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 Table of Contents  
ORIGINAL RESEARCH
Year : 2017  |  Volume : 9  |  Issue : 2  |  Page : 65-70

Management of infraorbital rim and orbital floor fractures: A comparison of subciliary and infraorbital approaches


1 Department of Oral and Maxillofacial Surgery, Sparkle Dental Hospital, Hyderabad, Telangana, Telangana
2 Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Dentistry, Prince Sattam Bin Abdulaziz University, Al-Kharj, Kingdom of Saudi Arabia
3 Department of Oral and Maxillofacial Surgery, Malla Reddy Institute of Dental Sciences, Hyderabad, Telangana, India
4 Department of Oral and Maxillofacial Surgery, S. B. Patil Dental College and Hospital, Bidar, Karnataka, India
5 Department of Oral and Maxillofacial Surgery, Nanded Rural Dental College and Hospital, Nanded, Maharashtra, India
6 Department of Oral and Maxillofacial Surgery, Jayalakshmi Dental Hospital, Hyderabad, Telangana, India

Date of Web Publication13-Apr-2017

Correspondence Address:
Mohammed Ahtesam Aleem
Department of Oral and Maxillofacial Surgery, Sparkle Dental Hospital, Hyderabad, Telangana
Telangana
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_26_17

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  Abstract 


Background: Selection of approach to treat orbital fractures involves multiple factors such as visibility and esthetics. Aims and Objectives: The aim of this study is to compare subciliary and infraorbital incisions for orbital floor and infraorbital rim fractures. Materials and Methods: We carried our study in twenty patients, who reported to the department of oral and maxillofacial surgery with orbital floor and infraorbital rim fractures. The patients were divided into two groups (Group A - subciliary incision and Group B - infraorbital incision), with ten patients in each group. We compared infraorbital and subciliary incisions to approach the infraorbital rim and orbital floor in orbital fractures using criteria such as exposure time, esthetics, and complications. Results: All the analysis was done using SPSS version 14.P < 0.05 was considered statistically significant. We found that infraorbital incision took shortest time for exposing fractured site, caused more edema after 1 month of procedure, and lead to more visible scarring when compared to subciliary incision. Conclusion: We recommend subciliary incision to approach the infraorbital rim and orbital floor fractures.

Keywords: Infraorbital, edema, orbital floor, scar, subciliary


How to cite this article:
Aleem MA, Nasyam FA, Parameshwar Reddy K R, Karpe T, Singh T, Shailaja AB. Management of infraorbital rim and orbital floor fractures: A comparison of subciliary and infraorbital approaches. J Int Oral Health 2017;9:65-70

How to cite this URL:
Aleem MA, Nasyam FA, Parameshwar Reddy K R, Karpe T, Singh T, Shailaja AB. Management of infraorbital rim and orbital floor fractures: A comparison of subciliary and infraorbital approaches. J Int Oral Health [serial online] 2017 [cited 2019 Jun 17];9:65-70. Available from: http://www.jioh.org/text.asp?2017/9/2/65/204536




  Introduction Top


Fractures involving orbit make a considerable percentage of facial trauma (30%–40%).[1] The floor of the orbit is made of zygomatic, maxillary, and palatine bones. Infraorbital groove, on the orbital surface of maxilla contains infraorbital nerves and vessels, is prone to get fractured easily in floor fractures or during surgery in this region.[2]

For the treatment of orbit fractures, subciliary and infraorbital surgical approaches have been used in the past. The selection of surgical approach depends on factors such as visibility, esthetics, postoperative scarring, complications, and operative time.[1]

Access to the orbit can be done by transcutaneous or transconjuntival approaches. Transcutaneous techniques include subciliary, infraorbital, and subtarsal incisions. Each incision has some pros and cons. Hence, there is always a dilemma to the treating surgeon, which approach to be carried out.[1],[2],[3] We carried out this study to compare subciliary and infraorbital incisions for orbital floor and infraorbital rim fractures.


