Traumatic Telecanthus Research Articles

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.

Pneumocephalus after surgical treatment of NOE fracture: Case report

Introduction: Naso-orbital-ethmoidal fractures are complex fractures involving the bones of the nose, orbit region, maxilla and ethmoid. This complex structure has a close relationship with the brain and the orbital region, which frequently suffer injuries during trauma. Among traumatic brain injuries, there is the pneumoencephalon. The present study aims to report the treatment of a patient who suffered an accident involving a rural animal. Case Report: A 63-year-old male patient was brought to the highly complex hospital for the Oral and Maxillofacial Surgery and Traumatology service, five days after the trauma. The physical examination showed traumatic telecanthus,anisocoria and mydriasis of the right eye, right eyelid ptosis, laceration in the right eyebrow and deviation of the nasal bone to the left. In the imaging exam (computed tomography), traces of fractures were observed in the nasal bone region, medial orbital wall, infra-orbital margin, frontal-zygomatic pillar and right orbital blow out fracture. After a surgical approach to fix the fractures, it was observed the development of a hypodense area in the intracranial region, suggestive of pneumocephalus. Conclusion: These complications, such as pneumocephalus, must be diagnosed early and appropriate treatment must be started as soon as possible to reduce possible sequelae, requiring the intervention of a multidisciplinary team.

Transnasal Medial Canthopexy Supported with Autogenous Bone Graft: A New Method for Repair of Traumatic Telecanthus.

The medial canthus is an important structure to maintain the shape of the eye and assist in drainage of the lacrimal sac. Traumatic telecanthus is a difficult deformity to treat which involves both esthetic and functional aspects. Transnasal wiring remains the gold standard for repair of the medial canthal tendon (MCT) avulsion; however, it is often complicated by canthal drift, extrusion of wires, and in-fracture of the contralateral orbital bones from pressure by tied wires. In order to overcome traditional transnasal wiring technique pitfalls, this study proposes a transnasal wiring fixation method supported with a bone graft to treat patients presenting with telecanthus following complex nasoorbitoethmoid fractures. From December 2018 to October 2020, 12 patients with traumatic telecanthus underwent transnasal wiring fixation of the MCT supported with bone graft. The wire holding the MCT was delivered through a single hole to the contralateral side and secured to a small bone graft by passing the wire through 2 holes in the graft in a button-like fashion. Then the wire end is pulled again to the affected side through the same hole and the 2 wires ends are tightly twisted after setting the MCT posterior to the lacrimal crest. Restoration of the MCT to its normal position was achieved in all patients. There were no observed major complications. Only 2 cases of wound infection and 1 case of dacrocystitis were encountered, which settled with conservative management. The preoperative palpebral fissure width (mean: 28.33mm ± 2.188mm) was significantly lower than the postoperative palpebral fissure width (mean: 34.17mm ± 1.03mm) ( P< 0.05). This study introduces a modified technique of transnasal wiring fixation to restore palpebral shape and intercanthal distance. The proposed technique could eliminate most of the frequently observed complications of the traditional methods.

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.

Pediatric Nasoorbitoethmoid Fractures: Cause, Classification, and Management.

Currently, there is a paucity of information on the presentation and proper management of pediatric nasoorbitoethmoid fractures. The purpose of this study was to examine the incidence, cause, associated injuries, and management of these fractures. Furthermore, the authors sought to assess outcomes after transnasal wiring or suture canthopexy for type III nasoorbitoethmoid fractures. A retrospective cohort review was performed of all patients with nasoorbitoethmoid fractures who presented to a Level I trauma center from 1990 to 2010. Charts and computed tomographic imaging were reviewed, and nasoorbitoethmoid fractures were labeled based on the Markowitz-Manson classification system. Patient fracture patterns, demographics, characteristics, and outcomes were recorded. Univariate and multivariate methods were used to compare groups. A total of 63 pediatric patients were identified in the study period. The sample's mean age was 8.78 ± 4.08 years, and 28.6 percent were girls. The sample included 18 type I injuries, 28 type II injuries, and 17 type III injuries. No significant demographic differences were found between patients with type I, II, and III fractures (p > 0.05). Operative intervention was pursued in 16.7, 46.4, and 82.4 percent of type I, II, and III nasoorbitoethmoid fractures, respectively. In patients with type III nasoorbitoethmoid fractures, no patients with transnasal wiring developed telecanthus. Pediatric nasoorbitoethmoid fractures are uncommon injuries. Type I fracture can often be treated with close observation. However, type II and III injury patterns should be evaluated for operative intervention. Transnasal wiring is an effective method to prevent traumatic telecanthus deformity in type III fracture patterns.

