Reconstruction using a three-dimensional orbitozygomatic skeletal model of titanium mesh plate and soft-tissue free flap transfer following total maxillectomy

The surgical strategy for maxillary reconstruction after maxillectomy has yet to be standardized. The authors developed a technique using a three-dimensional orbitozygomatic skeletal model of a titanium mesh for skeletal reconstruction after maxillectomy. From May of 1996 to September of 2000, 18 patients underwent reconstruction using the titanium mesh model in conjunction with a soft-tissue free flap following total maxillectomy for a maxillary malignancy. The soft-tissue free flap was conventional and consisted of two skin paddles to the maxillary defect. One skin paddle became the lateral nasal wall and the other was used to close the palatal defect. After modeling, the titanium mesh plate was implanted between the orbital contents and the upper edge of the free flap to lie over the front of the flap. The model was fixed to the residual zygoma laterally and to the nasal or frontal bone medially. The palatal skin paddle was anchored by three or four dermal stitches to the bottom edge of the titanium mesh to create a concave neopalate that allowed the patient to wear a denture. Thirteen of 18 patients who underwent implantation had good facial appearance and oral function. This procedure prevented lagophthalmos, facial deformity, and sagging of the palatal skin paddle caused by gravitational force. Five patients (27.8 percent) developed exposure or infection of the implant and lost the benefit of having the prosthesis. However, treatment did not require total removal of the implant. Maintaining adequate tissue volume during soft-tissue transfer on either side of the mesh plate may minimize the complication rate. Titanium mesh implantation for skeletal reconstruction after maxillectomy avoids the need for bone grafting and may be especially beneficial in fragile or aged patients.     

Aesthetic and restorative midface lifting with hand-carved,expanded polytetrafluoroethylene orbital rim implants

The midface lift represents an important advance in aesthetic and reconstructive surgery. However, the need for reliable fixation along the orbital rim has been a significant challenge. Furthermore, volume is needed at the orbital rim, to compensate for long-term remodeling of the bone of the orbital rim and malar face. A technique using a hand-carved, expanded polytetrafluoroethylene implant that is permanently anchored to the orbital rim with titanium microscrews, creating a site for fixation of the advanced midface soft tissues, was developed. This report presents a retrospective, uncontrolled, case series of 41 consecutive patients who underwent transconjunctival midface operations with these implants, and it addresses a variety of midface aesthetic and reconstructive deficits. Only patients with at least 6 months of follow-up data were included in the study. To date, significant complications have been limited. The complications included two cases of implant palpability, with only one requiring surgical modification. One patient underwent implant removal because of skin breakdown and infection related to recurrent squamous cell carcinoma. One patient required revisional lateral canthoplasty for reasons of symmetry. On the basis of this series, hand-carved, expanded polytetrafluoroethylene implants seem to have significant advantages, compared with previously available orbital rim implants. These advantages include the ability to easily modify the implant for the individual anatomical needs, the creation of a secure anchor for fixation of advanced midface soft tissues, excellent tolerance of the implant material, and the ability to place the implant with limited exposure. The greatest disadvantage is the need for the surgeon to carve the implant, which requires time and carving skill. Despite this limitation, the technique is promising.     

Use of the radial forearm flap for deep,central, midfacial defects

Six cases that required soft-tissue replacement in the central midface are presented. The greatest number of flaps were used for large defects in patients with cleft palates who had undergone multiple previous operations. Several were for palatal defects attributable to cocaine abuse, and one was used for lining in a nasal reconstruction. There were no flap losses and, on the basis of these experiences, it is concluded that this is an excellent method for providing soft tissue in these difficult situations.     

Nasal cavities and paranasal sinuses in newborns and children]

The paranasal or accessory nasal sinuses begin their development as evaginations of the mucosa during the 3rd and 4th fetal months, but undergo their major expansion after birth according to the development of the facial cranium and the teeth. While in the newborn the sphenoidal and frontal sinuses are still only predispositioned, the ethmoidal labyrinth and particularly the maxillary sinus are of appreciable size. In the 4-year-old the frontal and sphenoidal sinuses are already developed and in the 12-year-old the paranasal sinuses reach their final form and a size equivalent to the adult.     

Primary reconstruction of complex midfacial defects with combined lip-switch procedures and free flaps.

