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The aim of this study was to elucidate the precise anatomic location and tension of the medial palpebral ligament (MPL). Eleven hemifaces of 10 fresh Korean adult cadavers were used in this study. Nine specimens were used for measurement of dissection and tension, and 2 were used for histologic study. Measurements of tensile strength of each part of the MPL and Horner muscle were performed using a force gauge.The MPL consisted of 2 layers in all specimens dissected. The superficial layer of the palpebral ligament (SMPL) was observed from the anterior lacrimal crest to the upper and lower tarsal plates. The deep layer of the palpebral ligament (DMPL) lay from the anterior lacrimal crest to the posterior lacrimal crest, covering the lacrimal sac. The Horner muscle was observed at the posterior lacrimal crest just lateral to the attachment of the DMPL and ran laterally to the tarsal plate deep to the SMPL. The SMPL began at 4.5 ± 2.3 mm lateral to the nasomaxillary suture line to the upper and lower tarsal plates. Its transverse length was 9.6 ± 1.5 mm, and vertical width was 2.4 ± 0.7 mm, and its thickness was 4.5 ± 2.3 mm. The transverse length of the DMPL was 3.7 ± 0.4 mm, and its vertical width was 2.9 ± 1.3 mm, with a thickness of 0.3 ± 0.1 mm. The transverse length of the Horner muscle was 7.6 ± 1.9 mm, and its vertical width was 4.06 ± 1.5 mm, with a thickness of 0.4 ± 0.1 mm. The tensile strength of the SMPL was 13.4 ± 3.2 N, that of the DMPL was 4.1 ± 1.7 N, and that for Horner muscle was 9.0 ± 3.1 N. The tensile strength of the SMPL was significantly higher than that of the DMPL (P = 0.003).We reconfirmed that the MPL consisted of 2 layers: superficial layer and deep layer. Our results might be of use in surgeries of the medial canthi.

The aim of this study is to elucidate anatomic detail of the lateral canthal area relating to lateral canthoplasty. Thirty-three hemifaces of 22 Korean adult fresh cadavers were used. Thirty-one specimens were used for tension measurement and 2 for histologic study. There were 3 components of the lateral canthal area under the skin; lateral palpebral raphe (LPR), superficial lateral palpebral ligament (SLPL), and deep lateral palpebral ligament (DLPL). Lateral ends of superior and inferior orbicularis oculi muscles interlaced at the lateral commissure and formed LPR. SLPL extended from the lateral ends of tarsal plate to the periosteum of lateral orbital rim. Its transverse length was 9.4 +/- 2.6 mm and vertical width was 3.6 +/- 1.3 mm. DLPL extended from the lateral ends of tarsal plate deep to the origin of SLPL to Whitnall's tubercle on zygomatic bone inside the orbital margin. It is located deeper than SLPL. Its transverse length was 7.3 +/- 1.6 mm and its vertical width was 9.0 +/- 1.6 mm. Tensile strength of DLPL was 73.2 +/- 26.8 N and stronger significantly than SLPL (30.0 +/- 17.3 N). Tensile strength of LPR was 12.2 +/- 8.0 N and weaker significantly than SLPL and DLPL. A detailed understanding of 3 layered structures (LPR, SLPL, and DLPL) at lateral canthal area is conducive to performing lateral canthoplasty.

Summary The correct anatomy of the external palpebral ligament is demonstrated, based on microscopic studies. An analogy to the structures of the internal palpebral ligament is found.

Introduction Although external DCR was considered to be the Gold Standard treatment for NLD obstruction, endoscopic DCR appears to give comparable results, with the advantage of the absence of external facial scar and no disruption of the medial palpebral ligament or the angular facial vessels. This study aims to evaluate the outcome of endoscopic dacryocystorhinostomy (DCR) and compare with the outcome of external DCR, based on data available on literature search. Materials and Methods In this prospective, longitudinal, interventional study, 67 cases of chronic dacryocystitis were operated endoscopically from January 2017 to December 2018. All patients were documented about detailed medical and operative history, thorough medical check up including ocular and ENT examination. Level of obstruction of nasolacrimal duct (NLD) was diagnosed by lacrimal syringing and probing. Surgery was performed under local anaesthesia except in uncooperative patients where general anaesthesia was used. 0˚ & 30˚ endoscopes were used in surgery. The surgical outcomes and complications were recorded, analyzed and compared to those of external DCR from available literature. Results The overall success rate of endoscopic DCR was 94.7%, which is closely comparable to external DCR. Conclusion Endoscopic DCR is an effective and safe alternative to external DCR, with comparable results and better patient satisfaction.