Management of traumatic telecanthus by medial canthopexy

The medial part of the orbital region is a complex structure of several facial bones. It has attachments for support of the eye and lacrimal collecting system. In that, medial canthus is an important structure for esthetic and functional reasons. Medial canthal deformities can result from nasoethmoidal trauma, cancer resection, craniofacial exposure, congenital malposition, or age-related change. Various techniques have been used for medial canthal reconstruction, specifically to achieve bony fixation of the medial canthal tendon. The surgical treatment of traumatic telecanthus remains one of the most challenging areas in facial reconstruction. Transnasal wiring has been one of the most commonly used methods to perform medial canthopexy. However, it is technically difficult and may cause damage to the contralateral orbital structures. Here, we present a case report of management of traumatic telecanthus by medial canthopexy in an 11-year-old female patient using titanium miniplate.

Post trauma craniofacial deformities and treatment protocol

Correction of post traumatic craniofacial deformities constitutes a challenging but worthwhile endeavor. Traumatic telecanthus, enopthalmos and occlusal deformity are the deformities most refractory to secondary correction. Aesthetic results are adversely affected by the severity and number of pre-existing abnormalities and by the presence of established deformities (beyond 6–12 months). The basic principles of treatment include an osseous reconstruction surgery as early as possible to restore the anatomically correct craniofacial architecture followed by selective ancillary procedures to address soft tissue deficits and functional deformities. The purpose of this study was to analyze the aesthetic and functional outcomes of secondary correction of post traumatic craniofacial deformities (PTCD) and to highlight the underlying principles and formulate treatment guidelines.

Traumatic Nasolacrimal Duct Obstruction: Clinical Profile, Management, and Outcome

To review clinical profile, management, and outcome in cases of traumatic nasolacrimal duct obstruction (NLDO). A retrospective analysis of 28 patients with the diagnosis of traumatic NLDO during a 12-year period was done. Data regarding nature and pattern of injury, associated damage, clinical features, investigations, management, outcome, and follow-up were reviewed. Of the 28 patients reviewed in the study, 19 (68%) were male and 9 (32%) were female. Mean age of the patients was 30.1 years. The most common cause of traumatic NLDO was high-velocity blunt injury encountered in road traffic accidents (70%), and the most common pattern of injury was naso-orbito-ethmoidal fractures (64%). Traumatic telecanthus was the most commonly associated periocular injury (54%). Twenty-one patients (75%) were investigated with computed tomography-dacryocystography. A total of 26 patients were treated with external dacryocystorhinostomy with (75%) or without (18%) silicon intubation and 2 (7%) patients underwent dacryocystectomy. General anesthesia was administered in 19 (68%) patients and local anesthesia in 9 (32%) patients. Mean follow-up period was 7.71 months (range 3 months to 6 years). Successful outcome was recorded in 25 out of 26 eyes (96%) operated with external dacryocystorhinostomy with or without silicone intubation. Naso-orbito-ethmoidal fracture is the main cause of traumatic NLDO, commonly in young male individuals. Telecanthus is an important presenting feature. Computed tomography-dacryocystography is a useful imaging modality in preoperative assessment and surgical planning. External dacryocystorhinostomy with or without intubation under general anesthesia gives good surgical outcome.

Anthropometry of the Medial Canthal Ligament Related to Naso-Orbitoethmoidal Fractures

Medial canthal ligament (MCL) and lacrimal system are often associated with naso-orbitoethmoidal fractures. The MCL anchors tarsal plate to medial orbit and has an important role in lacrimal pump system. The purpose of this study was to describe the anatomy of the MCL and present the anthropometric measurements on cadaveric specimens. Dissections were performed on 14 formalin-fixed cadavers. The length, thickness, width of the MCL, width of the nasal dorsum, and intercanthal distance were measured with a digital caliper. A surgical microscope and an digital photo camera were used in all dissections. Means, SDs, and paired-samples t test were computed. The mean lengths of the right and left MCLs were measured as 8.01 (SD, 2.27) and 7.93 (SD, 2.43) mm. The mean thicknesses of the right and left MCLs were 1.63 (SD, 2.41) and 1.75 (SD, 2.44) mm. The mean widths of the right and left MCLs were 4.20 (SD, 0.75) and 4.17 (SD, 0.61) mm. The intercanthal distance was 31.7 (SD, 1.7) mm. The width of the nasal dorsum was measured as 14.37 (SD, 1.9) mm. Length and thickness differed on both sides. Asymmetric insertion of medial canthi was observed in 5 specimens. Reconstruction of traumatic telecanthus requires reaproximation of medial canthi and the displaced nasoethmoid bony fragment with transnasal wiring or microplates. Identification and reconstruction of detached medial canthi could be accomplished successfully with anatomic familiarity of the region. The most developed and firmly adherent was the anterior limb of the MCL. Reattachment of that part seems to be adequate for repair of a detached canthus.

