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Lateral and Medial Canthoplasty
The Enophthalmos Syndromes
Next
Repair of Traumatic Telecanthus
David E. Holck, MD
Surgical goals
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 and contraindications
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
Preoperative evaluation
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.
Surgical techniques
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.
Postoperative care and follow-up
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
Complications
Persistent telecanthus
Epiphora/damage to nasolacrimal system
Must handle medial canthal tissue carefully
Low threshold for silicone stent placement
References and additional resources
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.
Nguyen M, Koshy JC, Hollier LH Jr. Pearls of nasoorbitoethmoid trauma management.
Semin Plast Surg
. 2010; 24(4): 383-388.
Shore JW, Rubin PA, Bilyk JR. Repair of telecanthus by anterior fixation of cantilevered miniplates.
Ophthalmology
. 1992 Jul;99(7):1133-1138.
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