Free flaps are generally the preferred method for reconstructing large defects of the midface, orbit, and maxilla that include the lip and oral commissure; commissuroplasty is traditionally performed at a second stage. Functional results of the oral sphincter using this reconstructive approach are, however, limited. This article presents a new approach to the reconstruction of massive defects of the lip and midface using a free flap in combination with a lip-switch flap. This was used in 10 patients. One-third to one-half of the upper lip was excised in seven patients, one-third of the lower lip was excised in one patient, and both the upper and lower lips were excised (one-third each) in two patients. All patients had maxillectomies, with or without mandibulectomies, in addition to full-thickness resections of the cheek. A switch flap from the opposite lip was used for reconstruction of the oral commissure and oral sphincter, and a rectus abdominis myocutaneous flap with two or three skin islands was used for reconstruction of the through-and-through defect in the midface. Free flap survival was 100 percent. All patients had good-to-excellent oral competence, and they were discharged without feeding tubes. A majority (80 percent) of the patients had an adequate oral stoma and could eat a soft diet. All patients have a satisfactory postoperative result. Immediate reconstruction of defects using a lip-switch procedure creates an oral sphincter that has excellent function, with good mobility and competence. This is a simple procedure that adds minimal operative time to the free-flap reconstruction and provides the patient with a functional stoma and acceptable appearance. The free flap can be used to reconstruct the soft tissue of the intraoral lining and external skin deficits, but it should not be used to reconstruct the lip.     

Direct local approach through a W-shaped incision in moderate or severe blowout fractures of the medial orbital wall

For moderate or severe blowout fractures of the medial orbital wall, the goals of treatment are complete reduction of the herniated soft tissue and anatomic reconstruction of the wall without surgical complications. Various surgical approaches have been used, depending on the anatomic location and the extent of medial wall fracture. However, there is no consistent method to achieve the treatment goals with minimal morbidity because of one or more problems of limitation of entire medial wall exposure, limitation of large implant or bone graft insertion, surgical damage of important periorbital or intraorbital structures, or postoperative scar deformities. In this study, a direct local approach through a 3-cm, W-shaped incision on the superior medial orbital area was used as a consistent method to reconstruct medial orbital blowout fractures. The angle of the W-limbs is 110 to 120 degrees. Four limbs of the W were placed parallel or oblique to the relaxed skin tension lines. This technique was applied to 39 orbits of 37 patients with moderate or severe blowout fractures of the medial orbital wall. This approach provided exposure of the entire medial orbital wall, adequate placement of a large implant, short operation time within 2 hours, and no damage of important internal structures. Postoperative computed tomographic scans showed complete reduction of the herniated orbital tissues and anatomic reconstruction of the medial orbital wall without complication related to the surgical approach in all cases. During the follow-up period of 6 to 14 months, excellent functional and cosmetic results were observed with an inconspicuous scar without secondary scar deformities. Therefore, a direct local approach through a W-shaped incision on the superior medial orbit may be a consistent method to gain the surgical goal in treatment of moderate or severe blowout fractures of the medial orbital wall.     

Three-dimensional endoscopic midface enhancement: a personal quest for the ideal cheek rejuvenation.

Standard face-lift techniques are excellent for the treatment of the jawline and neck. Treatment of the area between the lower eyelid and the corner of the mouth required the development of techniques in the intermediate lamella of the face. Alternative techniques of subperiosteal dissection by means of lower eyelid incisions were described with good aesthetic results but at the expense of increased morbidity and complications. All these techniques were also two-dimensional manipulations of the soft tissues of the face. The author presents a different approach that he believes is close to the ideal in terms of safety, morbidity, and complications.Although midface rejuvenation may be performed alone, it is more commonly done as a component of total facial rejuvenation. The midface is approached by means of a combination of a temporal slit incision and an upper oral sulcus incision; no eyelid access is used. Fifty percent of the midface dissection is performed under direct visualization, and 50 percent is performed under endoscopic control. Dissection of the temporal area is done under the temporoparietal fascia down to the zygomatic arch. The anterior two-thirds of the zygomatic arch periosteum is elevated along with a few millimeters of the intermediate temporal fascia and the fascia of the masseter muscle. The subperiosteal dissection of the zygoma and maxilla is completed with the medial extension of the dissection just medial to the infraorbital nerve. The orbital fat pads are released by means of intraoral route, and the lateral and middle fat pads are advanced over the orbital rim and fixed to the masseter tendon and the periosteum of the maxillary shelf at the intraoral incision. Three suspension points are typically used on the midface, each one with a different action. All are anchored to the temporal fascia proper. The vascularized Bichat's fat pad is mobilized and fixed with 4-0 polydioxanone sutures. This provides a volumetric cheek augmentation and improvement of the jowl. The inferior malar periosteum and fascia is used for malar imbrication with 4-0 polydioxanone sutures. This provides an anterior projection of the cheek and elevates the corner of the mouth. The suborbicularis oculi fat is used for en bloc vertical suspension of the cheek. This also improves the infraorbital V deformity.This technique has been used in close to 200 patients over the last 5 years. The complications have been minimal: two cases of temporary paresis of the levator of the upper lip, one case of paresis of the orbicularis oris (unilateral), one case of buccinator muscle dysfunction, and two moderate infections that were treated with simple drainage. The degree of facial edema has been minimal compared with the open or the transblepharoplasty approach. Typically, patients can return to work 2 weeks after surgery.The three-dimensional endoscopic midface enhancement provides a technique of midface remodeling that provides the missing dimension (volume) to the rejuvenation of the midface. This can be done with a minimal rate of complications, and the aesthetic results surpass by far the results of other midface techniques previously described by the author.     

