Medial Gene R.

Canthoplasty With Microplate

Howard, MD; Jeffrey A. Nerad, MD; Robert C. Kersten,

\s=b\ Six patients with malpositioned or surgically excised medial canthal tendons underwent repair with titanium microplate, and two patients underwent repair with titanium miniplate fixation. The T-shaped rigid fixation plates were cho-

for medial canthal reconstruction to allow for stabilization of the plate along the anterior lacrimal crest and extension of the plate over the posterior lacrimal crest. The medial canthal tissue was reattached to the titanium plate with 3.0 polypropylene (Prolene) suture. This technique appears to be safer, faster, and, in many cases, more effective than traditional techniques for reconstruction of the medial canthus after tendon avulsion or loss from excision of cutaneous carcisen

noma.

(Arch Ophthalmol. 1992;110:1793-1797) TX/Tediai canthoplasty may be required

" * to avoid telecanthus following trauma to the medial canthal tendon or

the bones that secure the tendon in proper position. This disruption may occur as the result of surgical or acci¬ dental trauma. Cutaneous carcinomas of the medial canthus often require re¬ section of the medial canthal tendon and underlying lacrimal system. Although the periosteum may be involved in some cases, the underlying bone is usually intact. Repair of the lacrimal system is often required in association with Accepted for publication July 9, 1992. From the Department of Ophthalmology, Medical University of South Carolina, Charleston (Dr Howard); the Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City (Dr Nerad); and the Department of Ophthalmology, University of Cincinnati (Ohio) Medical Center (Dr Kersten). The authors have no proprietary interest in any product mentioned in this article. Reprint requests to the Department of Ophthalmology, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425 (Dr Howard).

Fixation

MD

reattachment of the tendon to the intact bone. Frequently, in cases of se¬ vere accidental facial trauma, a combi¬ nation of bone and soft-tissue damage displaces the tendon laterally. In some cases, repair of the facial skeleton alone will prevent telecanthus. Often reat¬ tachment of the tendon will be required to give a correct anatomic result. A variety of surgical techniques have been described to reattach the tendon to the bones of the medial canthal ten¬ don. All techniques require proper re¬ positioning of the tendon deep to the medial orbital rim in the area of the posterior lacrimal crest. Unfortunately, the success of the canthoplasty is often limited by the lack of adequate bone to retain the tendon in proper position. The advent of titanium miniplate and microplate systems al¬ lows for simple and accurate reattach¬ ment of the medial canthal tendon. This new technique of medial canthoplasty with microplate fixation offers an ex¬ cellent alternative to traditional tech¬ niques. We describe successful medial canthoplasty using this technique in

eight patients.

SURGICAL TECHNIQUE

Microplating and miniplating systems are now available for repair of fractures of the face, cranium, and mandible. The use of these plates in the repair of orbital fractures has been described.1 These bone plates are far superior to traditional wiring techniques be¬ cause the fractured bones are held in position immediately after the plates are screwed into position (so-called rigid fixation). The use of very small plates (microplates) and screws facilitates their placement around the orbital rims. Angulation of these plates is

easy due to the malleable nature of the tita¬ nium. The immediate support, easy place¬ ment, and malleable nature of microplates make them ideal for reattachment of the medial canthal tendon to the bones of the

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medial canthus. A microplate is fixed to the stable bone on the anterior aspect of the or¬ bital rim such that the free end of the plate is angulated posteriorly over unstable or ab¬ sent bone in the area of the posterior lacrimal crest. Suturing the tendon to the plate places the tendon in the correct anatomic position posterior to the rim. Our experience has been with the Luhr maxillofacial fixation system (Howmedica, Rutherford, NJ). This system provides vari¬ able straight and angled patterns of titanium microplates with multiple screw holes for fixation. We use the six-hole, T-shaped plate that is 0.5 mm thick. This pattern allows for maxi¬ mal stabilization of the plate and flexibility in positioning the medial canthal tendon or me¬ dial eyelid tissue. The T-shaped plate is turned to a horizontal position with the top of the placed anteriorly toward the nasal bone and the base of the directed toward the ethmoid plate (Fig 1). The top of the is placed over the anterior lacrimal crest so that stable fixation will occur in the thick, underlying maxillary bone. Fixation anterior to this position may allow the plate to be felt under the thin nasal skin. Fixation posterior to this position is not possible in the delicate bone of the lacrimal fossa. Angulation or bending of the plate is per¬ formed by grasping the central hole of the three holes at the top of the using the pinin-plate bending forceps. Plate-cutting for¬ ceps are used to remove any section of the plate lying posterior to the posterior lacrimal crest when the top of the is placed on the an¬ terior lacrimal crest. The modified plate is sta¬ bilized with forceps in this position while screw holes are drilled. A 5-mm drill bit (0.60 mm in diameter) is chosen to provide ac¬ cess for a 4-mm-long screw (0.8 mm in diam¬ eter) and placed on a pneumatic drill (Surgairtome, Hall, Carpintaria, Calif). Three drill holes are placed along the anterior lacrimal crest corresponding to the three holes at the top of the T-shaped plate. Three 4-mm selftapping screws are then grasped with a cru¬ ciform screwdriver with a holding sleeve and placed in the predrilled sites. No screws are placed posterior to the anterior lacrimal crest.

