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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 31  |  Issue : 1  |  Page : 54-56

Management of traumatic telecanthus by medial canthopexy


1 Department of General Surgery, GMC, Dhule, Maharashtra, India
2 Department of Oral Medicine and Radiology, ACPM Dental College, Dhule, Maharashtra, India

Date of Web Publication15-Apr-2019

Correspondence Address:
Ujwala Rohan Newadkar
Department of Oral Medicine and Radiology, ACPM Dental College, Dhule - 424 003, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_15_19

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  Abstract 

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.

Keywords: Eye, medial canthal tendon, medial canthopexy, transnasal wiring, traumatic telecanthus


How to cite this article:
Newadkar RD, Newadkar UR. Management of traumatic telecanthus by medial canthopexy. Kerala J Ophthalmol 2019;31:54-6

How to cite this URL:
Newadkar RD, Newadkar UR. Management of traumatic telecanthus by medial canthopexy. Kerala J Ophthalmol [serial online] 2019 [cited 2019 Apr 24];31:54-6. Available from: http://www.kjophthal.com/text.asp?2019/31/1/54/256260


  Introduction Top


Medial canthal tendon (MCT) is the pivotal soft tissue in naso-orbito-ethmoid (NOE) area, which supports the canthus, enables proper apposition between the eyelid and the globe, and performs as the lacrimal pump.[1] Posttraumatic MCT, rupture with telecanthus leads to esthetic and functional impairments. The aim of the surgery is to restore medial canthal area to its natural and esthetic with preservation of function, for reinsertion or repositioning the MCT that has been avulsed or displaced.[2] Various techniques have been used in the past for this purpose, such as transnasal wiring, titanium screws,[3] titanium miniplates cantilevered from the nose,[4] commercially available anchoring systems (such as those from Mitek Inc., Westwood, Mass),[5],[6] periosteal flaps,[7] and medial tarsal strips.[8] Here, we present a case report of management of traumatic telecanthus by medial canthopexy in an 11-year-old female patient using titanium miniplate.


  Case Report Top


An 11-year-old female child was reported to the clinic with the complaint of slight watering from the right eye. She had a history of trauma to the facial region due to fall from the distance of 5–6 feet high about 6 months back. Clinical examination revealed telecanthus of the right eye [Figure 1]a and [Figure 1]b. There was a shift of MCT complex in inferolateral direction. Parents were more concerned about the esthetics and ready to get it done by surgical correction. The patient was then evaluated with three-dimensional reconstruction of the face and nasoendoscopy. Computed tomography images showed old healed fractures of the inferomedial wall of the right orbit and medial half of the anterior wall of the maxilla [Figure 1]c. Imaging confirmed the diagnosis of hypertelorism of the right eye because of the increased intercanthal distance. Medial canthopexy was planned. Surgical exposure was done with five-flap Z-plasty. MCT was identified. It was released from the nasal bone and fixed to the cribriform plate and part of the nasal bone in a superomedial direction with 1.5-mm two-hole titanium plate [Figure 1]d with nonabsorbable suture. Intraoperatively, ophthalmologist consultation was taken. Intranasal dacryocystorhinostomy was done by ear, nose, and, throat surgeon. After that, screws were tightened for the final results. Five-flap Z-plasty was closed in two layers. Sutures were removed at 8 days [Figure 2]. The patient was advised to use silicone gel and sunscreen lotion to minimize the scar.
Figure 1: (a and b) Clinical photographs, (c) 3-D CT imaging, (d) Intraoperative photograph

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Figure 2: Preoperative and postoperative photographs

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  Discussion Top


Fractures of the NOE complex account for approximately 5% of facial fractures in adults.[9] In children, the incidence is higher and NOE fractures account for nearly 15% of all facial fractures.[10],[11] One of the most common complications stemming from NOE fractures is traumatic telecanthus[12],[13] due to injury and the avulsion of the medial canthal ligament.[14] Surgical treatment of telecanthus carries one of the most challenging tasks in facial reconstruction due to the anatomical complexity of the NOE region and its utmost role in facial expression. Scarcity of tissue in this region makes it difficult to perform the operations without incurring the risk of the destroying the benefits of the preceding intervention.[15],[16]

Correction of the deformity requires adequate dissection and mobilization of the MCT, subperiosteal exposure of the medial orbit, precise identification of the correct anatomical location for tendon placement, and secure fixation of the tendon to the bone.[17] Transnasal wiring has been one of the most commonly used methods to perform medial canthopexy.[4],[5] However, it is technically difficult and may cause damage to the contralateral orbital structures.[5] In Terry's report, the transnasal wiring was achieved after adequate exposure via coronal incision, and surgeons needed to drill or select two (for unilateral injury) or four holes (for bilateral injury) in medial orbital wall reconstruction, which must accord to the position where the MCT normally attaches. After two 28-gauge wires went through the selected holes, the wires formed a tight bond and were placed in the nasal cavity for unilateral injury cases.[18] Kim et al.[19] reported an oblique transnasal wiring that was performed by a Y-V epicanthoplasty incision rather than the well-known classical bicoronal approach, which could assist in minimizing unsightly scar formation.

