to give his
approval to the study. Because the study design aimed
to evaluate routinely performed documentation like
standardized photographies or X-rays and did not influ-
ence the the diagnostical or therapeutic process the Eth-
ics Committee denied the necessity of special ethical Fig. 1. On the left coronar CT scan, on the right standardized
approval. Prior to surgery all included patients signed photography three months after surgery. The patients above
and in the middle were operated through a transconjunctival
an informed consent permitting the scientific evaluation approach, the patient below through a subciliary approach.

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Colored frontal view photographs with open eyes were tance between the upper palpebral margin and eyelid
taken postoperatively, after definite woundhealing, with sulcus. as percentage of the upper lid height (ULH, Os-
a Nikon D 80 camera (objective: Nikon AF Micro Nik- Ps), the distance between orbitale superioris and upper
kor 105 mm 1:2.8 D; aperture: f13; Nikon Corp, Tokyo, palpebral margin. Upper iris coverage (UIC) represents
Japan) with a standardized lens at a patient distance of the part of the upper iris covered by the upper eyelid. It
1 m in a standardized position and a slit lamp by a pro- was investigated by halving iris diameter and subtract-
fessional photographer. Only photographs in which the ing the free visible upper radius of the iris (Ic-Ps) as
interpupillary axis was at the same level as the camera percentage of the total iris diameter (ID). Lower iris
lens and faces were clearly at rest were selected to mini- coverage (LIC) represents the part of the lower iris cov-
mize photographic distortion (15,16). Further analysis ered by the lower eyelid. It was raised by halving the iris
was performed using Adobe Photoshop CS2 (Adobe diameter and subtracting the free visible upper radius of
Inc, San Jose, CA). the iris (Ic-Pi). In the case of scleral show or ectropion its
On the basis of predefined landmarks and data (Table values turned negative. The position of the lower eyelid
1), the following anthropometric dimensions based on to the lower iris describes the angulation of the inferior
the work of Farkas and Munro (9-12,14) as well as well eyelid to the center of the iris (8). It was measured by
known clinical data were investigated (Fig. 2): Eye Fis- placing a vertical reference line through the center of
sure Index is defined by the eye fissure height (EFH, the iris (Ic). Another line was drawn through the center
Ps-Pi), the vertical distance from the margin of the infe- of the iris (Ic) and the point of contact of the lower eye-
rior palpebra to the margin of the superior palpebra. The lid and cornea (Ic-CPi). The angle formed by both lines
EFH was then divided by the eye fissure width (EFW, was measured in degrees (Fig. 3). Medial deviations of
en-ex), which is defined by the intercanthal distance. the angle were measured as negative, lateral deviations
The eyelid sulcus of the upper eyelid divides the upper as positive value. Canthal tilt describes the intercanthal
eyelid in an upper and lower part. The upper lid sulcus fissure inclination (13) measured as the angle between
height (ULSH, LS-Ps) is depicted by the vertical dis- the EFW (en-ex) and a horizontal reference line passing

Table 1. Used anthropometric landmarks and distances based on the investigations by Farkas.

Ps Palpebrale superioris IW Intercanthal width, en-en

Pi Palpebrale inferioris BW Biocular width, ex-ex
En Endocanthion EFH Eye fissure height, Ps-Pi
Ex Exocanthion EFW Eye fissure width, En-Ex
Ic Iris centre ULSH Upper lid sulcus height, LS-Ps
LS Lid sulcus ULH Upper lid height, Os-Ps
Os Orbitale superioris ID Iris diameter, iris height
CPi Corneal palpebral inferior contact point UIRv upper iris radius visible
LIRv lower iris radius visible

Fig. 2. Schematic picture with description of the used anthropometric dis-

tances ULSH indicates upper lid sulcus height; ULH, upper lid height; UIC,
upper iris coverage; LIC, lower iris coverage; ID, iris diameter; EFH, eye
fissure height; EFW, eye fissure width.

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In order to analyse the influence of operated and con-

tralateral side, surgical approach selected and type of
orbital floor fracture on EFI, ULSH, UIC, LIC, position
of lower eyelid to lower iris and canthal tilt, univariate
and mixed model (Table 2) ANOVAs were conducted.
Fisher’s Exact Tests were conducted to compare oper-
ated and contralateral eyes with reference to ectropion
and scleral show. All calculations were done using SPSS
V 19.0 for Windows (SPSS, Inc, Chicago, IL).

