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Medial canthal tendon reconstruction
j. max.-fac. Surg. 12 (1984) J. max.-fac. Surg. 12 (1984) 131-132 © Georg Thieme Verlag Stuttgart . New York
Medial Canthal Tendon Reconstruction Anthony L. H. Moss
131
Summary A technique is described for reconstructing a resected medial canthal tendon using medially based orbicularis muscle flaps from both eyelids. A brief review of the literature is discussed.
Key-Words Medial Canthal Tendon Reconstruction - Tumour resection
Dept. of Plastic and Jaw Surgery (Head: Mr. R. W. Hiles, FRCS(E), FRCS), Frenchay Hospital, Bristol, England Accepted for publication 9 . 9 . 1983
Introduction The deformity resulting from disruption of the medial canthal tendon is usually unacceptable. In traumatic cases, the treatment of choice is primary repair. However, when the discontinuity of the medial canthal tendon is necessary for cancer resection, the emphasis is on adequate tumour excision, reconstruction of the nasolacrimal system and soft tissue cover. Little is advocated for reconstruction of the rare, totally resected medial canthal tendon, with the resulting telecanthus "a small price to pay" for a cancer procedure. A technique is described for reconstructing the totally resected medial canthal tendon following turnout resection using local muscle flaps, with an encouraging result.
Case Report A 40-year-old Caucasian woman presented with a recurrence, at the right medial canthus, of an inverted papilloma of the nasolacrimal duct (Fig. 1). Investigations, including CT scanning, showed clouding of the ethmoid sinuses without bone erosion. Through the upper part of a Fergusson-Weber incision, the mass was explored. It was found to be a 2.0 cm. x 2.5 cm. tumour involving the lacrimal sac and the upper part of the nasolacrimal duct. A formal lateral rhinostomy and antrostomy revealed no abnormality. The ethmoid sinuses were then explored and some thickened mucosa was excised. As the whole of the medial tendon had been resected with
Fig. 1 Showing the preoperative tumour recurrence in the right medial canthus.
the tumour, it was reconstructed using medially based orbicularis muscle flaps from the upper and lower eyelids sutured to the frontal process of the maxilla (Figs. 3 and 4). The nasolacrimal system was cannulated, via the canalicula, with silastic tubing which was left in the nose for four months. Histology confirmed a recurrence of an inverted papilloma of the nasolacrimal duct, with no evidence of malignancy. No other loci of disease were found on separate multiple biopsies. At six months, the patient had no evidence of recurrence, with an acceptable asymptomatic result (Fig. 2).
Discussion and Conclusion The anatomy of the medial canthus and its tendon has been well described (Robinson and Stranc, 1970; Converse et al., 1977; Zide and McCarthy, 1983). Division of the medial canthal tendon (or ligament) results in a forward and lateral drift of the nasal end of the palpebral fissure with loss of the angle between the upper and lower lids (Converse et al., 1977; Mustardd, 1980; Zide and McCarthy, 1983). In traumatic telecanthus, the treatment of choice is primary repair of the divided tendon or transosseous transnasal wiring of the attached bony fragment (Converse et al., 1977; Mustardd, 1980). Some surgeons maintain that in cases where the medial canthal tendon has been mobilized or divided at its medial attachment (e. g., dacocystorhinostomy) that it is not neces-
Fig. 2
The postoperative appearance at six months.
132
J. max.-fac. Surg. 12 (1984)
A. L. H. Moss: Medial Canthal Tendon Reconstruction
Ethmoid Sinus Cavity Upper Orbicularis Muscle Flap Canalpcul~
Hole in Nasal Process of Maxilla Silastic Tube Lower Orbicularis Muscle Flap Stump of Nasolacrtmal Duct
Fig. 3 Showing the intraoperative medial canthal tendon reconstruction using muscle flaps from the lids. The silastic tubing can be seen in situ.
Fig. 4
sary to reconstruct it and secondary deformities do not occur (Anderson, 1977). This, however, must be due to the intact superior vertical component of the medial canthal tendon described by Zide and McCarthy (1983). They maintain that this part is stronger than the posterior limb and thus more important for maintaining the medial canthai position. This also accounts for the recommended site for the reinsertion of the medial canthal tendon; that is, in a more posterior and superior position than the insertion of the horizontal part of the ligament (Converse et al., 1977; Mustardd, 1980). It is not common for all components of the medial canthal ligament to be resected but this may be necessary in infiltrating neoplasms (Mustardd, 1980). Soft tissue cover and lacrimal drainage procedures are well described but little is mentioned of reconstruction of the medial canthal tendon. Mustardd (1980) suggests attaching the tarsal plate to the periosteum of the medial orbital wall but Zide and McCarthy (1983) feel that this periosteum is too thin to expect the fixation to hold. Emmett (1980) describes diagrammatically a reconstruction of the medial canthal tendon by suturing the tendon remnant and "associated" muscle to the galea of a transposed forehead flap. Bachelor and Jobe (1980) have used Palmaris longus tendon to reconstruct congenitally absent lateral canthal ligaments with encouraging results. This technique could be used for reconstructing the medial tendon but would necessitate scarring a second area. The technique which has been described for reconstructing a totally resected medial canthal tendon using local muscle flaps avoids the disadvantages discussed above, with an acceptable result.
