Lateral canthopexy is a popular procedure in both reconstructive and cosmetic surgery. Stable transosseous fixation of the ligament in the appropriate position is considered the best option. 1, 2 The surgical access is centered over the lateral orbital rim, as it allows both the isolation of the lateral canthal ligament and the preparation of the site of bone fixation. Several techniques based upon the fixation of the ligament with permanent sutures have been reported. For this purpose, a permanent transosseous stabilizing device used in hand surgery has also been proposed. 3 The procedure requires technical skill as the proper angle for drilling has to be identified after exposure of the periosteum of the lateral orbital rim and of the anterior portion of the lateral orbital wall. At this stage, the delivery of the threads through the holes may be a critical step, especially if they are placed more posteriorly on the lateral orbital wall. This transosseous maneuver requires a good amount of endo-orbital surgical dissection. The wider the dissection, the higher the risk of damaging the delicate endo-orbital structures and the greater the impairment of the lymphatic drainage of the lateral orbital cavity content and the eyelids. To both minimize these risks and make the transosseous suture easier and quicker, we propose a simple and effective surgical tip: after minimal endo-orbital dissection, the eye-globe is protected with a periosteal elevator while the bone is drilled; at this stage, an intravenous cannula (IVC) is passed through the drill holes in the bone from lateral to medial; as the tip emerges on the medial end of the bone hole, within the orbit, the cannula is gently pushed further and easily retrieved with a pair of flat-tip forceps, thus projecting out of the orbit. Each end of the permanent thread anchoring the lateral canthal ligament and/or the lateral end of the lower tarsal plate can be passed in a retrograde direction into the plastic cannula through each hole in the bone (Fig. 1). (See Video online, which demonstrates the technique on a cadaveric model. ) The natural stiffness of the thread makes this delivery maneuver through the cannula easy and effective. As soon as the thread has been delivered through the holes, the cannula is withdrawn. "href": "Single Video Player", "role": "media-player-id", "content-type": "play-in-place", "position": "float", "orientation": "portrait", "label": "Video 1. ", "caption": "This video demonstrates the technique on a cadaveric model. ", "object-id": {"pub-id-type": "doi", "id": "", "pub-id-type": "other", "content-type": "media-stream-id", "id": "1wie77s54", "pub-id-type": "other", "content-type": "media-source", "id": "Kaltura"} Fig. 1.: An 18G IVC is passed through each hole in the bone from lateral to medial. Each end of the permanent thread anchoring the lateral canthal ligament and/or the lateral end of the lower tarsal plate can be passed in a retrograde direction into the plastic cannula through each hole in the bone to complete the transosseous lateral canthopexy. This very simple tip allows for the most effective repositioning of the lateral canthal ligament with the minimum surgical dissection, thus preventing inadvertent orbital entry and endo-orbital soft tissue damage. The risk of thread fraying and bone splintering is greatly reduced. The maneuver is simple, straightforward, fast, safe, inexpensive, and cost-effective. To date, this technical tip has been successfully used in 6 clinical cases using an 18G IVC (diameter 1. 3 mm, length 45 mm) and a permanent 4/0 Nylon thread. Obviously, according to the different clinical requirements, the size of the IVC may vary to fit the size of the drill holes and the selected thread. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. PATIENT CONSENT The patient provided written consent for the use of the image.
Nicoletti et al. (Sun,) studied this question.