  Materials and Methods Top


A prospective, randomized, case–control study was conducted on twenty patients with orbital floor and infraorbital rim fractures, reporting to the department of oral and maxillofacial surgery, from January 2016 to December 2016, comparing two incisions, i.e., subciliary and infraorbital. The patients were selected randomly and divided into two groups (Group A - subciliary incision and Group B - infraorbital incision), with ten patients in each group.

Inclusion criteria

  1. Patients in the age group of 20–45 years, who sustained orbital floor and infraorbital rim fractures
  2. Only cases of fractures in which the orbital floor and infraorbital rim were surgically exposed for open reduction and internal rigid fixation were considered.


Exclusion criteria

  1. Patients with comminuted fracture of the rim and orbital floor, with more than 5 mm of displacement of fractured segments
  2. Patients with extensive soft-tissue injury in the zygoma region
  3. Cases that presented with preoperative infection
  4. Patients diagnosed with a psychiatric disorder, dementia, and/or severe drug abuse were excluded from the study.


A complete history of all the patients was taken preoperatively in a standard case history pro forma after obtaining institutional ethical clearance. Detailed clinical and radiographic examinations were done by paranasal sinus view, submentovertex view, and/or computed tomography scan-coronal section. A written informed consent was obtained from all the patients. The treatment of fractures was done by standard method of reduction and fixation using 2 mm 2 hole/4 hole stainless steel plates and secured using 2 mm screws and suturing was done using 3-0 vicryl and 4-0 prolene. All enrolled patients had 6 months of follow-up.

Subciliary approach procedure

A subciliary skin incision was made as described by Converse. The incision was followed by tarsorrhaphy in a skin crease 2 mm below and parallel to the lash line, beginning near the punctum and extending 5–8 mm past the lateral canthus on a skin fold. Then, the incision was continued along a straight line downward to the tarsal plate, separating the preseptal orbicularis oculi fibers from it. Once the tarsal plate was cleared of orbicularis fibers, the orbital septum held tense by upward traction on the previously placed lid-margin sutures and likewise separated from the preseptal orbicularis by spreading the two layers by means of the scissors. Then, the procedure followed the orbital septum downward to the inferior orbital rim. A 5–8 mm incision through the orbicularis fibers underlying the lateral extension of skin incision allowed the skin-muscle flap to be pulled away from the site of fracture easily, without the danger of tearing the fragile lid-skin. Standard subperiosteal exposure of the fractured site was then performed, and the reduction of fracture was done and fixation was done using 2 mm, 2 holes or 4 holes stainless steel plate which was secured using 2 mm stainless steel screws. Suturing was done using 3-0 vicryl and 3-0 prolene. Patients were followed up regularly [Figure 1] and [Figure 2].
Figure 1: Intraoperative view - subciliary incision

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Figure 2: Postoperative image 6 months after subciliary incision

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Infraorbital approach procedure

The infraorbital incision was placed in a skin fold at the junction of thin skin over the eyelid and thicker skin over the cheek, over the inferior orbital rim. The orbicularis muscle was divided at this same level, and the skin muscle flap was reflected away from the fracture site. Standard periosteal exposure of the fracture site was then performed, and the reduction of fracture was done and fixation was done using 2 mm 2 holes or 4 holes stainless steel plate which was secured using 2 mm × 6 mm stainless steel screws. Suturing was done using 4-0 vicryl and 3-0 prolene. Patients were followed up regularly [Figure 3] and [Figure 4].
Figure 3: Intraoperative view - infraorbital incision

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Figure 4: Postoperative image 6 months after infraorbital incision

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Parameters for comparison included

  1. The average time from incision to fracture site exposure
  2. Satisfactory exposure of the fracture site
  3. Analysis of early and late complications
  4. Appearance of the scar.



