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Ageing increases risk of lower eyelid malposition after primary orbital fracture reconstruction

Open AccessPublished:August 22, 2022DOI:https://doi.org/10.1016/j.bjoms.2022.08.004

      Abstract

      Background

      Lower eyelid malposition (LEM) is a common sequela after orbital fracture reconstruction surgery. This study aimed to analyse the development of LEM, specifically ectropion and entropion, following primary orbital fracture reconstruction surgery, to identify predictive factors for LEM and to assess the effect of the eyelid complication on patients’ daily life.

      Material and Methods

      The retrospective cohort comprised patients who had undergone orbital floor and/or medial wall fracture reconstruction for recent trauma. Demographics, fracture type and site, surgery and implant-related variables, follow-up time and number of visits, type and severity of LEM, subsequent surgical correction, and patient satisfaction were analysed.

      Results

      The overall occurrence of LEM was 7.5%, with ectropion in 5.7% and entropion in 1.7% of patients. Older age, complex fractures, transcutaneous approaches, preoperative traumatic lower lid wound, and implant material were associated with development of LEM. Of all patients, 3.4% needed surgical correction of LEM. Six of the 13 patients (46.2%) who developed LEM, required surgical correction.

      Conclusions

      The transconjunctival approach and patient-specific implants should be preferred, especially in elderly patients and in those with more complex fractures. LEM often requires subsequent surgical correction and the treatment period is substantially prolonged, with multiple extra visits to the clinic.

      Keywords

      Introduction

      Facial injury and fracture reconstruction surgery may cause cosmetic and functional complications to the eyelid such as ectropion, entropion [
      • Al-Moraissi E.A.
      • Thaller S.R.
      • Ellis E.
      Subciliary vs. transconjunctival approach for the management of orbital floor and periorbital fractures: A systematic review and meta-analysis.
      ]. Lower eyelid malposition (LEM) is one of the most common sequelae after facial fracture surgery [
      • Kim C.H.
      • Choi W.Y.
      • Son K.M.
      • Cheon J.S.
      Prediction of Lower Eyelid Malpositioning After Surgical Correction of Orbital Fracture Using the Subciliary Approach Through the Canthal Area and Orbital Vector Analysis.
      ,
      • Harris G.J.
      Avoiding complications in the repair of orbital floor fractures.
      ]. The mechanism for LEM following fracture surgery is considered to be due to scar contracture [
      • North V.S.
      • Reshef E.R.
      • Lee N.G.
      • Lefebvre D.R.
      • Freitag S.K.
      • Yoon M.K.
      Lower eyelid malposition following repair of complex orbitofacial trauma.
      ,
      • Choi M.G.
      • Oh J.Y.
      • Lee J.K.
      Changes in Lower Eyelid Position and Shape After Inferior Orbital Wall Reconstruction.
      ]. LEM often resolves spontaneously or with such non-surgical treatment as lubrication, taping, and massage within six months [
      • Kim C.H.
      • Choi W.Y.
      • Son K.M.
      • Cheon J.S.
      Prediction of Lower Eyelid Malpositioning After Surgical Correction of Orbital Fracture Using the Subciliary Approach Through the Canthal Area and Orbital Vector Analysis.
      ,
      • Neovius E.
      • Clarliden S.
      • Farnebo F.
      • Lundgren T.K.
      Lower Eyelid Complications in Facial Fracture Surgery.
      ]. However, severe types of LEM require subsequent surgical correction.
      Depending on the severity, ectropion may cause lagophthalmos, impaired corneal lubrication or protection, inflammation, and epiphora [
      • Reich W.
      • Heichel J.
      • Fugiel E.
      • Eckert A.W.
      Lower eyelid ectropion as a sequela of different underlying diseases in maxillo-facial surgery: Diagnostics and treatment approaches.
      ], whereas entropion may result in pain, irritation, blurry vision, and foreign body sensation as the cilia are in contact with the cornea [
      • Neovius E.
      • Clarliden S.
      • Farnebo F.
      • Lundgren T.K.
      Lower Eyelid Complications in Facial Fracture Surgery.
      ,
      • Hakim F.
      • Phelps P.O.
      Entropion and ectropion.
      ]. All symptoms of the eyelid are noticeable and likely to impair patients’ quality of life [
      • Hakim F.
      • Phelps P.O.
      Entropion and ectropion.
      ].
      Among orbital fracture patients, LEM has been studied extensively with regard to the surgical approach [
      • Al-Moraissi E.
      • Elsharkawy A.
      • Al-Tairi N.
      • Farhan A.
      • Abotaleb B.
      • Alsharaee Y.
      • et al.
      What surgical approach has the lowest risk of the lower lid complications in the treatment of orbital floor and periorbital fractures? A frequentist network meta-analysis.
      ,
      • Ridgway E.B.
      • Chen C.
      • Colakoglu S.
      • Gautam S.
      • Lee B.T.
      The incidence of lower eyelid malposition after facial fracture repair: a retrospective study and meta-analysis comparing subtarsal, subciliary, and transconjunctival incisions.
      ] but less so regarding other factors. Our hypothesis was that older age, along with other yet undisclosed predisposing factors, would play a role in development of LEM following orbital fracture reconstruction surgery. The primary aim of this study was to analyse the development of LEM, specifically ectropion and entropion, following primary orbital fracture reconstruction surgery. Further aims were to identify new predictive factors for LEM and to assess the effect of the eyelid complication on patients’ daily life.

