Medial Canthal Tendon Research Articles

Surgical correction of medial canthal widening associated with aging: two case reports

Medial canthal widening due to aging is a frequent concern among elderly individuals, often resulting in cosmetic dissatisfaction. This condition commonly involves caruncle exposure and elongation of the medial canthus, sometimes requiring surgical intervention. While medial epicanthoplasty is commonly used to address medial canthal deformities, age-related changes call for a modified approach to optimize aesthetic results. We present two cases of elderly patients whose medial canthal widening was corrected using a modified V-Y advancement flap combined with medial canthal tendon tightening. This technique involves elevating a V-flap and suturing the pretarsal orbicularis oculi muscle and medial canthal tendon to restore medial canthal contour. In one case, an 85-year-old man with unilateral caruncle exposure experienced marked cosmetic improvement post-surgery. In the second case, a 71-year-old woman with bilateral medial canthal widening also reported significant improvement. Both patients had no complications and expressed satisfaction with their postoperative appearance. This surgical approach effectively reduced caruncle exposure and enhanced eye shape with no recurrence or wound healing problems. Medial canthal widening from aging can be successfully treated with a V-Y advancement flap and medial canthal tendon tightening, offering elderly patients a dependable solution with favorable cosmetic results.

CADS as a Decision-making Tool: Developing an Oculoplastic Management Algorithm for Facial Nerve Palsy.

The Cornea, Asymmetry, Dynamic, Synkinesis (CADS) score is a validated grading score for periocular involvement in facial nerve palsy (FNP). We conducted a retrospective review of FNP cases, including initial CADS scores and subsequent ophthalmic interventions. The results were used to inform the development of an oculoplastic management algorithm for FNP. Single-center retrospective cohort study of patients with FNP referred to a tertiary unit between 2016 and 2022. Data collected included demographic data, etiology of FNP, treatment initiated, and CADS grading at each visit. Adult patients with ≥6 months of follow-up were included, and cases were excluded if ocular surface or oculoplastic procedures were performed elsewhere prior to the initial review by the unit. Of 408 consecutive new patients with FNP, 80 fulfilled inclusion criteria (mean age 57 years, range 21-83 years). Presentations of FNP were unilateral in 98.8% (79/80), with an underlying preganglionic etiology in 75.0% (60/80). At the initial review, surgery was recommended for 61.3% (49/80) of cases. Subgroup analysis of surgical cases for each CADS domain showed 46.9% (23/49) had C-score ≥2, which was predictive of upper lid surgery requirement (e.g., upper lid platinum segment chain; levator recession). About 63.2% (31/49) had an A-score ≥1 which predicted for lower lid surgery requirement (e.g., retractor recession, lower lid sling, medial canthal tendon plication, and lower lid full thickness skin graft) as well as a brow lift. Almost 79.6% (39/49) had a D-score ≥2, which was associated with both upper lid and lower lid surgery requirements. Also, 59.2% (29/49) had an S-score of ≥1 however, this was not associated with the surgical requirement, highlighting a different approach compared with the other CADS domains. This study represents a large cohort of patients followed up with a validated ophthalmic-specific FNP grading scale. This was utilized to develop a CADS-based management algorithm to help guide decision-making for surgical intervention versus medical management in FNP.

Posterior medial canthal thermoplasty in facial palsy: A simplified technique

Abstract Purpose: The purpose of this study was to describe a new, simple, quick, reproducible, and minimally invasive surgical technique for medial canthal tendon (MCT) dehiscence and deformity in patients with facial palsy. Methods: A retrospective study of 10 patients having medial ectropion and MCT laxity in patients with facial palsy was included in the study. All patients underwent the simplified technique of posterior medial canthal thermoplasty and anchorage with 6/0 Vicryl. Ancillary procedures such as lateral tarsal strip, lower lid spacer, suborbicularis oculi fat lift, upper lid blepharotomy, and mullerectomy were also performed where warranted as a holistic treatment approach. Results: The study cohort included 10 patients. All patients had satisfactory outcomes concerning medial canthus position and lid-to-globe apposition. 9/10 patients had satisfactory punctum alignment. Conclusions: This technique is a safe alternate and reproducible procedure compared to the conventional open technique of anchoring the lid to the posterior lacrimal crest which is a challenging procedure even in experienced hands.