  Results Top


All the analysis was done using SPSS version 11.0 and Systat 8.0: SPSS Inc. Chicago, Illinois, USA. P< 0.05 was considered statistically significant. The obtained categorical variables were then compared using Chi-square test, and the continuous variables were compared using an independent sample t- test.

Demographic data

Age

  • Group A: Mean age was 38.50 years with a standard deviation of 8.33
  • Group B: Mean age was 29.30 years with a standard deviation of 9.52.


Gender

  • Group A: Included 9 (90%) males and 10 (10%) females
  • Group B: All the patients were males (100%).


Duration of exposure

We found that the duration of exposure was longer by subciliary incision (Group A) when compared to infraorbital incision (Group B) (independent sample t-test P≤ 0.001) [Table 1] and Graph 1].
Table 1: Duration of exposure of fractured site after two incisions

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  • Group A: Mean time of 5.10 min with a standard deviation of 0.28
  • Group B: Mean time of 2.96 min with a standard deviation of 0.3.


Amount of exposure

Adequate accessibility was seen in both Group A (subciliary incision) and Group B (infraorbital incision) [Table 2] and Graph 2].
Table 2: Edema 1 month postoperatively after two incisions

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Early complications

Edema

Edema on 1st day, 3rd day, and 1 week postoperatively: there was no statistically significant difference between Group A and Group B as all the patients in both groups presented with edema on the 1st day.

Edema 1 month postoperatively: 20% of patients in Group B presented with edema, whereas none of the patients reported with edema from Group A, though without statistical significance (Chi-square test, P= 0.136).

Late complications

  1. Scleral show - None of the patients from both groups showed scleral show
  2. Ectropion - No cases of ectropion were found in both groups
  3. Lymphedema - None of the patients from both groups showed lymphedema.


Appearance of scar

First month postoperatively

Seventy percent of patients in Group A had barely visible scar and 30% had visible scar, whereas in 30% of patients in Group B had barely visible scar and 70% had a visible scar. However, no statistical significance was present between the groups (Chi-square P= 0.074) [Table 3] and Graph 3].
Table 3: Scar 1 month postoperatively after two incisions

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Third month postoperatively

statistically significant difference between the two groups was seen 3 months postoperatively. Group A showed a higher rate of invisible scars in comparison to Group B (Chi-square P< 0.016) [Table 4] and Graph 4].
Table 4: Scar 3 months postoperatively after two incisions

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Sixth month postoperatively

Statistically significant difference between the two groups was seen 6 months postoperatively. Group A showed higher rate of invisible scars in comparison to Group B (Chi-squared P≤ 0.001) [Table 5] and Graph 5].
Table 5: Scar 6 months postoperatively after two incisions

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  Discussion Top


Road traffic accidents (RTAs) are one of the leading causes of morbidity and mortality in India. RTA commonly results in orbital fractures which not only cause functional impairment but also causes esthetic disfigurement.[4] Hence, contemporary oral and maxillofacial surgeons should plan treatment protocol, starting from the method of exposure of involved site to the actual treatment in such a way that it satisfies both functional and esthetic requirements. Recently, the preferred mode of treatment of fractures is by open reduction and bone grafting; hence, the incisions for exposure of fracture sites have a vital role in determining the success of the treatment and likelihood of complications postoperatively.[5],[6]

To expose the lower orbital rim and orbital floor, transcutaneous incisions such as subciliary, subtarsal, and infraorbital or transconjunctival incision with lateral canthotomy have been in practice. Complications after treatment of orbit fractures include scarring and increased risk of ectropion, epiphora impaired lymphatic drainage, and scleral inflammation.[6],[7],[8]

