Medial Canthal Ligament Research Articles

SUBCUTANEOUS FILLING OF TEAR DROP IN THE LOWER EYELID

The tear drip, medial portion of the lower part of the orbital cavity, presents a deformity of multifactorial origin, not only affecting patients in the facial aging process. One treatment possibility is to use fillers with specific flexibility characteristics for this region. When applying this technique, we deposit microdots in the subcutaneous tissue throughout the peri-orbicularis oculi region from the medial canthal ligament to the lateral canthal ligament. Approximately 0.4 ml was used on each side (right and left) distributed in application micropoints using the smart click syringe system throughout the lower eyelid in superficial and deeper points of the same subcutaneous layer so as not to concentrate the product under the skin. We chose not to perform overcorrection, since the product used by your Swelling Factor could, over the days, after absorbing water, form pockets in the treated region. The present descriptive observational study aimed to highlight the results of subcutaneous filling with Vital Light Skinboosters in the treatment of tear leakage.

Reconstruction of Medial Canthal Ligament With Autogenous Fascia Lata Graft.

An eyelid malignant tumor invading the medial canthus is a serious eyelid disease that requires extensive resection and complex destruction. The medial canthus ligament is especially difficult to repair because its reconstruction often requires special materials. In this study, we described our reconstruction technique using autogenous fascia lata. Data from 4 patients (4 eyes) who had medial canthal ligament defects after Mohs resection of eyelid malignant tumors were reviewed from September 2018 to August 2021. The reconstruction of the medial canthal ligament using autogenous fascia lata was performed in all of the patients. If combined with the upper and lower tarsus defects, autogenous fascia lata was split into 2 branches to repair the tarsal plate. The pathologic diagnosis was basal cell carcinoma in all patients. The mean follow-up time was 13.6±3.51 months (range, 8-24mo). There was no tumor recurrence, infection, or graft rejection. All patients achieved good eyelid movement and function and were satisfied with their medial angular shape and cosmetic contour. Autogenous fascia lata is a good material to repair medial canthal defects. It is easy to take and effectively maintains eyelid movement and function with satisfactory postoperative effects.

The Blocking Points: The Keys to Consistent Success in Preservation Rhinoplasty.

Preservation rhinoplasty is a growing area of interest among rhinoplasty surgeons. Dorsal preservation-a tenet of preservation rhinoplasty-is predicated on maintaining the integrity of the nasal midvault and effecting aesthetic change through alterations to the bony nasal pyramid and underlying septum. A challenge that is unique to dorsal preservation is the phenomenon of hump recurrence, because of the existence of anatomical blocking points. Blocking points are resistant tensile forces that either impede dorsal lowering intraoperatively or push the dorsum back to its native convexity over time. Five anatomical blocking points have previously been described, which the authors expand on and include an additional two. The seven anatomical blocking points are as follows: the cartilaginous septum, the perpendicular plate of the ethmoid, the lateral osteotomy site, the Webster triangle, the internal mucoperiosteum of the maxillary bone, the medial canthal ligament, and the lateral keystone area. It is critical that the surgeon be aware of the particular blocking points relevant to his or her chosen technique, and to appropriately and methodically address them to ensure consistent long-term results.

Modified external revision-DCR in previous failed endonasal, transcanalicular or external-DCR: technical strategy and teaching Pearls for success.