The present study aimed to determine the arrangement and terminal attachments of the zygomaticus minor (Zmi) muscle fibers connecting the orbital and mouth regions. The Zmi was examined in 32 specimens of embalmed Korean adult cadavers. The Zmi was present in all 32 specimens (100%). In 31 of the specimens (96.9%), the Zmi that inserted into the upper lip was formed by muscle fibers that arose from the zygomatic bone and muscle fibers that extended from the orbicularis oculi (OOc) muscle. In 14 of the specimens (43.8%), some fibers of the Zmi that arose from the zygomatic bone blended with the inferior margin of the OOc, while the other fibers inserted into the upper lip. After the Zmi fibers blended with the inferior margin of the OOc, these fibers constituted the inferior and medial margins of the OOc. These fibers were then attached to the medial palpebral ligament, the maxilla, the levator labii superioris alaeque nasi muscle, and the depressor supercilii muscle. In 30 of 32 specimens (93.8%), muscle fibers that extended from the OOc constituted the lateral margin of the Zmi, usually descending to the level between the nasal ala and the vermilion border of the upper lip and inserting into the upper lip. The obtained data will be helpful for understanding their connected movements and in kinematics and electromyographic analyses, therapies involving injections of botulinum toxin Type A, and various types of facial surgery. Clin. Anat. 31:974-980, 2018. © 2018 Wiley Periodicals, Inc.

The middle and distal part of the nose has multiple well-defined cosmetic units with a distinct outline, color, consistency, sebaceous content, texture and function. Crossing these units with surgical incisions can lead to a more visible scar. Here we will deal with the case of an 84-year-old patient with basal cell carcinoma of the junction between the dorsum and the alar of the nose and the management of the resulting loss of surgical substance with the Marchac flap. This frontal flap described by Marchac is an axial flap based on a vascular pedicle emerging near the inner palpebral ligament, allowing coverage of the loss of substance while respecting the nasal subunits and less thickness difference is present.

Background: Dacryocystitis is the inflammation of the lacrimal sac due to nasolacrimal duct obstruction. Chronic dacryocystitis is a constant threat to cornea and orbital soft tissue & always dictates surgery for correction of symptomatology. The gold standard procedure of choice for the treatment of epiphora is Dacryocystorhinostomy. This study proposes to evaluate and compare the surgical outcome of external DCR and endoscopic endonasal DCR. METHODS: A Retrospective, comparative, randomized interventional study was conducted from January 2012 to December 2013. 40 diagnosed cases of chronic dacryocystitis were randomized into two groups. Group A included 20 patients who underwent external Dacryocystorhinostomy and group B included the rest of the 20 patients who underwent endoscopic endonasal Dacryocystorhinostomy. RESULTS: In group A patients, 9 cases had bleeding during surgery, tearing of the anterior nasal flap was seen in 5 cases and punctal laceration in 4 cases. In group B patients 3 cases had bleeding, 5 cases had Trauma to the middle turbinate while accidental entry into anterior ethmoidal cells was in 4 cases. In 8 cases there was difficulty in making a bone window. In group A patients, duration of surgery is comparatively more than in group B. In post-operative period group A patients, had epistaxis, rhinostomy site closure, hypertrophied external scar and medial canthi damage as its complication while group B epistaxis, nasal Synechea, intra nasal granulation at the ostium are major complication. After a period of 3months by syringing the lacrimal sac of the patients in group A patients, 18 patients had a patent sac (success rate is 90%). In group B patients, 16 patients had a patent sac (success rate being 80%). CONCLUSION: DCR either by external or endonasal route can be considered for treatment of nasolacrimal duct obstruction. The external route has an easy and short learning curve with reduced cost of equipment. Whereas endoscopic DCR is time saving, avoids a facial scar and injury to the neighboring structures like the medial palpebral ligament and the angular facial vessels. In our study, the success rate of Endonasal DCR and External DCR are almost equal and comparable. This indicates that these two different DCR techniques are acceptable alternatives. However it's the preference of the patient, resource available and the surgeon himself to decide the right surgical option to axe the disease.

