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Lacrimal Injury After Rhinoplasty

Two Case Reports

Jafaripour, Masoud, MD*†; Kashfi, Seyed Abolfazl, MD

doi: 10.1097/SAP.0000000000001660
Aesthetic Surgery

Lacrimal injury is very uncommon after osteotomy in rhinoplasty. We present 2 cases of lacrimal injury after osteotomy in rhinoplasty and present the steps to managing such an injury. These cases were finally treated with endoscopic dacryocystorhinostomy. We concluded that osteotomies must be at least 3 mm from the medial canthus or medial to the line from the medial canthus to the alar base. Also, it is recommended that osteotome blades be sharpened before each osteotomy.

From the *ENT Department, Ordibehesht Hospital, Isfahan, Iran; and

Private Practice, Isfahan, Iran.

Received June 10, 2018, and accepted for publication, after revision August 20, 2018.

Conflicts of interest and sources of funding: none declared.

Reprints: Masoud Jafaripour, MD, No 19., Makan Medical Complex, Police Cross Rd, Tohid St, Isfahan, Iran. E-mail:

Direct injury of the nasolacrimal duct (NLD) is an uncommon complication of rhinoplasty.

Lacrimal system injury is theoretically possible owing to the close proximity of the lacrimal apparatus to the lateral osteotomy. However, the anterior lacrimal crest could protect the sac.

Most posttraumatic NLD obstructions, including iatrogenic cases, result from edematous tissues around the NLD, which is reversible.1

The lacrimal sac can be divided into a fundus superiorly and a body inferiorly. The fundus extends 3 to 5 mm above the superior portion of the medial canthal tendon, and the body extends approximately 10 mm below the fundus to the osseous opening of the nasolacrimal canal (Fig. 1).



The NLD consists of a 12-mm superior intraosseous portion and a 5-mm inferior membranous portion. The bony nasolacrimal canal is approximately 1 to 3 mm in diameter; the intraosseous part travels posterolaterally through the nasolacrimal canal within the maxillary bone, whereas the membranous part runs within the nasal mucosa, eventually opening into the inferior meatus under the inferior nasal turbinate.2 In surface anatomy, a line from medial canthus to the first upper molar tooth can show the estimated pathway of the NLD (Fig. 2).



Lateral osteotomies are performed along the frontal process of the maxilla, occasionally extending onto the nasal bone.

If the nasal bones are thick or if the infracturing is difficult, it may be prudent to perform medial and/or superior osteotomies. Usually, we have 3 techniques during osteotomy in rhinoplasty: low to low, low to high, and high to low to high. In the low-to-low osteotomy, it is very close to the lacrimal apparatus.

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A 20-year-old woman who demanding rhinoplasty in 2013 presented with an overprojected nose. Medial and lateral osteotomies were performed on her. Bony humps (1.5 mm) were rasped. The tip was deprojected by cutting and overlapping the lateral crura.

During osteotomy, left bony vault collapse occurred, which may be attributed to the wide periosteal elevation or complete osteotomy. This collapse was treated with spreader graft placement and suture fixation between the upper lateral cartilage and the septum.

The patient complained of the epiphoria after the surgery performed the same day. She then developed a red edema near the medial canthus 6 days postoperatively. An incision and drainage of the mass was performed in the office. The patient was advised to use antibiotic ophthalmic drops and massage the area to help subside the swelling. After 2 weeks, there was not any difference in her status.

One month after the surgery, a computed tomographic scan of her orbit showed a fracture of the lacrimal canal and dilation of the lacrimal sac.

The distortion and abnormal medialization of the left nasal bone can be seen in Figure 3, and dilation of the lacrimal sac can be seen in Figure 4.





Forty days after initial surgery, uneventful NLD dilation and probing was performed on her by an ophthalmologist colleague (A.K.) under local anesthesia. The probe passed thoroughly, and the patient swallowed irrigating fluid.

After this canalization, the patient became symptom-free for 2 days. On the third day, the tearing began again. We waited for 4 months in which the patient had 2 episodes of dacryocystitis, which were treated medically.

Five months after the rhinoplasty procedure, we performed a standard endoscopic dacryocystorhinostomy (DCR), and the silicon tube was left in place for 6 months. The patient had one episode of dacryocystitis 2 weeks after DCR, which was treated medically. After this final episode of infection, the patient has been symptom-free since then during the 4-year follow-up.

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This case involved a 26-year-old woman with a large hump and a high radix who desired rhinoplasty.

The reduction was 2 mm for the radix, 3.5 mm for the bony hump, and 4 mm for the cartilaginous hump.

Tip plasty and left and right osteotomy were performed per usual.

The nasal bones were very tough during osteotomy, and as such, much echymosis and swelling occurred after surgery. One week later, she came with a small bump near the medical canthus that was treated by incision and drainage in the office. This situation recurred 2 times.