Results
All patients included suffered from a unilateral isolated
blow-out fracture. 90 white Caucasian patients, 72 men
(72.0%) and 28 women (28.0%) were operated. Average
age was 42.08±18.70 at time of surgery. Reconstruction
of the orbital floor was performed in 64 patients (64.0%)
Fig. 3. Schematic picture of canthal tilt (An1), describing the incli- by a polydioxanone sheet, in 32 patients (32.0%) by a
nation of the horizontal axis of the eye between endocanthion (En)
and exocanthion (Ex). Furthermore description of the position of the
titanium mesh. Three patients (3.0%) did not need al-
lower iris (An2) as the aberration of the contact point between cornea loplastic reconstruction of the orbital floor. The orbital
and lower eyelid from the vertical reference line through the center floor was exposed via a transconjunctival approach in 74
of the iris. cases (74.0%), 52 men (70.3%) and 22 women (29.7%),
and via a subciliary approach in 26 cases (26.0%), 20
men (76.9%) and 6 women (23.1%). In 62 cases (62.0%),
through the endocanthion in degrees (Fig. 3). Further- 44 men (71.0%) and 18 women (29.0%), a Type 1 Frac-
more the rate of scleral show, ectropion, and entropion ture was observed, in 38 cases (38.0%), 28 men (73.7%)
was recorded. and 10 women (26.3%), a Type 2 fracture. No entropion
All parameters were measured on both eyes. Results was observed.
were evaluated comparing the operated and the con- The postoperative photographs evaluated were taken
tralateral (not operated, control) side. The impact of 3 months after surgery. A comparison of the results of
whether a transconjunctival or a subciliary approach the photographic measurements differentiated between
was performed was evaluated, as well. Furthermore the operated and the contralateral eyelid, surgical approach
influence of the type of orbital floor fracture was in- and type of fracture is shown in table 2. None of the in-
vestigated through an analysis of operation reports and vestigated parameters presented a significant difference
preoperative CT scans with coronal and sagittal refor- between operated and contralateral side.
mations. Type 1 consisted of small fractures of the an- The surgical approach to the orbital floor significant-
terior medial orbital floor and type 2 of larger fractures ly influenced EFI (p=.04), LIC (p=.01) and the rate of
involving the orbital floor and medial wall (17). Occur- scleral show (p=.01). The other investigated parameters
rence of diplopia was extracted out of patients´ records. presented no significant correlations with the surgical

Table 2. Comparison of the results of the photographic measurements of operated and the contralateral eyelids, surgical ap-
proach selected and fracture type.

Sign.OP* Sign. Sign. Type

Operated Contralateral Operated Contralateral
Contralateral Approach Fracture
transconjunctival subciliar
p p p
74 26
34.5±5.3 34.4±5.5 37.6±3.7 34.8±4.5 0.07 0.04 0.31
25.4±12.3 25.5±12.7 28.7±18.4 25.8±12.7 0.52 0.41 0.27
18.8±7.7 19.2±7.7 17.2±5.1 16.7±5.3 0.93 0.08 0.43
4.5±5.1 4.3±5.3 1.3±5.4 3.3±4.6 0.297 0.01 0.07
-0.2±6.1 -0.2±5.2 -2.4±7.3 -0.1±4.8 0.23 0.26 0.36
1.3±3.6 1.5±2.7 1.3±2.9 1.9±3.4 0.42 0.64 0.37
4.1 4.1 19.2 11.5 0.78* 0.01* 0.71*
0 0 3.8 0 1* 0.26* 0.36*