      Material and methods

      Study design

      Patient data were collected retrospectively from all orbital floor and/or medial wall fracture reconstructions performed at the Department of Oral and Maxillofacial Diseases, Helsinki University Hospital (HUH), from 1 January 2011 to 30 October 2019.

      Inclusion and exclusion criteria

      All patients who had undergone reconstruction of the orbital floor, medial wall, or both due to recent fracture (< 3 weeks) were included in the study. Patients requiring revision surgery and those with fewer than four weeks (28 days) of follow-up were excluded.

      Study variables

      The outcome variable was LEM (yes/no). LEM was established in patients who had either ectropion or entropion, which were visible eversions or inversions of the lower eyelid, with or without retraction of the lid vertically. Additional outcome variables were type of LEM (i.e. ectropion or entropion), severity of LEM, subsequent surgical correction of LEM (yes/no), total follow-up time, extra visits at the clinic due to LEM, and subjective patient satisfaction, which was assessed at the end of the treatment period. Severity of LEM was roughly classified as mild, moderate, or severe. Two authors with vast experience in orbital fracture surgery (JS and HR) reviewed the files of patients with LEM and performed the rough grading based on patient-reported subjective symptoms, treatments required (no treatment, non-surgical treatment, or surgical treatment), and duration of LEM.
      The primary predictor variable was age. For this purpose, patients were classified as <47-year-olds and ≥47-year-olds, based on the median age of the study population.
      Explanatory variables were sex, facial fracture type, orbital fracture site, presence of a traumatic wound in the lower lid preoperatively (yes/no), surgical approach, site of reconstruction, reconstruction material, screw fixation of orbital implant (yes/no), and orbital lower rim plate fixation (yes/no).
      Facial fracture type was classified as 1) isolated orbital fracture, 2) zygomatico-orbital fracture, or 3) midfacial fracture extending to orbit. Orbital fracture site was classified as 1) isolated orbital floor or 2) isolated orbital medial wall 3) orbital floor and associated medial wall fracture. Surgical approach was classified as 1) transconjunctival, 2) subtarsal, or 3) subciliar. Of transconjunctival approaches, those with an associated lateral canthotomy procedure were further identified. Site of reconstruction was classified as 1) orbital floor or 2) orbital floor and medial wall. Reconstruction materials were classified as 1) manually bent titanium mesh, 2) preformed three-dimensional titanium mesh, 3) patient-specific milled titanium implant, or 4) resorbable materials (bioactive glass, polymer of polylactide acid, or polyglycolic acid).

      Statistical analyses

      STATA (version 15, StataCorp, College Station, TX, USA) was used for the statistical analyses. Categorical variables are presented as counts with percentages and non-parametric continuous data as medians with interquartile ranges (IQRs), unless otherwise specified. The skewness of continuous variables was assessed using the Shapiro Francia W-test. The non-parametric test (Wilcoxon rank-sum test) was used to assess differences in distribution between groups. Differences in categorical variables between groups were tested using a two-sided χ2 test or Fisher’s exact test.
      To identify independent risk factors for LEM, differences in baseline features and risk factors between patients with and without LEM were analysed in univariate analysis. Variables with an associated p-value <0.05 in the univariate analysis were included in a multivariable logistic regression analysis to find factors independently associated with LEM. The association between age and risk of LEM was assessed by categorizing age into two groups based on patients’ median age and by using age as a continuous variable. The independent association between age and risk of LEM was assessed by using binominal generalized linear and logistic regression models.
      Results are shown as RRs (risk ratios), ORs (odds ratios) with 95% CIs (confidence intervals). P-values under 0.05 were considered statistically significant.
      Ethical approval
      The internal review board of the Head and Neck Centre, Helsinki University Hospital (HUS/356/2017) approved the study protocol. Written informed consent was obtained from all participants.