We performed reconstruction with a composite radial forearm palmaris longus tendon flap in patients with wide defects of upper or lower eyelids. In one upper eyelid reconstruction, a palmaris longus tendon was fixed to the frontal muscle to make it possible to open the eye. In the lower eyelid reconstruction, the tendon was fixed to both the medial palpebral ligament and the lateral orbital rim to support the flap. In wide upper and lower eyelid reconstruction with a forearm flap, it is convenient to utilise the palmaris longus tendon to support the flap.

A congenital medial canthal anomaly was identified as the cause of epiphora in 18 young adult male patients. This anomaly consists of anomalous anterior displacement of the medial palpebral ligament causing a lack of adequate apposition of the medial end of the lower lid to the globe. The lacrimal punctum does not dip into the lacrimal lake, thereby causing epiphora. An innovative surgical technique is described involving the passage of a suture in the pretarsal plane along the lid margin to correct the deformity.

Purpose: To clarify anatomically the facial nerve branches in the eyelids and periorbit. Methods: The facial nerve branches of the left periorbits from 31 Japanese cadavers were dissected under a surgical microscope. Results: The temporal, zygomatic, and deep buccal branches assembled posterior to the orbicularis oculi from its temporal or inferior side, and formed a dense plexus. The superficial buccal branches coursed, unlike the others, around the inferior nasal margin of the orbicularis oculi with some variations. The branches always passed across the “triangular window” that was outlined by the orbicularis oculi, the zygomaticus minor, and the levator labii superioris alaeque nasi. Then the branches crossed over the medial palpebral ligament, reaching both the procerus and corrugator supercilii in 94% of the specimens. The branches ramified the lower part of the orbicularis oculi in 65% and the upper part in 42% of the specimens. Conclusions: The superficial buccal branches are the main supplier to the muscles in the nasal periorbit. This anatomical finding may be important information for accurate procedures in facial nerve surgery.

Dystopies of the bony orbit are caused mainly by craniosynostosis, facial clefts and encephaloceles. This article presents the results of the surgical correction of orbital hypertelorism in 24 patients. Using this operation technique, the bony interorbital distance was decreased from an average of 47.6 mm to 22.8 mm. However, the distance between the soft tissues was not reduced by the same amount as the distance between the bony orbits. The intercanthal distance decreased from an average of 58.5 mm to 44.5 mm, whereby an additional refixation of the medial palpebral ligament resulted in a reduction of the intercanthal distance to 40.8 mm. A strabismus divergens was seen preoperatively in 18 patients, postoperatively only in 8 patients. Four of the latter had to undergo operative correction of the diplopia. We conclude that the operative technique is not reserved only for complex cases of hypertelorism because it shows satisfactory functional and aesthetic results with a low complication rate.

Purpose To present a new technique of ocular fixation to restore and maintain the ocular alignment in primary position for patients with total third nerve paralysis. Method We fixated the globe (medial rectus muscle insertion) to the medial palpebral ligament insertion at the anterior lacrimal crest by using nonabsorbable 5-0 polyester sutures in a prospective study of 5 patients (5 eyes) with congenital total third nerve paralysis. A large recession of the lateral rectus muscle (12 to 16 mm) was also performed in four patients. Results Four patients achieved satisfactory ocular alignment and one patient had residual exotropia. After an initial exotropic shift, no significant change in ocular alignment was observed during the follow-up period of 6 to 9 months. Mild fullness and congestion over the medial rectus muscle area was observed in the immediate postoperative period in all the patients, which resolved in about two months time. Conclusion This technique of ocular fixation is easy, safe, and effective for the management of exotropia secondary to total third nerve paralysis.