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approach selected. One ectropion was observed in the fissure index (EFI), upper lid sulcus height (ULSH), up-
group of a subciliary approach. per (UIC) and lower (LIC) iris coverage, canthal tilt and
The type of orbital floor fracture did not significantly position of lower eyelid to iris in our study.
influence on the parameters investigated. The eye fissure width, measured between the endo- and
The multivariate analysis performed did not yield sig- exocanthion, is referred to equal 30 mm. The eye fis-
nificant interaction effects between the factors operated sure height between the margins of the upper and low-
or not, surgical approach and type and severity of frac- er palpebra is reported to be 9-10 mm with open eyes
ture. However, for statistical reasons a significant inter- straight ahead (18). Because linear measurements are
action effect is not required to confirm the significant not exactly reproducible in standardized photographs,
effect of the surgical approach on EFI, LIC and scleral we preferred to apply the EFI reflecting the relation be-
show values. tween EFH and EFW.
Two patients (2.2%) suffered from persistent diplopia The LIC is very important for the look of the patient.
in the direction of ocular elevation at the time the post- The normative value is 7% (12). Negative values occur
operative photographs were taken. Both patients under- in the case of scleral show. Sclera should normally not
went a transconjunctival approach. None of them pre- be visible looking straight ahead (8). A reproducible
sented symptoms of entrapment or enophtalmos in the photographic quantification of scleral show is desirable
postoperative ophthalmologic examination. We were for the judgement of the quantity of distortion. There-
unable to find a medical, anatomic or surgical reason, fore scleral show was quantified by changes of EFI and
which is not unusual (15). LIC.
Ectropia are linked to lower lid retraction, as well, but
Discussion not in such a direct manner as scleral show. Scleral show
A blow-out fracture is defined as a fracture of the orbit- describes a general and symmetric decline of the lower
al floor. It does not involve the orbital rim. Besides the eyelid attached to the eyeglobe. In case of an ectropi-
description of functional disabilities the most common on the lower eyelid turns inside out, leaving the inner
criteria of postoperative evaluation of orbital floor frac- eyelid and globe surface exposed and is subsequently
ture repair consists in the rate of lower lid retraction, prone to irritation. It may occur medially or laterally
ectropion and entropion (4). These common criteria do or on both sides and does not inevitably go along with
not allow detection of more subtle changes of the peri- excessive lower lid retraction.
orbital architecture. Measurements of the upper eyelid position were in-
The presented anthropometric measurements of the cluded in our study in order to secure that changes of
periorbital region may help us to objectify the morpho- the morphology of the upper eyelid did not affect the
logic outcome of orbital floor fracture repair. As differ- measurements of EFI. ULSH is a helpful measurement
ent grades of severity and types of trauma play a deci- in the appraisal of the composition of the eyelid to the
sive role in the risk of development of en- or ectropion eyebrow. UIC reflects the covered part of the upper iris
(2,3), we included only isolated blow-out fractures in (12).
our study, to improve the validity of our data. The sig- To adequately describe the shape of the eyelids two
nificance of the investigation of the impact of subcili- angles exhibiting decisive impact on the periorbital
ary or transconjunctival approaches on the periorbital appearance were measured: Canthal tilt (13) is of big
architecture are enhanced thereby, as well. concern for the facial appearance. Sad look may be the
Orbital floor fractures result from an abrupt increase of consequence of a negative canthal tilt (8). It was referred
intraorbital pressure and may be caused either by direct to be 2 mm or at an angle of 10 to 15 degrees above the
contact to the globe or contact with the inferior orbital medial canthus (19).
rim causing the floor to buckle. Forces applied to the The position of lower eyelid relative to iris describes the
orbital rim, described by Waterhouse et al. as type 1, normal contact point of the lower palpebra to the limbus
rather lead to small fractures of the mid medial floor corneae at the 6 o´clock position (8).
and rarely herniation of orbital content. Forces applied Clearly identifiable eyelid distortions such as unilateral
to the globe rather lead to larger fractures including the lower lid retraction and scleral show or a lowered can-
orbital floor and medial wall and herniation of orbital thal tilt lead to an unpleaseant appearance, which often
content and were described by Waterhouse et al. as type is noticed by the patients themselves.
2 (17). Due to the potential influence of the type of frac- Altogether the nine presented anthropometric and clini-
ture to postoperative eyelid malposition this easy and cally relevant parameters described in this study are
reproducible classification was used to investigate the able to describe and quantify such malpositions. They
influence of amount of fracture on eyelid morphology. were easily and reproduciblely definable in the frontal
Several anthropometric measurements of the periorbital view photographs and may be influenced by a blow-out
region have been described (9,10,12,14). We used the eye fracture or its surgical repair. The comparison of post-