Converse (1944) was first to use the subciliary incision to treat the fractures of the orbital floor.[9] He placed an incision in a skin crease below and parallel to the lash line, beginning medially at the punctum and continuing laterally beyond the lateral canthus. Then, the skin over the orbicularis was dissected down to the orbital septum and then to the infraorbital rim. The access to the fractured site was gained through periosteal incision. He suggested that scar formation can be minimized by this procedure. However, it had complications such as ecchymosis, skin necrosis, and ectropion. Later, this approach was modified to skin-muscle flap technique to minimize the complications and achieve esthetic outcomes with an added advantage of ease of technique. However, studies have shown that the subciliary approach results in high frequency of denervation of the pretarsal orbicularis oculi muscle and also postoperative ecchymosis, as only a thin strip remains between the incison and lid margin. Infraorbital incision is placed at the junction of the thin eyelid skin and the thicker cheek skin, over the inferior orbital rim dividing orbicularis muscle at this same level.[9],[10],[11]

In our study, we retrospectively analyzed and compared subciliary and infraorbital incisions to approach the infraorbital rim and orbital floor in orbital fractures in terms of duration of exposure, amount of exposure, early complications such as edema, late complications such as ectropion, scleral show, lymphedema, and appearance of scar to determine which type of incision offers best outcome.[10],[11]

We found male predominance in the ratio of 9:1. This is similar to the findings of some previous studies. This might be due to the fact that males usually work outdoors and hence are more likely to face RTAs.[12]

We found most of our patients were between 21 and 30 years. This is similar to the findings of some other studies. This may be due to greater physical activity seen in this group. Studies have shown that scleral show and ectropion to be the most frequent complications in young and elderly group of patients, respectively.[13],[14],[15]

We found that RTAs as the main cause of injury in our patients. This is similar to few other studies. This might be due to increased RTAs in India due to factors such as failure to follow traffic rules and drunken driving.[15],[16]

In our study, the shortest time for exposing the fractured site was by the infraorbital approach, mean time being 2.96 min, whereas subciliary incision took a mean time of 5.10 min. Our findings are similar to few other studies. Wray et al. found that the time for exposing the infraorbital rim and orbital floor as 5 min for infraorbital, 8 min for subciliary and subtarsal, and 20 min for transconjunctival approaches.[10] Whereas, Holtmann et al. found that subtarsal incision took less time than the subciliary incision.[5]

In our study, we found that both incisions provided satisfactory exposure of the infraorbital rim and orbital floor. The findings are in agreement with other similar studies.[10],[11],[12]

As with any surgical procedures, complications are likely to occur after treatment of orbital fractures. Management of the complications decides the success of the procedure and aids in recovery of the patient. We did not find any difference in occurrence of edema in both groups after 1 day, 3 days, and 1 week after the procedure. However, 20% of patients in Group B continued to have lid edema even after 1 month postoperatively, whereas none in Group A. Studies have shown that infraorbital incisions are comparatively easy to carry out than other incisions and in most of the cases heal well but are associated with eyelid edema due to disturbance of lymphatic drainage. De Melo Crosara et al. did found any statistically significant difference in occurrence of lid edema among the three different types of incisions subciliary, subtarsal, and infraorbital incisions, while in two cases, edema was observed in the infraorbital incision group.[17] Schmidseder and Esswein also did not found any incidence of edema after the subciliary incision, whereas the edema was found in 2 out of 30 cases after infraorbital incisions. They suggested that the incidence of edema will be higher in cases where incisions are placed more inferiorly as they interrupt lymphatic drainage.[18]

We did not find late complications such as scleral show, ectropion, and lymphedema in any of our cases in both groups. Whereas Bähr et al. found complications such as scleral show and ectropion. According to them, the success of treatment depends on the time interval between incidence of trauma and commencement of treatment.[11] Holtmann et al. found significantly higher rate of ectropion (42%) in the subciliary incision group.[5] Whereas, Antonyshyn et al. found a 16.6% incidence of sclera after subciliary incision.[6] They suggested the need of preservation of a pretarsal portion of the orbicularis in the upholding of proper lid tonus. Appling et al.[16] and Netscher et al.[19] found scleral show after subciliary approach in 28% and 70% of their cases, respectively. However, Heckler et al. did not find complications of permanent ectropion or scleral show in any of their cases.[20]