Medial Canthal Tendon Reflecting in Lower Eyelid Reconstruction After Palpebral Cancer Surgery: Description of a New Technique.

The aim of this article is to describe a new reconstructive technique of the lower eyelid in the surgery of tumors involving the medial canthal tendon. Our new technique consists of detaching and reflecting the most medial portion of the anterior medial canthal tendon and reinserting it into the posterior lamella. We describe the cases in which our technique can be useful, as well as the results we have obtained. The result after a year of follow-up showed no disruption of the angulation of the lower eyelid line and no changes in eyelid position. The medial canthal tendon reflection could provide both aesthetic and functional results that may be superior to the usual techniques.

Surgical management of oculomotor nerve palsy: a comparison of lateral rectus deactivation combined with either medial rectus resection or medial rectus fixation to the medial palpebral ligament

PurposeTo analyze and compare the outcome of two different surgical procedures in patients with complete oculomotor nerve palsy with large-angle exotropia. MethodsThe medical records of patients with total oculomotor nerve palsy and large-angle exotropia operated on at a single center from January 2006 to June 2020 were reviewed retrospectively. One group underwent lateral rectus deactivation with medial rectus resection (resection group); the other group underwent lateral rectus deactivation with medial rectus fixation to the medial palpebral ligament (fixation group). Surgical outcomes on the first postoperative day and at 6 months postoperatively were analyzed, including alignment and postoperative complications. All statistical analyses were performed using STATA version 14. A P value of <0.05 was considered significant. ResultsA total of 35 patients were included. There was a trend toward greater surgical success in the fixation group (93%) than in the resection group (65%), but these results were not statistically significant. Postoperative exotropic drifts were noted in both the procedures but tended to be more with patients in the resection group. Postoperative complications were noted only in the fixation group. ConclusionsLateral rectus deactivation with medial rectus fixation to the medial palpebral ligament requires more time and greater surgical expertise but appears to better prevent postoperative exotropic drift compared with lateral rectus deactivation combined with medial rectus resection.

Lacrimal Sac, Classified within the Orbital Tissue

ABSTRACT Purpose To disclose that the lacrimal sac is classified within the orbital tissue. Materials and Methods Ten orbits of 9 Japanese cadavers aged 64 to 85 years at death were included. The attachment site of the orbital septum in the medial canthal area was grossly dissected. The relationship between the orbital septum attachment site and the location of the lacrimal sac was examined. Results In the upper region, the orbital septum was attached to the most superior area of the lacrimal fossa and the medial canthal tendon. In the lower region, the septum was attached to the anterior lacrimal crest and the medial canthal tendon. In both the upper and lower regions, none of the septa attached to the posterior lacrimal crest. The lacrimal sac was situated behind the orbital septum. Conclusion The lacrimal sac, which is situated behind the orbital septum, is classified within the orbital tissue.

The Central Facial Defect Reconstruction Using a Radial Forearm Free Flap after Malignant Cutaneous Tumor Ablation.

Acquired defects of the central face pose significant challenges in achieving acceptable cosmetic and functional outcomes. The site, size, and depth of tissue loss often render local tissues inadequate for the repair of major nasal defects. In this article, we aim to demonstrate the efficacy of radial forearm-free flaps as an ideal choice for various central facial unit reconstructions. This study encompassed patients treated between 2020 and 2022 who underwent facial reconstruction using radial forearm flaps. These flaps were employed in eleven patients with defects involving the lower lid, nose, upper lip, and lower lip. Additionally, we used osteocutaneous flaps in one patient to reconstruct a right nasal bone defect. In three patients requiring medial and lateral canthal tendon reconstruction in one case and oral sphincter reconstruction in two cases, the palmaris longus tendon was included with the flap. In the majority of cases, we achieved good to excellent aesthetic and functional results. Notably, there were no instances of flap failure or partial necrosis in this series. All patients experienced uneventful healing at the donor site. The radial forearm-free flap stands as an ideal and reliable method for reconstructing various facial defects. It offers efficient and thin-conforming skin coverage.

