The Precaruncular Approach to the Medial Orbit

ORIGINAL ARTICLE The Precaruncular Approach to the Medial Orbit

Kris. S. Moe, MD

Background: Most approaches to the medial orbit and bit, with a clear, avascular path of dissection and im- lower provide suboptimal access and leave visible scars. proved exposure. In 15 consecutive procedures, there were The transcaruncular approach is an improvement over no complications. The patients healed rapidly, with mini- previous procedures, but disadvantages remain: there is mal postoperative morbidity. no defined surgical plane through the caruncle; the caruncular tissue is highly vascular; and the approach may Conclusions: The precaruncular approach was demon- cause considerable postoperative morbidity. For these rea- strated on cadavers to be more efficacious than ap- sons, cadavers were studied to develop a surgical approaches directly through or lateral to the caruncle. This proach that would avoid the caruncle. A prospective out- finding was confirmed in a prospective evaluation of 15 come evaluation was then performed. procedures, in which no complications occurred. More rapid healing was noted than with prior experience us- Materials and Methods: Two male and 2 female ca- ing the transcaruncular route. The precaruncular ap- davers were studied to ascertain whether the plane me- proach provides a preseptal plane to the medial orbit that dial or lateral to the caruncle provided optimal access to can be extended to the orbital floor or roof as needed, the medial orbit. Fifteen consecutive procedures were then and offers a direct connection between the posterior lac- prospectively evaluated using the medial approach. rimal crest and the tarsal plate for medial canthopexy.

Results: The “precaruncular” approach medial to the caruncle provided the most direct route to the medial or- Arch Facial Plast Surg. 2003;5:483-487

URGICAL ACCESS to the me- be extended into a transconjunctival ap- dial orbit is necessary to treat proach that reaches the orbit floor and/or a diverse range of patho- roof as well. logic conditions, including In 1999, I began using this approach neoplasia, infection, trauma, for medial canthopexy. As with the lateral Sand malposition or laxity of the medial can- canthal tendon, correction of laxity of the thal tendon. The majority of surgical ap- medial canthus requires tightening of the proaches in use today, such as the Lynch tendon in all 3 vectors (horizontal, verti- incision, are transcutaneous and thus cre- cal, and especially anteroposterior). This ate scars. In addition to the cosmetic dis- can only be accomplished using a advantage of this location, incisions placed posterior-superior approach with tighten- between the medial canthus and the na- ing of the posterior limb of the tendon sal dorsum are prone to scarring and web (Figure 2). This procedure was found formation.1,2 Furthermore, incisions in this to provide a distinct advantage over the area may provide poor surgical access, par- standard techniques of canthopexy that ticularly during correction of laxity of the tighten only the anterior limb of the ten- medial canthal tendon. don and thus address only the horizontal The transcaruncular approach has re- and perhaps vertical vectors. The first 3 cently been gaining popularity for access cases in which this was attempted pro- 3 From the Department of to the medial orbit. Because the incision vided the desired surgical correction but Surgery, Division of is made through the conjunctiva and car- caused prolonged edema, erythema, and Otolaryngology–Head and uncle (Figure 1), no cutaneous scars are irritation in the caruncle, which lasted up Neck Surgery, University of formed. The exposure provided is also ex- to several weeks. Delayed healing has California, San Diego. cellent and allows ample access that may also been noted by Fante and Elner,4 who

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©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 Lacrimal Canal Edge of Conjunctiva Anterior Limb of Medial Canthal Tendon Plica Semilunaris Edge of Skin

Lacrimal Sac

Lacrimal Caruncle Posterior Lacrimal Crest Anterior Lacrimal Crest

Posterior-Inferior Limb of Medial Tarsal Plate Canthal Tendon (Horner Muscle)

Figure 1. Medial aspect of the right eye, oblique view. The lacrimal caruncle Figure 2. Anatomy of the medial canthal tendon. The anterior and posterior and plica semilunaris are illustrated, along with the position of the tarsal limbs of the medial canthal tendon are illustrated, with the caruncle and plate and the superior and inferior lacrimal puncta. adjacent conjunctiva reflected laterally. The lacrimal canaliculi are shown entering into the lacrimal sac (medial to the canthal tendon).