      Results

      A total of 265 orbital reconstruction surgeries were identified from a database search. Of these, 10 were excluded for being tumour surgery, 18 for being late or secondary reconstructions (> 3 weeks from injury), 15 for being revision surgery, and 48 for lacking the required minimum follow-up time of 28 days (4 weeks). Altogether 174 reconstructions were included in the final analysis. The median follow-up time of patients was 113.0 days (mean 181.2, range 29−862 days). All orbital reconstructions were unilateral.
      Table 1 presents the age, sex, and clinical characteristics of the injuries. The majority (64.9%) of the patients were men. The median age was 46.7 years. Assault (40.2%) and fall on level ground (27.0%) were the most common mechanisms of injury. Isolated orbital fracture was the predominant facial fracture type (70.1%). None of the patients had an isolated orbital medial wall fracture.
      Table 1Demographic data and injuries of 174 patients with orbital fracture reconstruction.
      VariableNo. of patients% of 174
      Age (years)
      median46.7
      mean47.9
      range5.4-87.6
      < 478850.6
      ≥ 478649.4
      Sex
      male11364.9
      female6135.1
      Aetiology
      assault7040.2
      fall on ground level4727.0
      sports1910.9
      motor vehicle accident158.6
      high-energy fall137,5
      bicycle84.6
      other21.1
      Facial fracture type
      isolated orbital12270.1
      midfacial extending to orbit3419.5
      zygomatico-orbital1810.3
      Orbital fracture site
      floor10057.5
      floor and medial wall7442.5
      Lower eyelid wound
      yes52.9
      In Table 2, the characteristics of reconstructions and LEM are shown. Surgical access to the fracture site was most often gained via transconjunctival approach (61.5%), with additional lateral canthotomy in 19.5%. Materials used in the reconstruction included manually bent titanium mesh (Synthes/DePuySynthes, Stryker), preformed three-dimensional titanium mesh (Synthes/DePuySynthes, KLS Martin, Stryker), patient-specific milled titanium implant (mtPSI), (Planmeca Ltd.) [
      • Kärkkäinen M.
      • Wilkman T.
      • Mesimäki K.
      • Snäll J.
      Primary reconstruction of orbital fractures using patient-specific titanium milled implants: the Helsinki protocol.
      ], and resorbable materials that were bioactive glass (BAGS53P4 BonAlive Biomaterials Ltd [
      • Stoor P.
      • Mesimäki K.
      • Lindqvist C.
      • Kontio R.
      The use of anatomically drop-shaped bioactive glass S53P4 implants in the reconstruction of orbital floor fractures–A prospective long-term follow-up study.
      ] or a polymer of polyactide acid or polyglycolic acid or both (PLA/PGA/PLGA, Synthes, Stryker). All manually bent titanium meshes were modified to their final shape intraoperatively by the surgeon.
      Table 2Data of orbital fracture reconstruction and lower eyelid malposition in 174 patients.
      VariableNo. of patients% of 174
      Surgical approach
      transconjunctival10761.5
      subtarsal5632.2
      subciliar116.3
      Transconjunctival and lateral canthotomy
      yes3419.5
      Site of reconstruction
      floor15287.4
      floor and medial wall2212.6
      Reconstruction material
      manually bent titanium mesh7241.4
      patient specific implant5229.9
      preformed titanium mesh3721.3
      resorbable material137.5
      Screw fixation of orbital implant
      yes148.0
      Orbital lower rim fixation
      yes4023.0
      LEM
      yes137.5
      Ectropion
      yes105.7
      Entropion
      yes31.7
      Severity of LEM
      mild10.6
      moderate63.4
      severe63.4
      Subsequent surgical correction of LEM
      yes63.4
      Abbreviations: LEM=lower eyelid malposition
      The overall occurrence of LEM was 7.5% (Table 2). Ectropion was observed in 5.7% and entropion in 1.7% of patients. Of the 13 LEM cases, 12 were considered moderate or severe. Subsequent surgical correction of LEM was required in 3.4% of patients.
      Table 3 summarizes the differences between age groups with respect to other explanatory variables. Sex (p<0.001) and aetiology (p<0.001) were significantly associated with age group. Males predominated in the younger age group. Assaults and sport injuries were more common in the younger age group, whereas falls were more common in the older age group.
      Table 3Association between explanatory variables and patientś age.
      < 47 years (n=88)≥ 47 years (n=86)
      VariableNo. of patients% of 88No. of patients% of 86p-value *
      Sex
      male7079.54350.0<0.001
      female1820.54350.0
      Aetiology<0.001
      assault5259.11820.9
      fall on ground level89.13945.3
      sports1415.955.8
      motor vehicle accident910.267.0
      high-energy fall33.41011.6
      bicycle22.367.0
      other00.022.3
      Facial fracture type0.06
      isolated orbital6877.35462.8
      midfacial extending to orbit1517.01922.1
      zygomatico-orbital55.71315.1