Objective: To report perioperative findings of patients with multiple failed-dacryocystorhinostomy (DCR) and to determine the success rate of revision external (rEx-DCR) performed by a modified technique. Methods: Thirty-one eyes of 31 patients (19 women, 12 men) with recurrent dacryocystitis or epiphora following at least one previous failed-DCR were assessed regarding the time from initial surgery to recurrence and revision surgery, type of primary surgery (endoscopic, transcanalicular, Ex-DCR), recurrence number, stent usage and the success rate. Relief of epiphora and positive dye test were established as functional and anatomical successes, respectively. Results: The mean age was 43.0 years (8-78), with a mean follow-up period of 21.4 months (6-46). The mean reoperation number was 1.4 (1-5). The mean time from initial surgery to recurrence was 15.2 months (1-55) and to rEx-DCR, 19.8 months (4-65). Untouched medial canthal ligament was observed in 28 (90.3%), improper rhinostomy location in 26 (83.8%), inadequate osteotomy size in 25 (80.6%), single-anterior-flap-only in 5 (16.1%), membranous ostial scar formation in four (12.5%) and no flap in three (9.6%) patients. The success rate was 93.5%, which was lower than our primary modified Ex-DCR (99.1%). Conclusions: The most common reasons for recurrence were small and unsuitable osteotomy locations with intact medial canthal ligaments. "Double-mucosal flap" approach with an anterior sacco-mucosal complex suspension increases the functional success rate, and stent implantation is not obligatory if canalicular problems or small/ atrophic sacs do not exist. The knowledge of technical strategy and teaching pearls improves the success rates of primary and revision surgeries. Abbreviations: DCR = dacryocystorhinostomy, Ex-DCR = external DCR, EE-DCR = endoscopic endonasal DCR, TC-LA-DCR = transcanalicular laser-assisted DCR.

Refined Concept of Motor Supply to the Medial Periorbital Area Relevant to Periorbital Surgery.

Mimetic muscles in the medial periorbital area have been thought to be innervated solely by the angular nerve. Recently, however, the upper medial palpebral branch and lower palpebral branch were reported as additional motor suppliers in this area. This study aimed to define all the motor nerve systems passing through the medial canthal area. Motor nerve branches that passed through the medial canthal region were identified and traced thoroughly from the parotid gland to their destinations under a surgical microscopic field in 74 hemifaces. The courses, anatomical positions of, and anatomical relationships between the angular nerve and the upper medial palpebral branch were observed. The upper medial palpebral branch and the angular nerve were found in all samples within a 3-mm to 6-mm area lateral to the intersecting point of the medial orbital rim and medial canthal ligament. The upper medial palpebral branch supplied the upper eyelid, whereas the angular nerve supplied the extraorbicularis muscles in the medial periorbital area. The medial pretarsal area of the upper eyelid was supplied solely by the pretarsal branches of the upper medial palpebral branch, which was formed by uniting three or four minor branches that traveled throughout the anterior cheek. Two separate motor nerve systems, the upper medial palpebral branch and the angular nerve, exist in the medial canthal area. The upper medial palpebral branch course along the medial orbital rim is considered as a facial nerve danger zone.

Local Approaches for the Reconstruction of Frontal and Naso-Orbito-Ethmoidal (NOE) Fractures: Presentation of a Clinical Case and Literature Review

Naso-orbito-ethmoidal (NOE) fractures are considered a challenge in reconstruction, due to the anatomical structures involved, such as the medial canthal ligament and the lacrimal apparatus [1], which leads to a complex functional and aesthetic compromise. For surgical access to the area, the use of the coronal, Lynch-Howarth, glabellar “open sky”, “gull wings” and a combination of the last two are described. However, the severity of the trauma and mainly the neurological compromise of the patient will dictate the choice of the approach that allows functional and comprehensive repair of the affected region. In cases where there is no neurological compromise and it is not necessary to carry out a subcranial approach, the use of local approaches is justified, providing adequate visibility and direct access to the fractured region, allowing an adequate reduction and placement of fixing material. A clinical case of anterior frontal sinus wall fracture and NOE fracture are presented, performing the combination of the gull-wing and open-sky approach, described as butterfly wings, achieving adequate visibility and reconstruction.

Lateral Tarsoplasty for Managing Ectropion and Laxity of the Lower Eyelid.