Fig 2.—Photograph of a 75-year-old woman following Mohs' excision of a basal cell carci¬ noma overlying the right medial canthus with Fig 1.—Position of the T-shaped microplate along the anterior lacrimal crest. Note the position of the open hole over the posterior lacrimal crest. A single-armed 3.0 polypropylene (Prolene) (Ethicon, Somerville, NJ) on an FS-1 cutting needle (Ethicon) is passed through the stump of the medial canthal tendon in a horizontal mattress fashion and sutured to the posterior hole overlying the posterior lacrimal crest. Separate sutures may be used to reattach the superior and inferior tarsus to the posterior hole of the plate if the medial portions of the eyelid are absent (Figs 1 and 2). In tumor resection cases in which soft tissue is absent, the titanium plate should be covered with a myocutaneous flap. Our cases resulting from Mohs' micrographie surgery have re¬ quired a combination of a myocutaneous cheek rotational flap and a midline forehead flap. Traumatic medial canthal avulsion without surgical exposure via a skin laceration can be approached through a Lynch incision or a bicoronial forehead flap. This procedure can be performed in patients with acute or delayed accidental tendon disruption.

loss of canthal attachments to the medial tar¬ sal border.

suture

Fig 3.—Reattachment of the medial tarsal borders of the right upper and lower eyelids to the posterior hole using 3.0 polypropylene (Prolene) suture.

REPORT OF CASES

75-year-old woman under¬ micrographie surgery for basal cell carcinoma, resulting in a large right me¬ CASE 1.—A

went Mohs'

dial canthal defect with loss of the medial canthal tissue, canaliculi, and lacrimal sac (Fig 2). Reconstruction of the medial canthus was performed with a T-shaped (Luhr) miniplate and 4-mm screws (Fig 3). A doublearmed 3.0 Prolene suture was passed through the upper and lower tarsal borders before being passed into the miniplate hole overlying the posterior lacrimal crest. The remaining reconstruction required a lateral canthotomy and cantholysis followed by a midline forehead flap and Mustarde cheek rotation flap (Fig 4). The canalicular system was not repaired. After surgery, the medial canthal tendon was in good position. The midline nasal to medial canthal distance was 18 mm on the unaffected left side and 20 mm on the affected right side.

Fig 4.—Postoperative photograph showing reconstruction of the right medial canthus with mi¬ croplate fixation.

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Fig 5.—Photograph of a 69-year-old man with loss of the left medial canthal tissue following Mohs' excision of a basal cell carcinoma.

Case 2.—A 69-year-old man underwent Mohs' micrographie surgery for a basal cell carcinoma. Excision of the tumor required extensive tissue loss, including skin, muscle, and periosteum across the glabella and left medial canthus. Additional tissue loss in¬ cluded the left canaliculi, medial canthal ten¬ don, nasolacrimal sac, and periosteum over¬ lying the lacrimal fossa (Fig 5). A T-shaped microplate (Luhr) was screwed into position across the left anterior lacrimal crest with 4-mm screws. The eyelid margin was reat¬ tached to the miniplate with 3.0 Prolene su¬ ture in a horizontal mattress fashion (Fig 6). Periosteal coverage was completed with a midline forehead flap and a myocutaneous advancement flap from the left cheek. One month after surgery, the palpebrai fissure heights measured 8 mm on the right side and 6 mm on the left side. The levator function was 13 mm on the right side and 10 mm on the left side (Fig 7). The midline nasal to medial canthal distance was 16 mm on the right side and 15 mm on the left side after surgical correction.