The dermis-prelaminated scapula flap for reconstructions of the hard palate and the alveolar ridge: a clinical and histologic evaluation.

Ideal reconstructions of complex defects in the midface require the restitution not only of bone and soft tissue, but also of a thin and durable lining of the oral cavity. So far, split-thickness skin grafts, intestinal grafts, and in vitro cultured mucosal grafts have been used for the reconstruction of the oral lining. The use of skin as a substitute for oral mucosa is controversial because contraction, hair growth, maceration, and dysplastic changes can occur. This clinical and histologic study was performed to evaluate the suitability of dermis as a substitute for oral lining. Twelve complex defects of the midface were reconstructed with dermis-prelaminated scapula flaps. A bony flap from the lateral border of the scapula was prepared, and osseointegrated implants were placed. The bone flap was then prelaminated with dermis and covered with a Gore-Tex membrane to prevent adhesions. The composite flap was transferred to the midface 2 to 3 months later. The oral lining of the flap was evaluated clinically and histologically at 2, 4, and 6 weeks and at 3 to 41 months after the reconstruction. In all patients, the reconstructed bone was covered with a thin and lubricated surface without hair growth. None of the patients showed any signs of maceration. Histologically, these findings corresponded to a keratinized stratified squamous epithelium with highly developed connective-tissue papillae. These features closely resemble those of the normal mucosa of the hard palate and the gingiva. Thus, dermis prelamination is an effective method for reconstructing the mucosa of the alveolar ridge and the hard palate.     

Morphology of the endocranial cavities of Campinasuchus dinizi (Crocodyliformes: Baurusuchidae) from the Upper Cretaceous of Brazil

Two specimens of Campinasuchus dinizi (CPPLIP 1319 and CPPLIP 1360) belonging to Baurusuchidae (Crocodyliformes, Notosuchia) from the Upper Cretaceous Bauru Group of Minas Gerais state (Brazil) were scanned in a Toshiba Aquilion 64 CT machine. Based on these data, it was possible to identify and reconstruct the paranasal sinuses, the nasal cavity proper, the nasopharyngeal duct, the encephalon, the paratympanic sinuses, and the semicircular canals of the inner ear. The paranasal sinuses present similar morphology to those of other mesoeucrocodylians, especially eusuchians. The nasal cavity proper occupies the entire rostral region, with an expansion in the olfactory region. The expansion in the nasal cavity is present in other notosuchians and theropod dinosaurs (e.g., Tyrannosaurus rex Osborn, 1905), but less developed in aquatic crocodilians, which may indicate an olfactory acuity related to terrestrial habits. The encephalon is similar in shape to that of other mesoeucrocodylians. The rostral semicircular canal is smaller than the caudal one, differing from most mesoeucrocodylians. The paratympanic sinuses are more developed in C. dinizi than in eusuchians, being more similar to Tyrannosaurus rex. Campinasuchus dinizi presents few variations in the internal structures of the skull in relation to taxa with different ecological niches, probably indicating that ecological factors do not strongly influence the morphology of these structures.     

Wood exposure and smoking: association with cancer of the nasal cavity and paranasal sinuses in British Columbia.