found that the edema persisted more than 2 months in some of their patients who underwent a transcaruncular dissecting behind Horner’s muscle and can protect the approach. Furthermore, there is no defined surgical lacrimal canaliculi and retract the eyelids by keeping the plane within the caruncle; landmarks for dissection lacrimal probes in place during the procedure. The ques- within the structure are lacking; and the tissue is quite tion thus becomes whether the preseptal plane behind vascular. For these reasons, I decided to investigate the Horner’s muscle should be entered medial or lateral to possibility of an alternative approach, avoiding incisions the caruncle. in the caruncle, with the purpose of developing an approach with improved landmarks and diminished METHODS postoperative edema. A cadaver study was planned to explore other options, and a prospective evaluation of ANATOMICAL CADAVER STUDY the results was undertaken. In designing a surgical approach to the medial or- Four fresh cadaver heads, 2 male and 2 female, were inspected to ensure that there were no visible abnormalities of the upper bit, the goal should be to encounter the posterior lacri- or lower eyelids. On each side (N=8), the following proce- mal crest (Figure 2). Approaching bone anterior to this dure was performed. Size 4-0 lacrimal probes were placed structure places the posterior limb of the medial canthal through the upper and lower canaliculi into the lacrimal sac tendon as well as the lacrimal sac at risk of injury. Ap- and used for retraction of the upper and lower eyelids. To evalu- proaching the orbital wall posterior to the posterior crest ate the proposed lateral approach, an incision was made with is suboptimal because of crowding of the orbital con- a No. 11 blade immediately lateral to the lacrimal caruncle tents, and this type of approach may cause damage to through the conjunctiva of the plica semilunaris (Figure 1). A structures of the medial orbit, such as the medial rectus Wescott scissors was used to dissect along the lateral aspect of muscle. Furthermore, a more posteror approach will fail the caruncle inferiorly until Horner’s muscle was encoun- to raise the periosteum of the anterior lamina papyra- tered. Horner’s muscle was then followed medially to its insertion on the posterior lacrimal crest. The periosteum of the cea, where fractures may be located. The most expedi- medial orbit was then incised and elevated off the lamina papy- tious guide to this area is Horner’s muscle (the posterior- racea to expose the medial wall. inferior limb of the medial canthal tendon), which can To evaluate the medial approach, a No. 11 blade was used be followed medially to its insertion on the posterior lac- to make an incision medial to the caruncle at the border of the rimal crest. By approaching immediately posterior to Hor- medial canthal skin. The incision was continued toward the in- ner’s muscle, the dissection is performed in the presep- ferior and superior aspects of the plica semilunaris. Horner’s tal plane, which prevents herniation of the orbital fat muscle was identified immediately medial and deep to the con- during the procedure and allows a direct avascular path junctiva at the medial apex and inferior limb of the incision, to the orbit floor, should extended access be required. and a preseptal plane was developed posterior to the muscle At the medial aspect of the posterior limb of the canthal by spreading the tips of the scissors. Horner’s muscle was then followed to its insertion on the posterior lacrimal crest, leav- tendon, the septal tissue is a continuation of the supe- ing the tissue isolated between the medial and lateral ap- rior orbital septum, where it inserts on the posterior lac- proaches attached to bone. The surgical exposure of the area rimal crest, while more laterally the septum originates of the posterior lacrimal crest and lamina papyracea was then on the inferior orbital rim and inserts on the anterior lac- compared by viewing medial and lateral to the caruncle and rimal crest. The surgeon can protect the lacrimal sac by associated soft tissue.

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Grade Description 0 Normal eyelid appearance and function I Normal appearance but symptomatic; laxity present on examination Lacrimal Probe II Sclerae show without eversion of eyelid Caruncle III Ectropion without eversion of inferior lacrimal punctum Conjunctival Incision IV Advanced ectropion with eversion of punctum from lacrimal lake V Ectropion with complication (eg, conjunctival metaplasia, retraction of anterior lamella, or stenosis of lacrimal system) L Predominantly lateral M Predominantly medial Incision for r Previous surgical revision (number of prior corrections may Canthal Tightening be indicated by the addition of a number after the r, eg, L III/M Ir2) Incision for Orbital Floor Extension PROSPECTIVE OUTCOME EVALUATION Figure 3. Conjunctival incisions for the precaruncular approach. Lacrimal The following data were collected prospectively on 15 consecu- probes are placed in the superior and inferior lacrimal puncta. The scissors tive procedures (13 patients): age, sex, diagnosis (in those pa- indicates the location of the conjunctival incision. The incision may be tients with ectropion, an ectropion grading scale5 was used carried laterally for additional access to the orbit floor (dark dashed line) or [Table 1]), additional procedures performed, any intraopera- anteriorly for full access to the medial canthal tendon and tarsal plate (light tive difficulties, and perioperative complications. The exclu- dashed line). sion criterion for the study was patient age younger than 18 years. The surgical procedure was performed as follows (Figure 3). The patient was given intravenous sedation by the anesthesia service. One to 2 mL of 1% lidocaine hydrochloride with epinephrine (1:100000) was injected through the plica semilunaris to the lamina papyracea and through the skin medial to the canthus, directed toward the anterior lacrimal crest. Topical tetracaine hydrochloride drops were placed on the con- Caruncle junctiva. Size 4-0 lacrimal probes were then placed through the superior and inferior lacrimal puncta into the lacrimal sac. The Edge probes were then taped to the skin of the forehead and cheek, of Conjunctiva respectively, both protecting the canaliculi from transection and providing retraction of the eyelids for exposure of the surgical field. A Wescott scissors was then used to make an incision between the caruncle and medial canthal skin at the mucocuta-