RESULTS

We have used this technique in eight cases from 1989 to 1992 (Table). Four patients presented with medial canthal tendon loss secondary to Mohs' micrographic excision of basal cell carcino¬ mas. Three patients presented with an acute medial canthal tendon avulsion with associated facial fractures. One patient presented with medial canthal dystopia and cicatricial lower-eyelid ectropion years after experiencing midfacial trauma. Medial canthal reconstruc¬ tion was completed with titanium-plate fixation to the anterior lacrimal crest in all patients, who also had injury or ex¬ cision of the nasolacrimal sac. Adequate lid function was noted after medial canthai reconstruction in all patients, pre¬ venting corneal exposure. In the initial two cases, the larger titanium miniplates were used. When the smaller mi¬ croplates became available in 1990, they were used in the subsequent six cases. None of the eight patients required reoperations for medial canthal dystopia or the removal of a titanium plate. COMMENT

Fig 6.—Photograph demonstrates the position of the microplate and placement of polypropy¬ (Prolene) horizontal mattress sutures.

lene

Fig 7.—Photograph 1 month after surgery showing adequate levator function on the left side. Note that the forehead scar at left developed from previous excision of cutaneous carcinoma.

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The most common presentation of medial canthal dystopia results from blunt trauma to the midface. Unilateral facial trauma occurs frequently. Bilat¬ eral medial canthal tendon injury may follow craniomaxillofacial injury, in¬ cluding nasoethmoid fractures, Le Fort II fractures, and Le Fort III fractures. Variation in the surgical approach and the complexity of repair in traumatic me¬ dial canthal dystopia depends on the time elapsed between injury and surgical cor¬ rection. Adequate exposure to injured tissue through adjacent lacerations elim¬ inates the need for further surgical inci¬ sions in many acutely traumatized pa¬ tients. Furthermore, lacerations to the canaliculi and nasolacrimal duct can be repaired before permanent functional loss with posttraumatic scarring. A delay in surgical repair of weeks to months generally results in a loss of clearly de¬ marcated canthal tendon. Late fibrosis of the damaged tear-drainage tract can re¬ quire a dacryocystorhinostomy with Jones tube placement. In many cases, medial canthal tendon loss is an unavoidable consequence of resection for invasive cutaneous carci¬ noma.2 Excision of tumor in this area with frozen-section or Mohs' micrographic techniques can result in the partial or complete loss of the medial canthal tendon and adjacent adnexal structures. Surgical repair of these de¬ fects requires reattachment or com¬ plete reconstruction of a medial canthal tendon to prevent canthal dystopia. Multiple procedures have been sug-

Cases of Medial Canthal Reconstruction With Titanium-Plate Fixation Canthal mm*

Distance, Patient

No./Age, y/Sex

1/62/F 2/27/M 3/46/F 4/75/F 5/72/M 6/69/M 7/8/F 8/39/M

•Postoperative

Cause Basal cell carcinoma Trauma Trauma Basal cell carcinoma Basal cell carcinoma Basal cell carcinoma Trauma Trauma

taneous defects in the medial

of myocu¬

eyelid, as

well as repair of the nasolacrimal drain¬

system.311

Callahan and Callahan12 described unsuccessful attempts at medial canthal tendon reattachment, using gut or silk sutures, in cases of avulsion. Later efforts by these authors involved drilling two vertical holes along the posterior lac¬ rimal crest and inserting a 25-gauge steel wire or 2.0 polyfilament surgical suture (Supramid). These later techniques were abandoned for reasons of surgical diffi¬ culty, trauma to nasal mucosal vessels, and recurrent infection.12 Mustarde13 developed the concept of transnasal wiring in 1966. Repair of a unilateral tendon avulsion required sur¬ gical access to the normal contralateral medial canthus. Transnasal wiring has been a well-accepted method for man¬ agement of naso-orbital fractures with loss of the medial canthal insertion and for treatment of congenital telecanthus. Variations of the transnasal wiring technique have been extensively reported.1420 Ipsilateral wiring tech¬ niques popularized by A. Callahan were modified in recent years.18,19,21 Wilkins developed a procedure for ipsilateral medial canthal repair using a stainless steel bar in 1979.12 During the same pe¬ riod, Callahan developed the concept of a steel piton and later recommended placement of a stainless steel screw in the naso-orbital region to anchor an avulsed medial canthal tendon.12,22 Despite the variety of techniques for bilateral and ipsilateral repair of medial canthal dystopia, several limitations ex¬ ist that have encouraged the search for alternative surgical approaches. Limi¬ tations of transnasal wiring include the risk of injury to ocular and periocular structures on the contralateral side in unilateral cases, pressure necrosis and skin ulcération during early postopera¬ tive stabilization from splints underly¬ ing transcutaneous wires, intranasal hemorrhage with the need for postop-

