Reconstruction of Medial Canthal Tendon Using Novel Suture Anchoring System: A Case Report.

For medial canthal tendon reattachment, many kinds of surgical technique have previously been reported. They are complicated and generally require technical skill and prolonged operating times. We, for the first time, describe a novel device, the Caraji Anchor Suture System, used for reattaching the medial canthal tendon to the medial orbital wall after removal of squamous cell carcinoma. The medial canthal tendon was excellently fixed with this rapid and simple method. No complications, such as local infection or exposure, have occurred up to the present. This technique appears to be safe, fast, and effective for reconstruction of the medial canthus after tendon avulsion or loss from excision of cutaneous carcinoma in plastic and reconstructive surgery.

Many kinds of surgical technique have previously been described to reattach the medial canthal tendon to the orbital medial wall. They generally require technical skill, take much time for the procedure, and some of the techniques require invasive operation. We report, for the first time, a novel device, Caraji Anchor Suture System (Medical U&A, Inc., Osaka, Japan), for medial canthal tendon reattachment to the orbital wall after removal of squamous cell carcinoma. In this system, 2 holes for fixation are made with self-tapping screws using the included driver. The canthal tendon could be fixed simply within a short time, and no local infection or exposure occurred after surgery. This system is useful for medial canthoplasty after skin tumor resection and trauma in the plastic and reconstructive surgery field.

CASE

The patient was an 82-year-old man who presented with squamous cell carcinoma in the right medial canthal area. The tumor was resected at a 5-mm margin distant from the nodule margin. Excision of the tumor required tissue loss, including skin, muscle, periosteum across the medial canthal area, and anterior limb medial canthal tendon enclosing canaliculi. Bilayer artificial dermis composed of a collagen sponge and silicone film, Pelnac (Gunze Corp., Osaka, Japan), was applied to the skin defect in the presence of an open wound. After the margin and bottom of the resected tissue were free of squamous cell carcinoma on pathological examination, the medial canthal tendon was fixed using the Caraji Anchor Suture System (Fig. 1). The Caraji Anchor Suture System is comprised of self-tapping screws and an exclusive driver. Fixation is simple and is completed within about 3 minutes. The screw is combined with independent washers with 2 holes for threading (Fig. 2). Because the washer does not move with rotation of the screw, suture for fixation does not get entangled with the screw. First, 3-0 clear nylon threads were applied to the stump of the medial canthal tendon and passed through the holes of the Caraji individually and tied, followed by fixation by self-tapping using the exclusive driver (see video, Supplemental Digital Content 1, which displays the procedure of the fixation of the Caraji Anchor Suture System. The video of this method being applied to a facial bone model. This video is available in the “Related Videos” section pf the Full-Text article at PRSGlobalOpen.com or at http://links.lww.com/PRSGO/A840). When tension is sufficiently applied in this state to fix to the bone, the washer automatically stops at the optimum position and it does not rotate. The skin and soft-tissue defect was covered with a median forehead flap (Fig. 3). As of 8 months after surgery, the medial canthus morphology was favorable and no local infection or exposure was noted (Fig. 4). At the time, it was easy for the patient to open and close the eyelids, and there were no complaints of tearing, tenderness, or swelling.

Fig. 1.

The medial canthal tendon was fixed using the Caraji Anchor Suture System.

Fig. 2.

The screw is combined with independent washers with 2 holes for threading.

Fig. 3.

The skin defect was covered with the left median forehead flap.

Fig. 4.

The local findings postoperatively at 8 months.

See video, Supplemental Digital Content 1, which displays the procedure of the fixation of the Caraji Anchor Suture System. The video of this method being applied to a facial bone model. This video is available in the “Related Videos” section pf the Full-Text article at PRSGlobalOpen.com or at http://links.lww.com/PRSGO/A840.

DISCUSSION

Repositioning and reconstruction of the medial canthal tendon due to malignant tumor resection and repair of trauma including comminuted fractures at the medial canthal area is a key procedure.[1] Once the tendon is malpositioned or loosened, it usually results in the medial canthus being deformed laterally and the palpebral fissure being shortened. Therefore, surgical repair of these defects requires reattachment or complete reconstruction of a medial canthal dystopia. To date, a variety of surgical techniques have been described to reattach the medial canthal tendon to the orbital medial wall.[2-10] However, they generally require technical skill, take much time for the procedure, and some of the techniques require invasive operation. Mustarde[2] and Converse and Smith[3] developed transnasal wiring techniques and their methods have been modified by various researchers.[4,5] Fixation of the medial canthal tendon with a stainless steel screw and microplate has also been developed.[6] However, the procedure of making a burr hole using a motor system and passing wire through it is complex, being problematic. Furthermore, advantageous of Caraji over a self-tapping screw and miniplate is that the bone fixation point can be decided after applying thread to the medial canthal tendon, which facilitates accurate simulation of the stop region of the medial canthal tendon.

Recently, fixation methods of medial canthal tendon using a suture anchor system have been reported.[9,10] The representative suture anchor system, Mitek Anchor System (Mitek Surgical Products Inc., Mass.) was developed to fix soft tissue to bone tissue, and its use in the plastic surgery field has been reported.[9,10] In this system, a burr hole is prepared using an exclusive drill and an anchor with thread is inserted into the hole using an exclusive inserter. Accordingly, the anchor is first fixed to the bone and then, the medial canthal tendon is sutured to it. This method has disadvantages that threads other than those contained in the Mitek Anchor System package cannot be freely selected, and removal of the anchor is difficult.

The Caraji Anchor Suture System used in the present patient has 5 advantages as follows: (1) The bone fixation point can be decided after applying thread to the medial canthal tendon, which facilitates accurate simulation of the stop region of the medial canthal tendon. (2) Removal of the screw is possible. The bone fixation position can be corrected and the screw can be removed when infection occurs. (3) Because the anchor device and suture are separated, operators can freely select a suture. (4) Because a self-tapping screw is used, it is not necessary to make a burr hole using a motor system. Careful management of screwing self-tap screws is only needed against the bony fractured pieces in traumatic cases, although this system is adequate for the stable basal bony structure in resecting the soft-tissue malignancy. (5) The washer for threading has 2 holes, which makes knotting easier even in a narrow surgical field. The Caraji Anchor Suture System appears to be safe, fast, and effective for reconstruction of medial canthus after tendon avulsion or loss from excision of cutaneous carcinoma in plastic and reconstructive surgery.

CONCLUSIONS

The Caraji Anchor Suture System appears to be safe, fast, and effective for reconstruction of the medial canthus after tendon avulsion or loss from excision of cutaneous carcinoma in plastic and reconstructive surgery.