The secondary correction of post-traumatic craniofacial deformities

To analyze the aesthetic and functional outcomes in a large series of patients who underwent secondary correction of post-traumatic craniofacial deformities (PTCD) and to highlight the underlying principles and formulate treatment guidelines. A single surgeon's retrospective case series of 57 patients who underwent correction of PTCD. Evaluation by multiple surgeons who assessed aesthetic results and functional parameters after secondary correction of PTCD. A good to excellent aesthetic outcome was achieved in the majority of patients. Traumatic telecanthus, enophthalmos, and occlusal deformity were the deformities most refractory to secondary correction. Aesthetic results were adversely affected by the severity and number of pre-existing abnormalities and by the presence of established deformities (beyond 6 to 12 months). The basic principles of treatment include an initial major osseous reconstructive surgery to restore an anatomically correct craniofacial architecture followed by selective ancillary procedures to address soft tissue deficits and functional deformities. Soft tissue deformity is the major deterrent to achieving an ideal outcome.

Poster 25: Comparison of intercanthal, interpupillary, and alar base distance in Caucasian, African-American, Hispanic, and Asian populations

Intercanthal, interpupillary, and alar base distance are important measurements in the evaluation of post-traumatic maxillofacial injuries. In this study objective measurements and comparisons were made of the intercanthal distance, interpupillary distance, and alar base width in Caucasian, African-American, Hispanic, and Asian populations. Knowledge of population averages aids in reconstruction of traumatic telecanthus and midface maxillofacial trauma. Previous studies have been performed on the Caucasian and African-American adult populations; however, no study has objectively compared these measurements with those of Hispanic and Asian populations.

Effectiveness of primary correction of traumatic telecanthus

To assess the aesthetic and functional results of primary treatment of telecanthus in patients with naso-orbito-ethmoidal fractures, the results in 36 patients were evaluated in a retrospective study. Twenty had double-sided telecanthus: 13 required an indirect technique of canthopexy and seven a direct technique. Sixteen had unilateral telecanthus, of whom six were treated by the indirect and 10 by the direct technique. The intercanthal distance (ICD) was measured directly postoperatively and more than 12 months after reconstruction. The late ICD after application of the direct technique was nearly 3 mm smaller (ANOVA, P≤0.02, mean, 34.3 mm) and yielded 2 mm less relapse (ANOVA, P≤0.02) as compared with the indirect technique. Delayed or late-primary treatment showed a significantly higher frequency of epiphora (chi-square test, P≤0.05). Early primary treatment of traumatic telecanthus produced the best aesthetic and functional result.

Repair of Telecanthus by Anterior Fixation of Cantilevered Miniplates

Background: The accepted surgical method for telecanthus repair is transnasal wiring. This procedure requires a stable posterior lacrimal crest on the affected side and surgical manipulation of the wires as they exit the contralateral side. A method for repairing telecanthus that obviates these prerequisites is presented. Indications for use of this technique and comparison to transnasal wiring is discussed. Methods: A Y-shaped titanium rigid orbital plating system (miniplate) was used to surgically correct traumatic telecanthus in five patients, two in the acute setting and three in late reconstruction. The miniplate was cantilevered from the lateral aspect of the nose and directed posteriorly into the orbit. This provided a stable fixation point for the medial canthal tendon. Results: Marked resolution of the telecanthus was noted in four patients. No postoperative complications have been encountered to date. Conclusions: Miniplate fixation was used successfully to repair unilateral traumatic telecanthus. Miniplate fixation of the medial canthal tendon should be considered in unilateral cases of traumatic telecanthus and in cases where poor bony support for transnasal wires is evident.