neous junction. The incision was continued superiorly in the Medial Orbit fornix toward the plica semilunaris and inferiorly toward ei- ther the fornix or the tarsal plate, depending on the goals of the procedure. Dissection proceeded from the apex of the incision medially to expose Horner’s muscle, which was then followed a short distance laterally and then medially to its insertion on the posterior lacrimal crest. The medial palpebral artery passing into the caruncular tissue was cauterized with a bipo- lar cautery. A periosteal elevator was used to open the subperi- Figure 4. Completed precaruncular approach to medial orbit. The osteal plane lateral to the lamina papyracea toward the orbit appearance of the completed approach is illustrated, with the caruncle and roof and floor, as needed (Figure 4). In cases such as frac- adjacent conjunctiva retracted laterally. tures, when access to the orbit floor was required, the posterior aspect of Horner’s muscle was followed laterally in the preseptal plane and then inferiorly to the orbital rim and onto the rior to Horner’s muscle and follow it directly to the pos- orbit floor. When the relevant surgical correction was com- terior crest of the lacrimal bone. I found that approaches pleted, the wound was reapproximated and closed with a bur- both lateral and medial to the caruncle provided dis- ied 6-0 fast-absorbing gut suture at the apex and the superior tinct surgical planes. There was a consistent small branch and inferior limbs of the incision. of the medial palpebral artery at the central medial aspect of the caruncle that had to be cauterized with the RESULTS medial approach, but this did not cause problematic bleeding. The exposure offered by the medial approach was ANATOMICAL CADAVER STUDY superior, however, because it allows the caruncle to be retracted laterally with the globe, increasing the width The goal of this access procedure is to enter, in the saf- of surgical exposure. In addition, there is a more direct, est and most direct fashion, the preseptal plane poste- linear path to the posterior lacrimal crest, which is ben-

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Patient No./ Sex/Age, y Diagnosis Primary Procedure Ancillary Procedures 1/M/77 Ectropion Left PMC Bilateral LTC, FTSG of lower eyelid 2/M/49 Intraorbital bullet fragment Removal of bullet Drainage of orbital abscess 3/M/85 Facial paralysis Left PMC LTC, endoscopic brow-lift, gold weight 4/F/83 Cicatricial ectropion Left PMC LTC, FTSG 5/F/41 Facial paralysis Left PMC LTC, hypoglossal-facial neurorrhaphy and cross-facial nerve grafting 6/F/74 Facial paralysis Right PMC Endoscopic brow-lift 7/F/79 Facial paralysis Right PMC Open brow-lift 8/M/57 Pan−facial fractures ORIF of right orbit ORIF of multiple facial fractures 9/M/37 Orbital fractures ORIF of right orbit None 10/M/45 Facial paralysis Right PMC Right LTC 11/M/74 Bilateral entropion Bilateral PMC Bilateral LTC, lower retractor reinsertion 12/M/40 Facial paralysis Left PMC Hypoglossal-facial neurorrhaphy 13/F/55 Bilateral cicatricial ectropion Bilateral PMC Bilateral LTC

Abbreviations: PMC; precaruncular medial canthopexy; LTC, lateral transorbital canthopexy; FTSG, full-thickness skin graft; and ORIF, open reduction and internal fixation.