Digital Compression of the Origin of the Nasal Branch of the Ophthalmic Artery During Filler Augmentation: A Review of the Anatomical Literature and an Analysis of Plastinated Specimens.

The aim of this study was to determine the exact site of digital compression on the origin of the nasal branch of the ophthalmic artery during filler augmentation, by conducting a review of anatomical literature and examining plastinated specimens. According to 4 textbooks (Gray's Anatomy, Whitnall's Anatomy on the Human Orbit, Wolff's Anatomy, and Duke-Elder's System of Ophthalmology), the dorsal nasal artery leaves the orbit by piercing the orbital septum between the trochlea and the medial palpebral ligament and anastomoses with the angular part of the facial artery. In plastinated arterial specimens, the ophthalmic artery exits the orbit and divides into the supratrochlear artery and the dorsal nasal artery at the upper border of the lacrimal fossa. The dorsal nasal artery then anastomoses with the angular part of the facial artery. Branches of the dorsal nasal artery anastomose with their counterparts on the opposite side. During filler augmentation of the nose, bilateral digital compression is applied to the origins of the nasal branches of the ophthalmic artery, specifically at the point where the ophthalmic artery pierces the orbital septum. Applying compression just above the medial palpebral ligament against the bone, directly above the lacrimal sac, using the index finger and thumb can help prevent the migration of injected droplets to the ophthalmic artery. This straightforward maneuver, grounded in anatomical understanding, aims to prevent the migration of injected droplets to the ophthalmic artery.

Role of the Medial Canthus Fibrous Band in Forming Moderate and Severe Epicanthal Folds in Asians and Its Clinical Application.

Epicanthal folds (EFs) are skin folds located at the medial canthus in Asians. However, the anatomical structure of EFs remains unclear. The authors discovered a fibrous band connected to the medial canthal tendon (MCT) and referred to it as the medial canthal fibrous band (MCFB). This study aimed to verify whether the MCFB is different from the MCT and whether its unique anatomical relationship with the MCT plays an important role in EF formation. Forty patients who underwent epicanthoplasty from February of 2020 to October of 2021 were included. EFs from 11 patients underwent biopsy and were stained with hematoxylin and eosin, Masson trichrome, and Weigert stains to reveal their composition. Expression of collagens I and III and elastin was determined through immunohistochemical staining, and their mean optical density was measured. Preoperative and immediate exposed lacrimal caruncle area (ELCA) was measured after removing the MCFB. The MCFB is a fibrous tissue located in the EF and above the MCT. The orientation and composition of collagen fibers of the MCFB are different from those of the MCT ( P < 0.001). The MCFB also has more elastin fibers than the MCT ( P < 0.05). Immediate ELCA was significantly higher than before ELCA ( P < 0.001) once the MCFB was removed. The MCFB is composed of collagen fibers different from those in the MCT and plays a role in EF formation. Removing the MCFB during epicanthoplasty can result in a more attractive appearance postoperatively. Therapeutic, IV.

Post-traumatic Telecanthus Induced by a Missed Diagnosis of Avulsion Fracture of the Medial Canthal Tendon.