Aim To find out intra operatively the most common cause of failure of previous dacryocystorhinostomy. Materials and methods 8 patients referred over a period of 4 years (January 2008 December 2012) who underwent successful repeat EDCR were selected. All the patients who had persistence tearing and ROPLAS positive were included in the study and those with regurgitation from the same punctum or canalicular obstruction were excluded from the study. Results Average age of the patients undergoing repeat EDCR was 48 years.The most frequent cause of failed DCR was a scarred ostium. Conclusion: Proper identification of the anterior lacrimal crest, lacrimal sac, and bigger osteotomy (10mm) in diameter is important for a successful primary EDCR. Introduction The original external DCR was first described by Toti in 1904. In 1921 Dupuy-Dutemps and Bourguet described a technique of external dacryocystorhinostomy modifying Toti’s operation. They emphasized the importance of making an anastomosis of sac to nose with sutured mucosal flaps.External dacryocystorhinostomy (EDCR) is still considered an effective surgery for complete nasoloacrimal duct in adults with a success rate of over 90%. Despite meticulous surgery, failures are often met with. Various studies have stated various causes for failure of DCR [1-4].Secondary surgery on the lacrimal drainage system, is likely to be successful in a high proportion of cases [5].In this study we assess the most common intra operative cause for a failed EDCR and the success rate of repeat EDCR. Materials and methods: 8 patients referred over a period of 4 years(January 2008 December 2012)who underwent successful repeat EDCR were selected. All these patients had undergone primary surgery elsewhere and were referred due to the persistence of symptoms. After taking the demographic details, a thorough examination of eyelids to identify matting of eye lashes and purulent discharge in the medial canthal area was performed. ROPLAS (Regurgitation on pressure over the lacrimal sac) along with syringing in the outdoor. ENT consult was sought to rule out any high posterior deviation of septum blocking the rhinostomy or causing synaechiae formation. Patients with regurgitation from the same punctum or canalicular obstruction and patients with gross nasal pathology were excluded from the study. Written informed consent was obtained. A revision was done in all the cases and the likely causes for failure of the first surgery were analyzed.All surgeries were performed under local anaesthesia under the operating microscope. Procedure: Prior to surgery nasal packing was done with a gauze soaked in 2% xylocaine with 1:2,00,000 adrenaline to reduce the risk of intra operative bleed. The skin was painted with povidone iodine. Local infiltration of 2% xylocaine with adrenaline was used in all cases. A skin incision of 8 mmis made through the original scar. Orbicularis was separated and medial palpebral ligament if present was cut for better exposure. Lacrimal sac was identified and intactness was checked.The osteotomy was inspected for its presence or closure by fibrosis. The anterior aspect of the previous rhinostomy was identified and enlarged anteriorly to find nasal mucosa.Anastomosis if present was checked for its patency. Bowman’s probe was inserted to check for common cannalicular obstruction.Anastomosis was made between the medial wall of the sac and nasal mucosa after enlarging/creating an osteotomy. The 2 were sutured with 6-0 vicryl. Orbicularis and tendon are repositioned with an absorbable suture, and the skin is closed with an interrupted nylon suture. After discharge the day after operation patients were reviewed and syringing was performed at one week postoperatively, at six weeks, and again at three months.All patients received topical and systemic antibiotics post operatively. Sutures were removed on day 7. The data collected from the patients were recorded and analyzed using Statistical Package for the Social Sciences (SPSS) version 16. Chi square and Fisher exact tests were used to assess the association between surgical outcome and cause for failed dacrocystorhinostomy, with pvalue 3 months in 25%

Purpose Lower eyelid ectropion is usually accompanied by a variable degree of medial and lateral eyelid laxity. This work investigates a clinical evaluation scheme and a surgical plan to repair ectropion associated with different stages of such associated laxity. Patients and methods Forty-two procedures on 30 patients with lower eyelid ectropion associated with variable degree of medial palpebral ligament laxity were performed on the basis of the ectropion classification and management protocol described in this work. Patients were followed up for at least 6 months postoperatively. Results Firm medial eyelid fixation against lateral traction and correction of ectropion were achieved in all cases. Epiphora was cured in 26 eyes. The planned cosmetic outcome was achieved in 28 cases. Conclusion Individualizing the surgical repair for involutional ectropion on the basis of the clinical findings is cosmetically and functionally rewarding.

