Functional and Aesthetic Outcomes of the Subtarsal Approach in Zygomaticomaxillary Complex Fractures With Orbital Floor Involvement: A Prospective Cohort Study

TL;DR

This study evaluates the subtarsal approach for treating facial fractures involving the eye socket, showing improvements in function and appearance.

Contribution

The study provides empirical evidence on the subtarsal approach's effectiveness for zygomaticomaxillary complex fractures with orbital floor involvement.

Findings

Significant improvements in nerve paresthesia, eyelid position, and visual acuity were observed three months post-surgery.

Fracture stability and scar visibility improved significantly, with minimal complications reported.

Ocular movement improvements were not statistically significant.

Abstract

Introduction

Zygomaticomaxillary complex (ZMC) fractures, often resulting from high-impact trauma, frequently involve the orbital floor, leading to functional and aesthetic complications such as diplopia, enophthalmos, and facial asymmetry. The subtarsal approach, which involves an incision through the skin, provides access to the orbital floor while potentially reducing complications. This study aimed to evaluate the efficacy and safety of the subtarsal approach in managing ZMC fractures with orbital floor discontinuity, focusing on functional outcomes (nerve paresthesia, ocular movement, and visual acuity), lower eyelid position, fracture stability, and scar visibility at one and three months post-surgery.

Materials and methods

A prospective cohort study was conducted in the Department of Oral and Maxillofacial Surgery at Annasaheb Chudaman Patil Memorial Dental College, Dhule, Maharashtra, between February 2022 and February 2024. Twenty-four patients aged 18-65 years with displaced ZMC fractures and orbital floor discontinuity confirmed via CT were included. The exclusion criteria were prior orbital surgery, severe comorbidities, ocular pathology, infected or comminuted fractures, and refusal to consent. Preoperative assessments included clinical examinations of facial symmetry, ocular motility, visual acuity, and nerve function, along with CT imaging. The subtarsal approach involved a 4-7 mm incision below the lash line, with layered dissection to access the orbital floor for fracture reduction and fixation using titanium miniplates and mesh. Outcomes were assessed at one and three months for nerve paresthesia, eyelid position, ocular movement, visual acuity, fracture stability, and scar visibility using the Patient and Observer Scar Assessment Scale (POSAS). Statistical analysis employed chi-square and Wilcoxon signed-rank tests, with p < 0.05 indicating significance.

Results

The study population was predominantly male, with tetrapod fractures being the most common type. All patients exhibited periorbital edema, 18 (75%) had infraorbital nerve dysfunction, and 14 (58.3%) had reduced visual acuity at 0.3 preoperatively. By three months post-surgery, significant improvements were observed: nerve paresthesia decreased (p = 0.017), normal eyelid position increased (p = 0.009), and visual acuity improved (p = 0.012). Fracture stability scores improved from a median of 5 (mean 5.17 ± 0.702) to 1 (mean 1.21 ± 0.833, p = 0.001), and scar evaluation scores decreased from a median of 7 (7.33 ± 1.007) to 3 (3.33 ± 0.637, p = 0.001). The improvement in ocular movement from full restriction was not statistically significant (p = 0.08).

Conclusion

The subtarsal approach proved effective and safe, achieving significant functional and aesthetic improvements in ZMC fracture management with minimal complications. Further studies with larger sample sizes and longer follow-up periods are required to validate these findings.

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