Telecanthus is commonly accompanied by severe naso-orbito-ethmoid fractures. If there is only an avulsion fracture of the medial canthal tendon (MCT), the initial diagnosis may be missed, and post-traumatic telecanthus may follow. To avoid misdiagnosis of post-traumatic telecanthus, the following should be considered: avulsion fracture of the MCT should be suspected in the presence of an injury or edema of the medial canthal area; the facial computed tomography images should be carefully analyzed to confirm the presence of bone segment caused by the avulsion fracture of the MCT; physical examinations, such as the bowstring test and bimanual palpation, also provide essential data for early diagnosis. And even if early diagnosis is delayed, post-traumatic telecanthus can be improved through aggressive surgical correction.

Increased Reliability in Medial Canthal Tendon Reposition in Nasoorbitoethmoidal Fractures with Computer-assisted Surgery and Surgical Navigation

Summary: Avulsion of the medial canthal tendon secondary to nasoorbitoethmoidal fractures leads to severe aesthetic and functional impairments. The tendon should be repositioned at the posterior lacrimal crest. Owing to the complexity of nasoorbitoethmoidal fractures, accurate location of this point during surgery can be challenging. With the aid of computer-assisted planning and surgical navigation, the point at which the medial canthal tendon should be repositioned can be easily and precisely located. We have developed an innovative navigation-assisted technique that increases the reliability and safety of internal canthus repositioning. We performed a case series of three consecutive patients who underwent medial canthal tendon repositioning using computer-assisted planning and surgical navigation. We believe that this innovation provides a new and useful application of computer-assisted planning and surgical navigation in craniomaxillofacial surgery.

D77. In-fracture and Out-fracture: Novel Conceptions of Nasoorbitoethmoid Injury

PURPOSE: Nasoorbitoethmoid (NOE) fractures are commonly categorized by the Markowitz-Manson classification system, which grades severity of injury by degree of comminution and involvement of the medial canthal tendon. However, this system does not account for directionality of bony injury, which may impact clinical findings. We propose these fractures may be conceived as either in-fractured, resulting in nasal airway obstruction, or out-fractured, resulting in traumatic telecanthus. METHODS: A retrospective review was conducted of all patients with NOE fractures referred to plastic surgery at a tertiary academic medical center from 2017—2022. Radiographic data (CT) were evaluated to assess for directionality of NOE segment involvement. Frequencies of in-fracture and out-fracture across NOE type were compared by chi-squared test. RESULTS: Among 57 adults, 73 NOE fractures were identified with 39.7% (29) as Type 0 (non-displaced), 43.8% (32) as Type I, 12.3% (9) as Type II, and 4.1% (3) as Type III. Type I fractures were significantly associated with in-fracture (p < 0.0001), whereas Type III fractures were more likely out-fractured (p = 0.02). Type II fractures were not significantly associated with either presentation (p = 0.32). CONCLUSION: We discover that Type I NOE fractures more frequently present with in-fracture, whereas comminuted injuries such as Type III are typically out-fractured. Further study will validate these findings in a larger cohort and correlate radiography with clinical symptoms.

Lower eyelid lengthening in facial nerve palsy: when is a periosteal flap required?

Background/aimsTo present a case series of patients with facial nerve palsy (FNP) undergoing lower eyelid surgery where inadequate horizontal tarsal length was encountered and managed with a periosteal flap.MethodsA two-centre...

Результаты реконструктивно-восстановительной хирургии после тяжелой сочетанной травмы глаза, век и глазницы

Purpose. Presentation of the clinical result of complex surgical rehabilitation in a patient with combined traumatic injury of the eye, its adnexa and orbit. Material and methods. A clinical case is presented. Described step by step: surgical reconstruction of orbital walls with «Ekoflon» material (Russia), of lacrimal duct by Taumi method, of medial palpebral ligament, of upper eyelid coloboma with free skin graft, evisceration with plastic surgery of the musculoskeletal stump and ocular prosthetics. Results. Evaluation of the results of the surgical treatment performed at the final examination 14 months after the injury showed that the dimensions of the patient’s palpebral fissure had no obvious differences from the healthy side, the mobility of the upper eyelid was restored, and the lacrimal drainage function was preserved. There was a normal position and good mobility of the ocular prosthesis. Conclusion. Complex specialized rehabilitation of patients after a severe concomitant injury of the organ of vision using the achievements of modern reconstructive ophthalmic surgery makes it possible to restore the anatomy and function of the adnexal apparatus of the eye as much as possible, to carry out cosmetic prosthetics with a satisfactory aesthetic outcome. Key words: combined ocular injury, reconstructive and cosmetic eyelid surgery, lacrimal duct reconstruction; periorbital reconstruction; eye prosthesis