eficial in procedures to tighten the medial canthal ten- within 24 to 48 hours after surgery. One patient (No. 11, don. Furthermore, Horner’s muscle was reached imme- Table 2) who underwent unilateral medial canthopexy diately below the incision, with less dissection. For these complained of bilateral diffuse itching and erythema of reasons, the medial approach was chosen for clinical use. the conjunctiva, but these symptoms rapidly responded to the instillation of 0.5% loteprednol etabonate drops. PROSPECTIVE OUTCOME EVALUATION COMMENT Fifteen consecutive procedures in 13 patients (5 female, 8 male; average age, 61 years) in which the precaruncu- The transcaruncular approach to the medial wall of the lar approach was used were analyzed (Table 2). The in- orbit appears to have definite advantages over other pre- dications for surgery included medial canthal instability vious approaches because of the direct access provided (n=11) (entropion or ectropion), drainage of orbital ab- and the lack of visible scarring. In my experience, the dis- scess and removal of bullet (n=1), orbital fracture (n=2), advantages of the transcaruncular approach are persis- and medial cantholysis (n=1) for lower eyelid recon- tent edema and irritation of the surgical site. These com- struction. plications are understandable, given that the caruncle is The surgical approach required minimal dissection a complex tissue consisting of nonkeratinized squa- and provided excellent exposure in this series of pa- mous and conjunctival epithelium, with multiple cuta- tients. For patients undergoing medial canthal tighten- neous and conjunctival elements, serous and sebaceous ing, there was ample space for placing a screw at the su- glands, hair follicles, and inflammatory cells.6 As such, perior aspect of the posterior lacrimal crest, to which the it is apparent that an incision through this structure could medial aspect of the tarsus was fixed. The safety of the induce significant inflammation and would probably be procedure was ensured by placement of the lacrimal suboptimal for surgical dissection. I found this to be true probes and fixing them to the skin of the forehead and in performing transcaruncular surgery. cheek, which provided excellent tissue retraction, while The cadaver study showed that there were no tech- ensuring that the canaliculi would not be inadvertently nical impediments to performing an approach medial to transected. Furthermore, dissecting posterior to Hor- the caruncle. Furthermore, by retracting the caruncle lat- ner’s muscle ensured that the lacrimal sac would not be erally and dissecting in the preseptal plane a better ex- damaged. The surgical plane was easily entered and di- posure of the posterior lacrimal crest and lamina papy- rected the dissection to the desired site, without ambi- racea could be achieved with the medial approach than guity. In all cases, excellent visualization was provided with an approach lateral to the caruncle. by the surgical approach. The surgical access was more In the evaluation in the operating room, I found that than adequate for all surgical procedures performed, in- proceeding medial to the caruncle decreased operating cluding the placement of resorbable fixation screws for time, created less bleeding, and placed the surgical dis- medial canthopexy and the placement of resorbable mesh section closer to the anatomical guideposts used in reach- (Macropore Inc, San Diego, Calif) for medial wall or or- ing the area to be corrected. bital floor fracture repair. By operating in the preseptal The goal of this approach is to enter the preseptal plane, herniation of orbital fat into the operative field did plane posterior to Horner’s muscle and follow it directly not occur, and the width of exposure made lateral can- to the posterior crest of the lacrimal bone. The preseptal thotomy/cantholysis unnecessary. approach prevents fat herniation, while allowing exten- There were no complications in the series. In no in- sion of the dissection to the orbital floor in the same plane. stances did patients complain of persistent irritation of Dissection posterior to the Horner muscle prevents dam- the surgical site, and in most cases the edema resolved age to the lacrimal sac and exposes the length of the pos-

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©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 terior limb of the medial canthal tendon for cantho- fort and the lack of surgical complications in a prospec- pexy, should this be necessary. Placement of lacrimal tive analysis of 15 procedures. probes prevents damage to the lacrimal canaliculi and common canal. Placement of a corneal protector will pre- Accepted for publication September 25, 2002. vent corneal abrasion. This study was presented in part at the Eighth Inter- national Symposium of Facial Plastic Surgery; May 4, 2002; New York, NY. CONCLUSIONS Corresponding author and reprints: Kris. S. Moe, MD, Department of Surgery, University of California, San Diego, The transcaruncular approach is a significant improve- 200 W Arbor Dr, Suite 8895, San Diego, CA 92103 (e-mail: ment over previous procedures in that it eliminates vis- [email protected]). ible scars and provides direct access to the medial orbit. In my experience, however, incisions through the caruncle may cause prolonged postoperative discomfort and REFERENCES healing time. Through cadaver dissections, I determined that the 1. Shorr N, Baylis HI, Goldberg RA, Perry JD. Transcaruncular approach to the me- optimal way to avoid a transcaruncular incision is to place dial orbit and orbital apex. Ophthalmology. 2000;107:1459-1463. 2. Baumann A, Ewers R. Transcaruncular approach for reconstruction of medial the incision medial to the caruncle at the apex of the me- orbital wall fracture. Int J Oral Maxillofac Surg. 2000;29:264-267. dial canthus, at the junction of the conjunctiva and skin. 3. Garcia GH, Goldberg RA, Shorr N. The transcaruncular approach in repair of or- By entering into the preseptal plane behind Horner’s bital fractures: a retrospective study. J Craniomaxillofac Trauma. 1998;4:7-12. muscle through this incision, the medial orbit can be ex- 4. Fante RG, Elner VM. Transcaruncular approach to medial canthal tendon plica- posed with the least possible dissection, minimal blood tion for lower eyelid laxity. Ophthal Plast Reconstr Surg. 2001;17:16-27. 5. Moe KS, Linder T. The lateral transorbital canthopexy for correction and preven- loss, and excellent exposure for the desired surgical cor- tion of ectropion. Arch Facial Plast Surg. 2000;2:9-15. rection. The efficacy of this procedure was confirmed by 6. Kathuria SS, Howarth D, Hurwitz JJ, Oestreicher J. An anatomic and histologic the minimal amount of postoperative edema or discom- study of the caruncle. Ophthal Plast Reconstr Surg. 1999;15:407-411.

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