      Orbital fracture site0.43
      floor4854.55260.5
      floor and medial wall4045.53439.5
      Lower eyelid wound1.00
      yes33.422.3
      Surgical approach0.06
      transconjunctival6169.34653.5
      subtarsal2123.93540.7
      subciliar66.855.8
      Transconjunctival and lateral canthotomy0.40
      yes1517.01922.1
      Site of reconstruction0.38
      floor7585.27890.7
      floor and medial wall1314.8910.5
      Reconstruction material0.22
      manually bent titanium mesh3236.44046.5
      patient-specific implant3135.22124.4
      preformed titanium mesh1719.32023.3
      resorbable material89.155.8
      Screw fixation of orbital implant0.29
      yes910.255.8
      Orbital lower rim fixation0.13
      yes1618.22427.9
      * Two-sided χ2 test and Fisher’s exact test
      Table 4 shows the bivariate associations between primary outcome variable, LEM, and age and other explanatory variables. Mean and median age was higher in patients with LEM than in those without LEM (p=0.040). Facial fracture type (p<0.001), orbital fracture site (p=0.009), presence of traumatic lower eyelid wound (p=0.003), surgical approach (p=0.001), site of reconstruction (p<0.001), reconstruction material (p<0.001), screw fixation of the orbital implant (p=0.002), and orbital lower rim fixation (p= 0.001) were significantly associated with the presence or absence of LEM. As shown in Table 5, there were no bivariate associations between age groups and LEM, LEM type, severity, or surgical treatment.
      Table 4Associations between age and explanatory variables and lower eyelid malposition.
      LEM presentLEM absent
      Variablen=13% of nn=161% of np-value*
      Age0.04
      median59.150.8
      mean5647.3
      Sex0.736
      male (n=113)98.010492.0
      female (n=61)46.65793.4
      Facial fracture type<0.001
      isolated orbital (122)32.511997.5
      midfacial extending to orbit (n=34)823.52676.5
      zygomatico-orbital (n=18)211.11688.9
      Orbital fracture site0.009
      floor (n=100)339797.0
      floor and medial wall (n=74)1013.56486.5
      Lower eyelid wound0.003
      yes (n=5)360240.0
      Surgical approach0.001
      transconjunctival (n=107)54.710295.3
      subtarsal (n=56)47.15292.9
      subciliar (n=11)436.4763.6
      Transconjunctival and lateral canthotomy (n=34)0.738
      yes38.83191.2
      Site of reconstruction<0.001
      floor (n=152)63.914696.1
      floor and medial wall (n=22)731.81568.2
      Reconstruction material<0.001
      manually bent titanium mesh (n=72)34.26995.8
      preformed titanium mesh (n=37)924.32875.7
      patient specific implant (n=52)11.95198.1
      resorbable material (n=13)0013100.0
      Screw fixation of orbital implant0.002
      yes (n=14)428.61071.4
      Orbital lower rim fixation0.001
      yes (n=40)8203280.0
      Abbreviations: LEM=lower eyelid malposition
      *Wilcoxon rank-sum test, two-sided χ2 test, and Fisher’s exact test
      Table 5Association between lower eyelid malposition types, severity, or surgical treatment and patientś age.
      < 47 years (n=88)≥ 47 years (n=86)
      VariableNo. of patients% of 88No. of patients% of 86p-value *
      LEM0.27
      yes55.789.3
      Type of LEM0.40
      ectropion33.478.1
      entropion22.311.2
      Severity of LEM1.00
      mild00.011.2
      moderate22.344.7
      severe33.433.5
      Subsequent surgical correction of LEM0.59
      yes33.433.5
      Abbreviations: LEM=lower eyelid malposition
      *Two-sided χ2 test and Fisher’s exact test
      Table 6 displays the results of the binominal generalized linear model. The association between age and LEM was significant, when age was a continuous variable. The risk for LEM increases by 4% each year (95% CI 1-8%). The results from the multivariable logistic regression analysis are shown in the supplementary material.
      Table 6Results from the binominal generalized linear model showing the association between age and lower eyelid malposition.
      VariableOccurrence of lower eyelid malpositionUnadjusted risk ratio(95% CI)Adjusted risk ratio*(95% CI)
      Age as continuousvariable13/174 (7.5%)1.02 (0.99-1.05)1.04 (1.01-1.08)
      Abbreviations: CI=confidence interval
      * Adjusted for facial fracture type, orbital fracture site, surgical approach, implant material, reconstruction site, screw fixation of implant, orbital lower rim plate fixation, and lower eyelid wound
      The total follow-up time in patients with LEM was a median of 245 days (mean 316.8, range 31-804 days), being 2.3 times longer than in those without LEM (p=0.006). Patients needed a median of four (mean 4.5, range 1−10) extra follow-up visits due to LEM.
      Most (61.5%) of the patients who developed LEM were subjectively satisfied at the last follow-up visit, not having a noticeable disadvantage in the lower eyelid after treatment. However, four patients (30.8%) were left with subjectively defined mild disadvantage and one patient (7.7%) with severe disadvantage despite all treatments for LEM.