Thus, at 8 months, we did endoscopic DCR. The silicon tube was left in place for 6 months. The patient has been symptom-free for 3.5 years as seen in a follow-up (Fig. 5).



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The upper third of the lacrimal sac is supported within a fossa of the lacrimal bone and surrounded by the periorbita. The middle third is enveloped by the 2 limbs of the medial canthal tendon. In contrast, the distal third of the lacrimal sac has no surrounding structures to protect it from injuries and is relatively vulnerable to external trauma.3

Lacrimal sac injury has been demonstrated but only in cases where subperiosteal tunneling and straight line or saw osteotomy technique was used. In one study, a temporary lacrimal obstruction was common in greater than two thirds of participants, which are usually due to postoperative edema.4

This shows that rhinoplasty, although not resulting in permanent obstruction of nasolacrimal system in most cases, can affect the nasolacrimal system through increasing tear passage time.5

Osguthorpe and Calcaterra6 reported 3 patients with surgical injury to the lacrimal system after rhinoplasty, which necessitated DCR for correction. They showed that the most vulnerable area to inadvertent surgical injury was the nasolacrimal sac, located just beneath the medial canthal ligament.

In our cases, we never use subperiosteal tunneling, so why do we have lacrimal injury?

In case 1, a nonsafe distance of the osteotome blade and NLD and lacrimal sac was the most probable reason for complication. After canalization of NLD, the duct was patent anatomically but not functionally. It postulated that because of trauma, the sac or the NLD could not function properly.

Yigit et al7 have mentioned that the average distance from the lacrimal drainage system to the lateral osteotomy site was found to be between 7 and 8.8 mm. Thomas and Griner4 showed that the average distance from the osteotomy line to the lacrimal crest was 7 mm.

In case 2, we were sure that the low-to-low osteotomy for our patient was at least 5 mm from the medial canthus. In this situation, the direct injury from the osteotome blade to the lacrimal sac is not the cause of this complication. Thus, we reviewed the anatomy more carefully.

The maxillary bone forms the anterior, lateral, and posterior walls of the canal. The medial wall of the NLD is formed superiorly by the descending process of the lacrimal bone, which articulates with the ascending processing of the inferior turbinate bone below. In some cases, the medial wall of the nasolacrimal canal is almost entirely formed by the maxilla, with a corresponding decrease in contribution from the lacrimal and inferior turbinate bones. This results in a narrowing of the nasolacrimal canal and corresponding NLD.8 Also, it makes the bone, which is the site of osteotomy, becomes harder to break. Clinically, the lateral descent of the nasolacrimal canal can be estimated by drawing a line between the tear sac and the ala nasae.9,10

Persons who have narrow interorbital distances and wide noses have the greatest lateral descent, whereas those with wide interorbital distances and narrow noses show a more vertical descent.2

Thus, in case 2, this anatomic variation a well as an unusually strong nasal and maxillary bone with dull osteotome most likely resulted in a comminuted fracture to the junction of the lacrimal sac and canal (narrowest part) and disturbance to the canal. As a result, we had lacrimal obstruction.

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The osteotomy lines and the NLD were closest to the medial canthal region. Placement of lateral osteotomies medial to the medial canthus–alar groove line would decrease the risk of NLD injury.10 Also, sharpening the osteotome just before osteotomy could decrease the risk of comminuted fracture of the maxilla and nasolacrimal canal.

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We appreciate Dr Maryam Ansari Chaharsoughi for consulting for control of infection and also Miss Shiva Jafaripour for editing the text.

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1. Shoshani Y, Samet N, Ardekian L, et al. Nasolacrimal duct injury after Le Fort I osteotomy. J Oral Maxillofac Surg. 1994;52:406–407.
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4. Thomas JR, Griner N. The relationship of lateral osteotomies in rhinoplasty to the lacrimal drainage system. Otolaryngol Head Neck Surg. 1986;94:362–367.
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6. Osguthorpe JD, Calcaterra TC. Nasolacrimal obstruction after maxillary sinus and rhinoplastic surgery. Arch Otolaryngol. 1979;105:264–266.
7. Yigit O, Cinar U, Coskun BU, et al. The evaluation of the effects of lateral osteotomies on the lacrimal drainage system after rhinoplasty using active transport dacryocystography. Rhinology. 2004;42:19–22.
8. Whitnal SE. The naso-lacrimal canal: the extent to which it is formed by the maxilla, and the influence of this upon its calibre. Ophthalmoscope. 1912;10:557.
9. Lemke BN. Lacrimal anatomy. Adv Ophthalmic Plast Reconstr Surg. 1984;3.
10. Tercan M, Yesiladali G, Ciloglu S, et al. Topographic evaluation of the medial canthus–alar groove line in terms of determining the boundaries of lateral osteotomies. Aesthetic Plast Surg. 2013;37:34–38.

rhinoplasty; lacrimal; complication; osteotomy; nasolacrimal duct

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