Repair of Telecanthus by Anterior Fixation of Cantilevered Miniplates

The accepted surgical method for telecanthus repair is transnasal wiring. This procedure requires a stable posterior lacrimal crest on the affected side and surgical manipulation of the wires as they exit the contralateral side. A method for repairing telecanthus that obviates these prerequisites is presented. Indications for use of this technique and comparison to transnasal wiring is discussed. A Y-shaped titanium rigid orbital plating system ("miniplate") was used to surgically correct traumatic telecanthus in five patients, two in the acute setting and three in late reconstruction. The miniplate was cantilevered from the lateral aspect of the nose and directed posteriorly into the orbit. This provided a stable fixation point for the medial canthal tendon. Marked resolution of the telecanthus was noted in four patients. No post-operative complications have been encountered to date. Miniplate fixation was used successfully to repair unilateral traumatic telecanthus. Miniplate fixation of the medial canthal tendon should be considered in unilateral cases of traumatic telecanthus and in cases where poor bony support for transnasal wires is evident.

Avulsion of the Canalicular System

Avulsion of the common canaliculus from its attachment to the lacrimal sac should be suspected in cases involving either deep lacerations on the lateral side of the nose or traumatic telecanthus in midfacial trauma. Blunting of the canalicular angle and rounding of the inner canthus are confirming signs. A canaliculodacryocystorhinostomy can be performed to reanastomize the lacrimal drainage pathways and relieve epiphora.

Avulsion of the Canalicular System

ABSTRACT Avulsion of the common canaliculus from its attachment to the lacrimal sac should be suspected in cases involving either deep lacerations on the lateral side of the nose or traumatic telecanthus in midfacial trauma. Blunting of the canalicular angle and founding of the inner canthus are confirming signs. A canaliculodacryocystorhinostomy can be performed to reanastomize the lacrimal drainage pathways and relieve epiphora.

Medial canthoplasty: Early and delayed repair

Naso-orbital trauma can cause medial orbital wall disruption and detachment of the medial canthal ligament. Damage to the nasolacrimal drainage apparatus, cerebrospinal fluid rhinorrhea and frontal sinusitis can occur. Twelve cases of naso-orbital trauma have been reviewed. There is a high incidence of associated injury to adjacent structures. Medial canthal ligament separation was missed acutely in a number of cases leading to the necessity of delayed repair. Important diagnostic and therapeutic points are stressed in the acute and delayed management, particularly medial canthal ligament separation. A wire to intranasal button technique for the delayed repair of traumatic telecanthus is presented.

The pulley canthopexy for residual telecanthus after hypertelorism repair or facial trauma.

The onset of canthal drift after hypertelorism repair can nullify the effectiveness of the repair, despite roentgenographic evidence of normal interorbital distance. The problem of hypertelorism is simply replaced by the problem of telecanthus. An excess of bulky tissue between the orbits contributes to the problem. A procedure is described in which excess soft tissue (fat, nasal muscles, and parts of the orbicularis oculi) are excised. A pulley canthopexy with a figure-of-eight suture of polypropylene is performed to bring the canthal tendons together using a hollow awl with a removable handle. The pulley gives a 4 to 1 mechanical advantage to the suture, adding control and distributing the forces over a wider area. The pulley canthopexy is a valuable tool not only in congenital anomalies but also for correcting long-standing traumatic telecanthus and acute detachment of the canthal ligaments.

Naso-ethmoid-orbital fractures.

This report reviews the experience with naso-ethmoid-orbital fractures at a major medical center. Thirty-three patients were treated between 1 October 1976 and 1 January 1979, who met our definition of naso-ethmoid-orbital fractures. The majority sustained trauma in a motor vehicle accident and 60% of the patients had associated nonfacial injuries. All patients had other facial injuries and fractures; orbital rim or floor, 94%; complex maxillary (LeForte II-III), 72%; and mandible fractures, 25%. Slightly over one half of the group of naso-ethmoid fractures were open; the remainder were closed injuries. Traumatic telecanthus was noted in 70% of the patients on initial examination. Cerebrospinal fluid rhinorrhea was evident in 40%, and frontal sinus fractures were detected in 25% of the group. Severe ocular injury with initial or subsequent loss of sight occurred in an alarming 30% of the patients. In addition, nasolacrimal duct system lacerations occurred in 20%. One patient developed a large carotid artery-cavernous sinus fistula 1 month postinjury. The severity of these injuries and the potential for deformity and dysfunction have not been properly emphasized in the past. Our experience has defined several diagnostic and therapeutic guidelines. For example, vastly improved results were obtained with an open reduction and internal fixation procedure. A multidisciplinary approach by a neurosurgeon, ophthalmologist, and plastic surgeon is mandatory.