      Discussion

      Our hypothesis was confirmed, as older age was found to be an independent risk factor for LEM and another previously unreported association between LEM and implant material emerged. This study also confirmed that LEM occurrence is associated with complex fractures in particular [
      • North V.S.
      • Reshef E.R.
      • Lee N.G.
      • Lefebvre D.R.
      • Freitag S.K.
      • Yoon M.K.
      Lower eyelid malposition following repair of complex orbitofacial trauma.
      ,
      • Choi M.G.
      • Oh J.Y.
      • Lee J.K.
      Changes in Lower Eyelid Position and Shape After Inferior Orbital Wall Reconstruction.
      ].
      Earlier research [
      • Choi M.G.
      • Oh J.Y.
      • Lee J.K.
      Changes in Lower Eyelid Position and Shape After Inferior Orbital Wall Reconstruction.
      ,
      • Reich W.
      • Heichel J.
      • Fugiel E.
      • Eckert A.W.
      Lower eyelid ectropion as a sequela of different underlying diseases in maxillo-facial surgery: Diagnostics and treatment approaches.
      ,
      • Hakim F.
      • Phelps P.O.
      Entropion and ectropion.
      ,
      • Hester Jr., T.R.
      • Douglas T.
      • Szczerba S.
      Decreasing complications in lower lid and midface rejuvenation: the importance of orbital morphology, horizontal lower lid laxity, history of previous surgery, and minimizing trauma to the orbital septum: a critical review of 269 consecutive cases.
      ] has reported mechanisms of degenerative processes in the eyelid that cause increased laxity of the lower eyelid. Hakim et al. [
      • Hakim F.
      • Phelps P.O.
      Entropion and ectropion.
      ] noted an association between older age and non-traumatic LEM. This study showed that elderly patients have an increased risk of cicatricial LEM postoperatively as well. This is a clinically relevant finding because orbital fractures are known to be more frequent and severe in elderly patients [
      • Toivari M.
      • Helenius M.
      • Suominen A.L.
      • Lindqvist C.
      • Thorén H.
      Etiology of facial fractures in elderly Finns during 2006–2007.
      ], and the proportion of elderly people in the general population is continuously increasing.
      The total occurrence of LEM (7.5%) is in concordance with the previous literature [
      • Kim C.H.
      • Choi W.Y.
      • Son K.M.
      • Cheon J.S.
      Prediction of Lower Eyelid Malpositioning After Surgical Correction of Orbital Fracture Using the Subciliary Approach Through the Canthal Area and Orbital Vector Analysis.
      ,
      • Schneider M.
      • Besmens I.S.
      • Luo Y.
      • Giovanoli P.
      • Lindenblatt N.
      Surgical management of isolated orbital floor and zygomaticomaxillary complex fractures with focus on surgical approaches and complications.
      ,
      • North V.S.
      • Reshef E.R.
      • Lee N.G.
      • Lefebvre D.R.
      • Freitag S.K.
      • Yoon M.K.
      Lower eyelid malposition following repair of complex orbitofacial trauma.
      ,
      • Kesselring A.G.
      • Promes P.
      • Strabbing E.M.
      • van der Wal K.G.
      • Koudstaal M.J.
      Lower Eyelid Malposition Following Orbital Fracture Surgery: A Retrospective Analysis Based on 198 Surgeries.
      ,
      • Choi M.G.
      • Oh J.Y.
      • Lee J.K.
      Changes in Lower Eyelid Position and Shape After Inferior Orbital Wall Reconstruction.
      ,
      • Holtmann B.
      • Wray R.C.
      • Little A.G.
      A randomized comparison of four incisions for orbital fractures.
      ,
      • Park H.J.
      • Son K.M.
      • Choi W.Y.
      • Cheon J.S.
      • Yang J.Y.
      Use of Triamcinolone Acetonide to Treat Lower Eyelid Malposition after the Subciliary Approach.
      ]. Occurrence rates vary between 0 and 42%, depending on the criteria for LEM. In this study, we included all clinically significant instances of visible ectropion or entropion that were noted in the medical records.