The most challenging complication associated with lower blepharoplasty is ectropion, and the traditional lateral canthopexy or canthoplasty procedure may carry the risk of eyelid malposition or subsequent chemosis. We propose lateral tarsoplasty with a detailed description of the techniques to treat and even prevent ectropion by not involving the medial or lateral canthal ligament so as to avoid complications. Lower eyelid laxity was analyzed with the snap-back test and distraction test before surgery. Approximately 5 mm medial to the lateral canthus, lateral tarsoplasty is performed through a full-thickness pentagonal tarsal-conjunctival resection according to the "overlapping test" for an accurate measurement of the amount of the tarsus to be resected. Seventy-two eyelids that received either ectropion correction or prevention with lateral tarsoplasty over an 8-year period at a single institution were collected and analyzed for this retrospective review. Lateral tarsoplasty was performed in 39 patients with a mean age of 63.8 years. Thirteen patients with 20 eyelids presented for ectropion correction, in whom 5 to 10 mm of tarsus was resected, 6.0 mm in average. The other 26 patients with 52 eyelids presented for ectropion prevention, in whom 3 to 7 mm of tarsus was resected, 4.1 mm in average. Apart from temporary mild chemosis, all patients experienced highly satisfactory results without any ectropion or malposition of the involved lower eyelids after a follow-up of 8.1 months in average. For patients with moderate and severe laxity of lower eyelids, lateral tarsoplasty without involvement of the lateral canthal ligament proves to be an effective way to treat and prevent lower eyelid ectropion.

Optimization of Diagnosis and Surgical Treatment of Involutional Entropion of the Lower Eyelid

Background: Rolling inwards of the lid margin is called entropion, and is produced by a disparity in length and tone between the anterior skin muscle, and posterior tarso-conjunctival laminae of the eyelid. Involutional, cicatricial, spastic, or congenital are some of the classifications involutional entropion there is general instability of the lid structures with age .A weakness of the posterior retractors of the lid occurs, together with a laxity of the medial and lateral canthal ligaments, accompanied by a loss of posterior support ,as atrophy of the orbital fat leads to enophthalmos. The current treatment modalities for this condition are surgical in nature, although non-surgical temporary medical treatment are also used. It's a commonest types of eyelid asymmetry. Corneal and conjunctival damage may lead to abrasions, scarring, corneal thinning, or corneal neovascularization due to this misalignment. Unilateral or bilateral entropion is possible. Involutional entropion of lower eyelids are common, but cicatricial upper eyelids are common. Entropion of lower eyelid is a much more prevalent than entropion of the upper eyelid.
 Objective: The purpose is to review the scientific literature on diagnosis and surgical management of involutional entropion of the lower eyelid.
 Methodology: The data were collected from the various electronic data bases like google scholar, PubMed and various books.
 Conclusion: After reviewing the articles, we come to the conclusion that the signs and symptoms of involutional entropion are easily manageable by given treatment.

Reconstruction of Extensive Periorbital Defects With Pericranial Flap.

Wide excision of recurrent malignant tumors of periorbital region leaves deep and large composite defects, requiring a reconstruction to restore both the form and function of the eyelids. In this study, a pericranial flap was utilized in the reconstruction of large, complex defects of periorbital region.This study included 5 patients who underwent wide excision of recurrent large medial canthus and supraorbital rim malignant tumors. All defects involved the medial parts of eyelids including medial canthal ligaments, nasal walls, periosteum, and medial orbital walls. Defects were reconstructed via a pericranial flap, which was facilitated by the natural concavity and the acute angled nature of the medial canthus.The pericranial flap is not only a versatile alternative to the local or regional flaps in the reconstruction of periorbital defects, but also has the advantages of availability of abundant amount of flap tissue.

Frontoethmoidal Encephalomeningocele Correction by Medial Orbital Composite-Unit Translocation Technique: 13 Years of Siriraj Hospital Experience.