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operative photographs by surgeons and/or independent orbitale, orbicularis muscle and surrounding tissue as
observers seems less reproducible to us than the pre- well as loss of muscle tonus may provoke scleral show
sented anthropometric measurements. and ectropion. Thus most authors prefer the transcon-
The consideration of the anthropometric parameters de- junctival approach (4,6,15,20,22-24). Transconjunctival
scribed may be relevant not only for scientific purposes approaches reduce complications such as ectropion to a
but also in the clinical care of these patients. If in the minimum (2), but include the highest risk of entropion
further clinical course a surgical revision is warranted, (3).
it is important to exactly plan the degree of correction During the past decades the transconjunctival approach
necessary. In order to achieve the best result possible it showed an uninterrupted increasing use. Altogether
is not only necessary to exactly estimate the degree of transconjunctival incisions seem to include a lower risk
vertical correction described in this study by EFI and of postoperative lower lid retraction and ectropion com-
LIC, but also to achieve an appealing shape of the lower pared to transcutaneous and especially subciliary ap-
eyelid towards the globe. Canthal tilt and position of proaches, as suggest our data (see Table 2).
lower eyelid to iris may facilitate this estimation. The classification of orbital floor fractures investigated
In the presented study we aimed to focus on morpho- here did not yield significant influence on the eyelid
logic aspects and the influence of trauma and surgical morphology in our study. Previous analyses investigat-
approach. Previous studies indicated, that the interpre- ing other classifications of orbital floor fracture locali-
tation of the raw data of ophthalmologic findings do zations reconfirm this result (4). Altogether this may
not correlate with the “real life” rate of complications. be interpreted as evidence, that a postoperative lower
Therefore the ophthalmologic evaluation has to be in- eyelid malposition is more dependent on the selection of
terpreted for every individual patient and was not evalu- the surgical approach than on the localization and type
ated and discussed in detail in this current study (5). of the fracture.
The comparison of operated and contralateral side as In our center we prefer the transconjunctival approach
well as of the surgical approach to the orbital floor did whenever possible. To our experience, the rate of ec-
not exhibit a significant effect on ULSH, UIC, canthal or entropion is related to inexperience. The level of the
tilt and position of lower eyelid to iris (see Table 2). The incision in the fornix is enormously relevant. The pres-
constant values of UIC and ULSH indicate that, not sur- ervation of the septal integrity as provided by the retro-
prisingly, the architecture of the upper eyelid and the septal incision seems most likely to us to prevent lower
shape of the eyelids were not influenced by the blow-out eyelid distortion (15).
fracture and its subsequent repair. We do not see indications for a transcutaneous approach
EFI and LIC did not show significant differences, when in isolated blow-out fractures, which are all satisfacto-
operated and contralateral side were compared (see Ta- rily accessable through a transconjunctival approach.
ble 2). This underlines, that preexisting scleral show on Only in case of more-fragment-fractures of the infe-
one side, which is often associated with scleral show on rior or lateroinferior orbital rim requiring extensive
the contralateral side, has no significant influence on exposure we do see indications for a transcutaneous
the rate of postoperative scleral show. Furthermore it approach in the form of a subtarsal approach. The inci-
could be interpreted as an indication, that surgery itself sion of the subtarsal approach should be placed as close
is not associated with higher rates and amount of eyelid as possible to the inferior border of the tarsal plate.The
deformities. subtarsal approach was judged to be cosmetically ac-
However increased values of EFI, decreased values of ceptable when concealed within a rhytid and less risky
LIC and an increased rate of sleral show were observed in matters of lid retraction than subciliary approaches
when a subciliary approach was performed. This indi- (20-22,25-28).
cates lower lid retraction, which did not seem to occur
in a significant manner, when a transconjunctival ap- Conclusion
proach was performed (see Table 2). Analyses of orbital fractures repair results should clear-
In this study one ectropion was observed. This may be ly distinguish isolated and combined orbital floor frac-
related to the lower number of patients included in this tures. The evaluation of the effects of isolated blow-out
study undergoing a subciliary approach. In previous fractures and their operative therapy on the periorbital
studies similar or even lower rates of ectropion were ob- architecture by using anthropometric data extracted
served. Overall these results are endorsed by the present from standardized photographs is reliable and adequate.
literature: Lower eyelid retraction is the most common The subciliary approach exhibited a significantly higher
complication after a subciliary approach (20,21). Scar rate of lower lid retraction than the transconjunctival
contracture, cicatricial connection between the septum approach.