      Very few studies examined or reported the development of LEM with respect to different fracture types. North et al. [
      • North V.S.
      • Reshef E.R.
      • Lee N.G.
      • Lefebvre D.R.
      • Freitag S.K.
      • Yoon M.K.
      Lower eyelid malposition following repair of complex orbitofacial trauma.
      ] showed a significantly higher occurrence of LEM (20%) in patients with complex fractures than in patients with an isolated orbital blowout fracture (4.2%). Our study supports the findings of North and colleagues, as significant associations existed between LEM and all predictors indicating more complex fractures, including associated midfacial fracture, more extensive orbital fractures and reconstructions, and additional orbital lower rim plate fixation.
      The transconjunctival approach has the lowest overall LEM rate compared with the transcutaneous (subciliar, subtarsal, and infraorbital) approaches, and the subciliar approach has the highest rate among the transcutaneous approaches [
      • Al-Moraissi E.
      • Elsharkawy A.
      • Al-Tairi N.
      • Farhan A.
      • Abotaleb B.
      • Alsharaee Y.
      • et al.
      What surgical approach has the lowest risk of the lower lid complications in the treatment of orbital floor and periorbital fractures? A frequentist network meta-analysis.
      ,
      • Ridgway E.B.
      • Chen C.
      • Colakoglu S.
      • Gautam S.
      • Lee B.T.
      The incidence of lower eyelid malposition after facial fracture repair: a retrospective study and meta-analysis comparing subtarsal, subciliary, and transconjunctival incisions.
      ]. However, in all three patients with entropion the transconjunctival approach was used. A probable reason for this is that the transconjunctival incision may cause scarring of the posterior lamella, while transcutaneous approaches cause scarring at the anterior lamella of the eyelid, creating an inward or outward retraction, respectively [
      • Pausch N.C.
      • Sirintawat N.
      • Wagner R.
      • Halama D.
      • Dhanuthai K.
      Lower eyelid complications associated with transconjunctival versus subciliary approaches to orbital floor fractures.
      ].
      Similar to Kesselring et al. [
      • Kesselring A.G.
      • Promes P.
      • Strabbing E.M.
      • van der Wal K.G.
      • Koudstaal M.J.
      Lower Eyelid Malposition Following Orbital Fracture Surgery: A Retrospective Analysis Based on 198 Surgeries.
      ], we found that preoperative traumatic wound of the lower eyelid was a significant predisposing factor for developing LEM. Presumably, lacerated skin may suffer from tissue deficiency, lack of soft tissue control, and unfavourable scarring. By contrast, there was no statistical significance between additional lateral canthotomy and LEM. Other studies have shown both positive [
      • De Riu G.
      • Meloni S.M.
      • Gobbi R.
      • Soma D.
      • Baj A.
      • Tullio A.
      Subciliary versus swinging eyelid approach to the orbital floor.
      ] and negative [
      • Kesselring A.G.
      • Promes P.
      • Strabbing E.M.
      • van der Wal K.G.
      • Koudstaal M.J.
      Lower Eyelid Malposition Following Orbital Fracture Surgery: A Retrospective Analysis Based on 198 Surgeries.
      ,
      • Salgarelli A.C.
      • Bellini P.
      • Landini B.
      • Multinu A.
      • Consolo U.
      A comparative study of different approaches in the treatment of orbital trauma: an experience based on 274 cases.
      ] associations between lateral canthotomy and LEM, and thus, the impact remains unclear.
      Very few studies have evaluated implant materials in connection with LEM development. Lee and Nunery [
      • Lee H.B.
      • Nunery W.R.
      Orbital adherence syndrome secondary to titanium implant material.
      ] described ectropion following the use of titanium implants for orbital fracture repair. Other studies [
      • Kim C.H.
      • Choi W.Y.
      • Son K.M.
      • Cheon J.S.