Frontoethmoidal encephalomeningocele (FEEM) is a congenital anomaly involving herniation of the glial tissues and the meninges. Our unit implemented single-stage repair in 1996, and this was followed by the introduction of the medial orbital composite-unit translocation (MOCUT) technique for encephalocele repair in 2001. This report describes the long-term outcomes of patients who underwent the MOCUT technique. Data were collected on 32 patients operated on between 2005 and 2018. A full analysis was subsequently made of the data from 4 selected patients who had been monitored for at least 5 years, and their age-related anterior interorbital distances were compared. Two of the patients, who had simple forms of FEEM, demonstrated improvements in their intercanthal and anterior interorbital distances, whereas telecanthus was experienced by the 2 other cases, both of whom had complex FEEM types. We recommend using the MOCUT technique for simple types of FEEM (especially Type IA) and patients whose medial canthal ligaments are still anatomically attached to the medial orbits.

Primäre Rekonstruktion der ableitenden Tränenwege nach Trauma – bikanalikulonasale Schienung mit autostabilen Silikonverweilsonden

Trauma of the medial canthal region can affect all parts of the lacrimal ducts. Depending on the patient's age, there may be different mechanisms of injury. Surgical reconstruction using two autostable ("self-retaining") monocanaliculonasal lacrimal tubes is demonstrated by two case reports. Here, a 6 years old girl attacked by a dog (Rottweiler) showed severe periocular soft tissue damage with deep involvement of the lacrimal ducts. The child's inferior canaliculus was lacerated. Furthermore, the common canaliculus was dissected from the lacrimal sac. Deep soft tissue damage consisted of blunt and sharp injuries down to the cheek and nose. After lacrimal intubation with two autostable monocanaliculonasal tubes, the soft tissue was reconstructed by direct canalicular suturing and stepwise closure of each layer. One of the lacrimal tubes was fixated at the lid by additional sutures, in order to avoid stent prolapse. Beside slight medial depression of inferior lid, there were no signs of functional disturbance of the lacrimal ducts. The follow-up was 18 months. The second case report presents a 43 years old man. He accidentally cut himself with a butcher's knife. He suffered a deep wound of his medial canthal region. The patient presented with proximal (located near the lacrimal sac) laceration of both canaliculi. The medial canthal ligament as well as the orbicularis muscle had been cut. Using two autostable monocanaliculonasal lacrimal tubes, the lacrimal ducts were stented and reconstructed with sutures. During the follow-up of 6 months, no epiphora or mucopurulent lacrimal discharge occurred. In lacrimal trauma, different parts of the lacrimal ducts may be affected at the same time. Identification of the injured structures with respect to the kind of injury, localisation and the extent of damage is crucial. Stepwise wound closure in respect to the topographic anatomy is mandatory. Here, lid and lacrimal ducts must be respected as one functional unit. Simultaneous use of autostable monocanaliculonasal lacrimal tubes in both canaliculi can be applied for trauma reconstruction of the lacrimal ducts in children and adults.

Medial canthopexy using mini-screws &/or micro plates for the surgical treatment of post traumatic telecanthus associated with naso-orbito-ethmoidal fractures