Morphometry of the Bony Orbit and Periorbital Structures: Personal Perspectives From Decades of Related Research.

The author introduces his personal perspectives on the bony orbit, nerves, arteries, and ligaments relating to orbital re- construction surgery. A supraorbital fissure was 40.0 ± 2.5 mm from the supraorbital notch. Posterior ethmoidal foramen was 31.7 ± 3.0 mm from the anterior lacrimal crest. The infraorbital fissure, where the infraorbital groove started, was 26.4 ± 2.6 mm from the infraorbital foramen. The supraorbital fissure was 34.3 ± 2.7 mm from the frontozygomatic suture. The medial palpebral ligament consisted of 2 layers. The superficial layer of the palpebral ligament (SMPL) was from the anterior lacrimal crest to the upper and lower tarsal plates. The deep layer of the palpebral ligament (DMPL) lay from the anterior lacrimal crest to the posterior lacrimal crest, covering the lacrimal sac. Horner muscle was at the posterior lacrimal crest just lateral to the attachment of the DLPL and ran laterally to the tarsal plate deep to the SLPL. Three components of the lateral canthal area are: (1) lateral palpebral raphe, (2) superficial lateral palpebral ligament (SLPL), and (3) deep lateral palpebral ligament (DLPL). The lateral ends of superior and inferior orbicularis oculi muscles interlaced at the lateral commissure and formed the lateral palpebral raphe. The superficial lateral palpebral ligament extended from the lateral ends of the tarsal plate to the periosteum of the lateral orbital rim. The lateral palpebral ligament extended from the lateral ends of the tarsal plate deep to the origin of SLPL to the Whitnall tu- bercle on the zygomatic bone. The palpebral branch of the in- fraorbital artery emerged from the infraorbital foramen and ran superior and lateral to the orbital septum. After passing through the orbital septum, distributed to the orbital fat.

Minimal lower eyelid epicanthoplasty combined with thermal contraction to treat epiblepharon in chinese children

BackgroundTo evaluate the clinical efficacy of combined minimal lower eyelid epicanthoplasty and thermal contraction for epiblepharon repair in Chinese children.MethodsBetween January 2017 and August 2020, a single surgeon corrected epiblepharon in Chinese children using minimal lower eyelid epicanthoplasty combined with thermal contraction. First, a minimal epicanthoplasty flap to balance the lower eyelid was made cross the lower eyelid epicanthus, which connected with a 20-mm-long incision 1.5 mm below the lower eyelid margin. After removing the hypertrophic orbicularis oculi muscle running between the lower epicanthal fold and the medial canthal tendon, thermal cauterization was applied to increase lower eyelid rotation by creating adhesions between the lower eyelid retractor and tarsus. The residual medial edge was sutured to the corner of the epicanthus to decrease the lower eyelid epicanthus. The postoperative follow-up ranged from 3 to 24 months. We retrospectively analyzed cases to determine whether this approach decreased the lower eyelid epicanthal fold to equalize the tension of the lower eyelid. The surgical outcomes including the direction of lower eyelid eyelashes, complications, and refractive errors were evaluated.ResultsData from each eye of 53 Chinese children (29 female, 24 males; mean age: 5.3 ± 2.3 years) who had undergone minimal lower eyelid epicanthoplasty combined with thermal contraction were included. During follow-up, recurrence was observed in just one of the 106 eyes (0.94%), and two eyes (1.89%) showed under-correction. No visible scars formed in the postoperative period. All patients’ parents were satisfied with the cosmetic results and had no serious complaints. The mean astigmatism was significantly reduced by the surgery from 1.82 ± 0.45 diopters (D) preoperatively to 1.43 ± 0.36 D postoperatively (P < 0.05).ConclusionThis surgery is easy to design, time-efficient, and is effective in the correction of epiblepharon. The procedure allows surgeons to achieve good appearance and natural eyelid contour without apparent complications.