      Prediction of Lower Eyelid Malpositioning After Surgical Correction of Orbital Fracture Using the Subciliary Approach Through the Canthal Area and Orbital Vector Analysis.
      ,
      • North V.S.
      • Reshef E.R.
      • Lee N.G.
      • Lefebvre D.R.
      • Freitag S.K.
      • Yoon M.K.
      Lower eyelid malposition following repair of complex orbitofacial trauma.
      ,
      • Peng M.Y.
      • Merbs S.L.
      • Grant M.P.
      • Mahoney N.R.
      Orbital fracture repair outcomes with preformed titanium mesh implants and comparison to porous polyethylene coated titanium sheets.
      ] have reported no correlation between LEM development and implant materials. Our study presents a significant association between implant material and LEM development. Preformed three-dimensional titanium mesh had the highest occurrence rate of LEM. It is designed to mimic the average anatomy but is poorly malleable and may therefore lead to suboptimal individual fit. No lower eyelid complications developed with resorbable material reconstruction. It must be noted, however, that resorbable implants are rarely used in the most challenging fractures, with wide fractures as well as fractures extending to both the orbital floor and medial wall. Thus, the most challenging fractures were reconstructed with titanium. Only one patient developed LEM following the use of mtPSI. According to the study of Nikunen et al. [
      • Nikunen M.
      • Rajantie H.
      • Marttila E.
      • Snäll J.
      Implant malposition and revision surgery in primary orbital fracture reconstructions.
      ], mtPSI received a significantly better scoring of implant position than preformed or manually bent titanium implants.
      Altogether 3.4% of the patients required subsequent surgical repair for LEM as the sequela persisted despite non-surgical treatments. North et al. [
      • North V.S.
      • Reshef E.R.
      • Lee N.G.
      • Lefebvre D.R.
      • Freitag S.K.
      • Yoon M.K.
      Lower eyelid malposition following repair of complex orbitofacial trauma.
      ] reported roughly the similar percentages; surgical repair was needed in 1.1% of the patients with isolated orbital fractures and in 4.2% of patients with complex fractures.
      The overall burden to the patient as well as to the health care system due to LEM was substantial, as 46.2% of patients with LEM, required subsequent surgical correction and the treatment period was substantially prolonged with multiple extra visits at the clinic. While most LEM was defined as moderate or severe, it often subsided spontaneously or without surgical treatment. In the long term, the majority of patients were satisfied with outcome.
      Our study is limited by its retrospective nature, the low number of occurrences of LEM, and multiple surgeons with varying experience and techniques. As the evaluation of the severity of LEM was performed retrospectively, we were unable to use more specific measurements.

      Conclusions

      LEM is fairly common sequela after orbital fracture reconstruction surgery. The transconjunctival approach and patient-specific implants (mtPSI) should be preferred, when possible, especially in elderly patients and in those with more complex fractures. LEM often requires subsequent surgical correction and the treatment period is substantially prolonged, with multiple extra visits to the clinic.
      Funding: H.R., M.N. and J.S. were funded by Helsinki University Hospital Fund.

      Ethics statement/confirmation of patient permission

      The internal review board of the Head and Neck Centre, Helsinki University Hospital (HUS/356/2017) approved the
      study protocol. Written informed consent was obtained from all participants. Patient permission obtained

      Uncited reference

      [
      • Stoor P.
      • Suomalainen A.
      • Lindqvist C.
      • Mesimäki K.
      • Danielsson D.
      • Westermark A.
      • et al.
      Rapid prototyped patient specific implants for reconstruction of orbital wall defects.
      ].

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