BackgroundThe normal bony insertion of the medial canthal tendon can be disrupted after trauma, as a result of ablative surgery or as a consequence of subperiosteal detachment during a craniofacial surgical procedure. Medial canthoplasty is required to avoid telecanthus following these events. Several surgical techniques have been described to reattach the tendon to the posterior lacrimal crest. The techniques of transnasal wiring had been used widely to reconstruct medial canthal tendon. However, some surgeons have preferred the use of ipsilateral techniques that include the nylon anchor suture, the stainless-steel screw and/or miniplates. Aim of the studyThis study aims to present a technique for Canthopexy and Medial canthal ligament reconstitution secondary to posttraumatic medial canthal degloving injuries using mini-screws and/or microplates to obtain a consistent and definitive reinforcement of the Medial Canthal ligament and its continuity to the postero-superior surface of the medial orbital wall. Materials and methodsThe present study enrolled 23 patients with posttraumatic medial telecanthus deformity that had been treated over a 3-year period from July 2016–June 2019. Clinical examination had been scheduled for all patients regarding evaluation of lacrimal system function, medial canthal position in addition to eyelid measurements. Visual impairment and movements of the eye were evaluated by ophthalmological consultation. Irrigation and probing were used for evaluation of the nasolacrimal system. MCT detachment can be determined by Bowstringing test through subcutaneous palpation of the MCT as one stretches the lid laterally.Eyelid evaluation comprised recording measurements of the inter-canthal distance (ICD), the interpupillary distance (IPD) and the palpebral fissure length (PFL). Telecanthus was assessed by recording the distance (in millimetres) measured between the facial midline and the medial canthus of the injured eye that will be compared to the corresponding values of the uninjured eye preoperatively and at all postoperative follow-up intervals. Radiographic assessment was evaluated by axial, coronal and sagittal C.T scans preoperatively and at 1, 3 and 6 months postoperatively. ResultsMedial Canthopexy with mini-screws was performed in 15 patients while a Y-shaped micro plate was utilized in 8 patients. The postoperative medial canthal position had been reported to be satisfactory in all patients, showing a considerable improvement compared with the preoperative position. The patients were re-evaluated at 1,3 and 6 months postoperatively demonstrating absence of any evidence of recurrence and with an acceptable cosmetic result, as the medial canthal concavity had been successfully achieved. All patients were satisfied except one that was overcorrected and re-operated for re correction. Another one was under corrected and had undergone revision. However, at 6 weeks postoperatively, one patient had a wound dehiscence resulting in medial canthal detachment and required retreatment. In all patients (except for the one of wound dehiscence), the post-canthopexy Bow String test failed to cause loss of canthal re-attachment and reconstruction or even lateral displacement of the medial canthal tendon throughout all the follow-up intervals. ConclusionsMedial Canthopexy using mini-screws and/or microplates is a simple, easy and reliable technique for the surgical correction of posttraumatic Telecanthus secondary to MCT detachment as this technique promotes satisfactory post-surgical outcomes with resultant acceptable esthetic and functional results.

Medial Epicanthoplasty Using a Lower Palpebral Margin Incision Combined With a Tiny Triangular Flap.

The incidence of epicanthus is extremely high in Asians. Although many techniques have been introduced to remove the epicanthus, there are still some complications. Herein, we introduced a method involving an incision on the lower palpebral margin combined with a tiny triangular flap for correction of epicanthal folds, which is always performed in combination with double eyelid plasty. After making an incision, the ectopic medial canthal ligament was removed. The ligament pulling the medial canthus was cut along the lower palpebral margin incision, so the medial canthus could be repositioned upward. The tiny triangular flap of the medial canthus would naturally move downward and cover the lower palpebral margin incision. The skin folds on the lower palpebral margin were trimmed and sutured. After epicanthoplasty was completed, double eyelid plasty was performed using the incision or non-incision method. A total of 547 epicanthoplasties were performed during the past 7 years. The follow-up time ranged from 1 month to 5 years. Ninety-eight percent of the patients were satisfied with the results of the epicanthoplasty. The scars in the medial canthal area were tiny, the enlargement of the medial canthus was obvious, and the double eyelid line in the medial canthal area was natural and smooth. The introduced method is simple in design and can preserve the original shape of the medial canthus while widening the palpebral fissure, which is a particularly suitable approach for epicanthoplasty in Asian patients. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Medial and lateral canthal ligaments shown in P45 sheet plastination and dissection.