Acknowledgement
Diagrammatic representation of Figure 3,
I wish to thank Mr. P. L. G. Townsend for allowing me to report his patient and to Mr. R. T. Routledge who was the main instigator for the idea. I would also like to thank the Medical Photography Department of Frenchay Hospital, Bristol, for the illustrations. References Anderson, R. L.: Medial canthal tendon branches out. Arch. Ophthaltool. 95 (1977) 2051 Bachelor, E. P., R. P. Jobe: The absent lateral cauthal tendon: Reconstruction using a Y graft of Palmaris longus tendon. Ann. Plast. Surg. 5 (1980) 362 Converse, J. M., B. Smith, D. Wood-Smith: Malunited fractures of the orbit. In: Converse, J. M.: Reconstructive Plastic Surgery. Saunders, Philadelphia, London, Toronto 1977, p. 989 Emmet& A. J. J.: Malignant skin tumours. In: Barron, J. N., M. N. Saad: Operative Plastic and Reconstructive Surgery. Churchill Livingstone, Edinburgh, London, Melbourne, New York 1980, p. 592 Mustardd, J. C.: Surgery of the medial canthus. In: Mustard G J. C.: Repair and Reconstruction in the Orbital Region: a Practical Guide. Churchill Livingstone, Edinburgh, London, New York 1980, p. 164 Robinson, T. J., M. F. Stranc: The anatomy of the medial canthal ligament. Brit. J. Plast. Surg. 23 (1970) 1 Zide, B. M., J. G. McCarthy: The Medial Canthns revisited - an anatomical basis for canthopexy. Ann. Plast. Surg. 11 (1983) 1
A. L. H. Moss, FRACS Department of Plastic and Jaw Surgery Frenchay Hospital Bristol, BS16 1LE Avon England
Medial Canthal Tendon Reconstruction Anthony L. H. Moss
131
Summary A technique is described for reconstructing a resected medial canthal tendon using medially based orbicularis muscle flaps from both eyelids. A brief review of the literature is discussed.
Key-Words Medial Canthal Tendon Reconstruction - Tumour resection
Dept. of Plastic and Jaw Surgery (Head: Mr. R. W. Hiles, FRCS(E), FRCS), Frenchay Hospital, Bristol, England Accepted for publication 9 . 9 . 1983
Introduction The deformity resulting from disruption of the medial canthal tendon is usually unacceptable. In traumatic cases, the treatment of choice is primary repair. However, when the discontinuity of the medial canthal tendon is necessary for cancer resection, the emphasis is on adequate tumour excision, reconstruction of the nasolacrimal system and soft tissue cover. Little is advocated for reconstruction of the rare, totally resected medial canthal tendon, with the resulting telecanthus "a small price to pay" for a cancer procedure. A technique is described for reconstructing the totally resected medial canthal tendon following turnout resection using local muscle flaps, with an encouraging result.
Case Report A 40-year-old Caucasian woman presented with a recurrence, at the right medial canthus, of an inverted papilloma of the nasolacrimal duct (Fig. 1). Investigations, including CT scanning, showed clouding of the ethmoid sinuses without bone erosion. Through the upper part of a Fergusson-Weber incision, the mass was explored. It was found to be a 2.0 cm. x 2.5 cm. tumour involving the lacrimal sac and the upper part of the nasolacrimal duct. A formal lateral rhinostomy and antrostomy revealed no abnormality. The ethmoid sinuses were then explored and some thickened mucosa was excised. As the whole of the medial tendon had been resected with
Fig. 1 Showing the preoperative tumour recurrence in the right medial canthus.
the tumour, it was reconstructed using medially based orbicularis muscle flaps from the upper and lower eyelids sutured to the frontal process of the maxilla (Figs. 3 and 4). The nasolacrimal system was cannulated, via the canalicula, with silastic tubing which was left in the nose for four months. Histology confirmed a recurrence of an inverted papilloma of the nasolacrimal duct, with no evidence of malignancy. No other loci of disease were found on separate multiple biopsies. At six months, the patient had no evidence of recurrence, with an acceptable asymptomatic result (Fig. 2).
