Resident Manual of Trauma to the Face, Head and Neck

i. Internal Transnasal Wiring Internal transnasal wiring can be applied after the medial canthal region has been exposed bilaterally. In the past, transnasal wiring was per- formed without necessarily exposing the bony fragments, with the wires tightened over skin buttons. This led to a high incidence of skin necrosis, so the preferred method currently is to use internal wiring. Small holes are drilled adjacent to the anterior lacrimal crest and just superior to the posterior lacrimal crest, avoiding the lacrimal sac and common canaliculus. Stainless steel wire is then threaded through the holes, across the septum and back again to cerclage the NOE complex, tightening the wires after manual reduction to achieve the correct intercanthal distance. The wires will normally remain in place beneath the periosteum, unless they cause discomfort to the patient at a later The more preferred method of fixating the NOE fractures is to apply low-profile miniplates to the fracture sites after reducing the fractures and achieving proper intercanthal distances. The area for plate attach- ment is small, so 2–4 hole plates are usually the surgeon’s choice. The plates will be secured in place with short screws, and caution is taken not to drill the holes too deeply to jeopardize the region of the ethmoid fovea or the cribriform plate. Exposure is normally gained for plate application through either a gull-wing incision medial to the attachment of the medial canthi, or a coronal forehead approach. It is important to plan the exposure incision well away from the plate, to lessen the risk of plate exposure. The plates may be left in place, unless they cause discomfort to the patient in the future. iii. Polymer Canalicular Tube Reconstruction of a damaged lacrimal drainage system will likely require the insertion of a polymer canalicular tube (Figure 3.27). Figure 3.27 date or become exposed. ii. Low-Profile Miniplates

Polymer canalicular tube stent for damaged lacrimal drainage system. Note the blunt metal tips for threading into canaliculi via the puncta.

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