Purpose:Ocular suspensory ligament is an important part of the lower eyelid retractors. However, there is a scarcity of studies examining detailed en-block histologies of ocular suspensory ligaments.Methods:In this study, we included the cadavers of Chinese adults as subjects. These cadavers of Chinese adults were processed using P45 plastination techniques. The polymer resulted in transparent plastination, and the P45 sheet-plastinated sections of the lower eyelid were observed. The gross anatomy results of three Chinese adult heads (six hemifaces) were included as gross dissection data. All photographic documentation was performed via a Canon EOS 7D Mark camera.Results:The results showed that the inferior rectus muscle, inferior oblique muscle, ocular suspensory ligament, and its arcuate expansion are under the eyeball. The medial and lateral parts of the ocular suspensory ligament end at the medial and lateral canthal ligament. The middle part, a hammock-like shape, is slightly lower. The ocular suspensory ligament holds up the inferior oblique muscle, inferior rectus muscle, and the eyeball. As the inferior oblique muscle passes through the sheath of the inferior rectus, the fascia is thickened, forming the ocular suspensory ligament. The ocular suspensory ligament connects to the intermuscular septum, the inferior tarsal muscle, and the medial and lateral check ligaments.Conclusion:This study observed the ocular suspensory ligament and arcuate expansion through P45 sheet plastination for the first time and identified the distribution of the lower eyelid ligaments, thus laying the foundation for further research.

Трансорбитальное клипирование решетчатых артерий как метод ранней деваскуляризации при удалении краниоорбитальных опухолей

Objective: To improve the results of surgical treatment of patients with cranioorbital tumors. For this purpose, for patient with high vascularized tumor of ethmoidal bone, adjacent to the medial wall of the orbit, early devascularization as the first stage and transnasal endoscopic removal of the tumor as the second stage was performed. Tumor devascularization was performed by clipping of anterior and posterior ethmoidal arteries through a transcaruncular endoscopic approach. For this, the incision of the conjunctiva, after infiltration with local anesthetics, was carried out posteriorly from the lacrimal caruncle, continuing it above and below the posterior border of the medial canthal ligament. Then, after dissection of the periosteum posterior to the posterior lacrimal crest, further stages of the surgical intervention are performed under the control of an endoscope with a viewing angle of 0°. Results. Transorbital endoscopic clipping of the ethmoid arteries allowed to significantly reduce the intensity of blood flow in the tumor tissue and perform endoscopic transnasal removal of the tumor with minimal blood loss. Intraoperative blood loss was 100 ml. No complications were recorded. Conclusion. Transorbital endoscopic clipping of the anterior and posterior ethmoidal arteries is an effective and safe method for early devascularization of partially embolized or non-embolized cranioorbital tumors. The technique is promising and requires further development.

Periorbital Trauma: A New Classification.

Overlooked injured structures in periorbital trauma could lead to aesthetic and functional deficits. As trauma may affect superficial, middle, and deep components, meticulous survey guided by a structured periorbital trauma classification is needed for proper management. Thus, a new classification for periorbital trauma is proposed to serve this purpose. Periorbital region was defined anatomically by anthropometric landmarks. The periorbital injuries were categorized according to anatomical and clinical basis. The new classification was used to study periorbital trauma cases received at Ain Shams University Hospitals between July 2013 and July 2016 retrospectively. The study included 260 patients: 196 (75.38%) males and 64 (24.62%) females. The type and severity of injury, time of primary intervention, type of surgery performed, and patients' visits to the outpatient clinic were evaluated. The status of the postinjury and postoperative (primary surgery) aesthetic status and functional status were evaluated. The periorbital region was identified. Anatomical categorization of periorbital injuries included periocular, frontal, temporal, and malar regions. Injuries/deficits were categorized into simple, composite, complex, and isolated bony injuries according to the depth and involved tissues. Subsequently, the classification was formulated. In the retrospective study, the incidence of extended simple injuries was the highest, while the least was the extended complex injuries. Functional deficits occurred in 24 patients (9.23%) and aesthetic deficits occurred in 55 patients (21.15%). Required secondary operations for this group included redo of fixation, correction of medial canthal ligament, repair of canalicular system, scar revisions, fat grafting, and creation of natural creases. The results of this study demonstrated that unsatisfactory aesthetic and functional results occurred when injuries of important structures were overlooked, aesthetic units were not respected, and when management was delayed. A three-dimensional, oriented, new classification of periorbital trauma based on anatomical and clinical categorization is proposed to help in identifying injured structures, stimulate the search for other injuries, structure preoperative evaluation, and recommend a surgical plan that would ultimately achieve precise primary repair with best aesthetic and functional outcome.