early

Canthus Left

Right Right Right Right Left Left

Right

Plate Size Mini Mini Micro Micro Micro Micro Micro Micro

Follow-up, 30 24 19 12

mo

Right

Left

16.5 18.0 18.5 20.0 16.0 16.0

17.0 18.0 17.5 18.0

15.0 21.0

15.0 18.0

17.0 15.0

distance between the medial canthus and nasal midline.

gested for the management age

Injury Excision Avulsion Avulsion Excision Excision Excision Avulsion Avulsion

erative nasal packing, and bilateral perinasal scarring.17 Postoperative readjustments in the vertical height of the canthal tendon require regaining access to the con¬ tralateral side, with renewed risk of these complications occurring.17 Stain¬ less steel pitons or screws have been recommended for isolated canthal ten¬ don avulsions, but are not useful in cases of complex naso-orbital frac¬ tures12 and do not allow proper poste¬ rior repositioning of the tendon. Medial canthoplasty using a titanium microplate avoids these complications and provides a mechanism for ipsilateral medial canthal repair with or without complex naso-orbital fractures. The use of miniplates for craniomaxillofacial reconstruction has been reported for more than a decade with few complications.23,24 More recently, titanium microplates and titanium mesh implants have been used for rigid fixa¬ tion of internal orbital fractures.2527

Surgical or postoperative complications using this technique are rare. Beals and Munro1 found no postoperative infec¬ tion in 74 cases of miniplate fixation for

craniomaxillofacial surgery. Glassman cases of infection in 38 orbital reconstructions with titanium mesh implants during a 3-year period. It remains unclear, however, whether these infections were associated with bone grafts. Concerns regarding softtissue adherence and tethering of eye movement also remain unfounded.26 Medial canthoplasty using titanium microplate fixation resolves several problems associated with other forms of medial canthal repair. Microplate systems are widely used and available in most hospital settings. This elimi¬ nates the need for ordering specific items, such as a piton or screw. Fur¬ thermore, microplates are used as an integral part of nasoethmoid recon¬ struction in the event of comminuted fractures. Stabilization of the bone at the medial canthal insertion site is et al25 reported two

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crucial to recreate the anatomically cor¬ rect position of the tendon. Placement of

the plate on the stable bone of the frontal process of the maxilla allows projection of the plate posteriorly into the correct anatomic position. This is not possible with piton fixation and is often difficult with transnasal wiring. Operating time is reduced compared with transnasal wir¬ ing since exposure on only one side is nec¬ essary. Intraoperative repositioning of the microplate is facilitated by bending the portion overlying the posterior lacri¬ mal crest. If necessary, the plate may be removed and new holes drilled. An addi¬ tional advantage over transnasal wiring is the prevention of injury to contralat¬ eral structures in cases of unilateral tu¬ mor excision or trauma. Last, the radiographic properties of titanium allow for

sharper computed tomographic scans and the use of magnetic resonance imaging. Although we recommend the T-shaped microplate for fixation along

the anterior lacrimal crest, we sus¬ pect that other shapes may be equally useful. Both an -shaped and a Y-shaped microplate may provide suf¬ ficient stabilization for the medial canthus. The advantage of the T-shape is its smaller size compared with the -shape and its three holes along the top of the for an additional screw compared with the Y shape. Although we encountered no problems with the two initial cases in which miniplates were used, we do not recommend miniplate fixation because the in¬ creased size provides no clear advan¬ tage for stabilization and there is an increased risk of cosmetic deformity to the overlying skin. Medial canthoplasty using titanium microplate fixation of the medial canthai tendon or adjacent tissue is a safe and useful technique to repair abnor¬ malities of the medial canthal tendon. Advantages over traditional wire or screw techniques may make this proce¬ dure the technique of choice.

This study was supported in part by an unrestricted departmental grant from Research to Prevent Blind¬ ness

Ine,

New

York,

NY.