A Comparative Study of Surgical Outcome in Endoscopic Endonasal Dacrocystorhinostomy with and without Stenting

Introduction To remove tears from people’s eyes’ – is one of the greatest challenges of lacrimal surgery. Epiphora is defined as watering eye due to inadequate drainage of normally produced tears. Dacryocystitis is the inflammation of the lacrimal drainage system which presents as acute dacryocystitis or a much commonly as chronic dacryocystitis. Other common causes of ephiphora are blepharitis, conjunctivitis, trichiasis, punctal eversion and foreign bodies. The conventional treatment for watering eyes due to Naso Lacrimal Duct (NLD) is the procedure of external dacryocystorhinostomy (DCR) which has its own limitations and disadvantages. With the introduction of high resolution endoscopes for paranasal sinuses, endoscopic endonasal DCR (EnDCR) is gaining popularity. The main advantages of the endoscopic technique are minimal morbidity, less intraoperative bleed, shorter operative time, preservation of pump function of orbicularis occuli muscle, presaccal fibers and medial canthal tendon and avoidance of cutaneous scar. In EnDCR the most common cause for failure of surgery is closure of rhinostoma and to prevent this silicone tube insertion is the most preferred method. It has also been claimed that silicone tubing would improve surgical results. But studies also indicate that silicone tubing itself results in certain problems like, foreign body sensation, increased granulation tissue leading to failure, prolapse of tube leading to injury to cornea, nasal migration of tube, fistula formation, pharyngitis and associated sinusitis &amp; recurrent nose bleed. The present study was undertaken to compare the surgical results of endoscopic endonasal DCR with and without silicone stent. Aims &amp; Objectives To compare the success rates of endonasal dacryocystorhinostomy and evaluate the presence of post-operative changes and their effect on the outcome of the surgery in endoscopic dacryocystorhinostomy with and without stenting. Material &amp; Methods This Prospective randomized comparative study was carried out amongst the patients attending department of ENT and referred cases from ophthalmology department for chronic nasolacrimal duct obstruction, both as inpatients and outpatients with complaint of chronic epiphora. 50 patients divided into two groups of 25 each fulfilling inclusion and exclusion criteria were included using convenient sampling. Participants were divided into two groups of 25 each based on randomization technique. Group 1 includes patients undergoing EnDCR with stenting and Group 2 includes patients undergoing EnDCR without stenting. Patients were assessed for post-operative complications like granulations, size of the neo ostium and patency of the neo ostium were assessed on nasal endoscopy. Data was entered in MS Excel work sheet. Data was analyzed using appropriate statistical methods. Result This study had Female predominance in both the groups. No predominance for any side was observed. No major intra operative complications were observed. Duration of surgery was more in Group I which was statistically significant. Post-operative complications are seen more in group without stenting (64.0%) than in group with stenting (56%) with no statistical difference between the two groups. Granulations had no effect on the outcome of the. On subjective assessment of symptoms 92% of patients in group I and 88% of patients in group II showed improvement of symptoms post operatively. No statistical difference had been found between the results of both the groups. On objective assessment of size of the neo ostium, no statistical difference was seen between the two groups. The size of the neo ostium had no effect on the outcome of the surgery. On objective assessment of patency of the neo ostium was observed in 92% of patients in group I and 88% patients in group II with no statistical difference between the two groups. Conclusion As success rates of the surgery with stenting and without stenting are comparable and