S13-07 SESSION 13: HYPERTELORISM / CRANIOFACIAL CLEFTS FLOATING FRONTAL FLAP COMBINED WITH INVERTED U-SHAPED OSTEOTOMY PROCEDURE IN ORBITAL HYPERTELORISM SECONDARY TO CRANIOSYNOSTOSES

Introduction: The clinical manifestation of orbital hypertelorism includes congenitally increased interorbital distance (the distance between bilateral lacrimale). Greg applied this term firstly in 1924. Orbital hypertelorism may be present in a variety of craniofacial deformities, such as craniofacial cleft, Apert syndrome, Crouzon syndrome and so on. However, orbital hypertelorism secondary to non-syndromic craniosynostosis is relatively rare. From 2013 to 2016, we performed modified surgery through intra-and-extra-cranial approach in three patients with congenital craniosynostosis associated with orbital hypertelorism and got satisfactory results. To report three patients who was diagnosed as orbital hypertelorism secondary to craniosynostoses treated by using inverted U-shaped osteotomy combined floating frontal flap procedure through intra-and-extra-cranial approach. Methods: Three patients diagnosed as orbital hypertelorism secondary to craniosynostosis, underwent floating frontal flap procedure combined with inverted U-shaped osteotomy by intra-and-extra-cranial approach. Inverted U-shaped orbit frame was formed and moved inward to attach the central bone bridge, with the fixation of titanium mesh and screw. Medial canthal ligament was cross fixed to contralateral orbit frame and thus the skin on inner canthus could fit bone surface tightly. With inverted U-shaped orbit frame fixed with each other, a structure of fronto-orbital bone bridge was formed. After that we made a center vertical osteotomy of the floating frontal flap and rotated both of the frontal flaps inward by 90 degrees. Appropriate shape of supraorbital area and proper volume of anterior skull were successfully achieved with the frontal flaps fixed to the fronto-orbital bone bridge. Results: These patients got satisfactory results, with the orbital distance being corrected to the normal range, meanwhile the premature fused coronary suture was released. The forehead and orbits region obtained normal appearance. Conclusion: The satisfactory result show that floating frontal flap combined with inverted U-shaped osteotomy procedure by intra-and-extra-cranial approach is one kind of safe and effective way to correct orbital hypertelorism secondary to craniosynostoses.

S13-08 SESSION 13: HYPERTELORISM / CRANIOFACIAL CLEFTS SUPRAORBITAL BIPARTITION FOR THE MANAGEMENT OF ORBITAL HYPERTELORISM

Introduction: Orbital hypertelorism can exist in a variety of craniofacial anomalies such as midline anterior encephaloceles, frontonasal dysplasia, and syndromic bicoronal craniosynostoses. Facial bipartition corrects hypertelorism and benefits patients with a narrow, V-shaped maxilla. However in young children with hypertelorism there is a higher risk of injury to dental follicles. The supraorbital bipartition allows for correction hypertelorism in this younger population of patients undergoing frontal craniotomy without the need for osteotomies extending into tooth-bearing segments of the maxilla. Methods: The supraorbital bipartition technique was performed in 15 patients with hypertelorism. Of these, 3 patients had associated meningoencephaloceles, 5 patients had facial clefting, and 7 patients had hypertelorism associated with Crouzon or Apert syndrome. All patients underwent preoperative evaluation by neurosurgery, ophthalmology and pediatrics. Neuropsychiatric testing and preoperative CT scans were performed. The technique, advantages and complications are described. Results: The patient age ranged from 8 months to 8 years old, with a mean of 40 months. Seven patients were female and eight were male. All cases were uneventful. The interorbital distance was normalized for age in 11 cases. The remainder 4 cases had dramatic improvement in interorbital distance. Blood loss ranged from 250 to 600 cc, with mean EBL of 350 cc. Blood transfusion was required in 12 patients. No major complications occurred. In 4 cases, unilateral detachment of the medial canthal ligament occurred. In one case, bilateral detachment of the medial canthal ligament occurred. In all cases, these detachments were repaired intraoperatively. Two cases had minor wound dehiscence that healed with local wound care. Conclusion: The classical techniques for management of hypertelorism entails either complete bilateral orbital osteotomies and translocation, or facial bipartition. These techniques are not suitable for younger patients given the presence of tooth buds before the eruption of permanent dentition. In the proposed technique, the infraorbital osteotomy was avoided, thus sparing the developing tooth buds. The rate of complication of the present technique is lower than in the classical techniques, with no major complications. The improvement in interorbital distance is comparable to that obtained with classical techniques.

