Journal Logo

VIEWPOINTS

The Transcaruncular-Transnasal Suture: A Simple Technique for Medial Canthopexy

Lauer, Günter M.D., Ph.D.; Pinzer, Thomas M.D.

Author Information
Plastic and Reconstructive Surgery: November 2008 - Volume 122 - Issue 5 - p 140e-141e
doi: 10.1097/PRS.0b013e318186cadf
  • Free

Sir:

Telecanthus or displacement of the medial canthus (e.g., after trauma or in congenital craniofacial deformities involving the naso-orbitoethmoidal complex) disturbs facial harmony. Different procedures have been described for its correction.1–3 However, medial canthopexy has the inherent risk of relapse because, from the periosteal side, the correct localization of the medial canthal tendon with sufficient grip is difficult to achieve.

To improve the simplicity and reliability of medial canthopexy, a transcaruncular-transnasal fixation technique was developed. By means of a bicoronal approach to the naso-orbitoethmoidal complex, the soft tissue is completely detached and extensively mobilized at the medial orbit and the upper and lower orbital rims, including the dystopic medial canthal tendon. After bony reconstruction or reshaping of the naso-orbitoethmoidal complex, the medial canthal tendon is reattached using 0 polydioxanone suture with a CT needle. The surface of the periosteum (i.e., tenon capsule) is rougher where the medial canthal tendon is fixed to the bone, but it may be difficult to localize in cases of secondary reconstruction. The needle is inserted from the posterior edge of this rough area and pushed laterally through the caruncula skin surface (Fig. 1). The suture is partially pulled through. Then, the needle is reinserted into the caruncula and pushed in the opposite direction, aiming again for the rough surface but in a slightly diverting way to ensure adequate soft-tissue grip (Fig. 1). The suture is pulled tight to check its effectiveness. The suture placing guarantees that the lacrimal duct and the canaliculi lacrimales are located anterior and the eye muscles lateral (Fig. 1) as it grasps the posterior ligament of the medial canthal tendon. Both suture ends are passed through the papyraceous part of the ethmoid bone to the opposite medial orbit. The second transcaruncular medial canthopexy is performed. The needle is fed back through the transnasal hole, and now both ends of the suture are pulled tight, narrowing the medial canthi and the surrounding periorbital soft tissue.

Fig. 1.
Fig. 1.:
Schematic drawing (cross-section) of the anatomy of the naso-orbitoethmoidal region, with the medial canthal tendon demonstrating the placement of the transcaruncular transnasal suture (1, caruncula; 2, posterior ligament of the medial canthal tendon; 3, lacrimal sac with canaliculi; 4, anterior ligament of the medial canthal tendon).

In malformations, the nasal and medial orbital bones are lifted off and the suture is placed behind this bone segment. It is put back and the ends of the sutures are threaded through bore holes at the supraorbital rim and knotted after tightening. The technique can also be used on one eye only, with the suture being anchored and tightened on the contralateral side of the frontal bone.

In trauma patients (n = 4), the intercanthal distance was narrowed from 41 mm on average to 38.5 mm following surgery; and in patients with congenital craniofacial deformities (frontoethmoidal meningoencephaloceles n = 9), the intercanthal distance was narrowed from 45.1 mm on average to 36.6 mm following surgery (Fig. 2). No postoperative complications were encountered.

Fig. 2.
Fig. 2.:
Patient with a frontoethmoidal meningoencephalocele after internal resection of the meningoencephalocele by means of a bicoronal approach and immediate reconstruction of the naso-orbitoethmoidal region using the transcaruncular-transnasal suture for bilateral medial canthopexy.

The transcaruncular-transnasal suture is a simple technique for reliably facilitating medial canthopexy. Especially in malformation surgery4 and in primary or secondary reconstruction5 after trauma, medial canthopexy by means of the transcaruncular suture provided a safe anchorage in the soft tissue and in the bone of the orbital rim. It does not interfere with delicate structures of the lacrimal duct system but instead allows for the ideal direction of pulling, ensuring anatomically correct reshaping of the medial canthus.

Günter Lauer, M.D., Ph.D.

Department of Oral and Maxillofacial Surgery

Thomas Pinzer, M.D.

Department of Neurosurgery

University Hospital Carl Gustav Carus Dresden

Technical University Dresden

Dresden, Germany

DISCLOSURES

Operations on patients with malformations were performed in Phnom Penh, Cambodia. Traveling costs for the surgeons (T.P. and G.L.) were funded by the charity organization Ärzte der Welt Deutschland e. V. There were no commercial associations or financial relationships that might pose or create a conflict of interest with information presented in this article.

REFERENCES

1. Zide, M. F., and McCarthy, J. G. The medial canthus revisited: An anatomical basis for canthopexy. Ann. Plast. Surg. 11: 1, 1983.
2. Kelly, C. P., Cohen, A. J., Yavuzer, R., Moreira-Gonzalez, A., and Jackson, I. T. Medial canthopexy: A proven technique. Ophthal. Plast. Reconstr. Surg. 20: 337, 2004.
3. Moe, K. S., and Kao, C. H. Precaruncular medial canthopexy. Arch. Facial Plast. Surg. 7: 244, 2005.
4. Lauer, G., Pinzer, T., and Gollogly, J. Plastisch-rekonstruktive Behandlung von Patienten mit frontoethmoidalen Meningoencephalozelen in der Dritten Welt. J. D.G.P.W. 30: 14, 2004.
5. Lauer, G., Pradel, W., Schneider, M., and Eckelt, U. Efficacy of computer assisted surgery in secondary orbital reconstruction. J. Craniomaxillofac. Surg. 34: 299, 2006.

Section Description

GUIDELINES

Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:

Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We strongly encourage authors to submit figures in color.

We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

©2008American Society of Plastic Surgeons