title: Tear Trough Incision for External Dacryocystorhinostomy.
abstract: OBJECTIVE
  Scar formation is a frequently cited complication of external dacryocystorhinostomy (exDCR). The purpose of this study is to evaluate scar appearance after exDCR with the skin incision placed in the tear trough.
  
  
  METHODS
  Multicenter, prospective, noncomparative interventional study was approved by the University of Colorado Institutional Review Board. Patients undergoing exDCR from February 2013 to January 2014 were included in the study, and surgeries were performed by all authors. The incision site for all patients started just under the medial canthal tendon and extended inferolaterally into the tear trough for 10 mm to 15 mm. External dacryocystorhinostomy was performed in the usual manner, and the incision was closed according to the surgeon's preference. At 3 months postop, all patients were asked to rate their scar on the basis of the following grading scale: 0, invisible incision; 1, minimally visible incision; 2, moderately visible incision; and 3, very visible incision. Functional success of the surgery was also determined by asking the patients if their symptoms resolved, improved, or did not change. External photographs taken at 3 months after surgery were graded by 3 independent oculofacial and facial plastic surgeons using the same grading scale.
  
  
  RESULTS
  Seventy-two surgeries were performed in 68 consecutive exDCR patients with nasolacrimal duct obstruction during the study period. Sixty-nine out of 72 patients reported improved or resolved symptoms (95.8%). The average patient scar grade was 0.21, while the average surgeon scar grade was 0.99 (p < 0.001). Sixty out of the 72 patients graded the scar as invisible (83.3%), and only 3 patients graded the scar as moderately visible (4.2%). No patients graded the scar as very visible. Of the 216 surgeon grades, 55 scars were graded as invisible (25.5%), while 8 were graded as very visible (3.7%).
  
  
  CONCLUSIONS
  Scar appearance after exDCR with the incision placed in the tear trough is minimally visible to surgeons, and more importantly, nearly invisible to patients.
authors.affiliation: *Oculofacial Plastic and Orbital Surgery, University of Colorado Hospital, Aurora, Colorado; †McCracken Eye and Face Institute, Parker, Colorado; ‡Denver, Colorado; §Texas Oculoplastic Consultants, Austin, Texas; and ‖Colorado Springs, Colorado, U.S.A.
authors.forename: Brett W
authors.initials: BW
authors.lastname: Davies
authors.forename: Michael S
authors.initials: MS
authors.lastname: McCracken
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Hawes
authors.forename: Eric M
authors.initials: EM
authors.lastname: Hink
authors.forename: Vikram D
authors.initials: VD
authors.lastname: Durairaj
authors.forename: Ron W
authors.initials: RW
authors.lastname: Pelton
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002921:Cicatrix / Q000175:diagnosis / Q000209:etiology; D003608:Dacryocystorhinostomy / Q000379:methods*; D006801:Humans; D007765:Lacrimal Apparatus / Q000601:surgery*; D007767:Lacrimal Duct Obstruction / Q000175:diagnosis / Q000628:therapy*; D008875:Middle Aged; D009301:Nasolacrimal Duct / Q000473:pathology / Q000601:surgery; D011446:Prospective Studies