Radiological assessment of the lateral osteotomy line–lacrimal system distance on three-dimensional models

AimsOne of the most commonly performed operations in aesthetic, plastic, and reconstructive surgery is rhinoplasty, the aim of which is to construct an altered nasal shape, either for aesthetic or functional reasons. The lateral osteotomy is the most traumatic step of rhinoplasty, and is generally difficult to perform. The lacrimal system can be damaged during the lateral osteotomy procedure. In this study, we aimed to measure the distance between the lacrimal system and the lateral osteotomy line, and to determine the safe and ideal osteotomy level, which is very important in rhinoplasty procedures. We also evaluated the safe relationship of this osteotomy level with the lacrimal system by constructing a three-dimensional model. Materials and methodsThe three-dimensional models were constructed on axial planes using paranasal computed tomographic (CT) images of 40 male and 40 female patients. The ‘lateral osteotomy model’ was designed in three dimensions. The axial CT images were obtained from the model. On the CT images, the distance between the lateral osteotomy line and the lacrimal system was assessed by measuring three distances. The first was the distance between the anterior lacrimal crest and the lateral osteotomy line. The second was the distance from the midpoint between the anterior lacrimal crest and the inferior meatus to the lateral osteotomy line. The third was the distance between the opening of the lacrimal canal to the inferior meatus and the lateral osteotomy line. ResultsNo lacrimal system injury was seen on any of the models. The shortest distance was found between the anterior lacrimal crest and the lateral osteotomy line, measured at 4.5 mm and 5.0 mm in the female and male patients, respectively. ConclusionPerforming the lateral osteotomy meticulously while paying attention to remaining anterior to the medial canthal ligament will not lead to any lacrimal system injury.

Adjustable V-Flap Epicanthoplasty Based on Desired Eyelid Morphology.

Eyelid shape is one key distinctive feature of the Asian eye. The presence of epicanthal folds is a common eyelid defect of Asians. Different surgical techniques have been developed to correct epicanthal folds. However, potential problems with these techniques are emerging, such as difficulty in design, recurrence and/or prominent scarring after surgery, and restricted application together with double eyelidplasty. An improved epicanthoplasty technique with high simplicity and flexibility is imperative. From October 2000 to March 2017, we performed V-flap epicanthoplasty procedures on 423 Asian patients. The whole procedure, including V-shaped skin incision, myotomy and pilication of the medial canthal ligament was performed layer by layer. A similar palpebral fissure distance and inner canthal distance were acquired with this surgical operation. Besides, this surgical technique will not cause limitations on double eyelid morphology when a double blepharoplasty is performed at the same period. The V-flap epicanthoplasty we described here is able to fully correct the epicanthal folds with a simple and flexible design, and the surgery can be adjusted according to patient needs for desired double eyelid shape. Satisfactory results were ideally achieved with no recurrence and finer scar.Level of evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the table of contents or the online instructions to authors www.springer.com/00266 .