Several authors suggested that to prevent the occurrence of ectropion and scleral show, precautions should be taken during surgical technique such as avoiding deep lateral dissection of the orbicularis muscle, maintaining proper hemostasis, avoiding wide incision, and placing incision of the periosteum away from the orbital septum. They also suggested that using suspensory or Frost suture, the incidence of ectropion can be reduced to almost 50%.[17],[18],[19],[20]

Scar formation is considered to be the most important complication that dictates the success of any surgical procedures. We found higher incidence of invisible scars in subciliary incision group. The same results were also observed by Holtmann et al. They suggested that significantly higher rate of unnoticeable scars are seen in situ ations where higher incisions are used. Hence, invisible scar formation is more after subciliary incision when compared to infraorbital incision.[5]

It has been found that the scars produced at the skin of the eyelid were esthetically better to those of cheek or brow skin. This might be due to the skin of eyelid being thinner and having a finer texture than cheek or brow skin. Heckler et al.[20] noticed a superior scar after subciliary incision, whereas Schmidseder and Esswein [18] noted four cases with scar out of 28 patients following infraorbital incisions. Bähr et al.[11] found superior scar formation after subciliary incision when compared to infraorbital incision. They suggested that quality of the skin and differential muscle mobility influence scarring. They also suggested that the esthetic manifestation of the scar possibly will be influenced by appropriate closure of the associated soft tissues. It is always best to close in layers beginning with the periosteum and fixing the soft tissues to the bone after fracture reduction as it is considered to influence the esthetic appearance of the scar. However, the closure of periosteum may be of concern in the infraorbital approach as the skin and the periosteum are divided at the same level.[9],[10],[11]

We did not find any significant difference in edema as a complication between the two incisions. However, Bähr et al. found more edema after infraorbital incision. According to them, obstruction to the lymphatic vessels might be the cause.[11]

Strength of the study

  1. Fewer complications after the procedures when compared to other similar studies
  2. Shorter operation time when compared to other similar studies
  3. To the best of our knowledge, after extensively searching the literature, we found that ours is the first study comparing subciliary and infraorbital incisions to treat orbit fractures.


Limitations of the study

  1. Lower sample size was the main limitation of our study
  2. Fewer parameters assessed.


Future perspectives

We suggest further such studies with a larger sample size and with more parameters to arrive at a statistically significant opinion.


  Summary and Conclusion Top


To treat fractures, one has to keep in mind various factors, one among which being the type of incision to expose fractured site. We compared infraorbital and subciliary incisions to approach the infraorbital rim and orbital floor in orbital fractures. We found that infraorbital incision took shortest time for exposing fractured site, more edema after 1 month of procedure, and lead to more visible scarring when compared to subciliary incision. Hence, we recommend subciliary approach.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Campbell AA, Grob SR, Yoon MK. Novel surgical approaches to the orbit. Middle East Afr J Ophthalmol 2015;22:435-41.  Back to cited text no. 1
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Boyette JR, Pemberton JD, Bonilla-Velez J. Management of orbital fractures: Challenges and solutions. Clin Ophthalmol 2015;9:2127-37.  Back to cited text no. 2
    
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Raschke G, Djedovic G, Peisker A, Wohlrath R, Rieger U, Guentsch A, et al. The isolated orbital floor fracture from a transconjunctival or subciliary perspective – A standardized anthropometric evaluation. Med Oral Patol Oral Cir Bucal 2016;21:e111-7.  Back to cited text no. 3
    
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Motamed Al Shariati SM, Dahmardehei M, Ravari H. Subciliary approach for inferior orbital rim fractures; case series and literature review. Bull Emerg Trauma 2014;2:121-4.  Back to cited text no. 4
    