ImageJ assessment of double-frequency YAG laser efficacy in treatment of mild lower eyelid ectropion with punctal eversion

PurposeTo describe a simple and minimally invasive technique using double-frequency YAG laser for correction of mild medial lower eyelid ectropion with punctal eversion and assess the efficacy of the technique by measuring the tear film meniscus pre- and post-laser treatment using imageJ software.MethodsThis study included 23 eyes of 19 patients with lower eyelid ectropion with punctal eversion. All patients were treated by double-frequency YAG laser applied to lower medial conjunctiva. Tear film thickness was assessed using imageJ software pre- and post-argon laser treatment.ResultsThere was a highly significant change detected after argon laser treatment as regarding the mean of the height of tear film which was found to be significantly lower after argon laser treatment compared to before it (81.1 pixels versus 193.1 pixels, respectively) (P < 0.001).ConclusionDouble-frequency YAG laser applied to lower medial palpebral conjunctiva is a simple, easy, safe, and effective procedure which can be used as a solo treatment in early cases of punctal eversion with no or mild medial canthal tendon laxity.

'Valves' of the angular vein: Orbicularis oculi, depressor supercilii, and zygomaticus minor.

ObjectivesThe aim of this study was to elucidate the positional relationship between the courses of the angular veins and the facial muscles, and the possible roles of the latter as alternative venous valves.MethodsThe angular veins of 44 specimens of embalmed Korean adult cadavers were examined. Facial muscles were studied to establish their relationships with the angular vein, including the orbicularis oculi (OOc), depressor supercilii (DS), zygomaticus minor (Zmi), zygomaticus major (Zmj), and levator labii superioris (LLS).ResultsIn the upper face of all specimens, the angular vein passed through the DS and descended to the medial palpebral ligament. In the midface, it passed between the origin of the levator labii superioris alaeque nasi (LLSAN) and the inferior OOc fibers. The vein coursed along the deep surface of the inferior margin of the OOc in all specimens. At the level of the nasal ala, the course of the angular vein was classified into three types: in type I it passed between the LLS and Zmi (38.6%), in type II it passed between the superficial and deep fibers of the Zmi (47.7%), and in type III it passed between the Zmi and Zmj (13.6%). In the lower face of all specimens, the angular or facial vein passed through the anterior lobe of the buccal fat pad.ConclusionThis study found that the angular vein coursed along the sites where facial muscle contractions are assumed to efficiently compress the veins, likely controlling venous flow as valves. The observations made and analysis performed in this study will improve the understanding of the physiological function of the facial muscles as alternative venous valves.

Hinged tarsal flap: A novel technique for canthal tendon reconstruction.

Reconstruction of the medial canthal region is challenging due to the complex regional anatomy. Options to reconstruct a medial canthal tendon sacrificed during tumour removal is limited. We present a novel surgical technique where hinged tarsal flap serves to substitute the canthal tendons. This is a retrospective consecutive case series of five patients that underwent canthal reconstruction using this novel technique between May and December 2020. Electronic patient records and medical photograph database were reviewed. Patient demographics, co-morbidities, location and histology of the lesion, size of the resultant defect, reconstructive technique and post-operative complications were noted. All patients had good eyelid stability with no malposition, lagophthalmos or exposure keratopathy. No or minimal distraction of the eyelid from the globe, good cosmetic outcomes and no troublesome watering was reported. No wound dehiscence, no sight loss and no further surgical intervention was warranted. Multiple techniques have previously been described to reattach the medial canthal tendon with silk or supramid sutures. Transnasal wiring, stainless-steel screw and mini-plate fixation are also described, but carry a high risk of complications and are unfamiliar amongst most oculoplastic surgeons. Our technique is quick and simple and utilises autogenous tissue without breaching the periosteum which acts as a natural barrier to tumour infiltration.Refashioning the canthal tendon aids to lengthen the remaining eyelid stump, reducing the horizontal length required to reform the newly constructed eyelid and facilitates the reconstruction.