Discussion and Conclusion The anatomy of the medial canthus and its tendon has been well described (Robinson and Stranc, 1970; Converse et al., 1977; Zide and McCarthy, 1983). Division of the medial canthal tendon (or ligament) results in a forward and lateral drift of the nasal end of the palpebral fissure with loss of the angle between the upper and lower lids (Converse et al., 1977; Mustardd, 1980; Zide and McCarthy, 1983). In traumatic telecanthus, the treatment of choice is primary repair of the divided tendon or transosseous transnasal wiring of the attached bony fragment (Converse et al., 1977; Mustardd, 1980). Some surgeons maintain that in cases where the medial canthal tendon has been mobilized or divided at its medial attachment (e. g., dacocystorhinostomy) that it is not neces-
Fig. 2
The postoperative appearance at six months.
132
J. max.-fac. Surg. 12 (1984)
A. L. H. Moss: Medial Canthal Tendon Reconstruction
Ethmoid Sinus Cavity Upper Orbicularis Muscle Flap Canalpcul~
Hole in Nasal Process of Maxilla Silastic Tube Lower Orbicularis Muscle Flap Stump of Nasolacrtmal Duct
Fig. 3 Showing the intraoperative medial canthal tendon reconstruction using muscle flaps from the lids. The silastic tubing can be seen in situ.
Fig. 4
sary to reconstruct it and secondary deformities do not occur (Anderson, 1977). This, however, must be due to the intact superior vertical component of the medial canthal tendon described by Zide and McCarthy (1983). They maintain that this part is stronger than the posterior limb and thus more important for maintaining the medial canthai position. This also accounts for the recommended site for the reinsertion of the medial canthal tendon; that is, in a more posterior and superior position than the insertion of the horizontal part of the ligament (Converse et al., 1977; Mustardd, 1980). It is not common for all components of the medial canthal ligament to be resected but this may be necessary in infiltrating neoplasms (Mustardd, 1980). Soft tissue cover and lacrimal drainage procedures are well described but little is mentioned of reconstruction of the medial canthal tendon. Mustardd (1980) suggests attaching the tarsal plate to the periosteum of the medial orbital wall but Zide and McCarthy (1983) feel that this periosteum is too thin to expect the fixation to hold. Emmett (1980) describes diagrammatically a reconstruction of the medial canthal tendon by suturing the tendon remnant and "associated" muscle to the galea of a transposed forehead flap. Bachelor and Jobe (1980) have used Palmaris longus tendon to reconstruct congenitally absent lateral canthal ligaments with encouraging results. This technique could be used for reconstructing the medial tendon but would necessitate scarring a second area. The technique which has been described for reconstructing a totally resected medial canthal tendon using local muscle flaps avoids the disadvantages discussed above, with an acceptable result.
Acknowledgement
Diagrammatic representation of Figure 3,
I wish to thank Mr. P. L. G. Townsend for allowing me to report his patient and to Mr. R. T. Routledge who was the main instigator for the idea. I would also like to thank the Medical Photography Department of Frenchay Hospital, Bristol, for the illustrations. References Anderson, R. L.: Medial canthal tendon branches out. Arch. Ophthaltool. 95 (1977) 2051 Bachelor, E. P., R. P. Jobe: The absent lateral cauthal tendon: Reconstruction using a Y graft of Palmaris longus tendon. Ann. Plast. Surg. 5 (1980) 362 Converse, J. M., B. Smith, D. Wood-Smith: Malunited fractures of the orbit. In: Converse, J. M.: Reconstructive Plastic Surgery. Saunders, Philadelphia, London, Toronto 1977, p. 989 Emmet& A. J. J.: Malignant skin tumours. In: Barron, J. N., M. N. Saad: Operative Plastic and Reconstructive Surgery. Churchill Livingstone, Edinburgh, London, Melbourne, New York 1980, p. 592 Mustardd, J. C.: Surgery of the medial canthus. In: Mustard G J. C.: Repair and Reconstruction in the Orbital Region: a Practical Guide. Churchill Livingstone, Edinburgh, London, New York 1980, p. 164 Robinson, T. J., M. F. Stranc: The anatomy of the medial canthal ligament. Brit. J. Plast. Surg. 23 (1970) 1 Zide, B. M., J. G. McCarthy: The Medial Canthns revisited - an anatomical basis for canthopexy. Ann. Plast. Surg. 11 (1983) 1
A. L. H. Moss, FRACS Department of Plastic and Jaw Surgery Frenchay Hospital Bristol, BS16 1LE Avon England