A Standardized Surgical Technique for Tessier Medial Transnasal Canthopexy

Tessier medial canthopexy is a technically-challenging surgical procedure that benefits greatly from video-assisted instruction for educational purposes. To begin, draw the incision line on each side of the face by following the Tessier orbitonasal incision along a bayonet-shaped line at the medial canthus, extending into a subtarsal approach. Create a sequence of broken lines along the incision to assist in dissection and reduce the risk of visible retractile scarring.

Infiltrate the incision sites and the medial canthus area with a subperiosteal injection of 1%adrenaline lidocaine solution, provided there are no contraindications. Using an 11 scalpel blade, perform a skin incision along the previously-marked lines, cutting down to the orbicularis muscle plane and extending laterally toward the lateral canthus. Then, using Ragnell scissors continued dissection through the preseptal plane until reaching the periosteum at the infraorbital margin.

Using a 15 scalpel blade incise the periosteum along the infraorbital margin. With an elevator, dissect the infraorbital margin in a subperiosteal plane. Then, roughen approximately two centimeters of the orbital floor and medial wall to achieve sufficient exposure.

Now, insert a lacrimal probe into the lower lacrimal passage to assist in identifying anatomical structures during dissection. Isolate the medial canthal tendon along its entire length. Using an elevator, dissect the medial orbital wall in a subperiosteal plane, pushing the lacrimal sac downward, and then continue dissection.

Expose the ascending process of the maxilla, using an elevator. To create the transosseous wire, using the largest square pin, make a bony perforation in between the anterior and posterior lacrimal crest. Angle the perforation slightly backward to direct the medial canthus traction within a posterior orientation.

Use a malleable retractor to shield the eye and lacrimal sac during the procedure. On the contralateral side, perform a bone perforation at the level of the lacrimal crest, just above the upper edge of the medial canthal tendon. Use a malleable retractor to protect the eyeball and the lacrimal sac during this step.

To begin creating a transnasal wire shuttle, fold the wire in half to form a loop. Pass this loop through the bone defect, from one side to the opposite side. Insert two additional wire loops head to head, using the first loop.

Gradually pull the loop from the opposite side to draw the steel wires transnasally through the bone tunnels. Once the loop has successfully pulled the wires through, remove the loop and arrange the wires separately. Carefully pass three separate 3/0 locking steel wires through the medial canthal tendon, ensuring each wire has a firm and secure hold.

Pass the wires in pairs through the metal loop, located on the affected side, and fold them back onto themselves to prepare for transnasal passage. Gradually pull the wire shuttle with the three attached steel wires at the opposite side in the transnasal passage. Then, remove the loop and place the wire distinctly for bilateral fixation later.

Create a metallic cleat by twisting together three or four number 1 steel wires, each approximately one centimeter in length, and tighten them securely. Anchor the passed steel wires onto the metallic cleat, positioning it firmly against the maxillary process. Then, cut the steel wires.

To close the orbitonasal approach, close the skin layer, using interrupted 6/0 polypropylene sutures. In patients with craniosynostosis, transnasal medial canthopexy achieved visibly-improved facial symmetry and orbital alignment post-operatively with corresponding changes confirmed by craniofacial CT scans. Over the past 10 years, nine unilateral and five bilateral transnasal medial canthopexies were performed in patients aged nine to 79 years with congenital dystopia or traumatic orbital bone injuries, achieving satisfactory results.

Two patients required dacryocystorhinostomy due to persistent epiphora following the procedure. There is a lack of educational and vital support concerning transnasal canthopexy. Our publication will help train surgeon for the realization of this technique.

Our protocol allows precise anatomical fixation of the medial canthal ligament with stable results, ensuring a satisfactory outcome.