A case-control study of 121 men seen for cancer of the nasal cavity or paranasal sinuses in British Columbia between 1939 and 1977 showed increased relative risks associated with occupations involving exposure to wood (2.5) and with smoking (4.9). The occupations involved were chiefly forestry and carpentry. Both risk factors appeared to be associated with the principal sites within the nasal cavity paranasal sinuses and with most histologic subtypes of cancer.     

Genetic Aspects of Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is a syndrome associated with persistent inflammation of the mucous membranes of the nose and paranasal sinuses. There are two forms of CRS: chronic rhinosinusitis with nasal polyposis (CRSwNP) and chronic rhinosinusitis without nasal polyposis (NP) (CRSsNP). Available data indicate that innate immunity, adaptive immunity, tissue remodeling, and influence of microorganisms can play a modified role in the development of CRSwNP. The genetic predisposition to the development of CRS is also possible. Today there are several groups of genes which influence the development of chronic rhinosinusitis. They include the genes associated with CFTR locus, HLA genes, genes of innate immunity, genes involved in the development of TH2-inflammatory reactions, genes responsible for tissue remodeling of paranasal sinuses, genes involved in the metabolism of arachidonic acid, genes of xenobiotic transformation, and other pro-inflammatory genes. Identification of genetic susceptibility to CRS would make it possible to develop personalized approaches for prevention, tactics, and effective treatment of chronic rhinosinusitis.     

Early definitive bone and soft-tissue reconstruction of major gunshot wounds of the face

The use of craniofacial surgical techniques, extended open reduction, rigid fixation with plates and screws, and the replacement of severely damaged or missing bone with immediate bone grafting in the treatment of complex facial fractures has been applied to the management of severe gunshot wounds of the face. Early definitive bone and soft-tissue reconstruction has been performed in 37 patients. One-hundred and seventy-seven primary bone grafts were utilized in 33 patients for orbital, nasal, zygomatic, and maxillary reconstruction. Twenty-six patients required mandibular repair with compression or reconstruction plates. Soft-tissue reconstruction was provided by a combination of flaps. Four patients had extensive soft-tissue loss replaced by free vascularized omental flaps. The omentum provided circumferential coverage of the mandibular reconstruction and reconstruction of the floor of the mouth and was then tunneled in a circle through both cheeks into the middle and upper face. The omentum reconstructed deficits in the hard palate and upper buccal sulcus and was then wrapped around all zygomatic, orbital, and midfacial bone grafts and used to fill in dead space in the maxillary, ethmoid, and frontal sinuses. The omentum is not used to provide contour and bulk, but to cover bone grafts and plates and fill in dead space. Carefully shaped bone grafts provide the correct craniofacial scaffold. Early restoration of a midfacial bony scaffold and the prevention of soft-tissue contraction facilitate secondary reconstruction. Four late total nasal reconstructions with tissue-expanded forehead skin wrapped around bone grafts were performed.     

Bipolaris australiensis in a Spanish patient with allergic chronic sinusitis

Allergic fungal sinusitis is a disease that results from hypersensitivity reaction of the host against fungi colonizing the paranasal sinuses. A 36 years old Spanish man with no history of travel abroad had a history of asthma, nasal polyps, allergic rhinitis and a chronic sinusitis with nasal congestion and headaches. Computed tomography showed pansinusitis and opacification of the paranasal sinuses. A pure culture of Bipolaris australiensis was grown from sinus tissues. Infections caused by Bipolaris spp. and treatment regimes are discussed.     

Low nitric oxide concentrations in exhaled gas and nasal airways of mammals without paranasal sinuses

To investigatewhether relevant levels of nasal nitric oxide (NO) are produced in theabsence of paranasal sinuses, we studied 17 healthy baboons, mammalswithout any paranasal sinuses. The animals were anesthetized withketamine hydrochloride and breathed spontaneously. While the baboonsbreathed through a face mask (mouths closed) connected to a respirator,NO concentrations in exhaled gas were sampled from the expiratory limband analyzed by chemiluminescence. While the animals were breathingambient air, nasal gas was sampled via a thin plastic tube and analyzed for NO concentrations by chemiluminescence. Mean NO concentration inthe exhaled gas was 1.00 ± 0.59 parts/billion, and NO release was4.28 ± 2.72 nl/min. A NO concentration of 4.79 ± 2.08 parts/billion was found in the nasal gas (NO release: 7.18 ± 3.13 nl/min). An age-dependent increase in nasal NO levelswas not observed. Exhaled and nasal NO concentrations in baboons weremarkedly lower than in mammals with paranasal sinuses, suggesting thatparanasal sinuses might be an anatomic requirement for production ofrelevant nasal NO levels.