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References 24. Kushner GM. Surgical approaches to the infraorbital rim and or-
1. Bogusiak K, Arkuszewski P. Characteristics and epidemiolo- bital floor: the case for the transconjunctival approach. J Oral Maxil-
gy of zygomaticomaxillary complex fractures. J Craniofac Surg. lofac Surg. 2006;64:108-10.
2010;21:1018-23. 25. Mullins JB, Holds JB, Branham GH, Thomas JR. Complica-
2. Ridgway EB, Chen C, Colakoglu S, Gautam S, Lee BT. The inci- tions of the transconjunctival approach. A review of 400 cases. Arch
dence of lower eyelid malposition after facial fracture repair: a ret- Otolaryngol Head Neck Surg. 1997;123:385-8.
rospective study and meta-analysis comparing subtarsal, subciliary, 26. Werther JR. Cutaneous approaches to the lower lid and orbit. J
and transconjunctival incisions. Plast Reconstr Surg. 2009;124:1578- Oral Maxillofac Surg. 1998;56:60-5.
86. 27. Salgarelli AC, Bellini P, Landini B, Multinu A, Consolo U. A
3. Ridgway EB, Chen C, Lee BT. Acquired entropion associated comparative study of different approaches in the treatment of orbital
with the transconjunctival incision for facial fracture management. J trauma: an experience based on 274 cases. Oral Maxillofac Surg.
Craniofac Surg. 2009;20:1412-5. 2010;14:23-7.
4. Kwon JH, Kim JG, Moon JH, Cho JH. Clinical analysis of sur- 28. Rohrich RJ, Coberly DM, Fagien S, Stuzin JM. Current concepts
gical approaches for orbital floor fractures. Arch Facial Plast Surg. in aesthetic upper blepharoplasty. Plast Reconstr Surg. 2004;113:32e-
2008;10:21-4. 42e.
5. Poeschl PW, Baumann A, Dorner G, Russmueller G, Seemann R,
Fabian F, et al. Functional outcome after surgical treatment of orbital Conflict of interest statement
floor fractures. Clin Oral Investig. 2012;16:1297-303. All authors state that there are no conflicts of interest. There were no
6. Holtmann B, Wray RC, Little AG. A randomized comparison of four financial or personal relationships that could inappropriately influ-
incisions for orbital fractures. Plast Reconstr Surg. 1981;67:731-7. ence their work.
7. Courtney DJ, Thomas S, Whitfield PH. Isolated orbital blowout
fractures: survey and review. Br J Oral Maxillofac Surg. 2000;38:496-
504.
8. Biesman BS. Blepharoplasty. Semin Cutan Med Surg. 1999;18:129-
38.
9. Farkas LG, Katic MJ, Forrest LG. Comparison of craniofacial
measurements of young adult African-American and North Ameri-
can white males and females. Ann Plast Surg. 2007;59:692-8.
10. Farkas LG, Katic MJ, Forrest CR, Alt KW, Bagic I, Baltadijev G.
International anthropometric study of facial morphology in various
ethnic groups/races. J Craniofac Surg. 2005;16:615-46.
11. Raschke GF, Bader RD, Rieger UM, Schultze-Mosgau S. Pho-
to-assisted analysis of blepharoplasty results. Ann Plast Surg.
2011;66:328-33.
12. Starck WJ, Griffin JE Jr, Epker BN. Objective evaluation of the
eyelids and eyebrows after blepharoplasty. J Oral Maxillofac Surg.
1996;54:297-302.
13. Codner MA, Wolfli JN, Anzarut A. Primary transcutaneous low-
er blepharoplasty with routine lateral canthal support: a comprehen-
sive 10-year review. Plast Reconstr Surg. 2008;121:241-50.
14. Koury ME, Epker BN. Maxillofacial esthetics: anthropometrics
of the maxillofacial region. J Oral Maxillofac Surg. 1992;50:806-20.
15. Raschke GF, Rieger UM, Bader RD, Guentsch A, Schaefer O,
Schultze-Mosgau S. The zygomaticomaxillary complex fracture - an
anthropometric appraisal of surgical outcomes. J Craniomaxillofac
Surg. 2013;41:331-7.
16. Flowers RS, Flowers SS. Diagnosing photographic distortion.
Decoding true postoperative contour after eyelid surgery. Clin Plast
Surg. 1993;20:387-92.
17. Waterhouse N, Lyne J, Urdang M, Garey L. An investigation
into the mechanism of orbital blowout fractures. Br J Plast Surg.
1999;52:607-12.
18. Stewart JM, Carter SR. Anatomy and examination of the eyelids.
Int Ophthalmol Clin. 2002;42:1-13.
19. Patel MP, Shapiro MD, Spinelli HM. Combined hard palate spacer
graft, midface suspension, and lateral canthoplasty for lower eyelid
retraction: a tripartite approach. Plast Reconstr Surg. 2005;115:2105-
14.
20. Raschke GF, Rieger UM, Bader RD, Schaefer O, Guentsch A,
Schultze-Mosgau S. Transconjunctical versus subciliary approach
for orbital fracture repair - an anthropometric evaluation of 221 cas-
es. Clin Oral Investig. 2013;17:933-42.
21. Cole P, Kaufman Y, Hollier L. Principles of facial trauma: orbital
fracture management. J Craniofac Surg. 2009;20:101-4.
22. Sharabi SE, Koshy JC, Thornton JF, Hollier LH. Facial fractures.
Plast Reconstr Surg. 2011;127:25e-34e.
23. Rohrich RJ, Janis JE, Adams WP. Subciliary versus subtar-
sal approaches to orbitozygomatic fractures. Plast Reconstr Surg.
2003;111:1708-14.

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