Reposition of malreduced nasoethmoid skeleton

If primary repair of the fracture is inadequate, the tissues will heal in a non-anatomic position, resulting in malposition of important structures eg, the medial canthal ligament. To recreate a normal tissue envelope, the soft tissues require elevation from the underlying skeleton prior to correction. When the skeletal correction is completed the soft tissues are then re-draped and the medial canthal ligaments reattached to their anatomic position.

This correction may be performed on unilateral as well as bilateral cases. Herein we illustrate the most common deformity, a bilateral case.

Note 1: In selected cases it may be advisable to intubate the lacrimal duct(s) prior to the procedure to avoid injury.

Note 2: All hardware is removed prior to performing any osteotomies.

In rare cases where the nasal skeleton is not widened and the deformity is a result of avulsion of the medial canthal ligament at the time of the initial injury (Markowitz and Manson type III). Transnasal canthopexy and soft tissue manipulation may be sufficient.

If there is thickening of the skin overlying the canthal ligaments it may be necessary to excise subcutaneous scarring.

The goal of the surgery is to reposition the canthal ligament into its proper anatomical position.

Overcorrection is not recommended.

A combination of the coronal and a lower eyelid approach ( transcutaneous or transconjunctival) is performed. In rare cases, existing scars can be used.

Wide undermining of the soft tissue is performed including release of the medial canthal ligament. The coronal and lower eyelid dissections are connected in a subperiosteal plane.

The following pages provide general information regarding orbital anatomy and dissection

• Preoperative considerations
• Anatomy of the bony orbit
• Correlation of surface and cross sectional anatomy
• Introduction to periorbital dissection
• Orbital floor dissection
• Medial orbital wall dissection
• Lateral orbital wall dissection
• Orbital roof dissection
• Adjunctive access procedures (orbitotomies)
• Retrobulbar hemmorage

The displaced fragments are osteotomized through the consolidated fracture lines.

The majority of the osteotomies are made from the coronal approach.

In most cases only the osteotomy at the level of the infraorbital rim is made through a lower eyelid approach.

If possible the osteotomies should not extend into the pyriform aperture to maintain a patent nasal airway.

The segments are then mobilized.

Narrowing of the nasal skeleton may require some trimming of the inner aspect of the fragments.

The fragments are stabilized with miniplates as described in the trauma section.

If possible, placement of a plate anterior to the medial canthal ligament should be avoided as it may be noticeable through the thin skin.

After the fixation is completed a bilateral transnasal medial canthopexy is performed as described in the trauma section.

Head of bed elevation may significantly reduce edema and pain.

The use of some of the following perioperative medication is controversial.

There is little evidence to make strong recommendations for postoperative care.

• Analgesia as necessary
• Antibiotics (many surgeons use perioperative antibiotics. There is no clear advantage of any one antibiotic, and the recommended duration of treatment is debatable.) The spectrum should be according to the existing bacterial flora, especially in the combined intra and extra cranial procedures.
• Corticosteroids may help with postoperative edema.

Nasal packings are usually removed two to three days after surgery.

The patient is seen 4 weeks, and if necessary, for the long-term follow-up six months and one year postoperatively.