     

Main patterns and individual differences in baboon skull split-lines and theories of causes of split-line orientation in bone

Split-line patterns are reported in skulls of five adult male baboons. While variations in pattern occur in all parts of the skull, these variations are relatively minor in the following regions: supraorbital, lateral orbital, medial orbital, nasal bones, zygomatico-alveolar crest, nasal opening, alveolar process of maxilla and mandible. Wide differences in pattern occur in these regions: infraorbital, zygomatic bone, body of maxilla, and frontal bone posterior to the supraorbital area. The major variability in split-line orientation indicates that oversimplified interpretations of the patterns in terms of (1) conformity to gross structure, or (2) direction of bone growth, are untenable. The variations do not contradict a functional interpretation in which mechanical forces and skull form interact to different degrees in different individuals, however. Skulls of a variety of primates are useful for functional analysis, because they have similar structural plans, but the differences are well outside the normal range of variation for a single species.     

Mitogenic responses of rat nasal epithelium to hexamethylphosphoramide inhalation exposure

Hexamethylphosphoramide (HMPA) is a rat nasal carcinogen that induces squamous cell carcinomas in the anterior portions of the nasal cavity following chronic inhalation exposures as low as 50 ppb. These tumors may arise as a result of P-450-mediated release of formaldehyde (HCHO), a known rat nasal carcinogen. The goal of this research was to investigate early responses of the nasal epithelium to inhaled HMPA. Rats were exposed nose-only to approximately 3 ppm HMPA for 6 h, and killed 18, 48, 96 or 144 h post-exposure. In a separate study, rats were exposed nose-only for 6 h for 1, 2, 3, or 5 consecutive days and killed 18 or 96 h post-exposure. With both single and repeated doses of HMPA, there was no evidence of cytotoxicity in the anterior nose. Olfactory degeneration and necrosis of the dorsal meatus, Bowman's glands and tips of the ethmoid turbinates increased in severity with repeated exposures to HMPA. Cell proliferation was assessed in levels of nasal tissue that included regions of squamous, respiratory, transitional and olfactory epithelium. Regional induction of cell proliferation was measured by BrdU incorporation, and reported as the number of labeled cells/mm basement membrane. At 18 h after a single exposure, there was an increase in cell proliferation in squamous epithelium, which returned to control levels within 48 h. A transitory increase in cell proliferation was observed regions of respiratory and transitional epithelium, although the response of each tissue, in terms of magnitude and peak time of response post-exposure, also differed. Along the dorsal meatus in Level 9, olfactory labeling initially decreased, returned to control levels by 96 h, but again declined at 144 h post-exposure. In repeat dose studies, the squamous epithelium response was variable 18 h post-exposure. For respiratory and transitional epithelium, increased cell proliferation 18 h post-exposure was correlated with increased dose (exposure) of HMPA. Cell proliferation responses following two or more exposures returned to near control levels within 96 h post-exposure. In conclusion, HMPA induced cell proliferation, but not cytotoxicity, in the anterior nose at approximately 3 ppm. These data suggest that HMPA induces proliferative, perhaps mitogenic, responses in the nasal epithelium, and this response may facilitate the fixation of low level genetic damage induced by liberated HCHO.     

The snout of Cricosaurus araucanensis: a case study in novel anatomy of the nasal region of metriorhynchids

Metriorhynchids are the only crocodyliforms adapted to pelagic marine life. Snout natural endocasts of the Tithonian (Late Jurassic) metriorhynchid Cricosaurus araucanensis indicated that skeletal changes defining the peculiar metriorhynchid body plan were coupled with changes of the soft cephalic anatomy such as the enlarged salt glands and restructuring of the paranasal sinus system. Seven new natural endocasts of the snout and a 3‐D reconstruction of C. araucanensis are described. Data from these casts and the reconstruction are congruent, and they are combined into an accurate reconstruction that improves our knowledge of the pre‐orbital anatomy. The olfactory tract, bulbs, olfactory nasal region and the anterior extension of the antorbital sinus within the maxilla are recognized. Osteological correlates of the salt gland body are also proposed. Palaeobiological inferences are erected based on the integration of natural endocasts and 3‐D reconstruction data. It is proposed that C. araucanensis nasal salt glands were highly vascularized with a blood supply comparable with those of extant marine birds. Reduced olfactory bulbs and olfactory nasal region indicate that the aerial olfaction, differing from extant crocodilians, was not well developed.     