Purpose: We present a new technique of anchoring the eyeball to the nasal periosteum with supramaximal recession of the lateral rectus muscle in one eye for exotropia management in bilateral total third nerve palsy combined with trochlear nerve palsy. Case summary: A 38-year-old man presented with drooping of both upper lids and exodeviation of the left eye with a history of intraventricular hemorrhage 9 months previously. We noted bilateral ptosis, dilated pupils, right fixing eye, left face turn, and left exotropia over 100 prism diopters (PD) in the primary position with an inability to move both eyes together except abduction. He was diagnosed with bilateral total third nerve palsy and trochlear nerve palsy. We fixated the left globe (sclera anterior to the insertion of the medial rectus muscle) to the nasal periosteum including the medial palpebral ligament using a nonabsorbable suture. A large recession of the left lateral rectus muscle (14 mm) was also performed. Ocular alignment in the primary position was exotropia of 25PD and cosmetically satisfactory after 6 months of follow-up. Conclusion: Supramaximal recession of the lateral rectus muscle and periosteal fixation using nonabsorbable suture is an effective technique for the management of exotropia secondary to total third nerve palsy.

The primary functional support for the medial eyelid is from the deep attachments of the orbicularis muscle to the posterior lacrimal crest and lacrimal diaphragm. A dehiscence of the deep medial canthal attachments can alter the position of the lower eyelid with subsequent tearing, medial ectropion, and ocular exposure. In this study, medial palpebral tendon reconstruction was performed on seven lower eyelids with medial instability or ectropion and a dehiscence of the medial palpebral tendon. A periosteal flap left attached to the posterior lacrimal crest was used to replace the attenuated or absent medial palpebral tendon. After a mean follow-up of 7 months, 86% (6/7) of the eyelids had acceptable cosmetic and functional results. The use of a periosteal flap to replace a dehiscence of the medial palpebral tendon has several advantages. The periosteal flap is readily available, strong, and autogenous. The lower eyelid and punctum are pulled tightly against the globe. Lastly, the procedure may be repeated or combined with other ectropion procedures.

THE ORBITAL contour may be distorted by comminution of bone and telescoping of fragments in maxillary and zygomatic fractures, congenital malformations, loss of bone from osteomyelitis, radiation necrosis and destructive surgical procedures necessary in the eradication of malignant disease. Such distortion or disorganization points to the need for a suitable technic for restoration of the orbital floor and replacement of missing bone. In the case of comminution of bone along the infraorbital rim and in the orbital floor the fragments may sink into the maxillary sinus. Contraction occurs during the healing of the torn mucosa of the maxillary sinus, and the scar tissue formed tends further to draw the comminuted fragments downward. When fracture of the zygomatic bone results in separation of the frontozygomatic junction, ptosis of the eyeball is particularly evident (fig. l a ). The lateral palpebral ligament and the thick portion of Tenon's capsule, known as the suspensory

In the case reported here coloboma followed the removal of a portion of the upper eyelid for basal cell carcinoma. The growth involved both the conjunctiva and the skin and was removed by excising a full thickness section of the lid extending from the free margin to a little above the upper border of the tarsus. Following operation, a small portion of the eyelid near the inner canthus remained, with the median palpebral ligament. Five months later there was no sign of recurrence, but the conjunctiva was becoming increasingly irritated from exposure. For repair of this defect, it is essential to have a lining to replace the conjunctiva and a cutaneous surface for the outside of the lid. In this case the remaining fibers of the orbicularis oculi muscle above and at the sides of the defect provided good closures, and sufficient of the levator attachment remained to

In the course of tumour excision the entire lateral canthus including the lateral palpebral ligament may have to be removed along with an upper or lower lid. In such cases it is difficult to conceal the defect and restore the function of the eyelids by plastic surgery. A combined advancement rotation flap has proved to be a technically simple method of reconstruction and successful functionally as well as cosmetically. A temporal flap is prepared and advanced medially. By making incision(s) into this flap it is possible to reconstruct both the canthus and the sulcus suprapalpebralis. The lateral tarsal margins are fixed to the periosteum by chromic catgut loops, and with a skin flap there is sufficient support to ensure normal function. An inner lining is provided by mobilising conjunctiva. The advantages and results of this method are discussed.