Loss of Lower Eyelid Bulge after the Reconstruction of Zygomatic Complex Fractures

BACKGROUND: Surgery for zygomatic complex fractures primarily aims to obtain facial symmetry. We investigated facial symmetry specific to lower eyelid bulges following zygomatic complex fractures approached through the lower eyelid. METHODS: Forty-one consecutive patients underwent treatment of zygomatic complex fractures by swinging eyelid approach or subciliary approach. In both approaches, the periosteum was incised 2 mm caudal to the inferior orbital rim and the orbicularis retaining ligament (ORL) was released. The orbital rim periosteum was interruptedly sutured and reconstruction of the orbital septum or ORL was not performed at the time of closure. In cases with a lower eyelid bulge on the nonfractured side, in a frontal photograph 6 months after the operation, the degree of loss of the lower eyelid bulge on the fractured side was classified as either “none,” “mild,” or “severe.” RESULTS: Lower eyelid bulge was present on the nonfractured side in 19 of 41 patients, all of whom were over 50 years old. Loss of lower eyelid bulge was observed on the fractured side in all cases: 15 cases following the swinging eyelid approach (mild/severe; 6/9) and four cases following the subciliary approach (mild/severe; 2/2). CONCLUSIONS: In reconstruction after zygomatic complex fractures, lower eyelid bulges were lost in both the swinging eyelid and subciliary approaches in patients over 50 years old. The cause was thought to be an ORL release or an unintended septal reset-like effect.