Surgical Science, 2011, 2, 147-150
doi:10.4236/ss.2011.23031 Published Online May 2011 (http://www.scirp.org/journal/ss)
Copyright © 2011 SciRes. SS
Swinging Eyelid Procedure: An Useful Approach for
Reduction of Zygomaticomalar Fracture
Hirohiko Kakizaki1*, Yasu hiro Takahashi1, Hidetaka Miyazaki2, Akihiro Ichinose3, WengOnn Chan4
1Department of Ophthalmol og y , Aichi Medical University, Nagakute, Aichi, Japan
2Department of S tomatology and Oral Surgery, Gunma University Graduate School of Medicine,
Maebashi, Gunma, Japan
3Department of Plastic Surgery, Kobe University, Graduate School of Mefice, Kobe, Japan
4South Australian Institute of Ophthalmology and Discipline of Ophtha lmology & Visual Sciences,
University of Adelaide , So uth Aust ralia, Aust rali a
Received January 14, 2011; revised February 20, 2011; accept e d April 1, 2011
The swinging eyelid procedure is a versatile technique to approach orbital and periorbital surgical fields with
less visible scar. Although mainly used in orbital surgeries, this procedure can also be used to expose the zy-
gomatic arch and periorbital areas. The swinging eyelid procedure, therefore, enables appropriate reduction
of zygomaticomalar fracture under direct visualization. We used this technique for a 27 years old man with a
displaced zygomaticomalar fracture that pushed on the lateral rectus muscle. Good functional and cosmetic
results were obtained postoperatively without ocular motility impairment.
Keywords: Swinging Eyelid Procedure, Transconjunctival Approach, Reduction; Zygomaticomalar Fracture,
Lateral Rectus Muscle
The swinging eyelid procedure is a versatile techniqu e to
approach orbital and periorbital surgical fields with less
visible scar and shorter surgical time . This is an ex-
tended transconjunctival approach with lateral can-
thotomy and cantholysis . Further incision of the
Lockwood’s ligament and its arcuate expansion enlarges
the operating field . The lower eyelid can be swung in
this state, by which the “swinging eyelid” was named
Zygomaticomalar fracture is one of the commonest fa-
cial fractures . In general, the zygomatic fracture re-
duction is performed via intraoral  or temporal ap-
proach . Although these techniques have several mer-
its such as minimal bleeding and no or minimal external
scar, the fracture site cannot be visualized adequately.
The swinging eyelid procedure enables direct visualiza-
tion of the surgical site that is vital to confirm appropri-
ate fracture reduction. However, no report has illustrated
effectiveness of the swinging eyelid procedure, in spite
of its popularity, for reduction of the zygomaticomalar
We present a case of a zygomaticomalar fracture, in
which we used the swinging eyelid procedure in reduc-
ing the fracture.
2. Case History
A 27-year-old man fell and hit his left cheek on the
ground. On initial examination, he showed a concaved
left cheek and left subconjunctival haemorrhage (Figure
1(a)). The patient had objective numbness in the area of
the left infraorbital nerve without trismus. Bilateral vis-
ual acuity, cornea and other intraocular tissues were not
impaired. Ocular motility was within normal range.
Computed tomography demonstrated a left displaced
zygomaticomalar fracture pushing on the lateral rectus
mus cle (Figures 1(b) and (c)).
We reduced the fracture using the swinging eyelid pro-
cedure  6 days after the injury. First, 2 cm length of
the direct lateral skin incision was made (Figure 2(a)).
The inferior crus of the lateral canthal band , the
Lockwood’s ligament, and its arcuate expansion were cut.
The inferior conjunctival fornix was incised parallel to
the lower edge of the tarsal plate and the dissection ex-
H. KAKIZAKI ET AL.
Figure 1. (a) Preoperative photograph of the patient show-
ing a concaved left cheek. Subconjunctival haemorrhage is
demonstrated; (b) Axial computed tomography (CT) scan
showing left zygomaticomalar bone fracture; (c) Three-
dimensional CT scan showing fractures of the left zygo-
maticomalar bone, left maxillary bone and the orbital floor.
Figure 2(a). Skin marking on the planned lateral can-
thotomy incision; (b) Exposure of the orbital floor and the
orbital rim; (c) Reduction of the zygomaticomalar fracture;
(d) Fixation of the zygomaticomalar fracture by absorbable
microplates; (e) Closure of the skin incision with a drain.
opyright © 2011 SciRes. SS
H. KAKIZAKI ET AL. 149
tended to the inferior orbital rim through the retro-septal
plane. The periosteum was then incised. Malleable re-
tracto r was used to expo se the surgical field. The inferior
and lateral orbital rims, orbital floor, lateral orbital wall,
zygomatic arch and the zygomatic pr ocess of the maxilla
were sufficiently exposed (Figure 2(b)). We pulled up
the concaved zygomatic arch and reduced the zygomatic
bone (Figure 2(c)). The bone was fixed with absorbable
plates (Super FIXORB®, Takiron Co., LTD. Osaka, Ja-
pan) (Figure 2(d)). The lateral canthal band was the re-
approximated and the skin was closed (Figure 2(e)).
Postoperatively, the concavity of the left cheek was
well reduced (Figure 3(a)). The infraorbital paresthesia
Figure 3. (a) Postoperative photograph with reduction of
the concaved cheek; (b) Postoperative axial CT scan show-
ing complete reduction with good alignment; (c) Postopera-
tive three-dimensional CT scan showing complete reduction
with good alignment.
resolved, and the patient did not develop postoperative
trismus. On ophthalmic examination, ocular motility
remained within normal range. The wound was incon-
spicuous, and the lateral canthal shape was preserved.
Postoperatively, there were no lower eyelid entropion,
ectropion or retraction. Postoperative computed tomo-
graphy demonstrated complete reduction with appropri-
ate alignment of the zygomatic bone (Figures 3(b) and
The swinging eyelid procedure enabled sufficient expo-
sure of the surgical field with short access time, good
safety and cosmetic ou tcomes. As illustrated in this case,
when the fracture is displaced and pushing on the lateral
rectus muscle, an open reduction is necessary to prevent
a lateral rectus muscle injury and to confirm the com-
plete reduction of the fracture.
Greater exposure of the surgical field is achieved by
the lateral canthotomy and cantholysis . In the simple
transconjunctival approach , the surgical field is lim-
ited around the orbital floor because of the narrow lower
conjunctival fornix space, and laceration may occur with
excess enlargement of the surgical field .
No lower eyelid malposition or lateral canthal dystopia
 was noted postoperatively in this case. As the dissec-
tion plane of the swinging eyelid procedure is behind the
orbital septum, damage to this area may not cause post-
operative lower eyelid retraction . The subciliary inci-
sion takes the preseptal plane, which is sometimes asso-
ciated with an unacceptable septum injury causing cica-
trisation and lower eyelid retraction . Subciliary inci-
sion should be, therefore, avoided in reduction of the
zygomaticomalar fractures .
In conclusion, the swinging eyelid procedure is an ef-
fective and safe technique for open reduction of zygo-
maticomalar fracture with good cosmetic and functional
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