Reconstruction of internal orbital fractures with Vitallium mesh

Trauma to the face frequently results in internal orbital fractures that may produce large orbital defects involving multiple walls. Accurate anatomic reconstruction of the bony orbit is essential to maintain normal appearance and function of the eye following such injuries. Autogenous bone grafts do not always produce predictable long-term support of the globe. Displacement and varying amounts of bone-graft resorption can lead to enophthalmos. This study examines the use of Vitallium mesh in the acute reconstruction of internal orbital defects. Fifty-four patients with 66 orbits underwent reconstruction of internal orbital defects with Vitallium mesh. Associated fractures were anatomically reduced and rigidly fixed. Forty-six patients and 57 orbits had adequate follow-up for analysis of results. The average follow-up was 9 months, with 85 percent of the patients followed 6 months or longer. There were no postoperative orbital infections, and none of the Vitallium mesh required removal. Large internal orbital defects can be reconstructed using Vitallium mesh with good results and little risk of infection. Vitallium mesh appears to be well tolerated in spite of free communication with the sinuses. Stable reconstruction of the internal orbit can be achieved and predictable eye position maintained without donor-site morbidity.     

Acoustic rhinometry in humans: accuracy of nasal passage area estimates, and ability to quantify paranasal sinus volume and ostium size.

A comprehensive study that compared acoustic rhinometry (AR) data to computed tomography (CT) data was performed to evaluate the accuracy of AR measurements in estimating nasal passage area and to assess its ability of quantifying paranasal sinus volume and ostium size in live humans. Twenty nasal passages of 10 healthy adults were examined by using AR and CT. Actual cross-sectional areas of the nasal cavity, sinus ostia sizes, and maxillary and frontal sinus volumes were determined from CT sections perpendicular to the curved acoustic axis of the nasal passage. Nasal cavity volume (from nostril to choana) calculated from the AR-derived area-distance curve was compared with that from the CT-derived area-distance curve. AR measurements were also done on pipe models that featured a side branch (Helmholtz resonator of constant volume but two different neck diameters) simulating a paranasal sinus. In the anterior nasal cavity, there was good agreement between the cross-sectional areas determined by AR and CT. However, posterior to the sinus ostia, AR overestimated cross-sectional area. The difference between AR nasal volume and CT nasal volume was much smaller than the combined volume of the maxillary and frontal sinuses. The results suggest that AR measurements of the healthy adult nasal cavity are reasonably accurate to the level of the paranasal sinus ostia. Beyond this point, AR overestimates cross-sectional area and provides no quantitative data for sinus volume or ostium size. The effects of paranasal sinuses and acoustic resonances in the nasal cavity are not accounted for in the present AR algorithms.     

Selective alteration of palpebral fissure form by lateral canthopexy

A method is described for altering the shape and position of the palpebral fissure at the lateral canthus. Three steps are essential to alter shape and position. They are (1) identification of a lateral canthal soft-tissue mass consisting of periosteum, lateral canthal ligament, and orbicularis muscle, (2) extensive subperiosteal soft-tissue mobilization of the lateral canthal soft-tissue mass (LCSTM) from a point just superior to the zygomaticofrontal suture and inferiorly along the infraorbital rim to a point corresponding with a vertical line drawn from the pupil downward, and (3) cutting of all soft tissue, including orbicularis muscle from dermis to bone and from bone to conjunctiva, from the lateral canthal soft-tissue mass medially to a point equal to a vertical line drawn from the pupil downward. After tension-free shifting laterally and superiorly has been accomplished, the lateral canthal soft-tissue mass is fixed into bone with minimal overcorrection. If there is still soft-tissue skin resistance, then overcorrection is desirable. The most difficult judgments in the procedure are the amount of superior and lateral tension to be placed on the palpebral fissure. As an aid in these judgments, the lateral-most extent of the palpebral fissure should be approximately 3 mm above the medial canthus horizontally and 3 to 4 mm medial to the medial-most portion of the lateral orbital rim. If overcorrection occurs, it can be released relatively simply.