• Primary: to restore the normal contour and function of the medial canthus following trauma
• Secondary — repair of
• associated orbital fractures and enophthalmos
• nasal deformities
• if injury present
• lacrimal drainage system
• frontal sinus

• Indications
• Lateral displacement of medial canthus (telecanthus)
• Indications for associated procedures
• enophthalmos
• flattening/widening of nasal bridge or nasal telescoping
• epiphora
• frontal sinus dysfunction
• Contraindications
• Any contraindication to general anesthesia
• Particularly consider risks from trauma to the cribriform plate and CSF leak

• Patient History
• Mechanism of injury
• Previous procedures: Patients with traumatic telecanthus often present for secondary repair or revision after previous surgery.
• Patient concerns, symptoms
• enophthalmos
• epiphora
• breathing difficulty, sinus issues
• Clinical examination
• Assess degree of facial asymmetry, telecanthus, and enophthalmos (exophthalmometry).
• Evaluation of external nose, nasal septum, airway.
• Examine lacrimal drainage system if symptomatic or radiologic evidence of compromise.
• Review studies: CT orbits or maxillofacial
• Consider neurosurgical evaluation for frontal sinus injuries.

Transnasal wiring

• Surgical access — incisions
• bicoronal
• gingivobuccal sulcus
• transconjunctival/caruncular
• Lynch
• DCR
• Can also use previous scars/incisions
• 3 anatomic subgroups must be addressed
• Medial canthus
• Identify bone fragment with attached medial canthal tendon.
• Free bone with osteotomies and reposition medially.
• Place 2 drill holes posteriorly to insertion of medial canthal tendon and pass 28-gauge wire from temporal to nasal through both holes,
• Pass wires transnasally with awl and fixate to plate in supratrochlear region of contralateral orbit.
• If the bone fragment is too small or the tendon has been stripped from the bone (Class II and III injury, respectively), purchase the medial canthus tendon with a figure‑8 of 28‑gauge wire and pass as above.
• Place compression plates at the conclusion of repair to maintain medial canthal position and prevent hematoma formation.
• Address the medial canthus anatomic subunit last.
• Nose
• Correct nasal width by infracturing nasal pyramid with or without osteotomy and repositioning central maxillary buttress.
• Restore nasal dorsum height and length with bone grafts.
• Medial wall, orbital floor
• Dissect subperiosteally to identify fracture.
• Reposit prolapsed soft tissue.
• Place orbital implant of choice based on surgeon preference, size of defect, and available support.

Microplate fixation

• Cantilevered miniplate fixation
• Cantilever Y-shaped titanium miniplate from lateral nose
• Direct posteriorly into orbit.
• Fixate bone fragment with medial canthal tendon to plate.

• Routine postoperative care with addition of nasal precautions
• Avoid nose blowing.
• Avoid sucking through a straw.
• Compression plates left for at least 1 week
• Medications
• Analgesia with opiate-acetaminophen combination
• Broad-spectrum antibiotic to cover nasal and sinus flora, e.g., Augmentin

• Persistent telecanthus
• Epiphora/damage to nasolacrimal system
• Must handle medial canthal tissue carefully
• Low threshold for silicone stent placement

1. Holck DEE and Ng J. Evaluation and Management of Chronic Naso-Orbito-Ethmoid Fractures. In: Evaluation and Management of Orbital Fractures: A Multidisciplinary Approach. Philadelphia, PA, Saunders, 2005. 183-192.
2. Nguyen M, Koshy JC, Hollier LH Jr. Pearls of nasoorbitoethmoid trauma management. Semin Plast Surg. 2010; 24(4): 383-388.
3. Shore JW, Rubin PA, Bilyk JR. Repair of telecanthus by anterior fixation of cantilevered miniplates. Ophthalmology. 1992 Jul;99(7):1133-1138.