The pitfall of the standard technique of transnasal wiring is the double drilling through the lacrimal and nasal bones which may subject the bones for further fragmentation and subsequent displacement and relapse of the telecanthus.[17] Miniplate and screw canthopexy is a short surgical procedure which provides precise alignment of the MCT and better postoperative symmetrical appearance, and better esthetic and functional results can be gained. Sharma et al. devised a technique wherein a two-hole titanium plate is used for this purpose. The plate is secured to the thick nasal bone, and the lower hole is kept at the level of lacrimal crest.[20],[21] Future studies are needed to confirm or differentiate this hypothesis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Rosenberger E, Kriet JD, Humphrey C. Management of nasoethmoid fractures. Curr Opin Otolaryngol Head Neck Surg 2013;21:410-6.  Back to cited text no. 1
    
2.
Williamson LK, Miller RH, Session RB. Treatment of naso fronto ethmoidal fractures. Otolaryngol Head Neck Surg 1981;89:587.  Back to cited text no. 2
    
3.
Mauriello JA Jr., Caputo AR. Treatment of congenital forms of telecanthus with custom-designed titanium medial canthal tendon screws. Ophthalmic Plast Reconstr Surg 1994;10:195-9.  Back to cited text no. 3
    
4.
Shore JW, Rubin PA, Bilyk JR. Repair of telecanthus by anterior fixation of cantilevered miniplates. Ophthalmology 1992;99:1133-8.  Back to cited text no. 4
    
5.
Antonyshyn OM, Weinberg MJ, Dagum AB. Use of a new anchoring device for tendon reinsertion in medial canthopexy. Plast Reconstr Surg 1996;98:520-3.  Back to cited text no. 5
    
6.
Okazaki M, Akizuki T, Ohmori K. Medical canthoplasty with the mitek anchor system. Ann Plast Surg 1997;38:124-8.  Back to cited text no. 6
    
7.
Edelstein JP, Dryden RM. Medial palpebral tendon repair for medial ectropion of the lower eyelid. Ophthalmic Plast Reconstr Surg 1990;6:28-37.  Back to cited text no. 7
    
8.
Jordan DR, Anderson RL, Thiese SM. The medial tarsal strip. Arch Ophthalmol 1990;108:120-4.  Back to cited text no. 8
    
9.
Nguyen M, Koshy JC, Hollier LH Jr. Pearls of nasoorbitoethmoid trauma management. Semin Plast Surg 2010;24:383-8.  Back to cited text no. 9
    
10.
Kelley P, Crawford M, Higuera S, Hollier LH. Two hundred ninety-four consecutive facial fractures in an urban trauma center: Lessons learned. Plast Reconstr Surg 2005;116:42e-9e.  Back to cited text no. 10
    
11.
Chapman VM, Fenton LZ, Gao D, Strain JD. Facial fractures in children: Unique patterns of injury observed by computed tomography. J Comput Assist Tomogr 2009;33:70-2.  Back to cited text no. 11
    
12.
Cruse CW, Blevins PK, Luce EA. Naso-ethmoid-orbital fractures. J Trauma 1980;20:551-6.  Back to cited text no. 12
    
13.
Merkx MA, Freihofer HP, Borstlap WA, van't Hoff MA. Effectiveness of primary correction of traumatic telecanthus. Int J Oral Maxillofac Surg 1995;24:344-7.  Back to cited text no. 13
    
14.
Mathog RH, Bauer W. Posttraumatic pseudohypertelorism. (Telecanthus). Arch Otolaryngol 1979;105:81-5.  Back to cited text no. 14
    
15.
Kala ND, Vrezos KW, Greatz GK, Eyrich HF, Sailer JR. Coll surgery. Edinburgh 2000;45:359.  Back to cited text no. 15
    
16.
Cohen MM Jr., Richieri-Costa A, Guion-Almeida ML, Saavedra D. Hypertelorism: Interorbital growth, measurements, and pathogenetic considerations. Int J Oral Maxillofac Surg 1995;24:387-95.  Back to cited text no. 16
    
17.
Elbarbary A, Ali A. Functional and aesthetic restoration of medial canthal region following naso-orbito-ethmoidal (NOE) traumatic telecanthus. Egypt J Plast Reconstr Surg 2012;36:173-80.  Back to cited text no. 17
    
18.
Shibuya TY, Chen VY, Oh YS. Naso-orbito-ethmoid fracture management. Oper Tech Otolaryngol 2008;19:140-4.  Back to cited text no. 18
    
19.
Kim TG, Chung KJ, Kim YH, Lim JH, Lee JH. Medial canthopexy using Y-V epicanthoplasty incision in the correction of telecanthus. Ann Plast Surg 2014;72:164-8.  Back to cited text no. 19
    
20.
Sharma RK, Makkar SS, Nanda V. Simple innovation for medial canthal tendon fixation. Plast Reconstr Surg 2005;116:2046-8.  Back to cited text no. 20
    
21.
Sharma RK. Prof. Mira Sen (Banerjee) C.M.E. Article. Indian J Plast Surg 2014;47:284-92.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2]



 

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