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Holtmann B, Wray RC, Little AG. A randomized comparison of four incisions for orbital fractures. Plast Reconstr Surg 1981;67:731-7.  Back to cited text no. 5
    
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Antonyshyn O, Gruss JS, Galbraith DJ, Hurwitz JJ. Complex orbital fractures: A critical analysis of immediate bone graft reconstruction. Ann Plast Surg 1989;22:220-33.  Back to cited text no. 6
    
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Shirania G, Vaezib T. Application of endoscope and conventional techniques in management of orbital floor and infra-orbital rim fracture reduction. J Craniomaxillofac Res 2015;2:122-7.  Back to cited text no. 7
    
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Park HJ, Son KM, Choi WY, Cheon JS, Yang JY. Use of triamcinolone acetonide to treat lower eyelid malposition after the subciliary approach. Arch Craniofac Surg 2016;17:63-7.  Back to cited text no. 8
    
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Davies BW, Hink EM, Durairaj VD. Transconjunctival inferior orbitotomy: Indications, surgical technique, and complications. Craniomaxillofac Trauma Reconstr 2014;7:169-74.  Back to cited text no. 9
    
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Wray RC, Holtmann B, Ribaudo JM, Keiter J, Weeks PM. A comparison of conjunctival and subciliary incisions for orbital fractures. Br J Plast Surg 1977;30:142-5.  Back to cited text no. 10
    
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Bähr W, Bagambisa FB, Schlegel G, Schilli W. Comparison of transcutaneous incisions used for exposure of the infraorbital rim and orbital floor: A retrospective study. Plast Reconstr Surg 1992;90:585-91.  Back to cited text no. 11
    
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Jose A, Nagori SA, Agarwal B, Bhutia O, Roychoudhury A. Management of maxillofacial trauma in emergency: An update of challenges and controversies. J Emerg Trauma Shock 2016;9:73-80.  Back to cited text no. 12
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Kumar S, Shubhalaksmi S. Clinical outcome following use of transconjunctival approach in reducing orbitozygomaticomaxillary complex fractures. Contemp Clin Dent 2016;7:163-9.  Back to cited text no. 13
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Vaibhav N, Keerthi R, Nanjappa M, Ashwin DP, Reyazulla MA, Gopinath AL, et al. Comparison of 'sutureless' transconjunctival and subciliary approach for treatment of infraorbital rim fractures: A clinical study. J Maxillofac Oral Surg 2016;15:355-62.  Back to cited text no. 14
    
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El-Sheikh MH, Bhoyar SC, Emsalam RA. Mandibular fractures in benghazi-libya: A retrospective analysis. JIDA 1992;63:367-70.  Back to cited text no. 15
    
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Appling WD, Patrinely JR, Salzer TA. Transconjunctival approach vs. subciliary skin-muscle flap approach for orbital fracture repair. Arch Otolaryngol Head Neck Surg 1993;119:1000-7.  Back to cited text no. 16
    
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de Melo Crosara J, da Rosa EL, Silva MR. Comparison of cutaneous incisions to approach the infraorbital rim and orbital floor. Braz J Oral Sci 2009;8:88-91.  Back to cited text no. 17
    
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Subramanian B, Krishnamurthy S, Suresh Kumar P, Saravanan B, Padhmanabhan M. Comparison of various approaches for exposure of infraorbital rim fractures of zygoma. J Maxillofac Oral Surg 2009;8:99-102.  Back to cited text no. 18
    
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Netscher DT, Patrinely JR, Peltier M, Polsen C, Thornby J. Transconjunctival versus transcutaneous lower eyelid blepharoplasty: A prospective study. Plast Reconstr Surg 1995;96:1053-60.  Back to cited text no. 19
    
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Heckler FR, Songcharoen S, Sultani FA. Subciliary incision and skin-muscle eyelid flap for orbital fractures. Ann Plast Surg 1983;10:309-13.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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