References 1. Beals SP, Munro MB. The use of miniplates in craniomaxillofacial surgery. Plast Reconstr

Surg. 1987;79:33-38. 2. Howard GR, Nerad JA, Carter KD, Whitaker

DC. Clinical characteristics associated with orbital invasion of basal cell and squamous cell tumors of the eyelid. Am J Ophthalmol. 1992;113:123-133. 3. Dortzbach RK, Hawes MJ. Midline forehead flap in reconstructive procedures of the eyelids and exenterated socket. Ophthalmic Surg. 1981;12:257\x=req-\ 268. 4. Rodriguez RL, Zide BM. Reconstruction of the medial canthus. Clin Plast Surg. 1988;15:255\x=req-\ 262. 5. Shotton FT. Optimal closure of medial canthal surgical defects with rhomboid flaps: 'rules of thumb' for flap and rhomboid defect orientations.

Ophthalmic Surg. 1983;14:46-52. 6. Harvey J. Modified 'double-z-plasty' in the closure of medial canthal defects. Ophthalmic Surg. 1987;18:120-122. 7. Putterman AM. Reconstruction of the eyelids following resection of carcinoma. Clin Plast Surg.

1985;12:393-410. 8. McCord CD, Wesley R. Reconstruction of the upper eyelid and medial canthus. In: McCord CD, Tannenbaum M, eds. Oculoplastic Surgery. New York, NY: Raven Press; 1987:73-91.

9. Iliff CE. A simplified dacryocystorhinostomy. Arch Ophthalmol. 1971;85:586-591. 10. Dortzbach RK. Dacryocystorhinostomy.

Ophthalmology. 1987;85:1267-1270. 11. Jones LT. Conjunctivodacryocystorhinostomy. Am J Ophthalmol. 1965;59:773-783.

12. Callahan A, Callahan MA. Fixation of the medial canthal structures: evolution of the best method. Ann Plast Surg. 1983;11:242-245. 13. Mustarde JC. Repair and Reconstruction in the Orbital Region: A Practical Guide. New York, NY: Churchill Livingstone Inc; 1966:292-298. 14. Converse JM, Smith B. Naso-orbital fractures and traumatic deformities of the medial canthus. Plast Reconstr Surg. 1966;38:147-162. 15. Smith B, Beyer CK. Medial canthoplasty. Arch Ophthalmol. 1969;82:344-348. 16. Stranc MF. Primary treatment of nasoethmoid injuries with increased intercanthal distance. Br J Plast Surg. 1970;23:8-25. 17. Freihofer HP. Experience with transnasal canthopexy. J Maxillofac Surg. 1980;8:119-124. 18. Duvall AJ, Foster CA, Lyons DP. Medial canthoplasty: early and delayed repair. Laryngoscope. 1981;2:173-183.

Currently

19. Beyer CK, Fabian RL, Smith B. Naso-orbital fractures, complications, and treatment. Ophthalmology. 1982;89:456-463. 20. Petrelli RL. Naso-orbital fractures: management and complications. Adv Ophthalmic Plast Reconstr Surg. 1987;7:27-32. 21. Mindlin AM, Nesi FA, Smith B. New suturing material for medial canthal plication and repair.

Ophthalmic Surg. 1984;15:210-211.

22. Callahan MA. Canthal fixation with a stainless steel screw: a report of ten patients. Adv Ophthalmic Plast Reconstr Surg. 1988;7:33-40. 23. Harle F. Le Fort I ostectomy (using miniplates) for correction of the long face. Int J Oral

Surg. 1980;9:427-432. 24. Drommer R, Luhr HG. The stabilization of osteotomized maxillary segments with Luhr miniplates in secondary cleft surgery. J Maxillofac Surg. 1981;9:166-169. 25. Glassman RD, Manson PN, Vanderkolk MD, et al. Rigid fixation of internal orbital structures. Plast Reconstr Surg. 1990;86:1103-1109. 26. Lo AK, Jackson IT, Dickson R, Dickson CB. Severe orbital floor fractures: repair with titanium implant. Plast Surg. 1992;15:35-40. 27. Rubin PA, Shore JW, Yaremchuk MJ. Complex orbital fracture repair using rigid fixation of the internal orbital skeleton. Ophthalmology. 1992; 99:553-559.

in Other AMA Journals

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Medial canthoplasty with microplate fixation.

Six patients with malpositioned or surgically excised medial canthal tendons underwent repair with titanium microplate, and two patients underwent rep...
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